Effect of an opioid-free anesthetic on postoperative opioid consumption after laparoscopic bariatric surgery: a prospective, single-blinded, randomized controlled trial.

INTRODUCTION: Opioid administration has the benefit of providing perioperative analgesia but is also associated with adverse effects. Opioid-free anesthesia (OFA) may reduce postoperative opioid consumption and adverse effects after laparoscopic bariatric surgery. In this randomized controlled study, we hypothesized that an opioid-free anesthetic using lidocaine, ketamine, and dexmedetomidine would result in a clinically significant reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique. METHODS: Subjects presenting for laparoscopic or robotic bariatric surgery were randomized in a 1:1 ratio to receive either standard opioid-inclusive anesthesia (group A: control) or OFA (group B: OFA). The primary outcome was opioid consumption in the first 24 hours postoperatively in oral morphine equivalents (OMEs). Secondary outcomes included postoperative pain scores, patient-reported incidence of opioid-related adverse effects, hospital length of stay, patient satisfaction, and ongoing opioid use at 1 and 3 months after hospital discharge. RESULTS: 181 subjects, 86 from the control group and 95 from the OFA group, completed the study per protocol. Analysis of the primary outcome showed no significant difference in total opioid consumption at 24 hours between the two treatment groups (control: 52 OMEs vs OFA: 55 OMEs, p=0.49). No secondary outcomes showed statistically significant differences between groups. CONCLUSIONS: This study demonstrates that an OFA protocol using dexmedetomidine, ketamine, and lidocaine for laparoscopic or robotic bariatric surgery was not associated with a reduction in 24-hour postoperative opioid consumption when compared with an opioid-inclusive technique using fentanyl.

How Reliable are Single-Question Workplace-Based Assessments in Surgery?

OBJECTIVE: Workplace-based assessments (WBAs) play an important role in the assessment of surgical trainees. Because these assessment tools are utilized by a multitude of faculty, inter-rater reliability is important to consider when interpreting WBA data. Although there is evidence supporting the validity of many of these tools, inter-reliability evidence is lacking. This study aimed to evaluate the inter-rater reliability of multiple operative WBA tools utilized in general surgery residency. DESIGN: General surgery residents and teaching faculty were recorded during 6 general surgery operations. Nine faculty raters each reviewed 6 videos and rated each resident on performance (using the Society for Improving Medical Professional Learning, or SIMPL, Performance Scale as well as the operative performance rating system (OPRS) Scale), entrustment (using the ten Cate Entrustment-Supervision Scale), and autonomy (using the Zwisch Scale). The ratings were reviewed for inter-rater reliability using percent agreement and intraclass correlations. PARTICIPANTS: Nine faculty members viewed the videos and assigned ratings for multiple WBAs. RESULTS: Absolute intraclass correlation coefficients for each scale ranged from 0.33 to 0.47. CONCLUSIONS: All single-item WBA scales had low to moderate inter-rater reliability. While rater training may improve inter-rater reliability for single observations, many observations by many raters are needed to reliably assess trainee performance in the workplace.

Endoscopic Management of Post-Sleeve Gastrectomy Complications.

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy.

Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.

Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population.

Gastrointestinal reflux disease (GERD) is a chronic, highly prevalent condition in the United States. GERD can significantly impact quality of life and lead to complications including aspiration pneumonia, esophageal stricture, Barrett's esophagus (BE) and esophageal cancer. Obesity is a risk factor for GERD, which often improves with weight loss and bariatric surgery. Though the incidence of bariatric surgery, in particular, minimally invasive sleeve gastrectomy, has risen in recent years, emerging data has revealed that the severity or new onset of GERD may follow bariatric surgery. We performed a literature review to provide a detailed analysis of GERD with an emphasis on bariatric surgery as both the cure and the cause for GERD in the morbidly obese population. We also describe the pathophysiological mechanisms, management approach and treatment strategies of GERD following bariatric surgery.

Implementation of a structured robotic colorectal curriculum for general surgery residents.

There is increasing demand for colorectal robotic training for general surgery residents. We implemented a robotic colorectal surgery curriculum expecting that it would increase resident exposure to the robotic platform and would increase the number of graduating general surgery residents obtaining a robotic equivalency certificate. The aim of this study is to describe the components of the curriculum and characterize the immediate impact of the implementation or residents. Our curriculum started in 2019 and consists of didactics, simulation, and clinical performance. Objectives are specified for both junior residents (post-graduate years [PGY]1-2) and senior residents (PGY3-5). The robotic colorectal surgical experience was characterized by comparing robotic to non-robotic operations, differences in robotic operations across post-graduate year, and percentage of graduates achieving an equivalency certificate. Robotic operations are tracked using case log annotation. From 2017 to 2021, 25 residents logged 681 major operations on the colorectal service (PGY1 mean = 7.6 ± 4.6, PGY4 mean = 29.7 ± 14.4, PGY5 mean = 29.8 ± 14.8). Robotic colorectal operations made up 24% of PGY1 (49% laparoscopic, 27% open), 35% of PGY4 (35% laparoscopic, 29% open), and 41% of PGY5 (44% laparoscopic, 15% open) major colorectal operations. Robotic bedside experience is primarily during PGY1 (PGY1 mean 2.0 ± 2.0 bedside operations vs 1.4 ± 1.6 and 0.2 ± 0.4 for PGY4 and 5, respectively). Most PGY4 and 5 robotic experience is on the console (PGY4 mean 9.1 ± 7.7 console operations, PGY5 mean 12.0 ± 4.8 console operations). Rates of robotic certification for graduating chief residents increased from 0% for E-2013 to 100% for E-2018. Our robotic colorectal curriculum for general surgery residents has facilitated earlier and increased robotic exposure for residents and increased robotic certification for our graduates.

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.

Crowd-Sourced and Attending Assessment of General Surgery Resident Operative Performance Using Global Ratings Scales.

OBJECTIVE: We sought to assess the extent to which both crowd and intraoperative attending ratings using objective structured assessment of technical skill (OSATS) or global objective assessment of laparoscopic skills (GOALS) would correlate with the system for improving procedural learning (SIMPL) Zwisch and Performance scales. DESIGN: Comparison of directly observed versus crowd sourced review of operative video. SETTING: Operative video captured at 2 institutions. PARTICIPANTS: Six (6) core general surgery procedures, 3 open and 3 laparoscopic, were selected from the American Board of Surgery's Resident Assessments list. Thirty-two cases performed by General Surgery residents across all training levels at 2 institutions were filmed. Videos were condensed using a standardized protocol to include the critical portion of the procedure.  Condensed videos were then submitted to crowd-sourced assessment of technical skills (C-SATS), an online crowd source-driven assessment service, for assessment using the appropriate resident assessment form (GOALS or OSATS) as well as with the SIMPL Zwisch and Performance scales. Crowd workers watched an educational tutorial on how to use the Zwisch and SIMPL Performance rating scales prior to participating. Attendings scored residents using the same tools immediately after the shared operative experience. Statistical analysis was performed using Pearson's correlation coefficient. RESULTS: Crowd raters evaluated 32 procedures using GOALS/OSATS, Zwisch and Performance (35-50 ratings per video). Attendings also evaluated all 32 procedures using GOALS/OSATS and 26 of the procedures using SIMPL Zwisch and Performance. Pearson correlation coefficients with 95% confidence intervals for crowd ratings were: GOALS and Zwisch -0.40 [-0.73 to 0.10], OSATS and Zwisch 0.11 [-0.41 to 0.57], GOALS and Performance -0.06 [-0.44 to 0.35], and OSATS and Performance 0.22 [-0.46 to 0.20]. Pearson correlation coefficients for attendings were: GOALS and Zwisch (0.77), OSATS and Zwisch (0.65), GOALS and Performance (0.93), and OSATS and Performance (0.59). CONCLUSIONS: Overall, correlations between crowd-sourced ratings using GOALS/OSATS and SIMPL global operative performance ratings tools were weak, yet for attendings, they were strong. Direct attending assessment may be required for evaluation of global performance while crowd sourcing may be more suitable for technical assessment.  Further studies are needed to see if more extensive crowd training would result in improved ability for global performance evaluation.

Concordance Between Expert and Nonexpert Ratings of Condensed Video-Based Trainee Operative Performance Assessment.

OBJECTIVE: We examined the impact of video editing and rater expertise in surgical resident evaluation on operative performance ratings of surgical trainees. DESIGN: Randomized independent review of intraoperative video. SETTING: Operative video was captured at a single, tertiary hospital in Boston, MA. PARTICIPANTS: Six common general surgery procedures were video recorded of 6 attending-trainee dyads. Full-length and condensed versions (n = 12 videos) were then reviewed by 13 independent surgeon raters (5 evaluation experts, 8 nonexperts) using a crossed design. Trainee performance was rated using the Operative Performance Rating Scale, System for Improving and Measuring Procedural Learning (SIMPL) Performance scale, the Zwisch scale, and ten Cate scale. These ratings were then standardized before being compared using Bayesian mixed models with raters and videos treated as random effects. RESULTS: Editing had no effect on the Operative Performance Rating Scale Overall Performance (-0.10, p = 0.30), SIMPL Performance (0.13, p = 0.71), Zwisch (-0.12, p = 0.27), and ten Cate scale (-0.13, p = 0.29). Additionally, rater expertise (evaluation expert vs. nonexpert) had no effect on the same scales (-0.16 (p = 0.32), 0.18 (p = 0.74), 0.25 (p = 0.81), and 0.25 (p = 0.17). CONCLUSIONS: There is little difference in operative performance assessment scores when raters use condensed videos or when raters who are not experts in surgical resident evaluation are used. Future validation studies of operative performance assessment scales may be facilitated by using nonexpert surgeon raters viewing videos condensed using a standardized protocol.

Patients support transfer of care for unexpected findings in laparoscopic cholecystectomy.

INTRODUCTION: Surgeons often assume patients may be dissatisfied if their operations were stopped due to suspicious intraoperative findings requiring transfer of care. We sought to assess patient opinions regarding transfer of care for unexpected intraoperative findings during laparoscopic cholecystectomy with and without bile duct injury (BDI). METHODS AND PROCEDURES: The investigators developed two clinical scenarios comparing transfer of care for unexpected intraoperative findings during elective laparoscopic cholecystectomy: without BDI and with BDI requiring open repair. A multi-institutional structured telephone interview process was conducted with patients ≥ 18 years of age who had an outpatient, uncomplicated laparoscopic cholecystectomy within the last year. The first scenario presented a case of suspicious findings prompting the surgeon to stop and transfer for specialized care; whereas the second case was a BDI requiring transfer of care. Textual and thematic analysis as well as descriptive statistics was used for analysis, with significance set at p < 0.05. RESULTS: Forty-five patients completed the survey. Satisfaction with transfer of care for unexpected intraoperative findings without BDI was 69%, and over 95% of respondents were satisfied their surgeon stopped the procedure to initiate transfer due to safety concerns; 64% of patients would return to that surgeon for postoperative care; and 78% would see that surgeon again. In the scenario with BDI requiring open repair, 86% were satisfied with their surgeon's decision to stop the operation; 91% of patients were satisfied with transfer of care; and 32% would see their first surgeon again. Themes of prioritizing safety and transparency were frequently cited. CONCLUSIONS: Patients prioritize safety and are satisfied with halting a procedure to facilitate transfer of care for suspicious intraoperative findings during routine laparoscopic cholecystectomy.

Improving attainment of the critical view of safety during laparoscopic cholecystectomy.

INTRODUCTION: We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum. METHODS: All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum. RESULTS: Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017). CONCLUSION: A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the Critical View of Safety during LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety.

When rural is no longer rural: Demand for subspecialty trained surgeons increases with increasing population of a non-metropolitan area.

BACKGROUND: Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons. METHODS: We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed. RESULTS: We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures. CONCLUSIONS: Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training.

Advanced laparoscopic skills: Understanding the relationship between simulation-based practice and clinical performance.

INTRODUCTION: The advanced laparoscopic skills (ALS) curriculum was created to address the need for improved laparoscopic training for senior surgical trainees. It focuses on the domain of laparoscopic suturing and consists of 6 tasks with established proficiency benchmarks. Tasks are performed using a standard laparoscopic box trainer. This study examines whether practicing on the ALS curriculum could translate to improved clinical suturing. METHODS: Surgery residents from four institutions participated in the study. Performance of the 6 ALS tasks and performance of a porcine gastrojejunostomy (GJ) and Nissen fundoplication were assessed before and after training. Video-recorded performance was de-identified and scored by three experts using both time and a previously published assessment instrument. Paired t-tests examined performance differences before and after the curriculum. Pearson correlations examined the relationship between performance on the porcine and ALS tasks. RESULTS: Twelve residents (PGY1-8) from 4 institutions completed the study. Average practice time on ALS tasks was 6.25 weeks (range 1-14 weeks) and 254 min (range 140-600min). Combined ALS task time decreased from 2748s ±â€¯603s to 1756s ±â€¯281s (p < 0.001). Each of the 6 task times significantly improved (p < 0.05). Total errors decreased from 5.8 ±â€¯3.2 to 3.7 ±â€¯1.9 (p < 0.05). Average GJ times decreased from 1043s ±â€¯698s to 643s ±â€¯183s (p = 0.055). Average Nissen times decreased from 990s ±â€¯531s to 685s ±â€¯265s (p < 0.05). CONCLUSION: Dedicated practice on the six ALS tasks led to decreased suturing time and fewer errors when completing both GJ and Nissen suturing in a porcine model. Further studies will be undertaken to determine the optimal application of the ALS task set in advanced laparoscopic training.

Rural surgeons' perspectives on necessity of post-residency training are stable across generations.

BACKGROUND: Training future rural surgeons is critical, but training needs are unclear. We hypothesize perspectives on necessity of subspecialty training differ among rural surgeons by generational cohort. METHODS: An online survey was sent to ACS Rural Surgery Listserv subscribers. Closed-ended elements were analyzed using bivariate testing and logistic regression. Purposively-sampled respondents participated in qualitative interviews analyzed using principles of grounded theory. RESULTS: Generation was irrelevant to respondents' hiring preferences, but older surgeons were more likely to state subspecialty training was ideal for any future rural surgeon. Controlling for practice context, younger rural surgeons were less likely to favor hiring a subspecialty-trained surgeon (p = 0.019). Themes emerged from qualitative analysis emphasizing broad training and the importance of practice context. CONCLUSION: Across generations, rural surgeons' perceptions about the training needed for rural surgery are largely stable. Considering practice context will allow educators to better prepare future rural surgeons for rural practices.

Training for a Career in Rural and Nonmetropolitan Surgery-A Practical Needs Assessment.

OBJECTIVE: The current shortage of surgeons in rural and smaller communities is predicted to get worse. In this study, we solicited practicing rural surgeons' opinions about the skill set needed in a rural practice in order to inform curriculum development for general surgery residents who intend to embark on rural careers. DESIGN: We developed an online survey consisting of demographic questions and closed- and open-ended questions regarding current practice environment and scope of practice. Priorities for training were identified using descriptive analyses of both the quantitative and qualitative data, including frequency of responses regarding specific skills training. PARTICIPANTS: We surveyed currently practicing surgeons who subscribe to the American College of Surgeons Rural Surgery listserv. RESULTS: 237 surgeons from 49 states and 1 Canadian territory responded; 60% of participants had been in practice for 20 or more years, and 70% did not pursue subspecialty training. Valuable skills identified for rural surgeons were: endoscopy, advanced laparoscopy, and basic non-general surgery subspecialty procedures. Regardless of years of practice or setting, respondents felt that rural experience during residency was highly valuable (82%) and overwhelmingly supported training future rural surgeons at residency programs with broad general surgery experiences and high case volumes with no or few fellows. CONCLUSIONS: Practicing rural surgeons identify endoscopy, basic non-general surgery subspecialty procedures, and advanced laparoscopy as key components of their current practice. These skills may not be strongly emphasized in traditional general surgery training programs. Surgical educators should focus on developing curricula that emphasize these areas in order to prepare residents for careers in rural surgery.

Identifying Priorities for Faculty Development in General Surgery Using the Delphi Consensus Method.

OBJECTIVE: Faculty teaching skills are critical for effective surgical education, however, which skills are most important to be taught in a faculty development program have not been well defined. The objective of this study was to identify priorities for faculty development as perceived by surgical educators. DESIGN: We used a modified Delphi methodology to assess faculty perceptions of the value of faculty development activities, best learning modalities, as well as barriers and priorities for faculty development. An expert panel developed the initial survey and distributed it to the membership of the Association of Program Directors in Surgery. Responses were reviewed by the expert panel and condensed to 3 key questions that were redistributed to the survey participants for final ranking. PARTICIPANTS: Seven experts reviewed responses to 8 questions by 110 participants. 35 participants determined the final ranking responses to 3 key questions. RESULTS: The top three priorities for faculty development were: 1) Resident assessment/evaluation and feedback 2) Coaching for faculty teaching, and 3) Improving intraoperative teaching skills. The top 3 learning modalities were: 1) Coaching 2) Interactive small group sessions, and 3) Video-based education. Barriers to implementing faculty development included time limitations, clinical workload, faculty interest, and financial support. CONCLUSIONS: Faculty development programs should focus on resident assessment methods, intraoperative and general faculty teaching skills using a combination of coaching, small group didactic and video-based education. Concerted efforts to recognize and financially reward the value of teaching and faculty development is required to support these endeavors and improve the learning environment for both residents and faculty.

Synoptic operative reporting for laparoscopic cholecystectomy and pancreaticoduodenectomy: A multi institutional pilot study evaluating completeness and surgeon perceptions.

BACKGROUND: Synoptic operative reports (SOR) are more accurate than dictated operative reports (DOR) in a few single institution experiences. We sought to examine the completeness of SOR for laparoscopic cholecystectomy (LC) and pancreaticoduodenectomy (PD) in a multi institutional pilot study. METHODS: Six institutions participated in SOR submission via a web-based survey. One institution collected DOR and case matched historical dictated operative reports (HOR) for subset analysis. A checklist evaluated completeness of all reports. A post-survey assessed participant opinions. RESULTS: 40 PD SORs were 98.5% complete and 35 LC SORs were 99.7% complete. Single institution subset analysis respective percent complete were: 11 PD SORs 99%, DORs 70% and HORs 74% and 14 LC SORs 99.7%, DORs 76%, and HORs 75%. Post-survey results yielded 10 PD and 24 LC responses. An overwhelming majority agreed that SOR were easy to use and would prefer to use SOR compared to DOR. CONCLUSION: SOR are more complete than both study associated DOR and HOR. The majority of surgeons indicated their preference for SOR and their willingness to use them.

Modified Appleby procedure for locally advanced pancreatic cancer.

Locally advanced pancreas cancer (LAPC) involving the celiac axis is typically considered unresectable and carries a poor prognosis. We present a case of a patient with LAPC who underwent a modified Appleby procedure for tumor clearance following neoadjuvant therapy. Technical aspects include diagnostic laparoscopy to exclude occult metastatic disease followed by complete mobilization of the pancreas and spleen, preservation of the left gastric artery, and resection and reconstruction of the common hepatic artery. With proper patient selection and preparation, LAPC with celiac axis involvement can be safely resected with favorable outcomes.

The Program Evaluation Committee in Action: Lessons Learned From a General Surgery Residency's Experience.

OBJECTIVE: To evaluate the success of the annual program evaluation process and describe the experience of a Program Evaluation Committee for a General Surgery residency program. DESIGN: We conducted a retrospective review of the Program Evaluation Committee's meeting minutes, data inputs, and outcomes from 2014 to 2016. We identified top priorities by year, characterized supporting data, summarized the improvement plans and outcome measures, and evaluated whether the outcomes were achieved at 1 year. SETTING: Virginia Mason Medical Center General Surgery Residency Program. PARTICIPANTS: Program Evaluation Committee members including the Program Director, 2 Associate Program Directors, 2 Senior Faculty Members, and 1 Resident. RESULTS: All outcome measures were achieved or still in progress at 1 year. This included purchasing a GI mentor to improve endoscopic simulation training, establishing an outpatient surgery rotation to increase the volume of cases, and implementing a didactic course on adult learning principles for faculty development to improve intraoperative teaching. Primary reasons for slow progress were lack of follow-through by delegates or communication breakdown. CONCLUSIONS: The annual program evaluation process has been successful in identifying top priorities, developing action plans, and achieving outcome measures using our systematic evaluation process.