Recurrent Right Upper Quadrant Pain Masquerading an Underlying Colon Adenocarcinoma-Induced Intussusception

Intussusception in adults is a challenging diagnosis that often requires a high degree of suspicion. In adults presenting with symptoms, almost 90% have underlying neoplasms. Most frequently, the presentation will include nonspecific abdominal pain, vomiting, and mucoid hematochezia. In this case, we present a 39-year-old female with a rare presentation of chronic, recurrent right upper quadrant abdominal pain over a 5-month interval. The misleading presentation with which the patient presented led to a delay in diagnosis and treatment of colon malignancy and serves to advocate for intussusception as a differential for adult patients presenting with obstructive symptoms of unknown origin and recurrent abdominal pain. Such cases should persuade physicians to plan prompt surgical intervention as to not delay optimal diagnostic and therapeutic outcomes

Mixed Goblet Cell Carcinoid-Adenocarcinoma: A Case Series

INTRODUCTION: Mixed goblet cell carcinoid-adenocarcinoma (GCC) tumors are a group of rare heterogenous neoplasms of the appendix accounting for \u3c 5% of all primary appendiceal tumors. They are characterized as an intermediate between classic carcinoid tumors and appendiceal adenocarcinomas, exhibiting both neuroendocrine and glandular/mucinous morphology that most commonly presents in Caucasian females in the fifth and sixth decades. We present three cases of mixed GCC presenting as acute appendicitis. CASE PRESENTATION: Case #1 A 65-year-old male presented with RLQ pain, nausea, emesis, and leukocytosis. CT of the abdomen revealed perforated appendicitis. The patient underwent a laparoscopic appendectomy. Pathology revealed a high-grade adenocarcinoma ex goblet cell carcinoid, signet ring type extending through the muscularis propria into the mesoappendix measuring \u3e3cm. The patient subsequently underwent a colonoscopy that revealed diverticulosis, but was otherwise normal. Patient then underwent a right hemicolectomy and partial omentectomy. Pathology revealed normal ileal, omental, and colonic tissue without evidence of carcinoma. 0/12 nodes were positive. Case #2 A 49-year-old male presented with periumbilical pain, nausea, emesis, and leukocytosis. CT of the abdomen revealed appendicitis. The patient underwent a laparoscopic appendectomy. Pathology revealed a high-grade, poorly differentiated, adenocarcinoma ex goblet cell carcinoid invading through the muscularis propria into the periappendiceal soft tissue measuring 1.5cm. The patient subsequently underwent a colonoscopy that revealed diverticulosis, but was otherwise normal. Patient then underwent a laparoscopic right hemicolectomy. Pathology revealed normal ileal and colonic mucosa without evidence of carcinoma. 0/14 nodes were positive. Case #3 A 70-year-old female presented with periumbilical pain. CT of the abdomen revealed appendicitis. The patient underwent a laparoscopic appendectomy. Pathology revealed a high-grade adenocarcinoma ex goblet cell carcinoid extending through the muscularis propria into the mesoappendix measuring 4cm. Patient then underwent an exploratory laparotomy with a right hemicolectomy. Pathology revealed normal ileal and colonic mucosa without evidence of carcinoma. 0/21 nodes were positive. CONCLUSION: Mixed GCC tumors are rare tumors that tend to present at an advanced stage and most commonly spread via direct extension. Surgical resection with a right hemi-colectomy after an appendectomy has been shown to improve the prognosis. HIPEC and adjuvant chemotherapy are other therapeutic options, but have not been shown to improve survival. In the current age of increasing rates of managing acute appendicitis non-operatively we strongly encourage surgical appendectomy in patients older than 45 years of age to avoid missing this important diagnosis and the opportunity to treat it in a timely manner

Medical student perceptions of assessments of clinical reasoning in a general surgery clerkship

Abstract Background Components factoring into general surgery clerkship grades vary by institution, and while evaluators attempt to remain unbiased when evaluating medical student performance, subjectivity and implicit bias remain an issue. Our institution recently implemented a case-based structured oral examination to provide the general surgery clerkship director objective insight into students’ clinical reasoning skills. We hypothesized that medical students believe this exam, along with graded clinical documentation and the Observed Standardized Clinical Encounter (OSCE), are fair assessments and increase students’ awareness of their clinical reasoning skills. Methods A survey was sent to third-year medical students in the classes of 2023 and 2024 at our institution who had completed their general surgery clerkship. Students rated five grading assessments (i.e., preceptor evaluations, the oral examination, clinical documentation, the OSCE, and the shelf exam) on fairness and the ability of the assessment to give them insight into their clinical reasoning on a five-point Likert scale 1–5 (with 1 = Strongly Agree, 5 = Strongly Disagree). Results One hundred and ten of 162 (67.9%) students responded to the survey. The shelf examination was the most highly regarded assessment tool followed by the oral examination. Seventy-three percent agreed or strongly agreed that the oral exam was a fair assessment, and 80% agreed or strongly agreed that it gave them insight into their clinical reasoning skills. Alternatively, only 41.8% of students agreed or strongly agreed that preceptor evaluations were fair assessments and 42.7% agreed or strongly agreed that it gave them insight into their clinical reasoning. Conclusions Third-year medical students on a general surgery clerkship favor the shelf examination and a case-based oral examination over other assessment tools regarding fairness and perception of their clinical reasoning. This type of examination can provide general surgery clerkship directors with additional objective data to assess medical students more fairly and improve students’ clinical reasoning

Short term outcomes and unintended benefits of establishing a HPB program at a university-affiliated community hospital.

BACKGROUND: In hepato-pancreato-biliary (HPB) surgery higher volumes are associated with improved outcomes; however, there are limitations to regionalization. Here we report our experience establishing multidisciplinary HPB program at a university-affiliated community hospital. METHODS: This is a retrospective review of patients who underwent HPB surgery between 2015 and 2017. Chief residents\u27 HPB case logs were collected. RESULTS: 61 pancreatic resections and 62 hepatic resections were performed. The morbidity, 30-day mortality and median length of stay following pancreatic resections were 27%, 1.5%, and 8 days, respectively. The morbidity, 90-day mortality, and median length of stay following hepatic resections were 24%, 3%, and 7 days, respectively. The median pancreatic and liver case volumes for graduating chief residents increased from 7 to 8 to 16 and 16, respectively (p \u3c 0.05), after the establishment of a HPB program. Participation in multidisciplinary care (p = 0.08) and clinical trial enrollment increased. CONCLUSION: Our study demonstrates short-term outcomes comparable to high volume centers. Development of a HPB program had a positive impact on resident operative experience, increased multidisciplinary care and increased clinical trial enrollment

Intrathoracic Mesenteroaxial Gastric Volvulus with Massive Gastric Necrosis Requiring Total Gastrectomy and Roux-En-Y Esophagojejunostomy Reconstruction

Introduction: Acute gastric volvulus is a surgical emergency with high morbidity and mortality due to associated ischemic gastric necrosis, perforation, and severe cardiorespiratory compromise. It is characterized by abnormal rotation of the stomach of more than 180°. It is classified based on the axis of rotation into organoaxial and mesenteroaxial volvulus. Intrathoracic gastric volvulus occurs uncommonly in association with organoaxial rotation which draws the stomach through a defect at the hiatus, mesenteroaxial rotation has rarely been reported intrathoracically. We report a case of Intrathoracic Mesenteroaxial volvulus associated with a para-esophageal hernia presenting with gastric necrosis. Case Report: A 70-year-old female, with a complex medical history including a known type III hiatal diagnosed via CT scan two years prior, presented to the emergency room with acute onset abdominal pain, nausea, and inability to vomit. She describes the abdominal pain initially as intermittent that started in the lower left quadrant and had progressively worsened with radiation to the back and left shoulder. Initial laboratory tests showed leukocytosis, anemia and elevated lipase. A nasogastric tube was inserted, and 1 L of dark red fluid was retrieved. Concerns for acute abdominal vascular catastrophe called for A CT angiogram of the abdomen and pelvis, which showed pneumoperitoneum and subphrenic fluid collection with a large para-esophageal hiatal hernia and intrathoracic stomach with pneumatosis and disruption of the anterior gastric wall. An emergency celiotomy was performed. The entire stomach was noted to be frankly ischemic and gangrenous. A Damage Control Surgery (DCS) was utilized. A total gastrectomy without reconstruction was performed (phase I) to control contamination. The patient was taken to the surgical intensive care unit for resuscitation (phase II). After 24 hours, the patient underwent a definitive surgery (phase III) that included a Roux-en-Y esophagojejunostomy with jejunal pouch reconstruction and feeding jejunostomy tube. The patient was discharged 15 days after the inciting operation. Conclusion: Gastric volvulus is a serious condition with a mortality rate ranging from 30 to 50%. Rarely a volvulus can present intrathoracically in the presence of a large hiatal hernia and should be considered a surgical emergency due to increased risk of ischemia. Giant hiatal hernia, in which \u3e50% of stomach resides in the chest, should undergo surgical repair to prevent this potentially devastating complication. We present this case report to raise clinical awareness of intrathoracic gastric volvulus complicated with gastric necrosis

The role of academic achievements and psychometric measures in the ranking process.

INTRODUCTION: Ranking candidates for residency positions is challenging. We hypothesize that applicant academic achievements and performance during the interview are equally important in the ranking process. METHODS: This is a retrospective study. Of 53 candidates interviewed during 2016-2017 cycle, 44 (83%) were ranked for 3 PGY1 positions. Each candidate was interviewed and scored in each of the following: USMLE Step 1 score, USMLE Step 2 score, research (RS), letters of recommendation (LOR), personal statement (PS), the way the candidate represented him/herself (RP), interest in the area (IN), answers to standardized questions (SQ), and degree of connection between the candidate and the interviewer (CN). RESULTS: Correlation and multiple regression analyses indicated an inverse relationship between ranking the candidates and USMLE2 (r = -0.14, p = -0.364), LOR (r = -0.513, p \u3c 0.001), PS (r = -0.414, p = 0.006), RP (r = -0.485, p = 0.001), CN (r = -0.605, p \u3c 0.001), IN (r = -0.349, p = 0.022), and SQ (r = -0.480, p = 0.001), USMLE1 (r = -0.036, p = 0.838) and RS (r = -0.008, p = 0.96). After controlling for the other variables, only CN reached statistical significance (p = 0.033). CONCLUSION: Candidate non-cognitive measures during the interview weigh higher than academic performance in the ranking process