This week, we discuss the experiences of residents and medical students in surgery who identify as LGBTQIA+. We discuss the question of disclosure during interviews, how to identify programs that are welcoming to diverse identities, and how AOSA has grown the community of trainees and faculty mentors and hopes to continue to support them in the future. Hosts: Jason Bingham, MD Nina Clark, MD Guests: Andrew Schlussel, DO, Colorectal and General Surgeon, Charlie Norwood VA Medical Center Christina Georgeades, MD, R4 General Surgery at Medical College of Wisconsin cgeorgeades@mcw.edu, Twitter/X: @CGeorgeades Cameron Smith, MS3 at Kansas City University Cameron.smith@kansascity.edu, Instagram: @cameron_smith_1996, Twitter/X: @cafe_aficionad0 Jillian Wothe, MD, R1 General Surgery at Brigham & Women’s Hospital jillian.wothe@gmail.com, Twitter/X: @JillianWothe 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 episode one in this series: https://behindtheknife.org/podcast/association-of-out-surgeons-allies-aosa-episode-1/

Has the pendulum swung too far?  Is it time to put the drill down??  Or, drill, baby, drill!  While the number of rib plating cases has exploded the data supporting the practice is less-than-stellar.  On this episode of the BIG T Trauma series Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill bring you up to speed on rib plating. If you haven’t already, we recommend you listen to Behind the Knife episode 298, published in May 2020. (https://behindtheknife.org/podcast/big-t-trauma-series-ep-10-rib-fractures/)  This episode covers comprehensive management of rib fractures, including multimodal pain control, regional blocks, pulmonary toilet, BiPAP, etc.   REFERENCES: GUIDELINES EAST PMG Rib Plating (2017): https://www.east.org/education-resources/practice-management-guidelines/details/rib-fractures-open-reduction-and-internal-fixation-of-update-in-process EAST PMG Rib Fracture Non-Surgical Management (2022): https://www.east.org/education-resources/practice-management-guidelines/details/nonsurgical-management-and-analgesia-strategies-for-older-adults-with-multiple-rib-fractures-a-systematic-review-metaanalysis Chest Wall Injury Society Guidelines (2020): https://cwisociety.org/wp-content/uploads/2020/05/CWIS-SSRF-Guideline-01102020.pdf FLAIL/UNSTABLE CHEST Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial, JAMA 2022: https://jamanetwork.com/journals/jamasurgery/fullarticle/2796556 Prospective randomized controlled trial of operative rib fixation in traumatic flail chest, JACS 2013: https://pubmed.ncbi.nlm.nih.gov/23415550/ Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status, Interact Cardiovasc Thoracic Surg 2005: https://pubmed.ncbi.nlm.nih.gov/17670487/ Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients, J Trauma 2002: https://pubmed.ncbi.nlm.nih.gov/11956391/ Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-analysis, J Surg Research 2022: https://pubmed.ncbi.nlm.nih.gov/35390577/ Surgical versus nonsurgical interventions for flail chest, Cochrane Review 2015: https://pubmed.ncbi.nlm.nih.gov/26222250/ NON-FLAIL CHEST Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury, Ann Surgery 2023: https://pubmed.ncbi.nlm.nih.gov/37317861/ Rib fixation in non-ventilator-dependent chest wall injuries: A prospective randomized trial, J Trauma 2022: https://pubmed.ncbi.nlm.nih.gov/35081599/ A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (NONFLAIL), J Trauma 2020: https://pubmed.ncbi.nlm.nih.gov/31804414/ Operative versus nonoperative treatment of multiple simple rib fractures: A systematic review and meta-analysis, Injury 2020: https://pubmed.ncbi.nlm.nih.gov/32650981/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out the rest of the BIG T Trauma episodes here: https://behindtheknife.org/podcast-series/big-t-trauma/

You have a young patient with a horseshoe abscess. How should you address the abscess initially? What is the best approach to drain it? Now that it is drained, what do I do with all the drains? Tune in to figure out how to best approach the most challenging of perianal abscesses.  Join Drs. Peter Marcello, Jonathan Abelson, Tess Aulet and special guest Dr. Julia Saraidaridis as they discuss the management of horseshoe abscess and complicated perianal fistula.  Learning Objectives 1. Describe the evaluation for perianal abscesses and fistula.  2. Discuss the different surgical options in managing horseshoe abscesses and post operative care to definitive management 3. Explain the rationale behind use of different fistula surgeries in complex perianal fistulas Link to episode video: https://behindtheknife.org/video/clinical-challenges-in-colorectal-surgery-management-of-horseshoe-abscess/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  Our Colorectal Surgery Oral Board Audio Review includes 51 high-yield scenarios designed for Colorectal Surgeons by Colorectal Surgeons.  Learn more here: https://behindtheknife.org/premium

To close or not to close - that is the question!  Internal hernias following bariatric surgery can be a vexing source of delayed postoperative morbidity.  Join Drs. Matthew Martin, Kunoor Jain-Spangler, Adrian Dan, and Vincent Cheng for this EXCELLENT Journal Review in Bariatric Surgery.   Article #1: Stenberg 2023 - Long-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery Two mesenteric defects are created during Roux-en-Y gastric bypass (RNYGB) Petersen’s Defect Jejuno-jejunostomy mesenteric defect  Consensus does not exist regarding the standard of care for mesenteric defect closure (e.g., closure of one or both defects, material used for closure).  Risks of leaving defects open: internal herniation with or without bowel ischemia  Risks of closing defects Kinking the bowel (especially near the jejunojejunostomy) leading to obstruction  Chronic abdominal pain This article discusses a randomized controlled trial of obese patients undergoing bariatric RNYGB Randomized into two groups: a closure group and a non-closure group  Followed patients for 10 years with 95-96% follow up rate Results analyzed using a Cox proportional hazards regression that included risk factors like BMI, total weight loss at 1 year after surgery, and the other  Highlighted outcomes  Within the first 30 postop days, there was a higher rate of SBO in the closure group (1.3%) compared to the non-closure group (0.2%). This was attributed to kinking of the jejunojejunostomy  After 30 postop days and up to 10 years, reoperation rates for SBO were higher in the non-closure group (14.9%) compared to the closure group (7.8%). This trend was consistent regarding each site of mesenteric defect.  No significant differences between the two groups regarding chronic opioid use as a metric of chronic abdominal pain. Article #2: Nawas 2022 - The Diagnostic Accuracy of Abdominal Computed Tomography in Diagnosing Internal Herniation Following Roux-en-Y Gastric Bypass Surgery Unless there is an indication to immediately operate on a RNYGB patient in whom internal herniation is suspected, computed tomography (CT) is the recommended diagnostic test This article is a meta-analysis of 20 studies published between 2007 and 2020 that analyzed the accuracy of CT or detecting internal hernias in adult patients who underwent RNYGB for morbid obesity. A collective total of 1,637 patients were included.   Accuracy was determined by comparing diagnostic CT with exploratory surgery or the combination of negative CT and a negative 90 days follow-up Internal herniation was defined as presence of herniated small bowel with or without obstruction or ischemia through a visible opening at the mesenteric defect Results Pooled sensitivity of CT was 82% and specificity was 85% Positive predictive value of CT was 83% and negative predictive value was 86% CT signs with the highest sensitivity (sensitivity of finding)  Venous congestion (79%) Swirl sign (78%)  Mesenteric edema (67%) 15% risk of an internal hernia even with a negative CT scan In conclusion, CT can provide useful information, but these are just additional data points to consider in the overall evaluation of a patient. Surgeons should still have a low threshold for diagnostic laparoscopy even with negative CT findings If you liked this episode, check out other bariatric episodes here: https://behindtheknife.org/podcast-category/bariatric/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

This week we sat down with the Association of Out Surgeons & Allies (AOSA) leadership in the first installment of a BTK/AOSA collaboration addressing issues important to LGBTQ+ surgeons, patients, and allies. We are joined by Guest Host Dr. Andrew Schlussel, BTK Members Drs. Nina Clark and Jason Bingham, and AOSA Leaders Drs. Nicole Goulet, Alexis Moren, and Courtney Collins. More information about AOSA and how to get involved can be found at https://www.outsurgeons.org. 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://behindtheknife.org/listen/

Join the Behind the Knife Surgical Oncology Team as we discuss the presentation, work-up, and management of gastrointestinal stromal tumors (GISTs)! 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 Daniel Nelson, DO, FACS (@usarmydoc24) is Surgical Oncologist and current HPB fellow at MD Anderson 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 gastrointestinal stromal tumors (GISTs), how to evaluate patients with presenting mass consistent with GIST, initial work-up, staging, and management.  We discuss key concepts including the genetic background of these tumors and high-yield targeted therapies that are relevant both in direct patient care and board exams. Reference: Gold JS, Gönen M, Gutiérrez A, Broto JM, García-del-Muro X, Smyrk TC, Maki RG, Singer S, Brennan MF, Antonescu CR, Donohue JH, DeMatteo RP. Development and validation of a prognostic nomogram for recurrence-free survival after complete surgical resection of localised primary gastrointestinal stromal tumour: a retrospective analysis. Lancet Oncol. 2009 Nov;10(11):1045-52. doi: 10.1016/S1470-2045(09)70242-6. Epub 2009 Sep 28. PMID: 19793678; PMCID: PMC3175638. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our surgical oncology oral board exam review here: https://behindtheknife.org/premium/

How do you counsel the patient with a large painful hernia who still smokes a pack of cigarettes every day? Join Drs. Michael Rosen, Clayton Petro, Sara Maskal, and Ryan Ellis as they discuss some of the highlights in the literature on smoking and its impact on postoperative outcomes in elective, clean open ventral hernia repairs.  Hosts:  - Michael Rosen, Cleveland Clinic - Clayton Petro, Cleveland Clinic - Sara Maskal, Cleveland Clinic - Ryan Ellis, Cleveland Clinic, @ryanellismd Learning objectives:  - Evaluate historical data on smoking in surgery - Compare with newer literature specific to contemporary ventral hernia repairs - Understand how the historical and new data can be applied in clinical practice References:  Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7. doi: 10.1016/S0140-6736(02)07369-5. PMID: 11809253. Kubasiak JC, Landin M, Schimpke S, Poirier J, Myers JA, Millikan KW, Luu MB. The effect of tobacco use on outcomes of laparoscopic and open ventral hernia repairs: a review of the NSQIP dataset. Surgical Endoscopy. 2017 Jun;31:2661-6. DeLancey JO, Blay Jr E, Hewitt DB, Engelhardt K, Bilimoria KY, Holl JL, Odell DD, Yang AD, Stulberg JJ. The effect of smoking on 30-day outcomes in elective hernia repair. The American Journal of Surgery. 2018 Sep 1;216(3):471-4. Sørensen LT. Wound healing and infection in surgery: the clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Archives of surgery. 2012 Apr 1;147(4):373-83. Petro CC, Haskins IN, Tastaldi L, Tu C, Krpata DM, Rosen MJ, Prabhu AS. Does active smoking really matter before ventral hernia repair? An AHSQC analysis. Surgery. 2019 Feb;165(2):406-411. doi: 10.1016/j.surg.2018.07.039. Epub 2018 Sep 13. PMID: 30220485. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out more hernia episodes here: https://behindtheknife.org/podcast-category/hernia/

Dr. Katie O’Connell, surgeon specialized in surgical palliative care, discusses the challenges of offering surgery as the right treatment. Learn about recognizing when surgery is not beneficial, communicating serious news to patients, integrating palliative care into surgical practices, limitations of surgery in end-of-life situations, communicating with patients about surgery and alternative treatment options, describing comfort-focused treatments, and the challenges of surgical palliative care.

While on your burn rotation, the emergency department calls due to a patient who may have been injured at his job site, coming in contact with a high-voltage line. Join Drs. Tam Pham, Clifford Sheckter, Alex Morzycki and Jamie Oh as they discuss the work-up, management, resuscitation, and subsequent complications and reconstruction for electrical injuries.  Hosts: - Dr. Tam Pham: UW Medicine Regional Burn Center - Dr. Clifford Sheckter: Stanford Medicine, Santa Clara Valley Medical Center - Dr. Alex Morzycki: UW Medicine Regional Burn Center - Dr. Jamie Oh: UW Medicine Regional Burn Center Learning Objectives: - Review the epidemiology and common mechanisms for electrical injuries  - Understand the impact of electrical injuries on different organ systems, including skin, musculoskeletal, cardiac, neurologic, and renal systems - Be able to guide initial work-up and resuscitation of acute electrical injuries including upper extremity compartment evaluation and release - Recognize possible long-term complications of electrical injuries and their subsequent management References: 1.     Daskal Y, Beicker A, Dudkiewicz M, Kessel B. [HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]. Harefuah. 2019 Jan;158(1):65-69. Hebrew. PMID: 30663297. 2.     Pawlik AM, Lampart A, Stephan FP, Bingisser R, Ummenhofer W, Nickel CH. Outcomes of electrical injuries in the emergency department: a 10-year retrospective study. Eur J Emerg Med. 2016 Dec;23(6):448-454. doi: 10.1097/MEJ.0000000000000283. PMID: 25969345. 3.     Davis C, Engeln A, Johnson EL, McIntosh SE, Zafren K, Islas AA, McStay C, Smith WR, Cushing T; Wilderness Medical Society. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S86-95. doi: 10.1016/j.wem.2014.08.011. PMID: 25498265. 4.     Zemaitis MR, Foris LA, Lopez RA, et al. Electrical Injuries. [Updated 2023 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448087/ 5.     Leversedge F, Moore T, Peterson B, Seiler J; Compartment syndrome of the upper extremity. J Hand Surg. 2011; 36(4):P544-559. doi: https://doi.org/10.1016/j.jhsa.2010.12.008 6.     Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res 2006, 27(4): 439-47  7.     Pilecky D, Vamos M, Bogyi P, et al. Risk of cardiac arrhythmias after electrical accident: a single-center study of 480 patients. Clin Res Cardiol 2019, 108(8): 901-908 8.     Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010, 81(10): 1400-33 9.     Kaergaard A, Nielsen KJ, Casrtensen O, Biering K. Electrical injury and the long-term risk of cataract: A prospective matched cohort study. Acta Ophthalmologica 2023, e88-e94 10.  Richard F. Edlich, MD, PhD and others, TECHNICAL CONSIDERATIONS FOR FASCIOTOMIES IN HIGH VOLTAGE ELECTRICAL INJURIES, The Journal of Burn Care & Rehabilitation, Volume 1, Issue 2, November-December 1980, Pages 22–26. 11.  Lee DH, Desai MJ, Gauger EM. Electrical injuries of the hand and upper extremity. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019 Jan 1;27(1):e1-8. 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://behindtheknife.org/listen/

While on your burn rotation, the emergency department calls due to a patient who may have been injured at his job site, coming in contact with a high-voltage line. Join Drs. Tam Pham, Clifford Sheckter, Alex Morzycki and Jamie Oh as they discuss the work-up, management, resuscitation, and subsequent complications and reconstruction for electrical injuries.  Hosts: - Dr. Tam Pham: UW Medicine Regional Burn Center - Dr. Clifford Sheckter: Stanford Medicine, Santa Clara Valley Medical Center - Dr. Alex Morzycki: UW Medicine Regional Burn Center - Dr. Jamie Oh: UW Medicine Regional Burn Center Learning Objectives: - Review the epidemiology and common mechanisms for electrical injuries  - Understand the impact of electrical injuries on different organ systems, including skin, musculoskeletal, cardiac, neurologic, and renal systems - Be able to guide initial work-up and resuscitation of acute electrical injuries including upper extremity compartment evaluation and release - Recognize possible long-term complications of electrical injuries and their subsequent management References: 1.     Daskal Y, Beicker A, Dudkiewicz M, Kessel B. [HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]. Harefuah. 2019 Jan;158(1):65-69. Hebrew. PMID: 30663297. 2.     Pawlik AM, Lampart A, Stephan FP, Bingisser R, Ummenhofer W, Nickel CH. Outcomes of electrical injuries in the emergency department: a 10-year retrospective study. Eur J Emerg Med. 2016 Dec;23(6):448-454. doi: 10.1097/MEJ.0000000000000283. PMID: 25969345. 3.     Davis C, Engeln A, Johnson EL, McIntosh SE, Zafren K, Islas AA, McStay C, Smith WR, Cushing T; Wilderness Medical Society. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S86-95. doi: 10.1016/j.wem.2014.08.011. PMID: 25498265. 4.     Zemaitis MR, Foris LA, Lopez RA, et al. Electrical Injuries. [Updated 2023 Apr 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448087/ 5.     Leversedge F, Moore T, Peterson B, Seiler J; Compartment syndrome of the upper extremity. J Hand Surg. 2011; 36(4):P544-559. doi: https://doi.org/10.1016/j.jhsa.2010.12.008 6.     Arnoldo B, Klein M, Gibran NS. Practice guidelines for the management of electrical injuries. J Burn Care Res 2006, 27(4): 439-47  7.     Pilecky D, Vamos M, Bogyi P, et al. Risk of cardiac arrhythmias after electrical accident: a single-center study of 480 patients. Clin Res Cardiol 2019, 108(8): 901-908 8.     Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010, 81(10): 1400-33 9.     Kaergaard A, Nielsen KJ, Casrtensen O, Biering K. Electrical injury and the long-term risk of cataract: A prospective matched cohort study. Acta Ophthalmologica 2023, e88-e94 10.  Richard F. Edlich, MD, PhD and others, TECHNICAL CONSIDERATIONS FOR FASCIOTOMIES IN HIGH VOLTAGE ELECTRICAL INJURIES, The Journal of Burn Care & Rehabilitation, Volume 1, Issue 2, November-December 1980, Pages 22–26. 11.  Lee DH, Desai MJ, Gauger EM. Electrical injuries of the hand and upper extremity. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019 Jan 1;27(1):e1-8. 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://behindtheknife.org/listen/