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Boffa DJ, Judson BL, Billingsley KG, Galetta D, Fontanez P, Odermatt C, Lindner K, Mitchell MR, Henderson CM, Carafeno T, Pinto J, Wagner JA, Ancuta MM, Beley P, Turner AL, Banack T, Laurans MS, Johnson DC, Yoo PS, Morton JM, Zurich H, Davis K, Ahuja N. Pandemic Recovery Using a COVID-Minimal Cancer Surgery Pathway. Ann Thorac Surg 2020; 110:718-724. [PMID: 32417195 PMCID: PMC7227551 DOI: 10.1016/j.athoracsur.2020.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 12/30/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented disruption in health care delivery around the world. In an effort to prevent hospital-acquired COVID-19 infections, most hospitals have severely curtailed elective surgery, performing only surgeries if the patient's survival or permanent function would be compromised by a delay in surgery. As hospitals emerge from the pandemic, it will be necessary to progressively increase surgical activity at a time when hospitals continue to care for COVID-19 patients. In an attempt to mitigate the risk of nosocomial infection, we have created a patient care pathway designed to minimize risk of exposure of patients coming into the hospital for scheduled procedures. The COVID-minimal surgery pathway is a predetermined patient flow, which dictates the locations, personnel, and materials that come in contact with our cancer surgery population, designed to minimize risk for virus transmission. We outline the approach that allowed a large academic medical center to create a COVID-minimal cancer surgery pathway within 7 days of initiating discussions. Although the pathway represents a combination of recommended practices, there are no data to support its efficacy. We share the pathway concept and our experience so that others wishing to similarly align staff and resources toward the protection of patients may have an easier time navigating the process.
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Fu W, Chai N, Yoo PS. Patterns of Information-Seeking among Potential Kidney Transplant Recipients and Evaluation of Online Kidney Transplant–Related Health Information. Am Surg 2020. [DOI: 10.1177/000313481908501108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kurbatov V, Shaughnessy M, Baratta V, Heller DR, Freedman-Weiss M, Resio BJ, Fleming M, Yoo PS. Application of Advanced Bioinformatics to Understand and Predict Burnout Among Surgical Trainees. JOURNAL OF SURGICAL EDUCATION 2020; 77:499-507. [PMID: 31889695 DOI: 10.1016/j.jsurg.2019.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/11/2019] [Accepted: 11/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Physician burnout, including surgical trainees, is multidimensional. Input variables used to predict burnout include grit, exhaustion, and financial stress. Each instrument has intrinsic limitations of scope and strength. We hypothesize that bioinformatics methods borrowed from oncogenetics may allow meta-analysis of existing predictive tools to improve identification of subpopulations at highest risk of burnout. DESIGN A composite survey was created using widely accepted instruments: demographic factors, burnout using the Single-Item Maslach Burnout Inventory Emotional Exhaustion Measure, grit using the Duckworth Grit Scale, occupational fatigue using the Occupational Fatigue Exhaustion/Recovery Scale, financial well-being, perceptions of physician leadership, and attitudes towards robotic surgery. Surveys were analyzed using k-means analysis and supervised/unsupervised clustering. SETTING Yale General Surgery Residency. PARTICIPANTS Survey participants consisted of Yale General Surgery residents. Of 70 residents, 53 responded (75.7%). Males comprised 57.1% and each postgraduate year had majority representation, 68.8% to 100%. RESULTS Unsupervised hierarchical clustering showed heterogeneous resident answer patterns and suggested clusters of responders. To define groups of dissimilar responders, we performed k-means clustering, testing 15 iterations with 50 attempts. The analysis revealed 3 discrete clusters of responders with differential risk for burnout (p = 0.021). The highest risk group demonstrated the lowest grit score, low interest in innovation and leadership, higher financial stress, and concordantly, the highest rates of anxiety, dread, and self-reported burnout. (p = 0.0004; 0.0014; 0.1217; 0.0625; 0.021; 0.0011; 0.0224) CONCLUSIONS: The limited scope of common tools aiming to predict burnout constrains their utility. The machine-learning technique of cluster analysis organizes compound data to describe complex outcomes such as oncologic risks. We apply this analysis technique to create a composite predictor of burnout among surgical residents. Our method determines subgroups of residents sharing unique traits predictive of burnout. Residencies can use this tool to allocate resources to best support resident well-being.
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Rao VS, Turner JM, Griffin M, Mahoney D, Asher J, Jeon S, Yoo PS, Boutagy N, Feher A, Sinusas A, Wilson FP, Finkelstein F, Testani JM. First-in-Human Experience With Peritoneal Direct Sodium Removal Using a Zero-Sodium Solution: A New Candidate Therapy for Volume Overload. Circulation 2020; 141:1043-1053. [PMID: 31910658 DOI: 10.1161/circulationaha.119.043062] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Loop diuretics have well-described toxicities, and loss of response to these agents is common. Alternative strategies are needed for the maintenance of euvolemia in heart failure (HF). Nonrenal removal of sodium directly across the peritoneal membrane (direct sodium removal [DSR]) with a sodium-free osmotic solution should result in extraction of large quantities of sodium with limited off-target solute removal. METHODS This article describes the preclinical development and first-in-human proof of concept for DSR. Sodium-free 10% dextrose was used as the DSR solution. Porcine experiments were conducted to investigate the optimal dwell time, safety, and scalability and to determine the effect of experimental heart failure. In the human study, participants with end-stage renal disease on peritoneal dialysis (PD) underwent randomization and crossover to either a 2-hour dwell with 1 L DSR solution or standard PD solution (Dianeal 4.25% dextrose, Baxter). The primary end point was completion of the 2-hour dwell without significant discomfort or adverse events, and the secondary end point was difference in sodium removal between DSR and standard PD solution. RESULTS Porcine experiments revealed that 1 L DSR solution removed 4.1±0.4 g sodium in 2 hours with negligible off-target solute removal and overall stable serum electrolytes. Increasing the volume of DSR solution cycled across the peritoneum increased sodium removal and substantially decreased plasma volume (P=0.005). In the setting of experimental heart failure with elevated right atrial pressure, sodium removal was ≈4 times greater than in healthy animals (P<0.001). In the human proof-of-concept study, DSR solution was well tolerated and not associated with significant discomfort or adverse events. Plasma electrolyte concentrations were stable, and off-target solute removal was negligible. Sodium removal was substantially higher with DSR (4.5±0.4 g) compared with standard PD solution (1.0±0.3 g; P<0.0001). CONCLUSIONS DSR was well tolerated in both animals and human subjects and produced substantially greater sodium removal than standard PD solution. Additional research evaluating the use of DSR as a method to prevent and treat hypervolemia in heart failure is warranted. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03801226.
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Fu W, Chai N, Yoo PS. Patterns of Information-Seeking Among Potential Kidney Transplant Recipients and Evaluation of Online Kidney Transplant-Related Health Information. Am Surg 2019; 85:e533-e536. [PMID: 31775983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Chiu AS, Freedman-Weiss MR, Jean RA, Cohen E, Yoo PS. No refills: The durable impact of a multifaceted effort by surgical trainees to minimize the prescription of postoperative opioids. Surgery 2019; 166:758-763. [DOI: 10.1016/j.surg.2019.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/18/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
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Shaughnessy MP, Ahle SL, Oliveira K, Longo WE, Yoo PS. Improving Satisfaction With Operating Room Feedback: An Effective, Low-Profile, No-Cost Intervention. JOURNAL OF SURGICAL EDUCATION 2019; 76:e138-e145. [PMID: 31628018 DOI: 10.1016/j.jsurg.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/12/2019] [Accepted: 10/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The objective of this study was to develop and implement an effective and minimally invasive tool to enhance formative and goal specific feedback for general surgery residents in the operating room. DESIGN Placards reminding surgical faculty and residents to engage in goal directed feedback were installed at scrub sinks outside of every operating room. The purpose was to encourage both residents and faculty to agree on a learning goal before the case, teach and learn that goal during the case, and discuss progress and next steps after the case. Preintervention and postintervention questionnaires were administered via Qualtrics Online Survey Software to all general surgery residents and core faculty members. SETTING Placards were installed at every scrub sink across all 4 hospitals associated with Yale School of Medicine General Surgery Residency over a 6-month time period. PARTICIPANTS Respondents included general surgery residents and core surgical faculty of the Yale School of Medicine General Surgery Residency. RESULTS Following the intervention, residents reported a statistically significant increase in preoperative discussion of learning goals, debriefing about specific learning goals postoperatively, and overall satisfaction with feedback (p < 0.01). Conversely, faculty perception of feedback did not change as a result of the intervention with faculty consistently reporting higher rates of preoperative learning goal discussions, providing goal specific feedback intraoperatively, and debriefing postoperatively when compared to residents (p < 0.01). CONCLUSIONS Formative feedback reminder placards placed near operating rooms serve as a low-profile, no-cost intervention to improve general surgery resident satisfaction with operative feedback and increase the perceived rate of goal specific feedback discussions both pre- and postoperatively.
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Brown TC, Yoo PS. Invited Commentary. J Am Coll Surg 2019; 228:838. [PMID: 31128666 DOI: 10.1016/j.jamcollsurg.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 11/18/2022]
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DeWane MP, Yoo PS. When a Surgical Trainee Is Sued: Supporting Residents Through Interactions With the Medicolegal System. JOURNAL OF SURGICAL EDUCATION 2019; 76:601-603. [PMID: 30396847 DOI: 10.1016/j.jsurg.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/08/2018] [Accepted: 10/07/2018] [Indexed: 06/08/2023]
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Dewane MP, Thomas DC, Longo WE, Yoo PS. Paying the Price: Understanding the Opportunity Cost of Dedicated Research Time during Surgical Training. Am Surg 2018. [DOI: 10.1177/000313481808401125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pursuit of dedicated research time during surgical residency prolongs training and delays entry into practice. Currently, there is a lack of research quantifying the financial implication of this delay and trainees’ understanding of its impact on career earnings. An opportunity cost analysis was performed regarding the impact of delay due to training within general surgery and selected subspecialties. An anonymous survey was distributed to general surgery categorical junior trainees in 2017 at a large academic hospital in the Northeast to determine understanding and beliefs regarding dedicated training on career earnings. For all specialties analyzed, dedicated research time was shown to negatively affect career earnings. The net cost was highest among those intending to pursue cardiothoracic surgery and lowest for those intending to pursue surgical oncology. A total of 26 of 35 (74%) present research residents and clinical residents intending to perform dedicated research time responded to an anonymous survey. On average, survey respondents underestimated the impact of dedicated research time on career earnings by $1.4 million. Dedicated research time during general surgery residency carries a substantial opportunity cost to overall career earnings. General surgery residents lack understanding of both the direction and the magnitude of this opportunity cost.
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DeWane MP, Thomas DC, Longo WE, Yoo PS. Paying the Price: Understanding the Opportunity Cost of Dedicated Research Time during Surgical Training. Am Surg 2018; 84:1723-1726. [PMID: 30747623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The pursuit of dedicated research time during surgical residency prolongs training and delays entry into practice. Currently, there is a lack of research quantifying the financial implication of this delay and trainees' understanding of its impact on career earnings. An opportunity cost analysis was performed regarding the impact of delay due to training within general surgery and selected subspecialties. An anonymous survey was distributed to general surgery categorical junior trainees in 2017 at a large academic hospital in the Northeast to determine understanding and beliefs regarding dedicated training on career earnings. For all specialties analyzed, dedicated research time was shown to negatively affect career earnings. The net cost was highest among those intending to pursue cardiothoracic surgery and lowest for those intending to pursue surgical oncology. A total of 26 of 35 (74%) present research residents and clinical residents intending to perform dedicated research time responded to an anonymous survey. On average, survey respondents underestimated the impact of dedicated research time on career earnings by $1.4 million. Dedicated research time during general surgery residency carries a substantial opportunity cost to overall career earnings. General surgery residents lack understanding of both the direction and the magnitude of this opportunity cost.
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Kulkarni S, Yoo PS, Batra R, Haakinson DJ, Schulam P, Mulligan DC. Building Local Communities of Prior Living Donors and Creating a Social Architecture to Improve Rates of Living Kidney Donation. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chiu AS, Ahle SL, Freedman-Weiss MR, Yoo PS, Pei KY. The impact of a curriculum on postoperative opioid prescribing for novice surgical trainees. Am J Surg 2018; 217:228-232. [PMID: 30180937 DOI: 10.1016/j.amjsurg.2018.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/22/2018] [Accepted: 08/11/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Surgical residents are frequently responsible for prescribing postoperative analgesia, yet the vast majority are never formally educated on the subject. METHODS A resident-led educational presentation on postoperative analgesia prescribing was provided to incoming surgical interns at a tertiary academic center. Pre- and post-surveys assessed comfort in prescribing postoperative analgesia. Following the educational intervention, opioid prescriptions during the interns' first two months were compared to that of the prior year's interns. RESULTS Education was provided to 31 interns. Prior to the session, few interns felt comfortable prescribing opioids (20%) or non-opioid analgesia (32%). After the session, 96% felt more comfortable prescribing opioids and 91% more comfortable prescribing multi-modal analgesia. Interns who received education prescribed an average of 127.8 Morphine Milligram Equivalents (MME) per prescription, compared to 208.5 MME by the prior year's interns (p < 0.01). CONCLUSION Education on postoperative analgesia targeting interns can be effective in preparing trainees in effective and judicious analgesic prescribing.
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Fu W, Merola J, Malinis M, Lacy J, Barbieri A, Liapakis AH, Mulligan DC, Yoo PS. Successful treatment of primary donor-derived human herpesvirus-8 infection and hepatic Kaposi Sarcoma in an adult liver transplant recipient. Transpl Infect Dis 2018; 20:e12966. [DOI: 10.1111/tid.12966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/25/2018] [Accepted: 07/09/2018] [Indexed: 12/20/2022]
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Mishra A, Lo A, Lee GS, Samstein B, Yoo PS, Levine MH, Goldberg DS, Shaked A, Olthoff KM, Abt PL. Liver paired exchange: Can the liver emulate the kidney? Liver Transpl 2018; 24:677-686. [PMID: 29427562 DOI: 10.1002/lt.25030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/14/2018] [Accepted: 02/05/2018] [Indexed: 02/07/2023]
Abstract
Kidney paired exchange (KPE) constitutes 12% of all living donor kidney transplantations (LDKTs) in the United States. The success of KPE programs has prompted many in the liver transplant community to consider the possibility of liver paired exchange (LPE). Though the idea seems promising, the application has been limited to a handful of centers in Asia. In this article, we consider the indications, logistical issues, and ethics for establishing a LPE program in the United States with reference to the principles and advances developed from experience with KPE. Liver Transplantation 24 677-686 2018 AASLD.
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Healy JM, Maxfield MW, Solomon DG, Longo WE, Yoo PS. Beyond 250: A Comprehensive Strategy to Maximize the Operative Experience for Junior Residents. JOURNAL OF SURGICAL EDUCATION 2018; 75:541-545. [PMID: 29097172 DOI: 10.1016/j.jsurg.2017.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 07/25/2017] [Accepted: 08/27/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Among surgical educators, duty-hour restrictions led to concern regarding the adequacy of operative experience during residency, especially for junior residents. The American Board of Surgery recently instituted guidelines mandating "a minimum of 250 operations by the end of the PGY-2 year". A series of programmatic and institutional changes were implemented at our institution to augment the junior resident operative experience and to exceed compliance with this mandate. METHODS Operative data from Accreditation Council for Graduate Medical Education case logs for categorical and nondesignated preliminary interns from our large academic surgical residency were identified for 5 consecutive academic years, 2011 until 2016. American Board of Surgery In-Training Examination (ABSITE) scores were collected anonymously. The program systematically instituted the following changes: night float minimization, identification of new surgical opportunities, augmenting use of midlevel care providers, identification of rotations with suboptimal operative experiences, maximizing rotations with involvement of junior residents in the operating room, and systematic review of junior case logs. RESULTS After implementation, average total cases for residents completing postgraduate year (PGY)-2 increased from 176 to 330 (p < 0.001). Specifically, there was an 18% increase for interns (p = 0.059) and a 118% increase for PGY-2 residents (p < 0.001). There were statistically significant increases in skin and soft tissue cases, vascular cases, endoscopy, and complex laparoscopic cases. Average case volumes for senior residents did not change. Night float time was significantly decreased (5.7 vs 3.4 wk; p = 0.04). ABSITE scores were not significantly changed during this time. CONCLUSIONS Before implementation of these interventions, our program would have had 0% compliance with the 250 junior resident case rule. Within 12 months of implementation, total case volumes for residents completing PGY-2 increased by 88%-exceeding minimum standards. Overall, 100% programmatic compliance was achieved. Our program's experience exemplifies how mandates from the American Board of Surgery can lead to programmatic changes that improve the experience of surgical house officers.
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Chiu AS, Healy JM, DeWane MP, Longo WE, Yoo PS. Trainees as Agents of Change in the Opioid Epidemic: Optimizing the Opioid Prescription Practices of Surgical Residents. JOURNAL OF SURGICAL EDUCATION 2018; 75:65-71. [PMID: 28705485 DOI: 10.1016/j.jsurg.2017.06.020] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/12/2017] [Accepted: 06/17/2017] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Opioid abuse has become an epidemic in the United States, causing nearly 50,000 deaths a year. Postoperative pain is an unavoidable consequence of most surgery, and surgeons must balance the need for sufficient analgesia with the risks of overprescribing. Prescribing narcotics is often the responsibility of surgical residents, yet little is known about their opioid-prescribing habits, influences, and training experience. DESIGN Anonymous online survey that assessed the amounts of postoperative opioid prescribed by residents, including type of analgesia, dosage, and number of pills, for a series of common general surgery procedures. Additional questions investigated influences on opioid prescription, use of nonnarcotic analgesia, degree of engagement in patient education on opioids, and degree of training received on analgesia and opioid prescription. SETTING Accreditation Council for Graduate Medical Education accredited general surgery program at a university-based tertiary hospital. PARTICIPANTS Categorical and preliminary general surgery residents of all postgraduate years. RESULTS The percentage of residents prescribing opioids postprocedure ranged from 75.5% for incision and drainage to 100% for open hernia repair. Residents report prescribing 166.3 morphine milligram equivalents of opioid for a laparoscopic cholecystectomy, yet believe patients will only need an average of 113.9 morphine milligram equivalents. The most commonly reported influences on opioid-prescribing habits include attending preference (95.2%), concern for patient satisfaction (59.5%), and fear of potential opioid abuse (59.5%). Only 35.8% of residents routinely perform a narcotic risk assessment before prescribing and 6.2% instruct patients how to properly dispose of excess opioids. More than 90% of residents have not had formal training in best practices of pain management or opioid prescription. CONCLUSION AND RELEVANCE Surgical trainees are relying almost exclusively on opioids for postoperative analgesia, often in excessive amounts. Residents are heavily influenced by their superiors, but are not receiving formal opioid-prescribing education, pointing to a great need for increased resident education on postoperative pain and opioid management to help change prescribing habits.
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Jean RA, Alexandre M, Yoo PS. Kidney Transplantation With and Without Native Nephrectomy for Polycystic Kidney Disease: Results of the National Inpatient Sample and the Rationale for a 2-Staged Procedure. J Am Coll Surg 2017; 226:1079-1084. [PMID: 29224797 DOI: 10.1016/j.jamcollsurg.2017.11.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Polycystic kidney disease (PKD) is one of the most common causes of end-stage renal disease requiring hemodialysis or transplantation. In patients requiring transplantation, there are several indications for native nephrectomy, including recurrent cyst infection, bleeding, or to provide room for the graft. There is disagreement about whether it is advisable to perform kidney transplantation alone (KT), or to perform KT with simultaneous native nephrectomy (KTN). We compared postoperative outcomes of KTN and KT in a large national cohort. STUDY DESIGN The Nationwide Inpatient Sample (NIS) between 2000 and 2014 was examined for a diagnosis of PKD with evidence for KT or KTN. Logistic regression, adjusting for age, sex, comorbidity, and hospital region, was used to compare groups for the need for blood transfusion, need for critical care interventions, and development of postoperative complications. RESULTS A total of 4,003 hospitalizations were identified, which was representative of 19,302 weighted discharges nationally. In adjusted logistic regression models, KTN demonstrated significantly higher risk for blood transfusion (odds ratio [OR] 2.06; 95% CI 1.44 to 2.96; p < 0.0001), postoperative complications (OR 1.44; 95% CI 1.05 to 1.96; p = 0.02), and critical care interventions (OR 1.44; 95% CI 1.07 to 1.95; p = 0.02). Other significant predictors for blood transfusion included female sex (OR 1.76; 95% CI 1.45 to 2.13; p < 0.0001), age older than 61 years (OR 1.60; 95% CI 1.21 to 2.10; p = 0.001), and Charlson comorbidity score ≥2 (OR 1.52; 95% CI 1.10 to 2.09; p = 0.01). CONCLUSIONS Among patients with PKD, in comparison with KTN, KT alone represents a decreased risk for negative postoperative outcomes. A 2-staged procedure should be considered, when feasible, to minimize adverse patient outcomes.
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Thiessen C, Wang J, Skrip L, Yoo PS. Patient and Graft Survival Among Sexagenarian and Septuagenarian Renal Transplant Recipients and Donors: The Context for Older Recipients. Prog Transplant 2017; 27:257-265. [PMID: 29187091 DOI: 10.1177/1526924817715469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Due to the increasing number of patients with end-stage renal disease, there is a growing demand for transplants for recipients and donors aged 60 years and older. Using data from the Scientific Registry of Transplant Recipients, we performed survival analyses and multivariate logistic regression to help guide transplant professional decisions regarding the selection of graft type (living vs deceased) and donor age (60-69 vs 70+ years) for recipients aged 60 years and older.
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Merola J, Yoo PS, Schaub J, Smith JD, Rodriguez-Davalos MI, Tichy E, Mulligan DC, Asch W, Formica R, Kashgarian M, Kulkarni S. Belatacept and Eculizumab for Treatment of Calcineurin Inhibitor-induced Thrombotic Microangiopathy After Kidney Transplantation: Case Report. Transplant Proc 2017; 48:3106-3108. [PMID: 27932157 DOI: 10.1016/j.transproceed.2016.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/27/2016] [Indexed: 11/25/2022]
Abstract
Thrombotic microangiopathy (TMA) after kidney transplantation is an uncommon and challenging cause of graft dysfunction and is associated with early graft loss. An idiosyncratic endothelial reaction to calcineurin inhibitors (CNIs) has been implicated as a frequent cause of TMA. This reaction is marked by uncontrolled activation of complement and subsequent cellular destruction. Usual therapy consists of withdrawal of the inciting drug and plasmapheresis to minimize levels of circulating complement. Recently, eculizumab, a monoclonal antibody to complement component C5, has been used for the treatment of atypical hemolytic uremic syndrome. Belatacept, an inhibitor of T cell costimulatory protein CTLA-4 has been used in immunosuppression strategies aimed at minimization of CNI. Here we report the first case of treatment of CNI-associated TMA/hemolytic uremic syndrome with withdrawal of tacrolimus and initiation of both belatacept and eculizumab. The case describes a favorable clinical course for both graft and patient, and is accompanied by a review of the literature.
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Tooley JE, Bohl DD, Kulkarni S, Rodriguez-Davalos MI, Mangi A, Mulligan DC, Yoo PS. Perioperative outcomes of coronary artery bypass graft in renal transplant recipients in the United States: results from the Nationwide Inpatient Sample. Clin Transplant 2016; 30:1258-1263. [PMID: 27440000 DOI: 10.1111/ctr.12816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). In fact, death from cardiovascular disease is the number one cause of graft loss in kidney transplant (KTx) patients. Compared to patients on dialysis, CKD patients with KTx have increased quality and length of life. It is not known, however, whether outcomes of coronary artery bypass graft (CABG) surgery differ between CKD patients with KTx or on dialysis. METHODS This was a retrospective cohort study comparing CKD patients with KTx or on dialysis undergoing CABG surgery included in the Nationwide Inpatient Sample from 2002 to 2011. Logistic and linear regression models were used to estimate the adjusted associations of KTx on all-cause in-hospital mortality, length of stay, cost of hospitalization, and rate of complications in CABG surgery. RESULTS CKD patients with KTx had decreased all-cause in-hospital mortality (2.68% vs 5.86%, odds ratio (OR)=0.56, 95% confidence interval (CI)=0.32 to 0.99, P=.046), length of stay (β=-2.96, 95% CI=-3.67 to -2.46, P<.001), and total hospital charges (difference=-$38 884, 95% CI=-$48 173 to -29 596, P<.001). They also had decreased rate of a number of perioperative complications. CONCLUSIONS CKD patient with KTx have better perioperative outcomes in CABG surgery compared to patients on dialysis.
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Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and Parenthood among Surgery Residents: Results of the First Nationwide Survey of General Surgery Residency Program Directors. J Am Coll Surg 2016; 222:1090-6. [DOI: 10.1016/j.jamcollsurg.2015.12.004] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 11/25/2022]
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Fonseca AL, Reddy V, Yoo PS, Gusberg RJ, Longo WE. Senior Surgical Resident Confidence in Performing Flexible Endoscopy: What Can We Do Differently? JOURNAL OF SURGICAL EDUCATION 2016; 73:311-316. [PMID: 26531744 DOI: 10.1016/j.jsurg.2015.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/21/2015] [Accepted: 09/25/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The American Board of Surgery endoscopy requirements for general surgery training are evolving. In 2006, the Residency Review Committee in Surgery increased the total number of endoscopy cases required before completion of general surgery residency training. This requirement is set to change further, given the new Flexible Endoscopic Curriculum that would be a requirement for applicants graduating surgical training during or after the 2017 to 2018 academic year. Given these changes, our goal was to evaluate the confidence of senior surgical residents performing flexible endoscopy. METHODS A survey was developed and sent to general surgery residents nationally, querying them regarding demographics and program-specific characteristics; additionally they were asked to rate their confidence level in performing flexible upper endoscopy and colonoscopy on a Likert scale of 1 to 5. We then compared those residents who indicated confidence (Likert scale 4-5) to those who did not (Likert scale 1-3). For the purpose of this study, only senior (postgraduate year 4 and 5) general surgery residents were assessed. RESULTS We received 1176 responses from senior surgical residents: 56% of these were postgraduate year 5 residents, 65% male, 68% from University Programs, and 56% from programs associated with a Veteran's Affairs Hospital; 33% were from programs in the Northeast, 29% in the South, 24% in the Midwest, and 14% in the West; 75% were going on to additional fellowship training after the completion of residency; 42% indicated that they would go into academic practice and 32% into private practice; 66.7% reported confidence performing upper endoscopy and 52.7% reported confidence performing colonoscopy. Male gender, overall operative volume, and graduating from a medium-sized program or program in the South were associated with increased confidence performing flexible endoscopy. CONCLUSIONS A large percentage of senior residents do not report confidence in performing flexible endoscopy. Although increasing the number of cases required for graduation has likely helped improve the training of residents in endoscopy, additional improvements in training are required. The Flexible Endoscopic Curriculum helps standardize the curriculum and demonstrate that the graduating resident has the fundamental knowledge and skills required in the performance of endoscopy. Simulation training and dedicated endoscopic rotations during the course of residency training could help improve endoscopy training and proficiency for future graduating residents.
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Bongiovanni T, Yeo H, Sosa JA, Yoo PS, Long T, Rosenthal M, Berg D, Curry L, Nunez-Smith M. Attrition from surgical residency training: perspectives from those who left. Am J Surg 2015; 210:648-54. [DOI: 10.1016/j.amjsurg.2015.05.014] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/24/2015] [Accepted: 05/29/2015] [Indexed: 11/26/2022]
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Merola J, Liapakis A, Mulligan DC, Yoo PS. Non-alcoholic fatty liver disease following liver transplantation: a clinical review. Clin Transplant 2015; 29:728-37. [PMID: 26147308 DOI: 10.1111/ctr.12585] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2015] [Indexed: 02/06/2023]
Abstract
Non-alcoholic steatohepatitis (NASH) is rapidly becoming the leading indication for liver transplantation (LT) in the United States. While post-transplantation outcomes are similar to other indications for transplant, recent evidence has suggested that reduction in risk factors for post-transplant metabolic syndrome may impose a significant survival benefit in this patient population. Cardiovascular mortality is the leading cause of death following transplantation for NASH. While pre-transplant pharmacologic and surgical approaches have been utilized to reduce cardiovascular risk factors following transplantation, the effectiveness of these treatment approaches in the post-transplant setting is poorly defined. Studies are urgently needed in the treatment of this rapidly growing population.
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