Cardiac arrhythmias such as atrial fibrillation are common in any ICU. But, adequately addressing additional perioperative considerations is key in the surgical ICU. In this Critical Care episode of Behind the Knife, Drs. Bankhead, Dumas, & Park will address how to approach a critically ill patient who presents with an arrythmia. Hemodynamically stable vs. unstable patients are discussed, as well as the current ACLS guidelines for management of a patient in cardiac arrest.  Referenced Articles and Guidelines: 1. Van Gelder I, Groenveld H, Crijns H, et al. Lenient versus Strict Rate Control in Patients with Atrial Fibrillation. NEJM 2010.  2. Walkey A, Hogarth K, Lip G. Optimizing Atrial Fibrillation Management: From ICU and Beyond. CHEST 2015.  3. AFFIRM Investigators. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. NEJM 2002.  4. ACLS Training Center: Tachycardia with a Pulse Algorithm. https://www.acls.net/acls-tachycardia-algorithm 5. ACLS Training Center: Cardiac Arrest Algorithm. https://www.acls.net/acls-secondary-survey 6. ACLS Training Center: Acute Coronary Syndromes Algorithm. https://www.acls.net/acute-coronary-syndromes-algorithm Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

November is Lung Cancer Awareness Month, and what better way is there to spend your time than getting to know the recent advances in adjuvant therapy for early-stage lung adenocarcinoma?  Learning Objectives -        Review work-up and treatment of lung adenocarcinoma -        Review evidence behind Osimertinib as an adjuvant therapy in EGFR mutation positive disease -        Review recent advances in gene expression profiles for targeted application of adjuvant chemotherapy -        Discuss future directions for research -        Discuss additional advancements in diagnosis, monitoring, and immunotherapy Referenced Material -        Wu Y, Tsuboi M, He J, et al. Osimertinib in resected EGFR-mutated non-small-cell lung cancer. N Engl J Med 2020; 383:1711-1723. DOI: 10.1056/NEJMoa2027071  https://www.nejm.org/doi/full/10.1056/NEJMoa2027071 -        Woodard GA, Wang SX, Kratz JR, et al. Adjuvant Chemotherapy Guided by Molecular Profiling and Improved Outcomes in Early Stage, Non-Small-Cell Lung Cancer. Clin Lung Cancer 2018;19(1):58-64. DOI: 10.1016/j.cllc.2017.05.015 https://www.clinical-lung-cancer.com/article/S1525-7304(17)30150-X/fulltext -        Woodard GA, Kratz JR, Haro G, et al. Molecular Risk Stratification is Independent of EGFR Mutation Status in Identifying Early-Stage Non-Squamous Non-Small Cell Lung Cancer Patients at Risk for Recurrence and Likely to Benefit From Adjuvant Chemotherapy. Clin Lung Cancer. 2021;20:S1525-7304(21)00212-6. DOI: 10.1016/j.cllc.2021.08.008 https://www.clinical-lung-cancer.com/article/S1525-7304(21)00212-6/fulltext Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Join Behind the Knife's very own Dr. Scott Steele, Chairman of the Department of Colorectal Surgery at Cleveland Clinic, for a high-level talk on the treatment of T2N0 rectal cancer.  There is an associated video that goes along with this episode.  Check it out at behindtheknife.org or YouTube. Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Drs. Nadler, Nantais, and Skelhorne-Gross tackle Cancer Emergencies, emphasizing multidisciplinary care, surgical options, and informed consent. They discuss the challenges and controversies in managing colorectal malignancy emergencies, emphasizing the importance of quality of life in treatment decisions. The podcast explores the complexities of offering surgery to patients with gynecological cancers and carcinomatosis, highlighting the need for thorough evaluation and consideration of potential complications.

In this episode from the Endocrine Surgery team at BTK we discuss the clinical applications of genetic testing for thyroid cancer. We walk through three cases of thyroid nodules and discuss why and how genetic testing can guide surgical and medical management. As usual we review key points such as imaging criteria for thyroid nodules, the Bethesda system for thyroid cytopathology, and MEN syndromes. We also go into a more nuanced discussion of how progress in genetic testing has led to more variability in management options.               Dr. Michael Yeh is a Professor of Surgery at UCLA and serves as Section Chief of the UCLA Endocrine Surgery program which he established.  Dr. Masha Livhits is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department  Dr. James Wu is an Assistant Professor of Surgery at UCLA and works in the Endocrine Surgery Department  Dr. Rivfka Shenoy is a PGY-5 General Surgery Resident at UCLA who has completed two years of research  Dr. Vivek Sant is an Endocrine Surgery Fellow at UCLA in his first year of fellowship Important Papers  Catherine Y Zhu, Ines Donangelo, Deepashree Gupta, Dalena T Nguyen, Joana E Ochoa, Michael W Yeh, Masha J Livhits, Outcomes of Indeterminate Thyroid Nodules Managed Nonoperatively after Molecular Testing, The Journal of Clinical Endocrinology & Metabolism, Volume 106, Issue 3, March 2021, Pages e1240–e1247, https://doi.org/10.1210/clinem/dgaa887 Xing, Mingzhao & Alzahrani, Ali & Carson, Kathryn & Viola, David & Elisei, Rossella & Bendlova, Bela & Yip, Linwah & Mian, Caterina & Vianello, Federica & Tuttle, R & Robenshtok, Eyal & Fagin, James & Puxeddu, Efisio & Fugazzola, Laura & Czarniecka, Agnieszka & Jarząb, Barbara & O'Neill, Christine & Sywak, Mark & Lam, Alfred & Sykorova, Vlasta. (2013). Association Between BRAF V600E Mutation and Mortality in Patients With Papillary Thyroid Cancer. JAMA : the journal of the American Medical Association. 309. 1493-501. 10.1001/jama.2013.3190. Wells SA Jr, Asa SL, Dralle H, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid. 2015;25(6):567-610. doi:10.1089/thy.2014.0335 Wang JR, Zafereo ME, Dadu R, Ferrarotto R, Busaidy NL, Lu C, Ahmed S, Gule-Monroe MK, Williams MD, Sturgis EM, Goepfert RP, Gross ND, Lai SY, Gunn GB, Phan J, Rosenthal DI, Fuller CD, Morrison WH, Iyer P, Cabanillas ME. Complete Surgical Resection Following Neoadjuvant Dabrafenib Plus Trametinib in BRAFV600E-Mutated Anaplastic Thyroid Carcinoma. Thyroid. 2019 Aug;29(8):1036-1043. doi: 10.1089/thy.2019.0133. PMID: 31319771; PMCID: PMC6707029. Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Adjuvant?  Neoadjuvant?  Short course?  Long course?  The treatment of rectal cancer treatment has come a long way.  Tune in to learn more about Total Neoadjuvant Therapy (TNT) and the mysterious HOLY PLANE. Learning Objectives: 1.    Describe the rationale for Total Neoadjuvant Therapy (TNT) for rectal cancer 2.    Review the history of chemo and radiation therapy in treatment of rectal cancer 3.    Describe total mesorectal excision  References Bahadoer RR, Dijkstra EA, van Etten B et al. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial. Lancet Oncol. 2021 Jan;22(1):29-42. doi: 10.1016/S1470-2045(20)30555-6. Epub 2020 Dec 7 https://doi.org/10.1016/S1470-2045(20)30555-6 Fokas E, Allgäuer M, Polat B et al. Randomized Phase II Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy for Locally Advanced Rectal Cancer: CAO/ARO/AIO-12. J Clin Oncol. 2019 Dec 1;37(34):3212-3222. doi: 10.1200/JCO.19.00308 https://ascopubs.org/doi/10.1200/JCO.19.00308 Colorectal Surgery 2021-2022 Virtual Education Series Follow us on Twitter @CRSVirtualEd Email us: colorectal.educational.series@gmail.com www.crsvirtualed.org Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

The American Board of Surgery has a new family leave policy for surgery trainees: https://www.absurgery.org/default.jsp?policygsleave.  What's new?  Is it enough?  And what does competency-based training have to do with it?  Join Drs. Patrick Georgoff and Shanaz Hossain as they discuss the details with ABS president Dr. Jo Buyske.  Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Tick tock tick tock, 5 min is up! There is a plus sign on the testing stick. And you are…. Pregnant! Congratulations??? Join Drs. Erika Rangel, Eugene Kim, Yue-yung Hu, and Debbie Li as they discuss the challenges surgeons and trainees face as they navigate through pregnancy and parenthood.  Learning objectives: In this episode, we learn about the personal experiences including the good, the bad, and the ugly behind pregnancy and parenthood. We discuss about the stigma faced and experienced by many surgeons and trainees, and most importantly, ways we can support our current and future trainees to navigate this deeply personal and should be celebrated occasion in their life.  References Incidence of Infertility and Pregnancy Complications in US Female Surgeons https://doi.org/10.1001/jamasurg.2021.3301 Pregnancy and Motherhood During Surgical Training - https://doi.org/10.1001/jamasurg.2018.0153 Perspectives of US General Surgery Program Directors on Cultural and Fiscal Barriers to Maternity Leave and Postpartum Support During Surgical Training - https://doi.org/10.1001/jamasurg.2021.1807 Factors Associated With Residency and Career Dissatisfaction in Childbearing Surgical Residents - https://doi.org/10.1001/jamasurg.2018.2571 Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

Post-operative pain is a challenging topic most surgeons would prefer not to have to think about, and post-inguinal hernia repair pain can be a particular pain in the…groin. Drs. Mike Weykamp, Andrew Wright, and Nick Cetrulo from the University of Washington provide a framework for approaching these challenging patients to help clarify when and how to best evaluate post-inguinal hernia repair pain and identify the patients who might benefit from surgical intervention. Referenced Articles and Videos:  1.     D Chen. Mapping for inguinal chronic pain: An approach that all surgeons can do. Your Session: Abdominal Wall Hernia - Provocative Questions in the Practice of Hernia Repair held during the 2017 SAGES Annual Meeting in Houston, TX https://www.youtube.com/watch?v=Yx5zSS3CA-U 2.     J Lange, R Kaufmann, A Wijsmuller, J Pierie, R Ploeg, P Amid. An international consensus algorithm for management of chronic postoperative inguinal pain. Hernia 2015.  https://pubmed.ncbi.nlm.nih.gov/25138620/ 3.     P Amid. Radiologic Images of Meshoma A New Phenomenon Causing Chronic Pain After Prosthetic Repair of Abdominal Wall Hernias. JAMA Surgery 2004. https://jamanetwork.com/journals/jamasurgery/fullarticle/397607 4.     McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev.  https://pubmed.ncbi.nlm.nih.gov/12535413/ 5.     Campanelli G, Pascual MH, Hoeferlin A, Rosenberg J, Champault G, Kingsnorth A, Miserez M. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg. 2012 https://pubmed.ncbi.nlm.nih.gov/22395092/ 6.     Jeroukhimov I, Wiser I, Karasic E, Nesterenko V, Poluksht N, Lavy R, Halevy A. Reduced postoperative chronic pain after tension-free inguinal hernia repair using absorbable sutures: a single-blind randomized clinical trial. J Am Coll Surg. 2014.  https://pubmed.ncbi.nlm.nih.gov/24210149/ 7.     Novik B, Nordin P, Skullman S, Dalenbäck J, Enochsson L. More Recurrences After Hernia Mesh Fixation With Short-term Absorbable Sutures: A Registry Study of 82 015 Lichtenstein Repairs. Arch Surg. 2011.  https://jamanetwork.com/journals/jamasurgery/fullarticle/406587 8.     Barazanchi AW, Fagan PV, Smith BB, Hill AG. Routine Neurectomy of Inguinal Nerves During Open Onlay Mesh Hernia Repair: A Meta-analysis of Randomized Trials. Ann Surg. 2016. https://pubmed.ncbi.nlm.nih.gov/26756767/ 9.     Bakker WJ, Aufenacker TJ, Boschman JS, Burgmans JPJ. Lightweight mesh is recommended in open inguinal (Lichtenstein) hernia repair: A systematic review and meta-analysis. Surgery. 2020. https://pubmed.ncbi.nlm.nih.gov/31672519/ Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

The CODA trial is back – this time to shed light on long-term outcomes for antibiotics versus surgery for appendicitis! Dr. David Flum, lead investigator of the CODA trial, and Dr. Lillian Kao join us today to discuss the results after at least 1 year of follow-up in their patients. Read the full update here in the New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMc2116018 Utilizing the CODA trial results, Dr. Flum has created an innovative online tool for physicians to use with patients when discussing treatment options for appendicitis. Check out this new resource and keep it in mind next time you wander down to the ED for another patient with appendicitis: www.appyornot.org Listen to our previous episodes on the CODA Trial: Episode #321 (October 5, 2020): CODA Trial Results – Antibiotics versus Surgery for Appendicitis  https://behindtheknife.org/podcast/coda-trial-results-antibiotics-versus-surgery-for-appendicitis/ o   Dr. Flum and his team discuss the 90-day outcomes for the CODA trial as antibiotic treatment gains favor in the setting of the COVID-19 pandemic.  Episode #109 (June 7, 2017): CODA Trial with Dr. David Flum  https://behindtheknife.org/podcast/109-coda-trial-with-dr-david-flum/ o   Dr. Flum introduces the CODA Trial and the basis of his “pragmatic trial”. Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.