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The manufacturing process of Regulatory T (Treg) cells for clinical application begins with the positive selection of CD25 + cells using superparamagnetic iron-oxide nanoparticle (SPION)-conjugated anti-CD25 antibodies (spCD25) and immunomagnetic cell separation technology. Our findings revealed that the interaction of spCD25 with its cell target induced the internalization of the complex spCD25-Interleukin-2 Receptor. Accumulation of intracellular spCD25 triggered oxidative stress, causing delayed Treg expansion and temporary reduction in suppressor activity. This activation delay hindered the efficient generation of clinically competent cells. During this early phase, Treg cells exhibited elevated mitochondrial superoxide and lipid peroxidation levels, with concomitant decrease on mitochondrial respiration rates. The results uncovered the increased mitochondrial unfolded protein response (mitoUPR). This protective, redox-sensitive activity is inherent of Tregs when contrasted with homologous, spCD25-treated, conventional T cells. While the temporary effects of spCD25 on clinically competent cells did not impede their use in a safety/feasibility pilot study with kidney transplant recipients*, it is reasonable to anticipate a potential reduction in their therapeutic efficacy. The mechanistic understanding of the adverse effects triggered by spCD25 is crucial for improving the manufacturing process of clinically competent Treg cells, a pivotal step in the successful implementation of immune cell therapy in transplantation. *Clinical trial registration number NCT03284242 at ClinicalTrials.gov., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: Workplace-based assessment (WBA) can facilitate evaluation of operative performance; however, implementation of WBA is sometimes unsuccessful. The American Board of Surgery Entrustable Professional Activities WBA project was launched in July 2023. Some programs will face the challenge of re-implementation of a WBA following previous failures. It is unknown what interventions are most effective for WBA re-implementation. Our goal is to identify barriers and facilitators to re-implementing SIMPL, an operative performance WBA., Methods: The System for Improving and Measuring Procedural Learning (SIMPL) was implemented at our residency in 2018, but usage rates were low. We interviewed residents and faculty to identify barriers to usage and opportunities for improvement. Residents reported that SIMPL usage declined because of several factors, including a low faculty response rate, while some faculty reported not responding because they were unable to login to the app and because usage was not mandated. We then re-implemented SIMPL using a plan based on Kotter's Model of Change. To evaluate impact, we analyzed rates of SIMPL usage when it was first implemented, as well as before and after the date of re-implementation., Results: In September 2022, we re-implemented SIMPL at our program with measures addressing the identified barriers. We found that, in the six months after re-implementation, an average of 145.8 evaluations were submitted by residents per month, compared with 47 evaluations per month at the start of the original implementation and 5.8 evaluations per month just prior to re-implementation. Faculty completed 60.6% of evaluations and dictated feedback for 59.1% of these evaluations, compared with 69.1% at implementation (44% dictated) and 43% prior to re-implementation (53% dictated)., Conclusions: After identifying barriers to implementation of a WBA, we re-implemented it with significantly higher usage by faculty and residents. Future opportunities exist to implement or re-implement assessment tools within general surgery programs. These opportunities may have a significant impact in the setting of national standardization of workplace-based assessment among general surgery residencies., (© 2024. The Author(s).)

Objective: We sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring veno-venous extracorporeal membrane oxygenation., Methods: Six academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared., Results: The cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1% of patients who received extracorporeal membrane oxygenation and 27.4% of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5% of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non-extracorporeal membrane oxygenation cohorts stratified by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7% vs 24.4%, P < .001), bleeding complications (77.1% vs 53.8%, P = .015), and worse survival independent of left ventricular dysfunction (39.6% vs 64.1%, P = .012). There was no significant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically significant differences in in-hospital outcomes., Conclusions: The presence of right ventricular dysfunction in patients with COVID-19-related acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation was associated with increased in-hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality., (Published by Elsevier Inc.)

Competing Interests: Disclosure: The authors have no conflicts of interest to report.

Over the past decade, medical education has shifted from a time-based approach to a competency-based approach for surgical training. This transition presents many new systemic challenges. The Society for Improving Medical Professional Learning (SIMPL) was created to respond to these challenges through coordinated collaboration across an international network of medical educators. The primary goal of the SIMPL network was to implement a workplace-based assessment and feedback platform. To date, SIMPL has developed, implemented, and sustained a platform that represents the earliest and largest effort to support workplace-based assessment at scale. The SIMPL model for collaborative improvement demonstrates a potential approach to addressing other complex systemic problems in medical education., Competing Interests: J.B.Z., S.S.S.-S., and B.C.G. have leadership positions, contracts, and grants with SIMPL. The remaining authors declare that they have nothing to disclose., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: We sought to determine the influence of venovenous extracorporeal membrane oxygenation (ECMO) on outcomes of mechanically ventilated patients with COVID-19 during the first 120 days after hospital discharge., Methods: Five academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 admitted during March through May 2020. Survivors had access to a multidisciplinary postintensive care recovery clinic. Physical, psychological, and cognitive deficits were measured using validated instruments and compared based on ECMO status., Results: Two hundred sixty two mechanically ventilated patients were compared with 46 patients cannulated for venovenous ECMO. Patients receiving ECMO were younger and traveled farther but there was no significant difference in gender, race, or body mass index. ECMO patients were mechanically ventilated for longer durations (median, 26 days [interquartile range, 19.5-41 days] vs 13 days [interquartile range, 7-20 days]) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes. Patients receiving ECMO experienced greater bleeding and clotting events (P < .01). However, survival at discharge was similar (69.6% vs 70.6%). Of the 217 survivors, 65.0% had documented follow-up within 120 days. Overall, 95.5% were residing at home, 25.7% had returned to work or usual activity, and 23.1% were still using supplemental oxygen; these rates did not differ significantly based on ECMO status. Rates of physical, psychological, and cognitive deficits were similar., Conclusions: Our data suggest that COVID-19 survivors experience significant physical, psychological, and cognitive deficits following intensive care unit admission. Despite a more complex critical illness course, longer average duration of mechanical ventilation, and longer average length of stay, patients treated with venovenous ECMO had similar survival at discharge and outcomes within 120 days of discharge., (Published by Elsevier Inc.)

We are developing a clinically practical percutaneous double lumen cannula (DLC)-based cavopulmonary assist (CPA) system to support failing Fontan patients. In this study, our CPA DLC was redesigned for even blood flow, minimal recirculation, and easy insertion/deployment. After bench testing, this new CPA system was evaluated for 4 hours (n = 10) and 96 hours (n = 5) in our clinically relevant lethal cavopulmonary failure (CPF) sheep model for ease of cannulation/deployment, reversal of CPF hemodynamics/end-organ hypoperfusion, and durability/biocompatibility. Cavopulmonary failure was achieved in all sheep. All DLCs were successfully inserted/deployed into Fontan anatomy. Cavopulmonary assist reversed CPF with normalized central venous pressure and cardiac output. All survival sheep were ambulatory with normal eating/drinking. One sheep was euthanized after 6 hours from cannula kinking, and one sheep died of hypokalemia after 8 hours. Three sheep survived 96 hours with normal hemodynamics. Free hemoglobin was only 3.7 ± 1.2 mg/dl at 96 hours, indicating negligible hemolysis. Creatinine, blood urea nitrogen, and lactate increased from hypoperfusion but normalized by 72 hours CPA. Necropsy showed only a small, immobilized thrombus ring at umbrella attachment to DLC. Our DLC-based system provided total ambulatory CPA in a lethal CPF sheep model with 96 hour survival and complete reversal of hemodynamics and end-organ hypoperfusion., Competing Interests: Disclosure: D.W. and J.B.Z. are co-owners of W-Z Biotech, LLC and they also receive royalties from the Getinge Group for their patented Avalon Elite. D.W. and C.B.-C. are part-time employees of W-Z Biotech, LLC. D.M. is a consultant/proctor/speaker for Abbott, Syncardia, Berlin, and Medtronic. The other authors have no conflicts of interest to report., (Copyright © ASAIO 2023.)

Objective: Upwards of 79%-88% of practicing surgeons report musculoskeletal pain due to operating. However, little is known about when these issues begin to become clinically significant. This survey evaluates the prevalence and impact of musculoskeletal pain among surgical residents., Design: After IRB approval, an anonymous 19-question survey based on Cornell Musculoskeletal Discomfort Questionnaire was sent to current surgical residents measuring frequency and degree of pain at 5 sites (neck, shoulder, upper back, lower back, and elbow/wrist) as well as impact on activities both at work and outside of work. Chi square analysis was used to identify differences between groups., Setting: Single academic medical center., Participants: Trainees in all surgical-based specialties., Results: Fifty-three residents responded from 8 different specialties (38% response rate). Respondents were a representative balance of male (53%)/female (47%) with a mean age of 30 ± 2 years. Residents in all specialties and all years of clinical training responded, with the greatest number from general surgery (the largest program with 48% of respondents), second year of clinical training (30%) and an overwhelming 96% of residents reported experiencing pain they felt was due to operating. The most common sites of pain were the neck (92%) and lower back (77%). This pain was a frequent issue for most with 74% reporting multiple times per month and 26% reporting pain nearly every day. Nearly half of residents reported that pain slightly to substantially interfered with their ability to work (44%) and with activities outside of work (47%). Most residents (75%) sought no treatment. No residents missed work despite reporting pain., Conclusions: Musculoskeletal pain begins during training, occurs regularly, and affects function. Neck pain is the most frequent, severe, and disabling site. This provides a target for interventions to reduce the impact of chronic pain on patient care, surgeon wellness, and career longevity., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Although all congenital heart defects (CHD) present unique challenges, univentricular CHD are especially challenging given the difficulty of passively perfusing pulmonary blood flow. Three surgical procedures are required within the first years of life, with the final completing a Fontan circulation in which the inferior vena cava is connected to the pulmonary artery and previously connected superior vena cava. This allows passive venous return to the pulmonary circulation then flow into the single ventricle for systemic circulation., Methods: Although a Fontan provides successful palliation for two to three decades, many complications can arise as pulmonary resistance must remain low to allow adequate forward flow. Eventually, the failing Fontan circulation requires temporary support as the patient awaits a heart transplant. We reviewed PubMed, Google Scholar, and U. Kentucky library for different techniques evaluated to support a failing Fontan circulation., Results: Multiple technologies have been developed as a bridge to transplant to decrease morbidity. Innovative types of extracorporeal membrane oxygenation, ventricular assist devices, and total artificial hearts have been attempted in laboratory settings as well as in Fontan patients with varying degrees of success. This article emphasizes the strengths and weaknesses of each technology in the context of Fontan physiology., Conclusion: The end game for these patients remains a heart transplant. Without easy access to donors, each of the options discussed is a potential bridge to limit morbidity and mortality until a suitable donor heart becomes available., (© 2022 Wiley Periodicals LLC.)

Objective: The aims of this study were to determine whether physical rehabilitation intervention for individuals who required extracorporeal membrane oxygenation (ECMO) is associated with clinical outcomes and to assess whether the patient mobility response over initial rehabilitation sessions early in the intensive care unit (ICU) course predicts or is associated with survival, lengths of stay, discharge disposition, and 30-day readmissions., Methods: This study was a 10-year retrospective practice analysis of adults who were critically ill and required ECMO for >72 hours in the cardiothoracic ICU at an academic medical center. Physical rehabilitation implemented during or following the initiation of ECMO was quantified on the basis of timing, frequency, and change in mobility level in response to the intervention over the first 4 consecutive sessions. The primary dependent outcome was in-hospital mortality. Secondary outcomes included 30-day readmission and discharge disposition ranked on an ordinal scale., Results: Three hundred fifteen individuals (mean age = 50 years [SD = 15 years]; 63% men; mean Sequential Organ Failure Assessment score = 11.6 [SD = 3.3]) met the inclusion criteria. Two hundred eighteen individuals (69%) received at least 1 physical rehabilitation session while requiring ECMO, 70 (22%) received rehabilitation after ECMO was discontinued, and 27 (9%) never received rehabilitation. Individuals discharged alive achieved higher mobility levels and had a steeper, more positive rate of change in mobility over the first 4 sessions than individuals who died in the hospital (2.8 vs 0.38; degrees of freedom = 199, t = 8.24). Those who received rehabilitation and achieved the milestones of sitting on the edge of the bed and walking for >45 m were more likely to survive (47% vs 13%; χ2 = 156) than those who did not (26% vs 3.5%; χ2 = 80)., Conclusion: A positive rate of change in mobility and the ability to achieve mobility milestones with rehabilitation were associated with improved clinical outcomes., Impact: An individual's mobility response to physical rehabilitation early in the ICU course is an important indicator of illness and should be used with clinical presentation to guide clinical decision-making and predict outcomes., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Ambulatory extracorporeal membrane oxygenation (ECMO) has shown promise as a bridge to lung transplantation. The primary goal of ambulatory ECMO is to provide enough gas exchange to allow patients to participate in preoperative physical therapy. Various strategies of ambulatory ECMO are utilized depending upon patients' need. A wide spectrum of ECMO configurations is available to tackle this situation. We discuss those configurations in this article., Competing Interests: Conflict of interestThe authors declare no competing interests., (© Indian Association of Cardiovascular-Thoracic Surgeons 2021.)

We present a low-cost, simple simulation model of major vascular injury repair for cardiothoracic trainees. This model uses commercially available orthopedic elastic bands to allow repetitive practice of the skills necessary during these rare but critical clinical scenarios. Practicing core skills in the simulation setting will help residents be better prepared when the situation arises., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a form of extracorporeal life support that provides total gas exchange (CO2 and O2) within the central venous circulation. The bicaval dual lumen cannula (DLC) is an option for patients requiring respiratory support with VV-ECMO. The catheter is inserted via the internal jugular vein into the superior and inferior vena cava, drains blood into the ECMO circuit for gas exchange, and then returns arterialized blood to the right heart for circulation. The DLC facilitates physical therapy, ambulation, and early extubation. This chapter will review the uses, advantages, and unique complications of the DLC., Competing Interests: Conflict of interestDr. Zwischenberger has the following to disclose: he receives royalties for a patent licensed to Avalon/Maquet for the Avalon Elite double lumen cannula, he is the recipient of grant funding from the NIH, he is a consultant on the Cytosorbents, Inc. Cardiac Advisory Board, and he is a partner in WZ-Biotech. Vanessa M. Bazan has nothing to disclose. Evan M. Taylor has nothing to disclose. Dr. Gunn has nothing to disclose., (© Indian Association of Cardiovascular-Thoracic Surgeons 2020.)

Objective: Minimally invasive surgery (MIS) is an integral component of General Surgery training and practice. Yet, little is known about how much autonomy General Surgery residents achieve in MIS procedures, and whether that amount is sufficient. This study aims to establish a contemporary benchmark for trainee autonomy in MIS procedures. We hypothesize that trainees achieve progressive autonomy, but fail to achieve meaningful autonomy in a substantial percentage of MIS procedures prior to graduation., Setting/participants: Fifty General Surgery residency programs in the United States, from September 1, 2015 to March 19, 2020. All Categorical General Surgery Residents and Attending Surgeons within these programs were eligible., Design: Data were collected prospectively from attending surgeons and categorical General Surgery residents. Trainee autonomy was assessed using the 4-level Zwisch scale (Show and Tell, Active Help, Passive Help, and Supervision Only) on a smartphone application (SIMPL). MIS procedures included all laparoscopic, thoracoscopic, endoscopic, and endovascular/percutaneous procedures performed by residents during the study. Primary outcomes of interest were "meaningful autonomy" rates (i.e., scores in the top 2 categories of the Zwisch scale) by postgraduate year (PGY), and "progressive autonomy" (i.e., differences in autonomy between PGYs) in MIS procedures, as rated by attending surgeons. Primary outcomes were determined with descriptive statistics, one-way analysis of variance (ANOVA) and Z-tests. Secondary analyses compared (i) progressive autonomy between common MIS procedures, and (ii) progressive autonomy in MIS vs. non-MIS procedures., Results: A total of 106,054 evaluations were performed across 50 General Surgery residency programs, of which 38,985 (37%) were for MIS procedures. Attendings performed 44,842 (42%) of all evaluations, including 16,840 (43%) of MIS evaluations, while residents performed the rest. Overall, meaningful autonomy in MIS procedures increased from 14.1% (PGY1s) to 75.9% (PGY5s), with significant (p < 0.001) increases between each PGY level. Meaningful autonomy rates were higher in the MIS vs. non-MIS group [57.2% vs. 48.0%, p < 0.001], and progressed more rapidly in MIS vs. non-MIS, (p < 0.05). The 7 most common MIS procedures accounted for 83.5% (n = 14,058) of all MIS evaluations. Among PGY5s performing these procedures, meaningful autonomy rates (%) were: laparoscopic appendectomy (95%); laparoscopic cholecystectomy (93%); diagnostic laparoscopy (87%); upper/lower endoscopy (85%); laparoscopic hernia repair (72%); laparoscopic partial colectomy (58%); and laparoscopic sleeve gastrectomy (45%)., Conclusions: US General Surgery residents receive progressive autonomy in MIS procedures, and appear to progress more rapidly in MIS versus non-MIS procedures. However, residents fail to achieve meaningful autonomy in nearly 25% of MIS cases in their final year of residency, with higher rates of meaningful autonomy only achieved in a small subset of basic MIS procedures., (Copyright © 2020. Published by Elsevier Inc.)

Background: The obesity epidemic has spread rapidly across the United States. Although overweight and obese patients have a paradoxically lower risk for postoperative morbidity and mortality, the risks associated with extreme classes of obesity (morbid obesity, super obesity, and super-super obesity) have not been described., Methods: We queried the National Surgical Quality Improvement Program database from 2012 to 2016. Of 1,815,251 surgical cases, there were 3,946 vascular cases, 237,777 emergency procedures, and 75,177 cases with missing data that were removed. The remaining 1,378,711 cases were included in this analysis. Multivariable linear and logistic regression was performed to assess the impact of body mass index on postoperative outcomes., Results: Patients within the super obesity and super-super obesity groups had the highest procedure-adjusted mortality risk among all body mass index classes (odds ratio = 2.31 and 2.63, respectively). Morbid obesity and underweight groups had moderate risk (odds ratio = 1.37 and 1.88, respectively), while those in the overweight and obesity class I and II cohorts had improved or equivocal mortality risk compared to normal body mass index class patients. Risk-adjusted and unadjusted multivariable models demonstrated that extreme obesity classes (morbid obesity, super obesity, and super-super obesity) have a graduated escalation of perioperative morbidity, infectious, and critical care complications., Conclusion: Further detailing extreme obesity-related risk beyond the obesity class III umbrella is necessary for accurate risk prediction, especially with the rising prevalence of elective nonbariatric surgery in this population. Preoperative risk assessment tools should consider subgroup risk adjustment to delineate true postoperative complication risk, facilitate patient education, and address modifiable risk factors before surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Hepatocellular Carcinoma (HCC) is the third most common cause of cancer related death worldwide. Adequate treatment options for patients with advanced HCC are currently limited., Materials and Methods: We studied the anti-HCC effect of FH535 and a novel derivative Y3, on proliferation, mitochondrial function and cellular metabolism focusing on the three key substrates, glutamine, glucose, and fatty acids., Results: FH535 and Y3 disrupted mitochondrial redox control in HCC cells that resulted from uncoupling mechanisms that increased proton leakage and decreased ATP production leading to apoptosis. The uncoupling effects of the sulfonamides in HCC cells were supported by the loss of activity of the methylated analogs. The accumulation of ROS significantly contributed to cell damage after the impaired autophagic machinery. These sulfonamides, FH535 and Y3, targeted glutamine and fatty acid metabolism and caused HCC cell reprograming towards the preferential use of glucose and the glycolytic pathway., Conclusions: FH535, and Y3, demonstrated potent anti-HCC activity by targeting OXPHOS, increasing dangerous levels of ROS and reducing ATP production. These sulfonamides target glutamine and FA metabolic pathways significantly increasing the cellular dependency on glycolysis., Competing Interests: CONFLICTS OF INTEREST DSW and CL have partial ownership in a for-profit venture, Epionc, Inc., that seeks to develop small-molecule inhibitors for cancer treatment. In accord with University of Kentucky policies, DSW and CL disclosed this ownership to the University of Kentucky’s Intellectual Property Committee and to a Conflict of Interest Oversight Committee.

Acute high-risk pulmonary embolism (PE) is characterized by life-threatening hemodynamic instability that may lead to refractory cardiac arrest. Recently, extracorporeal membrane oxygenation (ECMO) has been used to provide primary cardiopulmonary support for select high-risk PE patients or before surgical embolectomy. This article reviews the growing body of literature regarding ECMO support of acute high-risk PE., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The severe acute respiratory syndrome (SARS)-CoV-2 is an emerging viral pathogen responsible for the global coronavirus disease 2019 (COVID)-19 pandemic resulting in significant human morbidity and mortality. Based on preliminary clinical reports, hypoxic respiratory failure complicated by acute respiratory distress syndrome is the leading cause of death. Further, septic shock, late-onset cardiac dysfunction, and multiorgan system failure are also described as contributors to overall mortality. Although extracorporeal membrane oxygenation and other modalities of mechanical cardiopulmonary support are increasingly being utilized in the treatment of respiratory and circulatory failure refractory to conventional management, their role and efficacy as support modalities in the present pandemic are unclear. We review the rapidly changing epidemiology, pathophysiology, emerging therapy, and clinical outcomes of COVID-19; and based on these data and previous experience with artificial cardiopulmonary support strategies, particularly in the setting of infectious diseases, provide consensus recommendations from ASAIO. Of note, this is a "living document," which will be updated periodically, as additional information and understanding emerges.

The severe acute respiratory syndrome-CoV-2 is an emerging viral pathogen responsible for the global coronavirus disease 2019 pandemic resulting in significant human morbidity and mortality. Based on preliminary clinical reports, hypoxic respiratory failure complicated by acute respiratory distress syndrome is the leading cause of death. Further, septic shock, late-onset cardiac dysfunction, and multiorgan system failure are also described as contributors to overall mortality. Although extracorporeal membrane oxygenation and other modalities of mechanical cardiopulmonary support are increasingly being utilized in the treatment of respiratory and circulatory failure refractory to conventional management, their role and efficacy as support modalities in the present pandemic are unclear. We review the rapidly changing epidemiology, pathophysiology, emerging therapy, and clinical outcomes of coronavirus disease 2019; and based on these data and previous experience with artificial cardiopulmonary support strategies, particularly in the setting of infectious diseases, provide consensus recommendations from American Society for Artificial Internal Organs. Of note, this is a living document, which will be updated periodically, as additional information and understanding emerges.

Generation of plasma-free hemoglobin (pfHb) and activated complement during complex cardiac surgery contributes to end-organ dysfunction. This prospective, multicenter REFRESH I (REduction in FREe Hemoglobin) randomized controlled trial evaluated the safety and feasibility of CytoSorb hemoadsorption therapy to reduce these factors during prolonged cardiopulmonary bypass (CPB). Eligible patients underwent elective, nonemergent complex cardiac surgery with expected CPB duration ≥3 hours. Exclusions included single procedures including primary coronary artery bypass graft, single valves, transplant, and left ventricular assist device extraction. TREATMENT used 2 parallel 300 mL CytoSorb hemoadsorption cartridges in a side circuit during CPB. CONTROL was standard of care. Of 52 enrolled patients, 46 underwent surgery (Safety group, n = 23 vs Control, n = 23), and 38 were evaluated for pfHb reduction (EFFICACY group, n = 18 vs CONTROL, n = 20). Type and number of serious adverse events (44 vs 43 CONTROL) were similar, as was 30-day mortality. Transient reduction in platelets during CPB was observed in both groups, especially TREATMENT, but returned to pretreatment levels after CPB without bleeding. Peak pfHb was positively correlated with CPB length (P = 0.01) but the high variability of pfHb, due to the broad surgical procedure mix, prevented detection of changes in pfHb in the overall EFFICACY population. However, the valve replacement surgery subgroup (8 vs 10 CONTROL) had the highest peak pfHb levels, and TREATMENT demonstrated significant pfHb reductions vs CONTROL (P ≤ 0.05) in CPB ≥3 hours. In the EFFICACY group, C3a and C5a were significantly reduced by treatment throughout surgery. Intraoperative hemoadsorption with CytoSorb was safe and feasible in this randomized, controlled pilot study during complex cardiac surgery. Treatment with CytoSorb resulted in significant reductions in pfHb during valve replacement surgery and reductions in C3a and C5a in the overall EFFICACY group. Future studies will target complex cardiac surgery patients with prolonged CPB to assess hemoadsorption effect on end-organ dysfunction and outcomes., (Copyright © 2019. Published by Elsevier Inc.)

Background: Leveraging Internet technologies for academic activities can be complex and expensive, costing tens of thousands of dollars. This report describes an experience in eliminating financial barriers and realizing the potential for a new paradigm in applications for surgical education and practice., Methods: After developing multiple surgical smartphone applications (apps), the report describes the acquisition of skill sets and resources to create state-of-the-art tools. Learning these techniques is nontrivial but is attainable and clearly defined. The report then discusses the trivial costs associated with complex software development, thereby opening new doors to creative uses of technology., Results: Acquisition of coding skills for smartphones took approximately 100 hours. For a simple app without data storage, EuroSCORE (European System for Cardiac Operative Risk Evaluation), total programming time was 25 hours with no additional costs. The more complex autonomy evaluation app, Zwisch Me, was used to evaluate more than 1260 cases from 15 cardiothoracic surgery training programs between January 2016 and August 2018 by using smartphone apps for data collection and a Web dashboard for data reporting. During the first year, all enrollment and data reporting was done manually, at a cost of $124. Automating user enrollment and data reporting increased costs by roughly $240, for an annual expense of $364. Total programming time for this app was approximately 120 hours., Conclusions: Mobile software is underused in the academic surgical arena. The historically large financial barriers to adoption can be overcome by acquisition of coding skills by surgical team members. Direct physician involvement will spawn previously undreamed-of creative applications to enhance practice and education., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Double-lumen venovenous extracorporeal membrane oxygenation may be used as a bridge to lung transplantation. Predictors of outcome with this strategy have not been well described., Methods: All patients with irreversible lung disease who developed acute pulmonary failure and required double-lumen venovenous extracorporeal membrane oxygenation as a bridge to decision or lung transplant at our institution were included in this study. Survival of the extracorporeal membrane oxygenation patients was compared with listed patients who did not require extracorporeal membrane oxygenation with lung allocation score in the highest 10% for the same period., Results: Fifteen patients (46 ± 17 years old) received double-lumen venovenous extracorporeal membrane oxygenation cannula. Mean length of extracorporeal membrane oxygenation support was 18.2 (1-60) days. Of these, seven patients were bridged to lung transplant, six died on extracorporeal membrane oxygenation, and two weaned to recovery. Amount of red blood cell transfusion was significantly higher (3.3 vs 18.5 U, p = 0.003) and lowest oxygen saturation was significantly lower in non-survivors (84.5% vs 66.3%, p = 0.002). Of the seven patients who were already listed for lung transplant at the onset of extracorporeal membrane oxygenation, five were transplanted. Overall survival to hospital discharge was 60%. Survival of patients with lung allocation score in the highest 10% (average lung allocation score 83.4) in the same period was 80%., Conclusion: Double-lumen venovenous extracorporeal membrane oxygenation cannula is a feasible option to bridge patients to decision or lung transplantation. Blood transfusion requirement and low oxygen saturation are markers of poor prognosis. Listing status at the time of cannulation and ambulation during extracorporeal membrane oxygenation support may be important indicators of good outcome.

Background: Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees., Methods: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis., Results: A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training., Conclusion: There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The AvalonElite double lumen cannula (DLC) provides total cavopulmonary assist (CPA) in failing Fontan sheep, but recirculation limits reliability. To improve CPA performance, a two-valve extracardiac conduit (ECC) was used to bracket infusion blood toward pulmonary artery (PA). A total cavopulmonary connection with failing Fontan circulation adult sheep model was created with valved ECC (n = 6). The valved ECC was connected to superior/inferior venae cavae (SVC/IVC) and right PA. The AvalonElite DLC was inserted from right jugular vein with infusion opening between the ECC valves. The DLC drainage lumen withdrew blood from SVC/IVC, and the infusion lumen returned blood to ECC. A failing Fontan sheep model with valved ECC was successfully created. Central venous pressure increased from 9 ± 1 to 17 ± 1 mm Hg, systolic arterial pressure decreased from 103 ± 9 to 51 ± 13 mm Hg, and cardiac output decreased from 3.6 ± 0.3 to 1.4 ± 0.2 L/min. Serum lactate significantly increased, indicating poor tissue perfusion. At 4 L/min pumping flow, the AvalonElite DLC returned hemodynamics/lactate to baseline levels throughout 6 hour CPA. Necropsy revealed intact/well-functioning ECC valves and well-positioned DLC with no visible thrombosis. The AvalonElite DLC provides reliable CPA performance in failing Fontan sheep with valved ECC.

Venoarterial extracorporeal membrane oxygenation (ECMO) is a rescue therapy that can stabilize patients with hemodynamic compromise, with or without respiratory failure, for days or weeks. In cardiology, the main indications for ECMO include cardiac arrest, cardiogenic shock, post-cardiotomy shock, refractory ventricular tachycardia, and acute management of complications of invasive procedures. The fundamental premise underlying ECMO is that it is a bridge-to recovery, to a more durable bridge, to definitive treatment, or to decision. As a very resource- and effort-intensive intervention, ECMO should not be used on unsalvageable patients. As the use of this technology continues to evolve rapidly, it is important to understand the indications and contraindications; the logistics of ECMO initiation, management, and weaning; the general infrastructure of the program (including the challenges associated with transferring patients supported by ECMO); and ethical considerations, areas of uncertainty, and future directions., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We investigated attending surgeon decisions regarding resident operative autonomy, including situations where operative autonomy was discordant with performance quality., Methods: Attending surgeons assessed operative performance and documented operative autonomy granted to residents from 14 general surgery residency programs. Concordance between performance and autonomy was defined as "practice ready performance/meaningfully autonomous" or "not practice ready/not meaningfully autonomous." Discordant circumstances were practice ready/not meaningfully autonomous or not practice ready/meaningfully autonomous. Resident training level, patient-related case complexity, procedure complexity, and procedure commonality were investigated to determine impact on autonomy., Results: A total of 8,798 assessments were collected from 429 unique surgeons assessing 496 unique residents. Practice-ready and exceptional performances were 20 times more likely to be performed under meaningfully autonomous conditions than were other performances. Meaningful autonomy occurred most often with high-volume, easy and common cases, and less complex procedures. Eighty percent of assessments were concordant (38% practice ready/meaningfully autonomous and 42% not practice ready/not meaningfully autonomous). Most discordant assessments (13.8%) were not practice ready/meaningfully autonomous. For fifth-year residents, practice ready/not meaningfully autonomous ratings (9.7%) were more frequent than not practice ready/meaningfully autonomous ratings (7.5%). Ten surgeons (2.3%) failed to afford residents meaningful autonomy on any occasion., Conclusion: Resident operative performance quality is the most important determinant in attending surgeon decisions regarding resident autonomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Concerns exist regarding the competency of general surgery graduates with performing core general surgery procedures. Current competence assessment incorporates minimal procedural numbers requirements., Methods: Based on the Zwisch scale we evaluated the level of autonomy achieved by categorical PGY1-5 general surgery residents at 14 U.S. general surgery resident training programs between September 1, 2015 and December 31, 2016. With 5 of the most commonly performed core general surgery procedures, we correlated the level of autonomy achieved by each resident with the number of procedures they had performed before the evaluation period, with the intent of identifying specific target numbers that would correlate with the achievement of meaningful autonomy for each procedure with most residents., Results: Whereas a definitive target number was identified for laparoscopic appendectomy (i.e. 25), for the other 4 procedures studied (i.e. laparoscopic cholecystectomy, 52; open inguinal hernia repair, 42; ventral hernia repair, 35; and partial colectomy, 60), target numbers identified were less definitive and/or were higher than many residents will experience during their surgical residency training., Conclusions: We conclude that procedural target numbers are generally not effective in predicting procedural competence and should not be used as the basis for determining residents' readiness for independent practice., (Copyright © 2017. Published by Elsevier Inc.)

Background: Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents., Methods: We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty., Results: Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r = 0.74)., Conclusion: Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Discrimination against women training in medicine and surgery has been subjectively described for decades. This study objectively documents gender differences in the degree of autonomy given to thoracic surgery trainees in the operating room., Design: Thoracic surgery residents and faculty underwent frame of reference training on the use of the 4-point Zwisch scale to measure operative autonomy. Residents and faculty then submitted evaluations of their perception of autonomy granted for individual operations as well as operative difficulty on a real-time basis using the "Zwisch Me!!" mobile application. Differences in autonomy given to male and female residents were elucidated using chi-square analysis and ordered logistic regression., Setting: Seven academic medical centers with thoracic surgery training programs., Participants: Volunteer thoracic surgery residents in both integrated and traditional training pathways and their affiliated cardiothoracic faculty., Results: Residents (n = 33, female 18%) submitted a total of 596 evaluations to faculty (n = 48, female 12%). Faculty gave less autonomy to female residents with only 56 of 184 evaluations (30.3%) showing meaningful autonomy (passive help or supervision only) compared to 107 of 292 evaluations (36.7%) at those levels for male residents (p = 0.02). Resident perceptions of autonomy showed even more pronounced differences with female residents receiving only 38 of 197 evaluations (19.3%) with meaningful autonomy compared to 133 of 399 evaluations (33.3%) for male residents (p < 0.001). Potential influencing factors explored included attending gender and specialty, case type and difficulty, and resident level of training. In multivariate analysis, only case difficultly, resident gender, and level of training were significantly related to autonomy granted to residents., Conclusions: Evaluations of operative autonomy reveal a significant bias against female residents. Faculty education is needed to encourage allowing female residents more operative autonomy., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Residents frequently report inadequate feedback both in quantity and quality. The study evaluates the quality of faculty feedback about operative performance given using an app-based system., Design: Residents requested operative performance evaluation from faculty on a real-time basis using the "Zwisch Me!!" mobile application which allows faculty to provide brief written feedback. Qualitative analysis of feedback was performed using grounded theory., Setting: The 7 academic medical centers with thoracic surgery training programs., Participants: Volunteer thoracic surgery residents in both integrated and traditional training pathways and their affiliated cardiothoracic faculty., Results: Residents (n = 33) at 7 institutions submitted a total of 596 evaluations to faculty (n = 48). Faculty acknowledged the evaluation request in 476 cases (80%) and in 350 cases (74%) provided written feedback. Initial open coding generated 12 categories of feedback type. We identified 3 overarching themes. The first theme was the tone of the feedback. Encouraging elements were identified in 162 comments (46%) and corrective elements in 230 (65%). The second theme was the topic of the feedback. Surgical technique was the most common category at 148 comments (42.2%) followed by preparation for case (n = 69, 19.7%). The final theme was the specificity of the feedback. Just over half of comments (n = 190, 54.3%) contained specific feedback, which could be applied to future cases. However, 51 comments (14.6%) contained no useful information for the learners., Conclusions: An app-based system resulted in thoracic surgery residents receiving identifiable feedback in a high proportion of cases. In over half of comments the feedback was specific enough to allow improvement. Feedback was better quality when addressing error prevention and surgical technique but was less useful when addressing communication, flow of the case, and assisting. Faculty development around feedback should focus on making feedback specific and actionable, avoiding case descriptions, or simple platitudes., (Copyright © 2017. Published by Elsevier Inc.)

Objective: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy., Background: The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role., Methods: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation., Results: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%., Conclusions: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

The development of a successful extracorporeal membrane oxygenation (ECMO) program requires an institutional commitment and the multidisciplinary cooperation of trained specialty personnel from nursing, internal medicine, anesthesiology, pulmonology, emergency medicine, critical care, and surgery and often pediatrics as well. The specialized training necessary to cultivate an integrated team capable of providing life-saving ECMO cannot be underestimated. The development of a successful ECMO program is best suited to a tertiary medical center that is centrally/regionally located and capable of financially supporting the level of expertise required as well as managing the program's overall cost effectiveness., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Extracorporeal membrane oxygenation (ECMO) is a life-saving technique when patients require pulmonary and/or cardiac support for days to weeks for recovery, bridge to decision, or transplantation. Due to complications associated with ECMO, it is best to stay on ECMO as little time as necessary. Foremost is weaning from ECMO, but the post-ECMO period recapitulates the entire field of critical care. Identified issues include (1) potential for systemic inflammatory response syndrome post-decannulation; (2) post-ECMO complications, such as deep vein thrombosis, wounds, renal failure, and stroke; (3) delirium; (4) posttraumatic stress disorder; (5) rehabilitation; and (6) end of life., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A cavopulmonary assist device (CPAD) has been developed for failing Fontan support. This CPAD pumps blood from superior/inferior vena cavae (SVC/IVC) to pulmonary artery. In this study, we compared failing Fontan support with CPAD versus veno-arterial extracorporeal membrane oxygenation (VA ECMO) in silico. A numerical lumped-parameter circulatory system model was used to simulate Fontan circulation. Failing Fontan was simulated by increased pulmonary resistance. Central venous pressure (CVP), mean pulmonary arterial pressure (mPAP), left atrial pressure (LAP), and univentricular outflow (CO) were simulated and compared with published clinical data. The CPAD and VA ECMO were simulated using 1-5 L/min pump flows. In agreement with published clinical data, the simulated failing Fontan condition had increased CVP (19 mmHg) and mPAP (18 mmHg) with decreased LAP (7 mmHg) and cardiac output (3 L/min) compared with functional Fontan condition. The CPAD achieved total Fontan assistance with pump flows higher than original CO. Veno-arterial extracorporeal membrane oxygenation provided partial Fontan assistance with low pump flows. Blood went through pulmonary circulation with CPAD whereas VA ECMO bypassed pulmonary circulation and diminished univentricular blood flow (0.8 L/min). This in silico study demonstrated that CPAD preserved heart/lung function whereas VA ECMO had very low univentricular flow, potentially leading to thrombosis or univentricular atrophy.

Background: Differential hypoxia exists in peripheral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients with compromised lungs, causing hypoxic damage to heart or brain. We proposed an Avalon Elite (Maquet, Rastatt, Germany) double lumen cannula-based hybrid ECMO to add a venovenous (VV) blood flow into the pulmonary circulation onto the existing VA ECMO circuit to increase oxygen saturation in the left ventricle and ascending aorta, mitigating heart/brain hypoxia., Methods: This hybrid ECMO circuit consists of two cannulas (27F Avalon Elite double lumen cannula from the inferior vena cava to the superior vena cava to right atrium to inferior vena cava; 17F infusion cannula in femoral artery), a blood pump, and a gas exchanger. This hybrid ECMO circuit was tested in 7 adult sheep with simulated lung failure. Total ECMO blood flow (2.8 to 3.3 L/min) was split between VV and VA blood flow. The VV blood flow was adjusted from 0% to 50% of total ECMO flow by approximately 10% increments., Results: In VA ECMO, simulated respiratory failure resulted in differential hypoxia (low oxygen level in left ventricle and high oxygen level in abdominal aorta). In hybrid ECMO, adding VV blood flow (10% to 50% of total ECMO flow) to the VA ECMO circuit progressively increased left ventricle blood oxygen saturation from 70% ± 8% at zero VV blood flow (pure VA ECMO) to 82% ± 6% at 300 mL/min VV blood flow, and 96% ± 6% at 1,700 mL/min VV blood flow., Conclusions: The Avalon Elite double-lumen cannula-based hybrid ECMO circuit is a simple circuit that provides efficient performance and flexible VA/VV blood distribution. In this hybrid ECMO circuit, incremental VV blood flow (10% to 50%) progressively increased left ventricular blood oxygen level, ensuring adequate heart and brain oxygen supply., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There is concern about graduating thoracic trainees' independent operative skills due to limited autonomy in training. This study compared faculty and trainee expected levels of autonomy with intraoperative measurements of autonomy for common cardiothoracic operations., Methods: Participants underwent frame-of-reference training on the 4-point Zwisch scale of operative autonomy (show and tell → active help → passive help → supervision only) and evaluated autonomy in actual cases using the Zwisch Me!! mobile application. A separate "expected autonomy" survey elicited faculty and resident perceptions of how much autonomy a resident should have for six common operations: decortication, wedge resection, thoracoscopic lobectomy, coronary artery bypass grafting, aortic valve replacement, and mitral valve repair., Results: Thirty-three trainees from 7 institutions submitted evaluations of 596 cases over 18 months (March 2015 to September 2016). Thirty attendings subsequently provided their evaluation of 476 of those cases (79.9% response rate). Expected autonomy surveys were completed by 21 attendings and 19 trainees from 5 institutions. The six operations included in the survey constituted 47% (226 of 476) of the cases evaluated. Trainee and attending expectations did not differ significantly for senior trainees. Both groups expected significantly higher levels of autonomy than observed in the operating room for all six types of cases., Conclusions: Although faculty and trainees both expect similar levels of autonomy in the operating room, real-time measurements of autonomy show a gap between expectations and reality. Decreasing this gap will require a concerted effort by both faculty and residents to focus on the development of independent operative skills., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs., Methods: Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail., Results: A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures., Conclusions: SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed., (Copyright © 2016. Published by Elsevier Inc.)

A number of research teams are developing surface coatings for hollow fiber membrane (HFM) blood oxygenators to improve their biocompatibility and service life. Surface coating techniques can be quite sensitive to the presence of contaminants on the exterior surface of the hollow fibers. We found large amounts of leachable oils associated with several commercial HFMs, i.e., as much as 2.5-7.5 weight percent. Leachable residues were suspected when a surface coating, a surface-initiated atom transfer radical polymerization (s-ATRP) of poly(ethylene glycol) methacrylate, resulted in areas of 100 µm devoid of coatings on the exterior surfaces of HFMs. After leaching residual oils, s-ATRP coatings were uniform and continuous across the hollow fibers. Therefore, removal of residual material should be considered before applying coating technologies to commercial HFMs. The effects of such leachable agents on the performance of blood oxygenators are not known.

Background: Current guidelines for gastrointestinal cancer surgical intervention in high-risk patients recommend postoperative venous thromboembolism (VTE) chemical prophylaxis for 4 weeks with low-dose unfractionated heparin or low-molecular-weight heparin, but specific guidelines for esophagectomy are lacking. This survey identified the clinical patterns affecting postesophagectomy VTE chemoprophylaxis use among general thoracic surgeons., Methods: General Thoracic Surgery Club members were invited to complete an online survey on VTE prophylaxis to analyze clinical factors affecting their choices., Results: Seventy-seven surgeons (37% membership) responded; of these, 94% (72 of 77) completed fellowships, and 76% (58 of 77) worked at universities. VTE chemoprophylaxis administration varied widely in drug, dosing, and duration, with 30% using suboptimal dosing of unfractionated heparin (every 12 hours). Participants agreed that esophagectomy patients are at high VTE risk, yet 29% (22 of 76) of surgeons delay VTE chemoprophylaxis until postoperative day 1. Only 13% (10 of 77) prescribe postdischarge chemoprophylaxis. Minimally invasive surgeons (>90% of cases) were more likely to prescribe postdischarge prophylaxis (p = 0.007). Epidurals, routinely used by 65% (51 of 78), led to less compliance with recommended dosing. Only 53% (27 of 51) of pain teams allow unfractionated heparin every 8 hours, yet 73% (37 of 51) allow suboptimal dosing (every 12 h). Postoperative major complications were identified as a VTE risk factor by only 21% (15 of 72) of surgeons. Most (92% [68 of 74]) would follow esophagectomy-specific guidelines, if developed., Conclusions: Thoracic surgeons agree that VTE chemoprophylaxis is necessary for esophagectomy, yet substantial variability exists in current practice. A noteworthy proportion use suboptimal dosing, and very few choose postdischarge prophylaxis. To improve postesophagectomy morbidity and mortality outcomes, thoracic surgeons are willing to follow evidence-based guidelines for VTE chemoprophylaxis., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Our goal is to develop a double lumen cannula (DLC) for a percutaneous right ventricular assist device (pRVAD) in order to eliminate two open chest surgeries for RVAD installation and removal. The objective of this study was to evaluate the performance, flow pattern, blood hemolysis, and thrombosis potential of the pRVAD DLC., Methods: Computational fluid dynamics (CFD), using the finite volume method, was performed on the pRVAD DLC. For Reynolds numbers <4000, the laminar model was used to describe the blood flow behavior, while shear-stress transport k-ω model was used for Reynolds numbers >4000. Bench testing with a 27 Fr prototype was performed to validate the CFD calculations., Results: There was <1.3% difference between the CFD and experimental pressure drop results. The Lagrangian approach revealed a low index of hemolysis (0.012% in drainage lumen and 0.0073% in infusion lumen) at 5 l/min flow rate. Blood stagnancy and recirculation regions were found in the CFD analysis, indicating a potential risk for thrombosis., Conclusions: The pRVAD DLC can handle up to 5 l/min flow with limited potential hemolysis. Further modification of the pRVAD DLC is needed to address blood stagnancy and recirculation.

Minimally invasive approaches to diaphragm plication for eventration include thoracoscopic and laparoscopic techniques. The elevated hemidiaphragm and ribs limit thoracoscopic techniques. We report our modification of the laparoscopic approach using robotic assistance with the da Vinci Surgical System, (Intuitive Surgical Inc, Sunnyvale, CA) to avoid single-lung ventilation, facilitate exposure, and allow more precise placement of plication sutures to achieve an even tension and maximum plication. Critical steps include creation of a small defect in the diaphragm to equalize pressures between cavities and placement of multiple, pledgeted interrupted horizontal mattresses., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)