Robotic Enucleation of Pancreatic Head Insulinomas in Close Proximity to the Pancreatic Duct.

BACKGROUND: Insulinomas are rare pancreatic neuroendocrine tumors for which the main curative treatment is surgical resection. Enucleation is preferred over pancreatoduodenectomy to minimize morbidity and function loss.1 Robotic-assisted surgery offers improved versatility and less blood loss than laparoscopic surgery for pancreatic enucleation.2-4 Our video describes the technique for robotic enucleation of pancreatic head insulinomas in close proximity to the pancreatic duct. PATIENTS AND METHODS: The video describes the presentation, diagnostic imaging, and technical aspects of the surgical approach in two patients with pancreatic head insulinomas that underwent robotic enucleation. RESULTS: Case one was a 76-year-old woman who experienced syncope for 2 months. Case two was a 61-year-old man, previously treated for renal cancer, who had documented hypoglycemic symptoms. Computed tomography (CT) scan and magnetic resonance imaging (MRI) identified a 1.5 cm and 1.2 cm pancreatic head mass, respectively. Both patients presented with low glucose levels, and elevated C-peptide and proinsulin. In both cases, endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct stent placement were performed the same day of surgery for intraoperative identification and preservation of the duct. Robotic enucleation of the masses was performed, and an ultrasound was used to identify the masses and relation with main pancreatic duct. Pathology revealed a well-differentiated neuroendocrine tumor in both cases. The patient's postoperative course was uneventful, and they were discharged on day 5. Successful resolution of hypoglycemic events occurred in both patients. CONCLUSION: Robotic enucleation is a safe and feasible option for treating pancreatic head tumors in challenging locations. Intraoperative ultrasound is an essential tool for the successful robotic enucleation of pancreatic head tumors.

The case for a new post-graduate hernia designation: a review of fellowship council case logs from the past twelve-years.

BACKGROUND: The Fellowship Council (FC) is a robust accreditation body with numerous fellowships; however, no specific criteria exist for hernia fellowships. This study analyzed the case log database to evaluate trends in fellowship exposure to hernia repairs. METHODS: FC hernia case log records (2007-2019) were coded as inguinal or ventral hernias and with or without mesh repair. Retrospective analysis examined total hernia repairs logged, type of repair, program designation, and robotic adoption. Robotic adoption was categorized by quartiles of program performance according to the final year of analysis (2018-2019); yearly performance was then graphed by quartiles. RESULTS: Over this twelve-year period, 93,334 hernia repairs, 5 program designations, 152 unique programs and 1,558 unique fellows were analyzed. The number of fellows grew from 106 (2007-2008) to > 130 (2018-2019). Total hernias repairs per fellow increased from an average of 41.2 in 2007-2008 to 75.7 in 2018-2019 (183.7%). Open and robotic hernia repairs increased by 241.9% and 266.3%, respectively; laparoscopic hernia repairs decreased by 14.8%. Inguinal and ventral hernia repairs comprised 48.1% and 51.9% of total cases, respectively. Advanced GI/MIS and Advanced GI/MIS/Bariatrics programs logged the majority of hernia repairs (86.0-90.2%). 2014 began an exponential rise in robotic adoption, with fellows averaging < 1 robotic repairs before and > 25 repairs in 2019. A significant difference was found between all groups when comparing quartiles of robotic adopters (median robotic repairs per fellow; IQR): first quartile (72.0; 47.9-108.8), second quartile (25.5; 21.0-30.6), third quartile (13.0; 12.0-14.3) and fourth quartile (3.5; 0.5-5.0) (p-value < 0.05). CONCLUSIONS: This twelve-year analysis shows a near doubling in the growth of total hernia repairs, with a decrease in laparoscopic repairs as robotic repairs increased. These data show the importance of hernia repairs in FC fellows' training and warrant further granular analysis to determine specific accreditation criteria for hernia fellowship designations.

SAGES safe cholecystectomy modules improve practicing surgeons' judgment: results of a randomized, controlled trial.

BACKGROUND: Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice. METHODS: Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization. RESULTS: Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety. CONCLUSIONS: In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way.

The rising tide of revisional surgery: tracking changes in index cases among bariatric-accredited fellowships.

BACKGROUND: The field of bariatric surgery has seen peaks and troughs in the types of metabolic procedures performed. Our primary aim was to evaluate bariatric case volumes among fellows enrolled in bariatric Fellowship Council (FC)-accredited programs. Our secondary aim was to assess trends in revisional case volumes. METHODS: We reviewed de-identified FC case logs for all bariatric surgery-accredited programs from 2010 through 2019. The number of primary sleeve gastrectomy, gastric band, gastric bypass, biliopancreatic diversion, and major revisional bariatric surgical procedures (defined as a revision with creation of a new anastomosis) were graphed for each academic year. Fellows were stratified into quartiles based on the number of revisional operations per year and graphed over ten years. Volumes of primary gastric bypass, major revisions, and total anastomotic cases were compared over time using ANOVA with p < 0.05 considered significant. RESULTS: Case volumes for 822 fellows were evaluated. Sleeve gastrectomy had a significant surge in 2010 and plateaued in 2016. The fellows' number of primary gastric bypasses had a non-significant decrease from 84 to 75 cases/fellow from 2010 to 2019. This decrease was offset by a significant increase in major revisional surgery from 8 to 19 cases/fellow. As a result, the number of anastomotic cases did not change significantly over the study time period. Interestingly, as revisional volume has grown, the gap between quartiles of fellowship programs has widened with the 95th percentile growing at a much faster rate than lower quartiles. CONCLUSION: The volume of bariatric procedures performed in the last decade among FC fellows follows similar trends to national data. Major revisional cases have doubled with the most robust growth isolated to a small number of programs. As revisional surgery continues to increase, applicants interested in a comprehensive bariatric practice should seek out training programs that offer strong revisional experience.

Defining benchmarks for fellowship training in foregut surgery: a 10-year review of fellowship council index cases.

INTRODUCTION: Surgical treatment of foregut disease is a complex field that demands advanced expertise to ensure favorable outcomes for patients. To address the growing need for foregut surgeons, leaders within several national societies have become interested in developing a foregut fellowship. The aim of this study was to develop data-driven benchmarks that will aid in defining appropriate accreditation criteria for these fellowships. METHODS: We obtained case log data for Fellowship Council fellows trained from 2009-2019. We identified 78 complex foregut (non-bariatric) case codes and divided them into 5 index case categories including (1) hiatal/paraoesophageal hernia repair, (2) fundoplication, (3) esophageal myotomy, (4) major organ resection, and (5) minor organ resection. Median volumes in each index category were compared over time using Kruskall-Wallis tests. The share of cases done using open, laparoscopic, or robotic approaches were analyzed using linear regression analysis. RESULTS: For the 10 years analyzed, 1362 fellows logged 82,889 operations and 111,799 endoscopies. Median foregut cases per fellow grew significantly from 42 (IQR = 24-74) cases in 2010 to 69 (IQR = 33-106) cases in 2019. Median endoscopy volumes also grew significantly from 42 (IQR = 7-88) in 2010 to 69 (IQR 32-123) in 2019.The volume of hiatal/paraoesophageal hernia repairs increased significantly over time while volumes in the remaining 4 index categories remained stable. The share of robotic cases exhibited near perfect linear growth from 2.2% of all foregut cases in 2010 to 14.4% in 2019 (R = 0.99, p < 0.0001). Open cases exhibited linear decay from 7.2% of cases in 2010 to 4.7% of cases in 2019 (R = 0.92, p = 0.0001). Laparoscopic/thoracoscopic cases also exhibited linear decay from 90.6% of cases in 2010 to 80.9% of cases in 2019 (R = 0.98, p < 0.00001). CONCLUSIONS: FC fellows are exposed to robust volumes of foregut cases. This rich data set provides an evidence-based guide for establishing criteria for potential foregut fellowships.

SAGES Advanced GI/MIS Certificate Program.

SAGES partners with the Fellowship Council (FC) to offer fellowships in MIS and flexible endoscopy. The FC has a robust accreditation process for fellowship programs; however, the FC is not able to address certification of individual graduates. This situation is similar to the structure of residencies whereby the ACGME accredits programs but individual board certification is delegated to constituent boards of the American Board of Medical Specialties (ABMS). In light of this gap, sponsoring societies have developed programs for issuing certificates to graduates of fellowship programs who have met predetermined standards. The purpose of this paper is to describe the SAGES Certificate Process for Adv GI MIS and Flexible Endoscopy Fellowships. The SAGES Certificate program was developed through a rigorous process and has undergone recent revision to modernize the certificate criteria. Research has shown that as many as 80% of general surgery graduates go on to complete additional fellowship training. Given the number of graduates who complete this subspecialty training each year, general surgery board certification may not be an appropriate final benchmark. The SAGES certificate program joins a long list of certification pathways for surgical fellowship trainees in ACGME and non-ACGME programs. In the future, SAGES plans to assess competency in all of core content domains with validated assessments.

Thriving or surviving? A critical examination of funding models for fellowship council fellowships.

BACKGROUND: Since 1997, the Fellowship Council (FC) has evolved into a robust organization responsible for the advanced training of nearly half of the US residency graduates entering general surgery practice. While FC fellowships are competitive (55% match rate) and offer outstanding educational experiences, funding is arguably vulnerable. This study aimed to investigate the current funding models of FC fellowships. METHODS: Under an IRB-approved protocol, an electronic survey was administered to 167 FC programs with subsequent phone interviews to collect data on total cost and funding sources. De-identified data were also obtained via 2020-2021 Foundation for Surgical Fellowships (FSF) grant applications. Means and ranges are reported. RESULTS: Data were obtained from 59 programs (35% response rate) via the FC survey and 116 programs via FSF applications; the average cost to train one fellow per year was $107,957 and $110,816, respectively. Most programs utilized departmental and grants funds. Additionally, 36% (FC data) to 39% (FSF data) of programs indicated billing for their fellow, generating on average $74,824 ($15,000-200,000) and $33,281 ($11,500-66,259), respectively. FC data documented that 14% of programs generated net positive revenue, whereas FSF data documented that all programs were budget-neutral. CONCLUSION: Both data sets yielded similar overall results, supporting the accuracy of our findings. Expenses varied widely, which may, in part, be due to regional cost differences. Most programs relied on multiple funding sources. A minority were able to generate a positive revenue stream. Although fewer than half of programs billed for their fellow, this source accounted for substantial revenue. Institutional support and external grant funding have continued to be important sources for the majority of programs as well. Given the value of these fellowships and inherent vulnerabilities associated with graduate medical education funding, alternative grant funding models and standardization of annual financial reporting are encouraged.

The Impact of COVID-19 on Surgical Education.

BACKGROUND: At the onset of social distancing, our general surgery residency transitioned its educational curriculum to an entirely virtual format with no gaps in conference offerings. The aim of this study is to examine the feasibility of our evolution to a virtual format and report program attitudes toward the changes. METHODS: On March 15, 2020, due to the coronavirus disease (COVID-19) our institution restricted mass gatherings. We immediately transitioned all lectures to a virtual platform. The cancellation of elective surgeries in April 2020 then created the need for augmented resident education opportunities. We responded by creating additional lectures and implementing a daily conference itinerary. To evaluate the success of the changes and inform the development of future curriculum, we surveyed residents and faculty regarding the changes. Classes and faculty answers were compared for perception of value of the online format. RESULTS: Pre-COVID-19, residency-wide educational offerings were concentrated to one half-day per week. Once restrictions were in place, our educational opportunities were expanded to a daily schedule and averaged 16.5 hours/week during April. Overall, 41/63 residents and 25/94 faculty completed the survey. The majority of residents reported an increased ability (56%) or similar ability (34.1%) to attend virtual conferences while 9.9% indicated a decrease. Faculty responses indicated similar effects (64% increased, 32% similar, 4% decreased). PGY-1 residents rated the changes negatively compared to other trainees and faculty. PGY-2 residents reported neutral views and all other trainees and faculty believed the changes positively affected educational value. Comments from PGY1 and 2 residents revealed they could not focus on virtual conferences as it was not "protected time" in a classroom and that they felt responsible for patient care during virtual lectures. A majority of both residents (61%) and faculty (84%) reported they would prefer to continue virtual conferences in the future. CONCLUSIONS: The necessity for adapting our academic offerings during the COVID-19 era has afforded our program the opportunity to recognize the feasibility of virtual platforms and expand our educational offerings. The majority of participants report stable to improved attendance and educational value. Virtual lectures should still be considered protected time in order to maximize the experience for junior residents.

The Relationship Between Surgeon Faculty Emotional Intelligence and Medical Student Evaluations.

OBJECTIVE: We sought to measure the emotional intelligence (EI) of surgical faculty and the relationship between faculty EI and medical student (MS) evaluations of faculty. DESIGN: Faculty completed the Emotional Intelligence Appraisal. Aggregate, anonymous MS evaluations were collected from the Program Director's office. Parametric and nonparametric tests were used for analysis. SETTING: This study was first performed in a single surgical division at 1 center which informed an expanded study including the entire General Surgery Department at a single academic institution. PARTICIPANTS: A pilot study was conducted in 1 surgical division which was then expanded to all clinical faculty in the Department of Surgery. All clinical faculty in the Department of Surgery were eligible for enrollment. RESULTS: Pilot study faculty EI scores were positively correlated with MS evaluations (r = 0.92, p < 0.001). The follow-up study enrolled 41 surgeons with a median age of 48 (inter-quartile range 12). The sample was mostly white (70.7%). Mean EI for the group was 76 (standard deviation ± 7.8). Total faculty EI scores were not significantly correlated with MS evaluations (r = 0.30, p = 0.06). CONCLUSIONS: MS evaluations of surgeon faculty were not related to EI in the larger sample. However, EI did correlate to MS evaluations in 2 surgical specialties. Further exploration into the utility of EI training in surgical departments should be conducted to determine the true value of such endeavors.

Faculty Emotional Intelligence Matters for Resident Education.

OBJECTIVE: This study aimed to determine the emotional intelligence (EI) of surgical faculty and evaluate its relationship with resident evaluations of faculty behaviors. DESIGN: This study retrospectively collected faculty EI scores as well as general surgery resident evaluations of faculty. Parametric and nonparametric tests were used for statistical analysis. SETTING: The study was conducted at the University of Texas Southwestern in the Department of Surgery in Dallas, Texas. This is an academic, tertiary care center. PARTICIPANTS: Surgical faculty members at a single institution in 2018 completed the Emotional Intelligence Appraisal, a 28-item, electronic assessment with possible scores ranging from zero to 100. Aggregate, anonymous resident evaluations of faculty members were collected from the program director's office. Faculty with fewer than 8 resident evaluations were excluded. RESULTS: In total, 59 faculty members participated (89%). The sample was mostly white (69.2%), male (63.5%), with an average of 47 ± 10 years of age, 12.2 ± 10 years in practice, and 44 ± 24 evaluations per faculty member. The group's mean EI score was 76 ± 7.7. Faculty EI scores were found to have a moderate, positive correlation with resident rotational evaluations of faculty (r(51) = 0.52, p < 0.001). Faculty EI scores did not significantly correlate with resident evaluations of faculty intraoperative behaviors. CONCLUSIONS: The results of this study suggest that a majority of our faculty are competent with regard to EI. Furthermore, faculty EI is an important factor in the clinical learning environment and correlates with resident rotational evaluations of teaching behaviors.

Assessing quality and resources during campus-wide simulation integration.

INTRODUCTION: Our simulation center, supported by four departments (Surgery, OB/GYN, Urology, and Anesthesiology), is accredited as a comprehensive Accredited Educational Institute (AEI) and is now expanding to accommodate all departments on campus. METHODS: A 61-point questionnaire was administered to 44 stakeholders, representing all of UME and GME. Data were compared for AEI vs. non-AEI activities. RESULTS: Responses were collected from all 44 groups (100% response rate). Overall, 43 simulation activities were hosted within the AEI and 40 were hosted by non-AEI stakeholders. AEI activities were more likely to be mandatory (93% vs. 75%, p = 0.02), have written learning objectives (79% vs 43%, p < 0.001), and use validated assessment metrics (33% vs. 13%, p = 0.03). CONCLUSION: These data suggest that the AEI courses are more robust in terms of structured learning and assessment compared to non-AEI courses. Campus-wide application of uniform quality standards is anticipated to require significant faculty, course, and program development.

FES exam outcomes in year two of a proficiency-based endoscopic skills curriculum.

BACKGROUND: FES certification is required to sit for the ABS Qualifying Exam. Previous work demonstrated a 40% FES pass rate for residents with standard clinical endoscopy training. After implementing a proficiency-based simulation curriculum, our FES pass rate increased to 87%. The purpose of this study was to monitor the success of our curriculum in its second year. We also hypothesized that residents who took the FES exam within 30 days of their clinical endoscopy rotation would have superior pass rates to residents who waited longer. METHODS: PGY4 residents (N = 12) underwent flexible endoscopy training including a 1 month clinical rotation plus proficiency-based simulation training using bench-top models (Trus, Operation Targeting Task) and a virtual reality task on the GI Mentor. Residents that passed FES on their first attempt were compared to residents that did not pass based on number of endoscopies logged, hours spent practicing on simulators, and time elapsed between completing their endoscopy rotation and taking the FES exam. FES total scores and section scores were compared to historical controls. RESULTS: Nine residents (75%) passed FES on their first attempt. Overall, 80% of residents who tested within 30 days of their endoscopy rotation (n = 5) passed FES while 71% of residents who waited longer (n = 7) passed FES (p = non-significant). Residents that passed FES were not significantly different from residents who did not pass based on number of endoscopies logged or hours spent practicing on simulators. Compared to historical controls, scores on loop reduction improved significantly with the new curriculum. CONCLUSIONS: FES pass rates decreased during the second year of our curriculum. Based on other literature, our trainees would benefit from higher volumes of endoscopy and/or a more robust proficiency-based simulation curriculum. Scheduling the FES exam in the month following the endoscopy rotation did not significantly improve pass rates.

Providing complex GI surgical care with minimally invasive approaches: a survey of the practice patterns of Fellowship Council alumni.

INTRODUCTION: The Fellowship Council (FC) oversees 172 non-ACGME surgical fellowships offering 211 fellowship positions per year. These training programs cover multiple specialties including Advanced gastrointestinal (GI), Advanced GI/MIS, Bariatric, Hepatopancreaticobiliary (HPB), Flexible Endoscopy, Colorectal, and Thoracic Surgery. Although some data have been published detailing the practice environments (i.e., urban vs. rural) and yearly total case volumes of FC alumni, there is a lack of granular data regarding the practice patterns of FC graduates. The aim of this study was to gather detailed data on the specific case types performed and surgical approaches employed by recent FC alumni. METHODS: A 21-item survey covering 64 data points was emailed to 835 FC alumni who completed their fellowship between 2013 and 2017. Email addresses were obtained from FC program directors and FC archives. RESULTS: We received 327 responses (39% response rate). HPB, Advanced Colorectal, and Advanced Thoracic alumni appear to establish practices focused on their respective fields. Graduates from Advanced GI, Adv GI/MIS, and Bariatric programs appear to build practices with a mix of several complex GI case types including bariatrics, colorectal, foregut, HPB, and hernia cases. CONCLUSIONS: This is the first large data set to provide granular information on the practice patterns of FC alumni. FC trained surgeons perform impressive volumes of complex procedures, and minimally invasive approaches are extremely prevalent in these practices. Further, many graduates carve out practices with large footprints in robotics and endoscopy.

The Fuel Gauge: A Simple Tool for Assessing General Surgery Resident Well-Being.

OBJECTIVE: Resident well-being is an increasingly relevant issue in medical education; however, there is no consensus on how to best measure well-being. The "fuel gauge," is a simple, easy-to-use tool developed to measure resident well-being and previously applied in an Internal Medicine Residency Program at our institution. The current study sought to evaluate its acceptability and usefulness in a surgery program. DESIGN: Weekly fuel gauge data was retrospectively collected from August 2017 through December 2018 along with resident Postgraduate Year designations. SETTING: This study was conducted at a single, large general surgery residency program that rotates through a variety of hospitals, including a University hospital, a large county hospital, a Veterans Affairs hospital, and a freestanding Children's hospital. PARTICIPANTS: Categorical general surgery residents at every level of training as well as preliminary interns and off service intern rotators from urology, oral and maxillofacial surgery, and otolaryngology were eligible for the study. Fuel gauge submissions which did not denote a score were excluded from analysis. RESULTS: Out of 130 residents, 103 (79.2%) completed at least 1 fuel gauge assessment with a weekly mean response rate of 41.5%. Low scores were submitted by 39.8% of resident participants. Narrative feedback was provided in 6.2% of submissions with increased length associated with decreased fuel gauge score. CONCLUSIONS: The fuel gauge was well accepted by a large general surgery program with no decline in participation rates over the study period. The tool provided residents with a direct line of communication with their program's administration, and a feasible way for the program director's office to monitor and identify residents who were struggling with regard to their well-being.

Are you better off than you were 4 years ago? Measuring the impact of the ABS flexible endoscopy curriculum.

INTRODUCTION: In 2014, the ABS introduced the Flexible Endoscopy Curriculum (FEC). The FEC did not alter the minimum defined category case volumes for endoscopy; however, it did introduce specific cognitive and technical milestones for endoscopy training. It also mandated that residents pass the Fundamentals of Endoscopic Skills (FES) exam to qualify for board certification. Although significant research has been published regarding residents' success on the FES exam, very little is known regarding how the FEC has changed the way general surgery programs train their residents in surgical endoscopy. The aim of this study was to quantify changes in flexible endoscopy education at a large academic program in the 4 years since the FEC was published. METHODS: We classified the impact of FEC into four categories: (a) case volume or distribution, (b) clinical rotations, (c) required didactics or simulation exercises, and (d) FES pass rates. For category (a), we reviewed current and historical case logs for all categorical residents from 2013 to 2018. Mann-Whitney U tests were used to compare endoscopy volumes for each PGY level in 2013-2014 to the respective PGY level in 2017-2018 with p < 0.05 considered significant. For categories (b)-(d), we gathered historical records from the residency coordinator and endoscopy rotation director. RESULTS: Complete data were available for 57 residents in the 2013-2014 academic year and 56 residents in the 2017-2018 academic year. Median total endoscopies performed by PGY2, PGY3, and PGY5 residents all significantly increased during the FEC rollout. Our program's focus on endoscopy also expanded with absolute increases in endoscopy rotations, didactics, and simulation exercises. These changes translated into significantly increased pass rates on the FES exam from 40 to 100%. CONCLUSIONS: Implementation of the FEC at a large academic program led to measurable improvements in clinical experience, program structure, educational programing, and performance on high-stakes assessments.

Multidisciplinary Simulation Activity Effectively Prepares Residents for Participation in Patient Safety Activities.

PURPOSE: In 2017, The Accreditation Council for Graduate Medical Education (ACGME) issued Common Program Requirements that stipulated residents must participate in real or simulated interprofessional patient safety activities, such as root cause analyses (RCA). The requirements also stated that residents should have the opportunity to participate in the disclosure of patient safety events. Our institution supports a large graduate medical education (GME) cohort with approximately 1400 GME learners in more than 100 ACGME programs. Knowing that our university hospital system conducts approximately 15 RCA's per year, our GME leadership charged the Dean of Simulation with developing a pilot simulation activity that would satisfy these educational needs. METHODS: Four departments (Anesthesia, Emergency Medicine, OB/GYN, and Surgery) assigned a total of 39 learners to participate in the pilot simulation. Learners were divided into groups of 5 to 8 participants representing at least 3 departments. Before the simulation, learners were asked to complete a preactivity questionnaire rating their comfort with the learning objectives and a 10-question multiple choice quiz assessing knowledge of RCA principles. The simulation was 1-hour long and consisted of 2 parts. First, learners participated in a high-fidelity, mannequin-based resuscitation scenario that was scripted to include systems barriers to effective resuscitation. Second, our University Hospital's Vice President of Quality and Safety led participants in a simulated RCA analyzing the systems issues encountered. Finally, all learners completed a postactivity questionnaire and quiz. Preactivity and postactivity data were compared with repeated measures t-tests with p < 0.05 considered significant. RESULTS: Complete data were available for 38 learners. We observed significant improvements in quiz performance and learners' self-reported abilities to perform tasks related to patient safety and RCA. The simulation activity did not affect learners' anxiety regarding potential participation in an RCA. CONCLUSIONS: Our data indicate that a 1-hour, introductory-level simulation improved residents' confidence and knowledge related patient safety activities. This training format is efficient, effective, and consistent with the expectations of the new ACGME Common Program Requirement.

Administration of Tumescence in Pediatric Burn Patients Causes Significant Hypertension.

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33-3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

SAGES Advanced GI/MIS fellowship redesign: pilot results and adoption of new standards.

INTRODUCTION: SAGES is responsible for defining educational content for Advanced GI/MIS fellowships administered through the fellowship council (FC). In Fall 2016, to better define core content contained in these fellowships, SAGES proposed new case log criteria including minimum volumes within six defined categories. To test feasibility of these criteria, SAGES conducted a pilot study during the 2017-2018 academic year. METHODS: Advanced GI/MIS fellowship programs directors (PD's) who also held leadership roles in SAGES were invited to participate in the pilot. Fourteen programs including 17 fellows volunteered. To assess generalizability, 2016-2017 case log data for the volunteered pilot programs were compared to all other advanced GI/MIS programs (n = 92). To assess feasibility of the new criteria, pilot programs' 2017-2018 case logs were compared to 3 years of historical fellows' case logs (n = 326). Fisher's exact test was used for comparisons with p < 0.05 considered significant. RESULTS: Complete data were available for 16 pilot fellows (median 251.5 advanced MIS cases and 62.5 endoscopies per fellow). According to 2016-2017 data, pilot programs were not statistically different from non-pilot programs regarding achievement of any defined category minimum. Compared to historical controls, the 2017-2018 pilot fellows were significantly more likely to meet the defined category minimum for foregut cases and demonstrated a non-significant trend toward higher achievement of minimums for bariatrics, inguinal hernia, ventral hernia, and endoscopy. Pilot fellows were significantly less likely to meet the minimum for HPB/solid organ/colorectal/thoracic cases. Based on these data, SAGES eliminated the HPB/solid organ/colon/thoracic category and, in partnership with the FC, approved staged implementation of the remaining criteria over 3 years. CONCLUSIONS: The pilot study provided feasibility and generalizability evidence that allowed inclusion of appropriate defined categories for establishment of the new Advance GI/MIS fellowship criteria. We anticipate that the revised criteria will enhance the educational benefit of these fellowships.

A proficiency-based surgical boot camp May not provide trainees with a durable foundation in fundamental surgical skills.

BACKGROUND: Pre-internship boot camps have become popular platforms to rapidly teach skills to surgical interns. This study aimed to analyze psychomotor skill retention four months after completing a boot camp program. METHODS: Surgical interns (n = 20) took a baseline pre-test and then trained to proficiency (based on time and errors) for 5 knot tying, 4 simple suturing, and 2 running suturing tasks during a three-day boot camp. Three months later, all interns took a retention test. RESULTS: Proficiency scores significantly improved on all task types from pre-test to post test and significantly regressed on all task types from post-test to retention test. Normalized scores decreased as the tasks became more complex (knot tying = 93.5, simple suturing = 89.1, running suturing = 85.2, p = 0.05). CONCLUSIONS: Boot camp style training can rapidly teach fundamental surgical skills to novices; however, skills regress significantly over time with a greater degree of regression seen on more complex skills.

Proficiency-based preparation significantly improves FES certification performance.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) certification has recently been mandated by the American Board of Surgery but best methods for preparing for the exam are lacking. Our previous work demonstrated a 40% pass rate for PGY5 residents in our program. The purpose of this study was to determine the effectiveness of a proficiency-based skills and cognitive curriculum for FES certification. METHODS: Residents who agreed to participate (n = 15) underwent an orientation session, followed by skills pre-testing using three previously described models (Trus, Operation targeting task, and Kyoto) as well as the actual FES skills exam (vouchers provided by the FES committee). Participants then trained to proficiency on all three models for the skills curriculum and completed the FES online didactic material for the cognitive curriculum. Finally, participants post-tested on the models and took the actual FES certification exam. Values are mean ± SD; p < 0.05 was considered significant. RESULTS: Of 15 residents who participated, 8 (53%) passed the FES skills exam at baseline. Participants required 2.7 ± 1.3 h to achieve proficiency on the models and approximately 3 h to complete the cognitive curriculum. At post-test, 14 (93%, vs. pre-test 53%, p = 0.041) passed the FES skills exam. 14 (93%) passed the FES cognitive exam and 13/15 (87%) passed both the skills and cognitive exam and achieved FES certification. CONCLUSIONS: Our traditional clinical endoscopy curricula were not sufficient for senior residents to pass the FES exam. Implementation of a proficiency-based flexible endoscopy curriculum using bench-top models and the FES online materials was feasible and effective for the majority of learners. Importantly, with a modest amount of additional training, 87% of our trainees were able to pass the FES examination, which represents a significant improvement for our program. We expect that additional refinements of this curriculum may yield even better results for preparing future residents for the FES examination.