The Effect of Sizing Device Use During Laparoscopic Sleeve Gastrectomy on Rates of Postoperative Dehydration and Other 30-day Complications: An Analysis of the ACS-MBSAQIP Database.

BACKGROUND: During laparoscopic sleeve gastrectomy (LSG), many surgeons use an intraoperative sizing device. However, the choice of intraoperative sizing device varies and the optimal choice or combination of sizing devices, such as a bougie or esophagogastroduodenoscopy (EGD), is not known. The purpose of this study was to determine if there is an association between the use of a sizing device or a combination of sizing devices on rates of dehydration, bleeding, and staple line leak following LSG. MATERIALS AND METHODS: Patients between the ages of 18 to 80 who underwent elective LSG were identified using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (ACS-MBSAQIP) database from 2015 to 2019. Postoperative outcomes, including rates of dehydration, bleeding, and staple line leak, were compared across 4 groups: those that utilized bougie and EGD (both), those that utilized only bougie (bougie only), those that utilized only EGD (EGD only), and those that did not utilize either sizing device (neither). RESULTS: In all, 533,151 cases met the inclusion criteria. On univariate analysis, the bougie-only group experienced the highest rates of dehydration events. On multivariate analysis, the use of both sizing devices was associated with significantly lower odds of events related to dehydration versus bougie only (aOR 0.869, P =0.0002), and bougie only was associated with significantly higher odds of events related to dehydration versus EGD only (aOR 1.773, P =0.0006).The neither-sizing device group did not show any statistically significant differences in any of the comparisons. CONCLUSIONS: Bougie use alone was associated with more dehydration-related complications, while EGD use demonstrated a protective effect. Not using a sizing device was associated with equivalent outcomes to all combinations of sizing devices. These findings highlight the need for the standardization of sizing devices during LSG and suggest that foregoing sizing devices may be a management option without early adverse sequelae.

Trends in utilization of laparoscopic colectomy according to race: an analysis of the NIS database.

BACKGROUND: Laparoscopic colectomy has been associated with improved recovery and decreased complications when compared to an open approach. Consequently, the rates of laparoscopic colectomy have increased. Race has been identified as a factor that influences a patient's likelihood of undergoing laparoscopic colectomy. Therefore, the purpose of this study is to analyze the rates of laparoscopic colectomy stratified by race over time. METHODS: Patients were selected using procedure codes for colectomy within the National Inpatient Sample (NIS) database from 2009 to 2018. The primary independent variable was race (Black, BL; Hispanic, HI; White, WH), and the primary outcome was surgical approach (laparoscopic vs open). Covariates included age, sex, case complexity, insurance status, income, year of surgery, urbanicity, region, bedsize, and teaching status. We examined the univariable association of race with laparoscopic vs open colectomy with chi-square. We used multivariable logistic regression to examine the association of race with procedure type adjusting for covariates. All analyses were done using SAS (version 9.4, Cary, NC) with p < .05 considered significant. RESULTS: 267,865 patients (25,000 BL, 19,685 HI, and 223,180 WH) were identified. Laparoscopy was used in 47% of cases, and this varied significantly by race (BL 44%, HI 49%, WH 47%, p < .0001). After adjusting for covariates, Black patients had significantly lower adjusted odds of undergoing laparoscopic colectomy vs White patients (aOR 0.92, p < 0.0001). Utilization of laparoscopy was similar in Hispanic compared to White patients (aOR 1.00, p = 0.9667). Racial disparity in the adjusted odds of undergoing laparoscopic colectomy was persistent over time. CONCLUSION: Race was independently associated with the rate of laparoscopic colectomy, with Black patients less likely to receive laparoscopic surgery than White patients. This disparity persisted over a decade. Attention should be paid to increasing the rates of laparoscopic colectomy in under-represented populations in order to optimize surgical care and address racial disparities.

Analysis of Surgery Residency Website Content: Implications during the COVID-19 Era.

BACKGROUND: Surgery residency program websites (SRW) are an important source of information for prospective applicants. The COVID-19 pandemic spurred a pivot from the traditional in-person interview format to interviews via virtual platforms. Because of the inability to meet in person, the information provided on program websites takes on an increased relevance to applicants. We hypothesized that SRW may be missing content important to applicants. Our study aims to assess SRW for the content which impacts the applicant decision-making process. METHODS: An internal survey distributed to fourth-year medical students in 2020 at a single academic institution identified the website content most important to applicants. A list of ACGME-accredited SRW as of December 1, 2020 was obtained. Using the Fellowship and Residency Electronic and Interactive Database, websites were assessed for content parameters identified by the survey. RESULTS: Medical students applying to surgical specialties identified fellowship acquisition (94%), faculty information (88%), application contact information (82%), and resident wellness (77%) as the most important website content. Review of SRW websites identified content pertaining to fellowship acquisition and resident wellness in only 60% and 27% of cases respectively. Overall, the SRW of university programs included the most content parameters, followed by hybrid programs, then community programs. CONCLUSIONS: Many SRW are missing information that applicants deem important in their decision-making process. Most notably, there is a relative deficiency in information pertaining to fellowship match results and resident wellness. University based programs tend to include more of this information on their websites. SRW should continue to adapt to meet the needs of applicants in an increasingly virtual age.

Attending guidance advised: educational quality of surgical videos on YouTube.

INTRODUCTION: YouTube is the most used platform for case preparation by surgical trainees. Despite its popular use, studies have noted limitations in surgical technique, safety, and vetting of these videos. This study identified the most viewed laparoscopic cholecystectomy (LC) videos on YouTube and analyzed the ability of attendings, residents, and medical students to identify critical portions of the procedure, technique, and limitations of the videos. METHODS: An incognito search was conducted on YouTube using the term "laparoscopic cholecystectomy." Results were screened for length, publication date, and language. The top ten most viewed videos were presented to general surgery attendings, residents, and medical students at a single academic institution. Established rubrics were used for evaluation, including the Critical View of Safety (CVS) for LC, a modified Global Operative Assessment of Laparoscopic Skills (GOALS) score, a task-specific checklist, and visual analog scales for case difficulty and operator competence. Educational quality and likelihood of video recommendation for case preparation were evaluated using a Likert scale. Attending assessments were considered the gold standard. RESULTS: Six attending surgeons achieved excellent internal consistency on CVS, educational quality, and likelihood of recommendation scales, with Cronbach alpha (⍺) of 0.93, 0.92, and 0.92, respectively. ⍺ was ≥ 0.7 in all the other scales measured. Attending evaluations revealed that only one of the ten videos attained all three established CVS criteria. Four videos demonstrated none of the CVS criteria. The mean educational quality (mEQ) was 4.63 on a 10-point scale. The mean likelihood of recommendation (mLoR) for case preparation was 2.3 on a 5-point scale. Senior resident assessments (Postgraduate Year (PGY)4 + , n = 12) aligned with attending surgeons, with no statistically significant differences in CVS attainment, mEQ, and mLoR. Junior residents (PGY1-3, n = 17) and medical students (MS3-4, n = 20) exhibited significant difference with attendings in CVS attainment, mEQ, and mLoR for more than half the videos. Both groups tended to overrate videos compared to attendings. CONCLUSION: YouTube is the most popular unvetted resource used for case presentation by surgical trainees. Attending evaluations revealed that the most viewed LC videos on YouTube did not attain the CVS, and were deemed as inappropriate for case preparation, with low educational value. Senior resident video assessments closely aligned with attendings, while junior trainees were more likely to overstate video quality and value. Attending guidance and direction of trainees to high-quality, vetted resources for surgical case preparation is needed. This may also suggest a need for surgical societies with platforms for video sharing to prioritize the creation and dissemination of high-quality videos on easily accessible public platforms.

The Effect of a Microlearning Module on Knowledge Acquisition in Surgery Clerkship Students.

OBJECTIVE: Microlearning has been found to be beneficial in other areas of healthcare education. The purpose of this study was to investigate the effect of a microlearning module compared to a traditional online learning module in undergraduate medical education. DESIGN: A microlearning module was developed to cover the etiology and management of gallbladder disease. Surgery clerkship students were randomized into 2 groups. One group began with the microlearning module (MLM). The second group began with a 45 minute commercially available module centered on gallbladder disease (WISE-MD™). Halfway through the clerkship, the groups crossed over to the other learning intervention. Student knowledge was assessed with a test at three time points (pre-test, post-test1, post-test2). SETTING AND PARTICIPANTS: Third year surgery clerkship students at George Washington University. RESULTS: There were 56 students in the MLM and 57 in WISE-MDTM groups. In the MLM group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, but significantly decreased from post-test1 to post-test2. In the WISE-MD™ group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, with no significant change from post-test1 to post-test2. After the initial intervention, test scores of post-test1 of the MLM group were significantly higher than the WISE-MD™ group, while there were no significant differences between groups at the pre-test or post-test2 time points. CONCLUSIONS: Students exposed to the microlearning module first performed significantly better on a post intervention test than students that used a commercially available product in our standard curriculum. Therefore, the use of microlearning modules may lead to improved knowledge acquisition in surgery clerkship students.

Patient Risk Factors Associated with Increased Morbidity and Mortality Following Revisional Laparoscopic Bariatric Surgery for Inadequate Weight Loss or Weight Recidivism: an Analysis of the ACS-MBSAQIP Database.

PURPOSE: Revisional bariatric operations are associated with increased morbidity and mortality compared with primary bariatric operations. The purpose of this study was to determine if preoperative patient variables are associated with an increased risk of 30-day morbidity and mortality following revisional laparoscopic bariatric surgery for inadequate weight loss or weight recidivism and to generate expected model probabilities in order to risk stratify individual patients undergoing these operations. MATERIALS AND METHODS: All patients undergoing revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 to 2016 were identified with the American College of Surgeons Metabolic and Bariatric Surgery Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative patient variables with 30-day morbidity and mortality was investigated using multivariable logistic regression analysis. Predictive outcome models were developed for each outcome of interest. RESULTS: A total of 13,551 patients met inclusion criteria; 5310 (39.2%) underwent revisional RYGB. Each of the available preoperative variables was associated with one or more of the 30-day morbidity and mortality outcomes of interest. The strength of the predictive models, as reflected by the area under the curve, ranged from 0.63 for 30-day unplanned hospital readmission to 0.92 for cardiac events. CONCLUSION: Preoperative patient and surgical variables are associated with an increased risk of 30-day morbidity and mortality following laparoscopic revisional bariatric surgery. With these results, we have built a risk calculator that can be used as a resource for prehabilitation and patient counseling prior to revisional bariatric surgery.

Dietary Supplementation With Medium-Chain Triglycerides Reduces Candida Gastrointestinal Colonization in Preterm Infants.

BACKGROUND: Candida is an important cause of infections in premature infants. Gastrointestinal colonization with Candida is a common site of entry for disseminated disease. The objective of this study was to determine whether a dietary supplement of medium-chain triglycerides (MCTs) reduces Candida colonization in preterm infants. METHODS: Preterm infants with Candida colonization (n = 12) receiving enteral feedings of either infant formula (n = 5) or breast milk (n = 7) were randomized to MCT supplementation (n = 8) or no supplementation (n = 4). Daily stool samples were collected to determine fungal burden during a 3-week study period. Infants in the MCT group received supplementation during 1 week of the study period. The primary outcome was fungal burden during the supplementation period as compared with the periods before and after supplementation. RESULTS: Supplementation of MCT led to a marked increase in MCT intake relative to unsupplemented breast milk or formula as measured by capric acid content. In the treatment group, there was a significant reduction in fungal burden during the supplementation period as compared with the period before supplementation (rate ratio, 0.15; P = 0.02), with a significant increase after supplementation was stopped (rate ratio, 61; P < 0.001). Fungal burden in the control group did not show similar changes. CONCLUSIONS: Dietary supplementation with MCT may be an effective method to reduce Candida colonization in preterm infants.