Behind The Knife: The Surgery Podcast

Open the capsule, quit the cigarettes, and know when to cut: the essentials of managing marginal ulcers after bypass.

Marginal ulcers are among the most common complications after Roux-en-Y gastric bypass, with a pooled prevalence around 4.6%, and they span everything from mild postprandial pain to perforation with peritonitis. In this episode, our expert panel works through three clinical scenarios (an uncomplicated early ulcer, a refractory ulcer with recurrent stricture, and a perforated ulcer with peritonitis) to build a practical framework for prevention, workup, medical therapy, and surgical escalation.

Hosts

Learning objectives
1.     Identify the established and debated risk factors for marginal ulcers. Recognize smoking, diabetes, NSAIDs, and larger pouch size as key contributors. Appreciate that the role of H. pylori remains unsettled because of heavy heterogeneity across meta-analyses.

2.     Perform a complete etiologic workup for a new marginal ulcer. Assess NSAID and immunosuppressant use, smoking (including cotinine test), H. pylori status, and visible suture or staple material at the anastomosis, and know that endoscopy, not CT, is the diagnostic tool of choice unless perforation is suspected.

3.     Optimize first-line medical management. Use PPI therapy with instructions to open the capsules for faster healing, understand the limited evidence for adding sucralfate, confirm healing with repeat endoscopy, and individualize treatment duration, including when lifelong prophylaxis is reasonable.

4.     Define and evaluate the refractory ulcer. Apply the 6- to 12-month definition of refractory disease, rule out gastrogastric fistula, hypersecretory states (serum gastrin), and PPI rapid metabolism (CYP2C19), and recognize ulcer-related gastrojejunal stricture and the perforation risk of serial dilation.

5.     Weigh escalation options for refractory disease. Compare endoscopic suturing and stenting, truncal vagotomy, and GJ revision, including their mixed durability data, and address nutritional optimization and remnant access before reoperation.

6.     Manage a perforated marginal ulcer. Prioritize resuscitation, antibiotics, and IV PPI; take unstable patients straight to the OR, use primary repair with omental patch as the default approach, and reserve revision or damage control for select patients based on physiology, tissue quality, and expertise.

7.     Counsel patients on long-term recurrence risk. Communicate substantial recurrence rates after both repair and revision and emphasize that quitting smoking early (more than a year before surgery) meaningfully lowers reoperation risk.

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It’s 2 a.m. and a patient with a GSW to the thigh is rolling into the trauma bay. He’s hypotensive, tachycardic, and has a tourniquet in place. Do you get a CTA or go straight to the OR? What do you do with the tourniquet?

Join us as we work through this and two other cases of extremity vascular trauma and break down the literature to answer these questions and discuss how we should approach these challenging injuries.

Hosts:
·      Christian Hadeed - PGY 5 General Surgery, Brookdale Hospital Medical Center
·      Paul Haser -Division Chief, Vascular Surgery, Brookdale Hospital Medical Center
·      Andrew Harrington – Division Chief, Vascular surgery, Richmond University Medical Center
·      Lucio Flores - Vascular surgery, Brookdale Hospital Medical Center

Learning Objectives:
·      Apply the X-ABCDE approach to patients with extremity vascular trauma, including the role of early hemorrhage control and tourniquets.
·      Recognize the hard and soft signs of extremity arterial injury and determine when additional vascular imaging is indicated.
·      Describe the role of the ankle-brachial index, CT angiography, and conventional angiography in the evaluation of suspected extremity vascular injury.
·      Discuss the principles of operative management of extremity vascular injuries, including temporary shunting, vascular repair, and restoration of limb perfusion.
·      Briefly discuss mangles extremities and when saving the limb may not be appropritate

References:
·      American College of Surgeons Committee on Trauma. (2025). Advanced trauma life support (ATLS®) student course manual (11th ed.). American College of Surgeons.
·      Lynch, K., & Johansen, K. (1991). Can Doppler pressure measurement replace “exclusion” arteriography in the diagnosis of occult extremity arterial trauma? Annals of Surgery, 214(6), 737–741. https://doi.org/10.1097/00000658-199112000-00016
·      Inaba, K., Branco, B. C., Reddy, S., Park, J. J., Green, D., Plurad, D., Talving, P., Lam, L., & Demetriades, D. (2011). Prospective evaluation of multidetector computed tomography for extremity vascular trauma. Journal of Trauma, 70(4), 808–815. https://doi.org/10.1097/TA.0b013e3182118384
·      Polcz, J. E., White, J. M., Ronaldi, A. E., Dubose, J. J., Grey, S., Bell, D., White, P. W., & Rasmussen, T. E. (2021). Temporary intravascular shunt use improves early limb salvage after extremity vascular injury. Journal of Vascular Surgery, 73(4), 1304–1313. https://doi.org/10.1016/j.jvs.2020.08.137
·      Asensio, J. A., Kessler, J. J., Miljkovic, S. S., Kotaru, T. R., Dabestani, P. J., Kalamchi, L. D., Wenzl, F. A., Sanford, A. P., & Rowe, V. L. (2020). Brachial artery injuries: Operative management and predictors of outcome. Annals of Vascular Surgery, 69, 146–157. https://doi.org/10.1016/j.avsg.2020.05.049
·      Barnes, C. J., Pietrobon, R., & Higgins, L. D. (2002). Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. Journal of Trauma, 53(6), 1109–1114. https://doi.org/10.1097/00005373-200212000-00013
·      Mills, W. J., Barei, D. P., & McNair, P. (2004). The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: A prospective study. Journal of Trauma, 56(6), 1261–1265. https://doi.org/10.1097/01.TA.0000068995.63201.0B
·      Weinberg, D. S., Scarcella, N. R., Napora, J. K., & Vallier, H. A. (2016). Can vascular injury be appropriately assessed with physical examination after knee dislocation? Clinical Orthopaedics and Related Research, 474, 1453–1458. https://doi.org/10.1007/s11999-016-4730-6

Sponsor URL: https://www.goremedical.com/

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://behindtheknife.org/listen
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This mini-series on Behind the Knife will discuss the technical aspects of the Operative Standards for Cancer Surgery, developed through the American College of Surgeons Cancer Research Program and Cancer Surgery Standards Program. This episode highlights total mesorectal excision for rectal cancer.

Host:

• Jason Lizalek, MD (@JasonLizalekMD) is a Surgical Oncology fellow at Moffitt Cancer Center in Tampa, FL.

Learning Objectives: 
-       Understand the relevant pelvic anatomy that makes TME challenging.
-       Develop a step-by-step approach to TME that avoids major pitfalls and allows for a sfe low pelvic anastomosis.
-       Learn tips and tricks for exposure and progress in the more difficult cases.

Links to Papers Referenced in this Episode:

Operative Standards for Cancer Surgery, Volume 1: Breast, Lung, Pancreas, Colon
https://www.facs.org/quality-programs/cancer-programs/cancer-surgery-standards-program/operative-standards-for-cancer-surgery/purchase/

Kindle edition:
https://www.amazon.com/Operative-Standards-Cancer-Surgery-Section-ebook/dp/B07MWSNFSB

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement
https://pubmed.ncbi.nlm.nih.gov/37647138/

NCCN Guidelines for Rectal Cancer
https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1461

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://behindtheknife.org/listen
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Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
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Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-review
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ABSITE Question Bank: https://behindtheknife.org/premium/absite-question-bank
EPA Playbook: https://behindtheknife.org/course/epa-playbook
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ABSITE Review: https://behindtheknife.org/course/absite-2026-exam-review
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It’s postoperative day four after surgery for a perforated colon. The source appears controlled, but the patient is still intubated, the white count is eighteen, and nobody feels comfortable stopping piperacillin–tazobactam. Is four days really enough? Does the ICU buy another four—or is it time to ask what we’re missing?

Join Drs. Rushabh Dev, Skye Shultz, Kelly Ray, Desra Fletcher, and Brycen Ratcliffe from the Emergency General Surgery team in Tiger Country at Mizzou as they revisit STOP-IT and examine what more than a decade of evidence has added to the management of complicated intra-abdominal infection.

In this EGS Journal Review, the team appraises the landmark trial, explores its subgroup analyses and limitations, and puts contemporary SIS, IDSA, AAST, and Surviving Sepsis guidance into context. The discussion moves from source control and antibiotic duration to resistant organisms, cultures, de-escalation, ICU dosing, and the role of procalcitonin.

For most complicated intra-abdominal infections, approximately four days after adequate source control remains the default. Persistent illness should prompt a search for failed source control, ineffective therapy, or another diagnosis before simply extending the stop date.

By the end of this episode, listeners should be able to:
·       Describe the design, principal results, strengths, and limitations of STOP-IT, including why adequate source control is essential to applying its findings.
·       Apply short-course therapy after adequate operative or percutaneous source control and explain why sepsis alone, obesity, or diabetes does not automatically require a longer course.
·       Distinguish the four-day default from the weaker SIS recommendation supporting up to eight days in selected critically ill patients after adequate source control.
·       Recognize persistent or worsening illness that warrants reassessment of source control, drain function, microbiology, drug exposure, or alternative diagnoses.
·       Differentiate the treatment scope of SIS guidance from the diagnostic and microbiology focus of IDSA 2024, the AAST surgical ICU consensus, and broader sepsis and antimicrobial-resistance guidance.
·       Select and de-escalate antimicrobials using infection setting, resistance risk, cultures, local susceptibility data, and patient-specific dosing considerations.
·       Explain the limited adjunctive role of procalcitonin in antibiotic discontinuation when duration remains uncertain, including the implications of ADAPT-Sepsis.

1.     Sawyer RG, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372:1996–2005. STOP-IT. Article / guideline

2.     Huston JM, et al. The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update. Surg Infect. 2024;25:419–435. Article / guideline

3.     Rattan R, et al. Patients with complicated intra-abdominal infection presenting with sepsis do not require longer duration of antimicrobial therapy. J Am Coll Surg. 2016;222:440–446. Article / guideline

4.     Rattan R, et al. Percutaneously drained intra-abdominal infections do not require longer duration of antimicrobial therapy. J Trauma Acute Care Surg. 2016;81:108–113. Article / guideline

5.     Montravers P, et al. Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: the DURAPOP randomized clinical trial. Intensive Care Med. 2018;44:300–310. Article / guideline

6.     IDSA. 2024 Guideline Update on Complicated Intra-Abdominal Infections: Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation. Article / guideline

7.     Nohra E, et al. Fever and infections in surgical intensive care: an AAST Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open. 2024;9:e001303. Article / guideline

8.     IDSA. 2026 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections. Article / guideline

9.     Prescott HC, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med. 2026. Article / guideline

10.  Dark P, et al. Biomarker-guided antibiotic duration for hospitalized patients with suspected sepsis: the ADAPT-Sepsis randomized clinical trial. JAMA. 2025;333:682–693. Article / guideline

After adequate source control, most complicated intra-abdominal infections need approximately four days of antibiotics. If the patient is not improving, reassess the source and the treatment—not just the calendar.

Sponsor Disclosure: Visit goremedical.com/btkpod to learn more about GORE® SYNECOR Biomaterial, including supporting references and disclaimers for the presented content.  Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available. Rx only

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://behindtheknife.org/listen
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Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-review
Cardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-review
OBGYN Oral Board Review Course: https://behindtheknife.org/course/obgyn-oral-board-review
Surgical Critical Care Review: https://behindtheknife.org/premium/surgical-critical-care-review
ABSITE Question Bank: https://behindtheknife.org/premium/absite-question-bank
EPA Playbook: https://behindtheknife.org/course/epa-playbook
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Enlace del curso: https://behindtheknife.org/premium/repaso-para-el-examen-de-certificaci-n-en-cirug-a-general

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.

Este contenido incluye 97 descripciones operatorias para todos los procedimientos comunes —y la mayoría de los poco comunes— incluidos en el Currículo de Cirugía General SCORE. Cada descripción está diseñada para ayudar a los candidatos a prepararse de manera eficaz para el Examen de Certificación en Cirugía General.

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.

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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.

The course contains crisp, concise operative descriptions that cover all SCORE common topics and and most SCORE uncommon topics.

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.

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

Calcified peripheral artery disease (PAD) remains one of the most challenging problems in endovascular intervention. Calcium limits vessel expansion, increases the risk of dissection and procedural failure, and can ultimately lead to bailout stenting. The Disrupt PAD III program provided important evidence for a different approach: intravascular lithotripsy (IVL) as a vessel-preparation strategy. In this episode, we examine the randomized Disrupt PAD III trial published by Tepe and colleagues and the large, real-world observational analysis led by Armstrong and colleagues. Together, these studies explore whether IVL can make treatment of heavily calcified lesions more predictable, reduce the need for stenting, and support a “leave-nothing-behind” strategy.

Hosts:
Dr. Robert Beaulieu
Dr. Frank Davis
Dr. Luciano Delbono
Dr. Andrew Huang
Dr. Carolyn Judge

Learning Objectives
By the end of this episode, listeners should be able to:

Sponsor URL: https://www.goremedical.com/

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Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
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Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-review
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Breast cancer risk varies widely across patients, and surgeons play a central role in recognizing elevated risk and guiding appropriate management. In this episode, we review the spectrum of breast cancer risk and discuss practical strategies for risk assessment and risk reduction. We’ll cover surveillance, lifestyle interventions, risk-reducing medications, high-risk breast lesions, and prophylactic surgery—with an emphasis on translating the available evidence into individualized clinical care.

Hosts:
- Rashmi Kumar, MD, PhD
Resident, University of Michigan General Surgery Residency Program
Twitter/X: @RashmiJKumar
- Melissa Pilewskie, MD
Attending Breast Surgical Oncologist, Co-Director of the Weiser Family Center for Breast Cancer, Michigan Medicine
 Twitter/X: @MPilewskie
- Stephanie Downs-Canner, MD
Attending Breast Surgical Oncologist & Physician-Scientist, Memorial Sloan Kettering Cancer Center, Program Director of the Breast Surgical Oncology Fellowship Training Program
 Twitter/X: @SDownsCanner

Learning Objectives:

1. Bevers TB, Ward JH, Arun BK, et al. Breast cancer risk reduction, version 2.2015. J Natl Compr Canc Netw. 2015;13(8):880-915. doi:10.6004/jnccn.2015.0105

1. Centers for Disease Control and Prevention. Breast cancer risk factors. https://www.cdc.gov/breast-cancer/risk-factors/index.html

You stayed late again, the service is still short-staffed, and when you finally say something, the answer is: you just need to be more efficient. More resilient. That's the go-to explanation for almost everything hard about residency — but what if the problem isn't your resilience at all? In the finale of Beyond the Match, Mckenzie Roebuck, Carl Engelke, Michael Brinton, and Omer Hassan of CoSEF look downstream at what happens after residents match: working conditions, culture and mental health, the practical barriers that make transferring so difficult, why residents may not trust existing reporting systems, and what real accountability and resident voice would require.

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You matched into your dream program... but only after submitting 80 applications, spending thousands of dollars, and losing sleep wondering if anyone was even reading yours. Meanwhile, on the other side of the screen, a program director is staring down a thousand applications for six spots, trying to figure out who's actually serious about coming. Sound familiar? Join Mckenzie Roebuck, Milanie Milan, Sarah Lund, and Bryanna Stukes of CoSEF as they unpack the residency application arms race: why uncertainty drives overapplication, what preference signaling and application caps actually solve, the trade-offs of virtual versus in-person interviews, and how better transparency, advising, holistic review, and even AI might help applicants and programs find the right fit. 

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