Behind The Knife: The Surgery Podcast

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Clinical Challenges in Vascular Surgery: Intermittent Claudication Nov 21, 2024

Show notes

A 67 year old woman with a history of hypertension, hyperlipidemia, diabetes, and a 25 pack year smoking history is referred your clinic and is referred for evaluation of her peripheral arterial disease. She reports pain with walking that has limited her doing some daily activities. How can you optimally manage this patient? Does she need an operation? In this episode, we will cover the basics of peripheral arterial disease, discuss the specifics of optimal medical management and dive into the nuances of when (or if) you should offer these patients an operation.
Hosts:
Dr. Bobby Beaulieu is an Assistant Professor of Vascular Surgery at the University of Michigan and the Program Director of the Integrated Vascular Surgery Residency Program as well as the Vascular Surgery Fellowship Program at the University of Michigan.
Dr. Drew Braet is a PGY-5 Integrated Vascular Surgery Resident at the University of Michigan
Learning Objectives
- Review the definition, prevalence, and risk factors for peripheral arterial disease
- Understand the specifics of optimal medical management of patients with peripheral arterial disease
- Discuss the controversy regarding operative management of patients with claudication and review indications for an operation in patients with peripheral arterial disease
- Review the appropriate anti-platelet and anti-coagulation strategies after interventions in patients with peripheral arterial disease
References
1. Woo K, Siracuse JJ, Klingbeil K, Kraiss LW, Osborne NH, Singh N, Tan TW, Arya S, Banerjee S, Bonaca MP, Brothers T, Conte MS, Dawson DL, Erben Y, Lerner BM, Lin JC, Mills JL Sr, Mittleider D, Nair DG, O'Banion LA, Patterson RB, Scheidt MJ, Simons JP; Society for Vascular Surgery Appropriateness Committee. Society for Vascular Surgery appropriate use criteria for management of intermittent claudication. J Vasc Surg. 2022 Jul;76(1):3-22.e1. doi: 10.1016/j.jvs.2022.04.012. Epub 2022 Apr 22. PMID: 35470016.
https://pubmed.ncbi.nlm.nih.gov/35470016/
2. Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W; ESVS Guidelines Committee; Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A; Document Reviewers; Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg. 2024 Jan;67(1):9-96. doi: 10.1016/j.ejvs.2023.08.067. Epub 2023 Nov 10. PMID: 37949800.
https://pubmed.ncbi.nlm.nih.gov/37949800/

3. Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jun 11;149(24):e1313-e1410. doi: 10.1161/CIR.0000000000001251. Epub 2024 May 14. PMID: 38743805.
https://pubmed.ncbi.nlm.nih.gov/38743805/

4. Belch JJ, Dormandy J; CASPAR Writing Committee; Biasi GM, Cairols M, Diehm C, Eikelboom B, Golledge J, Jawien A, Lepäntalo M, Norgren L, Hiatt WR, Becquemin JP, Bergqvist D, Clement D, Baumgartner I, Minar E, Stonebridge P, Vermassen F, Matyas L, Leizorovicz A. Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial. J Vasc Surg. 2010 Oct;52(4):825-33, 833.e1-2. doi: 10.1016/j.jvs.2010.04.027. Epub 2010 Aug 1. Erratum in: J Vasc Surg. 2011 Feb;53(2):564. Biasi, B M [corrected to Biasi, G M]. PMID: 20678878.
https://pubmed.ncbi.nlm.nih.gov/20678878/
5. Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, Diaz R, Alings M, Lonn EM, Anand SS, Widimsky P, Hori M, Avezum A, Piegas LS, Branch KRH, Probstfield J, Bhatt DL, Zhu J, Liang Y, Maggioni AP, Lopez-Jaramillo P, O'Donnell M, Kakkar AK, Fox KAA, Parkhomenko AN, Ertl G, Störk S, Keltai M, Ryden L, Pogosova N, Dans AL, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik TJ, Verhamme PB, Vinereanu D, Kim JH, Tonkin AM, Lewis BS, Felix C, Yusoff K, Steg PG, Metsarinne KP, Cook Bruns N, Misselwitz F, Chen E, Leong D, Yusuf S; COMPASS Investigators. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med. 2017 Oct 5;377(14):1319-1330. doi: 10.1056/NEJMoa1709118. Epub 2017 Aug 27. PMID: 28844192.
https://pubmed.ncbi.nlm.nih.gov/28844192/

6. Bonaca MP, Bauersachs RM, Anand SS, Debus ES, Nehler MR, Patel MR, Fanelli F, Capell WH, Diao L, Jaeger N, Hess CN, Pap AF, Kittelson JM, Gudz I, Mátyás L, Krievins DK, Diaz R, Brodmann M, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR. Rivaroxaban in Peripheral Artery Disease after Revascularization. N Engl J Med. 2020 May 21;382(21):1994-2004. doi: 10.1056/NEJMoa2000052. Epub 2020 Mar 28. PMID: 32222135.
https://pubmed.ncbi.nlm.nih.gov/32222135/

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The Current State of Surgical Training in Advanced Abdominal Wall Reconstruction Nov 18, 2024

Show notes

In this BTK episode, the Hernia Content Team from Carolinas Medical Center discusses the evolution of training in hernia surgery. The team reviews residency and fellowship training requirements for hernia surgery and compares the training paradigm in the United States with other examples from around the world. As the field of hernia surgery continues to mature, so will training the next generation of hernia specialists.
Hosts:
- Dr. Sullivan “Sully” Ayuso, Minimally Invasive Surgery, Endeavor Health (Evanston, IL), @SAyusoMD (Twitter)
- Dr. Monica Polcz, Attending Surgeon, Baptist Health (Miami, FL)
- Dr. Vedra Augenstein, Professor of Surgery, Carolinas Medical Center (Charlotte, NC), @VedraAugenstein (Twitter)
- Dr. Todd Heniford, Chief of GI & MIS, Carolinas Medical Center (Charlotte, NC), @THeniford (Twitter)
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Clinical Challenges in Hepatobiliary Surgery: Pancreatic Anastomoses in Whipples Nov 14, 2024

Show notes

The pancreatic anastomosis is often regarded as the “Achilles Heel” of the Whipple operation, as technical failure and leakage is a significant source of perioperative morbidity and mortality. In this episode from the HPB team at Behind the Knife listen in as we discuss the standard techniques for the anastomosis, alternative techniques for the pancreatic anastomosis in patients with aberrant anatomy and/or physiology, key factors to consider when selecting the ideal approach/technique for the anastomosis, and mitigation strategies for leaks.
Hosts
Anish J. Jain MD (@anishjayjain) is a current PGY3 General Surgery Resident at Stanford University and a former T32 Research Fellow at the University of Texas MD Anderson Cancer Center.
Jon M. Harrison is a 2nd year HPB Surgery Fellow at Stanford University. He previously completed his general surgery residency at Massachusetts General Hospital, and will be returning to MGH as faculty at the conclusion of his fellowship.
Monica M. Dua (@MonicaDuaMD) is a Clinical Professor of Surgery and the Associate Program Director of the HPB Surgery Fellowship at Stanford University. She also serves as also serves as the regional HPB Surgeon at the VA Palo Alto Health Care System.
Learning Objectives
· Develop an understanding of the standard technical approaches to the pancreatic anastomosis during a Whipple (pancreatoduodenectomy) operation
· Develop an understanding of the alternative technical approaches to the pancreatic anastomosis during the Whipple when the standard approaches may not be feasible
· Develop an understanding of the key anatomic and physiologic factors in the decision making when selecting the optimal approach for the pancreatic anastomosis
· Develop an understanding of possible mitigation strategies in the event of a pancreatic anastomotic leak.
Suggested Reading
Jon Harrison, Monica M. Dua, William V. Kastrinakis, Peter J. Fagenholz, Carlos Fernandez-del Castillo, Keith D. Lillemoe, George A. Poultsides, Brendan C. Visser, Motaz Qadan. “Duct tape:” Management strategies for the pancreatic anastomosis during pancreatoduodenectomy. Surgery. Volume 176, Issue 4, 2024, Pages 1308-1311,
https://pubmed.ncbi.nlm.nih.gov/38796390/
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.
If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

USA vs. UK: ASGBI Ep. 2 - Surgical Careers Nov 11, 2024

Show notes

We’re excited to bring you the second episode in our BTK/ASGBI collaborative series, where we compare and contrast various aspects of surgery in the US and the UK, debating who does it better. In today’s episode, BTK fellow Jon Williams and ASGBI hosts Kellie Bateman and Jared Wohlgemut welcome the Christian Macutkiewicz from the UK and Scott Steele to discuss surgeon careers--from getting your first faculty job to broadening your impact to compensation structures.
Dr. Macutkiewicz is the President-Elect of the Association of Surgeons of Great Britain and Ireland. He is a General and HPB Surgeon in Manchester, England. He completed a Bachelor of Science in Biochemistry at the University of Birmingham, before studying medicine at the University of Manchester, and received an MD doctorate at the University of Manchester for research into sepsis. He underwent surgical training in North West Deanery, before completing an HPB and Liver Transplant Fellowship in Leeds. He has been a consultant surgeon in Nottingham, Leeds and most recently in Manchester since 2018. He also works privately at Spire Manchester Hospital.
Dr. Steele needs no introduction as a founder of BTK, but otherwise he is president of the Cleveland Clinic main campus and chair of the department of colorectal surgery. After graduating from West Point, Dr. Steele received his medical degree from University of Wisconsin. He then underwent general surgery residency training at Madigan Army Medical Center in Tacoma, WA followed by colorectal surgery fellowship training at University of Minnesota Medical Center. Dr. Steele then served in the military as an active duty surgeon until 2015, including several deployments and further faculty time at Madigan where he additionally served as Associate Program Director for general surgery. He then served as Division Chief of colorectal surgery at University Hospitals in Cleveland and associate director of surgical services at the Digestive Health Institute, prior to being named Chair of the department of colorectal surgery at the Cleveland Clinic in 2016, a position that he continues to hold today.
So, which country would you rather work in to carry out your illustrious surgical career? Give this episode a listen and decide for yourself!
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.
If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Clinical Challenges in Trauma Surgery: Traumatic Esophageal Injury Nov 07, 2024

Show notes

The dreaded esophageal injury. Do you still have nightmares about mock oral board scenarios torturing you with the ins and outs of how to manage traumatic esophageal injury? Think you remember all the nuances? Whether you do or you don’t, this episode should serve as a good refresher for all levels while offering some pearls for management of this tricky scenario.
Hosts:
- Michael Cobler-Lichter, MD, PGY4/R2:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@mdcobler (X/twitter)
- Dylan Tanzer, MD, 2nd-year Trauma/Surgical Critical Care Fellow
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
- Eugenia Kwon, MD, Trauma/Surgical Critical Care Attending:
Loma Linda University
Recent graduate of University of Miami/Jackson Memorial Hospital/Ryder Trauma Center Trauma/CC Fellowship
- Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery, 5 years in practice
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@jpmeizoso (twitter)
Learning Objectives:
- Describe the diagnostic workup of a suspected traumatic esophageal injury
- Identify when someone with suspected esophageal injury needs immediate surgical management
- Describe appropriate surgical techniques for repair of both cervical and thoracic esophageal injuries
Quick Hits:
1. Don’t forget the primary survey. Unstable patients should be in the OR, as should patients with hard signs of vascular or aerodigestive injury
2. If there is concern for esophageal injury but no immediate indication for the OR, this should be further investigated with CTA of the affected area. Clinical exam has poor sensitivity.
3. The esophagus should be primarily repaired if the defect is able to come together without tension after debridement. Don’t forget a well-vascularized buttress
4. If you cannot perform a primary repair, your procedure of choice should be lateral esophagostomy with feeding jejunostomy and gastrostomy for decompression. Repair over T-tube can be considered for injuries with small amounts of tissue loss
References
1. Biffl WL, Moore EE, Feliciano DV, Albrecht RA, Croce M, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Diagnosis and Management of Esophageal Injuries. J Trauma Acute Care Surg 2015;79(6):1089-95.
https://pubmed.ncbi.nlm.nih.gov/26680145/

2. Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Penetrating Neck Trauma. J Trauma Acute Care Surg 2013;75(6):936-40.
https://pubmed.ncbi.nlm.nih.gov/24256663/

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Journal Review in Colorectal Surgery: Diverticulitis Nov 04, 2024

Show notes

You have a patient with another episode of acute uncomplicated diverticulitis. This is the third episode. Do they need antibiotics? Is surgery the next step? What is their risk of recurrence with or without surgery? Tune in to find out!
Join Drs. Peter Marcello, Jonathan Abelson, Tess Aulet and special guest Dr. Jason Hall MD, MPH as they discuss high yield papers discussing diverticulitis.
Learning Objectives:
1. Describe the impact on quality of life for patients who undergo surgery or non-operative management of diverticulitis
2. Discuss the indications for surgery in patients with diverticulitis
3. Describe ongoing clinical trials in management of diverticulitis
**Video Link: https://app.behindtheknife.org/video/journal-review-in-colorectal-surgery-diverticulitis
References:
Santos A, Mentula P, Pinta T, et al. Quality-of-Life and Recurrence Outcomes Following Laparoscopic Elective Sigmoid Resection vs Conservative Treatment Following Diverticulitis: Prespecified 2-Year Analysis of the LASER Randomized Clinical Trial. JAMA Surg. 2023;158(6):593–601. doi:10.1001/jamasurg.2023.0466
https://pubmed.ncbi.nlm.nih.gov/37074706/
Bolkenstein HE, Consten ECJ, van der Palen J, van de Wall BJM, Broeders IAMJ, Bemelman WA, Lange JF, Boermeester MA, Draaisma WA; Dutch Diverticular Disease (3D) Collaborative Study Group. Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial). Ann Surg. 2019 Apr;269(4):612-620. doi: 10.1097/SLA.0000000000003033. PMID: 30247329.
https://pubmed.ncbi.nlm.nih.gov/30247329/
Hall J, Hardiman K, Lee S, Lightner A, Stocchi L, Paquette IM, Steele SR, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum. 2020 Jun;63(6):728-747. doi: 10.1097/DCR.0000000000001679. PMID: 32384404.
https://pubmed.ncbi.nlm.nih.gov/32384404/
Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C, Marcello PW, Schoetz DJ. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum. 2011 Mar;54(3):283-8. doi: 10.1007/DCR.0b013e3182028576. PMID: 21304297.
https://pubmed.ncbi.nlm.nih.gov/21304297/
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Clinical Challenges in Bariatric Surgery: Postoperative Leak Oct 31, 2024

Show notes

We are seeing a 42F in the emergency room who underwent a laparoscopic sleeve gastrectomy 11 days ago. The operation was uneventful, and she had a negative airleak test. She had an uneventful postoperative course and was discharged on POD 1. Her medical history is significant for hypertension and hyperlipidemia, and he has no other surgical history. She has been able to keep up with her clear liquid diet. She complains that this morning she experienced abdominal and palpitations. You note her vitals show a mildly elevated blood pressure and her latest heart rate is 120s. Join Drs. Matthew Martin, Adrian Dan, Crystall Johnson-Mann, and Paul Wisniowski on a discussion about initial evaluation and management of bariatric patients with internal hernias.
Show Hosts:
Matthew Martin
Adrian Dan
Crystal Johnson-Mann
Paul Wisniowski
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Hospital Design and Surgery Oct 28, 2024

Show notes

In this episode, we have a discussion about the intersection of health design/architecture and surgery with Dr. Andrew Ibrahim, a trained architect and practicing general surgeon and health services researcher. We discuss how hospitals, ICUs, operating rooms, and trauma bays are designed and the evidence behind them.
Host: Cody Mullens, general surgery resident at the University of Michigan, current Behind the Knife Surgery Education Fellow. (@Cody_Mullens)
Guest: Dr. Andrew Ibrahim. Associate Professor of Surgery at the University of Michigan, Maud T. Lane Research Professor, Co-Director for the Center for Healthcare Outcomes and Policy. (@AndrewMIbrahim)
Guide to hospital design on Dr. Ibrahim’s website: https://www.surgeryredesign.com/resources
Paper on measuring hospital design and quality of care using clinical data: https://shmpublications.onlinelibrary.wiley.com/doi/full/10.1002/jhm.12987
Science paper: https://www.science.org/doi/10.1126/science.6143402

CHEST paper: https://secure.jbs.elsevierhealth.com/action/getSharedSiteSession?redirect=https%3A%2F%2Fjournal.chestnet.org%2Farticle%2FS0012-3692%2810%2960225-5%2Ffulltext&rc=0
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Exploring the Future of Obesity Treatment: Medications, Surgery, and the Battle Against Bias Oct 24, 2024

Show notes

In this episode, Dr. Scott Butsch from the Cleveland Clinic’s Bariatric and Metabolic Institute discusses the evolving landscape of obesity medicine. He covers the history of obesity treatments, from behavioral interventions to groundbreaking medical therapies like GLP-1 receptor agonists and their future potential. The conversation also explores the challenges of bias, accessibility, and the integration of medications with surgical options for effective, long-term obesity management.
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.
If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Business of Surgery: Your Contract Oct 21, 2024

Show notes

In this, the fourth of 4 in our “What’s Your Worth” series, Matt and Mark discuss various compensation models including salary and hybrid models (e.g., productivity, quality-based, incentive-based) and fee-for-service. In addition, other variables that can be included in your contract when comparing jobs are covered (time away, professional fees, benefits, vacation). Finally, our guests cover aspects to think about when the job is not working out and you may need to leave an organization.
Matthew J. Donnelly, Esq,, Executive Director, Professional Staff Affairs, Cleveland Clinic, Cleveland, OH. https://my.clevelandclinic.org/about/overview/leadership/executive/donnelly-matt; Linkedin: https://www.linkedin.com/in/matthew-j-donnelly/

Mark Elinsky, Director, Professional Staff Compensation and Analytics, Cleveland Clinic, Cleveland, OH
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