The effect of transparency on the gender-based compensation gap in surgical disciplines within a large academic healthcare system.

BACKGROUND: Female representation in surgery and surgical subspecialties has increased over the last decade. Studies have shown a discrepancy in compensation in the field of surgery, and several groups have advocated for increasing transparency as a primary solution to decrease this gender salary gap in surgery. The aim of this study was to evaluate differences in compensation between genders in surgical specialties within a large academic healthcare system. METHODS: Using a public compensation database from January 1, 2016 through December 31, 2016, this retrospective observational study analyzed salaries of full-time faculty surgeons within a large multi-institutional academic healthcare system. Surgeons included those who were employed for the entirety of 2016 and were full-time faculty who were then stratified according to surgical specialty and rank. The median base and median total salaries were compared between male and female surgeons with adjustment for rank and surgical specialty. RESULTS: There were 170 surgeons from eight surgical subspecialties included in the study with 29% being female (n = 50). Overall, unadjusted and adjusted median total salaries were significantly lower for female compared to male surgeons by $121,578 and $45,904, respectively. The three subspecialties with the highest compensation had a median total salary of $558,998 and had a high male to female ratio (3.7 male to 1 female), whereas the three subspecialties with the lowest compensation had a median total salary of $376,174 and had a male to female ratio of 1.5 male to 1 female. CONCLUSIONS: In a large academic healthcare system with transparent and publicly accessible salaries, the gender compensation gap in surgery persists. In conjunction with transparency, future academic institutions should consider a value-based, objective compensation plan with personal and systemic introspection of traditional gender biases, in efforts to circumvent the impact of gender on salary.

Current practices in biliary surgery: Do we practice what we teach?

INTRODUCTION: Since the widespread adoption of laparoscopic techniques in biliary surgery, the incidence of bile duct injures (BDI) has not significantly declined despite increased operative experience and recognition of the critical view of safety (CVS) method for anatomic identification. We hypothesized that operative approaches in clinical practice may vary from well-described technical recommendations. The objective of this study was to access how practicing surgeons commonly identify anatomy during laparoscopic cholecystectomy (LC). METHODS: We performed a cohort study assessing practices in biliary surgery among current practicing surgeons. Surgeons belonging to the Midwest Surgical Association and the Society of American Gastrointestinal and Endoscopic Surgeons were surveyed. Items surveyed include preferred methods for cystic duct identification, recognition of the CVS, and use of intraoperative imaging. RESULTS: In total, 374 of 849 surgeons responded. The CVS was not correctly identified by 75 % of surgeons descriptively and by 21 % of surgeons visually. 56 % of surgeons practiced the infundibular method for identification of the cystic duct; 27 % practiced the CVS method. Intraoperative cholangiography was used by 16 % and laparoscopic ultrasound by <1 %. CONCLUSION: A majority of surgeons preferably do not use the CVS method of identification during LC. A large percentage of practicing surgeons are unable to describe or visually identify the CVS. These results suggest an urgent need to reexamine the tenets of how LC is being taught and disseminated and present a clear target for improvement to reduce BDI.

The impact of visiting student electives on surgical Match outcomes.

BACKGROUND: Residency applicants commonly complete visiting student electives (VSEs) hoping to increase their odds of matching at host institutions. Existing evidence on Match outcomes for applicants who complete VSEs is limited. As VSEs involve monetary and opportunity costs to students and administrators, data on their utility are vital for student well-being, preparedness for residency, and, ultimately, success in the Match. We investigated the utilization and impact of VSEs for all applicants. We hypothesized that completion of VSEs would increase the likelihood of matching at a host institution. MATERIALS AND METHODS: A retrospective review was conducted of academic records and National Resident Matching Program outcomes for the graduates of one institution and visiting students to that institution over the course of 7 y. RESULTS: Utilization of VSEs varied significantly among specialties. Across all specialties and in general surgery, applicants were more likely to match into host programs than others. The size of the effect of VSEs on outcomes varied by specialty. Host programs were applicants' top choice for residency in 48% of cases. CONCLUSIONS: Completion of VSEs may give surgical applicants increased control over Match outcomes. Our findings may assist future students in strategic decision making when determining whether and where to use VSEs.

The utilization of laparoscopy in ventral hernia repair: an update of outcomes analysis using ACS-NSQIP data.

BACKGROUND: Numerous prospective studies and randomized controlled trials have demonstrated shorter length of stay, lower morbidity rates, and similar recurrence rates with laparoscopic ventral hernia repair (VHR) when compared to open VHR. Despite these promising results, previous data showed low utilization of laparoscopic VHR. The aim of our study was to evaluate the utilization of laparoscopic VHR using the most updated information from the American College of Surgeons-National Surgical Quality Improvement Project (NSQIP) dataset. The secondary aim was to evaluate the outcomes from NSQIP for patients undergoing open versus laparoscopic VHR for the outcome of 30-day mortality and the peri-operative morbidities listed in the NSQIP dataset. METHODS: We performed this study using 2009-2012 data from the ACS-NSQIP database. The study population included patients who had undergone an open or laparoscopic ventral hernia repair as their primary procedure based on CPT codes. Demographic characteristics, overall morbidity, and complications were compared using Chi-square tests for categorical variables and two-sided t tests for continuous variables. Secondary outcomes (mortality and any complications) were further analyzed using logistic regression. RESULTS: Utilization of laparoscopic VHR was 22%. While adjusted mortality was similar, overall morbidity was increased in the open VHR group (OR 1.63; CI 95% 1.38-1.92). The open group had a higher rate of return to the OR, pneumonia, re-intubation, ventilator requirement, renal failure/insufficiency, transfusion, DVT, sepsis, and superficial and deep incisional wound infections. CONCLUSIONS: The utilization of laparoscopic VHR remained low from 2009 to 2012 and continued to lag behind the use of laparoscopy in other complex surgical procedures. The mortality rate between laparoscopic and open VHR was similar, but laparoscopic repair was associated with lower overall complication rates.

Laparoscopy has a superior diagnostic yield than percutaneous image-guided biopsy for suspected intra-abdominal lymphoma.

INTRODUCTION: To date, no study has compared laparoscopy (LB) to percutaneous (PB) biopsy for the diagnosis of abdominal lymphoma. The objective of this study is to compare the success rate and safety profile of laparoscopic lymph node biopsy to the percutaneous approach in patients with intra-abdominal lymphadenopathy concerning for lymphoma. MATERIALS AND METHODS: We performed a multi-institution, retrospective review of patients undergoing lymph node biopsy for suspected intra-abdominal lymphoma between 2005 and 2013. Our primary outcome was adequate tissue yield between the two techniques, both for histologic diagnosis and for ancillary studies such as flow cytometry. Secondary outcomes included 30-day morbidity, 30-day readmission rates, the need for additional lymph node biopsy procedures, and length of stay. RESULTS: All 34 of the LB patients had adequate specimen for histologic diagnosis compared to 92.3% of patients with a PB (p = 0.18). Significantly more patients in the LB group had sufficient tissue for ancillary studies when needed than in the PB group, 95.5 and 68.2%, respectively (p = 0.04). A second biopsy was pursued in 23.1% of failed PB patients, 0% with success on second attempt. DISCUSSION: When index of suspicion is high or when biopsy is performed for patient previously diagnosed with lymphoma and recurrence/transformation is suspected, LB safely and consistently provides adequate tissue for initial diagnosis and for ancillary studies. In contrast, image-guided PB may be more appropriate for patients for whom ancillary studies are unlikely to add to planned treatments or when there is a high risk of complications from either general anesthesia or patient comorbidities.

Annual case volume has no impact on patient outcomes in laparoscopic partial colectomy.

OBJECTIVES: Surgeon case volume has been utilized in the credentialing process as a surrogate for surgeon skill. The purpose of this study was to compare objective outcome measures of laparoscopic partial colectomies performed by laparoscopically skilled surgeons with varying annual case census. METHODS: We performed a retrospective cohort review of all patients (n = 255) undergoing elective laparoscopic partial colectomy. Patients were grouped according to surgeon's annual case volume as low annual case volume (LV; n = 48) and high annual case volume (HV; n = 207). HV is defined as performing >20 total cases and >25 cases per year. All demographic and clinical variables were evaluated with univariate logistic regression followed by a multivariate logistic regression model for variables approaching significance. RESULTS: Demographic variables were found to be similar between groups. Only median estimated blood loss (100 vs. 150 mL for HV; p = 0.040) was found to be significantly different between groups. However, this was clinically insignificant, as it did not lead to an increased rate of blood transfusions (0.0 vs. 3.9 % for HV surgeons; p = 0.184). All other variables were similar in both univariate and multivariate logistic regression models. CONCLUSIONS: Among surgeons with advanced laparoscopic training, the data suggest that LV surgeons are able to achieve similar outcomes as those who perform the operation routinely. Annual case volume should not be given undue emphasis when deciding whether to award privileges for laparoscopic partial colectomy.

Assessment and management of gastroesophageal reflux disease following bariatric surgery.

Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.

The Role of Endoscopic Stent in Management of Postesophagectomy Leaks.

INTRODUCTION: Anastomotic leak is a dreaded complication following esophagectomy. Conventional management for leaks includes invasive reoperation and even gastrointestinal diversion. OBJECTIVE: The aim of this study was to examine our contemporary outcome of using endoscopic esophageal stenting as primary therapy for management of anastomotic leak following minimally invasive esophagectomy (MIE). METHODS: We reviewed data on 11 patients who developed an esophageal leak following 111 MIE between January 2011 and December 2019. Of the 11 anastomotic leaks, 10 patients had an anastomotic disruption and underwent endoscopic esophageal stenting as primary therapy for management of leaks, while 1 patient had an anastomotic disruption complicated by an associated tracheoesophageal fistula that required surgical reoperation and subsequent colonic interposition. Main outcome measures focused on the 10 patients who were managed with endoscopic stenting, including length of hospital stay following leak management, need for thoracotomy or gastrointestinal diversion for leak, stent complications, and leak-associated mortality. RESULTS: Of the 10 patients who underwent endoscopic esophageal stenting as primary therapy for management of leaks, there were 8 males with a median age of 66 years. The median time to diagnosis of anastomotic leak was 10 days postoperatively. One of the ten patients also underwent percutaneous drain placement, while none of the patients required thoracotomy. Median duration of stent placement was 39 (range, 29-105) days. Median length of stay after stent placement was 10 (range, 4-43) days. The median number of stent exchange was 1 (range, 1-3) stent. Gastrointestinal continuity was maintained in all patients. The 90-day leak-associated mortality was 9.1% (1 of 11 patients). CONCLUSIONS: Endoscopic stenting is an effective primary therapy in the management of postesophagectomy leak and avoids the need for an invasive, reoperative thoracotomy or gastrointestinal diversion procedure.

The use of an essay examination in evaluating medical students during the surgical clerkship.

BACKGROUND: Third-year medical students are graded according to subjective performance evaluations and standardized tests written by the National Board of Medical Examiners (NBME). Many "poor" standardized test takers believe the heavily weighted NBME does not evaluate their true fund of knowledge and would prefer a more open-ended forum to display their individualized learning experiences. Our study examined the use of an essay examination as part of the surgical clerkship evaluation. METHODS: We retrospectively examined the final surgical clerkship grades of 781 consecutive medical students enrolled in a large urban academic medical center from 2005 to 2011. We examined final grades with and without the inclusion of the essay examination for all students using a paired t test and then sought any relationship between the essay and NBME using Pearson correlations. RESULTS: Final average with and without the essay examination was 72.2% vs 71.3% (P < .001), with the essay examination increasing average scores by .4, 1.8, and 2.5 for those receiving high pass, pass, and fail, respectively. The essay decreased the average score for those earning an honors by .4. Essay scores were found to overall positively correlate with the NBME (r = .32, P < .001). CONCLUSIONS: The inclusion of an essay examination as part of the third-year surgical core clerkship final did increase the final grade a modest degree, especially for those with lower scores who may identify themselves as "poor" standardized test takers. A more open-ended forum may allow these students an opportunity to overcome this deficiency and reveal their true fund of surgical knowledge.

Laparoscopic transgastric esophageal mucosal resection: a treatment option for patients with high-grade dysplasia in Barrett's esophagus.

BACKGROUND: We present long-term follow-up data on patients with esophageal high-grade dysplasia and/or carcinoma in situ who were treated with laparoscopic transgastric esophageal mucosal resection (LTEMR). METHODS: Patient demographics, operative outcomes, and follow-up results were tabulated. RESULTS: LTEMR was performed in 11 patients (9 male, 2 female). The median age was 54 (44 to 75) years. The 30-day morbidity or mortality was zero. The median follow-up was 5.2 (2 to 12) years. Upper endoscopy was performed at 3, 6, and 12 month, and yearly thereafter. All patients regenerated squamous epithelium at 6 months. One patient developed a recurrence of Barrett's epithelium 2 years after resection. No recurrences of high-grade dysplasia or carcinoma were observed in any of the patients. Two patients developed an esophageal stricture; both were treated successfully with endoscopic balloon dilation and have suffered no further sequelae. CONCLUSIONS: LTEMR is safe and effective alternative method to treat patients with Barrett's esophagus with high-grade dysplasia.

Training vs practice: A tale of opposition in acute cholecystitis.

Acute cholecystitis is one of the most common surgical diagnoses encountered by general surgeons. Despite its high incidence there remains a range of treatment of approaches. Current practices in biliary surgery vary as to timing, intraoperative utilization of biliary imaging, and management of bile duct stones despite growing evidence in the literature defining best practice. Management of patients with acute cholecystitis with early laparoscopic cholecystectomy (LC) results in better patient outcomes when compared with delayed surgical management techniques including antibiotic therapy or percutaneous cholecystostomy. Regardless of this data, many surgeons still prefer to utilize antibiotic therapy and complete an interval LC to manage acute cholecystitis. The use of intraoperative biliary imaging by cholangiogram or laparoscopic ultrasound has been demonstrated to facilitate the safe completion of cholecystectomy, minimizing the risk for inadvertent injury to surrounding structures, and lowering conversion rates, however it is rarely utilized. Choledocholithiasis used to be a diagnosis managed exclusively by surgeons but current practice favors referral to gastroenterologists for performance of preoperative endoscopic removal. Yet, there is evidence that intraoperative laparoscopic stone extraction is safe, feasible and may have added advantages. This review aims to highlight the differences between existing management of acute cholecystitis and evidence supported in the literature regarding best practice with the goal to change surgical practice to adopt these current recommendations.

Continuity of care in general surgery resident education.

BACKGROUND: Lack of continuity of care for patients managed by general surgery residents is a commonly recognized problem but objective data evaluating its incidence are limited. The goal of this pilot study was to determine the extent to which senior residents at a large American urban academic center participate in the full course of care for patients on whom they operate. METHODS: Two hundred twenty-eight total cases performed between January 1, 2012 and December 31, 2012 were reviewed and the operative senior resident was noted: laparoscopic cholecystectomy (n = 50), breast lumpectomy (n = 33), thyroidectomy (n = 50), laparoscopic appendectomy (n = 50), and open partial colectomy (n = 45). Frequency of operative resident involvement in the initial preoperative clinic visit, initial postoperative visit, or both (the entire course of care) was recorded. RESULTS: Overall rate of operative resident involvement was 9.2% for the initial preoperative consultation, 9.0% for the initial follow-up visit, and 0% for the entire course of a patient's care. Residents were on service for greater than 40 days, whereas the average total duration of care for an individual patient was 26 days. CONCLUSIONS: The results of this pilot study suggest that continuity of care among general surgery residents is lacking and cannot be entirely accounted for by rotation-specific time constraints. Further research is needed to identify and validate effective curricular strategies for improving opportunities to participate in this essential experience.

Long-term efficacy of laparoscopic cholecystectomy for the treatment of biliary dyskinesia.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for biliary dyskinesia; however, long-term outcomes remain unclear. METHODS: A retrospective review of patients diagnosed with biliary dyskinesia and treated with laparoscopic cholecystectomy at a single institution between 2001 and 2012 was conducted. Long-term outcome data were obtained by telephonic interview using a modified Likert scale. RESULTS: Sixty-seven patients met inclusion criteria, of which 34 patients (51%) had long-term follow-up data. Mean time of follow-up was 65 (range: 6 to 134) months. Long-term follow-up demonstrated symptom response in 88% (n = 30) of patients (responders), compared to no response in 12% (n = 4) of patients (nonresponders). Responders underwent a mean of 1.56 preoperative diagnostic procedures, compared to 2.5 for nonresponders (P = .01). CONCLUSION: This represents the longest mean time of follow-up study demonstrating the success of laparoscopic cholecystectomy to improve symptoms in patients with biliary dyskinesia.

Higher clinical performance during a surgical clerkship is independently associated with matriculation of medical students into general surgery.

BACKGROUND: The purpose of our study was to determine the predictive impact of individual academic measures for the matriculation of senior medical students into a general surgery residency. METHODS: Academic records were evaluated for third-year medical students (n = 781) at a single institution between 2004 and 2011. Cohorts were defined by student matriculation into either a general surgery residency program (n = 58) or a non-general surgery residency program (n = 723). Multivariate logistic regression was performed to evaluate independently significant academic measures. RESULTS: Clinical evaluation raw scores were predictive of general surgery matriculation (P = .014). In addition, multivariate modeling showed lower United States Medical Licensing Examination Step 1 scores to be independently associated with matriculation into general surgery (P = .007). CONCLUSIONS: Superior clinical aptitude is independently associated with general surgical matriculation. This is in contrast to the negative correlation United States Medical Licensing Examination Step 1 scores have on general surgery matriculation. Recognizing this, surgical clerkship directors can offer opportunities for continued surgical education to students showing high clinical aptitude, increasing their likelihood of surgical matriculation.

Permanent mesh results in long-term symptom improvement and patient satisfaction without increasing adverse outcomes in hiatal hernia repair.

BACKGROUND: The purpose of this study is to evaluate symptom relief, patient satisfaction, and safety of permanent mesh following Nissen fundoplication and hiatal hernia repair. METHODS: Patients who underwent Nissen fundoplication and hiatal hernia repair with permanent mesh (Crurasoft; Davol, Inc, Bard, Warwick, RI) between 2005 and 2011 were identified. A retrospective chart review was conducted. Long-term follow-up data were obtained via telephone interviews using a modified 5-point Likert scale. RESULTS: Forty-one patients were identified. Twenty-six patients (63%) had complete follow-up data. Mean follow-up period was 65 months (14 to 96 months). Symptomatic improvement occurred in 23 patients (88%). Twenty-three patients (88%) reported overall satisfaction with the procedure as either excellent or good, and 23 of 26 patients (89%) would undergo surgery again. Three patients (12%) reported hernia recurrence. There were no mesh erosions. CONCLUSION: The use of permanent (Crurasoft; Davol, Inc) mesh resulted in symptom improvement as well as patient satisfaction, and no mesh erosions were seen.

A subjective assessment of medical student perceptions on animal models in medical education.

BACKGROUND: There remains increasing societal pressure to limit the use of animals in medical education. The purpose of this study was to explore the subjective perceptions that medical students exposed to an animal model curriculum feel about the laboratory and its continued use. METHODS: A 6-month prospective study was performed during the medical college core surgical clerkship. Medical students participated in both a trainer-based simulation workshop (dry laboratory) and a live-tissue animal laboratory (wet laboratory) in addition to their operative experience. Students completed a 23-question Likert survey at the end of the surgical clerkship. Data were compared using the chi-square test. RESULTS: More students reported increased subjective stress levels in the wet laboratory (32.4%) compared with the dry laboratory (5.4%, p < 0.001). In addition, more students felt the wet laboratory (vs dry laboratory) prepared them for the anxiety (55.4% vs 24.3%, p < 0.001) and technical demands (67.6% vs 44.6%, p = 0.005) of the operating room. The majority of medical students (>90%) felt the wet laboratory was an important experience and should be continued. CONCLUSIONS: The results of this study show a subjective benefit perceived by medical students when it comes to participation in an animal laboratory during their surgical clerkship. As such, over 90% of participating medical students feel the animal laboratory is important in medical education and should be continued in their surgical curriculum.

Minimally invasive technique leads to decreased morbidity and mortality in small bowel resections compared to an open technique: an ACS-NSQIP identified target for improvement.

BACKGROUND: We hypothesize that currently minimally invasive techniques are underutilized, leading to unnecessary morbidity and mortality. The objective of the study was to compare morbidity and mortality rates in patients receiving a minimally invasive (MIS) small bowel resection to patients receiving an open (OP) small bowel resection. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent a small bowel resection between 2007 and 2011 were enrolled in the study and grouped whether they received a MIS procedure (n = 1,780) or an OP procedure (n = 17,701). The primary endpoint of the study was to evaluate the difference in morbidity (excluding mortality) and mortality in patients undergoing a minimally invasive procedure compared to an open procedure. RESULTS: The MIS technique is utilized in 9.0 % of patients undergoing a small bowel resection. Significantly lower mortality rate (2.9 vs. 8.2 %; p < 0.001) and mean morbidity rate (1.7 vs. 4.3 %; p < 0.001) were demonstrated in the MIS group. Significantly lower mean major morbidity rate (1.4 vs. 3.9 %; p < 0.001) and mean minor morbidity rate (2.6 vs. 5.5 %; p < 0.001) were demonstrated in the MIS group. CONCLUSION: The MIS technique in small bowel resections appears to be underutilized, with only 9.0 % of patients in need of a small bowel resection undergo the minimally invasive approach. Wider utilization of the MIS technique could lead to significantly decreased morbidity and mortality.

Resident training in single-incision compared with traditional cholecystectomy.

INTRODUCTION: As attending surgeons' comfort with single-incision laparoscopic surgery (SILS) grows, and with continued improvement in surgical instruments, advanced laparoscopic techniques are increasingly being incorporated into surgical training. The aim of our study was to evaluate resident performance and patient outcomes in patients undergoing resident-performed SILS versus a resident-performed traditional laparoscopic cholecystectomy (LC). METHODS: A retrospective case-control study of 80 patients undergoing elective surgical intervention with a resident-performed SILS (n = 20) or a resident-performed traditional LC (n = 60) for gallbladder disease over a 15-month period was performed. Surgical indications, common perioperative variables, complications, and length of stay were reviewed, and all variables were evaluated for statistical significance. RESULTS: Median operative times were similar for the resident-performed SILS cohort and the resident-performed traditional LC cohort (70.0 minutes and 66.0 minutes, respectively; P = .54). There were no complications in either the resident-performed SILS or resident-performed traditional LC groups. There was no difference in mean length of hospital stay between the resident-performed SILS group and resident-performed traditional LC group (0.95 days and 1.10 days, respectively; P = .50). CONCLUSION: Our data strongly support the ability to train senior residents to complete a SILS technique safely and with the same efficacy as with traditional LC.