SAGES guidelines for the use of laparoscopy during pregnancy.

BACKGROUND: When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD). METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient. RESULTS: The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy. CONCLUSIONS: Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

Guidelines for the performance of minimally invasive splenectomy.

BACKGROUND: Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear. OBJECTIVE: To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations. RESULTS: Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions. CONCLUSIONS: Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

BACKGROUND: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. METHODS: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. CONCLUSIONS: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

Surgical treatment of GERD: systematic review and meta-analysis.

BACKGROUND: Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients. METHODS: PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale. RESULTS: From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference = - 0.51, 95%CI - 0.63, - 0.40, I2 = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I2 = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I2 = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I2 = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I2 = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67). CONCLUSIONS: The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.

Intimate Partner Violence Among Surgeons: We are Not Immune.

OBJECTIVE: The incidence and risk factors for IPV are not well-studied among surgeons. We sought to fill this gap in knowledge by surveying surgeons to estimate the incidence and identify risk factors associated with IPV. SUMMARY OF BACKGROUND DATA: An estimated 36.4% of women and 33.6% of men in the United States have experienced IPV. Risk factors include low SES, non-White ethnicity, psychiatric disorders, alcohol and drug abuse, and history of childhood abuse. Families with higher SES are not exempt from IPV, yet there is very little data examining incidence and risk factors among these populations. METHODS: An anonymous online survey targeting US-based surgeons was distributed through 4 major surgical societies. Demographics, history of abuse, and related factors were assessed. Chi-square analysis and multivariable logistic regression were utilized to evaluate for potential risk factors of IPV. RESULTS: Eight hundred eighty-two practicing surgeons and trainees completed the survey, of whom 536 (61%) reported experiencing some form of behavior consistent with IPV. The majority of respondents were women (74.1%, P = 0.004). Emotional abuse was most common (57.3%), followed by controlling behavior (35.6%), physical abuse (13.1%), and sexual abuse (9.6%).History of mental illness, [odds ratio (OR) 2.32, P < 0.001], alcohol use (frequent/daily OR 1.76, P = 0.035 and occasional OR 1.78, P = 0.015), childhood physical abuse (OR 1.96, P = 0.020), childhood emotional abuse (OR 1.76, P = 0.008), and female sex (OR 1.46, P = 0.022) were associated with IPV. CONCLUSIONS: As the first national study of IPV among surgeons, this analysis demonstrates surgeons experience IPV and share similar risk factors to the general population.

Education and the pediatric surgeon.

There have been many changes in the domain of clinical surgery over the last 2 decades, but probably none more so than in education. The British Association of Pediatric Surgeons recognizes the importance of this topic and has commissioned a special session on this subject jointly with the International Pediatric Endosurgery Group. Free papers presented on a number of educational subjects and specific topics of recruitment and simulation were covered in invited lectures. The session was completed with a keynote lecture from the renowned educationalist Professor Roger Kneebone. LEVEL OF EVIDENCE: 5 (Expert Opinion).

Strategies for building an effective mentoring relationship.

Mentoring has been recognized as a critical aspect of the professional and/or personal development of the student, resident or faculty member. This career development resource discusses strategies for building effective mentoring relationships and outlines some of the challenges to contemporary mentoring.

General surgery career resource.

General surgery residency training can lead to a rewarding career in general surgery and serve as the foundation for careers in several surgical subspecialties. It offers broad-based training with exposure to the cognitive and technical aspects of several surgical specialties and prepares graduating residents for a wide range of career paths. This career development resource discusses the training aspects of general surgery.

Career development resource: promotion to associate professor.

This will most likely be the first time through the promotion and tenure process for the faculty member. The faculty member is responsible for meeting with the department chair and/or division chief on a regular basis to determine if she is on the right time line to successfully achieve promotion to associate professor. A physician will begin seriously preparing her portfolio for promotion to associate professor about 5 to 6 years out of training, at which time she will have some considerable experience running a practice and managing her time. However, the planning process for promotion should begin immediately upon starting the first academic position.

Clinical and molecular characteristics of staphylococcal skin abscesses in children.

Forty-nine children with skin abscesses (36 methicillin-resistant Staphylococcus aureus and 13 methicillin-susceptible S. aureus) exhibited similar disease severity. Both pathogen groups were pulse field type USA300, multilocus sequence type 8, and possessed Panton-Valentine leukocidin genes. Related microbial genetic architecture may account for similarities in disease severity despite differences in antibiotic susceptibility.

The view of surgery department chairs on part time faculty in academic practice: results of a national survey.

BACKGROUND: Reduced resident work hours sparked debate regarding lifestyle of clinical faculty. We hypothesized surgery department chairs would not be supportive of part-time clinical faculty (PTF) and would be reluctant to grant requests to reduce total institutional commitment (TIC) or total professional effort. METHOD: A 16-question survey was mailed to 202 surgery chairs requesting department demographics, and perception of PTF. Chairs were given the option of identifying themselves. PTF referred to full-time equivalent clinicians who reduce their TIC for personal/family reasons and did not include clinicians with research or teaching commitments limiting clinical responsibilities. RESULTS: A total of 112 of 186 (61.2%) delivered surveys were returned. Of these, 48.2% of respondents indicated clinicians had requested reduced TIC and 40.2% of departments had PTF. Only 1 chair was unable to grant a request to reduce TIC. A total of 42.8% of respondents indicated that PTF receive reduced salary-linked benefits but (58.9%) no change in either academic status or (52.7%) eligibility for promotion/tenure. The percentage of women faculty was 12.0% in departments with PTF and 10.5% in departments without PTF. A total of 42.8% of chairs agreed facilitating PTF would improve faculty retention versus 24.1% who disagreed (P<.0001). When compared with departments without PTF, chairs with PTF were more supportive that facilitating PTF would improve faculty retention (53.3% vs 32.7%, P<.001) and would be beneficial to their departments (57.8% vs 22.4%, P<.001). Sixty-two percent of respondents volunteered their names and contact information for follow-up. CONCLUSIONS: Contrary to our hypothesis, surgery department chairs appear to be supportive of PTF and were interested in discussing this further.

Reduced social morbidity of laparoscopic appendectomy in children.

Laparoscopic appendectomy has not been uniformly adopted by pediatric surgeons. Our children's hospital adopted laparoscopic appendectomy due to perceived benefits to patients and their families. We hypothesized that laparoscopic appendectomy in children resulted in less social morbidity than those undergoing open appendectomy. A questionnaire focused on a set of postoperative variables affecting the patient's and the family's return to normal activities. Families expressed their answers as a range of days. Five different ranges were assigned a numerical value for 10 different social morbidity variables. The numerical values were analyzed using Pearson chi2 test; statistical significance was defined as P < 0.05. The response rate was 55 per cent (134 of 244). Seventy-four had open and 47 laparoscopic appendectomy with a comparable incidence of acute and perforated appendicitis. Children undergoing laparoscopic appendectomy had shorter hospital stays and earlier resumption of feeding, return to school, return to pain-free walking and stair climbing, and resumption of normal activities including gym. Additionally, they had fewer wound problems, shorter duration of oral pain medication usage, and their parents returned to work quicker than the open group. All these were statistically significant. Laparoscopic appendectomy results in significantly reduced social morbidity for children and their families.

Minimal access extrapleural esophagoesophagostomy.

BACKGROUND/PURPOSE: Minimal access repair of esophageal atresia is gaining acceptance but usually requires a transpleural approach. An extrapleural approach using a 2-cm incision has been described. The purpose of this study was to develop a less-invasive approach to extrapleural esophagoesophagostomy. METHODS: A 5-8 kg nonsurvivor piglet model was used to develop this technique. The extrapleural dissection was performed under direct vision utilizing transpleural thoracoscopy. A 16-gauge needle and a spatula were used to create an extrapleural space that allowed insertion of a 3-mm trocar. An 8F catheter with a 3-mL balloon was inserted through the trocar and inflated to create enough space to exchange it for a 5-mm trocar. A 12F catheter with a 5-mL balloon was inserted through the 5-mm trocar and inflated to enlarge the space. These steps were repeated at each of the 3 extrapleural port sites until one confluent extrapleural space was created that did not communicate with the transpleural port site. Esophagoesophagostomy was then completed within the extrapleural space. RESULTS: Thoracoscopic guidance and balloon dissection facilitated creation of an adequate extrapleural working space. CONCLUSIONS: This new minimal access extrapleural approach offers an attractive alternative to the currently described minimal access approaches to esophagoesophagostomy.

Robotic-assisted esophagoesophagostomy.

BACKGROUND/PURPOSE: Minimally invasive repair of esophageal atresia has been described but remains technically challenging. Robotic surgical systems address many of these technical challenges. The purpose of this study was to develop the procedure for and evaluate the technical feasibility of performing a robotic-assisted esophagoesophagostomy using the Zeus Robotic Surgical System. METHODS: Esophagoesophagostomy was performed in 10 piglets using thoracoscopic (control, n = 5) and robotic-assisted (Zeus, experimental, n = 5) approaches. An interrupted esophageal anastomosis using intracorporeal knot tying techniques was performed and evaluated for leak, narrowing, caliber, and mucosal approximation. Anesthesia, operative, anastomotic, and robotic set-up times were recorded as was the number of stitches used. RESULTS: All 10 anastomoses were patent with no narrowing and with excellent mucosal approximation. One anastomosis in the control group had a small leak. There was no statistically significant difference between the groups for the parameters measured. Weight (kg): control (C), 6.4 +/- 0.8; experimental (E), 6.3 +/- 1.0, P =.08. Times (min): anesthesia, C-124 +/- 25, E-151 +/- 20, P =.09; operative, C-97 +/- 21, E-131 +/- 27, P =.06; anastomotic, C-89 +/- 20, E-125 +/- 34, P =.08; robotic set-up, C-6.4 +/- 9.3, E-15.6 +/- 20, P = 0.13. Stitches (No.): C-11.8 +/- 0.8, E-12.0 +/- 1.2, P =.7. Caliber (French):C-18F-5; E-18F-4, 14F-1. CONCLUSION: Robotic-assisted esophagoesophagostomy is technically feasible and offers an alternative approach to thoracoscopic repair of esophageal atresia.

Applications of robotic surgery in pediatric patients.

Minimally invasive surgery is increasingly becoming the standard approach to treatment for pediatric patients. Infants present a technical challenge due to the small size of structures and the small workspace available. Master-slave robotic surgical telemanipulators help overcome this challenge by facilitating microsurgery in a confined workspace. The Zeus Robotic Surgical System (Computer Motion, Inc., Goleta, CA, U.S.A.) was used to develop the robotic approach and to evaluate the technical feasibility of performing four technically challenging procedures that are typically performed in infants. Robotic enteroenterostomy, hepaticojejunostomy, portoenterostomy, and esophagoesophagostomy were performed in piglets and compared with the same procedures performed by standard minimally invasive techniques. Enteroenterostomy, hepaticojejunostomy, and esophagoesophagostomy procedures were successfully developed and are technically feasible. The portoenterostomy procedure needs further study to validate data from the second set of experiments, showing a lower complication rate in the robotic group. Survivor studies are needed to fully elucidate the advantages that may be provided by the robotic approach.