Behind The Knife: The Surgery Podcast

Latest Episodes:

Journal Review in Vascular Surgery: Updates on Size Threshold for Repair of Abdominal Aortic Aneurysms Jul 18, 2024

Show notes

A 70 year old healthy female is referred to you with a 5.7 cm abdominal aortic aneurysm. As an astute clinician you are aware that current guidelines support surgical repair for her AAA. What if there was new data to suggest this patient may not benefit from repair? What would be the optimal size threshold that she would benefit from AAA repair? Tune into this episode of Behind the Knife, where the vascular surgery subspecialty team discusses a paper that challenges current size threshold guidelines for AAA repair.
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. Frank Davis is an Assistant Professor of Vascular Surgery 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 current size threshold guidelines for surgical repair of abdominal aortic aneurysms
- Understand the limitations of the aforementioned guidelines
- Understand the methodology, findings, limitations, and clinical applications of the manuscript “Size thresholds for repair of abdominal aortic aneurysms warrant reconsideration.”

References
1. Columbo JA, Scali ST, Jacobs BN, et al. Size thresholds for repair of abdominal aortic aneurysms warrant reconsideration. Journal of Vascular Surgery. 2024;79(5):1069-1078.e8. doi:10.1016/j.jvs.2024.01.017
https://pubmed.ncbi.nlm.nih.gov/38262565/
2. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Journal of Vascular Surgery. 2018;67(1):2-77.e2. doi:10.1016/j.jvs.2017.10.044
https://pubmed.ncbi.nlm.nih.gov/29268916/
3. Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. Editor’s Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. European Journal of Vascular and Endovascular Surgery. 2024;67(2):192-331. doi:10.1016/j.ejvs.2023.11.002
https://pubmed.ncbi.nlm.nih.gov/38307694/
4. The UK Small Aneurysm Trial Participants, Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998;352 (9141) 1649- 1655
https://pubmed.ncbi.nlm.nih.gov/9853436/
5. Lederle FAWilson SEJohnson GR et al. Aneurysm Detection and Management Veterans Affairs Cooperative Study Group, Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002;346 (19) 1437- 1444
https://pubmed.ncbi.nlm.nih.gov/12000813/
6. United Kingdom EVAR Trial Investigators; Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med. 2010 May 20;362(20):1872-80. doi: 10.1056/NEJMoa0911056. Epub 2010 Apr 11. PMID: 20382982.
https://pubmed.ncbi.nlm.nih.gov/20382982/

7. Lederle FA, Johnson GR, Wilson SE, Ballard DJ, Jordan WD Jr, Blebea J, Littooy FN, Freischlag JA, Bandyk D, Rapp JH, Salam AA; Veterans Affairs Cooperative Study #417 Investigators. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002 Jun 12;287(22):2968-72. doi: 10.1001/jama.287.22.2968. PMID: 12052126.
8. Lancaster EM, Gologorsky R, Hull MM, Okuhn S, Solomon MD, Avins AL, Adams JL, Chang RW. The natural history of large abdominal aortic aneurysms in patients without timely repair. J Vasc Surg. 2022 Jan;75(1):109-117. doi: 10.1016/j.jvs.2021.07.125. Epub 2021 Jul 26. PMID: 34324972.
https://pubmed.ncbi.nlm.nih.gov/34324972/
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Lung in a Box: The Present and Future of Lung Preservation for Transplant Jul 15, 2024

Show notes

Take a listen into the wild and fascinating world of lung transplantation! One of the biggest challenges for any transplant is organ preservation to provide the best possible recovery and outcome for recipients. That’s especially important for lung transplant, which remains one of the most complex and challenging areas in the field of transplantation. This episode takes a deep dive into the lung transplant landscape and discusses new technologies and innovations that are revolutionizing the field. Jon Williams is joined by Dr. Elliot Wakeam, MD, a thoracic surgeon and lung transplant expert from University of Toronto to discuss the advent of ex-vivo lung perfusion (EVLP) systems and how that and other preservation techniques may impact the future of lung transplantation. Also, Dr. Wakeam provides unique perspectives as faculty from one of the best lung transplant programs in the world.
If you have any questions or comments, or find the episode interesting and want to learn more, feel free to reach out to us at hello@behindtheknife.org. Dominate the Day!
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Clinical Challenges in Surgical Education: Precision Surgical Education Jul 11, 2024

Show notes

As we move towards a model of Competency-Based Surgical Education, individualization of training may be needed. How can we get the right education to the right trainee at the right time? How can we link education to actual patient outcomes? Precision education aims to do just that, while leveraging technology, data, and analytics to decrease burden on assessors. While this approach offers a lot of promise to advance surgical education, it can be difficult to conceptualize how this would be implemented in practice. We’re joined by an expert in the field of precision medical education, Dr. Jesse Burk-Rafel, to break down what precision education is and how it might integrate into our current system of surgical education
Join hosts Nicole Brooks MD, Judith French PhD, and Jeremy Lipman MD, MHPE for this exciting conversation with Jesse Burk-Rafel MD.
Learning Objectives
1. Listeners will define precision education.
2. Listeners will describe examples of how precision medical or surgical education is being used currently.
3. Listeners will explain barriers that must be addressed with the implementation of precision surgical education, including bias and issues with data sharing.
4. Listeners will consider how precision surgical education will evolve, including possible use within their own institution to completement competency-based surgical education.
References
Desai SV, Burk-Rafel J, Lomis KD, et al. Precision Education: The Future of Lifelong Learning in Medicine. Academic Medicine. 2024;99(4).
https://pubmed.ncbi.nlm.nih.gov/38277444/
Richardson J, Santen SA, Mejicano GC, et al. Learner Assessment and Program Evaluation: Supporting Precision Education. Academic Medicine. 2024;99(4).
https://pubmed.ncbi.nlm.nih.gov/38166211/
Perrone KH, Abdelaal AE, Pugh CM, Okamura AM. Haptics: The Science of Touch As a Foundational Pathway to Precision Education and Assessment. Academic Medicine. 2024;99(4).
https://pubmed.ncbi.nlm.nih.gov/38109654/

Sukhera J. Precision Education and Equity: A Participatory Framework to Advance Equitable Assessment. Academic Medicine. 2024;99(4).
https://pubmed.ncbi.nlm.nih.gov/38109658/
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Journal Review in Hernia Surgery: What Defines a Hernia Center? Jul 08, 2024

Show notes

In this Journal Review episode, the Hernia Content Team from Carolinas Medical Center reviews the definition and meaning of a hernia center. In a subspecialty field that is in its relative infancy, the specialization of care at hernia centers is a relatively new concept. The team reviews two relevant publications on hernia centers that help to provide guidance on this topic for the hernia community.
Hosts:
- Dr. Sullivan “Sully” Ayuso, Chief Resident, Carolinas Medical Center (Charlotte, NC), @SAyusoMD (Twitter)
- Dr. Todd Heniford, Chief of GI & MIS, Carolinas Medical Center (Charlotte, NC), @THeniford (Twitter)
- Dr. Vedra Augenstein, Professor of Surgery, Carolinas Medical Center (Charlotte, NC), @VedraAugenstein (Twitter)
- Dr. Monica Polcz, Attending Surgeon, Baptist Health (Miami, FL), No Twitter handle
- Dr. Brittany Mead, GI & MIS Fellow, Carolinas Medical Center (Charlotte, NC), No Twitter handle
References:
-Shulkin et al, Characterizing Hernia Centers in the United States: What Defines a Hernia Center?, Hernia, 2022
https://pubmed.ncbi.nlm.nih.gov/33871743/
-Köckerling et al, Accreditation and Certification Requirements for Hernia Centers and Surgeons: the ACCESS Project, Hernia, 2019
https://pubmed.ncbi.nlm.nih.gov/33871743/
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Journal Review in Trauma Surgery: VTE Prophylaxis Jul 01, 2024

Show notes

VTE prophylaxis is more than just some squeezy leg socks and a one-size fits all dose of enoxaparin! Ever wonder how VTE prophylaxis is similar to constipation? Have you or a loved one been hurt by a hospital administrator telling you that VTE is a never event? Come with us, and our special guest Dr. Bryan Cotton, on this journey to the frontier of research attempting to debunk this myth and improve patient care by reducing VTE rates in trauma patients.
Hosts:
- Michael Cobler-Lichter, MD, PGY4/R2:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@mdcobler (X/twitter)
- Eva Urrechaga, MD, PGY-8, Vascular Surgery Fellow
University of Pennsylvania
Recent graduate of University of Miami/Jackson Memorial Hospital/Ryder Trauma Center General Surgery Residency
@urrechisme (X/twitter)
- 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
- Brandon Parker, DO, Assistant Professor of Surgery, 5 years in practice
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@BrandonParkerDO (X/twitter)
- Bryan Cotton, MD, MPH, FACS, Professor of Surgery, 20 years in practice
University of Texas Health Science Center at Houston/Red Duke Trauma Institute at Memorial Herman Hospital
@bryanacotton1 (X/twitter)
Learning Objectives:

- Describe the rationale for the addition of aspirin to chemoprophylactic regimens for VTE
- Identify appropriate screening systems for trauma patients at high risk for VTE
- Describe the rationale for monitoring anti factor Xa levels in the trauma population receiving VTE chemoprophylaxis
- List the major conclusions of the two studies discussed regarding the addition of aspirin to VTE chemoprophylaxis regimens in trauma patients, and the change in antithrombin activity levels over time in relation to enoxaparin responsiveness in polytrauma patients
Quick Hits:

1. On adjusted analysis, the standard VTE PPX plus aspirin group had a lower OR of developing VTE, though limitations of this study highlight need for future prospective work
2. Trauma patients often suffer from decreased activity of antithrombin 3, which may mediate the relatively higher rates of VTE in this population.
3. Trauma patients who went on to develop VTE were more likely to not achieve satisfactory anti Xa levels, with a VTE rate of 30% in the never-responder group, the group for which Xa levels were never higher than 0.2
4. Ex vivo supplementation of antithrombin seems to improve enoxaparin responsiveness. Remember, enoxaparin and heparin are HELPING AT3, not the other way around
References

1. Lammers D, Scerbo M, Davidson A, et al. Addition of aspirin to venous thromboembolism chemoprophylaxis safely decreases venous thromboembolism rates in trauma patients. Trauma Surg Acute Care Open. 2023;8(1):e001140. doi:10.1136/tsaco-2023-001140
https://pubmed.ncbi.nlm.nih.gov/37936904/
2. Vincent LE, Talanker MM, Butler DD, et al. Association of Changes in Antithrombin Activity Over Time With Responsiveness to Enoxaparin Prophylaxis and Risk of Trauma-Related Venous Thromboembolism. JAMA Surg. 2022;157(8):713-721. doi:10.1001/jamasurg.2022.2214
https://pubmed.ncbi.nlm.nih.gov/35731524/
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Resident Involvement in Lawsuits Jun 27, 2024

Show notes

Most surgeons know about malpractice lawsuits, but did you know that residents and even medical students can be involved in them? Join us for a discussion of what happens when patients sue their treatment teams -- and what happens when those teams involve trainees.
Host: Nina Clark, MD, MS
Guests:
Cindy Hamra, JD, MA is an associate dean in the GME Office at the University of Washington School of Medicine, where she leads the operational, administrative and finance functions. UW School of Medicine is sponsors clinical training for over 1600 medical and dental residents in fellows in over 200 programs. UW Medicine, through the School of Medicine, is the largest sponsor of GME programs in the five-state WWAMI region (Washington, Wyoming, Alaska, Montana and Idaho).
Lisa Hammel, JD is the senior director of clinical risk management for UW medicine. Prior to that, she spent over 20 years as a defense attorney primarily working in medical malpractice and professional liability defense.
References:
American College of Surgeons: https://www.facs.org/for-medical-professionals/news-publications/journals/rise/articles/litigation-overview/
AMA: https://www.ama-assn.org/medical-residents/residency-life/resident-medical-liability-lawsuits-why-and-how-often-they-happen
JAMA Surgery: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833625/ & https://jamanetwork.com/journals/jamasurgery/article-abstract/2670456
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Appendiceal Masses Jun 24, 2024

Show notes

Join Drs. Scott Steele and Dan Scheese as they engage in an in-depth conversation with Dr. Michael Valente about the intricate world of appendiceal masses, including carcinoid, adenocarcinoma, and mucinous neoplasms. Despite the complexity of the subject, this episode skillfully deconstructs the topic through the analysis of three distinct cases, illuminating the latest terminology, diagnostic approaches, and management strategies.
Hosts:
Scott Steele, MD (@ScottRSteeleMD)
Dan Scheese, MD (@DanScheese13)
Guest:
Michael Valente, MD (@DrMikeValente) is an Associate Professor of Surgery at the Cleveland Clinic and Program Director of the colon and rectal residency program. Dr. Valente's specialty and research interests include cancer of the appendix, peritoneum, colon, rectum and anus, cytoreductive surgery/HIPEC, complex re-operative surgery, inflammatory bowel disease, advanced endoscopic techniques, laparoscopic and minimally invasive colorectal surgery, and surgical education. Dr. Valente has published numerous peer-reviewed journal articles and book chapters and has presented his research interests both nationally and internationally.
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Surgical M&M: Can We Do Better? Jun 20, 2024

Show notes

M&M - we all do it, but what is its purpose? Join Jason and Nina as they talk to two experts about why we present at all, and what we can do to better reach the educational and quality improvement goals of morbidity and mortality conference.
Hosts: Jason Bingham, Nina Clark
Panelists

Keith Lillemoe, MD
- Chief of Surgery, Massachusetts General Hospital
- Professor of Surgery at the Harvard Medical School
Luise Pernar, MD, MHPE
- Bariatric Surgeon
- Associate Professor of Surgery, Boston University Chobanian and Avedisian School of Medicine

References
https://jamanetwork.com/journals/jamasurgery/article-abstract/2810740
https://pubmed.ncbi.nlm.nih.gov/26649585/
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Dominate the Match - Episode 7: Applying to Residency as an International Medical Graduate - Part 2 of 2 Jun 17, 2024

Show notes

It’s that time of year (again!)- when medical students- both US and International- are preparing their residency applications. This year, we have been focusing on the special challenges International Medical Graduates face when applying to US surgical residency positions. In our previous episode, we discussed how residents can make their applications stand out to program directors. Today, we will explore the unique challenges, experiences, and the future of IMGs with special guest Dr. Hasan Alam.
Guests:
Hasan Alam, MD- Chair of the Department of Surgery and Professor of Surgery (Trauma and Critical Care) and Cell and Developmental Biology- Northwestern University
Previous DOMINATE the Match Episodes:
Episode 2- “Choose Me” (Personal Statements and Letters of Recommendations)
https://behindtheknife.org/podcast/dominate-the-match-episode-2-choose-me/
Episode 3- “The Interview”
https://behindtheknife.org/podcast/dominate-the-match-episode-3-the-interview/

Episode 4- “Rank and Match”
https://behindtheknife.org/podcast/dominate-the-match-episode-4-rank-and-match/
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

Dominate the Match - Episode 6: Applying to Residency as an International Medical Graduate - Part 1 of 2 Jun 13, 2024

Show notes

It’s that time of year (again!)- when medical students- both US and International- are preparing their residency applications. In this episode, we will focus on the special challenges International Medical Graduates face when applying to US surgical residency positions and discuss tips and tricks for making IMG residency applicants standout to program directors in the US.
Guests:
David Hughes, MD- Clinical Associate Professor of Endocrine Surgery and General Surgery Residency Program Director- University of Michigan
Krishnan Raghavendran, MBBS- Professor of Acute Care Surgery and Critical Care- University of Michigan
Link to video:
You can watch Dr. Hughes’s full presentation here: https://youtu.be/iQ0CzH7xHwE
Previous DOMINATE the Match Episodes:
Episode 2- “Choose Me” (Personal Statements and Letters of Recommendations)
https://behindtheknife.org/podcast/dominate-the-match-episode-2-choose-me/

Episode 3- “The Interview”
https://behindtheknife.org/podcast/dominate-the-match-episode-3-the-interview/
Episode 4- “Rank and Match”
https://behindtheknife.org/podcast/dominate-the-match-episode-4-rank-and-match/

Residency Program Lists:
- FREIDA Residency and Fellowship Database: https://freida.ama-assn.org/
- Doximity: https://www.doximity.com/residency/?utm_campaign=marketing_resnav_competitor_broad_20210520&utm_source=google&utm_medium=cpc&gclid=CjwKCAjwt52mBhB5EiwA05YKo1J47BLAtTPtsJBmVvXGP2pDXLLqgDIwM0pgkSYjoBhFUOO1ktXDYRoC2bkQAvD_BwE
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

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