Audience Response System (ARS) Use in the SCORE (Surgical Council on Resident Education) Surgery Training Curriculum: A Mixed Methodology Study.

Background Audience Response Systems (ARS) could help overcome the limitations of traditional lectures by providing interactivity, engagement, and assessment. The perception of ARS use in surgical education is not well documented. Objective Examine the use of an ARS in teaching This Week In SCORE (Surgical Council on Resident Education)sessions to general surgery residents and medical students. Methods  ARS was used at weekly SCORE question sessions in a new general surgery residency program by four residents, 97 medical students, and 20 faculty. The study employed a mixed quantitative and qualitative method: two separate 10-question surveys for faculty and trainees (49% response rate) and a focus group discussion that included one faculty member, two residents, and two students. Results In 85 (85%) responses, the faculty favored the use of ARS in SCORE. Among the total of 510 responses from 51 residents and students, 57% agreed with the favorable use of ARS, while 28% were neutral and, in 14% of cases, negative. A greater proportion of faculty and learners preferred ARS over traditional lectures. The focus group content analysis showed a positive effect and preference from learners and faculty. Engagement, thinking stimulation, and group participation were the most common positive comments. No significant negative influence on ARS use was reported. Conclusions The use of an ARS in This Week In SCORE â€‹â€‹â€‹sessions were preferred by most of the faculty and a majority of learners. The benefits are ease of use and stimulation of discussion. ARS has the potential for more widespread utilization in additional educational settings.

Longer Wait Times Do Not Adversely Impact 90-Day Mortality in Patients With Stages I-III Gastric Cancer.

Introduction Gastric cancer is one of the leading causes of cancer-related death in the United States. Surgery remains integral to the curative management of non-metastatic gastric cancer. However, delays to the date of surgery for gastric cancer patients are commonplace. To investigate the impact of treatment delays on gastric cancer mortality, we conducted a multivariable analysis of over 36,000 patients. Materials & methods After querying the National Cancer Database and excluding patients who did not meet inclusion criteria, our sample included 36,598 patients with stage I-III gastric cancer. We ran multivariable logistic regressions by regressing 90-day mortality on wait time. Other co-variables included sex, race, age, area of residence, comorbidities, insurance, histology, tumor grade, tumor stage, resection margins, treatment facility type, and treatment with chemotherapy. Results Our results demonstrated that each day of increased waiting time is associated with a 0.5% decrease in 90-day mortality. Other statistically significant predictors of higher 90-day mortality risk included male sex, black or white race, living in a small metropolitan or non-metropolitan area, older age, more severe comorbidities, non-private insurance, non-gastric stromal tumor cancer, non-well differentiated tumors, worse clinical stage, residual cancer, treatment at non-academic center, and no adjuvant/neoadjuvant chemotherapy. Conclusion These findings demonstrate that patients with longer wait times until surgery do not experience worse outcomes. These results are reassuring and can be cited to alleviate patient concerns.

Veress needle insertion simulation model: A simple new module for advanced surgical skill training.

Introduction: Training on Veress needle (VN) insertion cannot be done by observation without practicing tactile feedback. In this study, a simple and reproducible VN insertion training model was created. The aim of this study was to evaluate the validity of using the proposed model in simulating actual real-life surgical experiences. Methods: The proposed VN insertion training model is made of three layers of synthetic rubber and plastic materials, simulating the tensile strength and texture of the three abdominal wall muscle layers. Surgeons and senior residents with experience in minimally invasive procedures were asked to practice VN insertion on this model, each completing the procedure three times. Participants were then asked to record their comments and answer six questions regarding their experience practicing on the model. Results: Ten surgeons and four senior residents participated in this study. All participants agreed or strongly agreed that the model simulates the surgery experience regarding the shape and overall structure, tactile feedback and confirmation of complete/successful insertion. Twelve participants (86%) agreed or strongly agreed that the pressure/force needed for VN insertion was like real surgery experience and that the overall experience with using this model is similar to the real surgical experience. Almost all participants (93%) agreed or strongly agreed that the model is a valuable resource for training before practicing the procedure on real patients. Conclusions: The VN insertion training model provides a valuable training opportunity on a demanding surgical skill. It is simple, reproducible and closely simulates surgery.

Inaccuracy of surgical irrigation fluid temperature hand assessment.

INTRODUCTION: Fluids are often used for irrigation during surgical procedures. The temperature of the fluid directly affects the exposed tissue and body temperature. The recommended practice is to use euthermic fluids to be homeostatic and optimise patient care. Hand checking the fluid temperature by surgeons and scrub practitioners is the commonly used method. This subjective measurement leaves room for error and can lead to inaccuracies. The purpose of the study is to assess the accuracy of the currently used method of checking irrigation fluids temperature by hand immersion. METHOD: Two sets of fluids were prepared. One was made at 37°C and the other was 30°C. Participants immersed their hands in the containers and then report if each of the two sets is (1) appropriately warm for irrigation, (2) too cool and (3) too warm. Data were collected and interpreted. RESULTS: Results showed that about half of participants in our study perceived normal physiologic fluid temperature as too hot for use in irrigation, 30°C fluid was perceived as appropriate and physiologic by about a quarter of participants. CONCLUSIONS: Perception of surgical irrigation fluid temperature by hand immersion is inaccurate. Standard objective methods of measuring the temperature are recommended.

Trends of the Extra-Hepatic Biliary Cancer and Its Surgical Management: A Cross-Sectional Study From the National Cancer Database.

Introduction Biliary cancers are rare cancers with poor prognoses. In this study, we aimed to evaluate trends in early detection and surgical treatment and approaches in extra-hepatic biliary tract cancers (EBCs) over 13 years in the US. Methods The most recent data on patients diagnosed with EBC between 2004 and 2016 were extracted from the National Cancer Database (NCDB). The patients' demographics (sex, age, race), primary tumor sites, tumor grades and stages, staging modalities, diagnostic confirmation, surgical treatment modalities and approaches, and 90-day mortality were analyzed to determine trends. Results Biopsy was the most common staging modality in 63.9% of total 60,291 patients. The bile duct was the primary tumor site (55.0%). Histologic examination was the most common confirmatory diagnostic modality (77.5%). The most common stage was stage II (23%). The most common surgical treatment modality was radical surgery (13.88%). The open surgical approach was used in 27.1% of patients, followed by a laparoscopic approach (4.3%). Conclusion EBC showed no significant change in the trends of the stage at diagnosis, treatment modality, and extent of surgical procedures despite advances in surgical diagnostic and therapeutic modalities; however, the total number of cases slightly increased between 2004 and 2016.

Maximizing the educational potential of Morbidity and Mortality Conferences.

Morbidity and Mortality Conferences (MMCs) are considered to be one of the most powerful education tools for clinicians; however, their current structure in many health care facilities focuses predominantly on quality and outcome improvement, and their retrospective approach limits their educational component. This article discusses how MMCs can be modified to enhance the educational outcomes and provide a valuable training session that adds to the quality control value.

E-Learning Satisfaction and Barriers in Unprepared and Resource-Limited Systems During the COVID-19 Pandemic.

Background The sudden and quick propagation of coronavirus-19 disease (COVID-19) has disrupted face-to-face lectures and practical sessions at Iraqi universities. E-learning has surfaced in most countries as an alternative way to continue educational programs. This study aimed to determine the degree of satisfaction and perceived barriers among college students with E-learning. Methods Students of two Iraqi universities studying through an online platform participated in this cross-sectional study. An online survey questionnaire was used to assess student perceptions of the level of satisfaction with and barriers to E-learning. Participants' non-identifying demographics were also collected. Results The majority of students (70.9%) were females, and more than half (57.9%) were from the Faculty of Science. About 64.8% of the students were not satisfied with the E-learning experience. Only 35.5% of the students attended synchronous electronic classes while the rest used asynchronous learning activities. Students' level of satisfaction was poor, as only 6.4% of students strongly believed that tutoring was informative and that technology and educational technology were adequate. On the contrary, 69% of students strongly agreed that E-learning saved them time and money. Barriers that were perceived by the student were slow internet speed, power interruption, and the lack of face-to-face interaction. Conclusions E-learning has significant barriers that require investment in infrastructures and teaching skills development to make students learning satisfactory.

Introducing advanced surgical tasks simulation for surgical training.

Acquiring surgical skills is one of the major objectives of surgical training. Trainees face increasing challenges to meet the continuously evolving surgical techniques and approaches during the limited time course of their surgical training. The limited availability of training tools for teaching advanced surgical skills is an additional barrier. Educators have increasingly used simulation tools for surgical skills training around the globe. However, current simulation training modules and curricula focus mainly on basic surgical skills. Hence, the development of advanced virtual simulation modules offers a precious laparoscopic training opportunity. This article provides an educational technology-based review and proposal (with selected examples) of simulation training modules on advanced surgical skills that can be used for advanced surgical training approaches.

The educational value of an audience response system use in an Iraqi medical school.

BACKGROUND: Medical education is continually evolving particularly through the modern implementation of educational technology. Enhancing interactive learning in the classroom or lecture settings is one of the growing uses of educational technology. The role and potential benefits of such technology may not be as evident in developing educational systems like the one in Iraq. The purpose of this study was to examine the effect and perception of the use of an audience response system (ARS) on interactive medical education in Iraq. A mixed quantitative and qualitative research methodology approach was used to study the effects and users' perceptions (both student and tutor) of the ARS. METHOD: The study was conducted in an Iraqi medical school in the Head and Neck course during the spring semester for third-year medical students. The course involved fifteen one-hour lectures over fifteen weeks. Users' perceptions were evaluated by survey and focus group discussions (FGD). Descriptive statistics were used for quantitative measures and thematic analysis for the qualitative data. An ARS system was installed and integrated into the course lectures throughout the course period of three months to enhance interactive learning. Three to five interactive questions were used in each lecture. Anonymous participation and answers were maintained. The appropriate discussion was initiated when pertinent depending on students' answers. RESULT: Most students (77% of survey, 85% of FGD) perceived the use of ARS as impactful on their learning. They found the ARS engaging (70%), motivating (76%), promoting interactions (73%), and augment learning through better understanding and remembering (81%). Through the FGD, students expressed improved focus, enhanced thinking and reflection, and joyful learning. The educator perceived the ARS use as practical, interactive, thinking-stimulator, and reflective of student's understanding. The required technology skills were reasonable; however, it demanded extra non-insignificant time to learn the use. CONCLUSION: The perception of the ARS in this study was overall positive, providing encouragement for wide application of this technology in medical education in the developing world. Further studies are needed to validate and prioritize ARS usage in medical education in Iraq.

Surgical Management of Advanced Achalasia With Sigmoid Esophagus: A Case Report.

The surgical management of achalasia with sigmoid esophagus involves multiple significant challenges due to the difficulty in endoscopic assessment, esophageal motility disorders, and potential complication and recurrence rates. We report a 34-year-old female with worsening dysphagia and malnourishment due to advanced achalasia. An esophagogastroduodenoscopy (EGD) revealed an esophageal dilation, tortuosity, and distal blockage with undigested food. Esophagram demonstrated the typical bird beak appearance with a tortuous dilated esophagus. She underwent a laparoscopic Heller myotomy with Dor fundoplication with no complications. She was discharged on the second postoperative day, tolerating clear liquids, and then a normal diet within six weeks. Several treatment options exist for the surgical management of a sigmoid esophagus with achalasia, but there is no clear gold standard. In our case, Heller myotomy with Dor fundoplication provided favorable results, but treatment should be individualized for each case.

Assessing clinical outcomes of modified laparoscopic gastrostomy in children: a case control study.

BACKGROUND: With gastrostomy becoming a common surgical procedure within the pediatric population surgeons continued to introduce modifications on the procedure to overcome some of the challenges and minimize complications. Modified U-stitches laparoscopic gastrostomy is gaining favor in some centers including the center of this study. Hence, this study was conducted to evaluate and compare its outcomes. METHODS: Eighty-nine gastrostomy procedures performed between 2013 and 2020 were reviewed to evaluate the surgical outcomes of a novel modified U-stitches laparoscopic gastrostomy (MLG) to the standard laparoscopic gastrostomy (LG) in children. The main outcome measured is the rate of postoperative complications encompassing dislodgement of gastrostomy button, leak around button, local infection, and development of granulation tissue post-surgery which is compared between the two population groups. RESULTS: The rate of leak around the button was found to be significantly less in the MLG (4%) compared to (15%) in the traditional LG approach with a p-value of 0.03. However, the overall complication rate for MGL is 63%; while it is 73% for LG. CONCLUSIONS: The modified U-stitches laparoscopic gastrostomy has a lower rate of complications in comparison to the standard laparoscopic gastrostomy making it a preferred technique for gastrostomy placement in children.

Prepyloric gastric diverticulum case report: A rare anatomic abnormality with limited clinical consequences.

INTRODUCTION: and Importance: Gastric diverticula (GDs) are typically formed on the posterior wall due to congenital or acquired causes. Although diverticula are not uncommon throughout the gastrointestinal tract, GDs are the least common type, and their presence in the prepyloric area is extremely rare. GDs are frequently asymptomatic but can present with serious complications that require surgical intervention in rare cases. CASE PRESENTATION: A 54-year-old woman with a history of morbid obesity, hyperlipidemia, and diabetes mellitus (DM) presents with acute onset left upper quadrant (LUQ) abdominal pain. Based on presenting symptoms, an esophagogastroduodenoscopy (EGD) was performed to evaluate possible causes of abdominal pain. Interestingly, EGD revealed a moderately sized (3 cm) prepyloric diverticulum with a small polyp surrounded by normal gastric tissue. Biopsying of the intra-diverticular polyp revealed no abnormal pathology. Further assessment with Computerized Tomographic (CT) scan identified the diverticulum but with no other related gastric or gastrointestinal changes or pathology. CLINICAL DISCUSSION: The diverticulum was excluded as a cause of the pain. Hence, a conservative management approach was followed with no change in status for the following three months of observation. The patient continued to report non-specific symptoms but denied further episodes of abdominal pain or serious symptoms. CONCLUSIONS: GDs present with a wide variety of symptoms making the diagnosis difficult without thoroughly examining the entire anatomic region of potential pathology. Although GDs are rare, they are easily identified via EGD or imaging modalities. However, long-term follow-up information is needed to understand this clinical entity's behavior fully.

Trends of core versus subspecialty operative procedures completed in general surgery residency training programs.

INTRODUCTION: General surgery residency involves performing subspecialty procedures in addition to the core general procedures. However, the proportion of core general surgery versus subspecialty procedures during training is variable and its temporal changes are unknown. The goal of our study was to assess the current trends in core general surgery and subspecialty procedure distributions during general surgery residency training. METHODS: Data were collected from the ACGME core general surgery national resident available report case logs from 2007 to 2019. Descriptive and time series analyses were used to compare proportions of average procedures performed per resident in the core general surgery category versus the subspecialty category. F-tests were conducted to show whether the slopes of the trend lines were significantly non-zero. RESULTS: The mean of total procedures completed for major credit by the average general surgery resident increased from 910.1 (SD=30.31) in 2007 to 1070.5 (SD=37.59) in 2019. Over that same period, the number of general, cardiothoracic, plastic and urology surgery procedures increased by 24.9%, 9.8%, 76.6% and 19.3%, respectively. Conversely, vascular and paediatric surgery procedures decreased by 7.6% and 30.7%, respectively. The neurological surgery procedures remain stable at 1.1 procedures per resident per year. A significant positive correlation in the trend reflecting total (p<0.0001), general (p<0.0001) and plastic (p<0.0016) surgery procedures and the negative correlation in the trend lines for vascular (p<0.0006) and paediatric (p<0.0001) surgery procedures were also noted. CONCLUSIONS: Trends in overall surgical case volume performed by general surgery residents over the last 12 years have shown a steady increase in operative training opportunity despite the increasing number of subspecialty training programmes and fellowships. Further research to identify areas for improvement and to study the diversity of operative procedures, and their outcomes is warranted in the years to come.

Radiation Proctitis and Management Strategies.

Radiotherapy (RT) is a treatment modality that uses high-energy rays or radioactive agents to generate ionizing radiation against rapidly dividing cells. The main objective of using radiation in cancer therapy is to impair or halt the division of the tumor cells. Over the past few decades, advancements in technology, the introduction of newer methods of RT, and a better understanding of the pathophysiology of cancers have enabled physicians to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues. However, RT has numerous complications, the most common being radiation proctitis (RP). It is characterized by damage to the rectal epithelium by secondary ionizing radiation. Based on the onset of signs and symptoms, post-radiotherapy RP can be classified as acute or chronic, each with varying levels of severity and complication rates. The treatment options available for RP are limited, with most of the data on treatment available from case reports or small studies. Here, we describe the types of RT used in modern-day medicine and radiation-mediated tissue injury. We have primarily focused on the classification, epidemiology, pathogenesis, clinical features, treatment strategies, complications, and prognosis of RP.

National Trends and Perioperative Outcomes of Robotic-assisted Hepatectomy in the USA: A Propensity-score Matched Analysis from the National Cancer Database.

BACKGROUND: A paucity of data exists on the national use of robotic hepatectomy. We assessed national trends and perioperative outcomes of robotic hepatectomy in the USA. In addition, factors associated with use of the robotic approach were analyzed. METHODS: The National Cancer Database (NCDB) was queried for patients undergoing hepatectomy from 2010 to 2016. Patients undergoing total hepatectomy for transplant were excluded. Factors associated with the use of the robotic approach were assessed using logistic regression multivariable analysis. Propensity-score analysis was performed (robotic vs. laparoscopic and robotic vs. open approaches), and perioperative outcomes were compared between the matched groups. RESULTS: The robotic approach was used in 287 patients (110 hospitals). Utilization of the robotic approach increased significantly on the national level from 0.8% in 2010 to 4.1% in 2016 (P<0.001). The number of hospitals performing a minimum of one robotic hepatectomy per year increased from 8 in 2010 to 35 in 2016. The median hospital length of stay was 4 days (IQR 3-6), 30-day readmission rate was 5%, and 30-day/90-day mortality rates were 3%/4%. Factors associated with using robotic approach were African-American race (95% CI 1.02-2.11), recent year of surgery (95% CI 1.11-1.32), HCC histology (95% CI 1.01-52.03), tumor size (95% CI 0.87-0.96), and early-stage tumor (Stage I-II, 95% CI 1.27-3.99). On propensity-matched analysis, there were no differences between robotic and open approaches (n=184 each group) in 30-day readmission (5% vs. 7%, P=0.651), 30-day mortality (2% vs. 4%, P=0.106), 90-day mortality (3% vs. 7%, P=0.080), or 5-year overall survival (58% vs. 43%, P=0.211). However, the robotic approach was associated with a significantly shorter hospital stay (median: 4 vs. 6 days, P<0.001). There were no differences between matched groups of patients undergoing robotic and laparoscopic approaches (n=182 in each group) in perioperative outcomes or length of hospital stay. CONCLUSION: National use of robotic-assisted hepatectomy has increased by fivefold over the seven-year study period. It was associated with a shorter hospital length of stay compared to the open approach without compromising perioperative outcomes or survival.

Virtual reality (VR) as a simulation modality for technical skills acquisition.

Efforts continue to facilitate surgical skills training and provide accessible and safe training opportunities. Educational technology has played an essential role in minimizing the challenges facing traditional surgical training and providing feasible training opportunities. Simulation and virtual reality (VR) offer an important innovative training approach to enhance and supplement both technical and non-technical skills acquisition and overcome the many training challenges facing surgical training programs. To maximize the effectiveness of simulation modalities, an in-depth understanding of the cognitive learning theory is necessary. Knowing the stages and mental processes of skills acquisition when integrated with simulation applications can help trainees achieve maximal learning outcomes. This article aims to review important literature related to VR effectiveness and discuss the leading theories of technical skills acquisition related to VR simulation technologies.

Applying Bloom's taxonomy in clinical surgery: Practical examples.

Bloom's cognitive learning taxonomy is widely used in medical education. The revised taxonomy published by David Kathwohl (1956) and his group describes the levels in action forms: Remember, Understand, Apply, Analyze, Evaluate, and Innovate. The taxonomy has been commonly used to design and structure educational goals and objectives. However, most uses occur at the course or program curriculum level, as was originally described. Whereas applying the taxonomy at the level of individual educational activities remained limited for different reasons. Hence, the aim of this article is to promote applying the taxonomy in daily clinical teaching by providing practical clinical examples in a simplified way.