Third Time's the Charm? Indications and Outcomes for Redo-Redo IPAA

BACKGROUND

Up to 20% to 40% cases of redo IPAA procedures will result in pouch failure. Whether to offer a second redo procedure to maintain intestinal continuity remains a controversial decision.

OBJECTIVE

To report our institutional experience of second redo IPAA procedures.

DESIGN

This was a retrospective review. Patient-reported outcomes were compared between patients undergoing second redo procedures and those undergoing first redo procedures using propensity score matching to balance the 2 cohorts.

SETTINGS

Tertiary referral center.

PATIENTS

Patients who underwent second redo IPAA procedures between 2004 and 2021 were included in this study.

INTERVENTIONS

Second redo IPAA.

MAIN OUTCOME MEASURES

Pouch survival and patient-reported outcomes were measured using the Cleveland Global Quality of Life survey.

RESULTS

Twenty-three patients were included (65% women), 20 (87%) with an index diagnosis of ulcerative colitis and 3 (13%) with indeterminate colitis. The final diagnosis was changed to Crohn's disease in 8 (35%) cases. The indication for pouch salvage was the same for the first and second redo procedures in 21 (91%) cases: 20 (87%) patients had both redo IPAAs for septic complications. After a median follow-up of 39 months (interquartile range, 18.5-95.5 months), pouch failure occurred in 8 (30%) cases (7 cases due to sepsis, of whom 3 never had their stoma closed, and 1 case due to poor function); all patients who experienced pouch failure underwent the second redo procedure due to septic complications. Overall pouch survival at 3 years was 76%: 62.5% in patients with a final diagnosis of Crohn's disease versus 82.5% in patients with ulcerative/indeterminate colitis ( p = 0.09). Overall quality-of-life score (0-1) was 0.6 (0.5-0.8). Quality of life and functional outcomes were comparable between first and second redo procedures, except incontinence, which was higher in second redo procedures.

LIMITATIONS

Single-center retrospective review.

CONCLUSIONS

A second pouch salvage procedure may be offered with acceptable outcomes to selected patients with high motivation to keep intestinal continuity. See Video Abstract .

LA TERCERA ES LA VENCIDA INDICACIONES Y RESULTADOS DE LA RERECONFECCION DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL

ANTECEDENTES:Hasta un 20-40% de los casos de rehacer anastomosis anal con bolsa ileal (IPAA) resultarán en falla de la bolsa. La posibilidad de ofrecer un segundo procedimiento para mantener la continuidad intestinal sigue siendo una decisión controvertida.OBJETIVO:Reportar nuestra experiencia institucional de una segunda re-confección de la anastomosis anal con bolsa ileal.DISEÑO:Revisión retrospectiva; los resultados informados por los pacientes se compararon entre los pacientes que se sometieron a una segunda re-confeccion con los de los pacientes que se sometieron a una la primera re-confeccion utilizando el puntaje de propensión para equilibrar las dos cohortes.AJUSTES ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes que se sometieron a una segunda re-confeccion de de la anastomosis anal con bolsa ileal entre 2004 y 2021.INTERVENCIONES:Segunda re-confeccion de la anastomosis anal con bolsa ileal.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia de la bolsa, resultados informados por los pacientes medidos mediante la encuesta Cleveland Global Quality of Life.RESULTADOS:Se incluyeron veintitrés pacientes (65% mujeres), 20 (87%) con diagnóstico inicial de colitis ulcerosa y 3 (13%) con colitis indeterminada. El diagnóstico final se cambió a enfermedad de Crohn en ocho (35%) casos. La indicación para el rescate de la bolsa fue la misma para la primera y segunda re-confeccion en 21 (91%) casos: 20 (87%) pacientes tuvieron ambas re-confecciones de la anastomosis anal con bolsa ileal por complicaciones sépticas. Después de una mediana de seguimiento de 39 meses (RIC 18,5 - 95,5), se produjo falla de la bolsa en 8 (30%) casos (7 casos debido a sepsis, de los cuales 3 nunca cerraron el estoma y 1 caso debido a una mala función); todos los pacientes que experimentaron falla de la bolsa se sometieron a una segunda re-confeccion debido a complicaciones sépticas. La supervivencia global de la bolsa a los 3 años fue del 76%: 62,5% en pacientes con diagnóstico final de enfermedad de Crohn, versus 82,5% en colitis ulcerativa/indeterminada ( p = 0,09). La puntuación general de calidad de vida (0 -1) fue 0,6 (0,5 - 0,8). La calidad de vida y los resultados funcionales fueron comparables entre la primera y la segunda re-confeccion, excepto la incontinencia, que fue mayor en la segunda re-confeccion.LIMITACIONES:Revisión retrospectiva de un solo centro.CONCLUSIONES:Se puede ofrecer un segundo procedimiento de rescate de la bolsa con resultados aceptables a pacientes seleccionados con alta motivación para mantener la continuidad intestinal. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Understanding General Surgery Recruitment and Attrition During the COVID-Era: A 1-Year Follow-Up Study

INTRODUCTION

The COVID-19 pandemic resulted in modifications to resident selection. The success of these new recruitment strategies as well as the impact on trainee attrition and competency is unknown. We previously evaluated how selection of general surgery applicants changed early in the pandemic. Here we supplement that work by reporting further modifications to the recruitment process and the perceived impact on resident attrition and competency.

METHODS

An anonymous cross-sectional survey sent via the Association of Program Directors in Surgery listserv in June 2022 to programs directors (PDs) at Accreditation Council for Graduate Medical Education accredited general surgery programs. Surveys contained demographic questions, 5-point Likert scale questions evaluating factors related to recruitment and match process, and postgraduate year 1 performance.

RESULTS

60 PDs responded to the survey. PDs continue to value the same post-COVID factors related to determining a resident's commitment to surgery but began to shift back to nonvirtual based strategies to recruit applicants in this new interview cycle. PD commentary frequently noted desire to return to in-person interviewing. 5.4% of postgraduate year 1s comprising this first class of residents who underwent virtual-only interviews and rotations did not reach Accreditation Council for Graduate Medical Education level 1 milestones, similar to prior years. The attrition rate amongst this class increased from 1.3% to 2.7%.

CONCLUSIONS

The attrition rate for postgraduate year 1 categorical general surgery residents has increased since the onset of the pandemic. The recruitment strategies adopted early in the pandemic have not maintained their initial perceived impact.

Tofacitinib Is Associated With Increased Risk of Postoperative Venous Thromboembolism in Patients With Ulcerative Colitis

BACKGROUND

In 2019, the Food and Drug Administration issued a black box warning for increased risk of venous thromboembolism in patients with rheumatoid arthritis exposed to tofacitinib. There are limited data regarding postoperative venous thromboembolism risk in patients with ulcerative colitis exposed to tofacitinib.

OBJECTIVE

To assess whether preoperative exposure to tofacitinib is associated with increased odds of postoperative venous thromboembolism.

DESIGN

Retrospective review.

SETTINGS

Tertiary academic medical center.

PATIENTS

Consecutive patients exposed to tofacitinib within 4 weeks before total abdominal colectomy or total proctocolectomy, with or without ileostomy, from 2014 to 2021, matched 1:2 for tofacitinib exposure or no exposure.

INTERVENTION

Tofacitinib exposure versus no exposure.

MAIN OUTCOME MEASURES

Ninety-day postoperative venous thromboembolism rate.

RESULTS

Forty-two patients with tofacitinib exposure and 84 case-matched patients without tofacitinib exposure underwent surgery for medically refractory ulcerative colitis. Nine (22.0%) tofacitinib-exposed patients and 7 (8.5%) unexposed patients were diagnosed with venous thromboembolism within 90 days of surgery. In univariate logistic regression, patients exposed to tofacitinib had 3.01 times increased odds of developing venous thromboembolism within 90 days after surgery compared to unexposed patients ( p = 0.04; 95% CI, 1.03-8.79). Other venous thromboembolism risk factors were not significantly associated with venous thromboembolisms. Venous thromboembolisms in both groups were most commonly portomesenteric vein thromboses (66.7% in the tofacitinib-exposed group and 42.9% in the unexposed group) and were diagnosed at a mean of 23.2 days (range, 3-90 days) postoperatively in the tofacitinib-exposed group and 7.9 days (1-19 days) in the unexposed group. There were no statistically significant differences in location or timing between the 2 groups.

LIMITATIONS

Retrospective nature of the study and associated biases. Reliance on clinically diagnosed venous thromboembolisms may underreport the true incidence rate.

CONCLUSIONS

Tofacitinib exposure before surgery for medically refractory ulcerative colitis is associated with 3 times increased odds of venous thromboembolism compared with patients without tofacitinib exposure. See Video Abstract .

TOFACITINIB SE ASOCIA CON UN MAYOR RIESGO DE TROMBOEMBOLISMO VENOSO POSTOPERATORIO EN PACIENTES CON COLITIS ULCEROSA

ANTECEDENTES:En 2019, la FDA emitió una advertencia de recuadro negro sobre un mayor riesgo de tromboembolismo venoso en pacientes con artritis reumatoide expuestos a tofacitinib. Hay datos limitados sobre el riesgo de tromboembolismo venoso postoperatorio en pacientes con colitis ulcerosa expuestos a tofacitinib.OBJETIVO:Evaluar si la exposición preoperatoria a tofacitinib se asocia con mayores probabilidades de tromboembolismo venoso postoperatorio.DISEÑO:Revisión retrospectiva.LUGARES:Centro médico académico terciario.PACIENTES:Pacientes consecutivos expuestos a tofacitinib dentro de las 4 semanas previas a la colectomía abdominal total o proctocolectomía total, con o sin ileostomía, entre 2014 y 2021, emparejados 1:2 para exposición a tofacitinib o ninguna exposición.INTERVENCIÓN(S):Exposición a tofacitinib versus ninguna exposición.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de tromboembolismo venoso posoperatorio a los 90 días.RESULTADOS:Cuarenta y dos pacientes con exposición a tofacitinib y 84 pacientes de casos similares sin exposición a tofacitinib se sometieron a cirugía por colitis ulcerosa médicamente refractaria. Nueve (22,0%) pacientes expuestos a tofacitinib y 7 (8,5%) pacientes no expuestos fueron diagnosticados con tromboembolismo venoso dentro de los 90 días posteriores a la cirugía. En la regresión logística univariada, los pacientes expuestos a tofacitinib tuvieron 3,01 veces más probabilidades de desarrollar un tromboembolismo venoso dentro de los 90 días posteriores a la cirugía en comparación con los no expuestos ( p = 0,04, IC del 95 %: 1,03-8,79). Otros factores de riesgo de tromboembolismo venoso no se asociaron significativamente con el tromboembolismo venoso. Los tromboembolismos venosos en ambos grupos fueron más comúnmente trombosis de la vena portomesentérica (66,7% en los expuestos a tofacitinib y 42,9% en los no expuestos) y se diagnosticaron en una media de 23,2 días (rango, 3-90 días) después de la operación en los expuestos a tofacitinib y 7,9 días. (1-19 días) en los grupos no expuestos, respectivamente. No hubo diferencias estadísticamente significativas en la ubicación o el momento entre los dos grupos.LIMITACIONES:Carácter retrospectivo del estudio y sesgos asociados. La dependencia de tromboembolismos venosos diagnosticados clínicamente puede subestimar la tasa de incidencia real.CONCLUSIONES:La exposición a tofacitinib antes de la cirugía para la colitis ulcerosa médicamente refractaria se asocia con probabilidades 3 veces mayores de tromboembolismo venoso en comparación con los pacientes sin exposición a tofacitinib. (Traducción-Dr. Mauricio Santamaria ).

A Systematic Review of Metrics Utilized in the Selection and Prediction of Future Performance of Residents in the United States

Background Aligning resident and training program attributes is critical. Many programs screen and select residents using assessment tools not grounded in available evidence. This can introduce bias and inappropriate trainee recruitment. Prior reviews of this literature did not include the important lens of diversity, equity, and inclusion (DEI). Objective This study's objective is to summarize the evidence linking elements in the Electronic Residency Application Service (ERAS) application with selection and training outcomes, including DEI factors. Methods A systematic review was conducted on March 30, 2022, concordant with PRISMA guidelines, to identify the data supporting the use of elements contained in ERAS and interviews for residency training programs in the United States. Studies were coded into the topics of research, awards, United States Medical Licensing Examination (USMLE) scores, personal statement, letters of recommendation, medical school transcripts, work and volunteer experiences, medical school demographics, DEI, and presence of additional degrees, as well as the interview. Results The 2599 identified unique studies were reviewed by 2 authors with conflicts adjudicated by a third. Ultimately, 231 meeting inclusion criteria were included (kappa=0.53). Conclusions Based on the studies reviewed, low-quality research supports use of the interview, Medical Student Performance Evaluation, personal statement, research productivity, prior experience, and letters of recommendation in resident selection, while USMLE scores, grades, national ranking, attainment of additional degrees, and receipt of awards should have a limited role in this process.

Female Representation at the Association of Program Directors in Surgery Annual Meeting: Moving Towards Gender Equality

OBJECTIVE

This study aims to evaluate the state and changes over time of female representation in Association of Program Directors in Surgery (APDS) leadership and annual meeting presenters and session leaders.

DESIGN, SETTING, AND PARTICIPANTS

APDS conference programs from 2013 to 2022 were reviewed to identify society leadership and meeting presenters and session leaders. Verified online profiles were used to gather professional role and reported gender. Descriptive statistics and t-tests compared female representation in the first half (2013-2017, prior) and second half of data (2018-2022, current).

RESULTS

Leadership of APDS was an average 22% women, increasing from 13% in 2013 to 37% in 2022, and significantly increased from prior to current period (p = 0.0004). Conference presenters and session leaders were 42% women overall, increasing from 30% in 2013 to 52% in 2022. An average 33% staff surgeons, 54% trainees, 64% education scientists, and 51% medical student participants were female. Staff were 44% female in 2022 from 24% in 2013, significantly increased from prior to current period (p = 0.021). Comparing prior and current period cohorts, female presenters for paper sessions increased from 38% to 55% (p = 0.011), moderators from 15% to 39% (p = 0.046), and last author listed on presentation sessions from 18% to 32% (p = 0.010), while panelists, workshop directors, and presenters at all sessions increased without statistical significance. Female poster presenters decreased over time.

CONCLUSIONS

Female representation at APDS meetings has increased over time. Women are well represented compared to the 2022 member population of 36% women. While positions typically held by more senior members, such as leadership, panelists, moderators, and last authors remain lower than other roles, increases over time are encouraging. APDS female representation compares favorably to many other surgical societies. Translation of successful practices regarding gender representation utilized by APDS to other surgical organizations could expedite progress toward gender parity in the field.

The Right Way to Teach Lefties - Exploring the Experiences of Left-Handed Trainees and Surgeons

OBJECTIVE

This study describes the educational experiences of left-handed (LH) surgeons and provides recommendations for educating LH trainees, who face challenges due to their handedness.

DESIGN, SETTING, AND PARTICIPANTS

A mixed methods analysis was performed. Semi-structured interviews were conducted with LH trainees, LH attendings, and right-handed (RH) attendings representing 4 hospitals within a large academic hospital system. Questions were curated from current literature to explore the educational experiences of LH trainees. Inductive and iterative coding techniques were employed to manually generate themes. Laterality questionnaires for skills in daily life and surgery were collected and analyzed.

RESULTS

Laterality questionnaires demonstrate that LH trainees and surgeons are more mixed-handed and use their nondominant hand to a greater extent in surgery compared to daily life than RH attendings. Key themes were identified in the dimension of learning, including that initial decisions for which hand to use remain fixed throughout career, LH learning is largely self-directed, forced conformation to RH norms and microaggressions are common, LH instruments are rarely practical, and LH surgeons are advantaged with situational ambidexterity. Key themes related to teaching include that communication regarding handedness is lacking, RH surgeons are often unaware of/resistant to a LH approach, the onus is on the trainee to suggest accommodations to use their left hand, and attendings rarely effectively mentor LH learners in using their left hand.

CONCLUSIONS

Left-handed surgeons face challenges in an environment designed for RH individuals, represented by themes regarding learning and teaching experiences of LH surgeons told by themselves and their teachers. Recommendations were created for LH trainees in learning, all attendings in teaching, LH attendings in their opportunity to mentor, and surgical societies in supporting LH trainees. Development of resources for LH trainees could fill a substantial gap. Exploration of how LH surgeons evolve situational ambidexterity could benefit all surgeons.

Salvage surgery is an effective alternative for J-pouch afferent limb stricture treatment

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients requiring surgery for inflammatory bowel disease. A stricture located at the inlet of the afferent limb can lead to small bowel obstruction in a limited number of patients with a pelvic pouch. This paper aims to examine our experience with afferent limb stricture surgical correction when other endoscopic treatment methods have failed to control obstructive symptoms.

METHODS

All consecutive eligible patients with ileal pouch-anal anastomosis and afferent limb stricture were identified from our institutional review board-approved database from 1990 to 2021. Patients surgically treated with excision and reimplantation/strictureplasty of afferent limb stricture were included in this study.

RESULTS

Twenty patients met our inclusion criteria. Fifteen (75%) were female, and the overall mean age was 41 ± 10.3 years at afferent limb stricture surgery. The interval from ileal pouch-anal anastomosis formation to surgery for afferent limb stricture was 13.5 ± 6.7 years. Nine (45%) underwent strictureplasty, and 11 (55%) had resection and reimplantation of the afferent limb into the pouch. Before afferent limb stricture surgery, 3 (15%) required a diverting ileostomy for their obstructive symptoms. An additional 12 (60%) had a stoma constructed during afferent limb stricture surgery, and 5 had a strictureplasty and no stoma. Postoperatively, 1 patient (5%) had a leak at the afferent limb stricture repair site. All patients had their ileostomy closed 3.2 (2.99-3.6) months after surgery. Long-term after afferent limb stricture surgery, recurrent small bowel obstruction symptoms recurred in 7 (35%) patients 3.9 (2.6-5.8) years later.

CONCLUSION

Afferent limb stricture can be treated effectively with salvage surgery. The surgical intervention appears durable and provides an acceptable outcome for their obstructive symptoms.

The Patient's Voice in Assessing Resident Communication Skills

OBJECTIVE

To generate validity evidence for using patient-reported satisfaction ratings of residents' communication skills to determine progress along the Interpersonal and Communication Skills (ICS) Milestones.

DESIGN

A single-institution, retrospective study analyzed a CAHPS Clinician and Group Survey (CG-CAHPS) database which collects inpatients' ratings of residents' communication skills using 6 questions on a scale of 1 (very poor) to 5 (very good). CG-CAHPS results for each resident were averaged for each question as well as across the 6 questions. The averaged ratings were compared between low and high performer groups.

SETTING

A large, academic, mid-western General Surgery residency program.

PARTICIPANTS

General Surgery residents with 3 or more survey responses from July 2020 to June 2021 were included. Residents were dichotomized into low or high performer groups based on their end-of-year ICS1 sub-competency milestone within their post-graduate year (PGY) cohort.

RESULTS

543 CG-CAHPS responses across 44 residents were analyzed with a median of 9 (Interquartile range 6, 17) responses per resident. When residents were compared based on PGY, ratings for the question "resident's knowledge about your medical care of condition" demonstrated statistically significant differences with PGY5s receiving the lowest score (p = 0.05). PGY5s received the lowest averaged ratings across all questions (p = 0.08, η² = 0.10). When residents were dichotomized into low (n = 21) and high performer groups (n = 23) based on ICS1 milestones, statistically significant differences were noted in ratings for the questions "concern the resident showed for your questions or worries" (4.81 vs. 5, p = 0.047) and "courtesy and respect of the resident" (4.75 vs. 5, p = 0.046).

CONCLUSIONS

Analysis of patient ratings of surgery residents' communication skills demonstrated concordant findings between ICS1 milestone and 2 domains of CG-CAHPS responses. When low and high performer groups were compared, CG-CAHPS responses demonstrated a similar pattern. These findings provide validity evidence for CG-CAHPS data as a source of information for ICS1 sub-competency assessment.

Managing Up: Approaching Mentoring From a Mentee's Perspective

OBJECTIVE

Discuss the evolution of mentorship models in surgical training and how educating the surgical trainees with the concepts from "manage up" theory can empower them to maximize the benefits afforded by mentoring relationships.

METHODS

"Manage up" theory is derived from the business world where the subordinate takes ownership of the mentoring relationship with their superior by assessing the strengths and weaknesses of both parties and applying that information in managing a productive relationship.

DISCUSSION

Surgery residency programs implement a variety of structured and unstructured mentorship programs to promote mentoring relationships and to encourage professional development. Mentees in successful mentoring relationships demonstrate characteristics and skills that residency programs can promote through formal training. Components of "manage up" theory can be applied by surgical trainees in approaching their mentors and in managing their mentor-mentee relationships.

CONCLUSIONS

The benefits gained from a successful mentoring relationship for both the mentor and the mentee depend on active roles played by both parties. Strong evidence supports the need for educating mentees through formal curricula to empower them to assume an active role in their mentoring relationships.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume

Introduction

Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic.

Materials and methods

A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys.

Results

Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01).

Conclusions

Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Video Coaching: A National Survey of Surgical Residency Program Directors

OBJECTIVE

Video coaching has been demonstrated to improve resident and attending skills and is overwhelmingly well received by the participants. However, misperceptions about its utility among those who do not use video coaching may be a barrier to widespread implementation.

DESIGN

Cross-sectional web-based survey SETTING: National survey PARTICIPANTS: Surgical program director members of the Association of Program Directors of Surgery STUDY DESIGN: The survey was developed via a deductive approach after a literature review and was piloted with surgical attendings and residents. All Likert scale were averaged and comparisons between groups was performed via independent t-tests.

RESULTS

There were 52 responses from PDs. 27/52(51.9%) PDs reported their program supported video coaching of residents. PDs from residences with video coaching programs were more likely to believe that video coaching was useful in identifying their own strengths and weakness (p = 0.005), was a useful adjunct for resident feedback (p = 0.024), and a personal library of video recordings would be helpful (p = 0.015) when compared to PDs from residencies without video coaching. Programs without video coaching were more likely to believe barriers to implementation included it being ineffective (p = 0.024) and that the technology was unavailable (p = 0.006). Over 50% of respondents from both groups believed expense, difficulty with set up, time required, and patient privacy were "Very" or "Extremely" likely to be barriers to implementation.

CONCLUSIONS

This is the first national survey of PDs regarding the use of video coaching. Residency programs without video coaching may underestimate the utility of video coaching in training surgical residents.

Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery

Children with colorectal diseases often undergo operative management in their youth. As these patients become adult, it is important for surgeons to understand their postoperative anatomy as well as the pathophysiology of their diseases. Here, we present a description of common colorectal diseases of childhood that may have significant impact on patients' presentations as adult. We also discuss the diagnosis and management of conditions that are usually seen early in life but may present during adulthood as well.

Mesenteric Excision and Exclusion for Ileocolic Crohn's Disease: Feasibility and Safety of an Innovative, Combined Surgical Approach With Extended Mesenteric Excision and Kono-S Anastomosis

INTRODUCTION

Ileocolic resection for Crohn's disease traditionally does not include a high ligation of the ileocolic pedicle, and most commonly is performed with a stapled side-to-side ileocolic anastomosis. The mesentery has recently been implicated in the pathophysiology of Crohn's disease. Two techniques have been developed and are associated with reduced postoperative recurrence: the Kono-S anastomosis that excludes diseased mesentery and extended mesenteric excision that resects diseased mesentery. We aimed to assess the technical feasibility and safety of a novel combination of techniques: mesenteric excision and exclusion.

TECHNIQUES

This initial report is a single-center descriptive study of consecutive adults who underwent mesenteric excision and exclusion for primary or recurrent ileocolic Crohn's disease from September 2020 to June 2021. Medication exposure and endoscopic balloon dilation before surgery were recorded. Phenotype was classified using the Montreal Classification. Thirty-day outcomes were reported. A video of the mesenteric excision and exclusion including the Kono-S anastomosis is presented.

RESULTS

Twenty-two patients with ileocolic Crohn's disease underwent mesenteric excision and exclusion: 100% had strictures, 59% had fistulas, 81% were on biologics, and 27% had previous ileocolic resection(s). Seventy-two percent underwent laparoscopic procedures, a mesenteric defect was closed in 86%, omental flaps were fashioned in 77%, and 3 patients were diverted. Median operative time was 175 minutes. Median postoperative stay was 4 days. At 30 days, there were 2 readmissions for reintervention: 1 seton placement and 1 percutaneous drainage of a sterile collection. There were no cases of intra-abdominal sepsis or anastomotic leak.

CONCLUSIONS

Mesenteric excision and exclusion represents an innovative, progressive, and promising approach that appears to be highly feasible and safe. Further study is warranted to determine if mesenteric excision and exclusion is associated with reduced postoperative recurrence of ileocolic Crohn's disease.

The Virtual Recruitment Onion: Peeling Back the Layers of the Interview Season During the COVID-era

OBJECTIVE

We sought to characterize General Surgery residency program directors' (PDs) baseline perspective on how the COVID-19 mandated changes to the recruitment and interview processes impacted how the PDs evaluated and recruited the applicants.

DESIGN

An anonymous cross-sectional questionnaire survey.

SETTING

A large, mid-western academic general surgery residency program.

PARTICIPANTS

47 PDs of Accreditation Council for Graduate Medical Education (ACGME) accredited General Surgery residency programs.

RESULTS

During the virtual-only interviews during the COVID-19 pandemic-era 2020-21 General Surgery residency application cycle, PDs shifted their focus to virtual outreach efforts and bolstered social media presences to recruit strong applicants. Also, our study found statistically significant changes to the increased value of letters of recommendation (LORs) for the PDs when assessing an applicant's commitment to surgery. These findings suggest that the necessity of adapting to the virtual-only interview format significantly altered how the PDs recruited and evaluated applicants for the General Surgery residency match.

CONCLUSIONS

A complete replacement of the in-person interviews with virtual-only interviews may be challenging unless buy-in exists from key stakeholders in the surgical community. Our study highlights the PDs' hesitation in assessing candidates' commitment to surgery from virtual interviews alone. Incorporating virtual interviews as a part of the screening process for applicants may serve as an avenue to maximize the benefits of the virtual interview format. Furthermore, COVID-19 pandemic has normalized the growing social media presence of residency programs, adding to the changing landscape of recruiting and interviewing applicants for General Surgery residency match.

The Impact of Simulation Training on Operative Performance in General Surgery: Lessons Learned from a Prospective Randomized Trial

BACKGROUND

Practice in the simulated environment can improve surgical skills. However, the transfer of open complex surgical skills to the operating room is unclear. This study evaluated the effect of resident operative performance following a simulation experience on a hand-sewn small bowel anastomosis and determined the impact of utilizing proficiency-based training.

METHODS

Nine categorical interns performed a hand-sewn small bowel anastomosis in the operating room prior to (pre-test) and following (post-test) a 3-h simulation training session with an assessment at the end. Participants were randomly assigned to 1of 2 simulation training groups: proficiency-based or standard. Operative performance was videotaped. 2 independent, blinded faculty surgeons assessed performances by a global rating scale. Pre- and post-confidence levels were obtained on a 5-point Likert scale.

RESULTS

Overall, pre-test and post-test operative performance was similar (3 [IQR, 2.5 -3.5] versus 3 [IQR, 3 -3], P = 0.59). Furthermore, no difference was observed in the post-test performance with proficiency-based or standard training (3 [IQR, 3 -3] versus 3 [IQR, 3 -3], P = 0.73). Self-reported confidence with the skills, however, significantly improved (median 1 versus 4, P = 0.007).

CONCLUSIONS

In this prospective, randomized study, we did not observe an improvement in operative performance following simulation instruction and assessment, with both training groups. Overcoming barriers to skills transfer will be paramount in the future to optimize simulation training in general surgery. These findings highlight the importance of continued study for the ideal conditions and timing of technical skills training.

Don't Judge a Letter by its Title: Linguistic Analysis of Letters of Recommendation by Author's Academic Rank

OBJECTIVE

This study analyzed the linguistic differences in letters of recommendation (LORs) for general surgery residency applicants written by authors of various academic ranks. Given that many general surgery residency programs require a LOR from the Chair of surgery, this study also examined whether LORs written by the Chair demonstrate linguistic differences to support this practice.

DESIGN

A single institution, retrospective review analyzed LORs from two application cycles of general surgery residency applicants who were selected for interview at a large academic institution. Word count (WC) and linguistic characteristics of LORs were analyzed with a previously developed institution-specific dictionary using the Linguistic Inquiry and Word Count software (LIWC2015; Pennebaker Conglomerates, Inc., Austin, Texas). WC and linguistic characteristics of LORs reported as frequencies of terms within twenty-four categories were examined based on the letter authors' academic rank. Further examination compared LORs written by a Chair of surgery with those written by non-Chairs.

SETTING

A single large, Midwestern academic general surgery residency program PARTICIPANTS: Four hundred and sixty-five letters of recommendation received during two interview cycles were included for analysis.

RESULTS

A total of 465 LORs written by assistant (n = 82), associate (n = 94), and full professors (n = 289) were included in the study. No statistically significant difference was noted in the WC of LORs based on the letter writers' academic ranks (p = 0.95). Assistant professors utilized grindstone, communal, and technical skill terms with higher frequencies compared to associate professors and full professors. LORs written by assistant professors demonstrated the highest authentic variable score followed by associate professors then full professors (4.94, 3.92, 3.28, p < 0.01). LORs written by Chairs (n = 128) had lower authentic variable scores compared to LORs written by non-Chairs (n = 337; 2.71 vs. 3.91, p = 0.001). Only 50 (39%) LORs written by Chairs indicated working directly with the applicant, and sub-group analysis demonstrated a higher authentic variable score in this group compared with LORs written by Chairs who did not indicate having worked directly with the applicant (3.51 vs. 2.5, p = 0.01).

CONCLUSIONS

Linguistic analysis of LORs for general surgery residency applicants demonstrated minor yet statistically significant differences based on the author's academic rank. If applicants can obtain linguistically similar LORs from surgeons of any academic rank, but less authentic LORs from writers with higher academic ranks, these LORs may be less valuable for the residency programs when evaluating applicants. Based on the subgroup analysis, less than 40% of Chair LORs indicated that the Chair worked directly with the applicant, calling into question the utility of the Chair LORs as meaningful evaluation of applicants. Further study to compare LORs of applicants selected and not selected for interview may add additional insight into linguistic differences in LORs written by authors of different academic ranks.

Content of an Educational Handover Letter From Medical Schools to Surgery Residencies: A Mixed Method Analysis

PURPOSE

To identify the content of an educational handover letter from undergraduate to graduate education in General Surgery.

METHOD

Expert consensus was attained on the content of an educational handover letter. A 3-stage Delphi technique was employed with 8 experts in each of 4 stakeholder groups: program directors in general surgery, medical student surgical acting internship or prep course directors, authors of medical student performance evaluations, and current categorical General Surgery residents. Data were collected from April through July 2019. A mixed method analysis was performed to quantitatively assess items selected for inclusion and qualitatively provide guidance for the implantation of such a letter.

RESULTS

All 32 experts participated in at least one round. Of the 285 initially identified individual items, 22 were ultimately selected for inclusion in the letter. All but one expert agreed that the list represents what the content of an educational handover letter in General Surgery should be. Qualitative analysis was performed on 395 comments and identified 4 themes to guide the implementation of the letter: "minimize redundancy, optimize impact, use appropriate assessments, and mitigate risk."

CONCLUSIONS

A framework and proposed template are provided for an educational handover letter from undergraduate to graduate medical education in General Surgery based on the quantitative and qualitative analysis of expert consensus of major stakeholders. This letter holds promise to enhance the transition from undergraduate to graduate medical education by allowing programs to capitalize on strengths and efficiently address knowledge gaps in new trainees.

Registry-based Trainee Assessments: Leveraging a Quality Collaborative for Surgical Education

INTRODUCTION

We present our experience developing and embedding a registry-based module for resident feedback.

METHODS

At our institution, entering operative data into the institutional quality collaborative registry is standard practice. In February 2019, a surgical education module was embedded into the registry to capture procedure-specific resident operative assessments. Faculty engagement with the sugical education module was assessed during its first year in existence (February 2019-February 2020).

RESULTS

In total, 1074 of 1269 (85%) operative assessments were completed by 27 faculty via the surgical education registry module. Median faculty engagement rate with the module following resident-assisted procedures was 91% [IQR 76%-100%]. Residents received a median of 7 operative assessments [IQR 2-19] over the study period.

CONCLUSION

By embedding a surgical education module into an existing surgical quality collaborative registry, procedure-specific operative assessments can be routinely captured.

Training for Minimally Invasive Surgery for IBD: A Current Need

Surgery for inflammatory bowel diseases (IBD) management has passed through an important evolution over the last decades, with innovative strategies and new technologies, especially in minimally invasive surgery (MIS) approaches. MIS procedures for IBD include multiport laparoscopy, single-port surgery, robotics, and the use of transanal platforms. These approaches can be used in the surgical management of both Crohn's disease (CD) and ulcerative colitis (UC). There are significant peculiarities in the surgical field in CD and UC, and their perfect understanding are directly related to better outcomes in IBD patients, as a consequence of improvement in knowledge by IBD surgeons. Different strategies to train colorectal surgeons were developed worldwide, for better application of MIS, usually for malignant or non-IBD benign diseases. There is a significant lack of evidence in specific training strategies for MIS in the IBD field. In this review, the authors outline the importance of adequate surgical training in IBD MIS, by discussing the current evidence on different approaches and emphasizing the need for better training protocols included in multidisciplinary teams in IBD centers throughout the globe.

Efficacy of Virtual Case-Based General Surgery Clerkship Curriculum During COVID-19 Distancing

OBJECTIVE

The COVID-19 pandemic created a paradigm shift in medical education with a reliance upon alternative teaching methods to deliver meaningful surgery clerkship content. This study examines the efficacy of a novel, case-based virtual surgery clerkship curriculum to determine its impact on student experience during quarantine.

STUDY DESIGN

Sixteen third-year medical students enrolled in the General Surgery clerkship between April through June 2020 during COVID-19 distancing at a quaternary medical center (Cleveland Clinic, Cleveland, OH) participated in this study. Course surveys, including a 10-question curriculum-based multiple-choice assessment, were administered before and after the clerkship. Analyses include student self-perception of readiness to see a surgical consult independently, students' interest in pursuing a General Surgery residency, and improvement of surgical knowledge.

RESULTS AND CONCLUSION

On a 5-point Likert scale, students felt significantly more assured in their ability to independently assess a surgical consult by the end of the course. Five (31%) students reported an influence of the curriculum on their personal interest in a career in General Surgery. Mean scores on the curriculum-based knowledge assessment increased. These findings highlight that a virtual platform can be a reliable alternative adjunct that delivers surgical content and positively impacts student experience.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-020-01126-5.

Beyond Medical Knowledge and Patient Care: A Program Director's Perspective for the Role of General Surgery Subinternships

OBJECTIVE

Established primary goals of general surgery subinternships are improvement in patient care and medical knowledge. However, the secondary gains such as obtaining recommendation letters and forming relationships are apparent but poorly defined. We sought the opinion of general surgery program directors (PDs) on the secondary purposes of subinternships. Our aim is to aide mentors and students to optimize the subinternship experience relative to the residency application process.

DESIGN

A survey was administered in July 2019. This questionnaire consisted of 11 items and was broken down into 3 sections: demographics, PD perspective on the secondary goals of a general surgery subinternship, and the role of general surgery subinternships on the students' residency application.

SETTING

An online, national survey through the Association for Program Directors listserv.

PARTICIPANTS

United States general surgery PDs affiliated with the Association for Program Directors listserv.

RESULTS

Sixty-one PDs completed the survey from 42 (69%) academic and 14 (23%) community programs. The majority of PDs (n = 33, 54%) reported that assessment of a subintern's suitability for their residency was the most important secondary purpose. Furthermore, PDs (n = 24, 39%) valued a letter of recommendation from faculty the student worked with during a subinternship as the most important criteria in the interview selection process. Away rotations were perceived as of equal value to subinternships completed at the student's home institution. Overall, PD opinions were similar at academic and community programs.

CONCLUSIONS

Our study suggests subinternships significantly impact a student's application to general surgery residency, clarifying a secondary role for these rotations. Subinternships are important for PDs to assess a student for ranking at their program. All students should pursue a letter of recommendation from subinternship faculty, when possible, as they can heavily influence the interview selection process. Away rotations should only be recommended for those students who need to strengthen their application.

Utilization of a quality reporting system to increase faculty participation in resident operative assessment

BACKGROUND

A quality collaborative across our hospital system was initiated to track surgical outcomes. We sought to determine whether incorporating a resident operative performance assessment into this quality collaborative would increase the quantity and quality of these assessments and impact relevant milestones.

METHODS

A resident operative assessment was added to a quality reporting system required to be completed by faculty at the completion of 2 operations. Three milestones directly related to operative performance were analyzed-Patient Care 3, Medical Knowledge 2, and Interpersonal and Communication Skills 3. Residents were divided in 2 groups: quality collaborative (≥10 operative assessments) and no quality collaborative (<10 operative assessments). Milestones from Spring 2019 and Fall 2019 were analyzed.

RESULTS

Faculty participation was 86% with 407 assessments completed from February to October 2019. A difference in the rate of change in resident performance for Patient Care 3 (+0.95 vs +0.55; P = .04) and Interpersonal and Communication Skills 3 (+1.05 vs +0.52; P = .02) was observed for those residents in the quality collaborative group (n = 20) compared with baseline data.

CONCLUSION

Addition of an operative assessment to a mandatory quality collaborative increases faculty participation and impacts resident milestone determination. These findings highlight opportunities to find innovative and efficient methods to improve faculty engagement.

Best Practices in Letters of Recommendation for General Surgery Residency: Results of Expert Stakeholder Focus Groups

OBJECTIVE

Performance inflation is rampant in applications to general surgery residency. The medical student performance evaluation, transcript, and letters of recommendation (LOR) have all been shown significantly biased in the applicants' favor. This study sought to determine best practices for LOR to improve transparency and alignment of applicant and program characteristics.

DESIGN

Two 1-hour focus groups were conducted using semi-structured interviews. Participants were asked to discuss the value and role of LOR characteristics, including standardized LOR, and provide recommendations for best practices. The transcribed discussions were coded by two educators using grounded theory and an inductive approach utilizing NVivo 12. Codes were then reviewed and revised to achieve consensus and recommendations.

SETTING

Focus groups were held during the annual Surgical Education Week meeting in April 2019.

PARTICIPANTS

General Surgery Program Directors from 10 institutions and Surgery Clerkship Directors from 11 other medical schools participated, with each group meeting independently from the other.

RESULTS

Individually, 18 codes were identified by the authors, with consensus agreed on ten. These were grouped into 4 themes: author factors, letter content, bias, and standardized letters. Overall, a checkbox and short-answer standardized LOR was not recommended, favoring a template of items to include and exclude. Ideal letter writers were felt to be surgeons who best know the applicant, and the Chair's letter, when they have no working knowledge of the applicant, was perceived to add little value. Use of specific examples to demonstrate applicant characteristics were favored, and descriptors for coded language should be included to aid in interpretation.

CONCLUSION

The focus groups identified best practices to guide writing LOR in support of applicants to general surgery residency. A template of content is provided to improve the efficiency, transparency, and accuracy of these letters for the benefit of students, medical schools, and residency programs.

Can an Academic RVU Model Balance the Clinical and Research Challenges in Surgery?

OBJECTIVE

The purpose of this study is to identify perceptions of academic surgeons regarding academic productivity and assess its relationship to clinical productivity. We hypothesized that these perceptions would vary based on respondent characteristics including clinical activity and leadership roles.

DESIGN

This retrospective, survey-based study was performed from August 26, 2019 to September 26, 2019.

SETTING

The setting was academic surgical departments across the US.

PARTICIPANTS

The survey instrument was administered to faculty members of the Association of Program Directors in Surgery. A total of 105 academic surgeons responded.

RESULTS

Most respondents were Program Directors (59%) of general surgery programs. Of the participants, 30% identified as Professor, 36% as Associate Professor, and 15% as Assistant Professor. Respondents agreed that multiple academic pursuits or factors should count towards academic productivity including the following (in descending order): completing a first-authored manuscript (98.8%), completing a senior-authored manuscript (97.7%), chairing a national committee (94.1%), serving on a national committee (88.2%), completing a second-authored manuscript (88.0%), completing a first lecture (83.7%), completing a middle-authored manuscript (71.8%), completing a lecture (whether or not repeated) (70.9%), impact factor of journal (60.7%), and attendance at grand rounds (57.0%). Perspectives did not vary significantly based on surgeon demographics, clinical setting, or leadership role (p > 0.05).

CONCLUSIONS

Perceptions regarding what constitutes academic productivity and merit a reduction in clinical expectation are remarkably similar across multiple surgeon characteristics including demographics, academic title, leadership role, and practice environment.

Ad astra per aspera (Through Hardships to the Stars): Lessons Learned from the First National Virtual APDS Meeting, 2020

OBJECTIVE

After COVID-19 rendered in-person meetings for national societies impossible in the spring of 2020, the leadership of the Association of Program Directors in Surgery (APDS) innovated via a virtual format in order to hold its national meeting.

DESIGN

APDS leadership pre-emptively considered factors that would be important to attendees including cost, value, time, professional commitments, education, sharing of relevant and current information, and networking.

SETTING

The meeting was conducted using a variety of virtual formats including a web portal for entry, pre-ecorded poster and oral presentations on the APDS website, interactive panels via a web conferencing platform, and livestreaming.

PARTICIPANTS

There were 298 registrants for the national meeting of the APDS, and 59 participants in the New Program Directors Workshop. The registrants and participants comprised medical students, residents, associate program directors, program directors, and others involved in surgical education nationally.

RESULTS

There was no significant difference detected for high levels of participant satisfaction between 2019 and 2020 for the following items: overall program rating, topics and content meeting stated objectives, relevant content to educational needs, educational format conducive to learning, and agreement that the program will improve competence, performance, communication skills, patient outcomes, or processes of care/healthcare system performance.

CONCLUSIONS

A virtual format for a national society meeting can provide education, engagement, and community, and the lessons learned by the APDS in the process can be used by other societies for utilization and further improvement.

Personal Statements in General Surgery: An Unrecognized Role in the Ranking Process

OBJECTIVE

Personal statements are a requirement of general surgery residency applications. Yet, their role in an applicant's final rank within a program remains unclear. This study explores the language used in personal statements to differentiate applicants in the general surgery residency ranking process.

DESIGN

A textual analysis of general surgery residency applicant personal statements was performed. Using inductive coding and grounded theory, 3 main themes from personal statements were identified: my story, my future, my goals. These themes were utilized to build a dictionary consisting of over 400 descriptive terms in multiple categories. Data was extracted using the Linguistics Inquiry and Word Count program, which can linguistically determine basic characteristics from text. The data was stratified according to final rank and gender for analysis, using correlation and descriptive statistics.

SETTING

Large, urban, academic general surgery residency program.

PARTICIPANTS

One hundred nineteen personal statements during the 2018 to 2019 application cycle were analyzed. All applicants were interviewed and considered for inclusion on our final rank list.

RESULTS

There were 68 (57%) females on the final rank list with no difference in the distribution of gender between those in the top and bottom halves (p = 0.11). Overall, personal statements for the top applicants scored higher in grit than those in the bottom half (median 0.42% vs 0.35%, p = 0.03). Males ranked in the top half had less use of agentic (p = 0.04) and efficient/organized (p = 0.03) words when compared with males ranked in the bottom half. In contrast, females ranked in the top half used more grit words compared to those in the bottom half (median 0.45% vs 0.35%, p = 0.004).

CONCLUSIONS

Linguistic differences existed in the personal statements of top- and bottom-ranked applicants to a general surgery residency program. These findings provide an adjunctive tool for differentiating applicants based on this underutilized component of the ranking process.

Digital Professionalism in Patient Care: A Case-Based Survey of Surgery Faculty and Trainees

BACKGROUND

Use of digital devices have become ubiquitous in healthcare and can create professionalism issues. This study presents opinions of faculty, residents, and medical students to inform policy on the appropriate use of digital devices in the patient care setting.

MATERIALS AND METHODS

A survey was administered from September 2018 to October 2018 to faculty and residents within the general surgery department at a large academic medical center and all fourth-year medical students at an affiliated university. The survey included direct statements and case-based scenarios on similar themes to triangulate responses.

RESULTS

There were 114 participants in the survey-50 faculty, 26 residents, and 38 medical students. Digital device utilization was equivalent among all groups, and all participants use a smartphone. Digital devices were most frequently used during rounds and clinical conferences. Overall, digital device use was found more appropriate when seen in the case-based format rather than as a direct statement. Furthermore, use of these devices was seen as most appropriate when the provider explained its use or left the room to use the device.

CONCLUSIONS

Digital devices are used by faculty and trainees at similar rates for parallel purposes, and the benefits for patient-related care are evident. However, the use of digital devices in the presence of patients should be minimized and always preceded by an explanation. These findings can inform institutional policy when creating guidelines on the professional use of these devices in the patient care setting.

Multidisciplinary Simulation Training Improves Surgical Resident Comfort With Airway Management

BACKGROUND

Airway management is an essential element of surgical training, but with fewer procedures performed during residency, simulation is crucial to fill educational gaps. We evaluated the effect of a multidisciplinary airway simulation on the comfort of general surgery residents in managing airways.

MATERIALS AND METHODS

All residents PGY 2-5 at a large academic general surgery residency program participated in a multidisciplinary airway management simulation. Precourse surveys evaluated self-perception of skills in three areas of airway management: surgical airway, basic ventilator strategies, and endotracheal intubation. Simulation consisted of didactic and procedural components and used high- and low-fidelity models including silicon airways, ventilators, porcine trachea, and airway adjuncts. Instruction was provided by anesthesia and otolaryngology faculty. Postcourse assessment was performed with a four-level Likert questionnaire. Results were analyzed using paired t-tests.

RESULTS

Of the 19 residents surveyed, 37% of residents had 1-5 h and 32% had 5-10 h of prior airway instruction. Significant increases in mean comfort were observed across all three studied areas. Residents reported increased comfort performing a surgical airway (1.16 versus 1.95), P < 0.0001, and troubleshooting ventilator issues (1.59 versus 2.16), P < 0.0001. Comfort regarding overall airway management including endotracheal intubation demonstrated similar improvement (1.84 versus 2.32), P = 0.02. Subgroup analysis by PGY level showed the greatest impact on comfort level in junior residents.

CONCLUSIONS

Multidisciplinary airway simulation can be effectively implemented in a general surgery training program and positively affect trainee comfort with these techniques, particularly among junior residents.

Impact of preoperative duration of ulcerative colitis on long-term outcomes of restorative proctocolectomy

BACKGROUND

It is unknown if ulcerative colitis (UC) duration has an impact on outcomes of ileal pouch anal anastomosis (IPAA). The aim of the study was to compare the long-term IPAA outcomes based on preoperative UC duration.

METHODS

All patients with pathologically confirmed UC who underwent IPAA were included from a prospectively maintained pouch database (1983-2017).Patient's cohort was stratified according to UC duration:< 5 years,5-10 years,10-20 years,> 20 years. UC duration was defined as time interval from date of preoperative diagnosis to colectomy date. The main outcome was Kaplan-Meier pouch survival. Secondary outcomes were pouch function and quality of life.

RESULTS

Out of 4502 IPAAs (1983-2016), 2797 patients were included. Treated with biologics versus 12% with UC duration > 20 years were 41% patients with UC duration < 5 years. Treated with steroids compared to shortest (34%,p < 0.001) were 54% patients with the longest disease. A total of 65% of patients with shortest disease had IPAAs performed mostly in 3 stages. Anastomotic separation and pelvic sepsis were more prevalent among shortest compared to longest disease groups. Rates of pouch-targeted fistulas, anastomotic strictures, and pouchitis were highest in longest disease group. Pouch survival was similar between groups. Multivariate analysis did not show a significant association between UC duration and pouch failure [1.05(0.97-1.1), p = 0.23].Longer UC duration was associated with increased odds of pouchitis [1.2(1.1, 1.3), p < 0.001]. Biologics agents were shown to be protective against pouchitis.

CONCLUSIONS

Preoperative UC duration does not increase pouch failure risk. Longer preoperative UC duration increases the pouchitis risk. Biologic agents and three-staged IPAA are protective against pouchitis and septic complications in long-term among patients with UC.

Educational Targets to Reduce Medication Errors by General Surgery Residents

OBJECTIVE

Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers.

DESIGN

This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018.

SETTING

A single large academic medical center located in the Midwest, United States.

PARTICIPANTS

General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders.

RESULTS

Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics.

CONCLUSIONS

This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.

How We Do It: Creation of a Low-Cost Endoscopic Skills Model for Fundamentals of Endoscopic Surgery Training

OBJECTIVE

To design a low cost, high fidelity endoscopic skills model to help surgical trainees pass the Fundamentals of Endoscopic Surgery (FES) testing.

DESIGN

A homemade synthetic colon model was designed using liquid silicon and other commercially available products. The construction and design of the model is described here. The model was then successfully integrated into our simulation curriculum and endoscopic skills training modules.

SETTING

Cleveland Clinic Foundation, Cleveland, Ohio; large academic quaternary referral institution.

PARTICIPANTS

PGY 1-5 general surgery residents preparing for Fundamentals of Endoscopic Surgery testing.

RESULTS

A versatile, high fidelity model was designed for a total cost of approximately 25 dollars per unit. The model can be used with clinical endoscopic towers and easily integrated into an institution's simulation and endoscopic training curriculum. The flexibility of design allows trainees to practice all of the key motor skills necessary for FES examination success.

CONCLUSIONS

A homemade endoscopic colon model can be constructed at an affordable price point using commercially available materials. These models have significant versatility, low cost, and flexibility of design allowing for easy incorporation into a surgical residency simulation training program.

Postoperative Steroid Taper Is Associated With Pelvic Sepsis After Ileal Pouch-anal Anastomosis

OBJECTIVE

We hypothesized that postoperative oral steroid taper after ileal pouch-anal anastomosis for inflammatory bowel disease would not be associated with pelvic septic complications.

BACKGROUND

Recent data has emphasized the possible association between biologic medication use and pelvic sepsis following ileal pouch-anal anastomosis. Limited contemporary data exist examining the effects of steroid use on these complications.

METHODS

Consecutive patients undergoing ileal pouch-anal anastomosis for inflammatory bowel disease at a single institution from January 2009 to December 2013 were included. Factors associated with anastomotic leak and pelvic sepsis were assessed using univariate and multivariate analysis.

RESULTS

A total of 686 patients were included (mean age 39.5 years, 59% males). Postoperative oral steroid taper was associated with both anastomotic leak and pelvic sepsis on univariate analysis. Stress dose intravenous steroid use was not associated with complications. Multivariate analysis indicated total proctocolectomy (odds ratio [OR] 2.2; confidence interval [CI] 1.01-4.7, P = 0.047), and postoperative oral steroid taper (OR 2.3; CI 1.06-5.1; P = 0.035) as independent factors significantly associated with pelvic sepsis.

CONCLUSIONS

Prolonged postoperative oral steroid taper after ileal pouch-anal anastomosis should be avoided. If preoperative steroid weaning is not possible before a planned total proctocolectomy and ileal pouch-anal anastomosis, patients should undergo an initial total abdominal colectomy.

Gender and Letters of Recommendation: A Linguistic Comparison of the Impact of Gender on General Surgery Residency Applicants✰

OBJECTIVE

We investigated letters of recommendation for general surgery residency applicants to determine if any gender-based disparities exist.

DESIGN

A dictionary of over 400 terms describing applicants and 24 unique categories into which these terms were classified was created. Word count and language comparisons were performed using linguistic analysis software to assess for differences in applicant characterization, letter length, and writing style between male and female applicants and letter writers.

SETTING

A large, Midwest, academic general surgery residency program.

PARTICIPANTS

Five hundred and fifty-nine letters of recommendation received during the 2015 and 2016 interview cycles were selected for analysis.

RESULTS

Average word count was approximately equal for male and female applicants (503 vs 508, respectively). Female writers wrote longer letters (mean word count 545.5 vs 497.1, p = 0.028). "Standout" terms were more likely to be used to describe female applicants. Otherwise no statistically significant differences in applicant characterization were discovered.

CONCLUSIONS

Letters of recommendation for general surgery are written using similar descriptive terms and lengths for male and female applicants. This suggests that there is no specific gender disadvantage with regard to letters of recommendation when applying for general surgery residency.

Attitudes Toward Communication and Collaboration After Participation in a Mock Page Program: A Pilot of an Interprofessional Approach to Surgical Residency Preparation

OBJECTIVE

A source of insecurity among new physicians and new nurses is communicating and managing acute changes in patient condition. Mock page programs are an effective method for teaching communication and clinical decision-making skills to medical students. Joint participation in a mock page program provides a unique opportunity for medical and nursing students to practice communication, collaboration, and clinical decision-making in a low-risk learning environment. The purpose of this pilot study was to examine attitudes toward communication and collaboration among medical and nursing students after participation in a mock page program.

DESIGN

Twenty-four medical students participating in a surgical residency preparatory course were paired with 24 senior level nursing students. Over a period of 3 weeks, nursing students delivered 5 mock pages to the medical students. Mock pages consisted of peer-reviewed, prescripted scenarios depicting patients experiencing common postoperative complications. A 12-question survey measuring attitudes toward communication and collaboration between physicians and nurses was administered prior to delivery of the first page and after delivery of the last page. A dependent sample t test was used to perform item analysis.

RESULTS

Individual item analysis of medical student surveys indicated significant improvement in attitudes toward communication and collaboration with nurses in 12 out of 12 survey items (p < 0.05). Individual item analysis of nursing student surveys indicated significant improvement in attitudes toward communication and collaboration with physicians in 6 out of 10 survey items (p < 0.05). There was no decline in attitudes among any of the survey items.

CONCLUSIONS

The results from this study suggest that an interprofessional mock page program improves attitudes toward communication and collaboration between medical and nursing students. This program has the potential to improve the quality of education and increase confidence among medical and nursing students as they prepare for their professional roles.

Current state of the art in laparoscopic colorectal surgery for cancer: Update on the multi-centric international trials

Laparoscopic colectomy is now widely applied to cases of malignancy, supported by early data from several large randomized controlled trials. Long-term follow-up is now available from those trials, supporting equivalency of cancer-free and overall survival for open and laparoscopic resections. This promising data has inspired further exploration of other applications of laparoscopic techniques, including use of single incision laparoscopy. This article reviews recent reports of long-term data for colorectal cancer resection from four randomized, prospective international trials.

Laparoscopic management of diverticular disease

Despite its potential advantages, laparoscopic management of diverticular disease is currently performed by a minority of surgeons on a small group of patients. However, the role for laparoscopy in diverticular disease continues to develop. At present, adequate evidence exists for the routine use of laparoscopy for uncomplicated diverticular disease. Complicated disease, including fistulizing disease and free perforation requires additional expertise and study. As the experience grows among individual surgeons and institutions, it can be expected that the complication and conversion rates will continue to decline allowing even further evolution of laparoscopy for the treatment of this challenging disease process.

Perioperative factors during ileal pouch-anal anastomosis predict pouchitis

PURPOSE

Pouchitis is the most common complication of IPAA. Identifying factors predictive of pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological pouchitis in the absence of clinical or endoscopic findings is unknown.

METHODS

Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed pouchitis, defined as symptoms of pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded.

RESULT

Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (±5.1), 12.4 (±5.4), and 13. (±4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters.

CONCLUSION

Patients with symptomatic, biopsy-confirmed pouchitis have worse long-term outcomes than those without pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of pouchitis will strengthen patient counseling and may facilitate risk stratification.

Objective evaluation of the performance of surgical trainees on a porcine model of open colectomy

Background

Evaluation of surgical trainee operative performance is rarely objective. A rating system is proposed that assesses trainee performance objectively and quantifies technical improvement.

Methods

General surgery trainees were evaluated while performing porcine segmental colectomy. Initial instruction was provided for the critical operative steps. Evaluations were later repeated without additional instruction. Performance in 17 critical areas was scored.

Results

Twenty-three trainees were evaluated. Performance was divided into thirds, with a significant difference detected between tertiles (P &lt; 0·001). Postgraduate year 2 trainees scored lower than those in years 3 and 4 (P &lt; 0·001), but there was no difference between year 3 and 4 trainees (P = 0·557). Mean repeat scores were improved by 35 per cent, with most improvement at postgraduate year 2 level (71 per cent). Mean time taken to complete the operation was reduced by 23 per cent, with the largest reduction in the year 2 group.

Conclusion

The results support the use of this rating system as a tool for the objective evaluation of trainee operative skill. Instruction in the performance of segmental colectomy using deconstructed, step-by-step direction improved the ability of junior trainees to complete the operation. This evaluation system may be useful in the assessment, instruction and technical development of surgical trainees.

Preoperative findings predict conversion from laparoscopic to open cholecystectomy

BACKGROUND

Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conflicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion.

METHODS

A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis.

RESULTS

Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, ultrasound finding of pericholecystic fluid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identified present and ranged from 2% when 1 factor was present to 89% with 6 factors.

CONCLUSIONS

These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care.

The toxicology of interleukin-12: a review

Recombinant murine interleukin (IL)-12 (rmIL-12) exhibits antitumor, antiviral, and antimicrobial activities and can modify allergic inflammatory reactions in animal models. Recombinant human IL-12 (rhIL-12) is currently in clinical trials for treatment of cancer, asthma, and viral hepatitis. Principally a phagocyte-derived cytokine, IL-12 targets natural killer cells and T lymphocytes, stimulating their activity and the secretion of interferon (IFN)-gamma. An understanding of the toxicology of IL-12, due in part to effects mediated by IFN-gamma, has emerged from preclinical safety and mechanistic studies and initial clinical trials. Target organs common to several animal species and humans include the lymphohematopoietic system, intestines, liver, and lung.

IRAG working group 2. CAM-based assays. Interagency Regulatory Alternatives Group

CAM-based assays, in which test material is applied to the chorion allantoic membrane (CAM) of embryonated chicken eggs, were assessed as alternatives to the Draize eye irritation test. Two general types of CAM-based assays are currently in use, the HET-CAM test and the CAMVA assay. Evaluations were made of five data sets produced with three different modifications of the HET-CAM test and two data sets obtained with the same CAMVA protocol. Data sets consisted of 9-133 test chemicals, usually from the sponsor's product line, and also from a validation trial. Each data set and assay protocol were analysed for quality of data, purpose and proposed use of the assay, range of responses covered, range of test materials amenable, current use in safety and risk assessment both in-house and for regulatory purposes. Since the MMAS Draize score was not available for all in vivo data sets, the sigma MMMIS, which correlates well with the MMAS, was used instead. In vitro/in vivo correlations calculated with Pearson's linear coefficient ranged from r = 0.6 to r = 0.9 for six of seven data sets. Corneal opacity and inflammation of the iris showed the best correlation to in vitro data. Prediction rates were significantly improved when partial linear regression was used, and the predictivity of three different HET-CAM protocols was almost the same. HET-CAM assays showed the best prediction with surfactants and surfactant-based formulations, whereas the CAMVA assay provided the best performance with alcohols.

Biologic effects of recombinant human interleukin-12 in squirrel monkeys (Sciureus saimiri)

BACKGROUND

Interleukin-12 is a novel heterodimeric cytokine that stimulates the proliferation of activated T and NK cells and induces lymphokine-activated killer cell activity in vitro. To investigate the biological effects of recombinant human IL-12 (rHuIL-12) in vivo, two exploratory studies were conducted in squirrel monkeys (Sciureus saimiri), which have been shown to be pharmacologically responsive to rHuIL-12 in vitro.

EXPERIMENTAL DESIGN

In the first study, 18 monkeys (3/sex/group) were given daily subcutaneous injections of 0 (vehicle control), 10, or 50 micrograms/kg/day rHuIL-12 for 14 days. In the second study, 18 monkeys were given 0, 0.1, or 1 micrograms/kg/day rHuIL-12 for 14 days The animals were monitored for clinical signs, hematology and clinical chemistry changes, and sacrificed on day 15 to evaluate gross and histopathologic changes. One monkey in the high dose group was sacrificed moribund on day 14.

RESULTS

Monkeys given rHuIL-12 had dose-related hematologic changes characterized by mild to moderate anemia and leukocytosis. Serum chemistry changes included hypoproteinemia, hypoalbuminemia, hypophosphatemia, and hypocalcemia. Gross pathologic findings included generalized lymph node enlargement and splenomegaly with pulmonary edema and peritoneal effusions in two high dose monkeys. Dose-related histopathologic findings included thymic cortical atrophy, splenic lymphoid hyperplasia with histiocytic hyperplasia and extramedullary hematopoiesis of red pulp, Kupffer cell hypertrophy and hyperplasia, trilineage bone marrow hyperplasia, and reactive hyperplasia of lymph nodes. Animals in the 10 and 50 micrograms/kg/day dose groups developed high titers of anti-rHuIL-12 antibodies by day 15.

CONCLUSIONS

These studies indicate that rHuIL-12 is bioactive over a wide dose range and induces prominent hyperplasia of hematopoietic and lymphohistiocytic tissues in squirrel monkeys. Moreover, positive immunomodulatory activity (enhanced lymphocyte lytic activity) was detected at a dose of rHuIL-12 that is 500-fold less than the dose causing severe toxicity.

Interleukin-12: a cytokine with therapeutic potential in oncology and infectious diseases

IL-12 is a cytokine that promotes cell-mediated immunity by promoting Th1-type cytokine responses, enhancing the lytic activity of NK/LAK cells, augmenting specific CTL responses, and inducing the production of IFN-gamma. On the other hand, IL-12 suppresses the development of Th2-type cytokine responses and humoral immunity, particularly IgGl and IgE responses. It is likely that IL-12 normally plays an important role in the host defense against intracellular microbial pathogens. In addition, the administration of rIL-12 to mice has been shown to have potent therapeutic effects in several tumour and infectious disease models. IL-12 has been shown to be more efficacious than IL-2 in several murine tumour models, and toxicology studies suggest that it may have a substantially better therapeutic index. In addition, the long serum half-life of IL-12 relative to other cytokines will allow more flexibility in dosing schedules. However, future clinical trials are required to determine whether the efficacy of IL-12 seen in these experimental models is predictive for its use as an immunomodulatory drug in humans.