Behind The Knife: The Surgery Podcast

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/ 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

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 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

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. 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

Two surgical experts, Keith Lillemoe and Luise Pernar, discuss improving morbidity and mortality conferences in surgery to enhance education and quality improvement. They explore the historical evolution of these conferences, challenges in connecting them with quality improvement initiatives, creating a supportive culture, and the importance of cultural factors in analyzing surgical complications.

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

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

In this engaging discussion, surgeons Andrew Wright, Nick Cetrulo, and Nicole White from UW Medical Center, alongside residents Paul Herman and Ben Vierra, dive deep into the evolution of cholecystectomy techniques. They explore the dramatic rise in robotic surgery and its implications for patient outcomes compared to traditional laparoscopic methods. The team examines the history of bile duct injuries and highlights ongoing efforts to minimize these risks. Insights into training challenges and the importance of surgeon experience add further depth to their analysis.

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   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

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 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

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/ 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