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Background Surgical peer coaching has been associated with high rates of practice change but remains largely unutilized. The purpose of this study was to survey surgeons internationally to investigate attitudes regarding peer coaching and to identify any international differences to inform the design of future coaching programs. Methods Practicing surgeons in general surgery or related subspecialties were eligible to participate. Invitations to complete the survey were distributed through 13 surgical associations, social media, and personal e-mail invitations. Responses were obtained between June 1st and August 31st, 2020. Results A total of 521 surveys were collected. The majority of participants practiced in North America (263; 50%) with remaining respondents from Asia (81; 16%), Europe (34;7%), South America (21; 4%), Africa (17; 3%), and Oceania (6; 1%). Duration of practice was equally distributed across 4 intervals (0–5 years; 6–15 years; 16–25 years; > 25 years). Respondents most frequently identified as general surgeons (290; 67%) and 325 (75%) were male. Awareness of peer coaching was reported by 275 (53%) respondents, with 197 (44%) never seeking formal feedback from peers. The majority of respondents (372; 84%) would be willing to participate in a peer coaching program, with monthly interactions the most desirable frequency reported (193; 51%). Coaching in the operating room was preferred by most participants (360; 86%). Few respondents (67; 14%) would accept coaching from someone unknown to them. Participants identified key coaching program elements as: feedback kept private and confidential (267; 63%); opportunity to provide feedback to the coach (247; 59%); personalized goal setting (244; 58%); and the option to choose one’s own coach (205; 49%). The most commonly cited potential barrier to participation was logistical constraints (334; 79%). Conclusion This international survey of practicing surgeons demonstrated that peer feedback is rarely used in practice, but there is high interest and acceptance of the peer coaching model for continuous professional development. Findings regarding preferred program structure may be useful to inform the design of future peer coaching programs. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08760-z.

Increased stressful experiences are pervasive among healthcare providers (HCPs) during the COVID-19 pandemic. Identifying resources that help mitigate stress is critical to maintaining HCPs’ well-being. However, to our knowledge, no instrument has systematically examined how different levels of resources help HCPs cope with stress during COVID-19. This cross-sectional study involved 119 HCPs (64 nurses and 55 physicians) and evaluated the perceived availability, utilization, and helpfulness of a list of personal, hospital, and healthcare system resources. Participants also reported on their level of burnout, psychological distress, and intentions to quit. Results revealed that HCPs perceived the most useful personal resource to be family support; the most useful hospital resources were a safe environment, personal protective equipment, and support from colleagues; the most useful system resources were job protection, and clear communication and information about COVID. Moreover, HCPs who perceived having more available hospital resources also reported lower levels of psychological distress symptoms, burnout, and intentions to quit. Finally, although training and counseling services were perceived as useful to reduce stress, training was not perceived as widely available, and counseling services, though reported as being available, were underutilized. This instrument helps identify resources that support HCPs, providing implications for healthcare management.

Objective Electrical cardioversion of ED patients is a well-described treatment strategy for certain patients presenting with atrial fibrillation (AF). The objective of this study was to describe the safety and outcomes of this practice in a cohort of patients undergoing ED electrical cardioversion for AF. Methods This retrospective health records survey investigated a 5-year cohort of consecutive ED patients presenting with AF who underwent electrical cardioversion in an academic, tertiary ED. Electronic and manual abstraction strategies were used, extracting data on demographics, clinical features, interventions, complications, and return visits within 1 month. Data were analyzed using descriptive statistics and agreement between trained abstractors on key variables was excellent (k = 0.94–0.98). Results Data from 887 patients were analyzed. Electrical cardioversion was successful in 781 (88%) encounters. There were 3 major complications (3/887; 0.3%) and 123 minor complications (123/887; 14%). Major complications included one post-cardioversion stroke (1/887; 0.1%), one jaw thrust maneuver for hypoxia (0.1%), and one overnight observation for hypotension (0.1%). 741 patients (84%) were discharged following cardioversion with a mean ED LOS of 218 min (95% CI: 206–231 min). 57 (6.4%) patients returned to the ED within 30 days; 43 (4.8%) returned with in AF or flutter. Conclusions In this cohort of ED patients with atrial fibrillation, ED electrical cardioversion followed by discharge to home was largely safe and effective. Most complications were transient and mild. There were remarkably few serious complications.

Investor-driven "short-termism" is said to harm EU public firms' ability to invest for the long term, prompting calls for the EU to better insulate managers from shareholder pressure. But the evidence offered---rising levels of repurchases and dividends---is incomplete and misleading: it ignores large offsetting equity issuances that move capital from investors to EU firms. We show that, over the last 30 years and the last decade, net shareholder payouts have been moderate, and investment and cash balances have increased. In sum, the data provide little basis for the view that short-termism in the EU warrants corporate governance reforms.

Background Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients’ preferences for treatment for low rectal cancer. Methods Ambulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection. Results A total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5−25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients. Conclusion An important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients’ value functional outcomes with a low anastomosis.

A central challenge in the regulation of controlled firms is curbing rent extraction by controllers. As independent directors and fiduciary duties are often insufficient, some jurisdictions give minority shareholders veto rights over related-party transactions. To assess these rights’ effectiveness, we exploit a 2011 Israeli reform that gave minority shareholders veto rights over related-party transactions, including the pay of controllers and their relatives (“controller executives”). We find that the reform curbed controller-executive pay and led some controller executives to resign or go with little or no pay in circumstances suggesting their pay would be rejected. These findings suggest that minority veto rights can be an effective corporate governance tool.

Continuous advancement of surgical skills is of utmost importance to surgeons in practice, but traditional learning activities without personalized feedback often do not translate into practice changes in the operating room. Peer coaching has been shown to lead to very high rates of practice changes and utilization of new skills. The purpose of this study was to explore the opinions of practicing surgeons regarding the characteristics of peer coaching programs, in order to better inform future peer coaching program design. Using a convenience sample, practicing general surgeons were invited to participate in focus group interviews. Allocation into groups was according to years in practice. The interviews were conducted using open-ended questions by trained facilitators. Audio recordings were transcribed and coded into themes by two independent reviewers using a grounded theory approach. Of 52 invitations, 27 surgeons participated: 74% male; years in practice: 15 years: 41%. Three main themes emerged during coding: ideal program structure, motivations for participation, and barriers to implementation. For the ideal structure of a peer coaching program all groups agreed coaching programs should be voluntary, involve bidirectional learning, and provide CME credits. Live, in situ coaching was preferred. Motivations for coaching participation included: desire to learn new techniques (48%), remaining up to date with the evolution of surgical practice (30%) and improvement of patient outcomes (18%). Barriers to program implementation were categorized as: surgical culture (42%), perceived lack of need (26%), logistical constraints (23%) and issues of coach–coachee dynamics (9%). Peer coaching to refine or acquire new skills addresses many shortcomings of traditional, didactic learning modalities. This study revealed key aspects of optimal program structure, motivations and barriers to coaching which can be used to inform the design of successful peer coaching programs in the future.

Incisional negative pressure wound therapy (iNPWT) may reduce surgical site infections (SSI), which can have devastating consequences after incisional hernia repair. Few comparative studies investigate the effectiveness of this wound management strategy in this population. The objective of this study is to determine the effect of iNPWT on the incidence of SSI after complex incisional hernia repair. All adult patients undergoing open incisional hernia repair at a single center from 2016 to 2019 were reviewed. A commercial iNPWT dressing was used at the discretion of the surgeon. Patients were grouped by type of dressing; iNPWT and standard sterile dressings (SSD). Coarsened exact matching was used to create balanced cohorts for comparison using age, sex, American Society of Anesthesiologists classification, wound classification, and surgical urgency. The primary outcome was the composite incidence of superficial and deep SSI within 30 days. Secondary outcomes included non-infectious surgical site occurrences (SSO), overall complications, length of stay (LOS), emergency department visits, and readmission at 30 days. 134 patients underwent complex hernia repair, with 114 patients included after matching (34 iNPWT, 51 SSD). Composite incidence of superficial and deep SSI was 19.3% (11.8% vs. 27.5%, p = 0.107), with significantly lower rates of deep SSI in patients receiving iNPWT (2.9% vs. 17.6%, p = 0.045). After accounting for residual differences between groups, iNPWT was associated with decreased incidence of composite SSI (RR 0.36, 95% CI [0.16, 0.87]). Median LOS was longer in patients with iNPWT (7 vs. 5 days, p = 0.001). There were no differences in SSO, overall complications, readmission, or emergency department visits. In patients undergoing incisional hernia repair, the use of iNPWT was associated with a lower incidence of SSI at 30 days. Future studies should focus on cost effectiveness of iNPWT, its impact on long-term hernia recurrences, and the identification of patient selection criteria in this population.

Despite a need for assessment of endoscopic submucosal dissection (ESD) skills in order to track progress and determine competence, there is no structured measure of assessing competency in ESD performance. The present study aims to develop and examine validity evidence for an assessment tool to evaluate the recorded performance of ESD for gastric neoplasms. The ESD video assessment tool (EVAT) was systematically developed by ESD experienced endoscopists. The EVAT consists of a 25-item global rating scale and 3-item checklist to assess competencies required to perform ESD. Five unedited videos were each evaluated by 2-blinded experienced ESD endoscopists to assess inter-rater reliability using intraclass correlation coefficients (ICC). Seventeen unedited videos in total were rated by 3 blinded experienced ESD endoscopists. Validity evidence for relationship to other variables was examined by comparing scores of inexperienced (fellows) and experienced endoscopists (attending staff), and by evaluating the relationship between the EVAT scores and ESD case experience. Internal consistency was evaluated using Cronbach’s alpha. The inter-rater reliability for the total score was high at 0.87 (95% confidence interval 0.11 to 0.99). The total score [median, interquartile range (IQR)] was significantly different between the inexperienced (71, 63–77) and experienced group (95, 91–97) (P = 0.005). The total scores demonstrated high correlation with the number of ESD cases (Spearman’s ρ = 0.79, P

Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the ‘Retraction and Exposure’ skill compared to the trainees. This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

Several grading schemes are available to assess surgical complications, but their relationship with patient-reported outcomes is not well understood. Therefore, our objective was to examine the effect of two complication grading schemas on health-related quality of life in colorectal surgery patients.An analysis of adult patients undergoing elective colorectal surgery from 2005 to 2013 was performed. Health-related quality of life was measured using the SF-36 preoperatively and at 4 weeks and 8 weeks postoperatively. The 30-day morbidity was classified using Clavien-Dindo grading (I-IV) and the Comprehensive Complication Index (0-100). The main outcomes were the postoperative changes in physical summary scores and mental summary scores. Multivariate logistic and fractional polynomial regression analyses were used to determine the relationship between complication severity and health-related quality of life.A total of 402 patients were included in the study. Overall morbidity was 46%. Patients with complications had lower physical summary scores and mental summary scores at 4-weeks and 8-weeks postoperatively compared with patients without complications (P.05). On multivariate regression, there was no dose-response relationship between Clavien-Dindo grade and postoperative physical summary scores and mental summary scores. Adjusted changes in the physical summary scores and mental summary scores had a more appropriate, dose-response relationship with the Comprehensive Complication Index scores.In patients undergoing colorectal surgery, there is a more consistent relationship between the Comprehensive Complication Index and postoperative health-related quality of life compared with the Clavien-Dindo classification.

Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted. A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included “laparoscopic suturing” and “clinical competence.” Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies. We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

A superpulse (500 W peak power) thulium fiber laser operating at a 1940 nm wavelength, suitable for lithotripsy, has recently been developed. The goal of this study was to compare stone fragmentation and dusting performance of the prototype superpulse thulium fiber laser with leading commercially available, high-power holmium:YAG lithotripters (wavelength 2100 nm) in a controlled in vitro environment. Two experimental setups were designed for investigating stone ablation rates and retropulsion effects, respectively. In addition, the ablation setup enabled water temperature measurements during stone fragmentation in the laser–stone interaction zone. Human uric acid (UA) and calcium oxalate monohydrate (COM) stones were used for ablation experiments, whereas standard BegoStone phantoms were utilized in retropulsion experiments. The laser settings were matched in terms of pulse energy, pulse repetition rate, and average power. At equivalent settings, thulium fiber laser ablation rates were higher than those for holmium:YAG laser in both dusting mode (threefold for COM stones and 2.5-fold for UA stones) and fragmentation mode (twofold for UA stones). For single-pulse retropulsion experiments, the threshold for onset of stone retropulsion was two to four times higher for thulium fiber laser. The holmium:YAG laser generated significantly stronger retropulsion effects at equal pulse energies. The water temperature elevation near the laser-illuminated volume did not differ between the two lasers. Distinctive features of the thulium fiber laser (optimal wavelength and long pulse duration) resulted in faster stone ablation and lower retropulsion in comparison to the holmium:YAG laser.

Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. A retrospective review was conducted for all Type II–IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p

Operative skills correlate with patient outcomes, yet at the completion of training or after learning a new procedure, these skills are rarely formally evaluated. There is interest in the use of summative video assessment of laparoscopic benign foregut and hiatal surgery (LFS). If this is to be used to determine competency, it must meet the robust criteria established for high-stakes assessments. The purpose of this review is to identify tools that have been used to assess performance of LFS and evaluate the available validity evidence for each instrument. A systematic search was conducted up to July 2017. Eligible studies reported data on tools used to assess performance in the operating room during LFS. Two independent reviewers considered 1084 citations for eligibility. The characteristics and testing conditions of each assessment tool were recorded. Validity evidence was evaluated using five sources of validity (content, response process, internal structure, relationship to other variables, and consequences). There were six separate tools identified. Two tools were generic to laparoscopy, and four were specific to LFS [two specific to Nissen fundoplication (NF), one heller myotomy (HM), and one paraesophageal hernia repair (PEH)]. Overall, only one assessment was supported by moderate evidence while the others had limited or unknown evidence. Validity evidence was based mainly on internal structure (all tools reporting reliability and item analysis) and content (two studies referencing previous papers for tool development in the context of clinical assessment, and four listing items without specifying the development procedures). There was little or no evidence supporting test response process (one study reporting rater training), relationship to other variables (two comparing scores in subjects with different clinical experience), and consequences (no studies). Two tools were identified to have evidence for video assessment, specific to NF. There is limited evidence supporting the validity of assessment tools for laparoscopic foregut surgery. This precludes their use for summative video-based assessment to verify competency. Further research is needed to develop an assessment tool designed for this purpose.

During the period 2005-2014, S&P 500 firms distributed to shareholders more than $3.95 trillion via stock buybacks and $2.45 trillion via dividends — $6.4 trillion in total. These shareholder payouts amounted to over 93% of the firms' net income. Academics, corporate lawyers, asset managers, and politicians point to such shareholder-payout figures as compelling evidence that “short-termism" and “quarterly capitalism" are impairing firms' ability to invest, innovate, and provide good wages.We explain why S&P 500 shareholder-payout figures provide a misleadingly incomplete picture of corporate capital flows and the financial capacity of U.S. public firms. Most importantly, they fail to account for offsetting equity issuances by firms. We show that, taking into account issuances, net shareholder payouts by all U.S. public firms during the period 2005-2014 were in fact only about $2.50 trillion, or 33% of their net income. Moreover, much of these net shareholder payouts were offset by net debt issuances, and thus effectively recapitalizations rather than firm-shrinking distributions. After excluding marginal debt capital inflows, net shareholder payouts by public firms during the period 2005-2014 were only about 22% of their net income. In short, S&P 500 shareholder-payout figures are not indicative of actual capital flows in public firms, and thus cannot provide much basis for the claim that short-termism is starving public firms of needed capital. We also offer three other reasons why corporate capital flows are unlikely to pose a problem for the economy.A prior version of this paper was circulated under the title “Short-Termism and Shareholder Payouts: Getting Corporate Capital Flows Right."

Thulium fiber laser (TFL) lithotripsy has recently been introduced in the clinic. Previous TFL laboratory studies demonstrated successful high-power delivery through ultra-small (50-150-µm-core) optical fibers. This preliminary study simulates the forces on fibers during insertion into an ureteroscope and determines the mechanical feasibility of ultra-small fibers in a clinical setting. Simulations were conducted for commercially avalaible silica fiber sizes (core/cladding): 50/70, 72/108, 100/140, 150/165, 150/180, and 200/240 μm. Solidworks software intregrating Euler’s buckling equation was used to calculate fiber buckling thresholds as a function of typical manual forces (0.3- 2.0 N) applied near the proximal end of a standard ureteroscope. Forces on fibers being inserted were modeled, assuming support from saline flow and resistance by the working channel wall. Simulation results were categorized based on force values previously reported in the literature, with smaller forces ( 1.6-2.0 N) at risk of damaging the working channel. Fiber sizes were simulated with two different types of holdings on each end to find a range of possible values that most closely simulate clinical behavior. The smallest usable standard flat tip fiber was found to be 150/190-μm (core/cladding), assuming a cladding thickness of ten times the laser wavelength of 1.94 μm (or extra 40 μm OD) to prevent leakage of evanescent waves through the core/cladding interface. The smallest usable ball tip fiber was found to be 110/150 μm. Numerical simulations predicted that optical fibers for TFL lithotripsy should be larger than 110/150 μm to provide effective manual manipulation within flexible ureteroscopes.

Under Delaware law, a securities issuance in which all existing investors may participate pro rata (a “rights offer”) is often seen as treating insiders and outsiders equally, making it difficult for nonparticipating outsiders to prevail on a claim that insiders sold themselves cheap securities. I show that insiders can use rights offers to sell themselves cheap securities, even if outsiders are sophisticated and well-capitalized. My analysis suggests courts applying Delaware law should more aggressively probe rights offers for substantive fairness. I conclude by describing red flags indicating a heightened risk of expropriation.

In December 2020, Nasdaq asked the Securities and Exchange Commission to approve new diversity rules. The aim is for most Nasdaq-listed firms to have at least one director self-identifying as female and another self-identifying as an underrepresented minority or LGBTQ+. While Nasdaq claims these rules will benefit investors, the empirical evidence provides little support for the claim that gender or ethnic diversity in the boardroom increases shareholder value. In fact, rigorous scholarship—much of it by leading female economists—suggests that increasing board diversity can actually lead to lower share prices. Adoption of Nasdaq’s proposed rules would thus generate substantial risks for investors.

AI is becoming ubiquitous, revolutionizing many aspects of our lives. In surgery, it is still a promise. AI has the potential to improve surgeon performance and impact patient care, from post-operative debrief to real-time decision support. But, how much data is needed by an AI-based system to learn surgical context with high fidelity? To answer this question, we leveraged a large-scale, diverse, cholecystectomy video dataset. We assessed surgical workflow recognition and report a deep learning system, that not only detects surgical phases, but does so with high accuracy and is able to generalize to new settings and unseen medical centers. Our findings provide a solid foundation for translating AI applications from research to practice, ushering in a new era of surgical intelligence.

Surgery is defined as the branch of medicine concerned with the treatment of disease, injury, and deformity by operation or manipulation. (Stedman’s Medical Dictionary, 28th edition).

Emergency department (ED) visits after surgery represent a significant cost burden on the healthcare system. Furthermore, many ED visits are related to issues of healthcare delivery services and may be avoidable. Few studies have assessed the reasons for ED visits after colorectal surgery. The main objectives of this study were to: (1) identify the reasons why patients presented to the ED within 30 postoperative days and (2) determine if these visits were potentially preventable. A retrospective chart review was conducted on elective major colorectal surgery cases performed in a single center between 01/2017 and 07/2019. Data collected included demographics, medical history, intraoperative details, postoperative complications, ED visits within 30 postoperative days, and readmissions. Each ED visit was assessed by two reviewers and graded on a scale adapted from the New York University ED algorithm. The gradings were: (1) non-emergent, (2) emergent but treatable in an ambulatory setting, (3) emergent/ED-care required but preventable if timely outpatient care was available, and (4) emergent/ED-care required and non-preventable. Grades 1–3 were deemed potentially preventable. Logistic regression identified independent predictors of potentially preventable visits. Six hundred and twenty five patients were included in the final analysis. 110 (17.6%) patients presented to the ED within 30 days. The most common cause of ED visit were ileus/small bowel obstruction (SBO) (16.4%), superficial wound infection (15.5%), genitourinary issues (10.9%), and non-infectious gastrointestinal issues (nausea, malnutrition, diarrhea, high output stomas) (10.9%). After review, 51.8% of visits were considered potentially preventable (Grade 1–3). The most common causes of preventable ED visits were superficial wound infection (24.6%), non-infectious gastrointestinal issues (19.3%), and minor bleeding (14.0%). Creation of a new stoma was the only independent risk factor for potentially preventable ED visits (OR 2.14, 95%CI 1.03–4.47). Approximately half of ED visits within 30 days of discharge were potentially preventable. These findings indicate a need to improve access to outpatient care to reduce preventable ED visits after elective colorectal surgery.

Background/Introduction Obesity is an important risk factor associated with poor cardiovascular and metabolic outcomes. Dietary, medical, and surgical weight loss strategies are often unsuccessful, unsustainable or accompanied by risks. Pre-clinical and early case series reported that transcatheter bariatric embolotherapy (TBE) of the left gastric artery reduces weight, by reducing “hunger” hormones from the gastric fundus. We studied TBE in a double-blind, sham procedure, first in human RCT of patients (pts) with obesity, and following completion of the initial study we asked subjects to return after 2 years post-embolization for further evaluation. Purpose The purpose of this extension study was to assess the long-term weight loss and other outcomes in subjects who underwent TBE for weight loss. Methods In the initial RCT subjects were randomized 1:1 to either a Sham (skin nick & 1 hr wait) or TBE following IV Propofol sedation. All pts received Lifestyle Therapy (behavioral and diet education); these staff following the pts were also blinded to treatment. Subjects completed the initial study when reaching the 1 year-follow-up visit. Subjects were then invited to return to the weight loss clinic at 2 years post-embolization for further evaluation on weight loss, blood pressure, pre-diabetic clinical status, satiety, and quality of life. Results A total of 44 pts (age 45.5±9.8; 36/8 M/F; BMI 39.6±3.8) were enrolled, of which 40 pts were randomized equally to groups, with no major complications. Mild, transient epigastric pain was seen, but EGDs showed no major abnormalities. Weight loss was improved with TBE by 6 mo, and maintained over the full 12 mo by both intention-to-treat and per-protocol analyses. At 2 years post-embolization, subjects treated with TBE demonstrated a mean 9% TBWL and 25% EBWL. Conclusion(s) Bariatric embolization is safe and when used along with lifestyle therapy, results in clinically significant weight loss. Long-term data demonstrates evidence that subjects treated with TBE continue to maintain their weight loss up to 2 years post-treatment. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Endobar Solutions LLC

Background/Introduction Obesity and its comorbid conditions (i.e. type II diabetes mellitus, atrial fibrillation, coronary artery disease, hypertension, etc...) is a growing burden globally, however, the current treatments (i.e. bariatric surgery, intragasrtic balloons and/or pharmaceutical therapy) pose substantial risks or are contraindicated for various populations. Transcatheter bariatric embolotherapy of left gastric artery by reducing “hunger” hormones from the gastric fundus is a procedure for weight loss that has been growing in prominence over the last several years, however, to date no randomized-controlled trial has been conducted until our study. We studied TBE in a double-blind, sham procedure, first in human RCT of patients (pts) with obesity. Purpose The purpose of this study was to assess the safety and efficacy of TBE for weight loss in obese patients as well as to evaluate metabolic changes. Methods After IV propofol, eligible pts (age 21–60; BMI 35–50 kg/m2) were randomized 1:1 to Sham (skin nick & 1 hr wait) or TBE. All pts received Lifestyle Therapy (behavioral and diet education). Study staff following the pts were also blinded to treatment. Blood samples for gastrointestinal hormones were collected in EDTA tubes containing a protease inhibitor cocktail and frozen per local laboratory standards. All collected samples were assessed together in two batches at the end of the study. The hormones analyzed included ghrelin, GIP, GLP-1, Visfatin, resistin, PAI-1 (total), Leptin, and C-Peptide. An Oral Glucose Tolerance Test (OGTT) and a diabetes assay was performed at baseline and at 6- and 12-months post-intervention. Note, while diabetes was an exclusion criterion for this study, pre-diabetes was not. Results 44 pts were enrolled, of which 40 pts were randomized equally to the groups, with no major complications in either group. TBE demonstrated superior weight loss over the control group at 6- and 12-months post-intervention in both intention-to-treat and per-protocol analyses. At 6 and 12 months, the TBE group demonstrated a clinically meaningful decrease in glucose 1-hour post-fasting by OGTT. GIP levels in the TBE group increased at a mean of 21%, indicative of an improvement in pre-diabetic milieu. Circulating plasma visfatin levels decreased 20% at 6 months and 26% at 12 months in the TBE group indicating a decrease in body fat. C-Peptide levels were noticeably increased in the TBE group at 6 months possibly indicating improvements in insulin sensitivity and beta-cell function. Conclusion(s) TBE is safe and results in clinically significant weight loss and demonstrated a positive effect on glucose homeostasis in pre-diabetic patients. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Endobar Solutions, LLC

The Thulium fiber laser (TFL) is being explored as a potential alternative to the gold standard Holmium:YAG laser for infrared laser ablation of kidney stones. Laser-induced vapor bubbles contribute to both the ablation mechanism and stone retropulsion. In this preliminary study, a biocompatible surfactant with concentrations of 1-5% was used to enhance the vapor bubble dimensions during the laser pulse. Bubble dimensions using surfactant increased on average by 25% compared with water only (control). With further development, introduction of the surfactant into the saline irrigation flow typically delivered through the working channel of the ureteroscope during laser lithotripsy, may contribute to more efficient stone ablation.Clinical Relevance-This preliminary study demonstrates that the dimensions of laser-induced vapor bubbles created during infrared laser lithotripsy can be enhanced by up to 25%, for potential clinical translation into more efficient lithotripsy and use in the "popcorn" ablation method.

In July 2020, the European Commission published the “Study on directors’ duties and sustainable corporate governance” by EY. The Report purports to find evidence of debilitating short-termism in EU corporate governance and recommends many changes to support sustainable corporate governance. In this paper, we point out deep flaws in the Report’s evidence and analysis. We recently submitted the content of this paper in response to the European Commission’s call for feedback. First, the Report defines the corporate governance problem as one of pernicious short-termism that damages the environment, the climate, and stakeholders. But the Report mistakenly conflates time-horizon problems with externalities and distributional concerns. Cures for one are not cures for the others and a cure for one may well exacerbate the others. Second, the Report’s main ostensible evidence for an increase in corporate short-termism is rising gross payouts to shareholders (dividends and stock repurchases). However, the more relevant payout measure to assess corporations’ ability to fund long-term investment is net payouts (gross payouts minus equity issuances), which is much lower and has left plenty of funds available for long-term and short-term investment. Third, when the Report turns to other evidence for short-termism, it selectively picks academic studies that support its views on short-termism, while failing to engage substantial contrary literature. Significant studies fail to detect short-termism and some substantial studies show excessive long-termism. Conceptually, some short-termism is an unfortunate but an inevitable side effect of effective corporate governance and may not be a first-order problem warranting wholesale reform. Finally, the Report touts cures whose effectiveness has little evidentiary support and, for some, there is real evidence that the cures could be counterproductive and costly.

Alibaba, the NYSE-traded Chinese ecommerce giant, is currently valued at over $700 billion. But Alibaba’s governance is opaque, obscuring who controls the firm. We show that Jack Ma, who now owns only about 5%, can effectively control Alibaba by controlling an entirely different firm: Ant Group. We demonstrate how control of Ant Group enables Ma to dominate Alibaba’s board. We also explain how this control gives Ma the indirect ability to disable (and perhaps seize) VIE-held licenses critical to Alibaba, providing him with substantial additional leverage. Alibaba is a case study of how corporate control can be created synthetically with little or no equity ownership via a web of employment and contractual arrangements.

Investor-driven "short-termism" is said to harm EU public firms' ability to invest for the long term, prompting calls for the EU to better insulate managers from shareholder pressure. But the evidence offered---rising levels of repurchases and dividends---is incomplete and misleading: it ignores large offsetting equity issuances that move capital from investors to EU firms. We show that, over the last 30 years and the last decade, net shareholder payouts have been moderate, and investment and cash balances have increased. In sum, the data provide little basis for the view that short-termism in the EU warrants corporate governance reforms.

Alibaba, the e-commerce giant that completed a record-setting IPO in the United States in 2014 and was valued at over $700 billion in early 2021, is one of hundreds of Chi-na-based firms listed in the United States whose controlling insiders are largely law-proof: the corporate and securities laws governing these firms are unenforceable because the firms’ insiders, records, and assets are in China. This casts doubt on the claim that foreign firms list in the United States to bond insiders to tough securities law. In fact, for China-based firms, listing in the United States but not in China effectively insulates insiders from any securities law. Yet U.S. securities law not only allows these firms to list, but also requires them to dis-close less than domestic firms. U.S. securities law thus favors foreign entrepreneurs and likely harms U.S. investors. We suggest ways to reduce this bias and better protect U.S. investors. More generally, we argue that enforceability is key to corporate governance.

Current methods for teaching and assessing competencies for endoscopic submucosal dissection (ESD) are highly variable, non-systematic, and are inefficient for the learner to acquire adequate skills. The present study aims to define and establish expert consensus regarding competencies required to perform ESD for gastric neoplasms. Fourteen ESD experts from 12 institutions in Japan were invited to complete an online survey to rate potential items for their importance in performing ESD proficiently. By using methodology based on the Delphi principles, the results of each round were analyzed and re-sent to the experts until consensus was established. Items were included if ranked 8 out of a 10-point Likert scale, by ≥ 80% of the respondents. A list of 29 potential items was generated through a review of the literature, textbooks, and experience of the steering group members. Ten new items were added through the survey. Consensus was reached after three rounds. Response rate ranged from 93 to 100%. Thirty-four items achieved consensus as important surrogates of competency in performing ESD. Essential competencies for performing ESD were identified through expert consensus. These competencies can serve as the foundation for structured training and for development of objective assessment tools to evaluate trainee performance in ESD.

The flashlamp-pumped, solid-state holmium:yttrium-aluminium-garnet (YAG) laser has been the laser of choice for use in ureteroscopic lithotripsy for the past 20 years. However, although the holmium laser works well on all stone compositions and is cost-effective, this technology still has several fundamental limitations. Newer laser technologies, including the frequency-doubled, double-pulse YAG (FREDDY), erbium:YAG, femtosecond, and thulium fibre lasers, have all been explored as potential alternatives to the holmium:YAG laser for lithotripsy. Each of these laser technologies is associated with technical advantages and disadvantages, and the search continues for the next generation of laser lithotripsy systems that can provide rapid, safe, and efficient stone ablation. New fibre-optic approaches for safer and more efficient delivery of the laser energy inside the urinary tract include the use of smaller-core fibres and fibres that are tapered, spherical, detachable or hollow steel, or have muzzle brake distal fibre-optic tips. These specialty fibres might provide advantages, including improved flexibility for maximal ureteroscope deflection, reduced cross section for increased saline irrigation rates through the working channel of the ureteroscope, reduced stone retropulsion for improved stone ablation efficiency, and reduced fibre degradation and burnback for longer fibre life.

Aim Postoperative ileus is the most commonly observed morbidity following ileostomy closure. Studies have demonstrated that the defunctionalized bowel of a loop ileostomy undergoes a series of functional and structural changes, such as atrophy of the intestinal villi and muscular layers, which may contribute to ileus. A single-centre study in Spain demonstrated that preoperative bowel stimulation via the distal limb of the loop ileostomy decreased postoperative ileus, length of stay and time to gastrointestinal function. Method A multicentre randomized controlled trial involving patients from Canadian institutions was designed to evaluate the effect of preoperative bowel stimulation before ileostomy closure on postoperative ileus. Stimulation will include canalizing the distal limb of the ileostomy loop with an 18Fr Foley catheter and infusing it with a solution of 500 ml of normal saline mixed with 30 g of a thickening agent (Nestle© Thicken-Up©). This will be performed 10 times over the 3 weeks before ileostomy closure in an outpatient clinic setting by a trained Enterostomal Therapy nurse. Surgeons and the treating surgical team will be blinded to their patient's group allocation. Data regarding patient demographics, and operative and postoperative variables, will be collected prospectively. Primary outcome will be postoperative ileus, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, that either requires nasogastric tube insertion or is associated with two of the following on or after post-operative day 3: nausea/vomiting; abdominal distension; and the absence of flatus. Secondary outcomes will include length of stay, time to tolerating a regular diet, time to first passage of flatus or stool and overall morbidity. A cost analysis will be performed to compare the costs of conventional care with conventional care plus preoperative stimulation. Discussion This manuscript discusses the potential benefits of preoperative bowel stimulation in improving postoperative outcomes and outlines our protocol for the first multicenter study to evaluate preoperative bowel stimulation before ileostomy closure. The results of this study could have considerable implications for the care of patients undergoing ileostomy closure.

Background Changes in surgical training have raised concerns about residents' operative exposure and preparedness for independent practice. One way of addressing this concern is by optimizing teaching and feedback in the operating room (OR). The objective of this study was to perform a systematic review on perioperative teaching and feedback. Methods A systematic literature search identified articles from 1994 to 2014 that addressed teaching, feedback, guidance, or debriefing in the perioperative period. Data was extracted according to ENTREQ guidelines, and a qualitative analysis was performed. Results Thematic analysis of the 26 included studies identified four major topics. Observation of teaching behaviors in the OR described current teaching practices. Identification of effective teaching strategies analyzed teaching behaviors, differentiating positive and negative teaching strategies. Perceptions of teaching behaviors described resident and attending satisfaction with teaching in the OR. Finally models for delivering structured feedback cited examples of feedback strategies and measured their effectiveness. Conclusions This study provides an overview of perioperative teaching and feedback for surgical trainees and identifies a need for improved quality and quantity of structured feedback.

Introduction Advanced laparoscopic suturing is considered a challenging skill to acquire. The aim of this study was to investigate the learning process for advanced laparoscopic suturing in the operating room to understand the obstacles trainees face when trying to master the skill. Methods A qualitative methodology using semistructured interviews and field observations was used. Data were analyzed using a Grounded Theory approach. Participants were general surgery residents and surgeons with advanced minimally invasive surgery (MIS) experience. Results Ten MIS surgeons across different institutions and 15 local general surgery residents were interviewed. The semistructured interviews and field observations of 9 advanced MIS operations (27h) yielded the following 6 themes around the acquisition of laparoscopic suturing skills for residents: complexity, training misalignment, variability of opportunities, inconsistency of techniques, lack of feedback, and differing expectations. Conclusion There are several unmet training needs around laparoscopic suturing skills. Training for advanced laparoscopic skills requires more emphasis on coaching and the development of advanced models. This study heralded the need to incorporate advanced laparoscopic skills into the surgical simulation curriculum.

Time and accuracy are commonly used metrics to assess laparoscopic skills in a simulated environment. However, they do not provide trainees with meaningful information about how to improve their skills. The objective of this study was to provide preliminary validity evidence for the creation a formative feedback tool (FFT) for advanced laparoscopic suturing skills. Videotapes of senior surgical residents (PGY3–5; SRs) and minimally invasive surgeons (MIS) performing 3 advanced laparoscopic suturing tasks were analyzed: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). A FFT was created based on a grounded theory analysis of interviews with MIS surgeons about the key technical aspects of each task. The FFT was used to assess the videotaped performances of SRs and MIS surgeons by two blinded independent raters. The FFT is composed of three parts: NH contains 10 items, UT 18, and CS 20. Each item was classified according to seven key surgical principles: depth perception, safety, bimanual dexterity, exposure, tissue handling, instrument manipulation, and forward planning. The videotaped performance of SR and MIS surgeons was graded on a 3-point Likert scale (“does well,” “needs some improvement,” and “does poorly”) and scores were calculated as a sum of the points. ICCs for all three tasks were high (NH 0.90, UT 0.87, and CS 0.90). FFT score correlated strongly with combined time and accuracy measurements for UT (0.82, p

Objective To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance. Background Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective-more task rather than procedure-oriented-and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety. Methods Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items. Results A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals. Conclusions This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery. A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3–5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy. A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2–19.3) in laparoscopic studies and 21.0% (95% CI 11.9–30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5. The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.

Speaking invitations are used by faculty promotion committees as evidence of external recognition. However, women are underrepresented as speakers at specialty society conferences despite the rise in women physicians. The purpose of this study was to estimate to what extent the gender of session conveners is associated with the gender distribution of invited speakers at SAGES meetings. A retrospective audit of annual SAGES meeting programs during 2009–2018 was performed. All invited panel speakers, defined as faculty delivering a prepared oral presentation in a session under the organization of one or more chairs, were identified. The gender of speakers and chairs/co-chairs was determined. Hands-on courses, paper sessions, military symposia, mock trials, and jeopardy sessions were excluded. We compared the proportion of all-male panels in sessions with all-male conveners versus sessions with at least one woman convener. Statistical analysis was performed using Chi-square and t tests. There were 3405 speakers and 459 panels identified. After applying inclusion and exclusion criteria, 2836 invited speakers on 402 panels were analyzed. Women represented 15% of all speakers, increasing from 9 to 19% (2009 to 2018). This reflects the rise in the proportion of women overall members (11% in 2010 to 19% in 2018). The proportion of panels with at least one woman convener increased from 12 to 58%. All-male panels represented 40% of all panels (n = 163) and their proportion significantly decreased over time from 50 to 31% (p trend

Delayed gastrointestinal (GI) recovery remains a significant morbidity after colorectal surgery. Intracorporeal anastomosis for right colectomy may hasten GI recovery. Therefore, the objective of this study was to determine the effect of intracorporeal versus extracorporeal anastomosis on GI recovery after elective laparoscopic right colectomy within an established ERAS program. Adult patients undergoing elective laparoscopic right colectomy at a single high-volume institution from 07/2014 to 12/2018 were reviewed. Patients were divided into two groups: intracorporeal (IC) and extracorporeal (EC). The primary outcome was time to GI-3 defined as days to tolerance of solid diet and first flatus/bowel movement. Prolonged postoperative ileus (PPOI) was defined as GI-3 not met by postoperative day 4. Secondary outcomes were length of stay (LOS) and overall 30-day complications. Sensitivity analysis was performed using coarsened exact matching to account for unmeasured confounding. Multiple regression was performed using a Cox proportional hazard model to identify predictors of GI recovery. A total of 346 patients were reviewed, of which 226 were included (71IC, 155EC). Patient characteristics were well balanced between groups: mean age was 64.9 years (SD 15.9), BMI was 26.3 (SD 5.7), 38.1% of patients had ASA ≥ 3, and 78.3% underwent surgery for neoplasms. IC anastomosis was associated with longer operative duration (165 min (SD 40); 144 min (SD 48), p = 0.002). There was no difference in the median time to GI-3 (IC 2 days [IQR1-2]; EC 2 days [IQR2-3], p = 0.135). The incidence of PPOI (IC 8.5%; EC 10.3%, p = 0.659), superficial SSI (4.2% vs. 5.8%, p = 0.757), deep SSI (2.8% vs. 5.2%, p = 0.729), and median LOS (3 days [IQR 2–4] vs. 3 [IQR 3–5], p = 0.059) were also similar. On multivariate analysis, IC anastomosis did not independently predict faster GI recovery (HR 0.98, 95% CI 0.71–1.34). Similar results were observed in the matched cohort (185 patients (61IC, 124EC)). In this study, IC anastomosis was not associated with faster GI recovery or reduced complication rate compared to EC anastomosis. Longer term studies may be required to determine the potential benefits of IC anastomosis.

Dual pulse mode has recently been integrated into Holmium:YAG laser systems to reduce stone retropulsion. This study explores similar pulse shaping approaches with Thulium fiber laser (TFL). A TFL at 1940 nm wavelength produced three temporal pulse profiles: (1) square pulse, (2) dual pulse, with low energy initial pulse followed by higher energy second pulse, and (3) ascending staircase pulse shape. Energies of 0.1 - 2.0 J, pulse rates of 5 - 200 Hz, average power of 10 and 20 W, and laser irradiation time of 5 s were used (n=5 per group). Stone phantoms (6-mmdiameter, 200-mg-mass) were placed on a horizontal, v-shaped trough, submerged in water, and then irradiated with TFL using a 200-μm-core optical fiber. Dual pulse stone displacements using pulse energies of 0.1, 0.2, 0.5, 1.0, and 2.0 J, measured 65%, 75%, 100%, 100%, and 110% of square pulse displacement at 10 W, and 65%, 60%, 60%, 90%, and 105% of square pulse displacement at 20 W. Staircase pulse stone displacements measured ~ 85% of square pulse stone displacement at 1.0 and 2.0 J for both 10 and 20 W. At lower energies (0.1 - 0.5 J), staircase profile produced a suction effect, resulting in the stone being pulled back to the fiber. Dual pulse mode only reduced stone retropulsion at lower energy settings, possibly due to excessive energy in initial pulse at higher settings. Low power (10 W) square, dual, and staircase pulse shapes ablated uric acid stones at rates of 1.7 ± 0.4, 1.9 ± 0.5, and 1.7 ± 0.5 mg/s, respectively. High power (20 W) square, dual, and staircase pulse shapes ablated stones at a rate of 2.6 ± 0.6, 3.0 ± 0.4, and 2.7 ± 0.7 mg/s, respectively. Future studies will utilize optical imaging of vapor bubble formation as a function of temporal pulse profile to optimize laser parameters for reducing stone retropulsion and enhancing TFL stone ablation rates.

Laser lithotripsy depends in part on fragmenting stones to sufficiently small size for spontaneous passage or extracting all large residual stone fragments to provide high stone free success rates, so a second repeat procedure is unnecessary. This preliminary study describes initial development of an optical system and software capable of tracking and labeling kidney stones. Machine learning and image processing techniques were implemented to track, label, and size, on a relative scale, stone fragments. Thresholds were placed on minimum stone fragment size (based on pixel sizes). For system validation, a series of still images from the laboratory setup and previously recorded clinical lithotripsy procedures were analyzed. A laboratory test was also conducted with homogenous background and video to determine number of true positives, false positives, and false negatives. In still images, 8/8 (100%) stones in the laboratory setup and 4/4 (100%) stones in clinical lithotripsy videos were correctly identified. A separate laboratory study correctly identified all five stones in each frame across a total of 110 video frames (550/550) (100%) with a total of 49/550 false positives (9%) and 0/550 (0%) false negatives, at a maximum frame rate of 50 Hz. This preliminary stone tracking study correctly identified stone fragments in laboratory frames for still and motion video and during still images from clinical lithotripsy procedures and experimental settings. Further development of software and optical tracking system is planned.

Previous Thulium fiber laser (TFL) studies using fiber optic muzzle brake tips reported reduced stone retropulsion and distal fiber tip degradation. This study compares muzzle brake tips of various dimensions using the TFL at 1908 and 1940 nm wavelengths in terms of stone phantom retropulsion displacement using a pendulum setup, needle hydrophone pressure transient measurements, and uric acid (UA) stone ablation rates. Low and high TFL pulse energies of 35 and 140 mJ, 500 μs pulse duration, and pulse rates up to 300 Hz were used with 100- and 200-μm-core optical fibers. “Small”, “medium”, and “large” muzzle brake tips dimensions measured 180/340, 360/560, and 550/710 μm inner/outer diameter, respectively, with a porthole positioned 500 μm from distal muzzle brake end. Pendulum displacement measured 50%, 200%, and 50% of bare trunk fibers for small, medium and large muzzle tips, respectively, in optimal configuration. Needle hydrophone pressures measured 300%, 20%, and 50% of bare trunk fiber for small, medium and large muzzle tips, respectively, in optimal configuration. Stone ablation rates at low pulse energy (35 mJ) were maintained for medium muzzle brake tips while small and large muzzle brake tips performed about 10 and 7.5 times worse than bare fibers. At high pulse energy (140 mJ), the large muzzle tip performed similar to a bare 200-μm-core fiber with 100%, 50%, and 100% the displacement, pressure, and ablation rate. These studies show feasibility of modifying muzzle brake tip dimensions to obtain comparative ablation rates and minimal stone retropulsion for lithotripsy.

Background Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias. Methods We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching. Results A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit. Conclusion Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction.

This statement presents my views on buybacks and my general reactions to provisions in four pieces of legislation relating to stock buybacks. Part I describes the role of stock buybacks in the economy and offers some “investor-benign” explanations for firms’ use of repurchases rather than dividends to distribute cash to investors. Part I then explains that the overall level of shareholder payouts (that is, the total amount of dividends and repurchases) does not appear to be too high; in fact, it may well be too low. Part II describes the current regulation of buybacks, which I believe is too lax and enables their abuse by corporate executives. In particular, I will explain how current regulation can enable executives to use buybacks to enrich themselves at the expense of public investors, through (1) indirect insider trading, (2) the manipulation of the stock price and EPS metrics in compensation arrangements, and (3) “false signaling:” announcing repurchases that executives do not intend to carry out, solely to boost the stock price before executives unload shares. Part III suggests a disclosure rule that would reduce executives’ ability to engage in the above-mentioned abuses, and therefore, better protect public investors: requiring public firms (like their insiders) to disclose trades in firm stock within two business days. I also describe additional measures that could be taken if this disclosure rule turns out be insufficient. Part IV offers initial reactions to key provisions in these four pieces of legislation.

Introduction: The principles of PEH repair involve primary closure of the hiatus around the esophagus after complete reduction of the hernia sac. However, this repair is associated with a high failure rate, leading surgeons to consider prosthetic materials to reinforce the hiatal closure. In this chapter, we review the literature comparing outcomes of hiatal mesh reinforcement to simple closure during laparoscopic PEH repair.