Hiatal hernia reporting: time to remove subjectivity?

INTRODUCTION: The size of a hiatal hernia (HH) is a key determinant of the approach for surgical repair. However, endoscopists will often utilize subjective terms, such as "small," "medium," and "large," without any standardized objective correlations. The aim of this study was to identify HHs described using objective axial length measurements versus subjective size allocations and compare them to their corresponding manometry and barium swallow studies. METHODS AND PROCEDURES: Retrospective chart reviews were conducted on 93 patients diagnosed endoscopically with HHs between 2017 and 2021 at Newton-Wellesley Hospital. Information was collected regarding their HH subjective size assessment, axial length measurement (cm), manometry results, and barium swallow readings. Linear regression models were used to analyze the correlation between the objective endoscopic axial length measurements and manometry measurements. Ordered logistic regression models were used to correlate the ordinal endoscopic and barium swallow subjective size allocations with the continuous axial length measurements and manometry measurements. RESULTS: Of the 93 endoscopy reports, 42 included a subjective size estimate, 38 had axial length measurement, and 12 gave both. Of the 34 barium swallow reads, only one gave an objective HH size measurement. Axial length measurements were significantly correlated with the manometry measurements (R2 = 0.0957, p = 0.049). The endoscopic subjective size estimates were also closely related to the manometry measurements (R2 = 0.0543, p = 0.0164). Conversely, the subjective size estimates from barium swallow reads were not significantly correlated with the endoscopic axial length measurements (R2 = 0.0143, p = 0.366), endoscopic subjective size estimates (R2 = 0.0481, p = 0.0986), or the manometry measurements (R2 = 0.0418, p = 0.0738). Mesh placement was significantly correlated to pre-operative endoscopic axial length measurement (p = 0.0001), endoscopic subjective size estimate (p = 0.0301), and barium swallow read (p = 0.0211). However, mesh placement was not significantly correlated with pre-operative manometry measurements (0.2227). CONCLUSIONS: Endoscopic subjective size allocations and objective axial length measurements are associated with pre-operative objective measurements and intra-operative decisions, suggesting both can be used to guide clinical decision making. However, including axial length measurements in endoscopy reports can improve outcomes reporting.

Safety and cost of performing laparoscopic sleeve gastrectomy with same day discharge at a large academic hospital.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common surgical treatment for morbid obesity. While certain specialized ambulatory surgery centers offer LSG on an outpatient basis, patients undergoing LSG at most academic centers are admitted to hospital for initial postoperative convalescence and monitoring. Our institution has begun to offer LSG with same-day discharge (SDD) in select patients. We aimed to compare the perioperative outcomes and costs for patients undergoing LSG with inpatient admission versus SDD. METHODS: All patients enrolled in the SDD program from December 2020 through July 2022 were identified from a prospectively maintained database. Patients enrolled in this pathway were analyzed on an intention-to-treat basis even if ultimately admitted postoperatively. Propensity scoring was used to match these patients 1:1 to those with planned inpatient recovery based on age, BMI, and ASA classification. RESULTS: Seventy-five patients were enrolled in the LSG with SDD program during the study period. Among these, 62 patients (82.7%) had successful immediate postoperative discharge. Reasons for cancelation of planned SDD included anxiety (n = 5), pain (n = 3), nausea (n = 2), and one patient each with hypotension, urinary retention, and bleeding. After matching, there were no differences in age, BMI, or ASA classification in a comparison group of patients with planned inpatient recovery. There were no differences in perioperative complications. There were no readmissions or requirements for outpatient intravenous fluids among patients with SDD, compared to n = 3 (4.0%) and n = 2 (2.7%) in the inpatient cohort, respectively. The total perioperative cost for patients undergoing LSG with planned SDD was 6.8% less than those with inpatient recovery. CONCLUSION: With appropriate protocols, LSG with same-day discharge can safely be performed at large academic surgery centers without increased morbidity or need for additional services in the perioperative period. SDD may be associated with decreased costs and allows for more efficient hospital bed allocation.

Thromboelastography with Platelet Mapping Identifies High Platelet Reactivity is Associated with Obesity, Diabetes, and Thrombotic Events.

BACKGROUND: Metabolic comorbidities such as diabetes and obesity are considered pro-inflammatory states which theoretically increase the risk of perioperative thrombotic events across many surgical disciplines. Currently, there is a paucity of objective metrics to determine such risk and ideal pharmacologic targets. Thromboelastography with Platelet Mapping (TEG-PM) provides a comprehensive profile of coagulation and may provide insight into clot dysregulation. METHODS: Patients undergoing lower extremity revascularization underwent serial TEG-PM analysis. The relationship between the TEG-PM metrics and thrombosis was evaluated. Preoperative TEG-PM samples of patients with body mass index (BMI)≥25 were compared to those of patients with a normal BMI, and between patients with diabetes mellitus (DM) and those without. RESULTS: 218 TEG-PM samples from 202 patients were analyzed. The BMI≥25 cohort showed significantly greater platelet aggregation [81.9% (±20.9) vs. 68.6% (±27.7), P < 0.01]. Patients with DM were more frequently on full-dose anticoagulation [47.7% vs. 29.7% P = 0.01] yet demonstrated increased clot strength, or adenosine diphosphate (ADP)-Maximum Clot Amplitude (MA) [49.1 (±16.1) vs. 41.5 (±17.1) and 37.7 (±19.6) vs. 31.6 (±17.4) P < 0.01]. 49 patients experienced thrombosis and exhibited greater platelet aggregation [76.6% (±17.8) vs. 66.8% (±30.4) P = 0.03] and greater ADP/arachidonic acid MA [47.1 (±16.6) vs. 41.9 (±18.8) and 38.2 (±17.8) vs. 32.5 (±19.9) both P = 0.05]. Patients who thrombosed were more often diabetic [69.5% versus 51.0% P = 0.03] and on full-dose anticoagulation [75.0% vs. 56.8% P = 0.02]. CONCLUSIONS: Patients with a BMI≥ 25 and those with diabetes demonstrated TEG-PM profiles similar to patients with thrombosis. Diabetes was independently associated with thrombosis, and full-dose anticoagulation was not protective. This suggests the potential utility of TEG-PM for thrombotic risk stratification based on metabolic factors and suggests antiplatelet agents may be effective at prevention of thrombotic events in this population.

Multidisciplinary perceptions on robotic surgical training: the robot is a stimulus for surgical education change.

BACKGROUND: It is unclear how to best establish successful robotic training programs or if subspecialty robotic program principles can be adapted for general surgery practice. The objective of this study is to understand the perspectives of high-volume robotic surgical educators on best practices in robotic surgery training and to provide recommendations transferable across surgical disciplines. METHODS: This multi-institutional qualitative analysis involved semi-structured interviews with high-volume robotic educators from academic general surgery (AGS), community general surgery (CGS), urology (URO), and gynecology (GYN). Purposeful sampling and snowballing ensured high-volume status and geographically balanced representation across four strata. Interviews were transcribed, deidentified, and independently, inductively coded. A codebook was developed and refined using constant comparative method until interrater reliability kappa reached 0.95. A qualitative thematic, framework analysis was completed. RESULTS: Thirty-four interviews were completed: AGS (n = 9), CGS (n = 8), URO (n = 9), and GYN (n = 8) resulting in 40 codes and four themes. Theme 1: intangibles of culture, resident engagement, and faculty and administrative buy-in are as important as tangibles of robot and simulator access, online modules, and case volumes. Theme 2: robotic OR integration stresses the trainee-autonomy versus patient-safety balance. Theme 3: trainees acquire robotic skills along individual learning curves; benchmark assessments track progress. Theme 4: AGS can learn from URO and GYN through multidisciplinary collaboration but must balance pre-existing training program use with context-specific curricular needs. CONCLUSIONS: Robotic surgical experts emphasize the importance of universal training paradigms, such as a strong educational culture that balances autonomy and patient safety, collaboration between disciplines, and routine assessments for continuous growth. Often, introduction and acceptance of the robot serves as a stimulus to discuss broader surgical education change.

ADAMTSL2 protein and a soluble biomarker signature identify at-risk non-alcoholic steatohepatitis and fibrosis in adults with NAFLD.

BACKGROUND & AIMS: Identifying fibrosis in non-alcoholic fatty liver disease (NAFLD) is essential to predict liver-related outcomes and guide treatment decisions. A protein-based signature of fibrosis could serve as a valuable, non-invasive diagnostic tool. This study sought to identify circulating proteins associated with fibrosis in NAFLD. METHODS: We used aptamer-based proteomics to measure 4,783 proteins in 2 cohorts (Cohort A and B). Targeted, quantitative assays coupling aptamer-based protein pull down and mass spectrometry (SPMS) validated the profiling results in a bariatric and NAFLD cohort (Cohort C and D, respectively). Generalized linear modeling-logistic regression assessed the ability of candidate proteins to classify fibrosis. RESULTS: From the multiplex profiling, 16 proteins differed significantly by fibrosis in cohorts A (n = 62) and B (n = 98). Quantitative and robust SPMS assays were developed for 8 proteins and validated in Cohorts C (n = 71) and D (n = 84). The A disintegrin and metalloproteinase with thrombospondin motifs like 2 (ADAMTSL2) protein accurately distinguished non-alcoholic fatty liver (NAFL)/non-alcoholic steatohepatitis (NASH) with fibrosis stage 0-1 (F0-1) from at-risk NASH with fibrosis stage 2-4, with AUROCs of 0.83 and 0.86 in Cohorts C and D, respectively, and from NASH with significant fibrosis (F2-3), with AUROCs of 0.80 and 0.83 in Cohorts C and D, respectively. An 8-protein panel distinguished NAFL/NASH F0-1 from at-risk NASH (AUROCs 0.90 and 0.87 in Cohort C and D, respectively) and NASH F2-3 (AUROCs 0.89 and 0.83 in Cohorts C and D, respectively). The 8-protein panel and ADAMTSL2 protein had superior performance to the NAFLD fibrosis score and fibrosis-4 score. CONCLUSION: The ADAMTSL2 protein and an 8-protein soluble biomarker panel are highly associated with at-risk NASH and significant fibrosis; they exhibited superior diagnostic performance compared to standard of care fibrosis scores. LAY SUMMARY: Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease worldwide. Diagnosing NAFLD and identifying fibrosis (scarring of the liver) currently requires a liver biopsy. Our study identified novel proteins found in the blood which may identify fibrosis without the need for a liver biopsy.

Surgeons' Coaching Techniques in the Surgical Coaching for Operative Performance Enhancement (SCOPE) Program.

OBJECTIVE: To evaluate coaching techniques used by practicing surgeons who underwent dedicated coach training in a peer surgical coaching program. BACKGROUND: Surgical coaching is a developing strategy for improving surgeons' intraoperative performance. How to cultivate effective coaching skills among practicing surgeons is uncertain. METHODS: Through the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 surgeons within 4 US academic medical centers were assigned 1:1 into coach/coachee pairs. All attended a 3-hour Surgical Coaching Workshop-developed using evidence from the fields of surgery and education-then received weekly reminders. We analyzed workshop evaluations and audio transcripts of postoperative debriefs between coach/coachee pairs, co-coding themes based on established principles of effective coaching: (i) self-identified goals, (ii) collaborative analysis, (iii) constructive feedback, and (iv) action planning. Coaching principles were cross-referenced with intraoperative performance topics: technical, nontechnical, and teaching skills. RESULTS: For the 8 postoperative debriefs analyzed, mean duration was 24.4 min (range 7-47 minutes). Overall, 326 coaching examples were identified, demonstrating application of all 4 core principles of coaching. Constructive feedback (17.6 examples per debrief) and collaborative analysis (16.3) were utilized more frequently than goal-setting (3.9) and action planning (3.0). Debriefs focused more often on nontechnical skills (60%) than technical skills (32%) or teaching-specific skills (8%). Among surgeons who completed the workshop evaluation (82% completion rate), 90% rated the Surgical Coaching Workshop "good" or "excellent." CONCLUSIONS: Short-course coach trainings can help practicing surgeons use effective coaching techniques to guide their peers' performance improvement in a way that aligns with surgical culture.

Evidence-based Guidelines on the Use of Virtual Surgical Education Pertaining to the Domains of Cognition and Curriculum, Psychomotor Skills Training, and Faculty Development and Mentorship.

OBJECTIVE: To identify, categorize, and evaluate the quality of literature, and to provide evidence-based guidelines on virtual surgical education within the cognitive and curricula, psychomotor, and faculty development and mentorship domains. SUMMARY OF BACKGROUND DATA: During the coronavirus disease 2019 pandemic, utilizing virtual learning modalities is expanding rapidly. Although the innovative methods must be considered to bridge the surgical education gap, a framework is needed to avoid expansion of virtual education without proper supporting evidence in some areas. METHODS: The Association for Surgical Education formed an ad-hoc research group to evaluate the quality and methodology of the current literature on virtual education and to build evidence-based guidelines by utilizing the SiGN methodology. We identified patient/problem-intervention-comparison-outcome-style questions, conducted systematic literature reviews using PubMed, EMBASE, and Education Resources information Center databases. Then we formulated evidence-based recommendations, assessed the quality of evidence using Grading of Recommendations, Assessment, Development, and Evaluation, Newcastle-Ottawa Scale for Education, and Kirkpatrick ratings, and conducted Delphi consensus to validate the recommendations. RESULTS: Eleven patient/problem-intervention-comparison-outcome-style questions were designed by the expert committees. After screening 4723 articles by the review committee, 241 articles met inclusion criteria for full article reviews, and 166 studies were included and categorized into 3 domains: cognition and curricula (n = 92), psychomotor, (n = 119), and faculty development and mentorship (n = 119). Sixteen evidence-based recommendations were formulated and validated by an external expert panel. CONCLUSION: The evidence-based guidelines developed using SiGN methodology, provide a set of recommendations for surgical training societies, training programs, and educators on utilizing virtual surgical education and highlights the area of needs for further investigation.

SAGES Advanced GI/MIS Certificate Program.

SAGES partners with the Fellowship Council (FC) to offer fellowships in MIS and flexible endoscopy. The FC has a robust accreditation process for fellowship programs; however, the FC is not able to address certification of individual graduates. This situation is similar to the structure of residencies whereby the ACGME accredits programs but individual board certification is delegated to constituent boards of the American Board of Medical Specialties (ABMS). In light of this gap, sponsoring societies have developed programs for issuing certificates to graduates of fellowship programs who have met predetermined standards. The purpose of this paper is to describe the SAGES Certificate Process for Adv GI MIS and Flexible Endoscopy Fellowships. The SAGES Certificate program was developed through a rigorous process and has undergone recent revision to modernize the certificate criteria. Research has shown that as many as 80% of general surgery graduates go on to complete additional fellowship training. Given the number of graduates who complete this subspecialty training each year, general surgery board certification may not be an appropriate final benchmark. The SAGES certificate program joins a long list of certification pathways for surgical fellowship trainees in ACGME and non-ACGME programs. In the future, SAGES plans to assess competency in all of core content domains with validated assessments.

Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training.

BACKGROUND: Low first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum. METHODS: Novice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA. RESULTS: Twenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion. CONCLUSION: A VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.

Challenges of virtual interviewing for surgical fellowships: a qualitative analysis of applicant experiences.

BACKGROUND: The COVID-19 pandemic forced surgical fellowship programs to transition from in-person to remote applicant interviews; the virtual interviewing format presented new and unique challenges. We sought to understand applicants' perceived challenges to virtual interviewing for a surgical fellowship program. METHOD: A grounded theory-based qualitative study was performed utilizing semi-structured interviews with fellowship applicants from the 2020 fellowship match. All Fellowship Council-registered applicants were eligible. We purposefully sampled participants to balance across gender, specialty-choice, and academic versus community-program affiliation. Interviews were inductively analyzed by two researchers for prominent themes. RESULTS: Fifteen interviews were conducted. Participants were 60% male (n = 9), with 33% (n = 5) from non-academic institutions. They applied for the following fellowships: Advanced Gastrointestinal/Minimal Invasive (55%), Bariatric (30%), Hepatopancreatobiliary (10%) and Surgical Oncology (5%). Four main themes emerged to describe virtual interview process challenges: (1) perceived data deficiency, (2) superficial personal connections, (3) magnification of non-professionalism, and (4) logistical frustrations. Applicants recommend program directors provide more information about the fellowship prior to interview day and offer informal independent interactions with current and previous fellows. CONCLUSIONS: According to fellowship applicants, virtual interviews resulted in a lack of information for rank-list decision making ultimately requiring them to rely on other information avenues to base their decisions. These applicants have offered advice to fellowship program directors and future applicants to better optimize this process.

A Needs Assessment of Video-based Education Resources Among General Surgery Residents.

BACKGROUND: Video-based education (VBE) is an effective tool for knowledge and skill acquisition for medical students, but its utility is less clear for resident physicians. We sought to determine how to incorporate VBE into a general surgery resident operative curriculum. METHODS: We conducted a single-institution, survey-based needs assessment of general surgery residents to determine desired content and format of an operative VBE module. RESULTS: The response rate was 84% (53/63), with 66% senior (postgraduate year ≥3) resident respondents. VBE was the most commonly cited resource that residents used to prepare for an operation (93%) compared with surgical textbooks (89%) and text-based website content (57%). Junior residents were more likely to utilize text-based website content than senior residents (P < 0.01). The three most important operative video components were accuracy, length, and cost. Senior residents significantly preferred videos that were peer-reviewed (P < 0.05) and featured attending surgeons whom they knew (P = 0.03). A majority of residents (59%) believed 5-10 min is the ideal length of an operative video. Across all postgraduate year levels, residents indicated that detailed instruction of each operative step was the most important content of a VBE module. Senior residents believed that the overall indications and details of each step of the operation were the most important contents of VBE for a junior resident. CONCLUSIONS: At this institution, general surgery residents preferentially use VBE resources for operative preparation. A centralized, standardized operative resource would likely improve resident studying efficiency, but would require personalized learning options to work for both junior and senior surgery residents.

Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons' practice.

BACKGROUND: Evidence for surgical coaching has yet to demonstrate an impact on surgeons' practice. We evaluated a surgical coaching program by analyzing quantitative and qualitative data on surgeons' intraoperative performance. METHODS: In the 2018-2019 Surgical Coaching for Operative Performance Enhancement (SCOPE) program, 46 practicing surgeons in multiple specialties at four academic medical centers were recruited to complete three peer coaching sessions, each comprising preoperative goal-setting, intraoperative observation, and postoperative debriefing. Coach and coachee rated the coachee's performance using modified Objective Structured Assessment of Technical Skills (OSATS, range 1-5) and Non-Technical Skills for Surgeons (NOTSS, range 4-16). We used generalized estimating equations to evaluate trends in skill ratings over time, adjusting for case difficulty, clinical experience, and coaching role. Upon program completion, we analyzed semi-structured interviews with individual participants regarding the perceived impact of coaching on their practice. RESULTS: Eleven of 23 coachees (48%) completed three coaching sessions, three (13%) completed two sessions, and six (26%) completed one session. Adjusted mean OSATS ratings did not vary over three coaching sessions (4.39 vs 4.52 vs 4.44, respectively; P = 0.655). Adjusted mean total NOTSS ratings also did not vary over three coaching sessions (15.05 vs 15.50 vs 15.08, respectively; P = 0.529). Regarding patient care, participants self-reported improved teamwork skills, communication skills, and awareness in and outside the operating room. Participants acknowledged the potential for coaching to improve burnout due to reduced intraoperative stress and enhanced peer support but also the potential to worsen burnout by adding to chronic work overload. CONCLUSIONS: Surgeons reported high perceived impact of peer coaching on patient care and surgeon well-being, although changes in coachees' technical and non-technical skills were not detected over three coaching sessions. While quantitative skill measurement warrants further study, longitudinal peer surgical coaching should be considered a meaningful strategy for surgeons' professional development.

Development and Evaluation of a Novel Instrument to Measure Severity of Intraoperative Events Using Video Data.

OBJECTIVE: To develop and evaluate a novel instrument to measure SEVERE processes using video data. BACKGROUND: Surgical video data can serve an important role in understanding the relationship between intraoperative events and postoperative outcomes. However, a standard tool to measure severity of intraoperative events is not yet available. METHODS: Items to be included in the instrument were identified through literature and video reviews. A committee of experts guided item reduction, including pilot tests and revisions, and determined weighted scores. Content validity was evaluated using a validated sensibility questionnaire. Inter-rater reliability was assessed by calculating intraclass correlation coefficient. Construct validity was evaluated on a sample of 120 patients who underwent laparoscopic Roux-en-Y gastric bypass procedure, in which comprehensive video data was obtained. RESULTS: SEVERE index measures severity of 5 event types using ordinal scales. Each intraoperative event is given a weighted score out of 10. Inter-rater reliability was excellent [0.87 (95%-confidence interval, 0.77-0.92)]. In a sample of consecutive 120 patients undergoing gastric bypass procedures, a median of 12 events [interquartile range (IQR) 9-18] occurred per patient and bleeding was the most frequent type (median 10, IQR 7-14). The median SEVERE score per case was 11.3 (IQR 8.3-16.9). In risk-adjusted multivariable regression models, history of previous abdominal surgery (P = 0.02) and body mass index (P = 0.005) were associated with SEVERE scores, demonstrating construct validity evidence. CONCLUSION: The SEVERE index may prove to be a useful instrument in identifying patients with high risk of developing postoperative complications.

#SurgEdVidz: Using Social Media to Create a Supplemental Video-Based Surgery Didactic Curriculum.

BACKGROUND: A general surgery resident may have competing clinical responsibilities that limit the ability to participate in educational didactics. Social media is an alternative delivery method for educational content that can be viewed at a resident's convenience. We sought to assess the feasibility of using social media to provide educational content for surgical residents. MATERIALS AND METHODS: We created a novel, supplemental surgical curriculum consisting of two-minute videos based on the This Week in SCORE modules. Videos were posted to Twitter weekly, indexed with the #SurgEdVidz hashtag and uploaded to YouTube to create a catalog of videos. Twitter and YouTube analytics were used to calculate public viewership and impact. RESULTS: A total of 43 videos were disseminated between January 30, 2019 and January 31, 2020. An average of 6.9 h (SD: 1.4; range: 5.0-10.0) was required to generate each video, including 1.5 h (SD: 0.6; range: 0-2.0) for content review and 5.4 h (SD: 1.1; range: 4.0-8.0) for video production. Between the two platforms, videos generated a total of 51,313 views with an average of 1193 views (SD: 715; range: 412-4096) per video. Account followers are geographically distributed across 28 states, 28 countries, and six continents. CONCLUSIONS: Social media can serve as an effective tool for the distribution of surgical educational content. Twitter, in conjunction with YouTube, allows for rapid dissemination of didactic content packaged into brief videos that is flexible in viewership with low time commitment. Social media offers visibility and engagement beyond the classroom without geographical or temporal borders.

The COVID-19 reset: lessons from the pandemic on Burnout and the Practice of Surgery.

BACKGROUND: Burnout among physicians is an increasing concern, and surgeons are not immune to this threat. The ongoing COVID-19 pandemic has caused dramatic changes to surgeon workflow, often leading to redeployment to other clinical areas, slowdown and shutdown of elective surgery practices, and an uncertain future of surgical practice in the post-pandemic setting. Paradoxically, for many surgeons who had to prepare for but not immediately care for a major surge, the crisis did allow for reflective opportunities and a resetting of priorities that could serve to mitigate chronic patterns contributory to Burnout. METHODS: SAGES Reimagining the Practice of Surgery task force convened a webinar to discuss lessons learned from the COVID pandemic that may address burnout. RESULTS: Burnout is multifactorial and may vary in cause among different generation/experience groups. Those that report burnout symptoms often complain of lacking purpose or meaning in their work. Although many mechanisms to address Burnout are from a defensive standpoint-including coping mechanisms, problem solving, and identification of a physician having wellness difficulties-offensive mechanisms such as pursuing purpose and meaning and finding joy in one's work can serve as reset points that promote thriving and fulfillment. Understanding what motivates physicians will help physician leaders to develop and sustain effective teams. Reinvigorating the surgical workforce around themes of meaning and joy in the service rendered via our surgical skills may diminish Burnout through generative and aspirational strategies, as opposed to merely reactive ones. Fostering an educational environment free of discriminatory or demeaning behavior may produce a new workforce conducive to enhanced and resilient wellbeing at the start of careers. CONCLUSION: Surgeon wellness and self-care must be considered an important factor in the future of all healthcare delivery systems, a need reaffirmed by the COVID-19 pandemic.

Feasibility and Perceived Usefulness of Using Head-Mounted Cameras for Resident Video Portfolios.

BACKGROUND: There is limited guidance on how to longitudinally administer simulation materials or to incorporate video recordings into assessment portfolios of simulated surgical skills. MATERIALS AND METHODS: We launched a longitudinal weekly simulation curriculum for PGY1-PGY3 surgical residents based on the ACS/APDS Curriculum. Residents underwent monthly objective structured assessment of technical skills (OSATS) while wearing head-mounted cameras. Videos of OSATS performance accrued into individual online video portfolios. Residents were surveyed about their attitudes toward video recording. RESULTS: Twenty-seven general surgical residents participated, completing 161 OSATS encompassing 11 distinct skills and generating 258 videos of simulated skills performance. The overall survey response rate was 88%. Residents viewed the curriculum favorably overall, and 36.4% of residents accessed their videos. Of those who did not watch their videos, 78.6% cited not having enough time, whereas 28.6% did not think the videos would be useful. Over 95% of surveyed residents expressed interest in having a video library of attending-performed procedures, 59.1% were interested in having their own operations recorded, and 45.5% were interested in video-based coaching. CONCLUSIONS: Residents viewed longitudinal administration of the ACS/APDS Curriculum positively. Although video recording in simulation is feasible, resident interest may be higher for intraoperative recordings than for simulated skills.

A proficiency-based virtual reality endoscopy curriculum improves performance on the fundamentals of endoscopic surgery examination.

INTRODUCTION: The fundamentals of endoscopic surgery (FES) examination is a national test of knowledge and skill in flexible gastrointestinal endoscopy. The skill portion of the examination involves five tasks that assesses the following skills: scope navigation, loop reduction, mucosal inspection, retroflexion, and targeting. This project aimed to assess the efficacy of a proficiency-based virtual reality (VR) curriculum in preparing residents for the FES skills exam. METHODS: Experienced (>100 career colonoscopies) and inexperienced endoscopists (<50 career colonoscopies) were recruited to participate. Six VR modules were identified as reflecting the skills tested in the exam. All participants were asked to perform each of the selected modules twice, and median performance was compared between the two groups. Inexperienced endoscopists were subsequently randomized in matched pairs into a repetition (10 repetitions of each task) or proficiency curriculum. After completion of the respective curriculum, FES scores and pass rates were compared to national data and historical institutional control data (endoscopy-rotation training alone). RESULTS: Five experienced endoscopists and twenty-three inexperienced endoscopists participated. Construct valid metrics were identified for six modules and proficiency benchmarks were set at the median performance of experienced endoscopists. FES scores of inexperienced endoscopists in the proficiency group had significantly higher FES scores (530 ± 86) versus historical control (386.7 ± 92.2, p = 0.0003) and higher pass rate (proficiency: 100%, historical control 61.5%, p = 0.01). CONCLUSION: Trainee engagement in a VR curriculum yields superior FES performance compared to an endoscopy rotation alone. Compared to the 2012-2016 national resident pass rate of 80, 100% of trainees in a proficiency-based curriculum passed the FES manual skills examination.

Simulation-based mastery learning significantly reduces gender differences on the Fundamentals of Endoscopic Surgery performance exam.

BACKGROUND: Analysis of the Fundamentals of Endoscopic Surgery (FES) performance exam showed higher scores for men than women. Gender differences have been reduced with task-specific practice. We assessed the effect of simulation-based mastery learning (SBML) on FES performance exam differences by gender. METHODS: Forty-seven surgical trainees [29 men (m), 18 women (w)] completed a SBML curriculum and were assessed by FES. Fourteen trained on the GI Mentor 2, 18 on the Endoscopy Training System, and 15 using the Surgical Training for Endoscopic Proficiency curriculum. Performance of male and female trainees was compared. RESULTS: On the pre-training assessment, there were large differences between genders in FES pass rates (m 77%, w 15%, p < 0.001), total scores (m 69 ± 11, w 50 ± 12; p < 0.001), and in four of five FES sub-task scores (Navigation, m 73 ± 19, w 55 ± 22, p = 0.02; Loop reduction, m 34 ± 29, w 14 ± 22, p = 0.02; Retroflexion, m 81 ± 17, w 47 ± 27, p < 0.001; Targeting, m 89 ± 10, w 66 ± 23, p = 0.002). No differences were discernible post training (Pass rate, m 100%, w 94%, p = 0.4; Total score, m 77 ± 8, w 72 ± 12, p = 0.2; Navigation, m 91 ± 13, w 80 ± 13, p = 0.009; Loop reduction, m 49 ± 26, w 46 ± 36, p = 0.7; Retroflexion, m 82 ± 18, w 81 ± 15, p = 0.9; Targeting, m 92 ± 15, w 86 ± 12, p = 0.12). Time needed to complete curricula was not discernably different by gender (m 3.8 ± 1.7 h, w 5.0 ± 2.6 h, p = 0.17). CONCLUSIONS: Gender-based differences are nearly eliminated through task-specific SBML training. This lends further evidence to the validity argument for the FES performance exam as a measure of basic endoscopic skills.

Sleeve gastrectomy telementoring: a SAGES multi-institutional quality improvement initiative.

BACKGROUND: Sleeve gastrectomy is a relatively new procedure that developed as a result of rapid innovation in the field of bariatric surgery. As with any newly developed operation, there is a learning curve that potentially can be associated with higher morbidity. Real-time surgical mentoring reduces the learning curve effect but can be time intensive for the mentor. The aim of this initiative was to evaluate the feasibility, effectiveness, and satisfaction of surgical telementoring for laparoscopic sleeve gastrectomy. This is the first national specialty society effort to determine if the "remote presence" of an expert surgeon (mentor) can help practicing surgeons improve skills. METHODS: The experience of 15 surgical trainees (mentees) who performed laparoscopic sleeve gastrectomy under real-time telementoring by 7 mentors was reviewed. Telementoring was implemented using the Visitor1® remote presence system with two-way live audio and video communication. The receiving platform utilized a conventional laptop, iPad, or iPhone. The mentee followed a structured telementoring program including didactic learning, live case teleobservation, and telementoring of 2-3 cases. A survey on the quality of the telecommunication and effectiveness of the mentoring was performed by the mentor and mentee on a scale of "exceeded," "met," "almost met," or "failed to meet" expectations. The overall telementoring experience was rated on a scale of 1 for "poor" to 5 for "excellent." RESULTS: Based on the mentees' survey, the overall telementoring experience was rated as 4.8. Despite the mentees having experience with laparoscopic sleeve gastrectomy, most commented that the telementoring experience was an excellent educational tool and they learned some new techniques they plan to apply it in their practice. Based on the mentors' survey, the overall telementoring experience was rated as 4.7. All mentors stated that they were satisfied with the telementoring sessions and there were no unexpected intraoperative occurrences. There were some logistical limitations including difficulties in scheduling of cases or the delay of cases. CONCLUSIONS: Surgical instruction by telementoring was shown to be feasible, practical, and successful, and was highly rated in this study by both the mentors and mentees. The currently utilized telementoring platform is thus an effective educational tool that can facilitate acquisition of surgical skills and assist with the conventional on-site surgical mentoring model.