Evaluation of a passive arm-support exoskeleton for surgical team members: Results from live surgeries.

BACKGROUND: Musculoskeletal symptoms and injuries adversely impact the health of surgical team members and their performance in the operating room (OR). Though ergonomic risks in surgery are well-recognized, mitigating these risks is especially difficult. In this study, we aimed to assess the impacts of an exoskeleton when used by OR team members during live surgeries. METHODS: A commercial passive arm-support exoskeleton was used. One surgical nurse, one attending surgeon, and five surgical trainees participated. Twenty-seven surgeries were completed, 12 with and 15 without the exoskeleton. Upper-body postures and muscle activation levels were measured during the surgeries using inertial measurement units and electromyography sensors, respectively. Postures, muscle activation levels, and self-report metrics were compared between the baseline and exoskeleton conditions using non-parametric tests. RESULTS: Using the exoskeleton significantly decreased the percentage of time in demanding postures (>45° shoulder elevation) for the right shoulder by 7% and decreased peak muscle activation of the left trapezius, right deltoid, and right lumbar erector spinae muscles, by 7%, 8%, and 12%, respectively. No differences were found in perceived effort, and overall scores on usability ranged from "OK" to "excellent." CONCLUSIONS: Arm-support exoskeletons have the potential to assist OR team members in reducing musculoskeletal pain and fatigue indicators. To further increase usability in the OR, however, better methods are needed to identify the surgical tasks for which an exoskeleton is effective.

Using ACGME General Surgery Milestones to Define the Competent Foundational Surgical Resident.

OBJECTIVE: In transitioning to competency-based surgical training, the need to clearly define competency is paramount. The purpose of this study is to define the well-prepared foundational resident using the ACGME General Surgery Milestones as our conceptual framework. DESIGN: Participants reflected on their expectations of a well-prepared resident at the end of PGY1, then assigned milestone levels reflecting this level of competence for General Surgery Milestones 1.0 and 2.0. Subcompetency scores were averaged among residents and faculty. The level of the well-prepared foundational resident was determined based on the highest level within one standard deviation of faculty, resident, and total group averages. SETTING: This took place during a dedicated education retreat at a single, large academic general surgery residency program. PARTICIPANTS: Key faculty stakeholders and a representative sample of residents (PGY 1-5) within our institution participated. RESULTS: Eight faculty and five residents completed Milestones 1.0 and 2.0 scoring. Mean scores between faculty and residents were compared. For 1.0, mean scores for Practice-Based Learning and Improvement 3 (PBLI 3) and Interpersonal Communication Skills 3 (ICS 3) were discernably lower for residents than for faculty (PBLI 3 1.3 (0.3) v 0.9 (0.2), p = 0.01; ICS3 1.6 (0.6) v 1.1 (1), p = 0.01). Scores of 2.0 were comparable across all subcompetency domains. With this broad agreement, Milestone-based competency standards were determined. Descriptive narratives of the KSAs were created for each subcompetency, combining the determined Milestones 1.0 and 2.0 levels. CONCLUSIONS: We were able to clearly define the competent foundational resident using the ACGME Milestones as a conceptual framework. These Milestone levels reflect the culture and expectations in our department, providing a foundation upon which to build a program of assessment. This methodology can be readily replicated in other programs to reflect specific expectations of the program within the larger ACGME frameworks of competency.

Eye tracking and audio sensors to evaluate surgeon's non-technical skills: An empirical study.

Non-Technical Skills (NTS) of medical teams are currently measured using subjective and resource-intensive ratings given by experts. This study explores if objective NTS assessment approaches with eye-tracking and audio sensors can measure teamwork and communication skills in surgery. Eight surgeons participated in a simulated two-phase surgical scenario developed to assess their NTS. Sensor-based audio, eye tracking and video data were collected and analyzed along with rating from the NOTSS scale. Different levels of communication were detected by the sensor data during the two phases of the simulated surgery. Sensor data detected leadership qualities among surgeons based on speech metrics, and eye tracking offered additional evidence about gaze patterns related to NTS. This objective approach to NTS measurement captured differences in communication in greater detail as opposed to a single collective rating obtained using current assessment tools.

The Blue Ribbon Committee II Report and Recommendations on Surgical Education and Training in the United States: 2024.

OBJECTIVE: An expert panel made recommendations to optimize surgical education and training based on the effects of contemporary challenges. BACKGROUND: The inaugural Blue Ribbon Committee (BRC I) proposed sweeping recommendations for surgical education and training in 2004. In light of those findings, a second BRC (BRC II) was convened to make recommendations to optimize surgical training considering the current landscape in medical education. METHODS: BRC II was a panel of 67 experts selected on the basis of experience and leadership in surgical education and training. It was organized into subcommittees which met virtually over the course of a year. They developed recommendations, along with the Steering Committee, based on areas of focus and then presented them to the entire BRC II. The Delphi Method was chosen to obtain consensus, defined as>80% agreement amongst the panel. Cronbach alpha was computed to assess the internal consistency of three Delphi rounds. RESULTS: Of 50 recommendations, 31 obtained consensus in the following aspects of surgical training (# consensus recommendation /# proposed): Workforce (1/5), Medical Student Education (3/8), Work Life Integration (4/6), Resident Education (5/7), Goals, Structure and Financing of Training (5/8), Education Support and Faculty Development (5/6), Research Training (7/9), and Educational Technology and Assessment (1/1). The internal consistency was good in Rounds 1 and 2 and acceptable in Round 3. CONCLUSIONS: BRC II used the Delphi approach to identify and recommend 31 priorities for surgical education in 2024. We advise establishing a multidisciplinary surgical educational group to oversee, monitor and facilitate implementation of these recommendations.

Evaluation of operating room inefficiencies and their impact on operating room duration using a surgical app.

BACKGROUND: Efficient utilization of the operating room (OR) is essential. Inefficiencies are thought to cause preventable delays. Our goal was to identify OR incidents causing delays and estimate their impact on the duration of various general surgery procedures. MATERIALS: Three trained observers prospectively collected intraoperative data using the ExplORer Surgical app, a tool that helped capture incidents causing delays. The impact of each incident on case duration was assessed using multivariable analysis. RESULTS: 151 general surgery procedures were observed. The mean number of incidents was 2.7 per each case that averaged 109min. On average, each incident caused a 2.8 â€‹min delay (p â€‹< â€‹0.001), however, some incidents were associated with longer delays. The procedural step of each procedure most susceptible to incidents was also defined. CONCLUSION: The identification of the type of incidents and the procedural step during which they occur may allow targeted interventions to optimize OR efficiency and decrease operative time.

Patients' perspectives on weight recurrence after bariatric surgery: a single-center survey.

BACKGROUND: Weight recurrence (WR) affects nearly 20% of patients after bariatric surgery and may decrease its benefits, affecting patients' quality of life negatively. Patient perspectives on WR are not well known. OBJECTIVES: Assess patient needs, goals, and preferences regarding WR treatment. SETTING: Single MBSAQIP-accredited academic center, and online recruitment. METHODS: An 18-item, web-based survey was distributed to adults seeking treatment for WR after a primary bariatric surgery (PBS), in addition to online recruitment, between 2021 and 2023. Survey items included somatometric data, questions about the importance of factors for successful weight loss, procedure decision-making, and treatment expectations. RESULTS: Fifty-six patients with > 10% increase from their nadir weight were included in the study. Patients had initially undergone Roux-en-Y gastric bypass (62.5%), sleeve gastrectomy (28.6%), adjustable gastric banding (3.6%), or other procedures (5.3%). When assessing their satisfaction with PBS, 57.1% were somewhat/extremely satisfied, 33.9% somewhat/extremely dissatisfied, while 8.9% were ambivalent. Patients considered the expected benefits (for example, weight loss) as the most important factor when choosing a treatment option for WR. Patient goals included "feeling good about myself" (96.4% very/extremely important), "being able to resume activities I could not do before" (91% very/extremely important), and "improved quality of life" and "-life expectancy" (> 90% very/extremely important). Finally, RBS, lifestyle modification with peer support, and anti-obesity medication were ranked as first treatment options for WR by 40%, 38.8%, and 29.8% of the respondents, respectively. CONCLUSIONS: Patients considered weight loss as the most important factor when choosing treatment modality for WR, with RBS and lifestyle changes being preferred over weight-loss medications. Large prospective randomized trials are needed to counsel this patient population better.

Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Practical Guide to Common Flaws With Surgical Education Research.

This Guide to Statistics and Methods provides an overview of common flaws with surgical education research, including how to recognize and avoid them.

Outcome comparison between primary and revisional bariatric surgery: A propensity-matched analysis.

BACKGROUND: Revisional bariatric procedures for weight recurrence are rising but are considered higher risk and less effective than primary bariatric procedures. This study aimed to compare clinical outcomes between primary and revisional bariatric surgery for weight recurrence. METHODS: Prospectively collected data from adult patients who underwent revisional or primary bariatric surgery from 2016 to 2020 in an academic institution were reviewed. Roux-en-Y gastric bypass and sleeve gastrectomy were performed primarily or as conversion procedures after laparoscopic adjustable gastric band, vertical banded gastroplasty, and sleeve gastrectomy. 1:1 propensity score matching was performed between revisional bariatric surgery and primary bariatric surgery, and logistic regression analysis was used to compare up to 2-year weight loss and comorbidity resolution outcomes. RESULTS: A total of172 cases (86 revisional bariatric surgery versus 86 primary bariatric surgery) were included. Groups were matched for age, sex, preoperative body mass index, bariatric procedure, diabetes, hypertension, and obstructive sleep apnea. Procedure duration (203 ± 78 vs 154 ± 69 minutes; P < .001) and length of stay (2.3 ± 2.1 vs 1.7 ± 1 days; P = .02) were longer for revisional bariatric surgery versus primary bariatric surgery, respectively. Total weight loss was less in revisional bariatric surgery compared with primary bariatric surgery at 1 year (23 ± 10% vs 32 ± 9%; P < .001) and 2 years (21 ± 12.% vs 32 ± 10%; P < .001) of follow-up; however, no differences were detected in postoperative occurrences, emergency department visits, readmissions, reintervention and reoperation rates, and comorbidity resolution. CONCLUSION: Although revisional bariatric surgery was associated with longer operation times, prolonged hospitalization, and lower weight loss than primary bariatric surgery, it was accomplished safely and led to substantial weight loss and comorbidity resolution. This information can guide patient counseling before revisional surgery for weight recurrence.

SAGES peritoneal dialysis access guideline update 2023.

BACKGROUND: Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed. RESULTS: After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction. CONCLUSIONS: In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion.

Does the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program bariatric risk/benefit calculator hold its weight? An assessment of its accuracy.

BACKGROUND: Bariatric clinical calculators have already been implemented in clinical practice to provide objective predictions of complications and outcomes. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Surgical Risk/Benefit Calculator is the most comprehensive risk calculator in bariatric surgery. OBJECTIVES: Evaluate the accuracy of the calculator predictions regarding the 30-day complication risk, 1-year weight loss outcomes, and comorbidity resolution. SETTING: MBSAQIP-accredited center. METHODS: All adult patients who underwent primary laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy at our institution between 2012 and 2019 were included. Baseline characteristics were used to generate the individualized outcome predictions for each patient through the bariatric risk calculator and were compared to actual patient outcomes. Statistical analysis was performed using c-statistics, linear regression models, and McNemmar chi-square test. RESULTS: One thousand four hundred fifty-three patients with a median age of 45 (37, 55) and consisting of 80.1% females were included in the study. The c-statistics for the complications and comorbidity resolution ranged from .533 for obstructive sleep apnea remission to .675 for 30-day reoperation. The number of comorbidity resolutions predicted by the calculator was significantly higher than the actual remissions for diabetes, hyperlipidemia, hypertension and obstructive sleep apnea (P < .001). On average, the calculator body mass index (BMI) predictions deviated from the observed BMI measurement by 3.24 kg/m2. The RYGB procedure (Coef -.89; P = .005) and preoperative BMI (Coef -.4; P = .012) were risk factors associated with larger absolute difference between the predicted and observed BMI. CONCLUSIONS: The MBSAQIP Surgical Risk/Benefit Calculator prediction models for 1-year BMI, 30-day reoperation, and reintervention risks were fairly well calibrated with an acceptable level of discrimination except for obstructive sleep apnea remission. The 1-year BMI estimations were less accurate for RYGB patients and cases with very high or low preoperative BMI measurements. Therefore, the bariatric risk calculator constitutes a helpful tool that has a place in preoperative counseling.

Augmenting mental imagery for robotic surgery using neurofeedback: results of a randomized controlled trial.

Background: Mental imagery (MI) can enhance surgical skills. Research has shown that through brain-computer interface (BCI), it is possible to provide feedback on MI strength. We hypothesized that adding BCI to MI training would enhance robotic skill acquisition compared with controls. Methods: Surgical novices were recruited. At baseline, participants completed the Mental Imagery Questionnaire (MIQ) and the Vandenburg Mental Rotation Test (MRT). Students also performed several tasks on a robotic simulator. Participants were stratified based on MIQ and robotic skill and randomized into three groups: controls, MI, and MI and BCI training. All participants completed five 2-h training sessions. One hour was devoted to practicing robotic skill on the simulator. Additionally, controls completed crosswords for one hour, the MI group completed MI training and crosswords for one hour, and the MI + BCI group completed MI training and MI-related BCI training. Following training, participants completed the same baseline assessments. A Kruskal-Wallis test was used to determine differences between groups. Mann-Whitney U tests were performed to determine specific differences between groups. Results: Twenty-seven undergraduates participated. There were post-test differences on the MRT and knot tying task. Sub-analyses revealed that the MI + BCI group significantly outperformed the other groups on knot tying. There were no appreciable differences between the control and MI groups on any measures. Conclusions: Augmenting MI training with BCI led to significantly enhanced MI and robotic skill acquisition than traditional MI or robotic training methods. To optimize surgical skill acquisition in robotic and other surgical skills curricula, educators should consider utilizing MI with BCI training.

Neuropsychological Differences Between Surgery Interns and Age-Matched Adults.

OBJECTIVE: The purpose of this study was to assess how neuropsychological factors differ between general surgery interns and normative data from age-matched adults in the general population. DESIGN: Participants completed a comprehensive neuropsychological assessment battery. Neuropsychological factors assessed included: executive function (Behavioral Rating Inventory of Executive Function, BRIEF), working memory (Wechsler Adult Intelligence Scale, or WAIS, digit span), psychomotor speed (WAIS coding, Trails A and B), selective attention (D2 Test of Attention), and problem solving (Tower of London, TOL). Data for all measures was compared to previously published normative data for age-matched, healthy adults in the general population using one-sample t-tests. SETTING: This study was completed at Indiana University School of Medicine in Indianapolis, IN, which is a large academic healthcare training institution. PARTICIPANTS: Postgraduate year 1 general surgery residents (PGY1s) voluntarily participated in this study. RESULTS: Twenty-six general surgery PGY1s completed all measures. We found that PGY1s had significantly better behavioral inhibition, working memory, selective attention, problem solving, and psychomotor speed than their counterparts in the general population (Table 1). Conversely, we found that PGY1s had significantly lower cognitive flexibility (p = 0.02) and ability to monitor task progress (p = 0.006) than the general population. CONCLUSIONS: The results from this study indicate that there are several neuropsychological factors that may help explain the high achievement of general surgery PGY1s. Assessment of these factors could aid general surgery programs in the selection and training of high-caliber residents. However, there are indicators that PGY1s struggle from cognitive inflexibility and task monitoring compared to the general population. These skills are needed to manage the complex and dynamic nature of surgical performance, so educators should consider methods to enhance junior residents' development of these characteristics.

What is the ideal timing of cholecystectomy after percutaneous cholecystostomy for acute cholecystitis?

BACKGROUND: Acute cholecystitis (AC) is one of the most prevalent diseases in clinical practice. Poor surgical candidates may benefit from early percutaneous cholecystostomy (PC) drainage followed by interval cholecystectomy (IC), which is the definitive treatment. The optimal timing between the PC drainage and the IC has not been identified. This study aimed to investigate how the duration between PC and IC affects perioperative outcomes and identify the optimal IC timing to minimize complications. METHODS: This retrospective cohort study included all adult patients diagnosed with AC who underwent PC followed by IC at a single institution center between 2014 and 2022. Patients with a history of hepatobiliary surgery, stones in the common bile duct, cirrhosis, active malignancy, or prolonged immunosuppression were excluded. The analysis did not include cases with major concurrent procedures during cholecystectomy, previously aborted cholecystectomies, or failure of the PC drain to control the inflammation. Linear and logistic regression models were used to analyze the impact of the interval between PC and IC on intra- and perioperative outcomes. RESULTS: One hundred thirty-two patients (62.1% male) with a mean age of 64.4 ± 15 (mean ± SD) years were diagnosed with AC (25% mild, 47.7% moderate, 27.3% severe). All patients underwent PC followed by IC after a median of 64 [48-91] days. Longer ICU stay was associated with longer time intervals between PC and IC (Coef 105.98, p < 0.001). No significant variations were detected in the intraoperative and perioperative outcomes between patients undergoing IC within versus after 8 weeks from PC placement. However, a higher percentage of patients with delayed IC (after 8 weeks) were discharged home (96.4% vs. 83.7%; p = 0.019). CONCLUSIONS: Patients may benefit from undergoing IC after the 8-week cutoff after PC. However, very long periods between PC and IC procedures may increase the risk of longer ICU stay.

Resolution and recurrence of anemia following repair of paraesophageal hernias.

BACKGROUND: Iron deficiency anemia is a common paraesophageal hernia (PEH) symptom and may improve after repair. When present, anemia has also been proposed to be associated with an increase in length of hospital stay, morbidity, and mortality after PEH repair. This study aimed to determine anemia-related factors in patients with PEH, the rate of anemia resolution after PEH repair, and the risk of anemia recurrence when repair failed. METHODS: We included patients who received a PEH repair between June 2019 and June 2020 and had 24 months of postoperative follow-up. Demographics and comorbidities were recorded. Anemia was defined as pre-operative hemoglobin values < 12.0 for females and < 13.0 for males, or if patients were receiving iron supplementation. Anemia resolution was determined at 6 months post-op. Length of hospital stay, morbidity, and mortality was recorded. Logistic regression and ANCOVA were used for binary and continuous outcomes respectively. RESULTS: Of 394 patients who underwent PEH repair during the study period, 101 (25.6%) had anemia before surgery. Patients with pre-operative anemia had larger hernia sizes (6.55 cm ± 2.77 vs. 4.34 cm ± 2.50; p < 0.001). Of 68 patients with available data by 6 months after surgery, anemia resolved in 36 (52.9%). Hernia recurred in 6 patients (16.7%), 4 of whom also had anemia recurrence (66.7%). Preoperative anemia was associated with a higher length of hospital stay (3.31 days ± 0.54 vs 2.33 days ± 0.19 p = 0.046) and an increased risk of post-operative all-cause mortality (OR 2.7 CI 1.08-6.57 p = 0.05). Fundoplication type (p = 0.166), gastropexy, or mesh was not associated with an increased likelihood of resolution (OR 0.855 CI 0.326-2.243; p = 0.05) (OR 0.440 CI 0.150-1.287; p = 0.05). CONCLUSIONS: Anemia occurs in 1 out of 4 patients with PEH and is more frequent in patients with larger hernias. Anemia is associated with a longer hospital stay and all-cause mortality after surgery. Anemia recurrence coincided with hernia recurrence in roughly two-thirds of patients.

Relationship between stress and resident non-technical skills during interdisciplinary trauma simulations.

BACKGROUND: Non-technical skills, such as communication and situation awareness, are vital for patient care and effective surgical team performance. Previous research has found that residents' perceived stress is associated with poorer non-technical skills; however, few studies have investigated the relationship between objectively assessed stress and non-technical skills. Accordingly, the purpose of this study was to assess the relationship between objectively assessed stress and non-technical skills. METHODS: Emergency medicine and surgery residents voluntarily participated in this study. Residents were randomly assigned to trauma teams to manage critically ill patients. Acute stress was assessed objectively using a chest-strap heart rate monitor, which measured average heart rate and heart rate variability. Participants also evaluated perceived stress and workload using the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index. Non-technical skills were assessed by faculty raters using the non-technical skills scale for trauma. Pearson's correlation coefficients were used to examine relationships between all variables. RESULTS: Forty-one residents participated in our study. Heart rate variability (where higher values reflect lower stress) was positively correlated with residents' non-technical skills overall and leadership, communication, and decision-making. Average heart rate was negatively correlated with residents' communication. CONCLUSION: Higher objectively assessed stress was associated with poorer non-technical skills in general and nearly all non-technical skills domains of the T-NOTECHS. Clearly, stress has a deleterious effect on residents' non-technical skills during trauma situations, and given the importance of non-technical skills in surgical care, educators should consider implementing mental skills training to reduce residents' stress and optimize non-technical skills during trauma situations.

A sensor-based framework for layout and workflow assessment in operating rooms.

Due to their large sizes and impediments to personnel workflows, integrating robotic technologies into the existing operating rooms (OR) is a challenge. In this study, we developed an ultra-wideband sensor-based human-machine-environment framework for layout and workflow assessments within the OR. In addition to providing best practices for use of the framework, we also demonstrated its effectiveness in understanding layout and workflow inefficiencies in 12 robotic-assisted surgeries (RAS) across 4 different surgical specialties. We found avoidable movements as the circulating nurse covers at least twice the distance of any other OR personnel before the patient cart (robot) is docked. OR areas of congestion and undesirable personnel-pair proximities across RAS phases that impose extra non-technical skill challenges were determined. Our findings highlight several implications for the added complexity of integrating robotic technologies into the OR, which can serve as drivers for objective evidence-based recommendations to combat RAS OR layout and workflow inefficiencies.

The degree of satisfaction and level of learning in male and female surgical residents: a nationwide questionnaire survey of graduating residents in Japan.

PURPOSE: Since 2002, the Japan Surgical Society has established a board certification system for surgeons to be certified for a specialty. Surgery remains a male-dominated field in Japan. This study aimed to clarify if the Japanese surgical residency training system is equally suitable for female and male residents. METHODS: The Japan Surgical Society conducted the first questionnaire survey regarding the system of surgical training for the residents in 2016. The questionnaire included the degree of satisfaction with 7 aspects of the training system, including the number and variety of cases experienced and duration and quality of instruction, and the learning level for 31 procedures. The degree of satisfaction and level of learning were compared between female and male residents. RESULTS: The degree of satisfaction was similar for all items between female and male residents. Female residents chose breast surgery as their subspecialty more frequently than male residents and were more confident in breast surgery procedures than male residents. Conversely, fewer female residents chose gastrointestinal surgery and were less confident in gastrointestinal surgery procedures than male residents. CONCLUSION: Female residents were as satisfied with the current surgical training system as male residents. However, there may be room for improvement in the surgical system, considering that fewer applications for gastrointestinal surgery come from female residents than from males.

Bariatric Surgeon Perspective on Revisional Bariatric Surgery (RBS) for Weight Recurrence.

BACKGROUND: Weight recurrence (WR) after bariatric surgery occurs in nearly 20% of patients. Revisional bariatric surgery (RBS) may benefit this population but remains controversial among surgeons. OBJECTIVES: Explore surgeon perspectives and practices for patients with WR after primary bariatric surgery (PBS). SETTING: Web-based survey of bariatric surgeons. METHODS: A 21-item survey was piloted and posted on social media closed groups (Facebook) utilized by bariatric surgeons. Survey items included demographic information, questions pertaining to the definition of suboptimal and satisfactory response to bariatric surgery, and general questions related to different WR management options. RESULTS: One hundred ten surgeons from 19 countries responded to the survey. Ninety-eight percent responded that WR was multifactorial, including behavioral and biological factors. Failure of PBS was defined as excess weight loss < 50% by 31.4%, as excess weight loss <25% by 12.8%, and as comorbidity recurrence by 17.4%. Surgeon responses differed significantly by gender (P = .036). 29.4% believed RBS was not successful, while 14.1% were unsure. Nevertheless, 73% reported that they would perform RBS if sufficient evidence of benefit existed. Most frequently performed revisional procedures included conversion of sleeve gastrectomy to Roux-en-Y gastric bypass (RYGB), adjustable gastric band to RYGB, and RYGB revision (21.9% versus 18.2% versus 15.3%, respectively). CONCLUSIONS: This survey demonstrates significant variability in surgeon perception regarding causes and the effectiveness of RBS. Moreover, they disagree on what constitutes a nonsatisfactory response to PBS and to whom they offer RBS. These findings may relate to limited available clinical evidence on best management options for this patient population. Clinical trials investigating the comparative effectiveness of various treatment options are needed.