A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Correlation of Supervised Independence and Performance with Procedure Difficulty amongst Surgical Residents Stratified by Post Graduate Year.

PURPOSE: This study investigates the role of procedure difficulty on attending ratings of supervised levels of independence and procedural performance amongst general surgery residents, while accounting for case complexity. METHODS: Attending ratings for residents were obtained from System for Improving and Measuring Procedural Learning (SIMPL) database. Current procedural terminology (CPT) codes were used to match procedures to a corresponding work relative value unit (wRVU) as a surrogate for procedure difficulty. Three categories of wRVU (<13.07, 13.07-22, >22) were identified using recursive partitioning. Procedures were also divided into 'Core' or 'Advanced' as defined by the American Board of Surgery Surgical Council on Resident Education (SCORE). Temporal advancement in resident skill was accounted for through academic quarterly analysis. A generalized estimating equations (GEE) approach was used to form separate multivariable logistic regression models for meaningful autonomy (MA) and satisfactory performance (SP) adjusted for potential clustering by program, subject, and rater. Models were further adjusted for core/advanced procedures, attending rated complexity, and academic quarter. RESULTS: A total of 33,281 ratings were analyzed. Overall, 51.6% were rated as MA and 44.4% as SP. For core procedures, surgical residents rated as MA (53.5%) and SP (45.7%), which was twice as high as those for advance procedures (MA-29.2%, SP-29.0%). MA and SP both decreased with increasing wRVU (Figure 2 &3). Using a wRVU<13.07 as a reference, the adjusted odds ratios of MA and SP were significantly lower with increasing procedure difficulty, 0.44 for wRVU 13.07-22.0 and 0.24 for wRVU >22.00 (Table 3). Post graduate year (PGY) 5 residents in the final quarter of training obtain MA in 95.5% and SP 92.9% for core procedures with wRVU <13.07 (Table 4). CONCLUSION: Increasing procedural difficulty is independently associated with decreases in meaningful autonomy and satisfactory performance. As residents approach graduation the level of meaningful autonomy and satisfactory performance both reach high levels for common core procedures but decrease as procedural difficulty increases.

Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection.

BACKGROUND: Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following distal pancreatectomy (DP). There is a lack of information regarding the impact of trauma on POPF rates when compared with elective resection. We hypothesize that trauma will be a significant risk factor for the development of POPF following DP. METHODS: A retrospective, single-institution review of all patients undergoing DP from 1999 to 2017 was performed. Outcomes were compared between patients undergoing DP for traumatic injury to those undergoing elective resection. Univariate and multivariable analyses were performed using SAS (version 9.4). RESULTS: Of the 372 patients who underwent DP during the study period, 298 met inclusion criteria: 38 DPs for trauma (TDP), 260 elective DPs (EDP). Clinically significant grade B or C POPFs occurred in 17 (44.7%) of 38 TDPs compared with 41 (15.8%) of 260 EDPs (p < 0.0001). On multivariable analysis, traumatic injury was found to be independently predictive of developing a grade B or C POPF (odds ratio, 4.3; 95% confidence interval, 2.10-8.89). Age, sex, and wound infection were highly correlated with traumatic etiology and therefore were not retained in the multivariable model. When analyzing risk factors for each group (trauma vs. elective) separately, we found that TDP patients who developed POPFs had less sutured closure of their duct, higher infectious complications, and longer hospital stays, while EDP patients that suffered POPFs were more likely to be male, younger in age, and at a greater risk for infectious complications. Lastly, in a subgroup analysis involving only patients with drains left postoperatively, trauma was an independent predictor of any grade of fistula (A, B, or C) compared with elective DP (odds ratio, 8.6; 95% confidence interval, 3.09-24.15), suggesting that traumatic injury is risk factor for pancreatic stump closure disruption following DP. CONCLUSION: To our knowledge, this study represents the largest cohort of patients comparing pancreatic leak rates in traumatic versus elective DP, and demonstrates that traumatic injury is an independent risk factor for developing an ISGPF grade B or C pancreatic fistula following DP. LEVEL OF EVIDENCE: Prognostic study, Therapeutic, level III.

Creation of Colonic Anastomosis in Mice.

Intestinal anastomoses are commonly performed in both elective and emergent operations. Even so, anastomotic leaks are a highly feared complications of colonic surgeries and can occur in up to 26% of surgical anastomoses, with mortality being up to 39% for patients with such a leak. Currently, there remains a paucity of data detailing the cellular mechanisms of anastomotic healing. Devising preventative strategies and treatment modalities for anastomotic leak could be greatly potentiated by a better understanding of appropriate anastomotic healing. A murine model is ideal as previous studies have shown that the murine anastomosis is the most clinically similar to the human case as compared with other animal models. We offer an easily reproducible murine model of colonic anastomosis in mice that will allow for further illustration of anastomotic healing.

Keeping Residents in the Dark: Do Night-Float Rotations Provide a Valuable Educational Experience?

OBJECTIVE: To qualify and characterize resident overnight activity. DESIGN: A prospective 3-phase study was conducted of surgical residents with attention to activities performed on the overnight rotation: needs assessment, direct observation of activities, and feedback. SETTING: This study was conducted at the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. This is both a tertiary referral center and the only American College of Surgeons (ACS) verified level 1 trauma center in the state. PARTICIPANTS: This study included current surgical residents within the residency program. RESULTS: During the study period, 270 pages were individually recorded, with 60% of these pages defined as time-sensitive activities. In addition, most of the pages involved pressing patient-care issues irrespective of postgraduate year level. Analyses revealed that residents spend most of their time performing educational activities (62%). On feedback, residents reported overall satisfaction with the learning opportunities during night-shift (6.4/7.0) and indicated their perceptions of an adequate balance of service and education on night float (6.6/7.0). This correlates with our annual rotation assessment where residents identify night-float as an overall positive experience which provides educational benefit. CONCLUSIONS: Work-hour restrictions induce residency programs to adapt to new training models. Our results report a breakdown of resident activities while on night-float and demonstrate that overnight shifts continue to provide important educational opportunities during training.

Medical student expectations from surgical education: A two-year institutional experience.

BACKGROUND: The third-year surgical rotation is the first exposure medical students have to the fundamentals of surgical education. It is known that medical students come to the surgical clerkship with preconceived ideas, many of them negative and based on prior student feedback and hearsay. METHODS: An anonymous survey was conducted of third-year medical students while on the surgical clerkship. We sought to quantify student's experiences and expectations by assessing the students' confidence levels before and after the rotation. RESULTS: Over a 26 month period from July 2013-August 2015, 250 surveys were conducted. In terms of confidence gained on the surgical rotation, students reported a statistically significant (p < 0.01) increase in confidence in fifteen different areas of interest. However, in terms of expectations, students reported discordance between anticipated experience and actual experience. Students' responses indicate that students felt confident with their knowledge of diseases; however, they desire more involvement in complex patient care and procedural skills. CONCLUSIONS: The third-year clerkship is the first exposure to surgery for many medical students. Surgical educators are tasked with providing a foundation for clinical medicine; however, students have expressed an expectation to be more involved with complex patient care and management.

Early Results from the Flexibility in Surgical Training Research Consortium: Resident and Program Director Attitudes Toward Flexible Rotations in Senior Residency.

OBJECTIVE: To assess the attitudes of residents and program directors (PDs) involved in flexible training to gauge satisfaction with this training paradigm and elicit limitations. DESIGN: Anonymous surveys were sent to residents and PDs in participant programs. Respondents were asked to rate responses on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). SETTING: A total of 9 residency programs that are collaborating to prospectively study the effect of flexible tracks on resident performance and outcome. PARTICIPANTS: A total of 138 residents who were in clinical years 4 and 5 and 10 PDs. RESULTS: Of the 138 possible residents, 100 responded to the resident survey (72.5% response rate). Among resident respondents, 33% were participating in a flexible track option. The most frequently listed specialties of focus were cardiothoracic surgery (19%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%). Participants in flexible tracks tended to strongly agree that their career would be enhanced by flexible rotations; interestingly, of those not in flexible tracks, most tended to also agree that flexible rotations would enhance their future careers. Flexible track participants report receiving greater autonomy on flexible rotations and believe they would be better prepared for fellowship and career. They express overall very high satisfaction with the flexible experience. Limitations expressed by residents (in flexible tracks or not) include uncertainty for how this paradigm serves those interested in comprehensive general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. Overall, 87.5% of PD respondents agreed or strongly agreed that those in flexible tracks have greater opportunities for mentorship in their chosen field. PDs also expressed high levels of satisfaction with flexible rotations. Limitations include concerns that the flexibility option presents scheduling difficulties and does not go far enough in reforming postgraduate education. CONCLUSIONS: This survey of 9 residency programs participating in flexible tracks indicates satisfaction with this training option. The role of comprehensive general surgery as a training end point and scheduling difficulties remain as major challenges. Outcomes of graduates in these tracks and control peers are being prospectively evaluated.

Informed consent training improves surgery resident performance in simulated encounters with standardized patients.

BACKGROUND: Although informed consent is vital to patient-physician communication, little training is provided to surgical trainees. We hypothesized that highlighting critical aspects of informed consent would improve resident performance. METHODS: Eighty (out of 88) surgical postgraduate year 1 surgical residents were randomly assigned to one of the 2 cases (laparoscopic cholecystectomy or ventral herniorrhaphy) and instructed to obtain and document informed consent with a standardized patient (SP) followed by a didactic training session. The residents then obtained and documented informed consent with the other case with the other SP. SPs graded encounters ("Checklist"); trained raters graded notes. Repeated measures multivariate analysis of variance (MANOVA) was used to determine differences between pre- and post-training and Checklist versus "Note" scores. RESULTS: Statistically significant pre- to post differences for Note (P < .01) and Checklist (P < .01) along with significant differences between Note and Checklist (P < .01) were noted. CONCLUSIONS: Training improved surgery residents' ability to discuss and document informed consent. Despite this improvement, significant differences between discussion and documentation persisted. Documentation training is a future area for improvement.

Variations in procedure time based on surgery resident postgraduate year level.

BACKGROUND: With increasing scrutiny being placed on the allocation of health care dollars, data supporting the increased resources used to teach residents in the operating room (OR) are lacking. METHODS: All cases of patients undergoing laparoscopic cholecystectomies (LCs) and pancreaticoduodenectomies (PDs) from July 1, 2006 to July 1, 2011 were analyzed. Procedures were excluded based on the following: more than one resident listed in the operative report, with the exception of interns; LC requiring cholangiogram or conversion to an open procedure; or if a PD required additional procedures. Multiple linear regression was used to evaluate the association between procedure time and postgraduate year (PGY), adjusting for patient age and estimated blood loss. RESULTS: A total of 236 PDs and 357 LCs were included in the study. For LCs, after multiple linear regression, the association between procedure time and resident PGY was marginally significant (P = 0.0519) and suggested an inverse relationship; for every increase in resident PGY, there was a 2.66-min decrease in OR time. Based on our institution's figure of $18.13/min of OR time, the cost difference between PGYs 1 and 5 performing a LC would be $192.90 per case. For PDs, however, the association between procedure time and resident PGY was not significant. CONCLUSIONS: Junior residents likely prolong procedure times for more basic procedures such as LC but not for more complex procedures such as PD.

Initial inferior vena cava diameter on computed tomographic scan independently predicts mortality in severely injured trauma patients.

BACKGROUND: In the trauma population, patients with physiologic compromise may present with "normal" vital signs. We hypothesized that the inferior vena cava (IVC) diameter could be used as a surrogate marker for hypovolemic shock and predict mortality in severely injured trauma patients. METHODS: A retrospective cohort study was performed at a Level I trauma center on 161 severely injured adult (aged ≥ 16 years) trauma patients who were transported from the scene and underwent abdominal computed tomography within 1 hour. Exposure of interest was dichotomously defined as having an infrarenal transverse to anteroposterior IVC ratio of ≥ 1.9 (flat IVC) or <1.9 (not exposed) based on the area under the curve analysis. The primary outcome was in-hospital mortality. Covariates included initial heart rate, systolic blood pressure, bicarbonate, base excess, creatinine, hemoglobin, and Injury Severity Score (ISS). Correlation analysis between IVC ratio and other known markers of hypoperfusion was performed. Logistic regression was used to determine the independent effect of the IVC ratio on mortality. RESULTS: Of the 161 patients, 30 had a flat IVC. The IVC ratio had a significant (p < 0.05) inverse correlation with initial bicarbonate, hemoglobin, and base excess and a direct correlation with Cr and ISS. After controlling for age, ISS, and presence of severe head injury, patients who had a flat IVC were 8.1 times (95% confidence interval, 1.5-42.9) more likely to die compared with the nonexposed cohort. Importantly, heart rate and systolic blood pressure had no predictive value in this patient population. CONCLUSION: A flat IVC on initial abdominal computed tomographic scan has a significant correlation with other known markers of shock and is an independent predictor of mortality in severely injured trauma patients. This finding should heighten the awareness of the need for aggressive intervention and potential for physiological decompensation in patients with otherwise "normal" vital signs. LEVEL OF EVIDENCE: Prognostic study, level III.

Establishing a swine model to compare vascular prostheses in a contaminated field.

OBJECTIVE: Patch arteriotomies are performed during many vascular procedures. Whereas synthetic materials are generally felt to be inappropriate for infected environments, the suitability of glutaraldehyde-treated bovine pericardium (GBP), a biologic material, in such instances is unknown. Our main objectives were to develop an animal model to study vascular prostheses while comparing the infectability of polyester (Dacron) and GBP in a topically infected environment. METHODS: Twenty-three pigs underwent transabdominal patch arteriotomy of the infrarenal aorta with either Dacron or GBP. The patches were inoculated with sterile saline (1 per group), Staphylococcus aureus 10(4) colony-forming units (CFUs) (4 per group), or S. aureus 10(5) CFUs (6 per group). At 3 wk, the animals were euthanized, and the patches were removed via a left retroperitoneal approach. Specimens were collected for microbiologic and histologic analysis. RESULTS: One animal from each group inoculated with 10(5) CFUs died during the study period, and another died immediately postoperatively of an airway complication. All aortas were patent and without evidence of pseudoaneurysm formation. Gross abscesses were found in 4/6 Dacron and 5/6 GBP animals receiving 10(5) CFUs. Similarly, 4/6 animals implanted with Dacron and 5/6 animals implanted with GBP had positive tissue cultures. A histologic grading system of inflammation substantiated the culture results. CONCLUSIONS: No significant difference exists between Dacron and GBP to resist bacterial infection at 3 wk. We have established a reproducible in vivo model to study arterial patch materials in a topically infected environment.

Defining incidence and outcome of contrast-induced nephropathy among trauma: is it overhyped?

Contrast-induced nephropathy (CIN) in trauma patients is uncommon and the incidence is unknown. We studied the incidence of CIN and its outcome. A retrospective chart review of trauma patients 16 years of age and older who were admitted to our Level I trauma center during 2005 was performed. Patients who received the intravenous contrast CT scan and had their serum creatinine (Cr) monitored at admission and at 48 to 72 hours were identified. CIN was defined as a 0.5-mg/dL rise of serum Cr or a 25 per cent increase from the baseline if the baseline Cr was abnormal. We excluded patients transferred from an outside facility, patients without repeated serum Cr measurements, patients who had cardiac arrest or persistent hypotension, and patients who had received N-acetylcysteine (Mucomyst) before their CT scan. We compared CIN and non-CIN groups. During 2005, 543 fit our study criteria, of whom 19 (3.5%) had CIN. CIN (vs non-CIN) had a higher baseline serum Cr (1.48 + 0.23 vs 1.06 + 0.02, P < 0.001), a longer intensive care unit stay (17 vs 5 days, P < 0.001), and a longer hospital stay (19 vs 8 days, P < 0.001); the mortality rate was not different (10 vs 4%, P = 0.2). We found elevated baseline serum Cr (OR, 1.92; 95% CI, 1.13 to 3.27; P = 0.016) to be associated with increased risk for CIN. All but two serum Cr levels peaked within 48 hours; all returned to baseline. One patient with an underlying congenital kidney disease required temporary dialysis. CIN incidence in trauma is low and the clinical course is benign.

Abdominal wall injuries occurring after blunt trauma: incidence and grading system.

BACKGROUND: Traumatic abdominal wall injuries (AWIs) are being increasingly recognized after blunt force injury. METHODS: All available abdominal/pelvic computed axial tomography (CAT) scans of blunt trauma patients evaluated at our level I trauma center from January 2005 to August 2006 were reviewed for the presence of AWI. AWI was graded using a severity-based numeric system. AWI grade was then compared with variables from a prospectively maintained trauma registry. RESULTS: Of 1,549 reviewed CAT scans, 9% showed AWI (grade I = 53%, grade II = 28%, grade III = 9%, grade IV = 8%, and grade V = 2%). There was no association between AWI and seatbelt use, Injury Severity Score, weight, or need for abdominal surgery. CONCLUSIONS: AWI occurs in 9% of blunt trauma patients undergoing abdominal/pelvic CAT scans. The incidence of herniation on CAT at presentation after blunt trauma is .2%, and the incidence of patients at risk of future hernia formation is 1.5%. AWI can be effectively cataloged using a straightforward numeric grading system.

Nonsurgical ablation of primary breast cancer.

The potential for these therapies is overwhelming when one considers that as many as 90,000 patients may be candidates annually in the United States. The ideal therapy should be safe, as painless as possible, accessible, and effective in reducing local recurrence. Because of the novelty of these techniques, no therapy has met all of these goals. Even if these ideals are attained, questions remain about how to follow these patients with regard to frequency and imaging modality for local recurrence. As these technologies are refined, and they mature; it is conceivable that the future treatment of breast cancer may be less morbid than the open breast biopsies now being used for just the diagnosis of the disease.