Join the Behind the Knife Surgical Oncology Team as we discuss the presentation, work-up, and management of gastrointestinal stromal tumors (GISTs)!



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



Daniel Nelson, DO, FACS (@usarmydoc24) is Surgical Oncologist and current HPB fellow at MD Anderson



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 gastrointestinal stromal tumors (GISTs), how to evaluate patients with presenting mass consistent with GIST, initial work-up, staging, and management.  We discuss key concepts including the genetic background of these tumors and high-yield targeted therapies that are relevant both in direct patient care and board exams.



Reference:

Gold JS, Gönen M, Gutiérrez A, Broto JM, García-del-Muro X, Smyrk TC, Maki RG, Singer S, Brennan MF, Antonescu CR, Donohue JH, DeMatteo RP. Development and validation of a prognostic nomogram for recurrence-free survival after complete surgical resection of localised primary gastrointestinal stromal tumour: a retrospective analysis. Lancet Oncol. 2009 Nov;10(11):1045-52. doi: 10.1016/S1470-2045(09)70242-6. Epub 2009 Sep 28. PMID: 19793678; PMCID: PMC3175638. 



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Clinical Challenges in Surgical Oncology: Gastrointestinal Stromal Tumors (GISTs)

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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. 



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HuMaNiSm + Surgery # 1

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 



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Clinical Challenges in Burn Surgery: Burn Resuscitation - Getting Things Started

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.  



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Clinical Challenges in Surgical Palliative Care: Communication Skills for Difficult Conversations

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/



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Journal Review in Hepatobiliary Surgery: ctDNA & Colorectal Liver Metastasis

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


Clinical Challenges in Surgical Oncology: Gastrointestinal Stromal Tumors (GISTs)

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