Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons' perspectives.

INTRODUCTION: Transparency about the occurrence of adverse events has been a decades-long governmental priority, defining external feedback to healthcare providers as a key measure to improve the services and reduce the number of adverse events. This study aimed to explore surgeons' experiences of assessment by external bodies, with a focus on its impact on transparency, reporting and learning from serious adverse events. External bodies were defined as external inspection, police internal investigation, systems of patient injury compensation and media. METHODS: Based on a qualitative study design, 15 surgeons were recruited from four Norwegian university hospitals and examined with individual semi-structured interviews. Data were analysed by deductive content analysis. RESULTS: Four overarching themes were identified, related to influence of external inspection, police investigation, patient injury compensation and media publicity, (re)presented by three categories: (1) sense of criminalisation and reinforcement of guilt, being treated as suspects, (2) lack of knowledge and competence among external bodies causing and reinforcing a sense of clashing cultures between the 'medical and the outside world' with minor influence on quality improvement and (3) involving external bodies could stimulate awareness about internal issues of quality and safety, depending on relevant competence, knowledge and communication skills. CONCLUSIONS AND IMPLICATIONS: This study found that external assessment might generate criminalisation and scapegoating, reinforcing the sense of having medical perspectives on one hand and external regulatory perspectives on the other, which might hinder efforts to improve quality and safety. External bodies could, however, inspire useful adjustment of internal routines and procedures. The study implies that the variety and interconnections between external bodies may expose the surgeons to challenging pressure. Further studies are required to investigate these challenges to quality and safety in surgery.

Association between anaesthesia-surgery team sex diversity and major morbidity.

BACKGROUND: Team diversity is recognized not only as an equity issue but also a catalyst for improved performance through diversity in knowledge and practices. However, team diversity data in healthcare are limited and it is not known whether it may affect outcomes in surgery. This study examined the association between anaesthesia-surgery team sex diversity and postoperative outcomes. METHODS: This was a population-based retrospective cohort study of adults undergoing major inpatient procedures between 2009 and 2019. The exposure was the hospital percentage of female anaesthetists and surgeons in the year of surgery. The outcome was 90-day major morbidity. Restricted cubic splines were used to identify a clinically meaningful dichotomization of team sex diversity, with over 35% female anaesthetists and surgeons representing higher diversity. The association with outcomes was examined using multivariable logistic regression. RESULTS: Of 709 899 index operations performed at 88 hospitals, 90-day major morbidity occurred in 14.4%. The median proportion of female anaesthetists and surgeons was 28 (interquartile range 25-31)% per hospital per year. Care in hospitals with higher sex diversity (over 35% female) was associated with reduced odds of 90-day major morbidity (OR 0.97, 95% c.i. 0.95 to 0.99; P = 0.02) after adjustment. The magnitude of this association was greater for patients treated by female anaesthetists (OR 0.92, 0.88 to 0.97; P = 0.002) and female surgeons (OR 0.83, 0.76 to 0.90; P < 0.001). CONCLUSION: Care in hospitals with greater anaesthesia-surgery team sex diversity was associated with better postoperative outcomes. Care in a hospital reaching a critical mass with over 35% female anaesthetists and surgeons, representing higher team sex-diversity, was associated with a 3% lower odds of 90-day major morbidity.

An Analysis of the Characteristics and Trends in Practicing Plastic Surgeons in California.

BACKGROUND: Studies suggest an increasing trend of plastic surgeons choosing private practice after training, with up to 90% pursuing private practice without future fellowships.1 Previous data showed that 66.7% of graduates from plastic surgery residency programs chose to pursue private practice without future fellowship, while more recent studies estimate this statistic has risen close to 90%.1,2 The literature has yet to characterize the current plastic surgery workforce and changes in its composition over time. This study aims to analyze the characteristics and training of plastic surgeons in California through a comparative study with general surgeons. METHODS: Surgeon demographics were extracted from the Centers for Medicare and Medicaid Services open database. Urban/rural classification and academic affiliation were crosslinked from the Inpatient Prospective System database and sole proprietorship status was cross-linked from the NPI Registry. Summary statistics and logistic regressions with chi-squared analysis were analyzed using STATA/MP17. RESULTS: Our analysis consisted of 3871 plastic and general surgeons in California. Compared to general surgeons, plastic surgeons were less likely to be females (P < 0.000), and more likely to be sole proprietors (P < 0.000), and affiliated with a teaching hospital (P < 0.005). There was no statistically significant difference in the percentage of rural-practicing plastic and general surgeons (P = 0.590). More recent plastic surgery graduates were more likely to be affiliated with an academic hospital (P < 0.0000). The composition of females significantly increased from the older graduated cohort to the most recent one. There was no significant difference in sole proprietorship and rural practice status between the oldest and youngest graduating cohorts. CONCLUSIONS: Although the California plastic surgery workforce is gaining female plastic surgeons and shifting to academic institutions, significant progress in serving rural communities is yet to be made. Our study suggests that there may be a shift in the trend of plastic surgeons opting for private practice, possibly driven by a desire for more stable positions in academia. Continued improvement in diversity and training of future plastic surgeons is needed to alleviate the rural care gap.

Influence of hospital-level and surgeon factors on the outcomes after ileo-anal pouch surgery for inflammatory bowel disease: systematic review.

BACKGROUND: Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The relationship between hospital-level/surgeon factors (including volume) and outcomes after pouch surgery is of increasing interest given arguments for increasing centralization of these complex procedures. The aim of this systematic review was to appraise the literature describing the influence of hospital-level and surgeon factors on outcomes after pouch surgery for inflammatory bowel disease. METHODS: A systematic review was performed of studies reporting outcomes after pouch surgery for inflammatory bowel disease. The MEDLINE (Ovid), Embase (Ovid), and Cochrane CENTRAL databases were searched (1978-2022). Data on outcomes, including mortality, morbidity, readmission, operative approach, reconstruction, postoperative parameters, and pouch-specific outcomes (failure), were extracted. Associations between hospital-level/surgeon factors and these outcomes were summarized. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42022352851). RESULTS: A total of 29 studies, describing 41 344 patients who underwent a pouch procedure, were included; 3 studies demonstrated higher rates of pouch failure in lower-volume centres, 4 studies demonstrated higher reconstruction rates in higher-volume centres, 2 studies reported an inverse association between annual hospital pouch volume and readmission rates, and 4 studies reported a significant association between complication rates and surgeon experience. CONCLUSION: This review summarizes the growing body of evidence that supports centralization of pouch surgery to specialist high-volume inflammatory bowel disease units. Centralization of this technically demanding surgery that requires dedicated perioperative medical and nursing support should facilitate improved patient outcomes and help train the next generation of pouch surgeons.

Care fragmentation in hepatopancreatic surgery and postoperative outcomes.

BACKGROUND: Practice fragmentation in surgery may be associated with poor quality of care. We sought to define the association between fragmented practice and outcomes in hepatopancreatic surgery relative to surgeon volume and sex. METHODS: Medicare beneficiaries who underwent hepatopancreatic surgery between 2016 and 2021 were identified. Multivariable analysis was performed to determine provider sex-based differences in the rate of fragmented practice relative to the achievement of a textbook outcome and health care expenditures after adjusting for procedure-specific case volume. RESULTS: Among 37,416 patients, almost one-half were female (n = 18,333, 49.0%) with the majority treated by male surgeons (n = 33,697, 90.8%). Female surgeons were more likely to have a greater rate of fragmented practice (females: n = 242, 84.9% vs males: n = 1,487, 78.4%, P = .003; odds ratio 2.66, 95% confidence interval 2.33-3.03, P < .001). Patients treated by high rate of fragmented practice surgeons had increased odds of postoperative complications (odds ratio 1.40, 95% confidence interval 1.28-1.54), extended length-of-stay (odds ratio 1.52, 95% confidence interval 1.38-1.68), 90-day-mortality (odds ratio 1.49, 95% confidence interval 1.28-1.72), and lower odds of achieving a textbook outcome (odds ratio 0.76, 95% confidence interval 0.71-0.83). This association persisted independent of surgeon-specific volume (textbook outcome, high vs low rate of fragmented practice: high-volume surgeon, odds ratio 0.53, 95% confidence interval 0.31-0.91, P = .021 vs. low-volume surgeon, odds ratio 0.76, 95% confidence interval 0.69-0.82, P < .001). Among patients treated by male surgeons, a high rate of fragmented practice was associated with reduced odds of achieving a textbook outcome (male surgeons: odds ratio 0.76, 95% confidence interval 0.70-0.82, P < .001; female surgeons: odds ratio 0.81, 95% confidence interval 0.63-1.05, P = .110). Treatment by surgeons with higher fragmented practice was associated with higher expenditures (index expenditure: percentage difference 9.87, 95% confidence interval, 7.42-12.36; P < .05). CONCLUSION: A high rate of fragmented practice adversely affected postoperative outcomes and healthcare expenditures even among high-volume surgeons with the impact varying based on surgeon sex.

Surgeon age in relation to patients' long-term survival after gastrectomy for gastric adenocarcinoma: nationwide population-based cohort study.

BACKGROUND: Increasing surgeon age may influence patient outcomes after complex procedures due to gained experience but also decreased technical and cognitive abilities. This study aimed to clarify whether surgeon age influences patients' long-term survival after gastrectomy for gastric adenocarcinoma. METHODS: Population-based cohort study including all patients who underwent open and curatively intended gastrectomy for gastric adenocarcinoma between 2006 and 2015 in Sweden, with follow-up throughout 2020. Surgeon age, categorized into three equal-sized groups (tertiles), was assessed in relation to 5-year all-cause mortality rate (main outcome) and 5-year disease-specific death (secondary outcome) using multivariable Cox regression adjusted for patient age, sex, education, co-morbidity, pathological tumour stage, tumour sublocation and neoadjuvant therapy. Lymph node yield, resection margin status, in-hospital complications and annual surgeon volume of gastrectomy were considered potential mediators. RESULTS: Among 1647 patients, the 5-year all-cause mortality rate was increased for surgeon age ≥55 years (adjusted HR 1.21, 95% c.i. 1.04 to 1.41) and borderline elevated for age 47-54 years (HR 1.16, 95% c.i. 0.99 to 1.36), compared with age ≤46 years. Five-year disease-specific death was increased for surgeon age ≥55 years (HR 1.25, 95% c.i. 1.06 to 1.48) and 47-54 years (HR 1.22, 95% c.i. 1.02 to 1.44), compared with age ≤46 years. The associations attenuated and became statistically non-significant after adjustment for lymph node yield, resection margin status and complications. CONCLUSION: Surgeon age ≥47 years might be associated with worse long-term survival in patients who undergo gastrectomy for gastric adenocarcinoma, possibly mediated in part by differences in lymph node yield, resection margin status and complications.

Operating room efficiency for a high-volume surgeon in simultaneous bilateral robotic-assisted total knee arthroplasty: a prospective cohort study.

Robotic-assisted total knee arthroplasty (RATKA) has been shown to achieve more accurate component positioning and target alignment than conventional jig-based instrumentation; however, concerns remain regarding its adoption since it is associated with steep learning curves, higher operational costs, and increased surgical time. This study aims to compare the operating times of three cohorts of patients undergoing simultaneous bilateral TKA, i.e., first 50 RATKA, last 50 RATKA (at the end of 1 year), and 50 conventional TKA. This prospective cohort study was conducted at a single high-volume tertiary care center by a single experienced surgeon on 150 patients (300 knees), who were allotted into three equal cohorts of 50, between February 2020 and December 2021. Simultaneous bilateral TKAs were done in all three groups and operative times recorded. We describe the technique for optimizing the surgical time of SB-RATKA for efficient operative room logistics. The operating times of the two robotic-assisted TKA cohorts were compared with the operating times of the conventional SB-TKA cohort. The mean age of the study population was 59(±6.2) years with the majority of females (82%). The mean coronal deformity was comparable between the cohorts. The mean operating time in the conventional CTKA, initial 50 RATKA, and final 50 RATKA cohorts were 115.56 (±10.7), 127.8 (±26), and 91.66 (±13.5) min, respectively, all of which showed a statistically significant difference (p < 0.001). The mean operating times of the final 50 RATKA at the end of 1 year improved by about 36 min with all the SB-RATKA cases being completed in under 120 min. The efficiency of SB-RATKA improved significantly with time and experience, resulting in shorter operational times within a year, revealing the potential of robotic-assisted surgery to surpass conventional approaches in TKA in terms of operating room efficiency.

Current status and issues regarding surgical education in the region: a questionnaire survey in Oita prefecture in Japan.

BACKGROUND: The shortage and aging of surgeons in regional surgical care has been remarkable, and the importance of surgical education for young surgeons in the region is only increasing. However, there are very few reports about regional surgical education. This study aimed to clarify the current status and issues regarding surgical education in regional surgical care and to examine the ideal way to provide surgical education in the region. METHODS: Two questionnaire surveys were carried out. (1) "Survey on the awareness regarding the education of young surgeons" was conducted by mail in institutions where surgeons worked. (2) "Survey on the current status of surgical education for young surgeons" was conducted via the Internet with surgeons under 40 years old and mentors at the same facility. RESULTS: There were 175 respondents to survey (1), among whom 131 (75%) surgeons were interested in educating young surgeons, and 112 (64%) were actively participating in this educating. Regarding the best evaluation methods for mentors who are educating young surgeons, the most frequent answer was "I don't know (51%)". The number of respondents in survey (2) was 87, including 27 (31%) young surgeons and 60 (69%) mentors. Although there was no difference between young surgeons and mentors in the level of satisfaction with the current status of young surgeons, 37% of young surgeons in urban areas were dissatisfied with their current status, compared to 0% in the regional area (p < 0.05). CONCLUSIONS: Although surgeons did not have confidence in their own education, the level of satisfaction among young surgeons was high even in those providing regional surgical care. Development of an evaluation system for surgical education is necessary for young surgeons to receive more effective surgical education in the region.

Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support.

BACKGROUND: It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems. METHODS: A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems. RESULTS: The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others. CONCLUSIONS: Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.

Surgeon Factors and Trends Associated With the Use of Subacromial Decompression at the Time of Rotator Cuff Repair.

PURPOSE: Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use. METHODS: Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability. RESULTS: During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio = 3.04). CONCLUSIONS: Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use. CLINICAL RELEVANCE: These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.

Using risk-adjusted cumulative sum to evaluate surgeon, divisional, and institutional outcomes-a feasibility study.

BACKGROUND: Few objective, real-time measurements of surgeon performance exist. The risk-adjusted cumulative sum is a novel method that can track surgeon-level outcomes on a continuous basis. The objective of this study was to demonstrate the feasibility of using risk-adjusted cumulative sum to monitor outcomes after colorectal operations and identify clinically relevant performance variations. METHODS: The National Surgical Quality Improvement Program was queried to obtain patient-level data for 1,603 colorectal operations at a high-volume center from 2011 to 2020. For each case, expected risks of morbidity, mortality, reoperation, readmission, and prolonged length of stay were estimated using the National Surgical Quality Improvement Program risk calculator. Risk-adjusted cumulative sum curves were generated to signal observed-to-expected odds ratios of 1.5 (poor performance) and 0.5 (exceptional performance). Control limits were set based on a false positive rate of 5% (α = 0.05). RESULTS: The cohort included data on 7 surgeons (those with more than 20 cases in the study period). Institutional observed versus expected outcomes were the following: morbidity 12.5% (vs 15.0%), mortality 2.5% (vs 2.0%), prolonged length of stay 19.7% (vs 19.1%), reoperation 11.1% (vs 11.3%), and 30-day readmission 6.1% (vs 4.8%). Risk-adjusted cumulative sum accurately demonstrated within- and between-surgeon performance variations across these metrics and proved effective when considering division-level data. CONCLUSION: Risk-adjusted cumulative sum adjusts for patient-level risk factors to provide real-time data on surgeon-specific outcomes. This approach enables prompt identification of performance outliers and can contribute to quality assurance, root-cause analysis, and incentivization not only at the surgeon level but at divisional and institutional levels as well.

Increased patient body mass index is associated with increased surgeon physiologic stress during total hip arthroplasty.

INTRODUCTION: While increased body mass index (BMI) in patients undergoing total hip arthroplasty (THA) increases surgical complexity, there is a paucity of objective studies assessing the impact of patient BMI on the cardiovascular stress experienced by surgeons during THA. The aim of this study was to assess the impact of patient BMI on surgeon cardiovascular strain during THA. METHODS: We prospectively evaluated three fellowship-trained arthroplasty surgeons performing a total of 115 THAs. A smart-vest worn by the surgeons recorded mean heart rate, stress index (correlate of sympathetic activation), respiratory rate, minute ventilation, and energy expenditure throughout the procedures. Patient demographics as well as perioperative data including surgical approach, surgery duration, number of assistants, and the timing of the surgery during the day were collected. Linear regression was utilized to assess the impact of patient characteristics and perioperative data on cardiorespiratory metrics. RESULTS: Average surgeon heart rate, energy expenditure, and stress index during surgery were 98.50 beats/min, 309.49 cal/h, and 14.10, respectively. Higher patient BMI was significantly associated with increased hourly energy expenditure (P = 0.027), mean heart rate (P = 0.037), and stress index (P = 0.027) independent of surgical approach. Respiratory rate and minute ventilation were not associated with patient BMI. The number of assistants and time of surgery during the day did not impact cardiorespiratory strain on the surgeon. CONCLUSION: The physiologic burden on surgeons during primary THA significantly increases as patient BMI increases. This study suggests that healthcare systems should consider adjusting reimbursement models to account for increased surgeon workload due to obesity. Further surgeons should adopt strategies in operative planning and case scheduling to handle this added physical strain. LEVEL OF EVIDENCE: III.

The Unseen Strain: Investigating the Awareness of Rhinoplasty Surgeons Regarding Their Spine Health.

BACKGROUND: Musculoskeletal pain is a common occupational health problem among surgeons that can affect work productivity and quality of life. OBJECTIVES: The aim of the study was to investigate the prevalence and causes of back pain among rhinoplasty surgeons, evaluate their routine practice, and identify unique risk factors. A further goal was to measure functional disabilities with the Total Disability Index (TDI) questionnaire. METHODS: A structured online questionnaire was distributed to plastic surgeons performing rhinoplasty internationally. The questionnaire comprised sections on biodata, routine practice posture, length of practice, surgical duration, and the history of surgery or hospitalization related to these issues. In the second part of the survey, participants were asked to complete the TDI questionnaire. RESULTS: The prevalence of back pain was reported by 93.6% of surgeons, with low back pain being the most common (76.7%). The average pain intensity for low back pain was 44.8 ± 26.8. The mean TDI score was calculated as 31 ± 12.1, with 58.2% of surgeons experiencing mild to moderate disability. Significant associations were found between musculoskeletal pain severity and disability index and factors such as BMI, exercise, years of rhinoplasty practice, number of surgeries performed per week, and average procedure length. Interestingly, only 16.4% of rhinoplasty surgeons had previous ergonomic training or education. CONCLUSIONS: Musculoskeletal issues related to the spine are prevalent among rhinoplasty surgeons. It is imperative to educate surgeons about this underestimated health problem, provide proper physical rehabilitation targeting ergonomic concerns, and make changes to current practices to address this issue effectively.

Sex-based Disparities Among Surgical Faculty Positions Across Medical Colleges in Pakistan.

INTRODUCTION: Despite women being under-represented in academic surgery, there is no publicly accessible repository describing the distribution of surgeons by sex and specialty in Pakistan. This short report aims to fulfill this gap by describing female representation across surgical faculty positions in medical colleges across Pakistan. METHODS: This cross-sectional study was conducted in 2021 across medical universities in Pakistan. A dual mode of data collection was employed, whereby data regarding sex, academic designation, and subspecialty of surgical faculty was retrieved via emails to representative faculty from medical colleges, and from medical colleges' websites. RESULTS: A total of 97/114 (85.1%) medical colleges across Pakistan were included, providing us with data of 2070 surgical faculty. Overall, only 10.3% of surgical faculty were women, with women comprising 14.1% of assistant professors, 9.3% of associate professors, and only 5.7% of professors. Most women surgical faculty were assistant professors (63.1%), with only 17.8% being professors. Sindh (14.3%) and Punjab (9.7%) had the greatest percentage of women across surgical faculty overall, while Khyber Pakhtunkhwa had the lowest (6.5%). Apart from breast surgery (100%), pediatric surgery (29.4%), ophthalmology (15.0%) and general surgery (11.6%), women did not represent more than 10% of surgical faculty for any surgical subspecialty. CONCLUSION: In Pakistan, there is a blatant lack of female representation across all faculty positions and in most surgical specialties, with imbalances more pronounced in the relatively under-developed Khyber Pakhtunkhwa and Balochistan. These sex disparities may aggravate the surgical disease burden and adversely impact surgical prospects for women across the country.

Venous thromboembolism (VTE) prophylaxis after bariatric surgery: a national survey of MBSAQIP director practices.

BACKGROUND: Venous thromboembolism (VTE) is the most common cause of death following metabolic/bariatric surgery (MBS), with most events occurring after discharge. The available evidence on ideal prophylaxis type, dosage, and duration after discharge is limited. OBJECTIVES: Assess metabolic/bariatric surgeon VTE prophylaxis practices and define existing variability. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers. METHODS: The members of the ASMBS Research Committee developed and administered a web-based survey to MBSAQIP medical directors and ASMBS members to examine the differences in clinical practice regarding the administration of VTE prophylaxis after MBS. RESULTS: Overall, 264 metabolic/bariatric surgeons (136 medical directors and 128 ASMBS members) participated in the survey. Both mechanical and chemical VTE prophylaxis was used by 97.1% of the participants, knee-high compression devices by 84.7%, enoxaparin (32.4% 40 mg every 24 hours, 22.7% 40 mg every 12 hours, 24.4% adjusted the dose based on body mass index) by 56.5%, and heparin (46.1% 5000 units every 8 hours, 22.6% 5000 units every 12 hours, 20.9% 5000 units once preoperatively) by 38.1%. Most surgeons (81.6%) administered the first dose preoperatively, while the first postoperative dose was given on the evening of surgery by 44% or the next morning by 42.2%. Extended VTE prophylaxis was prescribed for 2 weeks by 38.7% and 4 weeks by 28.9%. CONCLUSIONS: VTE prophylaxis practices vary widely among metabolic/bariatric surgeons. Variability may be related to limited available comparative evidence. Large prospective clinical trials are needed to define optimal practices for VTE risk stratification and prophylaxis in bariatric surgery patients.

InCISE: Instrument for Comprehensive Incisional and Surgical Evaluation.

OBJECTIVE: The evaluation of healing after head and neck surgery is currently qualitative and non-standardized, limiting the quality of surgical healing assessments in clinical and research settings. We sought to develop an objective, standardized wound assessment score, and hypothesize that a reliable instrument can be developed to evaluate head and neck surgical wounds. METHODS: A prospective cohort study was conducted in a tertiary-care, academic head and neck surgery practice. Patients undergoing head and neck surgery were enrolled. A digital photograph protocol was developed for evaluating healing surgical wounds. A panel of experts developed and refined a wound healing score and established reliability, reproducibility, internal consistency, and validity of the score. RESULTS: InCISE: Instrument for comprehensive incisional and surgical evaluation was created. The utility of our wound healing score was assessed using classical test theory. We performed the major steps of establishing reliability in head and neck surgeons: (1) internal consistency (Cronbach's α = 0.81), (2) inter-observer reliability (intra-class correlation = 0.76), and (3) intra-rater reliability (intra-class correlation = 0.87), and content validity (through focus groups). Our composite measure was found to have strong internal consistency, inter-rater reliability, and intra-rater reliability. Preliminary work suggests criterion validity via associations with physical health related quality of life (SF-12). CONCLUSION: A wound healing score for head and neck surgery, InCISE, has been developed and is reliable, reproducible, and consistent. Although content validity is present and criterion validity is suggested, work continues to establish validity in this instrument to allow for expanded clinical and research use. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2166-2173, 2023.

A Comparative Study of Diagnosis and Treatment of Pott's Spine Amongst Specialists and Super Specialists in India.

Background and Objective: There is a paucity of guidelines about the diagnosis and management of Pott's spine. In this study, we report the pattern of practice of diagnosis and treatment of Pott's spine among the specialists and super-specialists in India. Subject and Methods: Response to a 22-item questionnaire regarding the diagnosis and treatment of Pott's spine has been reported. The responses were compared between medical and surgical specialists, residents and consultants, and specialists and super-specialists. There were 84 responders: 42 physicians and 42 surgeons; 48 residents and 36 faculty or consultants; 53 specialists and 31 super-specialists. Results: Thirty-eight responders rarely recommended biopsy whereas others recommended biopsy more frequently, especially the surgeons (P < 0.007). Twenty-five responders recommended immobilization even in an asymptomatic patient whereas 38 would immobilize those with neurological involvement only. All but 4 responders would repeat imaging at different time points. The response of medical treatment was judged at 1 month by 53, and 3 months by 26 responders. Surgery was recommended in a minority of patients-in those with neurological involvement or abscess. Surgeons more frequently biopsied, immobilized the patients, and recommended surgery compared to the physicians. The residents also recommended biopsy and recommended immobilization more frequently compared to consultants or faculty members. Super-specialists more frequently recommended biopsy compared to specialists. Conclusion: There is marked variation in investigations and treatment of Pott's spine patients, suggesting the need for consensus or evidence-based guidelines.