Behind The Knife: The Surgery Podcast

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Journal Review in Minimally Invasive Surgery: Robotic Cholecystectomy and Bile Duct Injury Jun 10, 2024

Show notes

Laparoscopic cholecystectomy was introduced approximately 30 years ago and quickly became the gold standard due to multiple benefits over open cholecystectomy. It ushered in the laparoscopic revolution but also increased the number of bile duct injuries. Through the dedicated efforts of many the rate of bile duct injury has been reduced, now mirroring open cholecystectomy. The robotic surgery revolution is well underway and unsurprisingly this technology has been applied to cholecystectomy. Given the devastating nature of bile duct injury and the history of increased injury with the last major shift in operative approach, we examine the current literature on the comparative safety of robotic-assisted cholecystectomy vs. laparoscopic cholecystectomy.
1. Andrew Wright, UW Medical Center – Montlake and Northwest, @andrewswright
2. Nick Cetrulo, UW Medical Center - Northwest, @Trules25
3. Nicole White, UW Medical Center - Northwest
4. Paul Herman, UW General Surgery Resident PGY-3, @paul_herm
5. Ben Vierra, UW General Surgery Resident PGY-2 @benvierra95
Learning objectives:
1. Examine the history of the laparoscopic cholecystectomy and review the efforts to reduce bile duct injury (SAGES Safe Cholecystectomy Task Force and Multi-Society Practice Guideline)
2. Review literature on causes and prevention of bile duct injury
3. Review a recent article on robotic cholecystectomy vs laparoscopic cholecystectomy outcomes
4. Describe precautions that might mitigate expected increase in bile duct injury as a new approach is applied
References
1. https://www.sages.org/publications/guidelines/safe-cholecystectomy-multi-society-practice-guideline/
2. https://www.sages.org/safe-cholecystectomy-program/
3. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy. The United States experience. Surg Endosc. 1998 Apr;12(4):315-21. doi: 10.1007/s004649900661. PMID: 9543520. https://pubmed.ncbi.nlm.nih.gov/9543520/
4. Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006231. doi: 10.1002/14651858.CD006231. PMID: 17054285. https://pubmed.ncbi.nlm.nih.gov/17054285/
5. Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003 Apr;237(4):460-9. doi: 10.1097/01.SLA.0000060680.92690.E9. PMID: 12677139; PMCID: PMC1514483. https://pubmed.ncbi.nlm.nih.gov/12677139/
6. Kalata S, Thumma JR, Norton EC, Dimick JB, Sheetz KH. Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy. JAMA Surg. 2023;158(12):1303–1310. doi:10.1001/jamasurg.2023.4389 https://pubmed.ncbi.nlm.nih.gov/37728932/

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Association of Out Surgeons & Allies (AOSA) - Episode 4: Gender Affirming Care and Gender Affirming Surgery Jun 06, 2024

Show notes

Join for the forth episode in the Association of Out Surgeons & Allies (AOSA) series for a discussion on gender affirming care and gender affirming surgery.
Host:
Dan Scheese, MD
Andrew Schlussel, DO, Colorectal and General Surgeon, Charlie Norwood VA Medical Center
Guests:
1. Dr. Megan Lane (She/her)
megalane@med.umich.edu
Dr. Lane is a Plastic Surgery resident at the University of Michigan who is planning on going into Gender Affirming Surgery and general reconstruction, she completed a research fellowship in the National Clinician Scholars Program and focused primarily on patient-reported outcomes in gender affirming surgery.
2. Dr. Scott Chaiet (he/him/his/himself)
chaiet@surgery.wisc.edu
Dr. Chaiet is double board certified by the American Board of Otolaryngology and the American Board of Facial Plastic & Reconstructive Surgery and is currently at the University of Wisconsin. His areas of expertise include rhinoplasty and facial gender surgery. He also practices reconstructive surgery including facial paralysis reanimation. His gender affirming practice includes all areas of the face and Adam’s apple except for hair.
3. Dr. Amy Suwanabol
pasuwan@med.umich.edu
Amy Suwanabol is a colorectal surgeon at the University of Michigan and the Ann Arbor VA. She assists the gender affirming surgeons at the University of Michigan in performing robotic assisted vaginoplasty. Her research focuses on optimizing quality of life among surgical patients and their families, surgeon well being, and cancer survivorship.
4. Dr. Monica Llado-Farrulla
lladofar@ohsu.edu
Dr. Llado-Farulla was born and raised in Puerto Rico, completed a residency in general surgery and then plastic surgery at Tulane and Penn, respectively. She pursued a year of training in advanced gender surgery and is now currently at OHSU, her practice largely focuses on facial feminization, chest affirming surgeries, phalloplasty, autologous breast reconstruction, and limb salvage.
5. Dr. Michele “Mike” Fascelli (he/him/his)
FASCELM2@ccf.org
Dr. Fascelli is a practicing reconstructive urologist at Cleveland Clinic. He comppleted his urology training at the Cleveland Clinic in Ohio and then fellowship in urogenital gender affirming surgery with the urology team at OHSU with Dr. Llado-Farulla. He is now the Director of Urogenital Reconstruction and Co-Director of the Gender Affirming Surgery Program at Cleveland Clinic. He is very committed to LGBTQIA+ urologic access and actively works to protect and expand care to the rainbow community, and to our trans and gender diverse patients. His practice is currently focused on queer urologic health concerns and genital gender surgery (i.e. vaginoplasty, metoidioplasty and phalloplasty).
Learn more and get involved with AOSA: https://www.outsurgeons.org

Twitter/X: @OutSurgeons
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So, You Want to be a Cardiac Surgeon?: Training Paradigms Jun 03, 2024

Show notes

Interested in cardiac surgery? The training paradigm for cardiac surgery has changed significantly over the past decade and we know may students often struggle when deciding what pathway is best for them. For this episode, we assembled a robust team of attendings, fellows, and residents to discuss their journey as well as some of the research that has been conducted about these different pathways to help guide students navigating this decision.
Hosts:
- Jessica Millar, MD- PGY-5 General Surgery Resident, University of Michigan, @Jess_Millar15
Guests:
- Nick Teman, MD- Assistant Professor of Thoracic and Cardiovascular Surgery, University of Virginia, @nickteman
- Jolian Dahl, MD, MSc- Integrated Thoracic Surgery Resident (PGY-6), University of Virginia, @JolianDahl
- Lyndsey Wessels, MD- Traditional Thoracic Surgery Resident (CT-1), University of Virginia, @LyndseyWessels
Articles Referenced:
- Pathways to Certification: https://www.abts.org/ABTS/CertificationWebPages/Pathways%20to%20Certification.aspx

- Narahari AK, Patel PD, Chandrabhatla AS, Wolverton J, Lantieri MA, Sarkar A, Mehaffey JH, Wagner CM, Ailawadi G, Pagani FD, Likosky DS. A Nationwide Evaluation of Cardiothoracic Resident Research Productivity. Ann Thorac Surg. 2024 Feb;117(2):449-455. doi: 10.1016/j.athoracsur.2023.08.011. Epub 2023 Aug 26. PMID: 37640148; PMCID: PMC10842395
https://pubmed.ncbi.nlm.nih.gov/37640148/
- Bougioukas L, Heiser A, Berg A, Polomsky M, Rokkas C, Hirashima F. Integrated cardiothoracic surgery match: Trends among applicants compared with other surgical subspecialties. J Thorac Cardiovasc Surg. 2023 Sep;166(3):904-914. doi: 10.1016/j.jtcvs.2021.11.112. Epub 2022 Mar 22. PMID: 35461707.
https://pubmed.ncbi.nlm.nih.gov/35461707/
For episode ideas/suggestions/feedback feel free to email Jessica Millar at: millarje@med.umich.edu
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Journal Review in Bariatric Surgery: Are Less Anastomoses Better? May 30, 2024

Show notes

Bariatric surgery is an evolving field with new procedures, or variations of old ones, being developed to meet the needs of patients with obesity. The single anastomosis duodenoileal bypass (SADI) and one anastomosis gastric bypass (OAGB) are two such procedures which have recently entered the mainstream conversation. In this episode we will give a brief overview of the SADI and OAGB, go over some short and long term studies evaluating safety and efficacy, and discuss current sentiments about these options and how they may fit into bariatric practice.
Show Hosts:
Matthew Martin, MD
Adrian Dan, MD
Crystal Johnson-Mann, MD
Paul Wisniowski, MD
Article #1: Chao 2024 - Outcomes of SADI and OAGB Compared to RYGB from the Metabolic and Bariatric Surgery Quality Improvement Program: The North American Experience

Roux-en-Y gastric bypass (RYGB) and duodenal switch are well described procedure for weight loss; however, associated postoperative complications have led to the development of simpler techniques
- Single anastomosis duodenoileal bypass (SADI) - modification of the duodenal switch where by a loop of ileum of the bilopancreatic limb approximately 200-300cm from the ileal cecal valve is anastomosed to the distal duodenal cuff of a tubularized stomach
- One anastomosis gastric bypass (OAGB) – modification of the RYGB where a loop of jejunum of the bilopancreatic limb approximately 150-200cm from the ligament of treitz is anastomosed to the distal end of a gastric pouch.
There is increasing interest in these procedures given the perceived reduced risk reduction associated with one fewer anastomosis
Currently, there is insufficient data on the safety of these procedures compared to the established RYGB.
The article utilizes the MBSAQIP database to evaluate each procedure against the RYGB
- Matched groups: SADI vs RYGB and OAGB vs RYGB
- Matched against age, sex, BMI, operative time, and ASA classification
- 30-day outcomes included complications and health care utilization
- Results were analyzed with univariate comparative analysis, and significant outcomes were examined with logistic regression
  - SADI vs RYGB: SADI independently associated INCREASED odds with staple line leak, sepsis, organ space infection, and pneumonia.
  - OAGB vs RYGB: OAGB independently associated with REDUCED odds of SSI, transfusion requirement/GI bleed, ICU admission, bowel obstruction, and healthcare utilization (reoperation, readmissions, and reinterventions)
  - No significant differences in mortality
- Limitation: Article generally reviews technical complications of procedures. Unable to address significant bariatric outcomes such as weight loss and metabolic profile, as well as long term outcomes.
- https://pubmed.ncbi.nlm.nih.gov/38170422/

Article #2: Maud 2019 - Efficacy and safety of OAGB vs RYGB for obesity (YOMEGA trial): A multicentre, randomized, open label, non-inferiority trial

Limited long-term evidence on OAGB
- Mostly arising from retrospective analyses and one meta-analysis
- Two randomized clinical trials but with poor power and questionable methodology.
This is a randomized non-inferiority trial of in patients undergoing bariatric surgery
- Randomized into 2 groups: OAGB vs RYGB with 117 patients per group
- Patients were followed for 2 years with a loss to follow up of 21% in OAGB and 24% in RYGB cohorts
- The primary outcome was weight loss with a noninferiority threshold of 7% assuming 60% weight loss at 2 years. Secondary outcomes included complications and metabolic outcomes
- Groups were compared with Student’s T and Wilcoxon tests for quantitative data, and chi-squared and Fischer’s exact for qualitative endpoints.
- Cohorts were analyzed with the intention to treat, and missing data on the primary endpoint was imputed with prediction-based modeling.
Highlighted Outcomes
- Mean percent excess BMI loss of 87.9% in OAGB group compared to 85.8% in RYGB group demonstrating non-inferiority in terms of weight loss
- Increased number of serious adverse events (SAE) in the OAGB group, but no difference in the proportion of patients with at least 1 SAE
- OAGB demonstrated 70% complete or partial remission of diabetes compared to 44% in RYGB but underpowered to demonstrate significant difference.
- Equal rates of gastritis and esophagitis based on endoscopic biopsy results at 2 years.
- There were increased nutritional complications in the OAGB groups with 21% vs 0% in RYGB and high rates of diarrhea/anal fissures 14% vs 0%, respectively. This suggests a greater malabsorptive effect of OAGB.
- There was equal satisfaction in quality of life between RYGB and OAGB on two validated surveys with >80% satisfaction rates.
Limitations
- Data was imputed for the primary end point
- High rates of loss to follow up in both cohorts
- Use of “severe adverse events” instead of Clavien-Dindo classification
- Comparison of specific institutional/surgeon technique of OAGB vs RYGB
- https://pubmed.ncbi.nlm.nih.gov/30851879/

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Are we failing our patients? Ventral hernia recurrence with Drs. Todd Heniford and Michael Rosen May 27, 2024

Show notes

Join Drs. Jason Bingham (@BinghamMd) and Patrick Georgoff (@georgoff) for a thought-provoking discussion with titans of hernia surgery Drs. Todd Heniford (@THeniford) and Michael Rosen (@MikeRosenMD). You don't want to miss this one! This episode goes deep, touching on some of the most vexing questions in the world of abdominal wall reconstruction.
Highlights:

Hernia is chronic disease process. Surgeons should act like it and patients need to understand this.
Follow-up data is hard to come by and therefore limited. Studies must be interpreted with this in mind.
Hernia surgery is sexy, which is both exciting and concerning.
"Technology is not useful until it is boring." New techniques and devices can hurt patients.
Complicated hernias should be sent to hernia centers. Otherwise, general surgeons are more than capable of doing the repair.

Link to paper: https://jamanetwork.com/journals/jamasurgery/fullarticle/2816986
Link to ACHQC: https://achqc.org/
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Clinical Challenges in Surgical Oncology: Gastric Cancer May 23, 2024

Show notes

Join the Behind the Knife Surgical Oncology Team as we discuss the presentation, work-up, and management of gastric cancer.
Hosts:
- Timothy Vreeland, MD, FACS (@vreelant) is an Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at Brooke Army Medical Center
- Connor Chick, MD (@connor_chick) is a Surgical Oncology fellow at Ohio State University.
- Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a PGY-6 General Surgery resident at Brooke Army Medical Center
- Beth (Elizabeth) Carpenter, MD (@elizcarpenter16) is a PGY-5 General Surgery resident at Brooke Army Medical Center
Learning Objectives:
In this episode, we review the basics of gastric cancer, including presentation, work-up, staging, and treatment modalities as well as high yield topics including the Siewert classification system. We also briefly discuss trials establishing peri-operative chemotherapy regimens for gastric cancer and the controversy of D1 vs. D2 lymphadenectomy.
Links to Papers Referenced in this Episode

Perioperative Chemotherapy versus Surgery Alone for Resectable Gastroesophageal Cancer.
NEJM 2006 Jul;355(1):11-20.
https://www.nejm.org/doi/full/10.1056/NEJMoa055531
Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesphageal junction adenocarcinoma (FLOT4): a randomized, phase2/3 trial
Lancet 2019 May;393(10184):1948-1957.
https://pubmed.ncbi.nlm.nih.gov/30982686/

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Clinical Challenges in Colorectal Surgery: J Pouch Creation and Management of Postoperative Pouch Complications May 20, 2024

Show notes

Join Drs. Peter Marcello, Jonathan Abelson, Tess Aulet and special guest Dr. Philip Fleshner as they discuss the management of small bowel strictures in Crohn’s disease.
Learning Objectives
1. Discuss the role for J-pouch in a patient with inflammatory bowel disease
2. Identify the key steps in creation of the J-pouch and technical considerations.
3. Describe post operative complications and management in patients with a J-pouch
Video Link: https://www.youtube.com/watch?v=_PMFaQHah5A
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Journal Review in Hernia Surgery: Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release May 16, 2024

Show notes

How is each release of the TAR contributing to the final tension on the anterior and posterior fascia? Join Drs. Michael Rosen, Benjamin T. Miller, Sara Maskal, and Ryan C. Ellis as they discuss their group’s recent cohort study of tensiometry in 100 TARs.
Hosts:
- Michael Rosen, Cleveland Clinic
- Benjamin T. Miller, Cleveland Clinic
- Sara Maskal, Cleveland Clinic
- Ryan C. Ellis, Cleveland Clinic, @ryanellismd
Learning objectives:
- Review the steps of a TAR
- Understand the changes in tension on the anterior and posterior fascia with each step of the TAR
- Think about the application this data has to similar operations
References:
Miller BT, Ellis RC, Petro CC, Krpata DM, Prabhu AS, Beffa LRA, Huang LC, Tu C, Rosen MJ. Quantitative Tension on the Abdominal Wall in Posterior Components Separation With Transversus Abdominis Release. JAMA Surg. 2023 Dec 1;158(12):1321-1326. doi: 10.1001/jamasurg.2023.4847. PMID: 37792324; PMCID: PMC10551814. https://pubmed.ncbi.nlm.nih.gov/37792324/

Miller BT, Ellis RC, Walsh RM, Joyce D, Simon R, Almassi N, Lee B, DeBernardo R, Steele S, Haywood S, Beffa L, Tu C, Rosen MJ. Physiologic tension of the abdominal wall. Surg Endosc. 2023 Dec;37(12):9347-9350. doi: 10.1007/s00464-023-10346-w. Epub 2023 Aug 28. PMID: 37640951. https://pubmed.ncbi.nlm.nih.gov/37640951/

Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990 Sep;86(3):519-26. doi: 10.1097/00006534-199009000-00023. PMID: 2143588. https://pubmed.ncbi.nlm.nih.gov/2143588/

Hope WW, Williams ZF, Rawles JW 3rd, Hooks WB 3rd, Clancy TV, Eckhauser FE. Rationale and Technique for Measuring Abdominal Wall Tension in Hernia Repair. Am Surg. 2018 Sep 1;84(9):1446-1449. PMID: 30268173. https://pubmed.ncbi.nlm.nih.gov/30268173/

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HuMaNiSm + Surgery # 1 May 13, 2024

Show notes

Welcome to Humanism in Surgery, a new series where we take a deep dive into the extremes of humanity within the field of surgery. As surgeons, there are times when we feel deeply human and times when we feel we have lost our humanity. These experiences impact us immensely and shape our careers in important ways. It's time these stories are told! For those of you who are fans of NPR, think of this as Story Core for surgery.
Today, Dr. Patrick Georgoff is joined by Dr. Tamara Fitzgerald, Associate Professor of Pediatric Surgery at Duke University, and Dr. Ted Pappas, Professor of Surgery and Master Surgeon at Duke University.
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Clinical Challenges in Burn Surgery: Burn Resuscitation - Getting Things Started - Part 1 of 2 May 09, 2024

Show notes

A patient with a large TBSA burn injury presents to a local emergency department and you are the only surgeon on duty that evening. With snow covered roads and poor visibility, the patient requires initial stabilization prior to transfer to the regional burn center. You are faced with some difficult clinical decisions as you begin their resuscitation. Join Drs. Tam Pham, Rob Cartotto, Julie Rizzo, Alex Morzycki and Jamie Oh as they discuss the clinical challenges in initiating burn resuscitation, pitfalls in long-distance transport, and more.
Hosts:
· Dr. Tam Pham: UW Medicine Regional Burn Center
· Dr. Robert Cartotto: University of Toronto, Ross Tilley Burn Centre
· Dr. Julie Rizzo: Brooke Army Medical Center
· Dr. Alex Morzycki: UW Medicine Regional Burn Center
· Dr. Jamie Oh: UW Medicine Regional Burn Center
Learning Objectives:
· Describe initial fluid strategies, including the recommendations of the Advanced Burn Life Support (ABLS) course, traditional resuscitation formulas, and the Rule of 10.
· Describe logistical and medical challenges of long-distance transport to a regional burn center.
· Understand recent advances learned from recent conflicts in military burn casualty care.
· List options for intravenous access.
· Understand endpoints of resuscitation, including adjuncts which may help guide fluid titration.
1. Cartotto R, Johnson LS, Savetamal A, et al. American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation. J Burn Care Res 2023
https://pubmed.ncbi.nlm.nih.gov/38051821/
2. Renz EM, Cancio LC, Barillo DJ, et al. Long-Range Transport of War-Related Burn Casualties. J Trauma 2008 https://pubmed.ncbi.nlm.nih.gov/18376156/
3. Adibfar A, Camacho F, Rogers AD, Cartotto R. The Use of Vasopressors During Acute Burn Resuscitation. Burns 2021 https://pubmed.ncbi.nlm.nih.gov/33293152/

4. Chung KK, Wolf SE, Cancio LC, et al. Resuscitaiton of Severely Burned Military Casualties: Fluid Begets More Fluid. J Trauma 2009 https://pubmed.ncbi.nlm.nih.gov/19667873/

5. Chung KK, Salinas J, Renz EM, et al. Simple Derivation of the Initial Fluid Rate for the Resuscitation of Severely Burned Adult Combat Casualties: in Silico Validation of the Rule of 10, J Trauma 2009 https://pubmed.ncbi.nlm.nih.gov/20622619/

Joint Trauma System Clinical Practice Guideline (CPG)-Burn Care, updated 2022
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