Case Volume Research Articles

Determinants of Salary Variation and the Gender Pay Gap: A Survey of the American Association of Hip and Knee Surgeons (AAHKS) Surgeon Member Workforce

BackgroundThe increased emphasis on reimbursement, diversity, and burnout in hip and knee arthroplasty necessitates a foundational understanding of the surgeon workforce. The purpose of the study was to cross sectionally survey a representative sample of the AAHKS surgeon membership on the subject of salary, practice patterns, and demographic factors to establish a baseline framework for future advocacy efforts and initiatives. MethodsAn online survey was sent to AAHKS members between December 20, 2022 and January 19, 2023. Surgeon demographic data, experience, practice geography and type, and annual case volume were solicited. Univariate and multivariate analyses were performed to describe the association of respondent characteristics with reported salary directly from patient care, as well as indirect revenue streams. ResultsA total of 730 AAHKS members responded to the survey. The largest proportion of surgeons performed 251-400 cases annually (36%); 81% (n = 592) and 93% (n = 679) of respondents identified as white and male, respectively. Case volume was the primary determinant for surgeon salary, followed by practice type, years in practice, and gender. After controlling for confounding variables, multivariate analyses revealed the direct salary of women surgeons was 14.4% less than men [95% confidence interval, 0.4%-28.3%]. When considering indirect revenue, the gender pay gap widened. Salary was not associated with reported hours worked per week, geographic location, or ethnicity. ConclusionsSalary is an important but underdiscussed subject that reflects the realities of our culture and value system in medicine. A direct relationship between salary and modifiable variables like case volume is clear. However, after controlling for confounders, women arthroplasty surgeons still earn 86 cents on the dollar compared to their male colleagues from direct surgical revenue.

Left Atrial Size and Strain in Hypertensive Children Compared to Age-, Sex-, and Race/Ethnicity-Matched Controls.

Left atrial (LA) volume and peak longitudinal strain (LA strain) are indicators of left ventricular (LV) diastolic function in adults, but little is known about LA volume and strain in pediatric patients with hypertension (HTN). We evaluated LA volume and strain in pediatric cases with HTN compared to age-, sex-, and race/ethnicity-matched controls. This was a retrospective matched case-control study of patients who presented to the HTN clinic at CHOP from 12/2011 to 9/2018. Coarctation of the aorta, cardiomyopathy or heart transplantation cases were excluded. HTN was defined by an abnormal ambulatory blood pressure result. LA volume was measured by biplane area-length method and indexed to body surface area (BSA). LA strain and strain rate were measured using TOMTEC® software. Left ventricular mass index (LVMI) was measured by M-mode and the 5/6 area-length method indexed to height2.7. LV global longitudinal strain (LV GLS) was measured during the echocardiographic examination on the GE ultrasound machine for cases and offline using TOMTEC® software for controls. Measurements were compared using Chi-square, McNemar, or Wilcoxon signed rank tests. We included 47 cases and 47 controls. There was no difference in LA volume z-scores (-1.9 vs. -0.9, p = 0.068), LA strain (37.8% vs. 38.0%, p = 0.735) or LA strain rate (1.4 vs. 1.5, p = 0.852) in cases compared to controls. LVMI by M-mode and 5/6 area-length method was higher in cases compared to controls (40.0 vs. 33.7g/m2.7, p < 0.001 and 29.9 vs 24.4g/m2.7, p = < 0.001, respectively). LV GLS was decreased (less negative) in cases compared to controls. In summary there was no difference in LA volume or LA strain in cases compared to controls. In cases, LVMI was significantly elevated and LV GLS was significantly decreased, which may be the first response to HTN, prior to affecting LA size.

HPB SO53 - Implementation of High Volume-Low Complexity 'GIRFT' lists for laparoscopic cholecystectomy

Abstract Background Waiting times for elective surgery have risen steadily since 2010, with particularly sharp increases after the Covid pandemic. There have been several initiatives to improve theatre productivity and increase operative numbers and these are broadly encompassed within GIRFT standards and the development of the concept of a High Volume-Low Complexity list. Current GIRFT standards recommend six laparoscopic cholecystectomies on an all-day operating list. This study aimed to describe the development and implementation of these lists within out district general hospital setting and outline the key barriers and solutions for other units to learn from. Method All patients on the waiting list for laparoscopic cholecystectomy were assessed and screened by a panel of consultant surgeons to assess suitability for a HVLC list. Theatre staff, anaesthetists and surgeons were widely consulted within local focus groups and a novel method of remuneration for additional work was developed: a 'cost-per-case (CPC)' remuneration structure was introduced (in contrast to standard remuneration by session time) to ensure productivity and high quality surgery. Operations were carried out on weekend lists in a dedicated accredited Elective Surgical Hub and staff were able to finish the day when all operations were completed. Results CPC lists took place from August 2023 to May 2024. All lists had six laparoscopic cholecystectomies or eight hernia repairs (or a combination) in line with GIRFT standards. Overall 124 cholecystectomies were performed and 119 were completed on a day case basis. The remaining 5 patients had a single night stay. There were no returns-to-theatre or major morbidity. All lists had started by 830AM and the latest finish time throughout the study period was 1525PM. The utilisation of CPC lists contributed to waiting times falling dramatically from over 52 weeks to 28 weeks by the end of the study period. Conclusion By utilising a novel form of remuneration, based on volume of work completed rather than time, we were able to maximise productivity without compromising safety whilst developing employment conditions that encouraged colleagues to perform additional work. Key facets to successful implementation include appropriate screening of cases, allowing staff to leave when the work is completed (rather than have to wait till the end of the day) and standardising equipment and kit to reduce wastage and turnaround time between cases. These lessons can be implemented in any surgical unit to improve productivity and increase volume of cases performed.

EGS SO12 - A District General Hospital experience for setting up a "Hot Gallbladder" pathwayBackground

Abstract Background This project details a quality improvement initiative at Chesterfield Royal Hospital (CRH) to establish a “Hot Gallbladder” pathway (HGP) amidst immense NHS pressures. Before this service, CRH performed emergency cholecystectomies solely in an NCEPOD emergency theatre shared with other specialities, resulting in low case volumes, unpredictability, long patient waiting times with extended inpatient stays. The new service now dedicates two half-day lists per week to suitable patients admitted acutely and managed by five dedicated surgeons. Method This quality improvement project involves two separate yearly retrospective audits analysing patients who underwent gallbladder removal through the HGP in 2022 and 2023 at CRH. The primary objective was to assess the HGP's efficacy in terms of the number of cases performed and list completion (2 cases per half-day list). The secondary objective evaluatedadherence to the HGP protocol, appropriate patient selection, indications, and completion of adequate pre-operative investigations. The final objective assessed the HGP's safety by comparing incidence of complications and length of stay with patients undergoing cholecystectomy on the emergency NCEPOD list. Results 268 patients had gallbladder removal through the HGP and 84 cases in the emergencyNCEPOD theatre. The median age was 51, with a 3:1 female-to-male ratio. 75% of patients were managed through surgical ambulatory care. The HGP saw a 30% increase in cases and list completion rates rose from 41% to 61% in one year. NCEPOD emergency theatre usage reduced to 37%. All patients had appropriate indications and pre-operative investigations. 70% of cholecystitis patients were operated within 7 days. The HGP had a lower complication rate (6.2%) compared to emergencies (8%) and shorter post-operative stays (2 days vs 2.5 days). Conclusion This project demonstrates the benefits of establishing a HGP in a DGH. Inpatient stays were significantly reduced as 75% of patients were managed through the ambulatory carepathway. This led to financial benefits and greater patient satisfaction. Timely operations by dedicated surgeons resulted in a lower complication rate and shorter length of stay. The pathway increased the number of cases performed. The reduction in emergency theatre cases allowed better care for patients requiring emergency theatre access.

The Relationship Between Hospital Safety-Net Burden on Outcomes for High-Volume Thyroid Cancer Surgeons.

Background: Higher center and surgeon volume correspond to better outcomes for patients with thyroid cancer. This study aims to investigate how a hospital's safety-net burden, the proportion of a hospital's patients who are insured by state Medicaid plans or are uninsured, influences the outcomes of high-volume (HV) surgeons. Methods: We performed a retrospective cohort study of all patients who underwent surgery for thyroid cancer in California from 1999 to 2017. We stratified treating facilities by the proportion of Medicaid-type and indigent payors into safety-net burden quartiles. We compared the perioperative and oncologic outcomes of HV surgeons (annual case volume ≥10) for patients undergoing total thyroidectomy across safety-net burden quartiles. A mixed-effects regression model controlled for surgeon random effects and fixed effects of patient and tumor characteristics. Results: Our sample comprised 42,347 patients (78% female, median age 50), of whom 13,848 (32%) were treated by HV surgeons (n = 276). Compared to patients of lower-volume surgeons, patients of HV surgeons were more likely to be White, from the upper quartiles of socioeconomic status and well insured (all p < 0.001). HV surgeons in each hospital's safety-net burden quartile displayed similar case number distributions. Compared to patients treated by HV surgeons at Q1 (lowest safety-net burden) hospitals, those treated by HV surgeons at Q4 (highest safety-net burden) hospitals had higher absolute risks of endocrine complications (+7%, p = 0.007), airway complications (+6%, p = 0.004), disease-specific mortality (+1.3%, p = 0.046), and all-cause mortality during the study period (+3%, p = 0.046) in multivariable analysis. Conclusion: The performance of HV thyroid cancer surgeons differs by a hospital's safety-net burden, with patients treated at high safety-net burden hospitals experiencing higher rates of operative complications, disease-specific mortality, and all-cause mortality. Having a HV surgeon alone may be insufficient to provide optimal short- and long-term outcomes for patients with thyroid cancer.

No difference in surgical time and total theatre time between robotically assisted and computer assisted total knee arthroplasty

IntroductionA number of studies have demonstrated a significant reduction of surgical time for robotically assisted surgery (RAS) total knee arthroplasty (TKA) after the learning curve between 6 and 43 cases. It is unknown if the logistics of RAS produce a longer total theatre time since published literature only reflects the surgical time. It is also unknown how RAS surgical and total theatre times compare with computer assisted surgery (CAS) TKA.MethodsThis is a prospective study of 524 consecutive patients undergoing a CAS or a RAS TKA using the same cementless implant. We recorded age, sex, body mass index (BMI), incision time of the first case, total surgical time, total theatre time, length of stay and 90-day complication and readmission rate.ResultsDuring the study period, 205 CAS and 199 RAS TKA were performed. There was no difference at baseline in age (p = 0.546), sex (p = 0.920) or BMI (p = 0.791). Surgical time for CAS was 78.3 (± 22.2) min and for RAS was 80.1 (± 25.7) min, p = 0.451. Total theatre time for CAS was 117.4 (± 27.8) min and 119.3 (± 30.7) min for RAS, p = 0.515. There was no difference in length of stay (p = 0.674), 90-day complication (p = 0.530) or readmission rate (p = 0.930). There was a difference in skin-incision average time for the first case (p = 0.022).ConclusionsAlthough theatre set-up for the first case is 5 min longer, RAS-TKA does not prolong the surgical time or total theatre time when compared with CAS-TKA. There was no reduction in case volume since the introduction of robotics.Level of evidenceIII.

Surgical Training Pathways in the United Kingdom and the United States: Lessons for Resource-Limited Settings From High-Income Countries.

Background Surgical training is a critical component of healthcare, especially in high-income countries such as the United Kingdom (UK) and the United States (US), which have established distinct, well-organised training frameworks. Comparing these systems provides valuable insights that may enhance global surgical education, particularly in low- and middle-income countries, where training and retaining proficient surgeons are considerable challenges. Methodology This comparative study examines the surgical training systems in the UK and the US, focusing on key aspects, including training structure, competency-based assessments, and work-hour regulations. Data were sourced from regulatory organisations such as the General Medical Council, the Royal College of Surgeons, the Accreditation Council for Graduate Medical Education, and the American Board of Surgery. The analysis explores how elements of these models might be adapted to support sustainable surgical education frameworks in resource-limited environments. Ethical approval was not required due to the use of publicly accessible data and no patient involvement. Results The UK and US surgical training systems differ substantially in their structure, training duration, and specialisation timing. The UK employs a tiered approach, offering generalist experience before specialisation, while the US favours early specialisation directly after medical school. Both systems implement competency-based evaluations, though the US system places a greater emphasis on case volume and procedural exposure. Work-hour regulations also vary, with the UK capping weekly hours at 48 under the European Working Time Directive, compared to an 80-hour maximum in the US, which results in differing levels of trainee satisfaction and burnout rates. Conclusions The competency-based assessments in both the UK and the US offer adaptable frameworks for resource-limited settings. The phased training approach in the UK is well-suited for environments requiring versatile surgeons capable of handling a wide range of cases. By implementing these adaptable elements, along with cost-effective training innovations such as simulation tools, e-learning platforms, and international partnerships, resource-constrained regions can foster a sustainable, skilled surgical workforce. These insights offer pathways to improve healthcare outcomes and equity globally by enhancing surgical capacity in regions with limited resources.

Institutional case volumes of thyroidectomies in Brazil and the impact of the COVID-19 pandemic: insights from a national database.

Providing widespread access to thyroidectomies while consolidating services in high-volume centers is a significant challenge in healthcare. In this context, from a national perspective, we aimed to analyze the impact of the COVID-19 pandemic on the institutional case volumes of thyroid surgery in Brazil. We analyzed retrospective thyroidectomy data from the Department of Informatics of the Unified Health System (Datasus), stratifying institutions into low-volume, intermediate-volume, and high-volume centers (<10, 10-100, and >100 thyroidectomies/year, respectively). We assessed the differences in absolute numbers and percentages of thyroidectomies performed during the pandemic years (2020-2022) compared with the pre-pandemic year (2019). Differences in the proportion of institutions based on case volumes from 2019 to 2022 were assessed using Cochran's Q test. In 2019, 556 Brazilian institutions performed 15,331 thyroidectomies. Of these, 46.4% were categorized as low-volume, 48.4% as intermediate-volume, and 5.2% as high-volume institutions, accounting for 5.5%, 61.4%, and 33.1% of the thyroidectomies, respectively. Compared with 2019, the volume of thyroidectomies was lower by 41.2% in 2020, 37.0% in 2021, and 12.8% in 2022. When analyzing the proportions of institutions that maintained their pre-pandemic case volume in the first pandemic year, the intermediate and high-volume institutions experienced reductions of 34.9% (p < 0.001) and 58.6% (p < 0.001), respectively, while low-volume institutions presented a 4.3% reduction (p = 0.081). The COVID-19 pandemic disrupted the landscape of thyroidectomies in Brazil, particularly affecting intermediate-volume and high-volume institutions, while low-volume institutions showed greater resilience.

Institution-level Patterns of Care for Early-stage Oropharynx Cancers in the United States.

The adoption of transoral robotic surgery and shifting epidemiology in oropharyngeal squamous cell cancer have stimulated debate over upfront and adjuvant treatment. Institutional variation in practice patterns can be obscured in patient-level analyses. We aimed to characterize institutional patterns of care as well as identify potential associations between patterns of care and survival. This was a retrospective cohort study of patients identified from 2004-2015 in the National Cancer Database. We analyzed 42,803 cases of oropharyngeal squamous cell cancer Stage cT1-2N0-2bM0 (AJCC 7th edition) treated with curative intent surgery and/or radiotherapy. We defined facility-4-year periods to account for changing institutional practice patterns. The 42,803 patients were treated within 2578 facility-4-year periods. We assessed institutional practice patterns, including the ratio of upfront surgery to definitive radiotherapy, case volumes, use of adjuvant therapies (radiotherapy or chemoradiotherapy), and margin positivity rates. Survival associations with institutional practice patterns were estimated with Cox regression. The ratio of upfront surgery to definitive radiotherapy ranged from 80-to-1 to 1-to-23. The institution-level median rate of adjuvant radiotherapy was 69% (IQR 50%-100%), adjuvant chemoradiotherapy was 44% (IQR 0%-67%), and margin-positive resection was 33% (IQR 0%-50%). On patient-level MVA, worse overall survival was not significantly associated with institutional case volume, adjuvant radiotherapy, or adjuvant chemoradiotherapy utilization. High rates of multimodal therapy and positive margins underscore the importance of multidisciplinary care and highlight variable patterns of care across institutions. Further work is warranted to explore indicators of high-quality care and to optimize adjuvant therapy in the HPV era.

A Retrospective Analysis of Jordan's National COVID-19 Call Center: Operations, Effectiveness, and Lessons Learned.

Contact tracing has been a cornerstone of non-pharmaceutical interventions to control the COVID-19 epidemic, with highly mixed effectiveness internationally. In Jordan, the Ministry of Health (MOH) collaborated with the Jordan Nurses and Midwives Council and the USAID Local Health System Sustainability Project to set up a call center for contact tracing of COVID-19. This study described the operation and assessed the effectiveness of Jordan's COVID-19 call center activities in reaching COVID-19 cases and their contacts. A retrospective observational design was conducted using data from all calls made by the COVID-19 call center cases between November 2020 and April 2022. Data were collected from initial and follow-up calls to PCR-confirmed COVID-19 cases and their contacts. Data on socio-demographics, symptoms, and contact tracing activities were recorded. The study focused on key outcomes, including call success rates, the number of cases and contacts reached, and the role of different detection modes in identifying cases. During the study period, the call center attempted to contact 1,027,911 COVID-19 cases, successfully reaching 802,525 cases (78.1%). Follow-up calls were made to 1,126,334 cases, with a success rate of 74%. The call center appeared particularly valuable during the initial period of the pandemic until it was overwhelmed by the significantly more transmissible Omicron variant of the virus. Two weaknesses were identified: gaps in reaching non-Jordanian citizen cases and difficulty in keeping up with case volume during the Omicron wave of February-March 2022, when reported cases peaked at over 20,000 per day. One-third of all reached cases said that they had been referred for testing through contact tracing. Contact tracing activities led by the MOH were instrumental in identifying new cases, optimizing resource allocation, improving surveillance and data systems, targeting vulnerable population, and supporting mitigation strategies to combat the COVID-19 pandemic in Jordan.

Case Volume Is Not Associated With Outcomes After Adrenalectomy Performed by Urologic Surgeons.

Our goal was to compare outcomes of adrenalectomy performed by low-volume and high-volume academic urologists with extensive experience in renal surgery. A single-center retrospective review identified patients undergoing adrenalectomy by urologists from 2009 to 2023. Data were gathered on demographics, tumor characteristics, surgeon volume, surgical outcomes including length of procedure, estimated blood loss, length of stay, and complications identified by the Clavien-Dindo complication classification system. Bivariable and multivariable analyses adjusting for BMI, size of mass, age, and surgical approach compared outcomes between low- and high-volume adrenalectomy surgeons. A total of 304 adrenalectomies were performed by 7 urologic surgeons during the study period. One surgeon was high volume, with an average of 15 adrenalectomies per year during the study period. The remaining 6 surgeons ranged from < 1 to 4 adrenalectomies per year on average during the study period and were considered low volume. On multivariable analysis, the rate of any complication was found to be significantly different between the groups (5.3% vs 13.5%, P = .01). However, on analysis of Clavien 3 or higher complications, the rate was not found to be different (1% vs 4%, P = .22). Procedure time (130 vs 134 minutes, P = .33), estimated blood loss (30 vs 50 mL, P = .86), positive margin rate (11% vs 7%, P = .35), and length of stay (2 days vs 2 days, P = .22) were not different when the surgery was performed by a high-volume or low-volume urologist. Surgical volume may not affect outcomes of adrenalectomy when performed by urologists experienced in retroperitoneal surgery at a high-volume, specialized center.

High-Volume Hospital Had Lower Mortality of Severe Intracerebral Hemorrhage Patients.

Intracerebral hemorrhage (ICH) accompanies higher mortality rates than other type of stroke. This study aimed to investigate the association between hospital volume and mortality for cases of ICH. We used nationwide data from 2013 to 2018 to compare high-volume hospitals (≥32 admissions/year) and low-volume hospitals (<32 admissions/year). We tracked patients' survival at 3-month, 1-year, 2-year, and 4-year endpoints. The survival of ICH patients was analyzed at 3-month, 1-year, 2-year, and 4-year endpoints using Kaplan-Meier survival analysis. Multivariable logistic regression analysis and Cox regression analysis were performed to determine predictive factors of poor outcomes at discharge and death. Among 9086 ICH patients who admitted to hospital during 18-month period, 6756 (74.4%) and 2330 (25.6%) patients were admitted to high-volume and low-volume hospitals. The mortality of total ICH patients was 18.25%, 23.87%, 27.88%, and 35.74% at the 3-month, 1-year, 2-year, and 4-year, respectively. In multivariate logistic analysis, high-volume hospitals had lower poor functional outcome at discharge than low-volume hospitals (odds ratio, 0.80; 95% confidence interval, 0.72-0.91; p<0.001). In the Cox analysis, high-volume hospitals had significantly lower 3-month, 1-year, 2-year, and 4-year mortality than low-volume hospitals (p<0.05). The poor outcome at discharge, short- and long-term mortality in ICH patients differed according to hospital volume. High-volume hospitals showed lower rates of mortality for ICH patients, particularly those with severe clinical status.

Impact of Surgeon Volume on Perioperative Complications and Survival to Total Hip Arthroplasty Following Femoral Head Core Decompression

Introduction: Core decompression is a minimally invasive procedure considered in the treatment of early-stage femoral head osteonecrosis. This procedure is theorized to relieve vascular pressure and promote angiogenesis. Although a less invasive procedure, there are considerations related to learning curve, technique variations, etc. that may affect postoperative complications and longer term adverse events. Methods: Adult patients who underwent core decompression with a diagnosis of femoral head osteonecrosis were identified in the 2010-Q3 2021 PearlDiver M157 database. Core decompression surgeon volumes over the entire study period were assessed and divided into ranges: low (&lt;5 procedures), medium (5 ≤ x ≤ 19 cases), and high (&gt;19 cases) volumes. A 1:1:1 match based on age, sex, and Elixhauser Comorbidity Index was completed. Rates of 90-day complications were compared with univariable and multivariable analyses. Survival to total hip arthroplasty (THA) and to subsequent hip fracture at both 2 and 5 years were compared by Kaplan-Meier survival analysis. Results: The low-volume, medium-volume, and high-volume surgeon groups made up 87.5%, 11.9%, and 0.2% of core decompression volume, respectively. This was indicative of 6333 patients undergoing core decompression, and matching based on the surgeon-volume category led to 486 patients per group. No statistically significant differences were observed in shorter term complications and survival to THA or hip fracture at 2 or 5 years. Conclusion: Core decompression is a treatment option often considered for early-stage osteonecrosis. Critically, no differences were found in rates of any assessed complications between the surgeon-volume matched cohorts. These findings suggest that core decompression is a relatively safe procedure for surgeons of varying volume with this technique. Furthermore, this study suggests that higher volume surgeons are not conducting the procedure with expanded indications that might result in greater rates of conversion to THA.

Cancer center case volume is associated with differences in the effectiveness of neoadjuvant chemotherapy for advanced-stage epithelial ovarian cancer

Cancer center case volume is associated with differences in the effectiveness of neoadjuvant chemotherapy for advanced-stage epithelial ovarian cancer

The Relationship Between Surgeon Volume and Major Surgical Complications After Total Shoulder Arthroplasty: An Evaluation of 3177 US Orthopedic Surgeons.

Total shoulder arthroplasty (TSA), which includes anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA), is a technically demanding procedure and limited data exist on the relationship between case volume and complications. We sought to identify volume thresholds for TSA, aTSA, and rTSA at which risk of a major surgical complication decreased and to compare complications of patients treated by high-volume surgeons with those of patients treated by low-volume surgeons. Primary, elective TSAs (aTSA and rTSA) from January 1, 2016, to December 31, 2019, were identified in the Premier Healthcare Database. Multivariable logistic regression with restricted cubic splines modeled the relationship between annual TSA, aTSA, and rTSA surgeon volume and 90-day risk of major surgical complications. The 90-day complications of patients treated by high- and low-volume surgeons were compared. From 2016 to 2019, 3177 surgeons performed 78,639 TSAs. Increasing annual volume was associated with decreasing major surgical complication risk (thresholds: 50 TSAs, 25 aTSAs, and 36 rTSAs). High- and low-volume surgeons performed 24,595 and 54,044 TSAs, respectively. Patients of high-volume surgeons had lower risk of major surgical complications (adjusted odds ratio [aOR], 0.69; 95% CI, 0.56-0.84), myocardial infarction (aOR, 0.59; 95% CI, 0.36-0.97), and readmission (aOR, 0.71; 95% CI, 0.62-0.81). Importantly, 74.9% of high-volume and 93.0% of low-volume surgeon-year units had major surgical complication rates below the mean of all recorded surgeons. While most high- and low-volume surgeons had major surgical complication rates below the cohort average, increasing TSA volume was associated with a decreased risk of complications. [Orthopedics. 202x;4x(x):xx-xx.].

Can optical evaluation distinguish between t1a and t1b esophageal adenocarcinoma: an international expert inter-observer agreement study.

While piecemeal endoscopic mucosal resection (EMR) for T1a oesophageal adenocarcinoma is acceptable, enbloc-R0 excision is advocated for T1b disease as it may offer a potential cure and mitigate recurrence. Thus, distinguishing between T1a and T1b disease is imperative under current treatment paradigms. We sought to ascertain whether expert Barrett's endoscopists were able to make this distinction based on optical evaluation. Sixty sets of endoscopic images of histologically confirmed high grade dysplasia (HGD), T1a and T1b disease (n=20 for each) were compiled from consecutive patients at a single institution. Each set contained four images, and were standardized to include an overview, a close-up in high-definition white light, a near-focus magnification image, and a narrow-band image. Experts were invited to predict histology for each set. 19 experts from 8 countries (Australia, USA, Italy, Netherlands, Germany, Canada, Belgium, and Portugal) participated. The majority had been practicing for >20 years, with a median annual case volume for Barrett's EMR of 50 (IQR 18-75), and Barrett's ESD of 25 (IQR 10-45). Oesophageal adenocarcinoma (T1a/b) could be distinguished from HGD, with a pooled sensitivity of 89.1% (95% CI:84.7-93.4. When predicting T-stage for T1b adenocarcinoma cases, pooled sensitivity was 43.8% (95% CI:29.9-57.7). Fleiss' kappa was 0.421 (95% CI:0.399-0.442, P<0.001), indicating fair-to-moderate agreement. Expert Barrett's endoscopists can reliably differentiate T1a/T1b oesophageal adenocarcinoma from HGD. Although there is fair-to-moderate agreement for T-staging, T1b disease cannot be reliably distinguished from T1a disease. This may have implications on clinical decision making and selection of endoscopic treatment methods.

Assessing Neurosurgery Training: Accreditation Council for Graduate Medical Education Case Minimums Versus Surgical Autonomy.

The Accreditation Council for Graduate Medical Education (ACGME) requires neurosurgery residents to reach a set number of cases in specified procedure types (case minimums) before graduation and mandates completion of Milestones. We used the Surgical Autonomy Program, a validated method of autonomy-based resident evaluation, to determine the number of cases it took for residents to become competent and compared these with the ACGME case minimums. We collected data from neurosurgery residents at Duke University on 7 procedures (tumor craniotomy, trauma craniotomy, ventriculoperitoneal shunt, anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), discectomy/laminectomy, and posterior thoracolumbar spinal fusion [PSF]). We defined competency as being graded at the highest autonomy level in the Surgical Autonomy Program by attending neurosurgeons for the first and second time and determined the case volume on the ACGME case log when these were achieved. These results were analyzed with summary statistics. The median case volume among residents (N = 4-8) for the first and second competency rating (and ACGME minimum) for each procedure type was found to be: tumor: 44.5 and 64.5 (min. 60), trauma: 21 and 30 (min. 60), ventriculoperitoneal shunt: 11.3 and 13 (min. 20), ACDF: 30 and 32.5 (min. 20), PCF: 24 and 40 (min. 30), discectomy/laminectomy: 28 and 36 (min. 30), and PSF: 51 and 54 (min. 30). We found variation in the case numbers to reach competency and that for some procedures (tumor, ACDF, PCF, discectomy/laminectomy, and PSF), most residents required more cases than the ACGME case minimums to achieve competency. The ACGME case minimums may not accurately reflect the number of cases required for neurosurgical residents to reach competency. To promote trainee-centered education, individualized, competency-based evaluation systems may be better determining readiness for graduation, including a system that builds off the established ACGME Milestones.

Surgical training trends in the Americas: A cross-continental assessment of minimally invasive surgery and open surgery among surgical trainees.

Minimally invasive surgery (MIS) has become standard of care in many high-income countries, but its adoption in low- and middle-income countries (LICs/MICs) has been impeded by resource- and training-related barriers. We hypothesized that trainees in MICs perform MIS procedures less often, and that as procedure complexity increases, the rate of MIS decreases. A 22-question survey, distributed to representative leaders across Latin America, collected country-specific graduating trainee case requirements and volumes for four index procedures (cholecystectomy, appendectomy, inguinal hernia repair, colectomy) using MIS or open surgery (OS). USA data was obtained from the Accreditation Council for Graduate Medical Education. Kruskal-Wallis and Mann-Whitney U tests were performed to determine whether the rate of MIS differed across all countries, procedure complexity classes, and high income countries (HICs)/MICs. Seven experts (70% response rate) completed the survey, representing: Brazil, Chile, Ecuador, Guatemala, Mexico, Panama, and Paraguay. The percentage of MIS completed by trainees varied with mean and interquartile ranges as follows: cholecystectomy (60%±54%), appendectomy (41%±69%), inguinal hernia repair (19%±23%), colectomy (16%±29%). There was a significant difference in mean MIS experience across the eight countries (H=17.6, p=0.014) and between most complex and least complex procedures (p=0.039). No difference was found between MICs and HICs (p=0.786). We found a significant difference of general surgery trainee exposure to MIS versus OS across the Americas, but the difference was not significantly associated with World Bank Income Groups. Different trainee experiences with MIS and OS may highlight an opportunity for international and bidirectional collaboration.

Resident performance and program perception following merger of surgical residencies

PurposeThe primary objective of this study was to gauge resident and faculty sentiments surrounding a general surgery program merger between two programs, and to assess the effect on workplace morale and productivity. Secondarily, the authors sought to objectively examine the impact program expansion had on in-service training exam results and operative volumes.MethodsThis was a single-center, prospective, observational study that evaluated surgical resident and faculty feedback pertaining to the merger of two regional general surgery residency programs. The survey utilized the Likert scale at merger onset and post-merger to gather responses from residents and faculty from July 2020 to August 2021. Secondary outcomes evaluated case volume and ABSITE performance pre- and post-merger.ResultsA total of 27 residents and 31 faculty participated in the initial survey. The merger onset and post survey investigation found that there was increased workplace efficiency (78% onset, 96% post; p = 0.004), and increased comfort with effectively triaging patients (41% onset, 83% post; p = 0.001). Satisfaction levels regarding research infrastructure and mentorship also increased significantly (63% onset, 83% post; p = 0.03). ABSITE performance and operative volumes were not significantly changed post-merger.ConclusionThe merging of two academic programs led to feelings of increased mentorship, operative competency, and workplace efficiency among the residents. This was achieved without significant detriment to resident case volume or ABSITE performance. Our investigation also identified legitimate challenges that speak to the need for fluidity in a residency program and the constant need for continued growth and development.

Analysis of Surgeon and Center Case Volume and Stroke or Death after Transcarotid Artery Revascularization.

It has been suggested that the annual hospital volume of cases may affect the number of adverse events after carotid endarterectomy (CEA). We aim to study the associations between hospital as well as surgeon volume and the risk of stroke or death after transcarotid artery revascularization (TCAR). Retrospective review of the Vascular Quality Initiative data of patients undergoing TCAR from 2016 to 2021. Surgeon and center volume were calculated based on the mean number of cases (MNC) performed yearly by each surgeon and center. The primary outcome was a composite endpoint of in-hospital stroke or death. A total of 22,624 cases were included. Surgeon volume was divided into 3 quantiles: low (MNC = 4), medium (MNC = 10), and high (MNC = 26). Center volume was also divided into low (MNC = 14), medium (MNC = 32), and high (MNC = 64). After adjusting for potential confounders, and when compared with high-volume centers, low and medium center volumes were not associated with any increased odds of in-hospital stroke and death, stroke, death, or stroke with transient ischemic attack (TIA). Compared with high-volume surgeons, low surgeons' volume was associated with a higher odd of stroke (odds ratio 1.5, 95% CI 1.1 to 2.04, p = 0.008), and stroke and TIA (OR 1.5, 95% CI 1.2 to 1.9, p = 0.002). However, medium surgeon volume was not associated with higher odds of stroke and death, stroke, and stroke with TIA. Neither low nor medium surgeon volume was associated with a difference in mortality compared with high surgeon volume. In this retrospective study, center volume was not associated with any differences in outcomes among patients undergoing TCAR. On the other hand, surgeons with low volume were associated with a higher risk of stroke, death, or MI and stroke or TIA when compared with high surgeon volume. There was no difference in outcomes between medium and high surgeon volume.