Acid Peptic Disease.

The management of peptic ulcer disease has radically changed over the last 40 years from primarily surgical treatment to medical therapy nearly eliminating the need for elective surgery in these patients. Although there has been a decline in patients requiring acute surgical intervention for complications of peptic ulcer disease (perforation, bleeding, and obstruction), these patients still make up a significant proportion of hospital admissions every year. The modern acute care surgeon must have significant knowledge of the multiple treatment modalities used to appropriately care for these patients.

Who Will Be Able to Perform Open Biliary Surgery in 2025?

Background: Although laparoscopic cholecystectomy (LC) is the gold standard, some patients still require an open cholecystectomy (OC). This study evaluates the mean number of OCs performed by each graduating general surgery resident during each of 3 decades.

Study Design: Data were obtained from all patients undergoing a cholecystectomy during 3 decades: prelaparoscopic era (1981 to 1990), first decade of LC (1991 to 2001), and recent decade of LC (2004 to 2013).

Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography?

Background: Preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography (IOC) are standard procedures in evaluating patients with suspected choledocholithiasis. This study evaluates the changing practice patterns over time of these 3 procedures in a large cohort of patients undergoing laparoscopic cholecystectomy (LC) at a single tertiary care center.

Study Design: Data from all patients undergoing an LC with or without preoperative ERCP, MRCP, or an IOC from January 1, 2004 to December 31, 2013 were retrospectively reviewed from billing data obtained by CPT code and analyzed by chi-square testing.

Geographic maldistribution of general surgery PGYI residents: another US surgical desert.

Background: Practicing general surgeons are unevenly distributed across the country. This study evaluates the geographic distribution of categorical, general surgery (GS) PGYI positions per capita.

Methods: Data were obtained from the 2012 National Resident Matching Program match and the 2010 US Census.

The general surgery workforce shortage is worse when assessed at county level.

Background: Multiple studies have documented a significant decrease in the general surgery workforce in the United States, both rural and urban, for the past 3 decades. This 11-year study evaluates the Texas general surgery workforce at both the state and local level in 2002 and 2012.

Methods: Data were obtained from the Texas Medical Board, the United States Census Bureau/Texas State Library and Archives Commission, and the Texas Department of State Health Services for 2002 and 2012.

Tort reform is associated with significant increases in Texas physicians relative to the Texas population.

Introduction: Texas implemented comprehensive tort reform in 2003. We hypothesized that tort reform was followed by a significant increase of physicians practicing in Texas.

Methods: To test this hypothesis, we compared the rate of physician growth prior to and following tort reform, and the number of licensed physicians and physicians per 100,000.

Malpractice risk and cost are significantly reduced after tort reform.

Background: Rising medical malpractice premiums have reached a crisis point in many areas of the United States. In 2003 the Texas legislature passed a comprehensive package of tort reform laws that included a cap at $250,000 on noneconomic damages in most medical malpractice cases. We hypothesized that tort reform laws significantly reduce the risk of malpractice lawsuit in an academic medical center.

Nondiagnostic thyroid fine-needle aspiration biopsies are no longer a dilemma.

Background: Nondiagnostic fine-needle aspiration biopsy (ND-FNAB) of the thyroid leads to unnecessary thyroidectomy. The aims of this study were as follows: (1) to determine the risk of malignancy in ND-FNABs, and (2) to evaluate factors that may identify patients at risk for a ND-FNAB.

Methods: A total of 241 patients who underwent FNAB and thyroidectomy were evaluated for factors associated with a ND-FNAB.

The Mirizzi syndrome: multidisciplinary management promotes optimal outcomes.

The Mirizzi syndrome (MS) is a rare cause of obstructive jaundice produced by the impaction of a gallstone either in the cystic duct or in the gallbladder, resulting in stenosis of the extrahepatic bile duct and, in severe cases, direct cholecystocholedochal fistula formation. Sixteen patients were treated for MS in our center over the 12-year period 1993--2005 for a prevalence of 0.35% of all cholecystectomies performed.

Long-term outcomes in laparoscopic vs open ventral hernia repair.

Objective: To investigate whether there was a difference in morbidity, recurrence rate, and length of hospital stay between patients undergoing open or laparoscopic incisional hernia repair.

Design And Setting: Single-institution cohort study. We compared prospectively collected patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair.

A successful application of the intraoperative parathyroid hormone assay in tertiary hyperparathyroidism.

The role of the intraoperative parathyroid hormone (IOPTH) assay in patients with tertiary hyperparathyroidism (3HPT) is not well defined. To evaluate the utility of the IOPTH in 3HPT, we compared its use in 72 patients with primary hyperparathyroidism (1HPT) and 3HPT undergoing parathyroidectomy. Sixty-three patients with 1HPT and nine patients with 3HPT were identified.

Parathyroidectomy in secondary hyperparathyroidism: Is there an optimal operative management?

Background: Subtotal parathyroidectomy (SPTX) and total PTX with autotransplantation (TPTX + AT) are both accepted operations for secondary hyperparathyroidism (2HPT). Studies have shown the 2 procedures to have similar rates of recurrent or persistent HPT (0% to 10%). The majority of these reports are small case series and despite apparently similar outcomes; the optimal operative management for 2HPT remains controversial.

Gallbladder perforation: risk factors and outcome.

Background: Gallbladder perforation is difficult to diagnose and is associated with significant morbidity. This study investigates factors affecting outcome in patients with gallbladder perforation over two decades.

Materials And Methods: From 1982 to 2002 data from patients undergoing cholecystectomy at one institution were prospectively collected.

Early conversion for gangrenous cholecystitis: impact on outcome.

Background: Early conversion from laparoscopic to open cholecystectomy for patients with gangrenous cholecystitis has been advocated. This study investigated the impact of early conversion on patient outcome.

Methods: Data from all patients with gangrenous cholecystitis undergoing laparoscopic cholecystectomy between 1992 and 2002 whose procedure had been converted to open surgery were prospectively collected and analyzed.

Gangrenous cholecystitis in the decade before and after the introduction of laparoscopic cholecystectomy.

Background: Gangrenous cholecystitis is a severe form of acute cholecystitis with high morbidity. This study investigate the outcomes for patients undergoing cholecystectomy for gangrenous cholecystitis in the decade before and after the introduction of laparoscopic technology at our institution.

Methods: From 1982 to 2002, all patients undergoing cholecystectomy for gangrenous cholecystitis were prospectively entered into a database.

Open Rives-Stoppa ventral hernia repair made simple and successful but not for everyone.

Background: The Rives-Stoppa (RS) repair of ventral incisional hernias (VIHR) is technically difficult. It involves the retromuscular placement of mesh anterior to the posterior fascia and the primary closure of the anterior fascia. Recurrence rates are 0-8%.

Does the correlation of acute cholecystitis on ultrasound and at surgery reflect a mirror image?

Background: It remains unclear if sonography accurately describes the severity of gallstone disease.

Methods: Patients were prospectively enrolled if urgent cholecystectomy was indicated. Two radiologists, blinded to operative findings, evaluated the patients' ultrasound imagings.

Laparoscopic cholecystectomy for biliary dyskinesia: correlation of preoperative cholecystokinin cholescintigraphy results with postoperative outcome.

Background: A gallbladder ejection fraction (EF) on cholescintigraphy of less than 35% after cholecystokinin (CCK) has been considered to be pathophysiologic and an indication for laparoscopic cholecystectomy (LC).

Methods: All patients undergoing LC for biliary dyskinesia between 1994 and 2001 were prospectively entered into a database. These patients were retrospectively evaluated with regard to demographics, the number of preoperative studies obtained, postoperative symptoms, and the number of postoperative studies obtained.

Intraoperative parathyroid hormone assay: an accurate predictor of symptomatic hypocalcemia following thyroidectomy.

Hypothesis: Intraoperative parathyroid hormone (IOPTH) assay is useful for predicting symptomatic hypocalcemia following total thyroidectomy.

Design: A prospective study of 30 patients undergoing total thyroidectomy with IOPTH levels obtained following skin closure and ionized calcium (Ca2+) levels obtained 6 hours postoperatively and on postoperative day 1. All patients were evaluated for symptoms of hypocalcemia.

Laparoscopic cholecystectomy for elderly patients: gold standard for golden years?

Hypothesis: Laparoscopic cholecystectomy (LC) has known physiological benefits and positive socioeconomic effects over the open procedure. Although recent studies have questioned the technique's efficacy in elderly patients (>65 years), we hypothesize that LC is safe and efficacious in that patient group.

Methods: Five thousand eight hundred eighty-four consecutive patients (mean age, 40 years; 26% male) underwent an attempted LC (conversion rate, 5.

Diagnosis and treatment of intra-abdominal abscesses.

Despite recent advances in the diagnosis and management of intra-abdominal abscesses, these infections still cause substantial morbidity and mortality. Low pH, large bacterial inocula, poor perfusion, the presence of hemoglobin, and large amounts of fibrin (which impedes antibiotic penetration) make the abscess a cloistered environment that is penetrated poorly by many antimicrobial therapies. Therefore, management of these infections requires prompt recognition, early localization, and effective drainage, as well as appropriate antimicrobial use.

Reasons for conversion from laparoscopic to open cholecystectomy: a 10-year review.

Laparoscopic cholecystectomy is now considered the "gold standard" operation for patients with gallstone disease. A number of patients require conversion to an open cholecystectomy for the safe completion of the procedure. This study investigates how the etiology and incidence of conversion from laparoscopic to open cholecystectomy has changed over time.