Surgical Intelligence can Lead to Higher Adoption of Best Practices in Minimally Invasive Surgery.

OBJECTIVE: To examine the use of surgical intelligence for automatically monitoring critical view of safety (CVS) in laparoscopic cholecystectomy (LC) in a real-world quality initiative. BACKGROUND: Surgical intelligence encompasses routine, AI-based capture and analysis of surgical video, and connection of derived data with patient and outcomes data. These capabilities are applied to continuously assess and improve surgical quality and efficiency in real-world settings. METHODS: LCs conducted at two general surgery departments between December 2022 and August 2023 were routinely captured by a surgical intelligence platform, which identified and continuously presented CVS adoption, surgery duration, complexity, and negative events. In March 2023, the departments launched a quality initiative aiming for 75% CVS adoption. RESULTS: 279 procedures were performed during the study. Adoption increased from 39.2% in the 3 pre-intervention months to 69.2% in the final 3 months (P < .001). Monthly adoption rose from 33.3% to 75.7%. Visualization of the cystic duct and artery accounted for most of the improvement; the other two components had high adoption throughout. Procedures with full CVS were shorter (P = .007) and had fewer events (P = .011) than those without. OR time decreased following intervention (P = .033). CONCLUSION: Surgical intelligence facilitated a steady increase in CVS adoption, reaching the goal within 6 months. Low initial adoption stemmed from a single CVS component, and increased adoption was associated with improved OR efficiency. Real-world use of surgical intelligence can uncover new insights, modify surgeon behavior, and support best practices to improve surgical quality and efficiency.

Opportunities and Applications of Educational Technologies in Surgical Education and Assessment.

BACKGROUND: Surgical education is challenged by continuously increasing clinical content, greater subspecialization, and public scrutiny of access to high quality surgical care. Since the last Blue Ribbon Committee on surgical education, novel technologies have been developed including artificial intelligence and telecommunication. OBJECTIVES AND METHODS: The goals of this Blue Ribbon Sub-Committee were to describe the latest technological advances and construct a framework for applying these technologies to improve the effectiveness and efficiency of surgical education and assessment. An additional goal was to identify implementation frameworks and strategies for centers with different resources and access. All sub-committee recommendations were included in a Delphi consensus process with the entire Blue Ribbon Committee (N=67). RESULTS: Our sub-committee found several new technologies and opportunities that are well poised to improve the effectiveness and efficiency of surgical education and assessment (see Tables 1-3). Our top recommendation was that a Multidisciplinary Surgical Educational Council be established to serve as an oversight body to develop consensus, facilitate implementation, and establish best practices for technology implementation and assessment. This recommendation achieved 93% consensus during the first round of the Delphi process. CONCLUSION: Advances in technology-based assessment, data analytics, and behavioral analysis now allow us to create personalized educational programs based on individual preferences and learning styles. If implemented properly, education technology has the promise of improving the quality and efficiency of surgical education and decreasing the demands on clinical faculty.

Key Issues in Surgical Residency Education: Recommendations of the Blue Ribbon II Committee Residency Education Subcommittee.

In September 2022, a summit was convened by the American Board of Surgery (ABS) to discuss competency-based reform in surgical education. A key output of that summit was the recommendation that the prior work of the Blue Ribbon I Committee convened 20 years earlier be revived. With leadership from the American College of Surgeons (ACS) and the American Surgical Association (ASA) , the Blue Ribbon Committee (BRC) II was subsequently convened. This paper describes the output of the Residency Education Subcommittee of the BRC II Committee. The Subcommittee organized its work around prioritized themes including curriculum, assessment, and transition to practice. Top recommendations, time-based action steps, potential barriers, and required resources were detailed and vetted through group discussion, broader Committee review and critique, and subsequent refinement. Primary concluding emphases included transitioning to a competency-based training model, facilitating dynamically capable curricular reform emphasizing the digital transformation of surgical care, using predictive analytic assessment strategies to optimize training effectiveness and efficiency, and creating mentorship strategies to govern the transition from training to independent practice in an outcomes-accountable fashion. It was recognized that coordinated efforts across existing organizational structures will be required, informed by dataset integration strategies that meaningfully measure educational and related patient outcomes.

Teaching Chest Tube Insertion by Blended Learning: A Multi-Dimensional Analysis.

BACKGROUND: Emerging technologies are being incorporated in surgical education. The use of such technology should be supported by evidence that the technology neither distracts nor overloads the learner and is easy to use. To teach chest tube insertion, we developed an e-learning module, as part of a blended learning program delivered prior to in-person hands-on simulation. This pilot study was aimed to assess learning effectiveness of this blended learning, and cognitive load and the usability of e-learning. METHODS: The interactive e-learning module with multimedia content was created following learning design principles. In advance of the standard simulation, 13 first-year surgical residents were randomized into two groups: 7 received the e-learning module and online reading materials (e-learning group); 6 received only the online reading materials (controls). Knowledge was evaluated by pre-and post-tests; technical performance was assessed using a Global Rating Scale by blinded assessors. Cognitive load and usability were evaluated using rating scales. RESULTS: The e-learning group showed significant improvement from baseline in knowledge (P = .047), while controls did not (P = .500). For technical skill, 100% of residents in the e-learning group reached a predetermined proficiency level vs 60% of controls (P = .06). The addition of e-learning was associated with lower extrinsic and greater germane cognitive load (P = .04, .03, respectively). Usability was evaluated highly by all participants in e-learning group. CONCLUSION: Interactive e-learning added to hands-on simulation led to improved learning and desired cognitive load and usability. This approach should be evaluated in teaching of other procedural skills.

Considerations for designing and implementing a surgical peer coaching program: an international survey.

BACKGROUND: Surgical peer coaching has been associated with high rates of practice change but remains largely unutilized. The purpose of this study was to survey surgeons internationally to investigate attitudes regarding peer coaching and to identify any international differences to inform the design of future coaching programs. METHODS: Practicing surgeons in general surgery or related subspecialties were eligible to participate. Invitations to complete the survey were distributed through 13 surgical associations, social media, and personal e-mail invitations. Responses were obtained between June 1st and August 31st, 2020. RESULTS: A total of 521 surveys were collected. The majority of participants practiced in North America (263; 50%) with remaining respondents from Asia (81; 16%), Europe (34;7%), South America (21; 4%), Africa (17; 3%), and Oceania (6; 1%). Duration of practice was equally distributed across 4 intervals (0-5 years; 6-15 years; 16-25 years; > 25 years). Respondents most frequently identified as general surgeons (290; 67%) and 325 (75%) were male. Awareness of peer coaching was reported by 275 (53%) respondents, with 197 (44%) never seeking formal feedback from peers. The majority of respondents (372; 84%) would be willing to participate in a peer coaching program, with monthly interactions the most desirable frequency reported (193; 51%). Coaching in the operating room was preferred by most participants (360; 86%). Few respondents (67; 14%) would accept coaching from someone unknown to them. Participants identified key coaching program elements as: feedback kept private and confidential (267; 63%); opportunity to provide feedback to the coach (247; 59%); personalized goal setting (244; 58%); and the option to choose one's own coach (205; 49%). The most commonly cited potential barrier to participation was logistical constraints (334; 79%). CONCLUSION: This international survey of practicing surgeons demonstrated that peer feedback is rarely used in practice, but there is high interest and acceptance of the peer coaching model for continuous professional development. Findings regarding preferred program structure may be useful to inform the design of future peer coaching programs.

High incidence of potentially preventable emergency department visits after major elective colorectal surgery.

INTRODUCTION: Emergency department (ED) visits after surgery represent a significant cost burden on the healthcare system. Furthermore, many ED visits are related to issues of healthcare delivery services and may be avoidable. Few studies have assessed the reasons for ED visits after colorectal surgery. The main objectives of this study were to: (1) identify the reasons why patients presented to the ED within 30 postoperative days and (2) determine if these visits were potentially preventable. METHODS: A retrospective chart review was conducted on elective major colorectal surgery cases performed in a single center between 01/2017 and 07/2019. Data collected included demographics, medical history, intraoperative details, postoperative complications, ED visits within 30 postoperative days, and readmissions. Each ED visit was assessed by two reviewers and graded on a scale adapted from the New York University ED algorithm. The gradings were: (1) non-emergent, (2) emergent but treatable in an ambulatory setting, (3) emergent/ED-care required but preventable if timely outpatient care was available, and (4) emergent/ED-care required and non-preventable. Grades 1-3 were deemed potentially preventable. Logistic regression identified independent predictors of potentially preventable visits. RESULTS: Six hundred and twenty five patients were included in the final analysis. 110 (17.6%) patients presented to the ED within 30 days. The most common cause of ED visit were ileus/small bowel obstruction (SBO) (16.4%), superficial wound infection (15.5%), genitourinary issues (10.9%), and non-infectious gastrointestinal issues (nausea, malnutrition, diarrhea, high output stomas) (10.9%). After review, 51.8% of visits were considered potentially preventable (Grade 1-3). The most common causes of preventable ED visits were superficial wound infection (24.6%), non-infectious gastrointestinal issues (19.3%), and minor bleeding (14.0%). Creation of a new stoma was the only independent risk factor for potentially preventable ED visits (OR 2.14, 95%CI 1.03-4.47). CONCLUSION: Approximately half of ED visits within 30 days of discharge were potentially preventable. These findings indicate a need to improve access to outpatient care to reduce preventable ED visits after elective colorectal surgery.

Reciprocal peer coaching for practice improvement in surgery: a pilot study.

BACKGROUND: Peer coaching has been associated with much higher rates of practice changes and new skill implementation compared to common used modalities but bilateral peer coaching structures where seniority is not a requirement to coach have not been studied. The purpose of this study was to implement and evaluate a reciprocal peer coaching pilot program for practicing surgeons to inform future coaching program design. METHODS: A multicenter reciprocal peer surgical coaching program was designed according to the framework developed from previous studies by our group. The coach-coachee matching process was voluntary and autonomous. All participants received basic coaching skills training. Pairs were instructed to complete two coaching sessions, alternating between the coach or coachee role for each session. Data were collected through questionnaires and structured interviews. RESULTS: Twenty-two participants enrolled in the pilot study and completed the coach training (88% enrollment rate). During the first wave of COVID-19, 12 participants withdrew. Of the five pairs that completed the program, three pairs were composed of general surgeons, one of orthopedic surgeons, and one ophthalmologic surgeon. Three sessions were conducted live in the OR, five virtually, and one involved an in-person discussion. Overall satisfaction with the program was high and all participants expectations were met. Participants were significantly more likely to predict "routinely" asking for feedback from their partner after study completion (6, 66%) compared to pre-intervention (p = 0.02). CONCLUSION: This pilot study supports the feasibility of a peer coaching model for surgeons in practice that emphasized reciprocity and participant autonomy. These key elements should be considered when designing future coaching programs.

Establishing validity evidence for device-assisted advanced laparoscopic suturing tasks using simulation.

BACKGROUND: Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks. METHODS: This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods. RESULTS: Twenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061). CONCLUSION: In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study.

BACKGROUND: Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR). METHODS: In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2-3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points. RESULTS: Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training. CONCLUSION: The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.

Rethinking how health care professionals cope with stress: A process model for COVID-19 and beyond.

ISSUE: Prior to the COVID-19 pandemic, there was evidence of challenges surrounding the psychological well-being of health care professionals (HCPs). HCPs already frayed psychological ability to cope risks being further compromised by COVID-19-related stresses. CRITICAL THEORETICAL ANALYSIS: Most research on stress, psychological distress, and coping among HCPs is done in a piecemeal manner without a theoretical model connecting these different but related phenomena. This critical advancement article aims to apply and extend Wheaton and Montazer's model of stressors, stress, and distress to the literature on HCPs, generally, and COVID-19, specifically, to summarize past and guide future research on HCPs' mental health, resilience, and coping. Our model describes how different sources of support buffer the effect of stressors on stress and how coping strategies moderate the effect of stress on psychological distress. ADVANCE: We extended the model by (a) distinguishing context from the support in HCPs' environment; (b) distinguishing adaptive from maladaptive coping strategies and their relationships with antecedents and outcomes; (c) describing the adverse impacts that psychological distress has on patients, HCPs, and health services; and (d) describing how such outcomes can become stressors, in turn, further contributing to HCPs' stress in a vicious cycle. PRACTICE IMPLICATIONS: Our model provides a broader perspective of HCPs' work-related mental health and helps guide the creation, implementation, and evaluation of different sources of support and promote adaptive coping strategies. This model helps HCPs, researchers, and health services managers better understand and respond to the well-being crisis HCPs are facing, especially during the pandemic.

Defining the key skills required to perform advanced laparoscopic procedures: a qualitative descriptive study.

BACKGROUND: Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. METHODS: Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. RESULTS: 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees. CONCLUSION: This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Identifying optimal program structure, motivations for and barriers to peer coaching participation for surgeons in practice: a qualitative synthesis.

BACKGROUND: Continuous advancement of surgical skills is of utmost importance to surgeons in practice, but traditional learning activities without personalized feedback often do not translate into practice changes in the operating room. Peer coaching has been shown to lead to very high rates of practice changes and utilization of new skills. The purpose of this study was to explore the opinions of practicing surgeons regarding the characteristics of peer coaching programs, in order to better inform future peer coaching program design. METHODS: Using a convenience sample, practicing general surgeons were invited to participate in focus group interviews. Allocation into groups was according to years in practice. The interviews were conducted using open-ended questions by trained facilitators. Audio recordings were transcribed and coded into themes by two independent reviewers using a grounded theory approach. RESULTS: Of 52 invitations, 27 surgeons participated: 74% male; years in practice: < 5 years: 33%; 5-15 years: 26%; > 15 years: 41%. Three main themes emerged during coding: ideal program structure, motivations for participation, and barriers to implementation. For the ideal structure of a peer coaching program all groups agreed coaching programs should be voluntary, involve bidirectional learning, and provide CME credits. Live, in situ coaching was preferred. Motivations for coaching participation included: desire to learn new techniques (48%), remaining up to date with the evolution of surgical practice (30%) and improvement of patient outcomes (18%). Barriers to program implementation were categorized as: surgical culture (42%), perceived lack of need (26%), logistical constraints (23%) and issues of coach-coachee dynamics (9%). CONCLUSION: Peer coaching to refine or acquire new skills addresses many shortcomings of traditional, didactic learning modalities. This study revealed key aspects of optimal program structure, motivations and barriers to coaching which can be used to inform the design of successful peer coaching programs in the future.

Development and validation of an endoscopic submucosal dissection video assessment tool.

BACKGROUND: Despite a need for assessment of endoscopic submucosal dissection (ESD) skills in order to track progress and determine competence, there is no structured measure of assessing competency in ESD performance. The present study aims to develop and examine validity evidence for an assessment tool to evaluate the recorded performance of ESD for gastric neoplasms. METHODS: The ESD video assessment tool (EVAT) was systematically developed by ESD experienced endoscopists. The EVAT consists of a 25-item global rating scale and 3-item checklist to assess competencies required to perform ESD. Five unedited videos were each evaluated by 2-blinded experienced ESD endoscopists to assess inter-rater reliability using intraclass correlation coefficients (ICC). Seventeen unedited videos in total were rated by 3 blinded experienced ESD endoscopists. Validity evidence for relationship to other variables was examined by comparing scores of inexperienced (fellows) and experienced endoscopists (attending staff), and by evaluating the relationship between the EVAT scores and ESD case experience. Internal consistency was evaluated using Cronbach's alpha. RESULTS: The inter-rater reliability for the total score was high at 0.87 (95% confidence interval 0.11 to 0.99). The total score [median, interquartile range (IQR)] was significantly different between the inexperienced (71, 63-77) and experienced group (95, 91-97) (P = 0.005). The total scores demonstrated high correlation with the number of ESD cases (Spearman's ρ = 0.79, P < 0.01). The internal consistency was 0.97. CONCLUSIONS: This study provides preliminary validity evidence for the assessment of video-recorded ESD performances for gastric neoplasms using EVAT.

S116: Impact of incisional negative pressure wound therapy on surgical site infection after complex incisional hernia repair: a retrospective matched cohort study.

INTRODUCTION: Incisional negative pressure wound therapy (iNPWT) may reduce surgical site infections (SSI), which can have devastating consequences after incisional hernia repair. Few comparative studies investigate the effectiveness of this wound management strategy in this population. The objective of this study is to determine the effect of iNPWT on the incidence of SSI after complex incisional hernia repair. METHODS: All adult patients undergoing open incisional hernia repair at a single center from 2016 to 2019 were reviewed. A commercial iNPWT dressing was used at the discretion of the surgeon. Patients were grouped by type of dressing; iNPWT and standard sterile dressings (SSD). Coarsened exact matching was used to create balanced cohorts for comparison using age, sex, American Society of Anesthesiologists classification, wound classification, and surgical urgency. The primary outcome was the composite incidence of superficial and deep SSI within 30 days. Secondary outcomes included non-infectious surgical site occurrences (SSO), overall complications, length of stay (LOS), emergency department visits, and readmission at 30 days. RESULTS: 134 patients underwent complex hernia repair, with 114 patients included after matching (34 iNPWT, 51 SSD). Composite incidence of superficial and deep SSI was 19.3% (11.8% vs. 27.5%, p = 0.107), with significantly lower rates of deep SSI in patients receiving iNPWT (2.9% vs. 17.6%, p = 0.045). After accounting for residual differences between groups, iNPWT was associated with decreased incidence of composite SSI (RR 0.36, 95% CI [0.16, 0.87]). Median LOS was longer in patients with iNPWT (7 vs. 5 days, p = 0.001). There were no differences in SSO, overall complications, readmission, or emergency department visits. CONCLUSION: In patients undergoing incisional hernia repair, the use of iNPWT was associated with a lower incidence of SSI at 30 days. Future studies should focus on cost effectiveness of iNPWT, its impact on long-term hernia recurrences, and the identification of patient selection criteria in this population.

Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center.

INTRODUCTION: Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. METHODS: A retrospective review was conducted for all Type II-IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. RESULTS: A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p < 0.0001], and emergency patients were less likely to return directly to their original residence at discharge (13, 72% emergency vs 185, 99.4% elective, p < 0.0001). There were significantly more major complications (Clavien-Dindo score ≥ 3) in the emergency group (5, 28% emergency vs. 10, 5% elective, p = 0.005). There were no perioperative deaths in either group. Morbidity and mortality in both groups were less than historically reported. CONCLUSIONS: Informed consent discussions and patient selection for repair of giant PEHs should reflect modern era and institution-specific outcomes.

Is there a gender bias in the advancement to SAGES leadership?

BACKGROUND: The proportion of women in surgery has risen significantly yet there remains gender discrepancies in upper leadership positions in academia. Specialty societies play an important role in academic advancement but the progression of women in surgical societies has not been studied. The purpose of this study was to determine if there are gender differences in advancement within the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) leadership. METHODS: A retrospective audit of all SAGES committee members (CM) from 1992 to 2018 was performed. The overall membership gender distribution was available from 2010 to 2018. Leadership positions included Committee Chair/Co-chair, Board of Governors, and Executive Committee. Three phenomena were investigated: "pipeline," by determining the change in women CMs compared to overall membership over time; "sticky floors," by comparing advancement beyond CM by gender; "glass-ceiling," by analyzing the promotion trajectory and time to leadership positions between genders. Statistical analysis comparing trends over time was performed using Kendall-tau. RESULTS: There were 1546 surgeons who served on at least one committee during the study period. Women represented 21% of CMs, 18% of chairs/co-chairs, 16% of board members and 14% of executives, with one woman President. The proportion of women CMs has significantly increased over time from 3% in 1992 to 27% in 2018 (p-trend < 0.001). A similar proportion of women and men advanced beyond CM (17% vs. 14%, p = 0.194), with no difference in time to advancement. From 2010 to 2018, the increase in the proportion of women CMs and board members outpaced that of overall women members (p < 0.05). Women executives surpassed overall women members in 2018 (29% vs. 19%). A similar proportion of men and women "skipped ranks" to reach the Board/Executive (37% vs. 25%, p = 0.307). CONCLUSION: The proportion of women in leadership positions within SAGES is higher than in the overall membership. There were no gender differences in the advancement of CMs to leadership positions. While these data are encouraging, SAGES should continue to foster the advancement of women surgeons.

Intracorporeal versus extracorporeal anastomosis for right colectomy does not affect gastrointestinal recovery within an enhanced recovery after surgery program.

INTRODUCTION: Delayed gastrointestinal (GI) recovery remains a significant morbidity after colorectal surgery. Intracorporeal anastomosis for right colectomy may hasten GI recovery. Therefore, the objective of this study was to determine the effect of intracorporeal versus extracorporeal anastomosis on GI recovery after elective laparoscopic right colectomy within an established ERAS program. METHODS: Adult patients undergoing elective laparoscopic right colectomy at a single high-volume institution from 07/2014 to 12/2018 were reviewed. Patients were divided into two groups: intracorporeal (IC) and extracorporeal (EC). The primary outcome was time to GI-3 defined as days to tolerance of solid diet and first flatus/bowel movement. Prolonged postoperative ileus (PPOI) was defined as GI-3 not met by postoperative day 4. Secondary outcomes were length of stay (LOS) and overall 30-day complications. Sensitivity analysis was performed using coarsened exact matching to account for unmeasured confounding. Multiple regression was performed using a Cox proportional hazard model to identify predictors of GI recovery. RESULTS: A total of 346 patients were reviewed, of which 226 were included (71IC, 155EC). Patient characteristics were well balanced between groups: mean age was 64.9 years (SD 15.9), BMI was 26.3 (SD 5.7), 38.1% of patients had ASA ≥ 3, and 78.3% underwent surgery for neoplasms. IC anastomosis was associated with longer operative duration (165 min (SD 40); 144 min (SD 48), p = 0.002). There was no difference in the median time to GI-3 (IC 2 days [IQR1-2]; EC 2 days [IQR2-3], p = 0.135). The incidence of PPOI (IC 8.5%; EC 10.3%, p = 0.659), superficial SSI (4.2% vs. 5.8%, p = 0.757), deep SSI (2.8% vs. 5.2%, p = 0.729), and median LOS (3 days [IQR 2-4] vs. 3 [IQR 3-5], p = 0.059) were also similar. On multivariate analysis, IC anastomosis did not independently predict faster GI recovery (HR 0.98, 95% CI 0.71-1.34). Similar results were observed in the matched cohort (185 patients (61IC, 124EC)). CONCLUSION: In this study, IC anastomosis was not associated with faster GI recovery or reduced complication rate compared to EC anastomosis. Longer term studies may be required to determine the potential benefits of IC anastomosis.

Improved Disease-free Survival After Prehabilitation for Colorectal Cancer Surgery.

OBJECTIVE: The objective of this study was to investigate the effect of prehabilitation on survival after colorectal cancer surgery. SUMMARY OF BACKGROUND DATA: Preoperative multimodal exercise and nutritional programs (prehabilitation) improve functional capacity and recovery following colorectal surgery. Exercise may also affect cancer outcomes by mediating the systemic inflammatory response. The effect of prehabilitation on cancer outcomes is unknown. METHODS: Pooled data from 3 prehabilitation trials (2 randomized controlled trials, 1 cohort) in patients undergoing elective, biopsy-proven, primary non-metastatic colorectal cancer surgery from 2009 to 2014 within an enhanced recovery program were analyzed. Patients were grouped into +prehab or-prehab. The primary outcomes were 5-year disease-free (DFS) and overall survival (OS). DFS and OS were analyzed using Kaplan-Meier curves and multiple Cox regression. RESULTS: A total of 202 patients were included (+prehab 104, -prehab 98). Median prehabilitation duration was 29 days (interquartile range 20-40). Patient and tumor characteristics were well-balanced (33% stage III). Postoperative complications and time to adjuvant chemotherapy were similar. Mean duration of follow-up was 60.3 months (standard deviation 26.2). DFS was similar for the combined group of stage I-III patients (P = 0.244). For stage III patients, prehabilitation was associated with improved DFS (73.4% vs 50.9%, P = 0.044). There were no differences in OS (P = 0.226). Prehabilitation independently predicted improved DFS (hazard ratio 0.45; 95% confidence interval, 0.21-0.93), adjusting for stage and other confounders. Prehabilitation did not independently predict OS. CONCLUSION: In this report, prehabilitation is associated with improved 5-year DFS in stage III colorectal cancer. This finding should be confirmed in future trials.

Simulation platforms to assess laparoscopic suturing skills: a scoping review.

BACKGROUND: Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted. METHODS: A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included "laparoscopic suturing" and "clinical competence." RESULTS: Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies. CONCLUSION: We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

Comparison between conventional colectomy and complete mesocolic excision for colon cancer: a systematic review and pooled analysis : A review of CME versus conventional colectomies.

BACKGROUND: Complete mesocolic excision (CME) is advocated based on oncologic superiority, but not commonly performed in North America. Many data are case series with few comparative studies. Our aim was to perform a systematic review comparing outcomes between CME and non-CME colectomy. METHODS: A systematic review was performed according to PRISMA guidelines of MEDLINE, EMBASE, HealthStar, Web of Science, and Cochrane Library. Studies were included if they compared conventional resection (non-CME) to CME for colon cancer. Quality was assessed using methodological index for non-randomized studies (MINORS). The main outcome measures were short-term morbidity and oncologic outcomes. Weighted pooled means and proportions with 95% CI were calculated using a random-effects model when appropriate. RESULTS: Out of 825 unique citations, 23 studies underwent full-text reviews and 14 met inclusion criteria. Mean MINORS score was 13.3 (range 11-15). The mean sample size in CME group was 1166 (range 45-3756) and 945 (range 40-3425) in non-CME. Four papers reported plane of dissection, with CME plane achieved in 85.8% (95% CI 79.8-91.7). Mean OR time in CME group was 167 min (163-171) and 138 min (135-142) in conventional group. Perioperative morbidity was reported in six studies, with pooled overall complications of 22.5% (95% CI 18.4-26.6) for CME and 19.6 (95% CI 13.6-25.5) for non-CME. Anastomotic leak occurred in 6.0% (95% CI 2.2-9.7) of CME resections versus 6.0% (95% CI 4.1-7.9) in non-CME. CME had more lymph nodes, longer distance to high tie, and specimen length in all studies. Nine studies compared long-term oncologic outcomes and only three reported statistically significant higher disease-free or overall survival in favor of CME. Local recurrence was lower after CME in two of four studies. CONCLUSIONS: The quality of evidence is limited and does not consistently support the superiority of CME. Better data are needed before CME can be recommended as the standard of care for colon cancer resections.