95.12 A Robotic Surgical Curriculum for Chief Resident Exposure and Experience

Posted on January 18, 2018

M. P. Meara1, C. P. Rodman1, J. S. Schwartz1, D. B. Renton1, A. S. Meara1  1The Ohio State University Wexner Medical Center,Department Of Surgery,Columbus, OH, USA

Introduction:

This abstract will discuss a novel longitudinal curriculum that focuses on exposing residents to robotic surgery early in their training and developing that experience throughout their surgical residency.   Surgical robotics continues to evolve and is becoming more common for a variety of types of surgery.  One of the largest areas of growth is in General Surgery — specifically in hernia repair.  High volume surgeons are often in private practice and thus, ACGME trainees are frequently merely exposed to robotic surgery but have little console exposure or procedural education.  The majority of robotic surgery training is often done in post-resident training or is learned during a clinicians practice, placing a burden on the system and requiring significant funding to teach board certified surgeons expanded skills. There are few programs—and even fewer in general surgery—that describe an ACGME trainee curriculum for robotic surgery, and those which exist are primarily comprised of online modules, simulation, and a varying amount of console cases. Thus, there is a growing need to create a hands-on robotic surgery curriculum in surgical training. 

Methods:
The Ohio State University (OSU) has a single, dual-console Intuitive da Vinci Xi Robotic System with a dedicated General Surgery service line.  There are three attending general surgeons that have been successfully trained in robotic surgery and now help teach the surgical residents and fellows.  Privileges to operate on the console is a combination of online modules, laboratory simulation modules, and bedside assisting prior to console operating.

Results:

Since obtaining the dedicated service line robot in December of 2016, four Chief Surgical Residents have rotated on the surgical service (two-month rotations).  Each resident has performed on average 23.625 console cases per month or 47.25 cases per rotation as the primary console surgeon.  Each of the residents completing the rotation has obtained Intuitive certification of their experience.  This specific rotation can translate to privileging and credentialing at their respective institutions upon graduation.

Conclusion:

Due to the expanding role of robotic surgery, specifically in general surgery, it is vital that surgery-training programs begin to incorporate new curricula to not only expose ACGME trainees to robotic surgery but also develop competent future robotic surgeons.  Robotic curricula are described per the university training program and each is unique. The next step is to create validated assessment measures for the trainees as well as ACGME training expectations.

 

95.06 Introducing a Shadowing Experience to Surgical Intern Orientation: Hitting the Ground Running

Posted on January 18, 2018

K. F. Angell1, Z. Senders1, J. T. Brady1, J. Ammori1, J. M. Marks1  1University Hospitals Cleveland Medical Center,Surgery,Cleveland, OH, USA

Introduction: The transition from medical student to surgical intern is a challenging step, encompassing the use of new skills, new clinical sites, utilizing electronic medical records (EMR) systems and providing care for patients while supervising residents may be in the operating room. Surgical orientations covering a multitude of topics have been developed to prepare interns for this transition. Based on our previous orientation surveys, 83% of interns felt a shadowing experience would be very beneficial to internship preparation. We sought to implement a shadowing experience as part of intern orientation to simulate their clinical rotations and best prepare interns with the skills and knowledge required to be a successful intern. Our objective was to assess all orientation activities with a focus on the shadowing experience.

Methods: 15 incoming surgical interns participated in a preparatory orientation preceding the start of internship. Orientation activities included sessions on handoff skills, EMR use, administrative tasks, troubleshooting tubes and drains, surgical instruments and suturing. An optional activity was added for interns to shadow the surgical team on which they would start their internship. Interns participating in the shadowing experience met at one of three hospital rotation sites, attended morning rounds and observed current interns completing daily tasks.  Surveys assessing the value of orientation sessions in preparing for internship were administered to all participating interns 6 weeks after beginning internship.

Results: 13 of 15 incoming surgical interns participated in the shadowing session. The following sessions were assessed for usefulness: site tours, handoff practice, suturing and surgical instrument identification, tubes and drains management and general orientation. The tubes and drains lab and overall orientation were rated as most helpful, while surgical instrument labs and site tours rated as least helpful. The shadowing experience was rated ‘helpful’ by 6 of the participants and ‘very helpful’ by the remaining 7 participants. Comments reported shadowing as more valuable than EMR courses in learning EMR use, and multiple interns requested additional shadowing experiences.

 

Conclusion: The challenge of preparing incoming surgical interns for the transition to internship remains an area for continued improvement. Replicating the tasks required of surgical interns and covering key topics necessary for starting internship is an overwhelming task. A shadowing experience with surgical teams prior to the first day of internship may be a valuable and feasible experience that best exposes incoming interns to the tasks, knowledge and routine of surgical internship. This experience could easily be replicated at any surgical residency program. Surveying additional metrics may provide information to structure the shadowing experience to increase value and positively impact patient safety and workflow.

95.07 Implementing Survey-Based Changes in an Online Curriculum for Surgical Interns: A Follow-Up Study

Posted on January 18, 2018

M. E. Alishahedani1, G. A. Sarosi1, J. A. Taylor1  1University Of Florida,Department Of Surgery,Gainesville, FL, USA

Introduction:  To promote the growth of the online curriculum at the authors’ residency program, study habits and learning resources used by surgical interns were previously evaluated and presented in a pilot study. Based on the results, multiple changes were implemented to enhance the interns’ weekly teaching conferences. To assess the use of these curricular changes, the interns were surveyed at the end of the academic year.  The purpose of this study was to use the responses to determine utilization and satisfaction with the new materials, in an effort to continuously evolve the institution’s surgical educational environment.

Methods: Surgical interns at a single academic institution were given an IRB-approved survey at the end of the 2017 academic year.  The survey focused on study habits and material use.  The responses were de-identified; participation was voluntary.  The survey was validated through a modified Delphi technique.  Descriptive statistics were performed on demographics.  Likert responses underwent Mann-Whitney analysis (α = 0.05).

Results: The response rate was 52.9% (n=9). 55.6% of the respondents were male. 33.3% were categorical interns. The Internet was the most-used resource, compared to all others used (p<0.05). All respondents used the Internet to some degree for study.  As in the 2015 pilot, the Surgical Council on Resident Education (SCORE) website was the most-used Internet resource (66.7%). 77.8% used review books, making this the next-most used material. Although 33.3% responded never using textbooks to study, textbooks and the Internet were the two resources that 22.2% of the interns always used. There was a statistically significant increase in access of the Internet for study use between 2015 and 2017 (p<0.05). All other sources were similarly used, to no statistical significance. Regarding new online material organized based on pilot study feedback, 55.6% of interns reported sometimes using the weekly reading links associated with a proprietary question bank. These links aligned with their teaching conference schedule. 66.7% were somewhat satisfied with it. 44.4% were somewhat satisfied with the use of new video links, which were organized in parallel with the This Week in SCORE (TWIS) curriculum. There were no “always” use responses for any new material.

Conclusion: Changes implemented in the surgical interns’ online curriculum were based on previous analysis and survey feedback in a pilot study. Interns were overall satisfied with the enhanced curriculum. The statistically significant increase in the use of Internet resources warrants attention. Material that was organized based on the pilot study feedback was not widely used. This may be due to resource fatigue experienced by the learner. The learner’s interaction with provided material is critical to curricular success. Keeping changes focused in future curricular design may aid in creating a more effective learning environment.

 

95.01 Mistreatment of Medical Students During the Surgical Clerkship and its Effect on Career Choice

Posted on January 18, 2018

H. E. Pierce1, L. J. Hinyard1, T. L. Schwartz1  1Saint Louis University School Of Medicine, St. Louis, MO, USA

Introduction: Surgical education has historically implemented intimidation and fear into its teaching strategies. Surgical clerkships are thought to be especially authoritarian and experiences during the clerkship may influence a student’s decision to pursue surgery. The objective of this study was to assess medical students’ perceptions of mistreatment during their surgical clerkship and the influence those experiences had on the choice of general surgery as a specialty.

Methods: A modified version of the questionnaire created and published by Dr. Scott and colleagues at the University of Sydney and Melbourne medical schools assessing medical mistreatment was sent to all third year medical students (n = 175). We received 61 completed surveys for a final response rate of 35 percent. Descriptive statistics are reported as counts and proportions.

Results: Experience of personal humiliation was reported by 32 percent of students and 30 percent had witnessed another student be humiliated. Rude behavior from an attending physician or surgical resident was reported by 63 percent of students, while 37 percent of students reported experiencing being yelled at by a resident or attending. Reporting of this mistreatment was low; 93 percent of students did not report mistreatment, even though 83 percent of respondents reported knowing where reports could be made (Table 1). Reasons for not reporting included: 1) would not have impact; 2) normalization of behavior; 3) time constraints; 4) fear of retribution. Of the 61 respondents, only 6 students reported they would be applying to general surgery for their residency and 57 percent of students stated the surgery clerkship affected their career choice.

Conclusion: Perceived mistreatment remains a common theme in medical student education. Experiences during the surgical clerkship that are felt to be humiliating, or embarrassing may deter student from pursuing a career in a surgical specialty.

95.03 #obsm: Early Experience with an Interdisciplinary Social Media Chat on Obesity and Bariatric Surgery

Posted on January 18, 2018

H. J. Logghe1, A. A. Ghaferi2, B. Moeinolmolki4, N. Floch3, S. Arghavan5  1Allies for Health,Reno, NV, USA 2University Of Michigan,Ann Arbor, MI, USA 3Fairfield County Bariatrics And Surgical Specialists,Norwalk, CT, USA 4Moein Surgical Arts,Los Angeles, CA, USA 5Washington University,St. Louis, MO, USA

Introduction:  Thirty-six percent of American adults have obesity. Bariatric surgery is the most effective treatment for obesity, yet less than 1% of eligible Americans undergo surgery. This discrepancy is often blamed on limited understanding of surgical treatments by patients and primary care providers. We hypothesized that tweetchats would be a novel way for surgeons to bridge the education gap and engage with allied health professionals, patients, and advocates. In December 2016, we initiated a monthly #obsm (obesity social media) tweetchat aimed at creating an interdisciplinary, patient-inclusive community to improve awareness of and access to unbiased, evidence-based treatments for those with obesity.

Methods:  Tweetchat dates and topics were announced through blog posts written by the leadership team of five surgeons and posted on personal and institutional websites, which were shared and publicized on Twitter. The tweetchats lasted one hour and occurred monthly. During each chat five pre-determined questions were presented in ten-minute intervals by the #obsm Twitter account. Each chat was moderated by a content expert, with healthcare professionals and other stakeholders recruited to participate. Tweets and corresponding user profiles were prospectively collected through the Symplur Healthcare Hashtag Project. Customized stakeholder categorization of participants was performed using Symplur Signals.

Results: The first six chats resulted in an average of 692 (range: 498-974) tweets, 8.4 (range: 5.4-13.6) million impressions, and 51 (range: 26-74) participants per chat. Participants averaged 14 (range: 10-22) tweets per chat. The interchat periods averaged 12.0 (range: 5.3-21.3) million impressions with 1,232 (range: 612-1,940) tweets by 276 (range: 168-413) participants. Stakeholder categorization revealed representation by individuals and organizations both within and outside healthcare. Table 1 demonstrates select stakeholders in the #obsm community during the 6 months analyzed.

Conclusion: A surgeon-led tweetchat on obesity and bariatric surgery resulted in robust participation and impressions from diverse participants. Discussion was sustained beyond the scheduled tweetchat. Of note, our results only capture active engagement by participants. Twitter, a public social media platform, allows people to see the content freely. As such, the estimates of participation and engagement may be underestimated. Nonetheless our experience suggests tweetchats may serve as powerful forums for surgeons in other subspecialties to engage with their respective stakeholders to improve understanding of treatment options, to enhance the experience of patients, and to reduce barriers to care.

 

94.19 Resident Postgraduate Level Does Not Impact Outcomes Following Cholecystectomy

Posted on January 18, 2018

L. R. Taveras Morales1, J. Imran1, O. Renteria1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Department Of Surgery,Dallas, TX, USA

Introduction: Cholecystectomy is one of the most common operations performed in general surgery. Prior studies have shown no difference in outcomes after cholecystectomy between attending surgeons and resident physicians; however, there is a paucity of data comparing outcomes between senior- and junior-level residents. The aim of this study was to compare intraoperative and postoperative outcomes after cholecystectomy between the latter two groups. 

Methods:  A retrospective chart review was performed of all cholecystectomies performed over a 10-year period at the Veterans Affairs North Texas Health Care System. Procedures completed during gastric bypass or for cancer were excluded. Cohorts were divided into intern or postgraduate year (PGY) 2-3 residents and senior-level residents (PGY 4-5). Categorical and continuous data were analyzed using chi-squared and Student’s t tests where appropriate. 

Results: Overall, 721 cholecystectomies were performed during the study period, with 442 (61.3%) done by PGY 1-3 residents and 279 (38.7%) by PGY 4-5 residents. There was no difference in patient demographics between the two groups, including on measures of age, gender, race, and ASA classification. Comorbidities were similar between groups except for a history of myocardial infarction (MI), which was more common in the patients operated on by junior-level residents (8.3% vs. 4.3%; p = 0.03).

When comparing estimated blood loss, operative time, or conversion rate there was no difference between cohorts. Patients operated on by senior-level residents had a higher incidence of postoperative abscess (2.5% vs. 0.4%; p=0.01) and urinary tract infection (2.5% vs. 0.68%; p=0.04), while patients operated on by junior-level residents had a shorter length of stay (3.2 days vs. 4.5 days; p<0.01). There was no difference in 30-day morbidity, mortality, or postoperative complications such as pneumonia, biloma, postoperative MI or renal failure. 

Conclusion: There is no difference in major complications based on PGY-level following cholecystectomy.  While no statistic difference in patient demographics were noted, the observed higher rate of minor complications and LOS might be a reflection of senior residents undertaking more challenging cases of gallbladder disease.  
 

94.17 Medical School Clerkship Experience: Influence on Specialty Choice

Posted on January 18, 2018

A. D. Kaminski1, G. N. Falls1, P. P. Parikh1  1Wright State University,Department Of Surgery,Dayton, OH, USA

Introduction:
The primary objective of this study was to determine the influence of clerkship experience on specialty choice. Since students only experience six specialty rotations throughout third year, our goal was to determine if the lack of exposure is deterring students from certain specialties. We also identified factors that influence decision of students who choose a specialty that is not a part of third year curriculum.

Methods:
An IRB-approved questions based survey on Qualtrics was prepared and sent to all graduating 4th year medical students at our institution. The survey included questions related to specialty interests before and after clerkships and influence of clerkship experience on specialty choice. Students also provided descriptive response on specific factors influencing their specialty choice and things medical school could do to facilitate their decision. The data were then analyzed descriptively and qualitatively to identify themes.

Results:
Majority of students (87%) had at least minimal exposure to their chosen specialty prior to the clerkship. This exposure increased significantly following the clerkship (97%). 70% of students reported that the role of clerkship experience in selecting a specialty was either extremely significant or significant. Various aspects of clerkships were influential, as shown in Table 1. Specialty interests before and after clerkships were variable, for example 10 students were interested in surgery prior to clerkships, and 8 decided to pursue surgery as career. The most influential reasons for a student’s specialty choice to change after clerkships, were clerkship experience (56%) and mentors (28%). 34% of students chose a specialty that was not a part of 3rd year clerkships. Of those students, the most significant factors influencing their specialty choice were shadowing experience (65%) and lifestyle (61%). Qualitative analysis of data indicated that students requested earlier and more exposure to various specialties in order to make specialty selection process easier. 

Conclusion:
Clerkship experience plays a major role in selecting a specialty. Earlier exposure would help the decision-making process. Students who ultimately choose a non-core specialty would benefit from more shadowing and earlier exposure. 
 

94.12 Prediction Of Postoperative Surgical Risk: A Needs Assessment For Formal Curriculum

Posted on January 18, 2018

S. L. Ahle1, J. M. Healy1, K. Y. Pei1  1Yale University School Of Medicine,New Haven, CT, USA

Introduction:  For medically complex patients, determining postoperative surgical risk is challenging.  Previous studies demonstrated that resident and attending surgeons significantly overestimate risk of complications and death when compared to the ACS NSQIP risk calculator.  Given that medical students learn through observation and clinical exposure during their clerkships, they may model similar prediction practices to their teachers.  Medical students’ abilities to predict postoperative complications and death are unknown.  We hypothesize that medical students will lack confidence in determining surgical risk, and will significantly overestimate surgical risk for post-operative morbidities and mortality.  

Methods:  Following completion of their clerkships, third year medical students at an urban, tertiary, academic medical center were invited to participate in an online, anonymous survey to assess their abilities to predict surgical risk. General Surgery residents were also invited to participate in the same assessment.  The survey presented seven complex clinical scenarios representative of a diverse general surgery practice. Students were asked to assess the likelihood of any morbidity, mortality, surgical site infection, pneumonia, and cardiac complications on a 0-100% scale. Morbidity and mortality predictions were compared to the ACS NSQIP risk calculator.  Using independent samples t-tests and Mann-Whitney U non-parametric tests, we determined if students and residents had statistically different risk assessments for each case.

Results: 24 students (80% response rate) and 76 residents (64% response rate) participated in the assessment. Most students were not confident about predicting post-operative complications (83.3%) or mortality (70.8%).  Most students did not feel that the surgery clerkship adequately prepared them to assess surgical risk (69.6%). When compared to surgical residents for most presented cases (57% of cases), students and residents similarly over-estimated post-operative morbidities and mortality. For 3 cases, resident estimates were higher than medical students, but both groups still significantly overestimated when compared to the risk calculator.  Estimates varied significantly, with wide 95% confidence intervals.  Only 17% of NSQIP predicted estimates fell within the 95% confidence intervals (Figure 1: representative scenario). 

Conclusion: Medical students overestimate morbidity and mortality following surgery in complex patients.  Additionally, they lack confidence in their ability to predict surgical complications, and feel they are not adequately learning this skill on their surgical clerkship. A formal curriculum for risk prediction is needed for medical students. 

 

94.11 There is No Routine Gallbladder: A Call to Enhance the “Culture of Safety in Cholecystectomy”

Posted on January 18, 2018

T. T. Jayakrishnan1, M. Chimukangara1, T. P. Webb1, C. S. Davis1  1Medical College Of Wisconsin,Division Of Trauma, Critical Care, And Acute Care Surgery,Milwaukee, WI, USA

Introduction: Cholecystectomy for gallbladder disease is a common general surgery procedure. A “culture of safety in cholecystectomy” has been proposed to minimize bile duct injuries. However, the proposed culture fails to incorporate careful scrutiny of pre-operative imaging and laboratory analysis, as well as how to address unusual pathology.

Methods: We present three interesting cases of unusual gallbladder anatomy and pathology and propose an algorithm for a safe cholecystectomy that extends beyond aberrant biliary anatomy and the critical view of safety.

Results: With a prevalence less than 0.3%, a truly left-sided gallbladder is a rare anomaly that may provide a surprise during cholecystectomy if not identified pre-operatively. Intra-operative identification may necessitate modification of standard technique, assessment for possible vascular anomalies, and the addition of adjuncts such as intra-operative cholangiogram. Surgery can be performed safely in most cases without conversion to open technique. Similarly, foci of gallbladder wall calcification and the post-operative finding of ectopic pancreatic tissue in the gallbladder wall may lead to management dilemmas, especially when associated with other confounding factors such as elevated tumor markers. Our review of the literature identified no algorithm that incorporates pre-operative imaging, laboratory analysis, or expert consultation in the event that the atypical gallbladder is encountered.

Conclusion: Careful review of pre-operative imaging and laboratory results are critical to a safe treatment plan for patients with gallbladder pathology. Similarly, expert consultation in the event of atypical gallbladder pathology should be liberally entertained. In addition to safe surgical technique, these factors enhance the culture of safety in cholecystectomy and should be incorporated into an algorithm useful for both teaching and clinical purposes.

94.09 Live Tweeting the Academic Surgical Congress: Four Years of Growth and Focus

Posted on January 18, 2018

H. J. Logghe7, J. W. Suliburk5, A. Cochran4, N. J. Gusani1, L. S. Kao5, B. C. Nwomeh6, C. D. Jones2  1Penn State Hershey Medical Center,York, PA, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA 3Baylor College Of Medicine,Baltimore, MD, USA 4University Of Utah,Salt Lake City, UT, USA 5University Of Texas Health Science Center At Houston,Houston, TX, USA 6Nationwide Children’s Hospital,Columbus, OH, USA 7Allies For Health,Reno, NV, USA

Introduction:  Social media coverage of academic conferences has rapidly evolved from a novelty to an expectation. The first peer-reviewed publication describing the use of Twitter at a major surgical meeting reported tweeting about the 2013 Academic Surgical Congress (ASC), including quantification of posts and retweets. To evaluate the expansion of social media in a similar setting, the current study seeks to quantify the Twitter activity surrounding the 2016 and 2017 ASC and to compare findings to those of the previous work.

Methods:  Evaluation of tweets about the 2016 and 2017 ASC was designed to replicate the methods used in the 2013 study wherever possible. Tweets including the #ASC2016 and #ASC2017 hashtags were prospectively gathered using the Symplur Healthcare Hashtag Project and descriptive statistics were obtained for tweets posted from 1 day before to 1 day following the conference. Based on the prior categorization of 2013 tweets, power analysis was performed (α=0.05, β=0.2) to detect a small difference in proportions of tweets in each category (352). Thus, a random sample of 400 #ASC2016 tweets was obtained and manually categorized to one of four categories to compare the proportions of tweets in the same categories between 2013 and 2016 (the most recent year for which complete data was available).

Results: In combined original and retweet analysis, there were 6,288 tweets from #ASC2016 and 11,521 tweets from #ASC2017, representing 14 and 27-fold increases from 2013 respectively (443 #ASC2013 tweets). These were posted respectively by 1,089 and 2,108 participants, up from 58 in the original study, representing 19 and 36-fold increases. While 4 individuals (a designated “Twitter team”) posted 56% of all tweets in 2013, the top 4 posters in 2017 were responsible for only 16% (1835/11521) of tweets. Of the 334 random #ASC2016 tweets categorized, 184 (55%) were related to content of sessions, 85 (25%) were promotional, and 53 (16%) were social in nature, statistically significantly more containing research content (p<0.01) and less containing promotional content (p=0.01) in 2016 than in 2013. (Figure)

Conclusion: Live tweeting of the Academic Surgical Congress has evolved quickly from the product of a small team of users to a crowdsourced effort, while increasing the proportion of tweets reflective of session content. Live tweeting of this surgical conference demonstrates an improved ability to share knowledge and promote academic activity beyond the physical confines of the meeting. Social media’s use related to academic conferences should be considered integral to the mission of knowledge distribution.

 

94.05 Team-Based Learning in Surgery Clerkship: Perception and Impact on NBME Subject Examination Scores

Posted on January 18, 2018

C. Babbitt1, A. Kaminski1, M. C. McCarthy1, M. Roelle1, R. Markert1, P. P. Parikh1  1Wright State University,Dayton, OH, USA

Introduction:   Team-based learning (TBL) has been studied in several preclinical and a few clinical settings, but there is less evidence for its effectiveness in specialties, such as Surgery.  We developed and instituted TBLs in a 3rd year surgery clerkship and compared Surgery Subject Exam scores before and after implementation.  We also analyzed students’ feedback for their perception of TBLs.

Methods:   The study was approved by Wright State University’s IRB.   The TBLs were transitioned into the curriculum during the 2013-2014 academic year.  Thus, the before implementation period was the two academic years prior (2011-2013), and the after implementation period was 2014-2016. NBME Subject Examination scores at our institution and nationally were compared using the independent samples t-test.  Satisfaction with the clerkship was assessed with AAMC Graduation Questionnaire data. Student feedback regarding TBLs was gathered at the end of each surgery rotation (six per year) and were analyzed for themes, both positive and negative, using constant comparative method.

Results:  Table 1 shows that NBME Surgery Subject Exam mean score was higher at our institution than nationally, both before (77.10±8.75 vs. 75.20±8.95, p=0.032) and after (74.65±8.0 vs. 73.10±8.55, p=0.071) TBL implementation. The NBME Subject Exam mean was lower following TBL implementation at our medical school (77.10±8.75 vs. 74.65±8.00, p=0.039), but the mean was also lower at the latter period on a national basis  (75.20±8.95 vs. 73.10±8.55, p<0.001).  Further, students at our medical school were more likely to rate the surgery clerkship good or excellent after TBL implementation (84.6% vs. 73.7%).  Overall, qualitative assessment perceived our TBLs to be educationally effective.  Learners stated that TBLs were informative, helpful in studying for the shelf exam, and viewed them as an opportunity for interactive learning. Some students also requested more TBLs.  Areas for improvement included reading materials, TBL instructions, and organization of sessions.  Some students viewed TBLs as more time-consuming than traditional instruction.

Conclusion:  Team-based learning has been found to be an effective collaborative learning strategy in medical education.  Since introducing TBL into our surgery clerkship, student perception of TBL has been both positive and provided feedback for improvement.  In addition, our medical school graduates have continued to assess their surgery experience as good/excellent by large majorities.  Concurrently, our NBME Subject Exam scores remain one-half to one standard deviation above the national mean.  In summary, we believe our medical students benefit from a well-organized TBL and its active approach to learning during surgery clerkship with no loss of fundamental surgery knowledge.
 

94.02 Is there Gender Bias on the General Surgery Certifying Examination?

Posted on January 18, 2018

T. Q. Ong2, J. P. Kopp1, A. T. Jones1, M. A. Malangoni1  1American Board Of Surgery,Philadelphia, PA, USA 2James Madison University,Harrisonburg, VA, USA

Introduction: Candidates pursuing certification in general surgery by the American Board of Surgery (ABS) must first pass a written qualifying exam and then an oral certifying exam (CE). Examiners evaluate candidates’ clinical ability to diagnose and manage problems encountered across the breadth of general surgery on the CE. Previous research in other contexts has found that examiners may exhibit bias toward examinees based on demographic variables such as gender. Systematic examiner bias threatens the fairness, reliability, and validity of the examination. We explored whether the gender of examinees or examiners were associated with CE scores and the likelihood of passing the CE.

Methods: Data from examinees who attempted the general surgery CE in the 2016-2017 academic year were analyzed. There were 1,341 examinees (61% male) and 216 examiners (82% male). Each examinee was rated by three pairs of examiners (one board examiner and one associate examiner). Factorial ANOVA and logistic regression analyses were conducted to examine whether examinee and examiner gender influenced CE scores and the likelihood of passing the exam. All effects were examined for both statistical and practical significance.

Results: ANOVA results indicated examiner and examinee gender did not influence average exam scores or pass rates. CE average scores were not associated with examinee gender (p = .24), board examiner gender (p = .14), or associate examiner gender (p = .10). All interaction effects between examiner and examinee gender were also nonsignificant (p’s > .05). Similarly, the likelihood of passing the CE was not associated with examinee gender (p = .88), board examiner gender (p = .77), associate examiner gender (p = .49), or any interactions between examinee and examiner gender (p’s > .05).

Conclusion: These results show there was no significant gender bias on the ABS general surgery CE. As the proportion of women entering the field of surgery increases, it will remain important to continue monitoring exam results to ensure no gender bias occurs in the future. The ABS has implemented implicit bias training for examiners to help mitigate the possibility of bias. Future research is needed to examine possible bias due to other factors.

92.17 Surgery Of Non-tumoral Oeso-gastroduodenal Diseases By Laparoscopy. DiopPS, KaI,FayeA.C ,Fall B. ?

Posted on January 18, 2018

P. S. DIOP1, P. S. DIOP1  1Cheikh Anta DIOP University,Departement Surgery,Dakar, DAKAR, Senegal

Introduction: : Laparoscopy has upset all fields of surgery by introducing the concept of minimally invasive surgery. It has seen its use grow, making it a tool unavoidable today especially in non-tumoral oeso-gastro-duodenal pathology. The objective of this study was to describe the epidemiological profile of patients, to report the indications and results of the treatment of non-tumoral oeso-gastroduodenal diseases by laparoscopy.

Methods: This is a retrospective study of the general surgery department of the Grand-Yoff General Hospital of Dakar during the period from 1 January 2006 to 31 December 2015. The inclusion criteria Were patients with laparoscopic non-tumor oeso-gastroduodenal disease.

Results:During the study period, 481 patients underwent laparoscopic surgery. Of these, 95 patients, 19.75%, had a non-tumoral oes-gastroduodenal disease. The average age was 41.86 years. The sex ratio was 1.05. Our series involved 16 cases of achalasia, 33 cases of hiatal hernia, 40 pyloroduodenal and 6 ulcerative stenoses. The average life span was 26.56 days. Fibroscopy was performed in all patients. The oeso-gastroduodenal transit made it possible to make the diagnosis of achalasia in all the patients concerned. All our patients diagnosed with achalasia were operated by Heller's cardiomyotomy under laparoscopy. According to Nissen-Rosseti (66%), according to Nissen (19%), according to Toupet (12%) and Dor (3%), the different therapeutic procedures in hiatal hernia were represented by the cure. In our series, 92% of our patients suffering pyloroduodenal stenosis were operated by truncular vagotomy associated with gastroenterosanitary drainage. The overall average duration of interventions was 2.11h. Our conversion rate was 9.5%. The average feeding time was 4.38 days. Morbidity was 11.6%. Mortality was zero. The mean hospital stay was 9.55 days. In the postoperative follow-up, 88.4% of the patients were classified as VISICK I and 11.6% VISICK II.

Conclusion:

Laparoscopic approach in the treatment of non-tumoral oeso-gastroduodenal conditions is possible in our exercise conditions and offers considerable advantages with low morbidity and mortality.

 

92.16 A Comparison of Single-Site Robot Assisted Versus Laparoscopic Appendectomy

Posted on January 18, 2018

S. B. Bryczkowski1, D. M. Filiberto2, S. G. Pereira1  1Hackensack University Medical Center,General Surgery,Hackensack, NJ, USA 2University Of Tennessee Health Science Center,Surgical Critical Care,Memphis, TN, USA

Introduction:  Robot-assisted surgery is making its way into general surgery. There are currently no published data regarding single-site robot-assisted appendectomy. The purpose of this study was to evaluate and present our experience with robot-assisted single-single site appendectomy (RA) and compare it to laparoscopic appendectomy (LA) to determine the safety and cost effectiveness.  

Methods:  A single institution retrospective review was conducted from August 2013 to August 2014. Adult patients with the clinical diagnosis of acute appendicitis were included in the study. The intervention was either immediate appendectomy (RA or LA) for uncomplicated appendicitis or interval appendectomy (RA or LA) for complicated appendicitis. The primary outcomes were complications and cost. Secondary outcomes were length of stay (LOS), operative time, and estimated blood loss (EBL).

 

Results: Of the 22 patients who underwent appendectomy for appendicitis, 7 underwent RA and 15 LA. Cohorts were similar in terms of age (41.8 vs 42.4), gender (71 vs 60% female), and BMI (27.3 vs 27.8 kg/m2). There was one complication in the LA group and none for RA. The cost of RA was less than that of LA ($1,168 vs $1,932). Patients who underwent RA had longer operative times compared to LA (111 vs 54 minutes), similar blood loss (13.6 vs 18.6mL) and shorter LOS (0.86 vs 1.3 days). 

 

Conclusion: Appendicitis is a common surgical diagnosis. While Robot-assisted single-site appendectomy does have a longer operative time, this study showed that it is a safe and cost effective alternative compared to laparoscopic appendectomy.  
 

92.09 Cholecystectomy and the Risk of Gastric and Esophageal Adenocarcinoma-Meta-Analysis

Posted on January 18, 2018

H. Khadra1, T. Cushing1, S. Souza1, J. Crowther1, C. DuCoin1  1Tulane University School Of Medicine,Department Of Surgery,New Orleans, LA, USA

Introduction:
Conflicting data in the literature have reported the increased risk of esophageal and gastric adenocarcinoma after cholecystectomy. The purpose of this study was to determine if there is a risk of esophageal or gastric adenocarcinoma after cholecystectomy by performing a meta-analysis of the current literature. 

Methods:
Independent reviewers conducted a systematic review of publications from PubMed, EMBASE, and the Cochrane Database of Systematic Review using the following keyword searches: “esophageal adenocarcinoma and cholecystectomy,” “gastric adenocarcinoma and cholecystectomy,” “gastric cancer and cholecystectomy,” and “esophageal cancer and cholecystectomy.” Additional articles were retrieved by manual search of references. Studies reported either odds ratios or relative risks, which were treated as equivalent in the analysis since both values will be similar for diseases with low incidence. If a study provided both univariate and multivariate-adjusted relative risks, the multivariate-adjusted values were used.

Results:
33 publications were identified and seven studies met our inclusion criteria. The studies included spanned between 13-43 years. Cholecystectomy was not found to be associated with an increased risk of esophageal adenocarcinoma (RR 1.11; 95%CI: 0.87-1.40), nor was it associated with an increased risk of gastric adenocarcinoma (RR-1.06; 95%CI: 0.91-1.23).

Conclusion:

The results of this meta-analysis suggest that cholecystectomy does not increase the risk of esophageal or gastric adenocarcinoma. 

92.10 Predictors of Conversion from Laparoscopic to Open Lysis of Adhesion for Small Bowel Obstruction

Posted on January 18, 2018

D. Asuzu1, G. Chao1, K. Y. Pei1  1Yale University School Of Medicine,General Surgery,New Haven, CT, USA

Introduction:
Laparoscopic lysis of adhesion (LLOA) for small bowel obstruction (SBO) is associated with shorter operative times and lower complication rates compared to open lysis of adhesion (OLOA). However, intra-operative conversion from LLOA to OLOA still occurs even at experienced centers. Factors associated with this conversion remain poorly understood. 

Methods:

We retrospectively analyzed data from 9,920 patients undergoing OLOA (CPT 44005) for SBO (ICD10 560.81 and 560.9) in the prospectively collected American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2013. 92 cases were converted from LLOA to OLOA. Factors independently associated with conversion were identified using multivariable logistic regression adjusting for age, gender, weight and pre-operative functional status.

Results:
Age and weight were significant risk factors for conversion from LLOA to OLOA, with adjusted odds ratio (OR) per decade of 0.86, 95% confidence interval (CI) 0.76 – 0.97, P = 0.017; and adjusted OR per 50 lbs of 1.24, 95% CI 1.01 – 1.52, P = 0.048 respectively. Other factors significantly associated with conversion from LLOA to OLOA included pre-operative albumin, (adjusted OR 1.60, 95% CI 1.16 – 2.22, P = 0.005), aspartate aminotransferase (AST, adjusted OR 1, 95% CI 1 – 1.01, P = 0.038) and white blood cell (WBC) count (adjusted OR 0.93, 95% CI 0.88 – 0.99, P = 0.018). 

Conclusions:
Patients who are younger but weigh more are more likely to be converted from LLOA to OLOA. Patients with higher synthetic liver function and patients with high transaminases and lower WBC counts are also more likely to be converted from LLOA to OLOA. Our results warrant verification in large independent prospective datasets. 

92.07 Laparoscopic Cholecystectomy in Patients Supported with a Left Ventricular Assist Device (LVAD)

Posted on January 18, 2018

V. Suresh1, M. Bishawi5, B. Bryner5, M. Manning4, C. Patel3, J. Rogers3, C. Milano5, J. Schroder5, M. Daneshmand5, C. A. Sommer2  1Duke University Medical Center,School Of Medicine,Durham, NC, USA 2Duke University Medical Center,Division Of Acute Care Surgery, Department Of Surgery,Durham, NC, USA 3Duke University Medical Center,Division Of Cardiology, Department Of Medicine,Durham, NC, USA 4Duke University Medical Center,Division Of Cardiac Anesthesia, Department Of Anesthesia,Durham, NC, USA 5Duke University Medical Center,Division Of Cardiothoracic Surgery, Department Of Surgery,Durham, NC, USA

Introduction: An increasing number of end-stage heart failure patients are supported with Left Ventricular Assist Device (LVAD) implantation and must be maintained on a consistent anticoagulation regimen.  These patients are experiencing prolonged survival, and in some, the development of new biliary disease. Thus, the objective of this study was to describe the outcomes and management of LVAD patients undergoing laparoscopic cholecystectomy.

Methods: This study was a retrospective single center review. Adult patients supported on an implanted, continuous flow LVAD from January 1, 2007 to December 31, 2016 were included. Baseline characteristics were collected via retrospective chart review and the institutional LVAD registry. All laparoscopic cholecystectomies were performed in the operating room, utilizing cardiac anesthesia with endotracheal intubation, while LVAD settings were monitored by a trained perfusionist. Physical palpation and visual inspection were used to determine the course of the driveline and avoid driveline injury. Preoperative and postoperative hematology lab values, such as hemoglobin, international normalized ratio (INR), were collected via chart review. Continuous variables were presented as mean ± standard deviations, and compared using the Student t-test. Categorical variables were presented as proportions and percentages, and compared using chi-squared test or Fisher Exact test as appropriate. Statistical significance was established at a p < 0.05.

Results: After screening 798 patients, 5 (0.63%) were found to have undergone laparoscopic cholecystectomies after LVAD implantation. For 4 patients (80%), the indication was symptomatic cholelithiasis, and one patient (20%) had symptomatic acalculous cholecystitis. The average time from LVAD implantation to laparoscopic cholecystectomy was 254.4 ± 158.0 days.  Average pre-operative INR was 1.34 ± 0.30.  Average preoperative hemoglobin was 11.28 ± 2.41. Pre-operative FFP was administered to one patient. Preoperative Vitamin K was given to one patient.  All patients were on Coumadin pre-operatively and admitted prior to their operations for bridging with a heparin drip. Average post-operative change in hemoglobin was -1.16 ± 1.97. The only major post-operative complication in this cohort was the development of an abdominal wall hematoma in one patient, which was treated with drainage in the operating room and post-operative blood transfusion. The average length of stay (LOS) was 13.2 ± 4.6 days. 3 patients (60%) took an average of 12 days to reach therapeutic INR as the main driver for prolonged hospitalization.

Conclusions: Laparoscopic cholecystectomies can be performed safely in LVAD patients.  Prolonged hospital stay is mainly due to time to re-achieve INR goals. 

9.20 “FASTPASS” Gallbladder Diseases and Appendicitis from Emergency Department Help Improve Patient Care

Posted on January 18, 2018

N. Kulvatunyou1, B. Joseph1, S. Adikhari1, R. S. Friese1, L. Gries1, T. O’Keeffe1, A. L. Tang1, A. Jain1, G. Vercruysse1, N. Kulvatunyou1  1Banner-University Of Arizona,Trauma, Critical Care, Emergency General Surgery,Tucson, AZ, USA

Background: Efficient Emergency Department (ED) throughput depends on several factors, including the collaboration with surgical services. We, acute care surgery (ACS), collaborated with ED to implement this new process that we termed 'FASTPASS' which might improve patient-care process. The aim of this study was to evaluate 1-year outcome of the FASTPASS.

Methods: FASTPASS is a joint collaboration between ACS and ED. We provided ED physicians with a simple check-list for diagnosing young male (< 50-year old) with acute appendicitis (AA) and young male or female (< 50-year old) with gallbladder disease (GBD). Once ED deemed patients fit the check-list, patients got direct admitted (FASTPASS) to observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after institution of the FASTPASS. Outcomes of interest were ED length of stay (LOS), time from ED to operating room (OR), and hospital LOS (HLOS).

Results: During our 1-year study period, we were able to FASTPASS 56 (26%) GBD and 27 (26%) AA patients. When compared to non-FP patients, FP patients had shorter ED LOS, time from ED to OR, and shorter HLOS (Table), P < 0.001.

Conclusion: In this study, FP process helped streamline care process for a subset of patients with GBD and AA. For a future study, a larger sample size and an improvement in capture rate is needed.

9.18 Population Level Outcomes of Early vs. Delayed Appendectomy for Acute Appendicitis Using ACS-NSQIP

Posted on January 18, 2018

E. A. Alore1, J. L. Ward1, S. R. Todd1, C. T. Wilson1, S. D. Gordy1, M. K. Hoffman1, J. W. Suliburk1  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA

Introduction: The optimal timing of appendectomy for acute appendicitis has frequently been questioned with mixed results. We utilized population level data from the American College of Surgery National Surgical Quality Improvement Project (ACS-NSQIP) to evaluate outcomes of open and laparoscopic appendectomy performed on hospital day (HD) 1, HD 2 and HD 3 of admission. We hypothesized that delayed appendectomy would be associated with increased morbidity and 30-day mortality.

Methods:  The ACS-NSQIP database was queried for all patients undergoing an open or laparoscopic appendectomy from 2007-2015 within 3 days of admission. All had a post-operative diagnosis of appendicitis. Chi square test for trend, Pearson’s Chi square, Fisher’s exact and Kruskal-Wallis tests were employed using an alpha level of 0.05. A reverse stepwise logistic regression using the criterion of p>0.2 for removal from the model was performed to determine predictors of morbidity and mortality.

Results: In ACS-NSQIP, 212,577 patients underwent an appendectomy from 2007-2015 for acute appendicitis. There was a significant decrease in appendectomies performed on HD 1 over time (83% in 2007 vs. 78% in 2015; p<0.001). Of non-elective appendectomies performed from 2012-2015 (n=112,122), there were significantly worse outcomes for those performed on HD 3 as demonstrated by increased 30-day mortality, reoperation, surgical site infection as well as cardiovascular, pulmonary, and thromboembolic complications (Table 1). However, significantly more patients undergoing appendectomy on HD 3 had comorbid conditions (36%; p<0.001) in comparison to those on HD 1 (19%) or HD 2 (21%). On subgroup analysis of laparoscopic versus open appendectomy, open had significantly higher morbidity and mortality for all major postoperative complications, regardless of day of operation, including organ/space surgical site infections (4.6% open vs 2.1% laparoscopic; p<0.001). A significantly greater proportion of appendectomies performed on HD 3 were open (19%; p<0.001) in comparison to HD 1 (8%) or HD 2 (8%). On logistic regression, presence of comorbid conditions and open operation were predictive of major complications; however, HD was not (p=0.54). 

Conclusion: Population level data from ACS-NSQIP demonstrates similar outcomes of appendectomy for acute appendicitis when the operation is performed on HD 1 or HD 2; however, outcomes are significantly worse for appendectomies performed on HD 3. The increased morbidity and mortality of appendectomy performed on HD 3 is likely not attributable to the HD of operation, but rather a result of the increased number of comorbid conditions and open surgeries in this group.
 

9.19 Physician Beliefs about the Patient-Provider Relationship Influence Caring and Burnout

Posted on January 18, 2018

K. Leibowitz2, A. Crum2, C. Mueller1  1Stanford University,Surgery,Palo Alto, CA, USA 2Stanford University,Psychology,Palo Alto, CA, USA

Introduction: Research suggests that the patient-provider relationship influences satisfaction for both physicians and patients.  We propose that physicians have mindsets (lenses or frames though which we see and understand the world) about what it means to be a “good” doctor and about the costs and benefits of patient-provider interactions.  These mindsets influence provider behavior and communication with patients.  Further, we suggest that these mindsets can be linked to provider satisfaction and burnout.

Methods: 385 physicians across a range of medical specialties and years of practice participated in an online survey about their views of being a doctor and on the importance of patient relationships.

Results: We found that physicians who believe in the essential and enhancing quality of the patient-provider relationship spent significantly more time engaging in caring behaviors with patients and experienced less burnout than physicians who believe that connecting with patients is both an afterthought and undermining to clinical care.  We also found that surgeons were more likely to view relationships with patients as a negative and costly influence than were other physicians surveyed.

Conclusion: Surgeons and other physicians who view the patient-provider relationship more negatively display fewer caring behaviors and may be at higher risk for burnout than those with a positive view of this interaction. 

 

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