Longer shifts are not harmful to patients and encourage professionalism, argues Steven Stain. But Michael Farquhar emphasises the debilitating effect of sleep deprivation
BACKGROUND:Surgical site infection is a key hospital-level patient safety indicator. All risk factors for surgical site infection are not always taken into account and adjusted for.
OBJECTIVE:This ...study aimed to measure the impact of IBD in comparison with diverticulitis and colorectal cancer on the national rates of surgical site infection.
DESIGN:The American College of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing elective colectomy for colon cancer, diverticulitis, and IBD from 2008 through 2012.
OUTCOME MEASURES:The association between surgical site infection and IBD patients was assessed. Patient demographics, rates of surgical site infection, wound class, return to operating room, and various patient characteristics were analyzed. Logistic regression was performed to determine the association with surgical site infection.
RESULTS:The query yielded 71,845 patients undergoing elective colectomy. Of these patients, 42,132 had colon cancer, 22,143 had diverticulitis, and 7570 had IBD. The rate of surgical site infection was 12.0% for colon cancer, 12.8% for diverticulitis, and 18.0% for IBD. Return to operating room within 30 days was 7.3% for IBD patients, 4.4% for patients with diverticulitis, and 4.9% for patients with colorectal cancer. Return to operating room within 30 days had the highest correlation to surgical site infection in both univariate and multivariable analysis. Other associative factors for surgical site infection common to both analyses included diabetes mellitus, smoking, open procedures, and obesity.
LIMITATIONS:This study was limited by the data collection errors inherent to large databases, exclusion of emergent operations, and the inability to identify patients taking immunosuppressive agents.
CONCLUSIONS:Patients with IBD undergoing elective colectomy have significantly increased rates of surgical site infection, specifically deep and organ/space infections. Given this information, risk adjustment models for surgical site infection may need to include IBD in their calculation.
The COVID-19 pandemic disrupted the delivery of surgical services. The purpose of this communication was to report the impact of the pandemic on surgical training and learner well-being and to ...document adaptations made by surgery departments.
A 37-item survey was distributed to educational leaders in general surgery and other surgical specialty training programs. It included both closed- and open-ended questions and the self-reported stages of GME during the COVID-19 pandemic, as defined by the ACGME. Statistical associations for items with stage were assessed using categorical analysis.
The response rate was 21% (472 of 2,196). US stage distribution (n = 447) was as follows: stage 1, 22%; stage 2, 48%; and stage 3, 30%. Impact on clinical education significantly increased by stage, with severe reductions in nonemergency operations (73% and 86% vs 98%) and emergency operations (8% and 16% vs 34%). Variable effects were reported on minimal expected case numbers across all stages. Reductions were reported in outpatient experience (83%), in-hospital experience (70%), and outside rotations (57%). Increases in ICU rotations were reported with advancing stage (7% and 13% vs 37%). Severity of impact on didactic education increased with stage (14% and 30% vs 46%). Virtual conferences were adopted by 97% across all stages. Severity of impact on learner well-being increased by stage—physical safety (6% and 9% vs 31%), physical health (0% and 7% vs 17%), and emotional health (11% and 24% vs 42%). Regardless of stage, most but not all made adaptations to support trainees’ well-being.
The pandemic adversely impacted surgical training and the well-being of learners across all surgical specialties proportional to increasing ACGME stage. There is a need to develop education disaster plans to support technical competency and learner well-being. Careful assessment for program advancement will also be necessary. The experience during this pandemic shows that virtual learning and telemedicine will have a considerable impact on the future of surgical education.
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Adequate lymph node (LN) excision is imperative for pathologic staging and determination of adjuvant treatment.
he 2004–2017 National Cancer Database (NCDB) was queried for curative colon cancer ...resections. Tumors were categorized by location: left, right, and transverse colon cancers. Adequate (12–20 LNs) vs. inadequate (<12 LNs) lymphadenectomy was examined and sub-analysis of <12 LNs, 12–20 LNs or >20 LNs. Primary outcome was predictors of inadequate lymph node retrieval.
Of 101,551 patients, 11.2% (11,439) had inadequate lymphadenectomy. The inadequate lymphadenectomy rate steadily decreased. On multivariable analysis, inadequate LN retrieval was associated with transverse (OR 1.49, CI 1.30–1.71) and left colon cancers (OR 2.66, CI 2.42–2.93, whereas income >$63,333 had decreased likelihood of inadequate LN retrieval (OR 0.68, CI0.56–0.82.
We are making the grade as NCDB data demonstrates a steady decrease in inadequate lymphadenectomy (2004–2017). There remain socioeconomic risk factors for inadequate lymphadenectomy that need to be addressed.
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•Adequate lymphadenectomy for colon cancer resections has steadily increased.•Patients with >20 lymph nodes retrieved had optimal 5 year overall survival.•There are socioeconomic variables that predict inadequate lymph node retrieval.
Program directors use US Medical Licensing Exam (USMLE) scores as criteria for ranking applicants. First-time pass rates of the American Board of Surgery (ABS) Qualifying (QE) and Certifying (CE) ...Examinations have become important measures of residency program quality. USMLE Step 1 will become pass/fail in 2022.
American Board of Surgery QE and CE success rates were assessed considering multiple characteristics of highly ranked (top 20) applicants to 22 general surgery programs in 2011. Chi-square, t-test, Wilcoxon Rank sum, linear and logistic regression were used, as appropriate.
The QE and CE first attempt pass rates were 96% (235/244) and 86% (190/221), respectively. QE/CE success was not significantly associated with sex, race, research experience, or publications. Alpha Omega Alpha (AΩA) status was associated with success on the index CE (98% vs 83%; p = 0.008). Step 1 and Step 2 Clinical Knowledge (CK) scores of surgeons who passed QE on their first attempt were higher than scores of those who failed (Step 1: 233 vs 218; p = 0.016); (Step 2CK: 244 vs 228, p = 0.009). For every 10-point increase in Step 1 and 2CK scores, the odds of passing CE on the first attempt increased 1.5 times (95% CI 1.12, 2.0; p = 0.006) and 1.5 times (95% CI 1.11, 2.02, p = 0.008), respectively. For every 10-point increase in Steps 1 and 2CK scores, the odds of passing the QE on the first attempt increased 1.85 times (95% CI 1.11, 3.09; p = 0.018) and 1.86 times (95% CI 1.14, 3.06, p = 0.013), respectively.
USMLE Step 1 and Step 2 CK examination scores correlate with American Board of Surgery QE and CE performance and success. The USMLE decision to transition Step 1 to a pass/fail examination will require program directors to identify other factors that predict ABS performance for ranking applicants.
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Examine the association between sex, race, ethnicity, and family income, and the intersectionality between these identities, and sustained or cultivated paths in surgery in medical school.
This ...retrospective cohort study examines US medical students who matriculated in academic years 2014-2015 and 2015-2016. Data were provided by the Association of American Medical Colleges, including self-reported sex, race, ethnicity, family income, interest in surgery at matriculation, and successful placement into a surgical residency at graduation. This study examined 2 outcomes: (1) sustained path in surgery between matriculation and graduation for students who entered medical school with an interest in surgery and (2) cultivated path in surgery for students who entered medical school not initially interested in surgery and who applied to and were successfully placed into a surgical residency at graduation.
Among the 5074 students who reported interest in surgery at matriculation, 2108 (41.5%) had sustained path in surgery. Compared to male students, female students were significantly less likely to have sustained path in surgery adjusted relative risk (aRR): 0.92 (0.85-0.98), while Asian (aRR: 0.82, 95% CI: 0.74-0.91), Hispanic (aRR: 0.70, 95% CI: 0.59-0.83), and low-income (aRR: 0.85, 95% CI: 0.78-0.92) students were less likely to have a sustained path in surgery compared to their peers. Among the 17,586 students who reported an initial interest in a nonsurgical specialty, 1869 (10.6%) were placed into a surgical residency at graduation. Female students, regardless of race/ethnic identity and income, were significantly less likely to have cultivated paths in surgery compared to male students, with underrepresented in medicine female students reporting the lowest rates.
This study demonstrates the significant disparity in sustained and cultivated paths in surgery during undergraduate medical education. Innovative transformation of the surgical learning environment to promote surgical identity development and belonging for females, underrepresented in medicine, and low-income students is essential to diversify the surgical workforce.
Abstract Background Little is known about how the immunologic microenvironment changes during tumor progression and metastatic spread. Recently, murine models have shown the Th17 pathway to play an ...important role in promoting colorectal cancer. The purpose of this study was to compare cytokine profiles in the tumor microenvironment of colorectal cancer between local disease (stages I/II) and advanced disease (stages III/IV), and to determine whether these changes were manifest in the systemic circulation of patients with advanced disease. Materials and Methods Serum and tissue cytokine profiles were assayed among patients with documented adenocarcinoma prior to surgical resection at a single institution from September 2014 to February 2015. Using the Bio-Plex ProTM Human Th17 Cytokine Assay Kit (Bio-Rad Laboratories), the concentrations of multiple cytokines were determined. Multiple logistic regression analyses were used to evaluate the association between TNM staging and cytokine levels. Results A total of 33 patients with documented adenocarcinoma were included. None of the patients received neo-adjuvant chemotherapy. AJCC TNM classification was used. Advanced disease was associated with elevated tumor levels of TNF-α, IL-4, IL-10, IL-17A, and IL-17F, and only stage IV showed elevated systemic levels of Th17-associated cytokines IL-17F, IL-23, and IL-25. Conclusions The Th17 pathway likely has important mechanistic implications in human colorectal cancer. Metastatic disease was associated with elevated Th17-associated cytokines both in colonic tissue and systemically. These changes in systemic expression of Th17-associated cytokines could establish novel pathways for colorectal cancer and warrant further investigation.
Introduction
Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either ...simple diverticulitis (SD) or complicated diverticulitis (CD).
Purpose
To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis.
Methods
Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively.
Results
Of the 576 patients in the CRSD, 139 (24.1 %) had CD. The overall conversion rate was 12.8 % (
n
= 74). The average BMI was 29.8 kg/m
2
. The conversion rate for CD was 12.2 %. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days,
p
= 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days,
p
= 0.08). The overall anastomotic leak rate was 2.1 % (
n
= 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0 % (
n
= 38), whereas those with CD had a postoperative morbidity rate of 19.6 % (
n
= 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4 %,
n
= 5,
p
= 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95 % CI 1.11–3.46,
p
= 0.02) was found to be an independent risk factor for the development of postoperative complications.
Conclusions
Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.
Background Identification of factors that might predict readmission after bariatric surgery could help surgeons target high-risk patients. The purpose of this study was to identify comorbidities, ...surgical variables, and postoperative complications associated with readmission. Study Design Patients with bariatric surgery as their primary procedure were identified from the 2012 American College of Surgeons (ACS) NSQIP database. Patient variables, operative times, and major postoperative complications were analyzed for predictors of readmission. The ACS NSQIP estimated probability of morbidity (MORBPROB) was also considered. Chi-square tests and Poisson regression were used for statistical analysis to identify significant predictors. Results There were 18,186 patients who met inclusion criteria. There were 1,819 who had a laparoscopic gastric band, 9,613 who had laparoscopic Roux-en-Y gastric bypass (RYGB), 6,439 who had gastroplasties (vertical banded gastroplasty and sleeve), and 315 who had open RYGB. Age, sex, BMI, American Society of Anesthesiologists (ASA) class, diabetes, hypertension, steroid use, type of procedure, and operative time all were significantly associated with readmission within 30 days of operation. All major postoperative complications were significant predictors of readmission. Patients expected to be at high risk based on the ACS NSQIP MORBPROB had a significantly higher rate of readmissions. The overall readmission rate for patients undergoing bariatric surgery was 5%. The readmission rate among patients with any major complication was 31%. Conclusions Bariatric surgery is a low-risk procedure. Complexity of operation, ASA class, prolonged operative time, and major postoperative complications are important determinants of high risk for readmission. The ACS NSQIP MORBPROB may be a useful tool to identify and target patients at risk for readmission.
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