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Please join Drs. Brian Gray, Amanda Jensen and Manisha Bhatia from Indiana University as they discuss neuroblastoma management in pediatric surgery.

Journal Article links: 
Croteau N, Nuchtern J, LaQuaglia MP. Management of Neuroblastoma in Pediatric Patients. Surg Oncol Clin N Am 2021;30(2):291-304.
Madonna MB, Newman E. Handbook for Children with Neuroblastoma. Updated Spring 2018. Cancer Committee American Pediatric Surgical Association. 2018. https://www.pedsurglibrary.com/apsa/ub?cmd=repview&type=682-76&name=4_1884004_PDF
Newman EA, Abdessalam S, Aldrink JH, Austin M, Heaton TE, Bruny J, et al. Update on neuroblastoma. J Pediatr Surg 2019;54(3):383-9.
Nuchtern JG, London WB, Barnewolt CE, Naranjo A, McGrady PW, Geiger JD, et al. A prospective study of expectant observation as primary therapy for neuroblastoma in young infants: a Children’s Oncology Group study. Ann Surg 2012;256(4):573-80.
https://pubmed.ncbi.nlm.nih.gov/22964741/

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You are faced with a young patient with low rectal cancer who is a complete responder to neoadjuvant chemoradiotherapy. He asks if he should undergo surgical resection despite the absence of visible tumour. How do you approach such a question? 

Join Dr. Carole Richard, Dr. François Dagbert and Dr. Maher Al Khaldi in their conversation about the Watch and Wait strategy for rectal cancer, also known as the Organ Preservation strategy. 

Learning objectives 

–       To understand the rationale for Watch and Wait Strategy and the proportion of patients who become complete clinical responders. 
–       To explain how patients under the Watch and Wait Strategy protocol should be followed up and when to consider a patient a clinical nonresponder.
–       To understand the inclusion criteria for patients in the Watch and Wait Strategy

References

In order throughout the episode [1–3]:

1. Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U, Sousa AHS e, et al. Operative Versus Nonoperative Treatment for Stage 0 Distal Rectal Cancer Following Chemoradiation Therapy. Transactions Meet Am Surg Assoc. 2004;122(NA;):309–16.
2. Valk MJM van der, Hilling DE, Bastiaannet E, Kranenbarg EM-K, Beets GL, Figueiredo NL, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet. 2018;391(10139):2537–45.

3. Fernandez LM, Julião GPS, Figueiredo NL, Beets GL, Valk MJM van der, Bahadoer RR, et al. Conditional recurrence-free survival of clinical complete responders managed by watch and wait after neoadjuvant chemoradiotherapy for rectal cancer in the International Watch & Wait Database: a retrospective, international, multicentre registry study. Lancet Oncol. 2021;22(1):43–50.

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Marginal ulcers are a common cause of abdominal pain following Roux-en-Y gastric bypass. Ever wonder how bariatric surgeons triage abdominal pain in post-bariatric surgery patients? A simplified approach to the work-up of these patients as well as the long-term management of marginal ulcers is included in this episode from your bariatric surgery team at UNMC!

Journal Articles discussed:
1.     Opened Proton Pump Inhibitor Capsules Reduce Time to Healing Compared with Intact Capsules for Marginal Ulceration following Roux-en-Y Gastric Bypass: https://pubmed.ncbi.nlm.nih.gov/27773764/
2.     Thoracoscopic Truncal Vagotomy versus Surgical Revision of the Gastrojejunal Anastomosis for Recalcitrant Marginal Ulcers: https://pubmed.ncbi.nlm.nih.gov/30132208/

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Behind the Knife ABSITE 2022 – high yield learning to help you DOMINATE the exam.

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*Please note that we apologize for the static in this episode*

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Don’t forget to check out our ABSITE Podcast Companion Book available on Amazon: https://www.amazon.com/Behind-Knife-ABSITE-Podcast-Companion/dp/0578802767/ref=sr_1_2?keywords=behind+the+knife+podcast&qid=1639489872&sr=8-2

*Please note that we apologize for the static in this episode*

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Preoperative Optimization

Recurrences and complications following abdominal wall reconstruction and hernia repair are common challenges for the general surgery. In this episode, the Hernia and Abdominal Wall Reconstruction team discusses evidence-based approaches to preoperative optimization and prehabilitation.  We review patient modifiable risk factors and multi-disciplinary strategies for risk, complication, and recurrence reduction.
·       Dr. Vahagn Nikolian is an Assistant Professor of Surgery at Oregon Health & Science University, focused on abdominal wall reconstruction and hernia repair. 
·       Dr. Sean Orenstein is an Associate Professor of Surgery at Oregon Health & Science University, focused on abdominal wall reconstruction and hernia repair.
·       Dr. Emaad Iqbal is a resident in General Surgery at Columbia University Medical Center. 
·       Dr. Shahrose Rahman is a resident in General Surgery at Oregon Health & Science University. 

Seminal Papers in Preoperative Optimization
Preoperative Optimization by Orenstein and Martindale: https://pubmed.ncbi.nlm.nih.gov/30138281/
Impact of smoking cessation on wound healing: https://pubmed.ncbi.nlm.nih.gov/22508785/
Prehabilitation in abdominal wall reconstruction: https://pubmed.ncbi.nlm.nih.gov/30138261/

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Why should a surgeon care about breast cancer chemotherapy trials? Join Drs. Michael Alvarado, Rita Mukhtar, and Alexa Glencer as they discuss the benefits of neoadjuvant chemotherapy over upfront surgery and the role of adjuvant chemotherapy for select patients who harbor residual disease at the time of surgery.

Learning objectives:
– Understand the benefits conferred by neoadjuvant chemotherapy compared to upfront surgery in certain patients with breast cancer
– Learn about the study design and results of the CREATE-X phase 3 randomized controlled trial comparing adjuvant capecitabine to standard therapy in patients with HER2 negative invasive breast cancer with residual disease following cytotoxic neoadjuvant chemotherapy
– Describe the specific benefit of adjuvant capecitabine for triple negative breast cancer patients and discuss its evolving role with recent FDA approval of neoadjuvant pembrolizumab in this group
– Learn about the study design and results of the KATHERINE phase 3 randomized controlled trial comparing adjuvant T-DM1 to trastuzumab in patients with HER2+ invasive breast cancer with residual disease following cytotoxic and HER2-targeted neoadjuvant chemotherapy

Journal article links:
KATHERINE: https://www.nejm.org/doi/full/10.1056/NEJMoa1814017

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Has anyone else ever felt the anxiety of hearing the EMS radio call in a pregnant trauma patient, knowing you will soon be getting two patients in one? How do we prioritize our assessment, diagnostic work up, and treatment options for our patient when we have a second patient growing in her uterus?  Join our Miami Trauma team including Drs. Urréchaga, Neeman, and Rattan as they discuss how to navigate the physiologic changes and management considerations for the pregnant trauma patient! 

Learning Objectives: 
– Understand the physiology of the pregnant patient and how it changes how we clinically assess them in the trauma bay
– Emphasize the basics of the primary and secondary assessment in the pregnant patient 
– Identify when radiology adjuncts are appropriate
– Identify laboratory and diagnostic adjuncts that are unique to the pregnant patient’s work up
– Discuss treatment options for mom and fetus depending on clinical status

Quick Hits:
1. Sick mom before sick baby – stick to basics and treat mom like any other trauma patient
2. Misuse of seatbelts are an important risk factor for morbidity and mortality in pregnant patients. The lap belt must lie below the uterus and shoulder strap should lie between the breasts.
3. Injured pregnant women should be screened for intimate partner violence.
4. Despite changes in pregnant patient physiology, they can still present with compensated shock. Always have a high index of suspicion when interpreting vital signs and remember to offload patient to the left in order to decompress the IVC. 
5. For fetal viability: get FHT when mother’s condition allows. Remember- Fetal distress could be the first sign of maternal hypovolemia
6. NEVER withhold indicated imaging just to avoid radiation in a pregnant patient. Try shielding the uterus when possible, but always proceed with diagnostic imaging when necessary.
7. One more time- sick mom = sick baby!

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Welcome to the first Surgical Palliative Care Journal Club, the second of a six-part series focused on the integration of palliative care into the practice of surgery.  Join us as we discuss the first study of how to best integrate palliative medicine principles into the care of trauma ICU patients.  We then tackle the question:  Why are surgeons often unwilling to discontinue life-sustaining treatments in the post-operative period?   We discuss a 2013 study about “surgical buy-in” and review alternatives to making “informal contracts” with patients before surgery.  

References:
Mosenthal AC, Murphy PA, Barker LK, et al. Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma. 2008;64(6):1587-1593. doi:10.1097/TA.0b013e318174f112.

Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ. Surgeons expect patients to buy-in to post-operative life support preoperatively: results of a national survey. Crit Care Med. 2013;41(1):1-8. doi: 10.1097/CCM.0b013e31826a4650.
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 Associate 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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5 years of General Surgery residency? Check. Case numbers? Check. Ready for independent practice? Hmmm.  

Join Drs. John D. Mellinger, Jeremy Lipman, Judith French, and Amy Han as we discuss the past, present and future of operative assessment.

Learning objectives:

In this episode, we discuss the current practices of operative assessment in surgical training and the opportunities for improvement. We delve into evidence-based framework for operative performance assessment outlined in “A Proposed Blueprint for Operative Performance Training, Assessment, and Certification.” We explore the distinction between high versus low frequency operations, standards setting, training of assessors, and the role of technology in improving reliability, generalizability, and frequency of operative assessments.    

References:

Bansal N, Simmons KD, Epstein AJ, Morris JB, Kelz RR. Using Patient Outcomes to Evaluate General Surgery Residency Program Performance. JAMA Surg. 2016;151(2):111–119. doi:10.1001/jamasurg.2015.3637

Bell RH Jr, Biester TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009;249(5):719-724. doi:10.1097/SLA.0b013e3181a38e59

Williams RG, Sanfey H, Chen XP, Dunnington GL. A controlled study to determine measurement conditions necessary for a reliable and valid operative performance assessment: a controlled prospective observational study. Ann Surg. 2012;256(1):177-187. doi:10.1097/SLA.0b013e31825b6de4

Williams RG, George BC, Bohnen JD, et al. A Proposed Blueprint for Operative Performance Training, Assessment, and Certification. Ann Surg. 2021;273(4):701-708. doi:10.1097/SLA.0000000000004467

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Cardiac arrhythmias such as atrial fibrillation are common in any ICU. But, adequately addressing additional perioperative considerations is key in the surgical ICU. In this Critical Care episode of Behind the Knife, Drs. Bankhead, Dumas, & Park will address how to approach a critically ill patient who presents with an arrythmia. Hemodynamically stable vs. unstable patients are discussed, as well as the current ACLS guidelines for management of a patient in cardiac arrest. 

Referenced Articles and Guidelines:

1. Van Gelder I, Groenveld H, Crijns H, et al. Lenient versus Strict Rate Control in Patients with Atrial Fibrillation. NEJM 2010. 

2. Walkey A, Hogarth K, Lip G. Optimizing Atrial Fibrillation Management: From ICU and Beyond. CHEST 2015. 

3. AFFIRM Investigators. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. NEJM 2002. 

4. ACLS Training Center: Tachycardia with a Pulse Algorithm. https://www.acls.net/acls-tachycardia-algorithm

5. ACLS Training Center: Cardiac Arrest Algorithm. https://www.acls.net/acls-secondary-survey

6. ACLS Training Center: Acute Coronary Syndromes Algorithm. https://www.acls.net/acute-coronary-syndromes-algorithm

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November is Lung Cancer Awareness Month, and what better way is there to spend your time than getting to know the recent advances in adjuvant therapy for early-stage lung adenocarcinoma? 

Learning Objectives

–        Review work-up and treatment of lung adenocarcinoma
–        Review evidence behind Osimertinib as an adjuvant therapy in EGFR mutation positive disease
–        Review recent advances in gene expression profiles for targeted application of adjuvant chemotherapy
–        Discuss future directions for research
–        Discuss additional advancements in diagnosis, monitoring, and immunotherapy

Referenced Material

–        Wu Y, Tsuboi M, He J, et al. Osimertinib in resected EGFR-mutated non-small-cell lung cancer. N Engl J Med 2020; 383:1711-1723. DOI: 10.1056/NEJMoa2027071  https://www.nejm.org/doi/full/10.1056/NEJMoa2027071
–        Woodard GA, Wang SX, Kratz JR, et al. Adjuvant Chemotherapy Guided by Molecular Profiling and Improved Outcomes in Early Stage, Non-Small-Cell Lung Cancer. Clin Lung Cancer 2018;19(1):58-64. DOI: 10.1016/j.cllc.2017.05.015
–        Woodard GA, Kratz JR, Haro G, et al. Molecular Risk Stratification is Independent of EGFR Mutation Status in Identifying Early-Stage Non-Squamous Non-Small Cell Lung Cancer Patients at Risk for Recurrence and Likely to Benefit From Adjuvant Chemotherapy. Clin Lung Cancer. 2021;20:S1525-7304(21)00212-6. DOI: 10.1016/j.cllc.2021.08.008
https://www.clinical-lung-cancer.com/article/S1525-7304(21)00212-6/fulltext

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Join Behind the Knife’s very own Dr. Scott Steele, Chairman of the Department of Colorectal Surgery at Cleveland Clinic, for a high-level talk on the treatment of T2N0 rectal cancer. 

There is an associated video that goes along with this episode.  Check it out at behindtheknife.org or YouTube.

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

Join Drs. Ashlie Nadler, Jordan Nantais and Graham Skelhorne-Gross as they tackle Cancer Emergencies.  

Case 1 – Learning Points:

  1. These are complex patients and multidisciplinary care should be provided with input from oncology. 
  2. A step-up approach should be used, starting with medical management prior to considering surgery in appropriate patients.
  3. Highly selected patients may benefit from surgery, namely those with a high performance status, a prognosis of months if the bowel obstruction was resolved, minimal carcinomatosis, and a single transition point. Diversion, bypass, or resection are all options, but a patient’s capacity to heal related to recent systemic therapy needs to be taken into account. 
  4. Consent for surgery should focus on goals of care, quality of life, and achievable outcomes, and highlight the inherent risk in patients with advanced disease and a limited lifespan. 
Case 2 – Learning Points:
  1. Colorectal malignancy is an exceedingly common cause of general surgical emergency and requires a thoughtful, systematic approach
  2. The role of stenting as a bridge to surgery in obstructing distal colon malignancy is somewhat controversial but can help to avoid permanent stomas; however there is some potential risk of perforation and possibly disease recurrence
  3. Treatment decisions should take place in the context of an informed discussion with the patient and consideration of both quantity and quality of life whenever possible
  4. Consistent involvement of a multidisciplinary team, including radiology, enterostomal therapy, and surgical oncology can be extremely useful in guiding complex decisions

References:
  1. Shariff F, Bogach J, Guidolin K, Nadler A. Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review. Ann Surg Oncol. 2021 Oct 18. doi: 10.1245/s10434-021-10922-1. Epub ahead of print.
  2. Ripamonti C, Gerdes H and Easson A. Management of malignant bowel obstruction. Eur J Cancer 2008 May;44(8):1105-15
  3. Chen, T, Huang, Y. & Wang, G. Outcome of colon cancer initially presenting as colon perforation and obstruction. World J Surg Onc 15, 164 (2017). 
  4. Olmsted C, Johnson A, Kaboli P, et al. Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration. JAMA Surg. 2014;149(11):1169–75.
  5. Dunn GP, Martensen R, Weissman D.  Surgical palliative care: a resident’s guide. Essex: American College of Surgeons; 2009.
  6. Biondo S, Martí-Ragué J, Kreisler E, et al. A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer. Am J Surg. 2005;189:377–83.
  7. National Comprehensive Cancer Network. https://www.nccn.org/. Accessed October 15, 2021.
  8. Shariat-Madar B, Jayakrishnan TT, Gamblin TC, Turaga KK. Surgical management of bowel obstruction in patients with peritoneal carcinomatosis. J Surg Oncol. 2014 Nov;110(6):666-9. doi: 10.1002/jso.23707. 
Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  
In this episode from the Endocrine Surgery team at BTK we discuss the clinical applications of genetic testing for thyroid cancer. We walk through three cases of thyroid nodules and discuss why and how genetic testing can guide surgical and medical management. As usual we review key points such as imaging criteria for thyroid nodules, the Bethesda system for thyroid cytopathology, and MEN syndromes. We also go into a more nuanced discussion of how progress in genetic testing has led to more variability in management options. 
            
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. Rivfka Shenoy is a PGY-5 General Surgery Resident at UCLA who has completed two years of research 

Dr. Vivek Sant is an Endocrine Surgery Fellow at UCLA in his first year of fellowship

Important Papers 

Catherine Y Zhu, Ines Donangelo, Deepashree Gupta, Dalena T Nguyen, Joana E Ochoa, Michael W Yeh, Masha J Livhits, Outcomes of Indeterminate Thyroid Nodules Managed Nonoperatively after Molecular Testing, The Journal of Clinical Endocrinology & Metabolism, Volume 106, Issue 3, March 2021, Pages e1240–e1247, https://doi.org/10.1210/clinem/dgaa887

Xing, Mingzhao & Alzahrani, Ali & Carson, Kathryn & Viola, David & Elisei, Rossella & Bendlova, Bela & Yip, Linwah & Mian, Caterina & Vianello, Federica & Tuttle, R & Robenshtok, Eyal & Fagin, James & Puxeddu, Efisio & Fugazzola, Laura & Czarniecka, Agnieszka & Jarząb, Barbara & O’Neill, Christine & Sywak, Mark & Lam, Alfred & Sykorova, Vlasta. (2013). Association Between BRAF V600E Mutation and Mortality in Patients With Papillary Thyroid Cancer. JAMA : the journal of the American Medical Association. 309. 1493-501. 10.1001/jama.2013.3190.

Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid. 2015;25(6):567-610. doi:10.1089/thy.2014.0335

Wang JR, Zafereo ME, Dadu R, Ferrarotto R, Busaidy NL, Lu C, Ahmed S, Gule-Monroe MK, Williams MD, Sturgis EM, Goepfert RP, Gross ND, Lai SY, Gunn GB, Phan J, Rosenthal DI, Fuller CD, Morrison WH, Iyer P, Cabanillas ME. Complete Surgical Resection Following Neoadjuvant Dabrafenib Plus Trametinib in BRAFV600E-Mutated Anaplastic Thyroid Carcinoma. Thyroid. 2019 Aug;29(8):1036-1043. doi: 10.1089/thy.2019.0133. PMID: 31319771; PMCID: PMC6707029.

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Adjuvant?  Neoadjuvant?  Short course?  Long course?  The treatment of rectal cancer treatment has come a long way.  Tune in to learn more about Total Neoadjuvant Therapy (TNT) and the mysterious HOLY PLANE.

Learning Objectives:

1.    Describe the rationale for Total Neoadjuvant Therapy (TNT) for rectal cancer
2.    Review the history of chemo and radiation therapy in treatment of rectal cancer
3.    Describe total mesorectal excision 

References

Bahadoer RR, Dijkstra EA, van Etten B et al. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial. Lancet Oncol. 2021 Jan;22(1):29-42. doi: 10.1016/S1470-2045(20)30555-6. Epub 2020 Dec 7
Fokas E, Allgäuer M, Polat B et al. Randomized Phase II Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: CAO/ARO/AIO-12. J Clin Oncol. 2019 Dec 1;37(34):3212-3222. doi: 10.1200/JCO.19.00308
Colorectal Surgery 2021-2022 Virtual Education Series
Follow us on Twitter @CRSVirtualEd
www.crsvirtualed.org

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

The American Board of Surgery has a new family leave policy for surgery trainees: https://www.absurgery.org/default.jsp?policygsleave.  What’s new?  Is it enough?  And what does competency-based training have to do with it?  Join Drs. Patrick Georgoff and Shanaz Hossain as they discuss the details with ABS president Dr. Jo Buyske. 

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

Tick tock tick tock, 5 min is up! There is a plus sign on the testing stick. And you are…. Pregnant! Congratulations??? Join Drs. Erika Rangel, Eugene Kim, Yue-yung Hu, and Debbie Li as they discuss the challenges surgeons and trainees face as they navigate through pregnancy and parenthood. 

Learning objectives:
In this episode, we learn about the personal experiences including the good, the bad, and the ugly behind pregnancy and parenthood. We discuss about the stigma faced and experienced by many surgeons and trainees, and most importantly, ways we can support our current and future trainees to navigate this deeply personal and should be celebrated occasion in their life. 

References

Incidence of Infertility and Pregnancy Complications in US Female Surgeons https://doi.org/10.1001/jamasurg.2021.3301
Pregnancy and Motherhood During Surgical Training – https://doi.org/10.1001/jamasurg.2018.0153
Perspectives of US General Surgery Program Directors on Cultural and Fiscal Barriers to Maternity Leave and Postpartum Support During Surgical Training – https://doi.org/10.1001/jamasurg.2021.1807
Factors Associated With Residency and Career Dissatisfaction in Childbearing Surgical Residents – https://doi.org/10.1001/jamasurg.2018.2571

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Post-operative pain is a challenging topic most surgeons would prefer not to have to think about, and post-inguinal hernia repair pain can be a particular pain in the…groin. Drs. Mike Weykamp, Andrew Wright, and Nick Cetrulo from the University of Washington provide a framework for approaching these challenging patients to help clarify when and how to best evaluate post-inguinal hernia repair pain and identify the patients who might benefit from surgical intervention.

Referenced Articles and Videos: 
1.     D Chen. Mapping for inguinal chronic pain: An approach that all surgeons can do. Your Session: Abdominal Wall Hernia – Provocative Questions in the Practice of Hernia Repair held during the 2017 SAGES Annual Meeting in Houston, TX https://www.youtube.com/watch?v=Yx5zSS3CA-U
2.     J Lange, R Kaufmann, A Wijsmuller, J Pierie, R Ploeg, P Amid. An international consensus algorithm for management of chronic postoperative inguinal pain. Hernia 2015. 
3.     P Amid. Radiologic Images of Meshoma A New Phenomenon Causing Chronic Pain After Prosthetic Repair of Abdominal Wall Hernias. JAMA Surgery 2004. https://jamanetwork.com/journals/jamasurgery/fullarticle/397607
4.     McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 
5.     Campanelli G, Pascual MH, Hoeferlin A, Rosenberg J, Champault G, Kingsnorth A, Miserez M. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg. 2012
6.     Jeroukhimov I, Wiser I, Karasic E, Nesterenko V, Poluksht N, Lavy R, Halevy A. Reduced postoperative chronic pain after tension-free inguinal hernia repair using absorbable sutures: a single-blind randomized clinical trial. J Am Coll Surg. 2014. 
7.     Novik B, Nordin P, Skullman S, Dalenbäck J, Enochsson L. More Recurrences After Hernia Mesh Fixation With Short-term Absorbable Sutures: A Registry Study of 82 015 Lichtenstein Repairs. Arch Surg. 2011. 
8.     Barazanchi AW, Fagan PV, Smith BB, Hill AG. Routine Neurectomy of Inguinal Nerves During Open Onlay Mesh Hernia Repair: A Meta-analysis of Randomized Trials. Ann Surg. 2016.
9.     Bakker WJ, Aufenacker TJ, Boschman JS, Burgmans JPJ. Lightweight mesh is recommended in open inguinal (Lichtenstein) hernia repair: A systematic review and meta-analysis. Surgery. 2020.
https://pubmed.ncbi.nlm.nih.gov/31672519/

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The CODA trial is back – this time to shed light on long-term outcomes for antibiotics versus surgery for appendicitis! Dr. David Flum, lead investigator of the CODA trial, and Dr. Lillian Kao join us today to discuss the results after at least 1 year of follow-up in their patients. Read the full update here in the New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMc2116018

Utilizing the CODA trial results, Dr. Flum has created an innovative online tool for physicians to use with patients when discussing treatment options for appendicitis. Check out this new resource and keep it in mind next time you wander down to the ED for another patient with appendicitis: www.appyornot.org

Listen to our previous episodes on the CODA Trial:

Episode #321 (October 5, 2020): CODA Trial Results – Antibiotics versus Surgery for Appendicitis 
o   Dr. Flum and his team discuss the 90-day outcomes for the CODA trial as antibiotic treatment gains favor in the setting of the COVID-19 pandemic. 

Episode #109 (June 7, 2017): CODA Trial with Dr. David Flum 
o   Dr. Flum introduces the CODA Trial and the basis of his “pragmatic trial”.

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

It’s a brave new world people!  There has been an extraordinary and historic change in the way society interacts with information.  With the COVID pandemic raging misinformation and conspiracy theories have taken off like wildfire.  But why?  And what can we as providers do about it?  Join Drs. Patrick Georgoff and Brian Southwell for this timely discussion.  

Dr. Southwell is Senior Director of the Science in the Public Sphere Program at the Research Triangle Institute’s International Center for Communication Science. He is also Adjunct Professor at Duke University and Adjunct Associate Professor in Health Behavior at the University of North Carolina at Chapel Hill.  Dr. Southwell has published widely on topics such as public understanding of science and emerging infectious diseases. He co-founded the Duke Program on Medical Misinformation, a clinician training initiative to improve patient-provider conversations about misinformation. He also has organized several summits on trust in science and medical misinformation, such as the Misinformation Solutions Forum. In addition, Dr. Southwell created and hosts The Measure of Everyday Life, a public radio show that translates research for general audiences on WNCU, a station based at North Carolina Central University in Durham, NC.   

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Journal Review in HPB – Surgical Outcomes of the SWOG S1505 Trial

Description: Neoadjuvant chemotherapy remains a controversial topic for resectable pancreatic adenocarcinoma. This randomized trial examines surgical and clinical outcomes from peri-operative regimens, mFOLFIRNOX and gem-Abraxane. The HPB Behind the Knife team dives into the specifics of the trial design and findings, as well as sits down with the Principal Investigator Dr. Syed Ahmad himself to ask about the behind-the-scenes decision-making and the investigations yet to come. 

Links to Papers Reviewed in this Episode

Surgical Outcome Results from SWOG S1505: A Randomized Clinical Trial of mFOLFIRINOX Versus Gemcitabine/Nab-paclitaxel for Perioperative Treatment of Resectable Pancreatic Ductal Adenocarcinoma
Ann Surg. 2020 Sep;272(3):481-486

Efficacy of Periopertive Chemotherapy for Resectable Pancreatic Adenocarcinoma: A Phase 2 Randomized Clinical Trial
JAMA Oncol. 2021 Mar;7(3):421-427

Guest: 
Syed Ahmad, MD (@SyedAAhmad5) is a Professor of Surgery and Chief of the Division of Surgical Oncology at the University of Cincinnati College of Medicine, and the Director of the UC Cancer Center. He is the surgical chair of SWOG, and a co-Principal Investigator of the SWOG S1505 study in addition to numerous other national trials for pancreatic cancer.

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 (@usarmydoc24) 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-4 General Surgery resident at Brooke Army Medical Center

Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a PGY-3 General Surgery resident at Brooke Army Medical Center

Other References from this Episode

FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer
N Engl J Med. 2018 Dec 20;379:2395-2406

APACT: phase III, multicenter, international, open-label, randomized trial of adjuvant nab-paclitaxel plus gemcitabine (nab-P/G) vs gemcitabine (G) for surgically resected pancreatic adenocarcinoma
J Clin Oncol. 2019 May 20;37:no. 15 suppl:4000.

Operative Standards in Cancer Surgery: Pancreatoduodenectomy: Superior Mesenteric Artery Dissection
American College of Surgeons. 2020 Jun 18.

The AHPBA Podcast 
The Americas Hepato-Pancreato-Biliary Association
 
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Large diameter 26-32Fr chest tubes are the treatment of choice at many institutions for the treatment of traumatic hemothorax, but does the currently available data support that? Are there better options available? Join our team as we discuss the The Small 14-French (Fr) Percutaneous Catheter vs. Large (28-32Fr) Open Chest Tube for Traumatic Hemothorax (P-CAT): A Multi-center Randomized Clinical Trial by Dr. N Kulvatunyou et al to address this question. 


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). 

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-6 resident at the University of Illinois at Chicago who plans on going into trauma surgery. He did two years of research in surgical education at the University of Pennsylvania where he also received his Master’s in Medical Education. 


Journal Articles
The Small 14-French (Fr) Percutaneous Catheter vs. Large (28-32Fr) Open Chest Tube for Traumatic Hemothorax (P-CAT): A Multi-center Randomized Clinical Trial. https://pubmed.ncbi.nlm.nih.gov/33843831/ 

Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax. https://pubmed.ncbi.nlm.nih.gov/33415448/

Randomized clinical trial of pigtail catheter versus chest tube in injured patients with uncomplicated traumatic pneumothorax. https://pubmed.ncbi.nlm.nih.gov/24375295/ 

14 French pigtail catheters placed by surgeons to drain blood on trauma patients: is 14-Fr too small?
https://pubmed.ncbi.nlm.nih.gov/23188235/ 

A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter
https://pubmed.ncbi.nlm.nih.gov/28795207/ 

A History of Thoracic Drainage: From Ancient Greeks to Wound Sucking Drummers to Digital Monitoring https://www.ctsnet.org/article/history-thoracic-drainage-ancient-greeks-wound-sucking-drummer s-digital-monitoring

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

Peripheral Artery Disease – What the $#^% are we talking about?

Peripheral Artery Disease is all about saving peoples legs and lives, but we often don’t talk about PAD lesions with a common clinical language. In this episode of Behind the Knife, the vascular surgery team introduces the Global Vascular Guidelines anddiscusses the WIfI, TASC, and GLASS classifications systems designed to standardize our conversations about PAD lesions and how these fit into treatment decisions.

Dr. Nicholas Osborne is an Associate Professor of Vascular Surgery at the University of Michigan and the

Chief of Vascular Surgery at the Ann Arbor Veteran’s Affairs Healthcare System.

Dr. Frank Davis is a Chief Resident in the Integrated Vascular Surgery program at the University of

Michigan.

Dr. Craig Brown is a PGY-6 in the General Surgery program at the University of Michigan.

Papers discussed in this Episode:

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia:

Society for Vascular Surgery App:

https://apps.apple.com/app/id1014644425

Please visit behindtheknife.org to access our massive library of high-yield surgical education podcasts, videos and more.  

Learning Objectives:
·       Describe the role of portal vein embolization and how it is currently utilized in the setting of metastatic colon cancer
·       Understand adequate functional volume and delineate different methods of increasing a future liver remnant
·       Identify the leading causes of drug-induced liver failure and recognize how these have changed over time

Journal Articles:
·       Dueland, et al. “Survival Outcomes After Portal Vein Embolization and Liver Resection Compared With Liver Transplant for Patients With Extensive Colorectal Cancer Liver Metastases.” JAMA Surgery. 2021;156(6):550-557. https://doi.org/10.1001/jamasurg.2021.0267

·       Ghabril, et al. “Eight fold increase in the dietary supplement related liver failure leading to transplant waitlisting over the last quarter century in the US.” Liver Transplantation. 31 July 2021. https://doi.org/10.1002/lt.26246

Please visit behindtheknife.org to access our massive library of high-yield surgical education podcasts, videos and more.  

Description: 
 A patient being surveilled for untreated hepatitis C presents to your clinic for a newly identified liver mass. Hepatocellular carcinoma (HCC) accounts for ~90% of new liver cancers and infection by hepatitis B and hepatitis C viruses are the main risk factors. Non-alcoholic steatohepatitis associated with metabolic syndrome and diabetes mellitus, however, have contributed to HCC becoming the fastest growing solid organ tumor in the United States. In this episode from the Surgical Oncology team at Behind the Knife, join the discussion on a surgeons approach to this growing patient population.

Learning Objectives: 
In this episode, we review risk factors for hepatocellular carcinoma, key steps in the diagnostic work-up with a focus on pre-operative planning for hepatectomy in cirrhotic patients. We will cover interventions available preoperatively, options and considerations once in the operating room, as well as treatment strategies and shifting paradigms following successful resection. 

Hosts: 
Adam Yopp, MD, FACS (@AdamYopp) is an Assistant 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 2nd Year Complex General Surgical Oncology Fellow at the MD Anderson Cancer Center.

Gilbert Murimwa, MD (@GilbertZMurimwa) is a PGY-3 General Surgery Resident at the UT Southwestern Medical Center and a research fellow in the Hamon Center for Therapeutic Oncology Research.

Papers Referenced in this Episode:

Importance of low preoperative platelet count in selecting patients for resection of hepatocellular carcinoma: a multi-institutional analysis
J Am Coll Surg. 2011 Apr;212(4):638-48; discussion 648-50. doi: 10.1016/j.jamcollsurg.2011.01.004. PMID: 21463803 

Hepatobiliary Cancers, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology
J Natl Compr Canc Netw. 2021 May 1;19(5):541-565. doi: 10.6004/jnccn.2021.0022.
PMID: 34030131

Sequential arterial and portal vein embolizations before right hepatectomy in patients with cirrhosis and hepatocellular carcinoma
Br J Surg. 2006 Sep;93(9):1091-8. doi: 10.1002/bjs.5341. PMID: 16779884

Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis
J Clin Anesth. 2021 Aug 1;75:110467. doi: 10.1016/j.jclinane.2021.110467. Online ahead of print. PMID: 34343737

Portal vein embolization: rationale, technique and future prospects
Br J Surg. 2001 Feb;88(2):165-75. doi: 10.1046/j.1365-2168.2001.01658.x.
PMID: 11167863

Kinetic growth rate after portal vein embolization predicts posthepatectomy outcomes: toward zero liver-related mortality in patients with colorectal liver metastases and small future liver remnant
J Am Coll Surg. 2013 Feb;216(2):201-9. doi: 10.1016/j.jamcollsurg.2012.10.018. Epub 2012 Dec 7. PMID: 23219349 

IMbrave 050: a Phase III trial of atezolizumab plus bevacizumab in high-risk hepatocellular carcinoma after curative resection or ablation
Future Oncol. 2020 May;16(15):975-989. doi: 10.2217/fon-2020-0162. Epub 2020 Apr 30.
PMID: 32352320

Direct-Acting Antiviral Therapy for Hepatitis C Virus Infection Is Associated With Increased Survival in Patients With a History of Hepatocellular Carcinoma
Gastroenterology. 2019 Nov;157(5):1253-1263.e2. doi: 10.1053/j.gastro.2019.07.040. Epub 2019 Jul 30. PMID: 31374215
Ever wonder why some bariatric patients received extended VTE prophylaxis and others do not? Or what the ideal chemical VTE prophylaxis is for bariatric patients? All of your questions answered in this journal review discussion!

Journal articles:

A single-center comparison of extended and restricted thromboprophylaxis with LMWH after metabolic surgery: https://pubmed.ncbi.nlm.nih.gov/31641983/

Risk factors for postdischarge venous thromboembolism among bariatric surgery patients and the evolving approach to extended thromboprophylaxis with enoxaparin: https://pubmed.ncbi.nlm.nih.gov/33814315/

You’re faced with a challenging case of a patient with rectal cancer and synchronous liver lesion. Where do you start: chemotherapy, chemoradiotherapy, upfront surgery, liver first, rectum first? 
Join Drs. Carole Richard, François Dagbert and Maher Al Khaldi as they discuss the management of a patient with rectal cancer with a synchronous hepatic metastasis. 
Learning objectives
In this episode, we discuss the workup of a rectal tumour associated with synchronous liver metastases, indications for resection of the hepatic lesion, neoadjuvant and adjuvant treatment modalities, survival benefit of resection and patient follow-up.
Reference list:

Moulton C-A, Gu C-S, Law CH, Tandan VR, Hart R, Quan D, et al. Effect of PET Before Liver Resection on Surgical Management for Colorectal Adenocarcinoma Metastases: A Randomized Clinical Trial. JAMA. 2014;311(18):1863–9.

Bahadoer RR, Dijkstra EA, Etten B van, Marijnen CAM, Putter H, Kranenbarg EM-K, et al. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial. Lancet Oncol. 2021;22(1):29–42.

“The eyes do not see what the mind does not know.”
Trauma surgery is riddled with pitfalls.  Take your guard down for a minute and BAM, you are eating humble pie.  Don’t let this happen to you!  
Join Drs. Bryan Cotton, Teddy Puzio, Krislynn Mueck, and host Patrick Georgoff for a fun, high-yield review.  In this episode (2 of 2), we cover: 
  1. Splenic pseudoaneurysm
  2. Compartment syndrome
  3. Urogenital injury
  4. Diaphragm injury
  5. Esophageal injury
Please join Drs. Brian Gray, Amanda Jensen and Manisha Bhatia from Indiana University as they discuss ovarian mass in pediatric surgery.

Journal Article links: 

Madenci AL, Vandewalle RJ, Dieffenbach BV, Laufer MR, Boyd TK, Voss SD, et al. Multicenter pre-operative assessment of pediatric ovarian malignancy. J Pediatr Surg 2019;54(9):1921-5.

Dasgupta R, Renaud E, Goldin AB, Baird R, Cameron DB, Arnold MA, et al. Ovarian torsion in pediatric and adolescent patients: A systematic review. J Pediatr Surg 2018;53(7):1387-91.

“The eyes do not see what the mind does not know.”
Trauma surgery is riddled with pitfalls.  Take your guard down for a minute and BAM, you are eating humble pie.  Don’t let this happen to you!  
Join Drs. Bryan Cotton, Teddy Puzio, Rushabh Dev, and host Patrick Georgoff for a fun, high-yield review.  In this episode (1 of 2), we cover: 
  1. Extraperitoneal rectal injury
  2. Blunt cerebrovascular injury
  3. Chance fractures
  4. Cardiac injuries with a negative FAST exam
  5. Missed injuries during trauma ex lap
The chief residents in your program are at their wits end with some of their colleagues. Residents are yelling at nurses, skin closures look like they’re from a horror movie and a patient almost died because of a delay in being seen. How can the chiefs and program director help these struggling residents?

Join Drs. Kyla Terhune, Jeremy Lipman, Judith French and Amy Han as they discuss how to identify and support the struggling surgical resident.

Learning objectives:

After listening to this episode, the participant will be able to:

Recall some of the assessment tools available to identify struggling residents

Discuss strategies for identifying struggling surgical residents

Provide guidance to a struggling surgical resident who is struggling
Tune in to listen to two of the BTK original founders, Dr. Jason Bingham and Dr. Scott Steele, as they discuss clinical challenges in colorectal surgery, specifically large bowel obstruction.  

Want to win a free Behind the Knife ABSITE review book?  Simply leave us a review on Apple Podcasts before September 1st and you will be entered into the drawing.  Be sure to include your Twitter or Instagram handle in the review.  Or email us at [email protected] to let us know that you showed BTK some love.  DOMINATE THE DAY!

Incisional hernia is one of the most common long-term complications associated with surgical interventions. In this episode from the Hernia and Abdominal Wall Reconstruction team at Behind the Knife, we discuss evidence-based decision making to reduce incisional hernia rates following laparotomy. We review preoperative factors associated with hernia occurrence, intraoperative decision making related to fascial closure technique, and review literature on prophylactic mesh augmentation. 

·       Dr. Vahagn Nikolian is an Assistant Professor of Surgery at Oregon Health & Science University, focused on abdominal wall reconstruction and hernia repair. 
·       Dr. Sean Orenstein is an Associate Professor of Surgery at Oregon Health & Science University, focused on abdominal wall reconstruction and hernia repair.
·       Dr. Emaad Iqbal is a resident in General Surgery at Columbia University Medical Center. 
·       Dr. Shahrose Rahman is a resident in General Surgery at Oregon Health & Science University. 

Seminal Papers in Hernia Prevention Techniques
 
Want to win a free Behind the Knife ABSITE review book?  Simply leave us a review on Apple Podcasts before September 1st and you will be entered into the drawing.  Be sure to include your Twitter or Instagram handle in the review.  Or email us at [email protected] to let us know that you showed BTK some love.  DOMINATE THE DAY!
Welcome to the first of a six-part series focused on the integration of palliative care into the practice of surgery.  Dr. Geoffrey Dunn defines Surgical Palliative Care as “the treatment of suffering and the promotion of quality of life for seriously ill or terminally ill patients under surgical care.”  He has proposed that the Family Meeting is like a surgical procedure in which we “Prepare, Do and Close.”  Using the case of a geriatric trauma patient in multi-system organ failure, in this episode we discuss how to run a family meeting, how to discuss code status and how to discuss goals of care.

Family Meeting:
Fast Fact #16:  Moderating the Family Meeting

Fast Fact #222:  The Family Meeting Part 1- Preparing

Fast Fact #223: The Family Meeting Part 2- Starting the Conversation

Fast Fact #227: The Family Meeting Part 6-  Goal Setting and Future Planning

In-hospital CPR:
CPR in adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation

Development and validation of the good outcome following attempted resuscitation (GO-FAR) score to predict neurologically intact survival after in-hospital cardiopulmonary resuscitation

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. Fabian Johnston (@fabianjohnston) is Associate Professor of Surgery and Oncology and Chief, Division of GI Surgical Oncology at Johns Hopkins University.

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

Want to win a free Behind the Knife ABSITE review book?  Simply leave us a review on Apple Podcasts before September 1st and you will be entered into the drawing.  Be sure to include your Twitter or Instagram handle in the review.  Or email us at [email protected] to let us know that you showed BTK some love.  DOMINATE THE DAY!

Behind the Knife – ACS Cancer Surgery Standards Program

Host:
Shreya Gupta, MD (@shreyaguptaMD) 

Guests:
Mediget Teshome, MD, MPH, FACS (@drmediget) is an Assistant Professor in the Department of Breast Surgical Oncology at the University of Texas MD Anderson Cancer Center. She is the Chair of the Education Committee of the Cancer Surgery Standards Program (CSSP).

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. He is the Vice Chair of the Education Committee of the CSSP.

Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a PGY-4 General Surgery resident at Brooke Army Medical Center and a member of the Education Committee of the CSSP.

Description: The American College of Surgeons Cancer Surgery Standards Program is an initiative to improve the quality of cancer surgery by implementing evidence-based operative standards and its associated documentation. This episode discusses the CSSP’s role in not only enhancing the quality of care for patients, but also providing educational tools for trainees, resources for community surgeons caring for cancer patients, and a vehicle for research. 

Learning Objectives

In this episode, we learn about the mission and vision of the American College of Surgeons Cancer Surgery Standards Program and the associated operative standards. We discuss the current rollout of standards 5.7 and 5.8, concerning synoptic pathology reporting of total mesorectal excision for mid/low rectal cancer and mediastinal and hilar lymph node sampling in lung cancer. In addition, we discuss future implementation of synoptic operative reporting standards for melanoma, breast cancer, and colon cancer. These standards are important not only for the sub-specialist, but also to surgical residents and any general surgeon that cares for cancer patients.

Resources Referenced in this Episode

The ACS CSSP homepage: facs.org/cssp

Operative Standards for Cancer Surgery – find it on Amazon!
            Volume 1: Breast, Lung, Pancreas, Colon
            Volume 2: Thyroid, Gastric, Rectum, Esophagus, Melanoma

Follow CSSP on Twitter at @AmColSurgCancer, with the hashtag #CSSP

Want to win a free Behind the Knife ABSITE review book?  Simply leave us a review on Apple Podcasts before September 1st and you will be entered into the drawing.  Be sure to include your Twitter or Instagram handle in the review.  Or email us at [email protected] to let us know that you showed BTK some love.  DOMINATE THE DAY!
A young woman is referred urgently to your breast surgical oncology clinic for a second opinion. She has been told that she needs to have an urgent mastectomy for a palpable triple negative breast cancer with suspicious axillary lymphadenopathy. Are there other options she should consider? Join Drs. Michael Alvarado, Rita Mukhtar, and Alexa Glencer as they discuss the multidisciplinary management of a patient with triple negative breast cancer.
In this episode, we review the diagnosis and classification of triple negative breast cancer, its biologic implications, surgical management including the role of sentinel lymph node biopsy vs axillary dissection, and the role of targeted chemotherapy including the recent FDA approval of immunotherapy for triple negative breast cancer in the neoadjuvant setting and indication for adjuvant chemotherapy for patients with residual disease following neoadjuvant therapy.
Links:
Enhanced recurrence and survival benefit of adjuvant chemotherapy for hormone receptor negative breast cancer compared to hormone receptor positive breast cancer
Berry et al (2006). Estrogen-receptor status and outcomes of modern chemotherapy for patients with node-positive breast cancer. JAMA; 295(14): 1658-1667.

Neoadjuvant pembrolizumab for triple negative breast cancer
Schmid et al (2020). Pembrolizumab for early triple negative breast cancer. New England J of Medicine; 382(9): 810-821

ACOSOG 1071: Sentinel lymph node biopsy for patients who received neoadjuvant chemotherapy
Boughey at al (2013). Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG 1071 (Alliance) clinical trial. JAMA; 310(14): 1455-1461.

Adjuvant capecitabine for triple negative breast cancer patients with residual disease following neoadjuvant chemotherapy:
Masuda et al (2017). Adjuvant capecitabine for breast cancer after preoperative chemotherapy. New England J of Medicine; 376(22): 2147-2159.

Medical students – do you want to DOMINATE your surgery clerkship?  Of course you do!  Tune in and find out how.  In this episode we introduce Behind the Knife’s 5 Principles for Clerkship DOMINATION, we hear from clerkship directors at top-notch surgery programs around the country, and we review the primary learning environments in surgery and how you can excel in each of these environments.  

Hosts: Drs. Patrick Georgoff (@georgoff) and Amir Motameni (@motameniA)

Special guests: Drs. Gifty Kwakye, Luigi Pascarella, Mackenzie Cook, and Alodia Gabre-Kidan. 

Behind the Knife’s 5 Principles for Clerkship DOMINATION: 

1.  Be prepared
2. Take a proactive role in your education
3. Show enthusiasm and be engaged
4. Give quality presentations with thoughtful assessments and plans
5. Seek out feedback and incorporate it into what you do.

Systems based surgery plan:

•Neuro: Pain control, unneeded narcotics, sleep, home psych meds 

•Cardiovascular: HR, BP, home cardiac meds
•Pulmonary: Supplemental O2, pulmonary toilet (e.g. incentive spirometry), home inhalers
•GI: Diet, return of bowel function, bowel regimen, ostomy care
•GU/FEN: Urine output, foley catheter, IV fluids, electrolytes 
•Endocrine: Blood glucose
•ID: Identify and treat infections, duration of antibiotics 
•Heme: DVT chemoprophylaxis, anemia
•Skin: Wound care, pressure ulcers
•MSK: Activity restrictions, out of bed, PT/OT
•Lines: Central line, arterial line
•Disposition: PT/OT, social work, case management 

FELLOWSHIP APPLICATION: https://docs.google.com/forms/d/e/1FAIpQLSfxhjxgCE9Ek263XuGkpqqbaNiK9sVnu3M7_LFYUZxhr38SZw/viewform

Your patient is pregnant in her third trimester and she has acute cholecystitis…a relatively common but unnerving scenario.  What do you do?!  Do you operate?  Do you observe?  What about the baby?  Tune in and get the information you need to best care for this patient. 

Hosts: Drs. Graham Skelhorne-Gross, Ashlie Nadler and Jordan Nantais. 

Papers reviewed: 

1) Fong, Z. et. al. Cholecystectomy during the third trimester of pregnancy: proceed or delay? J Am Coll Surg. 2019. 228 (4): 494-502.

2) Hong. J. et. al. Considering delay of cholecystectomy in the third trimester of pregnancy. Surg Endosc. 2020. Online ahead of print.

FELLOWSHIP APPLICATION: https://docs.google.com/forms/d/e/1FAIpQLSfxhjxgCE9Ek263XuGkpqqbaNiK9sVnu3M7_LFYUZxhr38SZw/viewform

Episode Description
The timing of renal replacement therapy remains controversial and may be influenced by local resources, availability and institutional practices. In this episode from the Surgical Critical Care team at Behind the Knife, we provide a brief overview, introduce a clinical scenario and discuss two contemporary articles on the timing of initiation. 

Learning Objectives: 
In this episode, we review the indications for renal replacement therapy, the different modalities of continuous replacement therapy, and discuss two randomized control trials that may help us answer the question of dialysis initiation.

Hosts:

Brittany Bankhead-Kendall, MD, MS (@BBankheadMD) is an Assistant Professor of Surgery at Texas Tech University Health Sciences Center.

Ryan Dumas, MD, FACS (@PMH_Trauma_RPD) is an Assistant Professor at the University of Southwestern Medical Center and Parkland Memorial Hospital.

Caroline Park, MD, MPH, FACS (@CPark_MD) is an Assistant Professor at the University of Southwestern Medical Center and Parkland Memorial Hospital.

Links to Papers Referenced in this Episode:
Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis. N Engl J Med. 2018 Oct 11;379(15):1431-1442. doi: 10.1056/NEJMoa1803213.

Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med. 2020 Jul 16;383(3):240-251. doi: 10.1056/NEJMoa2000741.
Intro:  Join Drs. Brian Louie, Peter White, and Megan Lenihan as they discuss the management of spontaneous pneumothorax in its various presentations.

Learning Objectives

–        Management of primary spontaneous pneumothorax
–        Management of secondary spontaneous pneumothorax
–        Operative intervention
–        Nonoperative intervention
–        Recognition and management of uncommon causes of pneumothorax

Referenced Material

ACCP guidelines for spontaneous pneumothorax: 

BTS guidelines for spontaneous pneumothorax: 

Couldn’t log on to the American Association of Endocrine Surgeons Annual Meeting this year? No need to have FOMO, in this episode from the Endocrine Surgery team at Behind the Knife, we review key abstract presentations from the meeting. We discuss the strengths and limitations of the studies, and how the results translate to clinical practice. Specifically, we go into screening and surgery for primary hyperparathyroidism after a diagnosis of nephrolithiasis, and the role of prophylactic central lymph node dissection, radioactive iodine, and radiofrequency ablation for papillary thyroid carcinoma. 
                 
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. Rivfka Shenoy is a PGY-5 General Surgery Resident at UCLA who has completed two years of research 
Important Papers 

Viola, D., Materazzi, G., Valerio, L., Molinaro, E., Agate, L., Faviana, P., Seccia, V., Sensi, E., Romei, C., Piaggi, P. and Torregrossa, L., 2015. Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma: clinical implications derived from the first prospective randomized controlled single institution study. The Journal of Clinical Endocrinology & Metabolism, 100(4), pp.1316-1324.

Sippel, R.S., Robbins, S.E., Poehls, J.L., Pitt, S.C., Chen, H., Leverson, G., Long, K.L., Schneider, D.F. and Connor, N.P., 2020. A randomized controlled clinical trial: No clear benefit to prophylactic central neck dissection in patients with clinically node negative papillary thyroid cancer. Annals of Surgery, 272(3), pp.496-503.

Alore, E.A., Suliburk, J.W., Ramsey, D.J., Massarweh, N.N., Balentine, C.J., Singh, H., Awad, S.S. and Makris, K.I., 2019. Diagnosis and management of primary hyperparathyroidism across the Veterans Affairs health care system. JAMA internal medicine, 179(9), pp.1220-1227.

Ganesan, C., Weia, B., Thomas, I.C., Song, S., Velaer, K., Seib, C.D., Conti, S., Elliott, C., Chertow, G.M., Tamura, M.K. and Leppert, J.T., 2020. Analysis of primary hyperparathyroidism screening among US veterans with kidney stones. JAMA surgery, 155(9), pp.861-868.
You find a 2.3 cm polyp in the right colon during a screening colonoscopy.  Does this patient need a colectomy? Is polypectomy ok? What should I do?? Join Drs. Peter Marcello, Jonathan Abelson and Tess Aulet as they discuss the endoscopic management of advanced colorectal polyps. 

Be sure to check out Behind the Knife’s YouTube channel for the VideoCast version of this high-yield case: https://www.youtube.com/c/BehindTheKnifeTheSurgeryPodcast.  

Interested in learning more about specific topics in Colorectal Surgery? Check out the Virtual Education Series in Colorectal Surgery on Sunday Evenings at 7 pm EST @CRSVirtualEd or visit our website at http://jc.kethman.org.

References:

Cohan JN, Donahue C, Pantel HJ, Ricciardi R, Kleiman DA, Read TE, Marcello PW. Endoscopic Step Up: A Colon-Sparing Alternative to Colectomy to Improve Outcomes and Reduce Costs for Patients With Advanced Neoplastic Polyps. Dis Colon Rectum. 2020 Jun;63(6):842-849. doi: 10.1097/DCR.0000000000001645. PMID: 32118624.

Kudo Classification: Kudo S, Tamura S, Nakajima T, Yamano H, Kusaka H, Watanabe H. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 1996; 44: 8-14 [PMID:8836710]

UpToDate. Chromoendoscopy. Author:Marcia Irene Canto, MD, MHSSection Editor:John R Saltzman, MD, FACP, FACG, FASGE, AGAFDeputy Editor:Kristen M Robson, MD, MBA, FACG. Literature review current through: May 2021. | This topic last updated: Jan 14, 2021.

Haggit and Kikuchi classification: Haggitt RC, Glotzbch RE, Soffer EE, Wruble LD. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology 1985; 89: 328-36. 

Minimally Invasive Surgery Journal Review  

Evaluating the Robot Platform for use in General Surgery: ROLARR & RIVAL

The debate about whether or not robotic surgery has a place in mainstream general surgery practice has been raging years with critics highlighting concerns about cost and a lack of high-level evidence showing benefit in patient outcomes while proponents suggest benefits in visualization, dexterity, and ergonomics that have not yet been borne out in rigorous trials. Hosts, Drs. Mike Weykamp, Andrew Wright, and Nick Cetrulo use two recent JAMA articles to frame the debate surrounding the platform and offer insight into the future of robotic and minimally invasive surgery.

Learning objectives: 

In this episode we review the current landscape of the literature surrounding robot assisted surgery with a particular focus on how to thoughtfully evaluate emerging surgical technologies, the need to consider the broader concept of value rather than simply healthcare costs, and the role of surgeon-focused outcomes including ergonomics. 

Selected Articles: 

Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial

Robotic Inguinal vs Transabdominal Laparoscopic Inguinal Hernia Repair: The RIVAL Randomized Clinical Trial

RIVAL Author Interview with JAMA Surgery:
Dr. Shailesh Agarwal from Brigham and Women’s Hospital in Boston joins us once more on the podcast! This time he lends us his expertise in the surgical management of lymphedema. Come listen to how Dr. Agarwal is improving the lives of patients with this terrible, chronic condition, often produced as a result of prior surgery.
On this episode we are joined by Dr. Gretchen Schwarze, Associate Professor of Vascular Surgery at the University of Wisconsin in Madison.  Dr. Schwarze is an expert in surgical decision making, informed consent, advance directives, and end-of-life care, and in this episode we pick her brain for practical tips on how to talk to patients about surgery and end of life decisions.  Tune in to hear Dr. Schwarze’s 7 Habits for Highly Effective Surgery Communication, created just for Behind the Knife.  

1.     Be clear about the goal
2.     Stay away from anatomy and physiology
3.     Remember the downsides of surgery are more than just complications
4.     Help patients to anticipate and prepare
5.     Ask people about their hopes and fears
6.     Make a recommendation and show your work
7.     Attend to emotion

The Patient Preferences Project: https://patientpreferences.org/
On this episode we talk about an extremely important topic – end of life care and decision making.  We are lucky to be joined by Dr. Gretchen Schwarze, Associate Professor of Vascular Surgery at the University of Wisconsin in Madison.  Dr. Schwarze is the creator of the Best Case Worst Case tool, an incredibly useful resource.  The Best Case Worse Case tool helps improve communication between older patients and their surgeons so that patients can avoid unwanted treatment and make decisions that align with their values, preferences, and goals.  As most of our listeners know, these conversations are not easy.  Tune in and learn how to do better.  

The Patient Preferences Project: https://patientpreferences.org/

Managing Uncertainty — Harnessing the Power of Scenario Planning: https://www.nejm.org/doi/full/10.1056/NEJMp1704149

Description: Pancreatic adenocarcinoma is a highly lethal cancer with a dismal long-term prognosis requiring complex multidisciplinary planning in order to optimize outcomes. In this episode from the Hepato-Pancreato-Biliary team at Behind the Knife, we discuss a patient presenting with a borderline resectable pancreatic head mass. 

Learning Objectives: In this episode, we review risk factors for pancreatic adenocarcinoma, key steps of the diagnostic work-up and pre-operative planning, and definitions of resectable, borderline resectable, and unresectable tumors. The history of chemotherapy for pancreatic cancer is briefly reviewed, highlighting the importance of multi-agent regimens and role of neoadjuvant therapy. Finally, we highlight the critical steps of the Whipple procedure.

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 (@usarmydoc24) 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-4 General Surgery resident at Brooke Army Medical Center

Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a PGY-3 General Surgery resident at Brooke Army Medical Center

Links to Papers Referenced in this Episode

Treatment sequencing for resectable pancreatic cancer: influence of early metastases and surgical complications on multimodality therapy completion and survival
J Gastrointest Surg. 2014 Jan;18(1):16-24

Preoperative biliary drainage for cancer of the head of the pancreas
N Engl J Med. 2010 Jan 14;362(2):129-37

1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience
J Gastrointest Surg. 2006 Nov;10(9):1199-210; discussion 1210-1.

 Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial
JAMA. 2013 Oct 9;310(14):1473-81. 

Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial
Lancet. 2017 Mar 11;389(10073):1011-1024

FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer
N Engl J Med. 2018 Dec 20;379:2395-2406

Surgical Outcome Results From SWOG S1505: A Randomized Clinical Trial of mFOLFIRINOX Versus Gemcitabine/Nab-paclitaxel for Perioperative Treatment of Resectable Pancreatic Ductal Adenocarcinoma
Ann Surg. 2020 Sep 1;272(3):481-486.doi: 10.1097/SLA.0000000000004155

ASCO Guidelines Potentially Curable Pancreatic Adenocarcinoma

NCCN Guidelines Pancreatic Adenocarcinoma
Clinical Challenges in Trauma Surgery: Penetrating Cardiac Trauma

A patient presents with a stab wound to the THE BOX.  What do you do?  X-ray?  FAST?  Heal with steel?  In this episode, the BTK trauma team discusses your options and gives you a few pro tips along the way.

Join Drs. Haut, Feinman, and Sigmon for a high-yield clinical challenge.

Hosts:


Elliott 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).

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-5 resident at the University of Illinois at Chicago who plans on going into trauma surgery.  He did two years of research in surgical education at the University of Pennsylvania where he also received his Master’s in Medical Education.

Papers:

Inaba K, Chouliaras K, Zakaluzny S, et al. FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Ann Surg. 2015;262(3):512-518; discussion 516-518.
 https://pubmed.ncbi.nlm.nih.gov/26258320/

Teeter W, Haase D. Updates in traumatic cardiac arrest. Emerg Med Clin North Am. 2020;38(4):891-901.
https://pubmed.ncbi.nlm.nih.gov/32981624/

Israr S, Cook AD, Chapple KM, et al. Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death? Injury. 2019;50(9):1507
1510. https://pubmed.ncbi.nlm.nih.gov/31147/183/

Clinical Challenge in Surgery – Carotid Artery Stenosis

Carotid endarterectomy is a great option for most patients, but what do you do when the lesion extends high in the neck or the neck has been irradiated? In this episode from the Vascular Surgery team at Behind the Knife, we discuss carotid artery stenosis using a real patient case from the University of Michigan. We touch on diagnosis and imaging as well as medical and surgical management of carotid disease with a special discussion about Transcarotid Artery Revascularization (TCAR), a new technique available for the treatment of carotid lesions.

Dr. Nicholas Osborne is an Associate Professor of Vascular Surgery at the University of Michigan and the Chief of Vascular Surgery at the Ann Arbor Veteran’s Affairs Healthcare System.

Dr. Frank Davis is a Chief Resident in the Integrated Vascular Surgery program at the University of Michigan.

Dr. Craig Brown is a PGY-6 in the General Surgery program at the University of Michigan.

Seminal Papers in Carotid Artery Stenosis

Endarterectomy for Asymptomatic Carotid Artery Stenosis (ACAS Trial): https://jamanetwork.com/journals/jama/article-abstract/388335

The North American Symptomatic Carotid Endarterectomy Trial (NASCET Trial): https://www.ahajournals.org/doi/epub/10.1161/01.STR.30.9.1751

Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER Trial): https://pubmed.ncbi.nlm.nih.gov/26506270/

“If you could go back to your very first day of intern year and tell yourself one thing, what would it be?”  

In this episode, AlleaBelle Gongola joins Scott Steele, Kevin Kniery, and Patrick Georgoff to discuss this very question. Tune in to hear wise answers from previous BTK episodes and fill up on inspiration as we head into a new academic year.  

In this episode, we host the Joint Commission who tell us about their efforts to improve healthcare disparities and healthcare provider diversity. We first briefly discuss structural racism before pivoting to how COVID has revealed how deep the roots of inequity travel. Finally we discuss the ways that Joint Commission are tackling the problem. Dr. Ana McKee, Executive Vice President and Chief Diversity, Equity, and Inclusion Officer of the Joint Commission joins our discussion, along with return guest Dr. Fabian Johnston from Johns Hopkins University.

Dr. McKee mentions the Bernard J Tyson National Award for Excellent in the Pursuit of Healthcare Equity in this episode! Applications open on May 17. Please see go to THIS LINK to learn more about the process!

In this episode, we follow up with our friends at COVIDSurg (https://globalsurg.org/covidsurg/).  While the pandemic has been raging they have been hard at work, studying the interface between COVID and all things surgery.  They’ve produced some amazing work, most of which impacts the day to day lives of surgeons around the country.  

How long should you wait to operate on a patient who has had COVID?  And what do you tell your patients about this?  What about vaccines?  Should your next patient undergoing elective surgery be vaccinated before you take them to the operating room?  Find out!

Clinical Challenges in Surgery: ARDS

It’s the middle of the night…the ventilator is alarming, the patient is hypoxic, and the nurse wants to know if you would like to paralyze the patient.  What do you do?!  Join Drs. Matt Martin, John McClellan, and Patrick Georgoff as they discuss the management of a real patient with severe Acute Respiratory Distress Syndrome.  From paralytics and proning to steroids and ECMO, this episode has got you covered. 

Note: We couldn’t upload the video version to your podcast player because the file was just way too big! That’s because the operative video is so high quality! Please go our YouTube channel to watch it! Or click this link: https://youtu.be/xx7JMIe2d_o

In the first of our Surgical Technique video series, Mass Gen Transplant surgeons take us step by step through a kidney transplant! This is Part 2 of the series. We are joined by Dr. Leigh Anne Dageforde, Dr. Anushi Shah, and Dr. Ashley Aaron. Just in time for National Donate Life Month!

Note: We couldn’t upload the video version to your podcast player because the file was just way too big! That’s because the operative video is so high quality! Please go our YouTube channel to watch it! Or click this link: https://youtu.be/xx7JMIe2d_o

In the first of our Surgical Technique video series, Mass Gen Transplant surgeons take us step by step through a kidney transplant! This is Part 1 of the series. We are joined by Dr. Leigh Anne Dageforde, Dr. Anushi Shah, and Dr. Ashley Aaron. Just in time for National Donate Life Month!

Dr. Anton Fries, Chief of Plastic Surgery at UT San Antonio, joins the podcast to give us all a primer on all we need to know about flap-based reconstruction.

Don’t forget to visit GreenChef.com and use promo code 90Surgery to get $90 off your first organic, delivered meals. It’s a great way to support your body and the podcast!

Discussing a REAL TRAUMA CASE that happened just a few months ago, Patrick Georgoff, John McClellan, and Hasan Alam come together to detail their thought process in managing a patient with a gunshot wound to the abdomen.
We brought Dr. Mary Klingensmith and Dr. Amit Joshi on the show, executive leaders on the Surgical Council on Resident Education. Listen to them discuss the history of SCORE, how it has improved over time, and how these two leaders in surgical education anticipate residency training changing over the next decade!
Diverticulitis has got to be one of the most classic problems encountered by surgeons and medical students in their surgery rotation. In this inaugural “Clinical Challenges” episode, colorectal surgeons Scott Steele and Joshua Bleier join acute care and trauma surgeon Patrick Georgoff to discuss the important clinical pearls, starting from when you meet the patient, all the way to when you’re taking care of them after their surgery.