Impact of the fundamental use of surgical energy certification on surgeons' behavior and awareness of safe use of energy devices: a cross-sectional survey research.

BACKGROUND: The Fundamental Use of Surgical Energy (FUSE) program was established to educate surgeons and trainees to promote awareness and behaviors for the safe use of surgical energy devices. Despite its implementation, the impact of FUSE certification on surgeons' behavior and safety awareness regarding practice of energy devices remains unclear. This study aimed to identify the perceived impact of FUSE certification on surgeons' behavior and awareness regarding the safe use of surgical energy devices. METHODS: We performed a descriptive cross-sectional survey study, using non probabilistic purposive sampling, and distributed 22-item web-based questionnaires among all 59 FUSE-certified surgeons in Japan, excluding operating room nurses and medical students. The questionnaire items covered demographics, surgical techniques using various energy devices, changes in behavior and safety awareness, communication with colleagues about surgical energy devices, and educational activities related to energy devices. RESULTS: Fifty-seven participants completed the questionnaire (response rate 96.6%). Most surgeons (91.3%) could apply material learned from the FUSE program in practice, especially material related to monopolar electrosurgery. Fifty-six surgeons (98.3%) reported increased awareness of surgical safety, and 35 (61.5%) reported increased communication with operating room personnel about the safe use of energy devices. Moreover, 56 participants (98.3%) indicated a need for systematic education in surgical energy, with participants recommending fellows (94.7% of participants specified that fellows should participate in further education), residents (75.4%), and attending surgeons (63.2%) as the target recipients of this training. Conclusions After FUSE certification, not only did surgeons' knowledge increase, but their energy-related surgical techniques in practice also improved. Furthermore, FUSE-certified surgeons felt that they were more aware of surgical-energy safety and were dedicated to its promotion.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study.

BACKGROUND: Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR). METHODS: In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2-3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points. RESULTS: Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training. CONCLUSION: The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.

Establishing validity evidence for device-assisted advanced laparoscopic suturing tasks using simulation.

BACKGROUND: Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks. METHODS: This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods. RESULTS: Twenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061). CONCLUSION: In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Does your group matter? How group function impacts educational outcomes in problem-based learning: a scoping review.

BACKGROUND: Problem-based learning (PBL) is a common instructional method in undergraduate health professions training. Group interactions with and within PBL curricula may influence learning outcomes, yet few studies have synthesized the existing evidence. This scoping review summarized the literature examining the influence of group function on individual student PBL outcomes. Following Kirkpatrick's framework, experiential, academic, and behavioral outcomes were considered. The impacts of three aspects of group function were explored: (1) Group Composition (identities and diversity), (2) Group Processes (conduct and climate, motivation and confidence, and facilitation), and (3) PBL Processes (tutorial activities). METHODS: A literature search was conducted using Medline, CINAHL, and APA PsychInfo from 1980-2021, with the help of a librarian. English-language empirical studies and reviews that related group function to learning outcome, as defined, in undergraduate health professions PBL curricula were included. Relevant references from included articles were also added if eligibility criteria were met. The methods, results, discussions, and limitations of the sample were summarized narratively. RESULTS: The final sample (n = 48) varied greatly in context, design, and results. Most studies examined junior medical students (n = 32), used questionnaires for data collection (n = 29), and reported immediate cross-sectional outcomes (n = 34). Group Processes was the most frequently examined aspect of group function (n = 29), followed by Group Composition (n = 26) and PBL Processes (n = 12). The relationships between group function and outcomes were not consistent across studies. PBL experiences were generally highly rated, but favorable student experiences were not reliable indicators of better academic or behavioral outcomes. Conversely, problematic group behaviors were not predictors of poorer grades. Common confounders of outcome measurements included exam pressure and self-study. CONCLUSIONS: The main findings of the review suggested that (1) group function is more predictive of experiential than academic or behavioral PBL outcomes, and (2) different Kirkpatrick levels of outcomes are not highly correlated to each other. More research is needed to understand the complexity of group function in PBL tutorials under variable study contexts and better inform curricular training and design. Standardized tools for measuring PBL group function may be required for more conclusive findings.

Defining the key skills required to perform advanced laparoscopic procedures: a qualitative descriptive study.

BACKGROUND: Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. METHODS: Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. RESULTS: 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees. CONCLUSION: This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Development and validation of an endoscopic submucosal dissection video assessment tool.

BACKGROUND: Despite a need for assessment of endoscopic submucosal dissection (ESD) skills in order to track progress and determine competence, there is no structured measure of assessing competency in ESD performance. The present study aims to develop and examine validity evidence for an assessment tool to evaluate the recorded performance of ESD for gastric neoplasms. METHODS: The ESD video assessment tool (EVAT) was systematically developed by ESD experienced endoscopists. The EVAT consists of a 25-item global rating scale and 3-item checklist to assess competencies required to perform ESD. Five unedited videos were each evaluated by 2-blinded experienced ESD endoscopists to assess inter-rater reliability using intraclass correlation coefficients (ICC). Seventeen unedited videos in total were rated by 3 blinded experienced ESD endoscopists. Validity evidence for relationship to other variables was examined by comparing scores of inexperienced (fellows) and experienced endoscopists (attending staff), and by evaluating the relationship between the EVAT scores and ESD case experience. Internal consistency was evaluated using Cronbach's alpha. RESULTS: The inter-rater reliability for the total score was high at 0.87 (95% confidence interval 0.11 to 0.99). The total score [median, interquartile range (IQR)] was significantly different between the inexperienced (71, 63-77) and experienced group (95, 91-97) (P = 0.005). The total scores demonstrated high correlation with the number of ESD cases (Spearman's ρ = 0.79, P < 0.01). The internal consistency was 0.97. CONCLUSIONS: This study provides preliminary validity evidence for the assessment of video-recorded ESD performances for gastric neoplasms using EVAT.

The incidence of iron deficiency anemia post-Roux-en-Y gastric bypass and sleeve gastrectomy: a systematic review.

SETTING: The physiological and anatomical changes that occur as a consequence of bariatric surgery result in macro- and micro-nutritional deficiencies, especially iron deficiency. The reported incidence of iron deficiency and associated anemia after bariatric surgery varies widely across studies. OBJECTIVES: The aim of this systematic review is to quantify the impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on the incidence of iron deficiency. METHODS: Databases including Ovid Medline, Ovid Embase, Helthstar, Scopus, Cochrane (CDSR), LILACS, and ClinicalKey were searched for original articles with additional snowballing search. Search terms included Obesity, nutrient deficiency, iron deficiency, iron deficiency anemia, bariatric surgery, Roux-en-Y gastric bypass, and sleeve gastrectomy. Original articles reporting the incidence of iron deficiency and anemia pre- and post-RYGB and SG from January 2000 to January 2015 with minimum 1-year follow-up were selected. Data extraction from selected studies was based on protocol-defined criteria. RESULTS: There were 1133 articles screened and 20 studies were included in the final analysis. The overall incidence of iron deficiency was 15.2% pre-operatively and 16.6% post-operatively. When analyzed by procedure, the incidence of iron deficiency was 12.9% pre-RYGB versus 24.5% post-RYGB and 36.6% pre-SG versus 12.4% post-SG. The incidence of iron deficiency-related anemia was 16.7% post-RYGB and 1.6% post-SG. Risk factors for iron deficiency were premenopausal females, duration of follow-up, and pre-operative iron deficiency. Prophylactic iron supplementation was reported in 16 studies and 2 studies provided therapeutic iron supplementation only for iron-deficient patients. Iron dosage varied from 7 to 80 mg daily across studies. CONCLUSION: Iron deficiency is frequent in people with obesity and may be exacerbated by bariatric surgery, especially RYGB. Further investigation is warranted to determine appropriate iron supplementation dosages following bariatric surgery. Careful nutritional surveillance is important, especially for premenopausal females and those with pre-existing iron deficiency.

An Unmodulated Very-Low-Voltage Electrosurgical Technology Creates Predictable and Ultimate Tissue Coagulation: From Experimental Data to Clinical Use.

Objective. We analyzed the underlying principles of an unmodulated very-low-voltage (VLV) mode, designated as "soft coagulation" in hemostasis, and demonstrate its clinical applications. Summary Background Data. While the advantage of the VLV mode has been reported across surgical specialties, the basic principle has not been well described and remains ambiguous. Methods. Characteristics of major electrosurgical modes were measured in different settings. For the VLV mode, the tissue effect and electrical parameters were assessed in simulated environments. Results. The VLV mode achieved tissue coagulation with the lowest voltage compared with the other modes in any settings. With increasing impedance, the voltage of the VLV mode stayed very low at under 200 V compared with other modes. The VLV mode constantly produced effective tissue coagulation without carbonization. We have demonstrated the clinical applications of the method. Conclusions. The voltage of the VLV mode consistently stays under 200 V, resulting in tissue coagulation with minimal vaporization or carbonization. Therefore, the VLV mode produces more predictable tissue coagulation and minimizes undesirable collateral thermal tissue effects, enabling nerve- and function-preserving surgery. The use of VLV mode through better understanding of minimally invasive way of using electrosurgery may lead to better surgical outcomes.

Simulation platforms to assess laparoscopic suturing skills: a scoping review.

BACKGROUND: Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted. METHODS: A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included "laparoscopic suturing" and "clinical competence." RESULTS: Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies. CONCLUSION: We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

Assessment of surgical performance of laparoscopic benign hiatal surgery: a systematic review.

BACKGROUND: Operative skills correlate with patient outcomes, yet at the completion of training or after learning a new procedure, these skills are rarely formally evaluated. There is interest in the use of summative video assessment of laparoscopic benign foregut and hiatal surgery (LFS). If this is to be used to determine competency, it must meet the robust criteria established for high-stakes assessments. The purpose of this review is to identify tools that have been used to assess performance of LFS and evaluate the available validity evidence for each instrument. METHODS: A systematic search was conducted up to July 2017. Eligible studies reported data on tools used to assess performance in the operating room during LFS. Two independent reviewers considered 1084 citations for eligibility. The characteristics and testing conditions of each assessment tool were recorded. Validity evidence was evaluated using five sources of validity (content, response process, internal structure, relationship to other variables, and consequences). RESULTS: There were six separate tools identified. Two tools were generic to laparoscopy, and four were specific to LFS [two specific to Nissen fundoplication (NF), one heller myotomy (HM), and one paraesophageal hernia repair (PEH)]. Overall, only one assessment was supported by moderate evidence while the others had limited or unknown evidence. Validity evidence was based mainly on internal structure (all tools reporting reliability and item analysis) and content (two studies referencing previous papers for tool development in the context of clinical assessment, and four listing items without specifying the development procedures). There was little or no evidence supporting test response process (one study reporting rater training), relationship to other variables (two comparing scores in subjects with different clinical experience), and consequences (no studies). Two tools were identified to have evidence for video assessment, specific to NF. CONCLUSION: There is limited evidence supporting the validity of assessment tools for laparoscopic foregut surgery. This precludes their use for summative video-based assessment to verify competency. Further research is needed to develop an assessment tool designed for this purpose.

Defining competencies for endoscopic submucosal dissection (ESD) for gastric neoplasms.

BACKGROUND: Current methods for teaching and assessing competencies for endoscopic submucosal dissection (ESD) are highly variable, non-systematic, and are inefficient for the learner to acquire adequate skills. The present study aims to define and establish expert consensus regarding competencies required to perform ESD for gastric neoplasms. METHODS: Fourteen ESD experts from 12 institutions in Japan were invited to complete an online survey to rate potential items for their importance in performing ESD proficiently. By using methodology based on the Delphi principles, the results of each round were analyzed and re-sent to the experts until consensus was established. Items were included if ranked 8 out of a 10-point Likert scale, by ≥ 80% of the respondents. RESULTS: A list of 29 potential items was generated through a review of the literature, textbooks, and experience of the steering group members. Ten new items were added through the survey. Consensus was reached after three rounds. Response rate ranged from 93 to 100%. Thirty-four items achieved consensus as important surrogates of competency in performing ESD. CONCLUSIONS: Essential competencies for performing ESD were identified through expert consensus. These competencies can serve as the foundation for structured training and for development of objective assessment tools to evaluate trainee performance in ESD.

The physiological and lifespan alterations in Caenorhabditis elegans exposed to different dosages of melatonin.

Aging is a process that begins at birth and ends with death. This process is accompanied by environmental effects, which cause structural and functional changes in cells and tissues. With regards to healthy aging, melatonin significantly extends lifespan. This study aims to show the anti-aging effects of melatonin on lifespan by a model organism called Caenorhabditis elegans. The nematode strain N2 (wild-type) was acquired, and E. coli OP50 was used in the study. Worms were grouped into a control group (n=100), and six experimental groups (group 1, 2, 3, 4, 5 and group 6) (n=100 in each of them). Interventions were made by exposing Caenorhabditis elegans to various dosages of melatonin and follow up was made for 21 days. The survey of Caenorhabditis elegans, which depends on time and dosage as the main outcome measures, was examined microscopically. Different dosages of melatonin affected the lifespan and morphology of Caenorhabditis elegans. Melatonin might be used in the prevention of aging.

Trends in the Fundamentals of Laparoscopic Surgery® (FLS) certification exam over the past 9 years.

BACKGROUND: The Fundamentals of Laparoscopic Surgery® (FLS) certification exam assesses both cognitive and manual skills, and has been administered for over a decade. The purpose of this study is to report results over the past 9 years of testing in order to identify trends over time and evaluate the need to update scoring practices. This is a quality initiative of the SAGES FLS committee. METHODS: A representative sample of FLS exam data from 2008 to 2016 was analyzed. The de-identified data included demographics and scores for the cognitive and manual tests. Standard descriptive statistics were used to compare trends over the years, training levels, and to assess the pass/fail rate. RESULTS: A total of 7232 FLS tests were analyzed [64% male, 6.4% junior (postgraduate year-PGY1-2), 84% senior (PGY3-5), 2.8% fellows (PGY6), and 6.7% attending surgeons (PGY7)]. Specialties included 93% general surgery (GS), 6.2% gynecology, and 0.9% urology. The Pearson correlation between cognitive and manual scores was 0.09. For the cognitive exam, there was an increase in scores over the years, and the most junior residents scored the lowest. For the manual skills, there were marginal differences in scores over the years, and junior residents scored the highest. The odds ratio of PGY3+ passing was 1.8 (CI 1.2-2.8) times higher than that of a PGY1-2. The internal consistency between tasks on the manual skills exam was 0.73. If any one of the tasks was removed, the Cronbach's alpha dropped to between 0.65 and 0.71, depending on the task being removed. CONCLUSION: The cognitive and manual components of FLS test different aspects of laparoscopy and demonstrate evidence for reliability and validity. More experienced trainees have a higher likelihood of passing the exam and tend to perform better on the cognitive skills. Each component of the manual skills contributes to the exam and should continue to be part of the test.

A scoping review of assessment tools for laparoscopic suturing.

BACKGROUND: A needs assessment identified a gap in teaching and assessment of laparoscopic suturing (LS) skills. The purpose of this review is to identify assessment tools that were used to assess LS skills, to evaluate validity evidence available, and to provide guidance for selecting the right assessment tool for specific assessment conditions. METHODS: Bibliographic databases were searched till April 2017. Full-text articles were included if they reported on assessment tools used in the operating room/simulation to (1) assess procedures that require LS or (2) specifically assess LS skills. RESULTS: Forty-two tools were identified, of which 26 were used for assessing LS skills specifically and 26 for procedures that require LS. Tools had the most evidence in internal structure and relationship to other variables, and least in consequences. CONCLUSION: Through identification and evaluation of assessment tools, the results of this review could be used as a guideline when implementing assessment tools into training programs.

Advanced Injectable Alternatives for Osteoarthritis.

Osteoarthritis (OA) is a common form of arthritis, which is characterized by progressive degradation of joint cartilage resulting in pain, joint stiffness, deformity and disability that is also recently related to an increased incidence of mortality. Inhibition of the extracellular matrix (ECM) production by chondrocytes and accumulation of catabolic mediators associated with matrix degradation are the cause of OA. Nonsurgical treatments for OA can be characterised as symptom-modifying or disease-modifying approaches. It's estimated that 10% of the world population older than 60 years demonstrated symptoms of OA (Messier SP, Callahan LF, Beavers DP et al., BMC Musculoskelet Disord 18(1):91, 2017). A virtue of chondrocytes has a limited proliferation capability; nonsurgical OA therapies mostly include native cartilage extracellular component injections like hyaluronic acid, anti-inflammatory effected autologous cell implantations, platelet rich plasma injections and medicals like corticosteroids. Stem cells are searched to cure OA recently. Also nowadays we can develop injectable release systems, biocompatible hydrogels and micro/nano sized carriers to make these medicals more effective. In this review we cover injectable alternatives to modify the natural course of OA that gives a window for patients between conventional treatment methods and joint replacement surgery.

Development of a Model for the Acquisition and Assessment of Advanced Laparoscopic Suturing Skills Using an Automated Device.

BACKGROUND: Needs assessment identified a gap regarding laparoscopic suturing skills targeted in simulation. This study collected validity evidence for an advanced laparoscopic suturing task using an Endo StitchTM device. METHODS: Experienced (ES) and novice surgeons (NS) performed continuous suturing after watching an instructional video. Scores were based on time and accuracy, and Global Operative Assessment of Laparoscopic Surgery. Data are shown as medians [25th-75th percentiles] (ES vs NS). Interrater reliability was calculated using intraclass correlation coefficients (confidence interval). RESULTS: Seventeen participants were enrolled. Experienced surgeons had significantly greater task (980 [964-999] vs 666 [391-711], P = .0035) and Global Operative Assessment of Laparoscopic Surgery scores (25 [24-25] vs 14 [12-17], P = .0029). Interrater reliability for time and accuracy were 1.0 and 0.9 (0.74-0.96), respectively. All experienced surgeons agreed that the task was relevant to practice. CONCLUSION: This study provides validity evidence for the task as a measure of laparoscopic suturing skill using an automated suturing device. It could help trainees acquire the skills they need to better prepare for clinical learning.

Splenectomy-Induced Leukocytosis Promotes Intratumoral Accumulation of Myeloid-Derived Suppressor Cells, Angiogenesis and Metastasis.

BACKGROUND: Enlargement of the spleen is commonly observed in animal models of cancer. Here, in a breast cancer model, it was aimed to determine the effect of splenectomy on circulating and tumor-infiltrating myeloid-derived suppressor cells (MDSCs), tumor angiogenesis, and metastasis. METHODS: Mice were inoculated with 4T1 breast cancer cells and underwent splenectomy or sham laparotomy. Tumor growth and survival of animals were followed. Macroscopic and histopathological analyses were performed to determine splenomegaly and metastasis. Immunophenotyping of myeloid cells was performed with flow cytometric analysis of CD11b, Gr-1, F4/80, CD206, CD11c, and F4/80 markers. Suppressive function of MDSCs on T cell proliferation was studied in cocultures. Tumor angiogenesis and granulocytic myeloid cell infiltration in the metastatic foci were studied by CD31 and Ly6G immunohistochemistry, respectively. RESULTS: The mice bearing breast tumors underwent total splenectomy at an early time point of tumorigenesis when only low levels of MDSCs had accumulated in the spleen. Circulating and tumor-infiltrating MDSCs, and tumor-associated macrophages (TAMs) were increased following splenectomy. Nevertheless, splenectomy could only lead to a temporary deceleration in tumor growth but favored lung metastasis and angiogenesis in the long run. CONCLUSION: Our data demonstrated a link among splenectomy-induced leukocytosis, accumulation of circulating and tumor-infiltrating MDSC, and enhanced angiogenesis and metastasis. Therefore, as a part of oncological surgery, favorable and unfavorable facets of the splenectomy must be considered to improve therapeutic efficacy.

Don't fix it if it isn't broken: a survey of preparedness for practice among graduates of Fellowship Council-accredited fellowships.

BACKGROUND: General surgery residency may not adequately prepare residents for independent practice. It is unclear; however, if non-ACGME-accredited fellowships are better meeting training needs. The purpose of this mixed-method study was to determine perceived preparedness for practice and to identify gaps in fellowship training. METHODS: A survey was developed using an iterative qualitative methodology based on interviews and focus groups of graduated fellows and program directors. Five central themes emerged and were used as a framework: professional development, job marketability, autonomy, networking, and practice management. The survey was then circulated by email to fellows who graduated from Fellowship Council (FC)-accredited programs within the past 3 years. RESULTS: Of 201 respondents (response rate = 41 %), 95 and 97 % were highly satisfied with their operative and non-operative experiences; 83 % acquired jobs aligned with their skills and expectations, while 17 % sought additional training after fellowship. Respondents who intended to learn a given procedure felt competent after fellowship to perform 51(85 %) of the 60 procedures listed. They would have liked more experience in advanced therapeutic endoscopy, complex and revisional bariatric surgery, and uncommon laparoscopic procedures such as esophagectomy, adrenalectomy, and common bile duct exploration. Thirty-one percent expressed the desire for more autonomy in the management of complications. Educational gaps existed mostly in areas of coding and billing (42 %), hiring administrative staff (42 %), and managing insurance issues (34 %). CONCLUSIONS: FC-accredited fellowships seem to adequately prepare surgeons for independent practice and bridge training gaps after residency. Graduates are highly satisfied with the individualized training experience and acquire desired jobs aligned with their career goals.

Measuring intra-operative decision-making during laparoscopic cholecystectomy: validity evidence for a novel interactive Web-based assessment tool.

BACKGROUND: Errors in judgment during laparoscopic cholecystectomy can lead to bile duct injuries and other complications. Despite correlations between outcomes, expertise and advanced cognitive skills, current methods to evaluate these skills remain subjective, rater- and situation-dependent and non-systematic. The purpose of this study was to develop objective metrics using a Web-based platform and to obtain validity evidence for their assessment of decision-making during laparoscopic cholecystectomy. METHODS: An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from six institutions completed a 12-item assessment, developed based on a cognitive task analysis. Five items required subjects to draw their answer on the surgical field, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test", VCT). Test-retest reliability, internal consistency, and correlation with self-reported experience, Global Operative Assessment of Laparoscopic Skills (GOALS) score and Objective Performance Rating Scale (OPRS) score were calculated. Questionnaires were administered to evaluate the platform's usability, feasibility and educational value. RESULTS: Thirty-nine subjects (17 surgeons, 22 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.95; n = 10) and internal consistency (Cronbach's α = 0.87). The assessment demonstrated significant differences between novices, intermediates and experts in total score (p < 0.01) and VCT score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.83, p < 0.01) and between total case number and VCT (ρ = 0.82, p < 0.01), and moderate to high correlations between total score and GOALS (ρ = 0.66, p = 0.05), VCT and GOALS (ρ = 0.83, p < 0.01), total score and OPRS (ρ = 0.67, p = 0.04), and VCT and OPRS (ρ = 0.78, p = 0.01). Most subjects agreed or strongly agreed that the platform and assessment was easy to use [n = 29 (78 %)], facilitates learning intra-operative decision-making [n = 28 (81 %)], and should be integrated into surgical training [n = 28 (76 %)]. CONCLUSION: This study provides preliminary validity evidence for a novel interactive platform to objectively assess decision-making during laparoscopic cholecystectomy.