How does sleeve gastrectomy impact long-term eating-related symptoms, distress, and behavior? A cross-sectional study using the BODY-Q patient-reported outcome measures.

BACKGROUND: Patients undergoing sleeve gastrectomy (SG) experience transformative changes in eating-related experiences that include eating-related symptoms, emotions, and habits. Long-term assessment of these endpoints with rigorous patient-reported outcome measures (PROMs) is limited. We assessed patients undergoing SG with the Body-Q Eating Module PROMs. METHODS: All patients evaluated at the Emory Bariatric Center were given the Body-Q Eating Modules questionnaire at preoperative/postoperative clinic visits. Rasch scores and prevalence of relevant endpoints were assessed across six time-points of interest: preoperatively, post-operative months 0-6, 7-12, 12-24, 24-36, and over 36. Student's t-test and Chi-square test were used for analysis. RESULTS: Overall, 1,352 questionnaires were completed pre-operatively and 493 postoperatively. Survey compliance was 81%. Compared to the pre-operative group, the post-operative group had lower BMI (39.7 vs. 46.4, p < 0.001) and higher age (46.3 vs. 44.9, p = 0.019). Beginning one year after SG, patients experience more frequent eating-related pain, nausea and constipation compared to pre-operative baseline (p < 0.05). They also more frequently experience eating-related regurgitation and dumping syndrome-related symptoms beginning post-operative year two (p < 0.05). In the first year after SG, patients more rarely feel eating-related embarrassment, guilt, and disappointment compared to pre-operative baseline (p < 0.05). These improvements disappear one year after SG, after which patients more frequently experience feeling out of control, unhappy, like a failure, disappointed, and guilty (p < 0.05). In the first year after SG, patients experience an increased frequency in positive eating behaviors (ate healthy foods, showed self-control, stopped before full; (p < 0.05). Only two eating-related behavior improvements persist long-term: feeling in control and eating the right amount (p < 0.05). CONCLUSIONS: Patients undergoing SG may experience more frequent eating-related symptoms, distress, and behavior in the long-term. These findings can enhance the pre-operative informed consent and guide development of a more tailored approach to postoperative clinical management such as more frequent visits with the dietician.

Implementation of an Online Intraoperative Assessment of Technical Performance for Surgical Trainees.

INTRODUCTION: Assessment of surgical resident technical performance is an integral component of any surgical training program. Timely assessment delivered in a structured format is a critical step to enhance technical skills, but residents often report that the quality and quantity of timely feedback received is lacking. Moreover, the absence of written feedback with specificity can allow residents to seemingly progress in their operative milestones as a junior resident, but struggle as they progress into their postgraduate year 3 and above. We therefore designed and implemented a web-based intraoperative assessment tool and corresponding summary "dashboard" to facilitate real-time assessment and documentation of technical performance. MATERIALS AND METHODS: A web form was designed leveraging a cloud computing platform and implementing a modified Ottawa Surgical Competency Operating Room Evaluation instrument; this included additional, procedure-specific criteria for select operations. A link to this was provided to residents via email and to all surgical faculty as a Quick Response code. Residents open and complete a portion of the form on a smartphone, then relinquish the device to an attending surgeon who then completes and submits the assessment. The data are then transferred to a secure web-based reporting interface; each resident (together with a faculty advisor) can then access and review all completed assessments. RESULTS: The Assessment form was activated in June 2021 and formally introduced to all residents in July 2021, with residents required to complete at least one assessment per month. Residents with less predictable access to operative procedures (night float or Intensive Care Unit) were exempted from the requirement on those months. To date a total of 559 assessments have been completed for operations performed by 56 trainees, supervised by 122 surgical faculty and senior trainees. The mean number of procedures assessed per resident was 10.0 and the mean number per assessor was 4.6. Resident initiation of Intraoperative Assessments has increased since the tool was introduced and scores for technical and nontechnical performance reliably differentiate residents by seniority. CONCLUSIONS: This novel system demonstrates that an online, resident-initiated technical assessment tool is feasible to implement and scale. This model's requirement that the attending enter performance ratings into the trainee's electronic device ensures that feedback is delivered directly to the trainee. Whether this aspect of our assessment ensures more direct and specific (and therefore potentially actionable) feedback is a focus for future study. Our use of commercial cloud computing services should permit cost-effective adoption of similar systems at other training programs.

Does the use of a suction calibration system (SCS) reduce stapler load firings and operative time? A randomized controlled trial comparing use of endoscopic calibration vs. SCS in laparoscopic sleeve gastrectomy.

BACKGROUND: It is critical to ensure appropriate and consistent sleeve size and orientation during laparoscopic sleeve gastrectomy (LSG). Various devices are used to achieve this, including weighted rubber bougies, esophagogastroduodenoscopy (EGD), and suction calibration systems (SCS). Prior reports suggest that SCSs may decrease operative time and stapler load firings but are limited by single-surgeon experience and retrospective design. We performed the first randomized controlled trial comparing SCS against EGD in patients undergoing LSG to investigate whether the SCS decreases the number of stapler load firings. METHODS: This was a randomized, non-blinded study from a single MBSAQIP-accredited academic center. Appropriate LSG candidates ≥ 18 years of age were randomized to EGD or SCS calibration. Exclusion criteria included prior gastric or bariatric surgery, detection of hiatal hernia before surgery, and intraoperative hiatal hernia repair. A randomized block design was employed controlling for body mass index, gender, and race. Seven surgeons employed a standardized LSG operative technique. The primary endpoint was the number of stapler load firings. Secondary endpoints were operative duration, reflux symptoms, and change in total body weight (TBW). Endpoints were analyzed via t-test. RESULTS: A total of 125 LSG patients (84% female) underwent study enrollment, with an average age of 44 ± 12 years and average BMI of 49 ± 8 kg/m2. Overall, 117 patients were randomized to receive EGD (n = 59) or SCS (n = 58) calibration. No significant differences in baseline characteristics were identified. The mean number of stapler load firings for EGD and SCS groups were 5.43 ± 0.89 and 5.31 ± 0.81, respectively (p = 0.463). The mean operative times for EGD and SCS groups were 94.4 ± 36.5 and 93.1 ± 27.9 min, respectively (p = 0.83). There were no significant differences in post-operative reflux, TBW loss, or complications. CONCLUSION: Use of EGD and SCS resulted in a similar number of LSG stapler load firings and operative duration. Additional research is needed to compare LSG calibration devices in different patients and settings to optimize surgical technique.

S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work.

BACKGROUND: Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations. METHODS AND PROCEDURES: An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests. RESULTS: Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes. CONCLUSION: Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.

Elderly Patients Benefit From Enhanced Recovery Protocols After Colorectal Surgery.

BACKGROUND: Enhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols. METHODS: We queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile. RESULTS: Two hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value < 0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value < 0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days. CONCLUSION: Overall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.

Pediatric short bowel syndrome and subsequent development of inflammatory bowel disease: an illustrative case and literature review.

Short bowel syndrome (SBS) in neonates is an uncommon but highly morbid condition. As SBS survival increases, physiologic complications become more apparent. Few reports in the literature elucidate outcomes for adults with a pediatric history of SBS. We present a case report of a patient, born with complicated gastroschisis resulting in SBS at birth, who subsequently developed symptoms and pathologic changes of inflammatory bowel disease (IBD) as an adult. The patient lived from age 7, after a Bianchi intestinal lengthening procedure, to age 34 independent of parenteral nutrition (PN), but requiring hydration fluid via G-tube. He was then diagnosed with IBD, after presenting with weight loss, diarrhea, and malabsorption, which required resumption of PN and infliximab treatment. This report adds to a small body of the literature which points to a connection between SBS in neonates and subsequent diagnosis of IBD. Recent evidence suggests that SBS and IBD have shared features of mucosal immune dysfunction and altered intestinal microbiota. We review current treatment options for pediatric SBS as well as multidisciplinary and coordinated transition strategies. We conclude that there may be an etiologic connection between SBS and IBD and that this knowledge may impact outcomes and approaches to care.

The Association Between Hospital Finances and Complications After Complex Abdominal Surgery: Deficiencies in the Current Health Care Reimbursement System and Implications for the Future.

OBJECTIVE: To determine the relationship between complications after 3 common general surgery procedures and per-episode hospital finances. BACKGROUND: With impending changes in health care reimbursement, maximizing the value of care delivered is paramount. Data on the relative clinical and financial impact of postoperative complications are necessary for directing surgical quality improvement efforts. METHODS: We reviewed the medical records of patients enrolled in the American College of Surgeons' National Surgical Quality Improvement Program who underwent pancreaticoduodenectomy, hepatectomy, and colectomy at a single academic institution between September 2009 and August 2012. Clinical outcomes data were subsequently linked with hospital billing data to determine hospital finances associated with each episode. We describe the association between postoperative complications, hospital length of stay, and different financial metrics. Multivariable linear regression modeling tested linear association between postoperative outcomes and cost data. RESULTS: There was a positive association between the number of surgical complications, payments, length of stay, total charges, total costs, and contribution margin for the three procedures. Multivariable models indicated that complications were independently associated with total cost among the selected procedures. Payments increased with complications, offsetting increased costs. CONCLUSIONS: In the current fee-for-service environment, the financial incentives are misaligned with quality improvement efforts. As we move to a value-driven method of reimbursement, administrators and health care providers alike will need to focus on improving the quality of patient care while remaining conscious of the cost of care delivered. Reducing complications effectively improves value.

Combining laparoscopic giant paraesophageal hernia repair with sleeve gastrectomy in obese patients.

BACKGROUND: Surgical treatment for giant paraesophageal hernias (PEH) in morbidly obese patients (BMI > 35) continues to be a difficult problem. Prior studies have demonstrated recurrence rates of up to 40% with higher rates in morbidly obese patients. Reports have shown success combining repair with a bariatric procedure to decrease recurrence rates while achieving weight loss. We report mid-term results from a larger series with combining laparoscopic giant PEH repair with sleeve gastrectomy (SG). METHODS: We reviewed all combined cases of PEH repairs with SG done at a single institution from 2008 to 2013. The surgical technique was standardized and absorbable bio-prosthetic buttress crural closure reinforcement was used selectively. Yearly upper gastrointestinal radiographic (UGI) studies and postoperative Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaires were completed. 33 patients were enrolled; 18 patients (55%) completed the study RESULTS: No 30-day morbidity or mortality occurred. 16 patients were female; the average age was 55.3 ± 11.4 years (30-72) with follow-up from surgery of 19.9 ± 16.7 months (6-66). The average weight loss was 23.5 ± 12.7 kg (8-57); excess body weight loss was 46 ± 25.8% (18-112). Based on the UGIs, 9/18 (50%) had no evidence of hernia recurrence, while 6/18 (33%) demonstrated a small (<2 cm) recurrence. 3/18 (17%) patients had evidence of moderate recurrence (3-5 cm). Postoperative GERD-HRQL scores revealed an average score of 10 ± 7 (2-26). All patients reported being "satisfied" with their operation and weight loss and also had a significant improvement in foregut symptoms. No patient has required surgical revision and residual symptoms responded to conservative management. CONCLUSIONS: PEH in morbidly obese patients remain a complex surgical problem. Our case series shows that combination with SG may decrease recurrence rates but more importantly leads to lower rates of reoperation for symptomatic recurrence. Patients also garner the added medical benefits of weight loss.

Designing an ethics curriculum to support global health experiences in surgery.

BACKGROUND: The field of global health is rapidly expanding in many medical centers across the US. As a result, medical students have increasing opportunities to incorporate global health experiences (GHEs) into their medical education. Ethics is a critical component of global health curricula, yet little literature exists to direct the further development of didactic training. Therefore, we sought to define ethical encounters experienced by medical students participating in short-term surgical GHEs and create a framework for the design of ethics curriculum specific to global surgery. MATERIALS AND METHODS: Emory University Departments of Surgery, Urology, and Anesthesia, in partnership with the non-profit organization Project Medishare, have taken annual humanitarian surgical trips to Hinche, Haiti. All medical students returning from the trips in 2011 and 2012 received a 35-question survey to assess demographic data, extent of prior ethics education, frequency of exposure and situational confidence to ethical subject matter, as well as ethical conflicts involved in surgical GHEs. The same comparative data were also collected for domestic clinical clerkships. RESULTS: Seventeen out of 21 medical students completed the survey. Nearly all (88.3%) students had previous formal ethics training as an undergraduate or in medical school. Ethical issues were commonly encountered during domestic clinical encounters and volunteerism. However, students reported enhanced exposure to the professional obligation of surgeons (P = 0.025) and truth-telling/surgeon-patient relationships (P = 0.044) during surgical volunteerism. Despite increased exposure, situational confidence did not change. CONCLUSIONS: Ethical issues are commonly confronted during GHEs in surgery and differ from domestic clinical encounters. Healthcare ethics curriculum should be designed to meet the needs of medical students involved in global health.

A comparison of abdominal surgical outcomes between African-American and Caucasian Crohn's patients.

BACKGROUND AND OBJECTIVE: Whether race affects the natural history of Crohn's disease is a matter of debate. The aim of the current study was to evaluate the differences in surgical outcomes between African-American (AA) and Caucasian (C) Crohn's patients undergoing surgery at a tertiary care referral center. METHODS: With Institutional Review Board approval, the medical records of our institution were queried to identify consecutive AA and C patients who underwent surgery for Crohn's disease from December 1, 2009 to December 15, 2011. A retrospective chart review was performed using electronic medical records. RESULTS: A total of 77 patients were included in this study, including 32 AA (41 %) and 45 C (59 %). No significant differences were seen with respect to age, gender, type of insurance, preoperative exposure to immunosuppressives, body mass index, or smoking history between the two populations (p > 0.05). There was a trend toward lower albumin in AAs (p = 0.09). AA and C patients who underwent their first Crohn's disease (CD)-related surgery had similar lag periods between diagnosis and surgery. No significant differences were seen in location of disease, indication for operation, and need for open laparotomy over laparoscopy. No significant differences were seen in need for a repeat operation within 90 days of the original surgery or major postoperative complications. There was a trend toward higher rate of minor complications in the AA group (p = 0.07). CONCLUSION: No significant differences were noted in the current study in several preoperative variables and surgical outcomes between AA and C.

The Price of Courage: The Life and Legacy of Dr LaSalle D. Leffall Jr.

This historical retrospective details the life and legacy of Dr LaSalle D. Leffall Jr, a leader in the field of surgical oncology, passionate surgical educator, and indelible mentor. His courage, against the backdrop of the many obstacles presented by American racism, paved the way for the inclusion of multiple generations of women and minority surgeons leaving a lasting impact on the history of American surgery.

Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center.

BACKGROUND: Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized. OBJECTIVES: To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles. SETTING: Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital. METHODS: We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology. RESULTS: A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed. CONCLUSIONS: Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.

The Impact of the COVID-19 Pandemic on Geographic Placement of Applicants to General Surgery Residency Programs.

OBJECTIVE: COVID-19 greatly influenced medical education and the residency match. As new guidelines were established to promote safety, travel was restricted, visiting rotations discontinued, and residency interviews turned virtual. The purpose of this study is to assess the geographic trends in distribution of successfully matched General Surgery applicants prior to and after the implementation of pandemic guidelines, and what we can learn from them as we move forward. DESIGN: This was a retrospective review of 129 Accreditation Council for Graduate Medical Education (ACGME) accredited, academic General Surgery Residency Programs across 46 states and the District of Columbia. Categorically matched residents' medical schools (i.e., home institutions), medical school states, and medical school regions as defined per the Association of American Medical Colleges (AAMC), were compared to the same geographic datapoints as their residency program. Preliminary residents were excluded. Residents in the 2018, 2019, and 2020 cycles were sub-categorized into the "pre-COVID" group and residents in the 2021 and 2022 applications cycles were sub-categorized into the "post-COVID" group. The percentages of residents who matched at their home institution, in-state, and in-region were examined. SETTING: Multiple ACGME-accredited, university-affiliated General Surgery Residency Programs across the United States of America. PARTICIPANTS: A total of 4033 categorical General Surgery residents were included. RESULTS: Of 4033 categorical residents who matched between 2018 and 2022, 56.1% (n = 2,263) were in the pre-COVID group and 43.9% (n = 1770) were in the post-COVID group. In the pre-COVID group 14.4% (n = 325) of residents remained in-home (IH), 24.4% (n = 553) in-state (IS), and 37.0% (n = 837) in- region (IR), compared to 18.8% IH (n = 333), 27.8% IS (n = 492), and 39.9% IR (n = 706) in the post-COVID group, respectively. Significant increases for IH and IS resident matching at 4.5% and 3.4%, respectively, were noted in the post-COVID period (p < 0.05). CONCLUSION: The COVID-19 pandemic, and the ensuing changes adopted to promote safety, significantly impacted medical student opportunities and the General Surgery residency application process. General Surgery match data over the last 5 years reveals a statistically significant increase in the percentage of applicants matching at in-home and in-state institutions after the pandemic.

Factors predicting the increased risk for return to the operating room in bariatric patients: a NSQIP database study.

BACKGROUND: The objective of the study was to assess the risk factors associated with return to the operating room in bariatric surgery patients. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Project's participant-use file, patients who underwent laparoscopic gastric bypass (LRYGB) and adjustable gastric band (LAGB) procedures for morbid obesity were identified. Several pre-, peri-, and postoperative variables, including 30 day morbidity and mortality, were collected. The study population was divided into two groups: patients returning to the operating room (group 1), and patients not returning to the operating room (group 2). Variables analyzed included postoperative complications, overall morbidity, and mortality. Relationships between preoperative and perioperative factors leading to the return to the operating room also were analyzed. RESULTS: Of 28,241 (LRYGB = 18,671, LAGB = 9,570) patients included in the study, 644 (2.3 %) patients returned to the operating room. Of the study population, 30 day mortality rate was 0.13 % (37/28,241) and morbidity was 4.1 % (1,155/28,241). Patients returning to the operating room had a higher mortality [14/644 (2.2 %) vs. 23/27,597 (0.01 %); P < 0.001], and morbidity [258/644 (40 %) vs. 897/27,579 (3.3 %); P < 0.001] compared with those who did not return to the operating room. Postoperative complications (superficial wound infection, deep surgical site infection, organ space infection, pneumonia, pulmonary embolism, renal insufficiency, renal failure, septic shock, and length of stay) were significantly higher for patients who required reoperation. On multivariate logistic regression analysis, the bypass operation, bleeding disorder, patients on dialysis, preoperative hematocrit, preoperative low albumin, and length of operation were associated with increased risk of return to the operating room. In the bariatric population, return to the operating room is associated with significantly higher morbidity and mortality. Patients who are on dialysis, have a low preoperative serum albumin, and a history of bleeding disorders have a higher chance of return to the operating room. In addition, patients who have a long operation are at increased risk for return to the operating room. Increased awareness of these predictors will be helpful to counsel the patients before the operation.

From the Base of the Cecum to the Throne of England: King Edward VII's Appendix.

This historical retrospective explores the case of King Edward VII's appendicitis at the time of his planned coronation in 1902, as well as the contributions of the king's surgeons Frederick Treves and Joseph Lister, towards his medical care. The history of appendicitis, as well as a view of the king's medical management in the lens of modern surgical and sociopolitical contexts, is also examined.

"The Most Satisfactory Procedure in the Field of Pediatric Surgery": The History of Hypertrophic Pyloric Stenosis.

This historical retrospective explores the history of hypertrophic pyloric stenosis from its initial observations to the first surgical approaches to modern understandings of pathogenesis. The important work of Hirschsprung, Fredet, and Ramstedt remains a foundational part of management for this complex condition.

The Impact of Steroids and Inflammatory Bowel Disease in Colectomies in the Era of Enhanced Recovery.

INTRODUCTION: Enhanced recovery after surgery protocols are commonly used, but their utility in patients with inflammatory bowel disease and steroid use is poorly studied. We sought to examine influence of inflammatory bowel disease (IBD) and steroid use on hospital length of stay (LOS) and operative duration in patients undergoing colectomies in the era of ERAS. METHODS: We performed retrospective review of our institutional National Surgical Quality Improvement Program (NSQIP) registry (2016-2018) for colectomies. We performed 2 distinct analyses to examine influence of steroids and IBD on LOS and operative duration. Multivariable linear regression was used to predict outcomes after adjusting for relevant perioperative features. RESULTS: There were 366 patients in the cohort; 17.8% were on steroids and 16.4% had IBD. Patients using steroids had longer LOS (6 vs 4 days, P < .0001). IBD patients had a longer LOS (7 vs 5 days, P < .0001) and longer operative duration (383 min vs 335.5 minute, P = .01) compared to non-IBD patients. On multivariable analysis, steroid use was not associated with increased LOS or operative duration. Inflammatory bowel disease was associated with an increased hospital LOS and operative duration. DISCUSSION: Patients on steroids had longer LOS when compared to patients not on steroids. Inflammatory bowel disease regardless of steroid use was found to be a significant risk factor for both increased LOS and operative duration. A closer look at preoperative physiology may help to tailor ERAS protocols in patients with inflammatory conditions.

Extended postoperative venous thromboembolism prophylaxis after bariatric surgery: a comparison of existing risk-stratification tools and 5-year MBSAQIP analysis.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of 30-day mortality after metabolic and bariatric surgery (MBS). Multiple predictive tools exist for VTE risk assessment and extended VTE chemoprophylaxis determination. OBJECTIVE: To review existing risk-stratification tools and compare their predictive abilities. SETTING: MBSAQIP database. METHODS: Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed (2015-2019) for primary minimally invasive MBS cases. VTE clinical factors and risk-assessment tools were evaluated: body mass index threshold of 50 kg/m2, Caprini risk-assessment model, and 3 bariatric-specific tools: the Cleveland Clinic VTE risk tool, the Michigan Bariatric Surgery Collaborative tool, and BariClot. MBS patients were deemed high risk based on criteria from each tool and further assessed for sensitivity, specificity, and positive predictive value. RESULTS: Overall, 709,304 patients were identified with a .37% VTE rate. Bariatric-specific tools included multiple predictors: procedure, age, race, gender, operative time, length of stay, heart failure, and dyspnea at rest; operative time was the only variable common to all. The body mass index cutoff and Caprini risk-assessment model had higher sensitivity but lower specificity when compared with the Michigan Bariatric Surgery Collaborative and BariClot tools. While the sensitivity of the tools varied widely and was overall low, the Cleveland Clinic tool had the highest sensitivity. The bariatric-specific tools would have recommended extended prophylaxis for 1.1%-15.6% of patients. CONCLUSIONS: Existing MBS VTE risk-assessment tools differ widely for inclusion variables, high-risk definition, and predictive performance. Further research and registry inclusion of all significant risk factors are needed to determine the optimal risk-stratified approach for predicting VTE events and determining the need for extended prophylaxis.

Utilizing Simulation to Evaluate Robotic Skill Acquisition and Learning Decay.

BACKGROUND: We aim to evaluate how new robotic skills are acquired and retained by having participants train and retest using exercises on the robotic platform. We hypothesized that participants with a 3-month break from the robotic platform will have less learning decay and increased retention compared with those with a 6-month break. METHODS: This was a prospective randomized trial in which participants voluntarily enrolled and completed an initial training phase to reach proficiency in 9 robot simulator exercises. They were then instructed to refrain from practicing until they retested either 3 or 6 months later. This study was completed at an academic medical center within the general surgery department. Participants were medical students, and junior-level residents with minimal experience in robotic surgery were enrolled. A total of 27 enrolled, and 13 participants completed the study due to attrition. RESULTS: Overall, intragroup analysis revealed that participants performed better in their retest phase compared with their initial training in terms of attempts to reach proficiency, time for completion, penalty score, and overall score. Specifically, during the first attempt in the retesting phase, the 3-month group did not deviate far from their final attempt in the training phase, whereas the 6-month group experienced significantly worse time to complete and overall score in interrupted suturing {[-4 (-18 to 20) seconds vs. 109 (55 to 118) seconds, P =0.02] [-1.3 (-8 to 1.9) vs. -18.9 (-19.5 to (-15.0)], P =0.04} and 3-arm relay {[3 (-4 to 23) seconds vs. 43 (30 to 50) seconds, P =0.02] [0.4 (-4.6 to 3.1) vs. -24.8 (-30.6 to (-20.3)], P =0.01] exercises. In addition, the 6-month group had a significant increase in penalty score in retesting compared with the 3-month group, which performed similarly to their training phase [3.3 (2.7 to 3.3) vs. 0 (-0.8 to 1.7), P =0.03]. CONCLUSIONS: This study identified statistically significant differences in learning decay, skills retention, and proficiency between 3-month and 6-month retesting intervals on a robotic simulation platform.