Assessment of Chief Resident Practice Readiness in a Porcine Lab: A 4-Year Experience

OBJECTIVE

General surgery training prepares residents for the autonomous practice of surgery; however, assessment for readiness for independent practice presents several challenges. The simulation lab offers a safe and standardized environment for assessing the technical skills of a resident in the absence of numerous confounders of the real operating room. We describe our experience with evaluation and remediation of chief resident assessments in a porcine simulation lab.

DESIGN

Operative skill assessment of surgical residents was conducted using anesthetized porcine models. Procedure's representative of basic and complex operative skill was chosen for the assessment. Faculty assessed the residents using a checklist for the completion of all critical operative steps. A "failing" score or "critical fail" on a given procedure determined mandatory remediation. For remediation, faculty provided immediate post-procedure feedback on all errors, and residents were offered supervised practice. Residents were then retested to demonstrate competency.

SETTING

Large animal research center at Indiana University School of Medicine, Indianapolis, IN PARTICIPANTS: From 2017 to 2020, thirty-seven PGY5 residents participated in the porcine lab over a 4-year period. These general surgery residents were assessed at the beginning of their chief year.

RESULTS

There were a total of 6 residents that failed 1 or more procedures. There were no failures in the cholecystectomy, 3 failures for Nissen, 4 failures for Hand sewn anastomosis, and 1 failure for stapled anastomosis. Two residents failed 2 procedures. All residents received remediation with a faculty member and were subsequently able to perform the procedure competently.

CONCLUSIONS

A formal simulation-based assessment of procedural competence can identify technical performance deficiencies even at the chief resident level. Combined with a formal remediation program, such deficiencies can be addressed well in advance of residency graduation. Determining the relationship of such simulation-based assessments with operative performance is currently underway.

High-risk bariatric candidates: does red-flagging predict the post-operative course?

BACKGROUND

Standards for preoperative bariatric patient selection include a thorough psychological evaluation. Using patients "red-flagged" during preoperative evaluations, this study aims to identify trends in long-term follow-up and complications to further optimize bariatric patient selection.

METHODS

A multidisciplinary team held a case review conference (CRC) to discuss red-flagged patients. A retrospective chart review compared CRC patients to control patients who underwent bariatric surgery in the same interval. Patients under 18 years old, undergoing revisional bariatric surgery, or getting band placement were excluded. High-risk characteristics causing CRC inclusion, preoperative demographics, percent follow-up and other postoperative outcomes were collected up to 5 years postoperatively. If univariate analysis revealed a significant difference between cohorts, multivariable analysis was performed.

RESULTS

Two hundred and fifty three patients were red-flagged from 2012 to 2013, of which 79 underwent surgery. After excluding 21 revisions, 3 non-adult patients, and 6 band patients, 55 red-flagged patients were analyzed in addition to 273 control patients. Patient age, sex, initial BMI, ASA, and co-morbidities were similar between groups, though flagged patients underwent RYGB more frequently than control patients. Notably, percent excess BMI loss and percent follow-up (6 months-5 years) were similar. In multivariable analysis, minor complications were more common in flagged patients; and marginal ulcers, endoscopy, and dilation for stenosis were more common in flagged versus control patients who underwent RYGB. Perforation, reoperation, revision, incisional hernia, and internal hernia were statistically similar in both groups, though reoperation was significantly more common in patients with multiple reasons to be flagged compared to controls.

CONCLUSION

Bariatric patients deemed high risk for various psychosocial issues have similar follow-up, BMI loss, and major complications compared to controls. High-risk RYGB patients have greater minor complications, warranting additional counseling of high-risk patients.

Prospective, multicenter study of P4HB (Phasix™) mesh for hernia repair in cohort at risk for complications: 3-Year follow-up

BACKGROUND

This study represents a prospective, multicenter, open-label study to assess the safety, performance, and outcomes of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh for primary ventral, primary incisional, or multiply-recurrent hernia in subjects at risk for complications. This study reports 3-year clinical outcomes.

MATERIALS AND METHODS

P4HB mesh was implanted in 121 patients via retrorectus or onlay technique. Physical exam and/or quality of life surveys were completed at 1, 3, 6,12, 18, 24, and 36 months, with 5-year (60-month) follow-up ongoing.

RESULTS

A total of n = 121 patients were implanted with P4HB mesh (n = 75 (62%) female) with a mean age of 54.7 ± 12.0 years and mean BMI of 32.2 ± 4.5 kg/m2 (±standard deviation). Comorbidities included: obesity (78.5%), active smokers (23.1%), COPD (28.1%), diabetes mellitus (33.1%), immunosuppression (8.3%), coronary artery disease (21.5%), chronic corticosteroid use (5.0%), hypo-albuminemia (2.5%), advanced age (5.0%), and renal insufficiency (0.8%). Hernias were repaired via retrorectus (n = 45, 37.2% with myofascial release (MR) or n = 43, 35.5% without MR), onlay (n = 8, 6.6% with MR or n = 24, 19.8% without MR), or not reported (n = 1, 0.8%). 82 patients (67.8%) completed 36-month follow-up. 17 patients (17.9% ± 0.4%) experienced hernia recurrence at 3 years, with n = 9 in the retrorectus group and n = 8 in the onlay group. SSI (n = 11) occurred in 9.3% ± 0.03% of patients.

CONCLUSIONS

Long-term outcomes following ventral hernia repair with P4HB mesh demonstrate low recurrence rates at 3-year (36-month) postoperative time frame with no patients developing late mesh complications or requiring mesh removal. 5-year (60-month) follow-up is ongoing.

Laparoscopic sleeve gastrectomy is safe and effective in elderly patients: a comparative analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is gaining widespread popularity as a definitive bariatric operation that provides satisfactory and durable weight loss as well as comorbidity resolution. Although SG is being increasingly offered to patients of all ages, there is a paucity of reported outcomes in patients ≥62 years of age. The purpose of this study was to perform a comparative analysis of the outcomes of SG in patients >62 years versus a younger age group, with an emphasis on safety and efficacy.

METHODS

A retrospective analysis was performed from a prospectively collected database on patients who underwent SG from 2007 to 2012. All patients who were ≥62 years old were compared to those <62 years.

RESULTS

There were 182 patients who underwent SG, 17 of whom were ≥62 years old. There were no significant differences in demographics or comorbidity characteristics between the groups. The mean follow-up was 1 year. There was no 30-day mortality in either group. The percent excess weight loss for the younger age group was 44 ± 21 % and the older group was 44 ± 25 %. The percent total body weight loss was 22 ± 10 and 21 ± 10 %, respectively. Weight loss outcomes were maintained for up to 3 years. Comorbidity resolution and improvement rates were equivalent in both groups.

CONCLUSIONS

SG is safe and effective in patients ≥62 years. Weight loss and the beneficial effects on comorbidities are equivalent among elderly and younger patients. SG should be offered to elderly patients who are deemed to be appropriate candidates.

Endoscopic anterior fundoplication with the Medigus Ultrasonic Surgical Endostapler (MUSE™) for gastroesophageal reflux disease: 6-month results from a multi-center prospective trial

BACKGROUND

Both long-term proton pump inhibitor (PPI) use and surgical fundoplication have potential drawbacks as treatments for chronic gastroesophageal reflux disease (GERD). This multi-center, prospective study evaluated the clinical experiences of 69 patients who received an alternative treatment: endoscopic anterior fundoplication with a video- and ultrasound-guided transoral surgical stapler.

METHODS

Patients with well-categorized GERD were enrolled at six international sites. Efficacy data was compared at baseline and at 6 months post-procedure. The primary endpoint was a ≥ 50 % improvement in GERD health-related quality of life (HRQL) score. Secondary endpoints were elimination or ≥ 50 % reduction in dose of PPI medication and reduction of total acid exposure on esophageal pH probe monitoring. A safety evaluation was performed at time 0 and weeks 1, 4, 12, and 6 months.

RESULTS

66 patients completed follow-up. Six months after the procedure, the GERD-HRQL score improved by >50 % off PPI in 73 % (48/66) of patients (95 % CI 60-83 %). Forty-two patients (64.6 %) were no longer using daily PPI medication. Of the 23 patients who continued to take PPI following the procedure, 13 (56.5 %) reported a ≥ 50 % reduction in dose. The mean percent of total time with esophageal pH <4.0 decreased from baseline to 6 months (P < 0.001). Common adverse events were peri-operative chest discomfort and sore throat. Two severe adverse events requiring intervention occurred in the first 24 subjects, no further esophageal injury or leaks were reported in the remaining 48 enrolled subjects.

CONCLUSIONS

The initial 6-month data reported in this study demonstrate safety and efficacy of this endoscopic plication device. Early experience with the device necessitated procedure and device changes to improve safety, with improved results in the later portion of the study. Continued assessment of durability and safety are ongoing in a three-year follow-up study of this patient group.

Deep sedation in natural orifice transluminal endoscopic surgery (NOTES): a comparative study with dogs

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has been mostly performed with the animal under general and inhalational anesthesia (IA-NOTES). To date, NOTES using propofol sedation (PS-NOTES) has not been investigated. This study aimed to assess the feasibility and safety of PS-NOTES for transgastric oophorectomy with carbon dioxide insufflation and to compare its success rates with those of conventional IA-NOTES.

METHODS

In this prospective randomized study, NOTES oophorectomy was performed for 19 female dogs randomized to two conditions: PS (study group) and IA (control group). Sedation success rates (ability to visualize and resect ovaries without converting to IA), operative success rates (ability to resect and retrieve both ovaries in full using only NOTES), and vital parameters including hemodynamic and respiratory changes were documented.

RESULTS

In the PS-NOTES group (n = 9), the sedation success rate was 100 %. The operative success rate was 67 % (6 of 9 animals) compared with 80 % (8 of 10 animals) in the IA-NOTES group. No purposeful movement occurred during surgical manipulation and no respiratory or cardiovascular complications in occurred the PS group. Heart rate (HR) and end-tidal carbon dioxide (ETCO(2)) were significantly higher in the PS group than in the IA group. Blood pressure (BP) was significantly higher in the PS group only during the middle part of the procedure. Only mild respiratory depression was noted in the PS group, as indicated by elevated but acceptable ETCO(2). Elevations in BP and HR are thought to be related to elevated CO(2) but did not appear to have an adverse impact on the course of the procedure. Recovery was uneventful for all the animals.

CONCLUSION

The use of PS-NOTES appears to be feasible, resulting in outcomes comparable with those for IA in dogs. Further studies are needed to determine the applicability of this concept in human NOTES.

Comparison of hand-sewn, linear-stapled, and circular-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

BACKGROUND

There is no consensus on the ideal gastrojejunostomy anastomosis (GJA) technique in laparoscopic Roux-en-Y gastric bypass (LRYGB). We reviewed our experience with three GJA techniques (hand-sewn (HSA), linear-stapled (LSA), and 25-mm circular-stapled (CSA)) to determine which anastomosis technique is associated with the lowest early (60-day) anastomotic complication rates.

METHODS

From November 2004 through December 2009, 882 consecutive patients underwent LRYGB using three GJA techniques: HSA, LSA, and CSA. All patients had a minimum of 2 months follow-up. Records were reviewed for postoperative gastrojejunostomy leak, stricture, and marginal ulcer, and these early complications were classified according to anastomosis technique. Multivariate analysis was performed to determine associations between complications and anastomosis technique.

RESULTS

Preoperative demographics, length of hospital stay, and postoperative follow-up did not differ between the three groups. The majority of patients underwent LSA (n = 514, 61.6%) followed by HSA (n = 180, 21.6%) and CSA (n = 140, 16.8%). Using multivariate analysis, there were no statistically significant differences in the rates of leak (LSA 1.0%, HSA 1.1%, CSA 0.0%, p = 0.480), stricture (LSA 6.0%, HSA 6.1%, CSA 4.3%, p = 0.657), or marginal ulcer (LSA 8.0%, HSA 7.7%, CSA 3.6%, p = 0.180).

CONCLUSIONS

The three techniques can be used safely with a low complication rate. Our data do not identify a superior anastomosis technique.

Pancreas transplantation after bariatric surgery

Obese transplant candidates are at increased risk for perioperative and postoperative complications. In many transplant programs, morbid obesity is considered to be an exclusion criterion for transplantation. The only potential option that would grant these patients access to transplant is weight loss. Non-operative weight loss strategies such as behavioral modifications, exercise, diet, or medication have only very limited success in achieving long-term weight loss. In contrast, bariatric surgery was shown to achieve not only more excessive weight loss, but more importantly, this weight loss can be sustained for longer periods of time. Therefore, bariatric surgery presents an attractive option for weight loss for morbidly obese transplant candidates. We report our experience with four patients who underwent bariatric surgery prior to successful pancreas transplantation. Even though gastric bypass and laparoscopic adjustable gastric band present as equivalent alternatives for weight reduction, we believe that in the population of morbidly obese diabetic patients who are possible candidates for pancreas transplantation, laparoscopic adjustable gastric band placement is the more suitable procedure.

Evaluation of the learning curve for natural orifice transluminal endoscopic surgery: bilateral ovariectomy in dogs

OBJECTIVE

Study the learning curve for canine Natural Orifice Transluminal Endoscopic Surgery (NOTES) ovariectomy by evaluating operative times and complications.

STUDY DESIGN

Preclinical research study.

ANIMALS

Adult female dogs (n=20).

METHODS

NOTES ovariectomy procedures were performed as follows: Feasibility Group 1 (n=5), Feasibility Group 2 (n=5), and Early Clinical Group 3 (n=10). Six steps of the procedure were identified, timed separately, and the overall time was recorded from introduction to removal of the endoscope. Complications were recorded. Repeated measures analysis of variance using ranked data compared the effect of group (3 levels) on the time for each step. Nonlinear regression using an exponential model with nonzero asymptote was used to model the operative time-procedure number relationship.

RESULTS

Overall median operative time was significantly longer for Group 1 (195 minutes; range, 160-265 minutes) than Group 2 (108 minutes; range, 81-148 minutes; P=.048) and Group 3 (77 minutes; range, 41-136 minutes; P=.0008). The estimated asymptotic operative time was 71 minutes (95% confidence interval, 41-100 minutes); this time was reached after 10 procedures. Gastric cleansing and removing the left ovary took significantly longer in Group 1 than in Group 2 or 3. Operative complications included incomplete ovarian excision, dropping an ovary during retrieval, and conversion to an open procedure. No intraoperative complications occurred in Group 3.

CONCLUSION

NOTES procedures result in longer operative times in the early part of the learning curve and require considerable experience before reaching proficiency.

Comparison of pain and postoperative stress in dogs undergoing natural orifice transluminal endoscopic surgery, laparoscopic, and open oophorectomy

BACKGROUND

Few studies are available to compare the potential benefits of natural orifice transluminal endoscopic surgery (NOTES) approaches to traditional surgery.

OBJECTIVE

To compare complications, surgical stress, and postoperative pain.

DESIGN

Prospective study in dogs.

SETTING

Research laboratory.

SUBJECTS

Thirty dogs.

INTERVENTIONS

Oophorectomy procedures were performed via NOTES and laparoscopic and traditional open surgery.

MAIN OUTCOME MEASUREMENTS

Operative time, pain scores, systemic stress parameters (cortisol, glucose), surgical stress markers (interleukin 6, C-reactive protein), 3-day observation.

RESULTS

Median operative times were 76, 44, and 35 minutes for the NOTES, laparoscopic, and open procedures, respectively, with the NOTES procedure being significantly longer than the other 2 procedures. All ovaries were completely excised, and all the animals survived without complications. The NOTES animals had greater increases in serum cortisol concentrations at 2 hours but no statistically significant differences in glucose concentrations compared with the other groups. Serum interleukin 6 and C-reactive protein concentrations were significantly increased at specific times compared with baseline in the NOTES group, but not in the open or laparoscopic surgery groups. Based on the cumulative pain score and nociceptive thresholds, the animals in the NOTES group demonstrated less evidence of pain.

LIMITATIONS

Small sample size, limited follow-up.

CONCLUSIONS

Although the NOTES oophorectomy procedures took approximately twice as long and there may be more evidence of tissue damage as judged by increases in serum cortisol and interleukin 6 concentrations, the dogs in the NOTES group had lower pain scores, especially when compared with animals undergoing open surgery.

Single-port laparoscopic surgery

Laparoscopic surgery performed through a single-incision is gaining popularity. The demand from the public for even less invasive procedures will motivate surgeons, industry, and academic centers to explore the possibilities and refine the technology. Although the idea seems quite attractive, there are several technological obstacles that are yet to be conquered by improved technology or additional training. The question of safety has yet to be answered and will require well-designed randomized control trials. Opponents to the approach argue that the size of the single incision (see Table 1) is frequently larger than all the standard laparoscopy incisions combined. On the other hand, proponents remember a similar argument from traditional open surgeons during the initial development of laparoscopy. That argument was quickly discredited when the immediate benefits oflaparoscopy were compared with patients undergoing surgery with small laparotomy incisions. During the development of a new technique, the learning curve exposes patients to risk and society to expense. LESS pioneers appear to have reached a level of comfort with technology and techniques that paves the way for scientific scrutiny. Perhaps, the surgical community will capitalize on this situation with randomized, controlled studies and sound evidence to support or refute the benefits of LESS. If we do not seize this opportunity, patient demand and industry's dual edge message of financial success versus fear of losing referrals will lead to a scenario similar to the development of laparoscopic cholecystectomy in the 1990s. Regardless of its future, the surgical community will still benefit from a renewed excitement as surgeons aim to continually reduce the amount of pain and trauma our patients must endure. In addition, technological advances on instrumentation will benefit the field of laparoscopy and improve patient care.

Oophorectomy by natural orifice transluminal endoscopic surgery: feasibility study in dogs

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) represents a potentially less-invasive alternative to conventional or laparoscopic surgery.

OBJECTIVE

Our purpose was to develop a canine oophorectomy model for prospective evaluation of intraoperative complications, surgical stress, and postoperative pain and recovery with NOTES.

DESIGN

Feasibility study.

SETTING

Academic preclinical research.

PATIENTS

Ten healthy female dogs.

INTERVENTIONS

NOTES procedures were performed through gastric access with an electrocautery snare to resect and retrieve the ovaries. The gastrotomy was closed with prototype T-fasteners.

MAIN OUTCOME MEASUREMENTS

Operative time; complications; postoperative pain scores, and nociceptive threshold; surgical stress markers (interleukin-6 [IL-6], C-reactive protein); systemic stress parameters (cortisol, glucose); necropsy evaluation at 10 to 14 days.

RESULTS

The mean operative time was 154 minutes (SD +/- 58 minutes) and no animals died as a result of complications from the procedure. The primary difficulty was incomplete ovarian excision and conversion to an open procedure in 1 dog. Serum glucose concentrations increased after surgery and remained elevated for at least 36 hours. The serum cortisol concentration was transiently increased from baseline at 2 hours after surgery. The serum IL-6 concentration peaked at 2 hours after surgery and returned to the baseline value by 18 hours. The serum C-reactive protein concentration increased significantly from baseline, peaked at 12 hours after surgery, and then slowly declined toward baseline but remained elevated at 72 hours after surgery. Nociceptive threshold measurements indicated increased sensitivity to pain for 2 to 24 hours after surgery. At necropsy, surgical sites were healing uneventfully with no significant damage to surrounding organs, no significant growth on bacterial cultures, and no evidence of peritonitis.

LIMITATIONS

Small number of animals, single center.

CONCLUSIONS

The NOTES approach to oophorectomy in dogs appears to be a reasonable alternative to traditional surgery. Attention must be paid to ensure complete excision of the ovaries.

Laparoscopic incisional hernia repair after solid-organ transplantation

HYPOTHESIS

Laparoscopic incisional hernia repair (LIHR) is efficacious in transplant recipients.

DESIGN

Retrospective review.

SETTING

University hospital.

PATIENTS

Thirty-one transplant recipients who underwent LIHR between July 9, 2004, and October 27, 2005.

MAIN OUTCOME MEASURES

Operative complications and incisional hernia recurrence.

RESULTS

The mean (SD) mesh size required for LIHR was 611 (307) cm2. Median (range) hospital stay was 4 (1-28) days, with follow-up of 589 (22-953) days. Eighteen patients developed a postoperative complication, most frequently seroma formation, which occurred in 13 patients (72%). The mesh size required for LIHR was significantly larger in patients with a postoperative complication (n = 18; 706 [319] cm2 vs n = 13; 480 [244] cm2; P = .04). Seroma formation was not associated with previous open hernia repair, diabetes mellitus, or corticosteroid use. No statistically significant relationship was noted between the transplanted organ and seroma development. There were no post-LIHR wound infections. In 7 patients (23%), hernia recurred.

CONCLUSIONS

Laparoscopic incisional hernia repair in solid-organ transplant recipients is associated with a high rate of seroma formation but minimal long-term morbidity. The recurrence rate after LIHR is equivalent to that after open hernia repair. These results suggest that LIHR is a safe and effective alternative to open repair in this patient population.

Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis

BACKGROUND

Roux-en-Y (RNY) internal drainage has been our primary surgical strategy to definitively treat disconnected duct syndrome in patients after severe acute pancreatitis (SAP). This study compares the results of internal drainage with the results of distal pancreatectomy-splenectomy (DPS) performed in a contemporaneous group of patients.

METHODS

For 5 years (June 1995 to June 2000), 27 consecutive patients with disconnected duct syndrome after SAP were identified: 13 treated with internal drainage and 14 with DPS. Fistula characteristics, operative management, and clinical outcome were analyzed. Comparisons between groups were made with the Student t test and Fisher exact test, with statistical significance defined as P <.05.

RESULTS

Age, sex, etiology of pancreatitis, comorbid diseases, and prior operations were similar between groups. Internal drainage required less operative time (211 +/- 37 vs 269 +/- 88 minutes, P =.04), blood loss (735 +/- 706 vs 2757 +/- 3062 mL, P =.03), and transfusion requirements (0.69 +/- 1.7 vs 4.21 +/- 8.0 units, P =.05). Clinical outcomes--as measured by postoperative complication rate, reoperation rate, fistula recurrence rate, and death rate--were similar between groups.

CONCLUSIONS

RNY internal drainage, when technically feasible, is the best surgical option to treat disconnected duct syndrome after SAP.

Management of chylothorax after thoracoscopic splanchnicectomy

Thoracoscopic splanchnicectomy is a minimally invasive procedure used in the treatment of recalcitrant abdominal pain in patients with chronic pancreatitis or pancreatic carcinoma. Chylothorax, an uncommon complication of thoracoscopic splanchnicectomy, may lead to a protracted, costly hospital course of treatment usually consisting of central venous hyperalimentation, restricted oral intake, and tube thoracostomy. In our series of 25 patients who underwent thoracoscopic splanchnicectomy, 2 developed postoperative chylothorax. Both patients failed conservative management and ultimately underwent operative reintervention, at which time, leaking lymphatics were easily identified and closed using minimally invasive techniques. On the basis of this experience, we advocate early thoracoscopic reintervention in patients with chylothorax after thoracoscopic splanchnicectomy.