Trends of core versus subspecialty operative procedures completed in general surgery residency training programs.

INTRODUCTION: General surgery residency involves performing subspecialty procedures in addition to the core general procedures. However, the proportion of core general surgery versus subspecialty procedures during training is variable and its temporal changes are unknown. The goal of our study was to assess the current trends in core general surgery and subspecialty procedure distributions during general surgery residency training. METHODS: Data were collected from the ACGME core general surgery national resident available report case logs from 2007 to 2019. Descriptive and time series analyses were used to compare proportions of average procedures performed per resident in the core general surgery category versus the subspecialty category. F-tests were conducted to show whether the slopes of the trend lines were significantly non-zero. RESULTS: The mean of total procedures completed for major credit by the average general surgery resident increased from 910.1 (SD=30.31) in 2007 to 1070.5 (SD=37.59) in 2019. Over that same period, the number of general, cardiothoracic, plastic and urology surgery procedures increased by 24.9%, 9.8%, 76.6% and 19.3%, respectively. Conversely, vascular and paediatric surgery procedures decreased by 7.6% and 30.7%, respectively. The neurological surgery procedures remain stable at 1.1 procedures per resident per year. A significant positive correlation in the trend reflecting total (p<0.0001), general (p<0.0001) and plastic (p<0.0016) surgery procedures and the negative correlation in the trend lines for vascular (p<0.0006) and paediatric (p<0.0001) surgery procedures were also noted. CONCLUSIONS: Trends in overall surgical case volume performed by general surgery residents over the last 12 years have shown a steady increase in operative training opportunity despite the increasing number of subspecialty training programmes and fellowships. Further research to identify areas for improvement and to study the diversity of operative procedures, and their outcomes is warranted in the years to come.

A systematic review of the outcomes of percutaneous treatment modalities for pathologic saphenous and perforating veins.

OBJECTIVE: Minimally invasive techniques have been increasingly used to treat pathologic perforator veins (PVs). The goal of the present study was to summarize the current literature and determine the outcomes of treating PVs with or without the great saphenous vein/small saphenous vein using endovenous laser ablation (EVLA), radiofrequency ablation (RFA), and ultrasound-guided sclerotherapy (USGS). METHODS: A systematic review of the literature on the percutaneous treatment of PVs (35 studies) was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. Studies reported up to March 2020 were included. The incidence of several end points at different follow-up periods were calculated according to the availability of data within 3 to 12 months after the index procedure. RESULTS: Of the 35 studies, 15 (n = 1677) had reported on EVLA with or without sclerotherapy and/or microphlebectomy, 12 (n = 1477) had investigated the outcomes of RFA ablation with/without sclerotherapy, and 8 (n = 331) had investigated USGS alone. All techniques were safe in terms of periprocedural adverse events, with only a few complications occurring in each group. Immediate procedural success (within 30 days) was 95% in the EVLA group, 91% in the RFS group, and 58% to 70% in the USGS group. At 12 months of follow-up, the occlusion rates were 89%, 77%, and 83% in the EVLA, RFA, and USGS groups, respectively. The 12-month pooled estimate of ulcer healing between the EVLA and RFA groups was similar, although no direct comparisons were performed. CONCLUSIONS: Treatment of PVs with percutaneous techniques, such as EVLA, RFA, and USGS, is safe and associated with high technical success. EVLA and RFA exhibited the most favorable outcomes. Additional research is needed to validate these results, which were based on the limited level of evidence available to better determine the most optimal treatment approach for lower limb pathologic PVs.

Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery.

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

Endovascular abdominal aortic aneurysm repair: part I.

Endovascular repair of infrarenal abdominal aortic aneurysms has become a well-established and safe treatment modality. Since its development in 1991 by Juan Parodi, an increasing number of procedures have been performed worldwide. The advantages of an endovascular approach include decreased blood loss, length of hospitalization, and early morbidity and mortality. Endovascular therapy is particularly well-suited for the elderly, higher-risk patient and for those with prior aortic operations. This review summarizes the world's literature to date regarding endovascular aortic aneurysm repair in table form and should serve as a practical and prompt literature search tool.

Filter placement for duplicated cava.

Anatomic variations of the inferior vena cava (IVC) are found in 3-5% of the population. IVC duplication is a well-known anatomic variation that is important when relevant procedures are being planed. Therefore, the identification of IVC anomalies should be checked prior to pertinent interventions. We report two cases of dual IVC filter placement for duplicated cava including a missing left inferior vena cava and subsequent pulmonary embolism. The rationale of one versus two filters and the current literature are discussed.