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Biliary-enteric anastomosis is a common surgical procedure for benign and malignant pathologies involving bile ducts, pancreas and duodenum, as well as during liver transplantation. Imaging is key in detecting potential complications. Ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear scintigraphy provide complementary information. Ultrasound offers real-time assessment of bile duct dilation and fluid collection. CT scan, due to its wide availability, is often performed first and provides detailed cross-sectional anatomy. MRI, including MR cholangiography, excels in visualizing bile ducts and detecting subtle changes in anastomosis integrity. Common complications of BEA include bile leak, biliary anastomotic stricture, and cholangitis, each presenting with distinct imaging features. Effective imaging allows for early detection and management of these complications, improving patient outcomes. This review discusses the role of imaging in assessing post-BEA complications and emphasizes the importance of multimodal imaging approaches in the comprehensive evaluation of BEA and its complications., Competing Interests: Declarations. Conflict of interest: There is no conflict of interest from all the authors., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Backgrounds/aims: Socioeconomic determinants of health are incompletely characterized in cholangiocarcinoma (CCA). We assessed how socioeconomic status influences initial treatment decisions and survival outcomes in patients with CCA, additionally performing multiple sub-analyses based on anatomic location of the primary tumor., Methods: Observational study using the 2018 submission of the Surveillance, Epidemiology, and End Results (SEER)-18 Database. In total, 5,476 patients from 2004-2015 with a CCA were separated based on median household income (MHI) into low income (< 25th percentile of MHI) and high income (> 25th percentile of MHI) groups. Seventy-three percent of patients had complete follow up data, and were included in survival analyses. Survival and treatment outcomes were calculated using R-studio., Results: When all cases of CCA were included, the high-income group was more likely than the low-income to receive surgery, chemotherapy, and local tumor destruction modalities. Initial treatment modality based on income differed significantly between tumor locations. Patients of lower income had higher overall and cancer-specific mortality at 2 and 5 years. Non-cancer mortality was similar between the groups. Survival differences identified in the overall cohort were maintained in the intrahepatic CCA subgroup. No differences between income groups were noted in cancer-specific or overall mortality for perihilar tumors, with variable differences in the distal cohort., Conclusions: Lower income was associated with higher rates of cancer-specific mortality and lower rates of surgical resection in CCA. There were significant differences in treatment selection and outcomes between intrahepatic, perihilar, and distal tumors. Population-based strategies aimed at identifying possible etiologies for these disparities are paramount to improving patient outcomes.

Background: There is mixed evidence that patients who receive care in hospitals with a low case volume for complex gastrointestinal and hepatobiliary operations have an increased risk of inpatient death., Methods: A retrospective cohort study was performed of patients who had complex gastrointestinal and hepatobiliary operations in the Healthcare Cost and Utilization Project 2012 National Inpatient Sample. Multivariable weighted hierarchical generalized linear models were used to test the relationship between hospital case volume and probability of inpatient death, with detailed adjustments for the concurrent effects of differences in associated patient co-morbidities., Results: A total of 8260 pancreaticoduodenectomies, 2750 major hepatectomies and 3250 total gastrectomies were identified. Inpatient death occurred in 3·6 per cent of patients after pancreaticoduodenectomy, 4·9 per cent after major hepatectomy and 4·6 per cent after total gastrectomy. Mean hospital case volume was 50·6 (median 40) for pancreaticoduodenectomy, 23·6 (median 15) for major hepatectomy, 15·1 (median 10) for total gastrectomy and 70·2 (median 50) for any of the three operations. Hospital case volume was not a statistically significant predictor of mortality after any operation (all P ≥ 0·188). Patient characteristics including age and co-morbidity were highly significant predictors of mortality (P < 0·001). No significant improvements in model performance were obtained by adding hospital case volume to any model that already included adjustments for patient-level differences in age and co-morbid disease, for any functional format (P ≥ 0·146 for all C statistic differences from baseline)., Conclusion: Patient co-morbidity, not hospital case volume, was associated with significant differences in inpatient mortality following complex gastric, pancreatic and hepatobiliary resections.

Background: Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach., Results: There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients., Discussion: Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Enhanced recovery pathways (ERP) have not been widely implemented for hepatic surgery. The aim of this study was to evaluate the safety of an ERP for patients undergoing open hepatic resection., Methods: A single-surgeon, retrospective observational cohort study was performed comparing the clinical outcomes of patients undergoing open hepatic resection treated before and after implementation of an ERP. Morbidity, mortality, and length of hospital stay (LOS) were compared between pre-ERP and ERP groups., Results: 126 patients (pre-ERP n = 73, ERP n = 53) were identified for the study. Patient characteristics and operative details were similar between groups. Overall complication rate was similar between pre-ERP and ERP groups (37% vs. 28%, p = 0.343). Before and after pathway implementation, the median LOS was similar, 5 (IQR 4-7) vs. 5 (IQR 4-6) days, p = 0.708. After adjusting for age, type of liver resection, and ASA, the ERP group had no increased risk of major complication (OR 0.38, 95% CI 0.14-1.02, p = 0.055) or LOS greater than 5 days (OR 1.21, 95% CI 0.56-2.62, p = 0.627)., Conclusions: Routine use of a multimodal ERP is safe and is not associated with increased postoperative morbidity after open hepatic resection.

Background: A delayed post-pancreatoduodenectomy haemorrhage is associated with a significant increase in peri-operative mortality. Endovascular techniques are frequently used for a delayed haemorrhage. However, limited data exists on the short- and long-term outcomes of this approach. A retrospective review over a 10-year period at a quaternary-referral pancreatic centre was performed., Methods: Between 2002-2012, 1430 pancreatoduodenectomies were performed, and 32 patients had a delayed haemorrhage (occurring >24 h post-operatively) managed by endovascular techniques. The clinicopathological variables related to a haemorrhage were investigated., Results: A total of 42 endovascular procedures were performed at a median of 25 days, with the majority of delayed haemorrhages occurring after 7 days. There were four deaths (13%) with three occurring in patients with a grade C haemorrhage. Seven patients (22%) experienced rebleeding, and two patients developed hepatic abscesses., Conclusion: A delayed haemorrhage post-pancreaticoduodenectomy can be managed by endovascular techniques with acceptable morbidity and mortality. Rebleeding and hepatic abscesses may occur and can be managed non-operatively in most cases. The association of a delayed haemorrhage with a pancreatic fistula makes this a challenging clinical problem., (© 2015 International Hepato-Pancreato-Biliary Association.)

Background: The incidence of hepatocellular cancer (HCC) is increasing dramatically worldwide. Optimal management remains undefined, especially for well-compensated cirrhosis and HCC., Study Design: This retrospective analysis included 5 US liver cancer centers. Patients with surgically treated HCC between 1990 and 2011 were analyzed; demographics, tumor characteristics, and survival rates were included., Results: There were 1,765 patients who underwent resection (n = 884, 50.1%) or transplantation (n = 881, 49.9%). Overall, 248 (28.1%) resected patients were transplant eligible (1 tumor <5 cm or 2 to 3 tumors all <3 cm, no major vascular invasion); these were compared with 496 transplant patients, matched based on year of transplantation and tumor status. Overall survivals at 5 and 10 years were significantly improved for transplantation patients (74.3% vs 52.8% and 53.7% vs 21.7% respectively, p < 0.001), with greater differences in disease-free survival (71.8% vs 30.1% at 5 years and 53.4% vs 11.7% at 10 years, p < 0.001). Ninety-seven of the 884 (11%) resected patients were within Milan criteria and had cirrhosis; these were compared with the 496 transplantation patients, with similar results to the overall group. On multivariate analysis, type of surgery was an independent variable affecting all survival outcomes., Conclusions: The increasing incidence of HCC stresses limited resources. Although transplantation results in better long-term survival, limited donor availability precludes widespread application. Hepatic resection will likely remain a standard therapy in selected patients with HCC. In this large series, only about 10% of patients with cirrhosis were transplant-eligible based on tumor status. Although liver transplantation results are significantly improved compared with resection, transplantation is available only for a minority of patients with HCC., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize clinical and radiological features associated with biliary cystic tumors (BCTs) of the liver, and to define recurrence-free and overall survival., Background: Biliary cystadenoma (BCA) and biliary cystadenocarcinoma (BCAC) are rare tumors that arise in the liver., Methods: Between 1984 and 2013, 248 patients who underwent surgical resection of BCA or BCAC were identified. Clinical and outcome data were analyzed., Results: Median total bilirubin, CA19-9, and carcinoembryonic antigen (CEA) levels were 0.6 mg/dL, 15.0 U/mL, and 2.7 ng/mL, respectively. Preoperative imaging included computed tomography only (62.5%), magnetic resonance imaging only (6.9%), or CT + MRI (18.5%). Features on cross-sectional imaging included multiloculation (56.9%), mural nodularity (16.5%), and biliary ductal dilatation (17.7%). The presence of these factors did not reliably predict BCAC versus BCA (sensitivity, 81%; specificity, 21%). Median biliary cyst size was 10.0 cm (interquartile range, 7-13 cm). Operative interventions included unroofing/partial excision of the lesion (14.1%), less than hemihepatectomy (48.8%), or hemi-/extended hepatectomy (36.3%). On pathology most lesions were BCA (89.1%), whereas 27 (10.9%) were BCAC. At last follow-up, there were 46 (18.3%) recurrences; 2 patients who initially had BCA recurred with BCAC. Median overall survival was 18.1 years; 1-year, 3-year, and 5-year survival was 95.0%, 86.8%, and 84.2%, respectively. Long-term outcomes were associated with BCAC versus BCA, as well as the presence of spindle cell/ovarian stroma (both P < 0.05)., Conclusions: Among patients undergoing surgery for BCT, associated malignancy was uncommon (10%) and no preoperative findings reliably predicted underlying BCAC. After excision of BCA, long-term outcomes were good; however, patients with BCAC had a worse long-term prognosis.

Background: Autoimmune pancreatitis (AIP) is a rare subtype of chronic pancreatitis that may mimic adenocarcinoma of the pancreas. The aim of this study was to evaluate the short-term and long-term outcomes of pancreatectomy for patients with AIP., Methods: In this multi-institutional study, we identified all patients who underwent pancreatectomy for AIP from 1986 to 2011. AIP was confirmed by pathology review. Clinical presentation, operative details, and postoperative outcomes were analyzed., Results: Seventy-four patients (median age, 60 years; 69 % male) with AIP underwent pancreatectomy. The main indication for operation was concern for malignancy (n = 59, 80 %). No patients were found to have pancreatic adenocarcinoma on final pathology. Major complications occurred in ten (14 %) patients, with one perioperative death (1 %). Clinically relevant (grade B/C) pancreatic fistulae occurred in two patients. No patients required reoperation for AIP and 11 (17 %) patients developed recurrent AIP., Conclusion: Although we do not advocate pancreatectomy for AIP, strong suspicion of malignancy may require an operation in selected patients. For patients with AIP, pancreatectomy resulted in few pancreatic fistulae, a low rate of re-intervention, and a 17 % recurrence rate.

Background: The reported effects of biliary injury on health-related quality of life (HRQOL) have varied widely. Meta-analysis methodology was applied to examine the collective findings of the long-term effect of bile duct injury (BDI) on HRQOL., Methods: A comprehensive literature search was conducted in March, 2012. Because the HRQOL surveys differed among reports, BDI and uncomplicated laparoscopic cholecystectomy (LC) groups' HRQOL scores were expressed as effect sizes (ES) in relation to a common, general population, standard. A negative ES indicated a reduced HRQOL, with a substantive reduction defined as an ES ≤ -0.50. Weighted logistic regression tested the effects of BDI (versus LC) and follow-up time on whether physical and mental HRQOL were substantively reduced., Results: Data were abstracted from six publications, which encompass all reports of HRQOL after BDI in the current, peer-reviewed literature. The analytic database comprised 90 ES computations representing 831 patients and 11 unique study groups (six BDI and five LC). After controlling for follow-up time (P ≤ 0.001), BDI patients were more likely to have reduced long-term mental [odds ratio (OR) = 38.42, 95% confidence interval (CI) = 19.14-77.10; P < 0.001] but not physical (P = 0.993) HRQOL compared with LC patients., Discussion: This meta-analysis of findings from six peer-review reports indicates that, in comparison to LC, there is a long-term detrimental effect of BDI on mental HRQOL., (© 2012 International Hepato-Pancreato-Biliary Association.)

International-United States medical graduates (I-USMGs) are non-US citizen graduates of U.S. medical schools. Although academically equivalent to US-citizen peers, they are subject to the same visa requirements as non-US citizen international medical graduates. We hypothesized that visa sponsorship policies of general surgery programs (GSPs) may be discordant with the enrollment patterns of I-USMGs. A total of 196 GSPs participated in a telephone survey regarding visa sponsorship policies. Whereas GSPs preferred J-1 to H-1B sponsorship (64.2% vs. 32.6%), I-USMG enrollment favored programs supporting H-1B sponsorship (72.1% vs. 7.5%) (P = .01). University-affiliated programs were more likely to sponsor H1-Bs than independent programs (39.6% vs. 24.4%) (P = .03) and trained a greater proportion of I-USMGs than independent programs (40.6% vs. 14.0%) (P < .01). Restrictive policies against H-1B sponsorship may limit GSPs' I-USMG applicant pool and restrict I-USMGs' surgical training options.

Approximately 10000 deceased donor organs are available yearly for 85 000 US patients awaiting kidney transplant. Living kidney donation is essential to close this gap and offers better survival rates. However, nationally, 80% of potential donors evaluated fail to donate. Nurse coordinators who perform predonation screening and education need additional insight into the large number of potential donors who fail to complete the donation process. Reasons for nondonation in donor candidates undergoing medical evaluation, and variables affecting nondonation at Vanderbilt University Medical Center between 2004 and 2009 are examined. Multivariable logistic regression models are used to test the effects of age and race on donation status and reasons for nondonation. Summary data are frequencies, percentages, and means (SD). The sample included 706 candidates (63% female, 80% white; mean age, 40 [SD, 12] years). Almost half (46%) received clearance to donate. Undiagnosed hypertension (14%), abnormal glucose tolerance (10%), and protein-urea (9%) were the most prevalent medical reasons for nondonation. About 13% of candidates changed their minds during evaluation. Analyses demonstrated an increased likelihood of older candidates (P < .001) and a decreased likelihood of white candidates (P = .007) being excluded from donation. Within the nondonation group, increased age was associated with undiagnosed hypertension and abnormal glucose tolerance (both race-adjusted, P = .01). Younger candidates (race-adjusted, P = .003) and African Americans (age-adjusted, P = .04) were more likely to decide against donation. The most prevalent medical reasons for nondonation could be identified through enhanced prescreening, and improved preevaluation education could decrease nondonation rates.

Background: Operative resection of metastatic gastrointestinal stromal tumors (GIST) is controversial. Current treatment strategies rely on the response to tyrosine kinase inhibitors (TKIs), with resultant individualization of operative intervention. We investigated the role of operative therapy in patients with metastatic GIST., Methods: This retrospective cohort study included all consecutive patients treated for metastatic and/or recurrent GIST from January 2002 to June 2011. The patients were stratified by the use of operative therapy and disease response to TKI therapy. Kaplan-Meier survival analyses with log-rank comparisons tested the effects of operative therapy and the response to TKIs on survival., Results: Of the 438 patients treated for GIST during the study period, 87 (median age 61 y, interquartile range 50-71; 55% male) had metastatic GIST (84% metastatic, 3% recurrent, and 13% metastatic and recurrent). Of these patients, 54 (62%) underwent operative exploration. Subtotal resection for palliative debulking (R2 resection) were performed in 19 patients; 32 patients underwent R0 resection. Operative intervention was associated with improved overall survival (OS) compared with systemic therapy alone (1 y OS, 98% versus 80% and 5-y OS, 65% versus 11%, respectively; P < 0.001). A TKI was used before resection in 32 patients. The disease response was partial in 13 patients, stable in 10, and progressive in 9. The 1- and 5-y OS and progression-free survival were strongly associated with the preoperative response to TKI and an R0 resection (all P ≤ 0.002)., Conclusions: Among patients with metastatic GIST, preoperative response to TKI therapy and margin-negative resection were strongly associated with improved progression-free and OS., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: We investigated the role of operative therapy in non-cirrhotic patients who developed metastatic hepatocellular carcinoma (HCC)., Methods: This retrospective cohort study included consecutive non-cirrhotic patients with metastatic HCC after a prior hepatectomy treated between 1990 and 2009. Patients were stratified by operative therapy (resection, ablation, transcatheter therapy). Kaplan-Meier analyses with log-rank comparisons tested effects of operative therapy on overall survival (OS) and progression-free survival (PFS)., Results: Of 195 non-cirrhotic patients treated for HCC during the study period, 98 [median age 65, interquartile range (IQR) 53-71; 55 % male] subsequently developed metastatic HCC (55 intrahepatic only). Median time to development of metastases after the index operation was 10 months (IQR 5-20 months); median number of metastases was 3 (IQR 2-7). Half of these patients (n = 50) underwent operative treatment of metastases; 20 (40 %) underwent metastasectomy, 18 (36 %) ablation, and 12 (24 %) transcatheter therapy. Operative therapy was associated with improved OS (p < 0.001). Resection or ablation was associated with improved PFS and OS compared to transcatheter therapy (all p ≤ 0.006). Nine patients (seven resection, two ablation) are disease free at a median of 50 months (IQR 24-80 months) posttreatment., Conclusions: Resection and ablation are associated with an improved PFS and long-term OS and should be considered in select patients with metastatic HCC.

Wrist, hand, and finger trauma are the most common injuries presenting to emergency departments. Shortage of emergency hand care is an emerging problem, as on-call hand coverage declines. This study evaluates the availability of elective and emergency hand surgery services in Tennessee, with the use of telephone surveys administered to emergency department and operating facility management. One hundred eleven Tennessee hospitals completed the surveys (93% response rate). In all, 77% of hospitals offer elective hand surgery, 58% offer basic emergency hand services, 18% offer occasional hand specialist call coverage and only 7% of hospitals have 24/7 hand specialist call coverage. Hospitals with hand specialists have significantly more payer charges from commercial insurance than hospitals without hand specialists (26.1% vs. 16.1%, P < 0.001). Our results strongly support the need for increased emergency hand coverage. Solutions include creating multihospital coordinated call schedules, increasing incentives for call coverage, and training more hand specialists.

Background: Lack of health insurance is associated with poorer outcomes for patients with cancers amenable to early detection. The effect of insurance status on hepatocellular carcinoma (HCC) presentation stage and treatment outcomes has not been examined. We examined the effect of health insurance status on stage of presentation, treatment strategies, and survival in patients with HCC., Methods: The Tennessee Cancer Registry was queried for patients treated for HCC between January 2004 and December 2006. Patients were stratified by insurance status: (1) private insurance; (2) government insurance (non-Medicaid); (3) Medicaid; (4) uninsured. Logistic, Kaplan-Meier, and Cox models tested the effects of demographic and clinical covariates on the likelihood of having surgical or chemotherapeutic treatments and survival., Results: We identified 680 patients (208 private, 356 government, 75 Medicaid, 41 uninsured). Uninsured patients were more likely to be men, African American, and reside in an urban area (all P < 0.05). The uninsured were more likely to present with stage IV disease (P = 0.005). After adjusting for demographics and tumor stage, Medicaid and uninsured patients were less likely to receive surgical treatment (both P < 0.01) but were just as likely to be treated with chemotherapy (P ≥ 0.243). Survival was significantly better in privately insured patients and in those treated with surgery or chemotherapy (all P < 0.01). Demographic adjusted risk of death was doubled in the uninsured (P = 0.005)., Conclusions: Uninsured patients with HCC are more likely to present with late-stage disease. Although insurance status did not affect chemotherapy utilization, Medicaid and uninsured patients were less likely to receive surgical treatment.

Background: Failure to achieve fascial primary closure after damage control laparotomy (DCL) is associated with increased morbidity, higher healthcare expenditures, and a reduction in quality of life. The use of neuromuscular blocking agents (NMBA) to facilitate closure remains controversial and poorly studied. The purpose of this study was to determine whether exposure to NMBA is associated a higher likelihood of primary fascial closure., Methods: All adult trauma patients admitted between January 2002 and May 2008 who (1) went directly to the operating room, (2) were managed initially by DCL, and (3) survived to undergo a second laparotomy. Study group (NMBA+): those receiving NMBA in the first 24 hours after DCL. Comparison group (NMBA-): those not receiving NMBA in the first 24 hours after DCL. Primary fascial closure defined as fascia-to-fascia approximation by hospital day 7., Results: One hundred ninety-one patients met inclusion (92 in NMBA+ group, 99 in NMBA- group). Although the NMB+ patients were younger (31 years vs. 37 years, p = 0.009), there were no other differences in demographics, severity of injury, or lengths of stay between the groups. However, NMBA+ patients achieved primary closure faster (5.1 days vs. 3.5 days, p = 0.046) and were more likely to achieve closure by day 7 (93% vs. 83%, p = 0.023). After controlling for age, gender, race, mechanism, and severity of injury, logistic regression identified NMBA use as an independent predictor of achieving primary fascial closure by day 7 (OR, 3.24, CI: 1.15-9.16; p = 0.026)., Conclusions: Early NMBA use is associated with faster and more frequent achievement of primary fascial closure in patients initially managed with DCL. Patients exposed to NMBA had a three times higher likelihood of achieving primary fascial closure by hospital day 7.

Background: Transperitoneal (TP) and retroperitoneal (RP) approaches have equal efficacy in elective open abdominal aortic aneurysm (AAA) repair. The effect of open operative approach on patient-specific outcomes after AAA repair was tested., Methods: Consecutive patients undergoing open AAA repair at the Veterans Affairs Tennessee Valley Healthcare System between January 2000 and August 2008 were retrospectively reviewed. Analysis was performed to examine the effects of demographic and clinical covariates on postoperative outcomes., Results: A total of 106 patients were identified: 54 with TP approach and 52 with RP approach. Demographics and preoperative comorbidities were equivalent (p > or = 0.10), with the exception of chronic obstructive pulmonary disease which was more prevalent in the TP group (61 vs. 40%). Operative times were longer in the TP group (4.6 vs. 3.5 hours; p < 0.01); however, significantly more TP patients had reconstruction with a bifurcated graft (72 vs. 2%; p < 0.01). Postoperative nasogastric tube decompression times were shorter in the RP group (1 vs. 3 days; p < 0.01), and RP approach led to a quicker return to preoperative diet (4 vs. 6 days; p = 0.05). Patients undergoing RP repair developed fewer incisional hernias (2 vs. 15%; p = 0.03)., Conclusion: RP approach to AAA repair offers patients faster return of bowel function and is associated with fewer incisional hernias., (Copyright 2010 Annals of Vascular Surgery Inc. All rights reserved.)

Background: Several studies have described predictive models to identify trauma patients who require massive transfusion (MT). Early identification of lethal exsanguination may improve survival in this patient population. The purpose of the current study was to validate a simplified score to predict MT at multiple Level I trauma centers., Methods: All adult trauma patients treated at three Level I trauma centers from July 2006 to June 2007 who (1) were transported directly from the scene, (2) were trauma activations, and (3) received any blood transfusions during admission were included. Assessment of Blood Consumption (ABC) score developed using the same inclusion criteria for patients admitted to a single trauma center (Vanderbilt University Medical Center [VUMC]-1) between July 2005 and June 2006. ABC score calculated by assigning a value (0 or 1) to each of the four parameters: penetrating mechanism, positive focused assessment with sonography for trauma for fluid, arrival blood pressure <90 mm Hg, and arrival pulse >120 bpm. A score of 2 was used as "positive" to predict MT. Area under receiver-operating characteristic curve was calculated to compare the predictive ability of the score at each institution., Results: There were 586 patients in the developmental (VUMC-1), 513 patients at trauma center 1 (VUMC-2), 372 at trauma center 2 (PMH), and 133 at trauma center 3 (Johns Hopkins Hospital). MT rate was similar between centers: 14% to 15%. Sensitivity and specificity for the ABC score predicting MT ranged from 75% to 90% and 67% to 88%, respectively. Correctly classified patients and area under receiver-operating characteristic curve, however, were 84% to 87% and 0.83 to 0.90, respectively., Conclusions: The ABC score is a valid instrument to predict MT early in the patient's care and across various demographically diverse trauma centers. Future research should focus on this score's ability to prospectively identify patients who will receive MT.

Ciliated hepatic foregut cyst (CHFC) is a rare foregut developmental malformation usually diagnosed in adulthood; however, rare cases have been reported in the pediatric population. CHFC can transform into a squamous cell carcinoma resulting in death despite surgical resection of the isolated malignancy. We report the presentation, evaluation, and surgical management of a symptomatic 17-year-old girl found to have a 6.5 x 4.5 cm CHFC and suggest that all patients with suspected CHFC undergo prompt evaluation and complete cyst excision.

Background: The current residency training system in the United States (US) has inherent dependence on the international medical graduate (IMG). This article discusses the physician workforce shortage, especially related to general surgery, and examines the distribution of IMGs in general surgery ranks., Study Design: We performed a cross-sectional study using the American Medical Association Masterfile database of physicians licensed to practice in at least 1 state and determined the number and location of general surgeons in practice. We then stratified the distribution of these practicing surgeons, both IMGs and non-IMGs, according to rural urban commuting areas into small rural, large rural, or urban areas., Results: There were 17,727 general surgeons. IMGs were older (52 +/- 8 years versus 47 +/- 8 years; p < 0.001), more likely to be male (93% versus 82%; p < 0.001), and more likely to be further out of training (46% versus 28% > or =20 years out of training; p < 0.001). There were 2,216 IMGs in urban cores, constituting 15% of general surgeons in these areas. Large rural areas contained 223 IMGs (12% of general surgeons in these cores) and small rural areas contained 163 IMG general surgeons (16% of total general surgeons in these cores)., Conclusions: General surgeons are in high demand, and until now have remained inherently dependent on IMGs to reinforce their ranks. Current numbers of IMGs in practice are declining. This decline, coupled with inadequate numbers of trainees in domestic general surgery programs, creates a crisis of urgency., (Copyright (c) 2010. Published by Elsevier Inc.)

Bioabsorbable plating systems play an integral role in cranial vault remodeling. After experiencing a case of plate failure requiring emergent reexploration, we investigated the potential causes. We hypothesize that extended submersion in the molding bath during plate preparation might advance the rate of hydrolysis and compromise plate structural integrity. Using an absorbable poly-D/L-lactic acid plating system, we assessed the effect of extended submersion on plate strength and stiffness when loaded in a cantilever fashion and with pure tension. We assessed these differences with the Student t test and linear regression modeling. We also generated a computer model of the plates for finite element analysis. When left in the molding bath for extended periods, the plates changed color and lost strength. After 5 minutes, 30% of maximum plate load capacity was lost in a cantilever beam test (P < 0.001) consistent with use of a 15% thinner plate. Tensile testing revealed the initial elastic modulus of 6.42 +/- 0.13 GPa decreased 16% to 5.41 +/- 0.50 GPa after 5 minutes of submersion (P = 0.027). The changes in plate strength and elastic modulus both worsened with increased submersion times. Finite element analysis of the plates also predicted clinically significant increases in plate deviation under normal loading conditions. Our study demonstrates that extended submersion of absorbable plates during molding results in a significant loss of plate strength and stiffness. Further, our computer model predicts that these changes could result in an unacceptable plate deviation under normal loading conditions. Together, these data caution against overmolding of plates to avoid compromising their structural integrity.

Buprenorphine is a mixed opiate receptor agonist-antagonist growing in popularity as an office-based treatment for opioid-dependent patients. It has high affinity, but only partial agonism at the micro-opioid receptor resulting in a ceiling analgesic effect. At higher doses, buprenorphine potentiates antagonism at the kappa-opioid receptor. These properties make buprenorphine an effective maintenance treatment for opioid-dependent patients. These same properties, however, can interfere with the management of acute pain in patients on maintenance buprenorphine therapy. We present a case of a young multisystem trauma patient in whom adequate analgesia could not be achieved due to buprenorphine treatment before and through the early course of admission. Discontinuation of buprenorphine allowed for appropriate pain management and successful analgesia. Further education of acute care clinicians about buprenorphine pharmacology and careful selection of patients for buprenorphine maintenance therapy are needed to avoid delays of pain control in trauma patients.

Background: Recent studies demonstrate that obesity does not affect survival after kidney transplantation. However, overweight and obesity impair health-related quality of life (HRQOL) in patients with chronic illnesses. We wished to examine the effects of pre-transplant overweight and obesity on post-transplant physical HRQOL in kidney transplant recipients., Study Design: Patient-reported HRQOL data were systematically collected in kidney transplant recipients receiving post-transplant follow-up at Vanderbilt Transplant Center. Patients who received kidney transplants between 1998 and 2008, had at least 1 post-transplant physical component summary (PCS) measurement, and did not receive other solid organ transplants were included in this retrospective cohort study. Pre-transplant body mass index was stratified as normal, overweight, obese class I, and obese class II/extremely obese. HRQOL was measured primarily with the PCS scale of the Medical Outcomes Study Short Form 36 Health Survey. Multivariate linear and logistic regression models were used to test the effects of body mass index and demographic and clinical covariates on post-transplant HRQOL., Results: The study cohort included 464 adults (mean body mass index 27.5 +/- 5.1; range 18.5 to 47.4). After controlling for gender (p = 0.148), pre-transplant dialysis (p = 0.003), previous kidney transplantation (p = 0.255), donor type (p = 0.455), steroid avoidance immunosuppression (p = 0.070), and follow-up time (p = 0.352), there was no effect of pre-transplant overweight or obesity on post-transplant PCS (all p > or = 0.112). Kidney transplant recipients who did not require dialysis pre-transplant and those who were managed with steroid avoidance after transplantation were more likely to achieve post-transplant PCS scores at or above the general population average (both p < or = 0.011)., Conclusions: Pre-transplant overweight and obesity do not affect physical quality of life after kidney transplantation., (Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hepatic injury remains an important cause of exsanguination after major trauma. Recent studies have noted a dramatic reduction in mortality amongst severely injured patients when trauma exsanguinations protocols (TEP) are employed. We hypothesised that utilisation of our institution's TEP at the initiation of hospital resuscitation would improve survival in patients with significant hepatic trauma., Patients and Methods: All patients who (1) sustained intra-abdominal haemorrhage with Grades III-V hepatic injury and (2) underwent immediate operative intervention between February 2004 and January 2008 were included in the study. TEP was instituted in February 2006, and all subsequent patients who met inclusion criteria and were treated with TEP constituted the study group. Patients who met inclusion criteria, were treated before introduction of TEP, and received at least 10 units packed red blood cells in the first 24h constituted pre-TEP comparison group. Univariate and multivariate analyses evaluated the effects of TEP on the study population., Results: Seventy-five patients were included in the study: 39 in the pre-TEP cohort (31% 30-day survival) and 36 in the TEP cohort (53% 30-day survival). There were no differences in demographics, extent of hepatic injury, or operative approach between the patient groups (all p > or = 0.27). Injury Severity Scores were significantly higher in the TEP group (41+/-18 vs. 28+/-15, p<0.01). TEP patients received more plasma and platelets during operative intervention and significantly less crystalloid (all p<0.01). Occurrence of cardiac dysfunction and abdominal compartment syndrome was significantly lower in TEP patients who survived 24-h post-injury (both p < or = 0.04). After adjusting for the significant negative effects of Grade V injury and involvement of major hepatic vasculature (both p < or = 0.02), TEP significantly improved 30-day survival: OR=0.22, 95% CI: 0.06-0.81, p=0.02., Conclusions: TEP allows for an effective use of plasma and platelets during intra-operative management of severe hepatic injury. Utilisation of TEP is associated with significant reductions of cardiac dysfunction and development of abdominal compartment syndrome, as well as, significant improvement in 30-day survival.

Background: Large-volume blood transfusions have been implicated in the development of hyperkalemia. The purpose of the current study was to determine whether critically injured patients receiving massive transfusions are at an increased risk of hyperkalemia., Methods: Massive transfusion (MT) cohort, all trauma patients (02/2004-01/2008) taken directly to the OR and receiving >or=10 units of RBC in first 24h. Comparison cohort (No-RBC), all patients (02/2004-01/2008) transported directly to the OR who received no blood products in the first 24h. Hyperkalemia defined as K+ > 5.5 mEq/L., Results: There were 266 MT patients, 237 No-RBC patients. MT patients were more likely to have hyperkalemia in the immediate postoperative setting (1.8% versus 4.6%, P = 0.049). However, linear regression did not identify intraoperative blood transfusions as a predictor of postoperative K+ values (P = 0.417). Logistic regression identified only preop K+ (OR 1.79, P = 0.021) and postop pH (OR 0.009, P = 0.001), but not MT, as independent risk factors for postop hyperkalemia., Conclusions: Despite concerns of hyperkalemia following MT, we found less than a 5% incidence of postop K+ (>5.5 mEq/L). After adjusting for the significant effects of preop K+ and postop pH, MT patients were at no higher risk of hyperkalemia than those who received no blood products.

Background: Recent studies suggest that obesity does not affect survival after liver transplantation. Overweight and obesity, however, impair health-related quality of life (HRQOL) in patients with chronic illnesses. We tested the effect of pretransplant body weight on HRQOL in liver transplant recipients., Methods: Prospective, longitudinal HRQOL data were collected using the SF-36 health survey. Pretransplant body weight was stratified based on body mass index (BMI), as follows: normal (18.5-24.9), overweight (25.0-29.9), and obese (> or =30.0). Linear mixed-effects models were used to test the effects pretransplant BMI category on the trajectory of HRQOL after liver transplantation., Results: The sample included 154 adults who underwent liver transplantation. Thirty-one percent had normal BMI, 41% were overweight, and 28% were obese pretransplant. The mean pretransplant physical HRQOL did not differ by BMI group (P > or = .697). Physical and mental HRQOL improved (P < .001) in all groups after transplantation, but the rate of improvement in physical HRQOL was significantly greater during the first year posttransplant in the normal BMI compared with the overweight and obese patients (P < or = .032). There was no effect of BMI on the rate of improvement in mental HRQOL., Conclusion: Excess pretransplant body weight hinders the rate of improvement in physical quality of life during the first year after liver transplantation.

Background: Ventilator-associated pneumonia (VAP) causes significant morbidity and mortality in critically ill surgical patients. Recent studies suggest that the success of preventive measures is dependent on compliance with ventilator bundle parameters., Hypothesis: Implementation of an electronic dashboard will improve compliance with the bundle parameters and reduce rates of VAP in our surgical intensive care unit (SICU)., Design: Time series analysis of VAP rates between January 2005 and July 2008, with dashboard implementation in July 2007., Setting: Multidisciplinary SICU at a tertiary-care referral center with a stable case mix during the study period., Patients: Patients admitted to the SICU between January 2005 and July 2008., Main Outcome Measures: Infection control data were used to establish rates of VAP and total ventilator days. For the time series analysis, VAP rates were calculated as quarterly VAP events per 1000 ventilator days. Ventilator bundle compliance was analyzed after dashboard implementation. Differences between expected and observed VAP rates based on time series analysis were used to estimate the effect of intervention., Results: Average compliance with the ventilator bundle improved from 39% in August 2007 to 89% in July 2008 (P < .001). Rates of VAP decreased from a mean (SD) of 15.2 (7.0) to 9.3 (4.9) events per 1000 ventilator days after introduction of the dashboard (P = .01). Quarterly VAP rates were significantly reduced in the November 2007 through January 2008 and February through April 2008 periods (P < .05). For the August through October 2007 and May through July 2008 quarters, the observed rate reduction was not statistically significant., Conclusions: Implementation of an electronic dashboard improved compliance with ventilator bundle measures and is associated with reduced rates of VAP in our SICU.

Iatrogenic porta hepatis transection is a rare but devastating surgical complication. There are no systematic studies examining the best treatment strategy in patients with this injury. We report two cases of transection of all three portal structures, one during an open right adrenalectomy and another during a laparoscopic cholecystectomy, both of which were transferred to our tertiary care center hours postinjury. Diagnostic imaging and exploration revealed nonsalvageable livers, and both patients underwent total hepatectomies and portocaval shunting. Donor livers were available 12 to 20 hours after United Network for Organ Sharing Status 1 listing and both patients survived their postoperative course with 2- and 6-year follow up to date. Two-stage total hepatectomy with portocaval shunting followed by liver transplantation should be considered for patients presenting with porta hepatis transection.

Background: The prognostic role of lymph node metastases in well-differentiated thyroid carcinoma remains controversial. We investigated impact of lymph node involvement on survival in patients with well-differentiated thyroid cancer., Methods: We queried the Surveillance, Epidemiology, and End Results registry for patients diagnosed with well-differentiated thyroid carcinoma between 1988 and 2003. Cases were stratified by age (<45 vs >/=45 years) and pathology (papillary/follicular). Four separate Cox regression models were developed to test the effects of demographic and clinical covariates on survival., Results: We identified 33,088 patients. 30,504 patients (49% >/=45 years) had papillary carcinoma and 2,584 patients (55% >/=45 years) had follicular carcinoma. Age affected survival in all models (P < .001). In patients with papillary carcinoma <45 years, lymph node disease did not influence survival (P = .535), whereas in patients >/=45 years, lymph node involvement was associated with 46% increased risk of death (P < .001). In patients with follicular carcinoma, lymph node involvement conferred increased risk of death in both age groups (P /=45 years, but did not affect survival in patients with papillary carcinoma <45 years.

Although medullary thyroid cancer (MTC) can produce adrenocorticotropic hormone (ACTH) in up to 40 per cent of cases as determined by immunohistochemistry, clinical hypercortisolism is rarely seen. We report a medullary endocrine neoplasia 2A (MEN 2A) kindred whose proband case presented with Cushing's syndrome (CS). This 51-year-old woman presented with debilitating weakness, exertional dyspnea, 50 pound weight gain, moon facies, worsening hypertension, striae, and hirsutism. A comprehensive evaluation diagnosed ectopic ACTH production from unresectable metastatic MTC to the liver. Genetic testing revealed a germline RET proto-oncogene mutation at codon 609. Further genetic testing identified six family members with the same mutation. The patient underwent palliative bilateral laparoscopic adrenalectomies with significant improvement in major comorbidities. Overall CS resulting from ectopic ACTH overproduction by MTC is rare, occurring in 0.6 per cent of all patients with medullary thyroid carcinoma. About 50 cases have been previously reported in the literature, but only three in families with MEN 2A. We describe the first case of a MEN 2A kindred presenting with CS from ectopic ACTH production by metastatic medullary thyroid carcinoma. We advocate consideration of early bilateral laparoscopic adrenalectomies in patients with symptomatic hypercortisolism from unresectable metastatic medullary thyroid carcinoma.

Introduction: Tumor extent (T stage) and lymph node involvement (N stage) have a known combined negative effect on survival in patients with gallbladder adenocarcinoma, but the independent effects of these factors have been less well described. We investigated whether T stage and N stage independently predict survival after surgery for gallbladder adenocarcinoma., Methods: We queried the Surveillance, Epidemiology and End Results database for patients treated with surgical resection for gallbladder adenocarcinoma between 1988 and 2004. Cases were stratified by disease severity based on tumor extent and nodal involvement. Kaplan-Meier and Cox regression methods were used to test the effect of disease severity and to develop multivariate models of the effects of demographic and clinical covariates on survival. Univariate and multivariate models were tested in the entire cohort and in a subsample with pathologically confirmed lymph node status., Results: Four thousand and forty-eight patients who survived the immediate perioperative period comprised the full cohort. The subsample with pathologically confirmed lymph node status included 1298 patients. Age, gender, radiation treatment, tumor grade, tumor extent and lymph node status had statistically significant independent effects on survival in both models (all p<0.03). After accounting for T by N stage interactions, both tumor extent (1.21 < or = HR < or = 3.81, all p < or = 0.005) and lymph node involvement (1.80 < or = HR < or = 2.84, p<0.001) had independent effects on survival., Conclusions: Tumor extent and lymph node metastases are independent predictors of survival after surgical resection for gallbladder adenocarcinoma. Tumor penetration of the gallbladder wall and pathologically confirmed lymph node involvement each carry poor prognosis.

Background: A 70-year-old male approximately 3 years after laparoscopic cholecystectomy presented to his primary care physician with a 4-month history of generalized malaise., Methods: A workup included magnetic resonance imaging that revealed a perihepatic abscess. The patient underwent ultrasound-guided drainage, with the removal of 1400 mL of purulent fluid and placement of 2 drains. Computed tomographic scanning showed resolution, and he was discharged home on oral antibiotics. At 2-month follow-up, the patient was asymptomatic, denying any constitutional symptoms. However, abdominal computed tomographic scanning revealed recurrence of the abscess, which measured approximately 18 x 9 x 7.5 cm, with mass effect on the liver. The patient was placed on intravenous antibiotics and scheduled for operative drainage. The abdomen was entered with a right subcostal incision, and 900 mL of purulent fluid was drained. We also noted abscess erosion through the inferolateral aspect of the right diaphragm into the pleural space. The pleural abscess was loculated and isolated from the lung parenchyma. Palpation within the abscess cavity revealed 9 large gallstones. Following copious irrigation and debridement of necrotic tissue, 3 drains were placed and the incision was closed., Results: The patient had an uneventful recovery and was discharged home on postoperative day number 6. Follow-up imaging at 3 months demonstrated resolution of the collection., Conclusion: Spillage of gallstones is a complication of laparoscopic cholecystectomy, occurring in 6% to 16% of all cases. Retained stones rarely result in a problem, but when complications arise, aggressive surgical intervention is usually necessary.

Background: Severe central airway obstruction due to expiratory collapse occurs with malacia of intrathoracic trachea and main bronchi, often with chronic obstructive pulmonary disease. Bronchoscopically observed, it is confirmed by inspiratory-expiratory computerized tomographic chest scans. Prior attempts at surgical stabilization have not given dependable results., Methods: Posterior tracheobronchial splinting with polypropylene mesh (Marlex) holds cartilages in more normal configuration, and fixes redundant membranous walls. Fourteen consecutive patients were so treated for severe dyspnea. Prior trials of various autologous and exogenous splints failed., Results: All felt subjectively improved early, with decreased dyspnea, cough, and secretion retention, and with increased activities. Mean forced expiratory volume in 1 second rose from 51% predicted to 73% (p = 0.009), and peak expiratory flow rate from 49% to 70% (p < 0.00001). One patient was lost to follow-up (1 year), 1 died of unrelated cause (5 years), 1 died of chronic obstructive pulmonary disease (3 years), and 1 had decreased respiratory function over 5 years. Ten patients were available for long-term follow-up: 6 were judged to have an excellent result, 2 were good, and 2 were poor due to collapse of unsplinted main bronchi., Conclusions: Complete splinting of all malacic central airways with Marlex restores anatomic configuration and permanently prevents expiratory collapse, with relief of extreme dyspnea, cough, and secretion retention.