US Medical Licensing Exam Performance and American Board of Surgery Qualifying and Certifying Examinations.

BACKGROUND: Program directors use US Medical Licensing Exam (USMLE) scores as criteria for ranking applicants. First-time pass rates of the American Board of Surgery (ABS) Qualifying (QE) and Certifying (CE) Examinations have become important measures of residency program quality. USMLE Step 1 will become pass/fail in 2022. STUDY DESIGN: American Board of Surgery QE and CE success rates were assessed considering multiple characteristics of highly ranked (top 20) applicants to 22 general surgery programs in 2011. Chi-square, t-test, Wilcoxon Rank sum, linear and logistic regression were used, as appropriate. RESULTS: The QE and CE first attempt pass rates were 96% (235/244) and 86% (190/221), respectively. QE/CE success was not significantly associated with sex, race, research experience, or publications. Alpha Omega Alpha (AΩA) status was associated with success on the index CE (98% vs 83%; p = 0.008). Step 1 and Step 2 Clinical Knowledge (CK) scores of surgeons who passed QE on their first attempt were higher than scores of those who failed (Step 1: 233 vs 218; p = 0.016); (Step 2CK: 244 vs 228, p = 0.009). For every 10-point increase in Step 1 and 2CK scores, the odds of passing CE on the first attempt increased 1.5 times (95% CI 1.12, 2.0; p = 0.006) and 1.5 times (95% CI 1.11, 2.02, p = 0.008), respectively. For every 10-point increase in Steps 1 and 2CK scores, the odds of passing the QE on the first attempt increased 1.85 times (95% CI 1.11, 3.09; p = 0.018) and 1.86 times (95% CI 1.14, 3.06, p = 0.013), respectively. CONCLUSIONS: USMLE Step 1 and Step 2 CK examination scores correlate with American Board of Surgery QE and CE performance and success. The USMLE decision to transition Step 1 to a pass/fail examination will require program directors to identify other factors that predict ABS performance for ranking applicants.

Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients.

BACKGROUND: There is increasing interest in implementing comprehensive perioperative protocols, including preoperative optimization and education, perioperative goal-directed fluid management, and postoperative fast tracking, to enhance recovery after surgery. Data on the outcomes of these protocols in pancreatic surgery, however, are limited. STUDY DESIGN: A retrospective review of a prospectively maintained pancreas surgery database at a single institution from August 2012 to April 2015 was undertaken. An enhanced recovery protocol was initiated in October 2014, and patients were divided into groups according to preprotocol or postprotocol implementation. Preoperative, intraoperative, and postoperative data were tabulated. Statistical analysis was performed with Student's t-test and Fisher's exact tests, as well as equality of variances where appropriate, using SAS System software (SAS Institute). RESULTS: Three hundred and seventy-eight patients (181 men, mean age 54 years, BMI 28 kg/m(2)) underwent elective pancreatic surgery during the study period, 297 patients preprotocol and 81 postprotocol. There were no significant differences in preoperative or intraoperative characteristics. Mean postoperative length of stay was significantly lower in the Enhanced Recovery After Surgery group (7.4 vs 9.2 days; p < 0.0001). Hospital costs were similarly lower in the Enhanced Recovery After Surgery group ($23,307.90 vs $27,387.80; p < 0.0001). Readmission (29% vs 32%) and pancreatic fistula (26% vs 28%) rates were similar between groups. Delayed gastric emptying was lower in the Enhanced Recovery After Surgery group (26% vs 13%; p = 0.03). CONCLUSIONS: Implementation of an enhanced recovery after pancreatic surgery protocol significantly decreased length of stay and hospital cost without increasing readmission or morbidity. Despite patient complexity and the potential need for individualization of care, enhanced recovery protocols can be valuable and effective in high-risk patient populations, including pancreatic surgery patients.

Interprofessional collaborative care reduces excess service utilization among individuals with chronic pancreatitis.

BACKGROUND: Pain is common and multifactorial among patients with chronic pancreatitis. Underrecognized and undertreated psychosocial comorbidity can exacerbate pain experience. Excess inpatient service utilization within this patient population prompted a performance improvement initiative at a large academic medical center. METHODS: An interprofessional treatment approach with programmatic medical, surgical, and psychological and psychiatric interventions was rolled-out in January 2007 and length of stay (LOS) was measured on a quarterly basis for a 2-year period. Trends in resource utilization (LOS, estimated opportunity costs) were assessed with a novel modified bootstrapping technique, Simulation Modeling Analysis (SMA). RESULTS: From January 1, 2007, through December 31, 2008, SMA revealed a linear downward trend in LOS (ρ = -0.857, p = .0170), and the interprofessional treatment approach was associated with estimated opportunity cost savings of $670,750.27. There were no associated changes in 7-, 14-, and 30-day readmission rates, p > .05. CONCLUSION: Interprofessional care that combines behavioral approaches to pain management; behavioral contingency management for opioid medication management; psychological and psychotropic treatments for depression, anxiety, and addiction in addition to standard medical and surgical treatments for pancreatitis appears to be associated with lower healthcare costs. Future research should examine patient reported outcomes of this model.

Not just for trauma patients: damage control laparotomy in pancreatic surgery.

BACKGROUND: Damage control laparotomy (DCL) has been a major advance in modern trauma care. The principles of damage control which include truncation of operation to correct acidosis, hypothermia, and coagulopathy with subsequent planned definitive repair are applicable in managing patients undergoing abdominal operations. In order to define indications, technique, and outcome, we undertook a retrospective review and analysis of pancreatic surgery patients in whom DCL was utilized. METHODS: In a cohort of 835 patients who underwent elective pancreatic operations at the Medical University of South Carolina from 2001 to 2007, eight patients were identified who required DCL. Under Institutional Review Board approval, records were reviewed to define intraoperative blood loss, acidosis, hypothermia, coagulopathy, operative techniques, timing of definitive operation, and hospital outcome. RESULTS: There were five men and three women with a mean age of 51 years. The diagnosis was chronic pancreatitis in seven patients and cancer in one. The index operation was pancreatoduodenectomy in four patients, distal pancreatectomy in three, and total pancreatectomy in one. In four patients undergoing elective pancreatic resection intraoperative portal vein hemorrhage initiated damage control laparotomy. Four patients had damage control utilized at reoperation for abdominal sepsis (two) and hemorrhage (two). DCL techniques included external tube drainage (eight), abdominal packing (seven), staple closure of open bowel (four), and rapid abdominal closure (four). Operative blood loss ranged from 300 to 12,000 cc. Operative transfusions ranged from 0 to 44 U of packed red cells. Intraoperative INR was greater than 1.5 in four patients, pH ranged from 7.08 to 7.45, and temperature ranged from 34.8 to 38.8 degrees C. Laparotomy for pack removal and intestinal reconstruction was undertaken 1 to 7 days after DCL. Length of hospital stay ranged from 7 to 80 days. Hospital mortality was zero. CONCLUSIONS: Patients with exsanguinating hemorrhage and severe sepsis related to pancreatic surgery can be successfully managed with principles of DCL. Truncation of operation with abdominal packing, bowel closure, external drainage of bile and pancreatic ducts, and rapid abdominal closure with planned subsequent completion laparotomy should be considered in pancreatic operations when patients risk intraoperative acidosis, hypothermia, and coagulopathy due to sepsis or hemorrhage.