Diaphragm pacing in spinal cord injury can significantly decrease mechanical ventilation in multicenter prospective evaluation.

BACKGROUND: Cervical spinal cord injury (SCI) can lead to dependence on mechanical ventilation (MV) with significant morbidity and mortality. The diaphragm pacing system (DPS) was developed as an alternative to MV. METHODS: We conducted a prospective single-arm study of DPS in MV-dependent patients with high SCI and intact phrenic nerves. Following device acclimation, pacing effectiveness to provide ventilation was evaluated. The primary endpoint was the number who could use DPS to breathe for 4 continuous hours without MV. Secondary endpoints included the number of patients that could use DPS 24 h/day free of MV and the ability of DPS to maintain clinically acceptable tidal volume (Vt). In addition, we conducted a meta-analysis that included the prospective study along with data from four recently published studies to evaluate DPS hourly use. RESULTS: Fifty-three patients were implanted in the prospective study. Most were male (77.4%) with a median time from injury to treatment of 28.3 (IQR: 12.1, 83.3) months. Four- and 24-h use occurred in 96.2% (95% CI: 87.0%, 99.5%) and 58.5% (95% CI: 44.1%, 74.9%), respectively. Four and 24-h results in the meta-analysis cohort (n = 196) exhibited similar results 92.2% (95% CI: 82.6%, 96.7%) and 52.7% (95% CI: 36.2%, 68.6%) using DPS for 4 and 24 h, respectively. DPS use significantly exceeded the calculated basal tidal volume requirements by a mean of 48.4% (95% CI: 37.0, 59.9%; p < 0.001). CONCLUSIONS: This study demonstrates that in most ventilator-dependent patients, diaphragm pacing can effectively supplement or completely replace the need for MV and support basal metabolic requirements.

Simulation training for the endoscopic management of upper gastrointestinal bleeding: a nationwide survey of rural surgeons' needs and preferences analysis.

BACKGROUND: Published needs analyses of rural surgeons have identified a need for training in the endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB). The study aim was to survey rural surgeons regarding their requirements and preferences for a simulation model on which they could rehearse the endoscopic management of NVUGIB. METHODS: Rural surgeons were contacted via the American College of Surgery Advisory Council listserv and invited to complete an online survey. RESULTS: A total of 66 responses were received, representing all 4 US regional divisions. Seventy-seven percent of respondents perform > 100 endoscopy cases per year. A majority have no experience with simulation models (77%), citing cost, time, and access to training courses as the three most limiting factors. Thirty-three percent lacked confidence in managing UGIBs, and 73% were interested in receiving additional training. Preference analysis revealed that respondents preferred a portable simulation model (81%) that costs between $500 and $1000 (46%), and requires 1-2 weeks of training (34%). Verbal feedback from an expert was viewed as the most helpful type of feedback (61%). CONCLUSION: Rural surgeons frequently perform flexible endoscopy in their practice and are interested in further training for the endoscopic management of NVUGIB. These results will be used to develop a simulation platform for training in the endoscopic management of NVUGIB that meets rural surgeons' needs.

Video-based assessment for laparoscopic fundoplication: initial development of a robust tool for operative performance assessment.

INTRODUCTION: While better technical performance correlates with improved outcomes, there is a lack of procedure-specific tools to perform video-based assessment (VBA). SAGES is developing a series of VBA tools with enough validity evidence to allow reliable measurement of surgeon competence. A task force was established to develop a VBA tool for laparoscopic fundoplication using an evidence-based process that can be replicated for additional procedures. The first step in this process was to seek content validity evidence. METHODS: Forty-two subject matter experts (SME) in laparoscopic fundoplication were interviewed to obtain consensus on procedural steps, identify potential variations in technique, and to generate an inventory of required skills and common errors. The results of these interviews were used to inform creation of a task inventory questionnaire (TIQ) that was delivered to a larger SME group (n = 188) to quantify the criticality and difficulty of the procedural steps, the impact of potential errors associated with each step, the technical skills required to complete the procedure, and the likelihood that future techniques or technologies may change the presence or importance of any of these factors. Results of the TIQ were used to generate a list of steps, skills, and errors with strong validity evidence. RESULTS: Initial SMEs interviewed included fellowship program directors (45%), recent fellows (24%), international surgeons (19%), and highly experienced super SMEs with quality outcomes data (12%). Qualitative analysis of interview data identified 6 main procedural steps (visualization, hiatal dissection, fundus mobilization, esophageal mobilization, hiatal repair, and wrap creation) each with 2-5 sub steps. Additionally, the TIQ identified 5-10 potential errors for each step and 11 key technical skills required to perform the procedure. Based on the TIQ, the mean criticality and difficulty scores for the 11/21 sub steps included in the final scoring rubric is 4.66/5 (5 = absolutely essential for patient outcomes) and 3.53/5 (5 = difficulty level requires significant experience and use of alternative strategies to accomplish consistently), respectively. The mean criticality and frequency scores for the 9/11 technical skills included is 4.51/5 and 4.51/5 (5 = constantly used ≥ 80% of the time), respectively. The mean impact score of the 42/47 errors incorporated into the final rubric is 3.85/5 (5 = significant error that is unrecoverable, or even if recovered, likely to have a negative impact on patient outcome). CONCLUSIONS: A rigorous, multi-method process has documented the content validity evidence for the SAGES video-based assessment tool for laparoscopic fundoplication. Work is ongoing to pilot the assessment tool on recorded fundoplication procedures to establish reliability and further validity evidence.

Robotic and per-oral endoscopic myotomy have fewer technical complications compared to laparoscopic Heller myotomy.

BACKGROUND: Achalasia is an uncommon disease treated by decreasing the lower esophageal sphincter resting pressure. This study compared the safety and efficacy of esophago-gastric myotomy via laparoscopic, robotic, and per-oral endoscopic approaches. METHODS: A retrospective review of data on patients with achalasia or other esophageal dysmotility disorder undergoing laparoscopic, robotically assisted, or per-oral endoscopic myotomy (POEM) procedures between 2013 and 2017 was performed. Patient demographics, comorbidities, procedure details, length of stay, 30-day readmission rate, and combined technical complication (full-thickness injury, conversion to open, and delayed perforation) were compared. Multiple logistic regression analysis was performed to determine which factors contributed to combined technical complication. RESULTS: There were 171 patients who underwent esophago-gastric myotomy with 161 (94.2%) having achalasia. There were 40 laparoscopic Heller myotomies with partial fundoplication, 44 robotic Heller myotomies with partial fundoplication, and 87 POEM procedures performed during the study period. Baseline statistical differences were found among the groups in regard to gastroesophageal reflux symptoms, arrhythmia, hypertension, and congestive heart failure. Laparoscopic Heller myotomy had significantly higher combined technical complications (7, 17.5%) compared to robotically assisted Heller myotomy (0, 0%) and POEM (1, 1.1%). Multivariate analysis showed that laparoscopic Heller myotomy (OR 32.22; 95% CI 2.66, 389.83; p = 0.01), myocardial infarction (OR 27.94; 95% CI 1.66, 471.10; p = 0.02), and history of smoking (OR 8.87; 95% CI 1.29, 61.15; p = 0.03) were risks for developing combined technical complications. CONCLUSION: Robotically assisted Heller myotomy and POEM are safe and efficacious treatments for achalasia with lower rates of technical complications compared to laparoscopic Heller myotomy. With the advancements in endoscopic instruments and robotic surgery, POEM and robotically assisted Heller myotomy should be considered in the treatment of achalasia and esophageal dysmotility disorders.

Task Deconstruction of Colonic Endoscopic Submucosal Dissection (cESD): An Expert Consensus.

BACKGROUND: Slow adoption of colonic ESD (cESD) in the US is multifactorial due to: lack of clinical training construct (e.g., gastric ESD in Japan), complication risks, and technical difficulty. More than 28,000 patients/year undergo colonic resection for benign lesions that could be managed effectively with cESD. Selected patients could avoid surgery if procedural adoption of cESD increased due to more accessible training. Current US cESD training is scarce, and existing programs are piecemeal. There is a need to develop an effective national training program for practicing endoscopists. A prerequisite to training development is a comprehensive task list delineating procedural steps. The aim of this work was to describe an evidence-based method of deconstructing cESD into the essential steps to provide a task list to guide teaching and assessment. METHODS: Subject-matter experts (SMEs) performed a literature review to create an initial procedural step list. Eleven clinical cESD SMEs and four educational SMEs formed a 'cESD Working Group' to develop consensus regarding steps. Through a two-stage modified Delphi process, a consensus on a comprehensive standard cESD deconstructed task list was reached. The aim was to standardize cESD teaching to efficiently bring a novice to safe performance. RESULTS: A literature review identified eight initial cESD steps. First-round Delphi consensus was gained on seven steps. Semi-structured focus group discussions resulted in consensus on a modified version of 7 of the initial steps, with addition of two steps. Consensus on procedural actions needed to perform each step was achieved after the hands-on laboratory. The final result was a ten-step deconstructed task list for standard cESD. CONCLUSION: The development of a standardized cESD procedural task list provides a foundation to safely and efficiently teach cESD to practicing endoscopists. This list can be used to develop a training pathway to increase procedural adoption. Selected patients currently undergoing colonic resections could benefit from increased adoption of cESD.

Pursuing Excellence: The Power of Selection Science to Provide Meaningful Data and Enhance Efficiency in Selecting Surgical Trainees.

INTRODUCTION: As current screening methods for selecting surgical trainees are receiving increasing scrutiny, development of a more efficient and effective selection system is needed. We describe the process of creating an evidence-based selection system and examine its impact on screening efficiency, faculty perceptions, and improving representation of underrepresented minorities. METHODS: The program partnered with an expert in organizational science to identify fellowship position requirements and associated competencies. Situational judgment tests, personality profiles, structured interviews, and technical skills assessments were used to measure these competencies. The situational judgment test and personality profiles were administered online and used to identify candidates to invite for on-site structured interviews and skills testing. A final rank list was created based on all data points and their respective importance. All faculty completed follow-up surveys regarding their perceptions of the process. Candidate demographic and experience data were pulled from the application website. RESULTS: Fifty-five of 72 applicants met eligibility requirements and were invited to take the online assessment, with 50 (91%) completing it. Average time to complete was 42 ±â€Š12 minutes. Eighteen applicants (35%) were invited for on-site structured interviews and skills testing-a greater than 50% reduction in number of invites compared to prior years. Time estimates reveal that the process will result in a time savings of 68% for future iterations, compared to traditional methodologies. Fellowship faculty (N = 5) agreed on the value and efficiency of the process. Underrepresented minority candidates increased from an initial 70% to 92% being invited for an interview and ranked using the new screening tools. DISCUSSION: Applying selection science to the process of choosing surgical trainees is feasible, efficient, and well-received by faculty for making selection decisions.

Faculty Development for the Operating Room: An Examination of the Effectiveness of an Intraoperative Teaching Course for Surgeons.

OBJECTIVE: We describe a half-day faculty development course designed to equip surgical educators with evidence-based teaching frameworks shown to promote learning in the operating room (OR). We hypothesize that participating faculty will deliver improved instruction as perceived by residents. METHODS: Residents anonymously rated faculty teaching behaviors among whom they had recently worked in the OR (minimum 3 cases in preceding 6 months) using the Briefing - Intraoperative teaching - Debriefing Assessment Tool (BIDAT; 1 = never, 5 = always). Faculty then attended a half-day course. The curriculum was based on the "briefing-intraoperative teaching-debriefing" framework. Discussion and practice centered on goal setting, performance-enhancing instruction, dual task interference, and feedback. After the course, residents again evaluated the faculty. Paired-samples and independent-samples t tests were used to analyze pre and post course changes and differences between groups, respectively. RESULTS: Nineteen faculty completed the course. Associate professors (N = 4) demonstrated improved briefing (4.32 ±â€Š0.48 → 4.76 ±â€Š0.45, P < 0.01), debriefing (4.30 ±â€Š0.29 → 4.77 ±â€Š0.43, P < 0.01), and total teaching (4.38 ±â€Š0.78 → 4.79 ±â€Š0.39, P < 0.05). No significant changes were observed among assistant (N = 9) or full professors (N = 6). All 3 faculty members who served as course co-instructors, regardless of rank, improved significantly in briefing (4.42 ±â€Š0.22 → 4.98 ±â€Š0.29, P < 0.05), debriefing (4.27 ±â€Š0.23 → 4.98 ±â€Š0.29, P < 0.04), and total teaching (4.37 ±â€Š0.21 → 4.99 ±â€Š0.02, P < 0.05). Faculty with baseline teaching scores in the bottom quartile improved teaching behaviors in all phases of instruction (P < 0.05). Teaching scores over the same period did not change among faculty who did not attend. CONCLUSIONS: A half-day course aimed at enhancing intraoperative instruction can contribute to resident-perceived improvement in structured teaching behavior among participating faculty. Initiatives directed at intraoperative instruction might be best targeted towards midlevel faculty with established technical expertise who are motivated to expand teaching efforts and those who have low levels of baseline teaching scores.

ASGE EndoVators Summit: simulators and the future of endoscopic training.

Interest in the use of simulation for acquiring, maintaining, and assessing skills in GI endoscopy has grown over the past decade, as evidenced by recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines encouraging the use of endoscopy simulation training and its incorporation into training standards by a key accreditation organization. An EndoVators Summit, partially supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, (NIH) was held at the ASGE Institute for Training and Technology from November 19 to 20, 2017. The summit brought together over 70 thought leaders in simulation research and simulator development and key decision makers from industry. Proceedings opened with a historical review of the role of simulation in medicine and an outline of priority areas related to the emerging role of simulation training within medicine broadly. Subsequent sessions addressed the summit's purposes: to review the current state of endoscopy simulation and the role it could play in endoscopic training, to define the role and value of simulators in the future of endoscopic training and to reach consensus regarding priority areas for simulation-related education and research and simulator development. This white paper provides an overview of the central points raised by presenters, synthesizes the discussions on the key issues under consideration, and outlines actionable items and/or areas of consensus reached by summit participants and society leadership pertinent to each session. The goal was to provide a working roadmap for the developers of simulators, the investigators who strive to define the optimal use of endoscopy-related simulation and assess its impact on educational outcomes and health care quality, and the educators who seek to enhance integration of simulation into training and practice.

The SAGES flexible endoscopy course for fellows: a worthwhile investment in furthering surgical endoscopy.

BACKGROUND: The SAGES flexible endoscopy course for minimally invasive surgery (MIS) fellows improves confidence and skills in performing gastrointestinal (GI) endoscopy. This study evaluated the long-term retention of these confidence levels and investigated how fellows changed practices within their fellowships due to the course. METHODS: Participating MIS fellows completed surveys 6 months after the course. Respondents rated their confidence to independently perform 16 endoscopic procedures (1 = not at all; 5 = very), barriers to use of endoscopy, and current uses of endoscopy. Respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (FES) certification. Comparisons of responses from the immediate post-course survey to the 6-month follow-up survey were examined. McNemar and paired t tests were used for analyses. RESULTS: 23 of 57 (40%) course participants returned to the 6-month survey. No major barriers to endoscopy use were identified. Fellows reported less competition with GI providers as a barrier to practice compared to their original post-course expectations (50% vs. 86%, p < 0.01). In addition, confidence was maintained in performing the majority of the 16 endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (- 26%; p < 0.05), control of variceal bleeding (- 39%; p < 0.05), colonic stenting (- 48%; p < 0.01), BARRX (- 40%; p < 0.05), and TIF (- 31%; p < 0.05). Fewer fellows used the GI suite to manage surgical problems than was anticipated post course (26% vs. 74%, p < 0.01). Fellows who passed FES noted no significant loss of independence, changes in use, or barriers to use. 18% made additional partnerships with industry after the course. 41% stated flexible endoscopy has influenced their post-fellowship job choice. CONCLUSIONS: The SAGES flexible endoscopy course for MIS fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures 6 months later. Additionally, fellows experienced no major barriers to implementing endoscopy into practice.

EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice.

BACKGROUND: Acute diverticulitis (AD) presents a unique diagnostic and therapeutic challenge for general surgeons. This collaborative project between EAES and SAGES aimed to summarize recent evidence and draw statements of recommendation to guide our members on comprehensive AD management. METHODS: Systematic reviews of the literature were conducted across six AD topics by an international steering group including experts from both societies. Topics encompassed the epidemiology, diagnosis, management of non-complicated and complicated AD as well as emergency and elective operative AD management. Consensus statements and recommendations were generated, and the quality of the evidence and recommendation strength rated with the GRADE system. Modified Delphi methodology was used to reach consensus among experts prior to surveying the EAES and SAGES membership on the recommendations and likelihood to impact their practice. Results were presented at both EAES and SAGES annual meetings with live re-voting carried out for recommendations with < 70% agreement. RESULTS: A total of 51 consensus statements and 41 recommendations across all six topics were agreed upon by the experts and submitted for members' online voting. Based on 1004 complete surveys and over 300 live votes at the SAGES and EAES Diverticulitis Consensus Conference (DCC), consensus was achieved for 97.6% (40/41) of recommendations with 92% (38/41) agreement on the likelihood that these recommendations would change practice if not already applied. Areas of persistent disagreement included the selective use of imaging to guide AD diagnosis, recommendations against antibiotics in non-complicated AD, and routine colonic evaluation after resolution of non-complicated diverticulitis. CONCLUSION: This joint EAES and SAGES consensus conference updates clinicians on the current evidence and provides a set of recommendations that can guide clinical AD management practice.

Passing the fundamentals of endoscopic surgery (FES) exam: linking specialty choice and attitudes about endoscopic surgery to success.

INTRODUCTION: Previous work has shown that up to 30% of graduating surgery residents fail the fundamentals of endoscopic surgery (FES) exam. This study investigated the extent to which FES pass rates differ in a specific sample of individuals who have chosen a career in GI surgery and to examine the relationships between FES performance and confidence in performing flexible endoscopy. METHODS: Fellows attending the 2016 SAGES Flexible Endoscopy Course were invited to complete the FES manual skills examination. Participants also provided survey responses examining demographics, fellowship type, endoscopy curricula in residency, previous endoscopic case volume, confidence in performing endoscopy, and future practice plans. RESULTS: Twenty-nine (age: 32.24 ± 3.24; 72% men) fellows completed the FES skills examination. Reported fellowships were MIS/Bariatric (41.4%), MIS (24.1%), bariatric (13.8%), flexible endoscopy (6.9%), Advanced GI (6.9%), and MIS/bariatric/flexible endoscopy (6.9%). Almost half (41.4%) had previously participated in a simulation curricula, with 20.7% completing a didactic endoscopy curriculum. Fellows reported performing an average of 110 ± 109.48 EGDs and 77.44 ± 58.80 colonoscopies. The majority (96.4%) indicated that they will perform endoscopy at least occasionally in practice. Overall pass rate was 60%. Previous endoscopy experience did not correlate with overall FES examination scores. However, confidence performing EGDs (r = 0.57, p < 0.01), colonoscopies (r = 0.45, p < 0.05), polypectomy (r = 0.52, p < 0.01), and PEGs (r = 0.46, p < 0.05) did. CONCLUSIONS: These data support existing research suggesting that current flexible endoscopy training in residency may be insufficient for trainees to pass the FES examination, and that failure rates hold true even for this select group of trainees who have chosen a profession in GI surgery and intend to use endoscopy in practice.

All in: expansion of the acquisition of data for outcomes and procedure transfer (ADOPT) program to an entire SAGES annual meeting hands-on hernia course.

BACKGROUND: Continuing professional development (CPD) for the surgeon has been challenging because of a lack of standardized approaches of hands-on courses, resulting in poor post-course outcomes. To remedy this situation, SAGES has introduced the ADOPT program, implementing a standardized, long-term mentoring program as part of its hernia hands-on course. Previous work evaluating the pilot program showed increased adoption of learned procedures as well as increased confidence of the mentored surgeons. This manuscript describes the impact of such a program when it is instituted across an entire hands-on course. METHODS: Following collection of pre-course benchmark data, all participants in the 2016 SAGES hands-on hernia course underwent structured, learner-focused instruction during the cadaveric lab. All faculty had completed a standardized teaching course in the Lapco TT format. Subsequently, course participants were enrolled in a year-long program involving longitudinal mentorship, webinars, conference calls, and coaching. Information about participant demographics, training, experience, self-reported case volumes, and confidence levels related to procedures were collected via survey 3 months prior to 9 months after the course. RESULTS: Twenty surgeons participated in the SAGES ADOPT 2016 hands-on hernia program. Of these, seventeen completed pre-course questionnaires (85%), ten completed the 3-month questionnaire (50%), and four completed the 9-month questionnaire (20%). Nine of ten respondents of the 3-month survey (90%) reported changes in their practice. In the 9-month survey, significant increases in the annualized procedural volumes were reported for open primary ventral hernia repair, open components separation, and mesh insertion for ventral hernia repair (p < 0.001). CONCLUSIONS: The expansion of the ADOPT program to an entire hands-on hernia course is both feasible and beneficial, with evidence of Kirkpatrick Levels 1-4a training effectiveness. This expanded success suggests that it is a useful blueprint for the CPD of surgeons wishing to learn new techniques and procedures for their patients.

SAGES's advanced GI/MIS fellowship curriculum pilot project.

BACKGROUND: The American health care system faces deficits in quality and quantity of surgeons. SAGES is a major stakeholder in surgical fellowship training and is responsible for defining the curriculum for the Advanced GI/MIS fellowship. SAGES leadership is actively adapting this curriculum. METHODS: The process of reform began in 2014 through a series of iterative meetings and discussions. A working group within the Resident and Fellow Training Committee reviewed case log data from 2012 to 2015. These data were used to propose new criteria designed to provide adequate exposure to core content. The working group also proposed using video assessment of an MIS case to provide objective assessment of competency. RESULTS: Case log data were available for 326 fellows with a total of 85,154 cases logged (median 227 per fellow). The working group proposed new criteria starting with minimum case volumes for five defined categories including foregut (20), bariatrics (25), inguinal hernia (10), ventral hernia (10), and solid organ/colon/thoracic (10). Fellows are expected to perform an additional 75 complex MIS cases of any category for a total of 150 required cases overall. The proposal also included a minimum volume of flexible endoscopy (50) and submission of an MIS foregut case for video assessment. The new criteria more clearly defined which surgeon roles count for major credit within individual categories. Fourteen fellowships volunteered to pilot these new criteria for the 2017-2018 academic year. CONCLUSIONS: The new SAGES Advanced GI/MIS fellowship has been crafted to better define the core content that should be contained in these fellowships, while still allowing sufficient heterogeneity so that individual learners can tailor their training to specific areas of interest. The criteria also introduce innovative, evidence-based methods for assessing competency. Pending the results of the pilot program, SAGES will consider broad implementation of the new fellowship criteria.

Proficiency-based preparation significantly improves FES certification performance.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) certification has recently been mandated by the American Board of Surgery but best methods for preparing for the exam are lacking. Our previous work demonstrated a 40% pass rate for PGY5 residents in our program. The purpose of this study was to determine the effectiveness of a proficiency-based skills and cognitive curriculum for FES certification. METHODS: Residents who agreed to participate (n = 15) underwent an orientation session, followed by skills pre-testing using three previously described models (Trus, Operation targeting task, and Kyoto) as well as the actual FES skills exam (vouchers provided by the FES committee). Participants then trained to proficiency on all three models for the skills curriculum and completed the FES online didactic material for the cognitive curriculum. Finally, participants post-tested on the models and took the actual FES certification exam. Values are mean ± SD; p < 0.05 was considered significant. RESULTS: Of 15 residents who participated, 8 (53%) passed the FES skills exam at baseline. Participants required 2.7 ± 1.3 h to achieve proficiency on the models and approximately 3 h to complete the cognitive curriculum. At post-test, 14 (93%, vs. pre-test 53%, p = 0.041) passed the FES skills exam. 14 (93%) passed the FES cognitive exam and 13/15 (87%) passed both the skills and cognitive exam and achieved FES certification. CONCLUSIONS: Our traditional clinical endoscopy curricula were not sufficient for senior residents to pass the FES exam. Implementation of a proficiency-based flexible endoscopy curriculum using bench-top models and the FES online materials was feasible and effective for the majority of learners. Importantly, with a modest amount of additional training, 87% of our trainees were able to pass the FES examination, which represents a significant improvement for our program. We expect that additional refinements of this curriculum may yield even better results for preparing future residents for the FES examination.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae.

BACKGROUND: Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair. METHODS: Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone. RESULTS: A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543). CONCLUSIONS: Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.

Characterization of ventral incisional hernia and repair using shear wave elastography.

BACKGROUND: To assess the integrity of hernia repair, imaging modalities such as computed tomography or ultrasound (US) are commonly used. Neither modality has currently the capacity to simultaneously image the mesh and quantify a prosthetic and surrounding tissue stiffness. In this pilot study, we hypothesize that US shear wave elastography (SWE) can be used to identify a polyester mesh and a biologic graft and to assess their stiffness noninvasively in a rat model of bridging hernia repair. METHODS: Lewis rats underwent hernia creation and repair with Parietex or Strattice at 30 d. After 3 mo, the animals were euthanized, and the Young's Modulus was measured using SWE. Three-dimensional reconstructions of the hernia pre- and post-repair were performed using in-house image processing algorithms. RESULTS: SWE was capable of accurate and real-time assessment and diagnosis of the hernia defects in vivo. Young's Modulus of Parietex meshes and Strattice grafts as estimated from the shear wave elastograms were found to be statistically different from each other (P < 0.05). Accurate three-dimensional reconstructions of the hernia defects pre- and post-repair were generated. CONCLUSIONS: In this study, we demonstrate the feasibility of using US SWE to detect ventral hernias and evaluate mesh repair in vivo. Our results indicate that the presence of a hernia and repair can be reliably visualized by SWE and three dimensionally reconstructed. Thus, this technique may provide both structural and functional information regarding the hernia and the repair.

Hands-on 2.0: improving transfer of training via the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program.

BACKGROUND: Practicing surgeons commonly learn new procedures and techniques by attending a "hands-on" course, though trainings are often ineffective at promoting subsequent procedure adoption in practice. We describe implementation of a new program with the SAGES All Things Hernia Hands-On Course, Acquisition of Data for Outcomes and Procedure Transfer (ADOPT), which employs standardized, proven teaching techniques, and 1-year mentorship. Attendee confidence and procedure adoption are compared between standard and ADOPT programs. METHODS: For the pilot ADOPT course implementation, a hands-on course focusing on abdominal wall hernia repair was chosen. ADOPT participants were recruited among enrollees for the standard Hands-On Hernia Course. Enrollment in ADOPT was capped at 10 participants and limited to a 2:1 student-to-faculty ratio, compared to the standard course 22 participants with a 4:1 student-to-faculty ratio. ADOPT mentors interacted with participants through webinars, phone conferences, and continuous email availability throughout the year. All participants were asked to provide pre- and post-course surveys inquiring about the number of targeted hernia procedures performed and related confidence level. RESULTS: Four of 10 ADOPT participants (40%) and six of 22 standard training participants (27%) returned questionnaires. Over the 3 months following the course, ADOPT participants performed more ventral hernia mesh insertion procedures than standard training participants (median 13 vs. 0.5, p = 0.010) and considerably more total combined procedures (median 26 vs. 7, p = 0.054). Compared to standard training, learners who participated in ADOPT reported greater confidence improvements in employing a components separation via an open approach (p = 0.051), and performing an open transversus abdominis release, though the difference did not achieve statistical significance (p = 0.14). DISCUSSION: These results suggest that the ADOPT program, with standardized and structured teaching, telementoring, and a longitudinal educational approach, is effective and leads to better transfer of learned skills and procedures to clinical practice.

Changing attitudes and improving skills: demonstrating the value of the SAGES flexible endoscopy course for fellows.

BACKGROUND: The purpose of this study was to examine the effectiveness of the SAGES flexible endoscopy course in improving fellows' attitudes, confidence, and skills related to implementing endoscopy in practice. METHODS: Fellows participated in a 2-day course consisting of case presentations, expert panels, and hands-on laboratory training. Before and after the course, fellows completed a questionnaire assessing demographics, experiences in residency, practice plans, plans to implement flexible endoscopy in practice, and level of confidence performing 15 endoscopic procedures. Half of the fellows were randomly assigned to complete pre- and post-skills testing using a previously validated endoscopic targeting model. RESULTS: Fifty-four fellows (90 %; age 33.5 ± 2.8; 58 % male) completed the pre- and post-questionnaire. All MIS fellowship types were represented. Almost half (48 %) reported none or very little flexible endoscopy in their current fellowship. The average prior case volume among those completing an ACGME-approved residency (42/54) was 76 upper and 75 lower endoscopies with one-third reporting no experience in therapeutic EGD (33 %) or polypectomy (31 %). Intentions to implement flexible endoscopy in practice significantly improved after the course overall (3.72 ± .85-3.92 ± .69, p < 0.05; 1 = never; 5 = very frequently). Prior to the course, 39 % of fellows reported plans to use endoscopy in practice "occasionally" or "rarely." After, this decreased to 28 with 72 % planning to implement "frequently" or "very frequently." Mean levels of confidence performing all 15 endoscopic tasks improved significantly after the course. Skills performance for the 27 fellows improved significantly as well; participants decreased their time to perform the targeting task by 40 % (222.3 ± 119.8-133.0 ± 70.1 s; p < 0.001) and decreased errors by 49 % (2.9 ± 1.7-1.5 ± 1.5; p < 0.001). CONCLUSIONS: These results indicate that the SAGES flexible endoscopy course increases fellow confidence to implement endoscopic techniques, expands the ways in which they plan to include endoscopy in practice, and enhances their endoscopic skills.

The SmartOR: a distributed sensor network to improve operating room efficiency.

BACKGROUND: Despite the significant expense of OR time, best practice achieves only 70% efficiency. Compounding this problem is a lack of real-time data. Most current OR utilization programs require manual data entry. Automated systems require installation and maintenance of expensive tracking hardware throughout the institution. This study developed an inexpensive, automated OR utilization system and analyzed data from multiple operating rooms. STUDY DESIGN: OR activity was deconstructed into four room states. A sensor network was then developed to automatically capture these states using only three sensors, a local wireless network, and a data capture computer. Two systems were then installed into two ORs, recordings captured 24/7. The SmartOR recorded the following events: any room activity, patient entry/exit time, anesthesia time, laparoscopy time, room turnover time, and time of preoperative patient identification by the surgeon. RESULTS: From November 2014 to December 2015, data on 1003 cases were collected. The mean turnover time was 36 min, and 38% of cases met the institutional goal of ≤30 min. Data analysis also identified outlier cases (>1 SD from mean) in the domains of time from patient entry into the OR to intubation (11% of cases) and time from extubation to patient exiting the OR (11% of cases). Time from surgeon identification of patient to scheduled procedure start time was 11 min (institution bylaws require 20 min before scheduled start time), yet OR teams required 22 min on average to bring a patient into the room after surgeon identification. CONCLUSION: The SmartOR automatically and reliably captures data on OR room state and, in real time, identifies outlier cases that may be examined closer to improve efficiency. As no manual entry is required, the data are indisputable and allow OR teams to maintain a patient-centric focus.

SAGE(S) advice: application of a standardized train the trainer model for faculty involved in a Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) hands-on course.

INTRODUCTION: Currently, no prerequisite teaching qualification is required to serve as faculty for SAGES hands-on courses (SAGES-HOC). The Lapco-Train-the-Trainers (Lapco-TT) is a course for surgical trainers, in which delegates learn a standardized teaching technique for skills acquisition. The aims of this study were to 1) determine if this curriculum could be delivered in a day course to SAGES-HOC faculty and 2) assess the impact of such training on learners' educational experience taught by this faculty at a subsequent SAGES-HOC. METHODS AND PROCEDURES: Six experts attended a one-day Lapco-TT course. SAGES-HOC participants were split into two groups: Group A taught by Lapco-TT trained, and Group B by "untrained" course faculty. Opinion surveys were completed by both the SAGES-HOC learners and the Lapco-TT trained course faculty. Furthermore, the latter underwent self-, learner-, and observer-based evaluation using a previously validated teaching assessment tool (cSTTAR). Mean scores were reported and analyzed [Mann-Whitney U, t test (p < 0.05)]. RESULTS: All 6 Lapco-TT delegates found the course useful (5), and felt that it would influence the way they taught in the OR (4.83), that their course objectives were met (4.83), and that they would recommend the course to their colleagues (4.83). Of the SAGES-HOC participants, compared to Group B (n = 22), Group A learners(n = 10) better understood what they were supposed to learn (5 vs. 4.15 [p = 0.046]) and do (5 vs. 4 [p = 0.046]), felt that the session was well organized (5 vs. 4 [p = 0.046]), that time was used effectively (5 vs. 3.9 [p = 0.046]), and that performance feedback was sufficient (5 vs. 3.9 [p = 0.028]) and effective (5 vs. 3.95 [p = 0.028]). Group A faculty were rated significantly higher by their learners on the cSTTARs than Group B (p < 0.0005). Group A faculty rated themselves significantly lower than both expert observers (p < 0.0005) and compared to the Group B faculty's self-assessment (p < 0.002). CONCLUSIONS: The Lapco-TT course can be delivered effectively over one day and impacts the educational experience of learners at a SAGES-HOC. This could help establish a standardized method of teaching at SAGES-HOCs and thereby increase their value for learners.