Faculty Bibliography

BACKGROUND:With each succession along the surgical career pathway, from medical school to faculty, the percentage of those who identify as underrepresented in medicine (URiM) decreases. We sought to evaluate the demographic trend of surgical fellowship applicants, matriculants, and graduates over time. STUDY DESIGN:The Electronic Residency Application Service and the Graduate Medical Education Survey for general surgery fellowships in colorectal surgery, surgical oncology, pediatric surgery, thoracic surgery, and vascular surgery were retrospectively analyzed (2005 to 2020). The data were stratified by race and gender, descriptive statistics were performed, and time series were evaluated. Race/ethnicity groups included White, Asian, other, and URiM, which is defined as Black/African American, Hispanic/Latino(a), Alaskan or Hawaiian Native, and Native American. RESULTS:From 2005 to 2020, there were 5,357 Electronic Residency Application Service applicants, 4,559 matriculants, and 4,178 graduates to surgery fellowships. Whites, followed by Asians, represented the highest percentage of applicants (62.7% and 22.3%, respectively), matriculants (65.4% and 23.8% respectively), and graduates (65.4% and 24.0%, respectively). For URiMs, the applicants (13.4%), matriculants (9.1%), and graduates (9.1%) remained significantly low (p < 0.001). When stratified by both race and gender, only 4.6% of the applicants, 2.7% of matriculants, and 2.4% of graduates identified as both URiM and female compared to White female applicants (20.0%), matriculants (17.9%), and graduates (16.5%, p < 0.001). CONCLUSIONS:Significant disparities exist for URiMs in general surgery subspecialty fellowships. These results serve as a call to action to re-examine and improve the existing processes to increase the number of URiMs in the surgery subspecialty fellowship training pathway.

BACKGROUND:Adequate treatment requires control of hemorrhage and restoration of bile flow. Surgery is the last resort and is indicated when the other modalities fail. METHODS:A 65-year-old man with multiple comorbidities was admitted with cholangitis. The patient underwent PTBD (Figure 1) but had persistent cholestasis. Thus, he underwent endoscopic cholangiopancreatography (ERCP), in which a plastic stent was misplaced within the common bile duct (CBD) and could not be removed (Figure 2). Afterwards, as the patient had persistently high bilirubin levels and the previously placed stent was malpositioned, the decision was made to proceed with laparoscopic cholecystectomy and CBD exploration. RESULTS:The operation was performed with choledocoscope guidance, and the CBD was closed over a T-tube. The operative time was 280 min. Postoperative course was uneventful; the T-tube was clamped 1 week after discharge. Four weeks postoperatively, the T-tube cholangiogram showed a patent extrahepatic biliary tree with no filling defects (Figure 3). The T-tube was then removed. CONCLUSIONS:Biliary obstruction secondary to hemobilia is a rare occurrence after PTBD. Surgical CBD exploration is required when conservative management and endoscopic treatment fail and can be done successfully through a minimally invasive approach.

BACKGROUND:Portomesenteric vein thrombosis (PMVT) may occur after laparoscopic sleeve gastrectomy (LSG). Previous studies have shown that PMVT patients may have undiagnosed thrombophilia. We recently changed our practice to check thrombophilia panel in every LSG patient preoperatively. OBJECTIVES/OBJECTIVE:To estimate the thrombophilia prevalence in patients seeking LSG, and determine if extended chemoprophylaxis post LSG reduces PMVT. SETTINGS/METHODS:University hospital. METHODS:Thrombophilia panels were drawn on every patient seeking LSG after July 2018 at 2 high-volume accredited bariatric surgery centers. A positive panel included factor VIII >150%; protein C <70%; protein S <55%; antithrombin III <83%; and activated protein C resistance <2.13. Patients with a positive panel were discharged on extended chemoprophylaxis. PMVT rates and bleeding occurrences were recorded for LSG patients from August 2018 to March 2019 and were compared with a historic cohort of LSG performed from January 2014 to July 2018. RESULTS:, respectively. Of the cohort, 52.4% (563/1075) had positive thrombophilia panel, including factor VIII elevation (91.5%), antithrombin III deficiency (6.0%), protein S deficiency (1.1%), protein C deficiency (.9%), and activated protein C resistance (.5%). Between January 2014 and July 2018, 13 PMVT were diagnosed among 4228 LSG (.3%) and there were 17 bleeding occurrences (.4%). After August 2018, one PMVT was diagnosed among 745 LSG (.1%) and there were 5 bleeding occurrences (.6%). CONCLUSIONS:The estimated thrombophilia prevalence in patients seeking LSG is 52.4%. The majority (91.5%) of these patients have factor VIII elevation. Extended prophylaxis may decrease PMVT postLSG.

BACKGROUND:. At 3-year follow-up, surgery was very effective in T2D remission; furthermore, in the surgical group, those with a higher baseline soluble receptor for advanced glycation end products had a lower postoperative BMI. OBJECTIVES/OBJECTIVE:To provide long-term follow-up of this initial patient cohort. SETTING/METHODS:University Hospital. METHODS:Retrospective chart review was performed of the initial patient cohort. Patients lost to follow-up were systematically contacted to return to clinic for a follow-up visit. Data were compared using 2-sample t test, Fisher's exact test, or analysis of variance when applicable. RESULTS:; P = .007), and higher percent weight loss (21.4% versus 10.3%; P = .025). Baseline soluble receptor for advanced glycation end products was not associated with long-term outcomes. CONCLUSIONS:remains effective long term. Baseline soluble receptor for advanced glycation end products are most likely predictive of early outcomes only.

Background: The majority of patients having bariatric surgery are reproductive-age women who are advised to delay pregnancy for at least 12 months after surgery. Many women become pregnant sooner and the association between gestational weight gain (GWG) and maternal long-term weight is unknown.Objectives: The primary objective of this study was to compare weight outcomes in pregnancies occurring < 12 months versus ≥ 12 months after bariatric surgery. The secondary objectives were to determine the association between time interval from bariatric surgery to pregnancy and maternal nutritional status and maternal and neonatal outcomes.Study design: This is a retrospective cohort study of women with singleton livebirths after bariatric surgery who received care at a single tertiary care center between 2009 and 2017. GWG was the difference in weight between the first prenatal visit and delivery. GWG adequacy was determined by the IOM 2009 guidelines according to prepregnancy BMI (inadequate, adequate, excessive). Postpartum weight retention was calculated as the difference between weight at first prenatal visit and measured postpartum weight. Weight outcomes along with maternal nutritional status and maternal and neonatal outcomes were compared between < 12 months versus ≥ 12 months after bariatric surgery with t-tests, Mann-Whitney U and chi-square tests, as appropriate.Results: Of the 76 pregnancies that met inclusion criteria, 36.8% occurred < 12 months (median 7.2 months) and 63.2% occurred ≥ 12 months after surgery (median 26.9 months). Of those with pregnancies < 12 months from surgery, 34% had a restrictive procedure (adjustable gastric band or sleeve gastrectomy) while 66% had a combined restrictive-malabsorptive procedure (Roux-en-Y gastric bypass). In the ≥ 12 months group, 42.3% had a restrictive procedure while 57.7% had a combined restrictive-malabsorptive procedure. There were no significant differences in maternal age, ethnicity or nulliparity between groups, but there were more women with obesity in the < 12 months group (75 vs. 52%, p = .03). The mean prepregnancy BMI in the < 12 months group was 34.3 vs. 31.2 kg/m² in the ≥ 12 months group. The < 12 months group had lower mean GWG (4.9 vs. 10.9 kg, p = .01) and higher frequency of weight loss during pregnancy (28.6 vs. 4.2%, p < .01) compared to the ≥ 12 months group. The < 12 months group had significantly less postpartum weight retention at 6 months compared to the ≥ 12 months group (-1.3 vs. 8.3 kg, p = .02). The < 12 months group had a higher prevalence of vitamin B12 deficiency (23.1 versus 4.9%, p = .05). There were no differences in hyperemesis, hypertensive disorders, gestational diabetes or delivery mode between groups (p > .05). There were no differences in gestational age at delivery, birth weight and small for gestational age infants between groups (p > .05).Conclusion: Pregnancy < 12 months after bariatric surgery is associated with significantly lower mean GWG and a higher frequency of weight loss during pregnancy as well as less postpartum weight retention at 6 months. Although there were no differences birthweight, weight loss during pregnancy and its accompanying metabolic changes are concerning for a developing fetus. Further study is needed to determine the optimal timing of pregnancy after bariatric surgery with respect to both maternal and infant short and long-term outcomes.

Introduction: Numerous barriers prevent surgical faculty from leveraging existing evaluation systems to assess resident operative skill. Training programs disproportionately rely on lengthy, end-of-rotation assessments which are inconsistently completed, lack specifics pertaining to operative technique, and are subject to recall bias. Existing solutions for procedure-based evaluations require trainees to proactively seek out faculty - an unreliable and socially-awkward process. We designed a novel tool to improve procedural assessment efficacy by leveraging the electronic health record (EHR) to trigger questionnaires and link assessments to specific patient encounters using a mobile application that overcomes existing obstacles to completing operative skill assessments.
Method(s): The real-time resident assessment (RETRA) tool was deployed across an academic surgical department in August 2018. The "out-of-operating room (OR)" EHR event triggered push notifications to faculty smartphones, launching a survey with questions from the American Board of Surgery Operative Performance Rating System. We compared assessment volume, compliance, and dashboard usability around the implementation of RETRA.
Result(s): Comparing 5-month intervals before and after RETRA deployment, we observed increased volume of procedural assessments and improved faculty compliance. Additionally, dashboard interfaces of cumulative RETRA data offered improved user experiences over previous systems, as measured by an industry-standard usability scale.
Conclusion(s): RETRA represents a novel approach to automating assessment of resident operative performance, overcomes existing barriers, and increases volume of technical performance data. While some features of RETRA overlap with previously described electronic assessment applications, we believe this represents a first-in-kind iteration that combines a mobile interface, automated EHR-mediated triggers, and preserved linkage between clinical data and resident assessments.
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BACKGROUND: Portomesenteric vein thrombosis (PMVT) has been increasingly reported after laparoscopic sleeve gastrectomy (LSG). Factor VIII (FVIII) is a plasma sialoglycoprotein that plays an essential role in hemostasis. There is increasing evidence that FVIII elevation constitutes a clinically important risk factor for venous thrombosis. OBJECTIVES: To report the prevalence of FVIII elevation as well as other clinical characteristics in a multicenter series of patients who developed PMVT after LSG. SETTING: University hospitals. METHODS: A retrospective review was conducted of all patients that developed PMVT after laparoscopic bariatric surgery from 2006 to 2016 at 6 high-volume bariatric surgery centers. RESULTS: Forty patients who developed PMVT postoperatively, all after LSG, were identified. During this timeframe, 25,569 laparoscopic bariatric surgery cases were performed, including 9749 LSG (PMVT incidence after LSG = .4%). Mean age and body mass index were 40 years (18-65) and 43.4 kg/m2 (35-59.7), respectively. Abdominal pain was the most common (98%) presenting symptom. Of patients, 92% had a hematologic abnormality identified, and of these, FVIII elevation was the most common (76%). The vast majority (90%) was successfully managed with therapeutic anticoagulation alone. A smaller number of patients required small bowel resection (n = 2) and surgical thrombectomy (n = 1). There were no mortalities. CONCLUSIONS: A high index of clinical suspicion and prompt diagnosis/treatment of PMVT usually leads to favorable outcomes. FVIII elevation was the most common (76%) hematologic abnormality identified in this patient cohort. Further studies are needed to determine the prevalence of FVIII elevation in patients seeking bariatric surgery.

Importance: As the problem of obesity continues to grow, more patients are choosing to undergo bariatric surgery to lose weight and treat comorbidities, such as diabetes. Of the more than 200,000 procedures performed each year, 80% are in women, many of reproductive age. Taking care of a pregnant woman who has undergone bariatric surgery requires understanding of the risks, the need for additional surveillance, and the limitations of our knowledge about how bariatric surgery affects pregnancy. Objective: The aims of this study were to review the current literature on bariatric surgery and pregnancy and summarize the important evidence to help the obstetrician care for a pregnant woman after bariatric surgery. Evidence Acquisition: Evidence for this review was acquired using PubMed. Conclusions: Pregnancy after bariatric surgery is safe and may be associated with improved pregnancy outcomes; however, more research is needed to better understand how to manage pregnant women with a history of bariatric surgery. Relevance: Obstetricians will increasingly be caring for women who have undergone bariatric surgery and subsequently become pregnant.

BACKGROUND: There is debate regarding preoperative endoscopy (EGD) in patients undergoing bariatric surgery. Some centers perform EGD routinely in all patients; others perform EGD selectively. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to estimate how frequently preoperative EGD changes management. METHODS: Our review yielded 28 studies encompassing 6616 patients. Baseline characteristics including age and body mass index (BMI) were included. Patients were grouped based on EGD findings into two groups: Group 1-findings which did not significantly change management (e.g., mild/moderate duodenitis, Grade A/B esophagitis, mild/moderate gastritis, H. pylori infection, hiatal hernia <2 cm); Group 2-findings which delayed, altered, or cancelled surgery (e.g., severe duodenitis, Grade C/D esophagitis, gastric varices, hiatal hernia >2 cm, mass/carcinoma). A general estimating equation (GEE) model accounting for the correlated data within each study was used to calculate confidence intervals around the estimate of how frequently surgery was delayed or altered. RESULTS: Mean age was 41.4 +/- 2.9 years, the majority was women, and mean preoperative BMI was 47 +/- 3.2 kg/m2. Overall 92.4 % (n = 6112) had a normal EGD or findings that did not change clinical management and 7.6 % (n = 504); 95 % CI [4.6, 12.4 %] had findings that delayed/altered surgery. The revised estimate was 20.6 %; 95%CI [14.5, 28.2 %] if all esophagitis (regardless of grade) were categorized into Group 2. The approximate incidence of Barrett's esophagus and carcinoma were 0.1 and 0.08 %, respectively. CONCLUSION: A selective approach to preoperative EGD may be considered, based on the patients' symptoms, risk factors, and type of procedure planned.

BACKGROUND: Patients with type 2 diabetes (T2D) and body mass index (BMI)<35 may benefit from metabolic surgery. The soluble form of the receptor for advanced glycation end products (sRAGE) may identify patients at greater chance for T2D remission. OBJECTIVES: To study long-term outcomes of patients with T2D and BMI 30-35 treated with metabolic surgery or medical weight management (MWM) and search for predictors of T2D remission. SETTING: University METHODS: Retrospective review of the original cohort, including patients who crossed over from MWM to surgery. Repeated-measures linear models were used to model weight loss (%WL), change in glycated hemoglobin (HbA1C) and association with baseline sRAGE. RESULTS: Fifty-seven patients with T2D and BMI 30-35 were originally randomly assigned to metabolic surgery versus MWM. Mean BMI and HbA1C was 32.6% and 7.8%, respectively. A total of 30 patients underwent surgery (19 sleeves, 8 bypasses, 3 bands). Three-year follow-up in the surgery group and MWM group was 75% and 86%, respectively. Surgery resulted in higher T2D remission (63% versus 0%; P<.001) and lower HbA1C (6.9% versus 8.4%; P<.001) for up to 3 years. There was no difference in %WL in those with versus those without T2D remission (21.7% versus 20.6%, P = .771), suggesting that additional mechanisms other than %WL play an important role for the studied outcome. Higher baseline sRAGE was associated with greater change in HbA1C and greater %WL after surgery (P< .001). CONCLUSION: Metabolic surgery was effective in promoting remission of T2D in 63% of patients with BMI 30-35; higher baseline sRAGE predicted T2D remission with surgery. Larger-scale randomly assigned trials are needed in this patient population.