A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Establishing technical performance norms for general surgery residents.

BACKGROUND: Surgery residents are required to achieve performance milestones to advance in their residency. Level-specific, technical performance norms that could be used as milestones, however, do not currently exist. Our aim was to develop level-specific, technical performance norms for general surgery residents on select simulated tasks across multiple institutions. STUDY DESIGN: An IRB-approved, prospective, multi-institutional collaborative study with voluntary participation of residents was undertaken at the start of the 2011-2012 academic year. General surgery residents (PGY I-V) from seven institutions were tested on three laparoscopic and five open simulated surgical tasks, and their performance was assessed based on task time and errors. Means and standard deviations of performance for each resident level were calculated and compared. Residents with performance 1 standard deviation below the mean were considered outliers. RESULTS: A total of 147 residents were evaluated. Mean resident age was 28 ± 3 years; 42 % were female; and they had attended 74 different medical schools. Senior residents (PGY III-V) had more clinical and simulator experience than junior residents (PGY I-II) (p < 0.001). Resident performance scores progressively increased in all tasks reaching a plateau at a lower PGY level for open tasks. Depending on the task, 0-18 % of residents were outliers. When surveyed, 66 % of residents agreed that national performance norms for residents should exist. CONCLUSIONS: Performance norms were established for select tasks in a representative sample of US surgery residents. Such performance norms allow a more informed assessment of resident skill through comparison to national data and enable the identification of outliers who may benefit from additional training.

Should Organizational Investment in Robotic Surgical Technology Ever Influence Surgeons' Decisions About Surgical Approach to Patients' Surgical Care?

This commentary on a case considers balancing prospective benefits and harms of robotic technology use and argues that health care organizations should invest in centralizing robotic expertise in departments rather than having a mere collection of surgeons trained in robotics. This commentary also examines costs that should be considered in organizational determinations of robotics investments.

Value of fundamentals of laparoscopic surgery training in a fourth-year medical school advanced surgical skills elective.

BACKGROUND: Few data are available describing the benefits of initiating fundamentals of laparoscopic surgery (FLS) training during medical school. We hypothesized that an intense 1-month surgical skills elective that included FLS task training for fourth-year medical students (MS4s) would result in performance levels indistinguishable from graduating chief residents (PGY5) who had received clinical skill training and access to self-guided FLS curriculum. METHODS: From July 2007 through June 2011, 114 MS4s participated in a 1-month advanced surgical skills elective. The curriculum for the elective included cadaver dissections, patient management presentations, and surgical skill training (open surgical skills and basic laparoscopic skills modules performed on FLS trainers and virtual reality laparoscopic simulators). From June 2009 through June 2011, 21 PGY5s graduated who had never received formalized FLS skills training. These residents were tested on FLS by a certified proctor and the results recorded. The performance outcome measure was task completion time. Unpaired Student's t-test was used to compare the performance measures for each group. RESULTS: All PGY5s achieved FLS certification on their first attempt and completed enough cases for graduation. The MS4 group showed significantly better performance than the PGY5 group in the peg transfer and circle cut (P < 0.05). No difference was seen in the knot tying tasks between the two groups (P > 0.05) CONCLUSIONS: Incorporating FLS training into a 1 month-long medical school surgery elective enabled MS4s to achieve FLS performance similar to, or better than, the performance achieved by PGY5 surgery residents. We support the integration of FLS skills task training as a standard part of the skills training curriculum for medical students.

Impact of fundamentals of laparoscopic surgery training during medical school on performance by first year surgical residents.

BACKGROUND: Fundamentals of Laparoscopic Surgery (FLS) certification is a high stakes examination. The best training methods to enable successful certification are undetermined. We hypothesized that first year surgical residents (R01s) who had been pretrained as medical students would perform better during skills training than previously un-trained R01s. METHODS: This is an IRB-approved, retrospective review of FLS training data generated from a single surgical skills laboratory from July 2007 through June 2010. During the study period, there were 24 R01s with no previous FLS exposure (NOVICE group) and seven R01s who had undergone FLS task training while medical students (MS4 group). All R01s practiced the FLS skill tasks weekly for portions of the training sessions with informal feedback and teaching. Performance goals were proposed for each task based on local and national proficiency figures. The performance outcome measure was task completion time (TCT). Pretraining performance was designated iTCT and post-training fTCT. RESULTS: The MS4 group began with iTCTs for all four tasks that were significantly lower than the NOVICE iTCTs. At completion of the 16-wk training period, the MS4 group continued to demonstrate mean fTCTs that were lower for all four FLS skill tasks but only significantly for PEG, CIRCLE, and INTRA skill tasks. Both NOVICE and MS4 groups showed significant improvement for all four skill tasks (P < 0.05). CONCLUSIONS: In the current milieu of work-hour limitations, the integration of FLS skill training into medical school curriculum provided a durable advantage to the pretrained R01s, which was associated with higher levels of final performance.

Appendectomy in the gynecological setting: intraoperative findings and corresponding histopathology.

BACKGROUND/AIMS: To evaluate the intraoperative findings and corresponding histopathology associated with appendectomies performed during benign gynecological surgery. METHODS: Retrospective case series. RESULTS: Twenty-two appendectomies were performed from 2002 through 2008 at Hutzel Women's Hospital due to intraoperative findings of inflammation or erythema (n = 8), periappendiceal adhesions (n = 5), injury to the appendix or mesoappendix (n = 2), fecalith (n = 2), dilation of the appendix (n = 1), adnexal mass involving the appendix (n = 1), and suspected lipoma (n = 1). Final pathology was consistent with significant findings such as acute inflammation, periappendicitis, and adhesions or endometriosis involving the appendix in 68.2% of cases. CONCLUSION: In the benign gynecological setting, appendectomies were primarily performed due to inflammation or erythema. In the majority of cases, significant appendiceal pathology was confirmed.

Combined endoscopic and laparoscopic approach to a gastroesophageal tumor.

BACKGROUND AND OBJECTIVES: Smooth muscle tumors of the stomach, especially when benign, are a common clinical entity and can represent a therapeutic challenge. Classically the removal of such a tumor requires open laparotomy. We sought to perform this surgery utilizing minimally invasive technology. METHODS: We describe a minimally invasive technique combining laparoscopy with endoscopy to remove a sub-mucosal leiomyoma at the gastroesophageal junction. RESULTS: A 3.3-cm smooth muscle tumor of the gastroesophageal junction was removed completely and safely with the described procedure and thus saved the patient from requiring a laparotomy. CONCLUSION: Minimally invasive techniques can be used in combination to tackle difficult problems in general surgery leading to shorter hospital stays and improved patient satisfaction.

Signet-Ring Cell Colon Cancer in a Teenager: A Case Report.

The majority of colon cancers are diagnosed in the older population, though recent trends have demonstrated an increase in younger patients. Most colon cancers are considered adenocarcinoma. There are multiple histologic subtypes with varying prognoses. Mucinous types such as signet-ring cell carcinoma (SRCC) are more aggressive with poor outcomes. SRCC frequently presents with metastatic disease which contributes to its poor prognosis. It is most commonly diagnosed around age 40. SRCC of colonic origin is very rare and comprises only 1% of colorectal cancers. Rarer still is presentation in the teenaged patient, especially in the absence of any risk factors. We present a case of an 18-year-old male with colonic SRCC. The patient presented initially with vague abdominal discomfort and three weeks later was found to have a near-obstructing right-sided colon mass. He was taken to the operating room and found to have diffuse carcinomatosis. The patient underwent palliative loop ileostomy with plans for subsequent chemotherapy.

Effective Large Group Teaching for General Surgery.

Large group settings display no signs of disappearing. Most surgeons charged with this education have received no formal training. Lecturing remains the most common method of educating large groups. Even though factors required for an excellent lecture are known, their inconsistent application results in variation of effectiveness. Long-standing principles of rhetoric and recent advances in neuroscience, cognitive science, learning models, and teaching theory play a role in achieving effectiveness. This article makes recommendations for creating and delivering lectures, including active learning opportunities and modern innovations in information technology supporting teaching methods. Effective lecturing skills are acquired by persistent deliberate practice.

FLS skill retention (learning) in first year surgery residents.

BACKGROUND: Fundamentals of Laparoscopic Surgery (FLS) certification is reliable and valid; the American Board of Surgery requires FLS certification. Dynamics of skill retention after FLS training effect training schedules for residents. We hypothesized that the initial elevation of performance levels after FLS training would deteriorate predictably with time. METHODS: FLS performance data on 16 new surgical residents (R01s) was examined retrospectively. These R01s trained at 16 weekly sessions. Training included 4 FLS tasks, VR simulator tasks, and open surgical skills. FLS skills were practiced weekly with feedback but no instruction. Performance was tested PRE, POST, and DELAY. Outcome metrics were task completion times (TCTs). RESULTS: POST TCTs were below PRE TCTs in all R01s for all FLS tasks (P < 0.05). No difference was seen between the DELAY TCT and POST TCT for peg transfer (P = 0.726) and pattern cut (P = 0.114). The DELAY TCTs were longer than POST TCTs for extra- and intra corporeal knot-tying (P < 0.0001 and P = 0.029). Relative retention was 103% for peg transfer, 85% for pattern cut, 47% for extracorporeal knot tying, and 59% for intracorporeal knot tying. However, many individual's displayed DELAY TCT equal to or lower than POST TCT implying full retention. CONCLUSIONS: This study extends the data on FLS skill retention to an actual "production" training curriculum. This FLS training provided effective learning in R01s. Although performance levels fell across these tasks on average and for the majority of individual R01s, significant skill retention remained at 7-8 months. Early training will enable R01s to maintain or elevate skill levels with additional training sessions.

Ogilvie syndrome and herpes zoster: case report and review of the literature.

BACKGROUND: The very unusual association between herpes zoster and Ogilvie syndrome has received scant attention in the published literature. OBJECTIVES: This review discusses the published experience since 1950 and attempts to increase clinical awareness about the co-existence of both conditions. CASE REPORT: An 84-year-old male patient affected by herpes zoster presented with advanced acute colonic pseudo-obstruction and was successfully treated with colonic diversion. DISCUSSION: Twenty published studies (1950-2008) of 28 patients in whom the two conditions co-existed are reviewed. The review included 22 male and 7 female patients (24%) aged 32-87 years (mean, 61 years). Significant co-morbidities were present in 45% of the patients. The majority of patients were observed and treated conservatively (83%). Two patients died (7%), both suffering from respiratory complications and malignancy. CONCLUSION: Recognition of the combined syndrome may help to avoid unnecessary surgery. Laparotomy should be reserved as a last resort for when the obstruction cannot be successfully managed by endoscopy. A diverting colostomy can be used to monitor the blood supply and thus provide early warning for an impending abdominal catastrophe.

Prophylactic laparoscopic gastrectomy for hereditary diffuse gastric cancer: a case series in a single family.

BACKGROUND: Hereditary diffuse gastric carcinomas (HDGCs) are particularly troubling because of autosomal dominant heritance, high penetrance, early age of onset, and a lack of effective treatment once symptomatic. HDGC is further complicated by difficulty of effective screening. Gastrectomy provides definitive treatment for CDH1 mutation-positive patients. Attempting to minimize the morbidity and mortality of this procedure via a laparoscopic approach is appropriate. METHODS: Six consanguineous patients, 21 to 51 years of age, were identified as carriers of the CDH1 gene mutation. All of the patients' gastric mucosa was normal by endoscopic appearance and biopsy. After appropriate multispecialty counseling, all patients elected to undergo a laparoscopic total gastrectomy. Demographics, genealogy, operative approach, outcomes, and pathology were reviewed. RESULTS: All gastrectomies were completed using a laparoscopic approach. Gross examination of resected stomachs was unremarkable. Histological examination demonstrated multiple foci of invasive signet ring adenocarcinoma in all patients. There were no anastomotic leaks, one small bowel obstruction requiring reoperation, and one esophageal stricture requiring dilation. CONCLUSIONS: This series demonstrates the utility and safety of the laparoscopic approach for prophylactic total gastrectomy for carriers of the CDH1 gene mutation. It serves to highlight that patients with CDH1 mutations may be more likely to undergo gastrectomy if they are offered the lower risk laparoscopic approach.

Impact of Surgery Program Characteristics on Fate of Non-designated Preliminary Surgery Interns.

OBJECTIVE: Non-designated preliminary (NDP) general surgery residents face the daunting challenge of obtaining a categorical residency position while undertaking the rigors of a general surgery residency. This additional application cycle represents a stressful time for these trainees and limited data exists to help guide applicants and program directors regarding the factors predictive of application success. While previous studies have focused solely on applicant related factors, no study to date has evaluated the effect of the residency program structure, institutional resources, or administrative support on these outcomes. DESIGN/SETTING: A multicenter retrospective review of 10 general surgery residency programs over a 5-year period from 2014 to 2019 was performed. Applicant related information was compiled from NDP general surgery residents and the results of their attempted second application into a categorical position. Applicant factors including age, gender, standardized test scores (USMLE/ABSITE), and professional training were examined. Program and administrative structure including residency class size, number of NDP PGY-2 positions, number of assistant program directors and program director (PD) background were also examined. Primary success was defined as a NDP resident successfully obtaining a categorical position within general surgery or a surgical subspecialty. Secondary success was obtaining a categorical residency position in any field of medical practice other than surgery or a surgical subspecialty in the United States. RESULTS: A total of 260 NDP trainees were evaluated with an average age of 29.1. Almost seventy percent of applicants were male, 40% graduated from a non-U.S. medical school and 24.2% required a visa to work in the United States. Thirty 4 percent of NDPs successfully obtained a categorical surgery position and an additional 35% obtained a categorical residency position in a nonsurgical field for an overall match success rate of 68.9%. Factors associated with primary success included ABSITE score (p < 0.001), US medical school graduation (p = 0.02), visa status (p = 0.03), presence of preliminary PGY-2 positions (p = 0.02), and PD professional development time (p = 0.004). Overall success was associated USMLE Step 1 scores (p = 0.02), number of approved chiefs (p = 0.03), presence of dedicated faculty researchers (p = 0.001), and PD professional development time (p < 0.001). CONCLUSIONS: Applicant, program-related, and administrative factors all have a significant impact on the success of NDP general surgery residents in obtaining a categorical surgical position. Trainees should consider all of these factors when applying to NDP residencies and in approaching their second application cycle to maximize their likelihood of a successful match.

Sternal osteomyelitis after minor trauma.

Sternal osteomyelitis secondary to minor trauma occurs rarely. Only a handful of cases have been reported. A 24-year-old male patient who had history of intravenous drug abuse and recent minor sternal trauma presented with signs and symptoms of sternal infection. Imaging studies suggested osteomyelitis and the patient underwent sternal resection, with a successful outcome. Sternal osteomyelitis should be suspected in immunocompromised patients, including intravenous drug abusers presenting with sternal inflammatory symptoms. Increased awareness, rapid diagnosis, and appropriate empiric antibiotic and radical surgical treatments can successfully manage life-threatening osteomyelitis of the sternum.

Intravenous pantoprazole utilization in a level 1 trauma center.

BACKGROUND: In recent years there has been a rapid increase in the use of proton pump inhibitors. Our institution has recently had several shortages of IV pantoprazole, each lasting 7-10 days. The purpose of our study was to evaluate in-patient usage of IV pantoprazole. We hypothesized that hospitalized patients with upper gastrointestinal bleeding (GIB) or risk for stress ulcers inappropriately received IV pantoprazole based on current literature. METHODS: This was a retrospective study of 165 consecutive in-patients identified as receiving pantoprazole from December 2004 to March 2005. Only patients receiving IV pantoprazole were included (n = 78). Data collected included demographics, indication and dosing of pantoprazole, admitting team (surgery vs. medicine), and risk factors for stress ulcers. RESULTS: Our study population had a mean age of 54 +/- 17 years and 62% were male. Overall, 45% (35/78) of patients receiving IV pantoprazole had an appropriate indication, and 19% (15/78) received the correct dose. Of the 78 patients, 43 (55%) were treated with pantoprazole for stress ulcer prophylaxis (SUP), and 35 (45%) patients were treated for GIB. We found that none of the 43 patients treated for SUP had an appropriate indication for pantoprazole, but all of the patients with GIB (35) had an appropriate indication. Of the 35 patients treated for GIB with pantoprazole, only 40% (14/35) received the correct dose. In all cases of incorrect dosing, the patients were underdosed. CONCLUSIONS: Pantoprazole is not being prescribed appropriately for stress ulcer prophylaxis in our patient population. Even in patients appropriately receiving pantoprazole the majority were prescribed an incorrect dose. Appropriate indications and dosing of pantoprazole could eliminate the shortages seen at our institution.

Gastric injury increases infections in trauma patients.

Some physicians feel gastric injury is not a significant contributing factor to the adverse outcome of trauma patients, but rather a marker of epigastric injury. We hypothesized the addition of a gastric injury to multiple injured trauma patients would increase infection rate. We conducted a retrospective study comparing 450 consecutive patients with full-thickness gastric injury with 983 patients without gastric injury during the same time period. Infection rate in patients with gastric injury was 44 per cent (200 of 455) and significantly higher than 36 per cent (357 of 983) seen without gastric injury (P = 0.006). Logistic regression revealed gastric injury was an independent risk factor for infection controlling for age, Injury Severity Scale, gender, mechanism of injury, shock, and associated injuries (P = 0.047). Requiring a transfusion, Injury Severity Scale, colon injury, age, pancreas injury, and emergency department shock were also independent risk factors for developing an infection. The addition of a gastric injury to a trauma patient appears to increase the risk for infection.

Post-traumatic hypotension: should systolic blood pressure of 90-109 mmHg be included?

It is generally accepted that patients with a systolic blood pressure (SBP)<90 mmHg are in "shock" and have a worse prognosis than patients with a higher SBP. Our objective was to determine if patients with a SBP of 90-109 mmHg have a worse outcome than patients with a higher SBP following trauma. Patients with gastric, small bowel, and/or diaphragm injuries were identified retrospectively through the trauma database from 1980-2003. All 2071 patients underwent emergent laparotomy at an urban, level one trauma center. The mortality rate of patients with a SBP of 90-109 mmHg in the ED or OR was 5% (17/354) and significantly higher than the 1% (12/1020) mortality seen in patients with a SBP of 110 mmHg or greater (P<0.001). The average length of stay of patients with a SBP of 90-109 mmHg was 15+/-14 days and was significantly longer than the 11+/-11 days seen in patients with a higher SBP. If the SBP was 90-109 mmHg, the infection rate was 39% (131/340), and this was significantly higher than the 22% (219/1016) infection rate seen in patients with higher SBP (P<0.001). Trauma patients with a systolic blood pressure of 109 mmHg or below are at increased risk for morbidity and mortality following trauma. Patients with a systolic blood pressure of 90-109 mmHg following trauma should be considered as a special group requiring aggressive resuscitation and surgery. Early operative control of hemorrhage in these patients can reduce mortality and infection.

Lower gastrointestinal bleeding: a review.

Lower gastrointestinal bleeding (LGIB) continues to be a problem for physicians. Acute LGIB is defined as bleeding that emanates from a source distal to the ligament of Treitz. Although 80% of all LGIB will stop spontaneously, the identification of the bleeding source remains challenging and rebleeding can occur in 25% of cases. Some patients with severe hematochezia require urgent attention to minimize further bleeding and complications. This article reviews the causes, diagnostic methods, and endoscopic treatment of LGIB.

Factors affecting prognosis in patients with gastric trauma.

Morbidity and mortality after gastric injury is usually the result of associated injuries. The authors conducted a retrospective study of 544 consecutive patients with gastric trauma requiring emergency surgery. Blunt injuries had the highest mortality and length of stay. The mortality of a proximal stomach injury was 43 per cent (9 of 21) and was significantly higher than the 19 per cent mortality seen in patients with more distal injuries (P < 0.01). The majority of gastric injuries were closed primarily (492 of 544 or 90%). The patients requiring more than a primary repair had a higher mortality (22 of 52 or 42% vs. 87 of 492 or 18%; P < 0.001), required more blood (16+/-16 U vs. 6+/-11 U; P < 0.001), had an increased rate of surgical site infections (17 of 52 or 33% vs. 75 of 492 or 15%; P = 0.001), and had an increased length of stay (20+/-30 days vs. 13+/-18 days; P = 0.024). There were 22 patients with an isolated gastric injury, and all of these patients survived. Patients with an associated arterial injury had the highest mortality (49%) and highest incidence of shock (64%). Patients with colon and gastric injuries had the highest (48 of 176 or 52%) surgical site infection rate. Isolated gastric injury is rare, but is associated with low morbidity and mortality. The mechanism of injury, location of injury, and type of repair used all affect patient outcomes with gastric injury.