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.

Attending guidance advised: educational quality of surgical videos on YouTube.

INTRODUCTION: YouTube is the most used platform for case preparation by surgical trainees. Despite its popular use, studies have noted limitations in surgical technique, safety, and vetting of these videos. This study identified the most viewed laparoscopic cholecystectomy (LC) videos on YouTube and analyzed the ability of attendings, residents, and medical students to identify critical portions of the procedure, technique, and limitations of the videos. METHODS: An incognito search was conducted on YouTube using the term "laparoscopic cholecystectomy." Results were screened for length, publication date, and language. The top ten most viewed videos were presented to general surgery attendings, residents, and medical students at a single academic institution. Established rubrics were used for evaluation, including the Critical View of Safety (CVS) for LC, a modified Global Operative Assessment of Laparoscopic Skills (GOALS) score, a task-specific checklist, and visual analog scales for case difficulty and operator competence. Educational quality and likelihood of video recommendation for case preparation were evaluated using a Likert scale. Attending assessments were considered the gold standard. RESULTS: Six attending surgeons achieved excellent internal consistency on CVS, educational quality, and likelihood of recommendation scales, with Cronbach alpha (⍺) of 0.93, 0.92, and 0.92, respectively. ⍺ was ≥ 0.7 in all the other scales measured. Attending evaluations revealed that only one of the ten videos attained all three established CVS criteria. Four videos demonstrated none of the CVS criteria. The mean educational quality (mEQ) was 4.63 on a 10-point scale. The mean likelihood of recommendation (mLoR) for case preparation was 2.3 on a 5-point scale. Senior resident assessments (Postgraduate Year (PGY)4 + , n = 12) aligned with attending surgeons, with no statistically significant differences in CVS attainment, mEQ, and mLoR. Junior residents (PGY1-3, n = 17) and medical students (MS3-4, n = 20) exhibited significant difference with attendings in CVS attainment, mEQ, and mLoR for more than half the videos. Both groups tended to overrate videos compared to attendings. CONCLUSION: YouTube is the most popular unvetted resource used for case presentation by surgical trainees. Attending evaluations revealed that the most viewed LC videos on YouTube did not attain the CVS, and were deemed as inappropriate for case preparation, with low educational value. Senior resident video assessments closely aligned with attendings, while junior trainees were more likely to overstate video quality and value. Attending guidance and direction of trainees to high-quality, vetted resources for surgical case preparation is needed. This may also suggest a need for surgical societies with platforms for video sharing to prioritize the creation and dissemination of high-quality videos on easily accessible public platforms.

The Role of Bariatric Surgery on Diabetes and Diabetic Care Compliance.

PURPOSE OF REVIEW: Bariatric surgery is a durable and long-term solution to treat both obesity and its associated comorbidities, specifically type 2 diabetes mellitus (T2DM). Many studies have demonstrated the benefits of bariatric surgery on T2DM, but weight recidivism along with recurrence of comorbidities can be seen following these procedures. Patient compliance post-bariatric surgery is linked to weight loss outcomes and comorbidity improvement/resolution. The role of compliance with respect to T2DM medication in bariatric patients specifically has not recently been examined. This article seeks to review the role of bariatric surgery on short- and long-term resolution of T2DM, recurrence, and compliance with T2DM medication following bariatric surgery. RECENT FINDINGS: Seven randomized control trials have examined metabolic surgery versus medical therapy in glycemic control in patients meeting criteria for severe obesity. Six out of seven studies demonstrate a significant advantage in the surgical arms with regards to glycemic control, as well as secondary endpoints such as weight loss, serum lipid levels, blood pressure, renal function, and other parameters. While patient compliance with lifestyle modifications post-bariatric surgery is linked to weight loss outcomes, there are no studies to date that directly evaluate the role of lifestyle modifications and T2DM medication adherence in the management of T2DM post-bariatric surgery. Bariatric surgery is an effective treatment option to achieve long-term weight loss and resolution of obesity-related medical comorbidities, specifically T2DM. Patient compliance to lifestyle modifications post-bariatric surgery is linked to weight loss outcomes and comorbidity resolution. The role of diabetic care compliance in bariatric patient outcomes, however, is poorly understood. Further studies are needed to elucidate the predictors and associated risk factors for non-compliance in this patient population.

SAGES Foregut Surgery Masters Program: a surgeon's social media resource for collaboration, education, and professional development.

BACKGROUND: Facebook is a popular online social networking platform increasingly used for professional collaboration. Literature regarding use of Facebook for surgeon professional development and education is limited. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has established a Facebook group dedicated to discussion of surgery of the esophagus, stomach, and small intestine-the "SAGES Foregut Surgery Masters Program." The aim of this study is to examine how this forum is used for professional development, education, and quality improvement. METHODS: Member and post statistics were obtained from https://grytics.com , a Facebook group analytics service. All posts added to the Foregut forum since its creation in April 2015 through December 2016 were reviewed and categorized for content and topic. Posts were reviewed for potential identifiable protected health information. RESULTS: As of December 2016, there were 649 total members in the group. There have been a total of 411 posts and 4116 comments with a median of 10.1 comments/post (range 0-72). Posts were categorized as operative technique (64%), patient management (52%), continuing education (10%), networking (10%), or other (6%). Video and/or photos were included in 53% of posts with 4% of posts depicting radiologic studies and 13% with intraoperative photos or videos. An additional 40 posts included links to other pages, such as YouTube, journal articles, or the SAGES website. One post (0.2%) contained identifiable protected health information and was deleted once recognized by the moderators of the group. CONCLUSION: Social media is a unique, real-time platform where surgeons can learn, discuss, and collaborate towards the goal of optimal treatment of surgical disease. Active online surgical communities such as the SAGES Foregut Surgery Masters Program have the potential to enhance communication between surgeons and are a potential innovative adjunct to traditional methods of continuing surgical education. Surgical societies should adopt and promote professional and responsible use of social media.

Viewer discretion advised: is YouTube a friend or foe in surgical education?

BACKGROUND: In the current era, trainees frequently use unvetted online resources for their own education, including viewing surgical videos on YouTube. While operative videos are an important resource in surgical education, YouTube content is not selected or organized by quality but instead is ranked by popularity and other factors. This creates a potential for videos that feature poor technique or critical safety violations to become the most viewed for a given procedure. METHODS: A YouTube search for "Laparoscopic cholecystectomy" was performed. Search results were screened to exclude animations and lectures; the top ten operative videos were evaluated. Three reviewers independently analyzed each of the 10 videos. Technical skill was rated using the GOALS score. Establishment of a critical view of safety (CVS) was scored according to CVS "doublet view" score, where a score of ≥5 points (out of 6) is considered satisfactory. Videos were also screened for safety concerns not listed by the previous tools. RESULTS: Median competence score was 8 (±1.76) and difficulty was 2 (±1.8). GOALS score median was 18 (±3.4). Only one video achieved adequate critical view of safety; median CVS score was 2 (range 0-6). Five videos were noted to have other potentially dangerous safety violations, including placing hot ultrasonic shears on the duodenum, non-clipping of the cystic artery, blind dissection in the hepatocystic triangle, and damage to the liver capsule. CONCLUSIONS: Top ranked laparoscopic cholecystectomy videos on YouTube show suboptimal technique with half of videos demonstrating concerning maneuvers and only one in ten having an adequate critical view of safety. While observing operative videos can be an important learning tool, surgical educators should be aware of the low quality of popular videos on YouTube. Dissemination of high-quality content on video sharing platforms should be a priority for surgical societies.

Evaluating the impact of a minimally invasive pediatric surgeon on hospital practice: comparison of two children's hospitals.

PURPOSE: Widespread adoption of minimally invasive surgery (MIS) techniques in pediatric surgery has progressed slowly, and the shift in practice patterns has been variable among surgeons. We hypothesized that a pediatric surgeon committed to MIS could effectively change surgical practice by creating an emphasis on MIS. METHODS: Annual case volumes from 2000 to 2009 at two tertiary care pediatric hospitals, one with a dedicated minimally invasive pediatric surgeon, were evaluated for trends in MIS for ten different operations. Univariate analyses of the differences between hospitals in the use of the open versus laparoscopic approach were performed. The Breslow-Day test was used to examine differences in use of laparoscopic procedures across hospitals in early versus middle and middle versus late time periods. RESULTS: Between the two hospitals, for 9 of the 10 types of surgery, the number of laparoscopic and open procedures differed significantly (p values ranged from <0.0001 to 0.003). Over the 10-year period, the hospital with a dedicated MIS surgeon had a larger proportion of procedures done laparoscopically for all years. This difference reached statistical significance for appendectomy (p < 0.0001), congenital diaphragmatic hernia (p < 0.0002), chest wall reconstruction (p < 0.0001), cholecystectomy (p = <0.0001), gastrostomy (p < 0.0001), nissen fundoplication (p < 0.0001) oophorectomy (p < 0.0001), pyloromyotomy (p < 0.0001) and splenectomy (p = 0.0006). After grouping the years into early (2000-2003), middle (2004-2006) and late (2007-2009) categories, the hospital with a dedicated MIS surgeon had a significantly higher rate of increase in use of laparoscopic surgery between the early and middle years for four procedures: diaphragmatic hernia repair (p = 0.003), chest wall reconstruction (p = 0.0086), cholecystectomy (0.0083) and endorectal pull-through (p = 0.025). CONCLUSION: The presence of a dedicated minimally invasive pediatric surgeon led to a significant change in surgical practice with an overall trend of increasing MIS several years in advance of a hospital that did not have a dedicated MIS surgeon. This has implications for resident training in academic medical centers and potential patient care outcomes.

Effects of experience and reference tools on laparoscopic length measurements.

INTRODUCTION: The accuracy of surgeons, and surgeons-in-training performing laparoscopic intestinal measurements is unknown. We evaluated the accuracy and precision of laparoscopic length measurements using a box-trainer model with and without the aid of a measuring tool. METHODS: Surgical attendings, residents, and medical students were studied. A 500 cm length of rope was placed within a laparoscopic box trainer. Subjects completed two length measurements (LM). Participants measured 150 cm of rope for LM #1 and repeated the task using a 10-cm suture as a reference for LM #2. Measurement accuracy was tested by comparing mean LM between training level groups using an independent t test. Measurement precision was tested by comparing the mean deviation of LM from 150 cm. RESULTS: 40 attendings, 40 residents, and 50 medical students were studied. In LM #1, there were no differences in mean length accuracy measured between training level groups. Residents significantly underestimated the true 150 cm length (p < 0.05). When LM #1 and LM #2 were compared, attending accuracy did not change but precision increased significantly (p < 0.01). Resident precision also significantly increased with the measuring tool (p < 0.001) and trended toward improved accuracy (p = 0.08). Student accuracy did not change, but a similar significant increase in precision was observed with the measurement tool (p = 0.001). Attendings performed both measurements faster than residents and students (p < 0.05). Residents performed faster than the students for both measurements (p < 0.05). Time for task completion significantly increased in medical students with the use of the measurement tool (p = 0.026). CONCLUSIONS: These data suggest that use of a measurement tool in laparoscopic length measurement will yield better precision with no effect on operative time or procedural flow in more experienced operators. Standardization of methods of use and optimal training techniques remains to be determined.

The impact of leukoreduced red blood cell transfusion on mortality of neonates undergoing extracorporeal membrane oxygenation.

BACKGROUND: Blood products containing leukocytes have been associated with negative immunomodulatory and infectious effects. Transfusion-related acute lung injury is partially explained by leucocyte agglutination. The Food and Drug Administration has therefore recommended leukoreduction strategies for blood product transfusion. Our institution has been using leukocyte-reduced blood via filtration for neonates on Extracorporeal Membrane Oxygenation (ECMO). We hypothesized that the use of leukocyte-reduced blood would decrease mortality and morbidity of neonatal ECMO patients. METHODS: Retrospective review of noncardiac ECMO in neonates from 1984-2011, stratified into year groups I and II (≤1996 and ≥1997). Demographics, duration and type of ECMO, complications, and outcome data were collected. Blood product use data was collected. Univariate, bivariate, and multivariate analyses determined predictors of risk-adjusted mortality by year group. RESULTS: Patients (827) underwent ECMO with 65.3% (540) in group I. Overall median blood product use in mL/kg/d was 36.2 packed red blood cells (pRBC), 8.1 platelets, and 0 cyroprecipitate and/or fresh-frozen plasma. Overall mortality was 16.4%. Median pRBC used or transfused was 42.1 mL/kg/d in group I versus 19.1 mL/kg/d group II (P <0.001). On bivariate analysis, there was no difference in crude mortality between the 2 year groups (17.2% versus 16.0%, P = 0.66). However, on multivariate analysis adjusting for demographics, diagnosis, complications, and blood product use other than pRBCs, each additional transfusion of 10 mL/kg/d of pRBC was associated with a 33% increase in mortality in group I (P <0.05). Group II also showed an increase in mortality with each additional transfusion (21%) but this was not statistically significant (P = 0.07). Days on ECMO were not associated with pRBC transfusion in group I but increased in group II (additional 3 d for each 10 mL/kg/d transfused). There was no difference in infectious complications between groups I and II. CONCLUSIONS: Blood transfusion requirement has diminished in newborns undergoing ECMO at our institution. Transfusion of non leukocyte-reduced blood is associated with an increase in mortality whereas transfusion of leukocyte-reduced blood provided no benefit with a trend toward increased mortality. Further research is recommended to understand these trends.

The changing population of the United States and use of extracorporeal membrane oxygenation.

BACKGROUND: Neonatal extracorporeal membrane oxygenation (ECMO) has been widely used for the last 25 y. The impact of ethno-demographic changes on ECMO outcomes has not been fully examined. We evaluated the Extracorporeal Life Support Organization registry over a 21-y period to understand these trends. METHODS: A retrospective review of all neonates undergoing noncardiac ECMO in the United States between the years 1990 and 2010 was conducted based on the years of available live birth census data. Demographic, clinical, and outcome data were collated. Patient specifics, ECMO type, ECMO length, arterial blood gases, and mortality were analyzed. Univariate, bivariate, and multivariate analyses were then performed. Changes in ethnic composition of neonates on ECMO were compared with similar ethnic trend in available U.S. live birth data. RESULTS: Data were available for 18,130 neonates. Comparing ethnicity by year, the proportion of Caucasian neonates requiring ECMO dropped from 64.3% in 1990 to 49.5% in 2010, while African-American and Hispanic neonates on ECMO increased from 21.1% and 11.1% to 26.1% and 17.4%, respectively (P < 0.001). By diagnosis, congenital diaphragmatic hernia surpassed meconium aspiration syndrome as the leading indication for ECMO compared with 1990 (congenital diaphragmatic hernia, 21.5%-28.4%; meconium aspiration syndrome, 47.0%-15.7%; P < 0.05). ECMO mortality nearly doubled, from 18.5% to 34.0% over the study period. On adjusted analysis, African-Americans were 17% less likely to die on ECMO compared with Caucasian neonates. CONCLUSIONS: Neonates of ethnic minorities continue to disproportionally require ECMO support in comparison to their birth rates. Although ethnicity alone does not impact the outcome of these newborns, the increased requirement of ECMO may highlight the need for targeted education, improved prenatal care, and decision making in these groups.

The Effect of Sizing Device Use During Laparoscopic Sleeve Gastrectomy on Rates of Postoperative Dehydration and Other 30-day Complications: An Analysis of the ACS-MBSAQIP Database.

BACKGROUND: During laparoscopic sleeve gastrectomy (LSG), many surgeons use an intraoperative sizing device. However, the choice of intraoperative sizing device varies and the optimal choice or combination of sizing devices, such as a bougie or esophagogastroduodenoscopy (EGD), is not known. The purpose of this study was to determine if there is an association between the use of a sizing device or a combination of sizing devices on rates of dehydration, bleeding, and staple line leak following LSG. MATERIALS AND METHODS: Patients between the ages of 18 to 80 who underwent elective LSG were identified using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (ACS-MBSAQIP) database from 2015 to 2019. Postoperative outcomes, including rates of dehydration, bleeding, and staple line leak, were compared across 4 groups: those that utilized bougie and EGD (both), those that utilized only bougie (bougie only), those that utilized only EGD (EGD only), and those that did not utilize either sizing device (neither). RESULTS: In all, 533,151 cases met the inclusion criteria. On univariate analysis, the bougie-only group experienced the highest rates of dehydration events. On multivariate analysis, the use of both sizing devices was associated with significantly lower odds of events related to dehydration versus bougie only (aOR 0.869, P =0.0002), and bougie only was associated with significantly higher odds of events related to dehydration versus EGD only (aOR 1.773, P =0.0006).The neither-sizing device group did not show any statistically significant differences in any of the comparisons. CONCLUSIONS: Bougie use alone was associated with more dehydration-related complications, while EGD use demonstrated a protective effect. Not using a sizing device was associated with equivalent outcomes to all combinations of sizing devices. These findings highlight the need for the standardization of sizing devices during LSG and suggest that foregoing sizing devices may be a management option without early adverse sequelae.

Cricothyrotomy Online: Quality Assessment of Educational Videos on YouTube.

BACKGROUND: Medical learners may use YouTube® videos to prepare for procedures. Videos are convenient and readily available, but without any uploading standards, their accuracy and quality for education are uncertain. We assessed the quality of emergency cricothyrotomy videos on YouTube through an expert panel of surgeons with objective quality metrics. METHODS: A YouTube® search for "emergency cricothyrotomy" was performed and results were filtered to remove animations and lectures. The 4 most-viewed videos were sent to a panel of trauma surgeons for evaluation. An educational quality (EQ) score was generated for each video based on its ability to explain the procedure indications, orient the viewer to the patient, provide accurate narration, provide clear views of procedure, identify relevant instrumentation and anatomy, and explain critical maneuvers. Reviewers were also asked if safety concerns were present and encouraged to give feedback in a free-response field. RESULTS: Four surgical attendings completed the survey. The median EQ score was 6 on a 7-point scale (95% CI [6, 6]). All but one of the individual parameters had a median EQ score of 6 (95% CI: indications [3, 7], orientation [5, 7], narration [6, 7], clarity [6, 7], instruments [6, 7], anatomy [6, 6], critical maneuvers [5, 6]). Safety received a lower EQ score (5.5, 95% CI [2, 6]). CONCLUSIONS: The most-viewed cricothyrotomy videos were rated positively by surgical attendings. Still, it is necessary to know if medical learners can distinguish high from low quality videos. If not, this suggests a need for surgical societies to create high-quality videos that can be reliably and efficiently accessed on YouTube®.

Mesh Versus No Mesh for Cruroplasty.

This review describes the evolution of hiatal hernia repair for the past several decades: From the use of a primary tissue repair only, the subsequent inclusion of synthetic mesh and its complications, to current day indications for mesh use. We will highlight the recent research in biologic and composite meshes as well as the ongoing limitations in studying their efficacy. Finally, we will describe our institutional indications and surgical technique practices in the utilization of biologic mesh.

Surgical Education and Training in the US: a Collaborative Effort to Deliver the Next Generation of Surgeons.

The foundational principles of surgical training in the USA are based on didactic education, structured skill training, and experiential learning in surgical patient care with the supervision of surgical faculty. A consortium of professional organizations, academic institutions, and teaching hospitals with surgical faculty provide the structural framework, policies, and curriculum to train and evaluate surgeons capable of independent practice. This manuscript describes the roles of the organizations responsible for surgical training in the USA and highlights areas in evolution in the modern surgical education landscape.

Analysis of Surgery Residency Website Content: Implications during the COVID-19 Era.

BACKGROUND: Surgery residency program websites (SRW) are an important source of information for prospective applicants. The COVID-19 pandemic spurred a pivot from the traditional in-person interview format to interviews via virtual platforms. Because of the inability to meet in person, the information provided on program websites takes on an increased relevance to applicants. We hypothesized that SRW may be missing content important to applicants. Our study aims to assess SRW for the content which impacts the applicant decision-making process. METHODS: An internal survey distributed to fourth-year medical students in 2020 at a single academic institution identified the website content most important to applicants. A list of ACGME-accredited SRW as of December 1, 2020 was obtained. Using the Fellowship and Residency Electronic and Interactive Database, websites were assessed for content parameters identified by the survey. RESULTS: Medical students applying to surgical specialties identified fellowship acquisition (94%), faculty information (88%), application contact information (82%), and resident wellness (77%) as the most important website content. Review of SRW websites identified content pertaining to fellowship acquisition and resident wellness in only 60% and 27% of cases respectively. Overall, the SRW of university programs included the most content parameters, followed by hybrid programs, then community programs. CONCLUSIONS: Many SRW are missing information that applicants deem important in their decision-making process. Most notably, there is a relative deficiency in information pertaining to fellowship match results and resident wellness. University based programs tend to include more of this information on their websites. SRW should continue to adapt to meet the needs of applicants in an increasingly virtual age.

The Effect of a Microlearning Module on Knowledge Acquisition in Surgery Clerkship Students.

OBJECTIVE: Microlearning has been found to be beneficial in other areas of healthcare education. The purpose of this study was to investigate the effect of a microlearning module compared to a traditional online learning module in undergraduate medical education. DESIGN: A microlearning module was developed to cover the etiology and management of gallbladder disease. Surgery clerkship students were randomized into 2 groups. One group began with the microlearning module (MLM). The second group began with a 45 minute commercially available module centered on gallbladder disease (WISE-MD™). Halfway through the clerkship, the groups crossed over to the other learning intervention. Student knowledge was assessed with a test at three time points (pre-test, post-test1, post-test2). SETTING AND PARTICIPANTS: Third year surgery clerkship students at George Washington University. RESULTS: There were 56 students in the MLM and 57 in WISE-MDTM groups. In the MLM group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, but significantly decreased from post-test1 to post-test2. In the WISE-MD™ group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, with no significant change from post-test1 to post-test2. After the initial intervention, test scores of post-test1 of the MLM group were significantly higher than the WISE-MD™ group, while there were no significant differences between groups at the pre-test or post-test2 time points. CONCLUSIONS: Students exposed to the microlearning module first performed significantly better on a post intervention test than students that used a commercially available product in our standard curriculum. Therefore, the use of microlearning modules may lead to improved knowledge acquisition in surgery clerkship students.

Association of Preoperative Glycosylated Hemoglobin Level with 30-Day Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of the ACS-MBSAQIP Database.

PURPOSE: Elevated glycosylated hemoglobin (HbA1c) levels have been associated with increased morbidity and mortality following several cardiac, colorectal, orthopedic, and vascular surgery operations. The purpose of this study was to determine if there is a HgA1c cut-point that can be used in patients undergoing laparoscopic Roux-en-Y gastric bypass to decrease the risk of 30-day wound events and additional 30-day morbidity and mortality. MATERIALS AND METHODS: All patients undergoing first-time, elective Roux-en-Y gastric bypass in 2017 and 2018 with a diagnosis of diabetes mellitus (DM) and a preoperative HbA1c level were identified within the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative HbA1c levels with 30-day morbidity and mortality was investigated. RESULTS: A total of 13,806 patients met inclusion criteria. Two natural HbA1c inflection points for composite wound events, including superficial, deep, and organ space surgical site infections (SSI) and wound dehiscence, were found. A HbA1c level of ≤ 6.5% was associated with a decreased odds of experiencing the composite 30-day wound event outcome while a HbA1c level of > 8.6% was associated with an increased odds of experiencing the composite 30-day wound event outcome. The differences in the incidence of the 30-day composite wound event outcomes were driven primarily by superficial and organ space SSI, including anastomotic leaks. CONCLUSION: Patients with DM being evaluated for RYGB surgery with a HbA1c level > 8.6% are at an increased risk for 30-day wound events, including superficial and organ space SSI.

Videos, Views, and Vaccines: Evaluating the Quality of COVID-19 Communications on YouTube.

OBJECTIVES: As the coronavirus disease 2019 (COVID-19) vaccine is introduced, it is critical to recognize that public opinion on vaccines is largely influenced by health communications, with YouTube being a major source of information and misinformation. This analysis graded the accuracy, quality, and reliability of the most viewed YouTube videos depicting COVID-19 and vaccinations over a 6-mo period. METHODS: We collected hyperlinks for the 150 most viewed YouTube videos discussing COVID-19 from January through June 2020. Closed captioning data were searched for the term "vaccine," yielding 32 videos. This sample was evaluated for quality, accuracy, and reliability using a rubric that incorporated existing instruments: Global Quality Scale (GQS), JAMA Benchmark Criteria, and DISCERN. RESULTS: These 32 videos had 139,764,188 views at the time of data collection. The majority of videos received low scores, with network news sources receiving the lowest scores overall. CONCLUSIONS: The overall quality of COVID-19 YouTube videos related to vaccines may be low and raises a precautionary alert for the public consuming these videos and for health-care providers working to provide the best information to their patients. Existing scoring tools may not capture the complexities of social media. New tools could allow for a better understanding of the modern landscape of health communications.

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).

Patient Risk Factors Associated with Increased Morbidity and Mortality Following Revisional Laparoscopic Bariatric Surgery for Inadequate Weight Loss or Weight Recidivism: an Analysis of the ACS-MBSAQIP Database.

PURPOSE: Revisional bariatric operations are associated with increased morbidity and mortality compared with primary bariatric operations. The purpose of this study was to determine if preoperative patient variables are associated with an increased risk of 30-day morbidity and mortality following revisional laparoscopic bariatric surgery for inadequate weight loss or weight recidivism and to generate expected model probabilities in order to risk stratify individual patients undergoing these operations. MATERIALS AND METHODS: All patients undergoing revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 to 2016 were identified with the American College of Surgeons Metabolic and Bariatric Surgery Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative patient variables with 30-day morbidity and mortality was investigated using multivariable logistic regression analysis. Predictive outcome models were developed for each outcome of interest. RESULTS: A total of 13,551 patients met inclusion criteria; 5310 (39.2%) underwent revisional RYGB. Each of the available preoperative variables was associated with one or more of the 30-day morbidity and mortality outcomes of interest. The strength of the predictive models, as reflected by the area under the curve, ranged from 0.63 for 30-day unplanned hospital readmission to 0.92 for cardiac events. CONCLUSION: Preoperative patient and surgical variables are associated with an increased risk of 30-day morbidity and mortality following laparoscopic revisional bariatric surgery. With these results, we have built a risk calculator that can be used as a resource for prehabilitation and patient counseling prior to revisional bariatric surgery.