A reflection on the personal impact of complications on surgeons.

Department of Surgery, University of Kansas School of Medicine, Salina, KS Disclosure Information: Dr Hughes is the American College of Surgeons Vice President and a paid consultant for the Western Surgical Association. Presented at the Western Surgical Association 131 st Scientific Session, Dana Point, CA, November 2023. Corresponding Author: Tyler G Hughes, MD FACS Department of Surgery University of Kansas School of Medicine 138 N Santa Fe Avenue, Salina KS 67401 Salina, KS [email protected]

Over the past 5 years, The University of Alabama at Birmingham (UAB) Department of Surgery has taken a keen interest in the practice of surgery in rural Alabama and has established the UAB surgery community network. Our goal is to improve the delivery of surgical care in rural areas through active recruitment of rural surgeons, the development of research around rural surgery practice, and the expansion of a surgery network throughout the state. Here, we will present the challenges faced by rural surgery, our early work to address these challenges, and offer a plan for moving forward.

Abstract Aim Ventral incisional hernia (VIH) is a common complication after abdominal surgery. The use of prophylactic mesh can reduce its incidence however, this also has risks. Our aim was to determine the percent risk of wound complications that surgeons and patients would be willing to accept in the use of prophylactic mesh for a reduced risk of VIH. Materials and Methods We performed a cross-sectional standard gamble study with three clinical scenarios: abdominal surgeries at low, medium, and high-risk of VIH and wound complications. Participants were given an option of suture or mesh closure and provided the estimated mean risk of VIH with either technique. In a step-wise fashion, participants were provided increasing risks of wound complications until they chose suture over mesh. Estimated mean risk of VIH and wound complications were compiled through systematic review of randomized controlled trials and ACS-NSQIP risk calculator. Results Overall, 35 surgeons and 9 patients were surveyed. For the low, medium, and high-risk scenarios surgeons’ and patients’ maximal accepted risks was 3% and 11%, 11% and 18%, and 23% and 28%, respectively. For all three scenarios, surgeons reported risk-tolerance of prophylactic mesh far below that of the ACS-NSQIP risk calculator while patients were willing to accept more risk than the surgeons. Conclusions Surgeons and patients have different risk tolerances for various types of complications. Substantial education is needed for both surgeons and patients prior to widespread adoption of prophylactic mesh.

Purpose of Review This review discusses the most recent studies and guidelines regarding the treatment of acute diverticulitis. It specifically focuses on current controversies in initial evaluation, management, and follow-up after discharge. Recent Findings Many recent large-scale randomized control studies (such as the AVOD and DIABOLO trials) and systematic reviews have changed our current understanding of diverticulitis. Specifically, this review focuses on new evidence in stratifying patients, use of antibiotics, the indications for new therapies, and recommended follow-up after an acute episode. Summary The most important aspects of initial evaluation are a thorough history, physical exam, appropriate imaging, and lab work. Clinically well-appearing patients with uncomplicated diverticulitis without significant comorbidities may be able to avoid antibiotic therapy entirely. Recent studies have found little utility to medications such as mesalamine and probiotics and adjunct therapies for the prevention or resolution of diverticulitis. There has been no evidence to suggest that nuts and seeds should be avoided in preventing diverticulitis. Evidence surrounding high-fiber diet and diverticulitis has been inconsistent. All patients with complicated diverticulitis should receive a colonoscopy on follow-up.

The title of my paper is much like the title of my favorite book; you don’t have to read once you’ve read the title. That book isWhat Got You Here Won’t Get You There. As my title states, this is a call for our profession to recognize that rural surgery has evolved to the point that calling it a specialty is in the best interest of patients, surgeons, our country, and the world at large. Let us not forget that this is a named lecture for Henry Laws II and that it is only fitting to pay homage to this great surgeon. Dr Laws was a member of the Southeastern from 1967 to 2014, serving as its president in 1997. He was a clinician, a teacher, a leader, and fondly remembered for his contributions to surgery and society. Any one of us should be so lucky to make such a mark upon humankind. The origins of recognizing rural surgery as a body of knowledge and area of expertise largely has come about post World War II. It doesn’t take long in studying the origins of rural surgery to come across the name of Richard Field, Jr Dr Field is what we envision as the rural surgical specialist. A product of the town of Centerville, MS, he went to Tulane for medical school, learned surgery at Charity Hospital, received additional training at the Lahey Clinic, served in the US Navy, and returned to Centerville, where he practiced while finding the time to become an American College of Surgeons (ACS) Governor, Chair of the National Trauma Committee, second VP of the ACS, and a Regent of the ACS. Truly, that is a broad-based career serving a rural community. I would be remiss if I did not also emphasize our recently departed J. David Richardson. He figures prominently in the history of surgery and especially rural surgery. Dave Richardson was a friend to all, never forgetting the surgeons in the trenches while becoming one of the great icons of surgery. He, too, was a past president of the Southeastern. My story about rural surgery begins with him. In the fall of 2011, I was minding my own business in my office when I my office staff told me a Dr Richardson was on the telephone. My staff was clueless as to who this Dr David Richardson was. I was not clueless but rather thunderstruck. Why in the world would the commander of the surgical universe be calling me? Rather tremulously, I picked up the phone, and on the other end, lo and behold, was the famous J. David Richardson. In his soft southern accent and with a manner as if he and were old friends, he asked me if I would consider having breakfast with him in San Francisco at the Clinical Congress and bring about 4 or 5 other surgeons who practice in rural venues along with me. Dave felt that the ACS was not alive to the critical nature of rural surgery. He wanted to talk directly with those who were doing the work on the ground in rural America. And so it was that by June of 2012, I found myself catapulted into the chair of the Advisory Council for Rural Surgery. Dave Richardson was not the only avid supporter of rural surgery. Along the way Brent Eastman, Patricia Numann, George F. Sheldon, Julie Freischlag, and Carlos Pellegrini, all Presidents of the ACS, lent support. It seemed that a great many surgeons in leadership had direct ties to rural surgery. Brent Eastman grew up in Wyoming, the son of a locomotive engineer. Patricia Numann attributes her life to being saved by a rural surgeon after an automobile accident when she was a resident. George Sheldon was also a strong supporter of rural surgery. He who grew up in rural Salina, KS, where I teach at the KU School of Medicine. Julie Freischlag has run health systems and understands well the importance of rural surgery. Carlos Pellegrini initially wanted to practice in rural Argentina. He immigrated to the United States after Dr Carlos Ledesma was appointed to the rural position Dr Pellegrini sought. That serendipity worked out well. Carlos Pellegrini subsequently became a leader in American surgery while the other Carlos went on to write

Debriefing after a major event is a key component in ongoing improvement in performance. Likewise, reflecting on one's career at the time of leaving the operating room environment is an opportunity to transmit the lessons learned from decades of surgical practice. The authors, recently retired from daily operating and leaders in American surgery, reflect on the impact of surgical life on surgeons and their personal lives. Observations regarding selection of medical students, surgical trainees and practice models are presented from this perspective.

Background: Surgeons often impose restrictions on patient activities after an abdominal operation in an effort to prevent complications such as incisional hernia. This study addresses the current recommendations concerning the restriction of activities given by a diverse group of surgeons to their patients after abdominal surgery. Methods: A 14-item survey was posted on surgeon-specific social media platforms, primarily the American College of Surgeons Communities. This survey included questions about demographics, practice type, and activity recommendations after open and minimally invasive abdominal surgery. Descriptive, multivariable, and qualitative analyses were performed. Results: A total of 420 surgeons completed the survey. The majority of respondents identified as general surgeons (76.2%). Practice types included private (37.6%), academic (34.3%), underserved (10.1%), and Veterans Affairs (5.6%). After an open laparotomy, the majority of respondents (53.1%) recommended that patients refrain from heavy lifting or strenuous activity for 6 weeks. For a minimally invasive abdominal operation, recommendations were even more variable, restricting activity for 2 weeks (34.4%), 4 weeks (23.8%), 6 weeks (15.5%), or no restrictions (12.6%). On average, participating surgeons recommended an earlier return to activity by 2.3 weeks for patients undergoing minimally invasive surgery compared with an open operation (95% confidence interval 2.1-2.5, P < .001). Qualitative analysis provided additional information regarding surgeons' rationale for decision making. Only 23.8% of the respondents indicated that their recommendations were based on evidence in literature. Conclusion: This survey on surgeon recommendations for convalescence after an abdominal operation indicates the wide variation in practices with insufficient evidence to guide decision making. Future clinical trials examining various durations and intensities of postoperative restrictions will be important to determine a safe and patient-centered approach for recovery after an abdominal operation. (C) 2020 Elsevier Inc. All rights reserved.

When one examines life in various countries of the world regardless of type of government, health system, or even culture, one sees the great diversity of the world but also large areas of commonality among all people and all places. The twentieth century’s history is one of almost constant war, two of those wars having affected the majority of the global population, but only one event parallels today’s pandemic in impact on almost every individual on planet Earth: the great pandemic of 1918, which by various accounts took between 20 to 100 million lives over a three-year period.

Objective: Medical students should develop skills in assessing their own learning needs and developing strategies to meet those needs. Medical curricula should be designed to provide active and enriching ways to explore medicine beyond the classroom. The program should enrich the elements of motivation, discovery, innovation, social services, cultural exploration, and personal development. The University of Kansas School of Medicine instituted a new curriculum in 2017 called ACE (Active, Competency-based, and Excellence-driven). Eight 1-week courses of enrichment experiences are embedded within the first 2 years of the curriculum. Methods: After each of 8 medical content blocks, students are required to participate in a 1-week, nongraded enrichment experience according to their own learning needs and interests. Students choose the type of enrichment activities including clinical experiences, professional development, leadership development, research and scholarly activity, and community engagement. Students select their top enrichment choices and a computer lottery makes the assignments from their designations. Students engaged in research and scholarly activity are guided to appropriate research mentors. Results: A total of 196 enrichment activities at 3 campuses were developed for 211 students during the first 2 years of medical school. Most students selected clinical experiences with enrichments available in most medical specialties and subspecialties. Students also use enrichment weeks to conduct research/scholarly activity, particularly those students pursuing the Honors Track. A total of 2071 enrichment experiences were completed in the first 2 years. Conclusions: Most enrichments involved clinical experiences, although research/scholarly activity and professional development enrichments also were popular. Evaluations from students and antidotal data suggested enrichments are popular among students and a good change of pace from the usual rigorous activities of the curriculum. Because of the large number of experiences required to conduct the enrichment weeks, a continuous process of evaluation is required to maintain the program. Therefore, flexibility is required to administer the program.

Background Many surgeons rely on the American College of Surgeons (ACS) Community Forums for advice on managing complex patients. Our objective was to assess the safety and usefulness of advice provided on the most popular surgical forum. Methods Overall, 120 consecutive, deidentified clinical threads were extracted from the General Surgery community in reverse chronological order. Three groups of three surgeons (mixed academic and community perspectives) evaluated the 120 threads for unsafe or dangerous posts. Positive and negative controls for safe and unsafe answers were included in 20 threads, and reviewers were blinded to their presence. Reviewers were free to access all online and professional resources. Results There were 855 unique responses (median 7, 2-15 responses per thread) to the 120 clinical threads/scenarios. The review teams correctly identified all positive and negative controls for safety. While 58(43.3%) of threads contained unsafe advice, the majority (33, 56.9%) were corrected. Reviewers felt that a there was a standard of care response for 62/120 of the threads of which 50 (80.6%) were provided by the responses. Of the 855 responses, 107 (12.5%) were considered unsafe/dangerous. Conclusion The ACS Community Forums are generally a safe and useful resource for surgeons seeking advice for challenging cases. While unsafe or dangerous advice is not uncommon, other surgeons typically correct it. When utilizing the forums, advice should be taken as a congregate, and any single recommendation should be approached with healthy skepticism. However, social media such as the ACS Forums is self-regulating and can be an appropriate method for surgeons to communicate challenging problems.

BACKGROUND:Social media is a growing medium for disseminating information among surgeons. The International Hernia Collaboration Facebook Group (IHC) is a widely utilized social media platform to share ideas and advice on managing patients with hernia-related diseases. Our objective was to assess the safety and utility of advice provided.METHODS:Overall, 60 consecutive de-identified clinical threads were extracted from the IHC in reverse chronological order. A group of three hernia specialists evaluated all threads for unsafe posts, unhelpful comments, and if an established evidence-based management strategy was provided. Positive and negative controls for safe and unsafe answers were included in seven threads and reviewers were blinded to their presence. Reviewers were free to access all online and professional resources (except the IHC).RESULTS:There were 598 unique responses (median 10, 1-26 responses per thread) to the 60 clinical threads/scenarios. The review team correctly identified all seven positive and negative controls. Most responses were safe (96.6%) but some were unhelpful (28.4%). For sixteen threads, the reviewers believed there was an established evidence-based answer; however, only six were provided. In addition, 14 responses were considered unsafe, but only four were corrected.CONCLUSIONS:The vast majority of responses were considered helpful; however, evidence-based management is typically not provided and unsafe recommendations often go uncontested. While the IHC allows wide dissemination of hernia-related surgical advice/discussions, surgeons should be cautious when using the IHC for clinical advice. Mechanisms to provide evidence-based management strategies and to identify unsafe advice are needed to improve quality within online forums and to prevent patient harm.

BACKGROUND:Patients with symptoms of gastroesophageal reflux disease (GERD) are often given a trial of proton pump inhibitors (PPIs). When they respond, patients usually continue PPI therapy. If this empiric treatment fails, esophagogastroduodenoscopy (EGD) is recommended. When EGD findings are equivocal, pH study is warranted. We hypothesize that this algorithm results in prolonged PPI therapy, repetition of EGDs and patient dissatisfaction. This study evaluates the impact of placing a pH probe at the time of the initial EGD.METHODS:IRB approval was obtained for retrospective chart review of patients who presented with GERD symptoms between August 2015 and March 2019. Patients were included if they underwent EGD with placement of wireless pH probe.RESULTS:A total of 379 patients (260 females, 119 males) with average age was 56.7±14.2 years. There were 253/379 (66.7%) patients who had previous EGDs (1-10). Health Satisfaction Survey was completed by 357/379 (94.2%) patients and 250/357 (70%) reported dissatisfaction with GERD control. PPI use was noted in 299/379 (78.8%) patients with average duration of 10.9±9.1 years. Testing off antisecretory medication was performed in 360/379 (94.9%). The average time interval between the clinic visit and performing EGD and pH study was 22±25 days.CONCLUSION:The current GERD algorithm results in prolonged PPI therapy, repeated endoscopies and patient dissatisfaction. Placing a pH probe at the time of initial endoscopy is safe and expedient in a rural setting. Positive pH studies avoid repeating EGDs and negative pH studies warrant a search for potential alternative diagnosis.

Background: Surgery in larger, non-metropolitan, communities may be distinct from rural practice. Understanding these differences may help guide training. We hypothesize that increasing community size is associated with a desire for subspecialty surgeons. Methods: We designed a mixed methods study with the ACS Rural Advisory Council. Rural (<50,000 people), small non-metropolitan (50,000-100,000), and large non-metropolitan (>100,000) communities were compared. Quantitative and qualitative data were analyzed. Results: We received 237 responses, and desire to hire subspecialty-trained surgeons was associated with practice in a large non-metropolitan community, OR 4.5, (1.2-16.5). Qualitative themes demonstrated that rural surgeons limit practices to align with available hospital resources while large non-metropolitan surgeons specialize according to interest and market pressures. Conclusions: Surgery in rural versus large non-metropolitan communities may be more distinct than previously understood. Rural practice requires broad preparation while large non-metropolitan practice favors subspecialty training. (C) 2019 Elsevier Inc. All rights reserved.

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