Management of High Grade Splenic Injuries in Rural America.

BACKGROUND: Rural surgeons face unique challenges when managing patients with high-grade (III-V) blunt splenic injury (BSI) given limited access to interventional radiology and blood products. Patients therefore may require transfer for splenic artery embolization (SAE) when resuscitation may still be ongoing. This study aims to evaluate current resource utilization in a rural trauma population with limited access to SAE and blood products. METHODS: Retrospective analysis of adult patients with high-grade BSI at one Level 1 trauma center and two Level 2 trauma centers was performed. Patients were evaluated for resources used after transfer to the regional trauma center. Primary outcomes measured were SAE, operative management (OM), and blood product utilization. Secondary outcomes measured included injury severity score (ISS) and mortality. RESULTS: Final analysis included 134 transferred patients. 16% underwent SAE, 16% underwent OM, and 69% were treated successfully with nonoperative and non-procedural management (NOM). 52% of the SAE patients had sustained a grade III splenic injury, 38% grade IV, and 10% grade V. 84% of patients required <3 units of packed red blood cells (PRBC) and 57% of patients required none. 80% of transferred patients required <3 total units of all combined blood products. DISCUSSION: The majority of patients with BSI transferred to a tertiary trauma center from a rural facility were successfully managed without SAE and required minimal transfusion of blood products. In the absence of other injuries necessitating transfer to a tertiary trauma center, rural surgeons should consider management of high grade splenic injuries at their home institution.

Current Trends in Surgical Procedures Performed in Rural General Surgery Practice.

BACKGROUND: The procedures that rural general surgeons perform may be changing. It is important to recognize the trends and practices of the current rural general surgeon in efforts to better prepare general surgeons who desire to enter a practice in a rural environment. The aim of this review is to detail the recent operative case volumes of 6 rural locations in the upper Midwest where general surgery is practiced. METHODS: The Enterprise Data and Analytics department of Sanford Health compiled all surgical procedures performed within the Sanford Health System between January 1, 2013 and August 31, 2018. Procedures performed by a total of 58 general surgeons in locations of under 50 000 people are included in this review. RESULTS: From January 1, 2013 to August 31, 2018, 38 958 surgical procedures were performed in rural locations. Endoscopic procedures made up 61.6% of a rural general surgeon's practice. Cholecystectomy (6.3%), hernia repair (6.3%), and appendectomy (3.7%) were the principle nonendoscopic procedures performed by rural surgeons, comprising 16.3% of the case volume. Added together, endoscopy, cholecystectomy, hernia repair, and appendectomy made up 77.9% of the rural general surgeon's caseload. Vascular procedures (2.5%), breast procedures (1.8%), obstetrics (0.4%), and urology procedures (0.2%) are also included in this review. CONCLUSIONS: Rural general surgeons are vital to the surgical workforce in the United States. Recognizing a trend that rural general surgeons perform less subspecialty procedures and more endoscopic procedures will provide direction for those interested in pursuing a career in rural general surgery.

Incidental Pancreatic Solid Pseudopapillary Tumor Masked by Hemorrhagic Trauma.

An 18-year-old female presented to a tertiary care center after sustaining blunt abdominal trauma. Work up, including computer tomography (CT) revealed a hypo-attenuated collection in the pancreatic body with concern for ductal injury on magnetic resonance cholangiopancreatography (MRCP). These findings were consistent with posttraumatic intrapancreatic hematoma. An exploratory laparotomy with distal pancreatectomy and splenectomy were performed with concern for a grade 3 pancreatic injury. Pathology of the excised pancreas showed presence of a solid pseudopapillary tumor in the body of the pancreas which had been obscured by the hematoma on imaging.

Initial and Ongoing Training of the Rural Surgeon.

Over the last 2 decades, rural locations have realized a steady decrease in surgical access and direct care. Owing to societal expectations for equal general and subspecialty surgical care in urban or rural areas, the ability to attract, train, and hold onto the rural surgeon has come into question. Our current general surgery training curriculum has been reevaluated as to its relevance for rural surgery and several alternatives to the traditional surgical training model have been proposed. The authors discuss and evaluate current and proposed methods for surgical training curriculums and methods for rural surgeon retention through continuing education models.

Implementation of a standardized approach to borderline resectable pancreatic cancer in a multisite community oncology program.

BACKGROUND: Treatment paradigms for borderline resectable pancreatic cancer are evolving with increasing use of neoadjuvant chemotherapy and neoadjuvant chemoradiation. Variations in the definition of borderline resectable pancreatic cancer and neoadjuvant approaches have made standardizing care for borderline resectable pancreatic cancer difficult. We report an effort to standardize management of borderline resectable pancreatic cancer throughout Sanford Health, a large community oncology network. METHODS: Starting in October 2013, cases of pancreatic adenocarcinoma without known metastatic disease were categorized as borderline resectable pancreatic cancer if they met ≥ 1 of the following criteria: (1) abutment of superior mesenteric, common hepatic, or celiac arteries with < 180° involvement, (2) venous involvement deemed potentially suitable for reconstruction, and/or (3) biopsy-proven lymph node involvement. Patients with borderline resectable pancreatic cancer were treated with neoadjuvant chemotherapy followed by reimaging and surgery if venous involvement had improved; if disease remained borderline resectable, patients underwent neoadjuvant chemoradiation and surgical exploration as long as reimaging did not reveal evidence of progressive disease. RESULTS: Forty-three patients from October 2013 to April 2017 were diagnosed with borderline resectable pancreatic cancer. Twelve of 42 (29%) patients proceeded to surgical exploration directly after neoadjuvant chemotherapy; 23 (55%) received neoadjuvant chemoradiation. Overall, 28/43 (65%) underwent exploration with 19 (44%) able to undergo resection. Of those, 14/19 (74%) attained R0 resection and 11/19 (58%) were pathologic N0. No pretreatment or treatment variables were associated with resection rates; resection was the only variable associated with survival. CONCLUSION: This report demonstrates the feasibility of implementing a standardized approach to borderline resectable pancreatic cancer across multiple sites over a wide geographic area. Adherence to protocol therapies was good and surgical outcomes are similar to many reported series.

Delayed Internal Pancreatic Fistula and Pseudocyst Formation Three Years Status-Post Distal Pancreatectomy in the Setting of Acute Pancreatitis.

Pancreatic duct rupture and fistula formation are known complications of distal pancreatectomy (DP); however, internal pancreatic fistulas and duct ruptures as a result of pancreatitis with delayed onset after DP are rare. This case reports a 77-year-old man with acute pancreatitis presenting with a delayed pancreatic duct rupture, fistula, and pseudocyst formation at the resection site three years status-post distal pancreatectomy for resection of intraductal papillary mucinous neoplasm of pancreas. This case report is designed to bring attention to the possible risk of delayed internal pancreatic fistula years post distal pancreatectomy, in the setting of a first episode of acute pancreatitis.

Annular Pancreas in Adults: Case Report and Literature Review.

Annular pancreas is an uncommon congenital cause of gastric outlet obstruction. The incidence is usually referenced at between five and 15 per 100,000 based on autopsy series. When present, this rare condition surfaces with symptoms in the pediatric population during the first few months of life. An adult presenting with symptoms of gastric outlet obstruction due to annular pancreas is an unusual incident. This case describes gastric outlet obstruction due to a partial annular pancreatic band in an otherwise healthy 32-year-old male. Given the scarcity of this pathological process in adults; no specific guidelines exist about the management of this condition. Continued reporting of this pathology is essential for development of such guidelines. Literature review, embryology and treatment options will be discussed.

Indeterminate biliary strictures: a simplified approach.

INTRODUCTION: Pre-operative evaluation of biliary strictures remains challenging. The dilemma that exists is how to balance the risk of failing to detect malignancy and the potential morbidity caused by unnecessary surgery in patients with benign etiologies. With emerging novel diagnostic modalities, this study aims to assess the efficacy of diagnostic techniques and facilitate a clinical approach to indeterminate biliary strictures. Areas covered: Conventional imaging modalities are crucial in identifying the location of a stricture and are helpful for choosing further diagnostic modalities. Utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), is key in establishing a diagnosis. The emergence of novel diagnostic modalities, such as fluorescence in-situ hybridization (FISH), peroral cholangioscopy (POC), intraductal endoscopic ultrasound (IDUS) and confocal laser endomicroscopy (CLE), enhance the diagnostic yield in the evaluation of indeterminate biliary strictures. Expert commentary: More reliable and validated visual criteria for differentiating malignancy from benign biliary conditions, utilizing advanced imaging modalities such as POC and CLE, need to be established. It is of significance to further evaluate these novel diagnostic modalities through ongoing trials and to develop a diagnostic algorithm that reconciles cost-effectiveness with diagnostic accuracy.

Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association.

BACKGROUND: General surgery residency training has changed with adoption of the 80-hour work week, patient expectations, and the malpractice environment, resulting in decreased resident autonomy during the chief resident year. There is considerable concern that graduating residents are not prepared for independent surgical practice. STUDY DESIGN: Two online surveys were developed, one for "young surgeons" (American College of Surgeons [ACS] Fellows 45 years of age and younger) and one for "older surgeons" (ACS Fellows older than 45 years of age). The surveys were distributed by email to 2,939 young and 9,800 older surgeons. The last question was open-ended with a request to provide comments. A qualitative and quantitative analysis of all comments was performed. RESULTS: The response rate was 9.6% (282 of 2,939) of young and 10% (978 of 9,800) of older surgeons. The majority of young surgeons (94% [58.7% strongly agree, 34.9% agree]) stated they had adequate surgical training and were prepared for transition to the surgery attending role (91% [49.6% strongly agree, 41.1% agree]). In contrast, considerably fewer older surgeons believed that there was adequate surgical training (59% [18.7% strongly agree, 40.2% agree]) or adequate preparation for transition to the surgery attending role (53% [16.93% strongly agree, 36.13% agree]). The 2 groups' responses were significantly different, chi-square test of association (3) = 15.73, p = 0.0012. Older surgeons focused considerably more on residency issues (60% vs 42%, respectively), and young surgeons focused considerably more on business and practice issues (30% vs 14%, respectively). CONCLUSIONS: Young and older surgeons' perceptions of general surgery residents' readiness to practice independently after completion of general surgery residency differ significantly. Future work should focus on determination of specific efforts to improve the transition to independent surgery practice for the general surgery resident.

Undifferentiated carcinoma of pancreas: a rare entity with aggressive behavior and possible genetic link.

UNLABELLED: An aggressive undifferentiated carcinoma of pancreas is a rare tumor, especially with a strong personal and family history of malignant melanoma. Limited literature review and few case reports described a genetic association between distinct types of pancreatic cancer and malignant melanoma. CASE REPORT: We present an uncommon case of an aggressive undifferentiated carcinoma of the pancreas in a 50-year-old Caucasian female. Initially, she presented with intermittent epigastric postprandial pain and mild nausea. A computed tomography scan of the abdomen showed a 5 cm heterogenous pancreatic tail mass, which on biopsy was found to be a poorly differentiated non-small cell carcinoma. Past medical history included malignant melanoma, with extensive family history of pancreatic cancer and malignant melanoma. However, not genetically confirmed, a hereditary pancreatic linkage was highly suspected. A week later, repeat computed tomography demonstrated tremendous enlargement of the pancreatic tail mass. Within a few weeks, the patient developed aggressive metastasis in various organ systems, followed by multiple surgeries. An emergent first round of chemotherapy was started, followed by an intensive care unit stay, and she eventually died. CONCLUSION: Our case exposes the aggressive behavior of undifferentiated carcinoma of pancreas, along with possible hereditary link between pancreatic cancer and malignant melanoma.

Hyperparathyroidism: a rare mediastinal presentation of an ectopic adenoma.

The aortopulmonary window is a rare location of an ectopic parathyroid gland, but one that must be considered in persistent primary hyperparathyroidism despite previously attempted parathyroidectomy. Multiple diagnostic studies, including nuclear scans and anatomical imaging techniques, are crucial for identification of a parathyroid gland in the mediastinum and prevention of unnecessary exploratory surgical intervention. This case report presents a 55-year-old female patient with persistent hyperparathyroidism following a neck exploration and thyroidectomy for a parathyroid adenoma. Serial sestamibi scans and CT imaging over the subsequent few years were suggestive, but not diagnostic, of a mediastinal adenoma. Four years after the initial surgery, however, imaging studies identified the development of a soft tissue mass with increased uptake in the aortopulmonary window. A median sternotomy was performed at that time. An ectopic parathyroid gland was identified during surgery between the aortic arch and the bifurcation of the pulmonary artery, as demonstrated on imaging and confirmed by frozen section. Two years following the sternotomy, the patient remains symptom free with calcium and parathyroid hormone (PTH) levels within reference ranges.

Verrucous carcinoma of the esophagus: a potential diagnostic dilemma.

Verrucous carcinoma of the esophagus is a rare variant of squamous cell carcinoma associated with human papillomavirus. We report the case of a 58-year-old female who presented with ongoing symptoms of dysphagia. On previous endoscopies she had been noted to have a large polyp-like mass involving the esophagus, with negative biopsies for malignancy. Repeat endoscopy with concurrent endoscopic ultrasound showed a large semi-pedunculated polyp in the distal esophagus and a hypoechoic, irregular mass involving the gastroesophageal junction with esophageal thickening. Deep layer biopsies showed pseudoepitheliomatous hyperplasia with immunohistochemical staining positive for human papillomavirus. The patient was subsequently treated with chemo-radiation followed by esophagectomy.

Opting for Christian Science vs. surgical removal: a case report of a giant basal cell carcinoma arising on the back of a 66-year-old man.

Basal cell carcinoma is the most common form of skin cancer, with giant basal cell carcinoma comprising only 0.5 percent of all basal cell carcinomas. When a basal cell carcinoma is larger than 5 cm, it is designated as a giant basal cell carcinoma. Neglect is often a contributing factor to these lesions, and local recurrence and metastasis is not uncommon. Presented is a case of a 66-year-old man who presented with a chief complaint of increasing shortness of breath and fatigue. The patient was found to have a large 15 cm x 12 cm pedunculated tumor on his back that had been present for 10 years. The patient had forgone medical attention until presenting with a symptomatic anemia due to his belief in Christian Science, which relies on prayer and divine healing for the treatment of illness. Christian Scientists are allowed to see physicians, but they may present with advanced symptoms or disease presentations due to their beliefs. Fortunately, a computed tomography (CT) scan revealed that the tumor was confined to the skin, and biopsy revealed a basal cell carcinoma. Thus, the patient was able to undergo a wide local excision and split thickness skin graft with clear surgical margins.

Hypercalcemia: an unusual etiology of a common menopausal symptom.

OBJECTIVE: To describe atypical vasomotor symptoms that were secondary to primary hyperparathyroidism. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 57-year-old, postmenopausal woman with recalcitrant hot flushes. INTERVENTION(S): Parathyroid adenomectomy. MAIN OUTCOME MEASURE(S): Vasomotor symptom relief. RESULT(S): Postoperative relief of atypical vasomotor symptoms. CONCLUSION(S): A patient 17 years postmenopause presented with atypical vasomotor symptoms that did not respond to hormone therapy and proved to be due to hypercalcemia secondary to primary hyperparathyroidism. An atypical manifestation of a common condition or an uncharacteristic therapeutic response should alert health care providers to the possibility of a different diagnosis.

Hyperparathyroidism: robotic-assisted thoracoscopic resection of a supernumary anterior mediastinal parathyroid tumor.

Intrathoracic supernumary fifth-gland parathyroid disease is an unusual presentation for primary hyperparathyroidism. Patients generally present with enlargement of one of the normal four cervical parathyroid glands. This paper is a case report of a young woman who presented with typical symptoms of hyperparathyroidism. She, however, had an atypical anatomic finding, and this case offers a unique means of resection.