Measurement and Management of Cognitive Load in Surgical Education: A Narrative Review.

BACKGROUND: Cognitive load should be considered in designing optimal educational programs in health care. Despite the highly demanding nature of surgery and surgical education, a consensus on how to manage cognitive load has not been established. The objective of this review is to map out how recent surgical education research incorporates cognitive load. METHODS: A literature search was performed using keywords related to cognitive load and digital education up to December 2021. Studies published in English relevant to assessment and management of cognitive load in surgical education were included. Terminology, assessment tools, association with different surgical procedures and training modalities, and programs considering cognitive load were reported. RESULTS: We identified several terms to describe cognitive load. Cognitive load was measured by subjective, self-reported questionnaires and by objective measurements, such as physiological parameters or estimated by reaction time to secondary tasks. Subjective measurements reported cognitive load in one or multiple dimensions. Correlations between subjective and objective measurements were shown in multiple studies. Overall, higher cognitive load was observed in training for more complex tasks and high-fidelity modalities, and among less experienced trainees. Cognitive load theory has been lately incorporated into designing teaching programs. CONCLUSIONS: A broad range of terms and assessment tools were identified for cognitive load. To maximize the learning outcome, management of cognitive load is necessary in surgical education. This review summarizes the current knowledge in assessment and management of cognitive load in surgical education and provides suggestions for future studies.

Digital Education in General Thoracic Surgery: A Narrative Review.

BACKGROUND: Since advanced technologies were introduced into surgical education, a variety of new programs have been developed. However, a comprehensive review of digital education in general thoracic surgery has not been performed. This narrative review was conducted was to identify the current applications of digital education in general thoracic surgery. METHODS: A literature search was performed using keywords related to general thoracic surgery and digital education, including e-learning and virtual simulation, up to September 2021. Studies published in English investigating the effect of digital education in general thoracic surgery were included. RESULTS: Thirteen studies met the criteria. The settings were in undergraduate (n = 6) and postgraduate education (residency) (n = 5) and mixed audience with other disciplines (n = 2). Theoretical knowledge (n = 5), technical skills (n = 4), and both knowledge and technical skills (n = 4) were the stated educational objectives for the studies. The didactic materials were transferred to hardware, software, or online platforms and delivered with multimedia materials. Technical skills training for bronchoscopy and chest tube insertion (n = 5) were offered using virtual reality and computer-based simulations. Subjective evaluation was done in 10 studies. Although after the digital education training there was observed improvement in knowledge or skills in 8 studies, studies were not designed to test for superiority compared with controls through randomized controlled studies. CONCLUSIONS: This review summarizes the current applications of digital education in general thoracic surgery and helps establish the needs for future studies in this field.

Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial.

Importance: The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain. Objective: To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery. Design, Setting, and Participants: This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization. Interventions: Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge. Main Outcomes and Measures: Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle. Results: A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled. Conclusions and Relevance: The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT04254679.

Establishing validity evidence for device-assisted advanced laparoscopic suturing tasks using simulation.

BACKGROUND: Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks. METHODS: This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods. RESULTS: Twenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061). CONCLUSION: In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Reciprocal peer coaching for practice improvement in surgery: a pilot study.

BACKGROUND: Peer coaching has been associated with much higher rates of practice changes and new skill implementation compared to common used modalities but bilateral peer coaching structures where seniority is not a requirement to coach have not been studied. The purpose of this study was to implement and evaluate a reciprocal peer coaching pilot program for practicing surgeons to inform future coaching program design. METHODS: A multicenter reciprocal peer surgical coaching program was designed according to the framework developed from previous studies by our group. The coach-coachee matching process was voluntary and autonomous. All participants received basic coaching skills training. Pairs were instructed to complete two coaching sessions, alternating between the coach or coachee role for each session. Data were collected through questionnaires and structured interviews. RESULTS: Twenty-two participants enrolled in the pilot study and completed the coach training (88% enrollment rate). During the first wave of COVID-19, 12 participants withdrew. Of the five pairs that completed the program, three pairs were composed of general surgeons, one of orthopedic surgeons, and one ophthalmologic surgeon. Three sessions were conducted live in the OR, five virtually, and one involved an in-person discussion. Overall satisfaction with the program was high and all participants expectations were met. Participants were significantly more likely to predict "routinely" asking for feedback from their partner after study completion (6, 66%) compared to pre-intervention (p = 0.02). CONCLUSION: This pilot study supports the feasibility of a peer coaching model for surgeons in practice that emphasized reciprocity and participant autonomy. These key elements should be considered when designing future coaching programs.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study.

BACKGROUND: Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR). METHODS: In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2-3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points. RESULTS: Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training. CONCLUSION: The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.

High incidence of potentially preventable emergency department visits after major elective colorectal surgery.

INTRODUCTION: Emergency department (ED) visits after surgery represent a significant cost burden on the healthcare system. Furthermore, many ED visits are related to issues of healthcare delivery services and may be avoidable. Few studies have assessed the reasons for ED visits after colorectal surgery. The main objectives of this study were to: (1) identify the reasons why patients presented to the ED within 30 postoperative days and (2) determine if these visits were potentially preventable. METHODS: A retrospective chart review was conducted on elective major colorectal surgery cases performed in a single center between 01/2017 and 07/2019. Data collected included demographics, medical history, intraoperative details, postoperative complications, ED visits within 30 postoperative days, and readmissions. Each ED visit was assessed by two reviewers and graded on a scale adapted from the New York University ED algorithm. The gradings were: (1) non-emergent, (2) emergent but treatable in an ambulatory setting, (3) emergent/ED-care required but preventable if timely outpatient care was available, and (4) emergent/ED-care required and non-preventable. Grades 1-3 were deemed potentially preventable. Logistic regression identified independent predictors of potentially preventable visits. RESULTS: Six hundred and twenty five patients were included in the final analysis. 110 (17.6%) patients presented to the ED within 30 days. The most common cause of ED visit were ileus/small bowel obstruction (SBO) (16.4%), superficial wound infection (15.5%), genitourinary issues (10.9%), and non-infectious gastrointestinal issues (nausea, malnutrition, diarrhea, high output stomas) (10.9%). After review, 51.8% of visits were considered potentially preventable (Grade 1-3). The most common causes of preventable ED visits were superficial wound infection (24.6%), non-infectious gastrointestinal issues (19.3%), and minor bleeding (14.0%). Creation of a new stoma was the only independent risk factor for potentially preventable ED visits (OR 2.14, 95%CI 1.03-4.47). CONCLUSION: Approximately half of ED visits within 30 days of discharge were potentially preventable. These findings indicate a need to improve access to outpatient care to reduce preventable ED visits after elective colorectal surgery.

Considerations for designing and implementing a surgical peer coaching program: an international survey.

BACKGROUND: Surgical peer coaching has been associated with high rates of practice change but remains largely unutilized. The purpose of this study was to survey surgeons internationally to investigate attitudes regarding peer coaching and to identify any international differences to inform the design of future coaching programs. METHODS: Practicing surgeons in general surgery or related subspecialties were eligible to participate. Invitations to complete the survey were distributed through 13 surgical associations, social media, and personal e-mail invitations. Responses were obtained between June 1st and August 31st, 2020. RESULTS: A total of 521 surveys were collected. The majority of participants practiced in North America (263; 50%) with remaining respondents from Asia (81; 16%), Europe (34;7%), South America (21; 4%), Africa (17; 3%), and Oceania (6; 1%). Duration of practice was equally distributed across 4 intervals (0-5 years; 6-15 years; 16-25 years; > 25 years). Respondents most frequently identified as general surgeons (290; 67%) and 325 (75%) were male. Awareness of peer coaching was reported by 275 (53%) respondents, with 197 (44%) never seeking formal feedback from peers. The majority of respondents (372; 84%) would be willing to participate in a peer coaching program, with monthly interactions the most desirable frequency reported (193; 51%). Coaching in the operating room was preferred by most participants (360; 86%). Few respondents (67; 14%) would accept coaching from someone unknown to them. Participants identified key coaching program elements as: feedback kept private and confidential (267; 63%); opportunity to provide feedback to the coach (247; 59%); personalized goal setting (244; 58%); and the option to choose one's own coach (205; 49%). The most commonly cited potential barrier to participation was logistical constraints (334; 79%). CONCLUSION: This international survey of practicing surgeons demonstrated that peer feedback is rarely used in practice, but there is high interest and acceptance of the peer coaching model for continuous professional development. Findings regarding preferred program structure may be useful to inform the design of future peer coaching programs.

Identifying optimal program structure, motivations for and barriers to peer coaching participation for surgeons in practice: a qualitative synthesis.

BACKGROUND: Continuous advancement of surgical skills is of utmost importance to surgeons in practice, but traditional learning activities without personalized feedback often do not translate into practice changes in the operating room. Peer coaching has been shown to lead to very high rates of practice changes and utilization of new skills. The purpose of this study was to explore the opinions of practicing surgeons regarding the characteristics of peer coaching programs, in order to better inform future peer coaching program design. METHODS: Using a convenience sample, practicing general surgeons were invited to participate in focus group interviews. Allocation into groups was according to years in practice. The interviews were conducted using open-ended questions by trained facilitators. Audio recordings were transcribed and coded into themes by two independent reviewers using a grounded theory approach. RESULTS: Of 52 invitations, 27 surgeons participated: 74% male; years in practice: < 5 years: 33%; 5-15 years: 26%; > 15 years: 41%. Three main themes emerged during coding: ideal program structure, motivations for participation, and barriers to implementation. For the ideal structure of a peer coaching program all groups agreed coaching programs should be voluntary, involve bidirectional learning, and provide CME credits. Live, in situ coaching was preferred. Motivations for coaching participation included: desire to learn new techniques (48%), remaining up to date with the evolution of surgical practice (30%) and improvement of patient outcomes (18%). Barriers to program implementation were categorized as: surgical culture (42%), perceived lack of need (26%), logistical constraints (23%) and issues of coach-coachee dynamics (9%). CONCLUSION: Peer coaching to refine or acquire new skills addresses many shortcomings of traditional, didactic learning modalities. This study revealed key aspects of optimal program structure, motivations and barriers to coaching which can be used to inform the design of successful peer coaching programs in the future.

Patients' preferences for sphincter preservation versus abdominoperineal resection for low rectal cancer.

BACKGROUND: Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients' preferences for treatment for low rectal cancer. METHODS: Ambulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection. RESULTS: A total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5-25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients. CONCLUSION: An important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients' value functional outcomes with a low anastomosis.

S116: Impact of incisional negative pressure wound therapy on surgical site infection after complex incisional hernia repair: a retrospective matched cohort study.

INTRODUCTION: Incisional negative pressure wound therapy (iNPWT) may reduce surgical site infections (SSI), which can have devastating consequences after incisional hernia repair. Few comparative studies investigate the effectiveness of this wound management strategy in this population. The objective of this study is to determine the effect of iNPWT on the incidence of SSI after complex incisional hernia repair. METHODS: All adult patients undergoing open incisional hernia repair at a single center from 2016 to 2019 were reviewed. A commercial iNPWT dressing was used at the discretion of the surgeon. Patients were grouped by type of dressing; iNPWT and standard sterile dressings (SSD). Coarsened exact matching was used to create balanced cohorts for comparison using age, sex, American Society of Anesthesiologists classification, wound classification, and surgical urgency. The primary outcome was the composite incidence of superficial and deep SSI within 30 days. Secondary outcomes included non-infectious surgical site occurrences (SSO), overall complications, length of stay (LOS), emergency department visits, and readmission at 30 days. RESULTS: 134 patients underwent complex hernia repair, with 114 patients included after matching (34 iNPWT, 51 SSD). Composite incidence of superficial and deep SSI was 19.3% (11.8% vs. 27.5%, p = 0.107), with significantly lower rates of deep SSI in patients receiving iNPWT (2.9% vs. 17.6%, p = 0.045). After accounting for residual differences between groups, iNPWT was associated with decreased incidence of composite SSI (RR 0.36, 95% CI [0.16, 0.87]). Median LOS was longer in patients with iNPWT (7 vs. 5 days, p = 0.001). There were no differences in SSO, overall complications, readmission, or emergency department visits. CONCLUSION: In patients undergoing incisional hernia repair, the use of iNPWT was associated with a lower incidence of SSI at 30 days. Future studies should focus on cost effectiveness of iNPWT, its impact on long-term hernia recurrences, and the identification of patient selection criteria in this population.

Defining the key skills required to perform advanced laparoscopic procedures: a qualitative descriptive study.

BACKGROUND: Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. METHODS: Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. RESULTS: 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees. CONCLUSION: This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Development and validation of an endoscopic submucosal dissection video assessment tool.

BACKGROUND: Despite a need for assessment of endoscopic submucosal dissection (ESD) skills in order to track progress and determine competence, there is no structured measure of assessing competency in ESD performance. The present study aims to develop and examine validity evidence for an assessment tool to evaluate the recorded performance of ESD for gastric neoplasms. METHODS: The ESD video assessment tool (EVAT) was systematically developed by ESD experienced endoscopists. The EVAT consists of a 25-item global rating scale and 3-item checklist to assess competencies required to perform ESD. Five unedited videos were each evaluated by 2-blinded experienced ESD endoscopists to assess inter-rater reliability using intraclass correlation coefficients (ICC). Seventeen unedited videos in total were rated by 3 blinded experienced ESD endoscopists. Validity evidence for relationship to other variables was examined by comparing scores of inexperienced (fellows) and experienced endoscopists (attending staff), and by evaluating the relationship between the EVAT scores and ESD case experience. Internal consistency was evaluated using Cronbach's alpha. RESULTS: The inter-rater reliability for the total score was high at 0.87 (95% confidence interval 0.11 to 0.99). The total score [median, interquartile range (IQR)] was significantly different between the inexperienced (71, 63-77) and experienced group (95, 91-97) (P = 0.005). The total scores demonstrated high correlation with the number of ESD cases (Spearman's ρ = 0.79, P < 0.01). The internal consistency was 0.97. CONCLUSIONS: This study provides preliminary validity evidence for the assessment of video-recorded ESD performances for gastric neoplasms using EVAT.

Impact of data on generalization of AI for surgical intelligence applications.

AI is becoming ubiquitous, revolutionizing many aspects of our lives. In surgery, it is still a promise. AI has the potential to improve surgeon performance and impact patient care, from post-operative debrief to real-time decision support. But, how much data is needed by an AI-based system to learn surgical context with high fidelity? To answer this question, we leveraged a large-scale, diverse, cholecystectomy video dataset. We assessed surgical workflow recognition and report a deep learning system, that not only detects surgical phases, but does so with high accuracy and is able to generalize to new settings and unseen medical centers. Our findings provide a solid foundation for translating AI applications from research to practice, ushering in a new era of surgical intelligence.

Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery.

INTRODUCTION: C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery. METHODS: A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3-5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy. RESULTS: A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2-19.3) in laparoscopic studies and 21.0% (95% CI 11.9-30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5. CONCLUSIONS: The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.

Implementation and Effectiveness of Coaching for Surgeons in Practice - A Mixed Studies Systematic Review.

INTRODUCTION: Despite recent changes to medical education, surgical training remains largely based on the apprenticeship model. However, after completing training, there are few structured learning opportunities available for surgeons in practice to refine their skills or acquire new skills. Personalized observation with feedback is rarely a feature of traditional continuing medical education learning. Coaching has recently been proposed as a modality to meet these educational gaps; however, data are limited, and few coaching programs presently exist. The purpose of this study is to summarize the characteristics of coaching programs for surgeons in practice including participant satisfaction, program outcomes, and barriers to implementation, in the published literature. METHODS: A mixed studies systematic review was conducted according to PRISMA guidelines to identify all original studies describing or investigating coaching for practicing surgeons up to 06/2019. Quantitative analysis was used to summarize numerical data, and qualitative analysis using grounded theory methodology for descriptive data was used to summarize the results into themes across studies. RESULTS: After identification of articles, 27 were included in the final synthesis. Twenty-six articles described execution of a coaching program. Programs varied widely with 18/26 focusing on teaching new skills, and the remainder on refinement of skills. Thematic analysis identified 2 major data categories that guided deeper analysis: outcomes of and barriers to coaching. Of the 16 (62%) programs that reported outcomes of coaching, 42% to 100% of participants reported changes in clinical practice directly associated with coaching. Positive satisfaction after completion of a program was reported by 82% to 100% of participants. Reported barriers to participating in a coaching program emerged along 3 main themes: logistical constraints, surgical culture, and perceived lack of need. CONCLUSIONS: Coaching for surgeons in practice is highly rated by participants and often results in clinical practice changes, while cultural and logistical issues were identified as barriers to implementation. A better understanding of these factors is required to guide coaching program development and implementation.

Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center.

INTRODUCTION: Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. METHODS: A retrospective review was conducted for all Type II-IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. RESULTS: A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p < 0.0001], and emergency patients were less likely to return directly to their original residence at discharge (13, 72% emergency vs 185, 99.4% elective, p < 0.0001). There were significantly more major complications (Clavien-Dindo score ≥ 3) in the emergency group (5, 28% emergency vs. 10, 5% elective, p = 0.005). There were no perioperative deaths in either group. Morbidity and mortality in both groups were less than historically reported. CONCLUSIONS: Informed consent discussions and patient selection for repair of giant PEHs should reflect modern era and institution-specific outcomes.

Is there a gender bias in the advancement to SAGES leadership?

BACKGROUND: The proportion of women in surgery has risen significantly yet there remains gender discrepancies in upper leadership positions in academia. Specialty societies play an important role in academic advancement but the progression of women in surgical societies has not been studied. The purpose of this study was to determine if there are gender differences in advancement within the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) leadership. METHODS: A retrospective audit of all SAGES committee members (CM) from 1992 to 2018 was performed. The overall membership gender distribution was available from 2010 to 2018. Leadership positions included Committee Chair/Co-chair, Board of Governors, and Executive Committee. Three phenomena were investigated: "pipeline," by determining the change in women CMs compared to overall membership over time; "sticky floors," by comparing advancement beyond CM by gender; "glass-ceiling," by analyzing the promotion trajectory and time to leadership positions between genders. Statistical analysis comparing trends over time was performed using Kendall-tau. RESULTS: There were 1546 surgeons who served on at least one committee during the study period. Women represented 21% of CMs, 18% of chairs/co-chairs, 16% of board members and 14% of executives, with one woman President. The proportion of women CMs has significantly increased over time from 3% in 1992 to 27% in 2018 (p-trend < 0.001). A similar proportion of women and men advanced beyond CM (17% vs. 14%, p = 0.194), with no difference in time to advancement. From 2010 to 2018, the increase in the proportion of women CMs and board members outpaced that of overall women members (p < 0.05). Women executives surpassed overall women members in 2018 (29% vs. 19%). A similar proportion of men and women "skipped ranks" to reach the Board/Executive (37% vs. 25%, p = 0.307). CONCLUSION: The proportion of women in leadership positions within SAGES is higher than in the overall membership. There were no gender differences in the advancement of CMs to leadership positions. While these data are encouraging, SAGES should continue to foster the advancement of women surgeons.