Faculty Bibliography
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13
Promoting Specialty Diversity in Hospice and Palliative Medicine: A Call to Action [Editorial]
PMID: 36775535
ISSN: 1873-6513
CID: 5505352
Annual Structured Communication Skills Training for Surgery Residents
INTRODUCTION:There is no formalized communication curriculum for surgical training. The aim of this study is to determine the benefit of annual communication skill-building workshops for surgical residents over several years. METHODS:The general surgery and the integrated cardiothoracic surgery residents in a tertiary care, urban academic center participated in a 2-hour communication skill-building workshop each year from July 2017 to June 2021. Each participant was administered an anonymous pre-session and post-session survey with a 5-point Likert scale to assess their self-reported preparedness and their evaluation of the workshop. Survey responses were divided into three groups based on their experience in this workshop; no experience (Experience 0), 1 y of experience (Experience 1), and two or more years of experience (Experience 2+). They were compared among groups. RESULTS:Seventy-one surgical residents participated in the workshop generating 124 survey results (Experience 0, 71 [57.3%], Experience 1, 41 [33.1%], and Experience 2+, 12 [9.7%]). Self-reported preparedness scores improved for the overall group as well as for each experience group. While scores decreased significantly in the following years, they improved after each workshop. Scores were significantly better with more experience (4, interquartile range [IQR] 3-4 in Experience 0, 4, IQR 3-5 in Experience 1, 4, IQR 4-5 in Experience 2+, P < 0.001 between Experience 0 and Experience 1, P = 0.041 between Experience 1 and Experience 2+). All residents reported an overwhelmingly positive review of the curriculum. CONCLUSIONS:Yearly 2-hour communication skills practice increased surgical residents' self-reported preparedness, and the repetition helped the improvement. Annual workshops are important for residents to be more prepared for serious illness communication.
PMID: 36228342
ISSN: 1095-8673
CID: 5505342
The Safety and Efficacy of Tracheostomy in Patients Diagnosed With COVID-19: An Analysis of 143 Patients at a Major NYC Medical Center
OBJECTIVE:To determine the optimal surgical strategy for performing tracheostomy in COVID-19 patients. BACKGROUND:Many ventilated COVID-19 patients require prolonged ventilation. We do not know if tracheostomy will improve their care. Given the paucity of data on this topic, the optimal surgical approach has yet to be elucidated. METHODS:This is a cohort study of 143 ventilator dependent COVID-19 patients undergoing tracheostomy at an academic medical center from April 15th to May 15th, 2020, with follow up until June 1, 2020. We included adult patients admitted to a NYC medical center with COVID-19 who required invasive mechanical ventilation for greater than 2 weeks who were unable to be extubated and determined to have reasonable chance of recovery and fit defined tracheostomy candidate criteria. Patients underwent either a percutaneous tracheostomy (PT) or open surgical tracheostomy (ST) performed by 1 of 3 surgical services. RESULTS:One hundred forty-three patients underwent tracheostomy, 58 (41%) via a ST, and 85 (59%) via a PT. There were no significant differences in patient characteristics between the 2 groups, except that more patients who had a history of extracorporeal membrane oxygenation underwent PT (11% vs 2%, P = 0.049). There were no statistical differences observed between the PT and ST groups with regard to bleeding complications (3.5%vs 10.3%, P = 0.099), tracheostomy related complications (5.9% vs 8.6%, P = 0.528), inpatient death (12% vs 5%, P = 0.178), discharge from hospital (39% vs 36%, P = 0.751) or surgeon illness (0% vs 0%, P = 1). CONCLUSION AND RELEVANCE:The rapid formation of a multi-disciplinary team allows for the efficient evaluation and performance of a large volume of tracheostomies in a resource-limited setting. Bedside tracheostomy in COVID-19 does not cause additional harm to patients if performed after 2 weeks from intubation. It also seems to be safe for proceduralists to perform in this timeframe. The manner of tracheostomy does not change outcomes significantly if it is performed safely and efficiently.
PMID: 33214455
ISSN: 1528-1140
CID: 5505322
Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis
Importance/UNASSIGNED:Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days. Identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics could support more individualized decision-making. Objective/UNASSIGNED:To assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis. Design, Setting, and Participants/UNASSIGNED:In this cohort study using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial, characteristics among patients who initiated antibiotics were compared between those who did and did not undergo appendectomy within 30 days. The study was conducted at 25 US medical centers; participants were enrolled between May 3, 2016, and February 5, 2020. A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Data were analyzed from September 2020 to July 2021. Exposures/UNASSIGNED:Appendectomy vs antibiotics. Main Outcomes and Measures/UNASSIGNED:Conditional logistic regression models were fit to estimate associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for nonclinical reasons. Results/UNASSIGNED:Of 776 participants initiating antibiotics (mean [SD] age, 38.3 [13.4] years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days. After adjustment for other factors, female sex (odds ratio [OR], 1.53; 95% CI, 1.01-2.31), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09; 95% CI, 1.00-1.18), and presence of appendicolith (OR, 1.99; 95% CI, 1.28-3.10) were associated with increased odds of undergoing appendectomy within 30 days. Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28; 95% CI, 0.82-1.98) were not associated with odds of 30-day appendectomy. The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41; 95% CI, 1.49-3.91). Conclusions and Relevance/UNASSIGNED:This cohort study found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis were not associated with odds of 30-day appendectomy. This information may help guide more individualized decision-making for people with appendicitis.
PMID: 35019975
ISSN: 2168-6262
CID: 5118772
Joint Commission journal on quality & patient safety. 2022:48(6-7):319-325.DOI: 10.1016/j.jcjq.2022.03.001
Reduction of Unnecessary Gastrostomy Tube Placement in Hospitalized Patients
BACKGROUND:Many patients undergoing gastrostomy tube placement at one academic medical center were able to resume an oral diet prior to discharge or did not survive hospitalization. The objective of this study was to reduce placement of nonbeneficial gastrostomy tubes and to maintain or improve adherence to gastrostomy tube guidelines. METHODS:In February 2017 the Acute Care Surgery service began an initiative in which gastrostomy tube placement was deferred until the patient was deemed medically stable for discharge. This study retrospectively reviewed all patients who underwent percutaneous endoscopic gastrostomy (PEG) tube placement at Columbia University Irving Medical Center, January 2014-January 2017, prior to the intervention, and February 2017-December 2019, after the intervention. Primary outcomes included the proportion of patients undergoing PEG tube placement who resumed an oral diet or who died during the index hospital stay. Secondary outcomes included the timing of the PEG tube placement. RESULTS:PEGs were placed in 240 patients in the preintervention period and in 171 patients in the postintervention period. In the postintervention period, there was a lower percentage of patients resuming oral diet after PEG placement (17.1% vs. 7.6%, p = 0.0049), a lower duration between stroke diagnosis and PEG placement (mean of 21.0 days vs. 17,1 days, p = 0.0305), and a lower duration between PEG placement and hospital discharge (mean of 19.7 days vs. 13.6 days, p = 0.0035). CONCLUSION:Intentional delay in PEG placement until patients were medically stabilized and approaching discharge was associated with a reduction in unnecessary procedures and an overall reduction in the number of procedures, while maintaining alignment with clinical guidelines and avoiding delays in discharge attributable to the procedure.
PMID: 35418335
ISSN: 1938-131x
CID: 5505332
Antibiotics versus Appendectomy for Acute Appendicitis - Longer-Term Outcomes [Letter]
PMID: 34694761
ISSN: 1533-4406
CID: 5042232
A Complex History: Reckoning With Prejudice in Surgery's Past [Historical Article]
PMID: 33214431
ISSN: 1528-1140
CID: 5505312
Developing an Algorithm to Guide Resumption of Operative Activity in the COVID-19 Pandemic and Beyond
PMID: 32541231
ISSN: 1528-1140
CID: 4484602
Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study
BACKGROUND:The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. METHODS:This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. FINDINGS:This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047). INTERPRETATION:Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. FUNDING:National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
PMID: 32479829
ISSN: 1474-547x
CID: 4851402
Robotic-Assisted Transabdominal Preperitoneal Ventral Hernia Repair
Ventral hernia repair is one of the most common operations performed by surgeons worldwide. The widespread adoption of laparoscopic surgery has significantly reduced complications related to traditional open approaches. The most common approach in laparoscopic ventral hernia repair is the intraperitoneal onlay mesh (IPOM) approach. This technique, though simple to perform, has limitations, including bridging mesh, intraperitoneal positioning of mesh, transfascial fixation, circumferential mesh fixation, and the use of more expensive composite mesh materials. These limitations are magnified when hernias occur in anatomically difficult sites such as the subxiphoid, suprapubic, and flank regions. Robotic-assisted hernia repair using a transabdominal preperitoneal (TAPP) approach has emerged as a viable alternative to traditional IPOM by potentially addressing these limitations. We review the operative considerations, intraoperative approach, and current body of literature related to robotic-assisted TAPP ventral hernia repair and conclude that it is feasible and may result in improved outcomes related to the restoration of abdominal wall anatomy and reduced operative costs. Further studies are needed to assess if robotic-assisted TAPP should become the standard approach for repair of ventral hernia defects.
PMID: 32196564
ISSN: 1090-3941
CID: 5505302
