SAGES White Paper on the importance of diversity in surgical leadership: creating the fundamentals of leadership development (FLD) curriculum.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has long recognized and championed increasing diversity within the surgical workplace. SAGES initiated the Fundamentals of Leadership Development (FLD) Curriculum to address these needs and to provide surgeon leaders with the necessary tools and skills to promote diversity, equity, and inclusion (DEI) in surgical practice. In 2019, the American College of Surgeons issued a request for anti-racism initiatives which lead to the partnering of the two societies. The primary goal of FLD was to create the first surgeon-focused leadership curriculum dedicated to DEI. The rationale/development of this curriculum and its evaluation/feedback methods are detailed in this White Paper. METHODS: The FLD curriculum was developed by a multidisciplinary task force that included surgeons, education experts, and diversity consultants. The curriculum development followed the Analysis, Design, Development, Implementation and Evaluation (ADDIE) instructional design model and utilized a problem-based learning approach. Competencies were identified, and specific learning objectives and assessments were developed. The implementation of the curriculum was designed to be completed in short intervals (virtual and in-person). Post-course surveys used the Kirkpatrick's model to evaluate the curriculum and provide valuable feedback. RESULTS: The curriculum consisted of interactive online modules, an online discussion forum, and small group interactive sessions focused in three key areas: (1) increasing pipeline of underrepresented individuals in surgical leadership, (2) healthcare equity, and (3) conflict negotiation. By focusing on positive action items and utilizing a problem-solving approach, the curriculum aimed to provide a framework for surgical leaders to make meaningful changes in their institutions and organizations. CONCLUSION: The FLD curriculum is a novel leadership curriculum that provided surgeon leaders with the knowledge and tools to improve diversity in three areas: pipeline improvement, healthcare equity, and conflict negotiation. Future directions include using pilot course feedback to enhance curricular effectiveness and delivery.

A novel preoperative score to predict severe acute cholecystitis.

BACKGROUND: In a large multicenter trial, The Parkland Grading Scale(PGS) for acute cholecystitis outperformed other grading scales and has a positive correlation with complications but is limited in its inability to preoperatively predict high-grade cholecystitis. We sought to identify preoperative variables predictive of high-grade cholecystitis(PGS 4 or 5). METHODS: In a six-month period, patients undergoing cholecystectomy at a single institution with prospectively graded PGS were analyzed. Stepwise logistic regression models were constructed to predict high-grade cholecystitis. The relative weight of the variables was used to derive a novel score, the Severe Acute Cholecystitis Score(SACS). This score was compared to the Emergency Surgery Acuity Score(ESS), American Association for the Surgery of Trauma(AAST) preoperative score and Tokyo Guidelines(TG) for their ability to predict high-grade cholecystitis. SACS was then validated using the database from the AAST multicenter validation of the grading scale for acute cholecystitis. RESULTS: Of the 575 patients that underwent cholecystectomy, 172(29.9%) were classified as high-grade. The stepwise logistic regression modeling identified 7 independent predictors of high-grade cholecystitis. From these variable the SACS was derived. Scores ranged from 0 to 9 points with a C statistic of 0.76, outperforming the ESS(C statistic of 0.60), AAST(0.53), and TG(0.70)(p-value <0.001). Using a cutoff of 4 or more on the SACS correctly identifies 76.2% of cases with a specificity of 91.3% and a sensitivity of 40.7%.In the multicenter database, there were 464 patients with a prospectively collected PGS. The C statistic for SACS was 0.74. Using the same cutoff of 4, SACS correctly identifies 71.6% of cases with a specificity of 83.8% and a sensitivity of 52.2%. CONCLUSIONS: The Severe Acute Cholecystitis Score can preoperatively predict high-grade cholecystitis and may be useful for counseling patients and assisting in surgical decision making. LEVEL OF EVIDENCE: Prognostic Level III.

Imaging acute cholecystitis, one test is enough.

BACKGROUND: Patients with right upper quadrant pain are often imaged using multiple modalities with no established gold standard. A single imaging study should provide adequate information for diagnosis. METHODS: A multicenter study of patients with acute cholecystitis was queried for patients who underwent multiple imaging studies on admission. Parameters were compared across studies including wall thickness (WT), common bile duct diameter (CBDD), pericholecystic fluid and signs of inflammation. Cutoff for abnormal values were 3 mm for WT and 6 mm for CBDD. Parameters were compared using chi-square tests and Intra-class correlation coefficients (ICC). RESULTS: Of 861 patients with acute cholecystitis, 759 had ultrasounds, 353 had CT and 74 had MRIs. There was excellent agreement for wall thickness (ICC = 0.733) and bile duct diameter (ICC = 0.848) between imaging studies. Differences between wall thickness and bile duct diameters were small with nearly all <1 mm. Large differences (>2 mm) were rare (<5%) for WT and CBDD. CONCLUSIONS: Imaging studies in acute cholecystitis generate equivalent results for typically measured parameters.

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.

A Rare Case of Acute Pancreatitis in the Setting of Hemorrhagic Cholecystitis.

Hemorrhagic cholecystitis is a rare form of acute cholecystitis with very few cases reported in the literature. We report a novel case of a 79-year-old male who developed hemorrhagic cholecystitis and concomitant acute pancreatitis. The patient presented to the emergency department with a one-day history of severe epigastric pain radiating to his back. The patient was on an anticoagulant therapy for a history of pulmonary embolism. He had an elevated serum lipase and on a right upper quadrant ultrasound, a mildly distended gallbladder without stones was noted. Computed tomography (CT) the following day demonstrated heterogenous material in the gallbladder concerning for blood clots. Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) was performed that revealed a gallbladder filled with clots. He had an uneventful post-operative recovery.

"How to" Course for Resident Reviewers: from the Resident and Fellow Education Committee of the Society for Surgery of the Alimentary Tract (SSAT).

The Resident and Fellow Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) hosted a "How to" course for resident reviewers at the 2021 Annual Meeting at Digestive Disease Week. This panel drew from their extensive experience to help neophyte reviewers perform high quality, comprehensive peer reviews. Dr. Snyder kicked off the session with "Why Should I be a Resident Reviewer?" Dr. Talamini followed by "Defining the Review Process," while Dr. Keller presented "OK, You Are Ready to Review, Where to Start?" Dr. Pawlik ended the session with "How to Be an Excellent Reviewer." Residents are encouraged to apply the content from these sessions to volunteer as reviewers and develop critical skills to help further their academic surgery career.

Revision of the AAST grading scale for acute cholecystitis with comparison to physiologic measures of severity.

BACKGROUND: Grading systems for acute cholecystitis are essential to compare outcomes, improve quality, and advance research. The American Association for the Surgery of Trauma (AAST) grading system for acute cholecystitis was only moderately discriminant when predicting multiple outcomes and underperformed the Tokyo guidelines and Parkland grade. We hypothesized that through additional expert consensus, the predictive capacity of the AAST anatomic grading system could be improved. METHODS: A modified Delphi approach was used to revise the AAST grading system. Changes were made to improve distribution of patients across grades, and additional key clinical variables were introduced. The revised version was assessed using prospectively collected data from an AAST multicenter study. Patient distribution across grades was assessed, and the revised grading system was evaluated based on predictive capacity using area under receiver operating characteristic curves for conversion from laparoscopic to an open procedure, use of a surgical "bail-out" procedure, bile leak, major complications, and discharge home. A preoperative AAST grade was defined based on preoperative, clinical, and radiologic data, and the Parkland grade was also substituted for the operative component of the AAST grade. RESULTS: Using prospectively collected data on 861 patients with acute cholecystitis the revised version of the AAST grade has an improved distribution across all grades, both the overall grade and across each subscale. A higher AAST grade predicted each of the outcomes assessed (all p ≤ 0.01). The revised AAST grade outperformed the original AAST grade for predicting operative outcomes and discharge disposition. Despite this improvement, the AAST grade did not outperform the Parkland grade or the Emergency Surgery Score. CONCLUSION: The revised AAST grade and the preoperative AAST grade demonstrated improved discrimination; however, a purely anatomic grade based on chart review is unlikely to predict outcomes without addition of physiologic variables. Follow-up validation will be necessary. LEVEL OF EVIDENCE: Diagnostic Test or Criteria, Level IV.

Incarcerated Diaphragmatic Hernias After Roux-en-Y Gastric Bypass.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common operations performed for morbid obesity. Some of the known surgical complications include anastomotic leaks and small bowel obstructions due to internal hernias. Diaphragmatic hernias are common in the general population, and repair of symptomatic hernias is generally recommended. Diaphragmatic hernia after a prior LRYGB is markedly less common. Diaphragmatic hernias can occur via a hiatal defect or rarely a parahiatal defect that is found lateral to the hiatus. We present two cases of incarcerated diaphragmatic hernias after a LRYGB with vastly different presentations. The first patient presented with a giant defect containing incarcerated jejunum after a prior LRYGB. The second patient presented with a parahiatal defect with an incarcerated remnant stomach. The first patient was successfully managed laparoscopically by reinforcing the defect with a mesh after defect closure. The second patient required an open operation due to the inability to reduce the tightly incarcerated stomach and defect approximated with sutures without the need for mesh reinforcement. Both patients did well postoperatively and remain symptom-free.

Multicenter validation of the American Association for the Surgery of Trauma grading scale for acute cholecystitis.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) patient assessment committee has created grading systems for emergency general surgery diseases to assist with clinical decision making and risk adjustment during research. Single-institution studies have validated the cholecystitis grading system as associated with patient outcomes. Our aim was to validate the grading system in a multi-institutional fashion and compare it with the Parkland grade and Tokyo Guidelines for acute cholecystitis. METHODS: Patients presenting with acute cholecystitis to 1 of 8 institutions were enrolled. Discrete data to assign the AAST grade were collected. The Parkland grade was collected prospectively from the operative surgeon from four institutions. Parkland grade, Tokyo Guidelines, AAST grade, and the AAST preoperative grade (clinical and imaging subscales) were compared using linear and logistic regression to the need for surgical "bailout" (subtotal or fenestrated cholecystectomy, or cholecystostomy), conversion to open, surgical complications (bile leak, surgical site infection, bile duct injury), all complications, and operative time. RESULTS: Of 861 patients, 781 underwent cholecystectomy. Mean (SD) age was 51.1 (18.6), and 62.7% were female. There were six deaths. Median AAST grade was 2 (interquartile range [IQR], 1-2), and median Parkland grade was 3 (interquartile range [IQR], 2-4). Median AAST clinical and imaging grades were 2 (IQR, 2-2) and 1 (IQR, 0-1), respectively. Higher grades were associated with longer operative times, and worse outcomes although few were significant. The Parkland grade outperformed the AAST grade based on area under the receiver operating characteristic curve. CONCLUSION: The AAST cholecystitis grading schema has modest discriminatory power similar to the Tokyo Guidelines, but generally lower than the Parkland grade, and should be modified before widespread use. LEVEL OF EVIDENCE: Diagnostic study, level IV.

Assessment of the American College of Surgeons National Surgical Quality Improvement Program Calculator in Predicting Outcomes and Length of Stay After Ivor Lewis Esophagectomy: A Single-Center Experience.

BACKGROUND: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) calculator is a useful tool used by physicians to better inform patients on the surgical risk of postoperative complications. It makes use of the NSQIP database to derive the chance for several adverse outcomes to occur postoperatively given certain patient's factors. The aim of this study was to assess its applicability in a series of patients undergoing an Ivor Lewis esophagectomy. METHODS: Data from 100 consecutive patients who underwent an Ivor Lewis esophagectomy between September 2013 and November 2017 at our institution were reviewed. Each patient was assessed using the ACS NSQIP surgical risk calculator. Actual events in this group were compared with their particular NSQIP-assessed risk. Logistic regression models were used to compare surgical risk calculator estimates binary outcomes such as incidence of postoperative complications such as cardiac events, renal events, surgical site infection, and death. Mixed linear model was used for length of stay (LOS) duration versus observed LOS. C-statistic was for predictive accuracy each binary outcome and intraclass correlation was used for LOS. RESULTS: C-statistic values were higher than the cutoff (0.75) for surgical site infection and death. The ACS NSQIP risk calculator was poorly predictive of other reported outcomes by the calculator such as cardiac or renal complications. Corroboration between observed LOS and predicted LOS was weak (8 d versus 11 d, respectively, intraclass coefficient 0.04). CONCLUSIONS: This study suggests that the risk calculator is useful for identifying risk of death or surgical site infection but poor at discriminating likelihood of other reported outcomes occurring, such as pneumonia, acute renal failure and cardiac complications for patients who underwent an Ivor Lewis esophagectomy. Estimations for procedure-specific complications for esophagectomy may need reevaluated.

MR imaging findings of calcinosis cutis in primary Sjogren syndrome, a rare manifestation.

Soft tissue calcifications associated with various connective tissue diseases such as dermatomyositis and scleroderma have been well documented Plaque-like sheets of subcutaneous calcifications presenting as an indurated soft tissue mass in a patient with primary Sjogren syndrome have been rarely documented in the literature. We present the magnetic resonance and conventional radiographic findings of calcinosis cutis and calcinosis circumscripta of a 47-year-old woman with biopsy proven Sjogren syndrome. We also delineate various types of soft tissue calcification, histopathology of calcinosis cutis, and current treatment options. Recognizing the magnetic resonance characteristics of this phenomenon may prove useful to radiologists, especially in the absence of clinical history and conventional radiographs.

Minimally Invasive Ivor Lewis Esophagectomy (MILE): technique and outcomes of 100 consecutive cases.

BACKGROUND: Esophagectomy is the mainstay of therapy for esophageal cancer but is a complex operation that is associated with significantly high morbidity and mortality rates. The primary aim of this study is to report our perioperative outcomes, and long-term survival of Minimally Invasive Ivor Lewis Esophagectomy (MILE). METHODS: IRB approved retrospective study of 100 consecutive patients who underwent elective MILE from September 2013 to November 2017 at University of Florida, Jacksonville. RESULTS: Primary diagnosis was esophageal cancer (n = 96) and benign esophageal disease (n = 4). Anastomotic leak rate was observed in 6%; 30- and 90-day mortality rates were 2% and 3%, respectively. The mean length of hospital stay was 10.3 days; 87 patients were discharged to home, while 12 patients were discharged to rehabilitation facility, and there was one in-hospital mortality secondary to graft necrosis. At a mean follow-up was 37 months (2-74), the 3- and 5-year overall survivals are 63.9 ± 5.0% (95% CI 53.3-72.7%) and 60.5 ± 5.3% (95% CI 49.4-69.9%), respectively. The 3- and 5-year disease-free survival is 75.0 ± 4.8% (95% CI 64.2-83.0%) and 70.4 ± 5.5% (95% CI 58.0-80.0%). CONCLUSION: MILE can be performed with low perioperative mortality, and favorable long-term overall and disease-free survival.

The Spectrum of Surgical Remediation of Transoral Incisionless Fundoplication-Related Failures.

AIM: To evaluate outcomes of surgical remediation for symptomatic or anatomic failure after a transoral incisionless fundoplication (TIF). METHODS: This retrospective study was performed on 11 patients who underwent a remedial operation following TIF failure between June 2011 and September 2016 at the Mayo Clinic in Florida for persistent foregut symptoms. Upper gastrointestinal workup characterized 1 patient as having normal post-TIF anatomy and 10 as having anatomic failure. Ambulatory pH testing was performed in 7 patients and was abnormal in all. All patients underwent a laparoscopic takedown of the prior endoscopic fundoplication and removal of all accessible polypropylene T-fasteners. RESULTS: All patients had esophageal salvage and have not required a reoperation. Anatomical findings included hiatal hernia (7), esophageal diverticulum (2), hiatal mesh erosion of esophagus (1), long-segment esophageal stricture (1), and normal anatomy (1). Remedial operations included laparoscopic explant of fasteners in all patients with conversion to fundoplication (7), resection/imbrication of esophageal diverticulum (2), Heller myotomy (1), and mesh explant and complex esophageal repair (1). Mean operative time was 177 minutes and median length of stay 3 days (range 2-13 days). At mean follow-up of 10.7 months (range 1-42 months), 7 patients had persistent complaints. Esophagogastroduodenoscopy was repeated in these 7 patients and was normal (n = 3), mild stenosis requiring dilation (n = 2), Los Angeles grade B esophagitis (n = 1), and Barrett's esophagus (n = 1). CONCLUSION: Anatomic distortion of the distal esophagus after TIF can be significant, making subsequent operations complex. After remedial surgery, few patients will continue to have troublesome symptoms such as dysphagia.

Correction to: Endoscopic and surgical management of nonampullary duodenal neoplasms.

This article was updated to correct the author listing for Carlos Roberto Simons-Linares.

Endoscopic and surgical management of nonampullary duodenal neoplasms.

BACKGROUND: Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD). METHODS: We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients. RESULTS: Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention. CONCLUSIONS: Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.

Pancreaticoduodenectomy and Outcomes for Groove Pancreatitis.

BACKGROUND/AIMS: The operative management of groove pancreatitis (GP) is still a matter of controversy and pancreaticoduodenectomy (PD) can be a high-risk procedure for patients. The aim of this study was to report our 9-year experience of surgical resection for GP and to review relevant literature. METHODS: A retrospective review of patients undergoing pancreatectomy for GP from August 1, 2008, through May 31, 2017 was performed. Patients with clinical, radiologic, and final pathologic confirmation of GP were included. Literature on the current understanding of GP was reviewed. RESULTS: Eight patients from total 449 pancreatectomies met inclusion criteria. Four male and 4 female patients (mean age, 51.9 years; mean body mass index, 25.3) underwent pylorus-preserving pancreatoduodenectomy (3 by laparoscopy and 5 by open approach). Mean (range) operative time and blood loss was 343 (167-525) min and 218 (40-500) mL respectively. Pancreatic fistula and delayed gastric emptying were noted in one patient each. No major complications occurred, but minor complications occurred in 5 (62%) patients. Mean hospital stay was 6.1 (range 3-14) days. At median follow-up of 18.15 (interquartile range 7.25-33.8) months, all patients experienced a resolution of pancreatitis and improvement in symptoms. CONCLUSIONS: PD is a safe procedure for GP. Short-term surgical outcomes are acceptable and long-term outcomes are associated with improved symptom control.

Transthoracic repair of slipped Nissen fundoplications: technique and results.

BACKGROUND: Laparoscopic Nissen fundoplication is a common operation performed for reflux disease, generally with good results. A small percentage of patients experience transthoracic migration of the wrap, causing recurrent symptoms and eventually requiring transthoracic repair. METHODS: A retrospective chart review was performed for all patients who underwent a transthoracic repair of a slipped Nissen fundoplication at our institution from 2006 to 2010. Data included demographics, previous antireflux operations, symptoms at presentation, findings at operation, and overall outcome. RESULTS: Sixteen patients with a mean age of 61 years (range, 51-76 years) were identified who fit inclusion criteria. The most common presenting symptom was pain. Intraoperative findings included hiatal breakdown in all patients, shortened esophagus in 10 (62%) patients, and foreign body/mesh in 4 (25%) patients. Nine (56%) patients underwent a Collis gastroplasty along with a Nissen fundoplication. Nissen fundoplication alone was performed in 6 (38%) patients and a Belsey fundoplication with a Collis gastroplasty was performed in 1 (6%) patient. Minor complications occurred in 4 (25%) patients and major complications were seen in 2 (13%) patients. The median length of stay was 9 days (range, 6-30 days). There were no postoperative deaths. Overall, 12 (75%) of the patients were judged to have a good outcome, 3 (19%) a fair outcome, and 1 (6%) a poor outcome over a median 9-month follow-up. CONCLUSIONS: Transthoracic repair in patients who have had transthoracic migration of a previous Nissen fundoplication has acceptable surgical outcome and affords symptomatic relief to the majority of patients.

Sentinel lymph node biopsy in primary breast cancer: window to management of the axilla.

In patients with primary breast cancer, several large, randomized prospective trials have shown that sentinel node biopsy (SNB) substantially reduces the morbidity associated with axillary surgery compared with formal axillary lymph node dissection (ALND). Moreover, the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 trial has demonstrated that when the sentinel node reveals no evidence of metastatic disease, then no further ALND is required. Recently, the results of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial have challenged the notion that all patients with metastases to the sentinel node require ALND. The results of this trial suggest that in selected sentinel node-positive patients, ALND can be potentially avoided. Yet, some concerns about the ACOSOG Z0011 trial have been raised, and these concerns may have implications in the widespread implementation of the results of this trial. Since the advent of the SNB technology, occult metastases within the sentinel node are frequently observed, and the significance of these findings remains controversial. Finally, this review considers special situations, such as pregnancy and the neoadjuvant setting, where the use of SNB should be applied judiciously. The SNB technology has dramatically improved the quality of life for women with breast cancer, and further modifications of its role in breast cancer treatment should be based on evidence obtained from randomized, controlled trials.