General Surgery Subspecialties Research Articles

Patterns of Specialty Palliative Consultation for Patients Admitted to Surgical Services.

Background: Historically, there have been perceptions that engagement with palliative care (PC) services may preclude potentially curative but high-risk operations. As such, we sought to investigate the relationship between specialty PC consultation and the care trajectory of surgical patients. We hypothesized that PC consultation would be associated with increased frequency of nonoperative treatments being chosen among surgical inpatients. Design: All general surgery and general surgery subspecialty patients receiving PC consultation at a single tertiary academic medical center from 2020 to 2021 were identified. Surgical operations were stratified as "elevated risk" in accordance with 2014 American Heart Association guidelines. Retrospective chart review was performed, and comparisons were made with univariable statistics. Results: We identified a total of 729 patients who received specialty PC consultation, 159 of whom were admitted to a surgical service. PC was actively involved in consultation for surgical decision making in 27% (43/159) of these encounters. PC assistance with surgical decision making was associated with a greater incidence of elevated-risk operative procedures during admission compared with patients without presurgical PC consultation (OR 3.29 [2.51, 7.16]). There was no association between PC involvement with surgical decision making and odds of discharge to hospice (OR 0.42 [0.18, 1.51]) nor death during admission (OR 0.66 [0.21, 2.10]). Conclusions: We found that specialty PC involvement in surgical decision making does not preclude the pursuit of disease-directed surgical treatment. Contrary to our hypothesis, our single institutional data demonstrate that early PC consultation can be synergistic with surgical disease management and does not preclude elevated-risk operative care.

Perceptions of homelessness: Is there variation across medical careers and specialties?

Medical students, residents and faculty are all capable of holding biases towards stigmatised groups like people experiencing homelessness. This study sought to investigate how the level of training may influence perceptions of homelessness among medical students, residents and faculty. Additionally, we sought to understand how different specialities perceive people experiencing homelessness and whether this changes at various points in a career. The Health Professionals' Attitudes Towards the Homeless Inventory (HPATHI) was administered to medical students, residents and faculty at one institution in the United States. Basic demographics as well as length of time spent in practice were collected in addition to HPATHI responses. A total of 1,141 individuals were invited to complete the survey, including 736 medical students, 214 residents and 191 faculty. Two hundred and ninety individuals participated in the survey and 238 recorded complete responses were analysed for a sample response rate of 238/1141 (20.9%.) Overall perceptions of homelessness across the entire sample were positive and not greatly influenced by the level of training during a medical career. Medical students across classes were largely in agreement and there was a noticeable increase in positive perceptions for students engaged in clinical rotations. However, clinical specialties demonstrated wide variation in perceptions, with the most prominent differences amongst individuals from surgical subspecialties of General Surgery and Obstetrics & Gynaecology. Our study demonstrates the largely favourable attitudes physicians, residents and students have towards people experiencing homelessness with implications for future work to support greater exposure to underserved populations during training. Specialty choice appears to play a larger role in the formation of attitudes towards underserved populations rather than the length of time spent in a particular specialty.

Blood on the drapes: A multispecialty comparison of blood spill estimates.

Estimated blood loss (EBL) is an important part of the perioperative process. This project aims to determine the accuracy of perioperative team members to estimate blood volume on drapes and the operating room floor. Aliquots of unused human blood were used to create surgical scenarios, and standardized pictures and videos were taken. Physicians, residents, nurses, medical students, and surgical technicians were surveyed and asked to estimate the blood volume for each series. Accuracy and consistency of responses was analyzed. One hundred and forty five responses were recorded: 57 attending physicians, 36 residents, 27 registered nurses, 17 medical students, and seven circulating surgical techs. Median percent error (PE) for all cases was 211.11%, demonstrating a global overestimation of blood volume. PE for the 150mL images was statistically significantly lower than that of the 50 and 100mL images. Circulating Surgical Technicians were the most accurate group, with a median PE of 125%, followed closely by Medical Students (PE=158.33%). The most accurate specialty was Orthopedics (PE=168.06%). The least accurate groups were Attending Physicians (PE=286.11%) and General surgery (GSGY) (PE=327.78%). The most accurate orthopedic surgery and GSGY subspecialties were Hand (PE=237.64%) and Vascular (PE=108.33%), respectively. Statistical analyses showed no significant differences by clinical role, surgical specialty, or subspecialty. This study demonstrates a global overestimation of blood volume when using the visual method, with improved accuracy at higher volumes. Our findings highlight the limitations of visual estimation methods for EBL.

State of the Art: Advances in Hernia Care.

The field of hernia surgery has seen many recent advances and continues to evolve. Care of the hernia patient begins preoperatively by ensuring adequate preparation for surgery with surgeons now having the opportunity to accurately predict risk which can aid with informed consent. Imaging studies can now help surgeons diagnose and plan hernia surgery on an individual level based on hernia characteristics as well as abdominal wall musculature. In the operating room, new technology and surgical techniques have allowed surgeons to become increasingly sophisticated with goals of reducing tension on midline closures, utilizing minimally invasive and robotic techniques, and availability of new and varied mesh prosthetics. While modest improvements in outcomes have been witnessed by these advances, there is still opportunity for improvement which will be realized by continued research, use of registries, and education and training. Hernia prevention strategies focusing on minimally invasive surgery, laparotomy closure, and the use of prophylactic mesh will also help with the burden of incisional hernias. These advances in hernia surgery have led to the new field of Abdominal Core Health which helps represent this evolving and growing new subspecialty of general surgery.

Use of artificial intelligence in breast surgery: a narrative review.

We have witnessed tremendous advances in artificial intelligence (AI) technologies. Breast surgery, a subspecialty of general surgery, has notably benefited from AI technologies. This review aims to evaluate how AI has been integrated into breast surgery practices, to assess its effectiveness in improving surgical outcomes and operational efficiency, and to identify potential areas for future research and application. Two authors independently conducted a comprehensive search of PubMed, Google Scholar, EMBASE, and Cochrane CENTRAL databases from January 1, 1950, to September 4, 2023, employing keywords pertinent to AI in conjunction with breast surgery or cancer. The search focused on English language publications, where relevance was determined through meticulous screening of titles, abstracts, and full-texts, followed by an additional review of references within these articles. The review covered a range of studies illustrating the applications of AI in breast surgery encompassing lesion diagnosis to postoperative follow-up. Publications focusing specifically on breast reconstruction were excluded. AI models have preoperative, intraoperative, and postoperative applications in the field of breast surgery. Using breast imaging scans and patient data, AI models have been designed to predict the risk of breast cancer and determine the need for breast cancer surgery. In addition, using breast imaging scans and histopathological slides, models were used for detecting, classifying, segmenting, grading, and staging breast tumors. Preoperative applications included patient education and the display of expected aesthetic outcomes. Models were also designed to provide intraoperative assistance for precise tumor resection and margin status assessment. As well, AI was used to predict postoperative complications, survival, and cancer recurrence. Extra research is required to move AI models from the experimental stage to actual implementation in healthcare. With the rapid evolution of AI, further applications are expected in the coming years including direct performance of breast surgery. Breast surgeons should be updated with the advances in AI applications in breast surgery to provide the best care for their patients.

Surgeon Perspectives on Daily Presentation of Ethical Dilemmas: A Qualitative Study.

Surgeons encounter and navigate a unique set of ethical dilemmas. The American College of Surgeons (ACS) previously identified 6 core ethical issues central to the practice of surgery, but there have been no reports of the true range and complexity of ethical dilemmas encountered by surgeons in their daily practice. Qualitative research is well positioned to address this question. We conducted in-depth interviews with attending surgeons across multiple surgical subspecialties at a large, urban, academic medical center asking them to describe the most common ethical dilemmas they encounter in day-to-day practice. Interviews were recorded, transcribed, and coded according to a grounded theory, inductive approach. Thirty attending surgeons were interviewed, representing twelve different general surgery subspecialties. The majority of dilemmas identified pertained to 4 of the 6 ACS identified core ethical issues: professional obligations, competition of interests, truth telling, and end-of-life care. No participants described dilemmas relating to the themes of confidentiality or surrogate decision-making. Approximately one-third of participants identified ethical issues not well characterized by the ACS core principles, most often relating to the pressure to provide care that is not medically indicated. There was strong support for a formalized surgical ethics curriculum. Although the ACS-defined core ethical issues in surgery appropriately captured many ethical dilemmas identified by participants, surgeons described several scenarios not well characterized by these themes. A dedicated surgical ethics curriculum may help to better equip surgeons to navigate the ethical dilemmas they are likely to face in practice.

A Call to Action to Train Underrepresented Minorities in Surgical Subspecialties and Fellowships.

With each succession along the surgical career pathway, from medical school to faculty, the percentage of those who identify as underrepresented in medicine (URiM) decreases. We sought to evaluate the demographic trend of surgical fellowship applicants, matriculants, and graduates over time. The Electronic Residency Application Service and the Graduate Medical Education Survey for general surgery fellowships in colorectal surgery, surgical oncology, pediatric surgery, thoracic surgery, and vascular surgery were retrospectively analyzed (2005 to 2020). The data were stratified by race and gender, descriptive statistics were performed, and time series were evaluated. Race/ethnicity groups included White, Asian, other, and URiM, which is defined as Black/African American, Hispanic/Latino(a), Alaskan or Hawaiian Native, and Native American. From 2005 to 2020, there were 5,357 Electronic Residency Application Service applicants, 4,559 matriculants, and 4,178 graduates to surgery fellowships. Whites, followed by Asians, represented the highest percentage of applicants (62.7% and 22.3%, respectively), matriculants (65.4% and 23.8% respectively), and graduates (65.4% and 24.0%, respectively). For URiMs, the applicants (13.4%), matriculants (9.1%), and graduates (9.1%) remained significantly low (p < 0.001). When stratified by both race and gender, only 4.6% of the applicants, 2.7% of matriculants, and 2.4% of graduates identified as both URiM and female compared to White female applicants (20.0%), matriculants (17.9%), and graduates (16.5%, p < 0.001). Significant disparities exist for URiMs in general surgery subspecialty fellowships. These results serve as a call to action to re-examine and improve the existing processes to increase the number of URiMs in the surgery subspecialty fellowship training pathway.

EGS P20 Emergency General Surgery – A state of the nation survey

Abstract Background ERAS (enhanced recovery after surgery) programmes have delivered improved outcomes across the elective surgery landscape but emergency surgery has historically lagged behind with its improvements. The introduction of acute care surgery principles in the United States and projects such as NELA (National Emergency Laparotomy Audit) in the United Kingdom are working to change this. Despite the improvement in outcomes seen by NELA there lacks clarity over the structure and provision of services across the UK. No study to date has examined how Emergency General Surgery care is currently organised and therefore how these organisational structures are changing as new innovations to patient care are delivered. This study aims to ascertain the current organisation structures of emergency surgical care within England and whether there are plans for this to change. Methods A survey was defined and sent to hospitals across England via Freedom of Information (FOI) Requests. Trusts were identified from the online NHS Service Directory and cross referenced with the NELA list of participating hospitals. This led to FOIs sent to 123 acute Trusts in England. Responses not received within 8 weeks were not included in the study. Questions were identified and wording agreed by the authors. Trusts were asked their current working structure and whether they have plans to change within the next five years. Organisational structures were categorised as A; Mixed general surgical take under a non-specific general surgery consultant, B; Daily allocation of acute admission to a general surgery subspecialty (Upper GI / Colorectal / Hepatobiliary), C; Dedicated Emergency General Surgery consultants / service during weekdays only (Monday to Thursday, or Monday to Friday), D; Dedicated Emergency General Surgery consultants / service weekdays and weekends, or E; Other. Results 101 out of 124 trusts responded within the 8-week timeframe. 3 trusts declined to supply information on organisational structure. The remaining reported organisational structures of A; n=36, B; n= 16, C; n=10, D; n=30, E; n=5. In total 41.24% of hospitals reported having an active EGS service in place. Mean bed numbers across different organisational types were Group A; 617.62, Group B; 867, Group C; 648, Group D; 559.5, Group E; 800.71. Mean admissions were Group A; 3983.08, Group B; 6088.29, Group C; 4432.14, Group D; 4123.52, Group E; 4578. Mean NELA cases were Group A; 134.29, Group B; 187, Group C; 164, Group D; 142.11, Group E; 187.17. Regarding number of consultants in place to run an EGS service group C reported a range of 2 to 14 consultants, with a mean of 6. Group D reported a range of 3 to 13 consultants, with a mean of 8.14. Regarding plans to move towards an EGS service group A reported Yes; 9 (25%), No; 22 (61.11%), TBD; 2 (5.56%), no answer given; 3 (8.33%). Group B reported Yes; 3 (18.75%), No; 10 (62.5%), TBD; 3 (18.75%). Conclusions The speciality of Emergency General Surgery (EGS) within the United Kingdom is expanding with annual EGS symposiums being held by professional bodies such as ASGBI, EGS trainee groups forming such as the Moynihan Academy, and large institutions altering their service specifically towards hiring consultants in EGS positions. This follows the Royal College's Acute and Emergency Care joint position statement, the consensus statement from ASGBI and the Getting It Right First Time (GIRFT) emergency surgery report which explicitly state that a dedicated surgical assessment unit, with senior surgeon directing patient throughput has been shown to reduce costs and increase effectiveness of a surgical department. This study shows that 41.24% of trusts in England deliver an EGS service but in heterogenous structured formats. What is clear is that a dedicated EGS service is becoming more popular, with 25% of group A services, and 18.75% of group B services reporting active plans in the next 5 years to create this service. This further impresses the need for categorisation of service provision types, and the sharing of information, to ensure that England does not end with a patchwork of service types confusing patients and rotating clinical practitioners alike.

NIH Funding Across Surgical Specialties; How Do Women Fare?

BackgroundMuch has been written about the under-representation of women in academic medicine. However, no study has comprehensively described the gender-based trends of National Institutes of Health funding across surgical specialties; this study provides such an overview. MethodsWe queried a previously created database to identify both male and female National Institutes of Health-funded surgeons. Surgical specialties and subspecialties were determined based upon formal training. Total grant costs and average costs per R01 and K grant were calculated and compared. Bivariate χ2 analyses were performed using population totals. ResultsIn 2020, the specialties with the highest proportion of National Institutes of Health-funded female surgeon-scientists were obstetrics and gynecology (57%) and vascular surgery (40%). The general surgery subspecialties with the highest proportion of women were breast (85%), endocrine (58%), and colorectal surgery (40%). An analysis of total grant costs in 2020 revealed that in most specialties, the proportion of funding held by women was substantially less than the proportion of women investigators. In obstetrics and gynecology, women comprised 57% of surgeons, but held only 46% of the funding. Similarly, in breast surgery, women comprised 85% of surgeons, but held only 45% of the funding. Women and men had similar changes in the average total cost per R01 and K grant awarded from 2010 to 2020. In 2020, women were awarded less than men per R01 grant in general, otolaryngology, plastic and reconstructive, urology, and vascular surgery. ConclusionAlthough female surgeon-scientists have made significant advances in some surgical specialties, they continue to lag in others. An in-depth analysis of the factors contributing to these trends is necessary to achieve gender parity across all academic surgical specialties.

Trends in leadership at breast surgical oncology fellowships

IntroductionBreast surgical oncology is a defined sub-specialty of general surgery that focuses on the surgical management of breast disease and malignancy within a multidisciplinary context. The fellowship directors (FD) that lead these programs have been selected for their abilities. As programs do research to ensure proper training for the next generation of breast surgical oncologists, we wanted to look into the FDs responsible for their training.MethodsThe Breast Surgical Oncology care program list was compiled via the Society of Surgical Oncology and American Society of Breast Surgeons Accredited programs (n = 60). The demographic information that was of interest included, but was not limited to, gender, age, ethnicity/background, past residency training, past fellowship training, year graduated from residency and fellowship, year since graduation to FD appointment, time at institution till FD appointment, and Hirsch index (h-index).ResultsData were collected on all 60 FDs. The average age of FDs was 52 years old, 27% of FDs are men and 73% of FDs are women. The average H-index, number of publications, and number of citations were 19, 67, and 2648, respectively. The mean graduation year from residency was 2003, and from fellowship was 2006; with a mean of 9 years post fellowship graduation until becoming an FD. The most frequently attended residency was Rush (n = 4), and the most common fellowships were Memorial Sloan Kettering (n = 8), MD Anderson Cancer Center (n = 7), and John Wayne Cancer Institute (n = 4). Nine of the FDs stayed at the same institution after doing both residency and fellowship there (15%).ConclusionThis is the first study to examine the demographics of those in FD positions in Surgical Breast Oncology, which is a relatively young fellowship. We found that FDs in Breast Surgical Oncology are defined by their high output of research. This qualification may be why the average age, and the number of years to FD are higher compared to other specialties where this research has been undertaken. Initial evaluation of FDs suggest more diversity in this field is needed. Further insight into the leaders training our next generation of surgeons is warranted.

Surgical Clinical Trials in India: Underutilized Opportunities.

Clinical trials in Surgery are central to research; however, very few surgical clinical trials are conducted in India. Such paucity of surgical trials is a cause for concern, and prompted us to explore the recent landscape of surgical trials in India. We reviewed all clinical trials from general surgery or subspecialties of general surgery registered with the Clinical Trials Registry of India website between 2018 to 15 th May 2021. Specific details such as the surgical subspecialty, study design, multicentric or single institution and funding were obtained. We found a total of 16,710 trials, out of these 4119 (24.6%) were related to all surgical fields. Only 136 (0.8%) trials were found from general surgery and its subspecialties. Most trials were registered from Central Government Institutions (48%), followed by State Government Medical Colleges (11%). Most number of trials was registered from GI surgery (32%). Most (90.5%) trials were single centre based. Common barriers to research are well known; if the State Government Medical Colleges can mentor a culture of research from an early stage of surgical training it can improve research productivity. Multicentre trials, involving smaller hospitals from tier 2 and tier 3 cities, are a potential solution to one of the major obstacles of surgical trials i.e. small number of patients; especially in this pandemic induced draught of elective surgical operations. A positive change in attitude of surgeons and provision of necessary funding can encourage more surgical clinical trials in India.

Physician Confidence in Neck Ultrasonography for Surveillance of Differentiated Thyroid Cancer Recurrence

ImportanceNeck ultrasonography, a mainstay of long-term surveillance for recurrence of differentiated thyroid cancer (DTC), is routinely used by endocrinologists, general surgeons, and otolaryngologists; however, physician confidence in their ability to use ultrasonography to identify lymph nodes suggestive of cancer recurrence remains unknown.ObjectiveTo evaluate physicians’ posttreatment surveillance practices for DTC recurrence, specifically their use of and confidence in ultrasonography.Design, Setting, and ParticipantsCross-sectional study of 448 physicians in private and academic hospitals who completed a survey on DTC posttreatment practices from October 2018 to August 2019 (response rate, 69%) and self-reported involvement in long-term surveillance for thyroid cancer recurrence. Physicians were identified by patients affiliated with the Surveillance, Epidemiology, and End Results Program registries in Georgia State and Los Angeles County. Of the respondents, 320 physicians who reported involvement with DTC surveillance were included in the analysis.Main Outcomes and MeasuresPhysician-reported long-term surveillance practices for DTC, including frequency of use and level of confidence in ultrasonography for detecting lymph nodes suggestive of cancer recurrence.ResultsIn the cohort of 320 physicians who reported involvement with DTC surveillance, 186 (60%) had been in practice for 10 years to less than 30 years; 209 (68%) were White; and 212 (66%) were men. The physicians included 170 (56%) endocrinologists, 67 (21%) general surgeons, and 75 (23%) otolaryngologists. Just 84 (27%) physicians reported personally performing bedside ultrasonography. Only 57 (20%) had high confidence (rated quite or extremely confident) in their ability to use bedside ultrasonography to identify lymph nodes suggestive of recurrence; 94 (33%) did not report high confidence in either their ability or a radiologist’s ability to use ultrasonography to detect recurrence. Higher confidence in ultrasonography was associated with the general surgery subspecialty (odds ratio [OR], 5.7; 95% CI, 2.2-14.4; reference endocrinology) and with treating a higher number of patients per year (>50 patients: OR, 14.4; 95% CI, 4.4-47.4; 31-50 patients: OR, 8.4; 95% CI, 2.6-26.7; 11-30 patients: OR, 4.3; 95% CI, 1.5-12.1; reference 0-10 patients).Conclusions and RelevanceGiven the importance of neck ultrasonography in long-term surveillance for thyroid cancer, these findings of physicians’ low confidence in their own ability and that of radiologists to use ultrasonography to detect recurrence point to a major obstacle to standardizing long-term DTC surveillance practices.

The impact of surgical subspecialization on patient outcomes following emergency colorectal resections in the north of England: a retrospective cohort study.

Emergency colorectal surgery is associated with significant morbidity and mortality. Most general surgeons have a subspecialty, which forms the focus of their elective work, allowing development of specialist skill sets. The aim of this study was to assess the impact of consultant subspecialization on patient outcomes following emergency colorectal resections. Data were requested for all emergency admissions under a general surgeon between 1 January 2002 and 31 December 2016 within the north of England. These were acquired from individual Trusts following Caldicott approval. Data included demographics, diagnoses and any procedures undertaken. Patients were assigned to cohorts based on the subspecialist interest of the consultant they were under the care of. The primary outcome of interest was 30-day postoperative mortality. Categorical data were compared with the chi-squared test, and continuous data with the t test or ANOVA. A logistic regression model determined factors associated with 30-day in-hospital mortality. Overall, 7648 emergency colorectal resections were performed with a 30-day postoperative mortality of 13.8%. This was significantly lower if the responsible consultant was a colorectal surgeon compared with other general surgery subspecialties (11.8% vs. 15.2%, P < 0.001). This was significant on univariate analysis (OR 0.75, P<0.001); however, following multivariable adjustment, this was not statistically significant (P=0.380). The colorectal specialists had a higher laparoscopy rate than their colleagues-9.8% versus 6.8% (P<0.001). Stoma rates were also lower (46.9% vs. 51.0%, P=0.001) and anastomosis rates higher (55.9% vs. 49.3%, P<0.001) amongst colorectal surgeons. These findings add to the growing body of evidence that patient outcomes may be improved by involving subspecialists in colorectal emergencies.

Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey

Cognitive task load can affect providers' ability to perform their job well and may contribute to burnout. The researchers evaluated whether task load, measured by the National Aeronautics and Space Administration (NASA) Task Load Index (TLX), correlated with burnout scores in a large national study of US physicians between October 2017 and March 2018 with a 17.1% response rate. Burnout was measured using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, and a high score on either score was considered a manifestation of professional burnout. The NASA-TLX was chosen to evaluate physician task load (PTL) due to its robust validation and use across many industries, including health care, over the past 30 years. The domains included in the PTL were mental, physical, and temporal demands, and perception of effort. Mean score in task load dimension varied by specialty. In aggregate, high emotional exhaustion, depersonalization, and one symptom of burnout was seen in 38.8%, 27.4%, and 44.0% of participants, respectively. The mean PTL score was 260.9/400 (standard deviation = 71.4). The specialties with the highest PTL score were emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties. A dose response relationship between PTL and burnout was observed. For every 40-point (10%) decrease in PTL there was 33% lower odds of experiencing burnout (odds ratio = 0.67, 95% confidence interval = 0.65-0.70, p < 0.0001). The relationship between PTL and burnout may suggest areas of particular focus to improve the practice environment and reduce physician burnout.

Can the Use of Video-Based Interventions Increase Public Knowledge About Endocrine Surgeons?

BackgroundEndocrine surgery (ES) is a relatively young subspecialty of general surgery, and prior research has shown low public awareness of these specialists’ roles. We hypothesized that a video-based intervention could increase public knowledge of the specialty in an effective and efficient manner. MethodsParticipants were recruited at three public locations (a farmer's market, a public park, and a university hospital) and were given a three-question survey to assess baseline knowledge of ES. They then watched one of two video-based educational interventions and completed an identical postintervention survey. Two surveyors recruited 80 individuals per site, with 40 participants in each intervention group. Participants’ sex and age and whether or not they were on clinical staff at the University of Alabama at Birmingham were recorded. ResultsA total of 240 participants were recruited; 61.3% female with median age 40 y. Preintervention, only 42.1% of participants could correctly define ES. ES were confused with endocrinologists by 44.6%, which was not different between sites (P = 0.09). Significantly, more participants at all sites could correctly define ES postintervention (67.9% versus 42.1%; P < 0.001). Clinical staff did not perform better than the lay public at any location (P = 0.32). The long video had a significantly greater increase in correct responses compared with the short video overall (32.5% versus 19.1%; P < 0.001) and at each location. ConclusionsThis study confirms the public's general lack of knowledge about ES and their scope of practice. A video-based intervention was successful in improving knowledge of the practice of ES, with a longer, explanatory video being most effective.

Vascular surgery's identity

Vascular surgery's identity

The pediatric surgery match by the numbers: Defining the successful application

BackgroundPediatric surgery remains the most competitive general surgery subspecialty. The authors suspected significant inflation in academic metrics since the last published paper. This study aimed to identify factors associated with applicant success in the match. MethodsAfter IRB approval, all applications to a single accredited pediatric surgery fellowship program were reviewed for match years 2014–2018. Matched and unmatched applicants were compared in an unadjusted and adjusted analysis. ResultsThis training program received 414 of 425 total applications (97%). Match results were available for 388 (94%). Matched applicants were more likely to train in programs with pediatric surgery fellowships (64% vs. 28%) and to have dedicated research time (55% vs. 21%; all p < 0.01). Matched applicants had more total publications (median: 12 vs. 7, p < 0.01) and higher ABSITE scores (median: 64th vs. 59th percentile, p < 0.01). Training in multiple programs negatively impacted the chance to match (p < 0.01). The median number of publications per applicant increased over the study time period from 7 to 11 (p < 0.01). ConclusionsThe likelihood of matching into a pediatric surgery fellowship was related to the type of residency attended, dedicated research time, ABSITE scores, and number of publications. Overall, the total number of publications reported by all applicants increased. Type of StudyRetrospective Comparative Study. Level of EvidenceLevel III.

Towards Development of an Open Surgery Competency Assessment for Residents (OSCAR) Tool – A Systematic Review of the Literature and Delphi Consensus

Competency-based education has mandated accurate intra-operative assessment tools. We aimed to define consensus-based open surgical skills perceived by experts as critical for assessment. A mixed-method design was employed: systematic review and e-Delphi methodology. The study was performed at McGill University-affiliated large tertiary academic centers in Montreal, Quebec, Canada. Per PRISMA guidelines, a peer-reviewed search strategy was employed. Studies published in English and those describing technical skill assessment of open abdominal surgery were included; subspecialty-specific skills, conference abstracts, academic memoirs were excluded. Most-cited skills were subjected to e-Delphi methodology to identify those deemed essential by experts, based a 3-point Likert scale. Eighteen McGill University-affiliated general surgeons, representing a variety of subspecialties of General Surgery, were invited to answer the questionnaire. Around 120 of 4285 references were retained for analysis. The 12 most cited skills included suturing, tissue and instrument handling, movement economy, instrument knowledge, knot tying, flow, knowledge of procedure, completion time, dissection technique, knowledge of anatomy and sterile technique; 6 of these achieved high or perfect scores and agreement after 2 rounds of survey: suturing, sterile technique, knot tying, knowledge of anatomy, knowledge of procedure, and tissue handling. Median standard deviation decreased (0.495 to 0.450) from first to second round, indicating improvement in consensus. These results will help develop and validate the OSCAR (objective structured clinical assessment rubric) assessment tool for immediate intra-operative feedback of open technical skills for surgical trainees.

What does a (general and abdominal) surgeon need to know on plastic surgery?

Plastic surgery was first introduced as a sub-specialty of general surgery in Germany in 1978. Since then, this surgical subspecialty/discipline has evolved enormous potential, e.g. in collaboration with other disciplines such as general andabdominal surgery. To highlight and summarize the basic potential, technical options and novel aspects of plastic surgery, which are relevant for the common interdisciplinary surgical strategies of plastic and general as well as abdominal surgery in clinical practice. Short and compact narrative review based on 1) a selection of relevant references from the medical scientific literature and 2) surgical experiences obtained in daily practice. R esults (selected corner points): 1) Biological protection procedures in vascular surgery by flap coverage after meticulous debridement with or without autogenic vascular reconstruction are used to overcome infection of a vascular prosthesis, a serious problem, associated with the risk of anastomotic rupture and bleeding by transfer of immunological competence due to tissue coverage and finally to induce healing in the area of an infected vascular prosthesis. 2) Fistula treatment for aorto-tracheal or aorto-duodenal fistulas, a big challenge for the referring general surgeon, can be treated by flap coverage, i.e. interposition of the pectoralis-major flap and the omentum-majus flap, respectively. 3) With regard to nerve surgery, encouraging results have been reported after early microsurgical recurrent laryngeal nerve repair, i.e. improved subjective voice quality or reconstitution of respiratory capacity in diaphragmatic. 4) Lymphatic surgery for lymphedema occurring either primarily due to an absence or lack of lymphatic vessels or secondarily due to infection, trauma, radiation therapy or surgery can be indicated in specialized microsurgical centers, e.g. for surgical repair of the lymphatic pathway: I) the interrupted lymphatic system can be reconstructed by an interposition, or II) the lymphatic fluid can be drained extraanatomically (e.g. by a lymphatic-venous anastomosis). Further techniques are the following: free lymph node transplantation included in a free vascularized groin flap or autologous lymphatic vessel transfer or vein graft interposition (used for lymphatic vessel interposition). 5) Mass reduction such as dermolipectomy with subsequent split-thickness is a valuable option, which provides excellent volume reduction. 6) Defect coverage: A. Split- or full-thickness skin grafts are a common method of defect coverage (in cases of clean and well-vascularized wound bed and lacking donor skin, or if the graft bed is of questionable quality) using various allogenic or xenogenic skin substitute materials. B. Further methods offer a wide-range armamentarium of local and free fasciocutaneous and musculocutaneous flaps, e.g. after abdomino-perineal rectum extirpation using the vertical rectus-abdominis myocutaneous flap (VRAM) or propeller flaps according to the "angiosome". 7) Abdominal wall hernia closure with instable skin coverage, flap closure, either alone or in combination with mesh is superior to mesh closure only. 8) Free flaps: If there is no option for a local or pedicled flap available, free flaps can be well used for abdominal wall defect closure (complication rate in experienced hands is low). Plastic surgery is an indispensable partner for specific surgical problems and clinical situations of general and abdominal surgery, which indicates that each general and abdominal surgeon should be well notified on great options and surgical techniques offered by modern plastic surgery to achieve best outcomes and quality of life for patients and should combine the expertise of these two surgical disciplines.

Vascular surgery: taking the next steps toward autonomy

The recognition of vascular surgery as an independent surgical specialty is inevitable, but the pathway to full autonomy remains uncertain. Vascular surgery emerged from general surgery in the mid-1950s with the advent of synthetic grafts and microvascular techniques. By the early 1980s, Accreditation Council for Graduate Medical Education–approved fellowships were established in most large academic medical centers. The American Board of Surgery recognized this additional specialty training by awarding vascular graduates a Certificate of Special Qualifications distinguishing them from general surgeons. The emergence of endovascular surgery radically changed the face of vascular surgery from a general surgery subspecialty to a unique surgical specialty with a growing array of minimally invasive tools. With the establishment of a primary Certificate in Vascular Surgery and the subsequent development of integrated residencies, vascular surgery moved ever closer to recognition as an independent surgical specialty. Despite the remarkable progress that has been observed over the past 50 years, there is a desire in the vascular community for formal recognition of the unique body of knowledge and surgical skills that serve as the foundation of contemporary vascular care.