Our data show a high incidence of early acute rejection or thrombotic microangiopathy in A2 to O kidney transplants with high recipient anti-A IgM titers despite low IgG titers. Steps to lower anti-IgM pre-transplant may reduce the risk of early allograft dysfunction in A2 to O or B kidney transplants. Attention should be paid to IgM titers in establishing individual center selection criteria for A2 to B kidney transplants under the new UNOS kidney allocation system.

Adrenocortical carcinoma (ACC) is rare within the adult population. Ectopic ACC proves even rarer. This variant is formed by cortical fragments arrested during embryologic migration. ACC is also known to be associated with several genetic syndromes and has recently been linked to Lynch syndrome in 3% of cases. We present the case of a 68-year-old male with a confirmed diagnosis of Lynch syndrome secondary to a germline MSH2 mismatch-repair gene-mutation who presented with 2 months history of non-specific abdominal pain. After imaging work-up, the patient was found to have a right upper quadrant, retroperitoneal mass. Biochemical tests were without any evidence of a hormonally active process. Fine needle aspiration of the mass revealed a poorly differentiated carcinoma of unknown etiology. The lesion was resected and found to be consistent with ectopic ACC with an associated MSH2 mutation.

The type of residency training and current practice setting of general surgeons has a significant influence on the volume of endoscopic procedures performed. This study identifies areas where more emphasis on endoscopic skills training is needed, such as FES.

The development of post-ERCP cholangitis due to stent occlusion is strongly associated with the presence of malignancy, the placement of multiple biliary stents, and low serum albumin. A decreased threshold to monitor for stent occlusion, including routine liver function tests and prophylactic stent removal or exchange, should be employed in patients with these characteristics.

The surgical workforce is predicted to be in crisis. The Association of American Medical Colleges forecasts a deficit of 41 000 general surgeons by 2025, which is 33% of the predicted total physician shortage. 1 Much has been written describing the crisis, particularly in rural and underserved urban populations, but few workable solutions have been proposed. The situation is further complicated by the long process to produce a surgeon: medical school followed by 5 to 7 years of residency training and even more as most graduates opt for fellowships beyond. 2 A simple solution would be to increase the number of medical school and residency positions. Increasing training positions was proposed by the Council on Graduate Medical Education and the Association of American Medical Colleges following their physician workforce studies in 2006 and 2008, respectively. 1,3 The medical education community responded, and we are now on track to meet the recommended 30% increase in medical school enrollment by 2019. 4 This has not been matched with a similar increase in federally supported residency positions. A cap on the number of residency positions has been in place since the Balanced Budget Act of 1997. The Resident Physician Shortage Reduction Act, designed to establish 15 000 new residency positions over 5 years, was first introduced in 2009 but did not pass. The most recent iteration (2015) is still in committee at the time of this writing.One must consider whether an increase in trainees will produce the number of surgeons needed, primarily general surgeons. There has been a modest increase in general surgery residency positions under the Affordable Care Act (2010), as one provision of the law allowed for a redistribution of unused residency slots to fund new positions in primary care and general surgery. Also, new training programs have opened. Review of National Residency Matching Program (NRMP) general surgery categorical positions offered in the past 2 decades shows an initial decline followed by an increase in recent years. An overall 7.4% increase in categorical surgery positions has been observed in the period from 1990 to 2015. 5 However, one must also consider that most general surgery trainees choose to specialize with additional fellowship training, noted as high as 70% in 2008. 2 There is anecdotal evidence that the percentage of trainees entering fellowship is even higher in 2016. It is not clear how many trainees who choose to specialize will also include general surgery as a component of their practice. Thus, the number of general sur-VIEWPOINT