Background:Postoperative delirium is a frequent, serious complication triggered by various factors including systemic inflammation. Dexamethasone, an inexpensive anti-inflammatory steroid frequently administered for prophylaxis of postoperative nausea and vomiting, attenuates inflammation. We hypothesised that intraoperative dexamethasone administration is associated with a lower risk of postoperative delirium and assessed whether this is modified by the occurrence of its key side effect, hyperglycaemia. Methods:This retrospective cohort study analysed electronic health data from adult hospitalised patients undergoing non-cardiac, non-neurosurgical, and non-transplant procedures at Beth Israel Deaconess Medical Center (Boston, MA, USA) between January 1, 2008, and January 15, 2024. Patients with missing data, preoperative delirium or glucocorticoid use, mechanical ventilation for 72 h or more, and those not expected to survive without the procedure, were excluded. The primary exposure was intraoperative administration of intravenous dexamethasone. The primary outcome was 7-day postoperative delirium, identified by keyword-triggered manual discharge note reviews, diagnostic codes, and the Confusion Assessment Method. Hyperglycaemia was defined as peak 24-h postoperative blood glucose of more than 180 mg/dL. All analyses were adjusted for 43 patient-related and procedure-related variables. Findings:92,832 patients were included (55.8% female, median age 60 years [IQR 48-70]), of which 41,983 (45.2%) received dexamethasone at a median dose of 8 mg (IQR 4-8). 2575 (2.8%) patients developed postoperative delirium. Emergency procedures accounted for 11,970 (12.9%) of cases. Intraoperative administration of dexamethasone was associated with a lower risk of delirium (adjusted odds ratio [aOR] 0.63, 95% CI 0.56-0.70; p < 0.001; adjusted absolute risk difference -1.1%, 95% CI -1.3 to -0.8). The exploratory four-way mediation analysis suggested a 10.4% greater dexamethasone-associated reduction of postoperative delirium risk when hyperglycaemia did not occur (no hyperglycaemia aOR 0.59, 95% CI 0.51-0.67; p < 0.001; hyperglycaemia aOR 0.85, 95% CI 0.68-1.07; p = 0.17). Interpretation:Intraoperative dexamethasone administration is associated with a lower risk of postoperative delirium, although this association was not evident in patients experiencing hyperglycaemia. Prospective studies should investigate the role of dexamethasone and optimised blood glucose control in delirium prevention. Funding:Unrestricted philanthropic grant by Dr. J. and J. Buzen.

BACKGROUND:Pancreatectomy carries significant risk of morbidity and mortality, particularly in the geriatric population; the risk of postoperative loss of independence (LOI) remains underexplored. The aim was to identify perioperative factors associated with LOI following pancreatectomy in this population. METHODS:The NSQIP database was queried to identify adults ≥75 years who underwent pancreatectomy from 2021 to 2024. LOI was the primary outcome, defined as decline in functional status and/or non-home discharge and/or home discharge services. Multivariable logistic regression was performed to identify predictors of LOI. RESULTS:Of 6227 patients, 1731(27.8%) experienced LOI at discharge. Factors associated with LOI included failure to wean from mechanical ventilation >48 h (OR 4.14,95%CI:2.19-7.85), cognitive impairment (OR 2.16,95%CI:1.50-3.10), and history of falls (OR 1.96,95%CI:1.56-2.48). Additional predictors included age >80 years (OR 1.4,95%CI:1.23-1.58), female sex (OR:1.26,95%CI:1.1-1.43), and COPD (OR 1.49,95%CI:1.13-1.95). The presence of home support prior to surgery (OR 0.81,95%CI:0.7-0.94) and early discharge (≤5 days) (OR 0.41,95%CI:0.33-0.51) were demonstrated to be protective. DISCUSSION:The understanding of LOI in this population can facilitate preoperative counseling and expectation setting. Care teams should work to mitigate LOI and/or obtain necessary support in the perioperative period.

Ethnic/racial bias was found in MSPEs of general surgery residency applicants. However, which portion(s) of the MSPEs is/are associated with the bias remains unknown. We aim to answer the question: what portion(s) of the MSPEs is/are associated with ethnic/racial bias as measured by differential use of communal and agentic terms? Retrospective study evaluating the source of ethnic/race bias, as measured by differential use of agentic and communal terms, in all MSPEs of residency applicants to a single institution from two consecutive match cycles. A separate bias score was calculated for the different portions of the MSPE, and multivariable regression was used to assess the association between each score (of the different portions) and ethnicity/race (URiM versus non-URiM). US medical students applying for a categorical surgery residency position at a single academic institution for two consecutive Match cycles were included. 1314 MSPEs from 146 medical schools were included. Baseline characteristics were comparable between application cycles. Genders were similarly distributed (women, 51.6

BACKGROUND:Although minimally invasive surgery is widely accepted across surgical disciplines, its role in pancreatic cancer continues to be debated. The objective of the São Paulo Consensus on Minimally Invasive Pancreatic Surgery (MIPS) was to establish consensus statements on the use of MIPS for pancreatic cancer, integrating contemporary evidence and recent advances. METHODS:A scoping literature review informed statement development across five thematic groups: (1) Left Pancreatectomy for Pancreatic Cancer, (2) Pancreatoduodenectomy and Total Pancreatectomy for Pancreatic Cancer, (3) Neuroendocrine Pancreatic Tumors, (4) Patient Evaluation and Surgical Technique, and (5) Implementation, Training, and Innovation. A three-round modified Delphi process was conducted with an international panel of 52 expert pancreas surgeons. Consensus was defined as ≥90 % agreement. RESULTS:From 2590 publications, 185 studies were selected for inclusion. Fifty-two hepatopancreatobiliary surgeons, with a median of 22 years of experience, achieved consensus through a three-round Delphi process. Ultimately, 22 of the initial 28 statements met the ≥90 % agreement threshold. The resulting recommendations provide evidence-based guidance on minimally invasive pancreas resection for cancer, including neuroendocrine tumors, patient evaluation, program implementation, and innovation. DISCUSSION:The São Paulo Consensus provides contemporary, evidence-based recommendations to guide the safe and judicious adoption, implementation, and practice of minimally invasive techniques.

BACKGROUND:Intraoperative dexamethasone is routinely administered to prevent postoperative nausea and vomiting. Limited research has investigated dexamethasone safety during pancreatectomy. We investigated whether intraoperative dexamethasone administration affects clinically relevant postoperative pancreatic fistula (CR-POPF) development. METHODS:We performed a retrospective cohort study of patients undergoing pancreatoduodenectomy or distal pancreatectomy at a single academic institution (2014-2021). Impact of dexamethasone administration on CR-POPF (ISGPF Grade B/C) was assessed using multivariable logistic regression and inverse probability weighted regression analysis. RESULTS:503 patients were included (pancreatoduodenectomy n=307; distal pancreatectomy n=196). Of these, 59 (11.7%) received low-dose dexamethasone (4-6 mg) and 100 (19.9%) received high-dose dexamethasone (8-10 mg). High dose dexamethasone (aOR:2.47, 95% CI:1.40-4.36), but not low dose dexamethasone (aOR:1.32, 95% CI:0.61-2.86), was associated with increased odds of CR-POPF. After inverse probability weighted regression adjustment, the average treatment effect of high dose dexamethasone on CR-POPF was +11.1% (95% CI:1.7-20.3%) above the baseline risk of 12.5% (95% CI:9.0-16.1%) in patients receiving no dexamethasone. DISCUSSION:Intraoperative administration of high dose (8-10mg) dexamethasone was associated with a meaningfully increased risk of CR-POPF after pancreatectomy. High-dose dexamethasone is a modifiable risk factor for CR-POPF and should be avoided unless there is clear clinical indication.

OBJECTIVE:The field of surgery is highly visual and technical. Yet, there is a paucity of data evaluating how a mandatory visual arts-based workshop may benefit surgical trainees. We report upon the feasibility of and short-term outcomes of a novel, visual art-based curriculum for surgery residents. DESIGN:A validated survey was administered at the end of each visual art workshop to measure resident self-reported skills in problem-solving, interpersonal skills, and wellness. All questionnaire items were measured on a 4-point Likert scale (0-3) with added responses that were analyzed qualitatively. SETTING:3-hour singular workshops were hosted at The Museum of Fine Arts, Boston. PARTICIPANTS:General and vascular surgery residents in their first and second postgraduate year were required to participate in the new curriculum. RESULTS:Moderate to great improvement was reported for most questionnaire items. The greatest improvement was reported for making intentional observations (2.46), attentiveness to detail (2.42), viewing others as multidimensional people (2.57), and forming connections with colleagues (2.5). When asked how the workshop would impact their future practice, many residents described setting goals to: slow down when thinking through clinical problems, to consider alternative diagnoses, work on perspective taking, and paraphrase back to patients to enhance their relationships and accuracy of communication. CONCLUSIONS:Required workshops for surgery residents early in their training at an art museum is feasible and beneficial. Future studies to measure the long-term impact such session and the ideal content and timing (e.g., PGY 1-5) are required to better understand the potential of this methodology.

Distinguishing chronic pancreatitis (CP) from pancreatic ductal adenocarcinoma poses a significant diagnostic challenge given overlapping symptoms, risk factors, and imaging findings. Misclassification can result in delayed oncologic treatment or unnecessary resection. Advances in diagnostic modalities have improved diagnostic accuracy, but there is still limited ability to differentiate these diagnoses with certainty in certain cases. Multimodal diagnostic approaches, combined with multidisciplinary evaluation, are critical to guide management. Current guidelines focus on screening high-risk patients, emphasizing the importance of clinical judgment, and maintaining a high level of concern for malignancy in ambiguous cases to optimize patient outcomes.

INTRODUCTION:Senior residents near the end of their training must be prepared to start an independent practice. To become board-certified they must pass an oral exam, the ABS Certifying Exam (ABSCE). Prior work has introduced the resident Individual Clinical Evaluations (rICE), a low-cost tool developed to assess residents' clinical judgment in level-appropriate clinical scenarios. rICE is a comprehensive program/curriculum that supports residents in preparing for their ABSCE. We evaluated residents' perceived utility of the rICE, present curricular components, and compared mock oral and ABSCE pass rates. DESIGN:PGY1-3 surgical residents completed 3 level-appropriate rICE per AY. Immediate feedback was provided after each encounter. After passing all scenarios, residents were invited to take a post-rICE survey on their perceived curriculum utility. A mixed methods approach was used for data analysis. SETTING:This study occurred at an academic tertiary care center in Boston, Massachusetts, USA. PARTICIPANTS:All PGY1-3 surgical residents between AY 2016-2020 were eligible to participate. RESULTS:We collected 102 post-rICE surveys. Most trainees agreed that they felt better prepared to manage the evaluated clinical scenarios after rICE (81.37%), that these evaluations were an outstanding learning experience (87.25%), and that they would recommend the curriculum to other residents (85.29%). Relevant free-text comments were favorable toward the utility of this curriculum. rICE participants had an increase in mock orals pass rates over time (trending towards significance; p ≈ 0.06), and a 44% absolute increase in ABSCE pass rates (p ≈ 0.01) compared to non-rICE participants. CONCLUSION:Residents had a favorable impression of rICE; offering an adaptable and implementable curriculum that provides a platform for self-reflection on their knowledge base and presentation skills. rICE is sustainable and low-resource intensive, providing residents early exposure to face-to-face clinical evaluations, and was associated with improved board pass rates, and possibly improved mock oral pass rates (although not statistically significant).

Background The Charlson Comorbidity Index (CCI) is widely used in surgical research to summarize patients' baseline comorbidities. However, large surgical databases such as the ACS-NSQIP lack key CCI components, limiting its applicability. Developing a modified CCI (mCCI) using available ACS-NSQIP variables could improve baseline risk stratification for patients undergoing pancreatoduodenectomy (PD). We aimed to define such an mCCI and evaluate its performance in comparison to the conventional CCI. Methods Two-phase retrospective study including patients who underwent PD. In the derivation phase, our institutional ACS-NSQIP database (2015-2021) was used to construct the mCCI, with scores reweighted to the observed 14-point maximum. Spearman’s rank correlation was used to evaluate the relationship between CCI and mCCI. The nationwide ACS-NSQIP database (2022) served as external validation. Unadjusted logistic regression models were constructed to predict discharge disposition and postoperative complications. Model discrimination was evaluated using AUC/ROC analysis with AUCs compared using DeLong's test. Results A total of 333 institutional and 4,867 national patients who had undergone PD were included. In the derivation cohort, the mCCI was strongly correlated with the CCI (r=0.85, p<0.001). For discharge disposition, both indices yielded an AUC of 0.74. For postoperative complications, AUCs were 0.50 for CCI and 0.55 for mCCI. Similar trends were observed in external validation. No significant differences were found in the discriminatory capacities between models. Conclusion mCCI is a reasonable alternative to account for baseline comorbidities in patients undergoing PD using the ACS-NSQIP database. Further studies should refine weighting schemes across diverse populations to optimize mCCI performance.

Intraductal papillary mucinous neoplasms (IPMNs) are commonly identified cystic lesions in the pancreas that may carry malignant potential for pancreatic ductal adenocarcinoma. Risk stratification of identified lesions is critical to determine which patients may benefit from surgical resection. Key high-risk features include size, growth, main pancreatic duct involvement, obstructive jaundice, and enhancing solid components on imaging. The surgical technique of choice depends on IPMN location, with pancreatoduodenectomy being the most common procedure due to the high incidence of high-risk IPMNs in the head of the pancreas. The extent of resection is guided by imaging and/or endoscopic data, potentially including intraoperative frozen section analysis to assess for high-grade dysplasia or invasive IPMN. Postoperative surveillance of the remnant gland is crucial and based on the risk of disease recurrence after the surgery, which is determined by the anatomopathological report.

This cross-sectional study assesses the association of postoperative loss of independence and 30-day mortality among patients aged 75 years or older and whether procedural risk level modifies the association.

BACKGROUND:The Charlson Comorbidity Index (CCI) is widely used in surgical research to summarize patients' baseline comorbidities. However, large surgical databases, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), lack key CCI components, limiting its applicability. Developing a modified CCI (mCCI) using available ACS-NSQIP variables could improve baseline risk stratification for patients undergoing pancreatoduodenectomy (PD). This study aimed to define such an mCCI and evaluate its performance compared with that of the conventional CCI. METHODS:This was a 2-phase retrospective study that included patients who underwent PD. In the derivation phase, our institutional ACS-NSQIP database (2015-2021) was used to construct the mCCI, with scores reweighted to the observed 14-point maximum. The Spearman rank correlation was used to evaluate the relationship between CCI and mCCI. The nationwide ACS-NSQIP database (2022) was used for external validation. Unadjusted logistic regression models were constructed to predict discharge disposition and postoperative complications. Model discrimination was evaluated using area under the receiver operating characteristic curve (AUC)/receiver operating characteristic curve analysis with AUCs compared with the DeLong test. RESULTS:A total of 333 institutional and 4867 national patients who underwent PD were included. In the derivation cohort, the mCCI was strongly correlated with the CCI (r = 0.85; P <.001). For discharge disposition, both indices yielded an AUC of 0.74. For postoperative complications, AUCs were 0.50 for CCI and 0.55 for mCCI. Similar trends were observed in external validation. No significant differences were found in the discriminatory capacities between the models. CONCLUSION:mCCI is a reasonable alternative to account for baseline comorbidities in patients undergoing PD using the ACS-NSQIP database. Further studies should refine weighting schemes across diverse populations to optimize mCCI performance.

BACKGROUND: Art engagement during surgical training often occurs informally and is difficult to characterize. The purpose of this study is to understand practices of surgical educators in using visual aids for teaching encounters, if program directors consider artistic aptitude when assessing residency applicants, perspectives regarding the incorporation of art into surgical training, and barriers that may exist toward the development of visual art curricula for surgery residents. METHODS: A survey study of all general surgery, orthopedic surgery, neurosurgery, otolaryngology, urology, vascular surgery, and cardiothoracic surgery program directors in the United States was conducted from September 2022 to June 2024. RESULTS: Responses from 198 program directors indicate that residencies rarely participate in graphic design courses (1.5%), visual abstract training (2.5%), art museum visits (3.5%), drawing activities (6.1%), or art related social events (15.7%). Sixty-six percent reported that they either "often" or "always" draw for patients to explain diagnoses. Forty-two percent considered having drawing skills to be favorable among residency applicants. Seventy-four percent answered that the ability to draw may be related to technical skills. Eighty-two percent considered that the ability to draw the steps of an operation was related to having the ability to perform that same operation. Barriers to incorporating art into training included lack of expertise, time, resources, and evidence. CONCLUSIONS: Resident opportunities to participate in organized art-related activities through their surgery programs are rare, but survey responses indicate that program directors do perceive that there is value in art- related exercises for surgical trainees. Future studies ought to consider the effectiveness of incorporating different types of art-based teaching strategies for resident learning. ( J Surg Ed 82:103465. (c) 2025 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

BACKGROUND:Despite differences in tumour behaviour and characteristics between duodenal adenocarcinoma (DAC), the intestinal (AmpIT) and pancreatobiliary (AmpPB) subtype of ampullary adenocarcinoma and distal cholangiocarcinoma (dCCA), the effect of adjuvant chemotherapy (ACT) on these cancers, as well as the optimal ACT regimen, has not been comprehensively assessed. This study aims to assess the influence of tailored ACT on DAC, dCCA, AmpIT, and AmpPB. PATIENTS AND METHODS:Patients after pancreatoduodenectomy for non-pancreatic periampullary adenocarcinoma were identified and collected from 36 tertiary centres between 2010 - 2021. Per non-pancreatic periampullary tumour type, the effect of adjuvant chemotherapy and the main relevant regimens of adjuvant chemotherapy were compared. The primary outcome was overall survival (OS). RESULTS:The study included a total of 2866 patients with DAC (n = 330), AmpIT (n = 765), AmpPB (n = 819), and dCCA (n = 952). Among them, 1329 received ACT, and 1537 did not. ACT was associated with significant improvement in OS for AmpPB (P = 0.004) and dCCA (P < 0.001). Moreover, for patients with dCCA, capecitabine mono ACT provided the greatest OS benefit compared to gemcitabine (P = 0.004) and gemcitabine - cisplatin (P = 0.001). For patients with AmpPB, no superior ACT regime was found (P > 0.226). ACT was not associated with improved OS for DAC and AmpIT (P = 0.113 and P = 0.445, respectively). DISCUSSION:Patients with resected AmpPB and dCCA appear to benefit from ACT. While the optimal ACT for AmpPB remains undetermined, it appears that dCCA shows the most favourable response to capecitabine monotherapy. Tailored adjuvant treatments are essential for enhancing prognosis across all four non-pancreatic periampullary adenocarcinomas.

Objective While graphics are commonly used by clinicians to communicate information to patients, the impact of using visual media on surgical patients is not understood. This review seeks to understand the current landscape of research analyzing impact of using visual aids to communicate with patients undergoing surgery, as well as gaps in the present literature. Design A comprehensive literature search was performed across 4 databases. Search terms included: visual aids, diagrams, graphics, surgery, patient education, informed consent, and decision making. Inclusion criteria were (i) full-text, peer-reviewed articles in English; (ii) evaluation of a nonelectronic visual aid(s); and (iii) surgical patient population. Results There were 1402 articles identified; 21 met study criteria. Fifteen were randomized control trials and 6 were prospective cohort studies. Visual media assessed comprised of diagrams as informed consent adjuncts (n = 6), graphics for shared decision-making conversations (n = 3), other preoperative educational graphics (n = 8), and postoperative educational materials (n = 4). There was statistically significant improvement in patient comprehension, with an increase in objective knowledge recall (7.8%-29.6%) using illustrated educational materials (n = 10 of 15). Other studies noted increased satisfaction (n = 4 of 6), improvement in shared decision-making (n = 2 of 4), and reduction in patient anxiety (n = 3 of 6). For behavioral outcomes, visual aids improved postoperative medication compliance (n = 2) and lowered postoperative analgesia requirements (n = 2). Conclusions The use of visual aids to enhance the surgical patient experience is promising in improving knowledge retention, satisfaction, and reducing anxiety. Future studies ought to consider visual aid format, and readability, as well as patient language, race, and healthcare literacy.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)’s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Introduction: Prescription opioids, including those prescribed after surgery, have greatly contributed to the US opioid epidemic. Educating opioid prescribers is a crucial component of ensuring the safe use of opioids among surgical patients.Methods: An annual opioid prescribing education curriculum was implemented among new surgical prescribers at our institution between 2017 and 2022. The curriculum includes a single 75-min session which is comprised of several components: pain medications (dosing, indications, and contraindications); patients at high risk for uncontrolled pain and/or opioid misuse or abuse; patient monitoring and care plans; and state and federal regulations. Participants were asked to complete an opioid knowledge assessment before and after the didactic session.Results: Presession and postsession assessments were completed by 197 (89.6%) prescribers. Across the five studied years, the median presession score was 54.5%. This increased to 63.6% after completion of the curriculum, representing a median relative knowledge in-crease of 18.2%. The median relative improvement was greatest for preinterns and interns (18.2% for both groups); smaller improvements were observed for postgraduate year 2-5 residents (9.1%) and advanced practice providers (9.1%). On a scale of 1 to 10 (with 5 being comfortable), median (interquartile range) self-reported comfort in prescribing opioids increased from 3 (2-5) before education to 5 (4-6) after education (P < 0.001).Conclusions: Each year, the curriculum substantially improved provider knowledge of and comfort in opioid prescribing. Despite increased national awareness of the opioid epidemic and increasing institutional initiatives to improve opioid prescribing practices, there was a sustained knowledge and comfort gap among new surgical prescribers. The observed effects of our opioid education curriculum highlight the value of a simple and efficient educational initiative.(c) 2023 Elsevier Inc. All rights reserved.

Objective: To understand medical interpreters' perspectives on surgical informed consent discussions and provide feedback for surgeons on improving these conversations.Background:Informed consent is a critical component of patient-centered surgical decision-making. For patients with limited English proficiency, this conversation may be less thorough, even with a medical interpreter, leaving patients with an inadequate understanding of their diagnosis or treatment options. Methods:A semistructured interview guide was developed with input from interpreters and a qualitative research expert. We purposively sampled medical interpreters representing multiple languages until thematic saturation was achieved. Participants discussed their experience with the surgical consent discussion and process. Interview transcripts were analyzed using emergent thematic analysis. Results: Among 22 interpreters, there were 10 languages represented and an average experience of 15 years (range: 4-40yr). Four major themes were identified. First, interpreters consistently described their roles as patient advocates and cultural brokers. Second, interpreters reported unique patient attributes that influence the discussion, often based on patients' cultural values/expectations, anticipated decisional autonomy, and family support. Third, interpreters emphasized the importance of surgeons demonstrating compassion and patience, using simple terminology, conversing around the consent, providing context about the form/process, and initiating a pre-encounter discussion. Finally, interpreters suggested reducing legal terminology on consent forms and translation into other languages. Conclusions: Experienced interpreters highlighted multiple factors associated with effective and culturally tailored informed consent discussions. Surgeons should recognize interpreters' critical and complex roles, be cognizant of cultural variations among patients with limited English proficiency, and improve interpersonal and communication skills to facilitate effective understanding.