Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium.

OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.

Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium.

OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.

Updated outcomes of laparoscopic versus open umbilical hernia repair in patients with obesity based on a National Surgical Quality Improvement Program review.

BACKGROUND: Currently, there's not a well-accepted optimal approach for umbilical hernia repair in patients with obesity when comparing laparoscopic umbilical hernia repair (LUHR) versus open umbilical hernia repair (OUHR). OBJECTIVE: The objective of this study was to evaluate if there's a difference in postoperative complications after LUHR versus OUHR with the goal of indicating an optimal approach. METHODS: A retrospective analysis was completed using the 2016 National Surgical Quality Improvement Program (NSQIP) database to identify patients with obesity (Body Mass Index (BMI) ≥ 30 kg/m2) who underwent LUHR or OUHR. Patients were divided into OUHR and LUHR groups, and post-operative outcomes were compared, focusing on wound complications. RESULTS: A total of 12,026 patients with obesity who underwent umbilical hernia repair were identified; 9695 underwent OUHR, while 2331 underwent LUHR. The LUHR group was found to have a statistically significant higher BMI (37.5 kg/m2 vs. 36.1 kg/m2; p < 0.01) and higher incidence of diabetes mellitus requiring therapy (18.4% vs. 15.8%; p < 0.01), hypertension (47.5% vs. 43.8%; p < 0.01), and current smoker status (18.6% vs. 16.5%; p < 0.02). Superficial surgical site infection (SSI) was significantly higher in the OUHR group (1.5% vs. 0.9%; p < 0.03), and there was a trend towards higher deep SSI in the OUHR group (0.3% vs. 0.5%; p = 0.147). There was no difference in organ space SSI, wound disruption, or return to OR. On logistic regression, composite SSI rate (defined as superficial, deep, and organ space SSIs) was significantly increased in the OUHR group (p < 0.01). Predictive factors significantly associated with increased morbidity included female gender and higher BMI. CONCLUSIONS: In patients with obesity, even though the LUHR group had an overall higher BMI and higher rates of diabetes, hypertension, and current smoking status, they experienced decreased post-operative wound complications compared to the OUHR group.

A multi-institutional study from the US ROPE consortium examining factors associated with endocrine surgery exposure for general surgery residents.

BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.

Mathilde Schott, A Woman's Influence in the Revolution of the Scalpel in the 1890s.

Surgery relies on the scalpel; the surgeon's first instrument in every case. From early knives crafted in the pre-historic era to today, the scalpel has evolved along with medical and surgical fields but maintained its critical role and symbolism of operative intervention. A significant catalyst for change in surgical instrument development in the late 1800s was the evolution of anesthesia and antisepsis. Surgical instruments were affected by harsh sterilization techniques, creating need for a method to maintain surgical scalpel sharpness. Mathilde Schott, an early female biomedical engineering innovator, filed a patent (US431153) in 1890 for a detachable scalpel blade. Schott identified and responded to the needs of surgeons at the turn of the 20th century and created a detachable blade and stabilizing lever. Schott persevered in a society unaccustomed to women leaders, subsequently improving medicine, surgery, and engineering.

A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation.

BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Does Colectomy Improve Type 2 Diabetes?

Gastrectomy and gastric bypass improve type 2 diabetes (T2DM), potentially through alterations in intestinal hormones and the microbiome. The aim of this study was to analyze whether colorectal resections result in improvement of T2DM. A total of 171 patients with T2DM who underwent colectomy for benign diseases were studied with a median postoperative follow-up of 3 years (interquartile range [IQR] 1-5). The median BMI and glycated hemoglobin (HbA1c) at baseline and post-colectomy were 30.3 kg/m2 (IQR 26.6-34.6) versus 30.4 kg/m2 (IQR 26.2-35) (p = 0.1), and 6.7% (IQR 6.2-7.5) versus 6.5% (IQR 6.5-7.1) (p = 0.5), respectively. The proportion of patients taking diabetes medications at baseline versus post-colectomy did not differ significantly. Changes in BMI, HbA1c, and status of diabetes medications were not statistically different between the subtypes of colorectal resection. Our experience suggests that colectomy for benign colorectal diseases is not associated with long-term changes in body weight or glycemic control.

Effect of Gastrogastric Fistula Closure in Type 2 Diabetes.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) has been shown to significantly improve glucose control in patients with type 2 diabetes (T2DM). The formation of a gastrogastric fistula (GGF) allows nutrients to pass through the native route, rather than bypassing the duodenum in typical RYGB configuration. We sought to evaluate the effect of revisional bariatric surgery for known GGF on control of diabetes. METHODS: A retrospective chart review of a single academic institution was performed to identify patients who had T2DM at the time of corrective surgery for a GGF. Baseline characteristics, and postoperative outcomes including changes in body mass index (BMI), glycated hemoglobin, fasting blood glucose (FBG), and diabetes medications were assessed. RESULTS: Ten patients were identified with GGF who had T2DM at the time of corrective surgery. Patients had a male-to-female ratio of 2:3, a mean age of 59.2 ± 10 years, a mean baseline BMI of 38.1 ± 17.6 kg/m2, and a median duration of 9 years (interquartile range 6-14) from initial RYGB to revision. At a mean follow-up of 14.9 ± 8.5 months, a mean reduction in BMI of 4.9 ± 6 kg/m2 was associated with a significant mean reduction in FBG (167.1 ± 88.2 vs. 106.1 ± 20.4 mg/dL, p = 0.04) and number of diabetes medications (1.4 ± 0.8 vs. 0.7 ± 0.7, p = 0.04). CONCLUSION: In patients with diabetes and GGF, a corrective surgery for closure of fistula and restoration of bypass anatomy results in improvement of glucose control and status of diabetes medications. This finding can highlight the potential metabolic significance of duodenal exclusion.

Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management.

BACKGROUND: Uncontrolled hyperglycemia in patients undergoing surgery has been shown to be a risk factor for postoperative complications. OBJECTIVE: To assess the clinical significance of perioperative hyperglycemia on infectious complications and clinical outcomes in patients undergoing bariatric surgery. SETTING: Single academic center. METHODS: Retrospective chart review of all patients who underwent primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2013 and 2016 was performed. The association between any elevated perioperative glucose value (hyperglycemia: ≥126 mg/dL) and level of elevation (≥126 or ≥200 mg/dL) with 30-day infectious complications, reoperation, length of hospital stay, and readmission was assessed. Patients who developed early complications (within 3 d of surgery), which could potentially lead to immediate postoperative hyperglycemia, were not included in the analysis. Outcomes of patients with and without diabetes were separately analyzed. RESULTS: A cohort of 1981 patients was studied, including Roux-en-Y gastric bypass (n = 1171, 59%) and sleeve gastrectomy (n = 810, 41%) patients. In patients with diabetes (n = 751, 38%), perioperative hyperglycemia was independently associated with higher composite infectious complications (defined as presence of any of 6 infectious complications; odds ratio [OR] 3.1, 95% confidence interval [CI] 1.2-8.2, P = .018) and higher readmission rate (OR 2.2, 95% CI 1.1-4.6, P = .027). In patients without diabetes (n = 1230, 62%), 19.2% had perioperative hyperglycemia (≥126 mg/dL). Perioperative hyperglycemia in patients without diabetes was associated with higher composite infectious complications (OR 2.6, 95% CI 1.1-5.5, P = .018) and prolonged length of stay (OR 3.0, 95% CI 1.5-5.9, P = .001). CONCLUSIONS: An elevated perioperative glucose value is adversely associated with infectious complications and key clinical outcomes after bariatric surgery. The increased risk is correlated with the extent of glucose elevation (dose-response relationship). Our findings highlight the importance of glucose control during the perioperative period in bariatric surgical patients.

Thirty-Day Readmission Rate Using an Outpatient Infusion Pathway after Laparoscopic Roux-en-Y Gastric Bypass.

The objective of this study was to determine whether implementing an outpatient infusion pathway (OIP) resulted in a decreased 30-day readmission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB). Data were retrospectively gathered on all patients who underwent LRYGB at our institution between April 1, 2015, and March 31, 2016, after instituting an OIP (postinfusion group). Thirty-day readmission rate, length of stay, and 30-day mortality rate were compared with patients who underwent LRYGB between January 1, 2014, and December 31, 2014, before implementing the OIP (preinfusion group). Patients not able to take 40 ounces of fluid orally at discharge after surgery were enrolled in the OIP. One OIP session would include an antiemetic, 1 liter bolus of 0.9 per cent saline, and intravenous multivitamin, thiamine, and folic acid. A total of 174 patients were included for analysis. Seventy-nine patients were in the preinfusion group and 95 patients in the postinfusion group. Of the 95 patients in the postinfusion group, 18 patients (18.9%) met inclusion criteria for the OIP. There was a 45 per cent decrease in 30-day readmission rate after the institution of the OIP for patients who underwent LRYGB, however this was not statistically significant (11.39% vs 6.31%; OR 1.907; 95% confidence interval: 0.648-5.613, P = 0.235). There was no difference in postoperative length of hospital stay (1.65 vs 1.41 days, P = 0.114) or mortality (0.7% vs 0%, P = 0.454), in the pre- and postinfusion groups, respectively. Implementation of an OIP decreased 30-day readmission rate after LRYGB by 45 per cent; however, this was not statistically significant.

Neurologic Manifestations of Vitamin B Deficiency after Bariatric Surgery.

INTRODUCTION: The aim of this study was to assess the incidence, clinical presentation, and outcomes of neurologic disorders secondary to vitamin B deficiencies following bariatric surgery. METHODS: Patients at a single academic institution who underwent bariatric surgery and developed neurologic complications secondary to low levels of vitamins B1, B2, B6, and B12 between the years 2004 and 2015 were studied. RESULTS: In total, 47 (0.7%) bariatric surgical patients (Roux-en-Y gastric bypass n = 36, sleeve gastrectomy n = 9, and duodenal switch n = 2) developed neurologic manifestations secondary to vitamin B deficiencies. Eleven (23%) patients developed postoperative anatomical complications contributed to poor oral intake. Median duration to onset of neurologic manifestation following surgery was 12 months (IQR, 5-32). Vitamin deficiencies reported in the cohort included B1 (n = 30), B2 (n = 1), B6 (n = 12), and B12 (n = 12) deficiency. The most common manifestations were paresthesia (n = 31), muscle weakness (n = 15), abnormal gait (n = 11), and polyneuropathy (n = 7). Four patients were diagnosed with Wernicke-Korsakoff syndrome (WKS) which was developed after gastric bypass (n = 3) and sleeve gastrectomy (n = 1). Seven patients required readmission for management of severe vitamin B deficiencies. Overall, resolution of neurologic symptoms with nutritional interventions and pharmacotherapy was noted in 40 patients (85%). The WKS was not reversible, and all four patients had residual mild ataxia and nystagmus at the last follow-up time. CONCLUSIONS: Nutritional neurologic disorders secondary to vitamin B deficiency are relatively uncommon after bariatric surgery. While neurologic disorders are reversible in most patients (85%) with vitamin replacements, persistent residual neurologic symptoms are common in patients with WKS.

Factors Influencing Primary Care Physicians' Referral for Bariatric Surgery.

BACKGROUND AND OBJECTIVES: Bariatric surgery has been shown to be an effective weight loss treatment for the morbidly obese, but some primary care physicians remain hesitant about postoperative treatment and management of patients who have undergone the surgery and recommend it to their obese patients infrequently. The purpose of this study was to evaluate perceptions of primary care physicians of the role of bariatric surgery in the management of obese patients and to identify possible barriers to treatment. METHODS: A survey of PCPs within our institution was conducted to determine attitudes, knowledge, and practices regarding the treatment of morbidly obese patients,with a specific focus on identifying factors that influence referral patterns for bariatric surgery. RESULTS: Among 161 eligible PCPs, 57 (35.4%) responded. Most respondents (59%) reported that at least 1 in 4 of their patients had a BMI 35 kg/m2. Although 39% thought that diet and exercise were an effective means of sustained weight loss, only 12% were satisfied with prescribing nonsurgical interventions. Sixty-three percent agreed that bariatric surgery is generally effective in the long term. All respondents were aware of the commonly established benefits, including improvement of diabetes, hypertension, and hyperlipidemia. In addition, 65% were familiar with the indications for bariatric surgery, and 70% felt comfortable discussing it with patients as a treatment option. Fewer than half of the respondents felt confident in providing postoperative management. Cost was a perceived limitation, with 53%reporting that most of their patients could not afford bariatric surgery. CONCLUSIONS: The general attitude of PCPs toward bariatric surgery is supportive. Physicians are largely aware of the indications and benefits; however, far fewer are comfortable in management of patients after surgery. A lack of supplemental information and concerns regarding the cost of surgery can impede treatment and referrals.