BackgroundPatients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as a diagnostic tool. The purpose of this study is to analyze the usefulness of POCUS in predicting the need for surgical intervention in biliary disease.MethodsA retrospective study of patients visiting the emergency department who received a biliary POCUS from December 1, 2016 to July 15, 2017 was performed. The physician interpretations of the biliary POCUS scans were collected, as well as data from the electronic health records including lab values, the subsequent use of diagnostic imaging, surgical consultation or intervention, and 28 days follow-up for representation or complication.ResultsTwo hundred and eighty-three patients were identified as having received biliary POCUS. Of the patients referred to general surgery who received biliary POCUS 43% received a cholecystectomy. For the outcome of cholecystectomy, the finding of gallstones on POCUS was 55% sensitive (95% CI 40% to 70%) and 92% specific (95% CI 87% to 95%). A sonographic Murphy’s sign was 16% sensitive (95% CI 7% to 30%) but 95% specific (95% CI 92% to 97%) and, gallbladder wall thickness was 18% sensitive (95% CI 9% to 33%) and 98% specific (95% CI 95% to 99%). Patients who received POCUS but did not proceed to confirmatory radiology department imaging had a shorter length of stay (433 min ± 50 min vs. 309 min ± 30 min, P<0.001).DiscussionPoint-of-care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gallstones and increased gallbladder wall thickness are highly predictive of the need for surgical intervention, and use of POCUS is associated with shorter ER visits.Level of evidenceRetrospective cohort study, level III.

BackgroundModern practice guidelines recommend index cholecystectomy (IC) for patients admitted with gallstone pancreatitis (GSP). However, this benchmark has been difficult to widely achieve. Previous work has demonstrated that dedicated acute care surgery (ACS) services can facilitate IC. However, the associated financial costs and economic effectiveness of this intervention are unknown and represent potential barriers to ACS adoption. We investigated the impact of an ACS service at two hospitals before and after implementation on cost effectiveness, patient quality-adjusted life years (QALY) and impact on rates of IC.MethodsAll patients admitted with non-severe GSP to two tertiary care teaching hospitals from January 2008–May 2015 were reviewed. The diagnosis of GSP was confirmed upon review of clinical, biochemical and radiographic criteria. Patients were divided into three time periods based on the presence of ACS (none, at one hospital, at both hospitals). Data were collected regarding demographics, cholecystectomy timing, resource utilization, and associated costs. QALY analyses were performed and incremental cost effectiveness ratios were calculated comparing pre-ACS to post-ACS periods.ResultsIn 435 patients admitted for GSP, IC increased from 16 to 76% after implementing an ACS service at both hospitals. There was a significant reduction in admissions and emergency room visits for GSP after introduction of ACS services (p < 0.001). There was no difference in length of stay or conversion to an open operation. The implementation of the ACS service was associated with a decrease in cost of $1162 per patient undergoing cholecystectomy, representing a 12.6% savings.The time period with both hospitals having established ACS services resulted in a highly favorable cost to quality-adjusted life year ratio (QALY gained and financial costs decreased).ConclusionsACS services facilitate cost-effective management of GSP. The result is improved and timelier patient care with decreased healthcare costs. Hospitals without a dedicated ACS service should strongly consider adopting this model of care.

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Surgeon attitudes toward point of care ultrasound for biliary disease: a nationwide Canadian survey G allstone disease affects more than 20 million Americans yearly. 1 In Ontario, 260 elective cholecystectomies per 100 000 patients are performed each year. 2 Point of care ultrasound (PoCUS) has a growing role in the diagnosis of gallstone disease. 3 Results of PoCUS are similarly accurate compared with formal radiology-performed ultrasounds. 4 Emergency physicians who use biliary PoCUS improve emergency department (ED) throughput and reduce length of stay in the ED. 3 However, surgeons still depend on formal radiology-performed imaging for the management of biliary disease. 5 We surveyed surgeons about their opinions of biliary PoCUS. Our objectives were to quantify surgeon confidence in biliary PoCUS and elucidate possible barriers to use in order to improve surgeon utilization. Our apprOach A cross-sectional survey was emailed to general surgery program directors from the 14 primarily English-speaking academic programs in Canada. They were asked to distribute the survey to all general surgery residents, fellows and staff associated with their centre and to provide us with the number of survey recipients so we could determine the overall response rate. To explore the factors associated with confidence in biliary PoCUS, we dichotomized confidence by considering everyone who answered "slightly confident" to "extremely confident" as having some confidence with PoCUS and those who answered "unconfident" as being unconfident with PoCUS. All other variables were dichotomized as seen in Box 1. We also distilled 5 potential barriers to applying the results of biliary PoCUS in clinical practice: perceived poor test characteristics, user-dependent nature of the technology, poor documentation of results, lack of personal ability to replicate the test, and lack of detailed imaging findings. We analyzed the response data to model the relationships between the survey respondents'

Background: In Canada, residency programs do not have many objective measures for ranking candidates. Instead, ranking relies on subjective measures such as letters of reference, which can be affected by the genders of the writer and the applicant. Our study assesses letters of recommendation for a general surgery program in Canada to categorize differences in reference letters based on the genders of appli cant and letter writer. Methods:We assessed 215 reference letters from 51 general surgery candidates for systematic differences in the descriptors used for male and female applicants and dif ferences based on male and female authorship.Results: Female applicants were more often described as mature, pleasant and flexi ble. Male applicants were more often described as having initiative, completing research, earning awards and performing extracurricular activities. Female writers were more likely to highlight an applicant's interest, initiative, response to feedback, knowledge of their limits, flexibility, communication, achievement in research and awards, confidence and ability to be a good assistant. Significantly more female appli cants had female letter writers, compared with male applicants.

HighlightsGallstones may be lost in a laparoscopic cholecystectomy and cause morbidity.Diagnosis of complications are difficult.Findings may be mistaken for malignancies unless clinical suspicion remains high.Inflammation from lost stones can obstruct the lumen of the gastrointestinal tract.Lost gallstones are best managed during the initial cholecystectomy.

HighlightsDuodenal hematoma and necrosis should be recognized as part of the spectrum of consequences of acute pancreatitis.Surgical management is complex and challenging.General surgeons should have a surgical approach to this complication whether that be diversion or definitive resection.Definitive resection should be completed in multiple steps if there is extensive necrosis and the patient is clinically unwell.

Introduction: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making many emergency medicine physicians have pursued specialized training to perform point of care biliary ultrasound in the emergency department (BUSED). The purpose of this study was to determine the usefulness of BUSED in predicting the need for surgical consultation and intervention for biliary disease. Methods: A retrospective study of 283 consecutive patients visiting the emergency department who received a BUSED scan from December 1, 2016 to July 16, 2017. Physician interpretations of the BUSED scans were collected from the electronic image storage and interpretation system. Additional data was collected from the electronic health record including lab values, the subsequent use of diagnostic imaging, and outcomes data including disposition, surgical consultation or intervention, and 28 day follow up for representation or complication. Descriptive statistics and logistic regression were performed. Results: Of the patients who received a biliary POCUS scan, 29% were referred to general surgery, and 43% of those referred proceeded to eventual cholecystectomy. Factors found to be independently predictive of surgical intervention on point of care BUSED scans included presence of gall stones (OR 13.01, 95%CI 5.02 to 27.1) and increased gallbladder wall thickness (OR 6.01, 95%CI 1.7 to 11.1). A total of 30% of patients receiving BUSED required at least one additional, radiology based imaging test (CT or diagnostic US). Average emergency department length of stay was substantially longer for those who required additional imaging as compared to those who were able to be diagnosed by BUSED alone (16.1 versus 5.2 hours, 10.9 hours 95%CI 10.6 11.2, p<0.05) . Conclusion: Point of care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gall stones and increased gall bladder wall thickness are highly predictive of the need for surgical intervention. Future, prospective studies are warranted to determine if point of care sonography is sufficient to proceed to surgery in select cases of uncomplicated biliary disease.