The chimney procedure is an emergently available endovascular solution for visceral aortic aneurysm rupture.

A 79-year-old woman presented with a ruptured saccular thoracoabdominal aortic aneurysm involving the celiac and mesenteric artery. The patient was unfit for open surgical repair. A "chimney" procedure was performed, which involved placement of stents in the aortic side branches alongside the endograft. The patient underwent another chimney procedure 2 weeks later for a type I endoleak. Computed tomography angiography (CTA) at 1 and 6 months showed a good result with no endoleaks or graft migration. The chimney procedure provides an alternative for emergency patients unfit for open repair and has the advantage that stents can be used that are already available in most institutions.

Should all duty hours be the same? Results of a national survey of surgical trainees.

BACKGROUND: Although duty hours regulations (DHR) were introduced as a measure to improve patient safety and graduate medical education, new evidence suggests that the opposite might be happening. This study was designed to assess surgery resident perceptions of the impact that DHR have had on their education, the number of hours they believed would be ideal for their training, and to evaluate the effect of seniority on these opinions. STUDY DESIGN: An Internet-based survey was electronically distributed to all Resident and Associate members of the American College of Surgeons. RESULTS: Of 599 respondents, 247 (41%) believed that DHR were an important barrier to their education, and 266 (44%) believed that the ideal work week should have 80 to 100 hours. These two opinions were highly correlated, and were increasingly voiced with increased resident experience. Senior residents were more likely to view DHR as an important barrier to their education whether or not they were general surgery residents or were trained in small, medium, or large programs. CONCLUSIONS: A large subset of surgery residents, particularly senior residents, considered DHR an important barrier to their education and expressed a desire to work longer hours than restrictions allow. These findings suggest that strict and uniform DHR do not allow for optimal training of residents at different levels who have disparate educational goals and needs. Introducing some flexibility into senior residents' limitations should be considered.

Frequency of inappropriate continuation of acid suppressive therapy after discharge in patients who began therapy in the surgical intensive care unit.

STUDY OBJECTIVE: To determine the frequency with which patients who begin to receive stress ulcer prophylaxis in the surgical intensive care unit (SICU) are discharged receiving inappropriate acid suppressive therapy (AST). DESIGN: Prospective, observational evaluation. Setting. Level 1 trauma center and academic tertiary care hospital. PATIENTS: A total of 248 consecutive adult patients admitted to the SICU during a 6-month period who began to receive AST with a proton pump inhibitor or histamine(2)-receptor antagonist. MEASUREMENTS AND MAIN RESULTS: In most patients (237 [95.6%] of 248), initiation of AST was associated with one or more risk factors for gastrointestinal bleeding. Continuation of AST during hospitalization outside the SICU occurred in 215 patients (86.7%). Sixty patients (24.2%) were discharged from the hospital receiving AST: 52 patients (21.0%) went to skilled nursing facilities or rehabilitation centers, and eight (3.2%) were discharged home. Compared with those whose AST was discontinued in the hospital, patients who continued to receive AST after hospital discharge required extended mechanical ventilation (p=0.001), had twice as many risk factors for gastrointestinal bleeding (p<0.001), were frequently discharged with anticoagulant therapy (p<0.001), exhibited longer hospital and SICU stays (p<0.001), and more frequently demonstrated Glasgow Coma Scale scores of 8 or lower and/or had head injury (p<0.001), hepatic failure (p=0.004), and major trauma (p=0.049). Evaluation of continuation of AST during hospitalization revealed that only 7.4% (16/215) of patients at SICU transfer and 5.0% (3/60) of patients at hospital discharge had a compelling risk factor to continue AST as demonstrated by a coagulopathy at discharge; no patients required mechanical ventilation at hospital discharge. CONCLUSION: Most patients inappropriately continued to receive stress ulcer prophylaxis during post-SICU hospitalization. Presence of risk factors for stress ulcer-related gastrointestinal bleeding at SICU admission appears to influence continuation of AST after discharge from the hospital. A low percentage (3.2%) of patients was discharged home receiving inappropriate AST, yet overall, few study patients demonstrated a compelling risk factor for continuation of AST.