Behind The Knife: The Surgery Podcast

Upon encountering a patient who develops an anastomotic leak after a straight-forward low anterior resection, you are taken aback, as the patient is healthy and has no apparent risk factors. This prompts you to consider whether the microbiota may have played a role in causing the leak. Join Dr. Carole Richard, Dr. François Dagbert, Dr. Maher Al Khaldi, and Dr. Roy Hajjar in their conversation about the impact of gut microbiota on anastomotic healing and leak.  Learning objectives  - To list the known risk factors for anastomotic leak. - To understand how preoperative gut microbiota influence anastomotic healing and could lead to leak.  Reference Hajjar R, Gonzalez E, Fragoso G, et al. Gut microbiota influence anastomotic healing in colorectal cancer surgery through modulation of mucosal proinflammatory cytokines. Gut. Published Online First: 30 December 2022. doi: 10.1136/gutjnl-2022-328389 Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed robotic general surgery procedures. If you are a general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs,  reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com for more information on how you could be compensated $500 per video submitted of each (up to $1000 per surgeon). Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other colorectal surgery episodes here: https://behindtheknife.org/podcast-category/colorectal/

Dr. Cunningham is the section head of the Massachusetts General Hospital Endocrine Surgery unit, a NIH-funded researcher, and the immediate past-president of the Association for Academic Surgery. This episode is a recording of her presidential address at their annual Academic Surgical Congress.  Guest Dr. Carrie Cunningham, MD, MPH Associate Professor of Surgery, Harvard Medical School Learn More Association for Academic Surgery: https://www.aasurg.org/ Dr. Lorna Breen Heroes foundation: https://drlornabreen.org/  Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

While you are likely aware of BRCA mutations as a significant risk factor for development of breast cancer (60-80% lifetime risk), there are many other pathogenic gene variants that have been identified in recent years. The surgical treatment of women with hereditary breast cancer differs from that of women with sporadic breast cancer, and women with hereditary breast cancer are also eligible for prophylactic mastectomy or intensive surveillance protocols. In this episode of BTK, we examine current national consensus guidelines for management of hereditary breast cancer, discuss a recent population-based study that establishes risk associated with various genes, and address both surgical and surveillance strategy for patients without breast cancer but with known pathogenic gene variants. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other breast surgery episodes here: https://behindtheknife.org/podcast-category/breast/

Calling all surgeons! It’s time to take back common bile duct stones! Join our surgical education fellow, Shanaz Hossain, as she talks about laparoscopic common bile duct exploration (LCBDE) with Drs. Maggie Bosley, Lucas Neff, and Byron Fernando Santos. Dr. Bosley is a graduating chief resident at Wake Forest and incoming MIS fellow at Washington University in St. Louis. Dr. Neff is an assistant professor of pediatric surgery with Wake Forest Baptist Health and Brenner’s Children’s Hospital. Dr. Santos is an assistant professor of surgery at Dartmouth-Hitchcock Medical Center. As a research resident at Northwestern University, he co-invented a LCBDE simulator that is used to train surgeons in these techniques. He is also a member of the SAGES Safe Cholecystectomy Task Force and has led numerous LCBDE courses.  Join us for a discussion on LCBDE indications, implementation, techniques, and tips for incorporation into patient care. If you’re interested in learning more, check out the instructional video from these surgeons as well as some of their work on LCBDE: Instructional Video: https://behindtheknife.org/video-playlists/laparoscopic-common-bile-duct-tutorial-series/ Research Articles ·      Anterograde Balloon Sphincteroplasty as an Adjunct to Laparoscopic Common Bile Duct Exploration for the Acute Care Surgery: https://journals.lww.com/jtrauma/Citation/2022/03000/Antegrade_balloon_sphincteroplasty_as_an_adjunct.22.aspx ·      Choledocholithiasis – A New Clinical Pathway: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343507/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more. 

Hernias are some of the most common problems treated by general surgeons. The field of abdominal wall surgery has rapidly evolved as a result of innovation and the development of new techniques. In this podcast, Drs. Charlotte Horne and Jenny Shao join Vahagn Nikolian to discuss their decision to pursue careers as abdominal wall specialists, the role that hernia surgeons play in modern day surgical programs, and the pathway to becoming a hernia surgeon.  ·       Dr. Charlotte Horne is an Assistant Professor of Surgery at Pennsylvania State University. ·       Dr. Jenny Shao is an Assistant Professor of Surgery at the University of Michigan. ·       Dr. Vahagn Nikolian is an Assistant Professor of Surgery at Oregon Health & Science University. Recommended Reading: Shulkin JM, Mellia JA, Patel V, Naga HI, Morris MP, Christopher A, Heniford BT, Fischer JP. Characterizing hernia centers in the United States: what defines a hernia center? Hernia. 2022 Feb;26(1):251-257. doi: 10.1007/s10029-021-02411-x. Epub 2021 Apr 19. PMID: 33871743. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012 Nov;204(5):709-16. doi: 10.1016/j.amjsurg.2012.02.008. Epub 2012 May 16. PMID: 22607741. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other Hernia episodes here: https://behindtheknife.org/podcast-category/hernia/

Eva Rechuga, a PGY4 general surgery resident, joins experts Yuri Niman, a trauma surgeon, and Rishi Rattan, a trauma attending, to tackle the complexities of renal trauma. They discuss key decision-making points, like when to take a patient to surgery versus adopting a non-operative approach. Emphasis is placed on the importance of hemodynamic stability and when to involve interventional radiology for drainage. They also debate the management of penetrating zone II injuries, offering valuable insights for trauma care.

Have a grand idea for how to improve education and patient safety in surgery, but unsure how to make it a reality? Perhaps the OR Black Box can inspire you and set you on your path as an innovator. We are joined by Dr. Teodor Grantcharov, one of its creators. The OR Black Box is a system that collects, stores, and analyzes a large amount of data from the operating room beyond just surgical video, such as video and audio of the operating room and patient physiology data. Using the system for feedback through self-directed review, coaching, and integrated AI analysis has changed the way we can learn and teach in surgery, and may have implications for the future of evaluation and credentialing.  Learning Objectives Listeners will describe the value that accessible data review and analysis adds to surgical education. Listeners will describe how review of operative data could be utilized for more objective evaluation and credentialing, and how this can be used for continuous improvement. Listers will recognize common barriers to using new technology or process changes in surgery. Listeners will recognize the importance of a well-developed research question and its application to a clinical need when designing research or innovation in surgery and education. Listeners will appreciate the long and iterative process required to go from a research idea to implementation and impact on clinical outcomes. Listeners will organize their own ideas for research utilizing the advice offered in the episode.  References: 1. Goldenberg MG, Jung J, Grantcharov TP. Using Data to Enhance Performance and Improve Quality and Safety in Surgery. JAMA Surg. 2017;152(10):972. doi:10.1001/jamasurg.2017.2888 2. van Dalen ASHM, van Haperen M, Swinkels JA, Grantcharov TP, Schijven MP. Development of a Model for Video-Assisted Postoperative Team Debriefing. J Surg Res. 2021;257:625-635. doi:10.1016/j.jss.2020.07.065 **Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other surgical education episodes here: https://behindtheknife.org/podcast-category/surgical-education/ 

Please join BTK's Dr. Nina Clark and Dr. Shreya Gupta for a discussion with Dr. Edward Barksdale on the important and sensitive topic of the underrepresented in medicine.   Society of Black Academic Surgeons: https://www.sbas.net/ References:  Yeo HL, Abelson JS, Symer MM, Mao J, Michelassi F, Bell R, Sedrakyan A, Sosa JA. Association of Time to Attrition in Surgical Residency With Individual Resident and Programmatic Factors. JAMA Surg. 2018 Jun 1;153(6):511-517. doi: 10.1001/jamasurg.2017.6202. PMID: 29466536; PMCID: PMC5875388. McFarling, U.L. ‘It was stolen from me’: Black doctors are forced out of training programs at far higher rates than white residents. STAT. 6/20/2022. Accessed online: 10/1/2022. https://www.statnews.com/2022/06/20/black-doctors-forced-out-of-training-programs-at-far-higher-rates-than-white-residents/ Haruno LS, Chen X, Metzger M, et al. Racial and Sex Disparities in Resident Attrition Among Surgical Subspecialties. JAMA Surg. Published online February 08, 2023. doi:10.1001/jamasurg.2022.7640 **Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other recent episodes here: https://behindtheknife.org/listen/

Please join Drs. Graham Skelhorne-Gross, Jordan Nantais and Ashlie Nadler from our Emergency General Surgery Team for a discussion on cirrhotic patients.   Child-Pugh Score (https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality) ·      Bilirubin, albumin, INR, ascites, encephalopathy ·      Used to predict operative mortality based on cirrhosis severity ·      Mortality in EGS: - Child-Pugh A: 10% electively and 22% emergently - Child-Pugh B: 30% electively and 38% emergently - Child-Pugh C: 80% electively and up to 100% emergently Model for End Stage Liver Disease (MELD) (https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld?utm_source=site&utm_medium=link&utm_campaign=meld_12_and_older) ·      creatinine, bilirubin, INR, and sodium ·      MELD < 20 – 1% increase in mortality with each point increase ·      MELD > 20 – 2% increase in mortality with each point increase Pre-operative Planning ·      Identification of cirrhosis with physical examination, bloodwork and imaging ·      Involvement of other medical services (internal medicine, hepatology, ICU) as needed ·      Cirrhosis optimization, if possible ·      Abdominal wall mapping Unexpected Intraoperative Finding Communicate unexpected findings to the operative team and think of additional adjuncts you may need such as additional ports, topical hemostatic agents or energy devices. Think about why you are in the OR. If its an elective situation and can wait, consider bailing. If its emergent, you may have to do something more definitive. Exposure may be a challenge, you may have to alter your typical approach including where the assistant grabs and retracts. Extra hands are helpful. Bleeding can be a big deal. If possible, map out the abdominal wall ahead of time with cross-sectional imaging. Stay away from varices around the umbilicus or porta Ventral Hernia + Cirrhosis ·      Ideally, control ascites pre-operatively, if you can’t consider leaving drains ·      Small (< 2cm) hernias close primarily ·      Larger (>2cm) hernias repair with mesh unless infected filed (controversial) ·      Minimally invasive repairs can be performed Benign Biliary Disease + Cirrhosis ·      Incidence of gallstones is 4-5 times higher in cirrhotic patients ·      Prophylactic laparoscopic cholecystectomy (LC) generally not done ·      LC generally considered acceptable in CP A or B but not C (exceptions: HD instability, gangrenous cholecystitis, hemorrhagic cholecystitis) ·      Cholecystostomy and ERCP are safe References:  Bleszynski, M. et. Al. Acute care and emergency general surgery in patients with chronic liver disease: how can be optimize perioperative care? A review of the literature. 2018. World Journal of Emergency Surgery; 13:32 Mansour A, Watson W, Shayani V, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997;122:730–5. Yeom SK, Lee CH, Cha SH, Park CM. Prediction of liver cirrhosis, using diagnostic imaging tools. World J Hepatol. 2015 Aug 18;7(17):2069-79. doi: 10.4254/wjh.v7.i17.2069. PMID: 26301049; PMCID: PMC4539400. Jain D, Mahmood E, V-Bandres M, Feyssa E. Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery. Ann Gastroenterol. 2018 May-Jun;31(3):330-337. doi: 10.20524/aog.2018.0249. Epub 2018 Mar 15. PMID: 29720858; PMCID: PMC5924855. **Fellowship application link: https://forms.gle/PiKM2MMQpE5jSAeW7 Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other Emergency General Surgery episode here: https://behindtheknife.org/podcast-category/emergency-general-surgery/

In this episode, our team discusses the Checkmate 577 trial, the landmark paper which approved the use of nivolumab for adjuvant treatment of stage II & III esophageal & GE junction cancer. Listen as our team reviews the study population, methods and results of this trial & discusses its clinical application as well as potential areas of future research. Learning Objectives: -Review the staging and treatment of esophageal and GEJ cancer -Discuss the population, methods, and results of the Checkmate 577 trial -Understand the mechanism of action of nivolumab and the PD1 pathway -Discuss the implications of the Checkmate 577 trial in clinical practice and areas of future research Hosts: Kelly Daus MD, Megan Lenihan MD, Peter White MD, and Brian Louie MD Referenced Material https://www.nejm.org/doi/full/10.1056/NEJMoa2032125 Kelly RJ, Ajani JA, Kuzdzal J, et al. Adjuvant nivolumab in resected esophageal or gastroesophageal junction cancer. N Engl J Med. 2021;384(13):1191-1203. doi:10.1056/NEJMoa2032125 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136921/ Han Y, Liu D, Li L. PD-1/PD-L1 pathway: current researches in cancer. Am J Cancer Res. 2020 Mar 1;10(3):727-742. PMID: 32266087; PMCID: PMC7136921. Ad referenced in episode: A team at the Brooke Army Medical Center is working to better define proficiency-based metrics for competency in commonly performed robotic general surgery procedures. If you are a general surgery resident or practicing surgeon who performs robotic assisted cholecystectomies or inguinal hernia repairs,  reach out to the PI, Robert Laverty, MD, at rblaverty@gmail.com for more information on how you could be compensated $500 per video submitted of each (up to $1000 per surgeon). Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other thoracic surgery episodes here https://behindtheknife.org/podcast-category/cardiothoracic/