Propeller Flap Reconstruction Following Pilonidal Cyst Excision: A Single-Center Experience With Same-Day Discharge.

INTRODUCTION: Reconstruction following pilonidal cyst resection must balance risk of recurrence, healing time, and resumption of functional routine. Propeller flaps provide a reliable and effective reconstructive option. This study highlights our experience with propeller flap reconstruction following pilonidal cyst resection and demonstrates the efficacy of same-day discharge. METHODS: A single-institution retrospective chart review was performed for propeller flap reconstructions completed from March 2018 to July 2022. Patient demographics, pilonidal cyst details, operative details, and postoperative outcomes were collected. Primary outcomes included flap survival, flap complications, and pilonidal disease recurrence. RESULTS: Twenty-eight outpatient propeller flap reconstructions following pilonidal cyst resections were identified in 26 patients, with two patients receiving a second propeller flap due to recurrence. Most patients were male (n = 15, 57.7%) with a mean age at time of index operation of 25.5 ± 5.8 years and mean body mass index of 26.5 ± 4.1 kg/m2. Mean symptom duration prior to index surgery was 39.3 months. Mean skin defect size following resection was 28.3 ± 15.3 cm2, with a mean flap size of 44.7 ± 35.5 cm2. Flap survival was 100% (n = 28), with five flaps (17.9%) experiencing minor wound complications and one patient (3.8%) requiring return to the operating room. Mean time to functional improvement was 24.0 ± 22.8 days. Pilonidal disease recurrence occurred in three patients (11.5%). Mean follow-up was 4.1 ± 5.4 months. CONCLUSIONS: Propeller flaps provide a successful and reliable reconstructive option for pilonidal disease defects. Because patients in our cohort experienced favorable outcomes and functional improvement, we advocate for same-day discharge in order to reduce hospital and patient burden.

Addressing fatigue in medical residents with biomathematical fatigue modeling.

Fatigue in resident physicians has been identified as a factor that contributes to burnout and a decline in overall wellbeing. Fatigue risk exists because of poor sleep habits and demanding work schedules that have only increased due to the COVID-19 pandemic. At this time, it is important not to lose sight of how fatigue can impact residents and how fatigue risk can be mitigated. While fatigue mitigation is currently addressed by duty hour restrictions and education about fatigue, Fatigue Risk Management Systems (FRMSs) offer a more comprehensive strategy for addressing these issues. An important component of FRMS in other shiftwork industries, such as aviation and trucking, is the use of biomathematical models to prospectively identify fatigue risk in work schedules. Such an approach incorporates decades of knowledge of sleep and circadian rhythm research into shift schedules, taking into account not just duty hour restrictions but the temporal placement of work schedules. Recent research has shown that biomathematical models of fatigue can be adapted to a resident physician population and can help address fatigue risk. Such models do not require subject matter experts and can be applied in graduate medical education program shift scheduling. It is important for graduate medical education program providers to consider these alternative methods of fatigue mitigation. These tools can help reduce fatigue risk and may improve wellness as they allow for a more precise fatigue management strategy without reducing overall work hours.

Biomathematical Modeling Predicts Fatigue Risk in General Surgery Residents.

OBJECTIVE: To assess resident fatigue risk using objective and predicted sleep data in a biomathematical model of fatigue. DESIGN: 8-weeks of sleep data and shift schedules from 2019 for 24 surgical residents were assessed with a biomathematical model to predict performance ("effectiveness"). SETTING: Greater Washington, DC area hospitals RESULTS: As shift lengths increased, effectiveness scores decreased and the time spent below criterion increased. Additionally, 11.13% of time on shift was below the effectiveness criterion and 42.7% of shifts carried excess sleep debt. Sleep prediction was similar to actual sleep, and both predicted similar performance (p ≤ 0.001). CONCLUSIONS: Surgical resident sleep and shift patterns may create fatigue risk. Biomathematical modeling can aid the prediction of resident sleep patterns and performance. This approach provides an important tool to help educators in creating work-schedules that minimize fatigue risk.

The Impact of a Comprehensive Simulation-Based Training and Certification Program on Resident Central Venous Catheter Complication Rates.

INTRODUCTION: Millions of central venous catheters (CVCs) are placed annually in the United States, many by resident physicians. Simulation training has been proposed as a means to increase resident physician competence with CVC placement and decrease the incidence of line-associated mechanical complications. We aimed to evaluate the impact of a novel simulation-based CVC training program for resident physicians on CVC-associated mechanical complication rates. We hypothesized that the CVC-related mechanical complication rates would be lower among simulation-trained residents (STRs) compared with nonsimulation, traditionally trained residents (TTRs). METHODS: A retrospective chart review was performed of patients with a CVC placed by a resident physician between October 2014 and January 2017 at MedStar Georgetown University Hospital in Washington, DC. Incidence of CVC mechanical complications, including pneumothorax, hemothorax, arterial injury, or retained guidewire, were extracted from the electronic medical record and compared between STR and TTR cohorts. In contrast to TTRs who were trained to place CVCs in a supervised clinical setting, STRs underwent a CVC training program using online modules, a hands-on simulation training and testing checklist, and a series of successful supervised insertions before being credentialed to place lines independently. RESULTS: Nine hundred twenty-four CVCs placed by resident physicians during the study period were analyzed. There was no statistically significant difference in total mechanical complication rates between the STRs and TTRs in this study period (2.4% vs. 2.2%, P = 1). Simulation-trained residents were more likely to use ultrasound guidance when indicated during CVC insertion compared with TTRs (94.8% vs. 70.5%, P < 0.001). CONCLUSIONS: Mechanical complication rates associated with CVC insertion were similar between the simulation and TTRs and were consistent with previously published literature. These findings suggest that residents who underwent simulation training and certification demonstrated performance on par with more experienced TTRs. In addition, they were more likely to use best practices including ultrasound guidance in line placement.

Fatigue in surgical residents an analysis of duty-hours and the effect of hypothetical naps on predicted performance.

PURPOSE: Sleep loss and fatigue, common in resident physicians, are related to increased medical errors and decreased physician wellbeing. Biomathematical modeling of fatigue can illuminate the relationship between surgical resident fatigue and work scheduling. METHODS: General surgery resident schedules were analyzed using the Sleep, Activity, Fatigue and Task Effectiveness model to predict resident performance during work hours. Hypothetical naps were built into the model to assess their effect on predicted performance and fatigue risk. RESULTS: 12 months of duty-hours logged by 89 residents, ranging from post-graduate year (PGY) 1-5, were analyzed. Residents had moderate levels of fatigue risk over 12 month schedules, with at least an 8-h sleep debt during 24.36% of shifts. Performance scores decreased as shift lengths increased. The addition of hypothetical naps increased predicted performance and reduced shift time with fatigue risk. CONCLUSIONS: Biomathematical modeling of resident schedules and predicts a concerning level of fatigue and decreased effectiveness. Naps may improve performance without decreasing scheduled hours.

ACS/ASE Medical Student Simulation-Based Skills Curriculum Study: Implementation Phase.

OBJECTIVE: Patient safety initiatives have revealed a need for standardized medical student skills curricula. In 2014 the America College of Surgeons/Association for Surgical Education Medical Student Simulation-based Skills Research Collaborative initiated a multisite study to implement and study the effect of a skills curriculum during the surgical clerkship. DESIGN: Students underwent knot-tying and suturing sessions. They performed a self-evaluation survey before and after the modules to assess their comfort level with the skills. Faculty members also evaluated the students at the completion of the skills sessions. The comfort level choices were: needs further review; proficient in simulated setting with assistance; proficient in simulated setting without assistance; and proficient in clinical setting under supervision. RESULTS: At the completion of the modules greater than 99.3% and 98.5% of students reported that they were proficient in knot-tying and suturing, respectively, in either a simulated or clinical environment. Similarly, when faculty evaluated student performance after a session, simulated or clinically proficiency reached over 97% for both two-handed and instrument knot-tying. The faculty rated the students 86.6% proficient for suturing. CONCLUSIONS: After completing the modules, a large percentage of students obtained proficiency in knot-tying and suturing, representing technical skills improvements noted by both the participants and the evaluating faculty. The America College of Surgeons/Association for Surgical Education medical student surgical skills modules represent expert developed, low cost, easy to access resources that should continue to be evaluated and disseminated to medical student learners.

E-Mailed Conference Synopses as a Tool for Resident and Faculty Development.

OBJECTIVE: This study aims to investigate the utility and success of daily conference synopses emails ("Daily Dispatches") sent to surgical attending physicians, fellows, and residents to foster resident and faculty development. DESIGN: Emails were distributed by the surgical residency program director (PD), summarizing each day of a surgical conference. Two prospective electronic surveys were administered to surgical residents, fellows, and attending surgeons to evaluate the value of this Daily Dispatch method. SETTING: Institutional; Medstar Georgetown University Hospital, Department of Surgery, Washington, DC. PARTICIPANTS: Email synopses were sent to surgical attendings, fellows and residents. Pilot survey was distributed to 60 participants, main survey sent to 74 participants. RESULTS: The response rate for the pilot survey was 41.6% (25/60). When asked about the mode of delivery, 96% of respondents wanted to maintain the email medium when compared to a lecture, paper handout, or the use of social media. The response rate for the main survey was 31.1% (23/74). Almost all (91%) respondents reported reading the emails. Within this group, 70% "agreed" or "strongly agreed" that the emails were useful. Furthermore, 90% reported learning "at least one new thing" and 80% confirmed these "emails provide meaningful content they would not otherwise obtain". CONCLUSION: Individualized daily synopsis emails highlighting relevant content provided meaningful information from conferences to non-attendees. The emails were well received and useful. Daily Dispatches meet an important need in dissemination of information traditionally gathered only by the rate-limiting step of conference attendance.

Selection bias: Examining the feasibility, utility, and participant receptivity to incorporating simulation into the general surgery residency selection process.

BACKGROUND: Opportunities exist to revise the current residency selection process to capture desirable candidate competencies. We examined the extent to which components of the American College of Surgeons/Association for Surgical Education simulation-based medical student curriculum combined with a teamwork activity could be used as potential screening method. METHODS: Students participated in a workshop consisting of training/evaluation of knot tying, suturing, airway management, gowning/gloving, and teamwork. Surveys were given to medical students (MS) and faculty/resident/staff (FRS) to examine their opinions about the residency screening process, the most critical competencies to assess, and the effectiveness of each station for candidate evaluation. RESULTS: Communication (FRS, 4.86 ± .35; MS, 4.93 ± .26), leadership (FRS, 4.41 ± .80; MS, 4.5 ± .76), judgment (FRS, 4.62 ± .74; MS, 4.67 ± .62), professionalism (FRS, 4.64 ± .73; MS, 5.00 ± .00), integrity (FRS, 4.71 ± .78; MS, 4.87 ± .35), and grit/resilience (FRS, 4.71 ± .78; MS, 4.53 ± .74) were considered most valuable for candidate screening. The simulation-based curriculum for evaluation of residency candidates was rated lowest by both groups. Open response comments indicated positive perceptions of this process. CONCLUSIONS: Employing simulation to assess candidates may be most beneficial for examining nontechnical attributes. Future work should continue to explore this area.

A pilot program to improve nursing and surgical intern collaboration: Lessons learned from a mixed-methods study.

BACKGROUND: Inter-professional collaboration is an integral component of a successful healthcare team. We sought to evaluate the impact of nursing student participation in a one-day intensive inter-professional education (IPE) training session with surgical interns on participant attitudes toward inter-professional collaboration. METHODS: Following IRB approval, pre and post IPE session survey responses were compared to determine the impact on participant attitudes toward inter-professional collaboration. Pre and post session semi-structured interviews were transcribed and analyzed to identify relevant themes. RESULTS: Surgical interns (n = 38) more than nursing students (n = 11), demonstrated a measurable improvement in attitude towards 'collaboration and shared education' (interns: median score pre = 26, post = 28, p = 0.0004; nursing student: median score pre = 27, post = 28, p = 0.02). Qualitative analysis of interviews identified major themes that supplemented this finding. CONCLUSION: An eight hour, one day IPE session has a positive impact on collaborative attitudes and supports the case for increased inter-professional education amongst interns and nursing students.

Identifying the need for and content of an advanced laparoscopic skills curriculum: results of a national survey.

BACKGROUND: A recent survey of fellowship directors suggested significant deficits in the technical laparoscopic skills of graduated general surgery residents. Our aim was to define the need for and possible content of a simulation-based curriculum in advanced laparoscopic skills (ALS). METHODS: An anonymous online survey was distributed to all Fellowship Council program directors (PDs), current fellows, and recent fellowship graduates. The survey was designed to assess the perceived need for, possible content of, and implementation challenges to an ALS curriculum. Recently developed simulation-based advanced laparoscopic tasks included off-angle camera work and restricted space suturing. Images and descriptions of these tasks were evaluated by respondents, and suggestions for modifications or improvements solicited via free text response. RESULTS: Of 186 respondents (response rate: 64%), 40% were current fellows, 22% were fellowship graduates, and 37% were PDs. Respondents primarily self-identified as minimally invasive and/or bariatric surgeons (78%) and hepatobiliary surgeons (12%). Most respondents (73%) identified a need for an ALS curriculum. All 3 respondent groups cited laparoscopic needle positioning and suturing (78%) and bimanual coordination during dissection and retraction (72%) as the skills in most need of improvement. In addition, most of the responding PDs identified "lack of familiarity with anatomy and procedure" (74% of PDs) and "lack of proficiency at laparoscopic bowel anastomosis" (59% of PDs) as problem areas. Respondents felt that successful implementation of an ALS curriculum depended on both overall feasibility and the ability for repeated practice and should not be dependent on cost. Thematic analysis of free responses revealed the following priorities for possible ALS skills and tasks: (1) difficult dissections and exposures, (2) forehand and/or backhand and suturing under tension, (3) nondominant hand drills, (4) working with an off-set camera, and (5) suturing and handling fragile tissue with properties similar to peritoneum or bowel. CONCLUSIONS: We present survey results identifying several specific ALS set deficits among graduating general surgery residents, including advanced suturing, bimanual coordination, and managing difficult anatomy. Next, the results of this needs assessment will be used to develop an advanced laparoscopic curriculum for residents entering minimally invasive surgery fellowships and careers.

Report of 111 consecutive patients enrolled in the International Serial Transverse Enteroplasty (STEP) Data Registry: a retrospective observational study.

BACKGROUND: The International Serial Transverse Enteroplasty (STEP) Data Registry is a voluntary online database created in 2004 to collect information on patients undergoing the STEP procedure. The aim of this study was to identify preoperative factors that are significantly associated with transplantation or death or attainment of enteral autonomy after STEP. STUDY DESIGN: Data were collected from September 2004 to January 2010. Univariate and multivariate logistic regression analyses were applied to determine the predictors of transplantation or death or enteral autonomy post-STEP. Time to reach full enteral nutrition was estimated using a Kaplan-Meier curve. RESULTS: Fourteen of the 111 patients in the Registry were excluded due to inadequate follow-up. Of the remaining 97 patients, 11 patients died and 5 progressed to intestinal transplantation. On multivariate analysis, higher direct bilirubin and shorter pre-STEP bowel length were independently predictive of progression to transplantation or death (p = 0.05 and p < 0.001, respectively). Of the 78 patients who were 7 days of age or older and required parenteral nutrition at the time of STEP, 37 (47%) achieved enteral autonomy after the first STEP. Longer pre-STEP bowel length was also independently associated with enteral autonomy (p = 0.002). Median time to reach enteral autonomy based on Kaplan-Meier analysis was 21 months (95% CI, 12-30). CONCLUSIONS: Overall mortality post-STEP was 11%. Pre-STEP risk factors for progressing to transplantation or death were higher direct bilirubin and shorter bowel length. Among patients who underwent STEP for short bowel syndrome, 47% attained full enteral nutrition post-STEP. Patients with longer pre-STEP bowel length were significantly more likely to achieve enteral autonomy.

Long-term follow-up on the educational impact of ACGME duty hour limits: a pre-post survey study.

OBJECTIVE: To evaluate the long-term impact of the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hour limits on residents' perception of education. BACKGROUND: Eight years after the introduction of the ACGME duty hour limits, graduate medical education programs implemented a revised set of standards. Currently, limited data exist related to the long-term impact of the 2003 standards on resident education. METHODS: A yearly survey from 2003 to 2009 was administered to orthopedic residents in a multi-institutional program, inquiring about several aspects of the resident's educational experience, work hours, amount of sleep, fatigue and its impact, and preparedness for practice. RESULTS: A total of 216 responses (69%) were obtained from surveyed orthopedic residents between 2003 and 2009. There was no significant change in the average reported hours of sleep (34.6 hours per week in 2003 vs 33.7 hours per week between 2004 and 2009) despite a decrease in the mean reported number of work hours (74.5 hours in 2003 vs 66.2 hours in 2009; P = 0.046). However, a decrease in perceived fatigue and its negative impact on patient safety and quality of care was noted. The perceived sufficiency of direct clinical experience, the number of hours spent performing major procedures, and the overall satisfaction with education also decreased. Finally, the residents' sense of clinical preparedness diminished after the work hour limits were in place. CONCLUSIONS: After the implementation of the 2003 duty hour limits, residents' perceptions of fatigue improved without any increase in the reported amount of sleep. In addition, decreased resident satisfaction with their education and a diminished sense of clinical preparedness were noted. Additional studies are needed to better understand the influence of work hours and fatigue on the outcomes of education, resident well-being, and patient care to guide the optimal design and delivery of graduate medical education.

Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure.

PURPOSE: We sought to determine whether a regimen of 70% ethanol locks could reduce the rate of central venous catheter (CVC) infections in parenteral nutrition-dependent children with intestinal failure. METHODS: We performed a retrospective review of 23 parenteral nutrition-dependent children in our multidisciplinary intestinal rehabilitation clinic who started ethanol lock therapy between September 2007 and June 2009. The treatment regimen consisted of a 70% ethanol lock instilled 3 times per week in each catheter lumen. The rate of CVC infections before and after initiation of ethanol lock therapy was compared using the Wilcoxon signed ranks test with significance set at P < .05. RESULTS: The most common diagnoses leading to intestinal failure were necrotizing enterocolitis (26.1%), gastroschisis (21.7%), and intestinal atresia (14.3%). Ethanol locks were well tolerated with no reported adverse side effects. The infection rate decreased from 9.9 per 1000 catheter days prior to initiation of ethanol locks to 2.1 per 1000 catheter days during therapy (P = .03). CONCLUSIONS: A regimen of ethanol lock therapy administered three days per week appears to be a safe and effective means of reducing the rate of CVC infections in parenteral nutrition-dependent children with intestinal failure.

Relationship between biopsy-proven parenteralnutrition-associated liver fibrosis and biochemical cholestasis in children with short bowel syndrome.

PURPOSE: The aim of the study was to determine the frequency of biochemical cholestasis (direct bilirubin [DB] > or =2 mg/dL) in children with short bowel syndrome and biopsy-proven parenteral nutrition (PN)-associated liver disease and to define predictive factors for the occurrence and degree of hepatic fibrosis. METHODS: After institutional review board approval, a retrospective review was conducted of patients followed by 2 multidisciplinary intestinal rehabilitation programs between January 1, 2000, and September 30, 2008. Inclusion criteria were exposure to PN (>30 days) and having undergone a liver biopsy. Liver biopsy specimens were graded from 0 to 3 based upon degree of fibrosis in the pathology report. The most recent DB within 10 days before biopsy was recorded. RESULTS: A total of 66 children underwent 83 liver biopsy procedures. The most common diagnoses included necrotizing enterocolitis (NEC) (36.4%), gastroschisis (22.7%), and intestinal atresia (15.1%). Median age at biopsy was 6.1 months with a median duration of PN of 4.7 months. Of the patients, 70.3% had a history of exposure to parenteral omega-3 lipid emulsion. Of the liver biopsy specimens, 89% (74/83) demonstrated some degree of fibrosis (fibrosis scale 1-3), including 9.6% (8/83) with evidence of cirrhosis. 83% of biopsies without fibrosis and 55% of biopsies with fibrosis were obtained in patients without evidence of biochemical cholestasis (P = .20). Three (37%) of the 8 patients with cirrhosis on liver biopsy had no evidence of biochemical cholestasis. Univariate analysis identified only gestational age (GA) at birth as significantly associated with the degree of liver fibrosis (P = .03). A multivariate logistic regression model accounting for multiple biopsy procedures in patients revealed that GA was a predictor of fibrosis only in patients with a diagnosis other than NEC (P < .01). CONCLUSIONS: In children with short bowel syndrome, biochemical cholestasis does not reflect the presence or degree of histologically confirmed PN-associated liver fibrosis. Careful follow-up, combined with further refinement of diagnostic and hepatoprotective strategies, may be warranted in this patient population.