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1.
Joshua J. Weis Deborah Farr Kareem R. Abdelfattah Deborah Hogg Daniel J. Scott 《American journal of surgery》2019,217(2):244-249
Background
Pre-internship boot camps have become popular platforms to rapidly teach skills to surgical interns. This study aimed to analyze psychomotor skill retention four months after completing a boot camp program.Methods
Surgical interns (n?=?20) took a baseline pre-test and then trained to proficiency (based on time and errors) for 5 knot tying, 4 simple suturing, and 2 running suturing tasks during a three-day boot camp. Three months later, all interns took a retention test.Results
Proficiency scores significantly improved on all task types from pre-test to post test and significantly regressed on all task types from post-test to retention test. Normalized scores decreased as the tasks became more complex (knot tying?=?93.5, simple suturing?=?89.1, running suturing?=?85.2, p?=?0.05).Conclusions
Boot camp style training can rapidly teach fundamental surgical skills to novices; however, skills regress significantly over time with a greater degree of regression seen on more complex skills. 相似文献2.
Anghela Z. Paredes Eliza W. Beal Fabio Bagante Mary E. Dillhoff Jordan M. Cloyd Timothy M. Pawlik 《American journal of surgery》2019,217(3):413-416
Background
The objective of this study was to examine risk factors and outcomes of hospital readmission following complex hepatopancreatobiliary (HPB) surgery among the elderly.Methods
The Nationwide Readmissions Database was queried for patients?≥?60 years who underwent HPB surgery during 2010–2015.Results
The incidence of 30- and 90-day readmission was similar among patients 60–74 vs. ≥75 (P?>?0.05). Patients age 60–74 years with ≥2 comorbidities had an increased odds of 30-day (OR 1.13, p?=?0.021) and 90-day (OR 1.13, p?=?0.005) readmission. Patients ≥75 years with ≥2 comorbidities had the highest in-hospital mortality (5%) whereas patients 60–74 years with 0 or 1 comorbidity had the lowest in-hospital mortality on readmission (3%).Conclusion
Following an HPB procedure, roughly 1 in 7 elderly patients were readmitted within 30 days and 1 in 4 patients within 90 days. Elderly patients with multiple comorbidities were more likely to be readmitted at non-index hospitals. 相似文献3.
Elise A. Dasinger Westyn Branch-Elliman Steven D. Pizer Hassen Abdulkerim Amy K. Rosen Martin P. Charns Mary T. Hawn Kamal M.F. Itani Hillary J. Mull 《American journal of surgery》2019,217(4):605-612
Background
Opioid-related adverse drug events are common following inpatient surgical procedures. Little is known about opioid prescribing after outpatient surgical procedures and if opioid use is associated with short term risks of outpatient surgical adverse events (AEs).Methods
VA Corporate Data Warehouse was used to identify opioid use within 48?h for FY2012-14 chart-reviewed cases from a larger VA study of AEs in outpatient surgeries. We estimated a multilevel logistic regression model to determine the effect of opioid exposure on risk of AEs between 2 and 30 days postoperatively.Results
Of the 1730 outpatient surgical cases, 628 (36%) had postoperative opioid use and 12% had an AE. Opioid use following outpatient surgery was not significantly associated with higher surgical AE rates after controlling for relevant covariates (OR?=?1.1 95% CI 0.79–1.54). Only procedure RVUs were associated with higher odds of postoperative AEs.Conclusions
Postoperative opioid use following outpatient surgery is not a significant driver of postoperative AEs. 相似文献4.
Background
Few studies have evaluated surgical outcomes in long-term follow-up for patients undergoing Laparoscopic Ventral Hernia Repair (LVHR).Methods
A retrospective review of long-term follow-up of LVHR patients (2002–2005) at a single institution.Results
Sixty-three patients (37 males; mean age?=?63, mean BMI?=?33, 41% for recurrence) underwent LVHR. Mean operative time was 164?min. Mean hospital stay was 3.7 days. Short- and long-term complications occurred in 19% and 44% of patients, respectively.Mean follow-up was 12.4 years. Recurrent hernias were noted in 15 patients. Seroma formation occurred in 14 patients; small bowel obstruction occurred in 10 patients. Five patients developed mesh infection. Use of PTFE mesh, longer operative time, and a larger hernia defect were risk factors for mesh infection (p?<?0.05).Conclusions
Long-term outcomes for patients undergoing LVHR are fraught with complications (44%) and a considerable risk of hernia recurrence (23%). 相似文献5.
Christina Norrbom Marianne Steding-Jessen Carsten Thye Agger Merete Osler Marie Krabbe-Sorensen Annette Settnes Lisbeth Nilas Ellen Christine Leth Loekkegaard 《American journal of surgery》2019,217(4):694-703
Background
Adhesive bowel obstruction is associated with considerable morbidity and mortality, but the magnitude of the risk is debated.Method
In a national cohort of all Danish women with an abdominal operation (N?=?665,423) between 1977 and 2013, the risk of adhesive bowel obstruction was assessed by Cox multiple regression. Covariates were the number of abdominal operations, the surgical methods, the anatomical site involved, and the calendar year.Results
In the cohort, 1.4% experienced an episode of adhesive bowel obstruction. The risk increased 33–43% during the study period, was lower after gynecological and obstetrical procedures compared to gastrointestinal (HR 0.36 [0.34–0.38]), lower after laparoscopic compared to laparotomic surgery (HR 0.51 [0.48–0.54]) and increased proportionally after each additional operation.Conclusions
The risk of adhesive bowel obstruction after abdominal operations depends on the site of earlier operations, the method of access and the number of earlier operations. 相似文献6.
Cynthia M. Tom James D. Maciel Abraham Korn Junko J. Ozao-Choy Danielle M. Hari Angela L. Neville Christian de Virgilio Christine Dauphine 《American journal of surgery》2019,217(2):256-260
Background
Robotic surgery is increasingly adopted into surgical practice, but it remains unclear what level of robotic training general surgery residents receive. The purpose of our study was to assess the variation in robotic surgery training amongst general surgery residency programs in the United States.Methods
A web-based survey was sent to 277 general surgery residency programs to determine characteristics of resident experience and training in robotic surgery.Results
A total of 114 (41%) programs responded. 92% (n?=?105) have residents participating in robotic surgeries; 68%(n?=?71) of which have a robotics curriculum, 44%(n?=?46) track residents’ robotic experience, and 55%(n?=?58) offer formal recognition of training completion. Responses from university-affiliated (n?=?83) and independent (n?=?31) programs were not significantly different.Conclusions
Many general surgery residencies offer robotic surgery experience, but vary widely in requisite components, formal credentialing, and case tracking. There is a need to adopt a standardized training curriculum and document resident competency. 相似文献7.
Guy Sheahan Richard Reznick Don Klinger Leslie Flynn Boris Zevin 《American journal of surgery》2019,217(2):214-221
Purpose
Video feedback and faculty feedback has been shown to improve surgical performance; however, consistent access to faculty is challenging. We studied the utility of structured peer-feedback (PF) compared to faculty-feedback (FF) during acquisition of basic and intermediate surgical skills.Methodology
Two randomized non-inferiority trials were conducted with 1st (n?=?30) and 2nd year (n?=?29) medical students learning skin-lesion excision and closure (S), and single-layer hand-sewn bowel anastomosis (B), respectively. Five attempts were performed. PF participants used an Objective Structured Assessment of Technical Skills tool to guide feedback. Blinded raters assessed video-recorded performance, time and Integrity of the completed task were also assessed.Results
For both tasks performance by PF was comparable to FF (P?=?0.111). Both groups improved significantly: performance (B:P?<?0.0001, S:P?=?0.035), time (B:P?=?0.043, S:P?<?0.0001) and integrity (B:P?<?0.0001, S:P?<?0.032).Conclusion
Structured peer-feedback is equivalent to faculty-feedback in the acquisition of basic and intermediate surgical skills, giving students freedom to practice independently. 相似文献8.
Stephanie A. Valente Yitian Liu Siddhi Upadhyaya Chao Tu Debra A. Pratt 《American journal of surgery》2019,217(3):514-518
Introduction
The aim of this study was to determine whether complications following mastectomy with immediate breast reconstruction (IBR) were associated with breast cancer recurrence.Methods
A retrospective review was performed of women diagnosed with stage I-III breast cancer who underwent mastectomy with IBR between 2005 and 2010. Patient demographics, tumor data, surgical wound complications, treatment details and timing were recorded and analyzed.Results
We identified 458 women with a median follow up time of 7.6 years. A total of 22% of patients experienced IBR complications. There was a delay in initiation of adjuvant therapy in patients who had a complication (52 vs 41 days, p?<?0.001). There was no significant difference in recurrences between groups with and without complications (p?=?0.65).Conclusions
In breast cancer patients who undergo mastectomy with IBR, wound complications delayed initiation of adjuvant systemic therapy, but were not associated with an increased risk of cancer recurrence. 相似文献9.
Areg Grigorian Jeffrey Milliken Joshua K. Livingston Dean Spencer Viktor Gabriel Sebastian D. Schubl Allen Kong Cristobal Barrios Victor Joe Jeffry Nahmias 《American journal of surgery》2019,217(4):639-642
Background
Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI.Methods
We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients.Results
BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR?=?5.52, CI?=?5.32–5.73, p?<?0.001) compared to TAI (OR?=?4.82, CI?=?4.50–5.17, p?<?0.001). However, the strongest independent predictor was hemopneumothorax (OR?=?9.53, CI?=?7.80–11.65, p?<?0.001) followed by SF and esophageal injury (OR?=?5.47, CI?=?4.05–7.40, p?<?0.001).Conclusion
SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI.Summary
Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor. 相似文献10.
Leonard R. Henry Michael J. Minarich Rhonda Griffin Urs W. von Holzen Ashley N. Hardy Hubert Fornalik Roderich E. Schwarz 《American journal of surgery》2019,217(3):447-451
Background
Administrative data are widely used as determinants of surgical quality. We compared surgical complications identified in a structured surgical review to coding and billing data of over a 19-month period.Methods
A retrospective review of monthly morbidity and mortality conference reports was compared to a report over the same time period generated from hospital coding and billing data.Results
807 sequential operative procedures were included. Physician derived data compared to administrative data identified a complication of any severity in 205 (25.4%) versus 111 (13.8%) cases (r?=?0.39), and major complications in 68 (8.4%) versus 46 (5.7%) cases (r?=?0.36). Review of the administrative data regarding major complications identified 80 false negatives, 52 false positives, and 38 true positive designations. Overall sensitivity, specificity, positive and negative predictive values, and accuracy for administrative data in identifying major complications was 0.32, 0.99, 0.42, 0.99, and 0.99.Conclusions
The correlation between physician determined and administrative data with regard to identifying surgical complications is poor. Administrative data are insensitive and lack positive predictive value. 相似文献11.
Michelle R. Brownstein Mary R. Shen Paula D. Strassle Michael O. Meyers 《American journal of surgery》2019,217(2):329-334
Background
Despite efforts at standardization, evaluation and reporting of clerkships remains highly variable. This study reviews the current spectrum of surgical clerkship grading.Methods
Data were reviewed for every medical school from which an application was received to a single surgery residency program in 2017 and were evaluated for core surgical clerkship grading systems, distributions, and components. Fischer's exact tests and Wilcoxon-Mann-Whitney tests were used for analysis.Results
133 (49 private) schools were evaluated. Geographic distribution:34 Northeast, 50 South, 31 Midwest and 18 West. 120 reported grading tiers, with public schools (95%) more likely than private (80%) to report this (p?=?0.02). The number of grading categories ranged from 2 to 11; 90% with 3–5. Over 25% of the schools gave ≥40% of students the highest grade; median of 30% in the highest tier.Conclusions
Significant variation exists in core surgery clerkship grading between schools. Similarly, a sizeable difference exists in how grades are calculated and the reporting systems used. Standardizing grading schemes across medical schools would be beneficial. 相似文献12.
Gurjit Sandhu Julie Thompson-Burdine Niki Matusko Danielle C. Sutzko Vahagn C. Nikolian Anna Boniakowski Patrick E. Georgoff Kaustubh A. Prabhu Rebecca M. Minter 《American journal of surgery》2019,217(2):276-280
Background
Faculty entrustment decisions affect resident entrustability behaviors and surgical autonomy. The relationship between entrustability and autonomy is not well understood. This pilot study explores that relationship.Methods
108 case observations were completed. Entrustment behaviors were rated using OpTrust. Residents completed a Zwisch self-assessment to measure surgical autonomy. Resident perceived autonomy was collected for 67 cases used for this pilot study.Results
Full entrustability was observed in 5 of the 108 observed cases. Residents in our study did not report full autonomy. Spearman's rank correlation coefficient identified that resident entrustability was positively correlated with perceived resident autonomy (ρ?=?0.66, p?<?0.05). Ordinal logistic regression assessed the relationship between resident entrustability and autonomy. The relationship persisted while controlling for PGY level, gender, and case complexity (OR?=?8.42, SEM?=?4.54, p?<?0.000).Conclusions
Resident entrustability is positively associated with perceived autonomy, yet full entrustability is not translating to the perception of full autonomy for residents. 相似文献13.
Yeqian Huang Nayef A. Alzahrani Oliver M. Fisher Terence C. Chua Mathew A. Kozman Winston Liauw Arief Arrowaili Sarah J. Valle David L. Morris 《American journal of surgery》2019,217(4):704-712
Background
This study examines the impact of intraoperative macroscopic tumour consistency on short-term and long-term outcomes after cytoreductive surgery (CRS) with intraperitoneal chemotherapy (IPC) for appendiceal adenocarcinoma with peritoneal metastases.Methods
Macroscopic intraoperative tumour consistency was classified in three groups as soft (jelly-like geltatinous tumours), hard (hard tumour nodules without gelatinous features) and intermediate (both soft and hard features). In-hospital mortality, major morbidity, intensive care unit (ICU), high dependency unit (HDU) and total hospital stay, disease-free survival (DFS) and overall survival (OS) were compared.Results
The three groups had similar perioperative short-term outcomes. Patients with soft, intermediate and hard tumours revealed differences in OS (p?<?0.001) and DFS (p?=?0.03). Multivariable analysis revealed a shorter OS for patients with hard versus soft tumours (HR for hard tumours?=?4.43, 95%CI 2.19–9.00).Conclusions
Intraoperative macroscopic tumour consistency may be used as a prognostic marker for survival in patients with appendiceal adenocarcinoma with peritoneal metastases. 相似文献14.
Tarik Wasfie Avery Jackson Caramarie Brock Stefanija Galovska Jennifer R. McCullough Jacob A. Burgess 《American journal of surgery》2019,217(3):557-560
Background
There is a sizable proportion of elderly, both men and women, with fragility fractures, approximately 2 million fractures per year in the United States.Methods
A retrospective chart review of 365 patient presented between January 2012 and December 2017 with vertebral compression fractures. Pre-post study design to determine refracture between Group A (before Fracture Liaison Service (FLS)) and Group B, after. Calcium, Vitamin D, DEXA scans, FRAX scores, and refracture rates were measured.Results
Mean age for group A and B were 79.0 and 74.9 years, respectively, and predominantly females. Serum calcium was higher in group B (9.51?mg/d/L versus 9.40?mg/dL) but not significant (p?=?0.19). Fracture score among the groups was similar (20% versus 22%; p?=?0.44). The total refracture rate for both vertebral and other fracture was significantly less in the post FLS patients, 36.5% versus 56% p-value?=?0.01.Conclusion
FLS program benefited patients with fragility fractures by decreasing the incidence of all refracture rates. 相似文献15.
Faiz U. Shariff Adeline M. Deladisma Josué W. Menard Patricia A. Shewokis D. Scott Lind 《American journal of surgery》2019,217(2):250-255
Objective
We incorporated a hybrid-abdominal wound simulation to teach/assess the acquisition of three essential clinical skills in the ACS/ASE Medical Student Simulation-based Surgical Skills Curriculum.Method
Third year students (N?=?43) attended a workshop based on the ACS/ASE surgical skills curriculum for drain care/removal, staple removal and Steri-Strip application. Following a didactic session and demonstration using a simulated patient, student skill acquisition was assessed using the ACS/ASE module rating tool. Student interest/perceived usefulness of the workshop was evaluated using Keller's Motivational Survey.Results
We used median scores to identify low proficiency (n?=?20; scores 17–28) and high proficiency (n?=?23; scores 29–35) groups. The high proficiency group was more knowledgeable, performed better drain care, had a higher global score and was more confident than the low proficiency group. The students rated the workshop highly based on the Keller's Motivational Survey.Conclusion
All students were proficient in the procedure tasks and communication skills and most felt that the course was beneficial. The ACS/ASE Medical Student Simulation-based Surgical Skills Curriculum was successfully integrated into our third year surgical clerkship. 相似文献16.
Amy Li Rupen Shah Xiaoxia Han Akshay Sood Christopher Steffes David Kwon 《American journal of surgery》2019,217(3):458-462
Background
It is unclear whether placement of operative enteral access (OEA) during pancreaticoduodenectomy (PD) correlates with decreased morbidity.Methods
A retrospective chart review of patients undergoing PD with and without OEA placement between January 2016 and May 2018 was undertaken. Outcomes included length of stay (LOS), 30- and 90-day readmission, initiation of total parenteral nutrition (TPN), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and surgical site infection (SSI).Results
69 patients were evaluated; there was a trend toward decreased LOS for patients without OEA (9 vs. 7.5 days, p?=?0.07). There were no significant differences in initiation of TPN (9.1% vs 19.4%, p?=?0.311), POPF (21.2% vs 11.1%, p?=?0.999), DGE (24.2% vs 22.2%, p?=?0.999), organ/space SSI (12.1% vs 8.3%, p?=?0.702).Conclusion
OEA placement at the time of PD is not necessarily associated with improved perioperative morbidity and outcomes, suggesting that OEA may not be necessary and should be considered on a case by case basis.Summary
It is unclear whether placement of operative enteral access (OEA) during pancreaticoduodenectomy (PD) correlates with decreased morbidity. A retrospective review of patients undergoing PD with and without OEA placement between January 2016 and May 2018 was performed, demonstrating that there were no overall significant differences in postoperative complications and outcomes. 相似文献17.
Vernissia Tam Jeffrey Borrebach Stefanie Altieri Dunn Johanna Bellon Herbert J. Zeh Melissa E. Hogg 《American journal of surgery》2019,217(4):591-596
Background
While proficiency-based robotic training has been shown to enhance skill acquisition, no studies have shown that training leads to improved outcomes or quality measures.Methods
Board-certified general surgeons participated in an optional proficiency-based robotic training curriculum and outcomes from robotic hernia cases were analyzed. Multivariable analysis was performed for operative times to adjust for patient and surgical variables.Results
Six out of 16 (38%) surgeons completed training and 210 robotic hernia cases were analyzed. Longer operative times were associated with bilateral repairs (observed-to-expected operative time ratio [OTR]?=?1.41, p?<?0.001) and incarceration (OTR?=?1.24, p?=?0.006), while female patients (OTR?=?0.87, p?=?0.001) and increasing chronologic case order (OTR?=?0.94, p?<?0.001) were associated with shorter operative times. Surgeons who completed robotic training achieved shorter OTRs than those who did not (p?=?0.03). Comparing non-risk adjusted hospital costs, trainees had an average of $1207 in savings (20% reduction) per robotic hernia case.Conclusions
A structured proficiency-based robotics training curriculum is an effective way to reduce operative times and costs. 相似文献18.
Joshua Lyons Lauren McCaulley Nicole Maronian Jeffrey M. Hardacre 《American journal of surgery》2019,217(3):419-422
Background
The timing of inpatient discharges can impact hospital throughput with later discharges leading to decreased patient satisfaction, increased length of stay (LOS), and longer boarding times.Methods
A 12-month targeted intervention that included both pre-operative and inpatient components was implemented across all surgical inpatient services to increase the proportion of patients discharged by noon.Results
Discharge by noon rates increased from 14.3% to 21.5% during the 12-month initiative (p?<?0.01). The case mix index adjusted LOS (aLOS) decreased from 2.17 to 2.02 days (p?<?0.01). ED, PACU, and ICU boarding times were all significantly lower during the initiative (p?<?0.01, p?<?0.01, p?=?0.03 respectively).Conclusions
A targeted initiative to discharge surgical patients earlier resulted in a 50% increase in the proportion of patients discharged by noon. Associated with this finding were improvements in hospital throughput as measured by aLOS and boarding times in the ED, ICUs, and PACU. 相似文献19.
Cigdem Benlice Luca Stocchi Ipek Sapci Emre Gorgun Hermann Kessler David Liska Scott R. Steele Conor P. Delaney 《American journal of surgery》2019,217(3):502-506
Background
The purpose of this study was to determine the impact of the incision used for specimen extraction on wound infection during laparoscopic colorectal surgery.Methods
All patients undergoing elective laparoscopic colorectal resection in a single specialized department from 2000 to 2011 were identified from a prospectively maintained institutional database. Specific extraction-sites and other relevant factors associated with wound infection rates were evaluated with univariate and multivariate analyses.Results
2801 patients underwent specimen extraction through infra-umbilical midline (N?=?657), RLQ/LLQ (N?=?388), stoma site (N?=?58), periumbilical midline (N?=?629), Pfannenstiel (N?=?789) and converted midline (N?=?280). The overall wound infection rate was 10% and was highest in converted midline (14.6%) and Pfannenstiel (11.4%) incisions, while the lowest rate was associated with RLQ/LLQ (N?=?13, 3.3%). Independent factors associated with wound infection were increased BMI (p?<?0.001), extraction site location (p?=?0.006), surgical procedure (p?=?0.020, particularly left-sided colectomy and total proctocolectomy), diagnosis (p?<?0.001, particularly sigmoid diverticulitis and inflammatory bowel disease), intraabdominal adhesions (p?=?0.033) and intrabdominal rather than pelvic procedure (p?=?0.005).Conclusions
A RLQ/LLQ extraction site is associated with the most reduced risk of wound infection in laparoscopic colorectal surgery. 相似文献20.
Tomoko Mizota Nicholas E. Anton Dimitrios Stefanidis 《American journal of surgery》2019,217(2):222-227