examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand. MAIN OUTCOMES AND MEASURESThe primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis. RESULTSThis study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI,.0], P = .02), and minor (456.3 [95% CI,.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures. CONCLUSIONS AND RELEVANCEAfter accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.

Background This systematic review explored the efficacy of different pain relief modalities used in the management of postoperative pain following pancreatoduodenectomy (PD) and distal pancreatectomy (DP) and impact on perioperative outcomes. Methods MEDLINE (OVID), Embase, Pubmed, Web of Science and CENTRAL databases were searched using PRISMA framework. Primary outcomes included pain on postoperative day 2 and 4 and respiratory morbidity. Secondary outcomes included operation time, bile leak, delayed gastric emptying, postoperative pancreatic fistula, length of stay, and opioid use. Results Five randomized controlled trials and seven retrospective cohort studies (1313 patients) were included in the systematic review. Studies compared epidural analgesia (EDA) (n = 845), patient controlled analgesia (PCA) (n = 425) and transabdominal wound catheters (TAWC) (n = 43). EDA versus PCA following PD was compared in eight studies (1004 patients) in the quantitative meta-analysis. Pain scores on day 2 (p = 0.19) and 4 (p = 0.18) and respiratory morbidity (p = 0.42) were comparable between EDA and PCA. Operative times, bile leak, delayed gastric emptying, pancreatic fistula, opioid use, and length of stay also were comparable between EDA and PCA. Pain scores and perioperative outcomes were comparable between EDA and PCA following DP and EDA and TAWC following PD. Conclusions EDA, PCA and TAWC are the most frequently used analgesic modalities in pancreatic surgery. Pain relief and other perioperative outcomes are comparable between them. Further larger randomized controlled trials are warranted to explore the relative merits of each analgesic modality on postoperative outcomes with emphasis on postoperative complications.

This study assessed the experience and autonomy of general surgery trainees in New Zealand in 10 emergency general surgery procedures, and identified factors associated with reaching primary operator thresholds.

Background Subspecialty surgery experience during general surgery training in Australasia is influenced by many factors, including duration of training, training location and the introduction of post‐fellowship training programmes. Experience in hepato‐pancreato‐biliary (HPB) and transplant surgery is part of the general surgery curriculum, although trainee experience in these subspecialties has not been quantified in this region, which is relevant to post‐fellowship training programmes. Therefore, the aim of this study was to quantify the HPB and transplant operative experience of New Zealand (NZ) general surgery trainees. Methods Operative logbook data were analysed for all NZ trainees from 2013 to 2017, including procedures categorized as pancreatic, biliary, hepatic and transplant surgery only. The number of cases within each category was used to model the cumulative operative experience over a 5‐year training programme. Results During the study period, 118 trainees (303 trainee years) recorded 15 662 HPB and transplant procedures. Of these, 13 838 (88.4%) were cholecystectomies (mean cumulative experience 219.3 cases). Excluding cholecystectomy, trainees had a mean cumulative experience of 5.7 biliary, 7.5 pancreatic, 8.1 liver and 4.2 transplant procedures during their training. Transplant experience was predominantly access for peritoneal dialysis (228/260, 86.7%), with cumulative transplant experience otherwise reaching 0.47 procedures over 5 years. Conclusion Exposure to HPB and transplant surgery during general surgery training in NZ is limited beyond cholecystectomy. Additional exposure during post‐fellowship training is likely required for general surgeons to practice in these subspecialties.

Introduction: The median arcuate ligament syndrome (MALS) is a rare vascular disorder caused by an extrinsic compression of the celiac artery from the median arcuate ligament.It is associated with aneurysmal dilatation due to compression. Although it usually comes with the classical triad of chronic abdominal pain, weight loss and epigastric bruit , it still manifests a wide variety of symptoms. Method: We observed 3 cases of celiac trunk aneurysm associated with this condition presented to us initially with different symptoms and MALS were detected by computed tomography scan. Results:Case 1: a 67 year old lady presented with epigastric pain underwent CT showed superior and inferior pancreaticoduodenal artery aneurysm. Successful angioembolisation of aneurysm done and proceeded with release of median arcuate ligament.Case 2: A 56 year old gentleman presented with symptoms of gastric outlet obstruction, CT scan showed duodenal mass with GDA pseudoaneuryms, Whipple procedure was performed.Case 3. A 51 year old gentleman presented with obstructive jaundice and was diagnosed with pancreatic head carcinoma, proceeded with Whipple procedure, only to discover common hepatic and superior anterior pancreaticoduodenal artery pseudoaneurysm post surgery via digital subtraction angiography. Conclusion: Aneurysms associated with MAL syndrome is quite rare and may present with different symptoms at time of diagnosis. Angioembolisation should be the treatment of choice and followup for recurrence is warranted.