An International Collaborative Study on Surgical Education for Quality Improvement (ASSURED): A Project by the 2017 International Society of Surgery (ISS/SIC) Travel Scholars International Working Group.

BACKGROUND: There is a huge difference in the standard of surgical training in different countries around the world. The disparity is more obvious in the various models of surgical training in low- and middle-income countries (LMICs) compared to high-income countries. Although the global training model of surgeons is evolving from an apprenticeship model to a competency-based model with additional training using simulation, the training of surgeons in LMICs still lacks a standard pathway of training. METHODS: This is a qualitative, descriptive, and collaborative study conducted in six LMICs across Asia, Africa, and South America. The data were collected on the status of surgical education in these countries as per the guidelines designed for the ASSURED project along with plans for quality improvement in surgical education in these countries. RESULTS: The training model in these selected LMICs appears to be a hybrid of the standard models of surgical training. The training models were tailored to the country's need, but many fail to meet international standards. There are many areas identified that can be addressed in order to improve the quality of surgical education in these countries. CONCLUSIONS: Many areas need to be improved for a better quality of surgical training in LMICs. There is a need of financial, technical, and research support for the improvement in these models of surgical education in LMICs.

Can We Accurately Identify Peritoneal Metastases Based on Their Appearance? An Assessment of the Current Practice of Intraoperative Gastrointestinal Cancer Staging.

BACKGROUND: Peritoneal lesions are common findings during operative abdominal cancer staging. The decision to perform biopsy is made subjectively by the surgeon, a practice the authors hypothesized to be imprecise. This study aimed to describe optical characteristics differentiating benign peritoneal lesions from peritoneal metastases. METHODS: The study evaluated laparoscopic images of 87 consecutive peritoneal lesions biopsied during staging laparoscopies for gastrointestinal malignancies from 2014 to 2017. A blinded survey assessing these lesions was completed by 10 oncologic surgeons. Three senior investigators categorized optical features of the lesions. Computer-aided digital image processing and machine learning was used to classify the lesions. RESULTS: Of the 87 lesions, 28 (32%) were metastases. On expert survey, surgeons on the average misidentified 36 ± 19% of metastases. Multivariate analysis identified degree of nodularity, border transition, and degree of transparency as independent predictors of metastases (each p < 0.03), with an area under the receiver operating characteristics curve (AUC) of 0.82 (95% confidence interval [CI], 0.72-0.91). Image processing demonstrated no difference using image color segmentation, but showed a difference in gradient magnitude between benign and metastatic lesions (AUC, 0.66; 95% CI 0.54-0.78; p = 0.02). Machine learning using a neural network with a tenfold cross-validation obtained an AUC of only 0.47. CONCLUSIONS: To date, neither experienced oncologic surgeons nor computerized image analysis can differentiate peritoneal metastases from benign peritoneal lesions with an accuracy that is clinically acceptable. Although certain features correlate with the presence of metastases, a substantial overlap in optical appearance exists between benign and metastatic peritoneal lesions. Therefore, this study suggested the need to perform biopsy for all peritoneal lesions during operative staging, or at least to lower the threshold significantly.

Investigation of antidepressant medication usage after bariatric surgery.

BACKGROUND: Many patients seeking bariatric surgery have a history of mood disorders and are actively prescribed antidepressants. While extensive documentation exists on the impact of weight loss surgery on reductions in cardiac, diabetic, and hypertensive medications, little is known about the impact of bariatric surgery on the use of antidepressant medications. METHODS: A retrospective study of 439 patients who had undergone Roux-en-Y gastric bypass (RYGB) from January 2001 to November 2004 was examined for postoperative changes in the use of antidepressant medications. RESULTS: After RYGB, 23% of the patients had an increase in their antidepressant use, 40% continued to require the same antidepressant, 18% had a change in antidepressant medication, and only 16% had a decrease or discontinued their antidepressant. CONCLUSION: Unlike most medications, antidepressant usage did not decrease in the majority of patients after RYGB. These results highlight the prevalence of antidepressant prescription use in patients before and after RYGB and support the need for the careful monitoring of depressive symptoms.

Colonoscopic splenic injuries: incidence and management.

PURPOSE: Splenic injuries that occur during colonoscopies are rare. There is no available incidence of this serious complication, and the literature is limited to case reports. Our study looks at single institution experience of splenic injuries during colonoscopy to define the incidence and management of this serious complication. METHODS: All patients from 1980 through June 2008 sustaining a splenic injury during colonoscopy were reviewed. RESULTS: Four patients (of 296,248 colonoscopies) sustained a splenic injury directly from colonoscopy performed at our institution (incidence 0.001%). Three additional patients were treated at our tertiary referral center after splenic injury from colonoscopy performed elsewhere. The mean age at the time of colonoscopy was 54 years (range 40-70 years). The most common presenting symptom was abdominal pain (n = 4) with a mean decrease in hemoglobin of 6.5 g/dl (range 4.5-8.5 g/dl). Splenic injury was diagnosed by computed tomography in five patients. Six patients received a mean of 5.5 U of packed red blood cells (range 2-14 U). All patients were managed with splenectomy, six patients within 24 h of the index colonoscopy, and one patient presented more than 24 h after initial colonoscopy. There was no evidence of preexisting splenic disease in any of the patients by surgical pathology, and there were no postoperative complications or deaths. The mean duration of stay was 10 days (range 7-15 days). All patients are alive at a median follow up of 22 months (range 1-164 months). CONCLUSION: Splenic injury occurring during colonoscopy is a rare but serious complication. Patients presented with abdominal pain and a precipitous decrease in hemoglobin and have all required emergent splenectomy.

Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment.

BACKGROUND: Clinically significant morbid obesity is associated with an increased risk of gastroesophageal reflux disease. Vertical Roux-en-Y gastric bypass (RYGBP) is known to eliminate acid (and bile) in the pouch of cardia, which would provide control of reflux symptoms. The aim of our study was to assess the technical considerations, morbidity, and safety of RYGBP after previous antireflux surgery and evaluate postoperative reflux symptoms. METHODS: Retrospective review of all patients undergoing RYGBP after previous antireflux surgery from three institutions. Follow-up (mean 18 months) data were obtained from medical records and by questionnaire. RESULTS: A total of 19 patients (18 women and 1 man) underwent standard (n = 18) or distal (n = 1) RYGBP 8 +/- 1 years after Nissen (n = 18) or Toupet (n = 1) fundoplication. Open RYGBP was undertaken in 17 of 19 patients. No postoperative deaths occurred. Substantive complications occurred in 4 patients (21%) and included hemorrhage requiring transfusion, concomitant splenectomy, and reoperation for suspected leak in 2. Of the 19 patients, 16 returned the questionnaire, 15 of whom reported subjective improvement in reflux symptoms after RYGBP compared with after antireflux surgery. No patient in this series required medical therapy for reflux symptoms at the last follow-up visit. The body mass index decreased from 42 +/- 2 kg/m(2) to 32 +/- 2 kg/m(2) (mean +/- SEM); all patients with >or=1 year of follow-up had a body mass index of