1
|
Violante T, Ferrari D, Mathis KL, D'Angelo ALD, Dozois EJ, Merchea A, Larson DW. Robotic-assisted surgery conversion: the sooner, the better? Insights from a Single-Center Study. J Gastrointest Surg 2024:S1091-255X(24)00402-5. [PMID: 38583579 DOI: 10.1016/j.gassur.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA; Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA; School of General Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA; Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA; School of General Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amit Merchea
- Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
2
|
Violante T, Behm KT, Shawki SF, Ferrari D, D'Angelo ALD, Kelley SR, Nitin M, Larson DW. Robotic-assisted reoperative ileal pouch-anal anastomosis: robotic pouch excision and pouch revision. Tech Coloproctol 2024; 28:43. [PMID: 38561571 DOI: 10.1007/s10151-024-02918-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/09/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. METHODS All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. RESULTS Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien-Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. CONCLUSION Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes.
Collapse
Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- Department of Colon and Rectal Surgery, Mayo Clinic, Phoenix, ARZ, USA
- School of General Surgery, Alma Mater Studiorum, Università Di Bologna, Bologna, Italy
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Sherief F Shawki
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
- Department of Colon and Rectal Surgery, Mayo Clinic, Phoenix, ARZ, USA
- School of General Surgery, Alma Mater Studiorum, Università Di Bologna, Bologna, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Scott R Kelley
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Mishra Nitin
- Department of Colon and Rectal Surgery, Mayo Clinic, Phoenix, ARZ, USA
| | - David W Larson
- Department of Colon and Rectal Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, 200 First St. Southwest, Rochester, MN, 55905, USA.
| |
Collapse
|
3
|
Ferrari D, Violante T, Bhatt H, Gomaa IA, D'Angelo ALD, Mathis KL, Larson DW. Effect of previous abdominal surgery on robotic-assisted rectal cancer surgery. J Gastrointest Surg 2024; 28:513-518. [PMID: 38583904 DOI: 10.1016/j.gassur.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/04/2024] [Accepted: 01/13/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The effect of previous abdominal surgery (PAS) in laparoscopic surgery is well known and significantly adds to longer hospital length of stay (LOS), postoperative ileus, and inadvertent enterotomies. However, little evidence exists in patients with PAS undergoing robotic-assisted (RA) rectal surgery. METHODS All patients undergoing RA surgery for rectal cancer were reviewed. Patients with PAS were divided into minor and major PAS groups, defined as surgery involving >1 quadrant. The primary outcome was the risk of conversion to open surgery. RESULTS A total of 750 patients were included, 531 in the no-PAS (NPAS) group, 31 in the major PAS group, and 188 in the minor PAS group. Patients in the major PAS group had significantly longer hospital LOS (P < .001) and lower adherence to enhanced recovery pathways (ERPs; P = .004). The conversion rates to open surgery were similar: 3.4% in the NPAS group, 5.9% in the minor PAS group, and 9.7% in the major PAS group (P = .113). Estimated blood loss (EBL; P = .961), operative times (OTs; P = .062), complication rates (P = .162), 30-day readmission (P = .691), and 30-day mortality (P = .494) were similar. Of note, 53 patients underwent lysis of adhesions (LOA). On multivariate analysis, EBL >500 mL and LOA significantly influenced conversion to open surgery. EBL >500 mL, age >65 years, conversion to open surgery, and prolonged OT were risk factors for prolonged LOS, whereas adherence to ERPs was a protector. CONCLUSION PAS did not seem to affect the outcomes in RA rectal surgery. Given this finding, the robotic approach may ultimately provide patients with PAS with similar risk to patients without PAS.
Collapse
Affiliation(s)
- Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; Surgery of the Alimentary Tract, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Himani Bhatt
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ibrahim A Gomaa
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States.
| |
Collapse
|
4
|
Violante T, Ferrari D, Gomaa IA, Rumer KK, D'Angelo ALD, Behm KT, Shawki SF, Perry WRG, Kelley SR, Mathis KL, Dozois EJ, Cima RR, Larson DW. Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes. J Gastrointest Surg 2024; 28:501-506. [PMID: 38583902 DOI: 10.1016/j.gassur.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/03/2024] [Accepted: 01/07/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.
Collapse
Affiliation(s)
- Tommaso Violante
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; School of General Surgery, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Davide Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States; General Surgery Residency Program, University of Milan, Milan, Italy
| | - Ibrahim A Gomaa
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristen K Rumer
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Anne-Lise D D'Angelo
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kevin T Behm
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Sherief F Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - William R G Perry
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Scott R Kelley
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kellie L Mathis
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J Dozois
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Robert R Cima
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - David W Larson
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, United States.
| |
Collapse
|
5
|
D'Angelo ALD, Tevis SE, D'Angelo JD. Roses, thorns, and buds: Coping with failure in surgery. Am J Surg 2024; 227:247-248. [PMID: 37690909 DOI: 10.1016/j.amjsurg.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Affiliation(s)
| | - Sarah E Tevis
- University of Colorado, Division of Surgical Oncology, Aurora, CO, USA
| | | |
Collapse
|
6
|
D'Angelo ALD, Rivera M, Rasmussen TE, Nelson MH, Behm KT, Kelley SR, D'Angelo JD. Implementation of a Brief Evidence-Based Intraoperative Coping Curriculum. J Surg Educ 2023; 80:1737-1740. [PMID: 37679289 DOI: 10.1016/j.jsurg.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/06/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND AND RATIONALE Recent research has called for further resident training in coping with errors and adverse events in the operating room. To the best of our knowledge, there currently exists no evidence-based curriculum or training on this topic. MATERIALS AND METHODS Synthesizing three prior studies on how experienced surgeons react to errors and adverse events, we developed the STOPS framework for handling surgical errors and adverse events (Stop, Talk to your team, Obtain help, Plan, Succeed). This material was presented to residents in two teaching sessions. RESULTS AND CONCLUSION In this paper, we describe the presentation of, and the uniformly positive resident reaction to, the STOPS framework: an empirically based psychological tool for surgeons who experience operative errors or adverse events.
Collapse
Affiliation(s)
| | - Mariela Rivera
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Megan H Nelson
- Division of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Kevin T Behm
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, Minnesota
| | - Scott R Kelley
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, Minnesota
| | | |
Collapse
|
7
|
D'Angelo JD, Cook DA, D'Angelo ALD. Scrubbing With Aristotle: Cultivating Surgical Wisdom through Inflection Points. J Surg Educ 2023; 80:1751-1754. [PMID: 37752024 DOI: 10.1016/j.jsurg.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023]
Abstract
Surgical educators and researchers have well-considered a breadth of topics related to surgery. However, there is one concept that is notably absent in this corpus: surgical wisdom. In this perspective, we draw on work from Aristotle and psychology research to introduce the concept of phronesis, which we believe is useful for understanding surgical wisdom. We further illustrate how this concept can be a useful tool for surgical educators through the discussion of four distinct functions of phronesis, and illustrating the ability of these functions to help learners cultivate knowledge at important decision points, or inflection points, in surgical training and a surgical career.
Collapse
Affiliation(s)
| | - David A Cook
- Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science; Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
8
|
D'Angelo ALD, Kapur N, Kelley SR, Rivera M, Busch RA, Tevis SE, Hoedema RE, D'Angelo JD. The good, the bad, and the ugly: Operative staff perspectives of surgeon coping with intraoperative errors. Surgery 2023; 174:222-228. [PMID: 37188581 DOI: 10.1016/j.surg.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/15/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intraoperative errors are inevitable, and how surgeons respond impacts patient outcomes. Although previous research has queried surgeons on their responses to errors, no research to our knowledge has considered how surgeons respond to operative errors from a contemporary first-hand source: the operating room staff. This study evaluated how surgeons react to intraoperative errors and the effectiveness of employed strategies as witnessed by operating room staff. METHODS A survey was distributed to operating room staff at 4 academic hospitals. Items included multiple-choice and open-ended questions assessing surgeon behaviors observed after intraoperative error. Participants reported the perceived effectiveness of the surgeon's actions. RESULTS Of 294 respondents, 234 (79.6%) reported being in the operating room when an error or adverse event occurred. Strategies positively associated with effective surgeon coping included the surgeon telling the team about the event and announcing a plan. Themes emerged regarding the importance of the surgeon remaining calm, communicating, and not blaming others for the error. Evidence of poor coping also emerged: "Yelling, feet stomping and throwing objects onto the field. [The surgeon] cannot articulate needs well because of anger." CONCLUSION These data from operating room staff corroborates previous research presenting a framework for effective coping while shedding light on new, often poor, behaviors that have not emerged in prior research. Surgical trainees will benefit from the now-enhanced empirical foundation on which coping curricula and interventions can be built.
Collapse
Affiliation(s)
| | | | - Scott R Kelley
- Division Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | | - Rebecca A Busch
- Division of Acute Care and Regional General Surgery, University of Wisconsin, Madison, WI
| | - Sarah E Tevis
- Division of Surgical Oncology, University of Colorado, Aurora, CO
| | - Rebecca E Hoedema
- Spectrum Health Medical Group, Colon and Rectal Surgery Center for Digestive Diseases, Grand Rapids, MI
| | | |
Collapse
|
9
|
Kelley SR, D'Angelo JD, D'Angelo ALD, Behm KT, Colibaseanu DT, Merchea A, Mishra N, Dozois EJ, Mathis KL. The Effect of Advanced Practice Providers on ACGME Colon and Rectal Surgery Resident Diagnostic Index Case Volumes. J Surg Educ 2022; 79:426-430. [PMID: 34702690 DOI: 10.1016/j.jsurg.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/04/2021] [Accepted: 10/02/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes. DESIGN ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant. SETTING Mayo Clinic, Rochester, Minnesota (quaternary referral center). PARTICIPANTS Colon and rectal surgery resident year-end ACGME reports (2011-2019). RESULTS ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs. CONCLUSIONS At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes.
Collapse
Affiliation(s)
- Scott R Kelley
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, Minnesota.
| | | | | | - Kevin T Behm
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, Minnesota
| | | | - Amit Merchea
- Mayo Clinic, Division of Colon and Rectal Surgery, Jacksonville, Florida
| | - Nitin Mishra
- Mayo Clinic, Division of Colon and Rectal Surgery, Phoenix, Arizona
| | - Eric J Dozois
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, Minnesota
| | - Kellie L Mathis
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, Minnesota
| |
Collapse
|
10
|
D'Angelo JD, D'Angelo ALD, Mathis KL, Dozois EJ, Kelley SR. Program Director Opinions of Virtual Interviews: Whatever Makes my Partners Happy. J Surg Educ 2021; 78:e12-e18. [PMID: 33980475 DOI: 10.1016/j.jsurg.2021.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/16/2021] [Accepted: 04/16/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To assess the processes and outcomes of 2021 colon and rectal surgery match season: one of the first National Resident Matching Program (NRMP) match to conduct uniformly virtual interviews for all programs and candidates due to the Covid-19 pandemic. Since this if the first-year interviews were held entirely virtual for a (NRMP) match season, we sought to determine: (1) How did program directors (PDs) in this year's fellowship conduct their virtual interviews? (2) Were any of these conduct decisions associated with the PD satisfaction with the resulting match? (3) What is the PDs opinion of how interviews should occur next year if COVID-19 is not a factor? DESIGN AND SETTING The authors sent an anonymous survey to the PDs of all programs participating in the 2021 colon and rectal surgery residency match directly following match day 2020. PARTICIPANTS Forty-one colon and rectal residency PDs (70% response rate) responded to the survey (78% Male) representing a range of experience (M = 7.61, SD = 5.66, years as PD at current institution), and program type (77.5% Academic, 7.5% Independent Academic Medical Center, 15% Nonacademic). RESULTS While programs utilized several different platforms, conducted various forms of training for their faculty, and provided applicants with different types of information, interview day(s) across the specialty are reported to have proceeded smoothly. PDs as a whole were very satisfied with their match results this year (M = 4.65, SD = .66), and this satisfaction was not impacted by virtual interview decisions or processes. However, only 55% of PDs agree or strongly agree that next year's interviews should be virtual regardless of COVID-19, a judgement solely influenced by the opinion of other program faculty on virtual interviews, regardless of satisfaction with match or comfort with technology. CONCLUSION While PDs report high satisfaction with virtual interview processes and outcomes, there is less agreement that colon and rectal surgery residency interviews should move to a solely virtual platform.
Collapse
Affiliation(s)
| | | | - Kellie L Mathis
- Mayo Clinic, Division Colon and Rectal Surgery, Rochester, Minnesota
| | - Eric J Dozois
- Mayo Clinic, Division Colon and Rectal Surgery, Rochester, Minnesota
| | - Scott R Kelley
- Mayo Clinic, Division Colon and Rectal Surgery, Rochester, Minnesota
| |
Collapse
|
11
|
D'Angelo ALD, D'Angelo JD, Beaty JS, Cleary RK, Hoedema RE, Mathis KL, Dozois EJ, Kelley SR. Virtual interviews - Utilizing technological affordances as a predictor of applicant confidence. Am J Surg 2021; 222:1085-1092. [PMID: 34674848 DOI: 10.1016/j.amjsurg.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/18/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE In the midst of a pandemic, residency interviews transitioned to a virtual format for the first time. Little is known about the effect this will have on the match process. The study aim is to evaluate resident application processes and perceived outcomes. METHODS An electronic survey was distributed to 142 colon and rectal surgery residency applicants (95% of total). RESULTS A total of 77 applicants responded to the survey (54% response rate). Applicants reported high levels of satisfaction with virtual interviews but less comfort. Utilizing the mute button and using notes in a different way from face-to-face interviews were significantly associated with applicant confidence that they ranked the right program highest. A majority of applicants (73%) would recommend virtual interviews next year even if COVID-19 is not a factor. CONCLUSION While applicants appear generally satisfied with virtual interviews, they also reported less comfort. Applicant confidence was predicted by utilizing the unique technological affordances offered by the virtual platform.
Collapse
Affiliation(s)
| | | | - Jennifer S Beaty
- Creighton University, Division of Colon and Rectal Surgery, Omaha, NE, USA
| | - Robert K Cleary
- St Joseph Mercy Hospital, Department of Surgery, Ann Arbor, MI, USA
| | - Rebecca E Hoedema
- Spectrum Health Medical Group, Colon and Rectal Surgery Center for Digestive Diseases, Grand Rapids, MI, USA
| | - Kellie L Mathis
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, MN, USA
| | - Eric J Dozois
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, MN, USA
| | - Scott R Kelley
- Mayo Clinic, Division of Colon and Rectal Surgery, Rochester, MN, USA
| |
Collapse
|
12
|
Calini G, Abdalla S, Abd El Aziz MA, Saeed HA, D'Angelo ALD, Behm KT, Shawki S, Mathis KL, Larson DW. Intracorporeal versus extracorporeal anastomosis for robotic ileocolic resection in Crohn's disease. J Robot Surg 2021; 16:601-609. [PMID: 34313950 DOI: 10.1007/s11701-021-01283-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Abstract
To date, there is no cohort in the literature focusing on the impact of the type of anastomosis in robotic ileocolonic resections for Crohn's Disease (CD). We aimed to compare short-term postoperative outcomes of robotic ileocolic resection for CD between patients who had intracorporeal (ICA) or extracorporeal anastomosis (ECA). We retrospectively included all consecutive robotic ileocolonic resections for CD at our institution between 2014 and 2020. We compared baseline, perioperative characteristics, and postoperative outcomes between ICA and ECA. The analysis included 89 patients: 71% underwent ICA and 29% ECA. Groups were similar in age, sex, body mass index, smoking, CD duration, Montreal classification, surgical history, and previous CD medical treatments. Return to bowel function was achieved sooner in the ICA group (ICA 1.6 ± 0.7 day, ECA 2.1 ± 0.8 days; p = 0.026) despite longer operative time (ICA 235 ± 79 min, ECA 172 ± 51 min; p < 0.001), but no statistical difference was found regarding ileus rate and length of stay. Overall, 30-day postoperative complication rate was 23.6% (ICA 22.2%, ECA 26.9%; p = 0.635). There were no abdominal septic complications, anastomotic leaks, or severe postoperative complications. In conclusion, robotic ileocolic resection for CD shows acceptable 30 days outcomes for both ICA and ECA. ICA was associated with a faster return to bowel function without impact on the length of stay or 30-day complications. Further studies are needed to confirm the benefits of ICA in the setting of ileocolic resections for CD.
Collapse
Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Hamedelneel A Saeed
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Anne-Lise D D'Angelo
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Sherief Shawki
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
| |
Collapse
|
13
|
Calini G, Abd El Aziz MA, Abdalla S, Saeed HA, Lovely JK, D'Angelo ALD, Behm KT, Colibaseanu DT, Mathis KL, Larson DW. Patient colon and rectal operative outcomes when treated with immune checkpoint inhibitors. Eur J Surg Oncol 2021; 47:2436-2440. [PMID: 33883088 DOI: 10.1016/j.ejso.2021.03.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022] Open
Abstract
There is limited data about the safety of colorectal surgery after immune checkpoint inhibitors (ICI). We aimed to share our experience about postoperative outcomes of colorectal surgery for patients treated with ICI. Overall, 31 patients were identified, 22 (71%) underwent elective and nine (29%) underwent emergent/urgent surgery. The 30-day Clavien Dindo class ≥ III complication rates were 27.3% (n = 6) for elective and 55.5% (n = 5) for emergent/urgent cases. Four patients underwent emergency surgery for immune-related colonic perforation and developed postoperative septic shock; two died. Considering patients' comorbidities, cancer stage, and surgical complexity, elective colorectal surgery after ICI seems relatively safe. However, emergent/urgent colorectal surgery was associated with high postoperative morbidity. Indeed, colonic perforation in the setting of ICI treatment has a significant risk of postoperative mortality. Therefore, for patients on ICI with any acute abdominal symptoms, surgical consult should be involved, and colon perforation should be ruled out.
Collapse
Affiliation(s)
- Giacomo Calini
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Solafah Abdalla
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hamedelneel A Saeed
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jenna K Lovely
- Department of Pharmacy Services, Mayo Clinic, Rochester, MN, USA
| | - Anne-Lise D D'Angelo
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kevin T Behm
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dorin T Colibaseanu
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kellie L Mathis
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - David W Larson
- Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
14
|
D'Angelo JD, Lund S, Busch RA, Tevis S, Mathis KL, Kelley SR, Dozois EJ, D'Angelo ALD. Coping with errors in the operating room: Intraoperative strategies, postoperative strategies, and sex differences. Surgery 2021; 170:440-445. [PMID: 33810853 DOI: 10.1016/j.surg.2021.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Prior work has identified intraoperative and postoperative coping strategies among surgeons and has demonstrated surgical errors to have a significant impact on patient outcomes and physicians. Little research has considered which coping strategies are most common among surgeons and if there exist coping strategy differences among sex or training level. METHODS An electronic survey was distributed to surgical faculty and trainees at 3 institutions. Variables included coping techniques after making an error in the operating room. Participants were asked to report the effectiveness of their overall coping strategy. RESULTS A total of 168 participants (56% male, 45% faculty) experienced an operative error and answered questions regarding coping strategies. The only coping strategy significantly associated with positive ratings of coping effectiveness was, upon error, taking a step back and taking time to think and act (r = 0.17; P = .024). There were differences between men and women in both intra and postoperative coping strategies. Men (mean = 3.69/5, standard error = .09) viewed their overall coping strategy as more effective than women (mean = 3.38/5, standard error = .09), t(158.86) = 2.47; P = .015. CONCLUSION Although both male and female surgeons reported making errors in the operating room, differences exist in the strategies surgeons use to cope with these mistakes, and strategies differ in their ratings of effectiveness.
Collapse
Affiliation(s)
| | - Sarah Lund
- General Surgery, Mayo Clinic, Rochester, MN
| | - Rebecca A Busch
- Division Of Acute Care and Regional General Surgery, University of Wisconsin, Madison, WI
| | - Sarah Tevis
- Division of Surgical Oncology, University of Colorado, Aurora, CO
| | - Kellie L Mathis
- Division Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Scott R Kelley
- Division Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
15
|
Sakata S, McKenna NP, Allawi A, D'Angelo ALD, Chua HK, Dozois EJ. How to do an Altemeier perineal rectosigmoidectomy for full-thickness rectal prolapse. ANZ J Surg 2021; 91:1019-1020. [PMID: 33458932 DOI: 10.1111/ans.16572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/27/2020] [Indexed: 11/26/2022]
Abstract
Here, we offer a step-by-step description of the technique for an Altemeier perineal rectosigmoidectomy, which is our institution's preferred perineal approach for patients with full-thickness rectal prolapse. This article is supplemented by a series of high-quality clinical images that are available in Figs S1-S11. The principles of this technique are to excise the rectal prolapse and improve structural support of the pelvic floor.
Collapse
Affiliation(s)
- Shinichiro Sakata
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas P McKenna
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed Allawi
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anne-Lise D D'Angelo
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi K Chua
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric J Dozois
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
16
|
Achilli P, Crippa J, Grass F, Mathis KL, D'Angelo ALD, Abd El Aziz MA, Day CN, Harmsen WS, Larson DW. Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database. Int J Cancer 2020; 148:161-169. [PMID: 32638371 DOI: 10.1002/ijc.33203] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 12/21/2022]
Abstract
Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.
Collapse
Affiliation(s)
- Pietro Achilli
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacopo Crippa
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Courtney N Day
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota, USA
| | - William S Harmsen
- Department of Statistics and Probability, Mayo Clinic, Rochester, Minnesota, USA
| | - David W Larson
- Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
17
|
D'Angelo ALD, D'Angelo JD, Rogers DA, Pugh CM. Faculty perceptions of resident skills decay during dedicated research fellowships. Am J Surg 2018; 215:336-340. [DOI: 10.1016/j.amjsurg.2017.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/29/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
|
18
|
Law Forsyth K, DiMarco SM, Jenewein CG, Ray RD, D'Angelo ALD, Cohen ER, Wiegmann DA, Pugh CM. Do errors and critical events relate to hernia repair outcomes? Am J Surg 2017; 213:652-655. [DOI: 10.1016/j.amjsurg.2016.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022]
|
19
|
Gannon SJ, Law KE, Ray RD, Nathwani JN, DiMarco SM, D'Angelo ALD, Pugh CM. Do resident's leadership skills relate to ratings of technical skill? J Surg Res 2016; 206:466-471. [DOI: 10.1016/j.jss.2016.08.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 07/31/2016] [Accepted: 08/10/2016] [Indexed: 11/26/2022]
|
20
|
Law KE, Ray RD, D'Angelo ALD, Cohen ER, DiMarco SM, Linsmeier E, Wiegmann DA, Pugh CM. Exploring Senior Residents' Intraoperative Error Management Strategies: A Potential Measure of Performance Improvement. J Surg Educ 2016; 73:e64-e70. [PMID: 27372272 DOI: 10.1016/j.jsurg.2016.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/10/2016] [Accepted: 05/22/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The study aim was to determine whether residents' error management strategies changed across 2 simulated laparoscopic ventral hernia (LVH) repair procedures after receiving feedback on their initial performance. We hypothesize that error detection and recovery strategies would improve during the second procedure without hands-on practice. DESIGN Retrospective review of participant procedural performances of simulated laparoscopic ventral herniorrhaphy. A total of 3 investigators reviewed procedure videos to identify surgical errors. Errors were deconstructed. Error management events were noted, including error identification and recovery. SETTING Residents performed the simulated LVH procedures during a course on advanced laparoscopy. Participants had 30 minutes to complete a LVH procedure. After verbal and simulator feedback, residents returned 24 hours later to perform a different, more difficult simulated LVH repair. PARTICIPANTS Senior (N = 7; postgraduate year 4-5) residents in attendance at the course participated in this study. RESULTS In the first LVH procedure, residents committed 121 errors (M = 17.14, standard deviation = 4.38). Although the number of errors increased to 146 (M = 20.86, standard deviation = 6.15) during the second procedure, residents progressed further in the second procedure. There was no significant difference in the number of errors committed for both procedures, but errors shifted to the late stage of the second procedure. Residents changed the error types that they attempted to recover (χ25=24.96, p<0.001). For the second procedure, recovery attempts increased for action and procedure errors, but decreased for strategy errors. Residents also recovered the most errors in the late stage of the second procedure (p < 0.001). CONCLUSION Residents' error management strategies changed between procedures following verbal feedback on their initial performance and feedback from the simulator. Errors and recovery attempts shifted to later steps during the second procedure. This may reflect residents' error management success in the earlier stages, which allowed further progression in the second simulation. Incorporating error recognition and management opportunities into surgical training could help track residents' learning curve and provide detailed, structured feedback on technical and decision-making skills.
Collapse
Affiliation(s)
- Katherine E Law
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rebecca D Ray
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Elaine R Cohen
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Shannon M DiMarco
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Elyse Linsmeier
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Douglas A Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Carla M Pugh
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin; Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin.
| |
Collapse
|
21
|
Nathwani JN, Law KE, Ray RD, O'Connell Long BR, Fiers RM, D'Angelo ALD, DiMarco SM, Pugh CM. Resident performance in complex simulated urinary catheter scenarios. J Surg Res 2016; 205:121-6. [PMID: 27621008 DOI: 10.1016/j.jss.2016.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 04/25/2016] [Accepted: 06/07/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter-associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision-making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that during urinary catheterization, residents will make inconsistent decisions relating to catheter choices and clinical presentations. METHODS Forty-five general surgery residents (postgraduate year 2-4) in Midwest training programs were presented with three of four urinary catheter scenarios of varying difficulty. Residents were allowed 15 min to complete the scenarios with five different urinary catheter choices. A chi-square test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision-making for each scenario. RESULTS Eighty-two percent of residents performed scenario A; 49% performed scenario B; 64% performed scenario C, and 82% performed scenario D. For initial attempt for scenario A-C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, P's < 0.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, P < 0.01). Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (P < 0.001). Chi-square analyses showed no relationship between residents' first and subsequent catheter choices for each scenario (P's > 0.05). CONCLUSIONS Evaluation of clinical decision-making shows that initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or training in clinical decision-making with regard to urinary catheter choices in residents.
Collapse
Affiliation(s)
- Jay N Nathwani
- Department of Surgery, University of Wisconsin, General Surgery, Madison, Wisconsin
| | - Katherine E Law
- University of Wisconsin, Industrial and Systems Engineering, Madison, Wisconsin
| | - Rebecca D Ray
- Department of Surgery, University of Wisconsin, General Surgery, Madison, Wisconsin
| | | | - Rebekah M Fiers
- Department of Surgery, University of Wisconsin, General Surgery, Madison, Wisconsin
| | - Anne-Lise D D'Angelo
- Department of Surgery, University of Wisconsin, General Surgery, Madison, Wisconsin
| | - Shannon M DiMarco
- Department of Surgery, University of Wisconsin, General Surgery, Madison, Wisconsin
| | - Carla M Pugh
- Department of Surgery, University of Wisconsin, General Surgery, Madison, Wisconsin.
| |
Collapse
|
22
|
Law KE, Gwillim EC, Ray RD, D'Angelo ALD, Cohen ER, Fiers RM, Rutherford DN, Pugh CM. Error tolerance: an evaluation of residents' repeated motor coordination errors. Am J Surg 2016; 212:609-614. [PMID: 27586850 DOI: 10.1016/j.amjsurg.2016.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/30/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The study investigates the relationship between motor coordination errors and total errors using a human factors framework. We hypothesize motor coordination errors will correlate with total errors and provide validity evidence for error tolerance as a performance metric. METHODS Residents' laparoscopic skills were evaluated during a simulated laparoscopic ventral hernia repair for motor coordination errors when grasping for intra-abdominal mesh or suture. Tolerance was defined as repeated, failed attempts to correct an error and the time required to recover. RESULTS Residents (N = 20) committed an average of 15.45 (standard deviation [SD] = 4.61) errors and 1.70 (SD = 2.25) motor coordination errors during mesh placement. Total errors correlated with motor coordination errors (r[18] = .572, P = .008). On average, residents required 5.09 recovery attempts for 1 motor coordination error (SD = 3.15). Recovery approaches correlated to total error load (r[13] = .592, P = .02). CONCLUSIONS Residents' motor coordination errors and recovery approaches predict total error load. Error tolerance proved to be a valid assessment metric relating to overall performance.
Collapse
Affiliation(s)
- Katherine E Law
- Department of Industrial and Systems Engineering, School of Engineering, University of Wisconsin-Madison, 3214 Mechanical Engineering Building, 1513 University Avenue, Madison, WI 53706, USA
| | - Eran C Gwillim
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Clinical Science Center, K6/100, Madison, WI 53792, USA
| | - Rebecca D Ray
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Clinical Science Center, K6/100, Madison, WI 53792, USA
| | - Anne-Lise D D'Angelo
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Clinical Science Center, K6/100, Madison, WI 53792, USA
| | - Elaine R Cohen
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Clinical Science Center, K6/100, Madison, WI 53792, USA
| | - Rebekah M Fiers
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Clinical Science Center, K6/100, Madison, WI 53792, USA
| | - Drew N Rutherford
- Department of Health Professions, University of Wisconsin-La Crosse, 3062 Health Science Center, La Crosse, WI, USA
| | - Carla M Pugh
- Department of Industrial and Systems Engineering, School of Engineering, University of Wisconsin-Madison, 3214 Mechanical Engineering Building, 1513 University Avenue, Madison, WI 53706, USA; Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Clinical Science Center, K6/100, Madison, WI 53792, USA.
| |
Collapse
|
23
|
D'Angelo ALD, Rutherford DN, Ray RD, Laufer S, Mason A, Pugh CM. Working volume: validity evidence for a motion-based metric of surgical efficiency. Am J Surg 2016; 211:445-50. [PMID: 26701699 PMCID: PMC4724457 DOI: 10.1016/j.amjsurg.2015.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 09/29/2015] [Accepted: 10/02/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND The aim of this study was to evaluate working volume as a potential assessment metric for open surgical tasks. METHODS Surgical attendings (n = 6), residents (n = 4), and medical students (n = 5) performed a suturing task on simulated connective tissue (foam), artery (rubber balloon), and friable tissue (tissue paper). Using a motion tracking system, effective working volume was calculated for each hand. Repeated measures analysis of variance assessed differences in working volume by experience level, dominant and/or nondominant hand, and tissue type. RESULTS Analysis revealed a linear relationship between experience and working volume. Attendings had the smallest working volume, and students had the largest (P = .01). The 3-way interaction of experience level, hand, and material type showed attendings and residents maintained a similar working volume for dominant and nondominant hands for all tasks. In contrast, medical students' nondominant hand covered larger working volumes for the balloon and tissue paper materials (P < .05). CONCLUSIONS This study provides validity evidence for the use of working volume as a metric for open surgical skills. Working volume may provide a means for assessing surgical efficiency and the operative learning curve.
Collapse
Affiliation(s)
- Anne-Lise D D'Angelo
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, K6/135 CSC, Madison, WI, 53792, USA. ad'
| | - Drew N Rutherford
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, K6/135 CSC, Madison, WI, 53792, USA; Department of Kinesiology, School of Education, University of Wisconsin-Madison, Madison, WI, USA
| | - Rebecca D Ray
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, K6/135 CSC, Madison, WI, 53792, USA
| | - Shlomi Laufer
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, K6/135 CSC, Madison, WI, 53792, USA; Department of Electrical and Computer Engineering, College of Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Andrea Mason
- Department of Kinesiology, School of Education, University of Wisconsin-Madison, Madison, WI, USA
| | - Carla M Pugh
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, K6/135 CSC, Madison, WI, 53792, USA
| |
Collapse
|
24
|
Abstract
BACKGROUND The aim of this study was to evaluate recommendation patterns of different specialties for the work-up of a palpable breast mass using simulated scenarios and clinical breast examination models. METHODS Study participants were a convenience sample of physicians (n = 318) attending annual surgical, family practice, and obstetrics and gynecology (OB/GYN) conferences. Two different silicone-based breast models (superficial mass vs chest wall mass) were used to test clinical breast examination skills and recommendation patterns (imaging, tissue sampling, and follow-up). RESULTS Participants were more likely to recommend mammography (P < .001) and core biopsy (P < .0001) and less likely to recommend needle aspiration (P < .043) and 1-month follow-up (P < .001) for the chest wall mass compared with the superficial mass. Family practitioners were less likely to recommend ultrasound (P < .001) and obstetrics and gynecologists were less likely to recommend mammogram (P < .006) across models. Surgeons were more likely to recommend core biopsy and less likely to recommend needle aspiration across models (P < .001). CONCLUSIONS Recommendation patterns differed across the 2 models in line with existing practice guidelines. Additionally, differences in practice patterns between primary care and specialty providers may represent varying clinician capabilities, healthcare resources, and individual preferences. Our work shows that simulation may be used to track adherence to practice guidelines for breast masses.
Collapse
Affiliation(s)
- Shlomi Laufer
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Electrical and Computer Engineering, University of Wisconsin College of Engineering, Madison, WI, USA.
| | - Rebecca D Ray
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anne-Lise D D'Angelo
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Grace F Jones
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Carla M Pugh
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
25
|
Abstract
BACKGROUND Surgery residents may take years away from clinical responsibilities for dedicated research time. As part of a longitudinal project, the study aim was to investigate residents' perceptions of clinical skill reduction during dedicated research time. Our hypothesis was that residents would perceive a greater potential reduction in skill during research time for procedures they were less confident in performing. MATERIALS AND METHODS Surgical residents engaged in dedicated research training at multiple training programs participated in four simulated procedures: urinary catheterization, subclavian central line, bowel anastomosis, and laparoscopic ventral hernia (LVH) repair. Using preprocedure and postprocedure surveys, participants rated procedures for confidence and difficulty. Residents also indicated the perceived level of skills reduction for the four procedures as a result of time in the laboratory. RESULTS Thirty-eight residents (55% female) completed the four clinical simulators. Participants had between 0-36 mo in a laboratory (M = 9.29 mo, standard deviation = 9.38). Preprocedure surveys noted lower confidence and higher perceived difficulty for performing the LVH repair followed by bowel anastomosis, central line insertion, and urinary catheterization (P < 0.05). Residents perceived the greatest reduction in bowel anastomosis and LVH repair skills compared with urinary catheterization and subclavian central line insertion (P < 0.001). Postprocedure surveys showed significant effects of the simulation scenarios on resident perception for urinary catheterization (P < 0.05) and LVH repair (P < 0.05). CONCLUSIONS Residents in this study expected greater skills decay for the procedures they had lower confidence performing and greater perceived difficulty. In addition, carefully adapted simulation scenarios had a significant effect on resident perception and may provide a mechanism for maintaining skills and keeping confidence grounded in experience.
Collapse
Affiliation(s)
- Anne-Lise D D'Angelo
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin. ad'
| | - Rebecca D Ray
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Caitlin G Jenewein
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Grace F Jones
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Carla M Pugh
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| |
Collapse
|
26
|
Abstract
The demand for competency-based assessments in surgical training is growing. Use of advanced engineering technology for clinical skills assessment allows for objective measures of hands-on performance. Clinical performance can be assessed in several ways via quantification of an assessee's hand movements (motion tracking), direction of visual attention (eye tracking), levels of stress (physiologic marker measurements), and location and pressure of palpation (force measurements). Innovations in video recording technology and qualitative analysis tools allow for a combination of observer- and technology-based assessments. Overall the goal is to create better assessments of surgical performance with robust validity evidence.
Collapse
Affiliation(s)
- Drew N Rutherford
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 3236 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Anne-Lise D D'Angelo
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 3236 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Katherine E Law
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3215 Mechanical Engineering Building, 1513 University Avenue, Madison, WI 53706, USA
| | - Carla M Pugh
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 3236 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA; Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 3215 Mechanical Engineering Building, 1513 University Avenue, Madison, WI 53706, USA.
| |
Collapse
|
27
|
D'Angelo ALD, Law KE, Cohen ER, Greenberg JA, Kwan C, Greenberg C, Wiegmann DA, Pugh CM. The use of error analysis to assess resident performance. Surgery 2015; 158:1408-14. [PMID: 26003910 DOI: 10.1016/j.surg.2015.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/06/2015] [Accepted: 04/07/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to assess validity of a human factors error assessment method for evaluating resident performance during a simulated operative procedure. METHODS Seven postgraduate year 4-5 residents had 30 minutes to complete a simulated laparoscopic ventral hernia (LVH) repair on day 1 of a national, advanced laparoscopic course. Faculty provided immediate feedback on operative errors and residents participated in a final product analysis of their repairs. Residents then received didactic and hands-on training regarding several advanced laparoscopic procedures during a lecture session and animate lab. On day 2, residents performed a nonequivalent LVH repair using a simulator. Three investigators reviewed and coded videos of the repairs using previously developed human error classification systems. RESULTS Residents committed 121 total errors on day 1 compared with 146 on day 2. One of 7 residents successfully completed the LVH repair on day 1 compared with all 7 residents on day 2 (P = .001). The majority of errors (85%) committed on day 2 were technical and occurred during the last 2 steps of the procedure. There were significant differences in error type (P ≤ .001) and level (P = .019) from day 1 to day 2. The proportion of omission errors decreased from day 1 (33%) to day 2 (14%). In addition, there were more technical and commission errors on day 2. CONCLUSION The error assessment tool was successful in categorizing performance errors, supporting known-groups validity evidence. Evaluating resident performance through error classification has great potential in facilitating our understanding of operative readiness.
Collapse
Affiliation(s)
- Anne-Lise D D'Angelo
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.
| | - Katherine E Law
- Department of Industrial and Systems Engineering, School of Engineering, University of Wisconsin-Madison, Madison, WI
| | - Elaine R Cohen
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Jacob A Greenberg
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Calvin Kwan
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Caprice Greenberg
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Douglas A Wiegmann
- Department of Industrial and Systems Engineering, School of Engineering, University of Wisconsin-Madison, Madison, WI
| | - Carla M Pugh
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| |
Collapse
|
28
|
D'Angelo ALD, Rutherford DN, Ray RD, Mason A, Pugh CM. Operative skill: quantifying surgeon's response to tissue properties. J Surg Res 2015; 198:294-8. [PMID: 26003012 DOI: 10.1016/j.jss.2015.04.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/26/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate how tissue characteristics influence psychomotor planning and performance during a suturing task. Our hypothesis was that participants would alter their technique based on tissue type with each subsequent stitch placed while suturing. MATERIALS AND METHODS Surgical attendings (n = 6), residents (n = 4), and medical students (n = 5) performed three interrupted sutures on different simulated materials as follows: foam (dense connective tissue), rubber balloons (artery), and tissue paper (friable tissue). An optical motion tracking system captured performance data from participants' bilateral hand movements. Path length and suture time were segmented by each individual stitch placed to investigate changes to psychomotor performance with subsequent stitch placements. Repeated measures analysis of variance was used to evaluate for main effects of stitch order on path length and suture time and interactions between stitch order, material, and experience. RESULTS When participants sutured the tissue paper, they changed their procedure time (F(4,44) = 5.14, P = 0.017) and path length (F(4,44) = 4.64, P = 0.003) in a linear fashion with the first stitch on the tissue paper having the longest procedure time and path length. Participants did not change their path lengths and procedure times when placing subsequent stitches in the foam (P = 0.910) and balloon materials (P = 0.769). CONCLUSIONS This study demonstrates quantifiable real-time adaptation by participants to material characteristics during a suturing task. Participants improved their motion-based performance with each subsequent stitch placement indicating changes in psychomotor planning or performance. This adaptation did not occur with the less difficult tasks. Motion capture technology is a promising method for investigating surgical performance and how surgeons adapt to operative complexity.
Collapse
Affiliation(s)
- Anne-Lise D D'Angelo
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin. Ad'
| | - Drew N Rutherford
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin; Department of Kinesiology, School of Education, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rebecca D Ray
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Andrea Mason
- Department of Kinesiology, School of Education, University of Wisconsin-Madison, Madison, Wisconsin
| | - Carla M Pugh
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
29
|
Affiliation(s)
- Shlomi Laufer
- University of Wisconsin, School of Medicine and Public Health, Madison, WI
| | | | | | | | | | | | | | | |
Collapse
|
30
|
D'Angelo ALD, Rutherford DN, Ray RD, Laufer S, Kwan C, Cohen ER, Mason A, Pugh CM. Idle time: an underdeveloped performance metric for assessing surgical skill. Am J Surg 2015; 209:645-51. [PMID: 25725505 DOI: 10.1016/j.amjsurg.2014.12.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 12/06/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to evaluate validity evidence using idle time as a performance measure in open surgical skills assessment. METHODS This pilot study tested psychomotor planning skills of surgical attendings (n = 6), residents (n = 4) and medical students (n = 5) during suturing tasks of varying difficulty. Performance data were collected with a motion tracking system. Participants' hand movements were analyzed for idle time, total operative time, and path length. We hypothesized that there will be shorter idle times for more experienced individuals and on the easier tasks. RESULTS A total of 365 idle periods were identified across all participants. Attendings had fewer idle periods during 3 specific procedure steps (P < .001). All participants had longer idle time on friable tissue (P < .005). CONCLUSIONS Using an experimental model, idle time was found to correlate with experience and motor planning when operating on increasingly difficult tissue types. Further work exploring idle time as a valid psychomotor measure is warranted.
Collapse
Affiliation(s)
- Anne-Lise D D'Angelo
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin - Madison, 750 Highland Avenue, Madison, WI 53726, USA.
| | - Drew N Rutherford
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin - Madison, 750 Highland Avenue, Madison, WI 53726, USA; Department of Kinesiology, School of Education, University of Wisconsin - Madison, 2000 Observatory Drive, Madison, WI 53706, USA
| | - Rebecca D Ray
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin - Madison, 750 Highland Avenue, Madison, WI 53726, USA
| | - Shlomi Laufer
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin - Madison, 750 Highland Avenue, Madison, WI 53726, USA; Department of Electrical and Computer Engineering, College of Engineering, University of Wisconsin - Madison, 1415 Engineering Drive, Madison, WI 53706, USA
| | - Calvin Kwan
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin - Madison, 750 Highland Avenue, Madison, WI 53726, USA
| | - Elaine R Cohen
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin - Madison, 750 Highland Avenue, Madison, WI 53726, USA
| | - Andrea Mason
- Department of Kinesiology, School of Education, University of Wisconsin - Madison, 2000 Observatory Drive, Madison, WI 53706, USA
| | - Carla M Pugh
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin - Madison, 750 Highland Avenue, Madison, WI 53726, USA
| |
Collapse
|