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BACKGROUND: In the United States, the discrepancy between organ availability and need has persisted despite changes in allocation, innovations in preservation, and policy initiatives. Living donor liver transplant (LDLT) remains an underutilized means of improving access to timely liver transplantation and decreasing waitlist mortality. Liver paired exchange (LPE) represents an opportunity to overcome LDLT pair incompatibility due to size, anatomy, or blood type. METHODS: LPE was adopted as a strategy to augment access to liver transplantation at our institution. Specific educational materials, consent forms, and selection processes were developed to facilitate LPE. RESULTS: From 2019 through October 2023, our center performed 11 LPEs, resulting in 23 LDLT pairs. The series included several types of LPE: those combining complementary incompatible pairs, the inclusion of compatible pairs to overcome incompatibility, and the use of altruistic non-directed donors to initiate chains. These exchanges facilitated transplantation for 23 recipients, including 1 pediatric patient. CONCLUSIONS: LPE improved access to liver transplantation at our institution. The ethical application of LPE includes tailored patient education, assessment and disclosure of exchange balance, mitigation of risk and maximization of benefit for donors and recipients.
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INTRODUCTION: To explore gender discrepancies in publications at general surgery departments, we performed a cross-sectional comparing the number of women and men at each academic rank and their number of first author (FA), middle author (MA), last author (LA), and total publications. METHODS: Thirty academic general surgery departments were randomly selected. For each faculty, we tabulated: first, middle, last names, gender, academic rank, educational leadership, year of medical school graduation, and additional graduate degrees. Bibliography, H-index, and citations were downloaded from the Scopus database. RESULTS: One thousand three hundred twenty-six faculty sampled, 881 (66.4%) men and 445 (33.5%) women. Men outnumbered women at all ranks, with increasing disparity at higher ranks. Men outnumbered women in all subspecialties-largest difference in transplant surgery (84.4% versus 15.6%, P < 0.001). Men at all ranks had more MA publications: assistant professor (rate ratio 1.20; 95% confidence interval, 1.01-1.43, P = 0.024), associate professor (1.65; 1.31-2.06, P < 0.001), and professor (1.50; 1.20-1.91, P = 0.008). Men associate professors had more LA publications (1.74; 1.34-2.37, P < 0.001). No differences found in FA publications at any rank, nor LA publications at assistant professor and professor ranks. At subspecialty level, men in surgical oncology (1.95; 1.55-2.45, P < 0.001) and transplant surgery (1.70; 1.09-2.66, P = 0.02) had more MA publications. CONCLUSIONS: While FA and LA publications did not differ significantly across genders, the largest difference lies in MA publications, beginning at junior ranks and persisting with seniority. Discrepancies in MA publications may reflect gender discrepancies in collaborative opportunities, hence total publications should be used cautiously when determining academic productivity.
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Bibliometria , Docentes de Medicina , Humanos , Masculino , Feminino , Estados Unidos , Estudos Transversais , Eficiência , LiderançaRESUMO
AIM: Few data are available regarding the management of anorectal abscess in patients with leukopenia. The aim of this study was to investigate the impact of leukopenia among patients undergoing incision and drainage for anorectal abscess. METHOD: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. Perianal fistulas and supralevator abscesses were excluded. Patients were grouped based on white blood cell (WBC) count: WBC < 4.5 cells/µl, WBC = 4.5-11.0 cells/µl and WBC > 11.0 cells/µl. The 30-day overall complications and outcomes were compared using regression models, accounting for demographics and comorbidities. RESULTS: Ten thousand two hundred and forty (70.3% male) patients were identified. Univariate analysis showed that, compared with patients with leukocytosis (WBC > 11.0 cells/µl) and normal WBC count (WBC = 4.5-11.0 cells/µl), patients with leukopenia (WBC <4.5 cells/µl) had higher rates of overall (p < 0.001), pulmonary (p < 0.001) and haematological complications (p < 0.001). They also had higher rates of readmission (p < 0.001), reoperation (p = 0.005), discharge to a care facility (p = 0.003), increased length of hospital stay (p = 0.004) and death (p < 0.001). Multivariable analysis identified leukopenia as an independent risk factor for overall complications [odds ratio (OR) 2.31, 95% CI 1.65-3.24; p < 0.001], pulmonary complications (OR 5.65, 95% CI 1.88-16.97; p = 0.002), haematological complications (OR 4.30, 95% CI 2.94-6.28; p < 0.001), unplanned readmission (OR 2.20, 95% CI 1.43-3.40; p < 0.001), reoperation (OR 1.80, 95% CI 1.10-2.93; p = 0.019) and death (OR 2.77, 95% CI 1.02-7.52; p = 0.046). Discharge to a care facility and length of stay were not significant on multivariable analysis. CONCLUSION: Leukopenia is associated with increased risk for pulmonary and haematological complications, readmissions, reoperations, discharge to a care facility and death after incision and drainage for anorectal abscess.
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Doenças do Ânus , Leucopenia , Humanos , Masculino , Feminino , Abscesso/etiologia , Abscesso/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Doenças do Ânus/cirurgia , Estudos Retrospectivos , Leucopenia/epidemiologia , Leucopenia/etiologia , Readmissão do Paciente , DrenagemRESUMO
INTRODUCTION: While previous studies have documented adverse outcomes among obese patients undergoing ventral and inguinal hernia repairs, there is a lack of literature regarding the impact of obesity on parastomal hernia (PSH) repair. This retrospective study aims to determine the value of obesity stratification in predicting postoperative complications in patients undergoing PSH repair. MATERIALS AND METHODS: Outcomes of elective PSH repairs from 2010 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program database were analyzed. Patient demographics, preoperative characteristics, and postoperative outcomes were compared using bivariate analysis and multivariable regression models. RESULTS: A total of 2972 patients were retrospectively analyzed. Multivariable regression found, compared to nonobese patients, patients of obesity class ≥ II were 1.37 times more likely to develop complications overall (P = 0.006) and 1.55 times more likely to develop wound complications (P < 0.001). This group also yielded a 1.60 times higher risk of developing superficial wound infection (P = 0.007) and a 1.63 times greater risk of developing postoperative sepsis (P = 0.044). Total length of stay was longer for patients of obesity class ≥ II but not for obesity class I when compared to patients with body mass index <30.0 kg/m2. CONCLUSIONS: Patients with a body mass index ≥35.0 kg/m2 are more susceptible to an increased rate of complications after PSH repairs. The findings of this study will allow surgeons to stratify obese patients who would benefit from preoperative weight loss interventions prior to PSH repair and discuss associated risks with patients to facilitate informed consent.
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Hérnia Inguinal , Hérnia Ventral , Hérnia Incisional , Humanos , Herniorrafia/efeitos adversos , Hérnia Ventral/epidemiologia , Hérnia Ventral/etiologia , Hérnia Ventral/cirurgia , Estudos Retrospectivos , Hérnia Inguinal/cirurgia , Obesidade/complicações , Obesidade/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Hérnia Incisional/epidemiologia , Hérnia Incisional/etiologia , Hérnia Incisional/cirurgia , Telas Cirúrgicas/efeitos adversosRESUMO
As the decision to permanently suspend the USMLE Step 2 Clinical Skills exam resonates across the medical education landscape, it has different implications for the graduates of American allopathic (US-MD), osteopathic (DO) medical schools and international medical graduates (IMGs). Through this perspective, we as authors who represent each of these three diverse cohorts highlight the changes that resulted from the COVID-19 pandemic and delve into the multitude of ramifications that could ensue as a result of this decision. Our propositions are geared towards a standardized objective structured clinical examination for evaluating US-MDs and DOs, and a call for novel evaluation strategies to assure the minimum clinical standards of IMGs.
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Competência Clínica , Cirurgia Geral/educação , Internato e Residência , Humanos , Medicina Osteopática/educação , Estados UnidosRESUMO
INTRODUCTION: Active smoking is known to impair wound healing following free tissue transfer for reconstruction due to its vasoconstrictive effect on the microcirculation. The aim of this study was to evaluate the impact of flap selection on flap loss, in nonelective, traumatic extremity-free soft tissue transfer in active smokers. METHODS: All patients undergoing a free tissue transfer for acute trauma of the extremity at a level I trauma center from 2011 to 2017 were identified. Breast reconstruction and osseous/osseocutaneous flaps were excluded. The study population was divided in two groups based on the type of flap used (muscle versus perforator flap). Factors known to be associated with impaired wound healing were extracted from the database. Primary outcome was major smoking related complications (complete/partial flap loss). Secondary outcomes included minor flap-related complications (infection, dehiscence) and donor site complications. The impact of smoking was assessed for the different type of flaps using multivariate analyses. RESULTS: A total of 118 flaps were identified during the study period. Out of those, 52 were perforator-based fasciocutaneous flaps, while 66 were muscle flaps. Active smoking status resulted in a statistically significant increase in the incidence of major and minor complications in the perforator flap group (36% vs. 4%, adjusted odds ratio, AOR [95%CI]: 2.31[1.48,19.30], adj-p = 0.021 and 32% vs. 17%, AOR [95% CI]: 1.23[1.11,14.31], adj-p = 0.034) but had no impact in the muscle group. CONCLUSIONS: The present study suggests a higher incidence of flap related complications in smokers when a perforator flap was selected but no impact when a muscle flap was utilized.
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Retalhos de Tecido Biológico , Mamoplastia , Retalho Perfurante , Procedimentos de Cirurgia Plástica , Estudos de Casos e Controles , Extremidades , Humanos , Músculos , Estudos Retrospectivos , Fumar/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs. METHODS: Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility. RESULTS: 2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis. CONCLUSIONS: Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.
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Fragilidade , Herniorrafia , Humanos , Feminino , Masculino , Herniorrafia/efeitos adversos , Fragilidade/complicações , Fatores de Risco , Comorbidade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de RiscoRESUMO
OBJECTIVES: The Oxford English Dictionary defines "intern" as "a student or trainee who works, sometimes without pay, at a trade or occupation in order to gain work experience." In the medical realm, the label "intern" may introduce confusion as well as implicit and explicit bias. In this study, we sought to examine the general public's perception of the label "intern" compared to the more accurate label "first-year resident." DESIGN: We developed 2 forms of a 9-item survey that assessed an individual's level of comfort with surgical trainees' participation in various aspects of surgical care and knowledge of medical education and work environment. One form used the label "intern" and the other used "first-year resident." SETTING: San Antonio, TX. PARTICIPANTS: A total of 148 adults in the general population at 3 local parks on 3 separate occasions. RESULTS: A total of 148 individuals completed the survey (74 per form). Respondents who did not work in the medical field reported less comfort with interns vs first-year residents participating in various aspects of their care. Only 36% of respondents were able to correctly identify which surgical team members have completed a medical degree. Directly assessing perceptual incongruity between the labels "intern" and "first-year resident," 43% of respondents said interns have a medical degree compared to 59% for first-year residents (pâ¯=â¯0.008), 88% stated that interns work full-time in the hospital compared to 100% for first-year residents (pâ¯=â¯0.041), and 82% stated that interns get paid for their work in the hospital compared to 97% for first-year residents (pâ¯=â¯0.047). CONCLUSIONS: The label "intern" may confuse patients, family members, and perhaps other healthcare professionals regarding the level of experience and knowledge of first-year residents. We advocate for abolishing the term "intern" and replacing it with "first-year resident" or simply "resident."
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Educação Médica , Internato e Residência , Estudantes de Medicina , Adulto , Humanos , Hospitais , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Mistreatment is widespread in graduate medical education, and much attention has been generated on this topic and its relationship to burnout in general surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma - as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solving difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreatment in a surgery residency. FT starts with the performance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the situation ending in a collective solution. DESIGN: Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the residents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, corrective feedback with the understanding this would be presented to the residency at large. Following this, they developed a scenario for enactment which was implemented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situation until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered. SETTING: General surgery residency at University of Texas Health San Antonio. PARTICIPANTS: General surgery residents. 32 of 66 (48.5%) residents participated. RESULTS: Participants noted an improved understanding of mistreatment, felt more confident in recognizing mistreatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to recognize when they themselves were involved in mistreatment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended participating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professionalism. These trends remained steady in the survey 6 months after the intervention as well. CONCLUSIONS: We found FT was feasible to implement in a busy general surgery residency and well received with sustained, self- reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT interventions can be tailored to the local culture to address conflicts specific to that setting.
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Cirurgia Geral , Internato e Residência , Humanos , Estudos Retrospectivos , Educação de Pós-Graduação em Medicina/métodos , Inquéritos e Questionários , Autorrelato , Cirurgia Geral/educaçãoRESUMO
The use of robotic surgery has increased exponentially in the United States. Despite this uptick in popularity, no standardized training pathway exists for surgical residents or practicing surgeons trying to cross-train onto the platform. We set out to perform a systematic review of existing literature to better describe and analyze existing robotic surgical training curricula amongst academic surgery programs. A systematic electronic search of the PubMed, Cochrane, and EBSCO databases was performed for articles describing simulation in robotic surgery from January 2010 to May 2022. Medical Subject Heading (MeSH) terms and keywords used to conduct this search were "Robotic," "Surgery," "Robotic Surgery," "Training," "Curriculum," "Education," and "Residency Program." A total of 110 articles were identified for the systematic review. After screening the titles and abstracts, a total of 36 full-text original articles were included in this systematic review. Of these, 24 involved robotic surgery curricula designed to teach general robotic skills, whereas the remaining 12 were for teaching procedure specific skills. Of the 24 studies involving general robotic skills, 13 included didactics as a part of the curriculum, 23 utilized virtual reality trainers, 3 used inanimate tissue, and 1 used live animal models. Of the 12 papers reviewed regarding procedure specific curricula, seven involved urologic procedures (radical prostatectomy and nephrectomy), two involved general surgical procedures (colectomy and Roux-en-Y gastric bypass surgery), two involved obstetrics and gynecology procedures (hysterectomy with myomectomy and sacrocolpopexy, hysterectomy with pelvic lymphadenectomy) and one involved a cardiothoracic surgery procedure (robotic internal thoracic artery harvest). With the rapid implementation of robotic surgery, training programs have been tasked with the responsibility of ensuring their trainees are adequately proficient in the platform prior to graduation. However, due to the lack of uniformity between surgical training programs, when it comes to robotic surgical experience, a strong need persists for a standardized national robotics training curriculum.
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Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Animais , Feminino , Gravidez , Masculino , Procedimentos Cirúrgicos Robóticos/métodos , Currículo , Colectomia , Simulação por ComputadorRESUMO
BACKGROUND: Severe obesity could be an independent risk factor for peripheral artery disease (PAD) and critical limb ischemia (CLI). Bariatric surgery reduces cardiac risk factors, decreasing cardiovascular morbidity and mortality in subjects with severe obesity. OBJECTIVES: We aimed to describe the impact of bariatric surgery on risk of hospitalization due to PAD and CLI. SETTING: Academic hospital. METHODS: The National Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment was defined as patients with a previous history of bariatric surgery, and control was defined as patients with a body mass index ≥35 without a history of bariatric surgery. The primary outcome was hospitalization due to PAD; secondary outcomes were CLI, revascularization, major amputation, length of hospital stay (LOS), and total cost of hospitalization. Univariate and multivariate analyses were performed to assess the differences between groups. RESULTS: There were a total of 2,300,845 subjects: 2,004,804 controls and 296,041 treatment patients. Hospitalization rate for PAD was significantly lower compared to the control group (.10% versus .21%, P < .0001), which was confirmed after adjusting for covariables (control versus treatment: odds ratio= 1.20, confidence interval: 1.15-1.47). Subgroup analysis showed patients without a history of bariatric surgery had a higher prevalence of CLI (59.3% versus 52.4%, P < .0219) and a higher mean LOS (6.7 versus 5.7 days, P = .0023) and cost of hospitalization (78.756 versus 72.621$, P = .0089), with no significant differences in other outcomes. After multivariate analysis, only LOS and total costs were significantly different. CONCLUSIONS: Bariatric surgery may decrease the risk of hospitalization due to PAD, similarly to the LOS and total cost of hospitalization. Prospective studies should be performed to describe this relationship.
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Cirurgia Bariátrica , Obesidade Mórbida , Doença Arterial Periférica , Humanos , Isquemia Crônica Crítica de Membro , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Estudos Prospectivos , Isquemia/epidemiologia , Isquemia/etiologia , Hospitalização , Doença Arterial Periférica/complicações , Doença Arterial Periférica/epidemiologia , Doença Arterial Periférica/cirurgia , Fatores de Risco , Obesidade , Resultado do Tratamento , Estudos RetrospectivosRESUMO
While laparoscopic simulation-based training is a well-established component of general surgery training, no such requirement or standardized curriculum exists for robotic surgery. Furthermore, there is a lack of high-fidelity electrocautery simulation training exercises in the literature. Using Messick's validity framework, we sought to determine the content, response process, internal content and construct validity of a novel inanimate tissue model that utilizes electrocautery for potential incorporation in such curricula. A multi-institutional, prospective study involving medical students (MS) and general surgery residents (PGY1-3) was conducted. Participants performed an exercise using a biotissue bowel model on the da Vinci Xi robotic console during which they created an enterotomy using electrocautery, followed by approximation with interrupted sutures. Participant performance was recorded and then scored by crowd-sourced assessors of technical skill, along with three of the authors. Construct validity was determined via difference in Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and total number of errors between the two cohorts. Upon completion of the exercise, participants were surveyed on their perception of the exercise and its impact on their robotic training to determine content validity. 31 participants were enrolled and separated into two cohorts: MS + PGY1 vs. PGY2-3. Time spent on the robotic trainer (0.8 vs. 8.13 h, p = 0.002), number of bedside robotic assists (5.7 vs. 14.8, p < 0.001), and number of robotic cases as primary surgeon (0.3 vs. 13.1, p < 0.001) were statistically significant between the two groups. Differences in GEARS scores (18.5 vs. 19.9, p = 0.001), time to completion (26.1 vs. 14.4 min, p < 0.001), and total errors (21.5 vs. 11.9, p = 0.018) between the groups were statistically significant as well. Of the 23 participants that completed the post-exercise survey, 87% and 91.3% reported improvement in robotic surgical ability and confidence, respectively. On a 10-point Likert scale, respondents rated the realism of the exercise 7.5, educational benefit 9.1, and effectiveness in teaching robotic skills 8.7. Controlling for the upfront investment of certain training materials, each exercise iteration cost ~ $30. This study confirmed the content, response process, internal structure and construct validity of a novel, high-fidelity and cost-effective inanimate tissue exercise which successfully incorporates electrocautery. Consideration should be given to its addition to robotic surgery training programs.
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Procedimentos Cirúrgicos Robóticos , Robótica , Treinamento por Simulação , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Estudos Prospectivos , Robótica/educação , Currículo , Competência Clínica , Simulação por ComputadorRESUMO
BACKGROUND: The COVID-19 pandemic decreased the operative case volume for surgical residents. Our institution implemented Entrustable Professional Activities (EPAs) in all core surgical training programs to document the competency of graduating residents. Continuation of this project aimed to improve implementation. METHODS: This project occurred at a large academic center with eight surgical specialties during the 2020-21 (Year 1) and 2021-22 (Year 2) academic years. Each specialty chose five EPAs, and residents were asked to obtain three micro-assessments per EPA. After the initial pilot year, program directors were surveyed regarding perceptions of EPA utility and barriers to implementation. RESULTS: Seventy senior residents completed 732/906 (80.8%) micro-assessments. Of these, 99.6% were deemed practice ready. Total micro-assessment completion rates in four specialties, four specific EPAs (including one EPA identified "at risk" due to the COVID-19 pandemic), and overall were significantly higher in Year 2 than Year 1 (p â< â0.05) CONCLUSIONS: Implementing EPAs in all core surgical specialties at an institution is achievable, though expectedly initially imperfect. An ongoing quality collaborative initiative focused on barriers to implementation can improve completion rates.
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COVID-19 , Internato e Residência , Humanos , Pandemias , Melhoria de Qualidade , Educação Baseada em Competências , Competência Clínica , COVID-19/epidemiologiaRESUMO
Hepatitis C virus (HCV) infection is a common indication for liver transplantation. If the patient's HCV is untreated prior to liver transplant, infection of the allograft is nearly universal and can lead to graft failure. The demand for deceased-donor organ transplantation continues to surpass the available supply of donor organs. Waitlist mortality remains an important concern, and several strategies have been enacted to increase organ supply, such as using high-risk donors, including those who are HCV positive. The development of safe and highly effective HCV therapy with direct-acting antiviral agents has revolutionized the management of liver transplant candidates and transplantrecipients. Moreover, thenewer antiviral therapieshave paved the road for use of HCV-viremic organs, effectively expanding the donor pool and changing the landscape of solid organ transplantation. This article reviews the data on HCV treatment prior to and after organ transplantation.
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BACKGROUND: The impact of chronic kidney disease (CKD) on pancreaticoduodenectomy has not been well established. In this study, we investigated the effects of preoperative CKD in patients undergoing pancreaticoduodenectomy. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients who underwent pancreaticoduodenectomy between 2015 and 2019. The estimated glomerular filtration rate (eGFR) for each patient was calculated using the CKD-Epidemiology Collaborative (CKD-EPI) 2021 equation. Kidney function was stratified according to the Kidney Disease: Improving Global Outcomes (KDIGO) Classification: G1, normal/high function (estimated glomerular filtration rate ≥ 90 ml/min/1.73 m2); G2-G3, mild/moderate CKD (89-30 ml/min/1.73 m2); and G4-G5, severe CKD (≤ 29 ml/min/1.73 m2). The 30-day overall complications and outcomes were compared using regression models accounting for demographics and comorbidities. RESULTS: A total of 20,656 (55.7% men) patients were identified. Univariate analysis showed that compared to G1 patients, G2-G3 and G4-G5 had higher rates of overall complications (p < 0.001), need for readmission (p = 0.004), need for reoperation (p < 0.001), discharge to the care facility (p < 0.001), death (p < 0.001), and average length of stay (p < 0.001). On multivariable regression, G2-G3 renal function was found to be an independent risk factor for overall (1.10 [1.04-1.17], p = 0.002), pulmonary (1.23 [1.10-1.37], p < 0.001), hematologic (1.08 [1.02-1.16], p = 0.015), and renal (1.29 [1.11-1.49], p < 0.001) complications; discharge to care facility (1.10 [1.02-1.19], p = 0.045); and 30-day mortality (1.25 [1.01-1.56], p = 0.045). G4-G5 renal function was a predictor of worse outcomes for the prior variables and an independent risk factor for cardiovascular complications (2.70 [1.44-4.96], p = 0.001) and length of stay (1.32 [1.13-1.56], p < 0.001). CONCLUSIONS: The degree of CKD was related to the overall complications and outcomes after pancreaticoduodenectomy. Therefore, the CKD classification should be strongly considered in the preoperative risk stratification of these patients.
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Líquidos Corporais , Insuficiência Renal Crônica , Humanos , Masculino , Feminino , Pancreaticoduodenectomia/efeitos adversos , Pancreatectomia , Anastomose Cirúrgica , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologiaRESUMO
Palmar venous malformations are not well described in the surgical literature and are a therapeutic challenge due to the intricate anatomy of the hand. We present the case of a 19-year-old right-handed female patient from Mexico who was referred to us with a right palmar lesion present since birth, previously diagnosed as a venous malformation. The patient reported that she had undergone sclerotherapy 10 years before in addition to a prior aborted attempt at excision. Venous palmar malformations are rare occurrences. Although an individualized approach is important, the development of an algorithm may assist in the standardization of the treatment of this pathology to preserve the hand's functional status.
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OBJECTIVE: As USMLE Step 1 moves to pass/fail, residency programs are seeking alternate interview selection processes. Attrition in general surgery is reported as high as 26%. Thus, it is important to ensure that programs are selecting and matching applicants with shared values. Situational judgment tests (SJTs) measure educational and cultural values by posing ambiguous situations and individuals rate the effectiveness of possible reactions. SJTs have previously been shown to identify job applicants with shared values while promoting diversity. Scoring categories are high, moderate, or low values congruence. We sought to explore predictive validity of the SJT relative to program attrition. DESIGN: Residents who matched into our program between 2018 and 2021 completed the SJT. We tracked attrition. SETTING: UT Health San Antonio, Texas PARTICIPANTS: Fifty-six categorical general surgery residents RESULTS: Per SJT ratings, the numbers of residents who had high, moderate, and low values congruence were 27, 16, and 13, respectively. Attrition numbers for residents who scored high and moderate congruence were similar, indicating that these ratings were indistinguishable. As such, we combined those 2 categories to create a 2â¯×â¯2 matrix and used signal detection theory as a framework for analysis. Overall attrition was 16.1% (9/56). Of the 43 residents who scored high or moderate congruence, 90.7% remained in the program. There was a 9.3% chance of attrition for these residents. Of the 13 residents who scored low congruence, 38.5% attrited. While scoring as low congruence on the SJT does not definitively indicate attrition, it does indicate that attrition is 4.14 times more likely for these residents (chi-square, p = 0.0121). CONCLUSIONS: One of the most important aspects of residency applicant selection and interviewing is mitigating risk by identifying applicants who carry a high risk of attrition. The SJT significantly identifies at-risk applicants.
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Internato e Residência , Humanos , Julgamento , Pesquisa , Escolaridade , TexasRESUMO
One of the most challenging aspects of the kidney transplant operation is performing vascular anastomoses in the confines and depths of the iliac fossa. General surgery residents need to be adequately trained in this skill to maximize their intraoperative experience during their transplant surgery rotation. While several kidney transplant models have been developed, they are limited in their ability to simulate the challenges of performing anastomoses at varying depths and in confined spaces. Furthermore, they may be expensive or require specialized equipment, such as three-dimensional printers, to build. In this technical report, we describe how to build a low-fidelity, low-cost, and portable kidney transplant model capable of simulating vascular anastomoses at varying depths. Our model can be easily replicated for less than 30 USD using materials available in local stores. It uses inexpensive and reusable parts, allowing trainees a high volume of repetitions.
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Due to the complexity of liver transplant patients and the variability in exposure to transplantation by anesthesia trainees, simulation is often required as an adjunct to clinical experience. This systematic review identifies current simulation models in the literature that pertain to perioperative liver transplant anesthesia. Data were collected by performing an electronic search of the PubMed and Scopus databases for articles describing simulation in transplant anesthesia. Abstracts were screened using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Three reviewers analyzed 16 abstracts found in the search and agreed upon articles that met the inclusion criteria for the systematic review. A total of five publications met the inclusion criteria; they could be grouped as cognitive skills and technical skills simulators. Cognitive skills simulators utilized high-fidelity mannequins and animal models combined with traditional educational material to enhance pattern recognition of critical complications during liver transplantation. One manuscript focused on a technical skills acquisition by utilizing transesophageal echocardiography (TEE) to identify intraoperative pathologies. There is a heterogeneity in the exposure to liver transplant care during anesthesia training. Simulation provides low-stakes exposure to the high-stakes skills required in the operating room. Hence, it can be used as an adjunct to improve both cognitive and technical skill acquisition for perioperative transplant anesthesia. The goal of these simulation programs is to improve patient outcomes and produce more capable anesthesiologists.
RESUMO
Robot-assisted surgery (RAS) has undergone rapid adoption in general surgery due to features such as three-dimensional visualization, wrist dexterity, improved precision of movement, and operator ergonomics. While many surgical trainees encounter RAS during their residency, robotic skills training programs and curricula vary across institutions and there is broad variation in graduating general surgeons' robotic proficiency levels. Due to a need for a formalized process to achieve competence on the robotic platform, simulation-based training has become instrumental in closing this gap as it provides training in a low-stakes environment while allowing the trainee to improve their psychomotor and basic procedural skills. Several different models of simulation training exist including virtual reality, animal, cadaveric, and inanimate tissue platforms. Each form of training has its own merits and limitations. While virtual reality platforms have been well evaluated for face, content, and construct validity, their initial set-up costs can be as high as $125,000. Similarly, animal and cadaveric models are not only costly but also have ethical considerations that may preclude participation. There is an unmet need in developing high-fidelity, cost-effective simulations for basic videoscopic skills such as cautery use. We developed a cost-effective and high-fidelity inanimate tissue model that incorporates electrocautery. Using a double-layered bowel model secured to a moistened household sponge, this inanimate exercise simulates fundamental skills of robotic surgery such as tissue handling, camera control, suturing, and electrocautery.