Hepaticojejunostomy and combined leaks after pancreatoduodenectomy are rarer than pancreaticojejunostomy leaks; these patients are at a significantly increased risk of major morbidity and mortality.

Patient operative outcomes were the same between fellow- and resident-assisted PD. These results suggest that hepatopancreatobiliary surgery fellows and general surgery residents should be offered the same opportunities to participate in complex general surgery procedures.

Importance: An abnormal clinical presentation of foreign body ingestion and its therapeutic approach. Review of the literature to determine rate of perforation along the gastrointestinal tract by foreign body ingestion and to identify appropriate diagnosis and treatment of ingested foreign bodies in the duodenum. Observations: A case report of a 57-year-old female presenting with abdominal pain, chest pain, and headaches for two days. With computed tomography imaging, findings of an intraluminal mass in the duodenum and retroperitoneal air were identified, leading to suspicion of a perforated duodenal malignancy. On endoscopic ultrasound, a toothpick was identified protruding through the wall of the third portion of the duodenum, which was removed by upper endoscopic forceps. A review of the literature yielded 236 cases of foreign body perforation of the gastrointestinal tract between the years 2000 to 2015 in adults 18 years and older. Perforation rate of the small bowel was highest at 39.8% followed by the duodenum 22%, colon 20.3%, sigmoid 5.5%, and unidentified site 1.7%. Literature analysis for therapeutic options for gastrointestinal injury by foreign body ingestion included endoscopy, laparotomy, or laparoscopy. A diagnostic therapeutic algorithm for duodenal foreign body ingestion was created. Conclusions: Ingested foreign bodies can present with a variety of clinical symptoms. Thus, they should be considered as part of a differential diagnosis for cases with gastrointestinal symptoms without clear etiology. Even with imaging studies, foreign body ingestion can be difficult to diagnose initially. Sharp objects, especially toothpicks, have an increased rate of perforation of the gastrointestinal tract and have a high associated morbidity and mortality. As such, prompt diagnosis and management are necessary to improve outcomes.

Background The aim was to evaluate the effects of music on patients’ anxiety and satisfaction after undergoing dialysis access procedures under moderate sedation. Methods Patients (n = 30) undergoing moderate sedation for dialysis access procedures were evaluated at a single institution. Each patient filled out a survey preoperatively and postoperatively using the short form State-Trait Anxiety Inventory (STAI-6). Patient-selected music was provided by using a MP3 player with noise canceling headphones. Results Postoperatively, 77% of patients perceived music intervention as very or extremely helpful in decreasing anxiety during the procedure. Further, 93% of patients were somewhat or very satisfied with their procedure. The average pain rating was 3.1 on a scale of 0-10, in which 70% of patients had no to mild pain and 30% of patients rated moderate to severe pain. In comparison to prior procedures without music, 63% of patients rated better experience with the music intervention, 37% rated a similar experience, and 3.7% rated having a worse experience. Approximately, 93% of patients were willing to repeat procedure with music and would recommend it to other patients. Preoperative anxiety average score was 35.6 ± 13 and was reduced postoperatively to 28.9 ± 12.9 ( P = .006). Preoperatively, 23% of patients rated high anxiety and postoperatively only 6.7% of patients rated high anxiety ( P = .016). Conclusion Music is an easy, feasible, inexpensive intervention that may reduce patients’ anxiety and improve satisfaction during moderate sedation procedures and in the postoperative period.