Leaning in and moving forward: a call to action and review of diversity initiatives in SAGES.

BACKGROUND: Diversity, equity, and inclusion have been an intentional focus for SAGES well before the COVID-19 pandemic and the coincident societal recognition of social injustices and racism. Longstanding inequities within our society, healthcare, and the surgery profession have come to light in the aftermath of events that rose to attention around the time of Covid. In so doing, they have brought into focus disparities, injustices, and inequalities that have long been present in the field of surgery, selectively affecting the most vulnerable. METHODS: This White paper examines the current state of diversity within the field of surgery and SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) approach and effort to pave the way forward to meaningful change. We delineate the imperative for diversity, equity, and inclusion for all. By all, we mean to be inclusive of the diversity of gender and sexual orientation, race, ethnicity, geography, sex, and disability in the field of surgery. RESULTS: SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric. CONCLUSION: True diversity, equity, and inclusion within a surgical organization is vital for its longevity, growth, relevance, and impact. Unfortunately, the absence of DEI limits opportunity, robs the organization of collective intelligence in an environment in which its presence is critical, contributes to health inequities, and impoverishes all within the society and its value to all with whom it interfaces. SAGES is an organization that lives at the intersection of education and innovation. It has a vital role in assisting the surgical profession in addressing these issues and needs and being a force alongside others for sustained and necessary change. SAGES can only realize these goals through a commitment across all aspects of the organization to embed diversity, equity, and inclusion into our very fabric. Strategies like those highlighted in this White Paper, may be within our grasp and we can learn yet more if we remain in a place of humility and teachability in the future.

Educational implications for surgical telementoring: a current review with recommendations for future practice, policy, and research.

BACKGROUND: Surgical telementoring (ST) was introduced in the sixties, promoting videoconferencing to enhance surgical education across large distances. Widespread use of ST in the surgical community is lacking. Despite numerous surveys assessing ST, there remains a lack of high-level scientific evidence demonstrating its impact on mentorship and surgical education. Despite this, there is an ongoing paradigm shift involving remote presence technologies and their application to skill development and technique dissemination in the international surgical community. Factors facilitating this include improved access to ST technology, including ease of use and data transmission, and affordability. Several international research initiatives have commenced to strengthen the scientific foundation documenting the impact of ST in surgical education and performance. METHODS: International experts on ST were invited to the SAGES Project Six Summit in August 2015. Two experts in surgical education prepared relevant questions for discussion and organized the meeting (JP and HH). The questions were open-ended, and the discussion continued until no new item appeared. The transcripts of interviews were recorded by a secretary from SAGES. RESULTS: In this paper, we present a summary of the work performed by the SAGES Project 6 Education Working Group. We summarize the existing evidence regarding education in ST, identify and detail conceptual educational frameworks that may be used during ST, and present a structured framework for an educational curriculum in ST. CONCLUSIONS: The educational impact and optimal curricular organization of ST programs are largely unexplored. We outline the critical components of a structured ST curriculum, including prerequisites, teaching modalities, and key curricular components. We also detail research strategies critical to its continued evolution as an educational tool, including randomized controlled trials, establishment of a quality registry, qualitative research, learning analytics, and development of a standardized taxonomy.

A P300-based brain-computer interface for people with amyotrophic lateral sclerosis.

OBJECTIVE: The current study evaluates the efficacy of a P300-based brain-computer interface (BCI) communication device for individuals with advanced ALS. METHODS: Participants attended to one cell of a N x N matrix while the N rows and N columns flashed randomly. Each cell of the matrix contained one character. Every flash of an attended character served as a rare event in an oddball sequence and elicited a P300 response. Classification coefficients derived using a stepwise linear discriminant function were applied to the data after each set of flashes. The character receiving the highest discriminant score was presented as feedback. RESULTS: In Phase I, six participants used a 6 x 6 matrix on 12 separate days with a mean rate of 1.2 selections/min and mean online and offline accuracies of 62% and 82%, respectively. In Phase II, four participants used either a 6 x 6 or a 7 x 7 matrix to produce novel and spontaneous statements with a mean online rate of 2.1 selections/min and online accuracy of 79%. The amplitude and latency of the P300 remained stable over 40 weeks. CONCLUSIONS: Participants could communicate with the P300-based BCI and performance was stable over many months. SIGNIFICANCE: BCIs could provide an alternative communication and control technology in the daily lives of people severely disabled by ALS.

Surgical simulation: a current review.

BACKGROUND: Simulation tools offer the opportunity for the acquisition of surgical skill in the preclinical setting. Potential educational, safety, cost, and outcome benefits have brought increasing attention to this area in recent years. Utility in ongoing assessment and documentation of surgical skill, and in documenting proficiency and competency by standardized metrics, is another potential application of this technology. Significant work is yet to be done in validating simulation tools in the teaching of endoscopic, laparoscopic, and other surgical skills. Early data suggest face and construct validity, and the potential for clinical benefit, from simulation-based preclinical skills development. The purpose of this review is to highlight the status of simulation in surgical education, including available simulator options, and to briefly discuss the future impact of these modalities on surgical training.

Endoluminal and transluminal surgery: current status and future possibilities.

The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include "incisionless," "endoluminal," "transluminal," and "natural orifice" transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.

Patients with ALS can use sensorimotor rhythms to operate a brain-computer interface.

People with severe motor disabilities can maintain an acceptable quality of life if they can communicate. Brain-computer interfaces (BCIs), which do not depend on muscle control, can provide communication. Four people severely disabled by ALS learned to operate a BCI with EEG rhythms recorded over sensorimotor cortex. These results suggest that a sensorimotor rhythm-based BCI could help maintain quality of life for people with ALS.

Prophylactic total gastrectomy for familial gastric cancer.

BACKGROUND: An autosomal dominant syndrome of diffuse gastric cancer has been reported with germline mutations in the E-cadherin (CDH1) gene and has been identified in approximately 14 families and 50 individuals worldwide. Penetrance of the gene is 70% to 80%, and the average age of onset of gastric cancer is 37 years. These characteristics have led to the consideration of prophylactic total gastrectomy in family members with CDH1 mutations. METHODS: We report here the first use of prophylactic gastrectomy in 6 asymptomatic members of 2 families (2 males, 4 females; ages 22, 27, 28, 35, 39, and 40) based on family pedigree and genetic analysis. Total gastrectomy was performed via an upper midline incision, and reconstruction of the gastrointestinal tract was done via a Roux-en-Y esophagojejunostomy. Complete removal of all gastric mucosa was documented intraoperatively, and confirmation was made that only esophageal mucosa remained at the proximal specimen margin. RESULTS: The gastric specimens appeared normal, and the results of routine pathologic examination were negative for cancer. All specimens from patients who tested positive for E-cadherin mutations were subjected to a research protocol of microscopic sectioning in which 150 to 250 tissue blocks were examined. All of these patients had microscopic foci of cancer, often at multiple sites, with overlying normal gastric mucosa. CONCLUSIONS: E-cadherin gene mutations in association with familial gastric cancer is a new disease for which prophylactic surgery must be considered. The morbidity of this operation is much higher than that for other genetic diseases, but the alternative is a mortality risk of more than 80% at a young age.

Resident and faculty perceptions of a surgical residency program merger.

To evaluate resident and faculty perceptions of a residency merger process.Survey of faculty and residents of a recently merged general surgical residency. Nineteen separate program characteristics were evaluated via a numerical scoring system, and additional written commentary regarding dominant perceived benefits and detriments of the merger was solicited. Statistical significance was evaluated on numerically scored items by applying the Mann-Whitney U test to median values expressed with interquartile ranges, comparing resident and faculty responses.Scoring system responses from faculty and residents were generally similar. The merger was seen as neutral to positive in its impact on academic issues, but it had more negative effects on issues related to overall program atmosphere and morale. Statistically significant differences between resident and faculty responses were noted in 2 areas: teaching conference timing and overall program effectiveness in preparing for practice. Both of these areas were more favorably impacted by the merger from the residents' perspective, and more negatively as judged by the faculty (p < 0.05). Written commentary by both groups similarly emphasized areas of academic strengthening as a positive effect of the merger, and relationship and morale issues as being more negatively impacted.As reflected by resident and faculty perceptions, program mergers may provide opportunities to strengthen and enhance the academic and clinical foundation of residency. This may, however, occur at the expense of morale and relational issues, which may be negatively impacted by program administrative and geographic expansion.

Urachal-sigmoid fistula in an adult male.

Urachal cysts are unusual anomalies resulting from incomplete closure of the urachus. They comprise 38 per cent of urachal abnormalities. They present commonly in childhood, and there are only 20 reported cases of urachal cysts presenting in a person over the age of 40. Only one reported case appears of urachal-colonic fistula, and this was in the setting of colonic diverticulitis. This report presents the second reported case of urachal-colonic fistula and the first case of a fistula in a patient with a normal colon. The pathophysiology and management of urachal cyst are discussed.

Endoscopic retrograde cholangiopancreatography in a general surgery training program.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most complex procedures performed by endoscopists. ERCP has been performed primarily by gastroenterologists. There have been no reports in the literature regarding ERCP training within the framework of a general surgery residency program. The purpose of this study was to review ERCPs performed by surgical attendings and resident staff during a 6-year period and compare the success and complication rates with those found in published gastroenterological series. There were a total of 193 ERCPs performed on 171 patients for a success rate of 82.4 per cent and a complication rate of 6.7 per cent. A resident was the primary endoscopist in 51 procedures, with 42 (82.4%) successes and 2 complications (3.9%). There were no significant differences noted between our series and national complication rates, and between attending and resident procedures (P < 0.05, Chi-square analysis). This study has shown that surgical endoscopists can perform ERCP with success rates over 80 per cent, the currently regarded standard of expertise. The complication rates for these ERCPs were lower than accepted complication rates cited in current gastroenterological series. The results of this study support the hypothesis that ERCPs can be performed safely in a surgical residency.

Endoscopic evaluation of the postoperative stomach.

The endoscopic assessment of the postoperative stomach is one of the most challenging areas in endoscopy. This is a function of the plurality of disease entities and anatomic variations with which the endoscopist must be familiar in order to interpret the findings in this setting. At the same time, the diagnostic and therapeutic use of endoscopy in the postoperative environment is magnified because of the opportunity it provides to achieve information and relieve disability in situations of inherently significant morbidity. With the continuing maturation of endoscopic techniques, it is likely that the endoscopist of the future will have an increasingly significant role in the pre- and postoperative assessment and treatment of the patient with foregut pathology.

Progressive intracranial aneurysmal disease in a child with progressive hemifacial atrophy (Parry-Romberg disease): case report.

Intracranial aneurysms are uncommon in children, and their presence often leads to suspicion of a systemic connective tissue disorder. We describe the case of a young male patient with progressive hemifacial atrophy (Parry-Romberg disease) and multiple intracranial aneurysms, a previously undescribed association, and propose that a neural crest defect may be the underlying abnormality in this patient. At age 5 years, the patient was treated for a giant aneurysm of the left cavernous carotid artery with carotid ligation in the neck and a superficial temporal artery-middle cerebral artery bypass. At age 12 years, the patient was similarly treated for a giant aneurysm of the right cavernous carotid artery, which had progressed from a previously noted minute dilatation at age 5 years, with carotid ligation and a superficial temporal artery-middle cerebral artery bypass. At age 21 years, the patient was endovascularly treated for a de novo saccular aneurysm of the left posterior cerebral artery at the P1-P2 junction and a fusiform aneurysm of the distal left posterior cerebral artery. Various studies have suggested that the facial dermis, the subcutaneous tissues, and the skeleton, as well as the tunica media of the cervicocephalic arteries, all arise from neural crest cells, and a disorder of neural crest migration might explain the constellation of findings in this patient.

Cost-effectiveness of laparoscopic cholecystectomy.

This study retrospectively evaluated the cost-effectiveness of laparoscopic cholecystectomy compared to open cholecystectomy in a single university-affiliated community hospital. The medical records of all patients that underwent laparoscopic cholecystectomy during 1990 and open cholecystectomy during 1989 in one hospital were reviewed. Hospital stay, hospital charges, surgeons' and anesthesiologists' fees were determined. Fifty patients from each group were contacted to determine recovery time to full activity after surgery. Those having common duct exploration and those converted to open cholecystectomy after an attempted laparoscopic cholecystectomy (n = 8) were excluded. A summary of results is included below (Table 1). In our early experience with laparoscopic cholecystectomy we found that the total charges for laparoscopic cholecystectomy were more than for open cholecystectomy when one recognizes the 1-year difference in patient accrual between the two groups. Time to full recovery was markedly reduced in patients undergoing laparoscopic cholecystectomy compared to those having an open procedure. Despite the overall increased total charge with laparoscopic cholecystectomy, the shorter recovery period allowing the patients an earlier return to full preoperative activities contributes to its cost-effectiveness when compared to open cholecystectomy. Further experience with laparoscopic cholecystectomy and refinements in management of these patients should allow for further reductions in charges for this procedure.

Delayed gallstone abscess following laparoscopic cholecystectomy.

Delayed infectious complications following elective laparoscopic cholecystectomy have not been well delineated in the medical literature. Irretrievable spillage of gallbladder contents at the time of laparoscopic cholecystectomy is not rare, and has generally been felt to be of little consequence, particularly in the nonacute setting. The case presented documents an instance of delayed gallstone abscess formation after elective laparoscopic cholecystectomy. While rare, such cases highlight the need for refined techniques to prevent gallbladder, perforation during this procedure and to allow laparoscopic recovery of small gallstones spilled at the time of cholecystectomy.

Moyamoya disease: the disorder and surgical treatment.

OBJECTIVE: To discuss the clinical features of moyamoya disease, the studies that aid in diagnosing this disorder, and the reported outcomes of surgical treatment. DESIGN: We review the manifestations of moyamoya disease in children and adults and the recent reports of the various surgical procedures. MATERIAL AND METHODS: Moyamoya disease is a chronic cerebrovascular disorder in which stenosis of the major arteries of the circle of Willis at the base of the skull progresses to occlusion. The diagnosis is based on the angiographic findings of the "puff of smoke" appearance of the abnormal capillary vessels at the base of the skull. Three surgical procedures are used to manage this disease: anastomosis of the superficial temporal artery to the middle cerebral artery, encephalomyosynangiosis, and encephaloduro-arteriosynangiosis. RESULTS: In children with this disease, cerebral ischemic events, including strokes, occur. In adults, the fragile abnormal vessels can rupture and cause intracerebral hemorrhage. The mortality rate for adults is higher than that for children. Most published reports support the efficacy of surgical treatment in children but not in adults. CONCLUSIONS: The natural history of moyamoya disease is poor; neurologic deterioration due to strokes and hemorrhage is progressive. Seizures and intellectual deterioration can occur.