Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study.

OBJECTIVE: The study objectives were to characterize surgical outcomes for malignant small bowel obstruction (MaSBO) as compared to other small bowel obstructions (SBO) and to develop a prediction model for postoperative mortality for MaSBO. SUMMARY BACKGROUND DATA: MaSBO is a morbid complication of advanced cancers for which the optimal management remains undefined. METHODS: Patients who underwent surgery for MaSBO or SBO were identified from the National Surgical Quality Improvement Program (2005-2017). Outcomes [30-day morbidity, unplanned readmissions, mortality, postoperative length of stay (LOS)] were compared between propensity score-matched MaSBO and SBO patients. An internally validated prediction model for mortality in MaSBO patients was developed. RESULTS: Of 46,706 patients, 1612 (3.5%) had MaSBO. Although MaSBO patients were younger than those with SBO (median 63 vs 65 years, P < 0.001), they were otherwise more clinically complex, including a higher proportion with recent weight loss (22.0% vs 4.0%, P < 0.001), severe hypoalbuminemia (18.6% vs 5.2%, P < 0.001), and cytopenias. After matching (N = 1609/group), MaSBO was associated with increased morbidity [odds ratio (OR) 1.2, P = 0.004], but not readmission (OR 1.1, P = 0.48) or LOS (incidence rate ratio 1.0, P = 0.14). The odds of mortality were significantly higher for MaSBO than SBO (OR 3.3, P < 0.001). A risk-score model predicted postoperative mortality for MaSBO with an optimism-adjusted Brier score of 0.114 and area under the curve of 0.735. Patients in the highest-risk category (11.5% of MaSBO population) had a predicted mortality rate of 39.4%. CONCLUSION: Surgery for MaSBO is associated with substantial morbidity and mortality, necessitating careful patient evaluation before operative intervention.

Isolated limb perfusion and infusion in the treatment of melanoma and soft tissue sarcoma in the era of modern systemic therapies.

BACKGROUND AND OBJECTIVES: Isolated limb perfusion (ILP) and infusion (ILI) are treatment modalities for unresectable melanoma in-transit metastases and extremity soft tissue sarcomas (STS). We sought to characterize the national trend in their utilization in the context of novel melanoma therapies introduced in 2011. METHODS: Using the National Inpatient Sample (2005-2014), patients with a primary diagnosis of limb melanoma or STS who underwent ILP/ILI were identified by diagnosis and procedure codes. Annual percent change (APC) in ILP/ILI procedures was determined. RESULTS: From 2005 through 2014, 670 and 130 ILP/ILI procedures were performed for melanoma and STS, respectively. Mean age was 64 (SD 15) years for melanoma and 59 (SD 18) years for STS. Over time, procedures for melanoma decreased with an APC of -17 (P = .019). Comparing 2005-2010 and 2011-2014, the mean number of procedures for melanoma decreased from 91 to 32 per year (P = .007). In contrast, there was no change for STS (APC 6.5, P = .39; mean 11 and 16 per year in 2005-2010 and 2011-2014, respectively, P = .46). CONCLUSIONS: ILI/ILP utilization has decreased for melanoma, but not for STS. Whether trends for ILP and ILI differed could not be determined. ILP/ILI remains an important option to consider for regional disease control.

Qualities and Methods of Highly Effective Surgical Educators: A Grounded Theory Model.

OBJECTIVE: To identify personal qualities and teaching methods of highly effective surgical educators using a novel research design. DESIGN: In this qualitative study, surgical residents were sent an electronic survey soliciting nominations for faculty perceived as highly effective surgical educators. In-depth, semistructured interviews were conducted with surgeons receiving the most nominations. Grounded theory methodology identified themes for analysis. SETTING: General, vascular, and plastic surgery residents and faculty at the University of Pennsylvania Health System. PARTICIPANTS: A total of 77 surgical residents were surveyed. Data saturation occurred after 12 semistructured interviews with attending surgeons, corresponding to the top 15% of faculty. RESULTS: Interviewees described both personal characteristics and specific teaching approaches that facilitated successful learning. These included providing exceptional surgical education as a mission, a strong influence from past mentors and role models, a love for the profession, and a low rate of self-professed burnout. Desirable teaching methods included promoting a culture of psychological safety (the perceived ability to take interpersonal risks within one's environment), progressive autonomy, accountability of trainees, and individualized teaching for the learner. Interviewees saw education as inseparable from clinical duties, and all surgeons believed providing exceptional patient care was the foundation of effective surgical teaching. The derived themes suggested that educators prefer "cognitive-based" approaches, focusing on learning processes rather than specific outcomes. CONCLUSIONS: This study identified characteristics and educational styles of highly effective educators in a cohort of academic surgeons. This framework may inform the development of educational programs for residents and faculty in effective teaching methods.

Procedural Skills of the Entrustable Professional Activities: Are Graduating US Medical Students Prepared to Perform Procedures in Residency?

PURPOSE: Competency-based medical education has been successfully instituted in graduate medical education through the development of Milestones. Consequently, the Association of American Medical Colleges implemented the core entrustable professional activities initiative to complement this framework in undergraduate medical education. We sought to determine its efficacy by examining the experiences and confidence of recent medical school graduates with general procedural skills (entrustable professional activities 12). METHOD: We administered an electronic survey to the MedStar Georgetown University Hospital intern class assessing their experiences with learning and evaluation as well as their confidence with procedural skills training during medical school. Simple linear regression was used to compare respondent confidence and the presence of formal evaluation in medical school. RESULTS: We received 28 complete responses, resulting in a 33% response rate, whereas most respondents indicated that basic cardiopulmonary resuscitation, bag/mask ventilation, and universal precautions were important to and evaluated by their medical school, this emphasis was not present for venipuncture, intravenous catheter placement, and arterial puncture. Mean summed scores of confidence for each skill indicated a statistically significant effect between confidence and evaluation of universal precaution skills. CONCLUSIONS: More advanced procedural skills are not considered as important for graduating medical students and are less likely to be taught and formally evaluated before graduation. Formal evaluation of some procedural skills is associated with increased confidence of the learner.

Perceptions of gender-based discrimination during surgical training and practice.

BACKGROUND: Women represent 15% of practicing general surgeons. Gender-based discrimination has been implicated as discouraging women from surgery. We sought to determine women's perceptions of gender-based discrimination in the surgical training and working environment. METHODS: Following IRB approval, we fielded a pilot survey measuring perceptions and impact of gender-based discrimination in medical school, residency training, and surgical practice. It was sent electronically to 1,065 individual members of the Association of Women Surgeons. RESULTS: We received 334 responses from medical students, residents, and practicing physicians with a response rate of 31%. Eighty-seven percent experienced gender-based discrimination in medical school, 88% in residency, and 91% in practice. Perceived sources of gender-based discrimination included superiors, physician peers, clinical support staff, and patients, with 40% emanating from women and 60% from men. CONCLUSIONS: The majority of responses indicated perceived gender-based discrimination during medical school, residency, and practice. Gender-based discrimination comes from both sexes and has a significant impact on women surgeons.