Lessons Learned From an Early Hotspot During the COVID-19 Pandemic.

The Covid-19 pandemic has provided challenges for surgical residency programs demanding fluid decision making focused on providing care for our patients, maintaining an educational environment, and protecting the well-being of our residents. This brief report summarizes the impact of the impact on our residency programs clinical care and education. We have identified opportunities to improve our program using videoconferencing, managing recruitment, and maintaining a satisfactory caseload to ensure the highest possible quality of surgical education.

Euglycemic Diabetic Ketoacidosis in the Surgical Patient.

Postoperative euglycemic diabetic ketoacidosis (EDKA), a rare cause of acidosis, results from the metabolic derangement of diabetes and is not associated with a surgical complication requiring reoperation. Our acute care surgery service has managed several recent patients who developed postoperative EDKA. Our group was befuddled by the initial case but subsequently quickly recognized and managed the condition. The purpose of this report is to discuss the pathophysiology of EDKA, summarize 3 recent cases, and increase awareness about the condition to permit prompt recognition and treatment.

Factors That Predict Biological Aggressiveness in Estrogen Receptor-Positive / Human Epidermal Growth Factor Receptor 2-Negative / Lymph Node-Negative Breast Cancer.

Background: Traditionally, breast cancer is staged using TNM criteria: tumor size (T), nodal status (N), and metastasis (M). The Oncotype DX assay provides a recurrence score (RS) based on genomics that predicts the likelihood of distant recurrence in estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-)/lymph node-negative (LN-) tumors. Methods: We retrospectively reviewed the medical records of patients with ER+/HER2-/LN- breast cancer tumors who were evaluated between 2007 and 2017 with Oncotype DX RS. We compared the RS to tumor size, patient age, progesterone receptor (PR) status, and LN immunohistochemistry to assess for factors that may independently predict recurrence risk. We also compared tumor size to tumor grade. Results: The data set included 296 tumors: 248 ER+/PR-positive (PR+)/HER2- and 48 ER+/PR-negative (PR-)/HER2-. RS ranged from 0 to 66, patient age ranged from 33 to 77 years, and tumor size ranged from 1 to 65 mm. No significant correlation was found between age and RS (r=-0.073, P=0.208). PR- tumors had a significantly higher RS regardless of size (PR- mean RS 30.8 ± 12.7; PR+ mean RS 16.3 ± 7.3; t(53)=7.6, P<0.0001). No significant correlation was seen between tumor size and RS for all tumors (r=-0.028, P=0.635), and this finding remained true for the PR+ tumor subgroup (r=0.114, P=0.072). However, a significant negative correlation was seen between tumor size and RS in the PR- subgroup (r=-0.343, P=0.017). Further analysis to ensure that differences in tumor grade did not account for this correlation showed equal distribution of well differentiated, moderately differentiated, and poorly differentiated tumors with no significant correlation between tumor size and grade. Conclusion: Increasing tumor size may not be associated with increasing biological aggressiveness. Traditionally, smaller tumors are thought to be lower risk and larger tumors higher risk, with a tendency to use chemotherapy with large tumors. However, our data showed a negative correlation between tumor size and RS in the PR- subgroup. A tumor with PR negativity that reaches a large size without metastasizing may suggest a favorable tumor biology. These tumors may not receive as much benefit from chemotherapy as previously thought. Also, the higher RS seen in smaller PR- tumors may demonstrate PR- status as a predictor for higher risk of distant recurrence. We propose that all tumors meeting the ER+/PR-/LN- criteria, regardless of size, should be considered for genotyping, with the RS used to guide chemotherapy benefit.

Learning preferences of surgery residents: a multi-institutional study.

BACKGROUND: The VARK model categorizes learners by preferences for 4 modalities: visual, aural, read/write, and kinesthetic. Previous single-institution studies found that VARK preferences are associated with academic performance. This multi-institutional study was conducted to test the hypothesis that the VARK learning preferences of residents differ from the general population and that they are associated with performance on the American Board of Surgery In-Training Examination (ABSITE). METHODS: The VARK inventory was administered to residents at 5 general surgery programs. The distribution of the VARK preferences of residents was compared with the general population. ABSITE results were analyzed for associations with VARK preferences. χ2, Analysis of variance, and multiple linear regression were used for statistical analysis. RESULTS: A total of 132 residents completed the VARK inventory. The distribution of the VARK preferences of residents was different than the general population (P < .001). The number of aural responses on the VARK inventory was an independent predictor of ABSITE percentile rank (P = .03), percent of questions correct (P = .01), and standard score (P = .01). CONCLUSION: This study represents the first multi-institutional study to examine VARK preferences among surgery residents. The distribution of preferences among residents was different than that of the general population. Residents with a greater number of aural responses on VARK had greater ABSITE scores. The VARK model may have potential to improve learning efficiency among residents.

A Potential Additional Variable to Consider in the Surgical Treatment of Ductal Carcinoma in Situ.

BACKGROUND: HER2/neu is a potentially interesting variable that has been demonstrated to have a profound impact on the management of invasive breast carcinoma, and we performed this study to evaluate the differences between HER2-positive and HER2-negative ductal carcinoma in situ. The impetus for this study was our poor recruitment to the National Surgical Adjuvant Breast and Bowel Project Protocol B-43 trial that was designed to evaluate the potential role of trastuzumab in breast conservation therapy for patients with HER2-positive ductal carcinoma in situ. METHODS: All patients with ductal carcinoma in situ and an assessment for the HER2/neu receptor were identified. Patients with HER2-positive and HER2-negative ductal carcinoma in situ were compared to determine differences in demographic, hormone receptor status, nuclear grade, presence of necrosis, surgical procedure (lumpectomy or mastectomy), tumor size, and extent of margins. Quantitative variables were analyzed with t test, and nominal variables were assessed by chi square analysis. RESULTS: A total of 177 patients were identified with a mean age of 61.0 years. A total of 101 patients (57.1%) were treated with lumpectomy, and 76 had mastectomy (42.9%). Forty-four (24.9%) patients were positive, and 133 (75.1%) were negative for the HER2/neu receptor. HER2-positive tumors were larger (23.6 vs 13.8 mm, P=0.001) and more likely to undergo mastectomy (61.4% vs 36.8%, P=0.01). CONCLUSION: Based on these results, an HER2-positive ductal carcinoma in situ is likely to be larger than an HER2-negative tumor, leading to more frequent use of mastectomy. This finding would explain our poor recruitment to the National Surgical Adjuvant Breast and Bowel Project Protocol B-43 trial.

An Analysis of Factors that Predict Hospital Readmission after Surgery for Perforated Appendicitis.

We performed this study to develop an understanding of why patients were readmitted after appendectomy for perforated appendicitis. Patients who required surgery for perforated appendicitis during a recent five-year period were identified. We recorded the demographic data, length of symptoms, length of stay, vital signs, laboratory findings, surgical approach, length of surgery, time to readmission, length of readmission, and intervention required after readmission. We divided the cohort into two groups depending on whether the patient was readmitted. We used chi-squared analysis and t test to determine differences between the two groups. We identified 86 patients, with 14 (16.3%) requiring readmission. The only factors that predicted readmission were longer appendectomy surgery (P = 0.03) and open surgery (P = 0.04). After readmission, one patient required reoperation, and two required percutaneous abscess drainage. The remaining 11 patients were readmitted for a median of two days, received intravenous fluids, and required no additional clinically significant management. Patients requiring longer and open surgery are at an increased risk for hospital readmission after resection of a perforated appendix. Efforts to reduce readmission will likely be most successful if hydration and brief periods of clinical observation can be arranged when necessary for patients after discharge from surgery.

A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment.

OBJECTIVE: The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN: Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING: CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS: Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS: Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

An Assessment of Margins after Lumpectomy in Breast Cancer Management.

We performed this study to evaluate our indications for margin re-excision (MRE) in the management of cancer patients opting for breast conservation therapy (BCT). We identified patients choosing breast conservation therapy from January 2012 to May 2014. Margins were considered negative if >2 mm, close if <2 mm, and positive if ink was detected abutting tumor. Patients with close and positive margins underwent MRE. We identified 247 patients of which 190 had negative margins and did not require MRE, 46 patients had a close margin, and 11 had a positive margin, leading to an MRE rate of 23 per cent (57 of 247). The following variables were evaluated: tumor size, stage, estrogen receptor, progesterone receptor, HER2/neu receptor, and node status. None predicted the presence of tumor in the MRE specimen (P > 0.05). Patients with close margins had a 6.5 per cent (3 of 46), and patients with positive margins had a 36.4 per cent (4 of 11) incidence of tumor in the MRE specimens; this difference was statistically significant (P = 0.02). The low rate of finding tumor in MRE specimens of patients with close margins after lumpectomy for breast carcinoma argues for limiting MRE to patients with positive margins (ink on tumor) only. We have adopted this approach in our institution.

Parathyroid hormone levels predict posttotal thyroidectomy hypoparathyroidism.

We hypothesized that parathyroid hormone (PTH) determination would be the most effective strategy to identify posttotal thyroidectomy hypoparathyroidism (PTTHP) compared with other clinical and laboratory parameters. We retrospectively reviewed our recent experience with total thyroidectomy. We recorded demographics, malignancy, thyroid weight, parathyroid autotransplantation, hospital stay, use of postoperative calcium and hormonally active vitamin D3 (calcitriol), and postoperative serum calcium and PTH levels. Patients were divided into two groups depending on whether supplemental calcitriol was required to maintain eucalcemia and therefore reflecting the diagnosis of PTTHP. From October 2010 to June 2013, a total of 202 total thyroidectomies were performed. Twenty-four patients (12%) developed PTTHP and required calcitriol replacement. Logistic regression analysis revealed that only postoperative calcium levels (P = 0.02) and PTH levels (P < 0.0001) statistically significantly predicted PTTHP. Twenty-two of 29 patients with PTH 13 pg/mL or less had PTTHP. Only two of 173 patients with a PTH level greater than 13 pg/mL were diagnosed with PTTHP. We recommend using PTH levels after total thyroidectomy to determine which patients will have hypoparathyroidism requiring calcitriol therapy. An early determination of PTTHP allows for prompt management that can shorten hospital stay and improve outcomes.

Perceptions of graduating general surgery chief residents: are they confident in their training?

BACKGROUND: Debate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today. STUDY DESIGN: In May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR). RESULTS: Of the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills. CONCLUSIONS: Current graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery.

The etiology of enterocutaneous fistula predicts outcome.

BACKGROUND: The management of enterocutaneous fistula (ECF) provides a supreme challenge for the general surgeon. METHODS: We conducted a retrospective review of all cases of patients with ECF referred to the surgical service from July 2007 to June 2011 to achieve a better understanding of the factors that predict a successful outcome. RESULTS: A total of 35 patients were evaluated and managed in a systematic fashion that focused on treatment of abdominal sepsis, control of fistula output and wound management, nutritional optimization, and operative intervention when necessary. Age, gender, preoperative laboratory values, etiology of ECF, and prior abdominal surgery for ECF were reviewed and compared. Fisher exact test was used to compare patients who achieved a good outcome (n=23) to those with a poor outcome (n=12) to determine factors that might predict their ultimate result. Two factors that predicted poor outcome were the presence of abdominal malignancy (P=0.01) and ECFs that occurred in trauma patients with an open abdomen (P=0.03). CONCLUSION: The etiology of ECF proved to be a more reliable predictor of outcome than clinical indicators.

The evolution in management of patients with subcentimeter, node-negative, triple-negative breast cancer.

BACKGROUND: The aim of this study was to determine the evolution in treatment recommendations and outcomes for patients with subcentimeter, node-negative, triple-negative disease. METHODS: Patients were divided into a remote (diagnosed from 1997 to 2003) and a recent (diagnosed from 2004 to 2011) group. Demographics, tumor size, surgical treatment, use of adjuvant chemotherapy, survival, and disease recurrence were evaluated. RESULTS: Thirty patients were placed in the remote group and 31 in the recent group. Demographics, tumor sizes, and surgical treatment were similar between groups. The use of adjuvant chemotherapy increased from 7% to 42% in the recent group (P < .002). Disease-free survival and recurrence (7%) was not influenced by the use of chemotherapy. CONCLUSIONS: This study demonstrates that adjuvant chemotherapy is increasingly used in patients with the triple-negative phenotype, regardless of other favorable prognostic variables. The value of adjuvant chemotherapy for the subgroup of patients in our study is unclear and mandates further investigation.

Use of a sestamibi-only approach to routine minimally invasive parathyroidectomy.

We performed this study to compare a sestamibi-only radio-guided approach (MIBI) versus using intraoperative parathyroid hormone monitoring (IOPTH) in the performance of minimally invasive parathyroidectomy (MIP) in patients with a clearly positive preoperative sestamibi scan from January 2000 to June 2010. Five of 81 patients in the MIBI group required additional surgery, three at the time of MIP when the intraoperative findings were in conflict with the preoperative sestamibi scan and two required a second operation as a result of an undiscovered second adenoma. In the IOPTH group, five patients had an unnecessary bilateral neck exploration as a result of an inadequate drop in PTH levels, whereas six had their disease cured because the PTH levels predicted additional pathology. One patient in the IOPTH group remains hypercalcemic and represents the only surgical failure in this study. The MIBI group had a shortened operating room time and less cost (P < 0.001). No deaths or complications, including recurrent laryngeal nerve injuries, occurred in this study. Although both strategies are effective in managing hyperparathyroidism, a MIBI-only approach is less expensive and has shorter operative times with an occasional need for reoperation, whereas the IOPTH group results in more extensive surgery that will occasionally be unnecessary.

Neoadjuvant chemotherapy in the treatment of breast cancer.

Randomized prospective trials have demonstrated that patients with early-stage breast cancer preferring breast conservation can benefit from neoadjuvant chemotherapy, achieving about a 25% complete and greater than 80% partial pathologic response. These responses do not translate into a survival advantage. For earlier stage patients, neoadjuvant chemotherapy's primary advantage is the ability to increase the use of breast conservation. Patients who opt for neoadjuvant chemotherapy should have a clinical and radiographic assessment of the axilla. The inability to predict the extent and pattern of response to chemotherapy requires that surgeons monitor patient response during neoadjuvant chemotherapy to provide optimal surgical planning.

Response to neoadjuvant chemotherapy in the breast predicts axillary nodal status.

We hypothesize that the diminishing role of axillary node dissection (ALND) in early stage breast cancer could be further reduced in patients with advanced disease depending on the response to neoadjuvant chemotherapy (NC). We reviewed records of patients managed with NC and recorded demographics, tumor characteristics, pre/postoperative axillary nodal status, and NC response. We define a response to NC as follows: T2 tumors at least a 50 per cent reduction in the product of the length and width of the tumor and in T3-4 tumors a reduction in tumor size to less than 2 cm. We defined a negative axillary nodal status as either a negative sentinel node biopsy before or after NC or a negative ALND. We defined a positive axillary nodal status as clinical persistence of nodal disease despite NC or involved nodes determined by ALND. Fisher's exact test was used to evaluate the association between response to NC and nodal status. Over the past 4 years, 35 patients have completed NC and surgical treatment including lymph node assessment. Sixteen cancers demonstrated a response to NC and two (12.5%) had positive lymph nodes. Nineteen cancers failed to respond to NC and 13 (68.4%) had involved lymph nodes. Fisher's exact test shows a strong association between NC response and nodal status (two-tailed P value 0.0016). Patients with advanced locoregional breast cancer that respond to NC are unlikely to benefit from ALND. If this study's findings are confirmed in larger trials, ALND could be limited to patients with advanced locoregional breast cancer unresponsive to NC.

Miscellaneous disorders and their management in gastric surgery: volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction.

This article focuses on less common diseases that surgeons are called on for management options. Five topics-volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction from peptic ulcer disease-are frequently used to evaluate surgical knowledge. Knowledge of these topics is useful for residents preparing for an in-training examination or board certification. Patients with these diseases require multidisciplinary management with oncologists and/or gastroenterologists, and mastery of these topics allows surgeons to effectively participate in the multidisciplinary care of these patients and advocate for surgical management when appropriate.