Cold Steel: Canadian Journal of Surgery Podcast

On this episode, Dr. Elizabeth Squirrell joined us to talk about Crohns disease. Dr. Squirrell is a staff gastroenterologist at Queen’s University and has a special expertise in inflammatory bowel disease. In this two part series, we first talk about the diagnosis of crohns disease and the different patterns of its presentation. In part 2, we talk about the changing landscape of medical therapy for Crohns disease and how Dr. Squirrell approaches the treatment of Crohns. Make sure to check out the links below for all the papers that are discussed in both part 1 and part 2 of this series. 

Links:

1.  Is there an optimal sequence of biologic therapies for inflammatory bowel disease? – Brian Bressler: https://journals.sagepub.com/doi/10.1177/17562848231159452
2. Vedolizumab as Induction and Maintenance Therapy for Crohn's Disease – Sandborn et al. - https://www.nejm.org/doi/full/10.1056/NEJMoa1215739
   • They measured Clinical remission at week 6 and did have a significant result in one of their groups (p=0.02) but had a remission rate of 14.5% in the double-blind group and 17.7% in the open label group. Contrasted to the ustekinumab study (below) where they measured at 8 weeks and record 40.2% remission in biologic naïve patients and 20.9% remission in prior TNF exposed patients (the vedo study was a mix of bio exposed and bio naïve so would expect somewhere between). 
3.  Ustekinumab as Induction and Maintenance Therapy for Crohn’s Disease – Feagan et al. - https://nejm.org/doi/full/10.1056/NEJMoa1602773#APPNEJMoa1602773SUP
4. ECCO-ESCP Consensus on Surgery for Crohn’s Disease – Bemelman et al. - https://academic.oup.com/ecco-jcc/article/12/1/1/3813784
5. Cardiovascular and Cancer Risk with Tofacitinib in Rheumatoid Arthritis – Ytterberg et al. - https://www.nejm.org/doi/full/10.1056/NEJMoa2109927
6. ACG Clinical Guideline: Management of Crohn's Disease in Adults – Lichtenstein et al. - https://journals-lww-com.proxy.queensu.ca/ajg/Fulltext/2018/04000/ACG_Clinical_Guideline__Management_of_Crohn_s.10.aspx
7. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease – Panaccione et al. - https://www.cag-acg.org/images/publications/CAG-CPG-Luminal-Crohns-Disease-JCAG-July2019.pdf   

On this episode, Dr. Elizabeth Squirrell joined us to talk about Crohns disease. Dr. Squirrell is a staff gastroenterologist at Queen’s University and has a special expertise in inflammatory bowel disease. In this two part series, we first talk about the diagnosis of crohns disease and the different patterns of its presentation. In part 2, we talk about the changing landscape of medical therapy for Crohns disease and how Dr. Squirrell approaches the treatment of Crohns. Make sure to check out the links below for all the papers that are discussed in both part 1 and part 2 of this series. 

Links:

1.  EXPERIENCES WITH PREFRONTAL LOBOTOMY FOR INTRACTABLE ULCERATIVE COLITIS. https://jamanetwork.com/journals/jama/article-abstract/304807
2.  ACG Clinical Guideline: Management of Crohn's Disease in Adults. https://journals-lww-com.proxy.queensu.ca/ajg/Fulltext/2018/04000/ACG_Clinical_Guideline__Management_of_Crohn_s.10.aspx
3.  The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856208/

Dr. Sharmila Dissanaike is a trauma and acute care surgeon and is the chair of surgery at Texas Tech University. She holds multiple national leadership roles, including as President-Elect of the American Burn Association, Vice-President of the Southwest Surgical Congress, and Governor of the American College of Surgeons. We really delved into her thoughts on her philosophy on leadership. How do you create a supportive culture? How do you make the hard decisions and have the hard conversations? Most importantly, how do we stay true to ourselves and our own values?

X/Twitter: https://x.com/DissanaikeMD

Links:

• Burnout, shiftwork and suicide: 2022 Scott B. Frame Memorial Lecture. https://journals-lww-com.proxy.queensu.ca/jtrauma/fulltext/2022/07000/burnout,_shiftwork_and_suicide__2022_scott_b_.21.aspx
• New Yorker piece about Brittany Bankhead-Kendall, a trauma surgeon recruited & supported by Dr. Dissanaike: https://www.newyorker.com/science/medical-dispatch/a-doctors-dark-year
• How to prevent burnout (maybe): https://pubmed.ncbi.nlm.nih.gov/27810134/

Dr. Bellal Joseph is a trauma surgeon and the chief of the division of trauma, surgical critical care, burns, and acute care surgery at the University of Arizona in Tucson. While it was impossible to delve into the breadth and depth of his research interests, we did explore some of our favorites with Dr. Joseph, including his ongoing investigation into new technologies like REBOA, traumatic brain injuries, and frailty in surgery. What shines through in this conversation is Dr. Joseph’s incredible authenticity, energy and passion for injured and disadvantaged patients, as well as his vision for how physicians can embrace their own brand. 

X/Twitter: https://x.com/TopKniFe_B

1. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma: https://pubmed.ncbi.nlm.nih.gov/30892574/

2. Conflicts of interest and REBOA: https://pubmed.ncbi.nlm.nih.gov/37316993/

3. Brain Injury Guidelines? https://pubmed.ncbi.nlm.nih.gov/35343931/

4. Trauma Specific Frailty Index (TSFI)? https://journals.lww.com/jtrauma/abstract/2023/01000/prospective_validation_and_application_of_the.6.aspx

5. Evaluation of Frailty Assessment Compliance in Acute Care Surgery: Changing Trends, Lessons Learned. https://pubmed.ncbi.nlm.nih.gov/34710704/

1. Some of our favourite tweets:
2. https://x.com/TopKniFe_B/status/1759365974141321232
3. https://x.com/TopKniFe_B/status/1752607469552157060
4. https://x.com/TopKniFe_B/status/1752014880578949430

 Janice Kwan is an internist at Mount Sinai Hospital in Toronto. Her research interests focus on health care quality and diagnostic error. She collaborated with folks from the Canadian Medical Protective Association (CMPA) to investigate diagnostic errors in surgery. Her paper, published in the Canadian Journal of Surgery, highlight the significant consequences of diagnostic errors in surgery. We also talked about de-biasing techniques and other strategies for reducing diagnostic error in surgery.

Janice Kwan Twitter:  https://twitter.com/kwanjanice

 Links:

1.  Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada.  https://www.canjsurg.ca/content/67/1/E58
2.  Diagnostic Process:  https://www.improvediagnosis.org/processes/the-diagnostic-process/
3.  Improving Diagnosis in Healthcare:  https://nap.nationalacademies.org/resource/21794/interactive/
4.  I-PASS tool:  https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html
5.  Society to Improve Diagnosis in Medicine (SIDM) Fellowship in Diagnostic Excellence.  https://www.improvediagnosis.org/sidmfellowship/#:~:text=The%20Society%20to%20Improve%20Diagnosis,error%20community%2C%20and%20help%20you

 Most of us come out of training and have no idea on how to balance a busy clinical practice, academic interests, and most importantly, our home and personal lives. Mr. Adi Kumar is trying to change that. Mr. Kumar is a consultant neurosurgeon in the UK and has written a book called Work Less, Live More: The Doctor’s Guide for Time Freedom. We caught up with him to talk about his unconventional academic interests and his thoughts on how we as physicians can lead more fulfilling lives.

 Links:

1. Work Less, Live More e-book: https://adi-kumar.ghost.io/worklesslivemore/
2. https://adi-kumar.ghost.io/
3. Doctors and Writers: https://doctorsandwriters.com/
4. X/Twitter: https://twitter.com/adi_kumar1
5. #038 Why being a surgeon is a Loser's Game. https://adi-kumar.ghost.io/038-why-being-a-surgeon-is-a-losers-game/ 
6. The Neurosurgeons YouTube channel. https://www.youtube.com/c/TheNeurosurgeons

Shiva Jayaraman is a minimally invasive and hepatobiliary surgeon at St. Joseph’s Hospital. He’s been traveling around the world talking about his innovative peer-to-peer coaching program for bile duct injuries. Not only is this such an important clinical topic that virtually every general surgeon in the world has to deal with, but his group’s approach to coaching is something that we should be trying to replicate on a national and international level.

Make sure to check out part 2 of our interview with him, a masterclass on subtotal cholecystectomy: https://youtu.be/9ptTuPCJ8WA 

Twitter: @cutitoutPODCAS1

Shiva's YouTube: https://www.youtube.com/channel/UCKUnmUDH1z3c9VMR1iv6tpg 

Links:

1. Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury. https://pubmed.ncbi.nlm.nih.gov/34111530/
2. Shiva’s Approach to Tough Gallbags: https://www.youtube.com/watch?v=oX35O61qga0 
3. The inferior boundary of dissection as a novel landmark for safe laparoscopic cholecystectomy. https://pubmed.ncbi.nlm.nih.gov/33648820/
4. The Academy of Surgical Coaching. https://surgicalcoaching.org/
5. Personal Best by Atul Gawande. https://www.newyorker.com/magazine/2011/10/03/personal-best
6. Thinking your way through a difficult subtotal cholecystectomy. https://journals-lww-com.proxy.queensu.ca/journalacs/fulltext/2022/12000/thinking_your_way_through_a_difficult_laparoscopic.23.aspx
7. TVASurg: www.tvasurg.ca/lapchole

On this episode, we had the opportunity to speak with Beverly Blaney. Bev is a psychotherapist who has extensive experience doing therapy with physicians in particular, as well as conducting workshops on mindfulness for Queen’s School of Medicine. We asked her about her perspective on the psychological challenges surgeons experience during their training, and her thoughts on what we could do to make ourselves more resilient. 

Links

1.      Atomic habits by James Clear

2.      Essentialism: The Disciplined Pursuit of Less – Greg McKeown

We sat down with arguably the world expert on low anterior resection syndrome. Dr. Marylise Boutros (https://twitter.com/BoutrosMarylise) is an academic colorectal surgeon at Cleveland Clinic Florida.. Dr. Boutros talks about her pioneering research to understand and treat the challenging functional issues that patients must content with.

We also talk about her move to Cleveland Clinic and her advice for an academic surgical career.

Links:

1. Low Anterior Resection Syndrome: Predisposing Factors and Treatment.  https://pubmed.ncbi.nlm.nih.gov/34863592/
2. Low Anterior Resection Syndrome in a Reference North American Sample: Prevalence and Associated Factors. https://pubmed.ncbi.nlm.nih.gov/37466264/
3.  Financial and occupational impact of low anterior resection syndrome in rectal cancer survivors. https://pubmed.ncbi.nlm.nih.gov/33724620/
4.  Assessing the readability, quality and accuracy of online health information for patients with low anterior resection syndrome following surgery for rectal cancer. https://pubmed.ncbi.nlm.nih.gov/30609222/
5.  Comparison of the Colonic J-Pouch Versus Side-To-End Anastomosis Following Low Anterior Resection: A Systematic Review and Meta-Analysis. https://pubmed.ncbi.nlm.nih.gov/37507144/

Bio (from Cleveland Clinic website)

Marylise Boutros is a Staff Colorectal Surgeon at the Cleveland Clinic Florida and the Regional Digestive Disease InstituteDirector of Research. Previously, Dr. Boutros was a Colorectal Surgeon at the Jewish General Hospital, Professor of Surgery at McGill University, and Colorectal Surgery Program Director. Having completed General Surgery residency at McGill University and Colorectal Surgery residency at Cleveland Clinic Florida, her clinical interests are advanced minimally invasive approaches to benign and malignant colorectal and anorectal diseases. She treats colon and rectal cancer, inflammatory bowel disease, diverticular disease, fecal incontinence and all anorectal disorders. 

Dr Boutros is a federally funded researcher who currently leads an internationally renowned research program focused on assessing innovations to improve recovery and functional outcomes after colorectal surgery using multicentre prospective trials, patient-centred interventions and patient-reported outcome measures. Within her research program, Dr Boutros has mentored over forty trainees and graduate students. Dr Boutros also has leadership roles in multiple international societies including Society of American Gastrointestinal and Endoscopic Surgeons, American Society of Colon and Rectal Surgeons, Canadian Society of Colon and Rectal Surgeons and the Canadian Association of General.

This is a re-broadcast to honour the memory of the "Boss" Dr. Feliciano.

Original shownotes:

It’s not an understatement to say that Dr. David Feliciano is a true giant in trauma surgery. Dr. David V. Feliciano received his medical degree in 1970 from Georgetown University in Washington, D.C. He completed his general surgery training at Mayo Clinic, in trauma at Wayne State University, and vascular surgery at Baylor College of Medicine (where he trained under Dr. DeBakey). He was Professor of Surgery at Emory University and Surgeon-in-Chief at Grady Memorial Hospital in Atlanta, Georgia from 1991 to 2011. He is now a Clinical Professor of Surgery at the University of Maryland and an attending surgeon at Shock Trauma.

We discuss with him how he recruited such amazing faculty, developing one’s technical skills, research, and the future of trauma.

1.Trauma textbook: www.amazon.ca/Trauma-Eighth-Erne…oore/dp/1259860671

2.“Everything You Ever Wanted to Know about Trauma” public lecture: www.youtube.com/watch?v=99yddsDe6oU

3.“Leftovers” by Dr. Feliciano has one of the best lines in a paper ever: At this point, the chief surgical resident on the trauma service met with the attending surgeon for violating his own well-known rule—“wounds that don’t heal contain dead tissue, infected tissue, cancer, or a foreign body.” www.ncbi.nlm.nih.gov/pmc/articles/PMC6263419/

4.Pitfalls in the management of peripheral vascular injuries. www.ncbi.nlm.nih.gov/pmc/articles/PMC5877918/