Behind The Knife: The Surgery Podcast

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

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/2816986Link to ACHQC: https://achqc.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://app.behindtheknife.org/listen

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/ 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. 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 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

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, @ryanellismdLearning 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 operationsReferences: 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/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

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.  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

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 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

Your patient was in a terrible car crash and is currently intubated with multiple traumatic injuries that will need surgery. Family has just arrived and all they’ve heard is that he has a broken leg. How do you share this serious news with family? What do you do when they become angry, cry or bombard you with questions that you don’t have answers to? Join the surgical palliative care team from the University of Washington as we role play a difficult conversation with a standardized patient. We will identify common challenges that arise and discuss key skills to navigate these situations. Hosts:  Dr. Katie O’Connell (@katmo15) is an assistant professor of surgery at the University of Washington. She is a trauma surgeon, palliative care physician, director of surgical palliative care, and founder of the Advance Care Planning for Surgery clinic at Harborview Medical Center, Seattle, WA. Dr. Ali Haruta is a PGY7 current palliative care fellow at the University of Washington, formerly a UW general surgery resident and Parkland trauma/critical care fellow.  Dr. Lindsay Dickerson (@lindsdickerson1) is a PGY5 general surgery resident and current surgical oncology research fellow at the University of Washington. Dr. Virginia Wang is a PGY2 general surgery resident at the University of Washington. Learning Objectives: ·      Identify common pitfalls encountered during difficult conversations ·      Learn how to synthesize complex medical information and construct a succinct headline statement to deliver a digestible take-home message ·      Develop skills to respond to emotional cues using empathetic statements References: ·      “Responding to Emotion.” Vitaltalk. Accessed March 4, 2024. https://www.vitaltalk.org/guides/responding-to-emotion-respecting/ ·      “Serious News.” Vitaltalk. Accessed March 4, 2024. https://www.vitaltalk.org/guides/serious-news/ 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

Circulating tumor DNA, more commonly referred to as ctDNA, has emerged as an attractive and potentially highly sensitive biomarker for patients with colorectal cancer. But what exactly is ctDNA, does it have any prognostic value for patients with colorectal liver metastasis, and how can it be incorporated into the management of said patients? In this episode from the HPB team at Behind the Knife, listen in on the discussion about ctDNA and its role in the perioperative management of colorectal liver metastasis.   Hosts Anish J. Jain MD (@anishjayjain) is a T32 Research Fellow at the University of Texas MD Anderson Cancer Center within the Department of Surgical Oncology. Timothy E. Newhook MD, FACS (@timnewhook19) is an Assistant Professor within the Department of Surgical Oncology. He is also the associate program director of the HPB fellowship at the University of Texas MD Anderson Cancer Center.  Jean-Nicolas Vauthey MD, FACS (@VautheyMD) is Professor of Surgery and Chief of the HPB Section, as well as the Dallas/Fort Worth Living Legend Chair of Cancer Research in the Department of Surgical Oncology at The University of Texas MD Anderson Cancer Center Learning Objectives: -Develop an understanding of what circulating tumor DNA (ctDNA) is.  -Develop an understanding of what makes ctDNA unique from other “tumor markers” like CEA. -Develop an understanding of the prognostic value of ctDNA for colorectal liver metastasis (CRLM).  -Develop an understanding of the current role of ctDNA in the perioperative treatment of patients with CRLM. -Develop an understanding of how ctDNA can be incorporated into future treatment algorithms for patients undergoing hepatic resection for CRLM. Papers Referenced (in the order they were mentioned in the episode): 1)    Newhook TE, Overman MJ, Chun YS, et al. Prospective Study of Perioperative Circulating Tumor DNA Dynamics in Patients Undergoing Hepatectomy for Colorectal Liver Metastases. Ann Surg. 2023;277(5):813-820. https://pubmed.ncbi.nlm.nih.gov/35797554/ 2)    Nishioka Y, Chun YS, Overman MJ, et al. Effect of Co-mutation of RAS and TP53 on Postoperative ctDNA Detection and Early Recurrence after Hepatectomy for Colorectal Liver Metastases. J Am Coll Surg. 2022;234(4):474-483. https://pubmed.ncbi.nlm.nih.gov/35290266/ 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

Taking a lactating patient the OR? Prescribing antibiotics? What about a CT scan with IV contrast? Pump and dump, right? WRONG. It's time to get educated! Today, we review the finer points of caring for our lactating patients.  In this episode Dr. Patrick Georgoff is joined by Dr. Austin Eckhoff, general surgery resident at Duke University, Dr. Annie Dotson, family medicine and breastfeeding medicine physician at Duke University, and Dr. Katrina Mitchell, breast surgeon at Ridley Tree Cancer Center in Santa Barbara, CA.  Resources:  https://www.bfmed.org/ https://www.e-lactancia.org/ https://physicianguidetobreastfeeding.org/ - -  TRASH THE PUMP & DUMP: https://physicianguidetobreastfeeding.org/trash-the-pump-and-dump/trash-pump-dump/ 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