Racial Disparities in Breast Cancer Presentation and Diagnosis in COVID-Era Central Texas.

INTRODUCTION: The COVID-19 pandemic has significantly impacted the diagnosis of breast cancer (BC). With a large Hispanic/Latinx population, early revocation of mask mandates, and lower vaccination rate than many other states, this study explores the relationship between COVID-19 and the presentation and diagnosis of BC patients in the unique socio-politico-economic context of Central Texas. METHODS: This study is a retrospective review of the Seton Medical Center Austin tumor registry for BC patients from March 1, 2019 to March 2, 2021. We compared demographics, insurance status, clinical and pathologic stage, and time from diagnosis to intervention between "pre-COVID" (March 1, 2019- March 1, 2020) and "post-COVID" (March 2, 2020-March 2, 2021). We utilized descriptive, univariate, and multivariable logistic regression statistics. RESULTS: There were 781 patients diagnosed with BC, with 113 fewer post-COVID compared to pre-COVID. The proportion of Black patients diagnosed with BC decreased post-COVID compared with pre-COVID (10.1%-4.5%, P = 0.002). When adjusting for other factors, uninsured and underinsured patients had increased odds of presenting with late-stage BC (odds ratio:5.40, P < 0.001). There was also an association between presenting with stage 2 or greater BC and delayed time-to-intervention. CONCLUSIONS: Although fewer women overall were diagnosed with BC post-COVID, the return to baseline diagnoses has yet to be seen. We identified a pandemic-related decrease in BC diagnoses in Black women and increased odds of late-stage cancer among uninsured patients, suggesting a disparate relationship between COVID-19 and health care access and affordability. Outreach and screening efforts should address strategies to engage Black and uninsured patients.

Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop.

: A workshop on "Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities" was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of "deliberate practice," rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.

A Prospective Randomized Multicenter Trial of Distal Pancreatectomy With and Without Routine Intraperitoneal Drainage.

OBJECTIVE: The objective of this study was to test the hypothesis that distal pancreatectomy (DP) without intraperitoneal drainage does not affect the frequency of grade 2 or higher grade complications. BACKGROUND: The use of routine intraperitoneal drains during DP is controversial. Prior to this study, no prospective trial focusing on DP without intraperitoneal drainage has been reported. METHODS: Patients undergoing DP for all causes at 14 high-volume pancreas centers were preoperatively randomized to placement of a drain or no drain. Complications and their severity were tracked for 60 days and mortality for 90 days. The study was powered to detect a 15% positive or negative difference in the rate of grade 2 or higher grade complications. All data were collected prospectively and source documents were reviewed at the coordinating center to confirm completeness and accuracy. RESULTS: A total of 344 patients underwent DP with (N = 174) and without (N = 170) the use of intraperitoneal drainage. There were no differences between cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, or operative technique. There was no difference in the rate of grade 2 or higher grade complications (44% vs. 42%, P = 0.80). There was no difference in clinically relevant postoperative pancreatic fistula (18% vs 12%, P = 0.11) or mortality (0% vs 1%, P = 0.24). DP without routine intraperitoneal drainage was associated with a higher incidence of intra-abdominal fluid collection (9% vs 22%, P = 0.0004). There was no difference in the frequency of postoperative imaging, percutaneous drain placement, reoperation, readmission, or quality of life scores. CONCLUSIONS: This prospective randomized multicenter trial provides evidence that clinical outcomes are comparable in DP with or without intraperitoneal drainage.

Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop.

A workshop on ''Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities'' was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of ''deliberate practice,'' rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.

Is current surgery resident and GI fellow training adequate to pass FES?

BACKGROUND: The purpose of this study was to assess the adequacy of current surgical residency and gastroenterology (GI) fellowship flexible endoscopy training as measured by performance on the FES examination. METHODS: Fifth-year general surgery residents and GI fellows across six institutions were invited to participate. All general surgery residents had met ACGME/ABS case volume requirements as well as additional institution-specific requirements for endoscopy. All participants completed FES testing at the end of their respective academic year. Procedure volumes were obtained from ACGME case logs. Curricular components for each specialty and institution were recorded. RESULTS: Forty-eight (28 surgery and 20 GI) trainees completed the examination. Average case numbers for residents were 76 ± 26 colonoscopies and 45 ± 12 EGDs. Among GI fellows, PGY4 s (N = 10) reported 99 ± 64 colonoscopies and 147 ± 79 EGDs. PGY5 s (N = 3) reported 462 ± 307 colonoscopies and 411 ± 260 EGDs. PGY6 GI fellows (N = 7) reported 515 ± 111 colonoscopies and 418 ± 146 EGDs. The overall pass rate for all participants was 75 %, with 68 % of residents and 85 % of fellows passing both the cognitive and skills components. For surgery residents, pass rates were 75 % for manual skills and 85.7 % for cognitive. On the skills examination, Task 2 (loop reduction) was associated with the lowest performance. Skills scores correlated with both colonoscopy (r = 0.46, p < 0.001) and EGD experience (r = 0.46, p < 0.001). Receiver operating characteristics curves were examined among the resident cohort. The minimum number of total cases associated with passing the FES skills component was 103. Significant variability existed in curricular components across institutions. DISCUSSION: These data suggest that current flexible endoscopy training may not be sufficient for all trainees to pass the examination. Implementing additional components of the FEC may prove beneficial in achieving more uniform pass rates on the FES examination.

What do residents need to be competent laparoscopic and endoscopic surgeons?

BACKGROUND: Despite numerous efforts to ensure that surgery residents are adequately trained in the areas of laparoscopy and flexible endoscopy, there remain significant concerns that graduates are not comfortable performing many of these procedures. METHODS: Online surveys were sent to surgery residents (98 items, PGY1-5 Categorical) and faculty (78 items, general surgery, and gastrointestinal specialties) at seven institutions. De-identified data were analyzed under an IRB-approved protocol. RESULTS: Ninety-five faculty and 121 residents responded, with response rates of 65 and 52 %, respectively. Seventy-three percent of faculty indicated that competency of their graduating residents were dramatically or slightly worse than previous graduates. Only 29 % of graduating residents felt very comfortable performing advanced laparoscopic (AL) cases and 5 % performing therapeutic endoscopy (TE) cases immediately after graduation. Over half of interns expressed a need for fellowship to feel comfortable performing AL and TE procedures, and this need did not decrease as residents neared graduation. For these procedures, residents receive only "little to some" autonomy, as reported by both faculty and PGY5s. Residents reported that current curricula for laparoscopy and endoscopy consist primarily of clinical experience. Both residents and faculty, though, reported considerable value in other training modalities, including simulations, live animal laboratories, cadavers, and additional didactics. CONCLUSIONS: These data indicate that both residents and faculty perceive significant competency gaps for both laparoscopy and flexible endoscopy, with the most notable shortcomings for advanced and therapeutic cases, respectively. Improvement in resident training methods in these areas is warranted.

Design of vessel ligation simulator for deliberate practice.

BACKGROUND: Surgical residents develop technical skills at variable rates, often based on random chance of cases encountered. One such skill is tying secure knots without exerting excessive force. This study describes the design of a simulator using a force sensor to measure instantaneous forces exerted on a blood vessel analog during vessel ligation and the development of expert-derived performance goals. MATERIALS AND METHODS: Vessel ligations were performed on Silastic tubing at an offset from a Vernier Force Sensor. Nine experts (surgical faculty and senior residents) and 10 novices (junior residents) were recruited to each perform 10 vessel ligations (two square knots each) with two-handed and one-handed techniques. Internal consistency for the series of vessel ligations was tested with Cronbach alpha. Maximum forces exerted by novices and experts were compared using Student t-test. RESULTS: Internal consistency across the 10 ligations on the simulator was excellent (Cronbach alpha = 0.91). The expert group on average exerted a significantly lower maximum force when compared with novices while performing two-handed (0.76 ± 0.39 N versus 1.12 ± 0.49 N, P < 0.01) and one-handed (0.84 ± 0.32 N versus 1.36 ± 0.44 N, P < 0.01) vessel ligations. CONCLUSIONS: Although the expert group performed vessel ligations with significantly lower peak force than the novice group, there were novices who performed at the expert level. This is consistent with the conceptual framework of milestones and suggests that the skill of gentle knot-tying can be measured and develops at different chronologic levels of training in different individuals. This simulator can be used as part of a deliberate practice curriculum with instantaneous visual feedback.

Impact of liver-directed therapy in colorectal cancer liver metastases.

BACKGROUND: There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy. METHODS: We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001-2007). LDT was defined as liver resection and/or ablation-embolization. RESULTS: We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93-0.99), age >85 y (OR = 0.61, 95% CI 0.45-0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64-0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P < 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005-2007) period. CONCLUSIONS: Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.

Three Lessons Learned About Power and Improving Recruitment of Underrepresented Populations in Clinical Trials.

This Open Forum is relevant for investigators who conduct research with historically understudied and marginalized populations. The authors introduce a U.S. Department of Veterans Affairs clinical trial that experienced challenges with recruitment of African American or Black veterans and was terminated for not achieving its recruitment goals. The role of power dynamics in clinical research is discussed, specifically how unequal distributions of power may create recruitment challenges. The authors summarize three lessons learned and offer recommendations for sharing power equitably between investigators and potential participants. By recounting these experiences, the authors seek to promote culturally sensitive, veteran-centered approaches to recruitment in future clinical trials.

Patient-reported outcomes after single-incision versus traditional laparoscopic cholecystectomy: a randomized prospective trial.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) is a newer approach that may be a safe alternative to traditional laparoscopic cholecystectomy (TLC) based on retrospective and small prospective studies. As the demand for single-incision surgery may be driven by patient perceptions of benefits, we designed a prospective randomized study using patient-reported outcomes as our end points. METHODS: Patients deemed candidates for either SILC or TLC were offered enrollment in the study. After induction of anesthesia, patients were randomized to SILC or TLC. Preoperative characteristics and operative data were recorded, including length of stay (LOS). Pain scores in recovery and for 48 h and satisfaction with wound appearance at 2 and 4 weeks were reported by patients. We used the gastrointestinal quality of life index (GIQLI) survey preoperatively and at 2 and 4 weeks postoperatively to assess recovery. Procedural and total hospital costs per case were abstracted from hospital billing systems. RESULTS: Mean age of the study group was 44.1 years (±14.8), 87% were Caucasian, and 77% were female, with no difference between groups. Operative times were longer for SILC (median = 57 vs. 47 min, p = 0.008), but mean LOS was similar (6.8 ± 4.2 h SILC vs. 6.2 ± 4.8 h TLC, p = 0.59). Operating room cost and encounter cost were similar. GIQLI scores were not significantly different preoperatively or at 2 or 4 weeks postoperatively. Patients reported higher satisfaction with wound appearance at 2 weeks with SILC. There were no differences in pain scores in recovery or in the first 48 h, although SILC patients required significantly more narcotic in recovery (19 mg morphine equivalent vs. 11.5, p = 0.03). CONCLUSIONS: SILC is a longer operation but can be done at the same cost as TLC. Recovery and pain scores are not significantly different. There may be an improvement in patient satisfaction with wound appearance. Both procedures are valid approaches to cholecystectomy.

Ensuring competency: are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?

BACKGROUND: Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel. METHODS: Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ(2) analysis. RESULTS: The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73% compliance), 83 completed the baseline skills assessment, and 27 (33%) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (n = 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (p < 0.0001). One surgeon (1.3%) failed the skills certification, and nine (11.8%) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34% compliance). All achieved proficiency at skills, and 60% passed the cognitive exam. CONCLUSIONS: This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33% and a certification failure rate of 13% suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.

Duty Hours on Surgery Clerkship: From Compliance Nightmare to Leadership and Professional Development Opportunity.

OBJECTIVE: To evaluate the impact of an innovative leadership development initiative in the core surgery clerkship that addressed duty hours compliance and time-off requests. DESIGN: A combination of deductive and inductive analysis of medical student reflections written after rotating on Acute Care Surgery over 2 academic years (2019-2020 and 2020-2021) was performed. Reflections were part of criteria to receive honors and a prompt was given to discuss their experience in creating their own call schedules. We utilized a combined deductive and inductive process to identify predominant themes within the reflections. Once established, we quantitatively identified frequency and density of themes cited, along with qualitative analysis to determine barriers and lessons learned. SETTING: Dell Seton Medical Center, Dell Medical School at The University of Texas at Austin, a tertiary academic facility. PARTICIPANTS: There were 96 students who rotated on Acute Care Surgery during the study period, 64 (66.7%) of whom completed the reflection piece. RESULTS: We identified 10 predominant themes through the combined deductive and inductive processes. Barriers were cited by most students (n = 58, 91%), with communication being the most commonly discussed theme when cited with a mean 1.96 references per student. Learned leadership skills included: communication, independence, teamwork, negotiating skills, reflection of best practices by residents, and realizing the importance of duty hours. CONCLUSIONS: Transferring duty hour scheduling responsibilities to medical students resulted in multiple professional development opportunities while decreasing administrative burden and improving adherence to duty hour requirements. This approach requires further validation, but may be considered at other institutions seeking to improve the leadership and communication skills of its students, while improving adherence to duty hour restrictions.

Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery.

BACKGROUND: Routine preoperative laboratory testing for ambulatory surgery is not recommended. METHODS: Patients who underwent elective hernia repair (N = 73,596) were identified from the National Surgical Quality Improvement Program (NSQIP) database (2005-2010). Patterns of preoperative testing were examined. Multivariate analyses were used to identify factors associated with testing and postoperative complications. RESULTS: A total of 46,977 (63.8%) patients underwent testing, with at least one abnormal test recorded in 61.6% of patients. In patients with no NSQIP comorbidities (N = 25,149) and no clear indication for testing, 54% received at least one test. In addition, 15.3% of tested patients underwent laboratory testing the day of the operation. In this group, surgery was done despite abnormal results in 61.6% of same day tests. In multivariate analyses, testing was associated with older age, ASA (American Society of Anesthesiologists) class >1, hypertension, ascites, bleeding disorders, systemic steroids, and laparoscopic procedures. Major complications (reintubation, pulmonary embolus, stroke, renal failure, coma, cardiac arrest, myocardial infarction, septic shock, bleeding, or death) occurred in 0.3% of patients. After adjusting for patient and procedure characteristics, neither testing nor abnormal results were associated with postoperative complications. CONCLUSIONS: Preoperative testing is overused in patients undergoing low-risk, ambulatory surgery. Neither testing nor abnormal results were associated with postoperative outcomes. On the basis of high rates of testing in healthy patients, physician and/or facility preference and not only patient condition currently dictate use. Involvement from surgical societies is necessary to establish guidelines for preoperative testing.

Measuring what matters: identifying assessments that reflect learning on the core surgical clerkship.

Purpose: There are various assessments used during the core surgical clerkship (CSC), each of which may be influenced by factors external to the CSC or have inherent biases from an equity lens. In particular, the National Board of Medical Examiners' Clinical Subject Exams ("Shelf") is used heavily and may not reflect clerkship curriculum or clinical learning. Methods: This is a retrospective review of medical student characteristics and assessments during the CSC from July 2017-June 2021. Assessment methods included: subjective Clinical Performance Assessments (CPA), Shelf, Objective Structured Clinical Examinations, and a short-answer in-house examination (IHE) culminating in a Final Grade (FG) of Honors/Pass/Fail. A Shelf score threshold for Honors was added in academic years 2020-2021. Descriptive, univariate, and multivariable logistic and linear regression statistics were utilized. Results: We reviewed records of 192 students. Of these, 107 (55.7%) were female, median age was 24 [IQR: 23-26] years, and most were White/Caucasian (N = 106, 55.2%). Univariate analysis showed the number of Exceeds Expectations obtained on CPA to be influenced by surgical subspecialty taken (p = 0.013) and academic year (p < 0.001). Shelf was influenced by students' race (p = 0.009), timing of CSC before or after Internal Medicine (67.9 ± 7.3 vs 72.9 ± 7.1, p < 0.001), and Term taken (increasing from 66.0 ± 8.7 to 73.4 ± 7.5, p < 0.001). IHE scores did not have any external associations. After adjustment with multivariable logistic and linear regressions, CPA and IHE did not have external associations, but higher scores were obtained on Shelf exam in Terms 3, 5, and 6 (by 4.62 [95% CI 0.86-8.37], 4.92 [95% CI 0.53-9.31], and 7.56 [95% CI 2.81-12.31] points, respectively. Odds of FG honors were lower when Shelf threshold was implemented (OR 0.17 [95% CI 0.06-0.50]), and increased as students got older (OR 1.14 [95% CI 1.01-1.30]) or on specific subspecialties, such as vascular surgery (OR 7.06 [95% CI 1.21-41.26]). Conclusions: The Shelf is substantially influenced by temporal associations across Terms and timing in relation to other clerkships, such as Internal Medicine. An IHE reflective of a clerkship's specified curriculum may be a more equitable summative assessment of the learning that occurs from the CSC curriculum, with fewer biases or influences external to the CSC. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-022-00047-8.

Single-incision laparoscopic colectomy for malignant disease.

BACKGROUND: Laparoscopic colectomy has been shown to confer equivalent disease-free and overall survival compared to traditional open colectomy. Patients experience benefit in length of hospital stay as well as diminished narcotic use. Single-incision laparoscopic colectomy (SIL-C) may offer additional benefit compared to traditional laparoscopic colectomy without compromising oncologic principles. METHODS: We retrospectively reviewed records of patients who underwent SIL-C and traditional laparoscopic colectomy (TLC) for potentially malignant and malignant disease performed by a single surgeon. SIL-C consisted of a single-port access device with traditional lateral-to-medial laparoscopic technique. RESULTS: Between January and October 2009, 27 SIL-C procedures were performed. Forty-six TLC patients from the prior year were used as controls. Median age was 70 years and 54% were female, with no differences between the groups. The median body mass index (BMI) was 27 kg/m(2) (range = 18.3-39.9) and 26 kg/m(2) (16.6-71.4) for SIL-C and TLC, respectively. The median lymph node harvest was 15 (range = 3-32) and 17 (0-35) for SIL-C and TLC, respectively. The median operative time was 114 min (range = 59-268) and 135 min (45-314) for SIL-C and TLC, respectively. Five SIL-C required additional ports while six TLC required conversion to open technique. The median length of stay was 3 days (range = 2-17) and 5 days (range = 2-11) for SIL-C and TLC, respectively (p = 0.079). There were five significant postoperative complications in the SIL-C group and 16 in the TLC group, including four postoperative ileus and one leak. There were no postoperative deaths in the SIL-C group and two in the TLC group. CONCLUSIONS: SIL-C can be used safely in selected colon cancer patients with no difference in blood loss, OR time, or lymph node retrieval. SIL-C patients may have a shorter LOS.

Single-incision laparoscopic cholecystectomy: a comparison with the gold standard.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) may be a comparable alternative to conventional multiport laparoscopic cholecystectomy (LC). This study compared procedural outcomes and costs between SILC and LC. METHODS: A retrospective review of patients undergoing SILC over an 8-month period was performed. A cohort of LC patients from the same surgeons over the preceding 8 months was used as historic controls. Demographics, comorbidities, diagnosis, operative data, pain control in the recovery room, complications, length of hospital stay, and cost were compared between the two groups. RESULTS: Of the 285 patients, 177 underwent LC and 108 underwent SILC. The mean age was 49.7 years for the LC patients and 48.2 years for the SILC patients (p = 0.44). Two of the LC patients underwent conversion to open surgery. None of SILC patients were converted to open procedure, although nine had additional ports placed. After multivariate adjustment, SILC was associated with a 15% longer operative time (p = 0.053) and a 66% shorter hospital stay (p = 006) than LC. Biliary dyskinesia and biliary colic were independently associated with shorter operative times and a reduced hospital stay. No significant differences were noted in pain score, narcotics used in the postanesthesia care unit (PACU), 30-day complication rates (1.7 vs 1.9%; p = 1), hospital charges, or cost between the two groups. CONCLUSIONS: Single-incision LC is safe, significantly reduces the hospital stay, and is an acceptable alternative to traditional LC. Although further study is warranted, initial results indicate that SILC may offer the most benefit for outpatient procedures.

Mind the Gap: The Autonomy Perception Gap in the Operating Room by Surgical Residents and Faculty.

OBJECTIVE: Examine the concordance of perceived operative autonomy between attendings and resident trainees. DESIGN: Faculty and trainees rated trainee operative autonomy using the 4-level Zwisch scale over a variety of cases and training years. The respective ratings were then compared to explore the effects of experience, gender, case complexity, trainee, trainer, and other covariates to perceived autonomy. SETTING: This study was conducted over 14 general surgery programs in the United States, members of the Procedural Learning and Safety Collaborative. PARTICIPANTS: Participants included faculty and categorical trainees from 14 general surgery programs. RESULTS: A total of 8681 observations was obtained. The sample included 619 unique residents and 457 different attendings. A total of 598 distinct procedures was performed. In 60% of the cases, the autonomy ratings between trainees and attendings were concordant, with only 3.5% of cases discrepant by more than 1 level. An autonomy perception gap was modeled based on the discrepancy between the trainee and attending Zwisch ratings for the same case. The mean Zwisch score expected for a trainee was lower than the attending across all scenarios. Trainees were more likely to perceive relatively more autonomy in the second half of the year. The autonomy perception gap decreased with increasing case complexity. As trainees gained experience, the perception gap increased with trainees underestimating autonomy. CONCLUSIONS: Trainees and attendings generally demonstrated concordance on autonomy perception scores. However, in 40% of cases, a perception gap exists between trainee and attending with the trainee generally underestimating autonomy. The gap worsens as the trainee progresses through residency. This perception gap suggests that attendings and trainees could be better aligned on teaching goals and expectations.

Multidisciplinary approach to tumors of the pancreas and biliary tree.

Tumors of the pancreas and biliary tree remain formidable challenges to patients and clinicians. These tumors elude early detection, rapidly spread locally and systemically, and frequently recur despite apparently complete resection. Cystic tumors of the pancreas, however, may represent a subset of patients who do not uniformly require aggressive resection, and a thoughtful, evidence-based approach to work-up allows for the rational application of surgical therapy. Increasing evidence supports treating patients who have pancreaticobiliary disease in a multidisciplinary setting.

Development of a Model for Training and Assessing Open Image-Guided Liver Tumor Ablation.

BACKGROUND: Image-guided microwave ablation (MWA) is a technically demanding procedure, involving advanced visual-spatial perception skills. This study sought to create and evaluate a low-cost model and training curriculum for open ultrasound-guided liver tumor MWA. METHODS: Simulated tumors were created, implanted into bovine livers, and visualized by ultrasound. A high-fidelity abdominal model was constructed, with a total cost of $30. Experienced physicians in MWA performed simulated ablations and evaluated the model. Expert performance metrics were established and served as targets for our training curriculum. These included time, number of passes, number of repositionings, and percentage of tumor ablated. Next, 8 novice trainees completed our deliberate practice curriculum. Participants' performances were recorded throughout. RESULTS: Physicians completed a structured feedback questionnaire rating the model's realism and training utility at 8/10 and 10/10, respectively. Tumors appeared hyperechoic and were clearly visualized on ultrasound. Trainees performed a total of 32 ablations. Our trainees' performance improved significantly in all outcomes of interest in the postcurriculum ablations compared to precurriculum ablations. CONCLUSION: We have created a cost-effective, high-fidelity model of MWA, with a deliberate practice curriculum. Trainees can practice to proficiency with clear target metrics prior to participating in clinical cas.