Southwestern Surgical Congress Research Articles

Multicenter analysis of massive transfusion practices demonstrates variabilities across trauma centers in the Southwestern Surgical Congress

BackgroundThis study's purpose is to investigate emergent blood (EB) usage, massive transfusion protocols (MTP), and the use of pharmacologic adjuncts to resuscitation across trauma centers in the Southwestern Surgical Congress (SWSC). MethodsAnonymous, voluntary 26-question survey conducted by the SWSC multicenter trials group. Descriptive statistical analysis was performed. Results36 institutions across 14 states responded. EB is immediately available at 27 institutions. 53 ​% have LTOWB available. LTOWB is incorporated into MTP at 39 ​% of institutions and is the primary MTP product used at 4 centers. 65 ​% of institutions use thromboelastography to guide resuscitation. 70 ​% of institutions reported using TXA and 11 ​% used fibrinogen concentrate. 36 ​% of responding institutions routinely draw ionized calcium values. Four institutions have a calcium replacement protocol. Only 6 centers report redosing antibiotics during MTP. ConclusionEB availability and MTP practices are evolving with variability across the SWSC. Pharmacologic therapies remain poorly incorporated into the MTP.

Survey shows all surgical residents have exposure to robotic surgery yet no formalized curricula exist amongst programs: A Southwest Surgical Congress Survey

BackgroundIncreased robotic surgery exposure during general surgery training occurs at many institutions without a formal education curriculum. Our study evaluates the current state of general surgery robotic training within programs represented by the Southwestern Surgical Congress (SWSC). MethodsA web-based survey regarding robot-assisted surgery (RAS) and general surgery training was developed and sent to member institutions of the SWSC. General surgery program directors were asked to voluntarily complete the survey. Results were evaluated in aggregate. Descriptive analysis was used. ResultsIn total, 28 programs responded. All reported resident exposure to RAS during training. Case mix was diverse with exposure to multiple general surgical subspecialties. 89% of programs reported the presence of a formal RAS curriculum, however, only 53% reported recognition of training completion. Case volumes also varied amongst programs with 46% of programs reporting residents logging 21–40 cases and 35% logging more than 40 cases in total. ConclusionExposure to RAS among SWSC residency programs is ubiquitous, however, there is significant variation between programs in case volumes, case types, and elements of RAS curricula.

72nd Southwestern Surgical Congress Claude H. Organ, Jr. memorial lecture: Rise ofacutecareroboticsurgery forcommonemergencygeneralsurgeryconditions

Dr. Claude Organ rose above poverty, racism, and untold insurmountable odds to become a masterful surgeon and revered leader in numerous academic and professional circles. But it's his impact on surgical education and his philosophy to “teach, give back, and keep advancing” that inspired this lecture. Acute care robotic surgery (ACRS) utilizes the strengths of robotic assisted laparoscopic surgery (RALS) for a high-volume population of emergency general surgery (EGS) patients. The future benefits of ACRS may include improvements in resident training, patient safety, and outcomes. General surgery residencies that have a robust ACRS program are likely to be more competitive than those without.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey.

A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings. Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact. Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment. This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Protocol driven management of suspected common duct stones: A Southwestern Surgical Congress multi-centered trial

BackgroundSeveral options exist for the diagnosis and management of suspected common duct stones. We hypothesized that a protocol-directed approach would shorten length of stay in this patient population. MethodsPatients from four participating institutions with a peak bilirubin <4 mg/dL underwent surgery as the initial procedure, whereas patients with a bilirubin ≥4 mg/dL underwent endoscopy. The primary endpoint was length of stay. Analysis involved chi square and Wilcoxon-Mann-Whitney test with significance at p < 0.05. Results214 patients were managed under the protocol during six-month study period. 111 patients (52%) required endoscopy and surgery. Length of stay and the number of MRCPs performed pre-operatively significantly decreased following protocol implementation (p < 0.05). Conclusions“Surgery first” approach in patients with bilirubin <4 ml/dL resulted in low morbidity and mortality, reduced MRCP, and length of stay.

Follow-up trends after emergency department discharge for acutely symptomatic hernias: A southwestern surgical congress multi-center trial

BackgroundThe objective of this multi-center study was to examine the follow-up trends after emergency department (ED) discharge in a large and socioeconomically diverse patient population. MethodsWe performed a 3-year retrospective analysis of adult patients with acutely symptomatic hernias who were discharged from the EDs of five geographically diverse hospitals. ResultsOf 674 patients, 288 (43%) were evaluated in the clinic after discharge from the ED and 253 (37%) underwent repair. Follow-up was highest among those with insurance. A total of 119 patients (18%) returned to the ED for hernia-related complaints, of which 25 (21%) underwent urgent intervention. ConclusionThe plan of care for patients with acutely symptomatic hernias discharged from the ED depends on outpatient follow-up, but more than 50% of patients are lost to follow-up, and nearly 1 in 5 return to the ED. The uninsured are at particularly high risk.

The southwestern surgical congress multi-center trial on suspected common duct stones

BackgroundCholedocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones. MethodsA retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p < 0.05 for paired variables and p < 0.017 for multiple comparisons. ResultsTwelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31–94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8–3.7 mg/dl) and median common duct size 7 mm (IQR 5–10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one. ConclusionSignificant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.

Determining the impact of culture on venous thromboembolism prevention in trauma patients: A Southwestern Surgical Congress Multicenter trial

IntroductionVenous thromboembolism (VTE) remains one of the principal causes of morbidity and death in trauma patients that survive the first 24 h. Recent literature on VTE prevention focuses on choice of chemoprophylaxis, specifically unfractionated heparin (UFH) versus low molecular weight heparin (LMWH). This singular focus on a multifactorial process may be inadequate to fully understand the optimal approach to VTE prevention. We hypothesized that variations in care between trauma centers could be used to identify key components of VTE prevention associated with better outcomes. MethodsA 50 question survey of VTE management for years 2014–2016 was sent to 15 trauma centers. The survey included: demographics of the trauma centers, type and timing of chemoprophylaxis, ambulation expectations, and complementary services (geriatric trauma service (GTS), mobility teams, physical and occupational therapy (PT/OT)). Each center submitted their American College of Surgeons Trauma Quality Improvement Program (TQIP) Benchmark Report for Spring 2017. TQIP data included: mortality, observed rates of deep vein thrombosis (DVT) and pulmonary embolus (PE), and time to VTE prophylaxis. The survey and TQIP reports were blinded for analysis; descriptive statistics were utilized. The top DVT & PE TQIP performers were used to identify potential aspects of better care on the survey responses. The institutions’ DVT and PE rates were then compared for these responses using Wilcoxon-Rank-Sum test. ResultsFifteen trauma centers (13 Level-1, 2 Level-2) completed the survey; the centers admitted 1050–7200 trauma patients per year (median 3000). The majority of centers were University-affiliated (11 of 15) with general surgery residencies (14 of 15), Acute Care Surgery or Surgical Critical Care Fellowships, (9 of 15) and critical care boarded-surgeons only on-call (9 of 15). Few have geriatric trauma services (3 of 15) or mobility teams (1 of 15). Half the trauma centers have dedicated PT/OT teams for trauma or weekend coverage. With a total of 20,878 TQIP patients analyzed, the average observed DVT and PE rates were 1.27% (range 0.1–5.2%) and 0.68% (range 0–1.6%), respectively. Weekly lower extremity surveillance duplex (2 of 15) increased DVT detection (4.15% vs 0.80%, p = 0.034) but did not decrease PE rates (1.05% vs 0.62%, p = 0.229). Great variance was seen in choice, dosing and timing of chemoprophylaxis: UFH,4 LMWH daily,1 LMWH twice-daily,5 LMWH weight-based dosing,4 and LMWH anti-Xa dosing.1 The top 3 performers for DVT and PE all used different types of chemoprophylaxis. These top performers had a prominent culture of mobility: dedicated PT/OT teams for trauma or weekends and an expectation to ambulate 3-times per day. Weekend PT/OT teams were associated with lower DVT rates (median 0.40%, range 0.10–1.10% vs 1.30%, 0.60–5.20%, p = 0.018), and ambulation 3-times per day was associated with lower PE rates (median 0.20%, range 0.00–0.20% vs 0.80%, 0.40–1.60%, p < 0.005). ConclusionsConsiderable variation in VTE chemoprophylaxis exists among trauma centers. “Best practices” in this area requires further investigation. An expectation of mobility and investment in mobility resources may serve to decrease VTE rates in trauma patients compared to a singular focus on type of chemoprophylaxis administered.

Discussion of: “Outpatient laparoscopic appendectomy can be successfully performed for uncomplicated appendicitis: A Southwestern Surgical Congress multicenter trial”

Abstract Background Many laparoscopic procedures are now performed on an outpatient basis. We hypothesize laparoscopic appendectomy can be safely performed as an outpatient procedure. Methods Seven institutions adopted a previously described outpatient laparoscopic appendectomy protocol for uncomplicated appendicitis. Patients were dismissed unless there was a clinical indication for admission. Patient demographics, success with outpatient management, time of dismissal, morbidity, and readmissions were analyzed. Results Two hundred six men and one hundred seventy women with a mean age of 35.4 years were included in the protocol. Seventy-eight patients (21%) had pre-existing comorbidities. 299 patients (80%) were managed as outpatients. There were no conversions to open appendectomy. Postoperative morbidity was 5%. The time of patient dismissals was evenly distributed throughout the day and night. Twelve patients (3%) required readmission. Outpatient follow-up occurred in 63% of patients. Conclusions An outpatient laparoscopic appendectomy protocol was successfully applied at multiple institutions with low morbidity and low readmission rates. Application of this practice nationally could reduce length of stay and decrease overall health care costs for acute appendicitis.

Discussion of: “Southwestern Surgical Congress Jack A. Barney award competition presenters – Where are they now?”

Discussion of: “Southwestern Surgical Congress Jack A. Barney award competition presenters – Where are they now?”

Southwestern Surgical Congress Jack A. Barney award competition presenters – Where are they now?

BackgroundResident research presentations at surgical conferences may encourage future research endeavors. Methods2010–2016 SWSC annual meeting programs were reviewed for presenters eligible for the Jack Barney award. Award recipients from 1987 to 2016 were included. ResultsThere were 100 unique presenters eligible for the Jack Barney award, and 28 unique award recipients. Thirty-six (82%) presenters currently practice in a community setting, 5 (11%) at a university hospital, 2 (5%) internationally, and 1 (2%) in a military hospital. Scholarly articles were published by 41% of presenters. Sixteen of the 28 recipients (57%) practice in community hospitals, and 9 (32%) practice in university settings; 3 are still in training. Twenty recipients (71%) published after residency. Thirty percent and 25% of presenters and recipients are SWSC members, respectively. ConclusionsPeer-reviewed publications were frequent among eligible presenters and award recipients. Encouraging presenters to become SWSC members provides an opportunity for improved retention.

Outpatient laparoscopic appendectomy can be successfully performed for uncomplicated appendicitis: A Southwestern Surgical Congress multicenter trial

BackgroundMany laparoscopic procedures are now performed on an outpatient basis. We hypothesize laparoscopic appendectomy can be safely performed as an outpatient procedure. MethodsSeven institutions adopted a previously described outpatient laparoscopic appendectomy protocol for uncomplicated appendicitis. Patients were dismissed unless there was a clinical indication for admission. Patient demographics, success with outpatient management, time of dismissal, morbidity, and readmissions were analyzed. ResultsTwo hundred six men and one hundred seventy women with a mean age of 35.4 years were included in the protocol. Seventy-eight patients (21%) had pre-existing comorbidities. 299 patients (80%) were managed as outpatients. There were no conversions to open appendectomy. Postoperative morbidity was 5%. The time of patient dismissals was evenly distributed throughout the day and night. Twelve patients (3%) required readmission. Outpatient follow-up occurred in 63% of patients. ConclusionsAn outpatient laparoscopic appendectomy protocol was successfully applied at multiple institutions with low morbidity and low readmission rates. Application of this practice nationally could reduce length of stay and decrease overall health care costs for acute appendicitis.

The American Board of Surgery examinations: how are the Southwestern Surgical Congress programs performing compared to the rest of the United States?

BackgroundOur aim was to study pass rates of the American Board of Surgery (ABS) examinations for examinees from programs in the Southwestern Surgical Congress (SWSC) compared with the rest of the United States (Non-SWSC). MethodsA retrospective review of pass rates of ABS Qualifying Examination (QE), Certifying Examination (CE), and QE/CE index from 2005 to 2015 was conducted. ResultsFrom 2005 to 2010, SWSC outperformed Non-SWSC in QE (88% vs 85%, P < .02), CE (86% vs 82%, P < .01), and QE/CE (77% vs 72%, P < .01). From 2010 to 2015, SWSC outperformed Non-SWSC in QE (91% vs 86%, P < .01) and QE/CE (77% vs 71%, P < .01) but did not achieve statistical significance in CE (83% vs 81%, P = .09). ConclusionsSWSC programs outperformed Non-SWSC across QE and CE in the early period, but only on QE in the late period. We encourage SWSC states and regional surgical societies to evaluate performance on ABS examinations and collaborate to improve surgical training.

From the laboratory bench to the operating room: the role of the surgeon in cancer prevention

BackgroundThe last 200 years have seen remarkable achievements in the art and clinical practice of surgery. These advances include the introduction of antisepsis, anesthesia, vascular anastomosis, antimicrobials, organ transplantation, and the widespread application of minimally invasive operative procedures. Very recently, a surgical procedure has been shown to cure diabetes, representing the most effective treatment of a metabolic disorder by surgeons. MethodsThe author reviewed the major surgical milestones in the modern surgical era and prepared this monograph for presentation as the Claude H. Organ, Jr. Memorial Lecture at the 68th Annual Meeting of the Southwestern Surgical Congress. Results/ConclusionsThis address summarizes the story of medullary thyroid carcinoma and multiple endocrine neoplasia type 2, an archetype for a surgical procedure to prevent cancer development.

Perspectives on the profession

In his presidential address to the Southwestern Surgical Congress, he examines surgery as a profession from three different perspectives: his experience as a patient, a surgeon, and a photographer. He uses photography to illustrate the importance of perspective and illumination. He respectfully suggests that we should consciously choose to reframe the profession from a different perspective that accurately reflects its beauty. He also advises that we take effort to shine a gentle, soft light on the profession, a light that will reveal the beauty, the true beauty, of the profession. And finally, he submits that it is our responsibility to consciously and faithfully maintain and defend the profession from enemies inside and outside its borders.

A history of the American Board of Surgery: vignettes from the certifying examination: The Edgar J. Poth Memorial Lecture

The American Board of Surgery was established in 1937 to certify surgeons who through training, experience, and examination meet the highest standards of surgical care. This lecture was given as the Edgar Poth lecture at the April 2015 meeting of the Southwestern Surgical Congress. Dr Poth was a surgical educator from the University of Texas Medical Branch, Galveston who was President of the Southwestern in 1963. The paper presents the history of the founding of the American Board of Surgery, with particular emphasis on the certifying examination—Part 2. Vignettes of occurrences associated with the “Oral” examination are given. The examination has changed substantially from a 2-day event involving an actual surgical procedure to the 90-minute quiz given today. The oral examinations remain an important part in the process of certification of surgeons of the highest quality.

Geographic maldistribution of general surgery PGYI residents: another US surgical desert

BackgroundPracticing general surgeons are unevenly distributed across the country. This study evaluates the geographic distribution of categorical, general surgery (GS) PGYI positions per capita. MethodsData were obtained from the 2012 National Resident Matching Program match and the 2010 US Census. ResultsThe mean for GS PGYI positions per 106 population was 3.85 ± .61; 27 states fell below this value. The 7 American College of Surgeons (ACS) regions ranged from a low of 1.4 ± .50 (Intermountain) to a high of 9.89 ± 4.41 (Northeast). The mean (2.18 ± .34) for the 19 state membership of the Southwestern Surgical Congress was below the mean for the country. ConclusionsThere is a maldistribution of GS PGYI positions compared with state and regional populations, particularly in rural areas. This mirrors the maldistribution of practicing general surgeons across the United States. Additional GS residences and resident positions are urgently needed to correct this “Surgical Desert” of graduate surgical education.

Southwestern Surgical Congress presidential address 2013

Southwestern Surgical Congress presidential address 2013

Current Approaches to Journal Club by General Surgery Programs Within the Southwestern Surgical Congress

Journal club (JC) is a well-recognized education tool for many postgraduate medical education programs. Journal club helps residents learn critical analytic skills and keep up to date with current medical practices. To our knowledge, there is minimal evidence in the current literature detailing modern JC practices of general surgery training programs. Our study attempts to define how general surgery residency programs are implementing JC in their training process. We distributed by mail a 14-question survey to general surgery program directors within the Southwestern Surgical Congress. These surveys were redistributed 1 month after the initial attempt. The responses were collected and analyzed. Survey questions aimed to define JC practice characteristics, such as where JC is held, when JC is held, who directs JC, what journals are used, the perceived importance of JC, and average attendance. The surveys were sent to 32 program directors (PDs), which included 26 university and 6 community-based programs. We received responses from 26 (81%) PDs. Ninety-two percent of the programs have a consistent journal club (JC). Most JCs meet monthly (64%) or weekly (16%). The meeting places ranged from conference rooms (60%), faculty homes (20%), restaurants (8%), or in the hospital (12%). The meeting times were divided between morning (29%), midday (29%), and evening (42%). Most JCs lasted between 1 and 2 hours (88%), reviewed 1-4 articles (88%), and are attended by more than 60% of residents routinely (75%). Half of the programs (50%) had 3-4 faculty members present during discussion; 29% of the programs had only 1-2 faculty present. The articles were selected from more than 10 different journals. Seventy-five percent of the programs used the American Journal of Surgery and Annals of Surgery to find articles; only 13% of the programs used evidence-based reviews in surgery. PDs believe JC is very beneficial (42%), moderately beneficial (42%), or only fairly beneficial (16%). According to PDs, JC is most beneficial because it improves clinical knowledge (88%), initiates additional reading (62%), and improves American Board of Surgery In-Training Examination (ABSITE) scores (15%). Journal club has historically been an integral part of general surgery training. Our research indicates that journal club is still used widely as a beneficial educational resource and helps meet core competency requirements.

Done vida—donate life: a surgeon’s perspective of organ donation

Background This report is the Presidential Address of the 59th Annual Meeting of the Southwestern Surgical Congress. Organ donation is discussed from the perspective of a trauma surgeon, a prospective live organ donor and a father of a transplant recipient. Current issues to increase organ donation in the United States are addressed. Methods Recent publications of the Institute of Medicine (IOM) with respect to non–heart beating donation and efforts to increase organ donation were reviewed. Results Data from the Scientific Registry of Transplant Recipients/Organ Procurement and Transplant Network were reviewed and cited in the report. Data also were obtained from the Donor Network of Arizona. Conclusions The recommendations provided by the IOM and others should strengthen efforts to increase organ donation. It is hoped that collectively they will help to decrease the disparity between the number of solid organs available and the number of patients on the transplant recipient waiting list. The efforts of the participating organ procurement organization in the breakthrough collaborative are providing evidence that the IOM suggestions can be implemented with success.