6.05 Long Term Survival and Echocardiographic Findings After Left Ventricular Aneurysmectomy

Posted on January 18, 2018

A. A. Assi1, S. F. Bolling1, H. J. Patel1, M. Deeb1, M. A. Romano1, J. W. Haft1, R. L. Prager1, F. D. Pagani1, P. C. Tang1  1University Of Michigan,Department Of Cardiac Surgery,Ann Arbor, MI, USA

Introduction:
This study investigates the long term outcomes and predictors of mortality for left ventricular (LV) aneurysmectomy.

Methods:
From 1992 to 2017, there were 109 patients who underwent a LV aneurysmectomy procedure. Long term survival was determined from hospital records and the National Death Index. Preoperative demographics, clinical characteristics and features, operative technique and follow up echocardiography findings were analyzed using Cox regression and log-rank to determine variables influencing survival.

Results:
Median age was 63 (IQR=19) years, with 25 (22.9%) females. There were 101 (93%) true and 8 (7%) pseudo-aneurysms. Location of the aneurysm was antero-apical in 92 (84%) and posterior in 17 (16%).  Average preoperative left ventricular diastolic dimension (LVIDD) was 6.7+2.7cm.  Operative technique included primary closure without a patch in 58 (53%) and closure with patch in 51 (47%) patients.  Concomitant surgeries included mitral valve (MV) repair (n=40, 37%), MV replacement (n=5, 5%), tricuspid valve (TV) repair (n=4, 4%), aortic valve (AV) replacement (n=3, 3%), coronary bypass grafting (n=76, 70%; 1.6+1.3 grafts) and VSD closure (n=5, 5%). Redo-sternotomies were performed in 12 (11%) patients. Median echocardiography follow up was 2.9 yrs (IQR=9.0), and was obtained in 59 (54%) patients. LVEF improved from 28+13% to 33+16% (P=0.011).  There was a higher incidence of moderate to severe right ventricular (RV) function at follow-up (12% preoperatively versus 38% at follow-up; P=0.021) and higher incidence in severe TV regurgitation in patents who did not undergo repair (8.9% versus 22.2% respectively; P=0.004). Median echo follow up of MV repair was 3.6 (IQR=9.5) yrs. MV repair led to sustained improvements in MR (P=0.001) where only 2 (5%) experienced recurrent moderate-severe MR. For patients who did not undergo a MV procedure, there was no difference in preop and follow up MR severity (P=0.586). Median patient follow up was 7.1 yrs (IQR=8.5). Overall 5, 10, and 15 year survival were 71.9%, 48.1% and 26.2% respectively (Fig. 1). A multivariable analysis identified concomitant TV repair (P=0.001), increasing preoperative TV regurgitation (P=0.037), and concomitant AV replacement (P=0.086) as independent predictors of mortality.

Conclusion:
Long term survival following LV aneurysmectomy is adversely influenced by RV function.  While sustained improvement in LVEF and decreased MR following MV repair can be expected, RV function continues to decline accompanied by worsening tricuspid regurgitation. Close surveillance and aggressive medical management of RV failure is warranted in this patient population.
 

6.02 Comparison of Outcomes of Minimally Invasive and Open Pneumonectomy

Posted on January 18, 2018

A. Kumar1, H. Devishetty1, T. Demmy1, S. Yendamuri1  1Roswell Park Cancer Institute,Department Of Thoracic Surgery,Buffalo, NY, USA

Introduction:
Over the last decade minimally invasive surgery has been increasingly liberally utilized for the treatment of non-small cell lung cancer (NSCLC). This approach is increasingly used for the conduct of pneumonectomies. We sought to examine short and long term outcomes of the use of minimally invasive surgery for pneumonectomy in the United States.

Methods:
The National Cancer Database was queried for patients undergoing pneumonectomy between 2004 and 2014 and trends examined. As coding for surgical approach is only available from 2010 onwards, this subset was examined for the impact of surgical approach on short and long term outcomes of minimally invasive pneumonectomy. Univariate and multivariate analyses were performed to examine the impact of surgical approach using SPSS.

Results:
18,926 patients had a pneumonectomy between 2004 and 2014. The proportion of patients having a pneumonectomy steadily declined from 9.1% to 4.9% of all anatomic resections over this time period. From 2010 to 2014, 7407 pneumonectomies were performed. 2.0% and 13.5% of these cases were attempted to be performed robot-assisted and by VATS respectively and 1.4% and 8.5% were completed as intended. Intent to treat analysis did not show a difference between minimally invasive (MIS) and open approaches with respect to 30 day and 90 day mortality (6.7% vs 7.0%; P=0.90 and 11.7 vs 12.4%; P=0.51 respectively). There were no differences in age, gender, race, stage, laterality, length of stay and readmission rates between both approaches. Of note, there was no difference in the number of lymph nodes examined between both approaches (21.4 vs 21.9; P=0.56). However, overall survival was higher in patients undergoing MIS pneumonectomy vs. open pneumonectomy in univariable (57 months vs. 40 months; P=0.013) and multivariable analyses (Figure 1).

Conclusion:
Minimally invasive pneumonectomy appears safe with peri-operative outcomes comparable to open surgery.  MIS may improve long term pneumonectomy outcomes but confirmation by controlled studies is needed to reduce biases like high conversion and declining utilization rates observed in our cohort.
 

6.03 Impact of Depression on Readmission Outcomes after Coronary Artery Bypass Graft Surgery

Posted on January 18, 2018

E. A. Aguayo1, Y. Juo1, Y. Seo1, K. L. Bailey1, V. Dobaria1, Y. Sanaiha1, P. Benharash1  1University Of California – Los Angeles,Department Of Surgery/ Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction:
Postoperative depression affects between 10-40% of patients after cardiac operations and is associated with significantly worse cardiovascular outcomes. Indeed, depression screening has been recommended in the care of patients undergoing cardiac operations. While its exact causes are unknown, the incidence and impact of new onset depression beyond acute follow up remain ill defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression during 90-day readmission after coronary artery bypass surgery (CABG). 

Methods:
A retrospective cohort study was performed identifying patients with no prior depression who received CABG using the 2010-2014 National Readmissions Database (NRD). Adult CABG patients who were readmitted within 90 days of discharge were categorized based on the presence of new-onset depression. Association between development of postoperative depression and mortality/complications during rehospitalization was examined using logistic regression models, adjusting for comorbid conditions. In-hospital mortality and GDP-adjusted costs were evaluated using hierarchical linear models and comorbidity via the Elixhauser Index. 

Results:
A total of 423,455 patients without prior diagnosis of depression were identified as undergoing CABG during the study period. Nationally, 18.9% of patients were readmitted within 90 days of index discharge, of which 5.6% developed new-onset depression. Within the readmitted cohort, risk factors for new-onset depression included female gender (OR=1.45, 95% CI: 1.33-1.57, p<0.01), experiencing a surgery-related complication (OR=1.18, 95% CI: 1.03-1.34, p=0.01), prolonged stay during index stay (OR=1.23, 95% CI: 1.12-1.35, p<0.01) and being discharged to locations other than home (OR=1.61, 95% CI: 1.48-1.76, p<0.01). Postoperative depression was independently associated with elevated odds of systemic complication during readmission (OR=1.17, 95% CI: 1.09-1.27, p<0.01), prolonged hospital stay (OR=1.61, 95% CI: 1.42-1.82, p<0.01), discharge to disposition other than home (OR=1.51, 95% CI: 1.35-1.69, p<0.01) and higher hospitalization costs (coefficient $906.1, 95% CI: 130.9-1681.3, p=0.02). The overall mortality during readmission was 2.6% while new-onset depression was associated with lower odds of death after adjusting for baseline differences (OR=0.56, 95% CI: 0.42-0.74, p<0.01).

Conclusions:
New-onset of depression following discharge CABG was associated with significantly worse outcomes during rehospitalization. The results of this national study supports institution of psychiatric evaluation and measures to reduce the development of depression following cardiac operations. Programs to incorporate early detection and timely management of depression may reduce systemic complications during readmission and enhance quality of care and postoperative recovery.

6.01 National Volume-Outcome Relationships for Extracorporeal Membrane Oxygenation

Posted on January 18, 2018

K. L. Bailey1, Y. Sanaiha1, E. Aguayo1, Y. Seo1, V. Dobaria1, R. J. Shemin1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction:
With calls for value-based healthcare delivery, high-risk procedures are increasingly being performed at more experienced centers. Recent studies produced conflicting associations of hospital volume and outcomes for critically-ill patients on extracorporeal membrane oxygenation (ECMO), with some suggesting higher mortality at high-volume centers. We aimed to describe the relationship of institutional volume and mortality in ECMO patients and assess causes of discrepant outcomes. 

Methods:
Adult patients receiving ECMO from 2008-2014 were identified from the National Inpatient Sample (NIS). Volume was calculated as tertiles of total institutional discharges for each year independently. Statistical analyses included multivariable logistic regression and propensity matching to adjust for patient demographics and comorbidities as measured by the Elixhauser Index. 

Results:
Of the estimated 18,684 ECMO patients, 14%, 28% and 58% were admitted to low-, medium-, and high-volume centers, respectively. Large centers had the greatest relative fraction of respiratory failure cases (45%), while medium and small centers commonly treated postcardiotomy syndrome (44% and 56%, respectively). Mortality at low-volume hospitals (43.7%) was lower compared to the rate at medium (50.3%, P=0.03) and high-volume (55.6%, P=0.002). On multivariate regression, high-volume, respiratory failure, and cardiogenic shock were predictors of mortality. Length of stay was shorter at low-volume hospitals than at medium- (14.8 vs 21.1 days, P<0.001) and high-volume (14.8 vs 25.2 days, P<0.001). Similarly, cost was lower at small centers ($142,803) compared to medium ($166,458, P<0.001) and large ($176,397, P<0.001). In sub-group analysis of high-volume institutions, 4,183 (39%) patients were transferred to the reporting hospital and 6,676 (62%) patients were initial admissions. The majority of transferred patients received ECMO for respiratory failure (56%). After propensity matching, the transferred cohort had higher mortality (58.5% vs 53.7%, P=0.045) and greater cost ($190,300 vs $168,970, P=0.009) compared to patients admitted directly to the index hospital.  

Conclusion:
Our findings in this contemporary ECMO experience depict an association between high-volume institutions and greater mortality in the overall sample and in patients transferred to larger centers. Whether this phenomenon represents selection bias or transfer from another facility deserves further investigation and will aid with the identification of surrogate markers for quality of high-risk interventions. Improved selection criteria and the prediction of futile care are essential for the future growth of ECMO technology. 

57.19 Global Health Preparation: Surgery and Anesthesia Simulation

Posted on January 18, 2018

D. M. Langston1, M. Eskendar1, F. M. Peralta1, A. Doobay-Persaud1, N. Issa1, S. Galvin1, M. Swaroop1  1Northwestern University,Chicago, IL, USA

Introduction:
Five billion people lack access to safe, quality, and timely surgical healthcare. Basic surgical and anesthesia care can and should be provided by general practitioners in low resource settings. Training of these providers through simulation, a validated tool in educational programs for resident training, is a viable platform to impart surgical and anesthesia skills. No research is available, however, on the impact of basic skills simulation on preparedness for clinical care in global health field experiences, specifically involving surgery and anesthesia care. In preparation for a global health rotation, a team based simulation session was designed for non-surgical and anesthesia residents to evaluate the ability of simulation based learning to optimize knowledge, skills, and confidence levels as these relate to surgery and anesthesia care.

Methods:
Didactic and experiential training stations were developed based on six common surgical and anesthesia conditions identified by surgery and anesthesia global health faculty. Participants completed a pre- and post- self-assessment test utilizing a 3-point Likert Scale. Results were compared to evaluate the effectiveness of training and improvement in self-reported confidence in skill performance. 

Results:
Thirteen non-surgery and anesthesia resident physicians from 5 specialty areas participated in the training. All resident physicians spent 30 minutes at each of the 6 stations while being mentored and then monitored by surgery and anesthesia attending and resident physicians.  The participants who completed the post-test (n=13) considered the training either useful (85%, n=11) and/or of excellent quality (69%, n=9).  At the completion of the session, most trainees felt very comfortable performing intravenous line placement (92%, n=12), bag mask ventilation (100%), and incision and drainage (100%). Trainees felt the least comfortable performing laryngoscopy (23%, n=3) and conscious sedation (46%, n=6).

Conclusion:
Simulation for non-surgery and anesthesia resident trainees anticipating a global health experience is feasible and easily implemented. There continues to be a paucity of basic surgery and anesthesia care in low resource settings. Simulation training is a validated method to train not only general practitioners in basic surgery and anesthesia care, but also non-physician providers.
 

57.20 A Cadaver-Based Enteroatmospheric Fistula Model for Negative Pressure Therapy Training

Posted on January 18, 2018

A. Coleoglou Centeno1, C. B. Horn1, M. M. Frisella1, C. M. Donald1, G. V. Bochicchio1, S. R. Eaton1, J. P. Kirby1, L. J. Punch1  1Washington University,Department Of Surgery,St. Louis, MO, USA

Introduction:
Enteroatmospheric fistulas (EAFs) are associated with the need for complex wound care. Negative Pressure Therapy (NPT) is a helpful adjunct in management of complex wounds. The use of NPT in the management of an EAF allows for both enhanced wound care as well as control of fistula efflux, but is technically difficult to apply. As part of a Visiting Preceptorship in Acute Care Surgery, we developed a cadaver-based model for training of nurse practitioners (NPs) and physician assistants (PAs) in NPT application to EAFs.

Methods:
The training model was developed for use in a hands-on application of NPT on an EAF using a cadaver model.  The model was prepared by performing a midline laparotomy. Sigmoid colon was mobilized and ligated proximally. The distal bowel was cannulated with plastic tubing which was secured to the bowel and passed through the abdomen through a separate stab incision. This was connected to dilute solution of methylene blue mixed with saline. An additional resection of skin and fat was done to create a complex surrounding wound. We then performed a primary fascial closure and exteriorized the colon, maturing the edges of the bowel to the fascia thus simulating an EAF. Groups of two PAs or NPs along with course faculty applied the wound NPT to the EAF model. 

Results:
A cadaver based model for EAF was created and NPT was successfully applied by the course participants. All fistulas were successfully isolated with a barrier ring, sponge and ostomy bag (figure 1).

 

Figure 1. 1a. EAF model. Note exposed loop of sigmoid colon 1b. EAF model demonstrating methylene blue saline efflux. 1c. EAF model with NPT and ostomy appliance. Note cannula containing methylene blue tinted normal saline.

Conclusion:
We developed a cadaver-based EAF model for NPT training. This model could potentially impact practice by allowing all members of the surgical team to improve their application techniques. We acknowledge limitations to the model such as lack of pre- and post- course comparison and need for competency evaluation. Another limitation to the model could be its standardized implementation as a training system due to the costs and need for laboratory facilities. Future aims include further evaluation of the model’s impact on participant’s competence and confidence.

57.18 Video Gaming Influence on Technical Abilities Amongst Surgical and Non-Surgical Residents.

Posted on January 18, 2018

J. Lam1, C. Maeda1, T. Suzuki1, T. Pham1, D. Bernstein1, B. Sandler1, G. Jacobsen1, S. Horgan1  1University Of California – San Diego,Minimally Invasive Surgery,San Diego, CA, USA

Introduction:  Video games are ingrained into popular culture. They have been a strong presence for several decades and are a staple of modern day society. It has been established that having skill in video gaming correlates with improved skill in laparoscopic surgery. However, there has not been much data collected on the types of video game genres that are played, and if there is a belief that video games improve your ability to perform technical procedures. We hypothesize there may be a difference between surgical vs nonsurgical specialties regarding the type of video games that are played, as well as the amount of time dedicated to gaming. Our secondary aim is to assess if having a history of gaming effects perceived ability to perform technical procedures.

Methods:  A questionnaire was provided to surgical (n=45) and non-surgical residents and fellows (n=50), to assess video gaming experiences.  Analysis of demographic data, past and current gaming experience, and preference of genre was performed. Statistical analysis comparing surgical and non-surgical groups was performed using Chi-square test. 

Results: There were no significant demographic differences between the surgical and nonsurgical groups. Both groups had similar distribution in age, gender, and post-graduate year (PGY). The top three genres of video games played in the surgery group were roleplaying games (21%), shooter games (17%), and strategy games (12%). The top three genres in the non-surgical group were shooter games (19%), role-playing games, (18%), and fighting games (13%). There was no statistical difference in the genres of video games played by the two groups. In comparing the surgical and nonsurgical groups, there was a statistical difference in the belief that video gaming improved your technical ability (p-value = 0.036). Also, the average maximal amount of hours played per week was higher in those who believed that video games improved their technical ability (median 20 hrs/week). 

Conclusion: Surgical and non-surgical residents have similar patterns of video game play and types of video games that are played. However, surgical residents feel that their video gaming experiences improve their technical abilities. Also, increased gaming history correlated with perceived improvement of technical skills in performing procedures in both groups.

 

57.16 A Novel Cadaver-Based Model for Negative Pressure Therapy Training

Posted on January 18, 2018

C. B. Horn1, A. Coleoglou Centeno1, M. M. Frisella1, C. M. Donald1, G. V. Bochicchio1, S. R. Eaton1, J. P. Kirby1, L. J. Punch1  1Washington University,Department Of Surgery,St. Louis, MO, USA

Introduction:  Negative pressure therapy (NPT) is an increasingly important tool in the healing and management of soft tissue injuries, infections and wounds. However there are few hands-on training models available to teach the necessary skills for the safe and effective application of NPT.  As part a Visiting Preceptorship in Acute Care Surgery, we attempted to develop a cadaveric model, for use in training on NPT application.

Methods: The course consisted of didactic instruction by practicing physicians, operating room demonstration of NPT application and a hands-on laboratory consisting of cadaveric models of common scenarios where NPT could be applied. Two cadavers were prepared for each course. Each cadaver received a 10 centimeter laceration to the right leg, a 10cm x 3cm x 3cm debridement to the right inguinal region, medial and lateral left leg fasciotomies and a 15 x 6 superficial lesion. One cadaver received a laparotomy and was simply left open. The other cadaver received a midline laparotomy with cannulation of the bowel and debridement of the abdominal wall soft tissue so as to create an enteroatmospheric fistula (EAF) with subsequent closure of the fascia. Teams of two physician assistants (PAs) or nurse practitioners (NPs) and course facilitator applied NPT to all injuries. Course surveys were completed by all participants.

Results: Wounds were successfully created to simulate skin graft donor sites (figure 1), necrotizing soft tissue infections post debridement, partially closed fasciotomies (figure 2), open abdomens, lacerations and EAF (figure 3). NPT was successfully applied to all models by participating PA and NPs.  All 9 (100%) participants completed course surveys; 8 (88.9%) participants stated that the course would change their clinical care; 9 (100%) participants rated the lab as “excellent” overall. 

Figure 1. 1a. Lower extremity skin donor site model. 1b. Partially closed fasciotomy model. 1c. Enteroatmospheric fistula model. Note exposed loop of small bowel. 

Conclusion: We have developed a cadaveric model for use in NPT application training for a variety of clinical situations. The initial response to the training was positive, however we acknowledge significant methodological limitations, including lack of pre- and post- course comparison and lack of evaluation of NP and PA competency. Future work will aim to evaluate this model’s effect on trainee competence.

 

57.17 The Use of Virtual Humans for Team Training in the Operating Room

Posted on January 18, 2018

W. Goering1, J. W. Menard1, A. Deladisma1, M. Dimachk1, J. Wood3, B. Lok3, S. Lampotang4, A. Wendling2, A. Cordar3, D. S. Lind1  1University Of Florida-Jacksonville,General Surgery,Jacksonville, FL, USA 2University Of Florida-Jacksonville,Anesthesia,Jacksonville, FL, USA 3University Of Florida-Gainesville,Computer & Information Science & Engineering,Gainesville, FL, USA 4University Of Florida-Gainesville,Anesthesia,Gainesville, FL, USA

Introduction: Time constraints limit the ability to bring all OR team members together simultaneously to practice group communication skills. We hypothesize that virtual humans (VHs) can model behavior and scenarios for healthcare providers to learn communication and teamwork skills in the operating room (OR).  Therefore, we constructed and piloted an interactive team training exercise involving multiple VHs that represent essential OR team members.  To determine the initial face validity and realism of the VH interaction, volunteers participated in a surgery safety checklist scenario with the virtual team members.

Methods: Three virtual human teammates were assembled using a 40 inch 1080 pixel television mounted on a rolling stand with an HDMI connection to a Dell computer with Microsoft Kinect 2 software. The setting for all of the interactions was an actual OR in the outpatient surgical center (OSC) at the University of Florida – Jacksonville. The verbal responses of the VHs were controlled by a Wizard of Oz technique but VHs displayed normal speech, eye contact, facial expressions and movements when interacting with participants.

Results: Eleven medical professionals (4 Surgeons, 3 Nurses, 2 Medical Students and 2 Anesthesiologists) volunteered to participate in the mixed reality scenario.  Following the VH simulation activity, participants completed a survey regarding the face validity and realism of the interaction.

Conclusion: We created an interactive Virtual Human scenario aimed to teach and enhance communication skills in the operating room.  A pilot study with medical students, nursing, anesthesia, and surgery personnel demonstrated high face validity for the interaction with the virtual teammates.  The VHs were perceived by human teammates as real OR team members in the surgical safety checklist scenario and if generally applicable, may be useful for healthcare providers from diverse backgrounds to enhance team communication skills to improve patient safety

 

57.14 Multi-Lingual Pedagogy Techniques for Low Confidence First Responders: Innovative Global Trauma Defense

Posted on January 18, 2018

D. Vyas1, S. Huffman1, J. Wright1, E. Larumbe1, H. Purohit2  1Texas Tech Health Science Center School Of Medicine,Department Of Surgery,Odessa, TX, USA 2Arogyaa Healthcare Private Limited,Chennai, TAMIL-NADU, India

Introduction:

Trauma is one of the leading causes of death in the developing world and a significant source in the developed world. A major factor in morbidity and mortality in trauma patient depends on the skills and abilities of the first responders at the scene. In previous articles we had implemented the Save Trauma and Road NaviGators (STRONG) initiative, part of the Million Live Fighters (MLF) program, as an effective method to train laypersons in essential trauma skills. With this study the STRONG program will have been implemented in 6 different languages and we will demonstrate the longitudinal success of the program across multiple languages and cultural barriers.

Methods:

We recruited 135 first responders from Jaipur, India, primarily police officers, and 500 first responders from Telegana, India, a mixture of police, firefighters, nurses, and emergency medical technicians. The Jaipur group is primarily Hindi and English speaking and will be referred to as the 5th language group. The Telegana group primarily speak Telegu and English and will be referred to as the 6th language group. Each group was trained with the 10 hour Acute Trauma Training (ATT) course.

Changes in confidence and competence in 11 essential trauma skills (airway, hemorrhage, fracture, cervical spine, chest, IV lines, extrication, helmets, scene assessment, triage, and communication) were measured using voluntary pre training and post training surveys and compared using a two sample t test. These results were compared to the changes in confidence from previous studies to determine the longitudinal results of the program.

Results:

Results from the 5th and 6th Language groups demonstrated statistically significant increases in confidence levels in each of the 11 essential trauma skills (P<0.001). We found a consistent increase in confidence across all experience, education, prior trauma experience, and initial survey (p<0.01).

We observed similar unilateral increases in confidence that were consistent with previous studies in other languages. Based on these findings we can conclude that the success of the simulation based training program is highly reproducible and can be successfully translated across language and cultural barriers. With the six languages already included in the program we have a potential coverage of over one third of the global population.

Conclusion:

Participants in both language groups showed significant improvement in clinical confidence that is comparable to previous studies in other languages. Based on these results we show that the benefits to the STRONG program can be successfully transmitted across language and cultural barriers. With the current potential coverage and the rapid growth in new training locations we can rapidly increase global trauma care coverage in under served areas. In future studies we hope to include more languages such as Mandarin Chinese to increase our global coverage.

57.15 Surgical Skills Olympiad: A Four-Year Experience in a General Surgery Residency

Posted on January 18, 2018

A. D. Caine1, A. Kunac1, J. Schwartzman1, A. M. Merchant1, D. H. Livingston1  1Rutgers New Jersey Medical School,General Surgery,Newark, NJ, USA

Introduction:

Resident competition has been shown to increase usage of simulators for skills training and resident performance on simulation tasks. We examined the four-year experience with our “Surgical Skills Olympiad” at a large academic surgical residency in the Northeast. We hypothesize that residents perform better at Olympiad tasks since its implementation due to the competitive nature of the event.

Methods:

Surgical Olympiad is a yearly competition between teams formed with members of each post graduate year (PGY) class. Competition tasks are PGY specific: knot tying for PGY-1, basic FLS for PGY-2, hand-sewn bowel anastomosis for PGY-3, vascular anastomosis for PGY-4 and advanced laparoscopic skills for PGY-5. Competition task scores over a four-year period (2014-2017) were analyzed. In addition, a survey of teaching faculty who participated in Olympiad was conducted.

Results: 

Ten faculty members responded to the survey, for a response rate of 62.5%. Fifty percent of respondents felt that the caliber of surgical skills demonstrated at Olympiad has increased since its implementation. Ninety percent agreed that Surgical Olympiad is a good way for residents to assess their skills against their peers. Over four years there was an improvement in mean scores for knot tying (p<0.05), bowel anastomosis (p=0.08), and advanced laparoscopic skills (p<0.05).

Conclusion: 

Faculty perceive improvement in resident surgical skills since the adoption of Surgical Skills Olympiad and objective measures of resident skills suggest that the annual competition has led to improved performance. More data is needed to assess simulator use before and after Olympiad and long term surgical skill retention.

 

57.11 A Video-Based Coaching Intervention to Improve Surgical Skill in Fourth Year Medical Students

Posted on January 18, 2018

M. B. Alameddine1, M. Englesbe1, S. Waits1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  For senior medical students pursuing careers in surgery, specific technical feedback is critical for developing foundational skills in preparation for residency. This pilot study seeks to assess the feasibility of a video-based coaching intervention to improve the suturing skills of fourth year medical students. 

Methods:  Fourth-year medical students pursuing careers in surgery were randomized to intervention vs. control groups and completed two video recorded suture tasks. Students in the intervention group received a structured coaching session between consecutive suturing tasks, while students in the control group received no coaching in between suture tasks. Each coaching session consisted of a video review of the students’ first suture task with a faculty member that provided directed feedback regarding technique. Following each suturing task, students were asked to self-assess their performance and provide feedback regarding the utility of the coaching session. All videos were de-identified and graded by an independent faculty member for evaluation of suture technique. 

Results: All students who completed the coaching session (n=16) would definitely recommend the session for other students. 94% of the students strongly agreed that the exercise was a beneficial experience, and 75% strongly agreed that it improved their technical skills. Based on faculty grading, those in the control group demonstrated greater average increases in all domains of bimanual dexterity, efficiency, tissue handling, and consistency in between baseline and follow up tasks when compared to the intervention group. Conversely, on student self-assessments, those in the intervention group had greater subjective improvements in all domains of bimanual dexterity, efficiency, tissue handling, and consistency compared to the control group. Subjective, free-response comments centered on themes of becoming more aware of hand movements when viewing their suturing from a new perspective, and the usefulness of the coaching advice. 

Conclusion: This pilot study demonstrates the feasibility of a video-based coaching intervention for senior medical students. Students who participated in the coaching arm of the intervention noticed improvements in all domains of technical skill and noted that the experience was overwhelmingly positive. Although greater average improvements were seen in the control group based on faculty assessments, this result may be attributed to coached students trying new skills for the first time after being instructed on technique. In summary, video-based review shows promise as an educational tool in medical education as a means to provide specific technical feedback. 

 

57.12 Immediate Visual Feedback's Impact on Skill and Confidence During Complex Tourniquet Application

Posted on January 18, 2018

J. C. Xu1, C. Kwan1, C. Pugh1  1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction:

Junctional hemorrhage is a leading cause of preventable military death. Tourniquets for these difficult anatomical regions exist and are approved by the FDA to stop bleeding until arrival at a medical facility.  The purpose of this study is to compare preferences and changes in performance when using a newly designed visual bleeding feedback system(VBFS) when training novices. We hypothesize that users will indicate higher levels of confidence after training and greater improvements in training time with theleeding feedback system compared to those who train without feedback (WF).

Methods:

Medical students (N=15) and community emergency medics (N=4) with no junctional tourniquet experience were randomized in a single-blind, crossover, controlled study to start either in the VBFS group or the WF group. All subjects underwent training in the following order; instructional videos, hands on practice, three recorded skill trials in VBFS or WF, and crossover to WF or VBFS for another three trails. Participant agreement with statements asserting confidence in efficient and accurate tourniquet application and usefulness of the VBFS was assessed using a pre-and post-Likert scale with ratings from 1 to 7, with 1 being least agreement and 7 being most. Video and audio data were also collected and analyzed to assess total trail time and tourniquet application time. Group confidence scores and trial times were calculated via paired t-test. 

Results:

Participants indicated very high ratings for VBFS usefulness (6.37/7.0 +/-1.25) and recommendation to others (6.74/7.0 +/- 0.56). While there was no statistical difference in group confidence or time for the pre-and post-tests before the crossover, there was a significant reduction in application times between the 1st and 6th trial (80.5 s vs 44.4 s, p = 0.032) after crossover. It is also notable that participants in the in the VBFS spent more time than the WF groups (37.9 s vs 21.4 s, = 0.56) indicating active use of the visual feedback system. It is also noted that participants started with a fairly high confidence level in the pre-training phase compared to confidence after the 6th trial, (5.11/7.0 vs 5.37/7.0, p = 0.35). 

Conclusion: 

Trial times were increased when using the VBFS and all users rated VBFS highly. Participants were equally confident in tourniquet application after just watching a video compared to finishing the entire training with its six applications on a bleeding and non-bleeding model. Given that most participants were novices to this type of tourniquet, it is possible that they were overly confident in their original self-assessed abilities. This over confidence necessitates the need for developing effective scenario based training curricula for this deceptively straightforward life-saving task.

 

 

 

57.13 Simulation model for Laparoscopic and Robotic Foregut Surgery

Posted on January 18, 2018

F. Schlottmann1, N. S. Murty1, M. G. Patti1  1University Of North Carolina,Surgery,Chapel Hill, NC, USA

Introduction: The safe adoption of laparoscopic and robotic foregut surgery must maximize relevant training prior to transference to the clinical setting. A significant gap presently exists between box-lap and virtual-reality simulators and live surgery. Live animal and cadaver use have significant downsides. We have developed tissue-based simulator that allows for training in laparoscopic and robotic foregut operations.

Methods:  Our foregut surgery model is based on porcine tissue blocks that include lungs, heart, aorta, esophagus, diaphragm, stomach, duodenum, liver and spleen. Tissue is preserved in an alcohol based solution that retains fresh tissue characteristics for several weeks. The tissue block is mounted in a human mannequin and perfused with artificial blood. The anterior abdominal wall is constructed so as to allow for laparoscopic and robotic surgical training (Figure 1). Five expert attending foregut surgeons performed laparoscopic and robotic Heller myotomy, Nissen fundoplication and sleeve gastrectomy on the model. After completing the procedures, face validity was measured by surgeon responses to a questionnaire defining the perceived relationship to real surgery, ranging from really unrealistic to highly realistic.

Results: The initial cost of the simulator is $400. Once the initial expenses are covered (male torso mannequin and silicone based abdominal wall), the simulator cost is approximately $50 for each surgical training session (tissue block + artificial blood). The simulator was rated as highly realistic in terms of operative space, organs size and shape, and instrument usage for all three procedures in both laparoscopic and robotic surgery. In addition, all surgeons felt the model could significantly shorten the learning curve for performing these procedures.

Conclusion: The results of this study show that our model, based on animal tissue blocks, is economical, easy to use, and offers a very realistic representation of laparoscopic and robotic foregut operations, thus achieving a high level of face validity. Further validation studies are needed to assess if skills acquired by using our surgical simulator are transferable to the clinical setting

 

57.07 Resident Training in Robotic Surgery: Acquisition and Durability of Skills on a Simulation Console

Posted on January 18, 2018

K. D. Gray1, J. Burshtein1, T. M. Ullmann1, A. Elmously1, T. Beninato1, C. Afaneh1, T. J. Fahey1, R. Zarnegar1  1NEW YORK-PRESBYTERIAN-CORNELL,New York, NY, USA

Introduction:  Exposure to minimally invasive surgical techniques during residency is becoming increasingly important for surgical trainees. Our center developed a curriculum using the Da Vinci (Intuitive Surgical, Inc., Sunnyvale, CA) robotic simulation console that is available to all residents. We aimed to evaluate if skill acquisition and decay were related to post-graduate year.

Methods:  After implementation of a robotic curriculum in June 2016, residents in General Surgery (GS), Urology, and Obstetrics-Gynecology were given unlimited access to the console equipped with over 50 training modules selected by faculty. An overall score of 90% in each exercise was considered proficient, which was calculated by subtracting a penalty subscore from the efficiency subscore. Individual performance was tracked using unique login identifiers. Data was collected for all residents on the most commonly performed modules (n=18) over the first year of the robotic curriculum and analyzed by exercise type (coordination versus suturing) and PGY level.

Results: A total of 40 residents were included; 32/40 (80%) were GS residents and 23/40 (57.5%) were male. The median number of sessions on the simulator was 3 (range 1 – 15).

PGY level had no effect on initial score in coordination exercises (p = 0.28) or suturing exercises (p = 0.29) or on the number of attempts required to achieve proficiency for a given exercise (p = 0.70). PGY1s were most likely to be penalized for poor economy of motion (p < 0.001), whereas PGY5s were most likely to be penalized for excessive force (p < 0.001). Skill acquisition varied by exercise type (Figure). For coordination exercises, efficiency plateaued after the second attempt, and a passing score was subsequently reached by reduction in the penalty score. For suturing exercises, efficiency continued to increase with the number of attempts until a passing score was reached.  

Decay in skillset over time was observed in coordination exercises but not suturing exercises. In coordination exercises, a significantly greater median number of attempts were required to pass when comparing the initial session to sessions after six months without simulator exposure (3 attempts, IQR 2-5 versus 9 attempts, IQR 4.5 – 22.5, p = 0.006).  This difference was not seen in suturing exercises (3 attempts, IQR 2 – 4.5 versus 3 attempts, IQR 2 – 4, p = 0.31).

Conclusion: Proficiency in robotic training modules can be achieved regardless of level of training.  Coordination and suturing skills are acquired via different pathways, and suturing is a more durable skillset. Regular access to a robotic simulator beginning early in training has the potential to establish and sustain robotic skills. 
 

57.09 In-situ OR Simulations Increases Confidence and Knowledge of Emergency Events

Posted on January 18, 2018

S. Torres Landa1, R. Caskey1, V. Zoghbi1, J. H. Atkins1, N. N. Williams1, A. D. Brooks1, K. R. Dumon1  1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction:

In-situ simulations of operating room emergencies can lead to increased patient safety and more effective teamwork amongst operating room staff. They also serve to provide training to residents in the ACGME core competencies of practice-based learning and improvement and interpersonal and communication skills. We recently revitalized our in-situ OR simulation program to include one full day per month of training and have also incorporated the TeamSTEPPS® curriculum into the training. 

Methods:

Twelve teams were formed for the simulations which include: 12 PGY-2 surgery residents, 24 PGY-3 or PGY-4 anesthesia residents and 36 perioperative registered nurses. Each team then participated in two of the following 30-minute simulations: intra-operative myocardial infarction, acute hemolytic transfusion reaction, massive post-operative hemorrhage in PACU, and tension pneumothorax in PACU. Debriefing was performed following each scenario. All simulations took place in one of the main operating rooms or PACU at our institution. Participants received introductory material about TeamSTEPPS® two weeks prior to the simulations. TeamSTEPPS® concepts were discussed during the debrief following the first simulation and then reinforced with intentional pauses during the second simulation. Participants were surveyed before and after the simulations. All survey questions were rated on a Likert scale of 1-5. Results are listed as average ± standard error of the mean. Average pre and post survey questions were evaluated using a paired t-test. 

Results:

Participants self reported increased confidence in all scenarios performed: managing intra-operative myocardial infarction (2.83±0.21 vs 4.08± 0.13, p < 0.01), acute hemolytic transfusion reaction (3.04±0.23 vs 4.04±0.13, p < 0.01), massive post-operative hemorrhage in PACU (3.5±0.15 vs 4.25±0.12, p<0.001), and tension pneumothorax in PACU (2.71±0.17 vs 4.25±0.13, p < 0.001). Participants also reported a significant increase in knowledge of TeamSTEPPS® (2.0±0.17 vs 3.88±0.17, p <0.01). Average participant score for likelihood of using TeamSTEPPS® concepts during a future, real life emergency was 4.38±0.17. Participant opinion of in-situ simulations improved following the training (4.04±0.21 vs 4.63±0.1, p < 0.02).

Conclusion:

In-situ OR simulations led to increased confidence in participants for managing the emergency situations simulated.  Incorporation of the TeamSTEPPS® curriculum into our in-situ simulation program resulted in increased knowledge of TeamSTEPPS® concepts amongst participants and led them to report a willingness to use these concepts during real life emergencies. Future evaluations at both the individual and institutional level must be done to determine the lasting impact of this training. 

57.06 Astronaut Crew Non-Technical Skills for Medical Event Management on Deep Space Exploration Missions

Posted on January 18, 2018

S. Yule1,2,4,5, R. Dias2,5, J. Robertson2,5, A. Gupta4, S. Singh2, S. Lipsitz4,5, C. Pozner2,5, D. Smink1,4,5, J. Thorgrimson7, T. Doyle6, D. Musson7  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,STRATUS Center For Medical Simulation,Boston, MA, USA 4Brigham And Women’s Hospital,Center For Surgery & Public Health,Boston, MA, USA 5Harvard Medical School,Boston, MA, USA 6McMaster University,Department Of Electrical And Computer Engineering,Hamilton, ON, Canada 7Northern Ontario School Of Medicine,Thunder Bay, ON, Canada

Introduction:  In the unique context of deep space, long duration exploration spaceflight, an unforeseen inflight medical emergency could compromise crew health and jeopardize mission success. Returning prematurely to Earth or consulting with a flight surgeon via long distance communications may be challenging or impossible. In the operating room, non-technical skills (NTS) such as situation awareness, leadership, and team coordination have been shown to reduce performance errors and the risks associated with high acuity low frequency events. The aim of this study was to develop a NTS taxonomy and behavior markers to support astronaut crew training in preparation for the management of medical emergencies during long duration space missions.

Methods:  A Delphi method with an expert panel comprising physicians, astronauts, health service researchers, human factors scientists and space medicine practitioners (n=28) was used to reach consensus on critical non-technical skills required for an astronaut crew. Panelists ranked the potential impact of NTS on management of 30 medical events defined in NASA’s Space Medicine Exploration Medical Condition List. In a subsequent consensus meeting, panel members were assigned to four parallel groups and identified specific non-technical skills that may assist management of medical events in space.

Results: Panelists ranked the management of obstructed airway, cardiac arrest, shock, decompression sickness, anaphylaxis, and events requiring surgical treatment as most likely to be enhanced by effective NTS of the spaceflight crew. After several rounds of panel discussion, iterative development, and refinement, a taxonomy of the essential 20 behaviors for medical event management were identified and mapped to NASA’s existing team training framework (Figure 1). 

Conclusion: We developed the first medically-focused NTS taxonomy for spaceflight, reflecting an innovative translation of non-technical skills research in surgery. Future studies will test the reliability of the taxonomy using video scenarios filmed in a medical care capable spacecraft simulator. As in surgery, deliberate practice on non-technical skills can improve outcomes in spaceflight medical emergencies, reducing the risk of unanticipated medical events on long duration exploration missions such as a future mission to Mars.

 

57.05 Trauma Simulation Teaching in Cuba – A Model for Other Low- and Middle- Income Countries (LMICs)?

Posted on January 18, 2018

S. Rodriguez1, N. Lin1, M. L. Fabra2, J. A. Martinez2, M. DeMoya3, D. M. Valdés2, T. Zakrison1  2Hospital Universitario Calixto García, University Of Havana,Havana, HAVANA, Cuba 3Massachusetts General Hospital,Boston, MA, USA 1University Of Miami,Miami, FL, USA

Introduction:  Trauma-related injuries are the leading cause of death of youth under the age of 44 globally, disproportionately affecting low-and- middle income countries (LMICs). Cuba has had a long tradition of medical internationalism and the largest medical school in the world for foreign trainees, most originating from other LMICs.  Standardized, excellent trauma training and teaching is an important priority with significant global responsibility. Currently, there is no standardized method to teach trauma across Cuba, with local variability present.  Our objective was to assess the feasibility of teaching the Trauma Evaluation and Management (TEAM) course to medical trainees in Havana, Cuba, as a potential model for other LMICs in to increase exposure to standardized trauma care. 

Methods:  The first TEAM course in Havana, Cuba was taught at a major tertiary hospital in 2016. The course focuses on trauma assessment and management for medical students during clinical years of training and serves as a brief version of the Advanced Trauma Life Support (ATLS). We employed 4 ATLS instructors, (2 Cuban and 2 US trauma surgeons). The course was taught in Spanish using curriculum provided by the American College of Surgeons (ACS). Course materials were donated from the ACS while instructors donated their time. Course instruction included slideshows, books, and exams. We used a mixed methods approach to measure pre-and post-test scores for comprehension combined with qualitative focus groups for feedback and evaluation for improvement. Parametric statistics were used after determining skewedness.

Results:  30 health professional students from 5 countries (Cuba, South Africa, Angola, Chad and Germany) participated in the trauma simulation course. In the pre-test period, 53% of students passed compared to 80% of students in the post-test period (p = 0.00001). When focus groups examined the ideal way of teaching the principles of trauma in Cuba and globally, thematic analysis demonstrated two salient themes: i) the need for more ‘hands-on’ training, using simulation models and ii) standardized trauma courses are urgently needed to ensure a level of competency, consistency and sustainability in trauma care and education.

Conclusion:  Teaching TEAM in a low-income country, to a globally diverse group of medical students is feasible and needed. Promulgation of such courses that standardize trauma teaching and employ simulations should be a priority for the American College of Surgeons and other global surgical organizations. Bringing courses like TEAM to an international level can be a robust platform for global training in trauma that allow for sustainability and standardization of trauma care as well as reciprocal learning and collaboration.

 

57.03 Silicone-rubber as a Viable, Cheaper Alternative to Current Commercial Simulated Bowels

Posted on January 18, 2018

K. M. Bell1, B. Wise1, C. Kwan1, A. Witt1, C. M. Pugh1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
Surgical residency programs have relied on cadaveric animal tissue, to practice and teach surgical procedures and techniques. The drawbacks to using animal tissue are short shelf life, sporadic availability, and costs of manpower and management needs. For training purposes, commercial synthetic tissue and virtual reality simulators are also used, but can be very expensive. The aim of this study is to determine if our fabricated silicone-based bowels are valuable for surgical education and competitive with commercial products. We hypothesize that silicone-based bowels can be a useful training tool for general surgery residents and can be more cost effective than commercial products.

Methods:
General Surgery residents (N=6) evaluated three synthetic bowel prototypes. Two synthetic small bowels (Model B and C) were fabricated using cellulose fiber sheets, cotton fiber mesh, and silicone rubbers in different concentrations, to replicate the serosa, muscularis and mucosa. Cost for these models is $5. A third, commercial small bowel was purchased (Model A) for $60. Participants blindly selected what they felt to be most realistic from a covered basin and those choices were documented. Next, participants performed a suturing task on all three samples and evaluated the bowel’s realism using a Likert based survey. Favorable responses were denoted as ‘average’, ‘accurate’, or ‘highly accurate’. Unfavorable responses included ‘highly inaccurate’ and ‘inaccurate’.

Results:
83% of participants had previously used synthetic bowel for learning purposes, and 50% of participants reported performing 1 to 5 bowel Enterotomy repairs per month in the operating room. During the blind identification test, 66% of participants selected one of the silicone-based rubber bowels (B or C), over the commercial bowel (A) as feeling the most realistic. Model A tended to have more favorable responses regarding mechanical functionality of the bowel, with ten-out-of-ten of the favorable survey responses. Model B had seven-out of ten favorable responses, and Model C had a five-out-of-ten favorable responses. All the participants answered ‘accurate’ or ‘highly accurate’ in response to the survey statements confirming that simulation could highlight the strengths or weaknesses in their technical skill.

Conclusion:
The silicone-based bowels, models B and C, were more likely to be selected in the blind identification test. When the favorable properties of model B and C are combined, we will be able to produce a prototype that is financially, tactically, and mechanically competitive to the current commercial products. This study shows that silicone based rubber bowels have value for surgical education, and that with advancement; they can be a viable replacement to cadaveric animal tissue, commercial prototypes, and other, more costly training products.

57.04 Impact of Novel CVC Simulation Training Program for Residents on Line Associated Complications

Posted on January 18, 2018

C. Cairns1, M. Goyal1,3, J. Day1, A. Kumar4, Z. Winchester1, J. Katz1, J. Bell1, S. Fitzgibbons1,5  1Georgetown University School Of Medicine,Washington, DC, USA 3Medstar Washington Hospital Center,Emergency Medicine,Washington, DC, USA 4MedStar Health Research Institute,Hyattsville, MD, USA 5MedStar Georgetown University Hospital,General Surgery,Washington, DC, USA

Introduction:  Central venous catheters (CVC) are frequently placed by resident physicians in teaching hospitals. Simulation training aims to improve their technical performance and reduce procedure-associated complications. Our objective was to determine the impact of an intense simulation-based training program on residents' rates of CVC-associated complications.  We hypothesized that the CVC-associated complication rates of simulation trained residents (STRs) would be lower than those of traditionally-trained residents (TTRs).

Methods:  A single center, retrospective study was undertaken at an urban tertiary care teaching hospital, evaluating all CVCs placed by residents between October 1st 2014 and January 4th 2017, following hospital-wide introduction of the novel simulation–based training program.  All patients with CVCs placed by residents during the study period were included in the study.  Trained investigators extracted electronic medical record data regarding resident and patient demographics, CVC type, anatomic location, and post-procedure complications.  Complication rates were reported as either rate per lines placed (for immediate complications) or complication per 1000 catheter days (for delayed complications), and were compared between the two study groups using the exact Poisson test with a significant p-value set at 0.05.  

Results: 

During the study period, 931 CVCs were placed by residents, with the majority placed by STRs (62.3%) in the Internal Jugular (IJ) vein (74.22%).  A total of 36 delayed complications, including deep vein thrombosis (DVT), pulmonary embolism (PE) and central line associated blood stream infection (CLABSI), occurred, with more delayed complications occurring at the IJ site following STR insertion (STR 4.54/1000 catheter days vs. TTR 1.51/1000 catheter days, p 0.4256).   The majority of delayed complications were DVTs, with more IJ DVTs occurring after STR (n=17) as compared to TTR (n=5) placement (3.67/1000 catheter days vs. 1.08/1000 catheter days, p 0.017).  There was no difference in delayed complication rates for TTRs vs. STRs at the subclavian or femoral vein sites. 

There was no difference between the total mechanical complication rate (including pneumothorax, hemothorax, and arterial injury)  of STRs vs. TTRs (2.6% vs. 1.7%, p .50).  A total of 5 pneumothoraces occurred following CVC placement by an STR at the IJ site in comparison to 4 pneumothoraces following TTR procedures (1.0% vs. 1.31%, p 1.0).  Only one pneumothorax occurred following a subclavian CVC, placed by a TTR. Only one hemothorax occurred, following an IJ CVC placement by an STR.  IJ CVC catheter placement resulted in 8 arterial injuries, 7 following STR placed CVCs vs. 1 following a TTR placed CVC (1.2% vs. 0.3%, p 0.07).  

Conclusion: Central venous catheters placed by simulation trained residents and traditionally trained residents have an equivalent rate of mechanical complications and a slightly increased rate of DVT following CVC placement. 
 

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