Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program.

BACKGROUND: Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level. METHODS: We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux-en-Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression. RESULTS: Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25 years, p = 0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p = 0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI [0.12, 0.79], p = 0.02). CONCLUSIONS: In children with choledochal cysts, most short-term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision-making should be driven by long-term and biliary-specific outcomes.

Roles, Responsibilities, and Expectations of Medical Students on Surgical Subinternships: A Modified Delphi Consensus Study.

PURPOSE: Surgical subinternships are important rotations for students preparing for a career in general surgery; however, these rotations often vary by institution and service. This modified Delphi study was conducted to reach a consensus set of roles, responsibilities, and expectations of fourth-year medical students on their surgical subinternships. METHOD: Candidate statements on roles, responsibilities, and expectations of subinterns were categorized into 7 domains: rotation structure, rounding and patient care, operating room conduct, technical skills, knowledge base, clinic, and professionalism. Expert panels were assembled of key stakeholders: program directors, clerkship directors, other education faculty, trainees, and recent subinterns. Three Delphi rounds were conducted from January to April 2023 to reach consensus defined a priori as a Cronbach α ≥ 0.8 and 80% or greater panel agreement. RESULTS: Forty-six expert panelists were recruited to participate in Delphi rounds, with 100%, 95.7%, and 97.8% response rates in the first, second, and third rounds, respectively. By the third round, 67 statements reached consensus as essential roles, responsibilities, and expectations of surgical subinterns. Key themes from these 67 statements included subinterns approximating the role of an intern with respect to work hours, patient care responsibilities, basic technical skills, and knowledge base. Panelists rated rounding and patient care as the most important domain, followed closely by professionalism. Additional key domains for evaluation in descending order were knowledge base, operating room conduct, clinic, and technical skills. By the third round, notable disagreements in the Delphi process included technical skills and rounding and patient care (93.3% and 88.9% agreement, respectively). CONCLUSIONS: This study provides a national consensus on core roles, responsibilities, and expectations for medical students completing surgical subinternships. Students can use these recommendations to prepare for subinternships, whereas faculty as well as residents and fellows can use them to evaluate applicants for general surgery residency positions.