Associations Between Program Doximity Reputation Rank and Well-Being in General Surgery Residents.

INTRODUCTION: Burnout and mistreatment are prevalent among surgical residents with considerable program-level variation. Applicants consider "program reputation," among other factors, when ranking programs. Although highly subjective, the only available measure of program reputation is from a physician survey by Doximity. It is unknown how program reputation is associated with resident well-being and mistreatment. METHODS: Resident burnout and personal accomplishment were assessed via the 2019 post-American Board of Surgery In-Training Examination survey. Additional outcomes included mistreatment, thoughts of attrition, and suicidality. Residents were stratified into quartiles based on their program's Doximity reputation rank. Multivariable logistic regression models examined the relationship between each outcome with Doximity rank quartile. RESULTS: 6956 residents (85.6% response rate) completed the survey. Higher-ranked programs had significantly higher burnout rates (top-quartile 41.3% versus bottom-quartile 33.2%; odds ratio [OR] 1.35, 95% confidence interval [CI] 1.04-1.76). There was no significant difference in personal accomplishment by program rank (OR 1.26, 95% CI 0.86-1.85). There also was no significant association between program rank and sexual harassment (OR 0.90, 95% CI 0.70-1.17), gender discrimination (OR 1.14, 95% CI 0.86-1.52), racial discrimination (OR 1.18, 95% CI 0.91-1.54), or bullying (OR 1.03, 95% CI 0.76-1.40). Suicidality (P = 0.97) and thoughts of attrition (P = 0.80) were also not associated with program rank. CONCLUSIONS: Surgical residents at higher-ranked programs report higher rates of burnout but have similar rates of mistreatment and personal accomplishment. Higher-ranked programs should be particularly vigilant to trainee burnout, and all programs should employ targeted interventions to improve resident well-being. This study highlights the need for greater transparency in reporting objective program-level quality measures pertaining to resident well-being.

Use of Endoscopic Vein Harvest Yields Improved Outcomes in Popliteal Artery Aneurysm Repair.

BACKGROUND: There is growing literature showing that endoscopic vein harvest (EVH) is safe, with excellent patency rates and decreased wound complications when treating infrainguinal occlusive disease. Our institution has performed EVH since 2003 with a dedicated team of providers specializing in endoscopic vein harvest. The purpose of this study was to evaluate major outcomes of EVH as an adjunct to standard, open operative repair of popliteal artery aneurysms. METHODS: We performed a 12-year retrospective single-institution chart review from January 2005 to December 2017, identifying all patients undergoing popliteal artery aneurysm repair with EVH. Primary outcomes were procedural technical success, operative time, wound complication, major morbidity, and freedom from amputation. RESULTS: A total 37 limbs (in 31 patients) received EVH popliteal artery aneurysm repair at an average age of 65.2 ± 10 years; 65% of the patients presented without symptoms or with claudication and 35% with rest pain or tissue loss. Coexisting aneurysm was present in 68% of patients: 49% had contralateral popliteal artery aneurysms and 19% had concurrent aortic aneurysms. Of 37 limbs, 33 (89%) were treated through a medial approach with aneurysm ligation, and 4 patients (11%) were treated through a posterior approach. The average vein size was 4.4 ± 1.1 mm, with 86% harvested by the ipsilateral great saphenous vein. Average operative time was 3.89 ± 0.82 hr, with a median hospitalization of 2 days and a median of 1 day of intravenous narcotics use. Only 2 patients (5.4%) had Szilagyi class-2 surgical site infections remedied with debridement and antibiotics. Kaplan-Meier data showed a 5-year primary patency of 82.3% and primary-assisted patency of 88.2%. Additionally, 30-day primary patency was 89.2% and primary-assisted patency of 97.3%. CONCLUSIONS: EVH for popliteal aneurysmal disease provides a safe and efficacious means of popliteal artery aneurysm repair with shorter hospitalization, lower wound complication rates, and excellent long-term patency compared to standard open technique.

Ten-year experience of infrainguinal bypass with endoscopic vein harvest.

OBJECTIVES: There is conflicting data comparing minimally invasive vein harvest (MIVH) using endoscopic technique and open vein harvest (OVH) in terms of bypass patency, wound infection incidence, and patient morbidity. Our institution has performed MIVH since 2003 for peripheral bypass procedures with a consistent team of specialized endoscopic vein harvesters. This study reviewed the major outcomes of MIVH infrainguinal bypass at our institution given a predominant cohort of critical limb ischemia. METHODS: We performed a 10-year, retrospective, single-institution review from January 2005 to December 2014, identifying all patients undergoing MIVH for obstructive infrainguinal disease. Primary outcomes were primary patency, operative time, intraoperative complications, surgical site infection (SSI), and freedom from amputation. RESULTS: A total of 289 patients (70% male) underwent MIVH infrainguinal bypass at an average age of 68 ± 12 years old, an obesity prevalence of 28%, and with critical limb ischemia in 81% of the patient cohort (20% rest pain, 61% tissue loss/gangrene). Ninety-four percent of patients had no intraoperative complications, 2.5% had adverse cardiac or technical complications, and 4.2% of patients required transfusion. Average operative time was 4.2 h. Femoral-popliteal TASC classification C and D constituted 80% of our patient cohort. At the last follow-up, toe pressures had increased from 30 ± 30 to 62 ± 40 mmHg (p < 0.0001). Primary bypass patency in the first 30 days was 95%. SSI incidence requiring surgical treatment was only 6%. Our median length of stay was 4.0 days, with median intravenous narcotic use of 1 day. In addition, 77% of patients returned to their baseline mobility at first follow-up (median 19 days), and 83% of patients had freedom from amputation at last follow-up (median 820 days). CONCLUSIONS: In a center with experience in MIVH and a consistent group of experienced endoscopic vein harvesters, MIVH bypass has excellent patency, low surgical site infection, short length of stay, and prompt return to baseline mobility.

The Role of Personal Accomplishment in General Surgery Resident Well-being.

OBJECTIVE: To investigate the association of personal accomplishment (PA) with the other subscales, assess its association with well-being outcomes, and evaluate drivers of PA by resident level. BACKGROUND: Most studies investigating physician burnout focus on the emotional exhaustion (EE) and depersonalization (DP) subscales, neglecting PA. Therefore, the role of PA is not well understood. METHODS: General surgery residents were surveyed following the 2019 American Board of Surgery In-Training Examination regarding their learning environment. Pearson correlations of PA with EE and DP were assessed. Multivariable logistic regression models assessed the association of PA with attrition, job satisfaction, and suicidality and identified factors associated with PA by PGY. RESULTS: Residents from 301 programs were surveyed (85.6% response rate, N = 6956). Overall, 89.4% reported high PA, which varied by PGY-level (PGY1: 91.0%, PGY2/3: 87.7%, PGY4/5: 90.2%; P = 0.02). PA was not significantly correlated with EE (r = -0.01) or DP (r = -0.08). After adjusting for EE and DP, PA was associated with attrition (OR 0.60, 95%CI 0.46-0.78) and job satisfaction (OR 3.04, 95%CI 2.45-3.76) but not suicidality (OR 0.72, 95%CI 0.48-1.09). Although the only factor significantly associated with PA for interns was resident cooperation, time in operating room and clinical autonomy were significantly associated with PA for PGY2/3. For PGY4/5s, PA was associated with time for patient care, resident cooperation, and mentorship. CONCLUSION: PA is a distinct metric of resident well-being, associated with job satisfaction and attrition. Drivers of PA differ by PGY level and may be targets for intervention to promote resident wellness and engagement.

Adjunctive branch interventions during thoracic endovascular aortic repair for acute complicated type B dissection are not associated with inferior outcomes.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has been shown to effectively treat malperfusion associated with acute type B thoracic aortic dissection (TBAD). A subset of patients might still require adjunctive peripheral or visceral artery branch interventions during TEVAR to remedy persistent end organ malperfusion. Our objectives were to determine the incidence of these adjunctive interventions and to compare the outcomes between patients who had and had not undergone such interventions. METHODS: We performed a retrospective review of the TEVAR and complex EVAR module of the Vascular Quality Initiative from 2010 to 2019 to identify all patients treated for malperfusion due to acute TBAD. The anatomic branch and procedure performed at TEVAR were recorded. The 30-day mortality, need for reintervention, complication rates, and overall survival were compared between these patients stratified by adjunctive intervention status. RESULTS: A total of 426 patients had undergone TEVAR for acute TBAD with end organ malperfusion. Of the 426 patients, 126 (29.6%) had undergone 182 adjunctive branch interventions during TEVAR. The most common interventions were stenting (n = 86; 47.3%) and stent grafting (n = 49; 26.9%), with the most common site being the left renal artery (n = 49; 26.9%). The patients in both groups had similar 30-day mortality (12.4% with branch intervention vs 15.6% without; P = .511) and rates of in-hospital reintervention (19.2% with branch intervention vs 20.7% without; P = .732). No differences were found in the rates of postoperative complications or overall survival at 3 years between the two groups. CONCLUSIONS: Adjunctive peripheral and visceral artery branch interventions in conjunction with TEVAR for acute TBAD with malperfusion occurred in one third of index cases, but did not predispose patients to worse overall outcomes. Adjunctive arterial branch interventions should be included in the treatment paradigm for acute TBAD with end organ malperfusion that does not improve with primary entry tear coverage alone.

Adequate Lymphadenectomy as a Quality Measure in Esophageal Cancer: Is there an Association with Treatment Approach?

BACKGROUND: The national comprehensive cancer network defines adequate lymphadenectomy as evaluation of ≥ 15 lymph nodes in esophageal cancer. However, varying thresholds have been suggested following neoadjuvant therapy. OBJECTIVES: Our objectives were to (1) explore trends in adequate lymphadenectomy rates over time; (2) evaluate unadjusted lymphadenectomy yield by treatment characteristics; and (3) identify independent factors associated with adequate lymphadenectomy. METHODS: The National Cancer Data Base was used to identify patients who underwent esophagectomy for cancer from 2004 to 2015. Adequate lymphadenectomy trends over time were evaluated using the Cochrane-Armitage test, and lymph node yield by treatment approach was compared using the Mann-Whitney U and Kruskal-Wallis tests. Associations with treatment factors were assessed by multivariable logistic regression. RESULTS: Among 24,413 patients, 9919 (40.6%) had adequate lymphadenectomy. Meeting the nodal threshold increased over time (52.6% in 2015 vs. 26.0% in 2004; p < 0.01). Lymph node yield did not differ based on neoadjuvant therapy (median 12 [interquartile range 7-19] with and without neoadjuvant therapy; p = 0.44). Adequate lymphadenectomy was not associated with neoadjuvant therapy (40.5% vs. 40.8%, odds ratio [OR] 0.94, 95% confidence interval [CI] 0.82-1.07), but was associated with surgical approach (52.7% of laparoscopic cases, OR 1.28, 95% CI 1.06-1.56; 61.2% of robotic cases, OR 1.71, 95% CI 1.34-2.19, vs. 43.5% of open cases), and increasing annual esophagectomy volume (55.6% in the fourth quartile vs. 32.6% in the first quartile; OR 3.57, 95% CI 2.35-5.43). CONCLUSIONS: Despite increases over time, only 50% of patients undergo adequate lymphadenectomy during esophageal cancer resection. Adequate lymphadenectomy was not associated with neoadjuvant therapy. Focusing on surgical approach and esophagectomy volume may further improve adequate lymphadenectomy rates.

Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors?

BACKGROUND: Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity. METHODS: Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane-Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression. RESULTS: Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p < 0.001). Older patients (≥ 75 years) were more likely to have positive margins [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.42-2.92], as were patients with a Charlson-Deyo Index ≥ 3 (OR 1.84, 95% CI 1.08-3.12). Patients who received neoadjuvant therapy were less likely to have positive margins (OR 0.37, 95% CI 0.29-0.47), while laparoscopic surgical approach was associated with increased margin positivity (OR 1.70, 95% CI 1.40-2.06). As the hospital annual esophagectomy volume increased, margin positivity rates decreased (7.76% in the fourth quartile vs. 11.39% in the first quartile; OR 0.70, 95% CI 0.49-0.99). CONCLUSIONS: Use of neoadjuvant therapy, surgical approach, and hospital volume are modifiable risk factors for margin positivity in esophageal cancer. These factors should be considered in treatment planning, and margin positivity rates could be considered as a quality measure in esophageal cancer.

Unstable Carotid Artery Thrombus in a Patient With COVID-19 Infection.

We present a case of an unvaccinated, 43-year-old African American female patient with COVID-19 infection and clinical evidence of a left hemispheric stroke. A non-occlusive thrombus with a radiographic target lesion was identified on computed tomography angiography (CTA). A multi-disciplinary discussion regarding concern for embolization was provided due to its unstable nature, as well as evidence of recent stroke. Given her acute COVID-19 infection, symptomatology, and radiographic findings, it was concluded that the etiology of her stroke appeared most consistent with a hypercoagulable-related embolism rather than an atheroembolic event. The patient underwent left carotid artery thrombectomy with bovine patch angioplasty. Operative findings included: left carotid thrombus, minimal plaque after evacuation of the thrombus, and a small proximal internal carotid artery diameter. Given concern for stenosis with primary repair a bovine pericardial patch angioplasty was performed. We present a paradigm for extracranial carotid thrombectomy with therapeutic anticoagulation for COVID-related spontaneous arterial thrombosis.

Disparities in Mentorship and Implications for US Surgical Resident Education and Wellness.

Importance: Many surgeons cite mentorship as a critical component of training. However, little evidence exists regarding factors associated with mentorship and the influence of mentorship on trainee education or wellness. Objectives: To evaluate factors associated with surgical trainees' perceptions of meaningful mentorship, assess associations of mentorship with resident education and wellness, and evaluate programmatic variation in mentorship. Design, Setting, and Participants: A voluntary, anonymous survey was administered to clinically active residents in all accredited US general surgery residency programs following the 2019 American Board of Surgery In-Service Training Examination. Data were analyzed from July 2019 to July 2022. Exposure: Residents were asked, "Do you have a mentor who genuinely cares about you and your career?" Main Outcomes and Measures: Resident characteristics associated with report of meaningful mentorship were evaluated with multivariable logistic regression. Associations of mentorship with education (clinical and operative autonomy) and wellness (career satisfaction, burnout, thoughts of attrition, suicidality) were examined using cluster-adjusted multivariable logistic regression controlling for resident and program factors. Residents' race and ethnicity were self-identified using US census categories (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White), which were combined and dichotomized as non-Hispanic White vs non-White or Hispanic. Results: A total of 6956 residents from 301 programs completed the survey (85.6% response rate); 6373 responded to all relevant questions (2572 [40.3%] female; 2539 [39.8%] non-White or Hispanic). Of these, 4256 (66.8%) reported meaningful mentorship. Non-White or Hispanic residents were less likely than non-Hispanic White residents to report meaningful mentorship (odds ratio [OR], 0.81, 95% CI, 0.71-0.91). Senior residents (postgraduate year 4/5) were more likely to report meaningful mentorship than interns (OR, 3.06; 95% CI, 2.59-3.62). Residents with meaningful mentorship were more likely to endorse operative autonomy (OR, 3.87; 95% CI, 3.35-4.46) and less likely to report burnout (OR, 0.52; 95% CI, 0.46-0.58), thoughts of attrition (OR, 0.42; 95% CI, 0.36-0.50), and suicidality (OR, 0.47; 95% CI, 0.37-0.60) compared with residents without meaningful mentorship. Conclusions and Relevance: One-third of trainees reported lack of meaningful mentorship, particularly non-White or Hispanic trainees. Although education and wellness are multifactorial issues, mentorship was associated with improvement; thus, efforts to facilitate mentorship are needed, especially for minoritized residents.

Management and Long-Term Outcomes of Advanced Stage Thymoma in the United States.

BACKGROUND: Thymomas are rare tumors, with limited data regarding treatment of advanced stage disease. Although surgical resection is the mainstay of treatment, the role of additional therapy remains controversial. Our objectives were to describe treatment strategies for stage III/IV thymoma in the United States and compare survival outcomes among treatment approaches. METHODS: We identified Masaoka stage III/IV thymoma reported in the National Cancer Database between 2004 and 2016. Frequencies of treatment with surgery, chemotherapy, radiation, and combinations were calculated. Five-year overall survival was compared using the Kaplan-Meier method and log-rank test. Risk-adjusted proportional hazards modeling compared mortality between treatment regimens. RESULTS: A total of 1849 patients were identified (1108 stage III, 741 stage IV). Among stage III patients, 83.8% underwent resection (± other modalities) compared with 60.2% of stage IV. Surgery plus radiation was the most common regimen for stage III (32.6%), and nonsurgical treatment (definitive chemotherapy and/or radiation) was the most common for stage IV (36.4%). Overall 5-year survival was 70.3% for stage III and 58.5% for stage IV. In risk-adjusted analysis, surgery plus radiation had the lowest mortality (hazard ratio 0.41, 95% confidence interval 0.30-0.55). Patient age, tumor size, metastases, and non-academic treating hospital were associated with mortality. CONCLUSIONS: Current treatment regimens for advanced stage thymoma vary significantly. Regimens that include surgical resection are most common and are associated with superior outcomes. Patients selected to have surgery as primary treatment had the best survival. Adjuvant radiation treatment is associated with better survival and should be considered in patients who undergo resection.

Institutional factors associated with adherence to quality measures for stage I and II non-small cell lung cancer.

OBJECTIVE: Although previous studies have identified variation in quality lung cancer care, existing quality metrics may not fully capture the complexity of cancer care. The Thoracic Surgery Outcomes Research Network recently developed quality measures to address this. We evaluated baseline adherence to these measures and identified factors associated with adherence. METHODS: Patients with pathologic stage I and II non-small cell lung cancer from 2010 to 2015 were identified in the National Cancer Database. Patient-level and hospital-level adherence to 7 quality measures was calculated. Goal hospital adherence threshold was 85%. Factors influencing adherence were identified using multilevel logistic regression. RESULTS: We identified 253,182 patients from 1324 hospitals. Lymph node sampling was performed in 91% of patients nationally, but only 76% of hospitals met the 85% adherence mark. Similarly, 89% of T1b (seventh edition staging) tumors had anatomic resection, with 69% hospital-level adherence. Sixty-nine percent of pathologic stage II patients were recommended chemotherapy, with only 23% hospitals adherent. Eighty-three percent of patients had biopsy before primary radiation, with 64% hospitals adherent. Higher volume and academic institutions were associated with nonadherence to adjuvant chemotherapy and radiation therapy measures. Conversely, lower volume and nonacademic institutions were associated with inadequate nodal sampling and nonanatomic resection. CONCLUSIONS: Significant gaps continue to exist in the delivery of quality care to patients with early-stage lung cancer. High-volume academic hospitals had higher adherence for surgical care measures, but lower rates for coordination of care measures. This requires further investigation, but suggests targets for quality improvement may vary by institution type.

Survival of Primary Stereotactic Body Radiation Therapy Compared With Surgery for Operable Stage I/II Non-small Cell Lung Cancer.

BACKGROUND: Stereotactic body radiation therapy (SBRT) is an accepted primary treatment option for inoperable early-stage non-small cell lung cancer (NSCLC). The role of SBRT in the treatment of operable disease remains unclear. We retrospectively evaluated patients with operable early-stage NSCLC who elected to receive primary SBRT, examined factors associated with SBRT, and compared overall survival after surgical resection and SBRT. METHODS: The National Cancer Database was queried for patients with stage I/II, N0 NSCLC from 2004 to 2016. The proportion of patients who refused recommended surgery and were treated with SBRT was calculated. A propensity score predicting the probability of refusing surgery and receiving SBRT was generated and used to match SBRT and resected patients. Long-term overall survival was compared in the matched cohort using the Kaplan-Meier method and Cox regression. RESULTS: We identified 1359 patients (0.98%) who refused recommended surgery and elected SBRT. This proportion increased annually, from 0.1% in 2004 to 1.7% in 2016. Factors associated with SBRT were older age, black race, Medicaid coverage, lower T stage, and more recent diagnosis year. Propensity matching resulted in 1315 well-balanced pairs. Surgery was associated with higher median survival (74 vs 47 months, P < .01) in the matched cohort. Survival benefit persisted after adjusting for covariates on Cox regression (hazard ratio, 1.69; P < .01). CONCLUSIONS: Median survival was significantly higher after surgery compared with SBRT in a risk-adjusted matched cohort of patients judged to be surgical candidates. Operable patients considering primary SBRT should be educated regarding this difference in survival.

Utilization of Minimally Invasive Surgery and Its Association with Chemotherapy for Locally Advanced Gastric Cancer.

BACKGROUND: Minimally invasive surgery (MIS) is increasingly used to treat gastric cancer in the USA. A potential benefit of MIS is increased likelihood of receiving adjuvant chemotherapy. Our objectives were (1) to assess trends and predictors of MIS for gastric cancer, (2) to evaluate the association between MIS and postoperative chemotherapy, and (3) to investigate the relationship between MIS and survival. METHODS: Patients with T3 or greater and/or N+ gastric adenocarcinoma were identified from the National Cancer Database from 2010 to 2015. Patients aged ≥ 85, with metastatic disease, treated with only preoperative chemotherapy, or with contraindications to chemotherapy were excluded. Hierarchical logistic regression and Cox proportional hazards were used to assess associations between MIS and postoperative chemotherapy and survival. RESULTS: Of 21,872 gastric resections, 6083 (27.8%) were MIS and 15,789 (72.2%) open. The majority were partial/subtotal (68.3%). Utilization of MIS increased from 18 to 37% from 2010 to 2015 (p < 0.01). Predictors of MIS were Asian race, any insurance coverage, and treatment at high-volume centers. Among 7540 patients with locally advanced disease, MIS was associated with receiving postoperative chemotherapy compared to open surgery (77.7% vs. 71.9%; OR 1.31, 95% CI 1.11-1.54). MIS was associated with improved survival before adjusting for postoperative chemotherapy (HR 0.83; 95% CI 0.72-0.97) but not after (HR 0.87, 95% CI 0.75-1.01). DISCUSSION: Utilization of MIS for locally advanced gastric cancer approximately doubled during the study period. Compared to open surgery patients, MIS patients were more likely to receive postoperative chemotherapy. The increased utilization of postoperative chemotherapy may explain the associated survival advantage observed with MIS.

Post-Operative Complications and Readmissions Associated with Smoking Following Bariatric Surgery.

BACKGROUND: The link between smoking and poor postoperative outcomes is well established. Despite this, current smokers are still offered bariatric surgery. We describe the risk of postoperative 30-day complications and readmission following laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y gastric bypass in smokers. METHODS: The National Surgical Quality Improvement Program database was queried to identify patients who underwent laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass from 2012 to 2017. Patient outcomes were compared based on smoking status. Primary outcomes included 30-day readmission and death or serious morbidity. Secondary outcomes included wound and respiratory complications. Multivariable logistic regression was used to determine the association between smoking status and measured outcomes. RESULTS: Of the 133,417 patients who underwent bariatric surgery, 12,424 (9.3%) were smokers. Smokers more frequently experienced readmission (4.9% v 4.1%, p < 0.001), death or serious morbidity (3.8% v 3.4%, p = 0.019), wound complications (2% v 1.4%, p < 0.001), and respiratory complications (0.8% v 0.5%, p < 0.001). The likelihood of death or serious morbidity (OR 1.13, 95% CI 1.01-1.26), readmission (OR 1.21, 95% CI 1.10-1.33), wound (OR 1.44, 95% CI 1.24-1.68), and respiratory complications (OR 1.69, 95% CI 1.34-2.14) were greater in smokers. The adjusted ORs remained significant on subgroup analysis of laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass patients, with the exception of death or serious morbidity in laparoscopic Roux-En-Y gastric bypass (OR 1.04, 95% CI 0.89-1.24). CONCLUSIONS: Smokers undergoing bariatric surgery experience significantly worse 30-day outcomes when compared with non-smokers. There should be a continued emphasis on perioperative smoking cessation for patients being evaluated for bariatric surgery.

Preoperative patient education and patient preparedness are associated with less postoperative use of opioids.

BACKGROUND: Because many patients are first exposed to opioids after general surgery procedures, surgical stewardship for the use of opioids is critical in addressing the opioid crisis. We developed a multi-component opioid reduction program to minimize the use of opioids after surgery. Our objectives were to assess patient exposure to the intervention and to investigate the association with postoperative use and disposal of opioids. METHODS: We implemented a multi-component intervention, including patient education, the settings of expectations, the education of the providers, and an in-clinic disposal box in our large, academic, general surgery clinic. From April to December 2018, patients were surveyed by phone 30 to 60 days after their operation regarding their experience with postoperative pain management. The association between patient education and preparedness to manage pain was assessed using χ2 tests. Education, preparedness, and clinical factors were evaluated for association with quantity of pills used using ANOVA and multivariable linear regression. RESULTS: Of the 389 eligible patients, 112 responded to the survey (28.8%). Patients receiving both pre and postoperative education were more likely to feel prepared to manage pain than those who only received the education pre or postoperatively (91% vs 68%, P = .01). Patients who felt prepared to manage their pain used 9.1 fewer pills on average than those who did not (P = .01). Fourteen patients (24%) with excess pills disposed of them. Preoperative education was associated with disposal of excess pills (30% vs 0%, P < .05). CONCLUSION: Exposure to clinic-based interventions, particularly preoperatively, can increase patient preparedness to manage postoperative pain and decrease the quantity of opioids used. Additional strategies are needed to increase appropriate disposal of unused opioids.

Transthoracic Discectomy for Symptomatic Thoracic Disc Herniation: 2-Dimensional Operative Video.

Thoracic disc herniations are an infrequent occurrence, but can be a cause of significant myelopathy. Diagnosis typically requires a high clinical suspicion that is confirmed with appropriate imaging. Classically, the transthoracic approach for discectomy is the treatment of choice for symptomatic cases. This video concerns a 48-yr-old woman who presented with worsening mid-back pain and progressive gait difficulty. Her examination was significant for proximal lower extremity muscle weakness, difficulty with tandem gait, and urinary incontinence. Imaging demonstrated a large T7-8 disc herniation causing severe spinal cord compression. The patient underwent T7-8 transthoracic discectomy and interbody fusion. She tolerated the procedure well without complication, and postoperative imaging demonstrated decompression of her spinal cord. On follow-up, she had improved mid-back pain, strength, and ambulatory function. The patient consented to the recording of this surgical video for potential publication.

Primary aortojejunal fistula: a rare cause for massive upper gastrointestinal bleeding.

A 68-year-old man presented to the emergency department with haematemesis and shock. Upper endoscopy and selective angiography could not identify the source of bleeding. He underwent selective embolisation of the gastroduodenal artery. The patient then had a period of about 24 hours with relative haemodynamic stability before having another episode of massive upper gastrointestinal bleed. A second attempt to embolise the common hepatic artery and distal coeliac axis was unsuccessful. Hence, he was urgently taken to the operating room for exploratory laparotomy. The source of bleeding could not be identified in the operating room. The patient went into cardiac arrest and expired. Autopsy revealed a fistula between proximal jejunum and a previously unknown abdominal aortic aneurysm (AAA). We present an entity that has only been described a few times in the literature while highlighting the importance of having a broad differential with upper gastrointestinal bleeding, especially when the source is not clearly evident.