Enteral Access Outcomes in Patients Hospitalized With Cardiac Disease: A Retrospective Cohort Study.

INTRODUCTION: Patients admitted with principal cardiac diagnosis (PCD) can encounter difficult inpatient stays that are often marked by malnutrition. In this setting, enteral feeding may improve nutritional status. This study examined the association of PCD with perioperative outcomes after elective enteral access procedures. METHODS: Adult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care institution were reviewed retrospectively. Differences in baseline characteristics between patients with and without PCD were adjusted using entropy balancing. Multivariable logistic and linear regressions were subsequently developed to evaluate the association between PCD and nutritional outcomes, perioperative morbidity and mortality, length of stay, and nonelective readmission after enteral access. RESULTS: 912 patients with enteral access met inclusion criteria, of whom 84 (9.2%) had a diagnosis code indicating PCD. Compared to non-PCD, patients with PCD more commonly received percutaneous endoscopic gastrostomy by general surgery and had a higher burden of comorbidities as measured by the Charlson comorbidity index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups (standardized differences ranged from -2.45 × 10-8 to 3.18 × 108). After adjustment, despite no significant association with in-hospital mortality, percentage change prealbumin, length of stay, or readmission, PCD was associated with an approximately 2.25-day reduction in time to meet goal feeds (95% CI -3.76 to -0.74, P = 0.004) as well as decreased odds of reoperation (adjusted odds ratio 0.28, 95% CI 0.09-0.86, P = 0.026) and acute kidney injury (adjusted odds ratio 0.24, 95% CI 0.06-0.91, P = 0.035). CONCLUSIONS: Despite having more comorbidities than non-PCD, adult enteral access patients with PCD experienced favorable nutritional and perioperative outcomes.

Learning curve of laparoscopic appendectomy in a low-resource setting: a cumulative sum analysis of operative length.

BACKGROUND: Cumulative sum (CUSUM) analysis is a valuable tool for quantifying the learning curve of surgical teams by detecting significant changes in operative length. However, there is limited research evaluating the learning curve of laparoscopic techniques in low-resource settings. The objective of this study is to evaluate the learning curve for laparoscopic appendectomy within a single surgical team in Senegal. METHODS: This was a single-center prospective study conducted from May 1, 2018, to August 31, 2023 of patients who underwent laparoscopic appendectomy at a tertiary care institution in West Africa. The AAST classification was used to describe the severity of appendicitis. Parameters studied included age, sex, operative length, conversion rate, and postoperative outcomes. To quantify the learning curve, CUSUM analysis of operative length was performed. RESULTS: A total of 81 patients were included. The mean age was 26.7 years (range 11-70 years) with a sex ratio of 1.9. Pre-operative severity according to AAST was Grade I in 75.4% (n = 61), Grade III in 7.4% (n = 6), Grade IV in 6.1% (n = 5), and Grade V in 11.1% (n = 9). Conversion occurred in 5 cases (6.1%). The average operative length was 76.8 min (range 30-180 min) and the average length of hospitalization was 2.7 days (range 1-13 days). Morbidity was observed in 3.7% (n = 3) and there were no deaths. The CUSUM analysis showed that a steady operative length was achieved after 28 procedures, with decreasing operative lengths thereafter. CONCLUSION: Surgeons in our setting overcame the learning curve for laparoscopic appendectomy after performing 28 procedures. Moreover, laparoscopic appendectomy is safe and feasible throughout the learning curve. CUSUM analysis should be applied to other laparoscopic procedures and individualized by surgical teams to improve surgical performance and patient outcomes in low-resource settings.

Quality and readability assessment of online patient information on cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND AND OBJECTIVES: We aim to assess the quality and readability of online information available to patients considering cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: The top three search engines (Google, Bing, and Yahoo) were searched in March 2022. Websites were classified as academic, hospital-affiliated, foundation/advocacy, commercial, or unspecified. Quality of information was assessed using the JAMA benchmark criteria (0-4) and DISCERN tool (16-80), and the presence of a Health On the Net code (HONcode) seal. Readability was evaluated using the Flesch Reading Ease score. RESULTS: Fifty unique websites were included. The average JAMA and DISCERN scores of all websites were 0.72 ± 1.14 and 39.58 ± 13.71, respectively. Foundation/advocacy websites had significantly higher JAMA mean score than commercial (p = 0.044), academic (p < 0.001), and hospital-affiliated websites (p = 0.001). Foundation/advocacy sites had a significantly higher DISCERN mean score than hospital-affiliated (p = 0.035) and academic websites (p = 0.030). The HONcode seal was present in 4 (8%) websites analyzed. Readability was difficult and at the level of college students. CONCLUSIONS: The overall quality of patient-oriented online information on CRS-HIPEC is poor and available resources may not be comprehensible to the general public. Patients seeking information on CRS-HIPEC should be directed to sites affiliated with foundation/advocacy organizations.

Evaluation of the educational quality of publicly available online videos on laparoscopic jejunostomy by utilizing the LAP-VEGaS guidelines.

BACKGROUND: Despite its common nature, there is no data on the educational quality of publicly available laparoscopic jejunostomy training videos. The LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool, released in 2020, has been developed to ensure that teaching videos are of appropriate quality. This study applies the LAP-VEGaS tool to currently available laparoscopic jejunostomy videos. METHODS: A retrospective review of YouTube® videos was conducted for "laparoscopic jejunostomy." Included videos were rated by three independent investigators using LAP-VEGaS video assessment tool (0-18). Wilcoxon rank-sum test was used to evaluate differences in LAP-VEGaS scores between video categories and date of publication relative to 2020. Spearman's correlation test was performed to measure association between scores and length, number of views and likes. RESULTS: 27 unique videos met selection criteria. Academic and physician video walkthroughs did not demonstrate a significant difference in median scores (9.33 IQR 6.33, 14.33 vs. 7.67 IQR 4, 12.67, p = 0.3951). Videos published after 2020 demonstrated higher median scores than those published before 2020 (13 IQR 7.5, 14.67 vs. 5 IQR 3, 9.67, p = 0.0081). A majority of videos failed to provide patient position (52%), intraoperative findings (56%), operative time (63%), graphic aids (74%), and audio/written commentary (52%). A positive association was demonstrated between scores and number of likes (rs = 0.59, p = 0.0011) and video length (rs = 0.39, p = 0.0421), but not number of views (rs = 0.17, p = 0.3991). CONCLUSION: The majority of available YouTube® videos on laparoscopic jejunostomy fail to meet the basic educational needs of surgical trainees, and there is no difference between those produced by academic centers or independent physicians. However, there has been improvement in video quality following the release of the scoring tool. Standardization of laparoscopic jejunostomy training videos with the LAP-VEGaS score can ensure that videos are of appropriate educational value with logical structure.

Conversion to Roux-En-Y Gastric Bypass: a successful means of mitigating reflux after laparoscopic sleeve gastrectomy.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric procedure due to the technical ease and weight loss success of the operation. However, there has been concern that LSG contributes to gastroesophageal reflux disease (GERD) postoperatively with a proportion of patients requiring conversion to a Roux-En-Y Gastric Bypass (RYGB). The objective of this study was to characterize the patients who underwent revision in our hospital system and to better understand pre-operative predictors of GERD and revision. METHODS: After IRB approval, a retrospective review was conducted assessing for patients who had conversion of LSG to RYGB at three hospitals within the University of Pennsylvania Health System from January 2015 to December 2021. The patients' charts were then reviewed to evaluate for demographics, BMI, operative findings, imaging and endoscopic reports, and post-operative outcomes. RESULTS: 97 patients were identified who underwent conversion of LSG to RYGB between January 2015 and December 2021. The cohort was predominantly female (n = 89, 91.7%) with an average age of 42.7 ± 10.6 years at the time of conversion. The most common indications for revision were GERD (72.2%) and obesity/insufficient weight loss (24.7%). Patients lost an average of 11.1 ± 12.9 kg after revision to RYGB. Of the patients who underwent revision for GERD, 80.2% noted global symptomatic improvement after revision and 19.4% were able to stop their proton pump inhibitor (PPI) postoperatively, with most patients decreasing the frequency of the PPI use postoperatively. CONCLUSION: The majority of patients who underwent conversion from LSG to RYGB due to GERD and saw marked improvements in GERD symptoms and outcomes. These findings illuminate the real-world practices and outcomes of bariatric revisional procedures for reflux and the need for more research on standardized practice.

Evolution of laparoscopic surgery in a sub-Saharan African country: a 30-year literature review in Senegal.

INTRODUCTION: The advent of laparoscopy has significantly reduced the morbidity associated with the majority of abdominal surgeries. In Senegal, the first studies evaluating this technique were published in the 1980s. The objective of this systematic review is to assess the evolution of laparoscopy research in Senegal. METHODS: A search of PubMed and Google Scholar was carried out without limit of publication date. The keywords used were "senegal" AND "laparoscop*". Duplicates were removed, and remaining articles were assessed for selection criteria. We included all articles about laparoscopy published in Senegal. The parameters studied in each included article were the place and year of study, average age, sex ratio, assessed indications and results. RESULTS: 41 Studies published between 1984 and 2021 met selection criteria. The average age of patients was 33 years (range 4.7-63). The sex ratio was 0.33. The main indications for laparoscopy according to the studies were: benign gastrointestinal disorders in 11 studies (26.8%), abdominal emergencies in 9 studies (22%), gallbladder surgery in 5 studies (12.2%), benign gynecological pathology in 6 studies (14.6%), malignant gynecological pathology in 2 studies (4.9%), diagnostic laparoscopy in 2 studies (4.9%), groin hernia repair in 2 studies (4.9%) and testicular pathology in 1 study (2.4%). Overall mortality was estimated at 0.9% (95% CI 0.6-1.3) and overall morbidity for all complications was estimated at 5% (95% CI 3.4-6.9). CONCLUSIONS: This systematic review showed a predominance of the laparoscopy publications from the capital in Dakar with favorable outcomes. This technique should be popularized in the different regions of the country and its indications expanded.

Factors associated with conversion in laparoscopic surgery in a low-resource setting: a single-center prospective study.

INTRODUCTION: Laparoscopy has a clear patient benefit related to postoperative morbidity but may not be as commonly performed in low-and middle-income countries. The decision to convert to laparotomy can be complex and involve factors related to the surgeon, patient, and procedure. The objective of this work is to analyze the factors associated with conversion in laparoscopic surgery in a low-resource setting. METHODS: This is a single-center prospective study of patients who underwent laparoscopic surgery between May 1, 2018 and October 31, 2021. The parameters studied were age, sex, body mass index (BMI), intraoperative complication (e.g., accidental enterotomy, hemorrhage), equipment malfunction (e.g., technical failure of the equipment, break in CO2 supply line), operating time, and conversion rate. RESULTS: A total of 123 laparoscopic surgeries were performed. The average age of patients was 31.2 years (range 11-75). The procedures performed included appendix procedures (48%), followed by gynecological (18.7%), gallbladder (14.6%), digestive (10.56%), and abdominal procedures (4%). The average length of hospitalization was 3 days (range 1-16). Conversion to laparotomy was reported in 8.9% (n = 11) cases. Equipment malfunction was encountered in 9.8% (n = 12) cases. Surgical complications were noted in 11 cases (8.9%). Risk factors for conversion were shown to be BMI > 25 kg/m2 (OR 4.6; p = 0.034), intraoperative complications (OR 12.6; p = 0.028), and equipment malfunction (OR 9.4; p = 0.002). CONCLUSION: A better understanding of the underlying factors associated with high conversion rates, such as overweight/obesity, intraoperative complications, and equipment failure, is the first step toward surgical planning to reduce postoperative morbidity in low-resource settings.

Quality and readability of online patient information on the left ventricular assist device.

BACKGROUND: As patients seek online health information to supplement their medical decision-making, the aim of this study is to assess the quality and readability of internet information on the left ventricular assist device (LVAD). METHODS: Three online search engines (Google, Bing, and Yahoo) were searched for "LVAD" and "Left ventricular assist device." Included websites were classified as academic, foundation/advocacy, hospital-affiliated, commercial, or unspecified. The quality of information was assessed using the JAMA benchmark criteria (0-4), DISCERN tool (16-80), and the presence of Health On the Net code (HONcode) accreditation. Readability was assessed using the Flesch Reading Ease score. RESULTS: A total of 38 unique websites were included. The average JAMA and DISCERN scores of all websites were 0.82 ± 1.11 and 52.45 ± 13.51, respectively. Academic sites had a significantly lower JAMA mean score than commercial (p < 0.001) and unspecified (p < 0.001) websites, as well as a significantly lower DISCERN, mean score than commercial sites (p = 0.002). HONcode certification was present in 6 (15%) websites analyzed, which had significantly higher JAMA (p < 0.001) and DISCERN (p < 0.016) mean scores than sites without HONcode certification. Readability was fairly difficult and at the level of high school students. CONCLUSIONS: The quality of online information on the LVAD is variable, and overall readability exceeds the recommended level for the public. Patients accessing online information on the LVAD should be referred to sites with HONcode accreditation. Academic institutions must provide higher quality online patient literature on LVADs.

Online information for incisional hernia repair: What are patients reading?

PURPOSE: Patients increasingly access online materials for health-related information. Using validated assessment tools, we aim to assess the quality and readability of online information for patients considering incisional hernia (IH) repair. METHODS: The top three online search engines (Google, Bing, Yahoo) were searched in July 2022 for "Incisional hernia repair" and "Surgical hernia repair". Included websites were classified as academic, hospital-affiliated, commercial, and unspecified. The quality of information was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (0-4), DISCERN instrument (16-80), and the presence of Health On the Net code (HONcode) certification. Readability was assessed using the Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) tests. RESULTS: 25 unique websites were included. The average JAMA and DISCERN scores of all websites were 0.68 ± 1.02 and 36.50 ± 10.91, respectively. Commercial sites showed a significantly higher DISCERN mean score than academic sites (p = 0.034), while no significant difference was demonstrated between other website categories. 3 (12%) websites reported HONcode certification and had significantly higher JAMA (p = 0.016) and DISCERN (p = 0.045) mean scores than sites without certification. Average FRE and FKGL scores were 39.84 ± 13.11 and 10.62 ± 1.76, respectively, corresponding to college- and high school-level comprehensibility. CONCLUSIONS: Our findings suggest online patient resources on IH repair are of poor overall quality and may not be comprehensible to the public. Patients accessing internet resources for additional information on IH repair should be made aware of these inadequacies and directed to sites bearing HONcode certification.

Effect of Weight Loss on Upper Airway Anatomy and the Apnea-Hypopnea Index. The Importance of Tongue Fat.

Rationale: Obesity is the primary risk factor for obstructive sleep apnea (OSA). Tongue fat is increased in obese persons with OSA, and may explain the relationship between obesity and OSA. Weight loss improves OSA, but the mechanism is unknown.Objectives: To determine the effect of weight loss on upper airway anatomy in subjects with obesity and OSA. We hypothesized that weight loss would decrease soft tissue volumes and tongue fat, and that these changes would correlate with reductions in apnea-hypopnea index (AHI).Methods: A total of 67 individuals with obesity and OSA (AHI ≥ 10 events/h) underwent a sleep study and upper airway and abdominal magnetic resonance imaging before and after a weight loss intervention (intensive lifestyle modification or bariatric surgery). Airway sizes and soft tissue, tongue fat, and abdominal fat volumes were quantified. Associations between weight loss and changes in these structures, and relationships to AHI changes, were examined.Measurements and Main Results: Weight loss was significantly associated with reductions in tongue fat and pterygoid and total lateral wall volumes. Reductions in tongue fat were strongly correlated with reductions in AHI (Pearson's rho = 0.62, P < 0.0001); results remained after controlling for weight loss (Pearson's rho = 0.36, P = 0.014). Reduction in tongue fat volume was the primary upper airway mediator of the relationship between weight loss and AHI improvement.Conclusions: Weight loss reduced volumes of several upper airway soft tissues in subjects with obesity and OSA. Improved AHI with weight loss was mediated by reductions in tongue fat. New treatments that reduce tongue fat should be considered for patients with OSA.

Perspectives of adolescents with severe obesity on social Media in Preparation for weight-loss surgery: a qualitative study.

BACKGROUND: Currently the most effective treatment for severe obesity in adolescents is weight-loss surgery coupled with lifestyle behavior change. In preparation for weight-loss surgery, adolescents are required to make changes to eating and activity habits (lifestyle changes) to promote long term success. Social media support groups, which are popular among adolescents, have the potential to augment preoperative lifestyle changes. The purpose of this study was to qualitatively assess the perceived role of social media as a support tool for weight-loss, and to identify motivators and constraints to lifestyle changes and social media use in adolescents preparing for weight-loss surgery. METHODS: Thematic analysis of social media comments from 13 (3 male, 10 female) adolescents aged 16 ± 1.3 years with a body mass index (BMI) 45 ± 7.3 kg/m2 enrolled in a weight-management program preparing for bariatric surgery and who participated in a 12-week pilot social media intervention was performed. Participants commented on moderator posts and videos of nutrition, physical activity, and motivation that were shared three to four times per week. Social media comments were coded using NVivo 11.0 to identify recurrent themes and subthemes. RESULTS: 1) Social media provided accountability, emotional support, and shared behavioral strategies. 2) Motivators for lifestyle changes included family support, personal goals, and non-scale victories. 3) Challenges included negative peers, challenges with planning and tracking, and time constraints. CONCLUSION: Adolescents considering bariatric surgery identified social media as a tool for social support and reinforcement of strategies for successful behavior change. Important motivators and challenges to lifestyle changes were identified.

Reliability of acoustic radiation force impulse shear wave elastography in the evaluation of liver stiffness in morbidly obese patients.

PURPOSE: To evaluate technical and patient-related factors that can affect the reliability of acoustic radiation force impulse shear wave elastography (ARFI-SWE) in morbidly obese patients. METHODS: A prospective single-center study was performed on 41 patients (32 females, 78%) presenting for preoperative evaluation for bariatric surgery. ARFI-SWE was performed using a 6 to 1.5 MHz curved (6C1) transducer. Hepatic steatosis was mild, moderate, severe, and absent in 24.4%, 12.2%, 43.9%, and 19.5% of patients, respectively. Interquartile range/median (IQR/M) ranged from 0.05 to 2.07 (0.78 ± 0.56 m/s). Twenty patients (48.7%) had reliable measurements (IQR/M < 0.3). Shear wave velocity (SWV) values were >1.34 m/s (clinically significant fibrosis) in 25 of 41 patients (61%) and >2.2 m/s (advanced fibrosis) in 19 patients (46%). RESULTS: Median SWV was correlated with body mass index (BMI; correlation coefficient [CC] = .37; 95% CI, 0.07-0.61; P-value = .03) and skin-to-liver capsule distance (SLD) (CC = .38; 95% CI, 0.09-0.62; P-value = .01). IQR/M was higher in patients with BMI > 40 (0.24 ± 0.11 vs 0.39 ± 0.25, P-value = .031) and SLD > 3 cm (0.46 ± 0.27 vs 0.23 ± 0.08, P-value = .001), and there was higher number of unreliable examinations among patient with SLD > 3 cm (16/23 vs 5/18, P-value = .01). CONCLUSION: ARFI-SWE is technically more challenging among patients with higher BMI and SLD, resulting in a higher number of unreliable studies, which highlights the need for further advancement of ARFI technology.

Surgical Management of Early-Stage Esophageal Adenocarcinoma Based on Lymph Node Metastasis Risk.

BACKGROUND: In early-stage esophageal adenocarcinoma (EAC), esophagectomy improves staging but also increases mortality compared with endoscopic resection. Our objective was to quantify esophagectomy mortality and lymph node metastasis (LNM) risk in early-stage EAC to improve surgical treatment allocation. METHODS: We identified National Cancer Database (2004-2014) patients with nonmetastatic, Tis, T1a, or T1b EAC who had primary surgical resection and microscopic examination of at least 15 lymph nodes. Univariate and multivariable logistic regression identified predictors of LNM. Cox regression identified predictors of death. The Kaplan-Meier method predicted overall survival (OS). RESULTS: In 782 patients, LNM rates were: all patients 13.8%, Tis 0%, T1a 3.6%, T1b 23.4%. Independent predictors of LNM were submucosal invasion, lymphovascular invasion (LVI), decreasing differentiation, and tumor size ≥ 2 cm (P < 0.05). For T1a tumors with poor differentiation or size ≥ 2 cm, LNM rates were 10.2 and 6.7%, respectively; 90-day mortality was 3.1%. The LNM rate in well differentiated T1b tumors < 2 cm was 4.2%; 90-day mortality was 6.0%. Estimated 5-year OS was 80.2% versus 64.4% (T1a vs. T1b). LNM increased risk of death for T1a (hazard ratio [HR] 8.52, 95% confidence interval [CI] 3.13-23.22, P < 0.001) and T1b tumors (HR 2.52, 95% CI 1.59-4.00, P < 0.001). CONCLUSIONS: In T1a EAC with poor differentiation or size ≥ 2 cm, esophagectomy should be considered, whereas in T1b EAC with low-risk features (well-differentiated T1b EAC < 2 cm without LVI), endoscopic resection may be sufficient. Treatment guidelines for early-stage EAC should include all high-risk tumor features for LNM and stage-specific esophagectomy mortality.

The Malnourished Patient With Obesity: A Unique Paradox in Bariatric Surgery.

BACKGROUND: Hypoalbuminemia is a known risk factor for poor outcomes following surgery. Obesity can be associated with modest to severe malnutrition. We evaluated the impact of hypoalbuminemia on surgical outcomes in patients with obesity undergoing elective bariatric surgical procedures. MATERIALS AND METHODS: The 2015 metabolic and bariatric surgery accreditation and quality improvement program database was queried. Patients ≥ 18 y with body mass index ≥35 undergoing bariatric surgery were included. Revision procedures were excluded. Patients were classified by albumin level (albumin ≥3.5 g/dL [normal], 3.49-3.0 g/dL [mild], 2.99-2.5 g/dL [moderate], and <2.5 g/dL [severe]). Independent logistic regression models were developed to estimate the adjusted odds of (1) death or serious morbidity (DSM); (2) mild to moderate complications; (3) severe complications; and (4) 30-d readmissions by albumin level. In addition, effect modification by >10% weight loss was examined. RESULTS: A total of 106,577 patients were included in the study. Over 6% of patients had hypoalbuminemia. Fifty-five percent of complications were severe as categorized by the Clavien-Dindo classification. Patients with mild hypoalbuminemia had 20% increased odds of DSM (95% confidence interval: 1.1-1.4). There was increasing likelihood of DSM with severe hypoalbuminemia. Patients with mild hypoalbuminemia had 20% increased odds of 30-d readmission (confidence interval: 1.1-1.3). A >10% weight loss modified the effect of moderate to severe hypoalbuminemia on DSM. CONCLUSIONS: More than 6% of patients with obesity undergoing bariatric surgery are malnourished. Hypoalbuminemia is an important and modifiable risk factor for postoperative adverse outcomes following bariatric surgery. Preoperative weight loss >10% combined with moderate to severe hypoalbuminemia is synergistic for high rates of DSM and should be addressed before proceeding with bariatric surgery.

Comparing International and United States Undergraduate Medical Education and Surgical Outcomes Using a Refined Balance Matching Methodology.

OBJECTIVE: The aim of this study is to compare surgical outcomes of international medical graduates (IMGs) and United States medical graduates (USMGs). SUMMARY OF BACKGROUND DATA: IMGs represent 15% of practicing surgeons in the United States (US), and their training pathways often differ substantially from USMGs. To date, differences in the clinical outcomes between the 2 cohorts have not been examined. METHODS: Using a unique dataset linking AMA Physician Masterfile data with hospital discharge claims from Florida and New York (2008-2011), patients who underwent 1 of 32 general surgical operations were stratified by IMG and USMG surgeon status. Mortality, complications, and prolonged length of stay were compared between IMG and USMG surgeon status using optimal sparse network matching with balance. RESULTS: We identified 972,718 operations performed by 4581 surgeons (72% USMG, 28% IMG). IMG and USMG surgeons differed significantly in demographic (age, gender) and baseline training (years of training, university affiliation of training hospital) characteristics. USMG surgeons performed complex procedures (13.7% vs 11.1%, P < 0.01) and practiced in urban settings (79.4% vs 75.6%, P < 0.01) more frequently, while IMG surgeons performed a higher volume of studied operations (50.7 ±â€Š5.1 vs 57.8 ±â€Š8.4, P < 0.01). In the matched cohort analysis of 396,810 patients treated by IMG and USMG surgeons, rates of mortality (USMG: 2.2%, IMG: 2.1%; P < 0.001), complications (USMG: 14.5%, IMG: 14.3%; P = 0.032), and prolonged length of stay (pLOS) (USMG: 22.7%, IMG: 22.8%; P = 0.352) were clinically equivalent. CONCLUSION: Despite considerable differences in educational background, surgical training characteristics, and practice patterns, IMG and USMG-surgeons deliver equivalent surgical care to the patients whom they treat.

Mammographic breast density decreases after bariatric surgery.

PURPOSE: Breast density (BD), an important risk factor for breast cancer, can change over time in some women, but the underlying mechanism is unclear. Very little is known about the impact of surgical weight loss on BD. Our hypothesis is that weight loss after bariatric surgery is associated with a significant and favorable change in mammographic BD. METHODS: We identified 1097 women 40 years of age or older who underwent gastric bypass or sleeve gastrectomy at our institution from 2010 to 2014. Women who did not have either pre- and post-bariatric surgery mammograms performed at our institution were excluded; 110 had both mammograms and comprised the cohort. Breast density was determined both qualitatively, using reported BI-RADS density, and quantitatively, using the Laboratory for Individualized Breast Radiodensity Assessment. RESULTS: Qualitative BI-RADS density, quantitative breast area, and percent BD significantly decreased in post-bariatric surgery mammograms (p = 0.009, <0.001, and <0.001, respectively). CONCLUSIONS: Our retrospective study demonstrated that surgical weight loss was associated with a significant decrease in breast density. Additional studies are warranted to validate our findings and elucidate the molecular mechanisms underlying breast density change after weight loss surgery.

Laparoscopic transhiatal esophagectomy improves hospital outcomes and reduces cost: a single-institution analysis of laparoscopic-assisted and open techniques.

BACKGROUND: Several case series have demonstrated that laparoscopic transhiatal esophagectomy (LTHE) is associated with favorable perioperative outcomes compared to historical data for open transhiatal esophagectomy (OTHE). Contemporaneous evaluation of open and laparoscopic THE is rare, limiting meaningful comparison of techniques. METHODS: All patients who underwent OTHE (n = 32) and LTHE (n = 41) during the introduction of the latter procedure at our institution (1/2012-4/2014) were identified, and patient charts were retrospectively reviewed. RESULTS: Indications for operation included 69 patients with esophageal malignancy (adenocarcinoma: 64; squamous cell carcinoma: 4; melanoma: 1) and 4 patients with benign disease. There were no significant differences in clinicopathologic variables between OTHE and LTHE cohorts, except for an increased rate of cardiovascular disease in the LTHE cohort (p = 0.04). There was no significant difference in median operative time or operative complications, yet LTHE was associated with a lower incidence of intraoperative blood transfusion (p < 0.01). There were no 30-day mortalities. LTHE was associated with a reduced time to reach 24-h tube feeding goals (p = 0.02), shorter length of hospital stay (p = 0.01), and 6 % reduced median direct cost (p = 0.04). There were no significant differences in rates of major perioperative morbidities. Patients were followed for a median of 11.0 months during which there were no significant differences between cohorts in disease-free survival or overall survival. CONCLUSION: When compared to OTHE, LTHE improves surgical outcomes and decreases hospital costs; short-term oncologic outcomes are similar. LTHE is preferable to OTHE in patients requiring transhiatal esophagectomy.

Deliberate practice enhances quality of laparoscopic surgical performance in a randomized controlled trial: from arrested development to expert performance.

BACKGROUND: This study investigated whether deliberate practice leads to an increase in surgical quality in virtual reality (VR) laparoscopic cholecystectomies (LC). Previous research has suggested that sustained DP is effective in surgical training. METHODS: Fourteen residents were randomized into deliberate practice (n = 7) or control training (n = 7). Both groups performed ten sessions of two VR LCs. Each session, the DP group was assigned 30 min of DP activities in between LCs while the control group viewed educational videos or read journal articles. Performance was assessed on speed and dexterity; quality was rated with global (GRS) and procedure-specific (PSRS) rating scales. All participants then performed five porcine LCs. RESULTS: Both groups improved over 20 VR LCs in time, dexterity, and global rating scales (all p < 0.05). After 20 LCs, there were no differences in speed or dexterity between groups. The DP group achieved higher quality of VR surgical performance than control for GRS (26 vs. 20, p = 0.001) and PSRS (18 vs. 15, p = 0.001). For VR cases, DP subjects plateaued at GRS = 25 after ten cases and control group at GRS = 20 after five cases. At completion of VR training, 100 % of the DP group reached target quality of performance (GRS ≥ 21) compared with 30 % in the control group. There were no significant differences for improvements in time or dexterity over five porcine LCs. CONCLUSION: This study suggests that DP leads to higher quality performance in VR LC than standard training alone. Standard training may leave individuals in a state of "arrested development" compared with DP.

A comparative study of contrasting surgical residency programs.

BACKGROUND: Postgraduate training is completed in a 5-year surgical residency program in the USA, compared with 10 years in the UK. The UK Joint Committee on Surgical Training (JCST) has described quality indicators for surgical training. Similar indicators can be inferred from the American Board of Surgery and Accreditation Council for Graduate Medical Education. This exploratory study compares postgraduate surgical training between two regions following their respective national programs. METHODS: A questionnaire was developed based on JCST quality indicators. This was distributed electronically to all general surgical residents in the University of Pennsylvania (UPenn) (N = 64) and North and South West Thames general surgical registrars in London (N = 182). RESULTS: A total of 76 residents (31 %) completed the questionnaire and all data presented are self-reported. When residents operate electively, an attending is scrubbed for 57 % of cases in London versus 83 % at UPenn (p < 0.001). During emergency surgery, residents operate without an attending in the operating room (OR) for 60 % of cases in London versus 2 % in UPenn (p < 0.001). London versus UPenn residents have a mean 3.6 versus 5.0 (p < 0.001) operating sessions and 0.7 versus 2.3 (p < 0.001) teaching hours per week. In London, 68 % of residents have regular gastrointestinal endoscopy sessions compared with 39 % at UPenn (p = 0.036). CONCLUSIONS: UPenn residents receive more supervised operating opportunities and scheduled teaching than their London counterparts. However, they have less independent operating experience and less exposure to gastrointestinal endoscopy training.

Predicting Recurrent Deficiency and Suboptimal Monitoring of Thiamin Deficiency in Patients with Metabolic and Bariatric Surgery.

INTRODUCTION: Vitamin B1 (thiamine) deficiency (TD) after metabolic and bariatric surgery (MBS) is often insidious and, if unrecognized, can lead to irreversible damage or death. As TD symptoms are vague and overlap with other disorders, we aim to identify predictors of recurrent TD and failure to collect B1 labs. METHODS: We analyzed a large sample of data from patients with MBS (n = 878) to identify potential predictors of TD risk. We modeled recurrent TD and failure to collect B1 labs using classical statistical and machine learning (ML) techniques. RESULTS: We identified clusters of labs associated with increased risk of recurrent TD: micronutrient deficiencies, abnormal blood indices, malnutrition, and fluctuating electrolyte levels (aIRR range: 1.62-4.68). Additionally, demographic variables associated with lower socioeconomic status were predictive of recurrent TD. ML models predicting characteristics associated with failure to collect B1 labs achieved 75-81% accuracy, indicating that clinicians may fail to match symptoms with the underlying condition. CONCLUSIONS: Our analysis suggests that both clinical and social factors can increase the risk of life-threatening TD episodes in some MBS patients. Identifying these indicators can help with diagnosis and treatment.