Proportion Of Surgeons Research Articles

Questionnaire study of application about sentinel lymph node biopsy surgery in locally advanced breast cancer patients who received neoadjuvant chemotherapy.

Nodal staging from sentinel lymph node (SLN) biopsy has become the standard procedure for early-stage breast cancer patients. SLN biopsy implementation after chemotherapy has previously been evaluated. This questionnaire study aimed to investigate the current trend of SLN biopsy after neoadjuvant chemotherapy (NAC) for locally advanced breast cancer. We conducted a web-based survey among breast surgeons who are members of the Korean Breast Cancer Society. The survey comprised 14 questions about axillary surgery after NAC. Of 135 respondents, 48.1% used a combined method of dye and radioactive isotope (RI). In the absence of SLN metastasis, 67.7% would perform only SLN biopsy, while 3% would perform ALN dissection. In case of SLN metastasis, the proportions of surgeons who would proceed with ALN dissection were 60.2% and 67.2% for less than two and more than three positive SLNs, respectively. The present study confirmed the increasing tendency to adopt SLN biopsy for axillary staging in patients who achieved complete response with initial nodal metastasis. It could be expected that the mapping methods for patients receiving NAC have become diverse, including RI, vital dye, and indocyanine green fluorescence. The implementation of SLN biopsy after NAC will grow in the coming years due to an increasing demand of minimally invasive surgery.

A census of general surgery consultants in England and Wales: implications for the current and future surgical workforce.

This study aimed to describe the composition of the current general surgical consultant body in England and Wales and quantify levels of inequality within it as well as describe future workforce challenges. This is an observational study of all general surgical departments in England and Wales. Consultant general surgeons were identified and data regarding their gender, country of undergraduate medical education, subspecialty and private practice were recorded. Of the 2,682 consultant general surgeons in England and Wales identified for this study, just 17% are women, with gender inequality most marked in university teaching hospitals and among certain subspecialties. Almost 40% of consultants did not obtain their primary undergraduate degree in the United Kingdom and there are considerably fewer surgeons who studied abroad in university teaching hospitals. Over 40% of current general surgical consultants have been qualified for more than three decades and there is no equivalent sized group of younger consultants. There remains considerable gender and racial inequality in the consultant general surgical workforce, with pockets of a lack of diversity within university or teaching hospital surgical departments and some subspecialties. The proportion of surgeons in their fourth decade of clinical practice represents the largest group of current practising consultants, which points towards an impending workforce crisis should senior clinicians seek to reduce activity or consider taking early retirement.

Defensive medicine and its related risk factors: evidence from a sample of Iranian surgeons

ABSTRACT Objectives Defensive medicine (DM) is the deviation of a physician from normal behavior or what is a good practice and is aimed at reducing or avoiding the risk of legal litigation from patients or their families. Therefore, this study aimed to determine DM-related behaviors and associated risk factors among Iranian surgeons. Methods In this cross-sectional study, 235 surgeons were selected using convenience sampling. The data gathering tool was a researcher-made questionnaire confirmed as a reliable and valid tool. Factors associated with DM-related behaviors were identified using logistic regression analysis. Results DM-related behaviors ranged from 14.9% to 88.9%. The most common positive DM-related behaviors, including unnecessary biopsy (78.7%), imaging and laboratory tests (72.4% and 70.6%), and refusing high-risk patients (61.7%), was the most common negative DM-related behavior. The likelihood of DM-related behaviors was more in younger and less experienced surgeons. Other variables, such as gender, specialty, and lawsuit history, positively affected some DM-related behaviors (p < 0.05). Conclusion This study showed that the proportion of surgeons who frequently performed DM-related behaviors was higher than those who rarely performed it. Therefore, strategies including reforming the rules and regulations for medical errors and litigations, developing and implementing medical guidelines and evidence-based medicine, and improving the medical liability insurance system can reduce DM-related behaviors.

Effective peer review audit and identification of the surgeon outlier.

Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit. All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT). A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored. The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 2 Timing to Surgery.

Objective The objective of the present study was to evaluate the current practice in terms of timing to surgery in acute spinal cord injury (ASCI) patients among spinal surgeons from Iberolatinoamerican countries. Methods A descriptive cross-sectional study design as a questionnaire was sent by an email for all members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results A total of 162 surgeons answered questions related to the timing for surgery. Sixty-eight (42.0%) considered that ASCI with complete neurology injury should be treated within 12 hours, 54 (33.3%) performed early decompression within 24 hours, and 40 (24,7%) until the first 48 hours. Regarding ASCI with incomplete neurological injury, 115 (71.0%) would operate in the first 12 hours. There was a significant difference in the proportion of surgeons that would operate ASCI within ≤ 24 hours, regarding the type of injury (complete injury:122 versus incomplete injury:155; p < 0.01). In the case of patients with central cord syndrome without radiological evidence of instability, 152 surgeons (93.8%) would perform surgical decompression: 1 (0.6%) in the first 12 hours, 63 (38.9%) in 24 hours, 4 (2.5%) in 48 hours, 66 (40.7%) in the initial hospital stay, and 18 (11.1%) after neurologic stabilization. Conclusion All inquired surgeons favour early decompression, with the majority performing surgery in the first 24 hours. Decompression is performed earlier in cases of incomplete than in complete injuries. In cases of central cord syndrome without radiological evidence of instability, there is a tendency towards early surgical decompression, but the timing is still extremely variable. Future studies are needed to identify the ideal timing for decompression of this subset of ASCI patients.

An international survey characterizing Mohs tissue processing techniques and Mohs margin thresholds: how close is too close?

From practice, we identified heterogeneity in Mohs micrographic surgery (MMS) specimen tissue processing techniques and specifications, and in the Mohs surgeons' assessment of MMS specimen histological tumour clearance. By surveying an international cohort of Mohs surgeons, we determined to characterize variation in margin threshold assessment (number of wafers/sections free of tumour to declare tumour clearance). An online questionnaire was distributed to Mohs surgeons in the UK, European countries, Australia and New Zealand, assessing the background demographics of the surgeons and the technical factors involved in MMS tissue processing and posing three MMS scenarios to define margin thresholds. In total, 114 consultant/attending-level Mohs surgeons responded, giving a response rate of 33.5% from 20 countries (including UK nations). The first scenario posed was a 20-mm cheek basal cell carcinoma (BCC) excised by MMS with a fully complete first wafer (7 μm) clear of tumour and the second wafer (after trimming interval of 50 μm) demonstrating a small dermal focus of nodular BCC; of the 58 surgeons, 16 (27.6%) would not take another stage. With a follow-up question, 16 of the 58 (27.6%) surgeons specified wanting three clear sections to declare tumour clearance. When the same scenario had a change to a 20-mm infiltrative BCC, 84.2% (48 of 57 surgeons) required a second MMS stage, with a follow-up question clarifying that a third (19 of 57) wanted three clear sections to determine clearance. For a well-differentiated 15-mm squamous cell carcinoma with the same factors there was no majority consensus, with the same proportion of surgeons (22.6%; 12 of 53) calling tumour clearance after one, two and three clear section(s) respectively. For MMS specimen processing specifications, routine sections/wafers of 5-10 μm were reported by 77.4% of respondents (48 of 62) and for trimming interval values, 78.6% (48 of 61) specified a range between 20 and 200 μm. By surveying international Mohs surgeons, we highlight surgeon background characteristics, peer-compare assessment of margin thresholds for tumour clearance across three scenarios, and delineate tissue processing and intraoperative approaches.

Vertical Integration Versus Physician Owners: Trends in Practice Structure Among Breast Cancer Surgeons.

The objective of this study was to document changes in physician practice structure among surgeons who treat women with breast cancer. We merged cancer registry records from 5 large states with Medicare Part B claims to identify each surgeon who treated women with breast cancer. We added information from SK&A surveys and extensive internet searches. We analyzed changes in breast surgeons' practice structure over time. We assigned each surgeon-year a practice structure type: (1) small single-specialty practice; (2) single-specialty surgery or multispecialty practice with ownership in an ambulatory surgery center (ASC); (3) physician-owned hospital; (4) multispecialty; (5) employed. In 2003, nearly 74% of breast cancer surgeons belonged to small single-specialty practices. By 2014, this percentage fell to 51%. A shift to being employed (vertical integration) accounted for only a portion of this decline; between 2003 and 2014, the percentage of surgeons who were employed increased from 10% to 20%. The remainder of this decline is due to surgeons opting to acquire ownership in an ASC or a specialty hospital. Between 2003 and 2014, the percentage of surgeons with ownership in an ASC or specialty hospital increased from 4% to 17%. Dramatic changes in surgeon practice structure occurred between 2003 and 2014 across the 5 states we examined. The most notable was the sharp decline in the prevalence of the small single-specialty practice and large increases in the proportion of surgeons either employed or with ownership in ACSs or hospitals.

Australian breast surgeons and ultrasound usage: Have practices changed?

A recent survey of surgeon performed ultrasound usage was conducted amongst registered members of the Breast Surgeons of Australia and New Zealand Society (BreastSurgANZ) and was compared with a previous survey undertaken in 2010 to determine whether patterns of utilization had changed. From July to September 2019, members of BreastSurgANZ were invited to complete an electronic online survey of personal usage of breast ultrasound focusing on ultrasound equipment access, use of office and intraoperative ultrasound, biopsy interventions and training expectations. There were 73 respondents to the survey with 45 (61.6%) members indicating access to ultrasound within their practices. Whilst current regular ultrasound usage (68.1%) was only slightly greater than in 2010 (66%), the proportion of respondents not performing any form of needle intervention had increased (62.5% compared to 53% in 2010) and with the proportion of surgeons currently performing >10 biopsies per month decreasing from 10% to only 5.56%. However the percentage of surgeons utilizing intraoperative ultrasound had notably increased since 2010 with 49.3% currently using ultrasound in the operating room compared with only 17% previously. The majority of respondents believed that breast ultrasound training should be conducted through BreastSurgANZ post fellowship training programs. The overall utilization of surgeon-performed ultrasound amongst BreastSurgANZ members has remained similar over the past 9 years with the performance of needle interventions declining slightly, but with the application of intraoperative ultrasound having increased. An ultrasound training curriculum as part of the BreastSurgANZ post fellowship training program is a necessary imperative.

Liver Drains after Surgery, a Real-life Snapshot among the HPB Community: the LI.DR.A.S. World-wide Survey

Background: Although several trials have been conducted, the management of liver drains remains controversial among HPB surgeons. We conducted a world-wide survey to define actual clinical drain practices adopted by liver surgeons in the EA-HPBA, A-HPBA and AP-HPBA communities. Methods: An open survey consisting of 30 questions was prepared and then published on Google – Form, which was then delivered by email to members of the three major chapters of the international hepato-pancreato-biliary association (IHPBA). Results: 191 HPB surgeons responded to the web-survey. Twenty (10.5%) respondents were from the Asian-Pacific region, while 15 (7.9%) were from North America, 13 (6.8%) from South America and 143 (74.9%) from Europe and Africa. One hundred-twelve surgeons (58.6%) reported routine use of abdominal drains liver resection. Eighty-eight (46.1%) respondents responded that drain removal was driven by low volume and low bilirubin levels in the drains; 85 (44.5%) surgeons usually consider removal of the drain on 2-3 post-operative days (POD). In case of minor liver resection, 97 (50.8%) surgeons reported using drains only in select cases. When a major resection (>=3 liver segments) is performed, 134 (70.2%) surgeons preferred to always use a drain. Among patients with cirrhosis, 87 (45.5%) surgeons reported the routine use of drains, while 84 (44.0%) respondents considered drains only selectively. The lack of drains was most prevalent among surgeons from North America (12, 80%); in contrast, 14 (70.0%) surgeons in Asian-Pacific region, 87 (60.8%) in Europe and Africa and 8 (61.5%) in South America were more inclined to employ liver drains routinely (p=0.014). Among surgeons whose practice is mostly mini-invasive liver surgery (n=31), 23 (74.2%) reported draining only in selected cases, while the proportion of surgeons who use drains selectively among surgeons who performed mainly open liver resections was lower (n=56, 35.0%)(p<0.001). Conclusion: Despite several RCTs, use of drains at the time of liver resection remains highly variable. In particular, surgeons from North America, as well as surgeons who predominantly perform minimally-invasive hepatectomy, are much less likely to employ abdominal drains at the time of liver resection.

Evaluation of the Cataract Surgery 2018 Survey in Terms of Achieving Refractive Cataract Surgery Targets.

Objectives:The aim of this study was to show at what rate the technological equipment used in cataract surgery by Turkish ophthalmologists and their knowledge are reflected in practice and how up to date they are.Materials and Methods:A questionnaire conducted using SurveyMonkey was used to evaluate the answers to 17 questions from 823 members of the Turkish Ophthalmological Association. Results were evaluated in subgroups according to the participants’ age, occupational status, institutions, and whether they conducted relevant academic activities, and the data were compared as inadequate, standard, and contemporary approaches according to the determined criteria.Results:Optical biometry devices were used at rates of 77.7% and 67.3% for intraocular lens (IOL) power calculations and keratometric measurements in preparation for cataract surgery, respectively. For IOL power calculation, third-generation formulas, especially the SRK-T, were used most commonly (46.2%), followed by second-generation formulas (21.9%), and fourth/fifth-generation formulas and multiple evaluations for different axial lengths (31.9%). The most common incision size was 2.8 mm (51.6%), while the percentage of 2.2 mm and shorter incisions considered to be neutral in terms of surgically induced astigmatism was 18.8%. When selecting incision location, approaches to reduce corneal astigmatism were reported by 28.9%, neutral approaches by 26.2%, and insensitive approaches by 44.9%. Additionally, 55.6% of participants never implanted toric IOLs and 50.7% did not use presbyopia-correcting IOLs. The proportion of surgeons who have experience with femtosecond laser-assisted cataract surgery was 10.3% and the rate of intracameral antibiotic injection at the end of the operation was 89.4%.Conclusion:It was seen that Turkish cataract surgeons were able to use high technology for surgical preparation and surgery at high rates, but this was not reflected in practice at same rate in terms of achieving contemporary standards of refractive cataract surgery.

Postoperative management of lower limb split-thickness skin grafts in Australia

Background: Evidence for postoperative management of split-thickness skin grafts (SSGs) to lower leg wounds has shown early mobilisation has no adverse effects on graft take, while improving patient outcomes and significantly reducing hospitalisation costs. The development of negative-pressure wound therapy (NPWT) for SSGs led to new options for bolster dressings. This study aimed to determine the current postoperative mobilisation and dressing choices of Australian plastic surgeons. Methods: Australian plastic surgeons were invited electronically to participate in a questionnaire regarding their postoperative regimens for lower limb SSG in 2013, and again in 2018. A literature review was performed to establish whether surgeon-reported practice was in line with current evidence for early mobilisation of lower limb SSGs and also for NPWT on SSGs. Results: In 2013, 119 responses were received and in 2018, 110 responses were received. Survey responses showed significant reductions in the numbers of patients kept immobilised for more than five days (30% to 9%, p = 0.001) between 2013 and 2018. Surgeons reported immobilising their patients longer with standard dressings than with NPWT dressings (p = 0.003 by multinomial logistic regression). More than two-thirds of surgeons reported NPWT use in both 2013 (66%) and 2018 (70%). Conclusion: Between 2013 and 2018, NPWT use increased slightly and the percentage of surgeons mobilising their patients early significantly increased, in accordance with evidence in the literature. A link was noted between NPWT use and an increased tendency to early mobilisation. However, a large proportion of surgeons continued to prescribe bed rest postoperatively.

A small number of surgeons outside the control-limit: an observational study based on 9,482 cases and 208 surgeons performing primary total hip arthroplasties in western Sweden

Background and purpose — Feedback programs relating to surgeon levels have been introduced in some orthopedic quality registers around the globe. The aim of an established surgeon feedback program is to help surgeons understand their practice and enable an analysis of their own results. There is no surgeon feedback program in Sweden in the orthopedic quality registers and there is a fear that a feedback system might pinpoint surgeons as poor performers, partly due to patient case mix. As a step prior to the introduction of a future possible feedback program in Sweden, we assessed the variation in the occurrence of adverse events (AE) within 90 days and reoperations within 2 years between surgeons in western Sweden and explored the number of surgeons outside the control-limit following primary total hip arthroplasties (THAs).Patients and methods — Patient data, surgical data, and information on the surgeons, relating to surgeries performed in 2011–2016, were retrieved from 9 publicly funded hospitals in western Sweden. Data from medical hospital records, the Swedish Hip Arthroplasty Register (SHAR) and a regional patient register located in western Sweden were linked to a database. Funnel plots with control-limits based on upper 95% and 99.8% confidence intervals (CI) were used to illustrate the variation between surgeons in terms of the outcome and to explore the number of surgeons outside the control-limit. Both observed and standardized proportions are explored. The definition of surgeons outside the control-limit in the study is a surgeon above the upper 95% CI.Results — The study comprised 9,482 primary THAs due to osteoarthritis performed by 208 surgeons, where 91% of the included primary THAs were performed by orthopedic specialists and 9% by trainees. The mean overall annual volume for all surgeons was 27. The observed overall mean rate for AEs within 90 days for all surgeons was 6.2% (5.8–6.7) and for reoperations within 2 years 1.8% (1.7–2.2). The proportion of surgeons outside the 95% CI was low for both AEs (0–5%) and reoperations within 2 years (0–1%) in 2011–2016. The corresponding numbers were even lower for AEs (0–3%) but similar for reoperations (0–1%) after standardization for differences in case mix. In a sub-analysis when the number of surgeries performed was restricted to more than 10 primary THAs annually to being evaluated, almost half or more of all the surgeons were excluded from the annual analysis. The result of this restriction was that all surgeons outside the control-limit disappeared after standardization for both AEs and reoperations for all the years investigated. Considering the complete period of 6 years, less than 1% (1 high-volume surgeon for AEs and 2 high-volume surgeons for reoperations) after risk adjustments were outside the 95% CI, and no surgeons were outside the 99.8% CI.Interpretation — In a Swedish setting, the variation in surgeon performance, as measured by AEs within 90 days and reoperations within 2 years following primary THA, was small and 3% or less of the surgeons were outside the 95% CI for the investigated years after adjustments for case mix. The risk for an individual surgeon to be regarded as having poor performance when creating surgeon-specific feedback in the SHAR is very low when volume and patient risk factors are considered.

A survey of work-related musculoskeletal disorders associated with performing laparoscopic veterinary surgery.

To assess the prevalence of work-related musculoskeletal disorders (WRMD) associated with laparoscopy in veterinary surgery. Cross-sectional survey. Veterinary surgeons who perform laparoscopy. Responses were collected with data regarding laparoscopic activities and experience as well as whether the respondents experienced pain as a result of laparoscopy and, if so, additional information on this topic. Variables associated with the risk of experiencing pain were determined by using χ2 tests and odds ratios (OR). There were 149 respondents, an estimated 6% response proportion. Forty percent experienced pain that they attributed to the use of laparoscopic instruments during or after laparoscopic surgery. Surgeons who perform laparoscopic surgery frequently (at least monthly) were more likely to experience pain as a result of laparoscopic surgery compared with those who perform laparoscopic surgery infrequently (OR 2.25; 95% confidence interval 1.07-4.75; P = .033). Pain during or after laparoscopic surgery was most often experienced in the neck (81%), back (77%), and shoulders (75%), with 90% of respondents reporting that surgery exacerbated their pain. Fifty-four percent of respondents experienced the pain at home, 64% had taken painkillers for the pain, and 46% had sought other treatment for the pain such as physiotherapy, chiropractic treatment, or seeing a doctor. Laparoscopic surgery was a potential source of pain in a proportion of surgeons. Surgeons who frequently perform laparoscopic surgery were more likely to experience a WRMD. Work-related musculoskeletal disorders may occur as a result of performing laparoscopic surgery.

Evolving Trends in Textured Implant Use for Cosmetic Augmentation in the United States.

Breast implants have evolved for decades. In 2011, the U.S. Food and Drug Administration identified an association between textured breast implants and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The purpose of this study was to identify the trends of textured implant use since that time. Maintenance of Certification tracer data were queried between 2011 and 2015 for cosmetic breast augmentation cases submitted by American Board of Plastic Surgery diplomates. A nested random effects logistic regression analysis was used to identify associations between variables. Eleven thousand seven hundred sixteen breast augmentations were performed by 880 unique surgeons. The overall proportion of cases using textured implants increased steadily from 2.3 percent in 2011 to 13.0 percent in 2015 (p < 0.001). The proportion of surgeons whose cases included both textured and smooth implants increased (from 6.2 percent to 24.3 percent), as did those using only textured implants (from 0.4 percent to 4.4 percent) (p < 0.001). Significance remained after controlling for form-stable implants, suggesting an alternative motivation for use of textured implants. Subglandular cases (20.5 percent) were more likely to use a textured implant than submuscular (8.4 percent) or dual-plane (7.8 percent) (p < 0.001) cases. Maintenance of Certification tracer data represent a random sampling of American Board of Plastic Surgery-certified plastic surgeons spanning the gamut of practice settings. Despite ongoing education regarding the association of BIA-ALCL with textured implants, American Board of Plastic Surgery diplomates have trended toward increased use of textured implants for cosmetic breast augmentation since 2011. This finding does not appear to be driven by the introduction of anatomical implants during the study period.

Oncoplastic techniques: Attitudes and changing practice amongst breast and plastic surgeons in Great Britain

Abstract Purpose The availability, acceptability and practice of oncoplastic surgery has increased over the last 5 years. This study aims to describe how the breast and plastic surgical workforce has adapted to provide oncoplastic breast surgery. Methods A questionnaire was distributed to members of the Association of Breast Surgery and BAPRAS, and results compared to a survey completed in 2010. Results In 2010, 228 respondents completed the survey compared to 237 in 2015, of whom 204 were consultants (105 General or Breast Surgeons and 99 Plastic Surgeons). The range of procedures performed by Plastic Surgeons has remained static, the General and Breast Surgeons are performing proportionally more therapeutic mammaplasty (p Discussion Specific concerns about oncoplastic surgery have decreased over the last five years, with a greater proportion of surgeons performing oncoplastic surgery including lipomodelling. The majority of breast surgeons in 2015 remain interested in further training in oncoplastic techniques (75%) but over the last 5 years, plastic surgeons interest in further training in oncoplastic surgery has dropped from 62% to 27%. About half of all breast and plastic surgeons felt that oncoplastic surgery should be available for all women and oncological and wound healing concerns had significantly reduced between 2010 and 2015 (p

Surgical Human Resources According to Types of Health Care Facility: An Assessment in Low- and Middle-Income Countries

BackgroundA robust health care system providing safe surgical care to a population can only be achieved in conjunction with access to competent surgical personnel. It has been reported that 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed. This study aims to fill the existing gap in evidence by quantifying shortfalls in trained personnel delivering safe surgical and anaesthetic care in low- and middle-income countries (LMICs) according to the type of health care facility.MethodsWe conducted secondary analysis of 1323 health facilities, in 35 low- and middle-income countries using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care.ResultsThe majority of surgical and anaesthetic care in LMICs was provided by general doctors (range 13.8–41.1%; mean 27.1%). Non-physicians made up a significant proportion of the surgical workforce in LMICs. 26.76% of the surgical and anaesthetic workforce was provided by clinical medical officers and nurses. Private/NGO/mission hospitals, large, well-resourced institutions had the highest proportion of surgeons compared to any other type of health care facility at 27.92%. This compares to figures of 18.2 and 19.96% of surgeons at health centres and subdistrict/community hospitals, respectively, representing the lowest level of health facility.ConclusionsWe highlight the significant proportion of non-physicians delivering surgical and anaesthetic care in LMICs and illustrate wide variations according to the type of health care facility.

What drives overtreatment? Surgeon and radiation oncologist views on omission of adjuvant radiotherapy for elderly women with early stage breast cancer.

562 Background: Although trials have shown no survival advantage and only a modest improvement in local control from adjuvant radiotherapy after lumpectomy in older women with stage I, ER+ breast cancer, radiotherapy is commonly administered, raising concerns about overtreatment. Therefore, we sought to evaluate physician attitudes, knowledge, communication, and recommendations in this scenario. Methods: We mailed a survey to a national sample of 713 radiation oncologists and 879 surgeons between June to October 2015. Of these, 913 responded (57%). We assessed physicians’ attitudes, knowledge of pertinent risk information, and responses to clinical scenarios. Results: In patients age &gt; = 70 with stage I, ER+ breast cancer treated with lumpectomy and endocrine therapy, omission of radiotherapy was felt to be unreasonable by 40% of surgeons and 20% of radiation oncologists (p &lt; 0.001). Many surgeons (29%) and radiation oncologists (10%) erroneously associated radiotherapy in older women with improvement in survival. Similarly, 32% of surgeons and 19% of radiation oncologists tended to substantially overestimate the risk of locoregional recurrence in older women with omission of RT. In a scenario with an 81-year-old with multiple comorbidities, 31% of surgeons and 35% of radiation oncologists would still recommend radiotherapy. On multivariable analysis, erroneous attribution of a survival benefit to radiotherapy (OR 6.2; 95% CI 3.9-9.8) and overestimation of remaining life expectancy (OR 6.5; CI 4.2-9.9) were strongly associated with the opinion that radiotherapy omission is unreasonable. Conclusions: Many radiation oncologists and surgeons continue to consider omission of radiotherapy as substandard therapy. A sizeable proportion of surgeons overestimate radiotherapy’s benefits and consider omission of radiotherapy to be an unreasonable departure from the standard of care, suggesting that surgeon involvement in decisions about radiotherapy omission may be a key factor in reducing overuse of aggressive care in this setting.

Skin closure following fractured neck of femur surgery: a survey of orthopaedic surgeons’ practices

Surgical intervention for patients presenting with a fractured neck of femur is common, however the best method of skin closure remains unclear. It has been suggested that the use of metallic skin clips in the closure of hip wounds may increase the rate of surgical site infections, however there are few high quality studies evaluating this. We designed a survey to assess surgeons preferred skin closure method and their reasons for choosing it. This was sent to 545 consultant orthopaedic surgeons. The positive response rate to our survey was 68% (n = 370). The survey showed that 44% of surgeons used metallic skin clips, and this was the most common method of closure reported. Hip surgeons were less likely to use metallic skin clips when compared to surgeons with other principal subspecialty practices. Surgeons using clips were most likely to state the rationale for use as convenience, whereas those using non-clip skin closure methods were more likely to cite reduced rates of wound inflammation, discharge, and infection as the rationale for use. Only a small proportion of surgeons indicate that their decisions were evidence based. Skin closure following surgery for fractured neck of femur is not consistent amongst surgeons and is not driven by evidence. Greater levels of evidence in this field are required to improve outcomes in this patient group.

Abstract BL2: Changing paradigms in the local therapy of breast cancer: Making less more

Abstract The ability of surgery to cure breast cancer has not changed over time. What has changed is that the cancers seen in the screening era are smaller and have fewer nodal metastases, making them more amenable to surgical cure. Only 25% of patients enrolled in the landmark NSABP B-06 trial had cT1N0 disease compared to 80% of those enrolled in NSABP B32, which began 15 years later. At the same time, improved systemic therapy options and a better understanding of tumor biology have led to greater success in treating micrometastatic disease. Systemic therapy is now widespread for early-stage breast cancers and often for longer durations with anti-HER2 therapy given for 12 months and endocrine therapy for 5-10 years. The progressive addition of therapies has increased the burden of treatment for patients at the same time it has improved outcomes. The beneficial effect of systemic therapy on local control and the lower disease burden seen today offer the opportunity to decrease the morbidity of surgery without compromising outcomes. The ACOSOG Z011 trial, now with follow-up of 10 years, demonstrated no difference in locoregional recurrence or survival among patients with metastases in 1–2 sentinel nodes after sentinel node biopsy alone or axillary dissection (ALND) when treated with breast-conserving surgery (BCS) and whole breast irradiation (RT). In 9/2010 we began prospectively utilizing Z11 eligibility criteria in patients with cT1-2 N0 cancers undergoing breast conservation with ALND reserved for those with &amp;gt;2 nodal metastases or gross extracapsular extension. Of the initial 723 consecutive, unselected patients, ALND was avoided in 84%. At a mean follow-up of 33 months (12–68), there were no isolated axillary recurrences. The 5-year Kaplan Meier rate of any nodal recurrence was 98% (95% CI 96–99). In the 251 patients considered “high risk” based on triple negative, HER2+, or age &amp;lt;50 years or a combination of these factors, ALND was required in 15.5% vs 15.9% of postmenopausal, ER+ patients (p=.89). The same principles led us to address the issue of what constitutes an optimal negative margin in women with invasive breast cancer undergoing BCS and RT. After a metaanalysis and review of other relevant literature, an SSO-ASTRO sponsored consensus committee concluded that evidence did not support routinely obtaining margins more widely clear than no ink on tumor, and that adherence to this recommendation, disseminated in late 2013 and published 2/14, had the potential to significantly reduce the use of re-excision. Since that time, the proportion of surgeons in a population-based sample endorsing no ink on tumor as an adequate margin rose to over 60%, compared to 11% in a similar survey conducted in 2006–7. This change in attitude has translated into a reduction in the use of additional surgery, both re-excision and mastectomy after initial lumpectomy. In a SEER sample from 2013–15, this resulted in a 9% absolute increase in the use of BCS during the study period. The use of neoadjuvant therapy offers further opportunities to decrease the morbidity of surgery and individualize local therapy in the future. Citation Format: Morrow M. Changing paradigms in the local therapy of breast cancer: Making less more [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr BL2.

Surgeons' Perspectives of Contralateral Prophylactic Mastectomy.

Contralateral prophylactic mastectomy (CPM) is commonly performed for the treatment of breast cancer, despite its limited oncologic benefit. Little is known about surgeons' perceptions of performing CPM. We hypothesized that a proportion of surgeons would report discomfort with performing CPM, particularly when there is discordance between patients' perceived benefit from CPM and the expected oncologic benefit. A survey was sent to members of the American Society of Breast Surgeons seeking self-reports of surgeons' practice patterns, perceptions, and comfort levels with CPM. Of the 2436 members surveyed, 601 responded (response rate=24.7%). The median age of respondents was 52years, and 59% of responders were women. The majority (58%) reported that 80% of their practice was devoted to the treatment of breast disease. Fifty-seven percent (n=326) of respondents reported discomfort with performing CPM at some point in their practice. While most surgeons (95%) were comfortable with CPM on a patient with a deleterious BRCA mutation, only 34% were comfortable performing CPM on an average-risk patient. The most common reasons reported for surgeon discomfort with CPM were a concern for overtreatment, an unfavorable risk/benefit ratio, and inadequate patient understanding of the anticipated risks and benefits of CPM. Despite the increasing use of CPM for the treatment of breast cancer, many surgeons report discomfort with CPM. Concerns with performing CPM predominantly focus on ambiguities surrounding the oncologic benefit and relative risk of this procedure. Further research is needed to define optimal shared decision-making practices in this area.