Implementation of an Online Intraoperative Assessment of Technical Performance for Surgical Trainees.

INTRODUCTION: Assessment of surgical resident technical performance is an integral component of any surgical training program. Timely assessment delivered in a structured format is a critical step to enhance technical skills, but residents often report that the quality and quantity of timely feedback received is lacking. Moreover, the absence of written feedback with specificity can allow residents to seemingly progress in their operative milestones as a junior resident, but struggle as they progress into their postgraduate year 3 and above. We therefore designed and implemented a web-based intraoperative assessment tool and corresponding summary "dashboard" to facilitate real-time assessment and documentation of technical performance. MATERIALS AND METHODS: A web form was designed leveraging a cloud computing platform and implementing a modified Ottawa Surgical Competency Operating Room Evaluation instrument; this included additional, procedure-specific criteria for select operations. A link to this was provided to residents via email and to all surgical faculty as a Quick Response code. Residents open and complete a portion of the form on a smartphone, then relinquish the device to an attending surgeon who then completes and submits the assessment. The data are then transferred to a secure web-based reporting interface; each resident (together with a faculty advisor) can then access and review all completed assessments. RESULTS: The Assessment form was activated in June 2021 and formally introduced to all residents in July 2021, with residents required to complete at least one assessment per month. Residents with less predictable access to operative procedures (night float or Intensive Care Unit) were exempted from the requirement on those months. To date a total of 559 assessments have been completed for operations performed by 56 trainees, supervised by 122 surgical faculty and senior trainees. The mean number of procedures assessed per resident was 10.0 and the mean number per assessor was 4.6. Resident initiation of Intraoperative Assessments has increased since the tool was introduced and scores for technical and nontechnical performance reliably differentiate residents by seniority. CONCLUSIONS: This novel system demonstrates that an online, resident-initiated technical assessment tool is feasible to implement and scale. This model's requirement that the attending enter performance ratings into the trainee's electronic device ensures that feedback is delivered directly to the trainee. Whether this aspect of our assessment ensures more direct and specific (and therefore potentially actionable) feedback is a focus for future study. Our use of commercial cloud computing services should permit cost-effective adoption of similar systems at other training programs.

The financial impact of the COVID-19 pandemic on sleeve gastrectomy at a major academic institution.

INTRODUCTION: The COVID-19- pandemic significantly impacted metabolic and bariatric surgery (MBS) practices due to large-scale surgery cancellations along with staff and supply shortages. We analyzed sleeve gastrectomy (SG) hospital-level financial metrics before and after the COVID-19 pandemic. METHODS: Hospital cost-accounting software (MicroStrategy, Tysons, VA) was reviewed for revenues, costs, and profits per SG at an academic hospital (2017-2022). Actual figures were obtained, not insurance charge estimates or hospital projections. Fixed costs were obtained through surgery-specific allocation of inpatient hospital and operating-room costs. Direct variable costs were analyzed with sub-components including: (1) labor and benefits, (2) implants, (3) drug costs, and 4) medical/surgical supplies. The pre-COVID-19 period (10/2017-2/2020) and post-COVID-19 period (5/2020-9/2022) financial metrics were compared with student's t-test. Data from 3/2020 to 4/2020 were excluded due to COVID-19-related changes. RESULTS: A total of 739 SG patients were included. Average length of stay (LOS), Center for Medicaid and Medicare Case Mix Index (CMI), and percentage of patients with commercial insurance were similar pre vs. post-COVID-19 (p > 0.05). There were more SG performed per quarter pre-COVID-19 than post-COVID-19 (36 vs. 22; p = 0.0056). Pre-COVID-19 and post-COVID-19 financial metrics per SG differed significantly for, respectively, revenues ($19,134 vs. $20,983) total variable cost ($9457 vs. $11,235), total fixed cost ($2036 vs. $4018), total profit ($7571 vs. $5442), and labor and benefits cost ($2535 vs. $3734; p < 0.05). CONCLUSIONS: The post-COVID-19 period was characterized by significantly increased SG fixed cost (i.e., building maintenance, equipment, overhead) and labor costs (increased contract labor), resulting in precipitous profit decline that crosses the break-even in calendar year quarter (CQ) 3, 2022. Potential solutions include minimizing contract labor cost and decreasing LOS.

Does CPT Modifier 22 Appropriately Reflect a Difficult Pancreaticoduodenectomy? Retrospective Analysis of Operative Outcomes and Cost.

BACKGROUND: CPT coding allows addition of a 2-digit modifier code to denote particularly difficult procedures necessitating additional reimbursement, called the modifier 22. The use of modifier 22 in relation to pancreatic surgery and outcomes, specifically pancreaticoduodenectomy (PD), has not been explored. STUDY DESIGN: All PDs performed from 2010 to 2019 at a quaternary healthcare system were analyzed for differences in preoperative characteristics, outcomes, and cost based on the use of modifier 22. Adjusted logistic regression analysis was used to identify factors predictive of modifier 22 use. RESULTS: A total of 1,284 patients underwent PD between 2010 and 2019; 1,173 with complete data were included, of which 320 (27.3%) were coded with modifier 22. Patients coded with modifier 22 demonstrated a significantly longer duration of surgery (365.9 ± 168.4 vs 227 ± 97.1; p < 0.001). They also incurred significantly higher cost of index admission ($37,446 ± 34,187 vs $28,279 ± 27,980; p = 0.002). An adjusted multivariable analysis (specifically adjusted for surgeon variation) revealed duration of surgery (p < 0.001), neoadjuvant chemotherapy (p = 0.039), class II obesity (p = 0.019), and chronic pancreatitis (p = 0.005) to be predictive of modifier 22 use. CONCLUSIONS: Despite the subjective nature of this CPT modifier, modifier 22 is an appropriate marker of intraoperative difficulty. Preoperative and intraoperative characteristics that lead to its addition may be used to further delineate difficult PDs.

Frailty assessment in the acute care surgery population - the agreement and predictive value on length of stay and re-admission of 3 different instruments in a prospective cohort.

BACKGROUND: We compared the Emergency General Surgery Specific Frailty Index (EGSFI), Risk Analysis Index (RAI-C) and the Katz Index (KI) at assessing frailty in acute care surgery (ACS). METHODS: A prospective cohort of ACS patients was stratified into frail or non-frail by the EGSFI, RAI-C and KI. The agreement between scales were compared. RESULTS: Of 272 eligible patients, 72, 75, and 56 were categorized as frail by the EGSFI, RAI-C, and KI respectively. There was weak to no agreement between instruments and consensus among all three scales was 59.4%. CONCLUSION: Between 21 and 28% of patients seen in this ACS cohort were categorized as frail using the EGSFI, RAI-C and KI. These frailty tools have different measures of what constitutes frailty and there was poor agreement between them. Only the KI definition of frailty was associated with a longer LOS. The KI may be more useful for assessing ACS patients in a tertiary care facility.

The hidden costs of open hepatectomy: A 10-year, single institution series of right-sided hepatectomies.

BACKGROUND: Incisional ventral hernias(IVH) are a common complication following open abdominal surgery. The aim of this study was to uncover the hidden costs of IVH following right-sided hepatectomy. METHODS: Outcomes and hospital billing data for patients undergoing open(ORH) and laparoscopic right-sided hepatectomies(LRH) were reviewed from 2008 to 2018. RESULTS: Of 327 patients undergoing right-sided hepatectomies, 231 patients were included into two groups: ORH(n = 118) and LRH(n = 113). Median follow-up-times and time-to-hernia were 24.9-months(0.3-128.4 months) and 40.5-months(0.4-81.4 months), respectively. The incidence of hernias at 1, 3, 5, and 10 years was 6/231(2.6%), 13/231(5.6%), 15(6.5%), and 17/231(7.4%); ORH = 14, LRH = 3, p = 0.003), respectively. In terms of IVH repair(IVHR), total operative costs ($10,719.27vs.$4,441.30,p < 0.001) and overall care costs ($20,541.09vs.$7,149.21,p = 0.044) were significantly greater for patients undergoing ORH. Patients whom underwent ORHs had longer hospital stays and more complications following IVHR. Risk analysis identified ORH(RR-10.860), male gender(RR-3.558), BMI ≥30 kg/m2(RR-5.157), and previous abdominal surgery(RR-6.870) as predictors for hernia development (p < 0.030). CONCLUSION: Evaluation of pre-operative hernia risk factors and utilization of a laparoscopic approach to right-sided hepatectomy reduces incisional ventral hernia incidence and cost when repair is needed.

Academic inertia: Examining changes of scholarly output over time among academic minimally invasive surgeons.

INTRODUCTION: The purpose of this study is to assess how the Hirsch Index (h-index) and other academic metrics change over time for academic minimally invasive surgeons (MIS). METHODS: Through the Fellowship Council's website, MIS program-directors and associate program-directors were identified in 2017 and again in 2018. Using the Scopus database, the number of publications, citations, self-citations, and h-indices were calculated. RESULTS: A total of 222 surgeons were included. The median increase of publications, citations, and h-index were 4, 134, and 1, respectively. 75% of surgeons (166/222) saw their h-index increase. In 2017, 26% of surgeons (57/222) had an increase of their h-index due to self-citation. One-year later, 35% of those surgeons (20/57) no longer demonstrated that change. CONCLUSION: Self-citation remains infrequent within MIS. The h-index of most surgeons will increase over one-year. Many surgeons demonstrating an increase in h-index due to self-citation will see that change eliminated over time.

Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery.

BACKGROUND: With current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar. METHODS: MIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016. RESULTS: Average overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002). CONCLUSIONS: Using a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.

Transanal Minimally Invasive Surgery (TAMIS): Standardizing a Reproducible Procedure.

BACKGROUND: The recent introduction of transanal minimally invasive surgery (TAMIS) offers a safe and cost-effective method for the local resection of rectal neoplasms. The ability to standardize a technique for TAMIS will lead to the most reproducible outcomes and enable teaching. METHODS: A retrospective, IRB-approved chart review was conducted of 32 patients who underwent the TAMIS procedure at one institution over a 3-year period. RESULTS: TAMIS was performed for 11 benign and 21 malignant lesions. The majority of resections were full thickness (29/32) and all were R0. Average distance from the anal verge was 7.5 ± 3 cm, defect circumference was 43.7 ± 10%, operative time was 131 ± 80 min, and length of stay was 1.1 ± 1 days. Two patients had morbidities requiring readmission and further treatment for (1) an aspiration pneumonia with CHF exacerbation and (2) a rectal abscess. CONCLUSIONS: This report outlines an operative technique for TAMIS that is reproducible for the excision of rectal lesions, associated with low morbidity.

Laparoscopic vs open right hepatectomy: a value-based analysis.

BACKGROUND: Current literature lacks sufficient data on outcomes after extensive laparoscopic liver resections. We hypothesized that laparoscopic right hepatectomy (LRH) is associated with better clinical outcomes and less overall hospital costs than open right hepatectomy (ORH), supporting the notion that major laparoscopic hepatic resections carry increased value when compared with the open approach. STUDY DESIGN: We reviewed medical records of all patients at our institution who underwent elective LRH (n = 48) or ORH (n = 57) from May 16, 2008 to March 1, 2012. Patient demographics, preoperative comorbidities, operative details, and postoperative outcomes were compared between the 2 groups. Hospital billing data were collected for each case to determine the average hospital costs per case. RESULTS: Average operative duration, estimated blood loss, intravenous fluid resuscitation requirements, high-grade postoperative complications, the need for postoperative admission to the ICU, and hospital length of stay were significantly less within the LRH cohort. Thirty-day mortality and readmission rates were equivalent between the 2 groups. Despite higher operative costs for LRH ($16,605 vs $10,411, p < 0.001), total postoperative costs were significantly less ($9,075 for LRH vs $16,341 for ORH, p < 0.001), resulting in equivalent overall costs ($25,679 for LRH vs $26,751 for ORH, p = 0.65). CONCLUSIONS: Although overall costs between LRH and ORH are equivalent, clinical outcomes after LRH are comparable to those after ORH, supporting the value of laparoscopy in extensive right hepatic resections. Efforts to reduce operative costs of LRH, while maintaining optimal patient outcomes, should be the focus of surgeons and hospitals moving forward.

The value of continuous wound infusion systems for postoperative pain control following laparoscopic Roux-en-Y gastric bypass: an analysis of outcomes and cost.

BACKGROUND: Current health-care reform is focusing on improving patient outcomes while cutting health-care costs, and as such, surgeons should consider that postoperative pain management techniques can contribute to the overall value of care delivered to patients. The current study aims to evaluate the value of continuous wound infusion systems (CWIS) in patients following laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Records of all consecutive patients who underwent elective LRYGB by a single surgeon from January 2008 until June 2010 were reviewed. The presence of CWIS, patient pain scores, postanesthesia care unit (PACU) times, postoperative narcotic and antiemetic requirements, postoperative complications, and hospital length of stay (LOS) were recorded. Clinical data were subsequently linked and correlated with hospital financial data to determine overall hospital costs. RESULTS: Forty-four LRYGB patients were reviewed; 24 (54.5 %) received CWIS for postoperative pain control. There was no significant difference in PACU times, postoperative LOS, or postoperative complications. Patients with CWIS required significantly less narcotics (36.7 vs. 55.5 mg IV morphine equivalents for total LOS; p = 0.03) and antiemetics (5.0 vs. 12.4 mg ondansetron for total LOS; p = 0.02); however, patients with CWIS did not report better pain control and had slightly higher hospital costs ($13,627.00 vs. $13,395.05, p = 0.68). CONCLUSIONS: Data from the current study suggest that the value of CWIS for postoperative pain control following LRYGB is limited. As the environment for hospital reimbursement is changing to be one which is value driven, surgeons should consider analyses such as this when making decisions on which treatments to offer their patients.

Transoral technique for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) can accelerate learning curve and reduce cost.

BACKGROUND: The stapled gastrojejunostomy of the laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be created by linear and circular stapling techniques. In the circular-stapled technique, the anvil of the stapler can be introduced into the gastric pouch transabdominally or pulled down the esophagus (transorally) by attachment to a modified gastric tube. The purpose of this study is to determine if the transoral technique to introduce the anvil will reduce operative time and cost compared with the transabdominal technique, which requires creating a new gastrotomy to insert the anvil and followed by its closure. METHODS: We compared 60 consecutive morbidly obese patients who underwent laparoscopic RYGBP. First 30 cases were performed by transabdominal anvil insertion, followed by 30 cases using transoral anvil insertion. All of the transabdominal cases were assisted by experienced fellows. The first ten transoral cases were assisted by experienced fellows and the remaining 20 by new fellows in order to evaluate if the transoral technique shortens the learning curve. Surgery duration and operative costs were compared. Complications (bleeding, leaks, anastomotic strictures, ulcers, wound infections) and length of stay were also evaluated. Data are expressed as mean +/- SD. RESULTS: Mean operative time was shorter in the transoral group compared with the transabdominal group (162.2 +/- 35.8 vs. 186 +/- 33.6 min respectively, p = 0.01), even though most of the transoral cases (n = 20) were assisted by new fellows and all of the transabdominal cases by experienced fellows. Operative times were not different between new and experienced fellows in the transoral technique. Supply costs per patient were higher in the transabdominal technique compared with the transoral technique (2,983.5 +/- 540.9 vs. 2,658.8 +/- 474.4 USD, respectively, p = 0.03). Perioperative complications and length of stay were not statistically different. CONCLUSION: The transoral introduction of the anvil of the circular stapler into the gastric pouch is a simple, safe, and efficient technique for creating the gastrojejunostomy in laparoscopic RYGBP. In addition, the transoral technique is less expensive and appears to accelerate the learning curve compared with the transabdominal technique.

Neuroscience workshops for fifth-grade school children by undergraduate students: a university-school partnership.

The National Science Education Standards recommend that science be taught using inquiry-based approaches. Inspired by the Dana Alliance for Brain Initiatives, we examined whether undergraduate students could learn how to conduct field research by teaching elementary school children basic neuroscience concepts in interactive workshops. In an inquiry-based learning experience of their own, undergraduate psychology students working under the close supervision of their instructor designed and provided free, interactive, hour-long workshops focusing on brain structure and function, brain damage and disorders, perception and illusions, and drugs and hormones to fifth-graders from diverse backgrounds, and we assessed the effectiveness of the workshops using a pretest-post-test design. The results suggest that the workshops enhanced the children's knowledge of neuroscience concepts as measured using pre- and post-open-ended assessments. The undergraduates also found their learning experience engaging and productive. The article includes detailed descriptions of the workshop activities, procedures, the course in which the undergraduates implemented the workshops, and guidance for future university-school collaborations aimed at enhancing science literacy.

Assessment of cyclooxygense-2 expression with 99mTc-labeled celebrex.

Cyclooxygenase-2 (COX-2) plays an important role in angiogenesis and cancer progression. Since many tumor cells exhibit COX-2 expression, functional imaging of COX-2 expression using celebrex (CBX, a COX-2 inhibitor) may provide not only a non-invasive, reproducible, quantifiable alternative to biopsies, but it also greatly complements pharmacokinetic studies by correlating clinical responses with biological effects. Moreover, molecular endpoints of anti-COX-2 therapy could also be assessed effectively. This study aimed at measuring uptake of Tc-EC-CBX in COX-2 expression in tumor-bearing animal models. In vitro Western blot analysis and cellular uptake assays were used to examine the feasibility of using Tc-EC-CBX to measure COX-2 activity. Tissue distribution studies of Tc-EC-CBX were evaluated in tumor-bearing rodents at 0.5-4 h. Dosimetric absorption was then estimated. Planar scintigraphy was performed in mice, rats and rabbits bearing tumors. In vitro cellular uptake indicated that cells with higher COX-2 expression (A549 and 13762) had higher uptake of Tc-EC-CBX than lower COX-2 expression (H226). In vivo biodistribution of Tc-EC-CBX in tumor-bearing rodents showed increased tumor:tissue ratios as a function of time. In vitro and biodistribution studies demonstrated the possibility of using Tc-EC-CBX to assess COX-2 expression. Planar images confirmed that the tumors could be visualized with Tc-EC-CBX from 0.5 to 4 h in tumor-bearing animal models. We conclude that Tc-EC-CBX may be useful to assess tumor COX-2 expression. This may be useful in the future for selecting patients for treatment with anti-COX-2 agents.

Gastrojejunostomy during laparoscopic gastric bypass: analysis of 3 techniques.

HYPOTHESIS: Although perceived as a more technically demanding and time-consuming technique, the hand-sewn gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (RYGB) is associated with fewer complications and lower costs than stapled techniques. DESIGN: A retrospective medical record review of prospectively collected data. SETTING: University hospital. PATIENTS: One hundred eight consecutive patients undergoing laparoscopic RYGB between January 1, 1999, and December 31, 2001. INTERVENTION: Three techniques were compared: hand-sewn anastomosis (HSA), circular-stapled anastomosis (CSA), and linear-stapled anastomosis (LSA). MAIN OUTCOME MEASURES: Operative costs, including the cost of stapling devices, the cost of sutures, and operative times, were compared. Rates of anastomotic strictures, leaks, marginal ulcers, bleeding, and wound infections were determined. RESULTS: Eighty-seven patients underwent HSA; 13, CSA; and 8, LSA. Supply costs per patient were higher for CSA ($955) and LSA ($435) than for HSA ($2) (P<.001). The mean +/- SEM operative time for laparoscopic RYGB was longer when performing CSA than HSA or LSA (285 +/- 22 vs 215 +/- 8 and 204 +/- 28 minutes, respectively; P<.001). Stricture rates were higher after CSA than HSA and LSA (4 [31%] of 13 patients vs 3 [3%] of 87 patients and 0 of 8 patients, respectively; P<.01). The wound infection rate was higher after CSA than HSA and LSA (3 [23%] of 13 patients vs 1 [1%] of 87 patients and 0 of 8 patients, respectively; P<.001). There was no difference in anastomotic bleeding, and no anastomotic leaks occurred. CONCLUSIONS: In this experience, hand-sewn gastrojejunostomy during laparoscopic RYGB reduced operating room supply costs and was completed faster than stapled techniques. However, these differences may reflect the learning curve because these techniques were used early in our experience. Lower postoperative stricture and wound infection rates seem to be the primary benefits of the HSA technique.