Behind The Knife: The Surgery Podcast

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Behind The Knife: The Surgery Podcast episodes

November 05Clinical Informatics for Surgeons, Episode 2: Legal Discovery and Cybersecurity When a Case Goes Wrong
A case goes wrong. There is a complication, maybe a lawsuit, and suddenly the question is not just what happened in the room. It is what got recorded, who owns it, what a plaintiff's attorney can pull into discovery, and whether that same pile of data is a target for people who want to steal it. Join Drs. Scott Steele, Mason Pearce, and Teodor Grantcharov, the surgeon who built the OR Black Box, as they walk through what an instrumented operating room actually captures, why peer review privilege protects the review and not the facts, how AI outputs create a new evidentiary layer, and why cybersecurity is a patient safety issue. The surprising part: governed recording more often protects surgeons than exposes them.
Hosts:
Scott Steele, MD, MBA, Colon and Rectal Surgeon; President, Cleveland Clinic Main Campus
Mason Pearce, MD, General Surgery Resident and Clinical Informatics Fellow, University of South Florida; Behind the Knife Education Fellow
Teodor Grantcharov, MD, PhD, Professor of Surgery, Stanford University; Associate Chief Quality Officer for Innovation and Safety, Stanford Health Care; Founder, Aimbient (formerly Surgical Safety Technologies), the company behind the OR Black Box
Linkedin: https://www.linkedin.com/in/teodorgrantcharov/?isSelfProfile=true
Aimbient’s: https://www.linkedin.com/company/aimbient/
Disclosure: Dr. Grantcharov is the founder of Aimbient (formerly Surgical Safety Technologies). Platform figures discussed on air (hours of data, number of sites and rooms, data volume per OR-hour, retention period, security record, publication count) are company-reported.
Learning objectives:
Describe the data an instrumented operating room generates (field and room video, audio, device telemetry, EHR timestamps) and how ownership is layered across the institution, the patient's right of access, and the vendor.
Distinguish material that is routinely discoverable (the medical record, operative and anesthesia notes, device logs) from contested material (intraoperative video and quality review analytics).
Explain why peer review protections cover the review process rather than the underlying facts, vary by state, and depend on how the institution structures its quality program.
Recognize how AI alerts and risk scores add a new evidentiary layer to clinical decisions.
Explain why cybersecurity is a patient safety issue, using the 2024 Change Healthcare ransomware attack as an example, and name the security basics (multifactor authentication, least-privilege access, security risk analysis) surgeons should ask about.
Apply three practical steps: know who the custodian of your operative data is, insist that recording programs run as governed quality and peer review programs, and ask whether a security risk analysis was done before any new vendor goes live.
References:
Goldenberg MG, Jung J, Grantcharov TP. Using data to enhance performance and improve quality and safety in surgery. JAMA Surg. 2017;152(10):972-973. https://pubmed.ncbi.nlm.nih.gov/28813552/
Jung JJ, Jüni P, Lebovic G, Grantcharov T. First-year analysis of the operating room black box study. Ann Surg. 2020;271(1):122-127. https://pubmed.ncbi.nlm.nih.gov/29916872/
Prigoff JG, Sherwin M, Divino CM. Ethical recommendations for video recording in the operating room. Ann Surg. 2016;264(1):34-35. https://pubmed.ncbi.nlm.nih.gov/27123809/
Filicori F, Addison P. Intellectual property and data ownership in the age of video recording in the operating room. Surg Endosc. 2022;36(6):3772-3774. https://pubmed.ncbi.nlm.nih.gov/34468846/
van Dalen ASHM, Legemaate J, Schlack WS, Legemate DA, Schijven MP. Legal perspectives on black box recording devices in the operating environment. Br J Surg. 2019;106(11):1433-1441. https://pubmed.ncbi.nlm.nih.gov/31112294/
van de Graaf FW, Lange MM, Spakman JI, et al. Comparison of systematic video documentation with narrative operative report in colorectal cancer surgery. JAMA Surg. 2019;154(5):381-389. https://pubmed.ncbi.nlm.nih.gov/30673072/
Succar B, Vella MA, Holena D, et al. Trauma video review through the legal lens: improving care while minimizing risk. J Trauma Acute Care Surg. 2024;97(6):978-982. https://pubmed.ncbi.nlm.nih.gov/39240137/
Lavanchy JL, Vardazaryan A, Mascagni P, et al. Preserving privacy in surgical video analysis using a deep learning classifier to identify out-of-body scenes in endoscopic videos. Sci Rep. 2023;13(1):9235. https://pubmed.ncbi.nlm.nih.gov/37286660/
Neprash HT, McGlave CC, Cross DA, et al. Trends in ransomware attacks on US hospitals, clinics, and other health care delivery organizations, 2016-2021. JAMA Health Forum. 2022;3(12):e224873. https://pubmed.ncbi.nlm.nih.gov/36580326/
Kels CG. Odd man out? The medical peer review privilege in federal litigation. The Federal Lawyer. December 2013. Covers the Health Care Quality Improvement Act (immunity, no discovery privilege) and the Patient Safety and Quality Improvement Act of 2005. Not indexed in PubMed. https://www.fedbar.org/wp-content/uploads/2013/12/feature5-dec13-pdf-1.pdf
Healthcare IT News. New numbers from the Change Healthcare data breach: 193 million affected. August 6, 2025. Not indexed in PubMed. New numbers from the Change Healthcare data breach: 193 million affected | Healthcare IT News
Kapko M. Change Healthcare, compromised by stolen credentials, did not have MFA turned on. Healthcare Dive. April 30, 2024. Not indexed in PubMed. Change Healthcare, compromised by stolen credentials, did not have MFA turned on | Healthcare Dive
Alder S. Average cost of a healthcare data breach falls to $7.42 million (IBM Cost of a Data Breach Report 2025). The HIPAA Journal. July 30, 2025. Not indexed in PubMed. Average Cost of a Healthcare Data Breach Falls to $7.42 Million
The HIPAA Journal. Healthcare data breach statistics. Updated October 2026. Not indexed in PubMed. Healthcare Data Breach Statistics
American Medical Association. Medical cybersecurity: a patient safety issue. Not indexed in PubMed. https://www.ama-assn.org/practice-management/sustainability/medical-cybersecurity-patient-safety-is…
Surgical Safety Technologies rebrands as Aimbient, broadens ambient AI platform. Healthcare Innovation. July 8, 2026. Not indexed in PubMed. Surgical Safety Technologies Rebrands as Aimbient, Broadens Ambient AI Platform
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Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
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
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EPA Playbook: https://behindtheknife.org/course/epa-playbook
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33 min
November 02Clinical Informatics for Surgeons, Episode 1: What Is Clinical Informatics, and Why Should Surgeons Care?
You click an order set and ten seconds later the labs, imaging and meds are in. A drug interaction alert fires, and you override it without reading. A sepsis score in the corner of the chart flags your post-op patient. Who built those defaults, who set that alert threshold, and was that score ever validated on surgical patients? Join Drs. Kevin Kniery, Mason Pearce, and Genevieve Melton-Meaux, a practicing colorectal surgeon and the American College of Surgeons' first Chief Health Informatics Officer, as they kick off the Clinical Informatics for Surgeons series. They explain what clinical informatics actually is (hint: not the help desk), how it is already running your operative day, and the few habits that let any surgeon shape the tools everyone else is stuck with.
Hosts:
Genevieve Melton-Meaux, MD, PhD, Colon and Rectal Surgeon; Senior Associate Dean for Health Informatics and Data Science, University of Minnesota; Chief Health Informatics Officer, American College of Surgeons; Chair, AMIA Board of Directors
Kevin Kniery, MD, FACS, Vascular Surgeon, Brooke Army Medical Center
Mason Pearce, MD, General Surgery Resident and Clinical Informatics Fellow, University of South Florida; Behind the Knife Education Fellow
Learning objectives:
Define clinical informatics, distinguish it from information technology, and describe how physicians train and certify in the subspecialty (ACGME-accredited fellowship, ABPM/ABPath board exam).
Identify four everyday systems that shape surgical care (order set defaults, medication alerts, embedded risk scores, OR scheduling logic) and recognize them as clinical design decisions.
Explain alert fatigue as a patient safety problem and why independent external validation of predictive models matters, using the Epic Sepsis Model as an example.
Describe the three core areas of the surgeon informatician: clinical decision-making and care process improvement; health information systems, data and analytics; and leadership and change management.
Apply practical habits for informatics literacy: question a risk score's data and validation, report faulty alerts, and join the committees that maintain order sets and decision support.
References:
Felisberto M, Lima GDS, Celuppi IC, et al. Override rate of drug-drug interaction alerts in clinical decision support systems: a brief systematic review and meta-analysis. Health Informatics J. 2024;30(2):14604582241263242. https://pubmed.ncbi.nlm.nih.gov/38899788/
Ashton M. Getting rid of stupid stuff. N Engl J Med. 2018;379(19):1789-1791. https://pubmed.ncbi.nlm.nih.gov/30403948/
Rajamani G, Diethelm M, Gunderson MA, et al. Crowdsourcing electronic health record improvements at scale across an integrated health care delivery system. Appl Clin Inform. 2023;14(2):356-364. https://pubmed.ncbi.nlm.nih.gov/37164355/
Wong A, Otles E, Donnelly JP, et al. External validation of a widely implemented proprietary sepsis prediction model in hospitalized patients. JAMA Intern Med. 2021;181(8):1065-1070. https://pubmed.ncbi.nlm.nih.gov/34152373/
Osheroff J, Teich J, Levick D, Saldana L, Velasco F, Sittig D, Rogers K, Jenders R. Improving Outcomes with Clinical Decision Support: An Implementer's Guide. 2nd ed. HIMSS Publishing; 2012. ISBN 9780984457731. Book; not indexed in PubMed. Source of the CDS Five Rights framework. https://www.routledge.com/Improving-Outcomes-with-Clinical-Decision-Support-An-Implementers-Guide-S…
Gardner RM, Overhage JM, Steen EB, et al. Core content for the subspecialty of clinical informatics. J Am Med Inform Assoc. 2009;16(2):153-157. https://pubmed.ncbi.nlm.nih.gov/19074296/
Zhao J, Forsythe R, Langerman A, Melton GB, Schneider DF, Jackson GP. The value of the surgeon informatician. J Surg Res. 2020;252:264-271. https://pubmed.ncbi.nlm.nih.gov/32402396/
Anderson TN, Jenkins PD, Doberne JW, Mohan V, Thanawala RM. Defining the clinical informatics knowledge gap in general surgery: evaluation of resident experience and perspectives. J Surg Educ. 2025;82(11):103682. https://pubmed.ncbi.nlm.nih.gov/40911943/
Lyu HG, Doherty GM, Landman AB. Surgical informatics: defining the role of informatics in the current surgical training paradigm. J Surg Educ. 2020;77(1):9-12. https://pubmed.ncbi.nlm.nih.gov/31477548/
AMIA. AMIA's role in the clinical informatics subspecialty and history (ABMS approval 2011; first exam October 2013). AMIA's Role in CIS and History
Turner PL. Exploring artificial intelligence at the ACS. Bulletin of the American College of Surgeons. October 2024. Exploring Artificial Intelligence at the ACS | ACS
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
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Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
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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30 min
October 29USA vs. UK: ASGBI Ep. 11 - Surgeons Are Human Too - Breaking the Silence on Mental Health
How do we care for ourselves while caring for others?
Surgery is a demanding profession that requires resilience, sacrifice, and the ability to navigate high-stakes decisions. However, depression, anxiety, burnout, and the emotional consequences of complications are realities that many surgeons face but often struggle to discuss openly.
In this episode of the Behind the Knife/Association of Surgeons of Great Britain and Ireland (ASGBI) collaborative series, our guests share their personal experiences navigating mental health challenges throughout their careers, confronting stigma, finding support, and learning that being a successful surgeon does not require being perfect.
Hosts
Dr. Agnes Premkumar — Behind the Knife Surgical Education Fellow, General Surgery resident (US)
Dr. Gita Lingham — President, Moynihan Academy, trainee association within the Association of Surgeons of Great Britain and Ireland (ASGBI) (UK)
Dr. Elizabeth McLennan — Vice President, Moynihan Academy, trainee association within the Association of Surgeons of Great Britain and Ireland (ASGBI) (UK)
Guests
Dr. Luke Elms — Board-certified general surgeon specializing in abdominal wall reconstruction and hernia surgery; host of The Hernia Gods podcast.
Dr. Elizabeth “Liz” Miller — Former neurosurgical trainee and current occupational health physician, mental health advocate, and author of Mood Mapping.
Resources Mentioned
Mood Mapping — Dr. Elizabeth “Liz” Miller
A practical guide to understanding and managing emotional well-being through mood awareness, self-reflection, and strategies such as exercise, music, spending time outdoors, and connecting with others.
The Hernia Gods Podcast — Dr. Luke Elms
A podcast exploring the humanity behind surgery, including imposter syndrome, complications, professional identity, self-doubt, and the shared experiences of surgeons at every career stage.
Available on Apple Podcasts, Spotify, and YouTube.

Doctors' Support Network
https://www.dsn.org.uk/. A peer-support initiative discussed by Dr. Miller, emphasizing compassion, connection, and reducing the stigma associated with mental health challenges among physicians.
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Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
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43 min
October 26Demystifying Topical Hemostatic Agents: A Mental Model for Surgeons
The scrub tech holds up two boxes, “SURGICEL or EVARREST?”, and you realize nobody ever taught you the difference. Patrick Georgoff, MD, John McClellan, MD, Kevin Kniery, MD, and Nick Teman, MD, break down topical hemostatic agents, one of the most used and least taught tools in the OR. You’ll get a simple two-question model for picking the right product: can your patient make their own clot, and can a patch reach the bleeding? Through trauma, vascular, and cardiac cases, the team covers when these agents earn their keep and when two minutes of pressure (no peeking!) will do the job. Bottom line: hemostatic agents speed up hemostasis, but they’re a targeted adjunct to good surgical technique, not a substitute for it!
Hosts:
Patrick Georgoff, MD, Duke
Nick Teman, MD, University of Colorado
John McCllelan, MD, UNC
Kevin Kniery, MD, Madigan Army Medical Center
Topical Hemostatic Agent PDF link: https://drive.google.com/file/d/1Qv9V_0l20CTXKQ_83newveIahmxzlpcb/view?usp=sharing
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Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
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
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ABSITE Review: https://behindtheknife.org/course/absite-2026-exam-review
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43 min
October 22Journal Review in Surgical Oncology: Gastric Cancer
Join the Behind the Knife Surgical Oncology Team as we discuss the MATTERHORN trial and the addition of perioperative immunotherapy to FLOT for resectable gastric and gastroesophageal junction adenocarcinoma!

Hosts:
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 an Associate Professor of Surgery and Surgical Oncologist at the University of Tennessee Health Science Center, Chattanooga.
Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a Surgical Oncologist at Brooke Army Medical Center.
Joe (Joseph) Broderick, MD, MA (@joebrod5) is a General Surgery research resident between his second and third year at Brooke Army Medical Center.
Galen Gist, MD (@gistgalen) is a third-year General Surgery resident at Brooke Army Medical Center.
Learning Objectives:
In this episode, we review the evolution of perioperative therapy for resectable gastric and gastroesophageal junction adenocarcinoma, from the MAGIC and FLOT4 trials to the MATTERHORN trial, a phase III randomized controlled trial investigating the addition of perioperative durvalumab to FLOT. We discuss the mechanism of checkpoint inhibition, the trial design, the event-free and overall survival results, the pathologic and nodal response data, and the open questions this trial raises for surgeons.
References used in the making of this episode:
Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11-20. doi:10.1056/NEJMoa055531
Al-Batran SE, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-1957. doi:10.1016/S0140-6736(18)32557-1
Janjigian YY, Al-Batran SE, Wainberg ZA, et al. Perioperative durvalumab in gastric and gastroesophageal junction cancer. N Engl J Med. 2025;393(3):217-230. doi:10.1056/NEJMoa2503701
Tabernero J, Al-Batran SE, Wainberg ZA, et al. Final overall survival and the association of pathological outcomes with event-free survival in MATTERHORN: a randomised, phase III study of durvalumab plus FLOT in resectable gastric/gastroesophageal junction adenocarcinoma. Presented at: European Society for Medical Oncology (ESMO) Congress 2025; October 17, 2025; Berlin, Germany. Abstract LBA81.
Shitara K, Rha SY, Wyrwicz L, et al. Pembrolizumab plus chemotherapy versus chemotherapy as perioperative therapy in locally advanced gastric and gastroesophageal junction cancer: final analysis of the randomized, phase III KEYNOTE-585 study. J Clin Oncol. 2025;43(29):3152-3159. doi:10.1200/JCO-25-00486
Kang YK, Terashima M, Kim YW, et al. Adjuvant nivolumab plus chemotherapy versus placebo plus chemotherapy for stage III gastric or gastro-oesophageal junction cancer after gastrectomy with D2 or more extensive lymph-node dissection (ATTRACTION-5): a randomised, multicentre, double-blind, placebo-controlled, phase 3 trial. Lancet Gastroenterol Hepatol. 2024;9(8):705-717. doi:10.1016/S2468-1253(24)00156-0
André T, Tougeron D, Piessen G, et al. Neoadjuvant nivolumab plus ipilimumab and adjuvant nivolumab in localized deficient mismatch repair/microsatellite instability-high gastric or esophagogastric junction adenocarcinoma: the GERCOR NEONIPIGA phase II study. J Clin Oncol. 2023;41(2):255-265. doi:10.1200/JCO.22.00686
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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Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
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
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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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Download our App:
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28 min
October 19 Building a Career in Global Surgery - Purpose, Mentorship, and Impact
In this episode of the Behind the Knife Global Surgery Series, we explore what it actually takes to build a meaningful career in global surgery. Global surgery is not a single specialty or job title—it is a broad field that intersects with clinical care, education, research, policy, advocacy, implementation science, and health-system strengthening. So how do trainees and early-career surgeons find their place in it?
Host Mike M. Mallah is joined by Dr. Barnabas Alayande and Dr. Lacey LaGrone for a candid discussion about the personal and professional paths that brought them into global surgery. Dr. Alayande shares how experiences with limited access to healthcare in Nigeria shaped his decision to pursue medicine and ultimately global surgery, while Dr. LaGrone discusses her focus on translating evidence into clinical practice and building scalable approaches to knowledge dissemination.
Together, they discuss why purpose matters, why global surgery should be viewed as a field rather than a job title, and why aspiring global surgeons should first become excellent at something that allows them to add real value. The conversation also examines mentorship, the difference between visibility and impact, the importance of integrity in partnerships, and the personal sacrifices that can accompany a career devoted to this work.
For medical students, residents, fellows, and junior faculty interested in global surgery, this episode offers practical advice: develop meaningful expertise, seek mentors who are genuinely invested in your growth, focus less on recognition and more on impact, and keep doing the next right thing—excellently.
Hosts/Guests:
Mike M. Mallah, MD, FACS, FICS
Director of Global Surgery, Medical University of South Carolina
@MikeMMallahMD
@MUSCGlobalSurg
[email protected]

Barnabas Alayande, MD
Chair, Center for Equity and Global Surgery
University of Global Health Equity, Rwanda
General Surgeon, Surgical Educator, and Global Surgery Leader
@DrBarnabasAlay
Lacey LaGrone, MD
Associate Director of Research, Medical Center of the Rockies
Associate Clinical Faculty, University of Colorado
Co-Founder, Together Made
Acute Care Surgeon, Surgical Intensivist, and Global Surgery Leader
Papers noted:
· Abimbola S. The foreign gaze: authorship in academic global health. BMJ Global Health. 2019;4:e002068. https://doi.org/10.1136/bmjgh-2019-002068
· Essentialism: The Disciplined Pursuit of Less by Greg McKeown https://gregmckeown.com/books/essentialism/

Topics discussed: Career pathways in global surgery; finding your “why”; global surgery as a field rather than a specialty; developing expertise; implementation science; mentorship; visibility versus impact; ethical partnerships; professional sacrifice; work-life balance; and advice for the next generation of global surgeons.
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29 min
October 15Clinical Challenges in Bariatric Surgery: Marginal Ulcers
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
Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)
Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio)
Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida)
Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)
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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41 min
October 12 Journal Review in Vascular Surgery: Vascular Extremity Trauma
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

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48 min
October 08Operative Standards for Cancer Surgery Series: Total Mesorectal Excision for Rectal Cancer
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.
Guests:
Sean J Langenfeld, MD, FACS, FASCRS (@seanlangenfeld) is a professor of surgery and the chief of the division of colon and rectal surgery at the University of Nebraska Medical Center in Omaha, NE
Larissa Temple, MD, FACS, FASCRS is a professor of surgery and the chief of colon and rectal surgery at the University of Rochester in Rochester, NY.
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
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48 min
October 05Journal Review in Emergency General Surgery: STOP-IT - What a Decade of Data Has Taught Us
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.
Hosts
Dr. Rushabh Dev, MD, FACS – Moderator and Acute Care Surgeon, University of Missouri
Dr. Skye Shultz – Surgical Critical Care Fellow, University of Missouri
Dr. Kelly Ray – General Surgery Resident; STOP-IT appraisal and antimicrobial selection
Dr. Desra Fletcher – General Surgery Resident, University of Missouri; post-STOP-IT evidence and implementation
Dr. Brycen Ratcliffe – General Surgery Resident; society guidance and microbiology

Learning Objectives
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.
References
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.

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29 min

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