Protecting Our Own: A Method for Reducing Breast Radiation Exposure in Healthcare Workers.

ABSTRACT: Standard lead aprons do not protect the female breast adequately from radiation exposure, which has been associated with breast cancer in healthcare workers. A novel lead shield was designed to reduce radiation to the breast, axilla, and thyroid (BAT). A procedure room was simulated with an anthropomorphic phantom representing the operator. Dosimeters were positioned on the outer quadrant of each breast, the chest, the thyroid, and deep inside of a phantom acrylic female torso with neck and head. Standard lead vest plus a thyroid shield was used as control and compared to standard lead vest plus BAT shield. Three operator and two image receptor positions were tested. The reductions in radiation exposure were calculated. The standard vest plus BAT shield provided significant reductions in radiation exposure for all anatomic locations compared to control. When averaging all operator positions, the BAT provided reductions of 91% (p < 0.0001) for near breast. Reductions for far breast, chest, thyroid, and deep tissues were 76% (p = 0.016), 94% (p < 0.0001), 52% (p = 0.026), and 60% (p = 0.004). With operator 90° to the table using a cross-table lateral beam, the BAT provided a 97.7% reduction in radiation to the near breast and significant reduction in radiation to the chest, thyroid, and deep tissues. The BAT shield reduces radiation exposure to the breast, chest, thyroid and deep hematopoietic tissues. Such shields could benefit healthcare workers to reduce the risk of breast cancer and other radiation-associated cancers.

Prosthetic Outcomes after Amputation and the Impact of Mobility Level on Survival.

BACKGROUND: Lower extremity amputation continues to be necessary in a significant number of patients with peripheral vascular disease. The 5 year survival following lower limb loss is markedly reduced. Many of these patients are never fitted with a prosthesis and there is a dearth of knowledge regarding the barriers to prosthetic attainment. The goal of this study was to identify the risk factors for not receiving a prosthesis and the effect of mobility level on survival following major amputation. METHODS: This was a retrospective analysis of all patients that underwent lower-extremity amputation by surgeons in our practice from January 1, 2010 to December 31, 2019. Abstracted data included: age, sex, race, body mass index (BMI), comorbidities, American Society of Anesthesiologists (ASA) score, statin use, level of amputation, stump revision, fitting for prosthesis, type of prosthesis, and the United States' Medicare Functional Classification Level (MFCL) also called K level. Survival was determined using a combination of sources, including the Social Security Death Master File, searches of multiple genealogic registries and general internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis attainment. Multivariable Cox proportional hazard regression with time dependent covariates was performed to assess risk factors associated with 5-year mortality. RESULTS: 464 patients were included in this study. The mean age was 65 years and mean body mass index 27 kg/m2. Majority of patients were male (68%), white (56%), diabetic (62%), and hypertensive (76%), and underwent below-the-knee amputation (BKA) (69%). Prosthetic attainment occurred in 185 (40%). On multivariable analysis age >81 years and current tobacco use were associated with no prosthetic fitting. Overall 5-year survival was 41.9% (95%CI, 37.6%-46.6%) (BKA 47.7% [95%CI, 42.5%-53.5%], above-the-knee amputation 28.7 % [95%CI, 22.1%-37.2%]). On multivariable analysis age >60 years, CHF, AKA and no prosthetic attainment were associated with decreased survival. Increasing K level was incrementally associated with improved survival. CONCLUSION: This study has identified several patient factors associated with prosthetic attainment, as well as multiple factors predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. The MFCL K level predicts survival. More research is needed to determine the barriers to prosthetic attainment and if improving a patients K level will improve survival.

The impact of COVID-19 on surgical cases at a large quaternary referral hospital.

Introduction: Coronavirus-19 (COVID) stressed healthcare systems by increasing hospital admissions and in-hospital mortality. The impact of COVID on surgical patients is unknown. The purpose of this study was to evaluate how the COVID pandemic affected surgical patients at a large quaternary referral hospital. Methods: A retrospective review of patients undergoing surgical procedures was performed to evaluate patients undergoing surgery. The impact of COVID on surgical patients was divided into four timeframes based on government regulations: pre-COVID (January 1, 2020 to March 15, 2020), suspended (March 16, 2020 to May 4, 2020), backlogged cases (May 5, 2020 to June 14, 2020), and restoration (June 15, 2020 to September 30, 2020). Differences between patient characteristics and outcomes during these timeframes were evaluated. Results: A total of 21,424 surgical cases were performed between January 1, 2020 and September 30, 2020. During the suspended timeframe (when all elective cases were cancelled), the percentage of surgeries increased in men (53.8% compared to 49.2% pre-COVID; P < 0.01), in Black and Hispanic patients (23.1% and 15.3%, respectively; P < 0.05), and in Medicaid and self-pay patients (16.3% compared to 9.9% pre-COVID; P < 0.01). All service lines experienced similar trends in overall case volume except obstetrics (constant), trauma, vascular, and thoracic (which increased during the suspended timeframe). Conclusions: COVID-19 induced stresses in surgical patients, altering payor mix and impacting minority groups at a large quaternary referral hospital.

Exploring the Association of Metabolic Syndrome with In-Hospital Survival of Older Patients Hospitalized with COVID-19: Beyond Chronological Age.

BACKGROUND: Despite the variability and complexity of geriatric conditions, few COVID-19 reports of clinical characteristic prognostication provide data specific to oldest-old adults (over age 85), and instead generally report broadly as 65 and older. OBJECTIVE: To examine metabolic syndrome criteria in adults across 25 hospitals with variation in chronological age. DESIGN AND PARTICIPANTS: This cohort study examined 39,564 hospitalizations of patients aged 18 or older with COVID-19 who received inpatient care between March 13, 2020, and February 28, 2022. EXPOSURE: ICU admission and/or in-hospital mortality. MAIN MEASURES: Metabolic syndrome criteria and patient demographics were examined as risk factors. The main outcomes were admission to ICU and hospital mortality. KEY RESULTS: Oldest old patients (≥ 85 years) hospitalized with COVID-19 accounted for 7.0% (2758/39,564) of all adult hospitalizations. They had shorter ICU length of stay, similar overall hospitalization duration, and higher rates of discharge destinations providing healthcare services (i.e., home health, skilled nursing facility) compared to independent care. Chronic conditions varied by age group, with lower proportions of diabetes and uncontrolled diabetes in the oldest-old cohort compared with young-old (65-74 years) and middle-old (75-84 years) groups. Evaluations of the effect of metabolic syndrome and patient demographics (i.e., age, sex, race) on ICU admission demonstrate minimal change in the magnitude of effect for metabolic syndrome on ICU admission across the different models. CONCLUSIONS: Metabolic syndrome measures are important individual predictors of COVID-19 outcomes. Building on prior examinations that metabolic syndrome is associated with death and ARDS across all ages, this analysis supports that metabolic syndrome criteria may be more relevant than chronological age as risk factors for poor outcomes attributed to COVID-19.

The use of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh in ventral hernia repair: a systematic review and meta-analysis.

PURPOSE/BACKGROUND: Despite the growing use of bioabsorbable mesh in ventral hernia repairs (VHR), the evidence of its impact on patient outcomes remains limited. This study aims to investigate the efficacy and safety profile of poly-4-hydroxybutyrate (P4HB) mesh for ventral hernia repair through a systematic review and meta-analysis. METHODS: A literature search of five databases (PubMed, Embase, Ovid, Medline, and Google Scholar) produced a list of publications that analyzed the use of P4HB mesh in ventral hernia repair in both clean and contaminated cases. The primary postoperative outcomes of hernia recurrence, surgical site infections (SSI), and any complications were analyzed through a pooled meta-analysis. RESULTS: In our systematic review, 21 studies met the inclusion criteria with a total of 1858 patients (933 males and 925 females) and an average age of 56.8 years. The median follow-up ranged from 1.6 to 62.3 months. In our meta-analysis, the use of P4HB mesh in VHR in proportion of events demonstrated a recurrence rate of 9% [6%; 15%], SSI of 10% [6%; 16%] and 35% [9%; 42%] for rate of any complications. Sub-meta-analysis restricted to studies with follow up > 18 months continues to show low rates of recurrence of 9% (95%CI, 4-17%), SSI of 9% (95%CI, 4-16%), and 31% (95%CI, 23-41%) for any complications. CONCLUSION: Our study demonstrates that the use of P4HB mesh is both safe and effective in ventral hernia repairs. When further analyzed past 18 months, the time where P4HB mesh fully resorbs, the rates of hernia recurrence, SSI, and any complications remain low of upwards of 5 years and comparable to the rates seen in synthetic and biologics in similar patient populations.

Achieving fascial closure with preoperative botulinum toxin injections in abdominal wall reconstruction: outcomes from a high-volume center.

Preoperative injection of Botulinum Toxin A (Botox) has been described as an adjunctive therapy to facilitate fascial closure of large hernia defects in abdominal wall reconstruction (AWR). The purpose of this study was to evaluate the impact of Botox injections on fascial closure and overall outcomes to further validate its role in AWR. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2014 and March 2022. Patients who did and did not receive preoperative Botox injections were analyzed and compared. A total of 426 patients were included (Botox 76, NBotox 350). The Botox group had significantly larger hernia defects (90 cm2 vs 9 cm2, p < 0.01) and a higher rate of component separations performed (60.5% vs 14.4%, p < 0.01). Despite this large difference in hernia defect size, primary fascial closure rates were similar between the groups (p = 0.49). Notably, the Botox group had higher rates of surgical-site infections (SSIs)/surgical-site occurrences (SSOs) (p < 0.01). Following propensity score matching to control for multiple patient factors including age, sex, diabetes, chronic obstructive pulmonary disease (COPD), and hernia size, the Botox group still had a higher rate of component separations (50% vs 26.3%, p = 0.03) and higher incidence of SSIs/SSOs (39.5% vs 13.5%, p = 0.01). Multimodal therapy with Botox injections and component separations can help achieve fascial closure of large defects during AWR. However, adding these combined therapies may increase the occurrence of postoperative SSIs/SSOs.

Comparison of hospitalist service staffing models at Baylor University Medical Center.

Background: Baylor University Medical Center benefits from being a quaternary care center with 900+ licensed beds and multiple different models to staff patients on the hospitalist service. These models include hospitalist only, resident teaching teams, and two different advanced practice practitioner teams. The primary goal of this study was to assess these different staffing models and to ascertain which model, if any, has better outcomes related to length of stay, total hospital charges, 30-day readmission rates, patient satisfaction, hospital-acquired infections, mortality, and early discharges. Methods: The study was an observational retrospective chart review of all discharges from the hospitalist service at Baylor University Medical Center from October 1, 2021, to February 28, 2022. Patients were included if the hospitalist team was the primary team of record at the time of discharge. A total of 7803 patients were included. Results: There was no difference in patient satisfaction, hospital-acquired infections, and mortality between the groups. The teaching teams had a shorter length of stay before the removal of outliers. Independent advanced practice practitioners reliably had more patients discharged before 11:30 am. Results support the concept of continuity of care, as well as lower patient-to-provider ratios. Conclusions: These results have actionable implications that support the use of different advanced practice practitioner teams for the safe care of hospitalized patients as well as the safe integration of residents into patient care.

Coated poly-4-hydroxybutyrate (Phasix ST™) mesh is safe and effective for hiatal hernia repair: our institutional experience and review of the literature.

BACKGROUND: Poly-4-hydroxybutyrate (P4HB) is a bioabsorbable mesh with a non-adhesive coating on one side that is being used to reinforce the hiatus during hiatal hernia repair; however, there is limited data regarding its use. The aim of this study was to investigate outcomes after hiatal hernia repair using this mesh at our institution and through a review of the literature. METHODS: An institutional review board-approved prospective database was retrospectively reviewed for all patients undergoing hiatal hernia repair from April 2018 to December 2022. A systematic review with meta-analysis was conducted to evaluate outcomes using P4HB coated mesh. RESULTS: In our institutional cohort, there were 230 patients (59 males; 171 females) with a mean follow-up of 20 ± 14.6 months. No mesh-related complications occurred. Hernia recurrence was diagnosed in 11 patients (4.8%) with a median time to recurrence of 16 months. In the systematic review, 4 studies with 221 patients (76 males; 145 females) were included. Median follow-up ranged from 12 to 27 months. Recurrence rate in these studies was reported from 0 to 8.8%, with a total of 12 recurrences identified. Like our institutional cohort, no mesh-related complications were reported. After our recurrences were combined with those from the systematic review, a total of 23 recurrences were included in the meta-analysis. Our meta-analysis revealed a low recurrence rate following hiatal hernia repair with P4HB coated mesh (incidence rate per 100 person-years, 2.82; 95% confidence interval, 1.60, 4.04). CONCLUSION: P4HB coated mesh is safe and effective for hiatal hernia repairs.

Long-term Outcomes of the Kono-S Anastomosis: A Multicenter Study.

BACKGROUND: Postoperative recurrence remains a significant problem in Crohn's disease, and the mesentery is implicated in the pathophysiology. The Kono-S anastomosis was designed to exclude the mesentery from a wide anastomotic lumen, limit luminal distortion and fecal stasis, and preserve innervation and vascularization. OBJECTIVE: To review postoperative complications and long-term outcomes of the Kono-S anastomosis in a large series of consecutive unselected patients with Crohn's disease. DESIGN: Retrospective study of prospectively collected patients. SETTINGS: Four tertiary referral centers. PATIENTS: Consecutive patients with Crohn's disease who underwent resection with Kono-S anastomosis between May 2010 and June 2022. INTERVENTIONS: Extracorporeal handsewn Kono-S anastomosis. MAIN OUTCOME MEASURES: Postoperative outcomes and recurrence defined as endoscopic, clinical, laboratory, or surgical, including endoscopic, intervention. RESULTS: A total of 262 consecutive patients (53.4% male) were included. The mean duration of disease at surgery was 145.1 months. One hundred thirty-five patients (51.5%) had previous abdominal surgery for Crohn's disease. Forty-four patients (17%) were actively smoking and 150 (57.3%) were on biologic therapy. Anastomotic failure occurred in 4 (1.5%), with 2 patients requiring reoperation (0.7%). Sixteen patients had postoperative surgical site infection (6.1%). With a median follow-up of 49.4 months, 20 patients (7.6%) were found to have surgical recurrence. In the multivariate analysis, perianal disease (OR = 2.83, p = 0.001), urgent/emergent surgery (OR = 3.23, p = 0.007), and postoperative use of steroids (OR = 2.29, p = 0.025) were associated with increased risk of overall recurrence. LIMITATIONS: Retrospective study and variability of perioperative medical therapy. CONCLUSIONS: This study showed very low postoperative complication rates despite the complexity of the patient population. There was a low rate of surgical recurrence, likely due to the intrinsic advantages of the anastomotic configuration and the low rate of postoperative septic complications. In experienced hands, the Kono-S anastomosis is a safe technique with very promising short- and long-term results. Randomized controlled trials are underway to validate this study's findings. See Video Abstract . RESULTADO A LARGO PLAZO DE LA ANASTOMOSIS KONOS UN ESTUDIO MULTICNTRICO: ANTECEDENTES:La recurrencia posoperatoria sigue siendo un problema importante en la enfermedad de Crohn y el mesenterio está implicado en la fisiopatología. La anastomosis Kono-S fue diseñada para excluir el mesenterio de una anastomosis amplia, limitar la distorsión luminal y la estasis fecal y preservar la inervación y vascularización.OBJETIVO:Revisar las complicaciones posoperatorias y los resultados a largo plazo de la anastomosis Kono-S en una gran serie de pacientes consecutivos no seleccionados con enfermedad de Crohn.DISEÑO:Estudio retrospectivo de pacientes recolectados prospectivamente.ESCENARIO:Cuatro centros de referencia terciarios.PACIENTES:Pacientes consecutivos con enfermedad de Crohn sometidos a resección con anastomosis Kono-S entre mayo de 2010 y junio de 2022.INTERVENCIONES:Anastomosis Kono-S extracorpórea manual.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios y recurrencia definidos como endoscópicos, clínicos, de laboratorio o quirúrgicos, incluida la intervención endoscópica.RESULTADOS:Se incluyeron un total de 262 pacientes consecutivos (53,4% varones). La duración media de la enfermedad al momento de la cirugía fue de 145,1 meses. Ciento treinta y cinco pacientes (51,5%) habían tenido cirugía abdominal previa por enfermedad de Crohn. Cuarenta y cuatro pacientes (17%) eran fumadores activos y 150 (57,3%) estaban en tratamiento biológico. Se produjo filtración anastomótica en 4 (1,5%) y 2 pacientes requirieron reoperación (0,7%). Dieciséis pacientes tuvieron infección postoperatoria del sitio quirúrgico (6,1%). Con una mediana de seguimiento de 49,4 meses, se encontró que 20 pacientes (7,6%) tuvieron recurrencia quirúrgica. En el análisis multivariado, la enfermedad perianal (OR = 2,83, p = 0,001), la cirugía urgente/emergente (OR = 3,23, p = 0,007), el uso postoperatorio de esteroides (OR = 2,29, p = 0,025) se asociaron con un mayor riesgo de recurrencia general.LIMITACIÓN:Estudio retrospectivo. Variabilidad del tratamiento médico perioperatorio.CONCLUSIONES:Nuestro estudio mostró tasas de complicaciones postoperatorias muy bajas a pesar de la complejidad de la población de pacientes. Hubo una baja tasa de recurrencia quirúrgica, probablemente debido a las ventajas intrínsecas de la configuración anastomótica y la baja tasa de complicaciones sépticas posoperatorias. En manos experimentadas, la anastomosis Kono-S es una técnica segura con resultados muy prometedores a corto y largo plazo. Se están realizando estudios randomizados controlados para validar nuestros hallazgos. (Traducción-Dr. Felipe Bellolio ).

The use of a total bowel length measurement protocol may reduce reoperations and complications after single-anastomosis duodenal switch.

INTRODUCTION: Most surgeons who perform single-anastomosis duodeno-ileal switches (SADI-S) use a pre-determined common channel length without measuring total bowel length (TBL). However, TBL varies between patients, and a standardized common channel length could contribute to malabsorptive complications and reoperations following SADI-S. The purpose of this study was to determine whether using a TBL measurement protocol to individualize common channel length would be associated with reduced reoperations and complications. METHODS: A prospectively maintained data registry was retrospectively reviewed to identify all patients who underwent SADI-S between September 2017 and February 2022. In April 2021, we began using TBL measurements during SADI-S with 40% of the TBL used as the length for the common channel. Outcomes pre-TBL and post-TBL measurement protocol were compared. RESULTS: A total of 119 SADI-S recipients (59 pre-TBL; 60 post-TBL) were included. The pre-TBL group had a higher frequency of reoperations (23.7% vs 1.7%, p < 0.001) and late complications (29.3% vs 3.3%, p < 0.001). The mean time to reoperation was 13.7 months in the pre-TBL group and 6.7 months in the post-TBL group (p = 0.347). Patients in the post-TBL group had significantly higher serum albumin levels at 3 months (4.2 g/dL vs 3.5 g/dL, p < 0.001), 6 months (4.1 g/dL vs 3.6 g/dL, p < 0.001), and 12 months (4.2 g/dL vs 3.8 g/dL, p = 0.023) postoperatively when compared to the pre-TBL group. CONCLUSION: Using TBL measurements to individualize common channel length was associated with a significant reduction in reoperations and late complications following SADI-S.

Impact of an enhanced recovery after surgery program with a multimodal analgesia care pathway on opioid prescribing and clinical outcomes for patients undergoing colorectal surgery.

Background: Opioids are a mainstay for acute pain management, but their side effects can adversely impact patient recovery. Multimodal analgesia (MMA) is recommended for treatment of postoperative pain and has been incorporated in enhanced recovery after surgery (ERAS) protocols. The objective of this quality improvement study was to implement an MMA care pathway as part of an ERAS program for colorectal surgery and to measure the effect of this intervention on patient outcomes and costs. Methods: This pre-post study included 856 adult inpatients who underwent an elective colorectal surgery at three hospitals within an integrated healthcare system. The impact of ERAS program implementation on opioid prescribing practices, outcomes, and costs was examined after adjusting for clinical and demographic confounders. Results: Improvements were seen in MMA compliance (34.0% vs 65.5%, P < 0.0001) and ERAS compliance (50.4% vs 57.6%, P < 0.0001). Reductions in mean days on opioids (4.2 vs 3.2), daily (51.6 vs 33.4 mg) and total (228.8 vs 112.7 mg) morphine milligram equivalents given during hospitalization, and risk-adjusted length of stay (4.3 vs 3.6 days, P < 0.05) were also observed. Conclusions: Implementing ERAS programs that include MMA care pathways as standard of care may result in more judicious use of opioids and reduce patient recovery time.

Gastric per-oral endoscopic myotomy versus pyloric injection of botulinum toxin for the treatment of gastroparesis: our institutional experience and a systematic review of the literature.

INTRODUCTION: Gastric Per-Oral Endoscopic Myotomy (GPOEM) has been developed as an effective treatment option for patients with medically refractory gastroparesis. Other endoscopic options, such as pyloric injection of botulinum toxin (Botox), is often performed with limited efficacy. The purpose of this study was to evaluate GPOEM for the treatment of gastroparesis and compare its efficacy to Botox injection results reported in the literature. METHODS: A retrospective review was conducted to identify all patients who underwent a GPOEM for the treatment of gastroparesis between September 2018 and June 2022. Changes in Gastric Emptying Scintigraphy (GES) studies and Gastroparesis Cardinal Symptom (GCSI) scores from the preoperative to postoperative period were analyzed. In addition, a systematic review was conducted to identify all publications reporting the outcomes of Botox injections for the treatment of gastroparesis. RESULTS: A total of 65 patients (51 female, 14 male) underwent a GPOEM during the study period. Twenty-eight patients (22 female, 6 male) had both preoperative and postoperative GES studies in addition to GCSI scores. The etiologies of gastroparesis were diabetic (n = 4), idiopathic (n = 18), and postsurgical (n = 6). Fifty percent of these patients had undergone previous failed interventions including Botox injections (n = 6), gastric stimulator placement (n = 2), and endoscopic pyloric dilation (n = 6). Outcomes showed a significant decrease in GES percentages (mean difference = - 23.5%, p < 0.001) and GCSI scores (mean difference = - 9.6, p = 0.02) postoperatively. In the systematic review for Botox, transient mean improvements in postoperative GES percentages and GCSI scores were reported at 10.1% and 4.0, respectively. CONCLUSION: GPOEM leads to significant improvement in GES percentages and GCSI scores postoperatively and is superior to Botox injection results reported in the literature.

Comparison of long-term quality of life outcomes between endoscopic vacuum therapy and other treatments for upper gastrointestinal leaks.

BACKGROUND: While endoscopic vacuum assisted closure (EVAC) therapy is a validated treatment for gastrointestinal leaks, its impact on long-term quality of life (QoL) is uncertain. The purpose of this study was to evaluate the impact of successful EVAC management on long-term QoL outcomes. METHODS: An institutional review board approved prospectively maintained database was retrospectively reviewed to identify patients undergoing treatment for gastrointestinal leaks between June 2012 and July 2022. The Short-Form 36 (SF-36) survey was used to assess QoL. Patients were contacted by telephone and sent the survey electronically. QoL outcomes between patients who underwent successful EVAC therapy and those who required conventional treatment (CT) were analyzed and compared. RESULTS: A total of 44 patients (17 EVAC; 27 CT) completed the survey and were included in our analysis. All included patients had foregut leaks with sleeve gastrectomy being the most common sentinel operation (n = 20). The mean time from the sentinel operation was 3.8 years and 4.8 years for the EVAC and CT groups, respectively. When evaluating long-term QoL, the EVAC group scored higher in all QoL domains when compared to the CT group with physical functioning (87.3 vs 69.3, p = 0.04), role limitations due to physical health (84.1 vs 45.7, p = 0.02), energy/fatigue (60.0 vs 40.9, p = 0.04), and social functioning (86.2 vs 64.1, p = 0.04) reaching statistical significance. Overall, patients who achieved organ preservation via successful EVAC therapy scored higher in all domains with role limitations due to physical health (p = 0.04) being statistically significant. In a multivariable regression analysis, increased age and a history of prior abdominal surgery at the time of the sentinel operation were patient characteristics that negatively impacted QoL outcomes. CONCLUSION: Patients with gastrointestinal leaks successfully managed by EVAC therapy have better long-term QoL outcomes when compared to patients undergoing other treatments.

Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study.

Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p < 0.0001), 6 (2.5 vs 0, p < 0.0001), and 12 months (2.5 vs 0, p = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p < 0.0001) and 6 months (40 vs 1, p = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. .

COVID-19's impact on family medicine resident training and wellness.

Background: The COVID-19 global pandemic has raised many challenges in training family medicine residents. Family medicine is at the frontline for treating and managing patients with COVID-19. Attention is needed on the critical issue of the effect of the pandemic on resident training, the safety of those performing needed medical services, and the psychological well-being of trainees. Methods: We performed a cross-sectional, 25-question survey-based study to evaluate the perceived effect of the COVID-19 pandemic on family medicine residents' training and residents' well-being in the state of Texas. Results: A total of 250 Texas-based family medicine residents were surveyed with a response rate of 12.8% (n = 32). After the pandemic began, all residents worried about exposing their loved ones to COVID-19, and 65% felt like the COVID-19 pandemic negatively impacted their training overall. Respondents indicated that changes occurred in their respective residency curricula that altered training such as canceling of scheduled lectures (84.3%) and more telemedicine visits (56.25%). There was a significant difference for postgraduate year level and the effect on rotation assignments, with more disruption to the first- and third-year residents (P = 0.03). Conclusions: The COVID-19 pandemic has had a notable impact on the perception of quality of training and mental health within family medicine. Our findings may guide programs in how to proactively target pandemic-related training challenges.

Predictive factors of first-time failure on the American Board of Colorectal Surgery certifying and qualifying examinations.

Objective: To discover if first-attempt failure of the American Board of Colon and Rectal Surgery (ABCRS) board examination is associated with surgical training or personal demographic characteristics. Methods: Current colon and rectal surgery program directors in the United States were contacted via email. Deidentified records of trainees from 2011 to 2019 were requested. Analysis was performed to identify associations between individual risk factors and failure on the ABCRS board examination on the first attempt. Results: Seven programs contributed data, totaling 67 trainees. The overall first-time pass rate was 88% (n = 59). Several variables demonstrated potential for association, including Colon and Rectal Surgery In-Training Examination (CARSITE) percentile (74.5 vs 68.0, P = 0.09), number of major cases in colorectal residency (245.0 vs 219.2, P = 0.16), >5 publications during colorectal residency (75.0% vs 25.0%, P = 0.19), and first-time passage of the American Board of Surgery certifying examination (92.5% vs 7.5%, P = 0.18). Conclusion: The ABCRS board examination is a high-stakes test, and training program factors may be predictive of failure. Although several factors showed potential for association, none reached statistical significance. Our hope is that by increasing our data set, we will identify statistically significant associations that can potentially benefit future trainees in colon and rectal surgery.

Probability of additional intervention and long-term follow-up of esophagomyotomy.

INTRODUCTION: Two common surgical procedures used to treat esophageal motility disorders are laparoscopic Heller myotomy (LHM) with partial fundoplication and per-oral endoscopic myotomy (POEM). The difference in frequency of follow-up interventions following these procedures is unknown. This study was designed to report differences in post-surgical interventions as one of the major long-term follow-up expectations. METHODS: An IRB approved registry was used to identify all patients undergoing surgery with LHM or POEM. Following surgery, patients requiring additional interventions with esophageal non-pneumatic dilation, botox injection, or repeat myotomy, as well as persistent proton pump inhibitor (PPI) use were recorded. Multivariable logistic regression analysis was performed to estimate risk factors associated with return for additional post-operative intervention. RESULTS: A total of 203 patients were identified, 139 met inclusion criteria (33 LHM and 106 POEM). There was a higher rate of non-pneumatic EGD dilation (33% vs 15%, p = 0.04), repeat myotomy (18% vs 2%, p < 0.01), and higher rate of overall post-operative intervention in LHM than POEM. With POEM, there was a higher rate of post-operative PPI use (63 vs 29%, p < 0.01). There was no difference in time to post-operative intervention for either group, but if intervention were to occur the median time was within the first year. Patients with a change in pre- to post-operative Eckardt score of 4 or greater decreased their chance of having a post-operative intervention. CONCLUSION: Our results for both LHM and POEM emphasize the importance of long-term follow-up in patients with an esophageal motility disorder. We have found that patients undergoing LHM are more likely to have a post-operative intervention as well as a higher rate of repeat myotomy than POEM. With both interventions, a greater change in Eckardt score decreased the likelihood of reintervention.

National trends in distribution of underrepresented minorities within United States general surgery residency programs: A longitudinal panel study.

BACKGROUND: Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs. METHODS: We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance. RESULTS: Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated. CONCLUSIONS: Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted.

Enhanced Recovery After Surgery Protocol in Bariatric Surgery Leads to Decreased Complications and Shorter Length of Stay.

PURPOSE: Enhanced recovery after surgery (ERAS) programs have been shown in some specialties to improve short-term outcomes following surgical procedures. There is no consensus regarding the optimal perioperative care for bariatric surgical patients. The purpose of this study was to develop a bariatric ERAS protocol and determine whether it improved outcomes following surgery. MATERIALS AND METHODS: An IRB-approved prospectively maintained database was retrospectively reviewed for all patients undergoing bariatric surgery from October 2018 to January 2020. Propensity matching was used to compare post-ERAS implementation patients to pre-ERAS implementation. RESULTS: There were 319 patients (87 ERAS, 232 pre-ERAS) who underwent bariatric operations between October 2018 and January 2020. Seventy-nine patients were kept on the ERAS protocol whereas 8 deviated. Patients who deviated from the ERAS protocol had a longer length of stay when compared to patients who completed the protocol. The use of any ERAS protocol (completed or deviated) reduced the odds of complications by 54% and decreased length of stay by 15%. Furthermore, patients who completed the ERAS protocol had an 83% reduction in odds of complications and 31% decrease in length of stay. Similar trends were observed in the matched cohort with 74% reduction in odds of complications and 26% reduction in length of stay when ERAS was used. CONCLUSIONS: ERAS protocol decreases complications and reduces length of stay in bariatric patients.