The Enneagram as a Tool for Resident Wellness and Correlation With Accreditation Council for Graduate Medical Education Milestone Achievements.

INTRODUCTION: The Enneagram is an ancient personality typing system developed to improve self-knowledge. Broken down into nine personality types, each is driven by a core motivating factor. Other personality assessments have been used to study the personality profile of surgeons. The purpose of this study is to evaluate the variability in Enneagram type among a single institution's general surgery residents. METHODS: All categorical general surgery residents at a single institution completed an online Enneagram assessment as part of a wellness initiative. Accreditation Council for Graduate Medical Education milestone levels for professionalism (PRO) and interpersonal and communication skills were collected for each resident's intern year. Milestone levels were compared between the nine Enneagram types. RESULTS: All nine Enneagram types were represented among surveyed residents. The most frequent Enneagram type was type 3 (20.69%). There was no significant difference between PRO (P = 0.322) and interpersonal and communication skills (P = 0.645) scores among residents distributed by Enneagram type. CONCLUSIONS: Regardless of core Enneagram type, general surgery residents in this study all achieved appropriate Accreditation Council for Graduate Medical Education milestone levels for entry level of training. The Enneagram can provide self-awareness and understanding of resident differences but does not impact initial assessment of competency in PRO and interpersonal communication skills.

Use of a Guide-wire as an Adjunct for the Safe Removal of a 'Stuck' Indwelling Central Venous Catheter at Risk for Breaking.

Port-based central venous catheters may remain indwelling for years with subsequent fibrosis resulting in a "stuck" catheter. At time of removal, this can lead to complications such as catheter fracture or require additional operative techniques for safe extraction. We present a case utilizing a protocol wherein a J-tip guidewire is placed to assist in removal. We believe this serves the following beneficial functions: Mechanically, as the catheter stretches and collapses upon retraction it distributes the force circumferentially along the length of the catheter as well as reduces angular kinking, mitigating stress points of fracture. Second, in case of fracture, the distal portion should remain intubated by the J-tip guidewire, reducing embolic potential. Third, it allows more facile percutaneous transvenous retrieval if indicated. Though this does not represent a perfect solution to the "stuck" catheter problem, this technique increases safety and efficacy of removal with easy application at minimal additional cost.

Incidental Preduodenal Portal Vein Causing Partial Duodenal Obstruction and Hypertrophied Pre-Pyloric Gastric Polyp.

Preduodenal portal vein (PDPV) is a rare congenital anomaly in which the portal vein lies anterior to the duodenum rather than its normal posterior position. It is a known rare cause of duodenal obstruction and can be associated with other anomalies such as malrotation with or without jejunal atresia. Presented is an incidentally found PDPV causing partial duodenal obstruction during exploration for the resection of a gastric mass and placement of open gastrostomy tube for feeding. This was managed with duodenoduodenostomy, re-creating normal anatomy with portal.

Changes in Pediatric Non-accidental Trauma Emergency Department Visits During and Following the COVID-19 Lockdown.

A level 1 pediatric trauma registry database was examined for all non-accidental trauma (NAT) emergency department visits between 2016 and 2021, and average injury severity score assigned to those patients with physical injuries over 2019-2021. There was a decline in NAT visits in 2020 (267) from prior years (343 visits average over 2016-2019), with subsequent increase in 2021 (548). Injury severity score increased (ISS) in 2020 (7.3) when compared to 2019 (5.71), with a decline in average ISS in 2021 (5.42). This data highlights the potential for missed abuse during closures with increased detection following reopening. Our data regarding ISS demonstrates the pediatric population is at risk of more severe abuse during times of familial stress. We need increased awareness that periods of vulnerability to NAT exist, as seen during the COVID-19 pandemic.

Gastroschisis Complicated by Colonic Atresia.

INTRODUCTION: Gastroschisis with colonic atresia is a rare association. Due to its rarity and variation in presentation, no standardized surgical treatment option exists. Complicated gastroschisis is associated with a higher morbidity and mortality than intestinal atresia or gastroschisis alone. METHODS: This is a case report of a neonate with congenital gastroschisis. On day of life 1, a silo was placed. On day of life 4, the upper portion of silo contents appeared more congested with dusky discoloration and the patient was oliguric. She was taken to the operating room for exploration. RESULTS: The patient required resection of the terminal ileum and an atretic portion of the cecum due to necrosis. Four days later, primary closure of the gastroschisis defect was performed with creation of an end ileostomy. Elective ileostomy takedown was performed 5 months later. She returned to the operating room for anastomotic revision and gastrostomy tube placement for intestinal dysmotility and prolonged ileus. Tube feedings were discontinued 3 months post-operatively. CONCLUSIONS: Gastroschisis with intestinal atresia is associated with increased hospital length of stay, longer duration of parenteral nutrition, more severe intestinal dysfunction, increased surgical complications, and higher mortality than gastroschisis or intestinal atresia alone. With associated colonic atresia, loss of a significant length of bowel due to necrosis, including the ileocecal region, is almost unavoidable. An already compromised blood supply to the atretic bowel is further impaired by a tight abdominal wall defect and postnatal increases in gravitational force. Complicated gastroschisis remains a complex surgical challenge requiring further discussion.

Intraoperative Methadone Reduces Postoperative Opioid Requirements in Nuss Procedure for Pectus Excavatum.

INTRODUCTION: Surgical correction of pectus excavatum by Nuss procedure, commonly referred to as minimally invasive repair of pectus excavatum (MIRPE), often results in significant postoperative pain. This study investigated whether adding intraoperative methadone would reduce the postoperative opioid requirement during admission for patients undergoing MIRPE. METHODS: A retrospective cohort chart review was conducted for 40 MIRPE patients between 2018 and 2020. Patients were stratified into 2 groups: those who received multimodal anesthesia (MM, n = 20) and those who received multimodal anesthesia with the addition of intraoperative methadone (MM + M, n = 20). Data collected included total opioid consumption during hospital stay (morphine milligram equivalents [MMEs]), hospital length of stay (LOS), pain scores, time to ambulation, and time to tolerating solid food. RESULTS: Addition of intraoperative methadone for patients undergoing MIRPE significantly reduced postoperative opioid requirements (MME/kg) during admission (P = .007). On average, patients in the MM group received 1.61 ± .55 MME/kg while patients in the MM + M group received 1.16 ± .44 MME/kg. Hospital opioid (non-methadone) total was also significantly reduced between the MM (1.87 ± .54) and MM + M group (1.37 ± .46), P = .003. There was no significant difference in hospital opioid total MME/kg administered between the groups. There were no significant differences observed in hospital LOS, pain scores, time to ambulation, or time to toleration of solid food. DISCUSSION: Incorporating intraoperative methadone for patients undergoing MIRPE reduced postoperative opioid requirements and hospital opioid (non-methadone) totals without a significant change in pain scores. Patients undergoing the Nuss procedure may benefit from the administration of intraoperative methadone.

Is Pathological Exam for Disorders of the Appendix Testis Necessary?

Testicular appendages are remnants of embryologic structures commonly encountered during pediatric operations. The literature is vague on the management of incidentally discovered testicular appendages found intraoperatively. We performed a retrospective review of 93 pediatric patients who were found to have an incidental testicular appendage during inguinal hernia repair, cryptorchidism, or testicular torsion cases from December 2017 to June 2020. 100% of the incidental testicular appendage pathology results were benign. All of the specimens were 1.0 cm or less in their largest dimension. Removal of these specimens is considered the standard of care at our institution to help prevent torsion of the testicular appendage, which is one of the leading causes of acute scrotum in children. The authors of this study argue that pathological analysis is unnecessary and may result in excessive use of resources without proven benefit.

Results of proximal arch replacement using deep hypothermia for circulatory arrest: is moderate hypothermia really justifiable?

The use of selective cerebral perfusion with warmer temperatures during circulatory arrest has been increasingly used for arch replacement over concerns regarding the safety of deep hypothermic circulatory arrest (DHCA). However, little data actually exist on outcomes after arch replacement and DHCA. This study examines modern results with DHCA for proximal arch replacement to provide a benchmark for comparison against outcomes with lesser degrees of hypothermia. Between July 2005 and June 2010, 245 proximal arch replacements ("hemiarch") were performed using deep hypothermia; mean minimum core and nasopharyngeal temperatures were 18.0 ± 2.1°C and 14.1 ± 1.6°C, respectively. Adjunctive cerebral perfusion was used in all cases. Concomitant ascending aortic replacement was performed in 41 per cent, ascending plus aortic valve replacement in 23 per cent, and aortic root replacement in 32 per cent. Mean age was 58 ± 14 years; 36 per cent procedures were urgent/emergent. Mean duration of DHCA was 20.4 ± 6.2 minutes. Thirty-day/in-hospital mortality was 2.9 per cent. Rates of stroke, renal failure, and respiratory failure were 4.1 per cent (0.8% for elective cases), 1.2 per cent, and 0.4 per cent, respectively. Deep hypothermia with adjunctive cerebral perfusion for circulatory arrest during proximal arch replacement affords excellent neurologic as well as nonneurologic outcomes. Centers using lesser degrees of hypothermia for arch surgery, the safety of which remains unproven, should ensure comparable results.

Individualized thoracic aortic replacement for the aortopathy of biscuspid aortic valve disease.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve (BAV) disease is associated with an aortopathy resulting in aneurysmal dilatation spanning the root, ascending, and arch segments. To date, no large series of proximal aortic replacement in this population has been reported. The study aim was to report contemporary surgical outcomes for proximal aortic replacement in BAV disease, and to examine the relationships between valve morphology, valve pathophysiology, and pathology of the thoracic aorta. METHODS: Between September 2005 and December 2009, a total of 100 consecutive patients (mean age 54 +/- 13 years; range: 29-80 years) with BAV and proximal aortic enlargement underwent aortic replacement at a single referral institution. Of these patients, 16% had undergone prior aortic valve replacement (AVR). The aortic repair was individually tailored to treat the aortic valve and thoracic aortic pathology, and included supracoronary ascending aortic (AA) replacement (n = 17), AVR with separate supracoronary AA replacement (n = 39), aortic root replacement (n = 42), and valve-sparing root replacement (n = 2). Concomitant arch replacement was performed in 82 patients (80 hemi-arch, two full arch). Other concomitant cardiac procedures were performed in 28 patients. RESULTS: The 30-day/in-hospital rates of death and stroke were both 1%. The predominant aortic valve pathophysiology was aortic stenosis (AS; 33%), aortic insufficiency (AI; 29%), mixed AS/AI (17%), normally functioning BAV (17%), and unknown (4%). Valve morphology included Sievers Type I, R/L (75%), Type I, R/N (9%), Type I, L/N (2%), Type 0 (7%), and Type II (7%). BAV patients with predominantly AI had more frequent root dilatation (62%) than those with either AS (30%) or normal valve function (35%). Based on BAV morphology, there were no significant differences in maximal thoracic aortic diameters between groups. At a mean follow up of 16 months, there were no late deaths or valve-related complications. CONCLUSION: Proximal aortic replacement in patients with BAV can be performed with low rates of mortality and morbidity. The pathologic anatomy of the thoracic aorta was not predicted by the aortic valve morphology, although dilation of the aortic root was most common in BAV patients with a predominant AI pathophysiology. These findings convey the safety and feasibility of treating concomitant aortopathy, including arch replacement as needed, and may help tailor the specific operation needed to the patient's pathology.