The Elephant in the Room: Racial Microaggressions and Implicit Bias in Surgical Training.

OBJECTIVE: The aim of this study was to examine the association between race, experience of microaggressions, and implicit bias in surgical training. BACKGROUND: There is persistent underrepresentation of specific racial and ethnic groups in the field of surgery. Prior research has demonstrated significant sex differences among those who experience microaggressions during training. However, little research has been conducted on the association between race and experiences of microaggressions and implicit bias among surgical trainees. METHODS: A 46-item survey was distributed to general surgery residents and residents of surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. The questions included general information/demographic data and information about experiencing, witnessing, and responding to microaggressions during surgical training. The primary outcome was the prevalence of microaggressions during surgical training by self-disclosed race. Secondary outcomes were predictors of and adverse effects of microaggressions. RESULTS: A total of 1624 resident responses were obtained. General surgery residents comprised 825 (50.8%) responses. The female-to-male ratio was nearly equal (815:809). The majority of respondents identified as non-Hispanic White (63.4%), of which 5.3% of residents identified as non-Hispanic Black, and 9.5% identified as Hispanic. Notably, 91.9% of non-Hispanic Black residents (n=79) experienced microaggressions. After adjustment for other demographics, non-Hispanic Black residents were more likely than non-Hispanic White residents to experience microaggressions [odds ratio (OR): 8.81, P <0.001]. Similar findings were observed among Asian/Pacific Islanders (OR: 5.77, P <0.001) and Hispanic residents (OR: 3.35, P <0.001). CONCLUSIONS: Race plays an important role in experiencing microaggressions and implicit bias. As the future of our specialty relies on the well-being of the pipeline, it is crucial that training programs and institutions are proactive in developing formal methods to address the bias experienced by residents.

Impact of Surgeon Workload on Pregnancy Outcomes in Surgical Trainees and Faculty.

OBJECTIVE: To investigate the association between workload and pregnancy outcomes among US surgical faculty and trainees. SUMMARY BACKGROUND DATA: Despite the increased risk of pregnancy associated complications among surgeons, most US institutions do not have formalized support to help sustain a healthy pregnancy in surgeons. METHODS: An anonymous self-administered Qualtrics survey was distributed electronically to US surgeons across all surgical specialties. Female surgical trainees/faculty with current or previous pregnancy were invited to participate. Data pertaining to demographics, workload, and pregnancy outcomes were collected for each individual pregnancy resulting in live birth. Multivariate analysis was used to assess for workload and outcomes, controlling for age, race, gravidity, and use of assisted reproductive technology. A significance level of 0.0056 was used for each outcome (Bonferroni multiple-testing adjustment 0.05/9). RESULTS: 817 surgeons experiencing 1348 pregnancies resulting in live birth were included. The mean (SD) age at first live birth was 32(4). The most prevalent major and neonatal complications included preeclampsia/gestational hypertension (n=196, 14.5%) and preterm delivery (n=179, 12.8%), respectively. Most institutions did not have a policy regarding workload modification (n=1189, 88.5%). Most surgeons did not modify their workload (n=862, 63.9%). When looking at individual workload metrics, feeling overworked during the last week of pregnancy correlated with risk of major complication (P=0.0001), preeclampsia/gestational hypertension (P=0.0003), and intra/post-partum complication (P=0.0001). Association with unplanned cesarean section (P=0.0096) and preterm delivery (P=0.0036) reached nominal significance. CONCLUSIONS: Most surgeons do not modify their workload during pregnancy, potentially contributing to feeling overworked and peri-partum complications. There is an urgent need for a cultural shift and institutional policies to safeguard the health and wellbeing of pregnant surgeons.

Paraesophageal hernia recurrence following repair: making the case for reoperative surgery in a propensity-matched cohort.

BACKGROUND: Paraesophageal hernia repairs (PEHRs) have high rates of radiographic recurrence, with some patients requiring repeat operation. This study characterizes patients who underwent PEHR to identify the factors associated with postoperative symptom improvement and radiographic recurrence. We furthermore use propensity score matching to compare patients undergoing initial and reoperative PEHR to identify the factors predictive of recurrence or need for reoperation. METHODS: After IRB approval, patients who underwent PEHR at a tertiary care center between January 2018 and December 2022 were identified. Patient characteristics, preoperative imaging, operative findings, and postoperative outcomes were recorded. A computational generalization of inverse propensity score weight was then used to construct populations of initial and redo PEHR patients with similar covariate distributions. RESULTS: A total of 244 patients underwent PEHR (78.7% female, mean age 65.4 ± 12.3 years). Most repairs were performed with crural closure (81.4%) and fundoplication (71.7%) with 14.2% utilizing mesh. Postoperatively, 76.5% of patients had subjective symptom improvement and of 157 patients with postoperative imaging, 52.9% had evidence of radiographic recurrence at a mean follow-up of 10.4 ± 13.6 months. Only 4.9% of patients required a redo operation. Hernia type, crural closure, fundoplication, and mesh usage were not predictors of radiographic recurrence or symptom improvement (P > 0.05). Propensity weight score analysis of 50 redo PEHRs compared to a matched cohort of 194 initial operations revealed lower rates of postoperative symptom improvement (P < 0.05) but no differences in need for revision, complication rates, ED visits, or readmissions. CONCLUSIONS: Most PEHR patients have symptomatic improvement with minimal complications and reoperations despite frequent radiographic recurrence. Hernia type, crural closure, fundoplication, and mesh usage were not significantly associated with recurrence or symptom improvement. Compared to initial PEHR, reoperative PEHRs had lower rates of symptom improvement but similar rates of recurrence, complications, and need for reoperation.

Microaggressions and Implicit Bias in Surgical Training: An Undocumented but Pervasive Phenomenon.

OBJECTIVE: To examine the prevalence, nature, and source of microaggressions experienced by surgical residents during training. SUMMARY AND BACKGROUND DATA: The role of microaggressions in contributing to workplace culture, individual performance, and professional satisfaction has become an increasingly studied topic across various fields. Little is known about the prevalence and impact of microaggressions during surgical training. METHODS: A 46-item survey distributed to current surgical residents in training programs across the United States via the Association of Program Directors in Surgery listserv and social media platforms between January and May 2020. Survey questions explored the frequency and extent of events of experiencing, witnessing, and responding to microaggressions in the workplace. The primary outcome was the occurrence of microaggressions experienced by surgical residents. Secondary outcomes included the nature, impact, and responses to these events. RESULTS: A total of 1624 responses were collected, with an equal distribution by self-identified gender (female, n = 815; male, n = 809). The majority of trainees considered themselves heterosexual (n = 1490, 91.7%) and White (n = 1131, 69.6%). A majority (72.2%, n = 1173) of respondents reported experiencing microaggressions, most commonly from patients (64.1%), followed by staff (57.5%), faculty (45.3%), and co-residents (38.8%). Only a small proportion (n = 109, 7.0%) of residents reported these events to graduate medical education office/program director. Nearly one third (30.8%) of residents said they experienced retaliation due to reporting of micro-aggressions. CONCLUSIONS: Based on this large, national survey of general surgery and surgical subspecialty trainees, microaggressions appear to be pervasive in surgical training. Microaggressions are rarely reported to program leadership, and when reported, can result in retaliation.

Artificial Intelligence-enabled Decision Support in Surgery: State-of-the-art and Future Directions.

OBJECTIVE: To summarize state-of-the-art artificial intelligence-enabled decision support in surgery and to quantify deficiencies in scientific rigor and reporting. BACKGROUND: To positively affect surgical care, decision-support models must exceed current reporting guideline requirements by performing external and real-time validation, enrolling adequate sample sizes, reporting model precision, assessing performance across vulnerable populations, and achieving clinical implementation; the degree to which published models meet these criteria is unknown. METHODS: Embase, PubMed, and MEDLINE databases were searched from their inception to September 21, 2022 for articles describing artificial intelligence-enabled decision support in surgery that uses preoperative or intraoperative data elements to predict complications within 90 days of surgery. Scientific rigor and reporting criteria were assessed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. RESULTS: Sample size ranged from 163-2,882,526, with 8/36 articles (22.2%) featuring sample sizes of less than 2000; 7 of these 8 articles (87.5%) had below-average (<0.83) area under the receiver operating characteristic or accuracy. Overall, 29 articles (80.6%) performed internal validation only, 5 (13.8%) performed external validation, and 2 (5.6%) performed real-time validation. Twenty-three articles (63.9%) reported precision. No articles reported performance across sociodemographic categories. Thirteen articles (36.1%) presented a framework that could be used for clinical implementation; none assessed clinical implementation efficacy. CONCLUSIONS: Artificial intelligence-enabled decision support in surgery is limited by reliance on internal validation, small sample sizes that risk overfitting and sacrifice predictive performance, and failure to report confidence intervals, precision, equity analyses, and clinical implementation. Researchers should strive to improve scientific quality.

Body mass index and risk of mortality in patients undergoing bariatric surgery.

BACKGROUND: Prior literature has demonstrated that bariatric surgery is a safe approach for patients with morbid obesity. However, the relationship between body mass index (BMI) and risk of mortality in these patients has not been fully elucidated. Primary objective of this study was to evaluate the relationship between BMI and risk of mortality using data obtained from a national database, with a special focus on patients with BMI ≥ 70.0 kg/m2. METHODS: A retrospective cohort study of patients with morbid obesity (BMI ≥ 40 kg/m2) undergoing first-time bariatric surgery between 2015 and 2018 was performed using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Primary outcome was intra-operative death or death within 30 days post-operatively. Patients were categorized into quartiles according to BMI. Multivariable analysis was performed to evaluate the association of BMI with risk of mortality. Relative risk (RR) and 95% confidence interval (CI) are provided as measures of strength of association and precision, respectively. RESULTS: A total of 463, 436 patients were included with a 30-day mortality rate of 0.11%. Mean BMI (SD) was 48.2 (7.3) kg/m2; 1.5% of patients had BMI ≥ 70.0 kg/m2. On multivariable analysis, highest quartile patients had a significantly higher risk of mortality than lowest quartile patients. For patients with BMI ≥ 70.0 kg/m2, the risk of mortality was more pronounced with an eightfold increase compared to the lowest quartile. In patients with BMI ≥ 70.0 kg/m2, although sleeve gastrectomy (SG) was the most common procedure, the risk of mortality was significantly higher in patients undergoing Roux-en-Y gastric bypass (RYGB). CONCLUSIONS: BMI is associated with increased risk of 30-day mortality. The effect of BMI is more pronounced in patients with BMI ≥ 70.0 kg/m2. In these patients, RYGB is associated with increased risk of mortality compared to SG.

A study analyzing outcomes after bariatric surgery by primary language.

BACKGROUND: Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language. METHODS: This retrospective, observational cohort study of bariatric surgery patients age ≥ 18 years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race. RESULTS: Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (- 0.02 days, p = 0.677), nor significantly different mean healthcare costs (- $265, p = 0.309). There were no significant conditional effects of race seen among outcomes. CONCLUSIONS: Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

SAGES consensus recommendations on surgical video data use, structure, and exploration (for research in artificial intelligence, clinical quality improvement, and surgical education).

BACKGROUND: Surgery generates a vast amount of data from each procedure. Particularly video data provides significant value for surgical research, clinical outcome assessment, quality control, and education. The data lifecycle is influenced by various factors, including data structure, acquisition, storage, and sharing; data use and exploration, and finally data governance, which encompasses all ethical and legal regulations associated with the data. There is a universal need among stakeholders in surgical data science to establish standardized frameworks that address all aspects of this lifecycle to ensure data quality and purpose. METHODS: Working groups were formed, among 48 representatives from academia and industry, including clinicians, computer scientists and industry representatives. These working groups focused on: Data Use, Data Structure, Data Exploration, and Data Governance. After working group and panel discussions, a modified Delphi process was conducted. RESULTS: The resulting Delphi consensus provides conceptualized and structured recommendations for each domain related to surgical video data. We identified the key stakeholders within the data lifecycle and formulated comprehensive, easily understandable, and widely applicable guidelines for data utilization. Standardization of data structure should encompass format and quality, data sources, documentation, metadata, and account for biases within the data. To foster scientific data exploration, datasets should reflect diversity and remain adaptable to future applications. Data governance must be transparent to all stakeholders, addressing legal and ethical considerations surrounding the data. CONCLUSION: This consensus presents essential recommendations around the generation of standardized and diverse surgical video databanks, accounting for multiple stakeholders involved in data generation and use throughout its lifecycle. Following the SAGES annotation framework, we lay the foundation for standardization of data use, structure, and exploration. A detailed exploration of requirements for adequate data governance will follow.

Artificial Intelligence for Intraoperative Guidance: Using Semantic Segmentation to Identify Surgical Anatomy During Laparoscopic Cholecystectomy.

OBJECTIVE: The aim of this study was to develop and evaluate the performance of artificial intelligence (AI) models that can identify safe and dangerous zones of dissection, and anatomical landmarks during laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: Many adverse events during surgery occur due to errors in visual perception and judgment leading to misinterpretation of anatomy. Deep learning, a subfield of AI, can potentially be used to provide real-time guidance intraoperatively. METHODS: Deep learning models were developed and trained to identify safe (Go) and dangerous (No-Go) zones of dissection, liver, gallbladder, and hepatocystic triangle during LC. Annotations were performed by 4 high-volume surgeons. AI predictions were evaluated using 10-fold cross-validation against annotations by expert surgeons. Primary outcomes were intersection- over-union (IOU) and F1 score (validated spatial correlation indices), and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, ± standard deviation. RESULTS: AI models were trained on 2627 random frames from 290 LC videos, procured from 37 countries, 136 institutions, and 153 surgeons. Mean IOU, F1 score, accuracy, sensitivity, and specificity for the AI to identify Go zones were 0.53 (±0.24), 0.70 (±0.28), 0.94 (±0.05), 0.69 (±0.20). and 0.94 (±0.03), respectively. For No-Go zones, these metrics were 0.71 (±0.29), 0.83 (±0.31), 0.95 (±0.06), 0.80 (±0.21), and 0.98 (±0.05), respectively. Mean IOU for identification of the liver, gallbladder, and hepatocystic triangle were: 0.86 (±0.12), 0.72 (±0.19), and 0.65 (±0.22), respectively. CONCLUSIONS: AI can be used to identify anatomy within the surgical field. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.

Consensus priority research questions in gastrointestinal and endoscopic surgery in the year 2020: results of a SAGES Delphi study.

INTRODUCTION: The objectives of this study were to identify consensus priority research questions according to members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and to explore differences in priorities according to specific membership subgroups. METHODS: A modified Delphi study was conducted including active members of SAGES. An initial list of research questions was compiled by members of 26 SAGES Committees and Task Forces, and was further refined by the SAGES Delphi Task Force. The questions were divided into five research categories: (1) Surgical Outcomes; (2) Education, Training, and Simulation; (3) Health Services Research; (4) New Technology; and (5) Artificial Intelligence. Delphi respondents were asked to rank each question with regards to its importance in the field of gastrointestinal and endoscopic surgery (1-low; 5-high). "Priority" was defined as a single-round mean score of ≥ 3.5, and "consensus" as a single-round standard deviation < 1.0. Subgroup analyses were performed according to a priori selected respondent characteristics. RESULTS: The total number of respondents for each round was: Round 1 (n = 407); Round 2 (n = 569); Round 3 (n = 273). In each round, the majority of respondents were male (Round 1: 77.4%; Round 2: 77.1%; Round 3: 76.7%), self-identified as academic (vs. community) surgeons (Round 1: 57.1%; Round 2: 61.1%; Round 3: 60.2%), and practiced in North America (Round 1: 71.8%; Round 2: 70.8%; Round 3: 75.9%). A total of 29 out of 122 research questions met criteria for both "priority" and "consensus"-Surgical Outcomes, n = 6; Education, Training, and Simulation, n = 9; Health Services Research, n = 5; New Technology, n = 5; and Artificial Intelligence, n = 4. CONCLUSIONS: Consensus priority research questions in gastrointestinal and endoscopic surgery were identified across five different research categories. These results can provide direction and areas of interest for funding and investigation for future studies.

The incidence of reintervention and reoperation following Heller myotomy across multiple indications.

INTRODUCTION: Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8 years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention. RESULTS: Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0 years, the mean time to a subsequent procedure was 4.3 ± 3.74 years. Reintervention rates after 10 years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively. CONCLUSION: The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.

Clinical course of patients presenting to the emergency department with small bowel obstruction in New York State.

INTRODUCTION: Small Bowel Obstruction (SBO) is a common reason for emergency department (ED) visits in the United States. However, little is known regarding the clinical course of these patients. This study aims to identify all patients presenting to the ED in New York State with SBO and follow their clinical course. METHODS: The New York SPARCS administrative database was used to identify all patients who presented to an ED with the diagnosis of SBO from 2012 to 2014. Patients were followed to identify discharges from the ED, admissions, operations, 30-day readmissions, transfers, and in-hospital death. RESULTS: Between 2012 and 2014, 43,567 ED visits (events) from 35,646 patients were identified, with 2824 (6.5%) resulting in direct discharge from the ED. A majority (n = 31,193; 71.6%) of ED visits were admitted to the presenting institution without surgery, while 7673 (17.6%) were admitted and underwent surgery. A minority (n = 1947; 4.5%) were transferred to a tertiary center. The overall 30-day readmission rate was 17.9%. Those who underwent surgery were more likely to experience in-hospital death but less likely to have 30-day readmission. CONCLUSION: To our knowledge, this is the first study that examines the disposition of all patients presenting to the ED with SBO in a large statewide cohort. The majority of admitted patients underwent non-operative management, with overall low rates of readmission, transfer, and in-hospital death.

Incidence of colon resections is increasing in the younger populations: should an early initiation of colon cancer screening be implemented?

INTRODUCTION: The American Cancer Society recently lowered the recommended age for screening of colorectal cancer (CRC) to age 45 due to recent data showing increased incidence of CRC in younger populations. The purpose of this study was to evaluate if younger patients have increased likelihood of resection for CRC through the use of a statewide longitudinal database. METHODS: The New York SPARCS administrative database was used to identify all patients with diagnosis of colon cancer undergoing colorectal resections from 2000 to 2016. Patients were divided into seven age groups. Patients' characteristics, demographics, co-morbidities, and complications were evaluated. Chi-square test was used to compare patients' characteristics, comorbidities and complications among age groups. The linear trend of colon resection in different age groups over years was examined using log-linear Poisson regression models with year as an explanatory variable, as well as using multivariable logistic regression models after adjusting for patients' gender, race, payment, region, any comorbidity and any complication. RESULTS: There were 73,697 colon resection surgeries extracted from 2000 to 2016. Younger age was significantly associated with increased colorectal cancer resection over time. Patients age 21-70 had a significantly increasing trend over the years (age group 21-30: RR 1.06, p-value < 0.0001; age group 31-40: RR 1.04, p < 0.0001; age group 41-50: RR 1.04, p < 0.0001; age group 51-60: RR 1.02. p < 0.0001); age group 61-70: RR 1.01, p = 0.0012). Patient age > 70 was significantly associated with decreasing trend of colorectal cancer resection over the years (age group 71-80: RR 0.98, p < 0.0001 and age group > 80: RR 0.99, p-value < 0.0001). Such trends also existed after further adjustment for patients' characteristics, any comorbidity and any complication. CONCLUSION: Over the years, younger patients have an increased trend of undergoing colorectal resections for cancer, with up to a 6% yearly increase over the studied period. New screening initiation guidelines should be considered and awareness among clinicians and the general public should be increased.

Comparative perioperative and 5-year outcomes of robotic and laparoscopic or open inguinal hernia repair: a study of 153,727 patients in the state of New York.

OBJECTIVE: This study aimed to examine the perioperative outcomes of robotic inguinal hernia repair as compared to the open and laparoscopic approaches utilizing large-scale population-level data. METHODS: This study was funded by the SAGES Robotic Surgery Research Grant (2019). The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify all adult patients undergoing initial open (O-IHR), laparoscopic (L-IHR), and robotic (R-IHR) inguinal hernia repair between 2010 and 2016. Perioperative outcome measures [complications, length of stay (LOS), 30-day emergency department (ED) visits, 30-day readmissions] and estimated 1/3/5-year recurrence incidences were compared. Propensity score (PS) analysis was used to estimate marginal differences between R-IHR and L-IHR or O-IHR, using a 1:1 matching algorithm. RESULTS: During the study period, a total of 153,727 patients underwent inguinal hernia repair (117,603 [76.5%] O-IHR, 35,565 [23.1%] L-IHR; 559 [0.36%] R-IHR) in New York state. Initial univariate analysis found R-IHR to have longer LOS (1.74 days vs. 0.66 O-IHR vs 0.19 L-IHR) and higher rates of overall complications (9.3% vs. 3.6% O-IHR vs 1.1% L-IHR), 30-day ED visits (11.6% vs. 6.1% O-IHR vs. 4.9% L-IHR), and 30-day readmissions (5.6% vs. 2.4% O-IHR vs. 1.2% L-IHR) (p < 0.0001). R-IHR was associated with higher recurrence compared to L-IHR. Following PS analysis, there were no differences in perioperative outcomes between R-IHR and L-IHR, and the difference in recurrence was found to be sensitive to possible unobserved confounding factors. R-IHR had significantly lower risk of complications (Risk difference - 0.09, 95% CI [- 0.13, - 0.056]; p < 0.0001) and shorter LOS (Ratio 0.53, 95% CI [0.45, 0.62]; p < 0.0001) compared to O-IHR. CONCLUSION: In adult patients, R-IHR may be associated with comparable to more favorable 30-day perioperative outcomes as compared with L-IHR and O-IHR, respectively.

Evaluating readmissions following laparoscopic cholecystectomy in the state of New York.

INTRODUCTION: Hospital readmissions constitute an important component of associated costs of a disease and can contribute a significant burden to healthcare. The majority of studies evaluating readmissions following laparoscopic cholecystectomy (LC) comprise of single center studies and thus can underestimate the actual incidence of readmission. We sought to examine the rate and causes of readmissions following LC using a large longitudinal database. METHODS: The New York SPARCS database was used to identify all adult patients undergoing laparoscopic cholecystectomy for benign biliary disease between 2000 and 2016. Due to the presence of a unique identifier, patients with readmission to any New York hospital were evaluated. Planned versus unplanned readmission rates were compared. Following univariate analysis, multivariable logistic regression model was used to identify risk factors for unplanned readmissions after accounting for baseline characteristics, comorbidities and complications. RESULTS: There were 591,627 patients who underwent LC during the studied time period. Overall 30-day readmission rate was 4.94% (n = 29,245) and unplanned 30-days readmission rate was 4.58% (n = 27,084). Female patients were less likely to have 30-day unplanned readmissions. Patients with age older than 65 or younger than 29 were more likely to have 30-day unplanned readmissions compared to patients with age 30-44 or 45-64. Insurance status was also significant, as patients with Medicaid/Medicare were more likely to have unplanned readmissions compared to commercial insurance. In addition, variables such as Black race, presence of any comorbidity, postoperative complication, and prolonged initial hospital length of stay were associated with subsequent readmission. CONCLUSION: This data show that readmissions rates following LC are relatively low; however, majority of readmissions are unplanned. Most common reason for unplanned readmissions was associated with complications of the procedure or medical care. By identifying certain risk groups, unplanned readmissions may be prevented.

SAGES consensus recommendations on an annotation framework for surgical video.

BACKGROUND: The growing interest in analysis of surgical video through machine learning has led to increased research efforts; however, common methods of annotating video data are lacking. There is a need to establish recommendations on the annotation of surgical video data to enable assessment of algorithms and multi-institutional collaboration. METHODS: Four working groups were formed from a pool of participants that included clinicians, engineers, and data scientists. The working groups were focused on four themes: (1) temporal models, (2) actions and tasks, (3) tissue characteristics and general anatomy, and (4) software and data structure. A modified Delphi process was utilized to create a consensus survey based on suggested recommendations from each of the working groups. RESULTS: After three Delphi rounds, consensus was reached on recommendations for annotation within each of these domains. A hierarchy for annotation of temporal events in surgery was established. CONCLUSIONS: While additional work remains to achieve accepted standards for video annotation in surgery, the consensus recommendations on a general framework for annotation presented here lay the foundation for standardization. This type of framework is critical to enabling diverse datasets, performance benchmarks, and collaboration.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy.

BACKGROUND: BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. METHODS: Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. RESULTS: Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. CONCLUSIONS: These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Educational value of telementoring for a simulation-based fundamental use of surgical energy™ (FUSE) curriculum: a randomized controlled trial in surgical trainees.

INTRODUCTION: The SAGES Fundamental Use of Surgical Energy (FUSE) program accompanied by a bench-top simulation has shown to improve knowledge of the safe use of energy devices. However, there are significant barriers and costs associated with delivering an effective structured simulation curriculum to a widespread international audience. The purpose of this study was to evaluate if bench-top simulation FUSE curriculum through telementoring is as effective as a live-in house proctor for electrosurgical training. METHODS: A two-armed multi-institutional randomized controlled trial was designed, including a 1-h didactic electrosurgery course (FUSE curriculum), followed by a structured 1-h bench-top simulation training session. For the simulation, participants were randomized to either a live proctor who delivered the course on-site (LIVE group), or a proctor from a remote location using videoconferencing platform (TELEM group). Pre- and post-curriculum (immediate and 6 months) knowledge and self-perceived comfort and competence were assessed. Data are expressed as median [interquartile range], *p < 0.05. RESULTS: Sixty-five (35 LIVE; 30 TELEM) surgical trainees from three institutions participated. Baseline characteristics were similar. Total score on the exam improved from 47% [40-54] to 78% [71-84]* amongst all participants, with similar immediate post-curriculum scores in the LIVE group compared to the TELEM group (77% [69-83] vs 80% [75-85]). At 6 months, performance on the exam declined significantly for both groups, but remained similar between the two (LIVE: 59% [51-71] vs TELEM: 71% [57-77]). Participants in both groups reported feeling greater comfort and competence post-curriculum (immediate and at 6 months) compared to baseline, with no difference between the two groups. CONCLUSION: A bench-top simulation FUSE course delivered via a telementoring platform seems to improve surgical trainees' knowledge and comfort in the safe use of electrosurgical devices as effectively as when it is delivered by a live proctor, despite long-term decay for both methods.

Bariatric peri-operative outcomes are affected by annual procedure-specific surgeon volume.

BACKGROUND: There is limited data examining specific annual surgeon procedural volumes associated with improvement of postoperative outcomes following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). OBJECTIVES: Effect of surgeon volume on procedural outcomes. METHODS: Using the SPARCS Administrative database, patients undergoing laparoscopic RYGB or SG between 2010-2014 were analyzed. Multivariable generalized linear mixed regression models were first used to analyze the influences of 3 yearly mean volumes (combined, RYGB and SG mean volumes) on each of three surgical outcomes: 30-day readmission, peri-operative complications, and extended length of stay (LOS), while accounting for patient specific variables. RESULTS: A total of 46,511 laparoscopic bariatric procedures were included in the study. Risk for any complication and 30-day readmissions following RYGB decreased with increasing RYGB volume up to a specific volume and stayed similar afterward (OR 0.97, 95% CI 0.96-0.98 while volume < 247.9 cases/year and OR 0.99, 95% CI 0.98-0.99 while volume < 354.1 cases/year, respectively) while risk for extended LOS decreased with increasing combined bariatric mean volume up to a specific volume and stayed similar afterward (OR 0.9, 95% CI 0.85-0.95 while volume < 62.1 cases/year). Similar patterns were found for extended LOS and complications following SG (OR 0.82, 95% CI 0.72-0.93 while SG volume < 26.3 cases/year and OR 0.94, 95% CI 0.91-0.98 while combined volume < 62.1 cases/year, respectively), while 30-day readmission following SG significantly increased when combined bariatric volume being more than 138 cases/year (OR 1.10, 95% CI 1.00-1.21 while combined volume > 138 cases/year)). CONCLUSIONS: Bariatric procedure peri-operative outcomes are affected by procedure-specific annual surgeons' volume.

Early cholecystectomy (≤ 8 weeks) following percutaneous cholecystostomy tube placement is associated with higher morbidity.

INTRODUCTION: Percutaneous cholecystostomy tube (PCT) placement is often the initial management approach to severe acute cholecystitis in the unstable patient. However, the timing of cholecystectomy after PCT has not been carefully examined. The purpose of this study was to compare outcomes of early versus late cholecystectomy following PCT placement. METHODS: The New York SPARCS administrative database was searched for all patients undergoing PCT placement between 2000 and 2012. Patients were followed for subsequent cholecystectomy (CCX) procedures up to 2014. Subsequent cholecystectomies were divided into early (≤ 8 weeks) versus late (> 8 weeks) groups. Outcomes included overall complications, 30-day readmissions, 30-day Emergency Department (ED) visits, and length of stay (LOS). Multivariable regression models were used to examine the differences in clinical outcomes between these two groups, after adjusting for possible confounding factors. RESULTS: There were 9728 patients who underwent PCT placement identified during the time period, as early subsequent cholecystectomy was performed in 1211 patients (40.4%), while 1787 (59.6%) patients had a late cholecystectomy. Average time to cholecystectomy was 38 days in the early group, versus 203 days in the late group. After adjusting for other confounding factors, patients with early CCX had a significantly higher risk of overall complications and longer LOS compared to the late CCX group (P = 0.01 and P = 0.0004, respectively). There were no significant differences in 30-day readmissions and 30-day ED visits. Furthermore, there was no significant difference in the risk of CBD injury between the two groups (n = 21, 1.7% in the early cholecystectomy group and n = 26, 1.5% in the late cholecystectomy group). CONCLUSION: Early cholecystectomy (≤ 8 weeks) is associated with a higher risk of complications and longer hospital LOS compared to cholecystectomy performed at > 8 weeks. Surgeons should be aware and should delay cholecystectomy beyond 8 weeks to improve outcomes.