Integrated fellowship in vascular surgery and intervention radiology: a new paradigm in vascular training

OBJECTIVE: To evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases. SUMMARY BACKGROUND DATA: The rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results. METHODS: Since 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire. RESULTS: During the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology. CONCLUSIONS: Integration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively.     

Should Vascular Surgeons be Trained in Endovascular Techniques? – An Observational Study

INTRODUCTION

The aim of this study was to determine if there is a satisfactory cover for interventional radiology and whether vascular surgeons have received sufficient training in endovascular techniques.

MATERIALS AND METHODS

This was an observational study based on questionnaires sent to radiology and vascular trainers and vascular trainees in England. A total of 50 NHS trusts were chosen randomly to take part in the study and 320 questionnaires were sent out with an overall consultant response rate of 57%.

RESULTS

Of vascular consultants in the study group, 53% have had experience in endovascular procedures. Overall, 87% felt that there were not enough radiologists to fulfil the demand and 64% would like further training in endovascular procedures. In addition, 69% would like to be involved in a vascular rota without the general component. Similarly, 81% of radiologists felt that the demand was not being met, as emergency interventional radiology cover was not available on most nights in 65% of the trusts. Of responders, 72% would not object to training of vascular trainees in interventional work and 43% would be happy to be involved in training. Some 33% would accept a vascular trainee for 1 year.

CONCLUSIONS

Integrated fellowship in vascular surgery and interventional radiology has been implemented and tested in a number of centres in the US. This approach could be implemented in some of the larger vascular units in the UK.     

Comparison of specialties participating in the BEST-CLI trial to specialists treating peripheral arterial disease nationally

BackgroundThe Best Endovascular vs Best Surgical Therapy for Patients with Critical Limb Ischemia (BEST-CLI) trial compares open surgery and endovascular therapy for the treatment of critical limb ischemia (CLI). This report describes the types and proportion of investigators participating in BEST-CLI and determines how these compare with those specialists treating peripheral artery disease (PAD) outside of the trial.MethodsTo be credentialed to enroll in BEST-CLI, investigators must be approved by the Surgical and Interventional Management Committee to have sufficient experience and skill in the management of patients with CLI. Investigators must attest to having completed at least 12 below-knee interventions in the last 2 years on CLI patients for endovascular approval and 10 lower extremity below-knee bypass procedures in the last 2 years for open surgical treatment. Investigators who met these criteria but were within their first year of practice were conditionally approved to do procedures under the oversight of a fully approved investigator. The type and proportion of specialists credentialed in BEST-CLI were compared with those treating PAD on a national basis by auditing 10% of Medicare claims for PAD.ResultsAs of September 2017, a total of 865 physicians were credentialed to enroll in the BEST-CLI trial. Of these, 596 (69%) are vascular surgeons, 128 (15%) are interventional cardiologists, 123 (14%) are interventional radiologists, 7 (1%) are vascular medicine specialists, and 11 (1%) are other. Of the 596 vascular surgeons enrolling in the trial, 113 (19%) are credentialed for open surgery only, 409 (69%) are credentialed for both open surgery and endovascular therapy, and 3 (1%) are credentialed for only endovascular therapy. The remaining 71 participating vascular surgeons were conditionally approved. Of the 136 centers enrolling patients, multispecialty involvement is present in 98 (72%). In 38 (28%), vascular surgery alone is the service enrolling CLI patients. Endovascular treatment by specialty in BEST-CLI vs national Medicare claims is as follows: vascular surgery, 55% vs 51%; interventional cardiology, 17% vs 13%; interventional radiology, 16% vs 25%; and other, 2% vs 10%.ConclusionsBEST-CLI contains a diverse group of specialists enrolling and treating patients with CLI. Whereas a majority of the participating practitioners are vascular surgeons who do both open and endovascular procedures, a broad variety of specialists are represented in BEST-CLI in a pattern that represents national treatment patterns outside of the BEST-CLI trial. These treatment patterns will help ensure that findings from BEST-CLI are applicable to the real-world practice of treatments for PAD.     

Vascular Surgery Training: Is There Enough Case Material?

In recent years, vascular surgery fellowships have changed substantially to meet the requirements for interventional as well as open surgical training. Data from the Residency Review Committee for Surgery indicate that the average vascular fellow performed fewer than 15 interventional procedures in 2000, but that this volume had increased to more than 200 interventional procedures by 2005, an increase of 255%. During the same interval, there was a slight (4%) decrease in the average number of major open vascular reconstructions performed. In 2005, the average vascular fellow performed 450 primary procedures, nearly equally divided between open and interventional cases. Selected open operations, such as aortic aneurysm repair, have decreased in volume due to the substitution by endovascular procedures. Operative volume for vascular fellows has been preserved in part by a 19% reduction in major vascular operations performed by general surgery residents. However, with added overall volume due to the increased prevalence of vascular disease in the aging population, there appears to be adequate case material to train future vascular surgeons, as long as less commonly performed operations continue to be focused on vascular trainees.     

Schwindende Fachgrenzen zwischen Gefäßchirurgie und interventioneller Radiologie aus Sicht des Radiologen

Vascular surgeons increasingly claim that percutaneous interventional treatment of peripheral arterial disease belongs to their discipline. In further medical training interventional radiology is exclusively bound to the discipline of radiology and necessitates a minimum of 250 procedures for valid qualification. Training in vascular surgery requires 25 endovascular procedures which do not, however, fulfill the criteria of percutaneous interventional procedures for a number of reasons. The desired expansion of vascular surgery to include the complete field of vascular medicine is not based on adequate specific training, is functionally unnecessary and not achievable for practical reasons. However, this desired expansion endangers the consensus of an interdisciplinary concept of treatment as represented by interdisciplinary vascular centers which offer a high level of competence.     

Vascular surgical intervention for complications of cardiovascular radiology: 13 years' experience in a single centre.

This study investigates incidence and outcome of iatrogenic vascular complications needing surgery in a single vascular unit serving interventional vascular radiology and interventional cardiology. Evolution of diagnostic and interventional cardiovascular radiology, along with the introduction of non-surgical therapies for such complications, may have influenced the number of vascular complications requiring emergency surgery. Vascular surgical data were collected from information prospectively entered on computerised database and case note review. Radiology data were collated from prospective entries in logbooks and computerised database. In all 24,033 cardiovascular radiological procedures were performed between 1984 and 1996 (61% cardiac), numbers increasing annually. During this period, 62 patients (40 peripheral; 22 cardiac) required emergency surgical intervention after radiological procedures. Mean age was 61.9 years (range 1-92 years), male to female ratio was 1:1. The absolute number of cases requiring surgical intervention peaked in 1989, subsequently reducing annually. Sites of vascular injury included common femoral artery (40), brachial artery (6), iliac artery (6), popliteal artery (5), other (5). A total of 87 vascular surgical operations was performed (range 1-6 operations per patient). Interventions included thrombectomy/embolectomy (29), bypass grafting (16), direct repair (27). Seven major amputations were performed (two bilateral). Mortality after surgery was 9.7%. Mean inpatient hospital stay was 11.3 days (range 0-75 days). A Poisson regression model indicates a 5% reduction in risk for each successive year of observation; however, this did not reach statistical significance (P = 0.16, 95% CI 12% decreased risk to 2% increased risk). The risk of surgical intervention after diagnostic or interventional cardiovascular radiology is diminishing but still requires vigilance. Necessity for surgical intervention is associated with a high risk of morbidity and mortality.     

Image Guided Spine Interventions. J. M. Mathis (editor). Published by Springer-Verlag, New York. Pp. 371; indexed; illustrated. Price {pound}154.00. ISBN 0-387-40320-5.

This book is written by an interventional radiologist. His prefacestates that interventional radiology is under considerable pressureas cardiology and vascular surgery appropriate existing vascularinterventions, and interventional radiologists need to be lookingconstantly for new procedures to replace this loss. This bookhas therefore been written about spine intervention proceduresthat are possible rather than necessary     

Has endovascular surgery reduced the number of open vascular operations performed by an established surgical practice?

OBJECTIVE: Driven by new technology and the trend toward minimally invasive techniques, vascular surgeons have eagerly begun performing catheter-based arterial interventional procedures, a subspecialty termed endovascular surgery. How incorporation of endovascular surgery by vascular surgeons has influenced the number of standard open peripheral vascular operations is unknown. The purpose of this observational study was to examine the effect of endovascular surgery performed by the vascular surgeons of an established vascular surgery service on the volume of open peripheral vascular operations performed. METHODS: With our prospective vascular registry, we compared the number of index vascular procedures from 1996 to 1998 (immediately before the start of an endovascular program) with the numbers from 1999 to 2000 (immediately after the start of an endovascular program). Differences in proportions (endovascular versus open/standard) between the two time periods were compared with the chi(2) test for homogeneity. RESULTS: From 1996 to 1998, 122 procedures were referred to radiology for arterial intervention versus none from 1999 to 2000, reflecting the initiation of the endovascular program. During the entire study period, annual volume (endovascular + open/standard) of vascular procedures, excluding the procedures referred to radiology, increased by 70% (1996, n = 402; to 2000, n = 685). Although open procedures from 1996 to 1999 increased 49% (n = 356 to n = 531), the number decreased by 5% from 1999 to 2000 (n = 531 to n = 507). In contrast, the endovascular volume from 1996 to 2000 increased 324% (n = 42 to n = 178). A statistically significant reduction was seen over time in the proportion of open/standard cases to endovascular cases in comparison of 1996 to 1998 with 1999 to 2000 for total cases (n = 1539, 88% open; versus n = 1341, 77% open) and for all index procedures (aortoiliac, 70% versus 55%; abdominal aortic aneurysm, 100% versus 63%; brachiocephalic, 73% versus 47%; renal, 60% versus 24%) except carotid procedures (100% versus 99%) and femoral-popliteal/tibial procedures (87% versus 87%). CONCLUSION: The integration of endovascular procedures by vascular surgeons of an established vascular practice significantly reduced the proportion of all open vascular procedures except for carotid and femoral-popliteal/tibial intervention. These data may have important implications for the future training of general and vascular surgeons.     

Comparison of propofol-fentanyl with propofol-fentanyl-ketamine combination in pediatric patients undergoing interventional radiology procedures

Background: With an increase in the frequency of interventional radiology procedures in pediatrics, there has been a corresponding increase in demand for procedural sedation to facilitate them . The purpose of our study was to compare the frequency of adverse effects, sedation level, patient recovery characteristics in pediatric patients receiving intravenous propofol fentanyl combination with or without ketamine for interventional radiology procedures. Our main hypothesis was that the addition of ketamine would decrease propofol/fentanyl associated desaturation. Methods and materials: Sixty consenting American Society of Anesthesia physical status I–III pediatric patients undergoing interventional radiology procedures under sedation were studied according to a randomized, double‐blinded, institutional review board approved protocol. Group 1 received propofol 0.5 mg·kg^?1 + fentanyl 1 μg·kg^?1 + ketamine 0.5 mg·kg^?1, and group 2 received propofol 0.5 mg·kg^?1 + fentanyl 1 μg·kg^?1 + same volume of %0.9 NaCl intravenously. Results: While apnea was not observed in any of the groups, there were three cases (10%) in group 1, and nine cases (30%) in group 2 with oxygen desaturation (P = 0.052). In group 1, 12 (40%) patients and, in group 2, 21 (70%) patients required supplemental propofol during the procedure (P = 0.021). There was no evidence for difference between groups in terms of other side effects except nystagmus. Conclusions: In conclusion, addition of low dose ketamine to propofol‐fentanyl combination decreased the risk of desaturation and it also decreased the need for supplemental propofol dosage in pediatric patients at interventional radiology procedures.     

Five-year results of a merger between vascular surgeons and interventional radiologists in a university medical center

OBJECTIVES: We examined economic and practice trends after 5 years of a merger between vascular surgeons and interventional radiologists. METHODS: In 1998 a merger between the Division of Vascular Surgery and the Section of Interventional Radiology at the University of Rochester established the Center for Vascular Disease (CVD). Business activity was administered from the offices of the vascular surgeons. RESULTS: In 1998 the CVD included five vascular surgeons and three interventional radiologists, who generated a total income of $5,789,311 US dollars (34% from vascular surgeons, 24% from interventional radiologists, 42% from vascular laboratories). Vascular surgeon participation in endoluminal therapy was limited to repair of abdominal aortic aneurysms (AAAs). Income was derived from 1011 major vascular procedures, 10,510 catheter-based procedures in 3286 patients, and 1 inpatient and 3 outpatient vascular laboratory tests. In 2002 there were six vascular surgeons (five, full-time equivalent) and four interventional radiologists, and total income was $6,550,463 US dollars despite significant reductions in unit value reimbursement over the 5 years, a 4% reduction in the number of major vascular procedures, and a 13% reduction in income from vascular laboratories. In 2002 the number of endoluminal procedures increased to 16,026 in 7131 patients, and contributions to CVD income increased from 24% in 1998 to 31% in 2002. Three of the six vascular surgeons performed endoluminal procedures in 634 patients in 2002, compared with none in 1998. CONCLUSIONS: Gross revenues increased in a declining reimbursement and conventional practice environment, because of the increased number of endoluminal procedures, in part provided by vascular surgeons. The implications of these data should be considered by those responsible for training vascular surgeons.     

Does a “July Effect” Exist for Fellowship Training in Total Hip and Knee Arthroplasty?

BackgroundThe hypothetical association between health-care errors and the transition of the medical academic year has been termed the “July effect.” Data supporting its existence are conflicting, particularly in orthopedic surgery, and prior studies have inappropriately grouped fellows with resident trainees. No studies to date have examined whether a training initiation effect exists among surgical fellows in adult reconstructive orthopedics.MethodsThis is a level IV retrospective cohort study reviewing 15,650 primary hip and knee arthroplasties performed from 2006 to 2016 at a single institution. Forty arthroplasty fellows were trained during this 10-year period. Primary outcome measures included intraoperative complications, additional procedures, revisions, and nonoperative complications within 90 days of surgery. These complication rates were analyzed by quarter of academic year and by temporal progression through three-month fellowship rotations.ResultsThere were no differences in intraoperative complication, revision, or nonoperative complication rates between any academic quarter. There was a single statistically lower rate of additional procedures in the third quarter (1.2%) than in the fourth quarter (1.8%, P = .04). The most common complication in this subset was wound dehiscence for patients undergoing hip arthroplasty and stiffness for patients undergoing knee arthroplasty. There was no difference in complication rates during the first, second, or third month as fellows progressed through a single rotation.ConclusionThis study does not support the existence of a training-initiation effect among fellows in adult hip and knee reconstruction. Graduated autonomy can be safely employed in a fellowship program without negatively impacting patient outcomes, ensuring the continued high-caliber training of future surgeons.     

A survey of interventional radiology for the management of obstetric haemorrhage in the United Kingdom

BackgroundMassive haemorrhage remains a leading cause of maternal death worldwide. Interventional radiology can be used to prevent or treat life-threatening haemorrhage, but evidence for its efficacy is limited to case series predominantly from large tertiary centres. The current availability of interventional radiology for management of obstetric haemorrhage in the UK is unknown.MethodsA postal questionnaire on the use of interventional radiology was sent to the lead clinician for obstetric anaesthesia in 226 UK maternity units.ResultsThe response rate was 72%; 74 respondents (46%) had considered and 51 (31%) used interventional radiology for control of obstetric haemorrhage. Its use was primarily confined to large tertiary obstetric units and limited by availability of equipment and staff.ConclusionsInterventional radiology to assist in the management of obstetric haemorrhage is not uniformly available in the UK and experience remains limited. Access to this resource is subject to striking local variability and influenced by the size and nature of the hospital supporting the delivery unit.     

Trends in Medicare physician reimbursement and utilization for proximal humerus fixation and shoulder arthroplasty

BackgroundFixation and arthroplasty remain the mainstays of surgical treatment of degenerative and traumatic shoulder pathology. They also constitute an appreciable sum of Medicare expenditure. With continued concern for declines in Medicare reimbursement across orthopedic surgery, it is important to understand how trends in reimbursement correlate with relative procedure volumes. Our aims were to describe temporal changes in procedure volumes, physician payment, and patient charges for proximal humerus open reduction internal fixation (ORIF) and shoulder arthroplasty.MethodsUsing Medicare's Physician Fee Schedules from 2012 to 2017, we examined procedure volumes, number of unique surgeons performing, actual submitted patient charges, and surgeon payments from 2012 to 2017 for six shoulder procedures: proximal humerus ORIF (CPT-23615), traumatic hemiarthroplasty (HEMI) (CPT-23616), degenerative HEMI (CPT-23470), primary total shoulder arthroplasty (TSA) (CPT-23472), partial TSA revision (humeral or glenoid component, CPT-23473), and total TSA revision (CPT-23474). The reimbursement ratio was calculated by dividing surgeon payment by patient charges. Growth rates of charges and payment were adjusted for inflation using annual consumer price index inflation rates over the same time period.ResultsThe total number of traumatic and degenerative HEMI cases fell over ?60%. Similarly, the number of unique surgeons performing traumatic and degenerative HEMI fell over ?53%. In contrast, the number of TSA procedures rose by +70%, whereas partial and total revision TSA rose by +62% and +88%, respectively. The number of unique surgeons rose +28% and over +73% for primary and revision TSA, respectively. There was a large gap (between 3.4 and 4.4 times) between submitted charges and surgeon payment for all years analyzed. After adjusting for inflation, Medicare payment to surgeons decreased for all types of surgery (?6% to ?9%) other than ORIF, which increased +10%. Submitted patient charges during this period increased +14% and +9.7% for ORIF and revision TSA (total), respectively, but decreased by ?6% for traumatic HEMI. The reimbursement ratio was ≤29% for all procedures analyzed across all years and fell the most for revision TSA (partial and total).ConclusionFrom 2012 to 2017, there was a sharp decline in the use of shoulder HEMI with a correspondingly high increase in TSA. After accounting for inflation, HEMI and TSA showed appreciable declines in surgeon payment over time, whereas ORIF was the only surgery with increased surgeon payment. Revision TSA saw the largest declines in the reimbursement rate. Physicians and health care policy makers must be aware of these trends to ensure both a sustainable payment infrastructure for surgeons as well as to maintain access to care for these procedures.Level of evidenceLevel III; Economic Study     

Understanding radiation exposure and improving safety for vascular surgery trainees

ObjectiveDespite having robust radiation safety education procedures and policies in place, we discovered that the trainees at our Accreditation Council for Graduate Medical Education–approved integrated vascular surgery residency and fellowship program were exceeding the annual radiation exposure limits. In the present report, we have described our quality improvement project to identify the root causes and implement policies to improve radiation safety education, oversite, and, ultimately, the exposure levels of our trainees.MethodsA committee of faculty, fellows, radiology nurses, and radiation safety officers from each of the programs affiliated hospitals convened to identify the potential root causes of the increased radiation exposure and potential modifiable actions. The radiation exposure reports for postgraduate year 4 to 7 trainees were evaluated before and after the interventions.ResultsExcessive radiation exposure was found to be more prevalent than anticipated, with multiple trainees surpassing the annual exposure limits. The committee classified the factors at play and interventions into four categories: policies and procedures, curriculum, environment, resources, and equipment. The multisite status of our program was a key factor associated with the increased radiation exposure. In addition, we found that excessive radiation levels were occurring primarily at a single hospital site. After the interventions, the monthly average levels at this site had decreased considerably from 936 mrem to 272 mrem.ConclusionsWe found it alarming that the safety policies in place at vascular residency and fellowship programs were inadequate in securing the safety of their trainees. We found interventions such as inventorying and ensuring the availability of safety equipment, hands-on instruction to complement traditional didactics, lowering the default frame rates, and converting to real-time dosimetry to be effective measures for reducing radiation exposure.     

Variability in 2-year training programs in vascular surgery based on results of an Association of Program Directors in Vascular Surgery survey

Objective

Although a great deal of attention has recently focused on 5-year integrated (0+5) training programs in vascular surgery, a paucity of data exists concerning variability of daily assignments in 2-year (5+2) vascular fellowships.

Imaging equipment and techniques for optimal intraoperative imaging during endovascular interventions

Because endovascular procedures represent an ever-increasing portion of many vascular surgery practices, many surgeons are faced with difficult choices. Endovascular procedures often require open surgery, and open surgical techniques increasingly require fluoroscopic imaging. Without good intraoperative imaging, endovascular procedures are difficult and endovascular aneurysm repair is impossible. How does one balance the need for optimal imaging without sacrificing the ability to safely perform open surgical procedures, especially in the early stages of a developing endovascular program? Strategies include the use of a portable c-arm and carbon fiber table in the operating room (OR), adding a fixed imaging platform to an OR, gaining access to an angiography suite that does not meet OR requirements, and modifying it into an interventional suite that does meet operating room standards. Once the optimal equipment and facilities have been chosen, other choices must be considered. Should a radiology technician be hired? Should an interventional radiologist be available to assist or be incorporated as a routine member of the team? How will typical operating room procedures and technique need to be altered in an effort to optimize intraoperative imaging for endovascular procedures? This article gives an overview of the many issues that arise as a vascular surgery practice evolves to incorporate complex endovascular procedures.     

Iatrogenic Vascular Injuries With Lethal Outcome

Background

The aim was to study the nature of iatrogenic vascular injuries (IVIs) associated with postoperative death within 30 days.

Methods

Patients who had undergone vascular surgery for IVIs and were reported prospectively to the Swedish national vascular registry during 1987–2008 were identified. They were cross-checked with the national population registry. Those who died within 30 days of surgery were studied regarding case records and death certificates.

Results

A total of 56 patients with postoperative death within 30 days after IVI were identified. Among them, 52 case records were retrieved (93 %). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhage, 11 occlusive thrombosis), 11 by penetrating trauma during open surgery, 6 by occlusion after external compression, 6 by percutaneous accidental arterial puncture. Main symptoms were peripheral ischemia (19/52, 37 %), external bleeding (14, 27 %), and hypovolemic shock without external bleeding (10, 19 %). Main specialties involved were interventional radiology (n = 18), general surgery (n = 9), and interventional cardiology (n = 8). Overall, 22 (42 %) were avoidable, and only 13 (25 %) underwent autopsy. Within 2 weeks, 36 patients (69 %) were dead. Also, there was a higher proportion with uncertain correlation between IVI and death.

Conclusions

Interventional radiology, general surgery, and cardiology are the main specialities involved in IVIs with lethal outcome. Not all fatalities after IVI are attributable to the injury itself, but almost half of the injuries were considered avoidable.     

A comparison of surgical complications after appendicostomy and neoappendicostomy in pediatric patients

PurposeThere are limited data on neoappendicostomy complications owing to small patient populations. This study compares appendicostomy and neoappendicostomy procedures with an emphasis on major postoperative complications requiring either a surgical or interventional radiology procedure.MethodA single-institution retrospective review included all patients with complete medical charts in the Cincinnati Children's Colorectal Database who underwent either an appendicostomy or neoappendicostomy from August 2005 through December 2016. Demographics, details of the procedure, and major postoperative complications were evaluated.Results261 patients (appendicostomy n = 208, neoappendicostomy n = 53) with a median follow up time of 2.5 years resulted in 84 patients (appendicostomy n = 60, neoappendicostomy n = 24) experiencing a total of 118 complications requiring surgical or radiologic intervention with a significant difference between the groups (29% vs 45%, RR = 1.79 (95% CI: 1.24–2.60), p < 0.01). Skin level stricture was the most common complication (20% appendicostomies vs 30% neoappendicostomies, p = 0.13).ConclusionsAppendicostomies and neoappendicostomies can be an effective way to manage fecal incontinence; however, 32% of our patients experienced a complication that required either a surgical or interventional radiology procedure. Patients need to be informed of the possible complications that are associated with appendicostomy and neoappendicostomy construction.Type of studySingle institution retrospective review.Level of evidenceIV.     

Operative Surgical Education: Results of a Society of Surgical Oncology Fellowship Survey and Proposal for an Operative Database

Background: Preparation of surgical trainees for oncological operative procedures is challenging. The purpose of this survey was to focus on identifying methods and resources used by trainees to prepare for procedures and to ascess the need for additional educational tools.Methods: A 34-item survey was mailed electronically to 97 surgical oncology fellows at 14 Society of Surgical Oncology–approved training programs. General surgery residents at an affiliate training program (n = 65) and residents attending an American Board of Surgery In-Training Examination review course (n = 129) were polled via hard-copy mailings. The survey was distributed with the Dillman method. Self-education practices, factors influencing operative education, and strengths/weaknesses of available resources were identified.Results: Response rates were 56% and 78% for fellows and residents, respectively. Trainees prepare for more than 50% of cases they perform (82%; 169 of 205), devoting up to 1 hour (87%; 178 of 205) in review the evening before a procedure (64%; 131 of 205). Time availability and attending of record were dominant factors influencing resident preparation, whereas case complexity was the most important variable motivating fellows. Surgical atlases, texts, anatomical references, and case discussion with attending staff were the most useful and available resources rated by trainees. Skills stations were recognized as the least valuable. Critical assessment of six educational resources identified no one particular area for improvement.Conclusions: There is a need for contemporary operative educational tools, incorporating time-sensitive and procedure-specific needs of surgical trainees preparing for oncological operative procedures.