Decreasing Resident Vascular Case Volumes Have Not Changed National Numbers of Vascular Fellowship Applications in US General Surgery Residents Over the Past Twenty Years.

OBJECTIVES: With an aging workforce and high prevalence of vascular disease, the US is expected to face a pronounced shortage of vascular surgeons over the next 2 decades. This has driven initiatives to expand vascular surgery training positions leading to the rise of integrated residency programs (0 + 5) and the expansion of traditional fellowships (VSFs, 5 + 2). Given the increase in dedicated vascular surgery training positions, there has been a growing concern that general surgery residents (GSRs) are experiencing decreased vascular case volumes. We aim to evaluate trends in vascular surgery specialty choice relative to vascular case volumes for US GSRs over the last 20 years. DESIGN: Using the Accreditation Council for Graduate Medical Education (ACGME) Case Log Graduate Statistics National Report, a retrospective analysis of ACGME-accredited GSR vascular case volumes was performed from academic year 1999-2000 to 2021-2022. Fellowship data was retrospectively reviewed using the available National Resident Matching Program (NRMP) Fellowship Match Data & Reports for 2004-2023. RESULTS: Graduating GSRs logged increasing numbers of major cases between AY 1999-2000 and AY 2021-2022 (p < 0.001) with 2022 graduates logging on average 98 more cases per resident compared to 2000 graduates. Mean total vascular cases decreased (p = 0.005) with 2022 graduates logging approximately 78 fewer vascular cases on average compared to the 2000 graduates, a 40% decrease in vascular case volume. Despite the decrease, US GSRs have applied to VSF at a relatively consistent rate: 8.5% in 2001-2002, 8% in 2011-2012, and 6% in 2021-2022. 2023 demonstrated an increase to 8.3%. CONCLUSION: Over the past 2 decades, GSRs have experienced a substantial decrease in exposure to vascular surgery cases during their training; however, residents continue to apply for VSF at a relatively constant rate suggesting that interest in the specialty may be related to factors other than exposure to vascular cases.

Impact of Surgeon Workload on Pregnancy Outcomes in Surgical Trainees and Faculty.

OBJECTIVE: To investigate the association between workload and pregnancy outcomes among US surgical faculty and trainees. SUMMARY BACKGROUND DATA: Despite the increased risk of pregnancy associated complications among surgeons, most US institutions do not have formalized support to help sustain a healthy pregnancy in surgeons. METHODS: An anonymous self-administered Qualtrics survey was distributed electronically to US surgeons across all surgical specialties. Female surgical trainees/faculty with current or previous pregnancy were invited to participate. Data pertaining to demographics, workload, and pregnancy outcomes were collected for each individual pregnancy resulting in live birth. Multivariate analysis was used to assess for workload and outcomes, controlling for age, race, gravidity, and use of assisted reproductive technology. A significance level of 0.0056 was used for each outcome (Bonferroni multiple-testing adjustment 0.05/9). RESULTS: 817 surgeons experiencing 1348 pregnancies resulting in live birth were included. The mean (SD) age at first live birth was 32(4). The most prevalent major and neonatal complications included preeclampsia/gestational hypertension (n=196, 14.5%) and preterm delivery (n=179, 12.8%), respectively. Most institutions did not have a policy regarding workload modification (n=1189, 88.5%). Most surgeons did not modify their workload (n=862, 63.9%). When looking at individual workload metrics, feeling overworked during the last week of pregnancy correlated with risk of major complication (P=0.0001), preeclampsia/gestational hypertension (P=0.0003), and intra/post-partum complication (P=0.0001). Association with unplanned cesarean section (P=0.0096) and preterm delivery (P=0.0036) reached nominal significance. CONCLUSIONS: Most surgeons do not modify their workload during pregnancy, potentially contributing to feeling overworked and peri-partum complications. There is an urgent need for a cultural shift and institutional policies to safeguard the health and wellbeing of pregnant surgeons.

Weight loss and clinical outcomes following primary versus secondary Roux-en-Y gastric bypass: a multi-institutional experience.

BACKGROUND: Revisional bariatric surgeries are increasing for weight recurrence and return of co-morbidities. Herein, we compare weight loss and clinical outcomes following primary Roux-en-Y Gastric Bypass (P-RYGB), adjustable gastric banding to RYGB (B-RYGB), and sleeve gastrectomy to RYGB (S-RYGB) to determine if primary versus secondary RYGB offer comparable benefits. METHODS: Participating institutions' EMRs and MBSAQIP databases were used to identify adult patients who underwent P-/B-/S-RYGB from 2013 to 2019 with a minimum one-year follow-up. Weight loss and clinical outcomes were assessed at 30 days, 1 year, and 5 years. Our multivariable model controlled for year, institution, patient and procedure characteristics, and excess body weight (EBW). RESULTS: 768 patients underwent RYGB: P-RYGB n = 581 [75.7%]; B-RYGB n = 106 [13.7%]; S-RYGB n = 81 [10.5%]. The number of secondary RYGB procedures increased in recent years. The most common indications for B-RYGB and S-RYGB were weight recurrence/nonresponse (59.8%) and GERD (65.4%), respectively. Mean time from index operation to B-RYGB or S-RYGB was 8.9 and 3.9 years, respectively. After adjusting for EBW, 1 year %TWL (total weight loss) and %EWL (excess weight loss) were greater after P-RYGB (30.4%, 56.7%) versus B-RYGB (26.2%, 49.4%) or S-RYGB (15.6%, 37%). Overall comorbidity resolution was comparable. Secondary RYGB patients had a longer adjusted mean length of stay (OR 1.17, p = 0.071) and a higher risk of pre-discharge complications or 30-day reoperation. CONCLUSION: Primary RYGB offers superior short-term weight loss outcomes compared to secondary RYGB, with decreased risk of 30-day reoperation.

Increased incidence of marginal ulceration following conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: a multi-institutional experience.

BACKGROUND: Marginal ulcer (MU) formation is a serious complication following Roux-en-Y Gastric Bypass (RYGB). Incidental data suggested a higher incidence of MU following conversion of Sleeve Gastrectomy to RYGB (S-RYGB). Herein, we evaluate the incidence of MU after primary versus secondary RYGB. METHODS: After IRB approval, each institution's electronic medical record and MBSAQIP database were queried to retrospectively identify adult patients who underwent primary RYGB (P-RYGB), Gastric Banding to RYGB (B-RYGB), or S-RYGB between 2014 and 2019, with minimum 1 year follow-up. Patient demographics, operative data, and post-operative outcomes were compared. Numeric variables were compared via two-sample t test, Wilcoxon test or Kruskal Wallis rank sum test. Two-sample proportion test or Fisher's exact test was employed for categorical and binary variables. p < 0.05 marked statistical significance. RESULTS: 748 patients underwent RYGB: P-RYGB n = 584 [78.1%]; B-RYGB n = 98 [13.1%]; S-RYGB n = 66 [8.8%]. Most patients were female (83.2%). Mean age was 45.7 years. Forty-six (n = 6.1%) patients developed MU, a median of 14 ± 32.2 months (range 0.5-82) post-operatively. Incidence of MU was significantly higher for patients undergoing S-RYGB (n = 9 [13.6%]), compared to P-RYGB (n = 34 [5.8%]) and B-RYGB (n = 3 [3.1%]) (p = 0.023). Median time (months) to MU was significantly shorter for patients who underwent S-RYGB (5 ± 6) compared to P-RYGB or B-RYGB (19 ± 37.5) (p = 0.035). Among those who developed MU, there was no significant difference in H. pylori status, NSAID, steroid, or tobacco use, irrespective of operation performed. CONCLUSION: In this multi-institutional cohort, patients who underwent S-RYGB had a significantly higher incidence of MU than those with P-RYGB or B-RYGB. Further research is needed to elucidate its pathophysiology and prevention strategies.

Achieving Racial Representation in Food Allergy Research: A Modified Delphi Study.

BACKGROUND: The overrepresentation of White participants in food allergy research contributes to the development of research questions and interventions not driven by those disproportionately affected by the condition. This ultimately limits the generalizability of research findings and affects the development of knowledge about food allergy and food allergy management. OBJECTIVE: To develop recommendations to combat inequitable research paradigms and increase participation of racially underrepresented populations in food allergy research. METHODS: This study used a modified consensus development method, known as a Delphi method, to assemble the expertise of food allergy clinicians, advocacy leaders, community-engaged researchers, and patients. RESULTS: Findings resulted in 18 recommendations within four domains: community partnership, intentional engagement and messaging, recruitment activities, and dissemination. CONCLUSIONS: Findings from this study provide food allergy researchers with specific recommendations for examining their efforts more critically toward recruiting and engaging with racially underrepresented populations, effectively transitioning from a research-on to a research-with relationship with individuals and families living with food allergy.

First Clinical Experience With Single-Port Robotic Transanal Minimally Invasive Surgery: Phase II Trial of the Initial 26 Cases.

BACKGROUND: Many transanal platforms have been developed to address the challenge of reach and vision when operating transanally. The single-port robot was specifically designed for narrow-aperture surgery and is a promising platform for minimally invasive transanal surgery. OBJECTIVE: The purpose of this phase II trial is to evaluate the safety and feasibility of the initial clinical experience with single-port robot transanal minimally invasive surgery. DESIGN: In a prospective phase II trial, patients with rectal neoplasms eligible for local excision were enrolled for single-port robotic transanal minimally invasive surgery. SETTING: The study was conducted between October 2018 and March 2020 at a tertiary referral hospital. PATIENTS/INTERVENTION: Twenty-six consecutive patients underwent single-port robotic transanal minimally invasive surgery resection of rectal lesions. MAIN OUTCOME MEASURES: The primary end point of the study was the efficacy and safety of single-port robotic transanal minimally invasive surgery. RESULTS: There were 13 men and 13 women, with an average lesion size of 2.9 cm (range, 1.0-6.0 cm) and average level of 4.8 cm from the anorectal ring (range, 0-30 cm). Ten patients had a preoperative diagnosis of adenocarcinoma, 7 of whom received neoadjuvant chemoradiation (range, 4500-5580 cGy with concurrent oral capecitabine). Eighty-eight percent of cases were completed by single-port robotic transanal minimally invasive surgery; 2 were converted to transanal endoscopic microsurgery, and 1 patient underwent a low anterior resection. There were no piecemeal extractions, and all margins were negative on final pathology. There were no mortalities, and the morbidity rate was 15.4%. There have been no local recurrences, with a mean follow-up of 5.8 months (range, 0-15.9 months). LIMITATIONS: The study was limited by small sample size, short-term follow up, and a single-surgeon experience. CONCLUSION: Single-port robotic transanal minimally invasive surgery procedures are safe and feasible in patients with select benign and malignant rectal lesions. Future trials will need to evaluate the long-term safety and efficacy of single-port robotic transanal minimally invasive surgery. See Video Abstract at http://links.lww.com/DCR/B605. PRIMERA EXPERIENCIA CLNICA CON CIRUGA MNIMAMENTE INVASIVA TRANSANAL ROBTICA DE PUERTO NICO ENSAYO DE FASE II DE LOS CASOS INICIALES: ANTECEDENTES:Se han desarrollado muchas plataformas transanales para abordar el desafío del alcance y la visión cuando se opera de manera transanal. El robot de un solo puerto fue diseñado específicamente para la cirugía de apertura estrecha y es una plataforma prometedora para la cirugía transanal mínimamente invasiva.OBJETIVO:El propósito de este ensayo de fase II es evaluar la seguridad y viabilidad de la experiencia clínica inicial con la cirugía mínimamente invasiva transanal con robot de puerto único.DISEÑO:En un ensayo prospectivo de fase II, los pacientes con neoplasias rectales elegibles para la escisión local se inscribieron para la cirugía mínimamente invasiva transanal robótica de puerto único.AJUSTE:El estudio se realizó entre octubre de 2018 y marzo de 2020 en un hospital de referencia terciario.PACIENTES / INTERVENCIÓN:Veintiséis pacientes consecutivos fueron sometidos a cirugía mínimamente invasiva transanal robótica de puerto único para resección de lesiones rectales.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal del estudio fue la eficacia y seguridad de la cirugía mínimamente invasiva transanal robótica de puerto único.RESULTADOS:Hubo 13 hombres y 13 mujeres, con un tamaño de lesión promedio de 2.9 cm (rango 1.0-6.0 cm) y un nivel promedio de 4.8 cm del anillo anorrectal (rango 0-30 cm). Diez pacientes tenían un diagnóstico preoperatorio de adenocarcinoma, 7 de los cuales recibieron quimiorradiación neoadyuvante (rango 4500-5580 cGy con capecitabina oral concurrente). El 88% de los casos se completaron mediante cirugía mínimamente invasiva transanal robótica de puerto único; 2 se convirtieron a microcirugía endoscópica transanal y 1 se sometió a una resección anterior baja. No hubo extracciones parciales y todos los márgenes fueron negativos en la patología final. No hubo mortalidad y una tasa de morbilidad del 15,4%. No ha habido recidivas locales, con un seguimiento medio de 5,8 meses (rango 0-15,9 meses).LIMITACIONES:El estudio estuvo limitado por un tamaño de muestra pequeño, un seguimiento a corto plazo y la experiencia de un solo cirujano.CONCLUSIÓN:Los procedimientos de cirugía mínimamente invasiva transanal robótica de puerto único son seguros y factibles en pacientes con lesiones rectales benignas y malignas seleccionadas. Los ensayos futuros deberán evaluar la seguridad y eficacia a largo plazo de la cirugía mínimamente invasiva transanal robótica de puerto único. Consulte Video Resumen en http://links.lww.com/DCR/B605. (Traducción-Dr. Eduardo Londoño-Schimmer).

Carotid Blowout Management in the Endovascular Era.

BACKGROUND: Carotid blowout syndrome (CBS) is a potential complication of head and neck cancer, and its therapy is associated with high morbidity and mortality. Recent advances in endovascular techniques have improved patient outcomes. In this study, we report outcomes of emergent endovascular intervention for CBS. METHODS: We conducted a retrospective analysis of a prospectively maintained neurovascular database and identified 38 consecutive endovascular procedures for CBS from 2008-2019 at our institution. Data collection was performed on patient demographics, type of cancer, previous cancer treatments, type of CBS, location of bleed, diagnostic workup, endovascular treatment, and procedural outcomes and complications. RESULTS: A total of 38 consecutive endovascular procedures for CBS were performed from 2008-2019 at our single academic institution. Technical success was achieved in 100% of endovascular procedures. Procedural stroke occurred in 1 (2.6%) procedure, procedural mortality occurred in 1 (2.6%) procedure, recurrent CBS occurred in 4 (10.5%) procedures, and fatal rehemorrhage occurred in 1 (2.6%) procedure. Regarding secondary outcomes, delayed stroke/transient ischemic attack occurred in 1 (2.6%) procedure, whereas there were no cases of delayed infectious complications. CONCLUSIONS: The endovascular treatment of CBS is safe and effective with relatively low rates of morbidity and mortality compared with other currently available treatment modalities. However, the overall rate of complications demands attention and sheds light on the need for further improvement in management.

Cannabinoids: A Guide for Use in the World of Gastrointestinal Disease.

Cannabinoids have been known as the primary component of cannabis for decades, but the characterization of the endocannabinoid system (ECS) in the 1990s opened the doors for cannabis' use in modern medicine. The 2 main receptors of this system, cannabinoid receptors 1 and 2, are found on cells of various tissues, with significant expression in the gastrointestinal (GI) tract. The characterization of the ECS also heralded the understanding of endocannabinoids, naturally occurring compounds synthesized in the human body. Via secondary signaling pathways acting on vagal nerves, nociceptors, and immune cells, cannabinoids have been shown to have both palliative and detrimental effects on the pathophysiology of GI disorders. Although research on the effects of both endogenous and exogenous cannabinoids has been slow due to the complicated legal history of cannabis, discoveries of cannabinoids' treatment potential have been found in various fields of medicine, including the GI world. Medical cannabis has since been offered as a treatment for a myriad of conditions and malignancies, including cancer, human immunodeficiency virus/acquired immunodeficiency syndrome, multiple sclerosis, chronic pain, nausea, posttraumatic stress disorder, amyotrophic lateral sclerosis, cachexia, glaucoma, and epilepsy. This article hopes to create an overview of current research on cannabinoids and the ECS, detail the potential advantages and pitfalls of their use in GI diseases, and explore possible future developments in this field.

Planning for patient-reported outcome implementation: Development of decision tools and practical experience across four clinics.

INTRODUCTION: Many institutions are attempting to implement patient-reported outcome (PRO) measures. Because PROs often change clinical workflows significantly for patients and providers, implementation choices can have major impact. While various implementation guides exist, a stepwise list of decision points covering the full implementation process and drawing explicitly on a sociotechnical conceptual framework does not exist. METHODS: To facilitate real-world implementation of PROs in electronic health records (EHRs) for use in clinical practice, members of the EHR Access to Seamless Integration of Patient-Reported Outcomes Measurement Information System (PROMIS) Consortium developed structured PRO implementation planning tools. Each institution pilot tested the tools. Joint meetings led to the identification of critical sociotechnical success factors. RESULTS: Three tools were developed and tested: (1) a PRO Planning Guide summarizes the empirical knowledge and guidance about PRO implementation in routine clinical care; (2) a Decision Log allows decision tracking; and (3) an Implementation Plan Template simplifies creation of a sharable implementation plan. Seven lessons learned during implementation underscore the iterative nature of planning and the importance of the clinician champion, as well as the need to understand aims, manage implementation barriers, minimize disruption, provide ample discussion time, and continuously engage key stakeholders. CONCLUSIONS: Highly structured planning tools, informed by a sociotechnical perspective, enabled the construction of clear, clinic-specific plans. By developing and testing three reusable tools (freely available for immediate use), our project addressed the need for consolidated guidance and created new materials for PRO implementation planning. We identified seven important lessons that, while common to technology implementation, are especially critical in PRO implementation.