Clinical Challenges in Bariatric Surgery: Postoperative Leak

The pancreatic anastomosis is often regarded as the “Achilles Heel” of the Whipple operation, as technical failure and leakage is a significant source of perioperative morbidity and mortality. In this episode from the HPB team at Behind the Knife listen in as we discuss the standard techniques for the anastomosis, alternative techniques for the pancreatic anastomosis in patients with aberrant anatomy and/or physiology, key factors to consider when selecting the ideal approach/technique for the anastomosis, and mitigation strategies for leaks.  Hosts Anish J. Jain MD (@anishjayjain) is a current PGY3 General Surgery Resident at Stanford University and a former T32 Research Fellow at the University of Texas MD Anderson Cancer Center. Jon M. Harrison is a 2nd year HPB Surgery Fellow at Stanford University. He previously completed his general surgery residency at Massachusetts General Hospital, and will be returning to MGH as faculty at the conclusion of his fellowship.    Monica M. Dua (@MonicaDuaMD) is a Clinical Professor of Surgery and the Associate Program Director of the HPB Surgery Fellowship at Stanford University. She also serves as also serves as the regional HPB Surgeon at the VA Palo Alto Health Care System. Learning Objectives · Develop an understanding of the standard technical approaches to the pancreatic anastomosis during a Whipple (pancreatoduodenectomy) operation · Develop an understanding of the alternative technical approaches to the pancreatic anastomosis during the Whipple when the standard approaches may not be feasible · Develop an understanding of the key anatomic and physiologic factors in the decision making when selecting the optimal approach for the pancreatic anastomosis · Develop an understanding of possible mitigation strategies in the event of a pancreatic anastomotic leak. Suggested Reading Jon Harrison, Monica M. Dua, William V. Kastrinakis, Peter J. Fagenholz, Carlos Fernandez-del Castillo, Keith D. Lillemoe, George A. Poultsides, Brendan C. Visser, Motaz Qadan. “Duct tape:” Management strategies for the pancreatic anastomosis during pancreatoduodenectomy. Surgery. Volume 176, Issue 4, 2024, Pages 1308-1311, https://pubmed.ncbi.nlm.nih.gov/38796390/ 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

We’re excited to bring you the second episode in our BTK/ASGBI collaborative series, where we compare and contrast various aspects of surgery in the US and the UK, debating who does it better. In today’s episode, BTK fellow Jon Williams and ASGBI hosts Kellie Bateman and Jared Wohlgemut welcome the Christian Macutkiewicz from the UK and Scott Steele to discuss surgeon careers--from getting your first faculty job to broadening your impact to compensation structures.  Dr. Macutkiewicz is the President-Elect of the Association of Surgeons of Great Britain and Ireland. He is a General and HPB Surgeon in Manchester, England. He completed a Bachelor of Science in Biochemistry at the University of Birmingham, before studying medicine at the University of Manchester, and received an MD doctorate at the University of Manchester for research into sepsis. He underwent surgical training in North West Deanery, before completing an HPB and Liver Transplant Fellowship in Leeds. He has been a consultant surgeon in Nottingham, Leeds and most recently in Manchester since 2018. He also works privately at Spire Manchester Hospital.  Dr. Steele needs no introduction as a founder of BTK, but otherwise he is president of the Cleveland Clinic main campus and chair of the department of colorectal surgery. After graduating from West Point, Dr. Steele received his medical degree from University of Wisconsin. He then underwent general surgery residency training at Madigan Army Medical Center in Tacoma, WA followed by colorectal surgery fellowship training at University of Minnesota Medical Center. Dr. Steele then served in the military as an active duty surgeon until 2015, including several deployments and further faculty time at Madigan where he additionally served as Associate Program Director for general surgery. He then served as Division Chief of colorectal surgery at University Hospitals in Cleveland and associate director of surgical services at the Digestive Health Institute, prior to being named Chair of the department of colorectal surgery at the Cleveland Clinic in 2016, a position that he continues to hold today.  So, which country would you rather work in to carry out your illustrious surgical career? Give this episode a listen and decide for yourself! 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

The dreaded esophageal injury.  Do you still have nightmares about mock oral board scenarios torturing you with the ins and outs of how to manage traumatic esophageal injury?  Think you remember all the nuances?  Whether you do or you don’t, this episode should serve as a good refresher for all levels while offering some pearls for management of this tricky scenario. Hosts: - Michael Cobler-Lichter, MD, PGY4/R2: University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @mdcobler (X/twitter) - Dylan Tanzer, MD, 2nd-year Trauma/Surgical Critical Care Fellow University of Miami/Jackson Memorial Hospital/Ryder Trauma Center - 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 - Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery, 5 years in practice University of Miami/Jackson Memorial Hospital/Ryder Trauma Center @jpmeizoso (twitter) Learning Objectives: - Describe the diagnostic workup of a suspected traumatic esophageal injury - Identify when someone with suspected esophageal injury needs immediate surgical management - Describe appropriate surgical techniques for repair of both cervical and thoracic esophageal injuries Quick Hits: 1.     Don’t forget the primary survey.  Unstable patients should be in the OR, as should patients with hard signs of vascular or aerodigestive injury 2.     If there is concern for esophageal injury but no immediate indication for the OR, this should be further investigated with CTA of the affected area.  Clinical exam has poor sensitivity. 3.     The esophagus should be primarily repaired if the defect is able to come together without tension after debridement.  Don’t forget a well-vascularized buttress 4.     If you cannot perform a primary repair, your procedure of choice should be lateral esophagostomy with feeding jejunostomy and gastrostomy for decompression.  Repair over T-tube can be considered for injuries with small amounts of tissue loss References 1.     Biffl WL, Moore EE, Feliciano DV, Albrecht RA, Croce M, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Diagnosis and Management of Esophageal Injuries. J Trauma Acute Care Surg 2015;79(6):1089-95. https://pubmed.ncbi.nlm.nih.gov/26680145/ 2.     Sperry JL, Moore EE, Coimbra R, Croce M, Davis JW, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Penetrating Neck Trauma. J Trauma Acute Care Surg 2013;75(6):936-40. https://pubmed.ncbi.nlm.nih.gov/24256663/ 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

You have a patient with another episode of acute uncomplicated diverticulitis. This is the third episode. Do they need antibiotics? Is surgery the next step? What is their risk of recurrence with or without surgery? Tune in to find out! Join Drs. Peter Marcello, Jonathan Abelson, Tess Aulet and special guest Dr. Jason Hall MD, MPH as they discuss high yield papers discussing diverticulitis.  Learning Objectives: 1. Describe the impact on quality of life for patients who undergo surgery or non-operative management of diverticulitis 2. Discuss the indications for surgery in patients with diverticulitis 3. Describe ongoing clinical trials in management of diverticulitis  **Video Link: https://app.behindtheknife.org/video/journal-review-in-colorectal-surgery-diverticulitis References: Santos A, Mentula P, Pinta T, et al. Quality-of-Life and Recurrence Outcomes Following Laparoscopic Elective Sigmoid Resection vs Conservative Treatment Following Diverticulitis: Prespecified 2-Year Analysis of the LASER Randomized Clinical Trial. JAMA Surg. 2023;158(6):593–601. doi:10.1001/jamasurg.2023.0466 https://pubmed.ncbi.nlm.nih.gov/37074706/ Bolkenstein HE, Consten ECJ, van der Palen J, van de Wall BJM, Broeders IAMJ, Bemelman WA, Lange JF, Boermeester MA, Draaisma WA; Dutch Diverticular Disease (3D) Collaborative Study Group. Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial). Ann Surg. 2019 Apr;269(4):612-620. doi: 10.1097/SLA.0000000000003033. PMID: 30247329. https://pubmed.ncbi.nlm.nih.gov/30247329/ Hall J, Hardiman K, Lee S, Lightner A, Stocchi L, Paquette IM, Steele SR, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum. 2020 Jun;63(6):728-747. doi: 10.1097/DCR.0000000000001679. PMID: 32384404. https://pubmed.ncbi.nlm.nih.gov/32384404/ Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C, Marcello PW, Schoetz DJ. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum. 2011 Mar;54(3):283-8. doi: 10.1007/DCR.0b013e3182028576. PMID: 21304297. https://pubmed.ncbi.nlm.nih.gov/21304297/ 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

We are seeing a 42F in the emergency room who underwent a laparoscopic sleeve gastrectomy 11 days ago. The operation was uneventful, and she had a negative airleak test. She had an uneventful postoperative course and was discharged on POD 1.   Her medical history is significant for hypertension and hyperlipidemia, and he has no other surgical history. She has been able to keep up with her clear liquid diet. She complains that this morning she experienced abdominal and palpitations. You note her vitals show a mildly elevated blood pressure and her latest heart rate is 120s.  Join Drs. Matthew Martin, Adrian Dan, Crystall Johnson-Mann, and Paul Wisniowski on a discussion about initial evaluation and management of bariatric patients with internal hernias.  Show Hosts: Matthew Martin Adrian Dan Crystal Johnson-Mann Paul Wisniowski 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 episode, we have a discussion about the intersection of health design/architecture and surgery with Dr. Andrew Ibrahim, a trained architect and practicing general surgeon and health services researcher. We discuss how hospitals, ICUs, operating rooms, and trauma bays are designed and the evidence behind them.  Host: Cody Mullens, general surgery resident at the University of Michigan, current Behind the Knife Surgery Education Fellow. (@Cody_Mullens) Guest: Dr. Andrew Ibrahim. Associate Professor of Surgery at the University of Michigan, Maud T. Lane Research Professor, Co-Director for the Center for Healthcare Outcomes and Policy. (@AndrewMIbrahim) Guide to hospital design on Dr. Ibrahim’s website: https://www.surgeryredesign.com/resources Paper on measuring hospital design and quality of care using clinical data: https://shmpublications.onlinelibrary.wiley.com/doi/full/10.1002/jhm.12987 Science paper: https://www.science.org/doi/10.1126/science.6143402 CHEST paper: https://secure.jbs.elsevierhealth.com/action/getSharedSiteSession?redirect=https%3A%2F%2Fjournal.chestnet.org%2Farticle%2FS0012-3692%2810%2960225-5%2Ffulltext&rc=0 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 episode, Dr. Scott Butsch from the Cleveland Clinic’s Bariatric and Metabolic Institute discusses the evolving landscape of obesity medicine. He covers the history of obesity treatments, from behavioral interventions to groundbreaking medical therapies like GLP-1 receptor agonists and their future potential. The conversation also explores the challenges of bias, accessibility, and the integration of medications with surgical options for effective, long-term obesity management. 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, the fourth of 4 in our “What’s Your Worth” series, Matt and Mark discuss various compensation models including salary and hybrid models (e.g., productivity, quality-based, incentive-based) and fee-for-service.  In addition, other variables that can be included in your contract when comparing jobs are covered (time away, professional fees, benefits, vacation). Finally, our guests cover aspects to think about when the job is not working out and you may need to leave an organization.  Matthew J. Donnelly, Esq,, Executive Director, Professional Staff Affairs, Cleveland Clinic, Cleveland, OH.   https://my.clevelandclinic.org/about/overview/leadership/executive/donnelly-matt; Linkedin:  https://www.linkedin.com/in/matthew-j-donnelly/ Mark Elinsky, Director, Professional Staff Compensation and Analytics, Cleveland Clinic, Cleveland, OH 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

Behind the Knife es el podcast quirúrgico líder en el mundo y una plataforma de educación quirúrgica. Nuestra misión es crear contenido innovador de educación quirúrgica que sea accesible para todos. Estamos muy emocionados de expandirnos al público hispanohablante y ofrecerles 4 episodios de muestra de nuestro Curso de Repaso para el examen de certificación de Cirugía General. Hoy, escucharás un caso de muestra de este curso de repaso en audio, que incluye 100 escenarios. El curso tiene un formato emocionante y completamente único. Cada uno de los 100 caso consta de dos partes. La primera parte es un caso oral perfectamente ejecutado que imita la realidad. Cada caso tiene una duración de cinco a siete minutos e incluye una variedad de tácticas y estilos. Si logras alcanzar este nivel de desempeño en tu preparación, seguramente aprobarás el examen de certificación con éxito. La segunda parte introduce comentarios de alto rendimiento para cada escenario. Estos comentarios incluyen consejos y trucos para ayudarte a dominar los escenarios más desafiantes, además de una enseñanza práctica y fácil de entender que cubre los temas más confusos que enfrentamos como cirujanos generales. Estamos seguros de que encontrarás este enfoque único de doble formato como una forma altamente efectiva de prepararte para el examen. Nuestro contenido está disponible en nuestras aplicaciones para iOS y Android y en nuestro sitio web (behindtheknife.org). Por favor, consulta las notas del programa para más información. Nos encantaría escuchar tus comentarios sobre este episodio enviando un correo electrónico a [email protected] y apreciamos tu ayuda para difundir la palabra entre tus colegas si disfrutas del material. Si los comentarios son positivos, traduciremos todo nuestro curso al español. presentadores de podcast: - Auri P. Garcia Gonzalez, MD PhD nació en San Juan, Puerto Rico, y se trasladó a los Estados Unidos en el 2012 para sus estudios graduados. Actualmente, es estudiante de post-grado en cirugía general en Duke University. - Diego Schaps, MD, MPH es un residente de cirugía general en Duke y nació en Miami, en el estado de la Florida. Sus padres nacieron en El Salvador. Disclaimer: Los productos de contenido de Behind the Knife son únicamente para fines educativos. No diagnosticamos, tratamos ni ofrecemos consejos específicos para pacientes. ------ Behind the Knife is the world's leading surgical podcast and surgical education platform.  Our mission is to create innovative surgical education content that is accessible to all.  We are very excited to expand into the spanish audience and bring you 4 sample episodes of our General Surgery Oral Board Review Course which will be released over the course of the next week. Today, you'll hear a sample scenario from this comprehensive audio review course which includes 100 scenarios.  The course has an exciting and entirely unique format. Each of the 100 scenarios includes two parts. The first part is a perfectly executed oral board scenario that mimics the real thing. Scenarios are five to seven minutes long and include a variety of tactics and styles. If you're able to achieve this level of performance in your preparation, you are sure to pass the oral exam with flying colors. The second part introduces high yield commentary to each scenario. This commentary includes tips and tricks to help you dominate the most challenging scenarios in addition to practical, easy to understand teaching that covers the most confusing topics that we face as general surgeons. We are confident you will find this unique dual format approach a highly effective way to prepare for the test. Our content is available on our iOS and Android apps and website (behindtheknife.org).  Please check the show notes for more information. We would love to hear your feedback by emailing [email protected] and appreciate your help spreading the word to your colleagues if you enjoy the material.  If feedback is positive, we will translate our entire course to Spanish. Hosts: - Auri P. Garcia Gonzalez, MD PhD was born and raised in San Juan, Puerto Rico and moved to the US in 2012 for graduate studies. At present, she is a surgical resident at Duke University. - Diego Schaps, MD, MPH is a general surgery resident at Duke and was born in Miami, Florida. His parents were born in El Salvador. 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 the third episode in our 4 part “What’s Your Worth” series, Lauren covers the hospital-side of finances, going through the world of financial literacy.  In this episode, basic definitions and importance of income statements, metrics of financial performance, and others including revenue and expenses are reviewed. She also provides an inside view as to considerations that hospitals have to take into account for the overall financial portfolio and how that may play into determining salaries, wages, and benefits. Lauren Klein, MAcc, CPA, Executive Director, Financial Operations, Main Campus Submarket, Cleveland Clinic, Cleveland, OH.   Linkedin: https://www.linkedin.com/in/lauren-klein-cpa-67787213/ 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