Esophagram should be performed to diagnose esophageal perforation before inter-hospital transfer.

Background: Early recognition of esophageal perforation may prevent morbidity and mortality, and accurate diagnostic imaging facilitates triage. Stable patients with suspected perforation may be transferred to higher levels of care before appropriate work-up and diagnosis confirmation. We reviewed patients transferred for esophageal perforation to critically analyze the diagnostic workflow. Methods: We performed a retrospective review of patients transferred to our tertiary care institution from 2015-2021 for suspected esophageal perforation. Demographics, referring site characteristics, diagnostic studies, and management were analyzed. Bivariate comparisons were performed using Wilcoxon-Mann-Whitney tests for continuous variables and chi-squared or Fisher's exact tests for categorical variables. Results: Sixty-five patients were included. Etiology of suspected perforation was spontaneous in 53.8% and iatrogenic in 33.8%. Most patients were transferred within 24 hours from time of suspected perforation (66.2%). Transferring sites included seven states and were 101-300 miles (32.3%) or >300 miles (26.2%) away. CT imaging was obtained in 96.9% before transfer, most commonly demonstrating pneumomediastinum (46.2%). Only 21.5% of patients had an esophagram before transfer. Following transfer, 36.9% (n=24) were ultimately not found to have esophageal perforation, demonstrated by negative arrival esophagram in 79.1%. In patients with confirmed perforation (n=41), 58.5% had surgery, 26.8% endoscopic intervention, and 14.6% supportive care. Conclusions: After transfer a proportion of patients were ultimately found to not have esophageal perforation, typically demonstrated by negative esophagram upon arrival. We conclude that a recommendation of performing esophagram at the presenting site, when possible, may prevent unnecessary transfers, and will likely reduce costs, conserve resources, and decrease management delays.

Long-Term Patient-Reported Symptom Improvement and Quality of Life after Transthoracic Diaphragm Plication in Adults.

BACKGROUND: Open and robotic-assisted transthoracic approaches for diaphragm plication are accepted surgical interventions for diaphragm paralysis and eventration. However, long-term patient-reported symptom improvement and quality of life (QOL) remains unclear. STUDY DESIGN: A telephone-based survey was developed focusing on postoperative symptom improvement and QOL. Patients who underwent open or robotic-assisted transthoracic diaphragm plication (2008-2020) across three institutions were invited to participate. Patients who responded and provided consent were surveyed. Likert responses on symptom severity were dichotomized and rates before and after surgery were compared using McNemar's test. RESULTS: Forty-one percent of patients participated (43 of 105 responded, mean age 61.0 years, 67.4% male, 37.2% robotic-assisted surgery), with an average time between surgery and survey of 4.1 ± 3.2 years. Patients reported significant improvement in dyspnea while lying flat (67.4% pre- vs 27.9% postoperative, p < 0.001), dyspnea at rest (55.8% pre- vs 11.6% postoperative, p < 0.001), dyspnea with activity (90.7% pre- vs 55.8% postoperative, p < 0.001), dyspnea while bending over (79.1% pre- vs 34.9% postoperative, p < 0.001), and fatigue (67.4% pre- vs 41.9% postoperative, p = 0.008). There was no statistical improvement in chronic cough. 86% of patients reported improved overall QOL, 79% had increased exercise capacity, and 86% would recommend surgery to a friend with a similar problem. Analysis comparing open and robotic-assisted approaches found no statistically significant differences in symptom improvement or QOL responses between the groups. CONCLUSIONS: Patients report significantly improved dyspneic and fatigue symptoms after transthoracic diaphragm plication, regardless of open or robotic-assisted approach. The majority of patients report improved QOL and exercise capacity.

A comparison of short-term outcomes following robotic-assisted vs. open transthoracic diaphragm plication.

Diaphragm paralysis and eventration are rare conditions in adults. Symptomatic patients may benefit from surgical plication of the elevated hemidiaphragm. The objective of this study was to compare short-term outcomes and length of stay following robotic-assisted vs. open diaphragm plication. A multicenter retrospective study was conducted that identified patients undergoing unilateral hemidiaphragm plication from 5/2008 to 12/2020. The first RATS plication was performed in 11/2018. Electronic medical records were reviewed, and outcomes were compared between RATS and open approach. One hundred patients underwent diaphragm plication, including thirty-nine (39.0%) RATS and sixty-one (61.0%) open cases. Patients undergoing RATS diaphragm plication were older (64 years vs. 55 years, p = 0.01) and carried a higher burden of comorbidities (Charlson Comorbidity Index: 2.0 vs. 1.0, p = 0.02). The RATS group had longer median operative times (146 min vs. 99 min, p < 0.01), but shorter median hospital length of stays (3.0 days vs. 6.0 days, p < 0.01). There was a non-significant trend toward a decreased rate of 30-day postoperative complications (20.5% RATS vs. 32.8% open, p = 0.18) and 30-day unplanned readmissions (7.7% RATS vs. 9.8% open, p > 0.99). RATS is a technically feasible and safe option for performing diaphragm plications. This approach increases the surgical candidacy of older patients with a higher burden of comorbid disease without increasing complication rates, while reducing length of hospital stay.

Evaluating the implementation of robotic thoracic surgery on a Veterans Administration Hospital.

Robotic thoracic surgery has demonstrated benefits. We aimed to evaluate implementation of a robotic thoracic surgery program on postoperative outcomes at our Veteran's Administration Medical Center (VAMC). We retrospectively reviewed our VAMC database from 2015 to 2021. Patients who underwent surgery with intention to treat lung nodules were included. Primary outcome was patient length of stay (LOS). Patients were grouped by surgical approach and stratified to before and after adoption of robotic surgery. Univariate comparison of postoperative outcomes was performed using Wilcoxon rank sums and chi-squared tests. Multivariate regression was performed to control for ASA class. P values < 0.05 were considered significant. Outcomes of 108 patients were assessed. 63 operations (58%) occurred before and 45 (42%) after robotic surgery implementation. There were no differences in patient preoperative characteristics. More patients underwent minimally invasive surgery (MIS) in the post-implementation era than pre-implementation (85% vs. 42%, p < 0.001). Robotic operations comprised 53% of operations post-implementation. On univariate analysis, patients in the post-implementation era had a shorter LOS vs. pre-implementation, regardless of surgical approach (mean 4.7 vs. 6.0 days, p = 0.04). On multivariate analysis, patients who underwent MIS had a shorter LOS [median 4 days (IQR 2-6 days) vs. 7 days (6-9 days), p < 0.001] and were more likely to be discharged home than to inpatient facilities [OR (95% CI) 13.00 (1.61-104.70), p = 0.02]. Robotic thoracic surgery program implementation at a VAMC decreased patient LOS and increased the likelihood of discharging home. Implementation at other VAMCs may be associated with improvement in some patient outcomes.

Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery.

OBJECTIVE: To investigate inpatient satisfaction with surgical resident care. BACKGROUND: Surgical trainees are often the primary providers of care to surgical inpatients, yet patient satisfaction with surgical resident care is not well characterized or routinely assessed. METHODS: English-speaking, general surgery inpatients recovering from elective gastrointestinal and oncologic surgery were invited to complete a survey addressing their satisfaction with surgical resident care. Patients positively identified photos of surgical senior residents and interns before completing a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Adapted S-CAHPS items were scored using the "top-box" method. RESULTS: Ninety percent of recruited patients agreed to participate (324/359, mean age=62.2, 50.3% male). Patients were able to correctly identify their seniors and interns 85% and 83% of the time, respectively ( P =0.14). On a 10-point scale, seniors had a mean rating of 9.23±1.27 and interns had a mean rating of 9.01±1.49 ( P =0.14). Ninety-nine percent of patients agreed it was important to help in the education of future surgeons. CONCLUSIONS: Surgical inpatients were able to recognize their resident physicians with high frequency and rated resident care highly overall, suggesting that they may serve as a willing source of feedback regarding residents' development of core competencies such as interpersonal skills, communication, professionalism, and patient care. Future work should investigate how to best incorporate patient evaluation of surgical resident care routinely into trainee assessment to support resident development.

Introduction of robotic surgery does not negatively affect cardiothoracic surgery resident experience.

The objective of this study was to evaluate the educational impact following the implementation of a robotic thoracic surgery program on cardiothoracic (CT) surgery trainees. We hypothesized that the introduction of a robotic thoracic surgery program would adversely affect the CT surgery resident experience, decreasing operative involvement and subsequent competency of surgical procedures. CT surgery residents and thoracic surgery attendings from a single academic institution were administered a recurring, electronic survey from September 2019 to September 2020 following each robotic thoracic surgery case. Surveys evaluated resident involvement and operative performance. This study was exempt from review by our Institutional Review Board. Attendings and residents completed surveys for 86 and 75 cases, respectively. Residents performed > 50% of the operation independently at the surgeon console in 66.2 and 73.3% of cases according to attending and resident responses, respectively. The proportion of trainees able to perform > 75% of the operation increased with each increasing year in training (p = 0.002). Based on the Global Evaluative Assessment of Robotic Skills grading tool, third-year residents averaged higher scores compared to first-year residents (22.9 versus 17.4 out of 30 possible points, p < 0.001), indicating that more extensive prior operative experience could shorten the learning curve of robotic thoracic surgery. CT surgery residents remain actively involved in an operative role during the establishment of a robotic thoracic surgery program. The transition to a robotic thoracic surgery platform appears feasible in a large academic setting without jeopardizing the educational experience of resident trainees.

Neonatal heart transplant outcomes: A single institutional experience.

OBJECTIVE: Neonatal orthotopic heart transplantation was introduced in the 1980s as a treatment for complex congenital heart disease. Progress in single-ventricle palliation and biventricular correction has resulted in a decline in neonatal heart transplant volume. However, limited reports on neonatal heart transplants have demonstrated favorable outcomes. We report the long-term outcomes of patients with neonatal heart transplants at our institution spanning nearly 30 years. METHODS: A retrospective analysis of neonatal heart transplants and neonates listed for transplant was performed at Children's Hospital Colorado. Primary outcomes were early and late survival. Secondary outcomes were rejection episodes, retransplantation, and development of cardiac allograft vasculopathy or post-transplant lymphoproliferative disease. RESULTS: A total of 21 neonates underwent orthotopic heart transplantation at our institution. Among these, 10 neonates were transplanted from 1991 to 2000, 8 neonates were transplanted from 2001 to 2010, and 3 neonates were transplanted from 2011 to 2020. The average age of these patients was 17 days, and the average weight was 3.43 kg. Early survival was 95.2%. Survival at 1 and 5 years was 85.7% (confidence interval [CI], 61.9%-95.2%) and 75% (CI, 45.6%-85.5%), respectively. Of eligible patients, the 10-year and 20-year survival was 72.2% (CI, 45.1%-85.3%) and 50% (CI, 25.9%-70.1%), respectively. CONCLUSIONS: Our institution reports favorable outcomes of neonatal heart transplantation. These results should be considered within the context of outcomes for patients awaiting transplant and the limited donor availability. However, the successful nature of these procedures suggest it may be necessary to reevaluate the indications for neonatal heart transplantation, particularly where risk of mortality and morbidity with palliative or corrective surgery is high.

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education.

OBJECTIVE: A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence. DESIGN: Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks. SETTING: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. PARTICIPANTS: Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation. RESULTS: 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05). CONCLUSION: Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.

Management of refractory Mycobacterium abscessus sternal infection following reoperative cardiac surgery.

Mycobacterium abscessus surgical site infections are rare, but notoriously difficult to treat. Eradication requires aggressive surgical resection, removal of foreign material, prolonged antibiotics, and consideration of delayed reconstruction.

A comparison of patient satisfaction when office-based procedures are performed by general surgery residents versus an attending surgeon.

BACKGROUND: Patient satisfaction is an increasingly important quality metric nationwide. The impact that surgical trainees have on patient-reported satisfaction when they perform operations independently, however, has not been studied. METHODS: We conducted a prospective study at a single academic institution from October 2016 to June 2017. An office-based, postprocedure survey was developed by adapting questions from the validated Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey. Top-box scoring was used to determine satisfaction for categorical questions and a comparison of the means was used for overall quality ratings (scale 0-10). Patients indicated whether their operation was completed by an attending surgeon or a postgraduate year 3 general surgery resident. The primary outcome measured was patient satisfaction with overall quality of care. Individual questions were grouped by phase of care and composite scores were measured as a secondary outcome. RESULTS: The survey response rate was 87.4% (n = 195). There were no differences in patient demographics or the types of procedures performed by residents or an attending surgeon. Excision of a soft tissue mass (ie, lipoma) accounted for 89.2% of all procedures performed (n = 174). There were no differences between preprocedure (resident = 92.5% vs attending = 94.2%) or postprocedure (resident = 95.3% vs attending = 97.7%) composite scores. There was, however, a significant difference in periprocedure satisfaction (resident = 78.7% vs attending = 90.7%, P = .02). There was no difference in overall ratings of quality of care given by patients who had their procedure performed by residents (9.8 ± 0.5) versus an attending surgeon (9.9 ± 0.3, P = .15). Finally, on adjusted analysis, resident care did not independently impact the likelihood of a "best possible care" rating for overall quality of care (odds ratio 0.84 ± 0.27, confidence interval 0.45-1.57, P = .58). CONCLUSION: Patient satisfaction was very high when residents independently performed minor surgery operations in an office-based setting. Of note, there was no difference in satisfaction with overall quality of care compared with an attending surgeon. This study demonstrates that high resident operative autonomy and patient satisfaction are not mutually exclusive goals when postgraduate year 3 residents perform office-based outpatient procedures.

Impact of Intra-Operative Adverse Events on the Risk of Surgical Site Infection in Abdominal Surgery.

BACKGROUND: Intra-operative adverse events (iAEs) recently were shown to correlate independently with an increased risk of post-operative death, morbidity, re-admissions, and length of hospital stay. We sought to understand further the impact of iAEs on surgical site infections (SSIs) in abdominal surgical procedures and delineate which patient populations are most affected. We hypothesized that all patients with iAEs have an increased risk for SSI, especially those with pre-existing risk factors for SSI. PATIENTS AND METHODS: To identify iAEs, a well-described three-step methodology was used: (1) the 2007-2012 American College of Surgeons-National Surgical Quality Improvement Program database was merged with the administrative database of our tertiary academic center, (2) the merged database was screened for iAEs in abdominal surgical procedures using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "Accidental Puncture/Laceration," and (3) each flagged record was systematically reviewed to confirm iAE occurrence. Uni-variable and backward stepwise multi-variable analyses (adjusting for demographics, co-morbidities, type and complexity of operation) were performed to study the independent correlation between iAEs and SSIs (superficial, deep incisional, and organ-space). The correlation between iAEs and SSIs was investigated especially in patients deemed a priori at high risk for SSIs, specifically those older than age 60 and those with diabetes mellitus, obesity, cigarette smoking, steroid use, or American Society of Anesthesiologists class ≥III. RESULTS: A total of 9,288 operations were included, and iAEs were detected in 183 (2.0%). Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intra-operatively (92%). SSI occurred in 686 (7.4%) cases and included 331 (3.5%) superficial, 32 (0.34%) deep incisional, and 333 (3.6%) organ/space infections. iAEs were correlated independently with SSI (odds ratio [OR] = 1.67; 95% confidence interval [CI], 1.11-2.52, p = 0.013), and more severe iAEs were associated with a higher risk of infection. Analysis by SSI type revealed a significant association with organ/space SSI (OR = 1.81, 95% CI 1.07-3.05; p = 0.027), but not incisional infections. Most interestingly, the occurrence of an iAE was correlated with increased SSI rate in the low-risk but not the high-risk patient populations. Specifically, iAEs increased SSI in patients younger than 60 (OR = 2.69, 95% CI 1.55-4.67, p < 0.001), non-diabetic patients (OR = 1.64, 95% CI 1.04-2.58, p = 0.034), non-obese patients (OR = 2.9, 95% CI 1.81-4.66, p < 0.001), non-smokers (OR = 1.67, 95% CI 1.08-2.6, p = 0.022), with no steroid use (OR = 1.73, 95% CI 1.15-2.6, p < 0.008), and with ASA class

Do Not Blame the Resident: the Impact of Surgeon and Surgical Trainee Experience on the Occurrence of Intraoperative Adverse Events (iAEs) in Abdominal Surgery.

OBJECTIVE: Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs. DESIGN: The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (<6 years, 6-13 years, 13-20 years, >20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs. SETTING: A large tertiary care teaching hospital. PARTICIPANTS: Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident. RESULTS: A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with <6, 6-13, 13-20, and >20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with >20 years of experience compared to those with <6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs. CONCLUSIONS: The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.

A Pilot Study of Inpatient Satisfaction Rating of Surgical Resident Care.

OBJECTIVE: To describe inpatient satisfaction with surgical resident care given the increasing importance of patient satisfaction as a quality metric. DESIGN: Surgical inpatients were invited to complete a survey that addressed their satisfaction with and attitudes regarding surgical resident care. The survey was based on the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Patients were required to positively identify photos of resident physicians prior to providing ratings. Adapted S-CAHPS items were scored using the "top-box" method. SETTING: Massachusetts General Hospital, a tertiary academic center. PARTICIPANTS: General surgery inpatients recovering from elective, major abdominal surgery were recruited on postoperative days 2 to 4. RESULTS: Ninety-one percent of approached patients participated (102/112, mean age = 62.9, 51.6% male). Patients positively identified both seniors and interns 88% of the time. Thirteen seniors and 19 interns were rated, with 1 to 14 evaluations per trainee. Overall quality of care ratings for seniors and interns were 9.35 and 9.09, respectively (0-10 scale, 10 = "best possible care"). Sixty-three percent of senior resident evaluations and 60% of intern evaluations received a score of 10. The proportion of residents receiving top-box scores ranged from 59.5% to 97.7% depending on the item. Forty percent of senior resident and 38% of intern evaluations received top-box scores for all 8 items. Over 96% of patients reported strong or moderate agreement with the statements "I feel it is important to help in the education of future surgeons." CONCLUSIONS: Surgical inpatients willingly completed ratings about their surgery residents, typically can recognize their resident physicians, and rate quality of care highly. Despite many high ratings, there is room for improvement in some S-CAHPS domains. These results indicate patients are a valuable source of feedback regarding a resident's progress in several core competencies such as interpersonal skills, communication, professionalism, and patient care.

Hospital Teaching Status and Readmission after Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Readmission after abdominal aortic aneurysm (AAA) repair to a different (nonindex) hospital has been shown to be associated with high mortality rates. Factors influencing this association remain unknown. The objective of this study was to determine the impact of hospital teaching status on nonindex hospital readmission and mortality. METHODS: An observational analysis of the longitudinally linked California Office of Statewide Health Planning and Development database was conducted from 1995 to 2009. Patients who were readmitted within 30 days after open AAA repair were included. The primary outcome measured was mortality on readmission. RESULTS: Over the 15-year study period, 3,475 readmissions after AAA were analyzed, of which 1,020 (29.4%) were to a nonindex hospital. After adjusting for age, race, gender, insurance, comorbidities, perioperative factors, and reason for readmission, nonindex readmission for patients undergoing their initial operation at a teaching hospital did not impact mortality (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.28-2.17, P = 0.63). Nonindex readmission for patients undergoing their initial operation at a nonteaching hospital, however, significantly increased mortality (OR 1.63, 95% CI 1.04-2.54, P = 0.03). CONCLUSIONS: Readmission to a different hospital is associated with a higher mortality rate for patients undergoing AAA repair at nonteaching hospitals. This effect is not seen in patients having their initial operation performed at teaching hospitals, possibly due to infrastructure at these hospitals allowing for decreased impact from fragmentation of care. In cases where triage to an index hospital for readmission is not possible, communication at a high level between the index hospital and readmission hospital is paramount.

Structured Operative Autonomy: An Institutional Approach to Enhancing Surgical Resident Education Without Impacting Patient Outcomes.

BACKGROUND: Although barriers to granting surgical residents autonomy in the operating room are well described, few have proposed practical strategies to overcome these barriers. Our department adopted a multidisciplinary approach to develop a rotation that aimed to grant chief residents structured operative autonomy. In this study, we assess the feasibility of implementation, impact on patient safety, and educational benefit to residents after the program's pilot year. STUDY DESIGN: During a 1-month rotation, chief residents began cases alone using their own operative block time. The attending surgeon was notified when the critical portion of the operation was reached and supervised its completion. Postoperative complications, intraoperative adverse events, readmissions, operation duration, and length of stay in a subset of patients that underwent a cholecystectomy or appendectomy were compared with patients operated on by standard resident services. Follow-up surveys were administered to residents 1 year after graduation. RESULTS: One hundred and twenty-four operations, which ranged in complexity, were performed by chief residents. Unadjusted subset analysis comparing the structured operative autonomy (n = 54) and standard resident (n = 718) services outcomes for appendectomies and cholecystectomies revealed no significant differences in 30-day postoperative complications (5.6% vs 4.0%; p = 0.59), major intraoperative adverse events, or readmissions (3.7% vs 3.8%; p = 1.00), respectively. Multivariate analysis performed for 30-day complications (odds ratio 0.8; 95% CI 0.2 to 3.2; p = 0.76) and readmissions (odds ratio 0.4; 95% CI 0.1 to 2.1; p = 0.3) corroborated unadjusted findings. All participants (n = 8) strongly agreed that the rotation eased their transition to fellowship or independent practice. CONCLUSIONS: Structured operative autonomy overcomes known barriers to granting chief residents autonomy in the operating room. When used for select general surgery cases, resident education is enhanced without impacting patient outcomes. This training model has the potential to improve the surgical independence of graduating residents.

The Resident-Run Minor Surgery Clinic: A Pilot Study to Safely Increase Operative Autonomy.

OBJECTIVE: General surgery training has evolved to align with changes in work hour restrictions, supervision regulations, and reimbursement practices. This has culminated in a lack of operative autonomy, leaving residents feeling inadequately prepared to perform surgery independently when beginning fellowship or practice. A resident-run minor surgery clinic increases junior resident autonomy, but its effects on patient outcomes have not been formally established. This pilot study evaluated the safety of implementing a resident-run minor surgery clinic within a university-based general surgery training program. DESIGN: Single institution case-control pilot study of a resident-run minor surgery clinic from 9/2014 to 6/2015. Rotating third-year residents staffed the clinic once weekly. Residents performed operations independently in their own procedure room. A supervising attending surgeon staffed each case prior to residents performing the procedure and viewed the surgical site before wound closure. Postprocedure patient complications and admissions to the hospital because of a complication were analyzed and compared with an attending control cohort. SETTING: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. PARTICIPANTS: Ten third-year general surgery residents. RESULTS: Overall, 341 patients underwent a total of 399 procedures (110 in the resident clinic vs. 289 in the attending clinic). Minor surgeries included soft tissue mass excision (n = 275), abscess incision and drainage (n = 66), skin lesion excision (n = 37), skin tag removal (n = 15), and lymph node excision (n = 6). There was no significant difference in the overall rate of patients developing a postprocedure complication within 30 days (3.6% resident vs. 2.8% attending; p = 0.65); which persisted on multivariate analysis. Similar findings were observed for the rate of hospital admission resulting from a complication. Resident evaluations overwhelmingly supported the rotation, citing increased operative autonomy as the greatest strength. CONCLUSIONS: Implementation of a resident-run minor surgery clinic is a safe and effective method to increase trainee operative autonomy. The rotation is well suited for mid-level residents, as it provides an opportunity for realistic self-evaluation and focused learning that may enhance their operative experience during senior level rotations.

A20 Haploinsufficiency Aggravates Transplant Arteriosclerosis in Mouse Vascular Allografts: Implications for Clinical Transplantation.

BACKGROUND: Inflammation is central to the pathogenesis of transplant arteriosclerosis (TA). We questioned whether physiologic levels of anti-inflammatory A20 influence TA severity. METHODS: We performed major histocompatibility complex mismatched aorta to carotid artery interposition grafts, using wild type (WT) or A20 heterozygote (HET) C57BL/6 (H-2) donors and BALB/c (H-2) recipients, and conversely BALB/c donors and WT/HET recipients. We analyzed aortic allografts by histology, immunohistochemistry, immunofluorescence, and gene profiling (quantitative real-time reverse-transcriptase polymerase chain reaction). We validated select in vivo A20 targets in human and mouse smooth muscle cell (SMC) cultures. RESULTS: We noted significantly greater intimal hyperplasia in HET versus WT allografts, indicating aggravated TA. Inadequate upregulation of A20 in HET allografts after transplantation was associated with excessive NF-кB activation, gauged by higher levels of IkBα, p65, VCAM-1, ICAM-1, CXCL10, CCL2, TNF, and IL-6 (mostly localized to SMC). Correspondingly, cytokine-induced upregulation of TNF and IL-6 in human and mouse SMC cultures inversely correlated with A20 expression. Aggravated TA in HET versus WT allografts correlated with increased intimal SMC proliferation, and a higher number of infiltrating IFNγ and Granzyme B CD4 T cells and natural killer cells, and lower number of FoxP3 regulatory T cells. A20 haploinsufficiency in allograft recipients did not influence TA. CONCLUSIONS: A20 haploinsufficiency in vascular allografts aggravates lesions of TA by exacerbating inflammation, SMC proliferation, and infiltration of pathogenic T cells. A20 single nucleotide polymorphisms associating with lower A20 expression or function in donors of vascularized allografts may inform risk and severity of TA, highlighting the clinical implications of our findings.