Portal vein thrombosis associated with acute cholecystitis.

ABSTRACT: Portal venous thrombosis (PVT) is an uncommon clinical problem and is rare following cholecystectomy. This article describes a patient who developed PVT after an initially uneventful laparoscopic cholecystectomy. The patient was successfully treated with IV antibiotics and anticoagulation.

Resident Perspectives on the Value of Rural General Surgery Rotations: It's Not Just About the Cases.

PURPOSE: Understand the scope of cases that residents participate in during rural general surgery rotations and the value residents and program directors find in such rotations. In turn, our goal is to add to the ongoing conversation the value exposure to rural surgery brings to surgery training. METHODS: Qualitative study analyzed reviews of residents' self-reported case lists and field notes from exit interviews with the site director. RESULTS: Trainees participated in an average of 105 cases during the rotation, including basic and advanced endoscopy along with exposure to a wide array of surgical cases. Residents had exposure to the rural facility and its staff and participated in a busy outpatient surgical clinic, the hospital, and community activities. We received overwhelmingly positive qualitative feedback from residents regarding how this rural rotation advanced their skills, helped prepare them for life after residency, and for some confirmed their plans to practice in a rural location. CONCLUSION: With the decline in the number of rural general surgeons and projected continuance of this trend, it is important to understand how trainees view their residency experiences and how those experiences may be shaping their outlook on career choices. Our single-site, qualitative study showed that a rural general surgery rotation during residency has broad importance and value in general surgery resident training. Having a rural rotation also allowed residents to gain understanding of a rural lifestyle, workflow, and the social fabric including the rural surgeons' connections with their communities.

Quality and Value in Rural Cancer Care.

Nearly 60 million people reside in rural America with only 10% of US general surgeons providing for their surgical care. Rural cancer care has been maligned in the literature due to a lack of understanding of local resource limitations and to the difficulties involved in documenting the quality of local cancer care in small and rural communities. A majority of US cancer patients are diagnosed and treated in community cancer programs, many of which are Commission on Cancer accredited and deliver care that is of high quality and value. The article discusses the components of high quality health care and offers suggestions for solo or small group rural surgeons to assist in collection of their own quality data and comparison to national benchmarks. One small rural program in Appalachian Ohio is used for a best-case example.

Strategies to Improve the Rural Surgical Workforce.

The rural surgical workforce is in crisis, resulting in significant health care access issues for the 60 million rural Americans. Rural surgeons encounter unique barriers to providing care for patients that are different than their urban counterparts. Rural hospitals are failing at an alarming rate. The American College of Surgeons (ACS) and the ACS Advisory Council for Rural Surgery have worked to improve communication among isolated rural surgeons and to bring recognition to rural surgeons as a distinct group. The rural workforce is aging at a rapid rate and multiple factors prevent newly trained surgeons from replacing those that retire. Loss of a surgeon in a small community leads to significant economic losses and possibly even closure of the local hospital. Changes in surgical training, subspecialization, demographic trends, and economic issues all lead to less numbers of young surgeons choosing to practice in small communities. Increasing the numbers of trainees will not reverse the trend unless it is combined with a change in the training paradigm for surgeons with a rural interest, additional funding for more rural training programs and financial support for surgeons to work in rural areas, and collaboration with urban and academic health care systems and their surgeons.

Development of a multilevel intervention to increase colorectal cancer screening in Appalachia.

BACKGROUND: Colorectal cancer (CRC) screening rates are lower in Appalachian regions of the United States than in non-Appalachian regions. Given the availability of various screening modalities, there is critical need for culturally relevant interventions addressing multiple socioecological levels to reduce the regional CRC burden. In this report, we describe the development and baseline findings from year 1 of "Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) in Appalachia," a 5-year, National Cancer Institute Cancer MoonshotSM-funded multilevel intervention (MLI) project to increase screening in Appalachian Kentucky and Ohio primary care clinics. METHODS: Project development was theory-driven and included the establishment of both an external Scientific Advisory Board and a Community Advisory Board to provide guidance in conducting formative activities in two Appalachian counties: one in Kentucky and one in Ohio. Activities included identifying and describing the study communities and primary care clinics, selecting appropriate evidence-based interventions (EBIs), and conducting a pilot test of MLI strategies addressing patient, provider, clinic, and community needs. RESULTS: Key informant interviews identified multiple barriers to CRC screening, including fear of screening, test results, and financial concerns (patient level); lack of time and competing priorities (provider level); lack of reminder or tracking systems and staff burden (clinic level); and cultural issues, societal norms, and transportation (community level). With this information, investigators then offered clinics a menu of EBIs and strategies to address barriers at each level. Clinics selected individually tailored MLIs, including improvement of patient education materials, provision of provider education (resulting in increased knowledge, p = .003), enhancement of electronic health record (EHR) systems and development of clinic screening protocols, and implementation of community CRC awareness events, all of which promoted stool-based screening (i.e., FIT or FIT-DNA). Variability among clinics, including differences in EHR systems, was the most salient barrier to EBI implementation, particularly in terms of tracking follow-up of positive screening results, whereas the development of clinic-wide screening protocols was found to promote fidelity to EBI components. CONCLUSIONS: Lessons learned from year 1 included increased recognition of variability among the clinics and how they function, appreciation for clinic staff and provider workload, and development of strategies to utilize EHR systems. These findings necessitated a modification of study design for subsequent years. TRIAL REGISTRATION: Trial NCT04427527 is registered at https://clinicaltrials.gov and was registered on June 11, 2020.

US Rural Surgeons Leading During COVID-19: Where Are They Now?

Rural surgeons from disparate areas of the United States report on the effects of the COVID-19 pandemic in their communities as the virus has spread across the country. The pandemic has brought significant changes to the professional, economic, and social lives of the individual surgeons and their communities.

Simulation training for the endoscopic management of upper gastrointestinal bleeding: a nationwide survey of rural surgeons' needs and preferences analysis.

BACKGROUND: Published needs analyses of rural surgeons have identified a need for training in the endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB). The study aim was to survey rural surgeons regarding their requirements and preferences for a simulation model on which they could rehearse the endoscopic management of NVUGIB. METHODS: Rural surgeons were contacted via the American College of Surgery Advisory Council listserv and invited to complete an online survey. RESULTS: A total of 66 responses were received, representing all 4 US regional divisions. Seventy-seven percent of respondents perform > 100 endoscopy cases per year. A majority have no experience with simulation models (77%), citing cost, time, and access to training courses as the three most limiting factors. Thirty-three percent lacked confidence in managing UGIBs, and 73% were interested in receiving additional training. Preference analysis revealed that respondents preferred a portable simulation model (81%) that costs between $500 and $1000 (46%), and requires 1-2 weeks of training (34%). Verbal feedback from an expert was viewed as the most helpful type of feedback (61%). CONCLUSION: Rural surgeons frequently perform flexible endoscopy in their practice and are interested in further training for the endoscopic management of NVUGIB. These results will be used to develop a simulation platform for training in the endoscopic management of NVUGIB that meets rural surgeons' needs.

Rural Surgical Training in the United States: Delineating Essential Components Within Existing Programs.

BACKGROUND: Rural access to surgical care has reached crisis level. Practicing in rural America offers unique challenges with limited resources and specialists. Most training programs do not provide enough exposure to the endoscopic or the surgical subspecialty skills to prepare a resident for an isolated rural environment. As awareness has increased, many programs have modified curriculum to address this need. The Advisory Council on Rural Surgery (ACRS) of the American College of Surgeons set out to delineate important components of rural training programs and measure to what degree the existing heterogeneous programs contain these components. STUDY DESIGN: The ACRS identified 4 essential components of rural surgical training based on literature and expert opinion. These components included rotations in a rural setting, broad exposure to surgical specialties, endoscopy experience, and lack of competing specialty learners. A list of Accreditation Council for Graduate Medical Education programs from a prior publication was updated with the 2019 Fellowship and Residency Electronic Interactive Database self-identified "rural track" programs, reviewed, and categorized. RESULTS: We identified 39 programs that self-identified as having a rural emphasis. Depending on the extent of which 4 essential components were included, programs were categorized as either "Broad" (12 programs), "Basic" (20 programs), or "Indeterminate" (7 programs). CONCLUSION: The ACRS described the optimal components of a rural surgical training program and identified which components are present in those surgical residencies which self-identified as having a rural focus. This information is valuable to students planning a future in rural surgery and benefits programs hoping to enhance their curriculum to meet this critical need.

Rural Standards and the Quality Equation.

The article describes the barriers rural surgeons face when attempting to measure, analyze, and benchmark the quality and value of the care they provide for their patients. Examples of suboptimal care are presented as well as special geographic and resource-related circumstances for many of these disparities of care. The article includes in-depth descriptions of the American College of Surgeons (ACS) Optimal Resources for Surgical Quality and Safety Program and the ACS Rural Hospital Surgical Verification and Quality Improvement Program. The article concludes by discussing several documented clinical, economic, and social advantages of keeping surgical care local.

US Rural Surgeon Responses to the COVID-19 Pandemic: Leadership in a Time of Crisis.

Nine surgeons from rural and remote communities in the United States share early experiences preparing for the COVID-19 pandemic. Relating experiences remarkably different from health care providers in urban areas in America most affected by the first stages of the outbreak, they tell the challenges of organizing resources in facilities already struggling with poverty-stricken communities far from established health care resources and supplies. From Alaska to Appalachia and the Navajo Nation to the rural midwest, they show the leadership and professionalism that exemplify rural surgery.

When rural is no longer rural: Demand for subspecialty trained surgeons increases with increasing population of a non-metropolitan area.

BACKGROUND: Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons. METHODS: We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed. RESULTS: We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures. CONCLUSIONS: Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training.

Rural surgeons' perspectives on necessity of post-residency training are stable across generations.

BACKGROUND: Training future rural surgeons is critical, but training needs are unclear. We hypothesize perspectives on necessity of subspecialty training differ among rural surgeons by generational cohort. METHODS: An online survey was sent to ACS Rural Surgery Listserv subscribers. Closed-ended elements were analyzed using bivariate testing and logistic regression. Purposively-sampled respondents participated in qualitative interviews analyzed using principles of grounded theory. RESULTS: Generation was irrelevant to respondents' hiring preferences, but older surgeons were more likely to state subspecialty training was ideal for any future rural surgeon. Controlling for practice context, younger rural surgeons were less likely to favor hiring a subspecialty-trained surgeon (p = 0.019). Themes emerged from qualitative analysis emphasizing broad training and the importance of practice context. CONCLUSION: Across generations, rural surgeons' perceptions about the training needed for rural surgery are largely stable. Considering practice context will allow educators to better prepare future rural surgeons for rural practices.

Training for a Career in Rural and Nonmetropolitan Surgery-A Practical Needs Assessment.

OBJECTIVE: The current shortage of surgeons in rural and smaller communities is predicted to get worse. In this study, we solicited practicing rural surgeons' opinions about the skill set needed in a rural practice in order to inform curriculum development for general surgery residents who intend to embark on rural careers. DESIGN: We developed an online survey consisting of demographic questions and closed- and open-ended questions regarding current practice environment and scope of practice. Priorities for training were identified using descriptive analyses of both the quantitative and qualitative data, including frequency of responses regarding specific skills training. PARTICIPANTS: We surveyed currently practicing surgeons who subscribe to the American College of Surgeons Rural Surgery listserv. RESULTS: 237 surgeons from 49 states and 1 Canadian territory responded; 60% of participants had been in practice for 20 or more years, and 70% did not pursue subspecialty training. Valuable skills identified for rural surgeons were: endoscopy, advanced laparoscopy, and basic non-general surgery subspecialty procedures. Regardless of years of practice or setting, respondents felt that rural experience during residency was highly valuable (82%) and overwhelmingly supported training future rural surgeons at residency programs with broad general surgery experiences and high case volumes with no or few fellows. CONCLUSIONS: Practicing rural surgeons identify endoscopy, basic non-general surgery subspecialty procedures, and advanced laparoscopy as key components of their current practice. These skills may not be strongly emphasized in traditional general surgery training programs. Surgical educators should focus on developing curricula that emphasize these areas in order to prepare residents for careers in rural surgery.

A rare case of iron-deficiency anemia rapidly progressing to a life-threatening event.

Giant colonic diverticula are extremely rare; however, they should be considered in a patient with a history or susceptibility to diverticular disease because of the nonspecific presentation and life-threatening complications. Giant colonic diverticula often are overlooked because of their nonspecific gastrointestinal (GI) symptoms, leading to complications of obstruction, perforation, abscess formation, and sepsis. A rare and unusual presentation of a giant colonic diverticulum is the development of a bezoar. This case describes a patient whose GI bleeding led to the diagnosis of a giant colonic diverticulum with a bezoar.

Small bowel necrosis in association with jejunal tube feeding.

Early recognition and appropriate treatment of bowel ischemia is imperative to reduce morbidity and mortality in any situation, including in conjunction with enteral tube feeding. GI intolerance can manifest as increased nasogastric tube output, unexplained abdominal pain/distension, and pneumatosis intestinalis in critically ill patients who are on tube feedings and may be experiencing periods of splanchnic hypotension. Recommendations are to immediately cease tube feedings when these signs and symptoms are recognized, and total parenteral nutrition should be considered. Surgical exploration during the early stages should be considered to prevent the usual and fatal catastrophic cascade of widespread bowl infarction.