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Journal Review in Burn Surgery: Electrical Burns – Part 2 of 2

While on your burn rotation, the emergency department calls due to a patient who may have been injured at his job site, coming in contact with a high-voltage line. Join Drs. Tam Pham, Clifford Sheckter, Alex Morzycki and Jamie Oh as they discuss the work-up, management, resuscitation, and subsequent complications and reconstruction for electrical injuries. 

Hosts:
– Dr. Tam Pham: UW Medicine Regional Burn Center
– Dr. Clifford Sheckter: Stanford Medicine, Santa Clara Valley Medical Center
– Dr. Alex Morzycki: UW Medicine Regional Burn Center
– Dr. Jamie Oh: UW Medicine Regional Burn Center

Learning Objectives:
– Review the epidemiology and common mechanisms for electrical injuries 
– Understand the impact of electrical injuries on different organ systems, including skin, musculoskeletal, cardiac, neurologic, and renal systems
– Be able to guide initial work-up and resuscitation of acute electrical injuries including upper extremity compartment evaluation and release
– Recognize possible long-term complications of electrical injuries and their subsequent management

References:
1.     Daskal Y, Beicker A, Dudkiewicz M, Kessel B. [HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]. Harefuah. 2019 Jan;158(1):65-69. Hebrew. PMID: 30663297.

2.     Pawlik AM, Lampart A, Stephan FP, Bingisser R, Ummenhofer W, Nickel CH. Outcomes of electrical injuries in the emergency department: a 10-year retrospective study. Eur J Emerg Med. 2016 Dec;23(6):448-454. doi: 10.1097/MEJ.0000000000000283. PMID: 25969345.

3.     Davis C, Engeln A, Johnson EL, McIntosh SE, Zafren K, Islas AA, McStay C, Smith WR, Cushing T; Wilderness Medical Society. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S86-95. doi: 10.1016/j.wem.2014.08.011. PMID: 25498265.

4.     Zemaitis MR, Foris LA, Lopez RA, et al. Electrical Injuries. [Updated 2023 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448087/

5.     Leversedge F, Moore T, Peterson B, Seiler J; Compartment syndrome of the upper extremity. J Hand Surg. 2011; 36(4):P544-559. doi: https://doi.org/10.1016/j.jhsa.2010.12.008

6.     Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res 2006, 27(4): 439-47 

7.     Pilecky D, Vamos M, Bogyi P, et al. Risk of cardiac arrhythmias after electrical accident: a single-center study of 480 patients. Clin Res Cardiol 2019, 108(8): 901-908

8.     Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010, 81(10): 1400-33

9.     Kaergaard A, Nielsen KJ, Casrtensen O, Biering K. Electrical injury and the long-term risk of cataract: A prospective matched cohort study. Acta Ophthalmologica 2023, e88-e94

10.  Richard F. Edlich, MD, PhD and others, TECHNICAL CONSIDERATIONS FOR FASCIOTOMIES IN HIGH VOLTAGE ELECTRICAL INJURIES, The Journal of Burn Care & Rehabilitation, Volume 1, Issue 2, November-December 1980, Pages 22–26.

11.  Lee DH, Desai MJ, Gauger EM. Electrical injuries of the hand and upper extremity. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019 Jan 1;27(1):e1-8.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

Journal Review in Burn Surgery: Electrical Burns – Part 1 of 2

While on your burn rotation, the emergency department calls due to a patient who may have been injured at his job site, coming in contact with a high-voltage line. Join Drs. Tam Pham, Clifford Sheckter, Alex Morzycki and Jamie Oh as they discuss the work-up, management, resuscitation, and subsequent complications and reconstruction for electrical injuries. 
Hosts:
– Dr. Tam Pham: UW Medicine Regional Burn Center
– Dr. Clifford Sheckter: Stanford Medicine, Santa Clara Valley Medical Center
– Dr. Alex Morzycki: UW Medicine Regional Burn Center
– Dr. Jamie Oh: UW Medicine Regional Burn Center

Learning Objectives:
– Review the epidemiology and common mechanisms for electrical injuries 
– Understand the impact of electrical injuries on different organ systems, including skin, musculoskeletal, cardiac, neurologic, and renal systems
– Be able to guide initial work-up and resuscitation of acute electrical injuries including upper extremity compartment evaluation and release
– Recognize possible long-term complications of electrical injuries and their subsequent management

References:
1.     Daskal Y, Beicker A, Dudkiewicz M, Kessel B. [HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]. Harefuah. 2019 Jan;158(1):65-69. Hebrew. PMID: 30663297.

2.     Pawlik AM, Lampart A, Stephan FP, Bingisser R, Ummenhofer W, Nickel CH. Outcomes of electrical injuries in the emergency department: a 10-year retrospective study. Eur J Emerg Med. 2016 Dec;23(6):448-454. doi: 10.1097/MEJ.0000000000000283. PMID: 25969345.

3.     Davis C, Engeln A, Johnson EL, McIntosh SE, Zafren K, Islas AA, McStay C, Smith WR, Cushing T; Wilderness Medical Society. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S86-95. doi: 10.1016/j.wem.2014.08.011. PMID: 25498265.

4.     Zemaitis MR, Foris LA, Lopez RA, et al. Electrical Injuries. [Updated 2023 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448087/

5.     Leversedge F, Moore T, Peterson B, Seiler J; Compartment syndrome of the upper extremity. J Hand Surg. 2011; 36(4):P544-559. doi: https://doi.org/10.1016/j.jhsa.2010.12.008

6.     Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res 2006, 27(4): 439-47 

7.     Pilecky D, Vamos M, Bogyi P, et al. Risk of cardiac arrhythmias after electrical accident: a single-center study of 480 patients. Clin Res Cardiol 2019, 108(8): 901-908

8.     Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010, 81(10): 1400-33

9.     Kaergaard A, Nielsen KJ, Casrtensen O, Biering K. Electrical injury and the long-term risk of cataract: A prospective matched cohort study. Acta Ophthalmologica 2023, e88-e94

10.  Richard F. Edlich, MD, PhD and others, TECHNICAL CONSIDERATIONS FOR FASCIOTOMIES IN HIGH VOLTAGE ELECTRICAL INJURIES, The Journal of Burn Care & Rehabilitation, Volume 1, Issue 2, November-December 1980, Pages 22–26.

11.  Lee DH, Desai MJ, Gauger EM. Electrical injuries of the hand and upper extremity. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019 Jan 1;27(1):e1-8.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

Clinical Challenges in Surgical Education: Thriving as a Surgical Intern

Surgical residency is hard. In some ways, intern year may be the hardest. We’ve been there. We’re a group of surgical residents formally known as the Collaboration of Surgical Education Fellows (CoSEF), a multi-institutional organization of surgical education research fellows working together to foster peer mentorship, networking, and scholarly collaboration. We’ve collectively reflected on our experiences as surgical interns across the country. Join Drs. Ananya Anand, Joe L’Huillier, and Rebecca Moreci as they discuss three tips for thriving as a surgical intern. 

Hosts:
–Dr. Ananya Anand, Stanford University, @AnanyaAnandMD
–Dr. Joseph L’Huillier, University at Buffalo, @JoeLHuillier101
–Dr. Rebecca Moreci, Louisiana State University, @md_moreci
–COSEF: @surgedfellows

Learning Objectives: 
Listeners will: 
– List CoSEF’s three tips for thriving as a surgical intern
– Challenge their definition of patient ownership
– Recall the “Golden Rule” of treating others how you want to be treated
– Appreciate the importance of self-care in surgical residency 

References:
 L’Huillier, Joseph C. MD; Lund, Sarah MD; Anand, Ananya MD; Jensen, Rachel M. MD; Williamson, Andrea J.H. MD; Clanahan, Julie M. MD, MHPE; Moreci, Rebecca MD; Gates, Rebecca S. MD, MMHPE. Thriving as a Surgical Intern: Three Tips From the Collaboration of Surgical Education Fellows (CoSEF). Annals of Surgery Open 4(3):p e306, September 2023. | DOI: 10.1097/AS9.0000000000000306

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

Ad referenced in episode: https://jomi.com/

Journal Review in Hepatobiliary Surgery: Advances in Liver Venous Deprivation and Hypertrophy

For patients with insufficient future liver remnant (FLR) volume, adequate hypertrophy after Portal Venous Embolization (PVE) is associated with reduced likelihood of post-operative hepatic insufficiency. But what happens when PVE isn’t enough to obtain adequate volume prior to surgery? In this episode from the HPB team at Behind the Knife, listen in on the discussion about advances in venous deprivation techniques that can potentially increase resection rates and hypertrophy

Hosts
Anish J. Jain MD (@anishjayjain) is a T32 Research Fellow at the University of Texas MD Anderson Cancer Center within the Department of Surgical Oncology.
Timothy E. Newhook MD, FACS (@timnewhook19) is an Assistant Professor within the Department of Surgical Oncology. He is also the associate program director of the HPB fellowship at the University of Texas MD Anderson Cancer Center.
Jean-Nicolas Vauthey MD, FACS (@VautheyMD) is Professor of Surgery and Chief of the HPB Section, as well as the Dallas/Fort Worth Living Legend Chair of Cancer Research in the Department of Surgical Oncology at The University of Texas MD Anderson Cancer Center

Learning Objectives:
– Develop an understanding of Portal Venous Embolization (PVE)
– Develop an understanding of Sequential Hepatic Venous Embolization (HVE)
– Develop an understanding of Radiological Simultaneous Porto-hepatic Venous Embolization (RASPE)
– Develop an understanding of the traditional two-stage hepatectomy with PVE
– Develop an understanding of the Fast Track Two-Stage Hepatectomy

Papers Referenced (in the order they were mentioned in the episode):

1) Niekamp AS, Huang SY, Mahvash A, Odisio BC, Ahrar K, Tzeng CD, Vauthey JN. Hepatic vein embolization after portal vein embolization to induce additional liver hypertrophy in patients with metastatic colorectal carcinoma. Eur Radiol. 2020 Jul;30(7):3862-3868. doi: 10.1007/s00330-020-06746-4. Epub 2020 Mar 7. PMID: 32144462.
2) Laurent C, Fernandez B, Marichez A, Adam JP, Papadopoulos P, Lapuyade B, Chiche L. Radiological Simultaneous Portohepatic Vein Embolization (RASPE) Before Major Hepatectomy: A Better Way to Optimize Liver Hypertrophy Compared to Portal Vein Embolization. Ann Surg. 2020 Aug;272(2):199-205. doi: 10.1097/SLA.0000000000003905. PMID: 32675481.
3) Nishioka Y, Odisio BC, Velasco JD, Ninan E, Huang SY, Mahvash A, Tzeng CD, Tran Cao HS, Gupta S, Vauthey JN. Fast-track two-stage hepatectomy by concurrent portal vein embolization at first-stage hepatectomy in hybrid interventional radiology / operating suite. Surg Oncol. 2021 Dec;39:101648. doi: 10.1016/j.suronc.2021.101648. Epub 2021 Aug 16. PMID: 34438236.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

BTK Surgical Oncology Oral Board Review – Sample Episode 2 – Pancreatic Adenocarcinoma

Our Surgical Oncology Oral Board Audio Review includes 46 high-yield scenarios that cover all of the SCORE CGSO topics designed for Surgical Oncology Surgeons by Surgical Oncology Surgeons.

Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as surgical oncology surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test.

Learn more about the course and see all the episode topics here: https://behindtheknife.teachable.com/p/btk-surgical-oncology-oral-board-review-course

Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

BTK Surgical Oncology Oral Board Review – Sample Episode 1 – Ductal Carcinoma In Situ

Our Surgical Oncology Oral Board Audio Review includes 46 high-yield scenarios that cover all of the SCORE CGSO topics designed for Surgical Oncology Surgeons by Surgical Oncology Surgeons.

Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as surgical oncology surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test.

Learn more about the course and see all the episode topics here: https://behindtheknife.teachable.com/p/btk-surgical-oncology-oral-board-review-course

Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

Clinical Challenges in Cardiac Surgery: Common Post-Op Cardiac Surgery Problems

We know cardiac surgery can seem a bit daunting on the surface. However, most surgeons will come across cardiac surgery patients at some point whether in the OR, ICU, ED, etc. As the FIRST cardiac surgery specialty team for Behind the Knife, we are excited to bring you episodes focused on high-yield topics to help you navigate common cardiac surgery challenges, discuss relevant literature to help you in practice, and help our listeners feel more comfortable around cardiac surgery patients.

In this episode we’ll discuss common cardiac surgery post-op problems. Whether you’re on a cardiac surgery rotation or just covering an ICU with cardiac surgery patients for the night, these common post-op problems are bound to occur.

Hosts:
– Jessica Millar, MD- PGY-5 General Surgery Resident, University of Michigan, @Jess_Millar15
– Aaron William, MD- Cardiothoracic Surgery Fellow, Duke University, @AMWilliamsMD
– Nick Teman, MD- Assistant Profressor of Thorasis and Cardiovascular Surgery, University of Virginia, @nickteman

Learning objectives:
– Understand the workup and management strategies for post-operative bleeding in the post-cardiac surgery patient.
– Understand how to recognize and manage post-cardiotomy cardiogenic shock in the post-cardiac surgery patient.
– Understand the workup, short-term, and long-term management for post-cardiac surgery atrial fibrillation.

Helpful Resources:
– 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000665
– 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures, Executive summary: https://www.jtcvs.org/article/S0022-5223(14)00835-6/fulltext

For episode ideas/suggestions/feedback feel free to email Jessica Millar at: millarje@med.umich.edu

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our 4 Part Cardiac Surgery Crash Course Series here: https://behindtheknife.org/podcast/cardiac-surgery-crash-course-series-episode-1-intro-to-the-cardiac-or/

Continuing Medical Education (CME) – What? When? How?

CME – What is it? Why do I need it? How do I get it?  How much do I need?  How do I keep track of credits?

Listen to BTK’s Dr. Kevin Kniery’s interview with the CEO of ACCME, Dr. Graham McMahon, to learn about the nuts and bolts of CME as well as recent changes to the program.

Helpful Links:
Behind the Knife’s FREE CME: https://behindtheknife.org/cme/
CME Passport: CMEpassport.org
CME Passport/Behind the Knife: https://www.cmepassport.org/activity/search?specialty=behind%20the%20knife

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. 

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

Innovations in Surgery: PEG Tube

In the fifth episode of the “Innovation in Surgery” series, Dan Scheese sits down with Dr. Jeffrey Ponsky to discuss his innovation, the PEG tube. Dr. Ponsky shares many stories about his work with endoscopy in the late 1970s and how the idea for the PEG tube originated.

“The Development of PEG: How it was” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136860/

“Following the light: A history of the percutaneous endoscopic gastrostomy tube” https://www.facs.org/media/cyrndd5u/07_gastrostomy_tube.pdf

Dr. Ponsky completed his surgical training at University Hospitals of Cleveland in 1976. In 1979, he became the Director of the Department of Surgery at The Mount Sinai Medical Center in Cleveland, where he remained through 1997. In 1997, Dr Ponsky joined The Cleveland Clinic as the Director of Endoscopic Surgery and Executive Director of the Minimally Invasive Surgery Center. In 2005, he assumed the Oliver H. Payne Professorship and Chair of the Department of Surgery at Case Western University School of Medicine. He returned to The Cleveland Clinic as Director of Developmental Endoscopy in 2014. Dr Ponsky has served as president of many organizations including the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society for Gastrointestinal Endoscopy (ASGE). Additionally, Dr. Ponsky has received numerous awards and has published over 300 original articles and book chapters.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other innovation episodes here: https://behindtheknife.org/podcast-series/innovations-in-surgery/

Clinical Challenges in Colorectal Surgery: Let’s Talk Ostomies!

Have you ever struggled choosing which type of stoma to mature in an anatomically or medically challenging patient? What about wrestled with the associated postoperative complications? Join Drs. Galandiuk, Bolshinsky, Kavalukas, and Simon as they discuss ostomy creation and management of stoma complications.

Hosts:
– Susan Galandiuk MD, University of Louisville, Louisville, Kentucky, @DCREdInChief
– Vladimir Bolshinsky MD, Peninsula Health, Victoria, Australia, @bolshinskyv
– Sandy Kavalukas MD, University of Louisville, Louisville, Kentucky, @sandykava
– Hillary Simon DO, University of Louisville, Louisville, Kentucky, @HillaryLSimon

Producer:
– Manasa Sunkara MS3, University of Louisville, Louisville, Kentucky, @manasasunkara12

Learning objectives: 
– Review pre-operative stoma marking and ostomy education. 
– Understand “bail-out” ostomy creation options in medically and anatomically challenging patients. 
– Discuss common postoperative ostomy complications and management.
– Review common peristomal skin pathology and treatment options. 

Video References:
– Colwell, Janice C. A.P.R.N., C.W.O.C.N.1; Williams, Toyia M.S.N., R.N.2. Management of the Patient With a Prolapsed Ileostomy. Diseases of the Colon & Rectum 65(12):p e1073, December 2022. | DOI: 10.1097/DCR.0000000000002605 https://www.youtube.com/watch?v=Wx83CpRLkqk 
Non-operative management of stoma prolapse/reduction

– Colwell, Janice C. A.P.R.N.. Management of the Patient With a Retracted Loop Ileostomy Located in a Crease. Diseases of the Colon & Rectum 65(3):p e182-e183, March 2022. | DOI: 10.1097/DCR.0000000000002367 https://www.youtube.com/watch?v=mc6o7nG1fsQ 
Management of a retracted stoma, in a crease, with peristomal skin breakdown

– Watanabe, Kazuhiro M.D., Ph.D.; Kohyama, Atsushi M.D., Ph.D.; Suzuki, Hideyuki M.D., Ph.D.; Kajiwara, Taiki M.D., Ph.D.; Karasawa, Hideaki M.D., Ph.D.; Ohnuma, Shinobu M.D., Ph.D.; Kamei, Takashi M.D., Ph.D.; Unno, Michiaki M.D., Ph.D.. Slug Method: A Technique for Stoma Prolapse Reduction Using High Osmolality of the 50% Glucose Solution. Diseases of the Colon & Rectum 63(12):p e565, December 2020. | DOI: 10.1097/DCR.0000000000001798  https://cdn-links.lww.com/permalink/dcr/b/dcr_1_1_2020_09_01_watanabe_20-00282_sdc1.mp4 
Osmotic reduction

Other References:
– Baker ML, Williams RN, Nightingale J.. Causes and management of a high-output stoma. Colorectal Dis. 2011;13(2):191–197. doi: 10.1111/j.1463-1318.2009.02107.x.
– Behrenbruch, C., Carr, G., Johnston, M. and Woods, R. (2019), Three-point stapled fixation technique to manage ileostomy spout retraction. ANZ Journal of Surgery, 89: 423-424. doi: 10.1111/ans.15006
– O’Brien, Stephen J. M.B. B.Ch., B.A.O.; Ellis, C. Tyler M.D., M.S.C.R.. The Management of Peristomal Pyoderma Gangrenosum in IBD. Diseases of the Colon & Rectum 63(7):p 881-884, July 2020. | DOI: 10.1097/DCR.0000000000001701
– Paquette IM, Solan P, Rafferty JF, Ferguson MA, Davis BR.. Readmission for dehydration or renal failure after ileostomy creation. Dis Colon Rectum. 2013;56(8):974–979. doi: 10.1097/DCR.0b013e31828d02ba
– Steele S, Hull Tracy, Hyman N, Maykel J, Read T, and Whitlow C. The ASCRS Textbook of Colon and Rectal Surgery. 4th Edition. Volume II. Springer, Switzerland AG, 2022.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other recent Colorectal Surgery Episodes here: https://behindtheknife.org/podcast-category/colorectal/

Clinical Challenges in Thoracic Surgery: Complex Pleural Effusions & Empyema – Part 2 of 2

In this two-part episode our team debates management of complex pleural effusions and empyema. Our surgical team is joined by Dr. Jed Gorden, an interventional pulmonologist, as we explore the nuances of deciding on fibrinolytic therapy (part 1) versus surgical management (part 2).

Part 1: https://behindtheknife.org/podcast/clinical-challenges-in-thoracic-surgery-complex-pleural-effusions-empyema-part-1-of-2/

Learning Objectives:

-Discuss the pros and cons of small bore versus large bore chest tubes for complex pleural effusions 
-Review the evidence for fibrinolytic therapy for management of complex pleural effusions
-Describe the surgical management of a complex pleural effusion including VATS, open thoracotomy, empyema tube, Eloesser flap, and Clagett window
-Create a framework for shared-decision making with patients regarding management of a complex pleural effusion

Hosts:

Kelly Daus MD, Peter White MD, Jed Gorden, MD and Brian Louie MD

Referenced Material

https://pubmed.ncbi.nlm.nih.gov/15745977/
Maskell NA, et al. First Multicenter Intrapleural Sepsis Trial (MIST1) Group. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005 Mar 3;352(9):865-74. doi: 10.1056/NEJMoa042473. Erratum in: N Engl J Med. 2005 May 19;352(20):2146. PMID: 15745977.

https://pubmed.ncbi.nlm.nih.gov/21830966/
Rahman NM, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740. PMID: 21830966.

https://pubmed.ncbi.nlm.nih.gov/35830586/
Wilshire CL, et al. Comparing Initial Surgery versus Fibrinolytics for Pleural Space Infections: A Retrospective Multicenter Cohort Study. Ann Am Thorac Soc. 2022 Nov;19(11):1827-1833. doi: 10.1513/AnnalsATS.202108-964OC. PMID: 35830586.

https://pubmed.ncbi.nlm.nih.gov/37043201/
Wilshire CL, et al. Effect of Intrapleural Fibrinolytic Therapy vs Surgery for Complicated Pleural Infections: A Randomized Clinical Trial. JAMA Netw Open. 2023 Apr 3;6(4):e237799. doi: 10.1001/jamanetworkopen.2023.7799. PMID: 37043201; PMCID: PMC10098968.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. 

If you liked this episode, check out more thoracic surgery episodes here: https://behindtheknife.org/podcast-category/cardiothoracic/

Clinical Challenges in Thoracic Surgery: Complex Pleural Effusions & Empyema – Part 1 of 2

In this two-part episode our team debates management of complex pleural effusions and empyema. Our surgical team is joined by Dr. Jed Gorden, an interventional pulmonologist, as we explore the nuances of deciding on fibrinolytic therapy (part 1) versus surgical management (part 2).

Learning Objectives:

-Discuss the pros and cons of small bore versus large bore chest tubes for complex pleural effusions 
-Review the evidence for fibrinolytic therapy for management of complex pleural effusions
-Describe the surgical management of a complex pleural effusion including VATS, open thoracotomy, empyema tube, Eloesser flap, and Clagett window
-Create a framework for shared-decision making with patients regarding management of a complex pleural effusion

Hosts:

Kelly Daus MD, Peter White MD, Jed Gorden, MD and Brian Louie MD

Referenced Material

https://pubmed.ncbi.nlm.nih.gov/15745977/
Maskell NA, et al. First Multicenter Intrapleural Sepsis Trial (MIST1) Group. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005 Mar 3;352(9):865-74. doi: 10.1056/NEJMoa042473. Erratum in: N Engl J Med. 2005 May 19;352(20):2146. PMID: 15745977.

https://pubmed.ncbi.nlm.nih.gov/21830966/
Rahman NM, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740. PMID: 21830966.

https://pubmed.ncbi.nlm.nih.gov/35830586/
Wilshire CL, et al. Comparing Initial Surgery versus Fibrinolytics for Pleural Space Infections: A Retrospective Multicenter Cohort Study. Ann Am Thorac Soc. 2022 Nov;19(11):1827-1833. doi: 10.1513/AnnalsATS.202108-964OC. PMID: 35830586.

https://pubmed.ncbi.nlm.nih.gov/37043201/
Wilshire CL, et al. Effect of Intrapleural Fibrinolytic Therapy vs Surgery for Complicated Pleural Infections: A Randomized Clinical Trial. JAMA Netw Open. 2023 Apr 3;6(4):e237799. doi: 10.1001/jamanetworkopen.2023.7799. PMID: 37043201; PMCID: PMC10098968.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out more thoracic surgery episodes here: https://behindtheknife.org/podcast-category/cardiothoracic/

Entrustable Professional Activities (EPAs)- They’re Here, Now What

Entrustable Professional Activities, or EPAs, is a term you may have heard…or maybe not.  EPAs represent a tectonic shift in surgical training and how residents will be evaluated. So, what are EPAs?  How will they affect you?  And what do you need to know? We sat down with Dr. George Sarosi, previous member of the ABS EPA Advisory Council and current General Surgery Residency Program Director at the University of Florida, to answer all of our questions now that EPAs are here. 

Guests:
George Sarosi, MD- Professor of Surgery and General Surgery Residency Program Director- University of Florida
Patrick Georgoff, MD- Trauma Surgery and Surgical Critical Care- WakeMed Hospital; Co-director and Host of Behind the Knife
Jessica Millar, MD- General Surgery Resident- University of Michigan; Education Fellow- Behind the Knife
Daniel Scheese, MD- General Surgery Resident- Virginia Commonwealth University; Education Fellow- Behind the Knife

Helpful Websites: 
Resources Page
– ABS EPA resources page for Programs and Trainees: https://www.absurgery.org/default.jsp?eparesources
– FAQs about EPAs and the ABS EPA Project (continuously updated so be sure to check back periodically): https://www.absurgery.org/xfer/epaprogfaqs.pdf
– ABS EPA Program Timeline for program engagement (includes webinars, suggestions for activities for programs to consider, and an expected timeframe for the distribution of additional implementation resources): https://www.absurgery.org/xfer/absepaprogtimeline.pdf
– Checklists for Program directors/Residency administrators/Faculty (https://www.absurgery.org/xfer/epaimplementationchecklist_programs.pdf) and for Residents (https://www.absurgery.org/xfer/epaimplementationchecklist_residents.pdf) to guide and sequence implementation priorities and timing

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

Journal Review in Emergency General Surgery: Clostridium Difficile Infection

An ever-present spectre looming over the hearts of general surgeons everywhere! Please join our Emergency General Surgery team for a journal review about Clostridium difficile (C. diff) infection. Dr. Ashlie Nadler and Dr. Jordan Nantais are joined by guest Dr. Marika Sevigny, recent graduate of trauma and acute care surgery at the University of Toronto, as Dr. Graham Skelhorne-Gross prepares for his upcoming fellowship at Harborview.

Paper 1: Ahmed et al. Risk factors of surgical mortality in patients with Clostridium difficile colitis. A novel scoring system. Eur J Trauma Emerg Surg. 2022 Jun.
– Risk score development study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)
– 525 adult (18-89) patients undergoing colectomy between 2012 and 2016
– Split data into training (80%) and testing (20%) datasets
–  Identified mortality risk factors to create and validate a scoring system
– Scores ranged from 0 to 37 with the highest score predicting an 83.9% risk of mortality
– This scoring system appears relatively straight-forward and methodically sound but the lack of a currently available calculator limits use to some degree

Paper 2: McKechnie et al. Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016-2019. J Gastrointest Surg. 2023 Apr 20.
– Retrospective cohort study of adults (18+) in the National Inpatient Sample (NIS) admitted between Jan 2016 and Dec 2019 for C. difficile colitis, undergoing either a total abdominal colectomy (TAC) or diverting loop ileostomy (DLI) with antegrade vancomycin enemas
– Focus on not only mortality and complications but also admission cost and length of stay
– 886 TAC and 409 DLI patients were identified
– Multivariable logistic regression analysis showed no difference in mortality or overall complications
– TAC patients had shorter admissions (mean difference 4.06 days) and lower cost (mean difference $79,715.34)
– Study was limited as it considered only the initial admission and is unable to provide data on outcomes and costs beyond this time
– Furthermore, there is consideration for disease severity in the analysis, which may impede the ability to compare the two operative approaches

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If you liked this episode, check out our other Emergency General Surgery episodes here: https://behindtheknife.org/podcast-category/emergency-general-surgery/

Dominate the Match – Episode 5: “Meet the Match-2024”

It’s that time of year (again!)- when medical students across the country are preparing their residency applications. The process can be a bit daunting, and there have been a number of changes to process for the 2024 application cycle. Join our education fellow, Dr. Jessica Millar, and Dr. David Hughes as they review the “nuts and bolts” of this year’s residency application cycle.

Guests:
David Hughes, MD- Clinical Associate Professor of Endocrine Surgery, General Surgery Residency Program Director- University of Michigan

Important Dates:

– June 7, 2023: ERAS application opens at 9 a.m. ET.
– September 6, 2023: Residency applicants may begin submitting MyERAS applications to programs at 9 a.m. ET.
– September 15, 2023: Registration for the NRMP Match Opens
– September 27, 2023: Residency programs may begin reviewing MyERAS applications, MSPEs, and supplemental ERAS application data (if applicable) at 9 a.m. ET.

– October 26-31, 2023: Common Interview Release Window

– January 31, 2024: Registration for the NRMP Match Closes

Previous DOMINATE the Match Episodes:
Episode 2- “Choose Me” (Personal Statements and Letters of Recommendations)
https://behindtheknife.org/podcast/dominate-the-match-episode-2-choose-me/

Episode 3- “The Interview”
https://behindtheknife.org/podcast/dominate-the-match-episode-3-the-interview/

Episode 4- “Rank and Match”
https://behindtheknife.org/podcast/dominate-the-match-episode-4-rank-and-match/

Residency Program Lists:
– FREIDA Residency and Fellowship Database: https://freida.ama-assn.org/
– Doximity: https://www.doximity.com/residency/?utm_campaign=marketing_resnav_competitor_broad_20210520&utm_source=google&utm_medium=cpc&gclid=CjwKCAjwt52mBhB5EiwA05YKo1J47BLAtTPtsJBmVvXGP2pDXLLqgDIwM0pgkSYjoBhFUOO1ktXDYRoC2bkQAvD_BwE

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our intern bootcamp series here: https://behindtheknife.org/podcast-series/medical-student-and-intern-survival-guide/

BTK Throw Down: Trauma Vascular Access

The first BTK THROW DOWN!  A spicy debate…a war of words…a battle of ideas!  This fiery episode features leaders in the field of trauma surgery discussing the optimal approach to vascular access in trauma patients.  A recent study titled “Moving the Needle on Time to Resuscitation: An EAST Prospective multicenter study of vascular access in hypotensive injured patients using trauma video review” concluded that intraosseous access should be considered a first line therapy in hypotensive trauma patients.  Is this appropriate?  Crazy?  Just so crazy it might work?  Let’s get ready to ruuuummmmbbbbbbllllllleeeee!

Hosts: 
Patrick Georgoff, MD (@georgoff)
Nina Clark, MD (@clarkninam)

Guests: 
Ryan Dumas, MD – UT Southwestern (@RPDumasMD)
Michael Vella, MD, MBA – University of Rochester (@MichaelVella32)
Bellal Joseph, MD – University of Arizona (@TopKnife_B)

Moving the Needle on Time to Resuscitation: An EAST Prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.
– Dumas RP, Vella MA, Maiga AW, Erickson CR, Dennis BM, da Luz LT, Pannell D, Quigley E, Velopulos CG, Hendzlik P, Marinica A, Bruce N, Margolick J, Butler DF, Estroff J, Zebley JA, Alexander A, Mitchell S, Grossman Verner HM, Truitt M, Berry S, Middlekauff J, Luce S, Leshikar D, Krowsoski L, Bukur M, Polite NM, McMann AH, Staszak R, Armen SB, Horrigan T, Moore FO, Bjordahl P, Guido J, Mathew S, Diaz BF, Mooney J, Hebeler K, Holena DN. Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review. J Trauma Acute Care Surg. 2023 Jul 1;95(1):87-93. doi: 10.1097/TA.0000000000003958. Epub 2023 Apr 4. PMID: 37012624.

Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage.
– Deeb AP, Guyette FX, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Eastridge BJ, Joseph B, Nirula R, Vercruysse GA, Sperry JL, Brown JB. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. J Trauma Acute Care Surg. 2023 Apr 1;94(4):504-512. doi: 10.1097/TA.0000000000003820. Epub 2023 Jan 11. PMID: 36728324; PMCID: PMC10038862.

Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis
– van Loon FHJ, Buise MP, Claassen JJF, Dierick-van Daele ATM, Bouwman ARA. Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis. Br J Anaesth. 2018 Aug;121(2):358-366. doi: 10.1016/j.bja.2018.04.047. Epub 2018 Jul 2. PMID: 30032874.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

Journal Review in Endocrine Surgery: AAES Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism – Part 2 of 2

In this two-part series, we come to you LIVE! from the 2023 Annual meeting of the American Association of Endocrine Surgeons in Birmingham, Alabama. If you think evaluating and managing patients with primary hyperparathyroidism is difficult, patients with secondary and tertiary hyperparathyroidism can be even more difficult to evaluate and manage. Join Drs. Barb Miller, Sophie Dream, Jessica Liu McMullin, and Herb Chen as they break down the controversies and complexities associated with evaluation and management of these patients and discuss the recently published AAES guidelines on the definitive surgical management of patients with secondary and tertiary renal hyperparathyroidism. Part 1 focuses on the impetus for creation of these guidelines, the differences in evaluation and indication for surgery when seeing patients with renally mediated hyperparathyroidism, and preoperative planning. Part 2 focuses on intraoperative and postoperative management, parathyroid autotransplantation, and renal transplant recipients.

Hosts: 
– Barbra S. Miller, MD (Moderator), Clinical Professor of Surgery, The Ohio State University, @OSUEndosurgBSM
– Sophie Dream, MD, Assistant Professor of Surgery, Medical College of Wisconsin, @SDreamMD,
– Jessica Liu McMullin, MD, Endocrine Surgery Fellow, University of Alabama – Birmingham, @jess_mcmullin
– Herbert Chen, MD, Professor and Chair of Surgery, University of Alabama – Birmingham, @herbchen

Learning objectives:
– Understand the epidemiology and pathogenesis of kidney-related parathyroid disease and how these entities differ from primary hyperparathyroidism
– Describe the diagnosis of kidney-related hyperparathyroidism and its different presentations
– Define the indications for surgical intervention
– Recognize the different approaches and extents of surgery for treating the different types of renally mediated hyperparathyroidism including thymectomy and parathyroid autotransplantation
– Detail methods for safe and effective perioperative management

References:
– Dream S, Kuo LE, Kuo JH, Sprague SM, Nwariaku FE, Wolf M, Olson JA Jr, Moe SM, Lindeman B, Chen H. The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg. 2022 Sep 1;276(3):e141-e176. doi: 10.1097/SLA.0000000000005522. Epub 2022 Jul 18. PMID: 35848728.
– Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151:959–968.
– Ketteler M, Block GA, Evenepoel P, et al. Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: what’s changed and why it matters. Kidney Int. 2017;92:26–36.
– Andress DL, Coyne DW, Kalantar-Zadeh K, et al. Management of secondary hyperparathyroidism in stages 3 and 4 chronic kidney disease. Endocr Pract. 2008;14:18–27.
– Cozzolino M, Brancaccio D, Gallieni M, et al. Pathogenesis of parathyroid hyperplasia in renal failure. J Nephrol. 2005;18:5–8.
– Lau WL, Cobi Y, Kalantar-Zadeh K. Parathyroidectomy in the management of secondary hyperparathyroidism. Clin J Am Soc Nephrol. 2018;13:952–961.
– Parfrey PS, Chertow GM, Block GA, et al. The clinical course of treated hyperparathyroidism among patients receiving hemodialysis and the effect of cinacalcet: the EVOLVE trial. J Clin Endocrinol Metab. 2013;98:4834–4844.
– Costa-Hong V, Jorgetti V, Gowdak LH, et al. Parathyroidectomy reduces cardiovascular events and mortality in renal hyperparathyroidism. Surgery. 2007;142:699–703.
– McManus C, Oh A, Lee JA, et al. Timing of parathyroidectomy for tertiary hyperparathyroidism with end-stage renal disease: a cost-effectiveness analysis. Surgery. 2021;169:94–101.
– Finnerty BM, Chan TW, Jones G, et al. Parathyroidectomy versus cinacalcet in the management of tertiary hyperparathyroidism: surgery improves renal transplant allograft survival. Surgery. 2019;165:129–134.

Suture Kit:
Purchase on suturekit.com
Purchase on Amazon

How-to Video Series

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. 

If you liked this episode, check out other endocrine episodes here: https://behindtheknife.org/podcast-category/endocrine/

Journal Review in Endocrine Surgery: AAES Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism – Part 1 of 2

In this two-part series, we come to you LIVE! from the 2023 Annual meeting of the American Association of Endocrine Surgeons in Birmingham, Alabama. If you think evaluating and managing patients with primary hyperparathyroidism is difficult, patients with secondary and tertiary hyperparathyroidism can be even more difficult to evaluate and manage. Join Drs. Barb Miller, Sophie Dream, Jessica Liu McMullin, and Herb Chen as they break down the controversies and complexities associated with evaluation and management of these patients and discuss the recently published AAES guidelines on the definitive surgical management of patients with secondary and tertiary renal hyperparathyroidism. Part 1 focuses on the impetus for creation of these guidelines, the differences in evaluation and indication for surgery when seeing patients with renally mediated hyperparathyroidism, and preoperative planning. Part 2 focuses on intraoperative and postoperative management, parathyroid autotransplantation, and renal transplant recipients.

Hosts: 
– Barbra S. Miller, MD (Moderator), Clinical Professor of Surgery, The Ohio State University, @OSUEndosurgBSM
– Sophie Dream, MD, Assistant Professor of Surgery, Medical College of Wisconsin, @SDreamMD,
– Jessica Liu McMullin, MD, Endocrine Surgery Fellow, University of Alabama – Birmingham, @jess_mcmullin
– Herbert Chen, MD, Professor and Chair of Surgery, University of Alabama – Birmingham, @herbchen

Learning objectives: 
– Understand the epidemiology and pathogenesis of kidney-related parathyroid disease and how these entities differ from primary hyperparathyroidism
– Describe the diagnosis of kidney-related hyperparathyroidism and its different presentations
– Define the indications for surgical intervention 
– Recognize the different approaches and extents of surgery for treating the different types of renally mediated hyperparathyroidism including thymectomy and parathyroid autotransplantation
– Detail methods for safe and effective perioperative management

References:
– Dream S, Kuo LE, Kuo JH, Sprague SM, Nwariaku FE, Wolf M, Olson JA Jr, Moe SM, Lindeman B, Chen H. The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg. 2022 Sep 1;276(3):e141-e176. doi: 10.1097/SLA.0000000000005522. Epub 2022 Jul 18. PMID: 35848728.
– Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151:959–968.
– Ketteler M, Block GA, Evenepoel P, et al. Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: what’s changed and why it matters. Kidney Int. 2017;92:26–36.
– Andress DL, Coyne DW, Kalantar-Zadeh K, et al. Management of secondary hyperparathyroidism in stages 3 and 4 chronic kidney disease. Endocr Pract. 2008;14:18–27.
– Cozzolino M, Brancaccio D, Gallieni M, et al. Pathogenesis of parathyroid hyperplasia in renal failure. J Nephrol. 2005;18:5–8.
– Lau WL, Cobi Y, Kalantar-Zadeh K. Parathyroidectomy in the management of secondary hyperparathyroidism. Clin J Am Soc Nephrol. 2018;13:952–961.
– Parfrey PS, Chertow GM, Block GA, et al. The clinical course of treated hyperparathyroidism among patients receiving hemodialysis and the effect of cinacalcet: the EVOLVE trial. J Clin Endocrinol Metab. 2013;98:4834–4844.
– Costa-Hong V, Jorgetti V, Gowdak LH, et al. Parathyroidectomy reduces cardiovascular events and mortality in renal hyperparathyroidism. Surgery. 2007;142:699–703.
– McManus C, Oh A, Lee JA, et al. Timing of parathyroidectomy for tertiary hyperparathyroidism with end-stage renal disease: a cost-effectiveness analysis. Surgery. 2021;169:94–101.
– Finnerty BM, Chan TW, Jones G, et al. Parathyroidectomy versus cinacalcet in the management of tertiary hyperparathyroidism: surgery improves renal transplant allograft survival. Surgery. 2019;165:129–134.

Suture Kit:
Purchase on suturekit.com
Purchase on Amazon

How-to Video Series

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other endocrine episodes here: https://behindtheknife.org/podcast-category/endocrine/

Clinical Challenges in Trauma Surgery: Approach to Stab Wounds of the Torso

The anterior abdominal stab wound! Who gets explored? When do you get imaging? Who gets serial abdominal exams? How does this change depending on the location of injury? Join Drs. Cobler-Lichter, Kwon, Meizoso, and Urréchaga in their first episode as the new Miami Trauma team  – as they discuss how to navigate the nuances of stab wounds to the torso!

Hosts:
– Michael Cobler-Lichter, MD, PGY2:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@mdcobler (twitter)
– Eva Urrechaga, MD, PGY6/R4:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@urrechisme (twitter)
– Eugenia Kwon, MD, Trauma/Surgical Critical Care Fellow:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
– Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@jpmeizoso (twitter)

Learning Objectives:
– Identify the differences in management of abdominal/thoracoabdominal stab wounds depending on location of injury
– Identify who needs immediate operative intervention and who can undergo further evaluation
– Define the management pathways for patients with abdominal stab wounds without an immediate indication for the OR
– Define thoracoabdominal stab wound and when to evaluate for thoracic injuries
– Discuss the role of diagnostic imaging when evaluating a patient with a stab to the torso

Quick Hits:
1. Don’t forget about the blunt trauma that may be associated with an assault!
2.  Don’t miss injuries- always start with the ABCs and do a thorough head to toe exam 
3. For stab wounds to the torso- hemodynamic instability, evisceration, peritonitis, impalement, or gross blood should go to the OR.
4. The three general clinical pathways for patients without a clear indication for the OR, include serial abdominal exams, local wound exploration, or diagnostic imaging.
5. Serial abdominal exams require frequent monitoring ideally by the same team member every time to detect changes early.
6. Local wound exploration requires adequate lighting and retraction to visualize the anterior rectus fascia. A negative LWE rules out an intra-abdominal injury, but a positive LWE does not necessarily rule it in.
7. Left thoracoabdominal stab wounds require evaluation of the diaphragm to rule out a traumatic diaphragm injury.
8. If there are no clear indications for the OR, diaphragm evaluation should be performed via laparoscopy after a period of 8 – 12 hours from injury.
9. A negative pericardial ultrasound does not rule out a cardiac injury in patients with a left-sided hemothorax.
10. Patients with flank and back stab wounds should be evaluated with CT scan to rule-out retroperitoneal injuries

References
1. Martin MJ, Brown CVR, Shatz DV, Alam HB, Brasel KJ, Hauser CJ, de Moya M, Moore EE, Rowell SE, Vercruysse GA, Baron BJ, Inaba K. Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018 Nov;85(5):1007-1015. doi: 10.1097/TA.0000000000001930. PMID: 29659472.
2. Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, Ivatury RR, Scalea TM. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010 Mar;68(3):721-33. doi: 10.1097/TA.0b013e3181cf7d07. PMID: 20220426.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this trauma episode, check out our BIG T Trauma Series here: https://behindtheknife.org/podcast-series/big-t-trauma/

Innovations in Surgery: LifeFlow

In the fourth episode of the “Innovation in Surgery” series, Drs. Patrick Georgoff and Dan Scheese sit down with Dr. Mark Piehl to discuss his innovation, LifeFlow. Additionally, Dr. Piehl covers multiple other topics in this episode, including circulation-first resuscitation and the process of innovation from the physician’s perspective.

410 Medical Website: https://410medical.com

Reel Emergency trauma podcast: https://www.youtube.com/watch?v=unog3YkFSOE

Prehospital emergency care case report from the episode: https://pubmed.ncbi.nlm.nih.gov/36703273/

Dr. Piehl’s Resuscitation review article: https://link.springer.com/content/pdf/10.1007/s40138-021-00237-6.pdf

Dr. Piehl’s Shock article on circulation-first resuscitation in trauma: https://pubmed.ncbi.nlm.nih.gov/36703273/

Preliminary data on prehospital trauma resuscitation with LifeFlow (Larger version of this with historical controls to be presented at AAST): https://410medical.com/app/uploads/2023/04/ESO-Poster-Presentation-April-2023.pdf

“Unraveling the Fluid Confusion in Sepsis” webinar: https://www.youtube.com/watch?v=yip3AhEezA0

Dr. Mark Piehl is a pediatric critical care physician at WakeMed in Raleigh, NC, and a Medical Director with the WakeMed Mobile Critical Care transport team.  Mark is also Founder and Chief Medical Officer of 410 Medical, a company focused on improving resuscitation in shock, sepsis, and trauma.  He previously served as Medical Director of the WakeMed Children’s Hospital and Director of Pediatrics at WakeMed.  He has numerous Department of Defense grants funding the development of technology to improve trauma care. Mark is also Founder of the Samaritan Health Center, a clinic for the homeless and uninsured in Durham, NC.

Suture Kit:
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How-to Video Series

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other innovation episodes here: https://behindtheknife.org/podcast-series/innovations-in-surgery/

Clinical Challenges in Vascular Surgery: Aortic Graft Infections

In this episode of Behind the Knife the vascular surgery subspecialty team discusses a case of an infected endovascular aortic graft. Although rare, aortic graft infections remain a devastating complication.  What options do you have to fix this problem? In this episode, we will cover the who is at risk of this, how they present, and what options you have to fix it.
Hosts: 
Dr. Bobby Beaulieu is an Assistant Professor of Vascular Surgery at the University of Michigan
Dr. Frank Davis is an Assistant Professor of Vascular Surgery at the University of Michigan
Dr. David Schechtman is a Vascular Surgery Fellow at the University of Michigan
Dr. Drew Braet is a PGY-3 Integrated Vascular Surgery Resident at the University of Michigan

Learning Objectives
·      Understand the incidence of and the relevant risk factors for aortic graft infections
·      Review the spectrum of presenting symptoms and relevant workup for aortic graft infections
·      Understand surgical treatment options including options for in-situ bypass and extra-anatomic bypass
·      Review the different conduits that can be used for in-situ and extra-anatomic reconstruction
·      Discuss relevant post-operative considerations for patients undergoing operative intervention for aortic graft infection

References

·      Chiesa R, Astore D, Frigerio S, Garriboli L, Piccolo G, Castellano R, Scalamogna M, Odero A, Pirrelli S, Biasi G, Mingazzini P, Biglioli P, Polvani G, Guarino A, Agrifoglio G, Tori A, Spina G. Vascular prosthetic graft infection: epidemiology, bacteriology, pathogenesis and treatment. Acta Chir Belg. 2002 Aug;102(4):238-47. doi: 10.1080/00015458.2002.11679305. PMID: 12244902.
·      Bisdas T, Bredt M, Pichlmaier M, Aper T, Wilhelmi M, Bisdas S, Haverich A, Teebken OE. Eight-year experience with cryopreserved arterial homografts for the in situ reconstruction of abdominal aortic infections. J Vasc Surg. 2010 Aug;52(2):323-30. doi: 10.1016/j.jvs.2010.02.277. Epub 2010 Jun 8. PMID: 20570473.
·      PereraG. B.FujitaniR. M.KubaskaS. M.2006Aortic graft infection: Update on Management and Treatment Options.Vasc Endovascular Surg, 401Jan), 1101538-5744
·      Hallett J., Marshall D.M., Petterson T.M., et. al.: Graft-related complications after abdominal aortic aneurysm repair: Population-based experience. J Vasc Surg 1977; 25: pp. 277-284.
·      Kieffer E, Sabatier J, Plissonnier D, Knosalla C. Prosthetic graft infection after descending thoracic/ thoracoabdominal aortic aneurysmectomy: management with in situ arterial allografts. J Vasc Surg. 2001 Apr;33(4):671-8. doi: 10.1067/mva.2001.112314. PMID: 11296316.
·      Gutowski P. Zakazenie aortalno-biodrowej protezy naczyniowej jako problem diagnostyczny i leczniczy [Aortoiliac graft infection as a diagnostic and treatment problem]. Ann Acad Med Stetin. 1998;Suppl 41:1-72. Polish. PMID: 9766086. 
·      Capoccia L, Mestres G, Riambau V. Current technology for the treatment of infection following abdominal aortic aneurysm (AAA) fixation by endovascular repair (EVAR). J Cardiovasc Surg (Torino). 2014;55:381–389.
·      Setacci C, Chisci E, Setacci F, Ercolini L, de Donato G, Troisi N, Galzerano G, Michelagnoli S. How To Diagnose and Manage Infected Endografts after Endovascular Aneurysm Repair. Aorta (Stamford). 2014 Dec 1;2(6):255-64. doi: 10.12945/j.aorta.2014.14-036. PMID: 26798744; PMCID: PMC4682678.
·      Reinders Folmer E.I., Von Meijenfeldt G.C.I., Van der Laan M.J., Glaudemans A.W.J.M., Slart R.H.J.A., Saleem B.R., Zeebregts C.J. Diagnostic Imaging in Vascular Graft Infection: A Systematic Review and Meta-Analysis. Eur. J. Vasc. Endovasc. Surg. 2018;56:719–729. doi: 10.1016/j.ejvs.2018.07.010. 
·      Rafailidis V., Partovi S., Dikkes A., Nakamoto D.A., Azar N., Staub D. Evolving clinical applications of contrast-enhanced ultrasound (CEUS) in the abdominal aorta. Cardiovasc. Diagn. Ther. 2018;8:S118–S130. doi: 10.21037/cdt.2017.09.09.
·      Hayes P.D., Nasim A., London N.J., et. al.: In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: The Leicester experience (1992 to 1998). J Vasc Surg 1999; 30: pp. 92-98.
·      Oderich GS, Bower TC, Hofer J, Kalra M, Duncan AA, Wilson JW, Cha S, Gloviczki P. In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula. J Vasc Surg. 2011 Jan;53(1):99-106, 107.e1-7; discussion 106-7. doi: 10.1016/j.jvs.2010.08.018. PMID: 21184932.
·      Bisdas T., Bredt M., Pichlmaier M., et. al.: Eight-year experience with cryopreserved arterial homografts for the in situ reconstruction of abdominal aortic infections. J Vasc Surg 2010; 52: pp. 323-330.
·      O’Hara P.J., Hertzer N.R., Beven E.G., et. al.: Surgical management of infected abdominal aortic grafts: Review of a 25-year experience. J Vasc Surg 1986; 3: pp. 725-731.
·      Quiñones-Baldrich WJ, Hernandez JJ, Moore WS. Long-term Results Following Surgical Management of Aortic Graft Infection. Arch Surg. 1991;126(4):507–511. doi:10.1001/archsurg.1991.01410280111018
·      Kieffer E., Gomes D., Chieche L., et. al.: Allograft replacement for infrarenal aortic graft infection: Early and late results in 179 patients. J Vasc Surg 2004; 39: pp. 1009-1017.
·      Zhou W., Lin P.H., Bush R.L., et. al.: In situ reconstruction with cryopreserved arterial allografts for management of mycotic aneurysms or aortic prosthetic graft infections: A multi-institutional experience. Texas Heart Institute J 2006; 33: pp. 14-18. 2006
·      Ali AT, Modrall JG, Hocking J, Valentine RJ, Spencer H, Eidt JF, Clagett GP. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg. 2009 Jul;50(1):30-9. doi: 10.1016/j.jvs.2009.01.008. PMID: 19563952.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other vascular episodes here: https://behindtheknife.org/podcast-category/vascular/

Journal Review in Minimally Invasive Surgery: Robotic Emergency General Surgery

Have you transitioned a portion of your practice to the robot, but would be hesitant to book an urgent/call case on the robot? Have you wondered if the robot might be useful in your emergency or acute care surgery practice? Join University of Washington MIS Surgeons, Drs. Andrew Wright, Nicole White, and Nick Cetrulo, and Resident Drs. Ben Vierra and Paul Herman as they discuss the growing use of the robot for acute cases and provide tips on appropriate case selection. 

Hosts: 
1.     Andrew Wright, UW Medical Center – Montlake and Northwest, @andrewswright 
2.     Nick Cetrulo, UW Medical Center – Northwest, @Trules25 
3.     Nicole White, UW Medical Center – Northwest 
4.     Paul Herman, UW General Surgery Resident PGY-3, @paul_herm 
5.     Ben Vierra, UW General Surgery Resident PGY-2 

Learning objectives:  
– Describe the importance of the MIS approach in EGS 
– Review 3 articles on robotic EGS outcomes 
1) Robotic surgery in emergency setting: 2021 WSES position paper 
2) Emergent robotic versus laparoscopic surgery for perforated gastrojejunal ulcers: a retrospective cohort study of 44 patients 
3) Urgent robotic subtotal colectomy for severe acute ulcerative colitis has comparable periop outcomes to laparoscopic surgery 
– Discuss factors influencing appropriate case selection for urgent/emergent robotic cases 
– Discuss value as it pertains to robotic EGS 

References 
1.     Havens JM, Peetz AB, Do WS, Cooper Z, Kelly E, Askari R, Reznor G, Salim A. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg. 2015 Feb;78(2):306-11. doi: 10.1097/TA.0000000000000517. PMID: 25757115. 
2.     Scott JW, Olufajo OA, Brat GA, Rose JA, Zogg CK, Haider AH, Salim A, Havens JM. Use of National Burden to Define Operative Emergency General Surgery. JAMA Surg. 2016 Jun 15;151(6):e160480. doi: 10.1001/jamasurg.2016.0480. Epub 2016 Jun 15. PMID: 27120712.  
3.     Arnold M, Elhage S, Schiffern L, Lauren Paton B, Ross SW, Matthews BD, Reinke CE. Use of minimally invasive surgery in emergency general surgery procedures. Surg Endosc. 2020 May;34(5):2258-2265. doi: 10.1007/s00464-019-07016-1. Epub 2019 Aug 6. PMID: 31388806. 
4.     Sheetz KH, Claflin J, Dimick JB. Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. JAMA Netw Open. 2020 Jan 3;3(1):e1918911. doi: 10.1001/jamanetworkopen.2019.18911. PMID: 31922557; PMCID: PMC6991252.  
5.     de’Angelis N, Khan J, Marchegiani F, Bianchi G, Aisoni F, Alberti D, Ansaloni L, Biffl W, Chiara O, Ceccarelli G, Coccolini F, Cicuttin E, D’Hondt M, Di Saverio S, Diana M, De Simone B, Espin-Basany E, Fichtner-Feigl S, Kashuk J, Kouwenhoven E, Leppaniemi A, Beghdadi N, Memeo R, Milone M, Moore E, Peitzmann A, Pessaux P, Pikoulis M, Pisano M, Ris F, Sartelli M, Spinoglio G, Sugrue M, Tan E, Gavriilidis P, Weber D, Kluger Y, Catena F. Robotic surgery in emergency setting: 2021 WSES position paper. World J Emerg Surg. 2022 Jan 20;17(1):4. doi: 10.1186/s13017-022-00410-6. PMID: 35057836; PMCID: PMC8781145.  
6.     Robinson TD, Sheehan JC, Patel PB, Marthy AG, Zaman JA, Singh TP. Emergent robotic versus laparoscopic surgery for perforated gastrojejunal ulcers: a retrospective cohort study of 44 patients. Surg Endosc. 2022 Feb;36(2):1573-1577. doi: 10.1007/s00464-021-08447-5. Epub 2021 Mar 24. PMID: 33760973.  
7.     Anderson M, Lynn P, Aydinli HH, Schwartzberg D, Bernstein M, Grucela A. Early experience with urgent robotic subtotal colectomy for severe acute ulcerative colitis has comparable perioperative outcomes to laparoscopic surgery. J Robot Surg. 2020 Apr;14(2):249-253. doi: 10.1007/s11701-019-00968-5. Epub 2019 May 10. PMID: 31076952. 
8.     Gangemi A, Danilkowicz R, Bianco F, Masrur M, Giulianotti PC. Risk Factors for Open Conversion in Minimally Invasive Cholecystectomy. JSLS. 2017 Oct-Dec;21(4):e2017.00062. doi: 10.4293/JSLS.2017.00062. PMID: 29238153; PMCID: PMC5714218. 
9.     Bhama AR, Wafa AM, Ferraro J, Collins SD, Mullard AJ, Vandewarker JF, Krapohl G, Byrn JC, Cleary RK. Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Using the Michigan Surgical Quality Collaborative (MSQC) Database. J Gastrointest Surg. 2016 Jun;20(6):1223-30. doi: 10.1007/s11605-016-3090-6. Epub 2016 Feb 3. PMID: 26847352. 
10.   https://www.east.org/about-east/news-and-events/news/details/320/east-robotic-surgery-for-the-acute-care-surgeon-webinar-series

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other MIS episodes here: https://behindtheknife.org/podcast-category/minimally-invasive/

Intern Bootcamp – Dominate Intern Year

Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency. 

In this last episode of the intern bootcamp mini-series, we’ll talk about tips & tricks as well as good habits to establish in order to dominate intern year.

Hosts: Shanaz Hossain, Nina Clark

Tips for New Interns: 

GENERAL TIPS FOR SUCCESS ON THE WARDS
  • Spend time with the patient!
  • Trust, but verify.
  • Be kind to everyone.
  • Stay humble.
  • Be flexible.
  • Seek and apply feedback.

HOW TO LEARN IN THE OR
  • Double scrub as many cases as you can.
  • Write down/record everything after a case.

MAINTAIN YOUR PERSONAL SANITY
  • Figure out your stress outlets and what brings you joy.
  • Decompress after work.
  • Maintain work/life boundaries.
  • Keep in touch with loved ones.
  • Vacations are meant for relaxation.
    • Repeat after me: NO WORK ON VACATION!
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Intern Bootcamp – Scary Pages

Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency. 

Today, we’re hitting the wards and tackling some of the scary clinical scenarios you will see as an intern.

Hosts: Shanaz Hossain, Nina Clark

Tips for new interns:
THINGS TO REMEMBER
·       BREATHE. In most cases, you have a little bit of time – at least enough to take a breath and calm down outside the room before heading into an emergency. Panic doesn’t help anybody.
·       See the patient. Getting a bunch of pages? Worried about someone? Confused as to what’s going on? Go see the patient and chat with the bedside team.
·       Know your toolbox. There are a ton of people around who can help you in the hospital, and knowing the basic labs/imaging studies and when to use them can help you to triage even the sickest patients.
·       Load the boat. You’ve heard this one from us all week! Loop senior level residents in early.

HYPOTENSION
·       Differential: measurement error, patient’s baseline, and don’t miss – SHOCK.
           – Etiologies of shock: hemorrhagic, hypovolemic,
·       On the phone: full set of vitals, accurate I/Os,
·       On the way: recent notes, PMH/PSH including from this hospital stay, and vitals/I&Os/studies from earlier in the day
·       In the room: ABCDs – rapidly gives you a sense of how high acuity the patient is
·       Get more info: labs, consider imaging, work up specific types of shock based on clinical concern.
·       Initial management: depends on etiology of hypotension; don’t forget to consider peripheral or central access, foley catheterization for close monitoring of urine output, and level of care

 HYPOXEMIA
·       Differential: atelectasis, baseline pulmonary disease, pneumonia, PE, hemo/pneumothorax, volume overload
·       On the phone: full set of vitals, amount of supplemental oxygen required and delivery device, rate of escalation in oxygen requirement
·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
·       In the room: ABCDs, pulmonary and cardiac exam, volume status exam
·       Get more info: basic labs, ABG if worried about oxygenation, CXR, consider bedside US of the lungs/heart, if high suspicion for PE consider CTA chest
·       Initial Management: supplemental O2, higher level of care, consider intubation or other supplemental oxygenation adjuncts, additional management dependent on suspected etiology
·       ABG Vs VBG (IBCC): https://emcrit.org/ibcc/vbg/ 

ALTERED MENTAL STATUS
·       Differential: stroke, medication effect, hypoxemia or hypercarbia, toxic or medication effect, endocrine/metabolic, stroke or MI, psychiatric illness, or infections, delirium
·       On the way: review PMH/PSH, recent notes for evidence of altered mentation or agitation, or signs hinting at above etiologies
·       In the room: ABCDs, focal neuro deficits?, alert/oriented? Be sure the patient’s mental status is adequate for airway protection!
·       Get more info: basic labs, blood gas/lactate, CT head noncontrast if concerned for stroke.
·       Initial management: rule out above; if concerned about delirium, optimize sleep/wake cycles, pain control, and lines/drains/tubes. 

OLIGURIA
·       Differential: prerenal due to hypovolemia or low effective circulating volume, intrinsic renal disease, post-renal obstruction
·       On the phone: clarify functional foley or bladder scan results, full set of vitals
·       On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
·       In the room: ABCDs, confirm functioning foley catheter
·       Get more info: basic labs, urine electrolytes, consider fluid challenge to evaluate responsiveness, consider adjuncts including renal US
·       Initial management: typically consider IVF bolus initially, but if patient not volume responsive, don’t overload them — look for other etiologies! 

TACHYCARDIA
·       Differential: sinus tachycardia (pain, hypovolemia, agitation, infection), cardiac arrhythmia, MI, PE
·       On the phone: full set of vitals, acuity of change in heart rate, updated I/Os
·       On the way: Review PMH/PSH, known cardiac history, cardiac and PE risk factors, volume resuscitation, signs concerning for infection, updated I/Os
·       In the room: ABCDs, cardiac/pulmonary exam, evaluate for any localizing signs for infection
·       Get more info: basic labs, EKG, consider CXR, troponins
·       Initial management: depends heavily on etiology

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Intern Bootcamp – Consults

Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency. 
This episode, we’ll talk about how to give and receive consults in the hospital like a pro. We’ll also provide some tips on how to make those long call days a little more manageable.
Hosts: Shanaz Hossain, Nina Clark
Tips for New Interns: 
GIVING CONSULTS
  • Clear and Concise Question!
  • Develop a script, such as:
    • “Hi, this is XX with the general surgery team. We’re calling to request an evaluation for a patient presenting with XX. I can give you the MRN whenever you are ready…”
    • Follow this with a brief H&P.
  • If you are asking another team to perform a procedure on your patient, be prepared with the following information:
    • NPO Status
    • Ability to Consent or Proxy Contact
    • Blood Thinners
    • Urgency of Procedure
RECEIVING CONSULTS
  • Make sure you are clear on what the team is asking of you as a consultant.
  • Clarify if the patient is expecting to receive a surgery before talking to them about an operation!
  • Quickly gather information about the patient and their hospital course from the consultant, electronic medical record, and, most importantly, the patient!
  • Note the callback number on the primary team and call them with the plan after you have staffed the patient with your attending.
  • If you are asked to perform a procedure as a consultant, clarify the following information:
    • NPO Status
    • Ability to Consent or Proxy Contact
    • Blood Thinners
    • Urgency of Procedure
  • Develop a system to stay organized and keep track of your to-do list with consults!
CALL SHIFTS
  • Bring a survival bag with toothbrush/toothpaste, face wash, deodorant, change of clothes, etc to reset.
  • Try to nap when you can, but:
    • PM round to address non-urgent pages ahead of time
    • Set alarms!
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Intern Bootcamp – Medical Students

Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency. 
You’ve been a doctor for about 3.5 seconds, and suddenly that bright eyed, bushy-tailed medical student on service is looking to you for advice? Don’t fret, in this episode we’ll give you some tips for how to handle it.
Hosts: Shanaz Hossain, Nina Clark
Tips for new interns:
REMEMBER HOW INTERNS DO AND DO NOT TEACH
– Nobody, not even the med students, expect you to be an expert in everything or give a fully-planned formal lecture
– You WILL however spend a ton of time working with students on your team – and via modeling and teachable moments, you can help them learn how it’s done!

MODELING
– Remember how hard everything has been in the few days since you started residency? Think about all the information you’ve picked up, tips and tricks you’re developing for efficiency, and best practices you’re learning in the care of your patients. ALL of these are things you can pass on to students.
– Presentations, case prep, answering questions from senior members of the team are ALL excellent opportunities to teach (and show students how you learn yourself, so they can do it independently).

TEACHABLE MOMENTS
– Find small topics that you know or are getting to know well – things like looking at a CXR, CT scan, etc.
– Once you’re getting more comfortable caring for specific disease processes, think about high yield lessons for students:
– Acute trauma evaluation and management (ABCDE’s), appendicitis, diverticulitis, benign biliary disease all make great 5 minute chalk talks that you can have in your back pocket

IN THE OR
– Watch students practice skills, and try to give some feedback and tips that you use (you learned knot tying and suturing more recently than ANYONE else in the OR and probably have some tips that you’re still using to improve)
– If you’re not sure where or why the student is struggling with a particular skill (like tying a knot), model doing it yourself in slow motion while watching them do it – often the side by side comparison can help you identify where they’re going astray

BE THE RESIDENT YOU WISH YOU HAD
– Refer to EVERYONE with respect
– Model being a kind, conscientious, and curious physician
– Try to find universal lessons and crossover topics that non-surgeons need to know
– A great student makes their interns look even better – be explicit about how they can be successful, then advocate for them to have opportunities to show everything they’re learning!

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. 

If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Intern Bootcamp – Resource Overload

SHOW NOTES
Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency.
This episode, we’ll tackle the resources that you should know about to support your own learning throughout residency.
Hosts: Shanaz Hossain, Nina Clark
Tips for new interns: 
STRUCTURE YOUR STUDYING
– 2 things you need to do: (1) develop a knowledge base and (2) answer questions
– Knowledge base
  • Pick a level-appropriate textbook, read it (ideally all of it) yearly.
  • Ideally, lead a little bit every day – 10 pages/day is a good goal to start with and you may need to adjust.
– Questions
Do some questions every week – 50/week is a good goal to start
  • Plan to do more questions closer to ABSITE!
Consider storing everything you learn in one place – either a notebook you carry with you or a cloud-based note app
  • Share this with others, use it to take notes while reading, doing cases, getting feedback, or gaining experience while taking care of patients every day.
SPECIFIC RESOURCES
– Textbooks
  • Sabiston: big book, very dense, with a lot of great information.
  • Schwartz: shorter chapters, clinically oriented, ideal for junior residents
  • Cameron: shorter chapters, clinically oriented, ideal for senior residents
– ABSITE review books
  • Fiser: Classic, packed with facts but can be difficult to read, good for looking things up quickly
  • BTK ABSITE Companion: from yours truly! High quality illustrations and algorithms that pairs well with the BTK ABSITE podcast episodes. Stay tuned for an updated episodes and companion book in Fall 2023!
– Question banks
  • TrueLearn: high quality, can be pricy depending on program
  • SCORE: written/edited by ABS, free for subscribing programs
LEARN HOW TO OPERATE??
– Carry suture and a needle driver with you and practice basic moves
– Consider a home suture kit for practice when you don’t want to be in sim lab – BTK released one this year
– Use VIDEOS to ensure learning things the correct way!

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Intern Bootcamp – The First Day

Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency. 

First up, the first day of intern year. 

Hosts: Shanaz Hossain, Nina Clark

Tips for new interns:

  1. BRING WHAT YOU NEED
    1. Name badge
    2. Scrubs, white coat, and extra clinic clothes
    3. Comfortable shoes – even on clinic days
    4. Pager
    5. Phone
    6. Pen
    7. Bonus stuff that’s good to keep in your bag: Snacks, extras of everything, toothbrusth/toothpaste/deodorant, suture 
  2. STAY ORGANIZED
    1. Preround purposefully and systematically
      1. Look at the same things in the same order every day on every patient
      2. Write data in the same physical location on your sheet so you can quickly find information on the fly 
    2. Keep track of to-do’s from rounds
      1. Check box system:
        1. Nina’s system: empty = not done, half full = ordered/needs follow up, full = completely done and followed up on 
        2. Don’t forget to look at the results of imaging studies, labs, or consults after they are entered! 
      2. Prioritize urgent/emergent things first, then consults and discharges, then routine orders, then notes
        1. As you get more efficient, start drafting your notes as you pre-round – it will save you lots of time later in the afternoon! 
  3. OWN THE FLOOR
    1. During the day, be ready to shift your priorities as urgent issues arise. 
    2. Develop a system for remembering what happened after rounds so you can quickly update seniors
      1. Shanaz’s system: One color for AM rounds, a different color for afternoon events
    3. Load the boat! Your team is there to help you. If you are concerned about someone or have a question, ask. There is truly no better time than as an intern.
      1. Master the art of getting your seniors’ attention in the OR – be conscientious, be clear in what you’re asking, and be prepared to report back about urgent findings! 

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Clinical Challenges in Hernia Surgery: Loss of Domain

In their BTK debut, the Hernia team from Carolinas Medical Center discusses how to approach a hernia patient with loss of domain. This Clinical Challenges episode reviews strategies that optimize patients and provide them with the best chance of fascial closure. So, tune in, and enjoy a data driven conversation with our newest hernia enthusiasts! 

Hosts:
– Sullivan “Sully” Ayuso, MD – PGY4 General Surgery Resident, sullivan.ayuso@gmail.com, Carolinas Medical Center 
– Monica Polcz, MD – Clinical Fellow (PGY-8) in Abdominal Wall Reconstruction, monica.polcz@atriumhealth.org, Carolinas Medical Center 
– Vedra Augenstein, MD FACS – Associate Professor of Surgery (11 years in practice), vedra.augenstein@gmail.com, Carolinas Medical Center B 
– Todd Heniford, MD FACS – Professor of Surgery (25 years in practice), todd.heniford@gmail.com, Carolinas Medical Center

Links to articles:
– Katzen et al, Open Preperitoneal Ventral Hernia Repair: Prospective Observational Study of Quality Improvement Outcomes over 18 Years and 1,842 patients, Surgery, 2022
https://pubmed.ncbi.nlm.nih.gov/36280505/ 
– Bernardi et al, Primary Fascial Closure During Laparoscopic Ventral Hernia Repair Improves Patient Quality of Life: A Multicenter, Blinded Randomized Trial, Ann Surg, 2020
https://pubmed.ncbi.nlm.nih.gov/31365365/ 
– Deerenberg et al, The Effects of Preoperative Botulinum Toxin A on Abdominal Wall Reconstruction, J Surg Res, 2021
https://pubmed.ncbi.nlm.nih.gov/33360691/ 
– Bueno-Lledó, Preoperative Progressive Pneumoperitoneum and Botulinum Toxin A in Patients with Large Incisional Hernia, Hernia, 2017
https://pubmed.ncbi.nlm.nih.gov/28124308/ 
– Maloney et al, Twelve Years of Component Separation Technique in Abdominal Wall Reconstruction, Surgery, 2021
https://pubmed.ncbi.nlm.nih.gov/31358348/ 
– Ayuso et al, Delayed Primary Closure (DPC) of the Skin and Subcutaneous Tissues Following Complex, Contaminated Abdominal Wall Reconstruction (AWR): A Propensity-Matched Study, Surg Endo, 2022
https://pubmed.ncbi.nlm.nih.gov/34018046/

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out more hernia episodes here: https://behindtheknife.org/podcast-category/hernia/

How to do a Liver Transplant with Dr. Shah and Dr. Dageforde

Join BTK’s Dr. Kevin Kniery for a discussion on How to do a Liver Transplant with Dr. Shah and Dr. Dageforde.

Additional resources:

– Watch: Liver Transplant Surgical Techniques – https://www.youtube.com/watch?v=Vk1Ld7Fp5es

– Listen:
Surgical Technique: Kidney Transplant (Part 1) https://behindtheknife.org/podcast/surgical-technique-kidney-transplant-part-1/

Surgical Technique: Kidney Transplant (Part 2)
https://behindtheknife.org/podcast/surgical-technique-kidney-transplant-part-2/

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Healthcare Upside Down Interview with Dr. Buchwald

Dr. Buchwald is Professor Emeritus of Surgery and Biomedical Engineering at the University of Minnesota. He is a veteran, world-renowned metabolic surgeon, author, professor and patient healthcare advocate. His book “Healthcare Upside Down: A Critical Examination of Policy and Practice” was born out of Dr. Buchwald’s observations of the healthcare industry over the last 50 years. In it, he explores how healthcare has been turned upside down to serve the administrators of the system and away from its basic function of offering the best care for patients. More importantly, he discusses solutions for turning our broken healthcare system right-side up to better serve all patients.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out other recent episodes here: https://behindtheknife.org/listen/

Journal Review in Surgical Education: Recent Changes to the Residency Application Process

Application season is almost here! Whether you are about to apply to surgery residency or are part of a program recruiting applicants, there are several recent changes to the process that you should be aware of. Residency recruitment continues to see increased numbers of applications that create challenges for both students and programs. ERAS and other organizations are trying to address these issues with alterations to the application process. Today, we’ll discuss how the ERAS supplemental application, as well as new concepts like a single interview release period and decoupled rank lists, can help. We’re joined by Dr. Jennifer LaFemina, one of the leaders in these efforts within the general surgery recruitment process.

Learning Objectives
– Listeners will describe current challenges in the residency recruitment process.
– Listeners will describe the value that changes such as the ERAS supplemental application can add to the residency recruitment process.
– Listeners will recognize the results that changes to the residency application process have had during the first 2 years of implementation in surgery.
– Listeners will consider how alterations to the residency application process can be successfully applied within their own program or application.

References:
LaFemina J, Rosenkranz KM, Aarons CB, et al. Outcomes of the 2021-2022 APDS General Surgery Recruitment Process Recommendations. Journal of Surgical Education. 2023;80(6):767-775. doi:10.1016/j.jsurg.2023.02.019

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other surgical education episodes here: https://behindtheknife.org/podcast-category/surgical-education/

The Second Victim Syndrome with Dr. Haytham Kaafarani

You just finished a difficult case in which a complication occurred. Feelings of guilt, sadness, and anxiety are pouring over you. You can’t help but think you are a terrible surgeon, maybe even a terrible person. Does this sound familiar? Complications have profound psychological impact on surgeons. Find out how one surgeon decided to do something about it by creating a peer support program. Join Jessica Millar and Patrick Georgoff as they discuss the second victim syndrome with Dr. Haytham Kaafarani (@hayfarani). 

References: 

  1. The Surgeon as the Second Victim? Results of the Boston Intraoperative Adverse Events Surgeons’ Attitude (BISA) Study: https://pubmed.ncbi.nlm.nih.gov/28093300/ 
  2. Design and Impact of a Novel Surgery-Specific Second Victim Peer Support Program: https://pubmed.ncbi.nlm.nih.gov/31857209/ 
  3. When Things Go Wrong: The Surgeon as Second Victim: https://pubmed.ncbi. nlm.nih.gov/30480564/ 
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen/

Journal Review in Surgical Oncology: Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy

Join the Surgical Oncology team from UTSouthwestern and the University of Miami as they tackle a journal review covering how to choose perioperative antimicrobial prophylaxis for pancreatoduodenectomy. Listen in as they also review novel methodology and the origins of the study.

Learning Objectives: 
What antibiotics are you giving before your Whipple? In the group’s final episode together, we review the 1st of its kind, registry linked, pragmatic surgical trial in North America. In the episode we dissect “Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy – A Randomized Clinical Trial” and discuss the practice changing findings, and the future of surgical clinical trials. 

Hosts: 
Adam Yopp, MD, FACS (@AdamYopp) is an Associate Professor of Surgery at the UT Southwestern Medical Center and is Chief of the Division of Surgical Oncology. He also serves as Surgical Director of the Liver Tumor Program.

Caitlin Hester, MD (@CaitlinAHester) is a recent graduate of the MD Anderson Complex General Surgical Oncology fellowship and is now a new faculty member in the Division of Surgical Oncology within the Sylvester Cancer Center at the University of Miami where she specializes in surgery for cancers of the liver, pancreas, and other gastrointestinal sites. 

Gilbert Murimwa, MD (@GilbertZMurimwa) is a PGY-4 Research Fellow and General Surgery Resident at the UT Southwestern Medical Center. He is studying the pancreatic tumor microenvironment and targeted therapies in the lab of Rolf Brekken within the Hamon Center for Therapeutic Oncology Research. He also does work on access to care, social determinants of health, and interventions to mitigate disparities in surgical and oncologic outcomes under the mentorship of Patricio Polanco. 

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out surgical oncology episodes here: https://behindtheknife.org/podcast-category/surgical-oncology/

Leadership in Surgery: Dr. Amy Lightner

Join BTK’s Dr. Scott Steele for the first episode of a new leadership series that explores opportunities outside of clinical medicine.  In this episode, Dr. Steele sits down with Dr. Amy Lightner who is the Chief Medical Officer for Direct Biologics. 

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our other recent episode here: https://behindtheknife.org/listen/

Mattox Vegas TCCACS Keynote Dr. David Nott: Leaving a Legacy in Conflict Zones

This spectacular keynote address was given by Dr. David Knott at the “Mattox” Trauma Conference in 2023.

The David Nott Foundation: https://davidnottfoundation.com/

David gained his medical degree from Manchester University and in 1992 gained his FRCS from the Royal College of Surgeons of England to become a Consultant Surgeon.

He is a Consultant Surgeon at St Mary’s Hospital where he specialises in vascular and trauma surgery and also performs cancer surgery at the Royal Marsden Hospital. David is an authority in laparoscopic surgery and was the first surgeon to combine laparoscopic and vascular surgery.

For the past 30 years David has taken unpaid leave to work for the aid agencies Médecins Sans Frontières, the International Committee of the Red Cross and Syria Relief. He has provided surgical treatment to patients in conflict and catastrophe zones in Bosnia, Afghanistan, Sierra Leone, Liberia, Ivory Coast, Chad, Darfur, Yemen, the Democratic Republic of Congo, Haiti, Iraq, Pakistan, Libya, Syria, Central African Republic, Palestine, Nepal and Ukraine

As well as treating patients affected by conflict and catastrophe and raising hundreds of thousands of pounds for charitable causes, David teaches advanced surgical skills to local medics and surgeons when he is abroad. In Britain, he set up and led the teaching of the Surgical Training for the Austere Environment (STAE) course at the Royal College of Surgeons.

In 2015 David established the David Nott Foundation with his wife Elly. The Foundation supports surgeons in developing their operating skills for war zones and austere environments and has now trained over 900 doctors through their bespoke Hostile Environment Surgical Training (HEST) course. In 2019, Picador published David’s bestselling memoir, War Doctor.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our recent episode list here: https://behindtheknife.org/listen/

Journal Review in Bariatric Surgery: SPLENDID and BRAVES Studies

For our last submission as the BTK Bariatric Surgery Team, we thought we would take a minute to review some recent landmark trials in bariatric surgery. Get caught up on the impact of bariatric surgery on obesogenic cancers and non-alcoholic steatohepatitis. 

Journal articles:
Association of Bariatric Surgery with Cancer Risk and Mortality in Adults with Obesity: https://pubmed.ncbi.nlm.nih.gov/35657620/. 

Bariatric-Metabolic Surgery versus Lifestyle Intervention plus Best Medical Care in Non-Alcoholic Steatophepatitis (BRAVES): A Multicentre, Open-Label, Randomised Trial: https://pubmed.ncbi.nlm.nih.gov/37088093/.

Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed robotic general surgery procedures. If you are a general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs,  reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com for more information on how you could be compensated $500 per video submitted of each (up to $1000 per surgeon).

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other bariatric episodes here: https://behindtheknife.org/podcast-category/bariatric/

BTK Colorectal Surgery Oral Board Review – Sample Episode 2 – Pouch Complications

Our Colorectal Surgery Oral Board Audio Review includes 51 high-yield scenarios designed for Colorectal Surgeons by Colorectal Surgeons. 

Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as colorectal surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test.

Learn more about the full set of 51 scenarios here: https://behindtheknife.teachable.com/p/btk-colorectal-surgery-oral-board-review-course
Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

BTK Colorectal Surgery Oral Board Review – Sample Episode 1 – Familial Adenomatous Polyposis

Our Colorectal Surgery Oral Board Audio Review includes 51 high-yield scenarios designed for Colorectal Surgeons by Colorectal Surgeons.  

Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as colorectal surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test.

Learn more about the full set of 51 scenarios here: https://behindtheknife.teachable.com/p/btk-colorectal-surgery-oral-board-review-course
Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Clinical Challenges in Pediatric Surgery: Common Pediatric Surgery Scenarios

Please join Drs. Brian Gray, Amanda Jensen and Manisha Bhatia from Indiana University as they discuss the nuances of 3 common pediatric general surgery scenarios. 

Journal Article links: 
Nguyen HN, Navarro OM, Bloom DA, Feinstein KA, Guillerman RP, Munden MM, et al. Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022;218(6):931-9.
https://pubmed.ncbi.nlm.nih.gov/35107311/

Plut D, Phillips GS, Johnston PR, Lee EY. Practical Imaging Strategies for Intussusception in Children. AJR Am J Roentgenol 2020;215(6):1449-63.
https://pubmed.ncbi.nlm.nih.gov/33084362/

Markel TA, Scott MR, Stokes SM, Ladd AP. A randomized trial to assess advancement of enteral feedings 
following surgery for hypertrophic pyloric stenosis. J Pediatr Surg 2017;52(4):534-9.
https://pubmed.ncbi.nlm.nih.gov/27829521/

St Peter SD, Holcomb GW, 3rd, Calkins CM, Murphy JP, Andrews WS, Sharp RJ, et al. Open versus 
laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg 
2006;244(3):363-70.
https://pubmed.ncbi.nlm.nih.gov/16926562/
Dalton BG, Gonzalez KW, Boda SR, Thomas PG, Sherman AK, St Peter SD. Optimizing fluid resuscitation in 
hypertrophic pyloric stenosis. J Pediatr Surg 2016;51(8):1279-82.
https://pubmed.ncbi.nlm.nih.gov/26876090/

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other pediatric surgery episodes here: https://behindtheknife.org/podcast-category/pediatric/

BIG T Trauma Series Ep. 17 – Brain Death

On this episode of the BIG T Trauma series Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill discuss brain death and why you as a provider must be able to provide clarity when it is needed most.  This episode is packed with useful information on a very complicated topic.  So, sit back, relax, and enjoy the show.  

The World Brain Death Project (JAMA 2020): https://pubmed.ncbi.nlm.nih.gov/32761206/

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out the rest of the BIG T trauma series here: https://behindtheknife.org/podcast-series/big-t-trauma/

Journal Review in Colorectal Surgery: Anastomotic Healing, Leak and Gut Microbiome

Upon encountering a patient who develops an anastomotic leak after a straight-forward low anterior resection, you are taken aback, as the patient is healthy and has no apparent risk factors. This prompts you to consider whether the microbiota may have played a role in causing the leak.

Join Dr. Carole Richard, Dr. François Dagbert, Dr. Maher Al Khaldi, and Dr. Roy Hajjar in their conversation about the impact of gut microbiota on anastomotic healing and leak. 

Learning objectives 
– To list the known risk factors for anastomotic leak.
– To understand how preoperative gut microbiota influence anastomotic healing and could lead to leak. 

Reference
Hajjar R, Gonzalez E, Fragoso G, et al. Gut microbiota influence anastomotic healing in colorectal cancer surgery through modulation of mucosal proinflammatory cytokines. Gut. Published Online First: 30 December 2022. doi: 10.1136/gutjnl-2022-328389

Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed robotic general surgery procedures. If you are a general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs,  reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com for more information on how you could be compensated $500 per video submitted of each (up to $1000 per surgeon).

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other colorectal surgery episodes here: https://behindtheknife.org/podcast-category/colorectal/

Association for Academic Surgery: Removing the Mask with Dr. Carrie Cunningham

Dr. Cunningham is the section head of the Massachusetts General Hospital Endocrine Surgery unit, a NIH-funded researcher, and the immediate past-president of the Association for Academic Surgery. This episode is a recording of her presidential address at their annual Academic Surgical Congress. 

Guest
Dr. Carrie Cunningham, MD, MPH
Associate Professor of Surgery, Harvard Medical School

Learn More
Association for Academic Surgery: https://www.aasurg.org/
Dr. Lorna Breen Heroes foundation: https://drlornabreen.org/ 

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Journal Review in Breast Surgery: Management of Hereditary Breast Cancer

While you are likely aware of BRCA mutations as a significant risk factor for development of breast cancer (60-80% lifetime risk), there are many other pathogenic gene variants that have been identified in recent years. The surgical treatment of women with hereditary breast cancer differs from that of women with sporadic breast cancer, and women with hereditary breast cancer are also eligible for prophylactic mastectomy or intensive surveillance protocols. In this episode of BTK, we examine current national consensus guidelines for management of hereditary breast cancer, discuss a recent population-based study that establishes risk associated with various genes, and address both surgical and surveillance strategy for patients without breast cancer but with known pathogenic gene variants.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out other breast surgery episodes here: https://behindtheknife.org/podcast-category/breast/

Taking Back the (Bile) Duct: Lap Common Bile Duct Exploration

Calling all surgeons! It’s time to take back common bile duct stones!

Join our surgical education fellow, Shanaz Hossain, as she talks about laparoscopic common bile duct exploration (LCBDE) with Drs. Maggie Bosley, Lucas Neff, and Byron Fernando Santos. Dr. Bosley is a graduating chief resident at Wake Forest and incoming MIS fellow at Washington University in St. Louis. Dr. Neff is an assistant professor of pediatric surgery with Wake Forest Baptist Health and Brenner’s Children’s Hospital. Dr. Santos is an assistant professor of surgery at Dartmouth-Hitchcock Medical Center. As a research resident at Northwestern University, he co-invented a LCBDE simulator that is used to train surgeons in these techniques. He is also a member of the SAGES Safe Cholecystectomy Task Force and has led numerous LCBDE courses. 

Join us for a discussion on LCBDE indications, implementation, techniques, and tips for incorporation into patient care. If you’re interested in learning more, check out the instructional video from these surgeons as well as some of their work on LCBDE:

Instructional Video:

https://behindtheknife.org/video-playlists/laparoscopic-common-bile-duct-tutorial-series/

Research Articles

·      Anterograde Balloon Sphincteroplasty as an Adjunct to Laparoscopic Common Bile Duct Exploration for the Acute Care Surgery: https://journals.lww.com/jtrauma/Citation/2022/03000/Antegrade_balloon_sphincteroplasty_as_an_adjunct.22.aspx

·      Choledocholithiasis – A New Clinical Pathway: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343507/

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. 

Clinical Challenges in Hernia Surgery: Specialization in Hernia and Abdominal Wall Surgery

Hernias are some of the most common problems treated by general surgeons. The field of abdominal wall surgery has rapidly evolved as a result of innovation and the development of new techniques. In this podcast, Drs. Charlotte Horne and Jenny Shao join Vahagn Nikolian to discuss their decision to pursue careers as abdominal wall specialists, the role that hernia surgeons play in modern day surgical programs, and the pathway to becoming a hernia surgeon. 
·       Dr. Charlotte Horne is an Assistant Professor of Surgery at Pennsylvania State University.
·       Dr. Jenny Shao is an Assistant Professor of Surgery at the University of Michigan.
·       Dr. Vahagn Nikolian is an Assistant Professor of Surgery at Oregon Health & Science University.

Recommended Reading:

Shulkin JM, Mellia JA, Patel V, Naga HI, Morris MP, Christopher A, Heniford BT, Fischer JP. Characterizing hernia centers in the United States: what defines a hernia center? Hernia. 2022 Feb;26(1):251-257. doi: 10.1007/s10029-021-02411-x. Epub 2021 Apr 19. PMID: 33871743.
Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012 Nov;204(5):709-16. doi: 10.1016/j.amjsurg.2012.02.008. Epub 2012 May 16. PMID: 22607741.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other Hernia episodes here: https://behindtheknife.org/podcast-category/hernia/

Clinical Challenges in Trauma Surgery: Renal Trauma

To operate or not to operate, to drain the urine leak or to not drain it, those are the questions. Join our Miami Trauma team including Drs. Urréchaga, Neeman, and Rattan- in their final episode together! – as they discuss how to navigate the ins and outs of renal trauma! 

Learning Objectives: 
·       Define the different renal injury grades and how to manage each,
·       Identify when to take the renal trauma patient to the operating room,
·       Discuss when to involve IR for urinary drainage or embolization.
·       Explain when and how to perform a nephrectomy.
·       Debate the treatment of penetrating zone two injuries- to explore or not explore?

Quick Hits:
1.     Most kidney injuries, the vast majority, can be non-operatively managed. 
2.     For pretty much all AAST grade of injury, the choice to go to the OR immediately lies in whether the patient is stable or unstable. 
3.     If there is a urinary leak seen on imaging, it can usually just be observed and followed with repeat imaging to determine the need for drainage, unless the injury is significant or if there is injury to the renal pelvis- then the patient will usually need a drainage procedure. 
4.     Consider IR in any stable patient found to have active extravasation, fistula, or pseudoaneurysm.
5.     In the case of an unstable patient, except very rare circumstances, you should be going to the OR 
6.     If there is another cause of instability, address that first. If you’re opening Gerota’s fascia, be prepared to commit to a nephrectomy. 
7.     In penetrating injury, the formal teaching is mandatory exploration of a renal hematoma. Real world experience shows that this isn’t always necessary- such as in tangential injuries or injuries to the periphery- on a case-by-case basis.

References
1.     Federico C, Moore Ernest E, Yoram K, Walter B, Aari L, Yosuke M, et al. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg 2019;14:54.
2.     Morey AF, Brandes S, Dugi DD 3rd et al: Urotrauma: AUA guideline. J Urol 2014, 192: 327. Published 2014; Amended 2017, 2020.
3.     Aziz HA, Bugaev N, Baltazar G, Brown Z, Haines K, Gupta S, Yeung L, Posluszny J, Como J, Freeman J, Kasotakis G. Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma. BMC Surg. 2023 Jan 27;23(1):22. doi: 10.1186/s12893-023-01914-x. PMID: 36707832; PMCID: PMC9881253.
4.     Petrone P, Perez-Calvo J, Brathwaite CEM, Islam S, Joseph DK. Traumatic kidney injuries: A systematic review and meta-analysis. Int J Surg. 2020 Feb;74:13-21. doi: 10.1016/j.ijsu.2019.12.013. Epub 2019 Dec 21. PMID: 31870753.

**Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other trauma surgery episodes here: https://behindtheknife.org/podcast-category/trauma/

Journal Review in Surgical Education: The OR Black Box

Have a grand idea for how to improve education and patient safety in surgery, but unsure how to make it a reality? Perhaps the OR Black Box can inspire you and set you on your path as an innovator. We are joined by Dr. Teodor Grantcharov, one of its creators. The OR Black Box is a system that collects, stores, and analyzes a large amount of data from the operating room beyond just surgical video, such as video and audio of the operating room and patient physiology data. Using the system for feedback through self-directed review, coaching, and integrated AI analysis has changed the way we can learn and teach in surgery, and may have implications for the future of evaluation and credentialing.

Learning Objectives

  1. Listeners will describe the value that accessible data review and analysis adds to surgical education.
  2. Listeners will describe how review of operative data could be utilized for more objective evaluation and credentialing, and how this can be used for continuous improvement.
  3. Listers will recognize common barriers to using new technology or process changes in surgery.
  4. Listeners will recognize the importance of a well-developed research question and its application to a clinical need when designing research or innovation in surgery and education.
  5. Listeners will appreciate the long and iterative process required to go from a research idea to implementation and impact on clinical outcomes.
  6. Listeners will organize their own ideas for research utilizing the advice offered in the episode.

References:

– Goldenberg MG, Jung J, Grantcharov TP. Using Data to Enhance Performance and Improve Quality and Safety in Surgery. JAMA Surg. 2017;152(10):972. doi:10.1001/jamasurg.2017.2888

– van Dalen ASHM, van Haperen M, Swinkels JA, Grantcharov TP, Schijven MP. Development of a Model for Video-Assisted Postoperative Team Debriefing. J Surg Res. 2021;257:625-635. doi:10.1016/j.jss.2020.07.065

**Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out other surgical education episodes here: https://behindtheknife.org/podcast-category/surgical-education/ 

The Society of Black Academic Surgeons with Dr. Edward Barksdale

Please join BTK’s Dr. Nina Clark and Dr. Shreya Gupta for a discussion with Dr. Edward Barksdale on the important and sensitive topic of the underrepresented in medicine.  

Society of Black Academic Surgeons: https://www.sbas.net/

References: 
Yeo HL, Abelson JS, Symer MM, Mao J, Michelassi F, Bell R, Sedrakyan A, Sosa JA. Association of Time to Attrition in Surgical Residency With Individual Resident and Programmatic Factors. JAMA Surg. 2018 Jun 1;153(6):511-517. doi: 10.1001/jamasurg.2017.6202. PMID: 29466536; PMCID: PMC5875388.

McFarling, U.L. ‘It was stolen from me’: Black doctors are forced out of training programs at far higher rates than white residents. STAT. 6/20/2022. Accessed online: 10/1/2022. https://www.statnews.com/2022/06/20/black-doctors-forced-out-of-training-programs-at-far-higher-rates-than-white-residents/

Haruno LS, Chen X, Metzger M, et al. Racial and Sex Disparities in Resident Attrition Among Surgical Subspecialties. JAMA Surg. Published online February 08, 2023. doi:10.1001/jamasurg.2022.7640

**Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other recent episodes here: https://behindtheknife.org/listen/

Clinical Challenges in Emergency General Surgery: Cirrhotic Patients

Please join Drs. Graham Skelhorne-Gross, Jordan Nantais and Ashlie Nadler from our Emergency General Surgery Team for a discussion on cirrhotic patients.  
Child-Pugh Score (https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality)
·      Bilirubin, albumin, INR, ascites, encephalopathy
·      Used to predict operative mortality based on cirrhosis severity
·      Mortality in EGS:
– Child-Pugh A: 10% electively and 22% emergently
– Child-Pugh B: 30% electively and 38% emergently
– Child-Pugh C: 80% electively and up to 100% emergently
Model for End Stage Liver Disease (MELD) (https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld?utm_source=site&utm_medium=link&utm_campaign=meld_12_and_older)
·      creatinine, bilirubin, INR, and sodium
·      MELD < 20 – 1% increase in mortality with each point increase
·      MELD > 20 – 2% increase in mortality with each point increase
Pre-operative Planning
·      Identification of cirrhosis with physical examination, bloodwork and imaging
·      Involvement of other medical services (internal medicine, hepatology, ICU) as needed
·      Cirrhosis optimization, if possible
·      Abdominal wall mapping
Unexpected Intraoperative Finding
  • Communicate unexpected findings to the operative team and think of additional adjuncts you may need such as additional ports, topical hemostatic agents or energy devices.
  • Think about why you are in the OR. If its an elective situation and can wait, consider bailing. If its emergent, you may have to do something more definitive.
  • Exposure may be a challenge, you may have to alter your typical approach including where the assistant grabs and retracts. Extra hands are helpful.
  • Bleeding can be a big deal. If possible, map out the abdominal wall ahead of time with cross-sectional imaging. Stay away from varices around the umbilicus or porta
Ventral Hernia + Cirrhosis
·      Ideally, control ascites pre-operatively, if you can’t consider leaving drains
·      Small (< 2cm) hernias close primarily
·      Larger (>2cm) hernias repair with mesh unless infected filed (controversial)
·      Minimally invasive repairs can be performed
Benign Biliary Disease + Cirrhosis
·      Incidence of gallstones is 4-5 times higher in cirrhotic patients
·      Prophylactic laparoscopic cholecystectomy (LC) generally not done
·      LC generally considered acceptable in CP A or B but not C (exceptions: HD instability, gangrenous cholecystitis, hemorrhagic cholecystitis)
·      Cholecystostomy and ERCP are safe

References: 

Bleszynski, M. et. Al. Acute care and emergency general surgery in patients with chronic liver disease: how can be optimize perioperative care? A review of the literature. 2018. World Journal of Emergency Surgery; 13:32

Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122:730–5.
Yeom SK, Lee CH, Cha SH, Park CM. Prediction of liver cirrhosis, using diagnostic imaging tools. World J Hepatol. 2015 Aug 18;7(17):2069-79. doi: 10.4254/wjh.v7.i17.2069. PMID: 26301049; PMCID: PMC4539400.
Jain D, Mahmood E, V-Bandres M, Feyssa E. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Ann Gastroenterol. 2018 May-Jun;31(3):330-337. doi: 10.20524/aog.2018.0249. Epub 2018 Mar 15. PMID: 29720858; PMCID: PMC5924855.

**Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other Emergency General Surgery episode here: https://behindtheknife.org/podcast-category/emergency-general-surgery/

Journal Review in Thoracic Surgery: Adjuvant Treatment in Esophageal and GEJ Cancer

In this episode, our team discusses the Checkmate 577 trial, the landmark paper which approved the use of nivolumab for adjuvant treatment of stage II & III esophageal & GE junction cancer. Listen as our team reviews the study population, methods and results of this trial & discusses its clinical application as well as potential areas of future research.

Learning Objectives:
-Review the staging and treatment of esophageal and GEJ cancer
-Discuss the population, methods, and results of the Checkmate 577 trial
-Understand the mechanism of action of nivolumab and the PD1 pathway
-Discuss the implications of the Checkmate 577 trial in clinical practice and areas of future research

Hosts:
Kelly Daus MD, Megan Lenihan MD, Peter White MD, and Brian Louie MD

Referenced Material
https://www.nejm.org/doi/full/10.1056/NEJMoa2032125
Kelly RJ, Ajani JA, Kuzdzal J, et al. Adjuvant nivolumab in resected esophageal or gastroesophageal junction cancer. N Engl J Med. 2021;384(13):1191-1203. doi:10.1056/NEJMoa2032125

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136921/
Han Y, Liu D, Li L. PD-1/PD-L1 pathway: current researches in cancer. Am J Cancer Res. 2020 Mar 1;10(3):727-742. PMID: 32266087; PMCID: PMC7136921.

Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed robotic general surgery procedures. If you are a general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs,  reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com for more information on how you could be compensated $500 per video submitted of each (up to $1000 per surgeon).

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other thoracic surgery episodes here https://behindtheknife.org/podcast-category/cardiothoracic/

The Latino Surgical Society with Dr. Minerva Romero-Arenas

Please join BTK education fellow, Nina Clark, MD (University of Washington) along with Elina Serrano, MD, MPH (University of Washington) and Minerva Romero Arenas, MD (Weill Cornell Medicine) for a discussion inspired by the experience of trainees who are underrepresented in medicine.  

Latino Surgical Society: https://www.latinosurgicalsociety.org/
Society of Black Academic Surgeons: https://www.sbas.net/

References: 
Yeo HL, Abelson JS, Symer MM, Mao J, Michelassi F, Bell R, Sedrakyan A, Sosa JA. Association of Time to Attrition in Surgical Residency With Individual Resident and Programmatic Factors. JAMA Surg. 2018 Jun 1;153(6):511-517. doi: 10.1001/jamasurg.2017.6202. PMID: 29466536; PMCID: PMC5875388.

McFarling, U.L. ‘It was stolen from me’: Black doctors are forced out of training programs at far higher rates than white residents. STAT. 6/20/2022. Accessed online: 10/1/2022. https://www.statnews.com/2022/06/20/black-doctors-forced-out-of-training-programs-at-far-higher-rates-than-white-residents/

Haruno LS, Chen X, Metzger M, et al. Racial and Sex Disparities in Resident Attrition Among Surgical Subspecialties. JAMA Surg. Published online February 08, 2023. doi:10.1001/jamasurg.2022.7640

**Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other recent episodes here: https://behindtheknife.org/listen/

Clinical Challenges in Endocrine Surgery: Adrenalectomy Guidelines Review

In this episode the Endocrine Surgery team at BTK goes over two cases to review the American Association of Endocrine Surgeons Guidelines for Adrenalectomy. 

Dr. Michael Yeh is a Professor of Surgery at UCLA and serves as Section Chief of the UCLA Endocrine Surgery program which he established. 

Dr. Masha Livhits is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department

Dr. James Wu is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department 

Dr. Na Eun Kim is an Endocrine Surgery Fellow at UCLA in his first year of fellowship

Dr. Rivfka Shenoy is a PGY-5 General Surgery Resident at UCLA who has completed two years of research 

Dr. Max Schumm is a PGY-5 General Surgery Resident at UCLA who has completed two years of research. He is a future endocrine surgeon. 

Important Papers 

Yip L, Duh QY, Wachtel H, Jimenez C, Sturgeon C, Lee C, Velázquez-Fernández D, Berber E, Hammer GD, Bancos I, Lee JA, Marko J, Morris-Wiseman LF, Hughes MS, Livhits MJ, Han MA, Smith PW, Wilhelm S, Asa SL, Fahey TJ 3rd, McKenzie TJ, Strong VE, Perrier ND. American Association of Endocrine Surgeons Guidelines for Adrenalectomy: Executive Summary. JAMA Surg. 2022 Oct 1;157(10):870-877. doi: 10.1001/jamasurg.2022.3544. PMID: 35976622; PMCID: PMC9386598.

Schumm M, Hu MY, Sant V, Kim J, Tseng CH, Sanz J, Raman S, Yu R, Livhits M. Automated extraction of incidental adrenal nodules from electronic health records. Surgery. 2023 Jan;173(1):52-58. doi: 10.1016/j.surg.2022.07.028. Epub 2022 Oct 4. PMID: 36207197.

M. Conall Dennedy, Anand K. Annamalai, Olivia Prankerd-Smith, Natalie Freeman, Kuhan Vengopal, Johann Graggaber, Olympia Koulouri, Andrew S. Powlson, Ashley Shaw, David J. Halsall, Mark Gurnell, Low DHEAS: A Sensitive and Specific Test for the Detection of Subclinical Hypercortisolism in Adrenal Incidentalomas, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 3, 1 March 2017, Pages 786–792, https://doi.org/10.1210/jc.2016-2718

Amar, L., Pacak, K., Steichen, O. et al. International consensus on initial screening and follow-up of asymptomatic SDHx mutation carriers. Nat Rev Endocrinol 17, 435–444 (2021). https://doi.org/10.1038/s41574-021-00492-3

**Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other endocrine episodes here: https://behindtheknife.org/podcast-category/endocrine/

Journal Review in Surgical Critical Care: Nutrition in the ICU – when, how, why

In this episode the Critical Care BTK Team tackles nutrition in the ICU. High-yield journal articles will be presented, discussed, and reviewed. ICU nutrition myths will be busted, and listeners will learn about enteral nutrition, parenteral nutrition and other ICU nutrition pearls.
References
1.         Casaer, M.P., et al., Early versus Late Parenteral Nutrition in Critically Ill Adults. New England Journal of Medicine, 2011. 365(6): p. 506-517.
2.         Compher, C., et al., Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition. Journal of Parenteral and Enteral Nutrition, 2022. 46(1): p. 12-41.
3.         McClave, S.A., et al., Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition, 2016. 40(2): p. 159-211.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other Surgical Critical Care episodes here: https://behindtheknife.org/podcast-category/surgical-critical-care/

Innovations in Surgery: Surgical Robotics

In the third episode of the “Innovations in Surgery” series, Behind the Knife’s surgery education fellow, Dan Scheese, sits down with Adam Sachs and Dr. Igor Belyansky to discuss the current state and future of surgical robotics. They discuss the start up of Vicarious Surgical and how they are working to improve the current state of surgical robotics with their innovative ideas. 

Link for the Vicarious Surgical website which includes a short video demonstration of their single port design: https://www. vicarioussurgical.com/

Adam Sachs is the CEO and Co-founder of Vicarious surgical, a surgical robotics company founded in 2014. As an MIT trained roboticist, Adam has combined his passion for robots with this passion for helping patients and enhancing the work environment for surgeons through the development of proprietary surgical robotics. 

Dr. Igor Belyanksy, an internationally-recognized expert in the field of abdominal wall reconstruction and complex laparoscopic and robotic hernia repair. Dr. Belyansky has earned his medical degree from Virginia Commonwealth University, completed his residency at MedStar Union Memorial Hospital, and completed a minimally invasive fellowship at Carolinas Medical Center. Dr. Belyanksy is currently the Medical Director of Anne Arundel Medical Center in Annapolis Maryland.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other Innovations in Surgery episodes here: https://behindtheknife.org/podcast-series/innovations-in-surgery/

Journal Review in Colorectal Surgery: Local Excision for Rectal Cancer

You have a patient who underwent local excision of a rectal cancer. Final pathology demonstrates a T2 lesion. What is the rate of local recurrence? Is excision alone sufficient? Should the patient undergo radical resection or should chemoradiation be offered? Tune in to find out!
Join Drs. Peter Marcello, Jonathan Abelson, Tess Aulet and special guest Dr. Jose Guillem MD, MPH, MBA as they discuss high yield papers discussing local excision for Rectal Cancer.

You may follow along with the slides mentioned in this episode here: https://behindtheknife.org/video/journal-review-in-colorectal-surgery-local-excision-for-rectal-cancer/

Learning Objectives
1. Describe the features that increase risk of lymph node involvement in early stage rectal cancer
2. Discuss the different options for management of early-stage rectal cancer
3. Describe patient related factors that favor local excision of rectal cancer

References:
Kidane B, Chadi SA, Kanters S, Colquhoun PH, Ott MC. Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis Colon Rectum. 2015 Jan;58(1):122-40. doi: 10.1097/DCR.0000000000000293. PMID: 25489704.

Garcia-Aguilar J, Renfro LA, Chow OS, Shi Q, Carrero XW, Lynn PB, Thomas CR Jr, Chan E, Cataldo PA, Marcet JE, Medich DS, Johnson CS, Oommen SC, Wolff BG, Pigazzi A, McNevin SM, Pons RK, Bleday R. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. 2015 Nov;16(15):1537-1546. doi: 10.1016/S1470-2045(15)00215-6. Epub 2015 Oct 22. PMID: 26474521; PMCID: PMC4984260.
Friel CM, Cromwell JW, Marra C, Madoff RD, Rothenberger DA, Garcia-Aguílar J. Salvage radical surgery after failed local excision for early rectal cancer. Dis Colon Rectum. 2002 Jul;45(7):875-9. doi: 10.1007/s10350-004-6320-z. PMID: 12130873.
Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum. 2002 Feb;45(2):200-6. doi: 10.1007/s10350-004-6147-7. PMID: 11852333.
O’Neill CH, Platz J, Moore JS, Callas PW, Cataldo PA. Transanal Endoscopic Microsurgery for Early Rectal Cancer: A Single-Center Experience. Dis Colon Rectum. 2017 Feb;60(2):152-160. doi: 10.1097/DCR.0000000000000764. PMID: 28059911.
 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other colorectal episodes here: https://behindtheknife.org/podcast-category/colorectal/

Doctor Cure Thyself: An Interview With Dr. David Fajgenbaum

DO NOT MISS THIS EPISODE! Need a little inspiration? Tune in for Dave’s story. Links from the show: 

Chasing My Cure: https://chasingmycure.com/ CDCN: https://cdcn.org/
Every Cure: https://everycure.org/
AMF: https://healgrief.org/actively-moving-forward/young-adult-grief/

David Fajgenbaum, MD, MBA, MSc, FCPP, is an Assistant Professor of Medicine in Translational Medicine & Human Genetics at the University of Pennsylvania, Founding Director of the Center for Cytokine Storm Treatment & Laboratory (CSTL), Associate Director, Patient Impact of the Penn Orphan Disease Center, and Co-Founder/President of the Castleman Disease Collaborative Network (CDCN) and co-founder of Every Cure. He is also the national bestselling author of ‘Chasing My Cure: A Doctor’s Race to Turn Hope Into Action’ and a patient battling idiopathic multicentric Castleman disease (iMCD). He is in his longest remission ever thanks to a precision treatment that he identified, which had never been used before for iMCD. He has also identified and/or advanced 9 other treatment approaches for iMCD and cancer. 

One of the youngest individuals ever appointed to the faculty at Penn Medicine and in the top 1 percent youngest awardees of an NIH R01 grant, Fajgenbaum has published scientific papers in high-impact journals such as the New England Journal of Medicine, Journal of Clinical Investigation, and Lancet, been recognized with awards such as the 2016 Atlas Award along with then Vice President Joe Biden, and profiled in a cover story by The New York Times as well as by Good Morning America, CNN, Forbes 30 Under 30, and the Today Show. An authority on cytokine storms and their treatment, Fajgenbaum currently leads over 20 translational research studies including the CORONA Project, which is the world’s largest effort to identify, track, and advance COVID-19 treatments. He also serves on the Board of Directors for the Reagan-Udall Foundation for the FDA, co-Chair of the Advisory Board for the CURE Drug Repurposing Collaboratory, and co-Chair of the Scientific Advisory Board for the CDCN. 

Dr. Fajgenbaum earned a BS in Human Sciences with Distinction from Georgetown University, where he was USA Today Academic All-USA First Team and a Quarterback on the Division I football team, a MSc in Public Health from the University of Oxford as the 2007 Joseph L. Allbritton Scholar, a MD from the Perelman School of Medicine at the University of Pennsylvania, where he was a 21st Century Gamble Scholar, and a MBA from The Wharton School, where he was awarded the Joseph Wharton Award, Core Value Leadership Award, Kissick Scholarship, Wharton Business Plan Competition Social Impact Prize, Eilers Health Care Management Award, Mandel Fellowship, and Commencement Speaker.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out our other recent episodes here: https://behindtheknife.org/listen/

Journal Review in Surgical Education: Unions and Wellness

How do we actually improve wellness?  How do surgery trainees advocate for themselves as both learners and employees?  In this final surgical education episode with Matt Chia MD MS and Karl Bilimoria MD MS, we review two articles discussing unions and wellness in surgical training.  We’re joined by Meg Smith MD MS, Brian Brajcich MD MS, and Darci Foote MD MS to tackle this difficult topic and open the discussion for what’s next in surgical education.

Learning Objectives:

·       Identify potential benefits and limitations of unionization in surgery training

·       Describe strategies used by program leadership to improve wellness in surgery

References:

National Evaluation of the Association Between Resident Labor Union Participation and Surgical Resident Well-being https://doi.org/10.1001/jamanetworkopen.2021.23412 

How Program Directors Understand General Surgery Resident Wellness – https://doi.org/10.1016/j.jsurg.2022.07.022 

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other surgical education episodes here: https://behindtheknife.org/podcast-category/surgical-education/

Journal Review in Hepatobiliary Surgery: Intraductal Papillary Mucinous Neoplasm IPMN

Join the Behind the Knife HPB team as we dive deeper into the complex world of IPMNs with a journal article review of a recent JAMA Surgery publication and the first author of the article!

Learning Objectives: In this episode, we discuss the article, “Progression vs Cyst Stability of Branch-Duct Intraductal Papillary Mucinous Neoplasms After Observation and Surgery.”  This article describes a multicenter retrospective study of centers in Italy, Korea, Singapore, and the US that specifically assessed what dynamic variables are associated with malignant progression in pathologically proven IMPNs under at least a year of initial surveillance. 

Hosts:
Timothy Vreeland, MD, FACS (@vreelant) is an Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at Brooke Army Medical Center

Daniel Nelson, DO, FACS (@DWNelsonHPB) is an Associate Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at William Beaumont Army Medical Center

Connor Chick, MD (@connor_chick) is a PGY-6 General Surgery resident at Brooke Army Medical Center

Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a PGY-5 General Surgery resident at Brooke Army Medical Center

Beth Carpenter, MD (@elizcarpenter16) is a PGY-4 General Surgery resident at Brooke Army Medical Center

Guest: 
Dr. Giovanni Marchegiani is a pancreas surgeon within the department of general and pancreatic surgery at the University of Verona in Italy.  His research interests include exocrine and cystic neoplasms of the pancreas.  He is the first author of the study discussed in the episode in addition to over 100 additional scientific, peer-reviewed articles.

Journal Article:
1.     Marchegiani G, Pollini T, Andrianello S, et al. Progression vs Cyst Stability of Branch-Duct Intraductal Papillary Mucinous Neoplasms After Observation and Surgery. JAMA Surg. 2021;156(7):654–661. doi:10.1001/jamasurg.2021.1802

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other HPB episodes here: https://behindtheknife.org/podcast-category/hepatobiliary/

BTK Vascular Surgery Oral Board Review – Sample Episode 2 – Lower Extremity Trauma

Our Vascular Surgery Oral Board Audio Review includes 72 high-yield scenarios that cover the majority of the VSCORE topics designed for Vascular Surgeons by Vascular Surgeons.
Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as vascular surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test.

Learn more about the full set of 72 scenarios here: https://behindtheknife.org/premium/vascular-surgery-oral-review/

Our Vascular Surgery Oral Board Book is available on Amazon here: https://www.amazon.com/Vascular-Surgery-Oral-Board-Review/dp/0578382296/ref=sr_1_4?crid=VUNDNTCJOH8M&keywords=behind+the+knife&qid=1675087641&sprefix=behind+the+knif%2Caps%2C82&sr=8-4&ufe=app_do%3Aamzn1.fos.f5122f16-c3e8-4386-bf32-63e904010ad0

Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

BTK Vascular Surgery Oral Board Review – Sample Episode 1 – Fem and Pop Aneurysm

Our Vascular Surgery Oral Board Audio Review includes 72 high-yield scenarios that cover the majority of the VSCORE topics designed for Vascular Surgeons by Vascular Surgeons.

Scenarios are 5 to 7 minutes long and include a variety of tactics and styles. If you are able to achieve this level of performance in your preparation you are sure to pass the oral exam with flying colors. The second part introduces high-yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy-to-understand teaching that covers the most confusing topics we face as vascular surgeons. We are confident you will find this unique, dual format approach a highly effective way to prepare for the test.

Learn more about the full set of 72 scenarios here: https://behindtheknife.org/premium/vascular-surgery-oral-review/

Our Vascular Surgery Oral Board Book is available on Amazon here: https://www.amazon.com/Vascular-Surgery-Oral-Board-Review/dp/0578382296/ref=sr_1_4?crid=VUNDNTCJOH8M&keywords=behind+the+knife&qid=1675087641&sprefix=behind+the+knif%2Caps%2C82&sr=8-4&ufe=app_do%3Aamzn1.fos.f5122f16-c3e8-4386-bf32-63e904010ad0

Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

Clinical Challenges in Minimally Invasive Surgery: Ergonomics

Surgery is a contact sport and can cause injuries that prevent us from taking care of our patients and even threaten our careers. Join Drs. Mike Weykamp, Nicole White, Nick Cetrulo, and Andrew Wright for a discussion on the ergonomic challenges of open, laparoscopic, and robotic surgery as well as some tips, tricks, and resources on how to protect yourself and your practice. 

*We apologize for some distracting background noise throughout the episode.*

Referenced Articles & Websites: 
1.     Wells, A. C., Kjellman, M., Harper, S. J., Forsman, M., & Hallbeck, M. S. (2019). Operating hurts: a study of EAES surgeons. Surgical endoscopy, 33, 933-940.
2.     Davis, W. T., Fletcher, S. A., & Guillamondegui, O. D. (2014). Musculoskeletal occupational injury among surgeons: effects for patients, providers, and institutions. Journal of surgical research, 189(2), 207-212.
3.     Wright, A.S. Ergonomic Injury and Surgery: The Hidden Epidemic.  Harkins Symposium at The University of Washington. October 21, 2022. https://www.youtube.com/watch?v=o1G1qGj4WaA 
4.     The Society of Surgical Ergonomics. https://www.societyofsurgicalergonomics.org/ 
5.     OR Stretch. https://www.mayo.edu/research/labs/human-factors-engineering/or-stretch/or-stretch-videos 

 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other MIS episodes here: https://behindtheknife.org/podcast-category/minimally-invasive/

Journal Review in Vascular Surgery: Introduction to Endovascular Surgery – A Primer

Vascular surgery is full of awesome anatomy and big open vessel exposures, but endovascular surgery is here to stay and can be hard to get into, particularly as a learner. The basics of endovascular surgery share very little with the basics of open surgery and getting up to speed can be a big challenge. This episode is an introduction to all things endovascular surgery, from wires, catheters and sheaths to balloons and stents. Take a listen to get up to speed quickly in prep for an upcoming vascular rotation and skip the pain of trying to follow your attendings words so you can instead pay attention to the actual case.

Dr. Frank Davis is an Assistant Professor of Vascular Surgery at the University of Michigan.

Dr. Craig Brown is a PGY-7 in the General Surgery program and the upcoming 2023 vascular surgery fellow at the University of Michigan.

Check out the accompanying video for this episode available here: https://behindtheknife.org/video-playlists/podcast-clips/

Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed robotic general surgery procedures. If you are a general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs,  reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com for more information on how you could be compensated $500 per video submitted of each (up to $1000 per surgeon).

To check out our Vascular Surgery Oral Board Audio Review and Book, please visit: https://behindtheknife.org/premium/

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Dominate the Match – Episode 4: “Rank and Match”

Interview season is over! There’s just one last hurdle in this residency application process to overcome- ranking and matching! Join our education fellow, Dr. Jessica Millar, and Dr. Charles Friel as they pull back the curtain on the ranking process and discuss how tooptimize your success in the match! 

Guest:
Charles Friel, MD- Professor of Colorectal Surgery, Surgical Director – Digestive Center of Excellence, Chief – Section of Colon & Rectal Surgery, and General Surgery Residency Program Director- University of Virginia, Charlottesville, VA

“How the NRMP Matching Algorithm Works”: https://www.youtube.com/watch?v=kvgfgGmemdA&list=PLr0LH_NifZSpvQTwTqXVYn9jXfUKOTFN6&index=11

Important Dates 
1.     Ranking opens 2/1 at 12PM 
2.     Rank lists are due 3/1 at 9PM 
3.     Match status available 3/13 at 10AM  
4.     Match day results available 3/17 at 12PM EST

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out the rest of our “Dominate the Match Series” here: https://behindtheknife.org/podcast-series/medical-student-and-intern-survival-guide/

Journal Review in Trauma Surgery: Blood Transfusions

In this episode, our team discusses the recent paper from JAMA Surgery Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers. Join us as we explore some of the history of blood transfusions, how we got to where we are today, and the role whole blood transfusion may play going forward

Hosts: 
Elliott R. Haut, MD, PhD, a senior, nationally recognized name in trauma and acute care surgery at Johns Hopkins University. Dr. Haut is a past president of The Eastern Association for the Surgery of Trauma (EAST) and editor-in-chief of Trauma Surgery and Acute Care Open.

Marcie Feinman, MD, MEHP, the current program director of General Surgery Residency at Sinai Hospital of Baltimore and editorial board member of SCORE. She received her Masters in Education in the Health Professions from Johns Hopkins. 

David Sigmon, MD, MMEd, a PGY-7 resident at the University of Illinois at Chicago who will be a fellow at Lincoln Medical Center in the Bronx next year. He did two years of research in surgical education at the University of Pennsylvania where he also received his Master’s in Medical Education. 

LITERATURE

  1. Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV. Association of whole blood with survival among patients presenting with severe hemorrhage in US and Canadian adult civilian trauma centers. JAMA Surg. Published online January 18, 2023.
     https://pubmed.ncbi.nlm.nih.gov/36652255/
  2. Sperry JL, Guyette FX, Brown JB, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315-326.
    https://pubmed.ncbi.nlm.nih.gov/30044935/
     
  3. Moore HB, Moore EE, Chapman MP, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet. 2018;392(10144):283-291.
    https://pubmed.ncbi.nlm.nih.gov/30032977/
     
  4. Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):605-617.
    https://pubmed.ncbi.nlm.nih.gov/28225743/
     
  5. Howley IW, Haut ER, Jacobs L, Morrison JJ, Scalea TM. Is thromboelastography (Teg)-based resuscitation better than empirical 1:1 transfusion? Trauma Surg Acute Care Open. 2018;3(1):e000140.
    https://pubmed.ncbi.nlm.nih.gov/29766129/
     
  6. Guyette FX, Brown JB, Zenati MS, et al. Tranexamic acid during prehospital transport in patients at risk for hemorrhage after injury: a double-blind, placebo-controlled, randomized clinical trial. JAMA Surg. 2020;156(1):11-20.
    https://pubmed.ncbi.nlm.nih.gov/33016996/
     
  7. Smart BJ, Haring RS, Zogg CK, et al. A faculty-student mentoring program to enhance collaboration in public health research in surgery. JAMA Surg. 2017;152(3):306-308.
    https://pubmed.ncbi.nlm.nih.gov/27973649/
     
  8. National Academies of Sciences E. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury.; 2016.
    https://nap.nationalacademies.org/catalog/23511/a-national-trauma-care-system-integrating-military-and-civilian-trauma
     
  9. Braverman MA, Smith A, Pokorny D, et al. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion. 2021;61 Suppl 1:S15-S21.
     https://pubmed.ncbi.nlm.nih.gov/34269467/

**Specialty team application link – https://forms.gle/DwrRcMYDaP3a3LaQA Please email hello@behindtheknife.org with any questions.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

If you liked this episode, check out other trauma episodes here: https://behindtheknife.org/podcast-category/trauma/

The King and Queen of Medical Comedy: Up Close and Personal with Dr. and Lady Glaucomflecken

Join Patrick Georgoff and Kevin Kniery for a special conversation with the king and queen of medical comedy Dr. Will Flanary, aka Dr. Glaucomflecken (@drglaucomflecken), and Kristin Flanary, aka Lady Glaucomflecken (@Lglaucomflecken).

Will is a practicing ophthalmologist and social media personality with over 4 million followers. During his 3rd year of medical school, he was diagnosed with testicular cancer, and he began using humor as a coping mechanism. Following a second bout with cancer three years into his medical career, he created a Twitter account under the pseudonym “Dr. Glaucomflecken”— because it is arguably the funniest word in ophthalmology. A cardiac event and near-death experience in 2020 only fueled his creativity. Kristin is formally trained in cognitive neuroscience and social psychology and now works in marketing and communications. Kristin is best known internationally as her social media alter ego, “Lady Glaucomflecken,” where she shares stories from her unique perspective of the healthcare system. She has been a patient, “married to medicine” through the entire medical training journey and beyond, a lay responder and CPR provider to her husband, and a caregiver and “co-survivor” of his two cancer occurrences and a sudden cardiac arrest. And, if that’s not enough, they also have a brand-new podcast called Knock, Knock – Hi! where they discuss quirky and unexpectedly hilarious medical stories.  Check out their website here: https://glaucomflecken.com/

**Specialty team application link – https://forms.gle/DwrRcMYDaP3a3LaQA Please email hello@behindtheknife.org with any questions.

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our library of episodes here: https://behindtheknife.org/listen/

EAST Papers That Should Change Your Practice

Did you miss this year’s Eastern Association for the Surgery of Trauma meeting?  Don’t sweat it!  Behind the Knife has got you covered.  In this episode we discuss “Scientific Papers that Should Change Your Practice” with EAST manuscript and literature committee members Drs. Laura Brown (@laurarbrownMD), Brittany Bankhead (@bbankheadMD), and Julia Coleman (@juliacolemanMD).  

Universal blunt cerebrovascular screening?  Early renal replacement therapy?  Artificial intelligence in emergency general surgery?  This episode is PACKED with high-yield material.  

To learn more about all the good things happening at EAST visit www.east.org. 

Papers discussed: 
1.     Do not forget the platelets: The independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients (https://pubmed.ncbi.nlm.nih.gov/35313325/)
2.     The 35-mm rule to guide pneumothorax management: Increases appropriate observation and decreases unnecessary chest tubes (https://pubmed.ncbi.nlm.nih.gov/35125448/)
3.     Timing of thromboprophylaxis in patients with blunt abdominal solid organ injuries undergoing nonoperative management (https://pubmed.ncbi.nlm.nih.gov/33048907/)
4.     Universal screening for blunt cerebrovascular injury (https://pubmed.ncbi.nlm.nih.gov/33502144/)
5.     A three-step support strategy for relatives of patients during in the intensive care unit: a cluster randomized trial (https://pubmed.ncbi.nlm.nih.gov/35065008/)
6.     Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest (https://pubmed.ncbi.nlm.nih.gov/34133859/)
7.     Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury (https://pubmed.ncbi.nlm.nih.gov/32668114/)
8.     Disparities in Spatial Access to Emergency Surgical Services in the US (https://pubmed.ncbi.nlm.nih.gov/36239953/)
9.     Validation of the AI-based Predictive Optimal Trees in Emergency Surgery Risk (POTTER) Calculator in Patients 65 Years and Older (https://pubmed.ncbi.nlm.nih.gov/33378309/)
10.  Accuracy of Risk Estimation for Surgeons Versus Risk Calculators in Emergency General Surgery (https://pubmed.ncbi.nlm.nih.gov/35594615/)

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Journal Review in Pediatric Surgery: Hirschsprung Disease

Please join Drs. Brian Gray, Amanda Jensen, and Manisha Bhatia from Indiana University as they discuss Hirschsprung disease in regard to variability of the transition zone and surgical operative and pathologic diagnosis reporting in pediatric surgery.
Journal Article links: 
Veras LV, Arnold M, Avansino JR, Bove K, Cowles RA, Durham MM, et al. Guidelines for synoptic reporting of surgery and pathology in Hirschsprung disease. J Pediatr Surg 2019;54(10):2017-23.
https://pubmed.ncbi.nlm.nih.gov/30935730/
Thakkar HS, Blackburn S, Curry J, De Coppi P, Giuliani S, Sebire N, et al. Variability of the transition zone length in Hirschsprung disease. J Pediatr Surg 2020;55(1):63-6.
https://pubmed.ncbi.nlm.nih.gov/31706615/
Coyle D, O’Donnell AM, Tomuschat C, Gillick J, Puri P. The Extent of the Transition Zone in Hirschsprung Disease. J Pediatr Surg 2019;54(11):2318-24.
https://pubmed.ncbi.nlm.nih.gov/31079866/

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Clinical Challenges in Surgical Oncology: Intrahepatic Cholangiocarcinoma – Hope in the Face of Nihilism

Join the Surgical Oncology team from UTSouthwestern and the University of Miami as they tackle a case of intrahepatic cholangiocarcinoma along with the data guiding current treatment paradigms. Listen in as they also review recent clinical trials changing the options available for patients with this dismal biliary tract cancer.
Learning Objectives: 
In this episode, we review the workup and diagnostic approach to intrahepatic cholangiocarcinoma with emphasis on the role and benefits of biopsy, lymphadenectomy, operative approach, and the current treatment strategies involving chemotherapy, immunotherapy, and targeted therapies against actionable mutations.
Hosts: 
Adam Yopp, MD, FACS (@AdamYopp) is an Associate Professor of Surgery at the UT Southwestern Medical Center and is Chief of the Division of Surgical Oncology. He also serves as Surgical Director of the Liver Tumor Program.
Caitlin Hester, MD (@CaitlinAHester) is a recent graduate of the MD Anderson Complex General Surgical Oncology fellowship and is now a new faculty member in the Division of Surgical Oncology within the Sylvester Cancer Center at the University of Miami where she specializes in surgery for cancers of the liver, pancreas, and other gastrointestinal sites. 
Gilbert Murimwa, MD (@GilbertZMurimwa) is a PGY-4 Research Fellow and General Surgery Resident at the UT Southwestern Medical Center. He is studying the pancreatic tumor microenvironment and targeted therapies in the lab of Rolf Brekken within the Hamon Center for Therapeutic Oncology Research.

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Journal Review in Bariatric Surgery: New ASMBS and IFSO Indications for Metabolic and Bariatric Surgery

Who is a candidate for metabolic and bariatric surgery and what has changed in the past 30 years? Find out in this review!

Journal articles:
Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 5 Year Outcomes. https://pubmed.ncbi.nlm.nih.gov/28199805/.

Association of Metabolic Surgery with Major Adverse Cardiovascular Outcomes in Patients with Type 2 Diabetes and Obesity. https://pubmed.ncbi.nlm.nih.gov/31475297/.

Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. https://pubmed.ncbi.nlm.nih.gov/26544725/.

2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery. https://pubmed.ncbi.nlm.nih.gov/36336720/.

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Clinical Challenges in Colorectal Surgery: Rectal GIST

You are faced with a patient complaining of pelvic fullness. On DRE, you feel a submucosal bulge without palpating a tumour in the lumen. A CT scan confirms a pelvic mass. The biopsy reveals a spindle cell type gastrointestinal stromal tumour (GIST) positive for CD117. 
Join Dr. Carole Richard, Dr. François Dagbert and Dr. Maher Al Khaldi in their conversation about the diagnosis and management of rectal GIST. 
Learning objectives 
–       To explain the origin of rectal GISTs
–       To recognize the prognostic factors associated with rectal GISTs
–       To understand the management of rectal GISTs in the era of Imatinib 
–       To list the surgical approaches for rectal GIST resection

*Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed robotic general surgery procedures. If you are a general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs,  reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com for more information on how you could be compensated $500 per video submitted of each (up to $1000 per surgeon).

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Journal Review in Transplant Surgery: Normothermic Machine Perfusion

In this episode, our transplant team will discuss an article that reviews normothermic machine perfusion including how it has evolved over the years, current benefits and challenges, as well as future directions. 
Learning objectives:
·      Understand the current role of machine perfusion in renal transplantation
·      Describe historical and current limitations of machine perfusion for abdominal organ transplantation
·      Review the benefits of improved and expanded preservation techniques

References:
1.     Hamelink, T. L., Ogurlu, B., de Beule, J., Lantinga, V. A., Pool, M. B. F., Venema, L. H., Leuvenink, H. G. D., Jochmans, I., & Moers, C. (2022). Renal Normothermic Machine Perfusion: The Road Toward Clinical Implementation of a Promising Pretransplant Organ Assessment Tool. In Transplantation (Vol. 106, Issue 2). https://doi.org/10.1097/TP.0000000000003817

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BTK ABSITE 2023 – DO NOT OPEN UNTIL MORNING OF ABSITE

Behind the Knife ABSITE 2023 – high yield learning to help you DOMINATE the exam.

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BTK ABSITE 2023 – Urology

Behind the Knife ABSITE 2023 – high yield learning to help you DOMINATE the exam.

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BTK ABSITE 2023 – Breast

Behind the Knife ABSITE 2023 – high yield learning to help you DOMINATE the exam.

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BTK ABSITE 2023 – ENT

Behind the Knife ABSITE 2023 – high yield learning to help you DOMINATE the exam.

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BTK ABSITE 2023 – Biostatistics

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BTK ABSITE 2023 – Anesthesia

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BTK ABSITE 2023 – Transplant

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BTK ABSITE 2023 – Pediatric Surgery

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BTK ABSITE 2023 – Thoracic

Behind the Knife ABSITE 2023 – high yield learning to help you DOMINATE the exam.

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BTK ABSITE 2023 – Hernias

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BTK ABSITE 2023 – Critical Care Part 2 with Dr. Matthew Martin

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BTK ABSITE 2023 – Critical Care Part 1 with Dr. Matthew Martin

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BTK ABSITE 2023 – Trauma Part 2 with Dr. Matthew Martin

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BTK ABSITE 2023 – Trauma Part I with Dr. Matthew Martin

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Clinical Challenges in Surgical Palliative Care: Non-Beneficial Surgery (and How to Avoid it) and Care of the Imminently Dying Patient

Welcome to the fifth of a six-part series focused on the integration of palliative care into the practice of surgery.   In this episode, we discuss nonbeneficial surgery (and how best to avoid it) as well as care of the imminently dying patient.

Nonbeneficial surgery is best defined as surgery that fails to meet the goals of the patient.   As our surgical patients become older and more medically complex, we must be aware of the factors which lead to nonbeneficial surgery – including patient, surrogate, system, and surgeon factors – and how best to approach each of these to avoid causing harm to our patients.  Nonbeneficial surgery not only causes harm to the patient, but can also cause harm to the surgical team, in the form of moral distress/injury.  Focusing on patients’ goals of care can help us to avoid nonbeneficial surgery.

One of the benefits of integrating palliative medicine into the practice of surgery is that there is never “nothing left to do.”  By learning how to recognize and then care for the imminently dying patient, as well as by having a basic understanding of the Medicare hospice benefit, we can support and care for the patient (and the family) beyond the operating room. 

Non-Beneficial Surgery:

Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution.
https://pubmed.ncbi.nlm.nih.gov/24866541/

Surgeons’ perspectives on avoiding nonbeneficial treatments in seriously ill older patients with surgical emergencies: a qualitative study.
https://pubmed.ncbi.nlm.nih.gov/27105058/

The association between factors promoting beneficial surgery and moral distress: a national survey of surgeons.
https://pubmed.ncbi.nlm.nih.gov/33214444/

The Imminently Dying Patient and Hospice:

Fast Fact #3:  Syndrome of Imminent Death
https://www.mypcnow.org/fast-fact/syndrome-of-imminent-death/

Fast Fact #82:  Medicare Hospice Benefit – Part 1: Eligibility and Treatment
https://www.mypcnow.org/wp-content/uploads/2019/01/FF-82-Medicare-Hospice.-1-3rd-Ed-1.pdf

Fast Fact #87:  Medicare Hospice Benefit – Part 2: Places of Care and Funding 
https://www.mypcnow.org/wp-content/uploads/2019/01/FF-87-Medicare-Hospic-2-4th-Ed.pdf

Fast Fact #140:  Medicare Hospice Benefit – Levels of Hospice Care
https://www.mypcnow.org/fast-fact/medicare-hospice-benefits-levels-of-hospice-care/

Dr. Red Hoffman (@redmdnd) is an acute care surgeon and associate hospice medical director in Asheville, North Carolina, host of the Surgical Palliative Care Podcast (@surgpallcare) and co-founder of the recently launched Surgical Palliative Care Society (www.spcsociety.org). 

Dr. Zara Cooper (@zaracMD) is an acute care surgeon at Brigham and Women’s Hospital where she serves as Kessler Director for the Center of Surgery and Public Health (@csph_bwh).  She is a Professor of Surgery at Harvard Medical School, associate faculty at Adriane Labs, and adjunct faculty at the Marcus Institute for Aging Research.  

Dr. Amanda Stastny (@manda_plez) is a PGY-2 in the General Surgery program at Mountain Area Health Education Center (MAHEC) in Asheville, NC.

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