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In This Issue of JAMA Surgery
September 2013

Highlights

JAMA Surg. 2013;148(9):801-803. doi:10.1001/jamasurg.2013.2202
Research

In the diagnostic workup of abdominal stab wounds, the role of computed tomography (CT) compared with serial physical examination remains controversial. In this prospective evaluation of the management of abdominal stab wounds by Inaba and colleagues, hemodynamically stable and evaluable patients without peritonitis or evisceration underwent both CT and serial physical examination to evaluate diagnostic accuracy for clinically significant injuries detected at laparotomy. Serial physical examination was able to clearly discriminate between patients requiring therapeutic laparotomy and those that can be safely observed, without the need for CT.

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Continuing Medical Education

To evaluate the association of rural training during general surgery residency with eventual practice type and locale, Deveney and colleagues compared the practice characteristics of 11 residents who spent 1 year of their training in a rural hospital with those of 59 residents who did not. They confirmed that the year-long rural experience was associated with a greater likelihood that residents would enter general surgery practice in a small town.

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In this prospective case series, Hwa and Wren examine whether an allied health professional telephone visit could safely substitute for an in-person clinic visit for patients in a Veterans Administration Hospital. A total of 141 patients (115 hernia patients and 26 laparoscopic cholecystectomy patients) were called by a physician assistant 2 weeks postoperatively. The main outcome measures were the percentage of patients who accepted telehealth follow-up and the complications that developed in telehealth patients within 30 days of surgery. Overall, 70.8% of hernia patients and 90.5% of laparoscopic cholecystectomy patients accepted telephone visits. These patients saved an average of 140.8 miles and 148.2 minutes of commuting, no complications were attributed to telephone follow-up, and 110 clinic slots were opened up for new patients.

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With the new 16-hour work limit for interns that was mandated by the Accreditation Council for Graduate Medical Education, concern has been raised regarding how it would affect intern operative experience. In this retrospective review of the operative case logs of 249 categorical general surgery interns across 10 residency programs, Schwartz and colleagues report substantial decreases in operative volume (major and first assistant cases) compared with the case logs of interns in the 4 years preceding the 16-hour work limit.

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The evolution of damage control strategies has led to significant changes in the use of resuscitation after traumatic injury. Kutcher and colleagues evaluate changes in the administration of fluids and blood products, hypothesizing that a reduction in crystalloid volume and a reduced red blood cell to fresh frozen plasma ratio over the last 7 years would correlate with better resuscitation outcomes. Data were prospectively collected from 174 trauma patients receiving a massive transfusion or requiring the activation of the institutional massive transfusion protocol by a dedicated transfusion service coordinator. They identify a dramatic shift toward a reduced crystalloid volume and the recreation of whole blood from component products in resuscitation. These changes are associated with markedly improved outcomes and a new paradigm in the resuscitation of severely injured patients.

Many surgeons consider their chief resident experience to be particularly formative, but changes in surgical education may have altered this experience. Drake and colleagues evaluated over 2 decades of case log data from the Accreditation Council for Graduate Medical Education. Secular trends were evaluated, and comparisons were also made between residents who graduated before the implementation of the 80-hour work week and residents who graduated after the implementation. Chief resident case volume dropped following the 80-hour work week but has since rebounded. Diversity of operative experience has diminished, with a significantly increased portion allocated to alimentary and intra-abdominal cases.

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The duodenum has long been maligned as an option for biliary reconstruction. In this retrospective record review, Rose and colleagues address these misgivings by retrospectively comparing the outcomes of 96 nonpalliative biliary reconstructions using either the jejunum or duodenum at a large tertiary care center. They show that reconstruction with the duodenum is at least as safe and effective as using the jejunum, with the added benefits of ease of operation and of postoperative endoscopic access to the anastomosis.

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Although the current recommendation for patients who present with mild gallstone pancreatitis is to undergo a cholecystectomy during their initial hospitalization, many patients do not. In this retrospective cohort study, Hwang and colleagues determined the risk of recurrence in patients who did not receive a cholecystectomy. A total of 1119 patients with acute gallstone pancreatitis in Kaiser Permanente Southern California were included. The overall recurrence rate was 15% for patients who did not have an initial cholecystectomy. Recurrence was approximately halved for patients who underwent endoscopic retrograde cholangiopancreatography.

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