Showing papers in "American Journal of Surgery in 2023"

Survey of student mistreatment experienced during the core clinical clerkships.

Abstract: The goal of this study was to learn more about the potential impact of medical student mistreatment on patient safety and care.A web-based survey was sent to members of the class of 2021 and 2022 who have completed their core clerkships at a single academic institution. Descriptive statistics were performed to understand how prior and future mistreatment impacted communication among students and team members.We received 290 of 376 responses (77.1%). 26% of respondents indicated that past mistreatment negatively impacted their communication with other team members. 30% of respondents reported that fear of future mistreatment negatively impacted their communication with other team members.Mistreatment of medical students has many sources and occurs throughout the clinical curriculum. Past and fear of future student mistreatment can negatively impact intrateam communication and therefore negatively impact patient care, with the potential of causing poor patient outcomes.

Trends in pancreatic surgery experience in general surgery residency in the US, 1990-2021.

Abstract: Background We hypothesized a decline in resident pancreatic operative experience. The study assesses trends in that experience since 1990. Methods Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residency graduates from 1990 to 2021 were reviewed. Collected and analyzed were the mean and median total number of pancreatic operations per resident, the mean number of specific case types performed, and the annual number of residency graduates. For selected procedures, the mean number of cases by resident role (Surgeon-Chief and Surgeon-Junior) was also analyzed. Results Both the mean and median total number of resident pancreatic operations has declined since 2009 as have the mean number of several specific pancreatic case types, including resections. The annual number of residency graduates has significantly increased since 1990, and particularly since 2009. Conclusions Resident volume in pancreatic operations has significantly declined over the last decade.

Socioeconomic and racial disparities in survival for patients with stage IV cancer.

Abstract: Disparities in cancer outcomes for minoritized people and groups experiencing disadvantages with Stage IV cancer is largely unknown.Patients with Stage IV pancreatic, colorectal, lung, breast, and prostate cancer were identified from 2004 to 2015 in the National Cancer Database. Cox proportional hazard models were used to quantify how demographics and treatments received were associated with overall survival.903,151 patients were included. Patients who were younger, non-Hispanic White, had private insurance, higher income, or received care at an academic center were more likely to receive surgery, chemotherapy, and/or radiation therapy (p < 0.001). Black patients, those with Medicare, Medicaid, no insurance, and lower income had lower survival rates across all five cancer types (p < 0.001). On multivariable analysis, receipt of surgery, radiation, and chemotherapy attenuated but did not eliminate this worse survival (p < 0.001).Survival for patients with Stage IV cancer differs by socioeconomic and self-reported racial classifications.

Simultaneous versus staged resection for synchronous colorectal liver metastases: The win ratio approach

Abstract: In order to investigate the optimal approach for synchronous colorectal liver metastases (sCRLM), we sought to use the "win ratio" (WR), a novel statistical approach, to assess the relative benefit of simultaneous versus staged surgical treatment.Patients who underwent hepatectomy for sCRLM between 2008 and 2020 were identified from a multi-institutional database. The WR approach was utilized to compare composite outcomes of patients undergoing simultaneous versus staged resection.Among 1116 patients, 642 (57.5%) presented with sCRLM; 290 (45.2%) underwent simultaneous resection, while 352 (54.8%) underwent staged resection. In assessing the composite outcome, staged resection yielded a WR of 1.59 (95%CI 1.47-1.71) over the simultaneous approach for sCRLM. The highest WR occurred among patients requiring major hepatectomy (WR = 1.93, 95%CI 1.77-2.10) compared with patients who required minor liver resection (WR = 1.55, 95%CI 1.44-1.70).Staged resection was superior to simultaneous resection for sCRLM based on a WR assessment.

Invited commentary: Virtual reality as a preoperative warm-up in surgical training.

Abstract: In surgical education, preoperative preparation is an important stage that serves as an underpinning for resident training in the operating room (OR) and may potentially enhance learning efficacy. Such preparations can range from the purely cognitive (e.g., mental imagery) to technical drills designed to prime the learner to perform specific physical skills requiring manual dexterity. Various interventions have been developed to enhance resident trainees’ preoperative preparation, such as the Brief-Intraoperative Teaching-Debrief (BID) model 1 Roberts N.K. Williams R.G. Kim M.J. Dunnington G.L. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009 Feb; 208 (Epub 2008 Dec 4. PMID: 19228544): 299-303https://doi.org/10.1016/j.jamcollsurg.2008.10.024 Crossref PubMed Scopus (168) Google Scholar and One-Minute Preceptor, 2 Neher J. Gordon K.C. Meyer B. Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992; 5: 419-424 PubMed Google Scholar in which a faculty usually plays a key role. In this issue, the study by Feeley and colleagues 3 Feeley A.A. Feeley I.H. Merghani K. Sheehan E. Preoperative priming results in improved operative performance with surgical trainees. Am J Surg. 2022 Nov 28; (S0002-9610(22)00772-3, Epub ahead of print. PMID: 36460492)https://doi.org/10.1016/j.amjsurg.2022.11.033 Abstract Full Text Full Text PDF Scopus (2) Google Scholar highlights a novel preoperative warm up using an immersive technology rather than a live faculty in the OR.

The history of European surgery in the 18th century: The Italian innovator Giovanni Alessandro Brambilla (1728-1800) at the Hapsburg court of Joseph II of Austria. A pioneer of medical and surgical education in the field of military medicine.

Abstract: The second half of the 18th century was a time of change in European surgery. Surgeons improved both their social status and their theoretical preparation, which became more closely linked to university studies and increasingly distinct from that of practitioners and barbers. In those years, which were marked by continual conflicts, surgery often acquired connotations of “war surgery”. Therefore, its history features individuals connected with the army: soldiers, in addition to healthcare professionals. A pivotal figure in Hapsburg surgery is the Italian Giovanni Alessandro Brambilla (1728–1800), who devoted much of his activity to reorganising the healthcare service of the Austrian army. This great challenge and Brambilla's long career are also recounted in an unpublished, “professional diary” written by Brambilla himself and conserved today in the Archive of Civic History in Pavia (Italy). This undiscovered manuscript constitutes a precious testimony and provides us with a detailed picture of surgeon military life. Brambilla (Fig. 1) was born in a small village near Pavia, which had been the seat of one of the most ancient universities worldwide, since 1361. In Pavia, Brambilla began his training in about 1747 and in 1752, he enlisted in the Hapsburg army as an assistant surgeon with the Hagenbach Infantry Regiment; here, he began a career that would, within a few years, take him to the highest levels of command in Vienna, where he occupied positions of power and prestige. In the manuscript the elderly surgeon reported that, in the period of peace preceding the Seven Years' War, no educated young man of good family willingly enlisted in the army, as he would be badly paid and scantly esteemed. 1 Brambilla GA. Storia Della Chirurgia Austriaca Dal 1750 Al 1800, Pavia, Archivio Storico Civico, Nascimbene. 1Brambilla GA. Storia Della Chirurgia Austriaca Dal 1750 Al 1800, Pavia, Archivio Storico Civico, Nascimbene. Assistant surgeons were inexperienced, poor and short of proper instruments. Often, they neglected the sick and wounded, preferring to supplement their own meagre wages in other ways, such as by shaving the soldiers and providing medical care for payment in the cities and the countryside. 1 Brambilla GA. Storia Della Chirurgia Austriaca Dal 1750 Al 1800, Pavia, Archivio Storico Civico, Nascimbene. Like the other soldiers, they had to pay for their own new uniforms and for the maintenance of their equipment. During military campaigns it was difficult to maintain the traditional distinction between physicians and surgeons, who treated “internal” and “external” diseases, respectively. Indeed, war overturned the established order and the separation between the profession of the physician and that of the surgeon was no longer practicable. One serious problem was that the inexperienced assistant surgeon often found himself faced with emergencies, without having any skill in internal medicine; he was therefore reduced to rapidly consulting manuals that summarised some basic notions. This was the situation in which the Seven Years' War unfolded. At the beginning of the war, regimental surgeons were provided, at the expense of the state, with three cases containing a few basic instruments, so that they would at least have the most essential surgical tools. However, these tools were of substandard quality; Brambilla complained that the blades of the saws were more suited to cutting wood than to performing amputations, and that the coarse scissors were not suitable for cutting soft tissues. 1 Brambilla GA. Storia Della Chirurgia Austriaca Dal 1750 Al 1800, Pavia, Archivio Storico Civico, Nascimbene. The most scrupulous surgeons, including Brambilla himself, who had in the meantime been promoted to chief surgeon, bought instruments at their own expense. Moreover, bandages were in short supply and surgeons sometimes had to improvise by using their own bedlinen. In 1763, at the end of the Seven Years' War, Brambilla was first appointed “surgeon of the noble imperial guard”, and then “surgeon to Their Imperial Majesties” and, specifically, to Archduke Joseph that in 1780, became the sole sovereign (Fig. 2). During the war he had successfully treated some nobels, including General Gacomo Botta Adorno, whose arm he had managed to sava from amputation. It was also thanks to his skill that Brambilla reached the imperial court. Joseph II himself, afflicted with an anal fistula, was operated on By Brambilla with an instrument specially designed for the operation (Fig. 3). As commander-in-chief of the armed forces, Joseph zealously devoted himself to continuing the already-initiated reform of military organisation, including health care. Being a soldier himself, Brambilla realised that the monarch's plans went some way to meeting the needs of military surgery, with which he was all too familiar. In reality, Joseph's aim was to create non-specialised personnel–physicians/surgeons with only generic skills; men who were able to cope with any type of emergency and also to carry out “administrative” healthcare functions in the Hapsburg dominions. Thus, Brambilla accompanied Joseph on his journeys and in his visits to military camps and hospitals. In 1778, the Emperor appointed Brambilla Chief Surgeon of the Army, later known as Proto-surgeon of the Army. Thanks to his experience in the field, Brambilla was able to begin improving military organisation, this involved years of hard work. In 1769-70, Brambilla was involved in the reorganisation of the Gumpendorf military hospital (in a suburb of Vienna). Brambilla had an ambitious project: the foundation of a school for military surgeons. In 1781, this plan began to take shape, with the first teaching post being assigned to Gabriel von Gabriely, a doctor with great experience in surgery and military medicine. However, other “trainers” were needed. Thus, it was decided that a few promising army surgeons should be selected and sent travelling for two years, so that they could gain experience in the most advanced medical schools. Brambilla arranged for some rooms in the building to be equipped with whatever would be needed for the teaching of the students. The young men who were admitted to this school for assistant surgeons had to know Latin and to be able to maintain themselves for 4 years. In addition, they had to purchase a uniform and a instrument-bag. Accommodation was provided free of charge, while students had to pay for their own meals, which could be bought at a modest price from the innkeeper who supplied the hospital with food. The trainees attended lectures and worked in the wards, where they assisted the nurses with medications and the distribution of medicines; they also performed minor operations under the direction of higher-ranking surgeons, and practised anatomical dissections. Another innovation had been introduced in 1780: no proprietor or colonel could autonomously employ a senior surgeon; he could only nominate a candidate, who then had to be approved by the Proto-surgeon. The new organisation introduced by Brambilla was much appreciated. Nevertheless, as the Gumpendorf hospital housed a few hundred patients, it proved insufficient for the army. A new and larger facility was therefore planned. For this purpose Joseph allocated a large area, where, in 1785, a larger hospital equipped with all the necessary services and the Academy for the training of surgeons were inaugurated. 2 In honour of the Emperor, the medical-surgical Academy was named Josephinum. 2In honour of the Emperor, the medical-surgical Academy was named Josephinum. The Academy housed over 200 students, in addition to some of the hospital staff. One of the storerooms contained surgical instruments, gathered in 300 leather cases. Each regiment or corps utilised 3 of these cases (one for amputations, one for trephinations and one containing a miscellany of instruments for other operations, such as lithotomy, paracentesis and herniotomy) (Fig. 4, Fig. 5). The Academy was endowed with a a precious collection of surgical instruments, displayed in various boxes which collected the instruments indicated for the operations performed at that time, from head to foot. 3 Brambilla GA. Instrumentarium chirurgicum militare austriacum. Viennae: Litteris Schmidtianis, 1782. 3Brambilla GA. Instrumentarium chirurgicum militare austriacum. Viennae: Litteris Schmidtianis, 1782. These boxes constitute therefore a testimony on late XVIII century surgery: bloodletting, cauterizations, treatment of skull fractures, eye operations (in particular that for cataracts), operation on the nose and on the oral cavity, dental therapy, obstetric and gynaecological operations, lithotomy (removal of bladder stones), compression of aneurysms, extractions of projectiles, amputations, enemas and insufflations (Fig. 6). Brambilla payed a great importance to the study of anatomy on human corpses. Various types of dissecting instruments and large syringes for injecting wax into blood vessels for making instructive anatomical preparations were part of the collection. 4 Garbarino MC. “Per il bene dell’umanità sofferente”. La chirurgia di Giovanni Alessandro Brambilla (1728-1800), Milano: Cisalpino, 2019. 4Garbarino MC. “Per il bene dell’umanità sofferente”. La chirurgia di Giovanni Alessandro Brambilla (1728-1800), Milano: Cisalpino, 2019. Various types of bandages were also on display and could be applied to a life-size model during lessons. The students could also utilise models of seats and tables for surgical operations, various physics instruments and apparatuses for use in cases of dislocation and fracture. Training was carried out on two different levels: those of trainee and master (or doctor in surgery): “trainees” were those students who followed the basic curriculum. They had to take a 6-month course, which could be repeated several times, and acquire notions of anatomy by attending operating theatres and military hospitals. Subsequently, they could enlist in the army as assistant surgeons. - After 6/8 years' service, an assistant surgeon became eligible for higher training-the so-called “great course”, which lasted two years. On completion of the course, and after passing rigorous examinations, the assistant surgeon was granted the title of “Master” or “Doctor in Surgery”. As in the case of the school previously instituted at the Gumpendorf hospital, the aspiring young students were examined by the Proto-surgeon. They were required to know Latin, as well as their native language, to be able-bodied and healthy and to have good eyesight. Applicants also had to have some basic knowledge of surgery and anatomy, and demonstrate that they were able to maintain themselves for two or three years and buy the required uniform, instruments and books. The new school supported the University in the training of more “generic” physicians/surgeons, as opposed to the more specialised and scientific training provided by the faculty of medicine. Thus, professionals were trained who were destined to become both “civilian surgeons” and “military doctors”. 5 Horn S, Lindenhofer P. Das Josephinum. Eine Institution im gesundheitspolitischen und wirtschaftstheoretischen Kontext des 18. Jahrunderts. In: Horn S, Ablogin A. (eds) Faszination Josephinum. Die anatomischen Wachspräparate und hir Haus, Wien: Verlagshaus der Ärtze GmbH, 2012, p 23-50.After the victory at Marengo, news of the French advance prompted Brambilla to try to reach Vienna. However, he died on the journey 5Horn S, Lindenhofer P. Das Josephinum. Eine Institution im gesundheitspolitischen und wirtschaftstheoretischen Kontext des 18. Jahrunderts. In: Horn S, Ablogin A. (eds) Faszination Josephinum. Die anatomischen Wachspräparate und hir Haus, Wien: Verlagshaus der Ärtze GmbH, 2012, p 23-50.After the victory at Marengo, news of the French advance prompted Brambilla to try to reach Vienna. However, he died on the journey The uniform of the army surgeons-an essential feature in order to immediately recognise who was able to assist the wounded-was definitively regulated, and consisted of scarlet trousers and tunic and a mare sea-green long jacket. The duties of military surgeons were summarised in five points: obedience to superiors, obligation to study and improve one's knowledge, to carry out one's duties zealously, to care for patients lovingly, and to maintain good moral conduct. Brambilla also established prizes to be awarded to the most deserving students in answering scientific questions that could be useful in surgical practices. One of the questions concerned, for example, wound dressing methods that could protect against unfortunate outcomes. The problem of interpreting and resolving infections was huge at the time, and would not find a solution until the mid-19th century. However Brambilla set out to discuss the matter scientifically. The most promising solutions were the subject of publications, which were then sent to surgeons employed “in the field”. Fig. 2Portrait of Joseph II of Habsburg-Lorraine, (1741–1790) at the University of Pavia Show full caption [Wikipedia Commons (public domain)]. View Large Image Figure Viewer Download Hi-res image Fig. 3The instrument designed by Brambilla to operate on Joseph II. It si an instrument composed of various complementary instruments connected to each other, which allowed the exploration of the part and subsequently the incision of the fistula without the blade, protected bu a special cover, causing damage to the healty parts. Thanks to Brambilla, a didactic collection of surgical instrument was also sent to Pavia. Show full caption [Museum for the History of Pavia University]. View Large Image Figure Viewer Download Hi-res image Fig. 4Instruments for surgical amputations: Show full caption Giovanni Alessandro Brambilla,Instrumentarium chirurgicum militare Austriacum, Wien, 1782. The volume contained a description of the teaching tools and of their construction characteristics, so that surgeons could also have similar ones built. [Museum for the History of Pavia University]. View Large Image Figure Viewer Download Hi-res image Fig. 5Box containing the amputation tools, from the didactic collection of surgical instruments created by Brambilla Show full caption [Museum for the History of Pavia University]. View Large Image Figure Viewer Download Hi-res image Fig. 6Box with tools for extracting bulletts, from the didactic collection of surgical instruments created by Brambilla Show full caption [Museum for the History of Pavia University]. View Large Image Figure Viewer Download Hi-res image [Wikipedia Commons (public domain)]. [Museum for the History of Pavia University]. Giovanni Alessandro Brambilla,Instrumentarium chirurgicum militare Austriacum, Wien, 1782. The volume contained a description of the teaching tools and of their construction characteristics, so that surgeons could also have similar ones built. [Museum for the History of Pavia University]. [Museum for the History of Pavia University]. [Museum for the History of Pavia University].

Beyond enhanced recovery after surgery (ERAS): Evolving minimally invasive colectomy from multi-day admissions to same-day discharge.

Abstract: Early discharge is increasingly important in the resource-limited COVID era. Some groups have reported early experiences with same day discharge (SDD) after colectomy. We implemented a routine SDD protocol and report the evolution in our program's outcomes.We studied a retrospective cohort of robotic colorectal surgeries from 2016 to 2022. Colectomies were analyzed as a sub-group and stratified by year.The cohort comprised 535 cases, of which 483 were colectomies. Annual case volume increased from 58 to 180 cases (p < 0.001). Operative console time concordantly decreased by 33% (p < 0.001). Average length of stay decreased from five to one days. By 2022, 58% of colectomies were selectively discharged on the same day of surgery. Complication and readmission rates remained constant.SDD is feasible and safe in selected patients. We illustrate the practical evolution of a surgical practice toward routine SDD, and discuss the factors we found critical to this transition.

Surgical outcomes after re-operation for excision of choledochal cyst with delayed biliary complications: A retrospective study on 40 patients.

Abstract: The purpose of this study is to review our experience in patients who underwent re-operation for delayed biliary complications after choledochal cyst (CDC) excision.All the patients who underwent re-operation. for delayed biliary complications after CDC excision between August 2007 and July 2020 were included in this retrospective study. The outcomes of these patients were compared with those who underwent primary surgery (CDC excision) at our institution.Of the total 40 patients with delayed biliary complications, 25 (62.5%) were female. Thirty-seven (92.5%) patients had a history of cholangitis. The median interval between CDC excision and the reoperation was 70 (4-216) months. The median duration of symptoms before reoperation was 12 (2.5-84) months. Re-do hepaticojejunostomy and direct hepaticojejunostomy were performed in 34 and in 6 patients respectively. Median operative time and blood losses were 219 min and 150 ml respectively. The median postoperative stay was 9 days. Postoperative complications developed in 10 (25%) patients. There was no operative mortality. Over a median follow-up of 71 months, a satisfactory outcome was achieved in 86% of patients. Restricture and intrahepatic stones developed in three and two patients respectively. Incidence of type IV cyst, cholangitis before operation, and operative blood loss were significantly more in the re-operative group. Clinical outcomes like the incidence of recurrent cholangitis, re-stricture, and postoperative hospital stay were comparable between the two groups.Surgery affords excellent results for majority of the patients with delayed biliary complications after CDC excision. Type IV cysts are more commonly associated with the development of delayed biliary complications.

How well do we understand our patients' perioperative experience? A qualitative analysis of themes derived from patient-centric resident conferences.

Abstract: Patient-centric resident conferences (PCRCs) provide meaningful time to connect with and learn from patients. This qualitative study explores themes of patients' perioperative experiences from PCRCs through patient and resident perspectives.General Surgery residents participated in six PCRCs, which include condensed standard didactics to accommodate a patient panel regarding their perioperative experience. Panel transcripts and resident survey responses describing what they learned were coded using grounded theory methodology. Themes were evaluated and compared.76 identified codes were grouped into major categories: "Medical/Surgical Knowledge," "Patient Perspective," "Patient-Physician Relationship," and "Communication." Themes from resident responses predominantly paralleled patient discussion, with common themes including "impact of disease and surgery on patient" and "compassion/empathy." "Medical/surgical knowledge" was only present in resident responses while themes regarding quality of life were more frequent in patient transcripts.PCRCs are a valuable tool in resident education to understand patients' perioperative experiences. Themes from patient panels complement, but do not replace, information covered in didactic lectures.

Audit of case cancellations on the day of surgery at a single tertiary healthcare institution.

Abstract: Operating rooms (OR) generate significant revenue for the hospital. Therefore, the OR productivity is essential for institutional success. 1 Zmijewski P. et al. Impact of a funds flow model on surgeon productivity at one academic medical center. Surg. Pract. Sci. 2022; 9100079 Google Scholar Hospital systems must ensure adequate availability of resources to maintain the efficiency for day-to-day operations of the OR. 2 Landau S.I. et al. Longitudinal evaluation of the surgical workforce experience during the Covid-19 pandemic. Am J Surg. 2022; 224: 1199-1206 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar ,3 Ross S.W. et al. Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center. Am J Surg. 2022; 224: 1409-1416 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In this regard, case cancellations on the day of surgery can impede the productivity of the OR by thwarting efficient resource utilization. This translates to financial loss borne by the hospitals, with estimated $1700 to $2025 (dollars in 2009) per case. 4 Knox M. Myers E. Hurley M. The impact of pre-operative assessment clinics on elective surgical case cancellations. Surgeon. 2009; 7: 76-78 Crossref PubMed Scopus (67) Google Scholar , 5 Argo J.L. et al. Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg. 2009; 198: 600-606 Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar , 6 Macario A. Dexter F. Traub R.D. Hospital profitability per hour of operating room time can vary among surgeons. Anesth Analg. 2001; 93: 669-675 Crossref PubMed Scopus (122) Google Scholar It also incurs significant physical and psychological distress in the patients. 7 Adler J.T. Mack E. Chen H. Equal oncologic results for laparoscopic and open resection of adrenal metastases. J Surg Res. 2007; 140: 159-164 Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar As the financial strains resulting from the national economic crisis and extraordinary circumstances such as the global pandemic become evident in the functioning of hospitals with current resource limitations, critical evaluation of productivity impedance factors is required. As such, case cancellations provide one such area of examination and subsequent improvement to save future costs to the patient and the hospital systems.

Using the tools we have to improve perioperative outcomes for mastectomy patients with severe persistent mental illness.

Abstract: In this month's issue, Deshpande et al. report on the relationship between severe persistent mental illness (SPMI) and surgical outcomes after inpatient mastectomy for breast cancer. 1 Despande A.J. Bhandarkar A. Bobo W. et al. Examining the relationship between severe persistent mental illness and surgical outcomes in women undergoing mastectomy for breast cancer. Am J Surg. 2022; https://doi.org/10.1016/j.amjsurg.2022.12.019 Abstract Full Text Full Text PDF Scopus (2) Google Scholar The authors used the National Inpatient Sample from the Healthcare Cost and Utilization Project and discovered that women with SPMI had a longer length of stay (LOS), were more likely to undergo bilateral mastectomies, less likely to undergo breast reconstruction, and that those who underwent reconstruction were at an increased risk of post-procedural infection and sepsis. 1 Despande A.J. Bhandarkar A. Bobo W. et al. Examining the relationship between severe persistent mental illness and surgical outcomes in women undergoing mastectomy for breast cancer. Am J Surg. 2022; https://doi.org/10.1016/j.amjsurg.2022.12.019 Abstract Full Text Full Text PDF Scopus (2) Google Scholar This work illuminates the negative impacts psychological distress and illness has on surgical breast cancer outcomes and provides insight into potential solutions to support this vulnerable population through their diagnosis and subsequent surgery.

Are patients with limited English proficiency less likely to undergo parathyroidectomy for primary hyperparathyoidism?

Abstract: Despite meeting operative indications for primary hyperparathyroidism (PHPT), many patients never undergo parathyroidectomy. We hypothesized that patients with limited English proficiency (LEP) would be less likely to undergo parathyroidectomy than English-proficient (EP) patients.We retrospectively analyzed patients with PHPT from an institution-wide registry who met operative criteria between 2010 and 2018. The cohort was stratified by English proficiency. Univariate associations between sociodemographic and clinical factors with parathyroidectomy were assessed. A multivariable logistic regression model was created to assess independent predictors of parathyroidectomy.Among a cohort of 1,104 patients, 262 (24%) underwent parathyroidectomy. LEP patients (n = 135, 12%) were significantly younger (mean age 62 vs. 69, p < 0.001), more likely non-white race and ethnicity (p < 0.001), and less likely to have private insurance (p < 0.001). After adjusting for covariates, non-English and non-Spanish preferred language was an independent negative predictor of undergoing parathyroidectomy (OR 0.46, 95% CI 0.21-0.95, p = 0.037).Limited English proficiency may be an independent barrier to appropriate surgical management of PHPT. Systems-level and disease-specific interventions are needed to address this disparity faced by patients with LEP.

The influence of Non-Technical Skills of a Technical Skills Trainer (NTS-TeST) checklist on skills training: Perceptions from trainers and trainees

Abstract: Surgical Training has been greatly affected by the COVID-19 Pandemic with limited opportunities and learning experiences for trainees in theatre.1 During recent years there has also been a shift from time and numbers-based training to competency-based training, as demonstrated by the new ISCP curriculum.2 As such, more than ever there is pressure for surgical trainers and trainees alike to maximise every learning experience.

Quality indicators for thyroid cancer care: What should surgeons know?

Abstract: Most individuals diagnosed with thyroid cancer (TC) have differentiated thyroid carcinoma (DTC) (97%) and a generally excellent prognosis. However, up to 20% of DTC patients may experience disease recurrence over several decades,1 making it challenging to evaluate treatment outcomes. Adopting other reliable indicators that reflect the quality of both surgical and medical TC management is imperative. This paper reviews key qualitative and quantitative cancer-related quality indicators (QIs) that surgeons should consider adopting into practice to provide optimal care for TC patients (Fig.

Impact of COVID-19 pandemic on treatment of colorectal cancer patients

Abstract: BackgroundModifications to practice during COVID pandemic impacted health maintenance and treatment of cancer patients.MethodsWe conducted a retrospective cohort study of all consecutive patients presenting to our institution with a new diagnosis of colorectal cancer pre-COVID (January 2017 to December 2019) and post-COVID (January to December 2020).ResultsThe total number of patients with a new diagnosis of CRC was 2196. The pre-COVID period had 1891 patients whereas post-COVID period had 305. The median number of patients diagnosed with CRC per month was 50 and 35.5 pre and post-COVID, respectively. Time to treatment initiation was similar with no difference in stage at presentation for the pre and post-COVID periods.ConclusionThere was a significant decrease in colorectal cancer diagnosis number and rate (p < 0.01) during the COVID era with no difference in staging at diagnosis or time to treatment initiation.

Is winning the only thing? - Examining the "win ratio" concept in synchronous colorectal liver metastasis.

Abstract: The dilemma of sequencing therapies in synchronous colorectal liver metastasis (CRLM) has been a seemingly continual topic of interest, particularly as a more aggressive surgical approaches to liver resection have emerged in recent decades. Improvement in perioperative management has driven morbidity and, more notably, mortality rates to low levels in even the most complex clinical circumstances. This has provided the oncology team with three distinct pathways to choose from for surgical management: synchronous resection of the primary tumor and liver disease, a liver-first approach, or a primary tumor-first approach. The potential benefit of synchronous resection is consolidating surgical management into a single surgical procedure to render the patient into a “no evidence of disease” status, balanced with concerns for increased morbidity and mortality by combining liver and colorectal surgery. The liver-first approach has been of increasing interest as the hepatic disease status appears to be a primary driver of cancer-related mortality in CRLM. Addressing the liver disease first allows for the patient to return to intended oncologic therapy in timely fashion while the patient remains asymptomatic from their primary tumor. This may also facilitate neoadjuvant radiotherapy prior to rectal resections. Staged surgery likely reduces morbidity and mortality concerns, though also comes with increased total length of stay and potential for disease progression in the perioperative interval while off systemic therapy. Finally, a primary tumor-first approach can be utilized but would typically be reserved for symptomatic tumor causing refractory bleeding or obstruction.

Normohormonal primary hyperparathyroidism: A systematic review and meta-analysis.

Abstract: We aim to evaluate the body of evidence reporting on normohormonal primary hyperparathyroidism (NHpHPT) patients to help guide their diagnosis, characterization and treatment.Normohormonal primary hyperparathyroidism is a term used to describe patients with a normal PTH and elevated calcium levels. There is limited understanding regarding the presentation and appropriate management of these patients.A systematic review was conducted: abstract and full-text screening were independently conducted by 2 investigators. Odds ratios (OR), standard mean differences (SMD) and 95% confidence intervals were calculated.Twenty-two studies were identified. Patients with NHpHPT were more likely to present with lower PTH (p < 0.00001) and calcium (p < 0.00001) levels. Intraoperatively, the NHpHPT group was 1.8 times more likely to undergo bilateral neck exploration (BNE) and harbor multigland disease. The rates of surgical cure were 93% in the NHpHPT and 96% in the pHPT groups (p = 0.0003).Symptomatic patients with NHpHPT benefit from parathyroidectomy with prolonged intraoperative PTH monitoring, and a low threshold for conversion to BNE.

Kirby I. Bland, M.D.: Opening moves.

Abstract: First impressions are important, but opening moves can make all the difference. In this celebration, the opening moves to focus on began in late 1999 and early 2000. It is good to remember that in 1999 the world was facing the predicted (but never realized) crash of computer clocks thus paralyzing the world at the opening of a new millennium. Yet, other important changes were taking place on a much more local basis.

Features of mixed medullary thyroid tumors: An NCDB analysis of clinicopathologic characteristics and survival.

Abstract: Mixed medullary-papillary thyroid carcinoma (MMPTC) and mixed medullary-follicular thyroid carcinoma (MMFTC) are rare variants with little known regarding behavior and prognosis.Using the National Cancer Database (NCDB), demographics, clinicopathologic features, treatment, and overall survival (OS) from patients with MMPTC and MMFTC were compared to more prevalent subtypes.There were 296,101 patients: 421 MMPTC (0.14%), 133 MMFTC (0.04%), 263,140 PTC (88.87%), 24,208 FTC (8.18%) and 8,199 MTC (2.77%). Compared to PTC, MMPTC and MMFTC patients were older (p < 0.001) with a higher Charlson-Deyo comorbidity index (p < 0.001). Mixed tumors exhibited lower rates of nodal disease but more distant metastases compared to PTC (p < 0.001). MMPTC demonstrated lower estimated 10-year OS than PTC and FTC (76.04%vs 89.04% and 81.95%,p < 0.001), yet higher than MTC (70.29%,p < 0.001). MMFTC had a worse OS compared to all groups (63.32%,p < 0.001).Patients with MMFTC had significantly worse OS compared to DTC, portending a worse prognosis.

Preoperative history and physical update visits offer limited clinical value in colorectal surgery.

Abstract: United States regulations require a history and physical (H&P) ≤30 days before planned procedures. We evaluated the impact of H&P update visits in colorectal surgery.Preoperative H&P update visits conducted in colorectal clinics at our institution during 2019 were identified. Two independent reviewers assessed whether update visits identified interval changes to history, exam, or operative plan. Secondary outcomes included visit times, estimated travel times and distances.For 132 visits, interval changes were identified in 39% of histories, but only 4.2% of exams and 6.8% of operative plans. When plans changed, visit goals could have been accomplished via telehealth in 77.8%. Median clinic and round-trip driving time were 61.5 and 62.2 min, respectively.H&P update visits conducted to satisfy the 30-day regulation rarely result in clinically relevant changes yet impose time and travel burdens on patients. Regulations should be revised to provide flexibility in H&P update modalities.

Elucidating academic surgical staff perspectives of medical student learning in the operating room: An embedded mixed methods study

Abstract: The operating room (OR) is a complex environment for medical students. Little is known about the OR staff's perception of medical students.We utilized an embedded mixed methods design to characterize surgical staff perceptions of students at an academic institution. We surveyed 408 OR nursing/technician staff with 16 follow-up interviews.139 respondents. 91.3% reported having daily-to-weekly interactions with medical students. Yet, only 37.9% agreed that "patient care is better when medical students are part of the team." 25.2% felt confident that they knew what a student's education entails outside the OR. 93.5% agreed that interprofessional training between physicians and OR staff should be included in educational programs. 54% agreed that their responsibilities include medical student training in the OR setting.Despite an overall desire for teamwork, this study highlights a lack of knowledge of each others' roles. To improve OR culture and team dynamics, concerted efforts need to be made around interprofessional training.

Bibliometric analysis of the classic cited papers in the American Journal of Surgery: Citation recapitulates surgical history.

Abstract: Background We performed a bibliometric analysis of the American Journal of Surgery (AJS) to identify, characterize and place within a historical context, its published classic cited papers (CCPs). Methods Bibliometric data from papers published in the AJS between January 1, 1945, and December 31, 2021 was extracted from the Web of Science database. Analysis was performed utilizing Bibliometrix and VOSViewer software. Results 27,070 papers were published in the AJS over the study period. There were 16 CCPs, including 5 Top CCPs, identified. Review of the Top CCPs reveals that they are based on careful clinical observations, innovation and generally build on prior published work. Top CCPs usually are specific to a particular diagnosis or a commonly performed procedure, as such papers frequently present a scoring or classification system, or important details related to new operative approaches or techniques. Conclusions Bibliometric study of the AJS has allowed for identification, characterization and appreciation of many of the key changes that have occurred in the discipline throughout the history of modern surgery.

Satellite internet technology implementation for the practice of medicine and surgery.

Abstract: The Russian invasion of Ukraine has widely disrupted internet services across the country and the capital city of Kyiv. The risk of a total internet shutdown brought on by shelling and cyberattacks has prompted Ukraine's Minister of Digital Transformation, Mykhailo Fedorov, to ask SpaceX's founder for aid. 1 Sheetz M. About 150,000 People in Ukraine Are Using SpaceX's Starlink Internet Service Daily. 2022 Google Scholar Federov's plea resulted in SpaceX, an American space and communications company, sending roughly 20,000 satellite terminals to Ukraine as of October 2022. Consequently, the Ukrainian populace and military can now access high-speed internet from SpaceX's satellite internet service, Starlink, which comprises numerous low Earth orbit satellites. 1 Sheetz M. About 150,000 People in Ukraine Are Using SpaceX's Starlink Internet Service Daily. 2022 Google Scholar Such an example demonstrates how satellite technology can provide internet support anywhere in the world, no matter the state of an area's infrastructure.

The combined effect of race, dual-eligibility and neighborhood deprivation on medicare spending after cancer surgery.

Abstract: Disparities in clinical outcomes following high-risk cancer operations are well documented, but, whether these disparities contribute to higher Medicare spending is unknown.Using 100% Medicare claims, White and Black beneficiaries undergoing complex cancer surgery between 2016 and 2018 with dual eligibility status and census tract Area Deprivation Index score were included. Linear regression was used to assess the association of race, dual-eligibility, and neighborhood deprivation on Medicare payments.Overall, 98,725 White(93.5%) and 6900 Black(6.5%) patients were included. Black beneficiaries were more likely to live in the most deprived neighborhoods(33.4% vs. 13.6%; P < 0.001) and be dual-eligible(26.6% vs. 8.5%; P < 0.001) compared to White beneficiares. Overall, Medicare spending was higher for Black compared to White patients($27,291 vs. 26,465; P < 0.001). Notably, when comparing Black dual-eligible patients living in the most deprived neighborhoods to White non-dual eligible patients living in the least deprived spending($29,507 vs. $25,596; abs diff $3911; P < 0.001).In this study, Medicare spending was significantly higher for Black patients undergoing complex cancer operations compared to White patients due to higher index hospitalization and post-discharge care payments.

A fast tract to foregut surgery: Pandemic-driven protocol development

Abstract: COVID-19 has overwhelmed many health care systems which has affected the landscape of elective surgery. A pandemic driven protocol was developed to perform foregut surgeries as a Same Day Surgery (SDS) discharge for all comers to reduce resource utilization.Retrospective review of all patients who underwent elective laparoscopic foregut surgery (hiatal hernia, paraesophageal hernia, heller myotomy, and fundoplication) from 8/1/2020-1/31/2022 by a single surgeon after the implementation of a SDS protocol. Patients were compared to a pre-pandemic cohort, from 8/1/2019-4/30/2020, when overnight admission was standard practice.There were 36 pre-pandemic patients, and 41 pandemic patients successfully discharged the same day of surgery. We failed to detect a statistically significant difference between the two groups regarding 30-day ED visit rate (p-value of 0.4557) and 30-day readmission rate (p-value of 0.6790).The creation of a SDS protocol for foregut surgery is a safe way to deliver much needed care to the community while decreasing resource utilization.

“I'll take my colectomy to go, please.”: Reflections on pandemic silver linings

Abstract: Sars-COVID-19 was the mother of invention for trailblazing authors, Vu et al.1Vu M.M. Curfman K.R. Blair G.E. Shah C.A. Rashidi L. Beyond enhanced recovery after surgery (ERAS): evolving minimally invasive colectomy from multi-day admissions to same-day discharge.Am J Surg. 2023 Jan 21; (00024-7): S0002-S9610https://doi.org/10.1016/j.amjsurg.2023.01.024Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Pandemic-related operating room closures, in part, due to a paucity of available hospital beds and a shortage of trained nurses to care for semi-elective surgical patients' inpatient needs, placed point pressure on providers and patients. These resource-limitations were the impetus for this team's creativity in accommodation. They took an existing protocol, which they coined “advanced-ERAS” (enhanced recovery after surgery), to an extreme for patients in need of colectomy. At the height of the pandemic, advanced-ERAS inpatient protocols pivoted – nearly overnight – to same day discharge. This innovation was not without evaluation. Could patients be better served by spending post-operative-day-zero in the comfort (and safety! aA likely, albeit impossible-to-track, side benefit of this approach was decreased COVID exposure and transmission in this post-operative population who convalesced in social isolation.) of their own beds at home? In carefully-selected and skillfully, painstakingly-primed patients the answer was “yes”. In this manuscript, the authors highlight a single colorectal surgeon's robotics practice [senior author L. Rashidi]. She tracked her cases and outcomes at two institutions in which she practiced after completion of fellowship training in colon and rectal surgery, with an emphasis in robotic surgery.2Curfman K.R. Poola A.S. Blair G.E. et al.Ambulatory colectomy: a pilot protocol for same day discharge in minimally invasive colorectal surgery.Am J Surg. 2022 Aug; 224 (Epub 2022 May 11. PMID: 35570059): 757-760https://doi.org/10.1016/j.amjsurg.2022.04.039Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar A longitudinal look at her cases, as explicitly detailed in this manuscript, showed a substantial increase in volumes (as enabled by single-surgeon's steep learning curve followed by steady-state mastery, combined with the team's efficiency), a marked decrease in the length of stay (from 5 days to 1 day) and significant increase in same day discharge rates (58% of all-comers in her robotic colectomy practice in the year 2021). What impacted their trends was a change in institution mid-study (2018 was the year she transitioned bRashidi, personal communication.). I can only imagine how starting with a new employer and instituting culture norms around ERAS as it relates to colectomy took Herculean effort. This may have resulted in the downtrend that is illustrated in Vu et al Figure 3, and the spike seen in Vu et al Figure 7 (depicted and annotated in this commentary as Fig. 1, Fig. 2). What sent her trends into hyperdrive was the March 2020 initial pandemic lock-down in the U.S. Impressively, subsequent spikes in COVID which caused shutdowns for the rest of us may not have impacted her team as greatly, because of their prowess with their SDD protocol.Fig. 2Length of stay by yearShow full captionArrow points to a spike which corresponds to the surgeon's employment transition.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Arrow points to a spike which corresponds to the surgeon's employment transition. Also attributable to COVID's silver linings in this team's success with SDD was the normalization of telehealth. This team utilized it greatly, with routine pre-scheduled telehealth appointments on post-op day 1, 3 and 7 (with day 7 suggested as an in-person visit). A major strength of the manuscript is that the sample size is large with a study population of 535 robotic surgery cases, 438 of which were colectomies. Another strength is that this team's SDD protocol is explicitly detailed in this manuscript and in their previous work.2Curfman K.R. Poola A.S. Blair G.E. et al.Ambulatory colectomy: a pilot protocol for same day discharge in minimally invasive colorectal surgery.Am J Surg. 2022 Aug; 224 (Epub 2022 May 11. PMID: 35570059): 757-760https://doi.org/10.1016/j.amjsurg.2022.04.039Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Those of us who are in a contemplative phase have been provided what we need to emulate. Curiosities which linger for me are related to several of the study's limitations. Namely, in terms of candidate selection for SDD, race and other social determinants of health are not yet available within this dataset. They will be critical factors to consider when evaluating whether implicit bias factors into selection. To foster health equity, what support can the hospital system (an entity which is presumably saving thousands of dollars by safely avoiding patients' inpatient stays) give to those who may not meet criteria due to health literacy issues, home support, and access to telecommunication technologies? In sum, I tip my surgical scrub cap to this incredible effort by a talented team who did not compromise on quality and transparency. During the 2019-to-2021 time-period when they committed to this phenomenal push for SDD, this team also achieved center of excellence status from the National Accreditation Program for Rectal Cancer (NAPRC), a program of the American College of Surgeons Commission on Cancer (ACS-COC). They are the second institution cThe first NAPRC-accredited institution in the state of Washington was Kadlec Regional Medical Center in Richland, WA, in 2020. in our state to achieve this distinction.3Kumar A.S. Kim H.C. Tan S.M. Whiteford M. Pacific Northwest Perspectives on National Accreditation Program for Rectal Cancer (NAPRC)” Presented at Pacific Coast Surgical Association. U.S.A., Monterey, CAFebruary 2023Google Scholar Full transparency of every rectal cancer patient's presentation and outcome within a hospital system over the previous 12 months is revealed before an accreditor's site visit is scheduled. Maintaining quality (NAPRC) while pushing our boundaries and comfort zones (SDD) is what was demonstrated during this presentation at 2022's North Pacific Surgical Association in the author's home town of Tacoma, WA. What's next? It won't be long before we see trending memes on social media: “Coming soon to an ambulatory surgery center near you – colectomy.”