Annals of surgery最新文献

Objective: To update and add to the first report commissioned by the Blue Ribbon Committee (BRC) about 20 years prior.

Background: Following a summit in late 2022 commissioned by the American Board of Surgery regarding competency-based reforms in surgical education and through a partnership with the American College of Surgeons and other stakeholders, a BRC-II on surgical education was formed. The BRC-II would have 7 subcommittees. This paper details the work of the Medical Student Subcommittee within the BRC-II.

Methods: The subcommittee's work, supported by staff from the American College of Surgeons, entailed a thorough literature review, which involved collating and aggregating the findings, identifying key challenges and opportunities, and committing to draft recommendations. These recommendations were then presented and refined through discussions with the BRC at large in multiple virtual and in-person settings.

Results: The subcommittee's work is detailed below and further summarized in table format. The section below elucidates the medical student education continuum and discusses the pertinent topics of recruitment, surgical engagement in medical student training and the surgical image, training for the current surgical practice model, trainee selection for graduate medical education, and optimizing the transition from undergraduate medical education to graduate medical education.

Conclusions: The last 2 decades have shown significant changes and shifts in medical education and surgical practice. The findings of BRC-II in this manuscript help to structure the current and future necessary improvements, focusing on different aspects of medical student education.

Objective: To review the current state of research training during surgical residency and make recommendations commensurate with current surgical training and academic environment.

Background: Research training has been a mainstay of academic surgical programs, yet the scientific disciplines have evolved significantly from the traditional years of bench research. It is time to reconsider how research training should prepare surgeons for future academic practice and ensure the foundational knowledge of research evidence.

Methods: As part of the Blue Ribbon Committee II, a research subcommittee was tasked to make recommendations on research training during surgical residency. Our 8-member panel brought diverse perspectives on the roles and goals of research training. We also sought input from a convenience sample of current and recent surgical residents on the impact of research training during their residency.

Results: We identified a lack of a common framework and foundational research training for all surgical residents. Participation in dedicated years of scholarly activity helped trainees meet several professional and personal goals. The lack of an integrated, dedicated research track may dissuade some medical school graduates from pursuing surgery.

Conclusions: We recommend incorporating a minimum standard for all trainees and flexibility in dedicated scholarly training to meet the needs of future academic surgeons.

Objective: To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

Background: HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

Methods: The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

Results: Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

Conclusions: The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Objective: As part of the Blue Ribbon Committee II, review current goals, structure and financing of surgical training in Graduate Medical Education (GME) and recommend needed changes.

Background: Surgical training has continually undergone major transitions with the 80-hour work week, earlier specialization (vascular, plastics, and cardiovascular), and now entrustable professional activities as part of competency-based medical education (CBME). Changes are needed to ensure the efficiencies of CBME are utilized, that stable graduate medical education funding is secured, and that support for surgeons who teach is made available.

Methods: Convened subcommittee discussions to determine the needed focus for recommendations.

Results: Five recommendations are offered for changes to GME financing, incorporation of CBME, and support for educators, students, and residents in training.

Conclusions: Changes in surgical training related to CBME offer opportunities for change and innovation. Our subcommittee has laid out a potential path forward for improvements in GME funding, training structure, compensation of surgical educators, and support of students and residents in training.

Objective: To report the first European series of full robotic whole liver transplantation (RLT) with technical details and future perspectives.

Background: Few cases of liver transplantation with a minimally invasive approach using partial grafts have been reported so far, and no cases of robotic whole liver transplantation have been reported in the scientific literature.

Methods: The adopted technique was full robotic liver hepatectomy, followed by robotic implantation after graft introduction through a small midline incision. Patients presenting with hepatocellular carcinoma in liver cirrhosis with a small caudate lobe, low degree of portal hypertension, no porto-mesenteric thrombosis, as well as low Model for End-Stage Liver Disease patients have been considered ideal candidates.

Results: Six patients underwent RLT between February and March 2024 at Lisbon and Modena University Liver Transplant Centers. Warm ischemia time during RLT ranged between 55 and 90 minutes, with a total surgery duration between 440 and 710 minutes. The median total operative time was 595 (±111.3) minutes. Only 1 recipient had prolonged hyperbilirubinemia, which was safely treated. The median in-hospital stay was 7.5 days (±4.8 d).

Conclusions: RLT is a promising technique to further reduce the impact of liver transplantation thanks to smaller incision, gentle tissue manipulation, high magnification and precision for vascular and biliary anastomosis, and reduced postoperative pain. This is the first step toward the demonstration of the feasibility of minimally invasive surgery in liver transplantation, although further selection and technical refinements are needed to improve reproducibility.

Objective: This study aims to appraise recommendations from an expert panel of surgical educators on optimizing surgical education and training in the setting of contemporary challenges.

Background: The Blue Ribbon Committee (BRC II), a group of surgical educators, was convened to make recommendations to optimize surgical training, considering the current changes in the landscape of surgical education. Surgical trainees were recruited to assess their impressions of the recommendations.

Methods: A mixed-methods study design was employed, with a survey, followed by focus group interviews. Participating residents and fellows were recruited through a purposeful sampling approach. Descriptive statistics were applied to analyze the survey data, and a thematic data analysis on interview transcripts was employed.

Results: The majority of trainee respondents (n=16) thought that all of the subcommittee recommendations should be included in the final BRC II recommendations and paper. According to the interviews, overall, the feedback from the trainees was positive, with particular excitement around work-life integration, education support and faculty development, and funding pitfalls. Some themes about concerns included a lack of clarity about the recommendations, concern about some recommendations being in conflict with one another, and a disconnect between the initial BRC II survey and the subsequent recommendations.

Conclusions: The residents gathered for this focus group were encouraged by the thought, effort, and intention that gathered the surgical leaders across the country to make the recommendations. While the trainees wanted clarity on some areas, the overall opinion was in agreement with the recommendations.

Objective: To identify the modifiable and nonmodifiable risk factors associated with postintubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay.

Background: ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain underinvestigated.

Methods: This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both preintubation and postintubation. Multivariable logistic regression analysis was performed to identify the modifiable and nonmodifiable factors associated with PIH.

Results: Seven hundred eight patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) years and 71% were male. Median [interquartile range] arrival Glasgow Coma Scale was 7 [3-13]. Patients who developed PIH had a lower mean (SD) preintubation systolic blood pressure [118 (46) vs 138 (28), P <0.001] and higher median [interquartile range] Injury Severity Score: 27 [21-38] versus 21 [9-26], P <0.001. Multivariable regression analysis identified body mass index >25, increasing Injury Severity Score, penetrating injury, spinal cord injury, preintubation packed red blood cell requirements, and diabetes mellitus as nonmodifiable risk factors associated with increased odds of PIH. In contrast, preintubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH.

Conclusions: More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and nonmodifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival.

Level of evidence: Level III-Prognostic study.

Objective: Define recommendations for work-life integration and wellness and provide a pathway for supporting, teaching, and strengthening the skills needed to live as an authentic, empathic, compassionate, emotionally intelligent surgeon who provides the best care to patients.

Background: Burnout is common during surgical residency. It is important to assess how we are addressing the human needs of surgical trainees. We report the recommendations of the work-life integration, wellness, and resilience subcommittee of the Blue Ribbon Committee II.

Methods: We met monthly via a virtual format and established the needs of the surgical trainee according to Maslow Triangle. Barriers to meeting needs were identified, classified (local, state, national, etc.), and assigned to "easy" or "hard to address." Recommendations were developed for each Maslow Triangle level and organized into 1- to 2- and 3- to 5-year goals. The Blue Ribbon Committee II (BRCII) narrowed these down to 6 recommendations that were included in a Delphi Analysis with 80% consensus needed to be included in the BRCII paper.

Results: Six recommendations were developed by the BRCII and 4 met consensus. Final recommendations addressed resident wages, a culture of belonging, workplace safety, and reporting mistreatment.

Conclusions: Creating a culture of belonging by focusing on program culture through accountability, safety, and collaboration can lead surgical training programs to train highly successful surgeons.