Case Reporting, Competence, and Confidence: A Discrepancy in the Numbers.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) continues to play an integral role in accreditation of surgical programs. The institution of case logs to demonstrate competency of graduating residents is a key component of evaluation. This study compared the number of vascular cases a surgical resident has completed according to the ACGME operative log to their operative proficiency, quality of anastomosis, operative experience, and confidence in both a simulation and operative setting. MATERIALS AND METHODS: General surgery residents ranging from PGY 1 to 5 participated in a simulation laboratory in which they completed an end-to-side vascular anastomosis. Each participant was given a weighted score based on technical proficiency and anastomosis quality using a previously validated Global Rating Scale (Duran et al, 2014). These scores were correlated to the General Surgery Milestones. Participants completed preoperative and postoperative surveys assessing resident operative experience using the 4-level Zwisch scale (DaRosa et al., 2013), confidence with vascular procedures and confidence performing simulated anastomoses. Confidence was assessed on a scale from 1 to 9 (not confident to extremely confident). Case logs were recorded for each participant. An IRB approved questionnaire was distributed to assess preoperative and postoperative roles of both the resident physician and faculty, with a defined goal. Univariate and multivariate analysis was performed. RESULTS: Twenty-one general surgery residents were evaluated in the simulation laboratory and 8 residents were assessed intraoperatively. The residents were evenly distributed throughout clinical years. Groups of residents were divided into quartiles based upon the number of vascular cases recorded in the ACGME database. No correlation was found between number of cases, Milestones score and the weighted score (p = 0.94). No statistical significance was found between confidence and quality of anastomosis (p = 0.1). Resident operative experience per the Zwisch scale was categorized most commonly as "Smart Help" by both the trainee and attending surgeon, despite mean resident confidence ratings of 6.67 (± 1.61) with vascular procedures. CONCLUSIONS: ACGME case logs, which are utilized to assess readiness for completion of general surgery residency, may not be indicative of a resident's operative competency and technical proficiency. Confidence is not correlated with technical ability. Faculty and resident insight as to their role in a procedure differ, as faculty feel that they are providing less help than the resident perceives. Careful examination of resident operative technique is the best measure of competency.

Endovascular Repair of Iatrogenic Iliocaval Fistula Causing High-Output Cardiac Failure after Spine Fusion.

The case being presented is a 35-year-old female with a 3-year history of progressive dyspnea and right-sided heart failure following spine surgery. Physical examination identified a continuous bruit in the lower abdomen radiating to her back which prompted further evaluation. Echocardiography showed normal left ventricle systolic function, enlarged right ventricle, functional tricuspid regurgitation, and moderate pulmonary hypertension. A computed tomography (CT) scan of the abdomen and pelvis demonstrated findings consistent with an arteriovenous fistula (AVF) between the right common iliac artery and the inferior vena cava. She underwent an uneventful endovascular repair without perioperative complication. The patient's symptoms resolved a few hours after the procedure and she continued to be symptom free at 3-month follow-up. This case illustrates an iatrogenic iliocaval fistula causing high-output cardiac failure which was successfully treated endovascularly with excellent clinical result.

Cryopreserved saphenous vein graft in infrainguinal bypass.

OBJECTIVE: Autogenous saphenous vein is the ideal conduit for lower extremity revascularization. Unfortunately, autogenous vein is unavailable in up to 20% of patients. Synthetic grafts provide an alternative; however, their use in distal revascularization has shown varying results. In addition, infected surgical sites preclude their use. Currently, there are limited outcome data for cryopreserved saphenous vein use in regard to long-term patency and limb salvage rates. METHODS: Cryopreserved saphenous vein allograft use in infrainguinal bypass was studied retrospectively in a community setting. End points included primary patency, limb salvage, and early complications. Records of patients receiving cryopreserved allografts by nine vascular surgeons within one hospital system from 2006 to 2012 were reviewed. RESULTS: Fifty-three patients, mean age 69 years (standard deviation, 12.3; range, 28-90 years), underwent 60 operations. Indications for surgery included limb-threatening ischemia (48%), tissue loss (30%), previous graft or site infection (10%), claudication (7%), or other (5%). The mean follow-up period was 23.9 months (standard deviation, 21.0; range, 0-64 months). Primary patency was maintained in 53% of patients at 1 year and in 22% at 3 years. Limb salvage was achieved in 74% of patients at 1 year and in 70% at 2 years. Thirteen early complications included 8 thromboses, 2 deaths, 2 amputations, and 1 anastomotic disruption. Fifteen patients (28%) underwent additional ipsilateral operations with use of synthetic conduits after initial cryopreserved allografts failed. CONCLUSIONS: Cryopreserved vein allografts displayed poor short-term and long-term patency, whereas limb salvage rates at 1 and 2 years remained acceptable. However, >25% of patients required additional ipsilateral operations with use of synthetic conduits after previous failed cryopreserved allograft use. Our data indicate that cryopreserved vein graft is a suboptimal choice of conduit in a noninfected field.