Introductory Video as a Supplemental Application for General Surgery Residency Candidates: Concept, Implementation, Preliminary Outcomes, and Future Directions.

OBJECTIVE: The residency selection process has changed dramatically over the past several years, primarily due to the COVID-19 pandemic causing a transition to virtual interviews and limiting sub-internship opportunities. Another new major change is the transition of the USMLE Step 1 examination from a numerical score to pass/fail as of January 2022. In anticipation of this major change, our program asked applicants to submit a short video clip expressing their interest. PARTICIPANTS: Review of each of the videos was completed by three members of the admission committee and each reviewer was required to complete formal implicit bias training prior to reviewing the videos. RESULTS: Over 1200 general surgery residency applications were received via the Electronic Residency Application Service (ERAS) for the 2022-2023 application cycle. 286 applicants were selected for a formal interview invitation and asked to submit a 2-minute introductory video. In response, 222 (77.62%) of the 286 cohort submitted introductory videos. 210 of these videos (94.59%) were submitted within the first week. The average length of the videos submitted was 105.10 seconds. CONCLUSION: Using optional introductory videos as a supplemental application has helped to narrow the applicant pool and identify individuals to offer interviews.

Inverted Meckel's Diverticulum Causing Adult Intussusception after Blunt Trauma.

Meckel's diverticulum is an uncommon though well described clinical entity. There are few cases of a Meckel's diverticulum having been identified as the lead point for adult intussusception. We report the surgical management of a 45-year-old patient with an inverted Meckel's diverticulum causing distal ileal intussusception after blunt abdominal trauma requiring small bowel resection.

Evaluating the Efficacy of Surgical Consent.

BACKGROUND: Patient autonomy is the most important of the core values of medical ethics, yet the process of obtaining surgical consent remains a lesser scrutinized area of modern surgical practice. Informed consent implies a patient's understanding of nature of the operation, indications, risks, benefits, and alternatives. Surgical consent has traditionally been obtained through verbal communication and formalized by signing a legal document. This process oftentimes leaves patients unequipped with adequate knowledge about the procedure they just consented to. In most cases, it is simply impossible for the non-medically trained layperson to fully understand the nuances of surgery in a conversation. Some may argue a degree of paternalism may be inevitable; we believe there is room for improvement. METHODS: We chose to examine English-speaking adult patients undergoing common procedures (laparoscopic cholecystectomy, open inguinal hernia repair, and skin mass/soft tissue excision). We asked 71 patients to complete a free response survey on the risks, benefits, and alternatives to the operation they had just consented to. The patients were administered the survey either in the outpatient clinic or in the preoperative area. RESULTS: Our analysis showed that most of our patients understand the inherent risks, benefits, and alternatives when being consented but that less than 50% of those consented were considered to have adequate understanding of the procedures they were consented for. DISCUSSION: This study highlights key deficits and potential areas of improvement in the informed consent process. Based on the results, we have significant room for improvement and the responsibility to do so.

Perforated Appendicitis With Migrated Inguinal Mesh Involvement.

Mesh-plug hernioplasty has been recognized as a safe and effective surgical repair for primary inguinal hernias and is a common procedure in the United States. Critics of the mesh-plug system describe erosion, migration, and chronic pain as reasons not to employ mesh plugs in primary hernia repair. To our knowledge, mesh graft infection associated with perforated acute appendicitis has been documented only once before in the surgical literature, highlighting an exceedingly rare but possible complication. We report the therapeutic management of a 50-year-old male with perforated appendicitis associated with a mesh-plug from previous open herniorrhaphy requiring mesh explantation and small bowel resection.

The value of the pretreatment neutrophil lymphocyte ratio vs. platelet lymphocyte ratio in predicting the long-term survival in colorectal cancer.

BACKGROUND: The neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) have been well studied as inflammatory markers and predictors for outcomes in colorectal cancer patients. Our aim was to determine the predictive value of both above ratios in colorectal cancer patients. METHODS: This is a longitudinal retrospective study of a prospectively maintained database, included 580 patients, who had a complete blood count recorded before treatment (surgery or chemotherapy). We excluded patients presented with obstruction, infection, active hematological disease or those receiving steroid. The primary outcome (4-year cancer-related mortality) was obtained from our cancer registry. RESULTS: The 4-year cancer-related mortality rate in the 3rd tertile of NLR was 37% in comparison with 13% and 19% in lower tertiles, P value < 0.001. Similarly the 3rd tertile of PLR was 32% with 18% and 19% in lower tertiles, P value < 0.0005. In the multivariate survival analyses, elevated NLR was associated with higher mortality (a hazard ratio of 2.31(1.4-3.8) for the highest tertile and 5% increase in mortality for each unit increase in NLR, p < 0.001). Similarly, elevated NLR was a significant predictor for a worse disease-free survival. However, PLR was not significant predictor of mortality when adjusted for other confounding variables. CONCLUSION: Elevated pretreatment NLR is an independent predictor of both worse overall and disease free survival in colorectal cancer, whereas PLR was not after adjusting for confounding variables.

The value of the pretreatment albumin/globulin ratio in predicting the long-term survival in colorectal cancer.

BACKGROUND: Low serum albumin was found as a predictor of long-term mortality in colorectal cancer (CRC) patients. Our aim was to evaluate the value of the pretreatment albumin/globulin ratio (AGR) to predict the long-term mortality in CRC patients. METHODS: Patients were included if they had comprehensive metabolic panel (CMP) before treatment (surgery or chemotherapy). The albumin/globulin ratio, routinely reported in CMP, is calculated [AGR = Albumin/(Total protein - Albumin)]. Patients were divided into three equal tertiles according to their pretreatment AGR. The primary outcome was cancer-related mortality, which was obtained from our cancer registry database. RESULTS: A total of 534 consecutive CRC patients had pretreatment CMP. The 1st AGR tertile had a significant higher 4-year mortality compared to the second and third AGR tertiles (42 vs. 19 and 7 %, p < 0.0001 according to Fisher's exact two-tailed test). In the multivariate model, AGR remained an independent predictor of survival with 75 % decrease in mortality among the highest AGR tertile in comparison to the lowest AGR tertile, p < 0.0001. In the subset of 234 patients with normal serum albumin (albumin of >3.5 g/dl), serum AGR continues to be an independent predictor of cancer-related mortality with an adjusted hazard ratio of the third tertile compared to the first tertile equal to 0.05 (95 % confidence interval 0.01-0.33, p = 0.002). CONCLUSION: Low AGR was a strong independent predictor of long-term cancer-specific survival among colorectal cancer patients. Additionally, among the patients with normal albumin (>3.5 g/dl), patients with lower globulins but higher albumin and AGR levels had better survival.

Value of the pretreatment albumin to globulin ratio in predicting long-term mortality in breast cancer patients.

BACKGROUND: Prior studies have demonstrated the prognostic value of pretreatment serum albumin in different types of cancer. The aim of this study was to assess the predictive value of the albumin to globulin ratio (AGR) on survival in breast cancer patients. METHODS: This retrospective study used an unselected cohort of 354 breast cancer patients who had documented total protein and albumin levels prior to chemotherapy. Survival status was obtained from our cancer registry. Survival analysis, stratified by AGR tertiles, was used to evaluate the prognostic value of AGR. RESULTS: Patients in the highest AGR tertiles (AGR > 1.45) had a lower 5-year mortality rate compared with those in the middle (AGR 1.21 to 1.45) and the lowest (AGR < 1.21) tertiles (6% vs. 18% and 32%, P < .001). After adjusting for confounding variables, AGR remained a significant predictor of mortality (P < .002). Moreover, after excluding the patients with albumin levels less than 3.6, the AGR remained a significant predictor of survival (P .0018). CONCLUSIONS: Pretreatment AGR is an independent, significant predictor of long-term mortality in breast cancer patients, even in patients with normal albumin levels.

Assessing the value of the SimPraxis laparoscopic cholecystectomy trainer.

BACKGROUND AND OBJECTIVES: Our aim was to determine whether the SimPraxis Laparoscopic Cholecystectomy Trainer is an effective adjunct for training both junior and senior surgical residents. METHODS: During the 2009-2010 academic year, 20 of 27 surgical residents at our institution completed training with the SimPraxis Laparoscopic Cholecystectomy Trainer. These 20 residents took an identical 25-question pre- and posttest prepared in-house by a senior laparoscopic surgeon, based on the SimPraxis Laparoscopic Cholecystectomy program content. Included within the SimPraxis program is a multiple data point scoring system. For our reporting purposes, we divided the residents into 2 groups, junior (PGY 1-2; n = 11) and senior (PGY 3-5; n = 9). RESULTS: The junior residents demonstrated a statistically significant improvement in their post-test scores (P = .001). On the contrary, the senior residents showed nonstatistically significant minor improvement in their examination scores (P = .09). While, the pretest scores were significantly higher for the senior residents compared with the junior residents (P = .003), the post-test scores were nonsignificantly different between the senior vs. the junior residents (P = .07). There was no significant difference between the time it took junior and senior residents to complete the SimPraxis program. CONCLUSION: Our data demonstrate that junior residents benefitted the most from the SimPraxis training program. Requiring junior surgical residents to complete both skills and cognitive training programs may be an effective adjunct in preparation for participation in laparoscopic cholecystectomy procedures.

Single-incision laparoscopic appendectomy using conventional instruments: an initial experience using a novel technique.

BACKGROUND: Laparoscopic appendectomy has gained wide acceptance. This study aimed to evaluate the feasibility, safety, and cosmetic results of a novel technique: single incision laparoscopic (SIL) appendectomy. METHODS: The study enrolled consecutive patients undergoing appendectomy for acute appendicitis. Appendectomy was performed using three trocars and conventional laparoscopic instruments through a single small umbilical incision (length, ~3 cm). The patients received standard pre- and postoperative care and presented for a follow-up visit after a mean of 27 days. RESULTS: The study cohort consisted of 26 patients (10 women and 16 men) with an average age of 44 years (range, 13-83 years). Of 26 appendectomies, 22 (85%) were achieved through a single surgical site. The mean SIL appendectomy operative time was 58 min (range, 33-107 min). No operative complications occurred. The average postoperative hospital stay was 1.2 days for nonperforated appendicitis and 2.7 days for perforated appendicitis. At the follow-up visit, no patient showed any evidence of incisional hernia. The operative incisions were minimally visible, and all the individuals reported a highly favorable cosmetic outcome. CONCLUSIONS: The results of the study demonstrated that laparoscopic appendectomy can be achieved through a single umbilical incision using conventional instruments and that this approach is successful, safe, and aesthetic.