Faculty and Resident Perspectives on the Implementation of Entrustable Professional Activities in General Surgery Residency.

OBJECTIVE: This study aimed to identify what best practices facilitate implementation of Entrustable Professional Activities (EPAs) into surgical training programs. DESIGN: This is a mixed methods study utilizing both survey data as well as semi-structured interviews of faculty and residents involved in the American Board of Surgery (ABS) EPA pilot study. SETTING: From 2018 to 2020, the ABS conducted a pilot that introduced five EPAs across 28 general surgery training programs. PARTICIPANTS: All faculty members and residents at the 28 pilot programs were invited to participate in the study. RESULTS: About 117 faculty members and 79 residents responded to the survey. The majority of faculty (81%) and residents (66%) felt that EPAs were useful and were a valuable addition to training. While neither group felt that EPAs were overly time consuming to complete, residents did report difficulty incorporating them into their daily workflow (44%). Semi-structured interviews found that programs that focused on faculty and resident -development and utilized frequent reminders about the importance and necessity of EPAs tended to perform better. CONCLUSIONS: EPA implementation is feasible in general surgery training programs but requires significant effort and engagement from all levels of program personnel. As EPAs are implemented by the ABS nationally a focus on resident and faculty development will be critical to success.

Opportunities to Increase Workplace Feedback: A Multi-institutional Examination.

OBJECTIVE: While feedback is an essential component of resident education, there are few large-scale studies examining when and under what conditions formative feedback is provided. Workplace-based assessment systems offer an opportunity to identify factors influencing when faculty provides feedback to trainees. Influential factors affecting feedback may provide targets for increasing and improving feedback in resident education. DESIGN: Data on whether dictated feedback was provided were obtained from the Society for Improving Medical Professional Learning (SIMPL) mobile application. We used generalized linear mixed effects models to identify the degree to which faculty members, procedures, surgical case characteristics, and trainee performance were associated with whether narrative feedback was provided using SIMPL. SETTING: This study was conducted using data from members of the SIMPL collaborative. PARTICIPANTS: 67,434 evaluations from 70 general surgery programs were included from 2015 to 2021. Of these, 25,355 evaluations included dictated feedback. RESULTS: Approximately 61% of the variation in whether dictated feedback was provided was attributable to the individual faculty member. Compared to residents who achieved autonomy ratings of "Active Help," residents who achieved ratings of "Supervision Only" (odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.72, 0.88) had a lower likelihood of receiving dictated feedback. Residents who achieved ratings of "Intermediate" (OR = 0.81, CI = 0.74, 0.89), "Practice-Ready" (OR = 0.50, CI = 0.45, 0.57), or "Exceptional (OR = 0.64, CI = 0.54, 0.76) showed a lower likelihood of receiving dictated feedback compared to those rated as "Inexperienced." Cases rated as "High" in terms of complexity were associated with an increased likelihood of having dictation (OR = 1.35, CI = 1.26, 1.44). CONCLUSIONS: The largest contributing factor for whether dictated feedback is included in a SIMPL evaluation are factors specific to the attending surgeon. Resident performance, resident autonomy, and case complexity had only modest associations with feedback decisions. Efforts to improve the amount of formative feedback for trainees should be directed towards reducing the variation in which attending surgeons elect to provide feedback.

Understanding General Surgery Applicant Expectations and Perceptions in the Virtual Interview Process.

OBJECTIVE: The COVID-19 pandemic has played a lasting role on residency recruitment through the virtual interview process. The objective of this study was to 1) examine general surgery applicants' priorities and perceptions following pre-interview virtual open houses and 2) to assess applicant expectations and efficacy of the virtual interview day process. DESIGN/SETTING/PARTICIPANTS: This study utilized two voluntary and anonymous cross-sectional surveys administered via email to evaluate the virtual interview process of a general surgery residency program. The first was administered to registrants following completion of three open houses of various topics. The second was administered following each interview day. The post-open house survey had 78 respondents, two excluded for no open house attendance. The post-interview survey was completed by 44 applicants (62.9% response rate). RESULTS: Majority of respondents reported that attending virtual open houses made them want to apply to (90.9%) and improved their perception of the program (94.7%). Applicants who felt a sense of obligation to attend open houses (68.4%) were significantly more likely to feel that they contributed to the stress and time commitment of applications (81.8% vs 18.2%, p=0.028). Interview expectations were identified in recurrent themes: 1. Clear organization with breaks, 2. Interactive resident sessions, 3. Meetings with program leadership, 4. Additional information unavailable on other resources. The pre-interview social and interview day improved 90.2% of the applicants' perceptions of the program. The interview significantly improved applicants' ability to assess nearly all aspects of the program, notably resident camaraderie and culture (30.8% vs 97.4%, p=0.01) and strengths and weaknesses (30.8% vs 92.3%, p=0.04). CONCLUSIONS: While virtual open houses can improve applicants' perceptions and desire to apply to a program, the associated stress and obligation should be considered. Virtual interviews should provide information unavailable using other resources and provide avenues for conveying the resident culture and camaraderie.

Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative.

BACKGROUND: Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS. METHODS: Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests. RESULTS: Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009). CONCLUSION: Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals. LEVEL OF EVIDENCE: Care management, Level IV.

Outcomes of 100 Patients More Than 4 Years After POEM for Achalasia.

OBJECTIVE: We aim to describe the long-term follow-up data from our institution's POEM experience. SUMMARY BACKGROUND DATA: Per-oral endoscopic myotomy (POEM) is a well-established endoscopic therapy for achalasia with excellent short-term efficacy, but long-term outcomes data are limited. METHODS: Patients older than 4 years removed from POEM for treatment of achalasia were studied. Clinical success was defined as an Eckardt Symptom (ES) score ≤3 and freedom from reintervention for achalasia. Patients underwent esophagogastroduodenoscopy (EGD), high-resolution manometry, impedance planimetry, and timed barium esophagram (TBE) preoperatively and at least 4 years postoperatively. Objective gastroesophageal reflux disease (GERD) was defined LA Grade B or worse esophagitis on EGD. RESULTS: One hundred and nineteen consecutive patients were included. Five patients died or had catastrophic events unrelated to achalasia or POEM. One hundred of the remaining patients (88%, 100/114) had long-term data available. Clinical follow-up for all patients was greater than 4 years postoperatively and the mean was 55 months. Mean current ES was significantly improved from preop (n = 100, 1 ±â€Š1 vs 7 ±â€Š2, P < 0.001). Overall clinical success was 88% and 92%. Five patients had a current ES >3 and 4 patients required procedural reintervention on the lower esophageal sphincter. Reinterventions were successful in 75% of patients (3/4), with current ES ≤3. The rate of objective GERD was 33% (15/45). Esophageal physiology was improved with a decrease in median integrated relaxation pressure (11 ±â€Š4 vs 33 ±â€Š15 mm Hg, P < 0.001), a decrease in median TBE column height (3 ±â€Š3 vs 13 ±â€Š8 cm, P < 0.001), and an increase in median distensibility index (5.1 ±â€Š2 vs 1.1 ±â€Š1 mm2/mm Hg, P < 0.001). CONCLUSIONS: POEM provides durable symptom relief and improvement in physiologic esophagogastric junction relaxation parameters over 4.5 years postoperatively. Reinterventions are rare and effective.

Comparison of preoperative, intraoperative, and follow-up functional luminal imaging probe measurements in patients undergoing myotomy for achalasia.

BACKGROUND AND AIMS: The functional luminal imaging probe (FLIP) is a novel catheter-based device that measures esophagogastric junction (EGJ) distensibility index (DI) in real time. Previous studies have demonstrated DI to be a predictor of post-treatment clinical outcomes in patients with achalasia. We sought to evaluate EGJ DI in patients with achalasia before, during, and after peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) and to assess the correlation of DI with postoperative outcomes. METHODS: DI (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured at 4 time points in patients undergoing surgical myotomy for achalasia: (1) during outpatient preoperative endoscopy (preoperative DI), (2) at the start of each operation after the induction of anesthesia (induction DI), (3) at the conclusion of each operation (postmyotomy DI), and (4) at routine follow-up endoscopy 12 months postoperatively (follow-up DI). Routine Eckardt symptom score, endoscopy, timed barium esophagram, and pH study were obtained 12 months postoperatively. RESULTS: Forty-six patients (35 POEM, 11 LHM) underwent FLIP measurements at all 4 time points. Preoperative and induction mean DI were similar for both groups (POEM, 1 vs .9 mm2/mm Hg; LHM, 1.7 vs 1.5 mm2/mm Hg). POEM resulted in a significant increase in DI (induction .9 vs postmyotomy 7 mm2/mm Hg, P < .001). There was a subsequent decrease in DI in the follow-up period (postmyotomy 7 vs follow-up 4.8 mm2/mm Hg, P < .01), but DI at follow-up was still significantly improved from preoperative values (P < .001). For LHM patients, DI also increased as a result of surgery (induction 1.5 vs postmyotomy 5.9 mm2/mm Hg, P < .001); however, the increase was smaller than in POEM patients (DI increase 4.4 vs 6.2 mm2/mm Hg, P < .05). After LHM, DI also decreased in the follow-up period, but this change was not statistically significant (5.9 vs 4.4 mm2/mm Hg, P = .29). LHM patients with erosive esophagitis on follow-up endoscopy had a significantly higher postmyotomy DI compared with those without esophagitis (9.3 vs 4.8 mm2/mm Hg, P < .05). CONCLUSIONS: EGJ DI improved dramatically as a result of both POEM and LHM, with POEM resulting in a larger increase. Mean DI decreased at intermediate follow-up but remained well above previously established thresholds for symptom recurrence. DI at the conclusion of LHM was predictive of erosive esophagitis in the postoperative period, which supports the potential use of FLIP for calibration of partial fundoplication construction during LHM.

Entrustable Professional Activity-Based Summative Performance Assessment in the Surgery Clerkship.

OBJECTIVE: The objectives of this study were to 1) assess the performance Entrustable Professional Activities (EPAs) when integrated into the summative assessment of third-year medical students on the surgery clerkship and 2) to compare EPAs to traditional clinical performance assessment tools. DESIGN: EPA assessments were collected prospectively from a minimum of 4 evaluators at the completion of each surgical clerkship rotation from November 2019 to June 2019. Overall EPA-based clinical performance scores were calculated as the sum of the mean EPA score from each evaluator. A rating of overall clinical performance called the clinical performance appraisal (CPA) was also collected. EPA ratings were compared to the CPA score, National Board of Medical Examiners exam score, objective structured clinical exam scores, and final clerkship grade. SETTING: Northwestern Memorial Hospital, a tertiary care teaching institution in Chicago, IL. RESULTS: Overall, 446 evaluations (111 students) were included in the analysis. The aggregate EPA scores ranged from 11.6-24.0 (mean 19.9 ± 2.0), and the CPA scores ranged from 4.4-9.0 (mean 7.6 ± 0.7). The variance among learners in EPA scores was significantly higher than CPA scores (p < 0.001). The aggregate EPA scores correlated well with CPA scores (Spearman's rho 0.803) but had lesser, positive correlations with the objective structured clinical exam (rho 0.153) and National Board of Medical Examiners (rho 0.265) scores. When all EPA scores were included in ordinal logistic regression, only EPA 6, oral presentation of patients, was independently associated with students' final grades (OR: 10.05, 95%CI 1.41-71.80; p = 0.02). CONCLUSION: Integration of EPAs for use in clinical performance assessment of medical students is feasible within a surgery clerkship. Compared to a global clinical performance assessment, EPA-based assessment provided better discrimination of clinical performance among learners. Use of EPAs may better identify advanced learners and those that need additional time.

Addressing the gap in laparoscopic common bile duct exploration training for rural surgeons: imparting procedural ability is not enough.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is an underutilized therapy for choledocholithiasis. The driving factors of this practice gap are poorly defined. We sought to evaluate the attitudes and practice patterns of surgeons who underwent training courses using an LCBDE simulator. METHODS: Surgeons completed a half-day simulator-based LCBDE curriculum at national courses, including the American College of Surgeons Advanced Skills Training for Rural Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons annual meeting. Attitudes were assessed with Likert surveys immediately before and after curriculum completion. Follow-up surveys were distributed electronically. RESULTS: 159 surgeons completed training during six courses. Surgeon attitudes regarding the overall superiority of LCBDE vs. ERCP shifted towards favoring LCBDE after course participation (4.0 vs 3.3; Likert scale 1-5, p < 0.001). 44% of surgeons completed follow-up surveys at a mean of 3 years post-course. Surgeons remained confident in their ability to perform LCBDE, with only 14% rating their skill as a significant barrier to practice, as compared with 43% prior to course participation (p < 0.01). However, only 28% of surgeons saw an increase in LCBDE volume. Deficiencies in operating room (OR) staff knowledge and instrument availability were the most significant barriers to post-course practice implementation and were inversely correlated with LCBDE case volume (ρ = - 0.44 and - 0.47, both p < 0.01). Surgeons for whom OR staff knowledge of LCBDE was not a significant barrier performed nearly 4 times more LCBDE than those who rated staff knowledge as a moderate, strong, or complete barrier. CONCLUSIONS: Surgeons trained at an LCBDE course retained long-term confidence in their procedural ability. Practice implementation was hindered by deficiencies in OR staff knowledge and instrument availability. Surgeons with knowledgeable operating room staff performed significantly more LCBDEs than those with less capable assistance. These barriers should be addressed in future curricula to improve procedural adoption.

Complications and Readmissions Associated with First Assistant Training Level Following Elective Bariatric Surgery.

BACKGROUND: Little is known regarding the variation in training level and potential clinical impact of the first assistant in bariatric surgery. We describe the postoperative 30-day complications and readmissions following elective bariatric procedures by training level of the first assistant. METHODS: The ACS-MBSAQIP database was queried to identify patients who underwent elective sleeve gastrectomy, Roux-En-Y gastric bypass, duodenal switch, band placement, and revision from 2015 to 2016. Patients were divided into cohorts based on training level of the first assistant (attending, fellow, resident, physician assistant/nurse practitioner, none). Outcomes included 30-day death or serious morbidity (DSM) and readmission. Multivariable logistic regression models, adjusting for patient and procedure characteristics, were estimated to examine differences in outcomes by first assistant training level. RESULTS: Of 410,535 procedures performed between 2015 and 2016, the training level of the first assistant included 21.3% attending, 8.7% fellow, 16.5% resident, 37.6% PA/NP, and 15.9% none. Operative time was significantly longer in the fellow and resident first assistant cohorts when compared with all other cohorts. Overall rates of 30-day DSM were low, ranging from 3.2 to 3.8%, while 30-day readmission rates ranged from 5.1 to 5.9%. Following adjustment for patient characteristics and type of procedure, first assistant training level had no significant impact on DSM or readmission. CONCLUSIONS: Variation in training level of the first assist during bariatric surgery had no influence on DSM or readmissions. This provides reassurance that the inclusion of a wide range of first assistants in bariatric procedures does not negatively impact patient outcomes.

Intraoperative use of FLIP is associated with clinical success following POEM for achalasia.

BACKGROUND: Esophagogastric junction distensibility index (DI), measured using the functional luminal imaging probe (FLIP), correlates with symptomatic outcomes after interventions for achalasia. The objective of this study was to determine if the intraoperative measurement of DI using FLIP was associated with improved clinical outcomes following per-oral endoscopic myotomy (POEM) for achalasia when compared with procedures in which FLIP was not utilized. METHODS: Patients undergoing POEM from 2012 to 2017 at a single institution by a single surgeon were studied. Use of FLIP during this time period was based on catheter and technician availability, resulting in two patient cohorts. In patients in whom FLIP was used, operative video recordings were reviewed to determine when DI measurements led to the performance of additional myotomy. Postoperative Eckardt symptom scores (ES) at 12 months and postoperative physiologic studies were compared between patients with and without intraoperative FLIP. Associations were assessed using Mann-Whitney U and Chi-square tests. RESULTS: 143 patients were included in the analysis (61 with intraoperative FLIP and 82 without FLIP). Video recordings were available for 85% of the FLIP cohort. Review of these operative recordings revealed that 65% of patients who underwent FLIP had additional myotomy performed following the initial postmyotomy FLIP measurement. At 12 months after POEM, the FLIP cohort had significantly more clinical successes (defined as ES ≤ 3) than patients in whom FLIP was not used (93% vs. 81%, p < 0.05). CONCLUSIONS: Use of intraoperative FLIP during POEM resulted in the surgeon performing additional myotomy in over half of cases and was associated with improved clinical outcomes. This study demonstrates the potential for a FLIP-tailored myotomy to improve outcomes in patients undergoing surgical myotomy for achalasia.

Intraoperative FLIP distensibility during POEM varies according to achalasia subtype.

BACKGROUND: The functional luminal imaging probe (FLIP) can be used to measure the esophagogastric junction distensibility index (DI) during myotomy for achalasia and increased DI has been shown to predict superior clinical outcomes. The objective of this study was to determine if the intraoperative DI and the changes produced by per oral endoscopic myotomy (POEM) differed between achalasia subtypes. METHODS: FLIP measurements were performed during POEM for achalasia at a single institution. DI (defined as the minimum cross-sectional area (CSA) at the EGJ divided by distensive pressure) was measured at three time points: after induction of anesthesia, after submucosal tunneling, and after myotomy. Measurements were reported at the 40 mL fill volume for the 8 cm FLIP (EF-325) and at the 60 mL fill volume for the 16 cm FLIP (EF-322). Measurements were compared using chi-square and Kruskal-Wallis tests. RESULTS: 142 patients had intraoperative FLIP performed during POEM for achalasia between 2012 and 2019 (30 type I, 68 type II, 27 type III, and 17 variant). Patients with type I achalasia had a significantly higher induction DI (median 1.7 mm2/mmHg) than type II (0.8 mm2/mmHg), type III (0.9 mm2/mmHg), and variants (1.1 mm2/mmHg; p < 0.001). These differences persisted after submucosal tunneling and final DI after myotomy was also significantly higher in type I patients (median 8.0 mm2/mmHg) compared to type II (5.8 mm2/mmHg), type III (3.9 mm2/mmHg), and variants (5.4 mm2/mmHg; p < 0.001). Achalasia subtypes were found to have similar CSA at all time points, whereas pressure differed with type I having the lowest pressure and type III the highest. CONCLUSION: The DI at each operative step during POEM was found to differ significantly between achalasia subtypes. These differences in DI were due to pressure, as CSA was similar between subtypes. Achalasia subtype should be accounted for when using FLIP as an intraoperative calibration tool and in future studies examining the relationship between DI and clinical outcomes.

Achalasia subtypes can be identified with functional luminal imaging probe (FLIP) panometry using a supervised machine learning process.

BACKGROUND: Achalasia subtypes on high-resolution manometry (HRM) prognosticate treatment response and help direct management plan. We aimed to utilize parameters of distension-induced contractility and pressurization on functional luminal imaging probe (FLIP) panometry and machine learning to predict HRM achalasia subtypes. METHODS: One hundred eighty adult patients with treatment-naïve achalasia defined by HRM per Chicago Classification (40 type I, 99 type II, 41 type III achalasia) who underwent FLIP panometry were included: 140 patients were used as the training cohort and 40 patients as the test cohort. FLIP panometry studies performed with 16-cm FLIP assemblies were retrospectively analyzed to assess distensive pressure and distension-induced esophageal contractility. Correlation analysis, single tree, and random forest were adopted to develop classification trees to identify achalasia subtypes. KEY RESULTS: Intra-balloon pressure at 60 mL fill volume, and proportions of patients with absent contractile response, repetitive retrograde contractile pattern, occluding contractions, sustained occluding contractions (SOC), contraction-associated pressure changes >10 mm Hg all differed between HRM achalasia subtypes and were used to build the decision tree-based classification model. The model identified spastic (type III) vs non-spastic (types I and II) achalasia with 90% and 78% accuracy in the train and test cohorts, respectively. Achalasia subtypes I, II, and III were identified with 71% and 55% accuracy in the train and test cohorts, respectively. CONCLUSIONS AND INFERENCES: Using a supervised machine learning process, a preliminary model was developed that distinguished type III achalasia from non-spastic achalasia with FLIP panometry. Further refinement of the measurements and more experience (data) may improve its ability for clinically relevant application.

POEM for Esophageal Achalasia.

Over the past decade, per-oral endoscopic myotomy has been shown to be a durable minimally invasive approach to the treatment of esophageal achalasia. Patients with suspected achalasia should undergo upper endoscopy, timed barium esophagram, and high-resolution manometry to confirm the diagnosis. The procedure includes several key steps including mucosotomy, submucosal tunneling, selective myotomy of the circular muscle layer, and mucosotomy closure. Specialized endoscopic dissection tools are used during the procedure to access the submucosal space. Common procedural challenges include minor bleeding and capnoperitoneum.

Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia.

BACKGROUND: The functional luminal imaging probe (FLIP) can evaluate esophagogastric junction (EGJ) distensibility and esophageal peristalsis in real time. FLIP measurements performed during diagnostic endoscopy can accurately discriminate between healthy controls and patients with achalasia based on EGJ-distensibility and distinct motility patterns termed repetitive antegrade contractions (RACs) and repetitive retrograde contractions (RRCs). We sought to evaluate real-time motility changes in patients undergoing surgical myotomy for achalasia. METHODS: FLIP measurements using a stepwise volumetric distention protocol were performed at three time points during assessment and performance of laparoscopic Heller myotomy and POEM: (1) During preoperative outpatient endoscopy, (2) Intraoperatively following induction of anesthesia, and (3) Intraoperatively after myotomy completion. EGJ-distensibility, contractility, RACs, and RRCs were measured. RESULTS: FLIP measurements were performed in 32 patients. The EGJ-distensibility index was similar between the preoperative and initial operative measurements (1.1 vs 1.4 mm2/mmHg, p = NS). There was a significant increase in distensibility following surgical myotomy (1.4 to 4.7 mm2/mmHg, p < 0.01). Intraoperative contractile patterns varied between achalasia subtypes. Contractility was seen in < 20% of assessments in patients with types I and II achalasia. Type III patients demonstrated contractility in 100% of assessments, with 70% exhibiting RRCs and 60% RACs. There was a reduction in the frequency of RRC presence (70% to 20%), and contractile vigor (80% to 0% of patients with lumen occluding contractions) in type III patients following surgical myotomy. CONCLUSIONS: This first report of real-time intraoperative measurement of esophageal motility using FLIP demonstrates the feasibility of such assessments during surgical myotomy for achalasia. Patients with type I and II achalasia exhibited rare intraoperative contractility, while the presence of motility was the norm in those with type III. Patients with type III achalasia demonstrated an immediate reduction in repetitive contraction motility patterns and contractile vigor following myotomy.

A comprehensive national survey on thoughts of leaving residency, alternative career paths, and reasons for staying in general surgery training.

BACKGROUND: General surgery residencies continue to experience high levels of attrition. METHODS: Survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination. Outcomes were consideration of leaving residency, potential alternative career paths, and reasons for staying in residency. RESULTS: Among 7,409 residents, 930 (12.6%) reported considering leaving residency over the last year. Residents were more likely to consider other general surgery programs (46.2%) if PGY 2/3 (OR: 1.93, 95%CI 1.34-2.77) or reporting frequent duty hour violations (OR: 1.58, 95%CI 1.12-2.24). Consideration of other specialties (47.0%) was more likely if dissatisfied with being a surgeon (OR 2.86, 95%CI 1.92-4.26). Residents were more likely to consider leaving medicine (49.7%) if female (OR: 1.54, 95%CI 1.16-2.06) or dissatisfied with a surgical career (OR: 2.81, 95%CI 1.85-4.27). Common reasons for remaining in residency included a sense of too much invested to leave (65.3%) and career satisfaction (55.5%). CONCLUSION: Profiles of trainees considering leaving residency exist based on factors associated with alternative careers. This may be a target for future interventions to reduce attrition.

Obtaining Meaningful Assessment in Thoracic Surgery Education.

Training in thoracic surgery has evolved immensely over the past decade due to the advent of integrated programs, technological innovations, and regulations on resident duty hours, decreasing the time trainees have to learn. These changes have made assessment of thoracic surgical trainees even more important. Shifts in medical education have increasingly emphasized competency, which has led to novel competency-based assessment tools for clinical and operative assessment. These novel tools take advantage of simulation and modern technology to provide more frequent and comprehensive assessment of the surgical trainee to ensure competence.

The surgical management of achalasia in the morbid obese patient.

INTRODUCTION: Morbid obesity and achalasia may coexist in the same patient. The surgical management of the morbidly obese patient with achalasia is complex, and the most effective treatment still remains controversial. The goal of our report is to provide our evidence-based approach for the surgical management of the patient with achalasia and morbid obesity. RESULTS: Three main surgical approaches have been used for the concomitant treatment of morbid obesity and achalasia: 1) a laparoscopic Heller myotomy and a laparoscopic Roux-en-Y gastric bypass (LRYGB); 2) a laparoscopic Heller myotomy with bilio-pancreatic diversion; and 3) a laparoscopic Heller myotomy with a sleeve gastrectomy. Our approach of choice is the first one discussed, that is the laparoscopic Heller myotomy with a LRYGB, as this approach can provide excellent relief of symptoms and control of reflux while at the same time treating obesity and its comorbidities. CONCLUSIONS: Achalasia and obesity can coexist, albeit infrequently. A laparoscopic Heller myotomy with a LRYGB allows the simultaneous treatment of both diseases. When a morbidly obese patient with achalasia chooses to have a myotomy alone and not a LRYGB, a thorough discussion of the risks and benefits should occur and the autonomy of the patient's decision-making should be respected.

Impact of preoperative smoking status on postoperative complication rates and pulmonary function test results 1-year following pulmonary resection for non-small cell lung cancer.

There is a lack of evidence in the literature regarding the impact of preoperative smoking status on pulmonary function test (PFT) results 1 year after resection for non-small cell lung cancer (NSCLC). Furthermore, there is disagreement in the literature regarding the impact of preoperative smoking cessation on postoperative complication rates. We performed a single-institution retrospective review of all NSCLC patients who underwent resection from April 2000 through April 2006. Timing of smoking cessation was stratified as follows: smoking cessation more than a month before surgery (Distant Smokers), smoking cessation within a month before surgery (Recent Smokers), and failure to achieve smoking cessation before surgery (Current Smokers). During the study period, 213 patients underwent NSCLC resection, 121 of whom (all males; mean age, 67.4 years) completed pre- and postoperative PFTs. After adjusting for potential confounding covariates (age, type of resection, and use of radiation therapy), we noted no significant difference (p>0.40) between groups after resection with regard to either relative (-12.20+/-15.77L [Distant Smokers], -15.38+/-19.38L [Recent Smokers], -9.61+/-15.54L [Current Smokers]) or absolute changes in percent predicted forced expiratory volume in 1s (-0.14+/-0.20L [Distant Smokers], -0.18+/-0.19L [Recent Smokers], -0.12+/-0.20L [Current Smokers]). Because 92 patients did not complete postoperative PFTs, we performed a stratified analysis to assess for selection bias; as compared with those who completed PFTs, baseline PFT results did not significantly differ. We found no significant differences between the 3 groups with regard the overall rate of postoperative complications or the rate of any specific postoperative complication. In conclusion, smoking cessation immediately before NSCLC resection does not significantly impact postoperative pulmonary complication rates or 1-year postoperative PFT results and therefore should not be a reason to delay surgical resection.

Impact of preoperative endoscopic ultrasound on non-small cell lung cancer staging.

AIM: To determine if the addition of preoperative endoscopic ultrasound (EUS) to non-small cell lung cancer staging can reduce the proportion of patients in whom malignant mediastinal lymph nodes (inoperable disease) are discovered at surgery. METHODS: All patients with lung cancer who underwent mediastinoscopy or thoracotomy for cancer diagnosis, staging, or treatment from 1999 to 2005 were identified. Patients who had undergone preoperative EUS were designated as the EUS group. The control group was composed of similar patients who had not undergone preoperative EUS, and were frequency matched to those in the EUS group in a 3:1 ratio by preoperative cancer stage. The proportion of patients in whom malignant mediastinal lymph nodes were diagnosed at surgery was the primary outcome. RESULTS: Forty-four patients (average age, 67.8 years) met criteria for the EUS group, and 132 patients (average age, 67.4 years) were selected as control subjects. Overall, in the EUS group, 3 of 44 patients (6.8%) were found to have malignant mediastinal lymph nodes at surgery, compared with 41 of 132 patients (31.1%) in the control group (p = 0.003). In patients undergoing thoracotomy for cancer resection, 3% in the EUS group, compared with 20% in the control group, were found to have malignant mediastinal lymph nodes at surgery (p = 0.01). There was also a trend toward lower yield of mediastinoscopy done for cancer diagnosis or staging in the EUS group (p = 0.08). CONCLUSIONS: Preoperative EUS in lung cancer patients may reduce unnecessary surgery at which advanced inoperable disease is discovered.