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Human factors in pelvic surgery

Symer, Matthew M; Keller, Deborah S
In the pelvis, anatomic complexity and difficulty in visualization and access make surgery a formidable task. Surgeons are prone to work-related musculoskeletal injuries from the frequently poor design and flow of their work environment. This is exacerbated by the strain of surgery in the pelvis. These injuries can result in alterations to a surgeons practice, inadvertent patient injury, and even early retirement. Human factors examines the relationships between the surgeon, their instruments and their environment. By bridging physiology, psychology, and ergonomics, human factors allows a better understanding of some of the challenges posed by pelvic surgery. The operative approach involved (open, laparoscopic, robotic, or perineal) plays an important role in the relevant human factors. Improved understanding of ergonomics can mitigate these risks to surgeons. Other human factors approaches such as standardization, use of checklists, and employing resiliency efforts can all improve patient safety in the operating theatre.
PMID: 35012835
ISSN: 1532-2157
CID: 5140982

Correction to: Systematic review of prospective studies focused on regionalization of care in surgical oncology

Goel, Shokhi; Symer, Matthew M; Alzghari, Talal; Nelson, Becky Baltich; Yeo, Heather L
PMID: 34081294
ISSN: 2038-3312
CID: 5140962

Systematic review of prospective studies focused on regionalization of care in surgical oncology

Goel, Shokhi; Symer, Matthew M; Alzghari, Talal; Baltich Nelson, Becky; Yeo, Heather L
To perform a systematic review of studies prospectively analyzing the impact of regionalization of complex surgical oncology care on patient outcomes. High volume care of complex surgical oncology patients has been repeatedly associated with improved outcomes. Most studies, however, are retrospective and have not prospectively accounted for confounders such as financial ability and social support. Four electronic databases (Ovid MEDLINE®, Ovid EMBASE, Cochrane Library (Wiley), and EBSCHOHost) were searched from inception until August 25, 2018. Two authors independently reviewed 5887 references, with a third independent reviewer acting as arbitrator when needed. Data extracted from 11 articles that met inclusion criteria. Risk of bias assessments conducted using MINORS criteria for the non-randomized, observational studies, and the Cochrane tool for the randomized-controlled trial. Of the 11 studies selected, we found 7 historically-controlled trials, two retrospective cohort studies with prospective data collection, one prospective study, and one randomized-controlled trial. 73% of studies were from Northern Europe, 18% from Ontario, Canada, and 9% from England. Pancreatic surgery accounted for 36% of studies, followed by gynecologic oncology (27%), thoracic surgery (18%), and dermatologic surgery (9%). The studies reported varying outcome parameters, but all showed improvement post-regionalization. Included studies featured poor-to-fair risk of bias. 11 studies indicated improved outcomes following regionalization of surgical oncology, but most exhibit poor methodological rigor. Prospective evidence for the regionalization of surgical oncology is lacking. More research addressing patient access to care and specialist availability is needed to understand the shortcomings of centralization.
PMID: 34028698
ISSN: 2038-3312
CID: 5140952

Nonoperative Treatment of Diverticulitis

Symer, Matthew; Yeo, Heather L
PMID: 34389099
ISSN: 1878-0555
CID: 5140972

Colonic Stents as a Bridge to Surgery Compared with Immediate Resection in Patients with Malignant Large Bowel Obstruction in a NY State Database

Dolan, Patrick T; Abelson, Jonathan S; Symer, Matthew; Nowels, Molly; Sedrakyan, Art; Yeo, Heather L
BACKGROUND:There is controversy surrounding the efficacy and safety of colonic stents as a bridge to surgery compared with immediate resection in patients presenting with an acute malignant large bowel obstruction. METHODS:Retrospective longitudinal cohort study using the NYS SPARCS Database. Patients with acute malignant large bowel obstruction who either had stent followed by elective surgery within 3 weeks (bridge to surgery) or underwent immediate resection between October 2009 and June 2016 in the state of New York were included. The primary outcome was rate of stoma creation at index resection. Secondary outcomes were 90-day readmission, reoperation, procedural complications, and discharge disposition. RESULTS:A total of 3059 patients were included, n = 2917 (95.4%) underwent an immediate resection and n = 142 (4.6%) underwent bridge to surgery. We analyzed 139 patients in propensity score-matched groups. Patients in the bridge to surgery group were less likely than those in the immediate resection group to get a stoma at the time of surgery (OR 0.33, 95% CI 0.18-0.60). They were also less likely to be discharged to a rehabilitation facility or require a home health aide upon discharge (OR 0.36, 95% CI 0.22-0.61). There were no differences in rates of 90-day readmission, reoperation, or procedural complications between groups. DISCUSSION:Colonic stenting as a bridge to surgery leads to less stoma creation, a significant quality of life advantage, compared with immediate resection. Patients should be counseled regarding these potential benefits when the technology is available.
PMID: 32939622
ISSN: 1873-4626
CID: 5140942

National prospective cohort study describing how financial stresses are associated with attrition from surgical residency

Dolan, Patrick T; Symer, Matthew M; Mao, Jialin I; Sosa, Julie A; Yeo, Heather L
BACKGROUND:Attrition from general surgery residency is high with a national rate of 20%. We evaluated potential associations between financial considerations and attrition. METHODS:National prospective cohort study of categorical general surgery trainees. RESULTS:Of the 1048 interns who started training in 2007, 681 (65%) had complete survey and follow-up data. In logistic regression, those with higher starting attending salary expectations (>$300K) were more likely to leave training (OR 2.9, 95% CI 1.2-6.9). Women with a partner who earned more (>$50K/year) were more likely to leave training (OR 4.1, 95% CI 1.6-10.5). In a subgroup of interns undecided about their future practice setting (academic, community, private practice, industry), those with less debt (≤$100K) were more likely to leave training (OR 2.4, 95% CI 1.1-5.2). CONCLUSIONS:Several financial matters were associated with attrition. Addressing these financial concerns may help decrease attrition in surgical training and improve surgical training.
PMID: 32200973
ISSN: 1879-1883
CID: 5140932

Does variability among surgical skills diminish throughout surgical internship? Analysis of a 5-task surgical simulation assessment program starting Day 1

Limberg, Jessica; Karnick, Aleksandrs; Bagautdinov, Iskander; Aveson, Victoria; Stefanova, Dessislava; Symer, Matthew M; Fehling, David; Fahey, Thomas J
BACKGROUND:Simulation assessments are not yet standardized among surgical programs. We instituted a 5-task simulation program to assess surgical technical skills longitudinally during internship. METHODS:First-year residents completed 5 simulation tasks: suturing, knot-tying, vascular anastomosis, and the peg-transfer and the intracorporeal suturing of the Fundamentals of Laparoscopic Skills. Assessments occurred just before residency, mid-year, and at the completion of the intern year. RESULTS:This study involved 19 residents: 8 categorical, 4 urology, 3 interventional radiology, 2 plastics, and 2 non-designated preliminary interns. Mean completion times improved in both the Fundamentals of Laparoscopic Skills peg-transfer (145 ± 50, 111 ± 47, and 95 ± 28 seconds) and suturing (526 ± 92, 392 ± 131, and 351 ± 158 seconds; each P < .001) tasks, and decreased variability was noted in the former. Total scores trended to improve (P = .013). Interns underwent similar training; 95% completed at least 1 core rotation by mid-year. Surgical specialty was associated with total scores during the first knot-tying session, with plastics residents scoring highest; however, all scores progressed toward the group median over time. CONCLUSION/CONCLUSIONS:Technical skills of beginning surgery residents were assessed longitudinally with the institution of a 5-task curriculum. Periodic assessments showed improvement in each task. Furthermore, as residents were exposed to equal surgical training, the variability in resident scores showed the greatest decrease in simpler motor tasks.
PMID: 31879091
ISSN: 1532-7361
CID: 5140922

Case Sequence Analysis of the Robotic Colorectal Resection Learning Curve

Symer, Matthew M; Sedrakyan, Art; Yeo, Heather L
BACKGROUND:Robotic surgery for colorectal cancer offers many potential benefits, but as with any new technology, there is a learning curve. OBJECTIVE:We sought to identify trends in the uptake of robotic resection and associated complication rates. DESIGN:This was a case sequence analysis of robotic surgery for colorectal cancer. SETTINGS:The study was conducted using the New York Statewide Planning and Research Cooperation System database. PATIENTS:Adults undergoing colorectal resection for cancer from 2008 through 2016 were identified in the New York Statewide Planning and Research Cooperative database. Case sequence analysis was used to describe surgeon experience, with cases grouped into quartiles based on the chronological order in which each surgeon performed them. MAIN OUTCOME MEASURES:Outcomes included in-hospital major events (myocardial infarction, pulmonary embolism, shock, and death) and iatrogenic complications. Generalized linear mixed models were used to estimate the relationship between case sequence and operative outcomes. RESULTS:A total of 2763 robotic procedures were included, with volume increasing from 76 cases in 2010 to 702 cases in 2015. The proportion of cases performed by surgeons earliest in their learning curve has increased to 18.2% in 2015. This quartile was composed of more black patients (11.4% earliest quartile vs 7.0% latest quartile; p < 0.001) and rectal resections (50.1% earliest quartile vs 38.9% latest quartile; p < 0.001). In adjusted analysis, major complications did not improve with increasing case sequence. However, with increasing cumulative surgeon case sequence iatrogenic complications were reduced, particularly in the highest volume quartile (OR = 0.29 (95% CI, 0.09-0.88); p = 0.03). Odds of prolonged length of stay (>75 percentile) were also decreased (OR = 0.50 (95% CI, 0.37-0.69); p < 0.001). LIMITATIONS:Data were derived from an administrative database. CONCLUSIONS:Robotic colorectal resection has been rapidly adopted. Surgeons earliest in their experience have increased iatrogenic complications and continue to make up a large proportion of cases performed. See Video Abstract at ANÁLISIS DE SECUENCIA DE CASOS DE LA CURVA DE APRENDIZAJE DE RESECCIÓN ROBÓTICA COLORRECTAL: La cirugía robótica para el cáncer colorrectal ofrece muchos beneficios potenciales, pero como con cualquier nueva tecnología, presenta una importante curva de aprendizaje. OBJETIVO:Se buscó identificar tendencias en la aceptación de la resección robótica y las tasas de complicaciones asociadas. DISEÑO:: Análisis de secuencia de casos de cirugía robótica para cáncer colorrectal AJUSTES:: Base de datos del Sistema de Cooperación para la Investigación y la Planificación del Estado de Nueva York. PACIENTES:Los adultos que se sometieron a una resección colorrectal en caso de cáncer desde 2008 hasta 2016 se identificaron en la base de datos de la Cooperativa de Investigación y Planificación del Estado de Nueva York. Se utilizó un análisis de secuencia de casos para describir la experiencia del cirujano, y los casos se agruparon en cuartiles según el orden cronológico en el que cada cirujano los operó. RESULTADOS PRINCIPALES:Los resultados incluyeron los eventos intrahospitalarios mayores (infarto de miocardio, embolia pulmonar, shock y muerte) y las complicaciones iatrogénicas. Se utilizaron modelos lineales generalizados mixtos para estimar la relación entre la secuencia de casos y los resultados operativos. RESULTADOS:Se incluyeron un total de 2.763 procedimientos robóticos, con un aumento del volumen de 76 casos en 2010 a 702 casos en 2015. La proporción de casos realizados por cirujanos en su primera curva de aprendizaje aumentó a 18.2% en 2015. Este cuartil estaba compuesto por una mayoría de pacientes de color (11.4% en el cuartil más temprano versus 7.0% en el último cuartil, p < 0.001) y de resecciones rectales (50.1% en el primer cuartil vs 38.9% en el último cuartil, p < 0.001). En el ajuste del análisis, las complicaciones mayores no mejoraron al aumentar la secuencia de casos. Sin embargo, al aumentar la secuencia acumulada de casos de cirujanos, se redujeron las complicaciones iatrogénicas, particularmente en el cuartil de mayor volumen (OR = 0,29; IC del 95%: 0,09 a 0,88; p = 0,03). Las probabilidades de una estadía hospitalaria prolongada (> percentil 75) también disminuyeron (OR 0,50; IC del 95%: 0,37 a 0,69; p < 0,001). LIMITACIONES:Los valores fueron derivados desde una base de datos administrativa. CONCLUSIONES:La resección colorrectal robótica ha sido adoptada rápidamente. Los cirujanos durante su experiencia inicial han presentado un elevado número de complicaciones iatrogénicas y éstas representan todavía, una gran proporción de casos realizados. Vea el Resumen del Video en
PMID: 31318771
ISSN: 1530-0358
CID: 5140912

Assessment of Public Attitudes Toward Weight Loss Surgery in the United States

Dolan, Patrick; Afaneh, Cheguevara; Symer, Matthew; Dakin, Gregory F; Pomp, Alfons; Yeo, Heather
PMID: 30540344
ISSN: 2168-6262
CID: 5140902

Barriers to Regionalized Surgical Care: Public Perspective Survey and Geospatial Analysis

Symer, Matthew M; Abelson, Jonathan S; Yeo, Heather L
OBJECTIVE:To describe public willingness to participate in regionalized surgical care for cancer. SUMMARY OF BACKGROUND DATA:Improved outcomes at high-volume centers following complex surgery have driven a push to regionalize surgical care. Patient attitudes toward regionalization are not well described. METHODS:As part of the Cornell National Social Survey, a cross-sectional telephone survey was performed. Participants were asked about their willingness to seek regionalized care in a hypothetical scenario requiring surgery. Their responses were compared with demographic characteristics. A geospatial analysis of hospital proximity was performed, as well as a qualitative analysis of barriers to regionalization. RESULTS:Cooperation rate was 48.1% with 1000 total respondents. They were an average of 50 years old (range 18 to 100 years) and 48.9% female. About 49.6% were unwilling to travel 5 hours or more to seek regionalized care for improved survival. Age >70 years [odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.19-0.60] and perceived distance to a center >30 minutes (OR 0.60, 95% CI 0.41-0.86) were associated with decreased willingness to seek regionalized care, while high income (OR 2.09, 95% CI 1.39-3.16) was associated with increased willingness. Proximity to a major center was not associated with willingness to travel (OR 0.92, 95% CI 0.67-1.22). Major perceived barriers to regionalization were transportation, life disruption, social support, socioeconomic resources, poor health, and remoteness. CONCLUSION:Americans are divided on whether the potential for improved survival with regionalization is worth the additional travel effort. Older age and lower income are associated with reduced willingness to seek regionalized care. Multiple barriers to regionalization exist, including a lack of knowledge of the location major centers.
PMID: 29064896
ISSN: 1528-1140
CID: 5140802