Managing Refractory Postoperative Fistulas as Chronic Wounds Using Video-Assisted Hydrodebridement (VAHD).

Postoperative fistula formation remains a serious complication following abdominal surgical procedures. Refractory fistulas requiring further surgical intervention delay adjuvant chemotherapy and functional recovery. Here, we present six cases of refractory fistulas and describe a new management technique, which we call video-assisted hydrodebridement. We postulate that refractory fistulas are a type of chronic wound, for which hydrodebridement may be used to hasten wound healing. In all cases, patients had undergone a prolonged period of conservative management and surgical intervention was not considered appropriate. Here, we describe the steps of the procedure in detail. We achieved timely closure of the refractory fistula in five of six cases. The median duration of attempted conservative management was 122 days (63-346 days) and median time to fistula closure after the procedure was 35 days (22-64 days) in the five successful cases. The findings during each procedure are discussed. We suspect that this procedure applies the same benefits to refractory fistulas that hydrodebridement provides to chronic wounds. The combination of endoscopic exploration and hydrodebridement can elucidate barriers to fistula resolution while creating a clean base for wound healing. This technique may be a useful tool to reduce the morbidity of refractory fistula management.

Perspectives of pregnancy and motherhood among general surgery residents: A qualitative analysis.

INTRODUCTION: Prior work shows pregnancy during surgical residency may negatively impact career satisfaction and increase risk of attrition. We sought to gain deeper insight into the experience of childbearing trainees. METHODS: An electronic survey with three open-ended questions was sent to surgeons who had ≥1 pregnancy during a US general surgery training program. Transcripts were analyzed using directed content analysis and the constant comparative approach. RESULTS: Six themes characterized the pregnancy experience of 219 surgeons in residency. RESPONDENTS: 1)desired work modifications during the late stages of pregnancy due to health concerns; 2)regarded maternity leave as too short; 3)perceived stigma related to pregnancy; 4)expressed need for greater lactation and childcare support; 5)desired mentorship on work-family integration; 6)placed value on supportive colleagues and faculty. CONCLUSION: Pregnancy is challenging during surgical residency. These findings may inform policy changes to improve retention and recruitment of women trainees who wish to begin families during residency.

Pregnancy and Motherhood During Surgical Training.

Importance: Although family priorities influence specialty selection and resident attrition, few studies describe resident perspectives on pregnancy during surgical training. Objective: To directly assess the resident experience of childbearing during training. Design, Setting, and Participants: A self-administered 74-question survey was electronically distributed in January 2017 to members of the Association of Women Surgeons, to members of the Association of Program Directors in Surgery listserv, and through targeted social media platforms. Surgeons who had 1 or more pregnancies during an Accreditation Council for Graduate Medical Education-accredited US general surgery residency program and completed training in 2007 or later were included. Important themes were identified using focus groups of surgeons who had undergone pregnancy during training in the past 7 years. Additional topics were identified through MEDLINE searches performed from January 2000 to July 2016 combining the keywords pregnancy, resident, attrition, and parenting in any specialty. Main Outcomes and Measures: Descriptive data on perceptions of work schedule during pregnancy, maternity leave policies, lactation and childcare support, and career satisfaction after childbirth. Results: This study included 347 female surgeons (mean [SD] age, 30.5 [2.7] years) with 452 pregnancies. A total of 297 women (85.6%) worked an unmodified schedule until birth, and 220 (63.6%) were concerned that their work schedule adversely affected their health or the health of their unborn child. Residency program maternity leave policies were reported by 121 participants (34.9%). A total of 251 women (78.4%) received maternity leave of 6 weeks or less, and 250 (72.0%) perceived the duration of leave to be inadequate. The American Board of Surgery leave policy was cited as a major barrier to the desired length of leave by 268 of 326 respondents (82.2%). Breastfeeding was important to 329 (95.6%), but 200 (58.1%) stopped earlier than they wished because of poor access to lactation facilities and challenges leaving the operating room to express milk. Sixty-four women (18.4%) had institutional support for childcare, and 231 (66.8%) reported a desire for greater mentorship on integrating a surgical career with motherhood and pregnancy. A total of 135 (39.0%) strongly considered leaving surgical residency, and 102 (29.5%) would discourage female medical students from a surgical career, specifically because of the difficulties of balancing pregnancy and motherhood with training. Conclusions and Relevance: The challenges of having children during surgical residency may have significant workforce implications. A deeper understanding is critical to prevent attrition and to continue recruiting talented students. This survey characterizes these issues to help design interventions to support childbearing residents.

A Pilot Study to Evaluate Compliance with Guidelines for Preprocedural Reconsideration of Code Status Limitations.

BACKGROUND: Periprocedural providers are encountering more patients with code status limitations (CSLs) regarding their preferences for resuscitation and life-sustaining treatment who choose to undergo palliative procedures. Surgical and anesthesia guidelines for preprocedural reconsideration of CSLs have been available for several years, but it is not known whether they are being followed in practice. OBJECTIVE: We assessed compliance with existing guidelines for patients undergoing venting gastrostomy tube (VGT) for malignant bowel obstruction (MBO), serving as an example of a palliative procedure received by patients near the end of life. DESIGN: Code status was determined at admission and throughout the hospitalization by chart review. Documentation of code status discussions (CSDs) was identified from provider notes and compared with existing guidelines. SETTING/SUBJECTS: An institutional database retrospectively identified patients who underwent VGT placement for MBO at two academic hospitals (2014-2015). MEASUREMENTS: We identified 53 patients who underwent VGT placement for MBO. Interventional radiologists performed 88% of these procedures. Other periprocedural providers involved in these cases included surgeons, gastroenterologists, anesthesiologists, and sedation nurses. RESULTS: CSLs were documented before the procedure in only 43% of cases, and a documented CSD with a periprocedural provider was identified in only 22% of CSL cases. Of all VGT placements performed in patients with CSLs before the procedure, only 13% were compliant with the guidelines of preprocedural reconsideration of CSLs. CONCLUSIONS: Increased compliance with guidelines published by the American Society of Anesthesiologists, the American College of Surgeons, and the Association of Perioperative Registered Nurses is necessary to ensure goal-concordant care of patients with CSLs who undergo a procedure. Efforts should be made to incorporate these guidelines into the training of all periprocedural providers.

Correlation of BK Virus Neutralizing Serostatus With the Incidence of BK Viremia in Kidney Transplant Recipients.

BACKGROUND: BK virus (BKV)-associated nephropathy is the second leading cause of graft loss in kidney transplant recipients. Due to the high prevalence of persistent infection with BKV in the general population, it is possible that either the transplant recipient or donor may act as the source of virus resulting in viruria and viremia. Although several studies suggest a correlation between donor-recipient serostatus and the development of BK viremia, specific risk factors for BKV-related complications in the transplant setting remain to be established. METHODS: We retrospectively determined the pretransplant BKV neutralizing serostatus of 116 donors (D)-recipient (R) pairs using infectious BKV neutralization assays with representatives from the 4 major viral serotypes. The neutralizing serostatus of donors and recipients was then correlated with the incidence of BK viremia during the first year posttransplantation. RESULTS: There were no significant differences in baseline demographics or transplant data among the 4 neutralizing serostatus groups, with the exception of calculated panel-reactive antibody which was lowest in the D+/R- group. Recipients of kidneys from donors with significant serum neutralizing activity (D+) had elevated risk for BK viremia, regardless of recipient serostatus (D+ versus D-: odd ratio, 5.0; 95% confidence interval, 1.9-12.7]; P = 0.0008). Furthermore, donor-recipient pairs with D+/R- neutralizing serostatus had the greatest risk for BK viremia (odds ratio, 4.9; 95% confidence interval, 1.7-14.6; P = 0.004). CONCLUSIONS: Donor neutralizing serostatus correlates significantly with incidence of posttransplant BK viremia. Determination of donor-recipient neutralizing serostatus may be useful in assessing the risk of BKV infection in kidney transplant recipients.