IMPORTANCE Within medical specialties, surgical disciplines disproportionately and routinely demonstrate the greatest underrepresentation of women and individuals from racial/ethnic minority groups. Understanding the role that diversity plays in surgical resident training may identify strategies that foster resident resiliency, optimize surgical training, and improve patient outcomes. OBJECTIVE To examine the implication of gender and visible minority (VM [ie, nonaboriginal people who are not White individuals]) status for resiliency and training experiences of general surgery residents in Canada. DESIGN, SETTING, AND PARTICIPANTS In this survey study, a 129-item questionnaire was emailed from May 2018 to July 2018 to all residents enrolled in all Canadian general surgery training programs during the 2017-2018 training year. Survey responses were extracted and categorized into 5 major themes. The survey was designed by the Resident Committee and reviewed by the Governing Board of the Canadian Association of General Surgeons.French and English versions of the survey were created, distributed, and administered using Google Forms.MAIN OUTCOMES AND MEASURES Survey questions were formulated to characterize resident diversity and training experience. Self-perceptions of diversity, mentorship, and training experience were evaluated using a 5-point Likert scale (1 for strongly disagree, 2 for disagree, 3 for neither agree or disagree, 4 for agree, and 5 for strongly agree) and open-ended responses. The frequency of perceived unprofessional workplace encounters was evaluated using a 5-point scale (1 for daily, 2 for weekly, 3 for monthly, 4 for annually, and 5 for never). RESULTSOf the 510 general surgery residents invited, a total of 210 residents (40.5%) completed the survey. Most respondents were younger than 30 years (119 [56.7%]), were women (112 [53.3%]), reported English as their first language (133 [63.3%]), did not identify as a VM (147 [70.0%]), had no dependents (184 [87.6%]), and were Canadian medical graduates (178 [84.8%]). Women residents who identified as VM compared with male residents who did not identify as a VM were less likely to agree or strongly agree that they had a collegial relationship with staff, (21 [63.6%] vs 61 [89.7%]; P = .01), to feel like they fit in with their training programs (21 [63.6%] vs 56 [82.3%]; P = .003), and to feel valued at work (15 [45.4%] vs 47 [69.1%]; P = .03). Both female residents and female residents who identified as VM described significant concerns about receiving fewer training opportunities because of their gender vs their male peers (54 [48.2%] vs 3 [3.0%]; P < .001). Ninety-one of 112 female residents (81.2%) reported feeling that their medical expertise was dismissed because of their gender at least once annually, with 37 women (33.0%) experiencing dismissal of their expertise at least once every week (P < .001). In contrast, 98% of male residents reported never experiencing dismissal of their medical expertise because of their gender. Similarly, residents w...
Objective: The aim of this study was to determine whether negative pressure wound therapy (NPWT) applied to primarily closed incisions decreases surgical site infections (SSIs) following open abdominal surgery. Background: SSIs are a common cause of morbidity following open abdominal surgery. Prophylactic NPWT has shown promise for SSI reduction. However, the results of randomized controlled trials (RCTs) conducted among patients undergoing laparotomy have been inconsistent. Methods: We performed a meta-analysis of English language RCTs comparing the use of prophylactic NPWT to standard dressings on primarily closed laparotomy incisions following open abdominal surgery. Medline, EMBASE, Cochrane Library, and CINAHL databases were searched from inception to December 31st, 2018, for relevant studies. A random-effects model was used for statistical analysis. Results: Five RCTs totaling 792 patients were included in our meta-analysis after application of our exclusion and inclusion criteria. There was no significant difference in the risk of SSIs identified among those patients who had NPWT compared to standard dressings; relative risk (RR) 0.56 (95% confidence interval 0.30–1.03, P = 0.064). There was significant statistical heterogeneity across studies (I 2 = 67.4%; P = 0.015). Conclusion: The adoption of NPWT for routine SSI prophylaxis following laparotomy is currently not supported and should be used primarily in the context of a clinical trial.
In Reply We thank Wu et al for their interest in our study. 1 They raised an issue regarding potential bias when randomized clinical trials with large sample sizes are performed to prove the benefits of fluorescent lymphography in improving the number of harvested lymph nodes. Investigator blinding is possible for most studies of medical treatment; however, it is not always possible for surgical clinical trials. It is impossible to blind an investigator in studies of surgical procedures that should be performed by surgeons. The increase of retrieved lymph nodes due to overextended lymph node dissection beyond D1+ or D2 area may create a critical bias. (D1 dissection entails gastrectomy and the resection of perigastric lymph nodes; D2 dissection is a D1 plus all the nodes along the left gastric artery, common hepatic artery, celiac artery, and splenic artery; and D1+ dissection is midpoint between D1 and D2.) Moreover, less lymph node removal from the specimen without fluorescent lymphography might intentionally happen. To reduce this bias, it will be mandatory to apply standardization of extent of surgery with consensus among surgeons as well as standardization of the methods used for lymph node retrieval. If surgeons separate dissected tissue in vivo depending on each lymph node station during surgery, the number of the retrieved lymph nodes is assessed more accurately according to each lymph node station or the extent of lymphadenectomy. However, separating the specimen in vivo should be avoided because it violates basic oncologic principles. Instead, labeling with a surgical clip or other measures at the border of each lymph node station could be helpful.Adequate lymphadenectomy is important to provide proper treatment for patients with advanced gastric cancer. The results of upcoming studies will show whether the minimally invasive approach for advanced gastric cancer is inferior to open surgery. 2,3 If noninferiority or similarity on long-term survival is revealed by those studies, more diverse studies for advanced gastric cancer could be conducted. Although we only showed an increased number of harvested lymph nodes in this study, the ultimate goal of the study is the presentation of survival benefit beyond conventional laparoscopic or robotic gastrectomy with the addition of fluorescent lymphography.As Wu et al mentioned, fluorescent lymphography has an additional benefit of localizing tumors, which necessitates localization methods, such as intraoperative endoscopy. We agree that the fluorescent method is a more ideal method, which can avoid unnecessary damage and may reduce the total operation time compared with intraoperative endoscopy. However, there are groups that prefer to perform endoscopy during surgery. 4 Thus, endoscopy could be imple-mented several hours before or just before starting the operation. We need to determine the optimal timing of the injection with further studies.
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