BACKGROUND:Artificial intelligence (AI)-powered platforms may be used to ensure that clinically significant lung nodules receive appropriate management. We studied the impact of a commercially available AI natural language processing tool on the detection of clinically significant indeterminate pulmonary nodules (IPNs) based on radiology reports and provision of guideline-consistent care.STUDY DESIGN:All CT scans performed at a single tertiary care center in the outpatient or emergency room setting between February 20, 2024, and March 20, 2024, were processed by the AI natural language processing algorithm. CT radiology reports mentioning a lung nodule or focal indeterminate lesion were flagged. All flagged reports were reviewed by a lung nodule expert 2 weeks after nodule identification. IPNs were classified as "appropriately followed" if follow-up imaging, referral to a nodule clinic, or other guideline-consistent care was ordered. IPNs were classified as "not appropriately followed" if no acknowledgment of the reported nodule was documented in the electronic health record within 2 weeks of being flagged.RESULTS:The AI software processed 76,507 unique radiology reports, identified 2,585 CT scans with chest imaging, and found 389 IPNs. Review determined that 272 (70%) nodules were appropriately followed, whereas 117 (30%) were not appropriately followed. Of the 117 nodules without documented follow-up, 67 (57%) were more than 8 mm and 24 (20.5%) were more than 15 mm. IPNs that would not have received follow-up in the absence of the AI software generated 43 additional clinical appointments and 3 procedures.CONCLUSIONS:At a large tertiary care center, 30% of clinically significant incidental pulmonary nodules that would have otherwise been missed were brought to the attention of lung nodule clinicians by an AI software, allowing for initiation of appropriate follow-up.

The American College of Surgeons, the American Board of Surgery, and the American Surgical Association have created a Blue Ribbon Committee II to evaluate the current status of surgical education in the United States. As part of this endeavor, a subcommittee was formed to address issues pertinent to the development of surgical faculty as teachers. This entailed multiple discussions among a group of experienced surgical educators, a review of the literature, and a Delphi analysis of possible suggested improvements for faculty educational support, resulting in a final set of recommendations for improvement for future surgical faculty development. These recommendations include a task force to establish a validated system of compensation for faculty teaching, a task force to determine an accurate assessment of the value of surgical trainees to health systems, a review by the Surgical Residency Review Committee and the Association of Program Directors in Surgery of minimal faculty resources for program accreditation in the area of teaching learners, collaborative efforts across surgical specialties for the definition of a national curriculum for faculty, and development of a tool for evaluation of faculty teaching performance.

BACKGROUND:The Glasgow Outcome Scale Extended (GOSE) is a measure of recovery after traumatic brain injury (TBI). Public surveys rate some GOSE states as worse than death. Direct family experience caring for patients with TBI may impact views of post-TBI disability. STUDY DESIGN:We conducted a national cross-sectional computer-adaptive survey of surrogates of TBI dependents incurring injury more than 1 year earlier. Using a standard gamble approach in randomized order, surrogates evaluated preferences for post-TBI GOSE states from GOSE 2 (bedridden, unaware) to GOSE 8 (good recovery). We calculated median (interquartile range [IQR]) health utilities for each post-TBI state, ranging from -1 to 1, with 0 as reference (death = GOSE 1), and assessed sociodemographic associations using proportional odds logistic regression modeling. RESULTS:Of 515 eligible surrogates, 298 (58%) completed scenarios. Surrogates were median aged 46 (IQR 35 to 60), 54% married, with Santa Clara strength of faith 14 (10 to 18). TBI dependents had a median GOSE5 (3 to 7). Median (IQR) health utility ratings for GOSE 2, GOSE 3, and GOSE 4 were -0.06 (-0.50 to -0.01), -0.01 (-0.30 to 0.45), and 0.30 (-0.01 to 0.80), rated worse than death by 91%, 65%, and 40%, respectively. Surrogates rated GOSE 4 (daily partial help) worse than the general population. Married surrogates rated GOSE 4 higher (p < 0.01). Higher strength of faith was associated with higher utility scores across GOSE states (p = 0.034). CONCLUSIONS:In this index study of surrogate perceptions about disability after TBI, poor neurologic outcomes-vegetative, needing all-day or partial daily assistance-were perceived as worse than death by at least 1 in 3 surrogates. Surrogate perceptions differed from the unexposed public. Long-term perceptions about post-TBI disability may inform earlier, tailored shared decision-making after neurotrauma.

The American College of Surgeons, the American Board of Surgery, and the American Surgical Association have created a Blue Ribbon Committee II to evaluate the current status of surgical education in the United States. As part of this endeavor, a subcommittee was formed to address issues pertinent to the development of surgical faculty as teachers. This entailed multiple discussions among a group of experienced surgical educators, a review of the literature, and a Delphi analysis of possible suggested improvements for faculty educational support, resulting in a final set of recommendations for improvement for future surgical faculty development. These recommendations include a task force to establish a validated system of compensation for faculty teaching, a task force to determine an accurate assessment of the value of surgical trainees to health systems, a review by the Surgical Residency Review Committee and the Association of Program Directors in Surgery of minimal faculty resources for program accreditation in the area of teaching learners, collaborative efforts across surgical specialties for the definition of a national curriculum for faculty, and development of a tool for evaluation of faculty teaching performance.

Vanderbilt University Medical Center, Nashville, TN Disclosure Information: Nothing to disclose. Presented at the Southern Surgical Association 135th Annual Meeting, Hot Springs, VA, December 2023 Corresponding Author: Kenneth W Sharp, MD Professor of Surgery D5203 Medical Center North Vanderbilt University Medical Center Nashville TN 37232-2577 [email protected]

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has accelerated a shift toward virtual telemedicine appointments with surgeons. While this form of healthcare delivery has potential benefits for both patients and surgeons, the quality of these interactions remains largely unstudied. We hypothesize that telemedicine visits are associated with lower quality of shared decision-making. STUDY DESIGN: We performed a mixed-methods, prospective, observational cohort trial. All patients presenting for a first-time visit at general surgery clinics between May 2021 and June 2022 were included. Patients were categorized by type of visit: in-person vs telemedicine. The primary outcome was the level of shared decision-making as captured by top box scores of the CollaboRATE measure. Secondary outcomes included quality of shared decision-making as captured by the 9-item Shared Decision-Making Questionnaire and satisfaction with consultation survey. An adjusted analysis was performed accounting for potential confounders. A qualitative analysis of open-ended questions for both patients and practitioners was performed. RESULTS: During a 13-month study period, 387 patients were enrolled, of which 301 (77.8%) underwent in-person visits and 86 (22.2%) underwent telemedicine visits. The groups were similar in age, sex, employment, education, and generic quality-of-life scores. In an adjusted analysis, a visit type of telemedicine was not associated with either the CollaboRATE top box score (odds ratio 1.27; 95% CI 0.74 to 2.20) or 9-item Shared Decision-Making Questionnaire (β −0.60; p = 0.76). Similarly, there was no difference in other outcomes. Themes from qualitative patient and surgeon responses included physical presence, time investment, appropriateness for visit purpose, technical difficulties, and communication quality CONCLUSIONS: In this large, prospective study, there does not appear to be a difference in quality of shared decision making in patients undergoing in-person vs telemedicine appointments.

OBJECTIVE We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI). SUMMARY BACKGROUND DATA After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors. METHODS We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures. RESULTS Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores. CONCLUSIONS Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.

BACKGROUND: Data linking ballistics to injury are lacking. To address this data chasm, a partnership with law enforcement was developed to describe clinical outcomes from specific firearms. STUDY DESIGN: A random sample of patients with gunshot wounds over a 20-year period ending in 2015, was identified. Circumstances of incident, firearm type, and/or caliber were extracted from police reports. Data on demographics, mortality, injury severity, and clinical outcomes were collected from the trauma registry, and these datasets were linked. Firearms were stratified by velocity (high > 2,500 ft/sec; low < 1,200 ft/sec) and caliber (large = .40 and .45; small = .20 and .25) and compared over time. RESULTS: Police reports were obtained on 366 patients who had a gun type or caliber documented. The majority were male (82%) with a median age of 28 years. Twenty-one percent of patients had an Injury Severity Score > 25, 60% required immediate operative intervention, and overall mortality was 13%. The use of large caliber firearms increased from 4% (1996 to 2000) to 33% (2011 to 2015); small caliber guns decreased from 33% to 7% over the same time period (p < 0.0001). High velocity firearm usage significantly increased (p = 0.0320). Recovered shell casings doubled from the first decade to the second (2 vs 4; p = 0.0006). Both median New Injury Severity Score (p = 0.0488) and hospital days (p = 0.0321) increased from 1996 to 2015. CONCLUSIONS: Larger caliber and higher velocity firearms have significantly increased over the past 20 years in conjunction with injury severity, hospital days, and mean number of gun-related homicides per year (112 in 1996 to 2000 vs 143 in 2011 to 2015). Robust data sharing partnerships can be built between police and trauma centers to address the dearth of data on firearm crime and resulting injury. (C) 2019 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Background: Perforation during colonoscopy is a rare but well recognized complication with significant morbidity and mortality. We aim to systematically review the currently available literature concerning care and outcomes of colonic perforation. An algorithm is created to guide the practitioner in management of this challenging clinical scenario. Data sources: A systematic review of the literature based on PRISMA-P guidelines was performed. We evaluate 31 articles focusing on findings over the past 10 years. Conclusion: Colonoscopic perforation is a rare event and published management techniques are marked by their heterogeneity. Reliable conclusions are limited by the nature of the data available - mainly single institution, retrospective studies. Consensus conclusions include a higher rate of perforation from therapeutic colonoscopy when compared to diagnostic colonoscopy and the sigmoid as the most common site of perforation. Mortality appears driven by pre-existing conditions. Treatment must be tailored according to the patient's comorbidities and clinical status as well as the specific conditions during the colonoscopy that led to the perforation. (c) 2017 Elsevier Inc. All rights reserved.

O VER THE LAST few decades, operative techniques have changed rapidly as laparoscopic and endoscopic technology has been developed among various surgical disciplines. Laparoscopy met initial resistance in its adoption, as it demanded surgeons to learn new skills and alter their operative approaches. However, it has become the preferred technique among a host of general, bariatric, obstetric, and urologic procedures. Surgical technology continues to evolve rapidly, requiring surgeons to modify their surgical technique to match growing demands for less postoperative pain, shorter hospital stays, faster return to activity, and improved cosmesis. The demand for fewer incisions has led to the development of single-port laparoscopy in efforts to reduce or eliminate surgical incisions. The improved cosmesis with equivalent or reduced postoperative pain demonstrated by this technique was met with initial excitement; however, it has failed to gain widespread adoption among most surgeons.1, 2 Criticisms include the necessity to significantly alter the technique of the surgeon, a steep learning curve, and longer operative times.2, 3 In addition,Marks et al. 4 noted a higher rate of incisional hernia formation at the umbilical port site in single-port laparoscopy when compared with traditional laparoscopic cholecystectomy, as well as a trend toward higher wound complications such as seroma, cellulitis, and infection. Thus, each surgeon is called to individualize the potential morbidity of a single-port approach with the anticipated benefits to patients. Microlaparoscopic or needlescopic surgery, defined as the use of laparoscopic instruments with a diameter of 3 mm or less, offers the potential advantages of improved pain scale and cosmesis compared with traditional laparoscopic surgery using larger ports of 5 or 10 mm sizes.58 Evaluation of microlaparoscopic surgery has demonstrated similar rates of complications when compared with traditional laparoscopic techniques.9, 10 In addition, reduced rates of hernia formation and postoperative wound complications have been attributed to smaller incisions and port sites.11 One of the most important advantages microlaparoscopy affords, is a similarity in traditional laparoscopy in respect to port placement, instrument triangulation, and technique.12 Despite this similarity, there are subtle differences between the two techniques that do call for some adjustment by the surgeon. Concerns have arisen around the use of smaller, finer instruments, which are associated with difficult tissue grasping and manipulation. In addition, the smaller instruments are thought to be subject to bending and breaking in obese patients.1315 To date, the patient population and procedures best-suited for microlaparoscopic ports have yet to be clearly defined. The purpose of this study was to evaluate barriers to the performance of microlaparoscopy and to assess the impact of these barriers on conversion to conventional laparoscopic surgery. Specifically, we aimed to identify the factors directly related to port conversion and the successful completion of microlaparoscopic surgery to better-define patients and procedures that may benefit from this approach.

BACKGROUND: True aneurysms of the gastroduodenal (GDA) and pancreaticoduodenal (PDA) arteries have been attributed to increased collateral flow due to tandem celiac artery stenosis or occlusion. Although GDA and PDA aneurysm exclusion is recommended because of the high reported risk of rupture, it remains uncertain whether simultaneous celiac artery reconstruction is necessary to preserve end-organ flow.STUDY DESIGN: We conducted a retrospective analysis of consecutive patients admitted from 1996 to 2015 with true aneurysms of the GDA or PDA.RESULTS: Twenty patients with true aneurysms of the PDA (n = 16) or GDA (n = 4) were identified. Mean age was 61.5 years (range 35 to 85 years) and 11 (55%) were women. Nine (45%) presented with rupture, 8 (40%) presented with pain, and 3 (15%) were asymptomatic. All 9 patients who presented with rupture had contained retroperitoneal hematomas, and none experienced rebleeding. Fifteen (75%) patients had an associated celiac artery > 60% stenosis or occlusion, and 2 (10%) had both celiac and superior mesenteric artery stenoses. Thirteen (65%) patients underwent successful endovascular coiling, only 1 of which had a prophylactic celiac artery bypass. Three (15%) patients underwent open aneurysm exclusion and celiac bypass, and 4 (20%) others were observed. There were no aneurysm-related deaths in this series, and none of the patients who underwent coiling without celiac revascularization had hepatic ischemia or other mesenteric morbidity develop during a median follow-up of 6 months (maximum 200 months).CONCLUSIONS: Gastroduodenal artery and PDA aneurysms present most commonly with pain or bleeding, and all should be considered for repair, regardless of size. Aneurysm exclusion is safely and effectively achievedwith endovascular coiling. Although associated celiac artery stenosis is found in themajority of cases, celiac revascularization might not be necessary. (J Am Coll Surg 2017; 224: 199e203. (C) 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term.

Surgeons perceive that some surgical transfers are futile, but the incidence and risk factors of futile transfer are not quantified. Identifying futile interfacility transfers could save cost and undue burdens to patients and families. We sought to describe the incidence and factors associated with futile transfers. We conducted a retrospective cohort study from 2009 to 2013 including patients transferred to a tertiary referral center for general or vascular surgical care. Futile transfers were defined as resulting in death or hospice discharge within 72 hours of transfer without operative, endoscopic, or radiologic intervention. One per cent of patient transfers were futile (27/1696). Characteristics of futile transfers included older age, higher comorbidity burden and illness severity, vascular surgery admission, Medicare insurance, and surgeon documentation of end-stage disease as a factor in initial decision-making. Among futile transfers, 82 per cent were designated as do not resuscitate (vs 9% of nonfutile, P < 0.01), and 59 per cent received a palliative care consult (vs 7%, P < 0.01). A small but salient proportion of transferred patients undergo deliberate care de-escalation and early death or hospice discharge without intervention. Efforts to identify such patients before transfer through improved communication between referring and accepting surgeons may mitigate burdens of transfer and facilitate more comfortable deaths in patients' local communities.

BACKGROUND:Ventral hernia repair (VHR) is a commonly performed surgical procedure. Unfortunately, long-term prospective information about quality of life and outcomes after VHR has been challenging to obtain. Decoupling follow-up from clinical visits via patient-reported outcomes (PROs) has been proposed as a means of achieving better long-term assessments after VHR. The Americas Hernia Society Quality Collaborative (AHSQC) is a national quality improvement (QI) effort in hernia repair that uses PROs to obtain long-term follow-up. However, the modality of PRO engagement to maximize participation has not been well established. A formal QI initiative was undertaken to determine if long-term PRO follow-up could be increased at a single AHSQC site by adding telephone communication to email communication for long-term postoperative VHR assessment.METHODS:Between September 2015 and July 2016, the long-term (greater than 1 year) AHSQC PRO completion rates after VHR at our institution were analyzed using plan-do-study-act cycles. Two interventions were implemented: contacting patients by telephone and changing timing of telephone calls.RESULTS:Two hundred thirty-two patients were identified, of whom 99 (42.7%) met eligibility criteria. Before this initiative, the long-term PRO completion rate was 16.3% in postoperative VHR patients. The completion rate after introducing telephone calls (intervention 1) was 35.7% and after changing the timing of telephone calls (intervention 2), was 55.1%. The mean participation rate was 45.4% (± 9.7%).CONCLUSIONS:A telephone-based approach markedly improved long-term PRO participation rates in postoperative VHR patients. Ultimately, a combination of email and telephone communication may be necessary to achieve higher levels of PRO follow-up in the VHR population.

Cancer survivorship focuses largely on improving quality of life. We aimed to determine the rate of ventral incisional hernia (VIH) formation after cancer resection, with implications for survivorship.

BACKGROUND: Delays to definitive care are associated with poor outcomes after trauma and medical emergencies. It is unknown whether inter-hospital transfer delays affect outcomes for nontraumatic acute surgical conditions.METHODS: We performed a retrospective cohort study of patient transfers for acute surgical conditions within a regional transfer network from 2009 to 2013. Delay was defined as more than 24 hours from presentation to transfer request and categorized as 1 or 21 days. The primary outcome was post-transfer death or hospice. Bivariate and multivariable logistic regression were performed.RESULTS: The cohort included 2,091 patient transfers. Delays of 2 or more days were associated with death or hospice in unadjusted analyses, but there was no difference after adjustment. Predictors of post-transfer death or hospice included older age, higher comorbidity scores, and greater severity of illness.CONCLUSIONS: Delays in transfer request were not associated with post-transfer mortality or discharge to hospice, suggesting effective triage of nontraumatic acute surgical patients. Published by Elsevier Inc.