Surgeon Gender and Early Complications in Elective Surgery: A Systematic Review and meta-analysis.

OBJECTIVE: To examine the association between surgeon gender and early postoperative complications, including 30-day death and readmission, in elective surgery. BACKGROUND: Variations between male and female surgeon practice patterns may be a source of bias and gender inequality in the surgical field, perhaps impacting quality of care. However, there are limited and conflicting studies regarding the association between surgeon gender and postoperative outcomes. METHODS: MEDLINE and Embase were searched in October 2023 for observational studies including patients who underwent elective surgery requiring general or regional anesthesia across multiple surgical specialties. Multiple independent blinded reviewers oversaw the data selection, extraction, and quality assessment according to the PRISMA, MOOSE, and Newcastle Ottawa Scale guidelines. Data were pooled as odds ratios, using a generic inverse-variance random-effects model. RESULTS: Of 944 abstracts screened, 11 studies were included in this systematic review and meta-analysis. A total of 4,440,740 postoperative patients were assessed for a composite primary outcome of mortality, readmission, and other complications within 30 days of elective surgery, with a total of 325,712 (7.3%) surgeries performed by 7,072 (10.9%) female surgeons. There was no association between surgeon gender and the composite of mortality, readmission, and/or complications (odds ratio=0.97, 95% CI 0.95 to 1.00; I2=64.9%; P=0.001). CONCLUSIONS: These results support that surgeon gender is not associated with early postoperative outcomes, including mortality, readmission, or other complications in elective surgery. These findings encourage patients, healthcare providers, and stakeholders not to consider surgeon gender as a risk factor for postoperative complications.

Limited Role for Routine Restaging After Neoadjuvant Therapy in Locally Advanced Rectal Cancer.

BACKGROUND: Although many patients with locally advanced rectal cancer undergo restaging imaging after neoadjuvant chemoradiotherapy and before surgery, the benefit of this practice is unclear. The purpose of this study was to examine the impact of reimaging on outcomes. MATERIALS AND METHODS: We performed a retrospective analysis of consecutive patients with stage 2 and 3 rectal adenocarcinoma treated with neoadjuvant chemoradiotherapy between May 2005 and April 2018. Patient and disease characteristics, imaging, treatment, and oncologic outcomes were compared between those who underwent restaging and those who went directly to surgery. Predictors of outcomes and cost effectiveness of restaging were determined. RESULTS: Of 224 patients, 146 underwent restaging. Six restaged patients had findings leading to a change in management. There was no difference in freedom from recurrence (P = 0.807) and overall survival (P = 0.684) based on restaging. Pretreatment carcinoembryonic antigen level >3 ng/mL (P = 0.010), clinical T stage 4 (P = 0.016), and pathologic T4 (P = 0.047) and N2 (P = 0.002) disease increased the risk of death, whereas adjuvant chemotherapy decreased the risk of death (P < 0.001) on multivariate analysis. Disease recurrence was lower with pelvic exenteration (P = 0.005) and in females (P = 0.039) and higher with pathologic N2 (P = 0.003) and N3 (P = 0.002) disease. The average cost of reimaging is $40,309 per change in management; however, $45 is saved per patient when downstream surgical costs are considered. CONCLUSIONS: Imaging restaging after neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer rarely changes treatment and does not improve survival. In a subset of patients at higher risk for worse outcome, reimaging may be beneficial.

Sortase-tag expressed protein ligation: combining protein purification and site-specific bioconjugation into a single step.

Efficient labeling of protein-based targeting ligands with various cargos (drugs, imaging agents, nanoparticles, etc.) is essential to the fields of molecular imaging and targeted therapeutics. Many common bioconjugation techniques, however, are inefficient, nonstoichiometric, not site-specific, and/or incompatible with certain classes of protein scaffolds. Additionally, these techniques can result in a mixture of conjugated and unconjugated products, which are often difficult to separate. In this study, a bacterial sortase enzyme was utilized to condense targeting ligand purification and site-specific conjugation at the C-terminus into a single step. A model was produced to determine optimal reaction conditions for high conjugate purity and efficient utilization of cargo. As proof-of-principle, the sortase-tag expressed protein ligation (STEPL) technique was used to generate tumor-specific affinity ligands with fluorescent labels and/or azide modifications at high purity (>95%) such that it was not necessary to remove unconjugated impurities. Click chemistry was then used for the highly efficient and site-specific attachment of the azide-modified targeting ligands onto nanoparticles.

Gastrointestinal Stromal Tumors and the General Surgeon.

Gastrointestinal stromal tumors (GISTs) are rare malignancies of the gastrointestinal tract but are the most common sarcoma. This review covers aspects of the care of patients with GIST relevant to surgeons. In particular, management of sub-2 cm GISTs, the utility of neoadjuvant and adjuvant therapy for primary GISTs, and indications for surgery in the setting of metastatic disease are discussed.

Practice Makes Perfect: Introducing a Question Bank for ABSITE Preparation Improves Program Performance.

BACKGROUND: The American Board of Surgery In-Training Examination (ABSITE) is an important predictor of passing the Qualifying Examination and a determinant of fellowship competitiveness. OBJECTION: Study the impact of providing program-wide access to a commercially available question bank for ABSITE preparation. STUDY DESIGN: The surgery residency program purchased access to the TrueLearn question bank in 2018 A paired sample t test analysis compared the 2018 ABSITE percentage and percentile scores, prior to practice question bank access to 2019 ABSITE percentile scores. A simple linear regression analysis was calculated to predict improvement in percentage scores from 2018 to 2019 based on total number of practice questions as well as number of correct practice questions completed. Data were analyzed using SPSS. RESULTS: Among the residents utilizing practice questions with serial exam scores, the individual resident ABSITE percentage of correct questions showed a statistically significant improvement after introduction of the question bank from 2018 (mean = 68.7, standard deviation = 7.3) to 2019 (mean = 72.2, standard deviation = 7.2; t(35) = -4.529, p < 0.001). A statistically significant regression equation both linear (F(1,33) = 6.274, p = 0.017) and logarithmic (F(1,33) = 7.405, p =0.01) was found with an R2 of 0.160 and 0.183, respectively, for total number of practice questions completed, signifying that more completed practice questions correlated with a higher improvement in ABSITE percentage score. The improvement in residents' ABSITE percentage score increased by 3 ± 1 percentage point for each 100 practice questions completed from 2018 to 2019 (Figure 1). A significant regression equation was also found for improvement in percentage score among all residents (F (1,33) = 8.211, p = 0.007) with an R2 of 0.199 for the number of correct practice questions completed. CONCLUSION: Use of a commercial question bank improved overall ABSITE scores. More questions answered translated into improved performance. Percent correct on the practice questions also correlated strongly with performance. Programs seeking to improve scores may wish to provide access to a question bank.

The Rise of Minimally Invasive Surgery: 16 Year Analysis of the Progressive Replacement of Open Surgery with Laparoscopy.

OBJECTIVE: The expansion of Minimally Invasive Surgery (MIS) has been exponential since the introduction of laparoscopic surgery in the late 1980s. This shift in operative technique has led many to believe that surgery residents are not developing the skills needed to adequately perform open operations. METHODS: We performed a retrospective review of the Accreditation Council for Graduating Medical Education national operative case log database of general surgery residents from January 2003 to December 2019. We compared the open vs. laparoscopic case numbers for six different operations, including cholecystectomy, appendectomy, inguinal hernia repair, colectomy, gastrectomy, and Nissen fundoplication. The Cochran-Armitage test was used to assess the linear trend in the procedures performed. RESULTS: Total average residency case volumes for the procedures studied have increased from 270 to 368 (36%) over the 16-year period with MIS steadily representing a greater proportion of these cases. From 2003 to 2018, MIS representation increased in all studied procedures: cholecystectomy (88% to 94%, p = 0.048), inguinal hernia repair (20% to 47%, p ≤ 0.001), appendectomy (38% to 93%, p ≤ 0.001), colectomy (8% to 43%, p ≤ 0.001), gastrectomy (43% to 84%, p = 0.048), and Nissen (71% to 91%, p = 0.21). CONCLUSION: While the overall operative volume has increased nationally for surgical residents, the representation of open cases has steadily declined since the advent of MIS. The experience needed in open surgery during resident training is still to be determined and may be necessary now that laparoscopy is progressively replacing open operations.

Trends in female surgeon authorship - The role of the middle author.

BACKGROUND: The objective of this study was to compare middle authorships between male and female general surgeons in the United States. METHODS: A stratified random sample of American College of Surgeons general surgery fellows was identified. Relevant author demographic, affiliation, and publication metrics were collected and compared across cohorts to determine which demographics were prognostic for each outcome variable. The primary endpoint was the number of middle author papers between genders. RESULTS: Males were more likely to enter into practice earlier (p<0.001), be fellowship-trained (p<0.001), obtain higher academic rank (p<0.001), and practice at more highly ranked academic institutions (p=0.019). Females had fewer middle author publications (p=0.044) and higher annual rates of first author publications (p=0.020) despite similar rates of total publications. CONCLUSIONS: Female surgeons hold the middle author position less frequently than males despite similar total publication numbers. Reasons for this finding should be the target of future study.

What publicly available quality metrics do hip and knee arthroplasty patients care about most when selecting a hospital in Maryland: a discrete choice experiment.

OBJECTIVE: To quantify which publicly reported hospital quality metrics have the greatest impact on a patient's simulated hospital selection for hip or knee arthroplasty. DESIGN: Discrete choice experiment. SETTING: Two university-affiliated orthopaedic clinics in the greater Baltimore area, Maryland, USA. PARTICIPANTS: One hundred and twenty-eight patients who were candidates for total hip or knee arthroplasty. PRIMARY AND SECONDARY OUTCOME MEASURES: The effect and magnitude of acceptable trade-offs between publicly reported hospital quality parameters on patients' decision-making strategies using a Hierarchical Bayes model. RESULTS: Publicly reported information on patient perceptions of attention to alleviation of postoperative pain had the most influence on simulated hospital choice (20.7%), followed by methicillin-resistant Staphylococcus aureus (MRSA) rates (18.8%). The understandability of the discharge instructions was deemed the least important attribute with a relative importance of 6.9%. Stratification of these results by insurance status and duration of pain prior to surgery revealed that patient demographics and clinical presentation affect the decision-making paradigm. CONCLUSIONS: Publicly available information regarding hospital performance is of interest to hip and knee arthroplasty patients. Patients are willing to accept suboptimal understanding of discharge instructions, lower hospital ratings and suboptimal cleanliness in exchange for better postoperative pain management, lower MRSA rates, and lower complication rates.