Measuring Impact of Simulation-Based Informed Consent Training on Surgical Intern's Long-Term Confidence.

OBJECTIVE: Our objective was to evaluate the outcome of a training program on long-term confidence of interns and attending physicians. DESIGN: In this prospective cohort study, general surgery interns underwent a training program on informed consent that involved didactics, standardized patient encounters, and supplemental procedure specific guides at the start of the academic year. At the end of the academic year, we surveyed interns from the classes of 2020 (trained) and 2019 (untrained) about their experience and confidence in obtaining an informed consent. Further, we queried attending physicians on their experience and confidence in the interns at the end of each academic year. SETTING: Single academic general surgery residency program based at 2 urban tertiary hospitals. PARTICIPANTS: General surgery interns including unmatched preliminary residents and categorical interns from general surgery, interventional radiology, and urology. RESULTS: Twenty-four incoming interns participated in the training program. Intern confidence discussing operation benefits improved from a median score of 4 to 5 (p = 0.03), and total confidence improved from a median score of 15 to 17.5 (p = 0.08). There was no difference in median total confidence scores (15 vs. 17.5; p = 0.21) between classes. Attending physicians had similar median total confidence scores following intervention (10 vs. 11; p = 0.87). Intern satisfaction was 80% with the didactic session, and 90% with standardized patient encounters. Twenty percent of learners used the supplemental procedure specific guides. CONCLUSIONS: Implementation of an intern targeted program on informed consent that incorporated didactics and standardized patient encounters was viewed as useful and may contribute to long-term improvements in confidence.

Percutaneous peritoneal drain placement: A pilot study of pediatric surgery simulation-based training for general surgery residents.

INTRODUCTION: General surgery residents often feel unprepared to perform pediatric surgery procedures since case volume and experience may be low. Previously, we successfully implemented a simulation-based training (SBT) module for placement of a silastic silo for gastroschisis. Therefore, we designed a single institution pilot study to assess whether SBT for placement of a percutaneous peritoneal drain for perforated necrotizing enterocolitis (NEC) was feasible and lead to skill acquisition and increased confidence. METHODS: Our newly created NEC module within our pediatric surgery SBT curriculum for general surgery residents was used. Residents completed two simulation sessions three months apart with confidence testing before and after each session. Skill acquisition and performance were assessed using a standardized case scenario and procedure checklist. Changes in residents' confidence and performance were determined using Wilcoxon Signed-Rank Tests. RESULTS: Nine post-graduate-year three general surgery residents completed this curriculum. Following completion, residents reported improved confidence completing each step of the procedure initially (p = 0.005) and at 3 months (p = 0.008) with improved technical scores (p = 0.011). The number of residents deemed proficient significantly improved (p = 0.031). CONCLUSION: Implementation of SBT module for perforated NEC was feasible and improved residents' confidence and proficiency completing the procedure.

Variation in bariatric surgery utilization by state from 2010 to 2019: analysis of the PearlDiver Mariner database.

BACKGROUND: Bariatric surgery is the most effective treatment for severe obesity and its associated complications, but it remains underutilized. The degree to which bariatric surgery utilization varies by state is unclear. OBJECTIVES: The aim of this study was to quantify variation in bariatric surgery utilization across U.S. states. SETTING: United States. METHODS: Patients who underwent sleeve gastrectomy or gastric bypass and patients with body mass index (BMI) >40 or BMI >35 with comorbidities between 2010 and 2019 were identified with Current Procedural Terminology, International Classification of Diseases-9 and -10 codes using the PearlDiver Mariner insurance claims database. Patients living in Puerto Rico and other U.S. territories were excluded. RESULTS: A total of 99,173 bariatric surgery patients were identified out of 1,789,457 patients eligible for bariatric surgery between 2010 and 2019 (5.5%). Bariatric surgery patients were more likely to be female (78.8% versus 65.6%) and have commercial insurance (81.4% versus 69.6%) compared with eligible patients who did not undergo bariatric surgery. Bariatric surgery utilization varied widely between states, from 10.4% in New Jersey to 2.1% in Vermont. The Northeast region had the highest rates at 7.95%, and the Midwest had the lowest at 4.47%. The proportion of bariatric surgeries that were sleeve gastrectomies also varied from <30% in Alaska, North Dakota, and Rhode Island to >80% in New Jersey, Nevada, and Mississippi. CONCLUSION: There is significant variation in bariatric surgery utilization between states, with almost a 5-fold difference between the states with the highest and lowest utilization.

Pediatric Surgery Simulation-Based Training for the General Surgery Resident.

BACKGROUND: Surgical simulation-based training (SBT) can increase resident confidence and improve performance. SBT in pediatric surgery is in its infancy and often geared toward training pediatric surgery fellows. Since case volume for various pediatric surgery-specific procedures can be low based on the rarity of the pathology involved and the level of care provided by the institution, our aim was to create a pediatric surgery simulation-based curriculum for general surgery residents to address this need. MATERIALS AND METHODS: We performed an institutional needs assessment consisting of 4 pediatric surgeons' and 28 general surgery residents' confidence in resident ability to independently perform pediatric surgery-specific tasks and procedures using a Likert-scaled survey. These included the placement of a silastic silo for gastroschisis, a percutaneous drain for perforated necrotizing enterocolitis, and completion of a laparoscopic pyloromyotomy for pyloric stenosis. Models simulating these pathologies and curriculum for performing each procedure were generated. RESULTS: We successfully created a model and SBT curriculum to teach general surgery residents how to place a silastic silo for patients with gastroschisis, a percutaneous drain for patients with perforated necrotizing enterocolitis, and how to complete a laparoscopic pyloromyotomy for patients with pyloric stenosis. These were deemed high fidelity models based on a survey of our pediatric surgeons. CONCLUSIONS: We created a pediatric surgery SBT curriculum for general surgery residents, which can be used to supplement learning of various high-acuity, low-occurrence procedures. Assessment of residents and validation of scores is underway.

Silo placement in gastroschisis: A pilot study of simulation-based training for general surgery residents.

INTRODUCTION: General surgery residents often feel unprepared for rotations on pediatric surgical services as case volume and experience performing pediatric procedures may be inadequate for high acuity, low volume procedures. We designed a single institution pilot study to assess whether simulation-based training (SBT) for placement of a silastic silo for gastroschisis was feasible and lead to skill acquisition, retention and increased resident confidence. METHODS: We used our newly created gastroschisis module within our pediatric surgery SBT curriculum for general surgery residents. Residents completed two simulation sessions three months apart, completed confidence testing before and after each session, and were assessed using a standardized case scenario and procedure checklist. Wilcoxon Signed-Rank Tests evaluated changes in residents' confidence and performance. RESULTS: Ten post-graduate-year three general surgery residents completed this curriculum. Residents reported improved confidence completing each step of the procedure initially (p=0.008) and at 3 months (p=0.005). They had improved technical scores across all steps of the procedure (p=0.005). The number of residents deemed proficient significantly improved (p=0.008). CONCLUSION: We demonstrated the feasibility of assessing the technical skills of general surgery residents performing a simulated placement of a silastic silo for gastroschisis. Residents' confidence and proficiency improved over the three-month period. STUDY TYPE: Prospective LEVEL OF EVIDENCE: Level II.

Do One, Do One, Teach One: Altering the Dogma Using Simulation-Based Training to Maximize Efficiency of Surgical Resident Education.

BACKGROUND: Graduating surgery residents often feel unprepared to practice autonomously in the current era of surgical training. We implemented an integrated simulation curriculum to improve residents' autonomy and increase their confidence to practice independently. In this study, we chose a laparoscopic ventral hernia repair (LVHR) as our pilot operation to test proof of concept and on which we would construct our integrated curriculum. STUDY DESIGN: The curriculum included a web-based cognitive component, inanimate model simulation session with follow-up at 2 weeks and 6 months, and self-confidence questionnaires. Faculty rated each resident's procedure-specific skill by using a modified Global Operative Assessment of Laparoscopic Skills (GOALS) criteria and a task-specific checklist. RESULTS: Thirteen junior residents, 7 senior residents, and 7 faculty surgeons completed the curriculum. Four junior residents (31%) achieved proficiency at their first session, 10 (77%) after the second session (p = 0.031), and 6 (67%) at 6 months (p ≥ 0.99). Three residents regressed and did not maintain proficiency after the second assessment. Performance (GOALS) scores improved (p = 0.0313) at week 2 and were maintained at 6 months (p = 0.5625). Required faculty direction decreased (p = 0.004), and resident confidence in completing the procedure independently improved (p < 0.004) over the 6-month curriculum. CONCLUSIONS: Assessing procedure-specific and global laparoscopic skills through a simulation-based curriculum is feasible and can be used to augment resident training. Our curriculum demonstrated improvement in proficiency and self-confidence while performing an LVHR. Additional study is needed to examine the optimal way to integrate procedure-specific simulation models into training programs.

Predicting aggressive behavior in nonfunctioning pancreatic neuroendocrine tumors.

PURPOSE: The biologic potential of nonfunctioning pancreatic neuroendocrine tumors (PNETs) is highly variable and difficult to predict before resection. This study was conducted to identify clinical and pathologic factors associated with malignant behavior and death in patients diagnosed with PNETs. METHODS: We used International Classification of Diseases 9th edition codes to identify patients who underwent pancreatectomy for PNETs from 1998 to 2011 in the databases of 4 institutions. Functioning PNETs were excluded. Multivariate regression Cox proportional models were constructed to identify clinical and pathologic factors associated with distant metastasis and survival. RESULTS: The study included 128 patients-57 females and 71 males. The age (mean ± standard deviation) was 55 ± 14 years. The body mass index was 28 ± 5 kg/m(2). Eighty-nine (70%) patients presented with symptoms, and 39 (30%) had tumors discovered incidentally. The tumor size was 3.3 ± 2 cm with 56 (44%) of the tumors measuring ≤2 cm. Seventy-three (57%) patients had grade 1 histology tumors, 37 (29%) had grade 2, and 18 (14%) had grade 3. Peripancreatic lymph node involvement was present in 31 patients (24%), absent in 75 (59%), and unknown in 22 (17%). Distant metastasis occurred in 18 patients (14%). There were 12 deaths, including 1 perioperative, 8 disease related, and 3 of unknown cause. With a median follow-up of 33 months, the overall 5-year survival was 75%. Multivariate Cox regression analysis identified age >55 (hazard ratio [HR], 5.89; 95% confidence interval [CI], 1.64-20.58), grade 3 histology (HR, 6.08; 95% CI, 1.32-30.2), and distant metastasis (HR, 8.79; 95% CI, 2.67-28.9) as risk factors associated with death (P < .05). Gender, race, body mass index, clinical symptoms, lymphovascular and perineural invasion, and tumor size were not related to metastasis or survival (P > .05). Three patients with tumors ≤2 cm developed distant metastasis resulting in 2 disease-related deaths. CONCLUSION: Age >55 years, grade 3 histology, and distant metastasis predict a greater risk of death from nonfunctioning PNETs. Resection or short-term surveillance should be considered regardless of tumor size.