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Surgery residency program websites (SRW) are an important source of information for prospective applicants. The COVID-19 pandemic spurred a pivot from the traditional in-person interview format to interviews via virtual platforms. Because of the inability to meet in person, the information provided on program websites takes on an increased relevance to applicants. We hypothesized that SRW may be missing content important to applicants. Our study aims to assess SRW for the content which impacts the applicant decision-making process.An internal survey distributed to fourth-year medical students in 2020 at a single academic institution identified the website content most important to applicants. A list of ACGME-accredited SRW as of December 1, 2020 was obtained. Using the Fellowship and Residency Electronic and Interactive Database, websites were assessed for content parameters identified by the survey.Medical students applying to surgical specialties identified fellowship acquisition (94%), faculty information (88%), application contact information (82%), and resident wellness (77%) as the most important website content. Review of SRW websites identified content pertaining to fellowship acquisition and resident wellness in only 60% and 27% of cases respectively. Overall, the SRW of university programs included the most content parameters, followed by hybrid programs, then community programs.Many SRW are missing information that applicants deem important in their decision-making process. Most notably, there is a relative deficiency in information pertaining to fellowship match results and resident wellness. University based programs tend to include more of this information on their websites. SRW should continue to adapt to meet the needs of applicants in an increasingly virtual age.

Background Preoperative biliary drainage (PBD) has been advocated to address the plethora of physiologic derangements associated with cholestasis. However, available literature reports mixed outcomes and is based on largely outdated and/or single-institution studies. Methods Patients undergoing PBD prior to pancreaticoduodenectomy (PD) for periampullary malignancy between 2014-2018 were identified in the ACS-NSQIP pancreatectomy dataset. Patients with PBD were propensity-score-matched to those without PBD and 30-day outcomes compared. Results 8,970 patients met our inclusion criteria. 4,473 with obstruction and PBD were matched to 829 with no preoperative drainage procedure. In the non-jaundiced cohort, 711 stented patients were matched to 2,957 without prior intervention. PBD did not influence 30-day mortality (2.2% versus 2.4%) or major morbidity (19.8% versus 20%) in patients with obstructive jaundice. Superficial surgical site infections (SSIs) were more common with PBD (6.8% versus 9.2%), however, no differences in deep or organ-space SSIs were found. Patients without obstruction prior to PBD exhibited a 3-fold increase in wound dehiscence (0.5% versus 1.5%) additionally to increased superficial SSIs. Conclusion PBD was not associated with an increase in 30-day mortality or major morbidity but increased superficial SSIs. PBD should be limited to symptomatic, profoundly jaundiced patients or those with a delay prior to PD.

Introduction Positive pressure remains the main treatment for obstructive sleep apnea (OSA). Compared to traditional continuous positive airway pressure (CPAP) machines with fixed pressure settings, AutoCPAP machines can titrate settings based on user requirements and transmit data to the pulmonologist. While bariatric surgery has been associated with improvement in OSA, there is little data examining associations between postoperative weight loss and positive pressure requirements longitudinally. The purpose of this study was to evaluate changes in AutoCPAP pressure settings as a function of weight loss over time. Methods A retrospective review of bariatric surgery patients at a single institution from 2018-2022 was performed. Participants included patients with OSA who used an AutoCPAP machine and had at least one appointment within the first 18 months postoperatively. Preoperative BMI, postoperative BMI and percent excess weight loss were analyzed. AutoCPAP parameters used as markers of OSA severity included 95th or 90th percentile pressure depending on the machine and apnea-hypopnea index (AHI). Paired t-tests were performed to evaluate changes in BMI and 90th/95th percentile pressures. Linear regressions with fixed effects were performed to investigate changes in pressures and BMI over time. Results 345 patients with OSA who underwent bariatric surgery and were prescribed AutoCPAP were evaluated. Of those, twenty-eight (8%) were compliant with their AutoCPAP and were included in this study. Overall, 90th/95th percentile pressures improved postoperatively by 1.32 cmH2O± 0.33 (P= 0.003). Patients with a preoperative BMI ≥40 demonstrated improved 90th/95th percentile pressures over time by 1.22 cmH2O± 0.34 (P=0.002) while those with a preoperative BMI < 40 did not (-1.7 cmH2O ± 0.86; P= 0.106). Reduction in BMI was associated with reduction in 90th/95th percentile pressures at 2-6 weeks and 2-6 months postoperatively. Conclusion Patients with a higher preoperative BMI demonstrated improved positive pressure requirements postoperatively compared to patients with a lower preoperative BMI. This suggests that there may be a critical BMI after which further weight loss is not associated with significant improvements in OSA. Further, positive pressure requirements may decrease most significantly within the first several months postoperatively. Support (if any)

YouTube is the most used platform for case preparation by surgical trainees. Despite its popular use, studies have noted limitations in surgical technique, safety, and vetting of these videos. This study identified the most viewed laparoscopic cholecystectomy (LC) videos on YouTube and analyzed the ability of attendings, residents, and medical students to identify critical portions of the procedure, technique, and limitations of the videos. An incognito search was conducted on YouTube using the term “laparoscopic cholecystectomy.” Results were screened for length, publication date, and language. The top ten most viewed videos were presented to general surgery attendings, residents, and medical students at a single academic institution. Established rubrics were used for evaluation, including the Critical View of Safety (CVS) for LC, a modified Global Operative Assessment of Laparoscopic Skills (GOALS) score, a task-specific checklist, and visual analog scales for case difficulty and operator competence. Educational quality and likelihood of video recommendation for case preparation were evaluated using a Likert scale. Attending assessments were considered the gold standard. Six attending surgeons achieved excellent internal consistency on CVS, educational quality, and likelihood of recommendation scales, with Cronbach alpha (⍺) of 0.93, 0.92, and 0.92, respectively. ⍺ was ≥ 0.7 in all the other scales measured. Attending evaluations revealed that only one of the ten videos attained all three established CVS criteria. Four videos demonstrated none of the CVS criteria. The mean educational quality (mEQ) was 4.63 on a 10-point scale. The mean likelihood of recommendation (mLoR) for case preparation was 2.3 on a 5-point scale. Senior resident assessments (Postgraduate Year (PGY)4 + , n = 12) aligned with attending surgeons, with no statistically significant differences in CVS attainment, mEQ, and mLoR. Junior residents (PGY1-3, n = 17) and medical students (MS3-4, n = 20) exhibited significant difference with attendings in CVS attainment, mEQ, and mLoR for more than half the videos. Both groups tended to overrate videos compared to attendings. YouTube is the most popular unvetted resource used for case presentation by surgical trainees. Attending evaluations revealed that the most viewed LC videos on YouTube did not attain the CVS, and were deemed as inappropriate for case preparation, with low educational value. Senior resident video assessments closely aligned with attendings, while junior trainees were more likely to overstate video quality and value. Attending guidance and direction of trainees to high-quality, vetted resources for surgical case preparation is needed. This may also suggest a need for surgical societies with platforms for video sharing to prioritize the creation and dissemination of high-quality videos on easily accessible public platforms.

The foundational principles of surgical training in the USA are based on didactic education, structured skill training, and experiential learning in surgical patient care with the supervision of surgical faculty. A consortium of professional organizations, academic institutions, and teaching hospitals with surgical faculty provide the structural framework, policies, and curriculum to train and evaluate surgeons capable of independent practice. This manuscript describes the roles of the organizations responsible for surgical training in the USA and highlights areas in evolution in the modern surgical education landscape.

Purpose: Instructional videos of medical procedures can be a useful guide for learners, demonstrating proper and safe technique. Open publishing sites such as YouTube are readily accessible, however the content is not peer reviewed and quality of videos vary greatly. Our aim was to evaluate a learner’s ability to interpret the quality of openly published content by comparing their rating of the most popular central line insertion videos on YouTube to expert evaluations. Method: YouTube search results for “central line placement” sorted by views or relevance compiled a list of the four most common videos. A fifth gold standard video, published by the New England Journal, was included, however was not found in the top results. Eleven expert practitioners from varying medical specialties (Critical Care, Surgery, Anesthesia, & Emergency Medicine) evaluated the 5 videos, utilizing a 22-item Likert scaled questionnaire emphasizing: preparation, sterility, anatomy, technique, & complications. Videos were compared as a composite average of the individual items on the survey. The highest, lowest, and 3rd ranked videos were evaluated by 45 residents (“learners”) in varying specialties (Internal Medicine, Emergency Medicine, Surgery, Anesthesia) and post graduate year (PGY). Learners assessed the videos using the same scale. A Welch T-test assessed statistical significance between the two groups. Subgroup analysis compared experts against different PGY and specialty cohorts. Results: The lowest scored video among the experts and learners was the most popular on YouTube, with 858,933 views at the time of inclusion. Though lowest in rank, this video was judged higher by learners than the experts (2.63/5 vs 2.18/5, P = 0.0029). The 3rd ranked video by experts with 249,746 views on YouTube, was also rated higher by learners (3.77/5 vs 3.45/5, P = 0.0084). The gold standard video by NEJM had 320,580 views and was rated highest by both the experts and learners (4.37/5 vs 4.28/5, P = 0.518). Subgroup analysis showed similar results with learners rating the videos overall better than experts, this was particularly true in the PGY-1 subgroup. Conclusion: The most popular central line insertion video was the worst rated by both experts and learners. Learners rated all the videos better than the expert. YouTube videos demonstrating medical procedures including central line insertion should come from peer reviewed sources if they are to be incorporated into educational curriculum.

Revisional bariatric operations are associated with increased morbidity and mortality compared with primary bariatric operations. The purpose of this study was to determine if preoperative patient variables are associated with an increased risk of 30-day morbidity and mortality following revisional laparoscopic bariatric surgery for inadequate weight loss or weight recidivism and to generate expected model probabilities in order to risk stratify individual patients undergoing these operations. All patients undergoing revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 to 2016 were identified with the American College of Surgeons Metabolic and Bariatric Surgery Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative patient variables with 30-day morbidity and mortality was investigated using multivariable logistic regression analysis. Predictive outcome models were developed for each outcome of interest. A total of 13,551 patients met inclusion criteria; 5310 (39.2%) underwent revisional RYGB. Each of the available preoperative variables was associated with one or more of the 30-day morbidity and mortality outcomes of interest. The strength of the predictive models, as reflected by the area under the curve, ranged from 0.63 for 30-day unplanned hospital readmission to 0.92 for cardiac events. Preoperative patient and surgical variables are associated with an increased risk of 30-day morbidity and mortality following laparoscopic revisional bariatric surgery. With these results, we have built a risk calculator that can be used as a resource for prehabilitation and patient counseling prior to revisional bariatric surgery.

The postoperative management of patients undergoing laparoscopic ventral hernia repair (VHR) remains relatively unknown. The purpose of our study was to determine if patient and hernia-specific factors could be used to predict the likelihood of hospital admission following laparoscopic VHR using the Americas Hernia Society Quality Collaborative (AHSQC) database. All patients who underwent elective, laparoscopic VHR with mesh placement from October 2015 through April 2019 were identified within the AHSQC database. Patients without clean wounds, those with chronic liver disease, and those without 30-day follow-up data were excluded from our analysis. Patient and hernia-specific variables were compared between patients who were discharged from the post-anesthesia care unit (PACU) and patients who required hospital admission. Comparisons were also made between the two groups with respect to 30-day morbidity and mortality events. A total of 1609 patients met inclusion criteria; 901 (56%) patients were discharged from the PACU. The proportion of patients discharged from the PACU increased with each subsequent year. Several patient comorbidities and hernia-specific factors were found to be associated with postoperative hospital admission, including older age, repair of a recurrent hernia, a larger hernia width, longer operative time, drain placement, and use of mechanical bowel preparation. Patients who required hospital admission were more likely than those discharged from the PACU to be readmitted to the hospital within 30 days (4% vs. 2%, respectively) and to experience a 30-day morbidity event (18% vs. 8%, respectively). Patient- and hernia-specific factors can be used to identify patients who can be safely discharged from the PACU following laparoscopic VHR. Additional studies are needed to determine if appropriate patient selection for discharge from the PACU leads to decreased healthcare costs for laparoscopic VHR over the long-term.

Surgeon and hospital volume are factors that have been shown to impact outcomes following bariatric surgery. Nevertheless, there is a paucity of literature investigating surgeon training on bariatric surgery outcomes. The purpose of our study was to determine if bariatric specialty training leads to improved short-term outcomes following laparoscopic bariatric surgery using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. All patients undergoing first-time, elective, laparoscopic bariatric surgery from 2015 to 2016 were identified within the ACS-MBSAQIP database. Patients were divided into two groups based on the type of bariatric procedure performed and the surgeon performing the procedure. Thirty-day outcomes were compared between the groups using multivariable logistic regression analysis. A total of 140,340 patients met inclusion criteria. Higher risk patients with more associated comorbidities underwent bariatric surgery by a metabolic and bariatric surgeon. After controlling for these differences, patients who underwent Roux-en-Y gastric bypass (RYGB) had similar 30-day irrespective of the surgeon performing the procedure while patients who underwent sleeve gastrectomy (SG) by a metabolic and bariatric surgeon (MBS) had improved 30-day outcomes. Surgeon type is associated with 30-day morbidity and mortality outcomes for SG but not for RYGB. These differences in 30-day morbidity and mortality outcomes may be facilitated by institutional factors, surgeon experience, and participation in bariatric surgery accredited centers. Standardization of the perioperative process for both surgeons and institutions may improve 30-day morbidity and mortality outcomes for all patients who undergo laparoscopic bariatric surgery.

Dehydration is the most common cause of readmission after laparoscopic sleeve gastrectomy (SG). Bougie size and distance from the pylorus, both of which have been associated with rates of dehydration postoperatively, varies by surgeon and across institutions.To determine if there is an association between bougie size or distance from the pylorus on the rate of dehydration after laparoscopic SG.American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database.All patients undergoing first-time, elective laparoscopic SG from 2015-2016 were identified. The association of bougie size and distance from the pylorus on the rate of dehydration within the first 30 days postoperatively was investigated.The inclusion criteria were met by 170,751 patients. The most commonly used bougie size was 36 Fr and the most common distance from the pylorus at which the gastric sleeve was started was 5 cm. Patients were divided into 4 groups based on bougie size and distance from the pylorus (Group 1: bougie size36 Fr, pylorus distance4 cm; Group 2: bougie size ≥36 Fr, pylorus distance4 cm; Group 3: bougie size ≥36 Fr, pylorus distance ≥4 cm; and Group 4: bougie size36 Fr, pylorus distance ≥4 cm). Patients in Group 4 were significantly less likely than any other group to experience dehydration-related complications.Both distance from the pylorus and bougie size are significantly associated with dehydration-related complications after SG. Consideration should be made for standardizing these technical aspects of SG to help reduce the rate of postoperative dehydration and hospital readmission.

Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure. A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction. A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P

A soft pancreas has been associated with an increased risk of post-operative pancreatic fistula formation. Few studies have evaluated the effect of anastomotic technique (duct to mucosa vs invagination) on fistula formation. This study aims to compare the effect of anastomotic technique on fistula formation among patients with a soft pancreas in a large multiinstitutional database. The targeted pancreas module of the American College of Surgeons–National Surgical Quality Improvement Program (NSQIP) Database was used. All patients with a soft pancreas who underwent pancreaticoduodenectomy from 2014 to 2015 were identified. Demographic data, comorbid conditions, operative variables, and 30-day outcomes were compared using univariate and multivariable analyses. A total of 975 patients met inclusion criteria. Eight-hundred fifty four (88%) underwent a duct to mucosa pancreaticojejunostomy technique and 121 (12%) underwent invagination. Patients who underwent invagination had higher 30-day mortality (5.8% vs 1.4%, p

Microlearning has been found to be beneficial in other areas of healthcare education. The purpose of this study was to investigate the effect of a microlearning module compared to a traditional online learning module in undergraduate medical education.A microlearning module was developed to cover the etiology and management of gallbladder disease. Surgery clerkship students were randomized into 2 groups. One group began with the microlearning module (MLM). The second group began with a 45 minute commercially available module centered on gallbladder disease (WISE-MD™). Halfway through the clerkship, the groups crossed over to the other learning intervention. Student knowledge was assessed with a test at three time points (pre-test, post-test1, post-test2).Third year surgery clerkship students at George Washington University.There were 56 students in the MLM and 57 in WISE-MDTM groups. In the MLM group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, but significantly decreased from post-test1 to post-test2. In the WISE-MD™ group, mean scores significantly increased from pre-test to post-test1 and pre-test to post-test2, with no significant change from post-test1 to post-test2. After the initial intervention, test scores of post-test1 of the MLM group were significantly higher than the WISE-MD™ group, while there were no significant differences between groups at the pre-test or post-test2 time points.Students exposed to the microlearning module first performed significantly better on a post intervention test than students that used a commercially available product in our standard curriculum. Therefore, the use of microlearning modules may lead to improved knowledge acquisition in surgery clerkship students.

YouTube is the most used platform for case preparation by surgical trainees. Despite its popular use, studies have noted limitations in surgical technique, safety, and vetting of these videos. This study identified the most viewed laparoscopic cholecystectomy (LC) videos on YouTube and analyzed the ability of attendings, residents, and medical students to identify critical portions of the procedure, technique, and limitations of the videos.An incognito search was conducted on YouTube using the term "laparoscopic cholecystectomy." Results were screened for length, publication date, and language. The top ten most viewed videos were presented to general surgery attendings, residents, and medical students at a single academic institution. Established rubrics were used for evaluation, including the Critical View of Safety (CVS) for LC, a modified Global Operative Assessment of Laparoscopic Skills (GOALS) score, a task-specific checklist, and visual analog scales for case difficulty and operator competence. Educational quality and likelihood of video recommendation for case preparation were evaluated using a Likert scale. Attending assessments were considered the gold standard.Six attending surgeons achieved excellent internal consistency on CVS, educational quality, and likelihood of recommendation scales, with Cronbach alpha (⍺) of 0.93, 0.92, and 0.92, respectively. ⍺ was ≥ 0.7 in all the other scales measured. Attending evaluations revealed that only one of the ten videos attained all three established CVS criteria. Four videos demonstrated none of the CVS criteria. The mean educational quality (mEQ) was 4.63 on a 10-point scale. The mean likelihood of recommendation (mLoR) for case preparation was 2.3 on a 5-point scale. Senior resident assessments (Postgraduate Year (PGY)4 + , n = 12) aligned with attending surgeons, with no statistically significant differences in CVS attainment, mEQ, and mLoR. Junior residents (PGY1-3, n = 17) and medical students (MS3-4, n = 20) exhibited significant difference with attendings in CVS attainment, mEQ, and mLoR for more than half the videos. Both groups tended to overrate videos compared to attendings.YouTube is the most popular unvetted resource used for case presentation by surgical trainees. Attending evaluations revealed that the most viewed LC videos on YouTube did not attain the CVS, and were deemed as inappropriate for case preparation, with low educational value. Senior resident video assessments closely aligned with attendings, while junior trainees were more likely to overstate video quality and value. Attending guidance and direction of trainees to high-quality, vetted resources for surgical case preparation is needed. This may also suggest a need for surgical societies with platforms for video sharing to prioritize the creation and dissemination of high-quality videos on easily accessible public platforms.

Background Morbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE. Methods The ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed. Results We identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R2 = 0.95) and predicted patients at low, intermediate, and high risk. Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p = 0.07) and ASA(p = 0.30). Conclusion PrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.

Introduction: Hypertonic saline is often used to treat patients with traumatic brain injury. It carries the undesired side effect of hyperchloremia, which has been linked to acute kidney injury (AKI). We sought to evaluate the relationship of hyperchloremia and AKI in this population and whether the absolute exposure to hyperchloremia, including maximal hyperchloremia and duration of hyperchloremia were associated with AKI. Methods: A retrospective study of severe traumatic brain injury patients who received hypertonic saline at a single academic institution. Demographics, head abbreviated injury scale, development of hyperchloremia (Cl ≥ 115), duration of hyperchloremia, highest chloride level, duration of hypertonic saline use, admission GFR, and administration of nephrotoxic medications were abstracted. The outcome of interest was the association between renal function and hyperchloremia. Results: A total of 123 patients were included in the study. Multivariable logistic regression analysis demonstrated that only duration of hyperchloremia ( p = 0.014) and GFR on admission ( p = 0.004) were independently associated with development of AKI. The number of days of hypertonic saline infusion ( p = 0.79) without the persistence of hyperchloremia and highest serum chloride levels ( p = 0.23) were not predictive of AKI development. Discussion: In patients with traumatic brain injury, admission GFR and prolonged hyperchloremia rather than the highest chloride level or the duration of hypertonic saline infusion were associated with the development of AKI.

INTRODUCTION Social media has been used as a resource for the dissemination of information in the medical profession. To date, information regarding Instagram use amongst general surgery residency programs is lacking. Our study seeks to detail the use of Instagram amongst general surgery residency programs and to provide suggestions for the practical and successful use of Instagram by general surgery residency programs. METHORDS We performed a cross-sectional search of general surgery residency program Instagram accounts through June 30, 2020. Descriptive details, the pattern of Instagram use by general surgery residency programs, and the use of Instagram by general surgery residency programs over time were investigated. RESULTS Ninety-six (29.1%) of the 330 Accreditation Council for Graduate Medical Education (ACGME) general surgery residency programs were identified on Instagram, of which 86 (89.6%) accounts had at least one post. Academic programs (N = 67; 77.9%) were the most common type of program to have an Instagram account (N = 67). The most popular category of posts was promotion of the residents and faculty. In terms of Instagram activity, nearly 20% of Instagram posts were made in the last three-month block of our study period. Using Pearson correlations, positive associations were found between the number of posts and number of followers (0.62, p < 0.0001), the number of posts and the number of likes (0.42, p < 0.0001) and the number of followers and the number of likes (0.78, p < 0.0001). None of these variables were significantly associated with region or program type. CONCLUSIONS To our knowledge, this is the first description of the use of Instagram by general surgery residency programs. Based on the pattern of use of Instagram by general surgery residency programs, we believe that there are five key elements to the successful use of Instagram by general surgery residency programs, including: Interact, Name, Promote, Utilize, and Team (INPUT).

Background: The rates of incidental appendiceal neoplasms after appendectomy performed for acute appendicitis is

Background Venous thromboembolism, including pulmonary embolism (PE) and deep venous thrombosis, is a leading cause of morbidity and mortality after bariatric surgery. Inferior vena cava filters (IVCFs) have been used as a method to reduce the incidence of clinically significant PEs after bariatric surgery. Objectives To compare the incidence of postoperative PEs in patients with IVCFs with those in patients without IVCFs at the time of bariatric surgery. Setting American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Methods All patients undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy from 2015 to 2016 were identified within the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Patients with an IVCF present at the time of surgery were compared with those patients without an IVCF present at the time of surgery with respect to preoperative patient variables, operative variables, incidence of 30-day PE, deep venous thrombosis, and additional 30-day morbidity and mortality. Results A total of 286,704 patients met the inclusion criteria; 2512 (.9%) patients had an IVCF present at the time of surgical intervention, of which 1747 (69.5%) were placed within 30 days of bariatric surgery. Patients with an IVCF were higher-risk patients as determined by previously established risk factors for venous thromboembolism events. When a subgroup matched analysis using variables associated with the risk of venous thromboembolism events was performed looking at higher-risk patients only, there was no statistically significant difference in the incidence of PE based on the presence of an IVCF. Conclusion IVCFs are being selectively placed in higher-risk patients. Despite their selective use, IVCFs do not appear to have a protective benefit with respect to the incidence of postoperative PE events.

Revisional bariatric operations are associated with increased morbidity and mortality compared with primary bariatric operations. The purpose of this study was to determine if preoperative patient variables are associated with an increased risk of 30-day morbidity and mortality following revisional laparoscopic bariatric surgery for inadequate weight loss or weight recidivism and to generate expected model probabilities in order to risk stratify individual patients undergoing these operations.All patients undergoing revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 to 2016 were identified with the American College of Surgeons Metabolic and Bariatric Surgery Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative patient variables with 30-day morbidity and mortality was investigated using multivariable logistic regression analysis. Predictive outcome models were developed for each outcome of interest.A total of 13,551 patients met inclusion criteria; 5310 (39.2%) underwent revisional RYGB. Each of the available preoperative variables was associated with one or more of the 30-day morbidity and mortality outcomes of interest. The strength of the predictive models, as reflected by the area under the curve, ranged from 0.63 for 30-day unplanned hospital readmission to 0.92 for cardiac events.Preoperative patient and surgical variables are associated with an increased risk of 30-day morbidity and mortality following laparoscopic revisional bariatric surgery. With these results, we have built a risk calculator that can be used as a resource for prehabilitation and patient counseling prior to revisional bariatric surgery.

Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death.This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection.This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database.The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2).A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection.Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention.The incidence of C difficile infection in the 30 days after surgery was measured.The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p0.001) in patients undergoing stoma reversal. After controlling for differences in cohorts, regression analysis suggested that stoma reversal (OR = 2.701 (95% CI, 1.966-3.711); p0.001), smoking (OR = 1.520 (95% CI, 1.063-2.174); p = 0.022), steroids (OR = 1.677 (95% CI, 1.005-2.779); p = 0.048), and disseminated cancer (OR = 2.312 (95% CI, 1.437-3.719); p = 0.001) were associated with C difficile infection incidence in the 30-day postoperative period.The study was limited because it was a retrospective database review with observational bias.Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at http://links.lww.com/DCR/A553.

Post-operative pancreatic fistulas remain a significant source of morbidity following pancreatic surgery. Few studies have evaluated the effect of neoadjuvant chemotherapy and radiation on this adverse outcome. This study aims to evaluate the effects of neoadjuvant therapy on 30-day morbidity and mortality following pancreaticoduodenectomy. A retrospective analysis was performed utilizing the targeted pancreas module of the National Surgical Quality Improvement Project (NSQIP) from 2014 to 2015 for patients undergoing pancreaticoduodenectomy with pancreaticojejunal reconstruction. A fistula was defined according to the NSQIP definition. Patient demographics, operative variables, and 30-day outcomes were compared between those who received no neoadjuvant therapy, chemoradiation, chemotherapy alone, and radiation alone. Univariate analysis was completed using chi-square, Fisher exact test, Student’s t test, and Mann-Whitney U test where appropriate. Independent predictors of fistula formation were established using multivariable regression. A P value

BACKGROUND Laparoscopic colectomies are associated with reduced perioperative morbidity and mortality compared with open surgery. Nevertheless, many surgeons continue to utilize an open surgical approach due to the perceived benefits of shorter operative times. This study aims to compare the outcomes of laparoscopic versus open colectomies of equal or shorter operative duration. METHODS All patients undergoing elective laparoscopic or open colectomy in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) were identified from the years 2005 through 2012. Patients were stratified first by operative procedure including partial colectomy, total colectomy, or low anterior resection. Each surgical group was then divided into 4 groups according to operative time

Percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy (LG) placements provide enteral access to patients unable to tolerate oral feeds. Limited data comparing PEG and LG outcomes is available in adults. This study compares complications between PEG and LG placements. A retrospective chart review was completed for patients undergoing PEG or LG placement at a single academic center between 2007 and 2014. Patient demographics, comorbidities, and Charlson Comorbidity Index (CCI) were compared. Logistic regression was utilized to identify independent predictors for complication. Two hundred and twenty-four patients (164 PEGs and 60 LGs) were evaluated. Patients undergoing LG had a higher incidence of prior surgery (42 vs 20%; P

BACKGROUND The complex nature of current morbidity and mortality predictor models do not lend themselves to clinical application at the bedside of patients undergoing emergency general surgery (EGS). Our aim was to develop a simplified risk calculator for prediction of early postoperative mortality after EGS. METHODS EGS cases other than appendectomy and cholecystectomy were identified within the American College of Surgeons National Surgery Quality Improvement Program database from 2005 to 2014. Seventy-five percent of the cases were selected at random for model development, whereas 25% of the cases were used for model testing. Stepwise logistic regression was performed for creation of a 30-day mortality risk calculator. Model accuracy and reproducibility was investigated using the concordance index (c statistic) and Pearson correlations. RESULTS A total of 79,835 patients met inclusion criteria. Overall, 30-day mortality was 12.6%. A simplified risk model formula was derived from five readily available preoperative variables as follows: 0.034*age + 0.8*nonindependent status + 0.88*sepsis + 1.1 (if bun ≥ 29) or 0.57 (if bun ≥18 and < 29) + 1.16 (if albumin < 2.7), or 0.61 (if albumin ≥ 2.7 and < 3.4). The risk of 30-day mortality was stratified into deciles. The risk of 30-day mortality ranged from 2% for patients in the lowest risk level to 31% for patients in the highest risk level. The c statistic was 0.83 in both the derivation and testing samples. CONCLUSION Five readily available preoperative variables can be used to predict the 30-day mortality risk for patients undergoing EGS. Further studies are needed to validate this risk calculator and to determine its bedside applicability. LEVEL OF EVIDENCE Prognostic/epidemiological study, level III.

Surgeon and hospital volume are factors that have been shown to impact outcomes following bariatric surgery. Nevertheless, there is a paucity of literature investigating surgeon training on bariatric surgery outcomes. The purpose of our study was to determine if bariatric specialty training leads to improved short-term outcomes following laparoscopic bariatric surgery using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database.All patients undergoing first-time, elective, laparoscopic bariatric surgery from 2015 to 2016 were identified within the ACS-MBSAQIP database. Patients were divided into two groups based on the type of bariatric procedure performed and the surgeon performing the procedure. Thirty-day outcomes were compared between the groups using multivariable logistic regression analysis.A total of 140,340 patients met inclusion criteria. Higher risk patients with more associated comorbidities underwent bariatric surgery by a metabolic and bariatric surgeon. After controlling for these differences, patients who underwent Roux-en-Y gastric bypass (RYGB) had similar 30-day irrespective of the surgeon performing the procedure while patients who underwent sleeve gastrectomy (SG) by a metabolic and bariatric surgeon (MBS) had improved 30-day outcomes.Surgeon type is associated with 30-day morbidity and mortality outcomes for SG but not for RYGB. These differences in 30-day morbidity and mortality outcomes may be facilitated by institutional factors, surgeon experience, and participation in bariatric surgery accredited centers. Standardization of the perioperative process for both surgeons and institutions may improve 30-day morbidity and mortality outcomes for all patients who undergo laparoscopic bariatric surgery.

Objectives To assess a multimodal physician-to-physician communication initiative that is low in cost and impact to daily workflow to reduce blood product wastage. Background Blood product stewardship is an important issue in all hospital systems. Previous studies have proposed low-cost interventions to reduce blood product wastage, but few have evaluated improvements in communication between the blood bank and providers. We undertook a prospective quality improvement project focusing on improving communication to reduce blood product wastage. Methods We conducted a prospective quality improvement project over the first quarter of 2017, identifying patients with issued but unused blood products. Each service overseeing the care of patients identified on the unit status report was contacted through two possible methods: (i) phone or (ii) proprietary Health Insurance Portability and Accountability Act of 1996 compliant digital messaging application. Collected variables included reserved blood product type and participant time spent. Outcomes included the rate of blood product release and changes in wastage compared with historical data tracked by the blood bank. Results Eight hundred and forty products were reserved during the study period, of which 436 (52%) were released. Average participant times ranged from 2 ± 1 min to 15 ± 4 min with no significant differences in time spent between participants (P = 0·194). Compared with the average product wastage 10 months prior to project initiation, there were significant reductions in the average wastage for platelets (5·3 ± 2·5 units vs 2·5 ± 1·5 units, P = 0·05), RBCs (6·1 ± 3·7 units vs 0 ± 0 units, P = 0·01) and overall wastage (58·3 ± 14·9 units vs 40 ± 15·7 units, P = 0·05). Conclusion Efforts focusing on improving provider-to-provider communication can reduce blood product wastage.

The long-term recurrence rate of ventral hernia repair is 20–50 %, with a higher rate of recurrence in cases that do not use mesh. Previous teachings have cautioned against the use of mesh in contaminated wounds. Therefore, emergent ventral hernia repair is often performed without the use of mesh. Our aim is to determine if mesh is used in these cases and its effect on 30-day wound-related morbidity using the American College of Surgeons National Surgery Quality Improvement Program database. All emergency ventral hernia repairs performed from 2005 to 2013 were identified. The effect of mesh on postoperative morbidity and mortality was investigated. Significance was defined as p

Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients.Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors.A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR.In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.

Objectives Small bowel obstructions (SBOs) occur 300,000 times annually leading to $1.3 billion in cost. Approximately 20% of patients require a laparotomy to manage the obstruction and either prevent or treat intestinal ischemia. Early management may play a role in reducing these complications. Nasogastric decompression is commonly used for early management. Our primary objective was to determine if NGD was associated with lower rates of surgery, bowel ischemia or length of stay. Methods We retrospectively enrolled 181 ED patients with SBO from 9/2013 to 9/2015 in order to determine if nasogastric decompression was associated with a reduction in rates of surgery, bowel ischemia or hospital length of stay. Results Our subject population was 46% female, median age of 60.27% of patients received surgery. Nasogastric decompression was used in 51% of patients. There was no association with a reduction in rates of surgery ( p = 0.20) or bowel resection ( p = 0.41) with patients receiving Nasogastric decompression, and no difference in baseline characteristics. Nasogastric decompression was associated with a two-day increase in hospital length of stay. Factors that were significantly associated with surgical exploration of SBO were: female (OR 2.32 (95% CI: 1.01–5.31)) and “definite SBO” on CT (OR 3.29 (95% CI: 1.18–9.20)). Abnormal vital signs, obstipation, and lab values were not predictors of surgery. Conclusion Nasogastric decompression is not associated with a reduction in need for surgery or bowel resection, but is associated with a 2-day increase in median LOS. Women were more likely to receive surgery than men.

Bariatric surgery is an effective and durable treatment for obesity. However, the number of patients that progress to bariatric surgery after initial evaluation remains low.The purpose of this study was to identify factors influencing a qualified patient's successful progression to surgery in a U.S. metropolitan area.Academic, university hospital.A single-institution retrospective chart review was performed from 2003 to 2016. Patient demographics and follow-up data were compared between those who did and did not progress to surgery. A follow-up telephone survey was performed for patients who failed to progress. Univariate analyses were performed and statistically significant variables of interest were analyzed using a multivariable logistic regression model.A total of 1102 patients were identified as eligible bariatric surgery candidates. Four hundred ninety-eight (45%) patients progressed to surgery and 604 (55%) did not. Multivariable analysis showed that patients who did not progress were more likely male (odds ratio [OR] 2.2 confidence interval [CI]: 1.2-4.2, P.05), smokers (OR 2.4 CI: 1.1-5.4, P.05), attended more nutrition appointments (OR 2.1 CI: 1.5-2.8, P.0001), attended less total preoperative appointments (OR .41 CI: .31-.55, P.0001), and resided in-state compared with out of state (OR .39 CI: .22-.68, P.05). The top 3 patient self-reported factors influencing nonprogression were fear of complication, financial hardship, and insurance coverage.Multiple patient factors and the self-reported factors of fear of complication and financial hardship influenced progression to bariatric surgery in a U.S. metropolitan population. Bariatric surgeons and centers should consider and address these factors when assessing patients.

There is a paucity of literature describing the association of age with the risk of adverse events following bariatric surgery. The purpose of this study is to investigate the association of age with 30-day morbidity and mortality following laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All adult patients undergoing laparoscopic Roux-en-Y gastric bypass (RNGYB) or sleeve gastrectomy (SG) were identified within the MBSAQIP database. Patients were divided into five equal age quintiles. Binary outcomes of interest, including cardiac, pulmonary, wound, septic, clotting, and renal events, in addition to the incidence of related 30-day unplanned reintervention, related 30-day mortality, and a composite morbidity and mortality outcome were compared across the age quintiles and procedures. A total of 266,544 patients met inclusion criteria. Older age was associated with an increased risk of all morbidity outcomes except venous thromboembolism events, 30-day mortality, and the composite morbidity and mortality outcome. Patients who underwent Roux-en-Y gastric bypass had worse outcomes per quintile for almost every outcome of interest when compared to patients who underwent sleeve gastrectomy. Older patients and patients who undergo Roux-en-Y gastric bypass are at an increased risk of perioperative morbidity and mortality following laparoscopic bariatric surgery. Additional studies are needed to determine the association of age with long-term weight loss and cardiometabolic comorbidity resolution following bariatric surgery in order to determine if the increased perioperative risk is offset by improved long-term outcomes in older patients undergoing bariatric surgery.

BACKGROUND Surgical Morbidity and Mortality (M&M) conference lacks a standardized structure across institutions. We compared implementation of structure and National Surgical Quality Improvement Program's (NSQIP) definitions to organize our M&M and identify cases for discussion versus the usually used method at many centers of case identification by an attending surgeon or resident. METHODS AND MATERIALS A prospective study was performed, over a 10-wk period, to compare the identification of adverse events and the educational value of our M&M conference before and after implementation of structured NSQIP-defined presentations. Chart review was performed by a trained surgical clinical reviewer and trained NSQIP resident of all cases over the study period to identify NSQIP-defined occurrences. All presented M&Ms were evaluated for adequate reporting of adverse events and areas for improvement on a three-point scale. Surveys were administered before and after intervention to assess educational value to resident and faculty on a five-point Likert scale. Survey and presentation data were compared using Student's t-tests. P-values

Femoral hernias occur less frequently than inguinal hernias, but are often more challenging to repair surgically. Femoral hernias constitute between 2% and 8% of groin hernias, with the majority afflicting women. Because of the narrow neck and unyielding surrounding structures, femoral hernias are more likely to incarcerate or strangulate than their inguinal counterparts. They commonly present with incarceration of fat or intra-peritoneal contents. There has been extensive controversy in the last several decades concerning optimal approaches to femoral hernia repair, beginning with inguinal vs femoral approaches initially, to current debates about open vs laparoscopic and mesh vs tissue. Annandale is credited with the first inguinal approach to femoral hernia repair. Many other techniques have been described, but the contributions of Chester McVay established the fundamental basis for understanding femoral hernia repair. The McVay repair requires a relaxing incision to obtain a tension-free repair. Since Lichtenstein and colleagues described the use of prosthetic mesh for tension-free herniorrhaphy, many have turned to mesh to address the difficulties of femoral hernia repair, obviating the need for a relaxing incision. The use of prosthetic mesh is not universally applicable to femoral or inguinal hernia repair due to the incidence of strangulation and necrosis causing a potentially contaminated field. In addition, mesh can lead to other complications, such as chronic pain, infection, migration, and erosion. An effective primary tissue repair for femoral hernia is a useful procedure in the armamentarium of the general surgeon. During two recent humanitarian missions to Guatemala, surgeons from the George Washington University Department of Surgery encountered an unusually large incidence of femoral hernias. A technique developed at George Washington University, which combines a classic McVay (Cooper’s ligament [CL]) repair with a

Prolonged operative time (ORT) is often considered a drawback to minimally invasive surgery (MIS) because of increased morbidity. Limited data exist comparing long laparoscopic ORT with similar or shorter open ORT. This study aims to identify ORT when a minimally invasive procedure becomes inferior to its open counterpart.Minimally invasive and open total and partial nephrectomies and nephroureterectomies were identified in the National Surgical Quality Improvement Program (NSQIP) from 2005 to 2012. Procedures were split into open and minimally invasive nephrectomy and then stratified into four ORT groups: 0 to 90 minutes, 91 minutes to 3 hours, 3 to 6 hours, and ≥ 6 hours. Thirty-day mortality and morbidity were analyzed. Univariate analysis was performed using chi-square and Fisher exact tests. Significant univariate results were then tested using stepwise logistic regression, controlling for demographics, comorbidities, and preoperative treatments.There were 14,813 patients identified. Both partial and total minimally invasive kidney procedures had significantly improved outcomes compared with open counterparts of similar ORT. In the total nephrectomy group, a minimally invasive approach had a lower rate of surgical site infections, sepsis, pneumonia, return to operating room, and overall length of stay when compared with open procedures of the same duration. Length of hospital stay decreased in MIS regardless of operative time, except when comparing minimally invasive cases longer than 6 hours with open cases less than 90 minutes. Transfusion rates also significantly decreased in minimally invasive total nephrectomy cases. In the partial nephrectomy group, similar outcomes were seen in terms of length of stay and infectious outcomes. Interestingly, transfusion risk was decreased in the open partial nephrectomy group when comparing cases less than 90 minutes with minimally invasive partial nephrectomies lasting 3 to 6 hours; otherwise there was no significant correlation with transfusion risk.Minimally invasive operations are less morbid than open operations of similar ORT. Longer and likely more complex laparoscopic procedures continue to provide a benefit to patients when compared with shorter and possibly less complex open procedures. These data should be considered during a surgeon's preoperative and operative decision-making.

Surgical residency training programs in the United States are modeled on the principle of graduated responsibility. Residents are given greater responsibility and autonomy in the operating room and during perioperative care as they gain surgical skills and progress through their training. The impact of this method of surgical training on patient outcomes remains unknown. The purpose of this study is to compare early patient morbidity and mortality after bariatric surgery in cases with and without resident participation using the American College of Surgeons National Surgical Quality Improvement Program database.All patients undergoing bariatric surgery from 2006 through 2010 were identified within the American College of Surgeons National Surgical Quality Improvement Program database. These patients were divided into three groups based on resident involvement in their surgery (no resident, senior-level resident, and junior-level resident). The effect of resident involvement and postgraduate year level on 30-d morbidity and mortality was investigated using composite outcomes, including cardiac events (acute myocardial infarction or cardiac arrest requiring cardiopulmonary resuscitation), pulmonary events (pneumonia, prolonged intubation, or unplanned reintubation), wound (superficial surgical site infection, deep surgical site infection, organ-space infection, or dehiscence), septic events (sepsis and septic shock), clotting events (pulmonary embolism and deep venous thrombosis), and renal events (urinary tract infection and acute kidney injury requiring dialysis). Length of hospital stay, unplanned return to the operating room, and 30-d mortality were also investigated.A total of 19,616 patients underwent bariatric surgery from the year 2006 through 2010; 8960 (45.7%) procedures were performed with resident involvement, with 5406 (36.7%) of these cases involving a senior-level resident. Operations involving a senior-level resident were more likely to experience postoperative cardiac events (P 0.006), pulmonary events (P = 0.03), wound events (P = 0.01), septic events (P 0.002), renal events (P ≤ 0.01), prolonged operative time (P 0.0001), and a prolonged length of hospital stay (P 0.0001) than those that involved either no resident or a junior-level resident.Although bariatric operations involving senior-level residents have more statistically significant morbidity outcomes, these morbidity outcomes are related more to perioperative care rather than intraoperative resident involvement. This suggests that more emphasis on perioperative progressive responsibility may be needed to match operative oversight.

In addition to increased perioperative morbidity, anastomotic leak following gastric resection for gastric cancer can have detrimental effects on overall and disease-free survival. The risk of anastomotic leak following neoadjuvant therapy remains unknown. The purpose of this study is to investigate the association of preoperative chemotherapy and radiation therapy with postoperative anastomotic leak and additional 30-day morbidity and mortality outcomes following total gastrectomy with reconstruction for gastric cancer using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Patients who underwent total gastrectomy with reconstruction for gastric cancer from 2005 to 2012 were identified. Within the NSQIP database, anastomotic leak is captured as an organ space infection. The association of preoperative chemotherapy and radiation therapy with anastomotic leak and additional 30-day morbidity and mortality outcomes was investigated using chi-squared analysis, Fisher’s exact test, and Student’s t test. A total of 1135 patients met inclusion criteria; 121 (10.7%) patients underwent preoperative chemotherapy within 30 days of surgery, and 53 (4.7%) patients underwent preoperative radiation therapy within 90 days of surgery. Neither preoperative chemotherapy nor radiation therapy was associated with an increased risk of anastomotic leak (p = 0.12 and p = 0.58, respectively). When compared to patients who did not undergo neoadjuvant therapy, patients who underwent either preoperative chemotherapy or radiation therapy did not experience a higher frequency of 30-day mortality (p = 0.41), cardiac (p = 0.49), wound (p = 0.76), renal (p = 0.13), septic (p = 0.55), or venous thromboembolism (p = 0.19) events and were significantly less likely to experience a pulmonary event (p = 0.02). Neoadjuvant therapy prior to gastric resection for gastric cancer is not associated with an increased risk of anastomotic leak or other additional short-term morbidity or mortality.

The accuracy of surgeons, and surgeons-in-training performing laparoscopic intestinal measurements is unknown. We evaluated the accuracy and precision of laparoscopic length measurements using a box-trainer model with and without the aid of a measuring tool. Surgical attendings, residents, and medical students were studied. A 500 cm length of rope was placed within a laparoscopic box trainer. Subjects completed two length measurements (LM). Participants measured 150 cm of rope for LM #1 and repeated the task using a 10-cm suture as a reference for LM #2. Measurement accuracy was tested by comparing mean LM between training level groups using an independent t test. Measurement precision was tested by comparing the mean deviation of LM from 150 cm. 40 attendings, 40 residents, and 50 medical students were studied. In LM #1, there were no differences in mean length accuracy measured between training level groups. Residents significantly underestimated the true 150 cm length (p

Observational studies have reported conflicting results with primary fascial closure (PFC) versus bridged repair during laparoscopic ventral hernia repair (LVHR).The aim of the study was to determine whether when evaluated in a randomized controlled trial (RCT), PFC compared to bridged repair would improve patient quality of life (QoL).In this blinded, multicenter RCT, patients scheduled for elective LVHR (hernia defects 3 to 10 cm on computed tomography scan) were randomized to PFC versus bridged repair. Primary outcome was change in QoL after LVHR using a validated, hernia-specific survey (1 = poor QoL and 100 = perfect QoL) that measures pain, function, cosmesis, and satisfaction. Secondary outcomes were postoperative surgical site occurrences (including hematoma, seroma, surgical site infection, and wound dehiscence), abdominal eventration, and hernia recurrence. The trial was powered to detect a difference in change in QoL of 7 points between the study groups. Outcomes were compared with Mann-Whitney U test or chi-square.A total of 129 patients underwent LVHR and 107 (83%) completed follow-up at 2 years. Patients from both groups were similar at baseline. On median follow-up of 24 months (range: 9-42), patients treated with LVHR-PFC had on average a 12-point higher improvement in QoL compared to bridged repair (improvement in QoL, 41.3 ± 31.5 vs 29.7 ± 28.7, P value = 0.047). There were no differences in surgical site occurrence, eventration, or hernia recurrence between groups.Among patients undergoing elective LVHR, the fascial defect should be closed. This is the first RCT demonstrating that PFC with LVHR significantly improves patient QoL.This trial was registered with clinicaltrials.gov (NCT02363790).