Laparoscopy and thoracoscopy have become established surgical modalities in children, with important implications for diagnosis, treatment, and outcome. The decreased incidence of surgical site infection, shorter hospital stay, and enhanced recovery makes these modalities attractive. Many conditions in Africa are amenable to minimal access surgery but equipment cost, maintenance, as well as training remain challenging in deploying this modality effectively in Africa.

Background: Stage 3 pancreatic ductal adenocarcinoma (PDAC) is defined by arterial involvement. This study objective was to evaluate outcomes for patients with stage 3 PDAC with potentially reconstructable arterial involvement, considered for neoadjuvant therapy (NAT) and pancreatic resection, and to compare outcomes following arterial (AR) and non-arterial resection (NAR). Methods: This study included patients from 2009 to 2016 with biopsy-proven stage 3 PDAC who were offered NAT before surgical exploration. AR was performed if required to achieve R0 resection. Time to event outcomes were analysed from diagnosis date. Results: 87/89 patients (97.8%) received NAT (chemotherapy 41.6%, chemotherapy/radiotherapy 56.2%). 46/89 (51.7%) underwent exploration; 31 underwent resection (AR n = 20, NAR n = 11). AR patients had longer operative time (681 vs. 563 min, p = 0.006) and more blood loss (1600 vs. 575 mL, p = 0.0004), with no difference for blood transfusion, pancreatic fistula, length of stay, reoperation, or mortality. R0 rate was 30/31. Post-resection 90-day mortality was 3.2%. Median overall survival was statistically comparable between the AR and NAR groups (19.7 vs. 28.4 months, p = 0.41). Conclusions: AR had comparable clinical and oncologic outcomes to NAR. Following careful selection and non-progression after NAT, major AR may cautiously be considered if required to obtain a negative resection margin.

BACKGROUND Although podcasts are increasingly being produced for medical education, their use and perceived impact in informal educational settings are understudied. OBJECTIVE This study aimed to explore how and why physicians and medical learners listen to The Rounds Table (TRT), a medical podcast, as well as to determine the podcast’s perceived impact on learning and practice. METHODS Web-based podcast analytics were used to collect TRT usage statistics. A total of 17 medical TRT listeners were then identified and interviewed through purposive and convenience sampling, using a semistructured guide and a thematic analysis, until theoretical sufficiency was achieved. RESULTS The following four themes related to podcast listenership were identified: (1) participants thought that TRT increased efficiency, allowing them to multitask, predominantly using mobile listening platforms; (2) participants listened to the podcast for both education and entertainment, or “edutainment”; (3) participants thought that the podcast helped them keep up to date with medical literature; and (4) participants considered TRT to have an indirect effect on learning and clinical practice by increasing overall knowledge. CONCLUSIONS Our results highlight how a medical podcast, designed for continuing professional development, is often used informally to promote learning. These findings enhance our understanding of how and why listeners engage with a medical podcast, which may be used to inform the development and evaluation of other podcasts.

362 Background: Stage 3 pancreas ductal adenocarcinoma (PDAC) is defined by arterial involvement, and its resection remains controversial. The objective of this study was to evaluate clinical and oncologic outcomes for patients with stage 3 PDAC who entered a treatment program of neoadjuvant therapy (NAT) and pancreatic resection, with comparison between those who underwent arterial (AR) vs. standard resection (SR). Methods: This cohort study included patients from 2009-2016 in a single academic institution, with biopsy-proven potentially resectable stage 3 PDAC who entered a treatment program of NAT followed by surgical exploration if non-progressive disease on imaging. AR was performed if required to achieve R0 resection. Oncological outcomes were analyzed as intention to treat from diagnosis date. Results: Eighty-nine patients met inclusion criteria, of whom 87 (97.8%) received chemotherapy and 50 (56.2%) received radiotherapy. 46/89 (51.7%) underwent surgical exploration; 31 underwent pancreas resection (AR n = 20, SR n = 11), and 15 were found to have metastatic or unresectable disease. The AR group had a longer operative time (681 vs. 563 minutes, p = 0.0059) and more blood loss (1600 vs. 575 mL, p = 0.0004) compared with SR, with no difference between groups for blood transfusion, overall complications, pancreatic fistula, length of stay, reoperation, readmission or mortality. R0 rate was 100% for resected patients. Post-operative 90-day mortality was 1.1%. Median overall survival of resected patients was longer than in non-resected patients (25.9 vs. 14.8 months, p = 0.01), while AR had comparable overall survival to SR (19.7 vs. 28.4 months, p = 0.41). Conclusions: Patients with non-progressive stage 3 PDAC after NAT should be considered for pancreas resection. AR had comparable clinical and oncologic outcomes to SR. Resection may offer a survival advantage over non-surgical therapy alone, and AR should be considered if required to obtain a negative resection margin.

Purpose Expectations of certainty and confidence in surgical culture are a source of internal conflict for surgeons and learners, with surgeons describing a pressure to project an image that is, at times, inconsistent with how they feel internally. The authors explored surgical residents' perceptions of "impression management" and its effects on surgical judgment and decision making. Method The authors used a constructivist grounded theory approach to conduct and analyze 15 semistructured interviews with general surgery trainees at an urban Canadian academic health center between 2012 and 2014. Interviews explored impression management in the context of resident learning and performance. Analysis was inductive, whereby emergent themes contributed to a developing conceptual framework, and deductive, using an existing theory of impression management. Results Residents described sensing an "expectation" to portray an image aligned with the ideal surgical stereotype of confidence and certainty, and shared strategies used to mirror this image. Impression management strategies were used to portray an image of competence, with the aim to improve access to teaching and evaluations. Unintended consequences of impression management on decision making, patient safety, and resident wellness were identified. Conclusions These findings contribute to a deeper understanding of the potential impact of the sociocultural context on residency training, and provide a language allowing for more explicit discussions about the impact of surgical culture on trainee behaviors. Translation includes formal instruction of these concepts in the curriculum so that trainees better recognize, reflect on, and cope with the pressures to perform in front of others.

Intrahepatic cholangiocarcinoma is a rare malignancy with an increasing incidence and an overall 5-year survival of 10–20%. 1 Benavides M Anton A Gallego J et al. Biliary tract cancers: SEOM clinical guidelines. Clin Transl Oncol. 2015; 17: 982-987 Crossref PubMed Scopus (25) Google Scholar , 2 Flemming JA Zhang-Salomons J Nanji S et al. Increased incidence but improved median overall survival for biliary tract cancers diagnosed in Ontario from 1994 through 2012: a population-based study. Cancer. 2016; 122: 2534-2543 Crossref PubMed Scopus (13) Google Scholar Hepatectomy has been considered the only curative treatment, and patients with margin-negative resection of solitary tumours without lymph-node metastasis or vascular invasion can have a median overall survival of up to 41 months. 3 de Jong MC Nathan H Sotiropoulos GC et al. Intrahepatic cholangiocarcinoma: an international multi-institutional analysis of prognostic factors and lymph node assessment. J Clin Oncol. 2011; 29: 3140-3145 Crossref PubMed Scopus (427) Google Scholar Unfortunately, many patients with intrahepatic cholangiocarcinoma localised to the liver are not candidates for hepatectomy, 1 Benavides M Anton A Gallego J et al. Biliary tract cancers: SEOM clinical guidelines. Clin Transl Oncol. 2015; 17: 982-987 Crossref PubMed Scopus (25) Google Scholar , 4 Weber SM Ribero D O'Reilly EM et al. Intrahepatic cholangiocarcinoma: expert consensus statement. HPB. 2015; 17: 669-680 Summary Full Text Full Text PDF Scopus (182) Google Scholar and liver transplantation for cholangiocarcinoma has historically been contraindicated given high recurrence rates. 5 Meyer CG Penn I James L Liver transplantation for cholangiocarcinoma: results in 207 patients. Transplantation. 2000; 69: 1633-1637 Crossref PubMed Scopus (360) Google Scholar , 6 Darwish Murad S Kim WR Harnois DM et al. Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers. Gastroenterology. 2012; 143: 88-98 Summary Full Text Full Text PDF PubMed Scopus (305) Google Scholar However, the results of liver transplantation for perihilar cholangiocarcinoma after neoadjuvant therapy have been encouraging, 6 Darwish Murad S Kim WR Harnois DM et al. Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers. Gastroenterology. 2012; 143: 88-98 Summary Full Text Full Text PDF PubMed Scopus (305) Google Scholar and it has been suggested that patients with early stages of intrahepatic cholangiocarcinoma with cirrhosis have improved long-term survival after liver transplantation. 7 Sapisochin G Facciuto M Rubbia-Brandt L et al. Liver transplantation for “very early” intrahepatic cholangiocarcinoma: international retrospective study supporting a prospective assessment. Hepatology. 2016; 64: 1178-1188 Crossref PubMed Scopus (115) Google Scholar Liver transplantation for locally advanced intrahepatic cholangiocarcinoma treated with neoadjuvant therapy: a prospective case-seriesSelected patients with locally advanced intrahepatic cholangiocarcinoma who show pre-transplant disease stability on neoadjuvant therapy might benefit from liver transplantation. Full-Text PDF

Expectations of certainty and confidence in surgical culture are a source of internal conflict for surgeons and learners, with surgeons describing a pressure to project an image that is, at times, inconsistent with how they feel internally. The authors explored surgical residents' perceptions of "impression management" and its effects on surgical judgment and decision making.The authors used a constructivist grounded theory approach to conduct and analyze 15 semistructured interviews with general surgery trainees at an urban Canadian academic health center between 2012 and 2014. Interviews explored impression management in the context of resident learning and performance. Analysis was inductive, whereby emergent themes contributed to a developing conceptual framework, and deductive, using an existing theory of impression management.Residents described sensing an "expectation" to portray an image aligned with the ideal surgical stereotype of confidence and certainty, and shared strategies used to mirror this image. Impression management strategies were used to portray an image of competence, with the aim to improve access to teaching and evaluations. Unintended consequences of impression management on decision making, patient safety, and resident wellness were identified.These findings contribute to a deeper understanding of the potential impact of the sociocultural context on residency training, and provide a language allowing for more explicit discussions about the impact of surgical culture on trainee behaviors. Translation includes formal instruction of these concepts in the curriculum so that trainees better recognize, reflect on, and cope with the pressures to perform in front of others.

OBJECTIVES:Peer-assisted learning (PAL) is a form of collaborative learning where members of a peer group act as teachers for each other. A reciprocal PAL program was designed to investigate whether there were differential gains in knowledge acquisition among tutors compared with tutees. DESIGN:Bayesian statistical analysis was used to quantitatively assess the effect of tutor status on performance in a knowledge-based examination. Subgroup analysis according to student achievement and question difficulty was performed. PARTICIPANTS AND SETTING:Final year undergraduate medical students in a 5-year degree program (n = 126). RESULTS:The overall probability of getting a correct answer on the knowledge examination was 49.7%. For questions on topics where a student had acted as a tutor this improved to 57.3%. However, students who performed in the upper quartile had a greater percentage gain in the probability of a correct answer in topics that they had taught vs students who performed in the lowest quartile. CONCLUSIONS:There was demonstrable overall knowledge gain associated with acting as a tutor in a PAL program but the greatest gain occurred in students of highest academic ability.

OBJECTIVE To explore surgeons' perceptions of and potential concerns about coaching. BACKGROUND There is growing recognition that the traditional model of continuing professional development is suboptimal. This has led to increasing interest in alternative strategies that take place within the actual practice environment such as coaching. However, if coaching is to be a successful strategy for continuing professional development, it will need to be accepted by surgeons. METHODS This was a qualitative interview-based study using a constructivist grounded theory approach. Participants included 14 surgeons from University of Toronto-affiliated hospitals. RESULTS Participants expressed 3 main concerns about coaching: questioning the value of technical improvement ("As you get older if you don't have the stimulation from surgery to get better or to do things that are different and you are so good at so much, why bother [with coaching]?" P009), worry about appearing incompetent ("I think it would be perceived as either a sign of weakness or a sign of inability" P532), and concern about losing autonomy ("To me that would be real coaching where it's self-identified, I'm motivated, I find the person and then they coach me" P086). CONCLUSIONS AND RELEVANCE Coaching faces unique challenges in the context of a powerful surgical culture that values the portrayal of competency and instills the value of surgical autonomy. This study suggests that hanging on to these tightly held values of competency and autonomy is actually limiting the ways, and extent to which, surgeons can improve their practice.

OBJECTIVES The purpose of this study was to explore how risk is perceived and experienced by the surgeon and how risk is actively managed in individual practice. BACKGROUND Risk in surgery has been examined from system-wide and personality perspectives. Although these are important, little is known about the perspective of the individual surgeon. METHODS A constructivist grounded theory study was conducted to explore surgeons' perspectives on risk in the context of their personal "Comfort Zones." Semistructured, 60-minute interviews were conducted with 18 surgeons who were purposively sampled for sex and subspecialty with a snowballing strategy applied to sample for differences in reputation (conservative vs aggressive). Data were collected and analyzed in an iterative manner until thematic saturation was reached. RESULTS Surgeons described cases that were inside or outside of their personal comfort zones. When considering cases at the boundary of their comfort zones, participants described a variety of factors that could make them feel more or less comfortable. Specific strategies used to modulate this border were also described. Two perspectives on risk taking became apparent: the procedure-centric perspective described how surgeons viewed their colleagues whereas the surgeon-centric perspective described how surgeons viewed themselves. CONCLUSIONS A framework for understanding surgeon's unique assessment of risk was elaborated. Increased awareness of the factors and strategies identified in this study can foster critical self-reflection by surgeons of their own risk assessments and those of their colleagues, and provide avenues for more explicit educational strategies for surgical training.

To explore surgeons' perceptions of and potential concerns about coaching.There is growing recognition that the traditional model of continuing professional development is suboptimal. This has led to increasing interest in alternative strategies that take place within the actual practice environment such as coaching. However, if coaching is to be a successful strategy for continuing professional development, it will need to be accepted by surgeons.This was a qualitative interview-based study using a constructivist grounded theory approach. Participants included 14 surgeons from University of Toronto-affiliated hospitals.Participants expressed 3 main concerns about coaching: questioning the value of technical improvement ("As you get older if you don't have the stimulation from surgery to get better or to do things that are different and you are so good at so much, why bother [with coaching]?" P009), worry about appearing incompetent ("I think it would be perceived as either a sign of weakness or a sign of inability" P532), and concern about losing autonomy ("To me that would be real coaching where it's self-identified, I'm motivated, I find the person and then they coach me" P086).Coaching faces unique challenges in the context of a powerful surgical culture that values the portrayal of competency and instills the value of surgical autonomy. This study suggests that hanging on to these tightly held values of competency and autonomy is actually limiting the ways, and extent to which, surgeons can improve their practice.

OBJECTIVE:The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process. DESIGN:HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency. SETTING:Division of General Surgery, University of Toronto. PARTICIPANTS:HPB surgeons affiliated with the University of Toronto. RESULTS:A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans. CONCLUSION:These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

# 1 Is laparoscopic sleeve gastrectomy a reasonable stand-alone procedure for super morbidly obese patients? {#article-title-2} Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well established standard of care in the treatment of obesity and its associated comorbidities. Laparoscopic sleeve

Background. Access to health care has been a source of controversy and public attention in health policy. The issues of access to and utilization of the healthcare system by infants and children is less well documented. Moreover, the impact on outcomes of race, ethnicity, and economic status in infants is vaguely addressed.Methods. We performed a retrospective analysis of children who had undergone pyloromyotomy from July 31, 1998 to July 31, 2008 at our public hospital and university teaching hospital. Data abstracted included gestational age at delivery, birth weight, gender, race, insurance status, age at presentation, symptom duration, preoperative ultrasound (US), operative date, laboratory evaluations, as well as preoperative, postoperative, and total length of stay (LOS).Results. The mean total preoperative LOS was twice as long at our public hospital than our private hospital (1.78 d versus 0.85 d, P = 0.003). Similarly, the mean total length of stay was 0.87 d longer at our public hospital (3.87 d versus 3 d), which trended toward significance (P = 0.06). Significantly, 72% (27/33) patients at the private hospital had their US either as an out-patient or on the day of admission, while only 58% (28/48) had an US performed as expeditiously at the public hospital (P = 0.03, chi(2) analysis).Conclusions. Care at our public hospital leads to delayed diagnosis and treatment, resulting in longer preoperative and total LOS in infants with pyloric stenosis, most likely related to the timing of the preoperative US. Efforts should be made to encourage patients to use the outpatient clinic facilities for their ill infants, or for physicians at public hospitals to expedite the US process once the diagnosis of pyloric stenosis is entertained. (C) 2010 Elsevier Inc. All rights reserved.

Background. Access to health care is a well-recognized issue in health policy, but use once patients have entered the health care system is uncommonly addressed. Methods. We performed a retrospective review of children between 2 and 17 years of age with pathologically confirmed appendicitis at our public city hospital and private university hospital and compared management and outcomes. Results. Among patients with acute appendicitis, the median length of stay was a day longer in the public hospital (2 days vs 1 day, P = < .001) despite a similar complication rate (12% vs 11%). More computed tomography (CT) scans were performed at the public hospital (36% vs 21%, P = .02) with a trend toward less use of ultrasound (US) (54% vs 65%, P = .13). Conclusions. Children at the public city hospital have a longer length of stay and undergo more expensive imaging. These findings may provide areas for improvement to optimize the care of children with appendicitis at government-funded institutions.

Here we present a case of successful non-operative management of an iatrogenic recto-urethral fistula in a 13-year-old boy. The fistula was created when urethroscopic repair of a urethral stricture was attempted. Due to the anatomy of the lesion and previous urinary diversion, it was deemed possible to spare this patient diverting colostomy or surgical repair of the fistula. The result was successful closure of the fistula, which was confirmed on retrograde urethrogram. While we do not support the routine use of non-operative management for recto-urethral fistulas we have demonstrated that there are circumstances where it can be safely applied.