Trends in minimally invasive and open inguinal hernia repair: an analysis of ACGME general surgery case logs.

BACKGROUND: Groin hernia repair is one of the most commonly performed surgical procedures and is often performed by surgical interns and junior residents. While traditionally performed open, minimally invasive (MIS) groin hernia repair has become an increasingly popular approach. The purpose of this study was to determine the trends in MIS and open inguinal and femoral hernia repair in general surgery residency training over the past two decades. METHODS: Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residents from 1999 through 2022 were reviewed. We collected means and standard deviations of open and MIS inguinal and femoral hernia repairs. Linear regression and ANOVA were used to identify trends in the average annual number of open and MIS hernia repairs logged by residents. Cases were distinguished between level of resident trainees: surgeon-chief (SC) and surgeon-junior (SJ). RESULTS: From July 1999 to June 2022, the average annual MIS inguinal and femoral hernia repairs logged by general surgery residents significantly increased, from 7.6 to 47.9 cases (p < 0.001), and the average annual open inguinal and femoral hernia repairs logged by general surgery residents significantly decreased, from 51.9 to 39.7 cases (p < 0.001). SJ resident results were consistent with this overall trend. For SC residents, the volume of both MIS and open hernia repairs significantly increased (p < 0.001). CONCLUSIONS: ACGME case log data indicates a trend of general surgery residents logging overall fewer numbers of open inguinal and femoral hernia repairs, and a larger proportion of open repairs by chief residents. This trend warrants attention and further study as it may represent a skill or knowledge gap with significant impact of surgical training.

Trends in utilization of laparoscopic colectomy according to race: an analysis of the NIS database.

BACKGROUND: Laparoscopic colectomy has been associated with improved recovery and decreased complications when compared to an open approach. Consequently, the rates of laparoscopic colectomy have increased. Race has been identified as a factor that influences a patient's likelihood of undergoing laparoscopic colectomy. Therefore, the purpose of this study is to analyze the rates of laparoscopic colectomy stratified by race over time. METHODS: Patients were selected using procedure codes for colectomy within the National Inpatient Sample (NIS) database from 2009 to 2018. The primary independent variable was race (Black, BL; Hispanic, HI; White, WH), and the primary outcome was surgical approach (laparoscopic vs open). Covariates included age, sex, case complexity, insurance status, income, year of surgery, urbanicity, region, bedsize, and teaching status. We examined the univariable association of race with laparoscopic vs open colectomy with chi-square. We used multivariable logistic regression to examine the association of race with procedure type adjusting for covariates. All analyses were done using SAS (version 9.4, Cary, NC) with p < .05 considered significant. RESULTS: 267,865 patients (25,000 BL, 19,685 HI, and 223,180 WH) were identified. Laparoscopy was used in 47% of cases, and this varied significantly by race (BL 44%, HI 49%, WH 47%, p < .0001). After adjusting for covariates, Black patients had significantly lower adjusted odds of undergoing laparoscopic colectomy vs White patients (aOR 0.92, p < 0.0001). Utilization of laparoscopy was similar in Hispanic compared to White patients (aOR 1.00, p = 0.9667). Racial disparity in the adjusted odds of undergoing laparoscopic colectomy was persistent over time. CONCLUSION: Race was independently associated with the rate of laparoscopic colectomy, with Black patients less likely to receive laparoscopic surgery than White patients. This disparity persisted over a decade. Attention should be paid to increasing the rates of laparoscopic colectomy in under-represented populations in order to optimize surgical care and address racial disparities.

Non-respiratory presentations of COVID-19, a clinical review.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) is a highly infectious viral syndrome currently threatening millions of people worldwide. It is widely recognized as a disease of the pulmonary system, presenting with fever, cough, and shortness of breath. However, a number of extrapulmonary manifestations have been described in the literature. OBJECTIVE: In this review, we seek to provide a comprehensive summary of the hematologic, gastroenterological, renal, dermatologic, neurologic, and psychiatric manifestations of COVID-19. DISCUSSION: Hematological presentations of COVID-19 include laboratory abnormalities such as decreased total lymphocyte count, prolonged prothrombin time (PT), elevated d-dimer, and increased lactate dehydrogenase (LDH). Several of these findings are associated with increased mortality among infected patients. The most common gastrointestinal symptoms include nausea, vomiting, diarrhea, and abdominal pain. Furthermore, presence of viral RNA in patient stool suggests the possibility of additional testing modalities for COVID-19. Nephrological findings such as proteinuria, hematuria, and elevated BUN and creatinine levels have been observed. Additionally, several studies demonstrated that patients with COVID-19 who developed acute kidney injury (AKI) had a greater risk of mortality. The virus can also present with cutaneous symptoms such as erythematous rashes, urticaria, and chicken pox-like lesions. Neuropsychiatric symptoms have been described in the literature, and patients can exhibit findings consistent with viral encephalitis, cerebral vascular disease, peripheral nerve disorders, and psychosis. CONCLUSION: Although COVID-19 does usually present primarily with respiratory symptoms, the extra-pulmonary manifestations of the virus are unpredictable and varied. Better understanding and awareness of these symptoms can lead to more efficient diagnosis, rapid treatment, isolation, and decreased spread of the disease.

Effect of conditions being present at time of surgery (PATOS) on outcomes in liver surgery.

INTRODUCTION: Information about condition(s) being present at time of surgery (PATOS) in the American College of Surgeons (ASC) National Surgical Quality Improvement Program (NSQIP) database can influence the postoperative complication rates after liver surgeries. Here, we compare the postoperative complication rates with and without taking condition(s) being PATOS into account. METHODS: We retrospectively reviewed the ACS NSQIP Participant User Files (PUFs) from 2015 through 2019. We analyzed rates of eight different postoperative complications: superficial surgical site infection (SSI), deep SSI, organ space SSI, pneumonia, urinary tract infection, ventilator, sepsis, and septic shock. In addition, we calculated the percent change in event rates after taking into account whether a condition is PATOS. RESULTS: Of the 22,463 patients in the ACS NSQIP PUFs for liver surgery, 334 (1.49%) had one or more conditions PATOS. The percentages of patients with PATOS events ranged from 2.03% for superficial SSI to 14.74% for sepsis. For all complications, event rates declined when taking condition(s) PATOS into account. From 2015 through 2019, the observed-to-expected ratios for most complications remained unchanged. CONCLUSION: Whether a condition is PATOS is important in reporting postoperative complication rates for patients undergoing liver surgery. When taking whether a condition is PATOS into account, we demonstrated an overall decrease in event rates across all eight postoperative complications.

Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database.

Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.

Comparative outcomes of treatment modalities in nonagenarians with nonmetastatic pancreatic adenocarcinoma.

BACKGROUND: There has been an increase in the elderly patient population seeking care for pancreatic ductal adenocarcinoma (PDAC). This study aimed to delineate the effectiveness of therapeutic options in nonagenarians (aged 90-99 years) diagnosed with resectable PDAC. METHODS: This study used the National Cancer Database to identify patients with nonmetastatic PDAC (stage I-III) from 2004 to 2021. The study compared median overall survival (mOS) using Kaplan-Meier curves among 5 treatment categories: surgery, surgery along with chemoradiation, chemotherapy alone, radiotherapy alone, and chemoradiation alone. Cox proportional hazards regression was used in multivariate analyses. RESULTS: Of 459,174 patients, 793 aged ≥ 90 years had nonmetastatic PDAC. Of 793 patients, 245 (30.9 %) underwent chemotherapy alone, 296 (37.3 %) underwent radiotherapy alone, 162 (20.4 %) underwent chemoradiation alone, 58 (7.3 %) underwent curative-intent resection, and 32 (4.0 %) underwent surgery combined with chemoradiation. The mOS estimates in different treatment modalities were 9.5 months (95 % CI, 6.7-14.5) for surgery alone, 19.1 months (95 % CI, 2.4-64.3) for surgery combined with chemoradiation, 8.2 months (95 % CI, 7.2-9.2) for chemotherapy alone, 8.4 months (95 % CI, 7.6-9.6) for radiotherapy alone, and 11.2 months (95 % CI, 8.7-12.9) for chemoradiation alone (P < .001). In multivariate analysis, the odds of survival were better for patients who underwent surgery alone than for those who underwent chemotherapy alone, although the odds of survival did not significantly differ between patients who underwent radiotherapy alone and those who underwent chemoradiation alone. Nonetheless, surgery combined with chemoradiation was associated with decreased mortality risk compared with surgery alone (hazard ratio, 0.46; 95 % CI, 0.25-0.87; P = .02). Operative 30-day mortality rate was 8.8 %, and 90-day mortality rate was 17.8 %. CONCLUSION: Surgery combined with chemoradiation improved the survival of nonagenarians with PDAC compared with other therapies. However, only 1 in 25 patients received all 3 treatment components. Moreover, our study highlights a very high operative mortality rate in nonagenarians.

Association between chronic steroids and outcomes in hepatobiliary and pancreatic surgery.

BACKGROUND: Chronic steroid use has been associated with increased postoperative complication; however, the association between chronic steroids and hepatobiliary and pancreatic surgery through all aspects of disease etiologies and types of surgery performed remains an area of active research. Therefore, this study analyzed the association of chronic steroids use with outcomes after hepatobiliary and pancreatic surgery. METHODS: The National Surgical Quality Improvement Program Participant Use Data Files for hepatobiliary and pancreatic surgeries performed between 2015 and 2019 were analyzed for chronic steroid use and postoperative adverse events. RESULTS: A total of 54,382 patients underwent hepatobiliary or pancreatic surgery during the study period, of which 1672 (3.1%) were on chronic steroids. In patients undergoing pancreatic surgery, steroid use was associated with higher rates of pneumonia (odds ratio [OR] 1.3, 95% confidence interval [95% CI] 1.2-2.2), unplanned intubation (OR 1.2, 95% CI 1.1-2.3), readmission (OR 1.4, 95% CI 1.3-2.4), intraoperative or postoperative transfusions (OR 1.5, 95% CI 1.2-2.3), being more likely to remain on a ventilator for greater than 48 h (OR 1.4, 95% CI 1.2-1.9), and greater mortality (OR 1.2, 95% CI 1.1-3.1) when compared to those, not on chronic steroids. In patients undergoing hepatobiliary surgery, chronic steroid use was associated with higher rates of sepsis (OR 1.3, 95% CI 1.2-2.9), unplanned intubation (OR 1.4, 95% CI 1.2-2.7), intraoperative or postoperative transfusions (OR 1.5, 95% CI 1.3-2.3), and readmission (OR 1.2, 95% CI 1.0-1.9). There was no difference in pancreatic fistula rates or post-hepatectomy liver failure rates after pancreatic and hepatobiliary resections, respectively. CONCLUSION: Chronic steroids use was associated with higher rates of poor outcomes both perioperatively and postoperatively in pancreatic and hepatobiliary surgery. These results will allow clinicians to be better equipped to counsel patients on surgery's increased risks and establish various perioperative protocols for chronic steroid users.

Trends in pancreatic surgery experience in general surgery residency in the US, 1990-2021.

BACKGROUND: We hypothesized a decline in resident pancreatic operative experience. The study assesses trends in that experience since 1990. METHODS: Accreditation Council for Graduate Medical Education (ACGME) national case log data of general surgery residency graduates from 1990 to 2021 were reviewed. Collected and analyzed were the mean and median total number of pancreatic operations per resident, the mean number of specific case types performed, and the annual number of residency graduates. For selected procedures, the mean number of cases by resident role (Surgeon-Chief and Surgeon-Junior) was also analyzed. RESULTS: Both the mean and median total number of resident pancreatic operations has declined since 2009 as have the mean number of several specific pancreatic case types, including resections. The annual number of residency graduates has significantly increased since 1990, and particularly since 2009. CONCLUSIONS: Resident volume in pancreatic operations has significantly declined over the last decade.

Effect of Present at Time of Surgery (PATOS) on Outcomes in Pancreatic Surgery.

INTRODUCTION: While there is some data available on the importance of accounting for the effect of present at time of surgery (PATOS) when estimating unadjusted postoperative complication rates, little is known about the impact of PATOS on outcomes in patients undergoing pancreatic surgery specifically. By taking PATOS into account, we hypothesized that unadjusted, observed postoperative complication rates might be reduced, with these reductions being different across outcomes; however, we expected fewer differences in risk-adjusted results, i.e., observed to expected ratios (O/E ratios). METHODS: We retrospectively analyzed the ACS NSQIP Participant Use Files (PUFs) from 2015 to 2019. PATOS data were analyzed for the 8 postoperative complications of superficial, deep, and organ space surgical site infection; pneumonia; urinary tract infection; ventilator dependence; sepsis; and septic shock. Postoperative complication rates were compared by ignoring PATOS vs. taking PATOS into account. RESULTS: Of the 31,919 patients in the ACS NSQIP PUFs who underwent pancreatic surgery, 1120 (3.51%) patients had one or more PATOS conditions. The event rates after taking PATOS into account declined for all outcomes-superficial surgical site infection (SSI) rates reduced by 2.56%, deep SSI rates reduced by 4.28%, organ space SSI rates reduced by 9.31%, pneumonia rates reduced by 2.91%, urinary tract infection rates declined by 4.69%, and septic shock rates declined by 9.27%. CONCLUSION: Our paper highlights that accounting for PATOS is important for estimating unadjusted postoperative complication rates in patients undergoing pancreatic surgery. Risk adjustment is essential to any attempt at quality assessment and benchmarking. Failure to account for PATOS may penalize surgeons who care for the sickest and most complicated patients and subsequently encourage cherry-picking of less risky patients and procedures.

The undisclosed disclosures: Conflicts of interest in studies related to robotics in hepatobiliary and pancreatic surgery.

BACKGROUND: The use of robotics in hepatobiliary and pancreatic surgery has increased. With this increased collaboration, there has also been a push toward improving the transparency of conflicts of interest in terms of funding provided by robotics companies. METHODS: Studies with ≥1 American author published between 2016 and 2020 discussing robotic hepatobiliary and pancreatic surgery were included in the analysis. The Centers for Medicare and Medicaid Services Open Payments Program was used to evaluate the accuracy of industry payment disclosures. Conflict of interest was defined as a lack of disclosure of ≥$100 funding from any robotics company in the United States. The primary outcome of this study was to determine the efficacy of the current standard conflict of interest reporting in surgery. RESULTS: A total of 355 studies (2,413 authors) were included. Of the studies that received robotics funding (n = 133), 20.3% did not disclose their conflicts of interest, whereas 79.7% had a conflict of interest disclosure. However, most of the disclosures (76.5%) were inaccurate. CONCLUSION: The findings of this study require an update in journal policies to ensure the accurate disclosure of conflicts of interest in robotic hepatobiliary and pancreatic surgery studies. Similarly, the investigators should ensure that their disclosures are accurate. Finally, surgeons must be more on top of their relationships with these companies and consider their vulnerability to bias.

Does Chronic Use of Steroids Affect Outcomes After Liver Resection? Analysis of a National Database.

INTRODUCTION: With the increasing age of patients, more patients on chronic preoperative steroids are undergoing liver resections. Our study aimed to assess the relationship between preoperative steroids and outcomes. METHODS: We performed a retrospective review of the 2014-2019 NSQIP database of all patients undergoing liver resections. Propensity score matching was utilized to match the two groups (chronic steroids vs. no steroids) based on demographics, preoperative laboratory data, and operative findings. The primary outcome measure was mortality. RESULTS: There were 712 patients in the chronic steroid group and 21,751 in the no steroid group. After propensity score matching; there were 420 patients in both groups. Post-match analysis again demonstrated that patients on chronic steroids were at higher risk of cardiac arrest than those not on steroids (OR 2.01, 95% CI 1.02-2.45, p = 0.04). In addition, rates of organ space wound infection (OR 2.66, CI 1.33-5.38, p = 0.03), superficial wound infection (OR 2.79, CI 1.08-5.41, p = 0.035), renal insufficiency (OR 1.25, CI 1.03-1.62, p = 0.02), postoperative sepsis (OR 1.28, CI 1.08-1.82, p = 0.04), DVT (OR 1.7, CI 1.01-2.82, p = 0.04), and bile leakage (OR 1.75, CI 1.24-3.36, p = 0.04) were also increased in patients on steroids. However, the matched cohorts were similar in postoperative mortality rates (OR 0.11, CI 0.6-1.17, p = 0.72). CONCLUSION: The study found higher morbidity rates in patients undergoing liver resections on chronic preoperative steroids but no differences in mortality.

The Evolving Role of Instagram in General Surgery Residency Programs and Keys to Successful Use in Yours: Input from an Academic, Tertiary Referral Program.

INTRODUCTION: Social media has been used as a resource for the dissemination of information in the medical profession. To date, information regarding Instagram use amongst general surgery residency programs is lacking. Our study seeks to detail the use of Instagram amongst general surgery residency programs and to provide suggestions for the practical and successful use of Instagram by general surgery residency programs. METHORDS: We performed a cross-sectional search of general surgery residency program Instagram accounts through June 30, 2020. Descriptive details, the pattern of Instagram use by general surgery residency programs, and the use of Instagram by general surgery residency programs over time were investigated. RESULTS: Ninety-six (29.1%) of the 330 Accreditation Council for Graduate Medical Education (ACGME) general surgery residency programs were identified on Instagram, of which 86 (89.6%) accounts had at least one post. Academic programs (N = 67; 77.9%) were the most common type of program to have an Instagram account (N = 67). The most popular category of posts was promotion of the residents and faculty. In terms of Instagram activity, nearly 20% of Instagram posts were made in the last three-month block of our study period. Using Pearson correlations, positive associations were found between the number of posts and number of followers (0.62, p < 0.0001), the number of posts and the number of likes (0.42, p < 0.0001) and the number of followers and the number of likes (0.78, p < 0.0001). None of these variables were significantly associated with region or program type. CONCLUSIONS: To our knowledge, this is the first description of the use of Instagram by general surgery residency programs. Based on the pattern of use of Instagram by general surgery residency programs, we believe that there are five key elements to the successful use of Instagram by general surgery residency programs, including: Interact, Name, Promote, Utilize, and Team (INPUT).