Teviah Sachs

See one, do one, and teach none: resident experience as a teaching assistant

BACKGROUNDnTraining of surgical residents depends on graduated autonomy in and out of the operating room. We sought to define trends in operative volume and number of teaching cases in graduating surgical residents over time.nnnMETHODSnWe queried the Accreditation Council for Graduate Medical Education general surgery case log (1999-2012) for all case categories in which graduating chief residents performed a median of 20 or more cases during their training. Median (10th and 90th percentiles) number of cases performed as surgeon chief, surgeon junior and teaching assistant (TA) were analyzed using R(2) for all trends.nnnRESULTSnThe median number of cases performed by graduating chief residents remained stable over time (965-971; R(2)xa0=xa00.01). Surgeon junior cases increased slightly (718-725; R(2)xa0=xa00.07), whereas surgeon chief cases decreased slightly (246-235; R(2)xa0=xa00.08). The most frequently performed cases were in the categories of the large intestine (125 [85,167], biliary (109 [74,167]), and abdominal hernia (99 [67.5,139]). The median number of TA cases decreased by 79% (126-27; R(2)xa0=xa00.34), with the most significant decrease occurring early in the study period (median: 126-22; R(2)xa0=xa00.91). The number of median teaching cases decreased in every category analyzed, with the most pronounced occurring in the categories of thoracic (9-0 [100%]; R(2)xa0=xa00.37) and breast (6-0 [100%]; R(2)xa0=xa00.55). The only categories with a median number of teaching cases >1 in 2012 were the large intestine (5), biliary (4), and abdominal hernia repairs (3).nnnCONCLUSIONSnDespite a relative stability of case volume over time, GSRs are graduating with relatively few cases recorded as TA. Improved opportunities for trainees to take on the role of TA while in residency may lead to improved confidence as surgeons on graduation.

Assessment of open operative vascular surgical experience among general surgery residents

BACKGROUNDnGeneral surgeons have traditionally performed open vascular operations. However, endovascular interventions, vascular residencies, and work-hour limitations may have had an impact on open vascular surgery training among general surgery residents. We evaluated the temporal trend of open vascular operations performed by general surgery residents to assess any changes that have occurred.nnnMETHODSnThe Accreditation Council for Graduate Medical Educations database was used to evaluate graduating general surgery residents cases from 1999 to 2013. Mean and median case volumes were analyzed for carotid endarterectomy, open aortoiliac aneurysm repair, and lower extremity bypass. Significance of temporal trends were identified using the R(2) test.nnnRESULTSnThe average number of carotid endarterectomies performed by general surgery residents decreased from 23.1xa0± 14 (11.6xa0± 9 chief, 11.4xa0+ 10 junior) cases per resident in 1999 to 10.7xa0± 9 (3.4xa0± 5 chief, 7.3xa0± 6 junior) in 2012 (R(2)xa0= 0.98). Similarly, elective open aortoiliac aneurysm repairs decreased from 7.4xa0± 5 (4xa0± 4 chief, 3.4xa0± 4 junior) in 1999 to 1.3xa0± 2 (0.4xa0± 1 chief, 0.8xa0± 1 junior) in 2012 (R(2)xa0= 0.98). The number of lower extremity bypasses decreased from 21xa0± 12 (9.5xa0± 7 chief, 11.8xa0± 9 junior) in 1999 to 7.6xa0± 2.6 (2.4xa0± 1.3 chief, 5.2xa0+ 1.8 junior) in 2012 (R(2)xa0= 0.94). Infrapopliteal bypasses decreased from 8.1xa0± 3.8 (3.5xa0± 2.2 chief, 4.5xa0± 2.9 junior) in 2001 to 3xa0± 2.2 (1xa0± 1.6 chief, 2xa0± 1.6 junior) in 2012 (R(2)xa0= 0.94).nnnCONCLUSIONSnGeneral surgery resident exposure to open vascular surgery has significantly decreased. Current and future graduates may not have adequate exposure to open vascular operations to be safely credentialed to perform these procedures in future practice without advanced vascular surgical training.

Resident and Attending Perceptions of Resident Involvement: An Analysis of ACGME Reporting Guidelines.

OBJECTIVEnFor general surgery residents (Residents) to log an operation, the ACGME requires significant involvement in diagnosis (DX), operation selection (SEL), operation (OPR), preoperative (PRE), and postoperative (POC) care. We compared how residents and attending surgeons (Attendings) perceived residents role in each of these core requirements.nnnDESIGNnResidents and attendings completed surveys postoperatively regarding responsibility for each core requirement on a 5-point Likert scale from Completely Attending to Completely Resident. Significance was determined using Chi-square analysis (p < 0.05) and degree of agreement was calculated using Spearmans rank correlation (rs).nnnSETTINGnBoston Medical Center, Boston, MA (tertiary institution).nnnRESULTSnA total of 302 paired surveys were analyzed. Residents more often performed a significant portion of the later stages of care (DX = 27%, PRE = 29%, SEL = 27%, OPR = 87%, and POC = 84%). Residents completed the majority of each requirement more frequently in operations performed in the acute setting compared to elective operations: DX (70% vs 8%, p < 0.01), PRE (74% vs 10%, p < 0.01), SEL (65% vs 11%, p < 0.01), OPR (100% vs 89%, p = 0.02), POC (100% vs 77%, p < 0.01). Resident participation was inversely related to operational complexity for DX (p < 0.01), PRE (p < 0.01), SEL (p < 0.01), and OPR (p = 0.01). Resident involvement in OPR increased at the end of the academic year (p = 0.05) and when working with junior attendings (<5 years in practice) (p = 0.01). Interpair agreement was greatest for DX (rs = 0.70) and lowest for POC (rs = 0.35). When residents and attendings did not agree in their answers, residents generally overstated their contribution to the DX (68%), PRE (58%), and SEL (64%) but understated their contribution in OPR (63%) and POC (62%).nnnCONCLUSIONSnResidents and attendings demonstrated reliable agreement for most core requirements, but residents were often unable to be involved in all 5 core requirements. Resident involvement was weighted toward later stages of patient care, yet residents often underestimated their contributions. Operational acuity, complexity, and attending experience correlated with resident operative involvement.

Postoperative Venous Thromboembolism in Patients Undergoing Abdominal Surgery for IBD: A Common but Rarely Addressed Problem.

BACKGROUND: Venous thromboembolism after abdominal surgery occurs in 2% to 3% of patients with Crohn’s disease and ulcerative colitis. However, no evidence-based guidelines currently exist to guide postdischarge prophylactic anticoagulation. OBJECTIVE: We sought to determine the use of postoperative postdischarge venous thromboembolism chemical prophylaxis, 90-day venous thromboembolism rates, and factors associated with 90-day thromboembolic events in IBD patients following abdominal surgery. DESIGN: This was a retrospective evaluation of an administrative database. DATA SOURCE: Data were obtained from Optum Labs Data Warehouse, a large administrative database containing claims on privately insured and Medicare Advantage enrollees. PATIENTS: Seven thousand seventy-eight patients undergoing surgery for Crohn’s disease or ulcerative colitis were included in the study. MAIN OUTCOME MEASURES: Primary outcomes were rates of postdischarge venous thromboembolism prophylaxis and 90-day rates of postdischarge thromboembolic events. In addition, patient clinical characteristics were identified to determine predictors of postdischarge venous thromboembolism. RESULTS: Postdischarge chemical prophylaxis was given to only 0.6% of patients in the study. Two hundred thirty-five patients (3.3%) developed a postdischarge thromboembolic complication. Postdischarge thromboembolism was more common in patients with ulcerative colitis than with Crohn’s disease (5.8% vs 2.3%; p < 0.001). Increased rates of venous thromboembolism were seen in patients undergoing colectomy or proctectomy with simultaneous stoma creation compared with colectomy or proctectomy alone (5.8% vs 2.1%; p < 0.001). The strongest predictors of thromboembolic complications were stoma creation (adjusted OR, 1.95; 95% CI, 1.34–2.84), J-pouch reconstruction (adjusted OR, 2.66; 95% CI, 1.65–4.29), preoperative prednisone use (adjusted OR, 1.57; 95% CI, 1.19–2.08), and longer length of stay (adjusted OR, 1.89; 95% CI, 1.41–2.52). LIMITATIONS: This study is limited by its retrospective design. CONCLUSIONS: The use of postdischarge venous thromboembolism prophylaxis in this patient sample was infrequent. Development of evidence-based guidelines, particularly for high-risk patients, should be considered to improve the outcomes of IBD patients undergoing abdominal surgery.

Survival Following Lung Metastasectomy in Soft Tissue Sarcomas

BACKGROUNDnThe most common site of metastasis for soft tissue sarcomas (STSs) is the lung. In patients who are candidates for resection, metastasectomy improves survival. Debate remains, however, on approach and patient selection for surgery.nnnMETHODSnWe retrospectively analyzed demographics, tumor characteristics, peri- and postoperative factors for 53 patients who underwent lung metastasectomy for STS from 1989 to 2013. Disease-free intervals (DFIs) and survival were determined. Kaplan-Meier estimates and log-rank test were used for comparison and survival analyses.nnnRESULTSnMedian overall survival (diagnosis to death or last visit) was 59.9 months (IQR: 118.5), with mean follow-up of 85.3 months (SD: 69.5). Post-lung metastasectomy survival was 82.9%, 52.2%, 28.3%, and 13.3% at 1, 3, 5, and 10 years, respectively. Age at diagnosis of less than 50 years (pu2009=u20090.037), a low pathologic grade (pu2009=u20090.040), and a DFI until metastasis of greater than 13.5 months (pu2009=u20090.007) were significant predictors of improved survival.nnnCONCLUSIONnPatients diagnosed at a younger age with low-grade tumors and those with a longer DFI prior to metastasis diagnosis gain the greatest survival advantage with surgery.

Characterization of Planned and Unplanned 30-Day Readmissions Following Vascular Surgical Procedures.

Objective: Thirty-day readmission is increasingly used as a quality of care indicator. Patients undergoing vascular surgery have historically been at high risk for readmission. We analyzed hospital readmission details to identify patients at high risk for readmission in order to better understand these readmissions and improve resource utilization in this patient population. Methods: A retrospective review and analysis of our medical center’s admission and discharge data were conducted from October 2012 to March 2015. All patients who were discharged from the vascular surgery service and subsequently readmitted as an inpatient within 30 days were included. Results: We identified 649 vascular surgery discharges with 135 (21%) readmissions. Common comorbidities were diabetes (56%), coronary artery disease (40%), congestive heart failure (CHF; 24%), and chronic obstructive pulmonary disease (19%). Index vascular operations included open lower extremity procedures (39%), diagnostic angiograms (35%), endovascular lower extremity procedures (16%), dialysis access procedures (7%), carotid/cerebrovascular procedures (7%), amputations (6%), and abdominal aortic procedures (5%). Average index length of stay (LOS) was 7.48 days (±6.73 days). Reasons for readmissions were for medical causes (43%), surgical complications (35.5%), and planned procedures (21.5%). Reasons for medical readmissions most commonly included malaise or failure to thrive (28%), unrelated infection (24%), and hypoxia/CHF complications (21%). Common surgical causes for readmission were surgical site infections (69%), graft failure (19%), and bleeding complications (8%). Of the planned readmissions, procedures were at the same site (79%), a different site (14%), and planned podiatry procedures (7%). Readmission LOS was on average 7.43 days (±7.22 days). Conclusion: Causes for readmission of vascular surgery patients are multifactorial. Infections, both related and unrelated to the surgical site, remain common reasons for readmission and represent an opportunity for improvement strategies. Improved understanding of readmissions following vascular surgery could help adjust policy benchmarks for targeted readmission rates and help reduce resource utilization.

Analysis of retracted articles in the surgical literature

BACKGROUNDnRetractions of scientific articles represent attempts to correct the literature. Our goal was to examine retracted surgical papers.nnnMETHODSnNCBI PubMed database was queried using the search terms surgery, surg, or surgical and retracted or retraction. Article details were recorded.nnnRESULTSnThere were 184 retracted surgical articles identified from 1991 through 2015. Average retraction time was 3.6 years. General (26%), Cardiac (22%), and Orthopedic (10%) surgery were most common. Reasons for retraction were duplication (35.3%), Institutional Review Board violations (18.5%), falsified data (14.7%), data errors (9.8%), author dispute (8.2%), plagiarism (7.6%), copyright violations (2.2%), financial disclosure violations (0.5%), and consent (0.5%). No reason for retraction was given in 8.7% of cases. Median IF was higher for administrative than content-related retraction reasons (3.0 vs. 2.0, Pxa0<xa00.01). A paywall, requiring a subscription to read, restricted access to 23.4% of retraction notices.nnnCONCLUSIONSnArticle retractions occur across all fields of surgery for various reasons, both administrative and content-related. The majority of surgical retraction notices have a reason for retraction listed and do not require payment to read.

Presentation and Survival of Gastric Cancer Patients at an Urban Academic Safety-Net Hospital

IntroductionGastric cancer is decreasing nationally but remains pervasive globally. We evaluated our experience with gastric cancer at a safety-net hospital with a substantial immigrant population.MethodsDemographics, pathology, and treatment were analyzed for gastric adenocarcinoma at our institution (2004–2017). Chi-square analyses were performed for dependence of staging on demographics. Survival was evaluated with Kaplan-Meier and Cox regression analyses.ResultsWe identified 249 patients (median age 65xa0years). Patients were predominantly born outside the USA or Canada (74.3%), non-white (70.7%), and federally insured (71.4%), and presented with late-stage disease (52.2%). Hispanic ethnicity, Central American birthplace, Medicaid insurance, and zip code poverty >u200920% were associated with late-stage presentation (all pu2009<u20090.05). Univariate analyses showed decreased survival for patients with late-stage disease, highest zip code poverty, and ageu2009≥u200965 (all pu2009<u20090.05). On multivariate analysis, survival was negatively associated with late-stage presentation (HR 4.45, pu2009<u20090.001), ageu2009≥u200965 (1.80, pu2009=u20090.018), and H. pylori infection (2.02, pu2009=u20090.036).ConclusionHispanic ethnicity, Central American birthplace, Medicaid insurance, and increased neighborhood poverty were associated with late-stage presentation of gastric cancer with poor outcomes. Further study of these populations may lead to screening protocols in order to increase earlier detection and improve survival.

Resident and attending assessments of operative involvement: do we agree?

BACKGROUNDnGeneral surgery residents (GSRs) operative experience likely improves with increased involvement. We explored GSRs and attending surgeons (ASs) perceptions of GSRs operative roles.nnnMETHODSnGSRs and ASs completed surveys postoperatively regarding responsibility for several operative tasks (incision opening, dissection of minor and major structures, major suturing, and incision closure). Analyses used chi-square test (P < .05) and Spearmans rank correlation (ρ).nnnRESULTSnA total of 151 pairs of surveys were collected. Interpair agreement on GSRs involvement varied for each category (ρ range: .30 to .67), and GSRs underestimated their involvement for every step. GSRs frequently performed the majority of each task (range: 86% to 97%). Decreasing operational complexity, acute operations, and junior ASs (<5 years in practice) were each associated with increased agreement and GSRs involvement in operative tasks.nnnCONCLUSIONSnGSRs involvement was extensive, and agreement with ASs was high overall. Some discrepancies remain in several categories based on operational complexity, acuity, and ASs experience.

The effect of statin use and intensity on stroke and myocardial infarction after carotid endarterectomy

OBJECTIVEnStatin use in patients with cerebrovascular disease undergoing carotid endarterectomy (CEA) has been advocated for prevention of stroke and cardiovascular events. However, the effect of statin therapy on long-term outcomesxa0after CEA still needs to be delineated.nnnMETHODSnOptumLabs Data Warehouse, a comprehensive, longitudinal, real-world dataset with deidentified lives across claims and clinical information, was used to analyze the rates of stroke, myocardial infarction (MI), and statin use after CEA. Both duration and intensity of statin therapy were investigated.nnnRESULTSnThere were 21,277 patients who underwent CEA from 2004 to 2014. The average age was 70xa0years, and 59.4% were male. The average Elixhauser index score was 4.2. Follow-up was a median of 2.4xa0years (range, 0.2-10.0xa0years). Long-term statin use was observed in 57.4%. Statin distribution included atorvastatin 35%, simvastatin 35%, pravastatin 11%, rosuvastatin 10%, and lovastatin 7%. The 30- and 90-day stroke rates were 1.3% and 2.2%, and the MI rates were 0.5% and 1.1%, respectively. Postoperative statin use was associated with a lower perioperative stroke rate at 30xa0days (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.61-0.98; Pxa0= .036) and 90xa0days (OR, 0.75; 95% CI, 0.62-0.90; Pxa0= .002). Postoperative statin use did not show a protective effect on 30-day or 90-day MI rates (OR, 1.01; 95% CI, 0.69-1.46; Pxa0= .975) or 90-day MI rates (OR, 0.85; 95% CI, 0.66-1.11; Pxa0= .213). High-intensity statin use when compared with standard therapy did not affect 30-day stroke outcomesxa0(OR, 0.96; 95% CI, 0.60-1.5; Pxa0= .847) or 90-day stroke outcomes (OR, 1.06; 95% CI, 0.74-1.5; Pxa0= .762); or 30-day MI (OR, 0.81; 95% CI, 0.39-1.68; Pxa0= .576) or 90-day MI (OR, 1.25; 95% CI, 0.79-1.96; Pxa0= .339). Statin use was independently protective against long-term stroke (hazard ratio, 0.82; 95% CI, 0.75-0.91; Pxa0< .001) and MI (hazard ratio, 0.83; 95% CI, 0.75-.92; Pxa0< .001).nnnCONCLUSIONSnPostoperative statin use among patients undergoing CEA was associated with a decreased risk of stroke at 30 and 90xa0days, as well as a long-term protective effect against MI and stroke. High-intensity statin use compared with standard use did not show an effect on outcomes of stroke or MI at 30 and 90-days after CEA.