Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation.

OBJECTIVE: To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively. BACKGROUND: POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet. METHODS: Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014-2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007-2016) to assess discrimination and calibration in an internal-external validation procedure. RESULTS: Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11-1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32-1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78-0.88) and 0.73 (95% CI: 0.70-0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%-25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74-0.85). CONCLUSIONS: The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com . The 3 distinct risk groups allow for personalized treatment and benchmarking.

A comparative analysis of video-based surgical assessment: is evaluation of the entire critical portion of the operation necessary?

BACKGROUND: Previous studies of video-based operative assessments using crowd sourcing have established the efficacy of non-expert evaluations. Our group sought to establish the equivalence of abbreviating video content for operative assessment. METHODS: A single institution video repository of six core general surgery operations was submitted for evaluation. Each core surgery included three unique surgical performances, totaling 18 unique operative videos. Each video was edited using four different protocols based on the critical portion of the operation: (1) custom edited critical portion (2) condensed critical portion (3) first 20 s of every minute of the critical portion, and (4) first 10 s of every minute of the critical portion. In total, 72 individually edited operative videos were submitted to the C-SATS (Crowd-Sourced Assessment of Technical Skills) platform (C-SATS) for evaluation. Aggregate score for study protocol was compared using the Kruskal-Wallis test. A multivariable, multilevel mixed-effects model was constructed to predict total skill assessment scores. RESULTS: Median video lengths for each protocol were: custom, 6:20 (IQR 5:27-7:28); condensed, 10:35 (8:50-12:06); 10 s, 4:35 (2:11-6:09); and 20 s, 9:09 (4:20-12:14). There was no difference in aggregate median score among the four study protocols: custom, 15.7 (14.4-16.2); condensed, 15.8 (15.2-16.4); 10 s, 15.8 (15.3-16.1); 20 s, 16.0 (15.1-16.3); χ2 = 1.661, p = 0.65. Regression modeling demonstrated a significant, but minimal effect of the 10 s and 20 s editing protocols compared to the custom method on individual video score: condensed, + 0.33 (- 0.05-0.70), p = 0.09; 10 s, + 0.29 (0.04-0.55), p = 0.03; 20 s, + 0.40 (0.15-0.66), p = 0.002. CONCLUSION: A standardized protocol for video editing abbreviated surgical performances yields reproducible assessment of surgical aptitude when assessed by non-experts.

Superficial Circumflex Iliac Artery Perforator Flap Reconstruction of the Upper Extremity.

The superficial circumflex iliac artery perforator (SCIP) flap is thin, pliable tissue well suited for reconstruction of injuries of the hand and upper extremity. Based upon perforators from the superficial circumflex iliac artery, the SCIP flap has advantages over the traditional groin flap due to reduced need for secondary procedures and improved donor site morbidity This article offers a detailed exploration of the SCIP flap design and technique, its advantages over traditional methods, and its potential applications in reconstructive surgery. Post-operative care and critical points are also discussed, and case examples are provided to guide readers through the intricacies of the technique, emphasizing the surgical skill and precision required for successful implementation.