Directed Teaching on Acute Abdominal Syndrome Effectively Improves Resident Physicians' Diagnostic Skills in Postoperative Complications of Gastric Tumor Surgery

Directed Teaching on Acute Abdominal Syndrome Effectively Improves Resident Physicians' Diagnostic Skills in Postoperative Complications of Gastric Tumor Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Directed Teaching on Acute Abdominal Syndrome Effectively Improves Resident Physicians' Diagnostic Skills in Postoperative Complications of Gastric Tumor Surgery Aksara Regmi, Suyue Yu, Lu Zang, Yu Mei, Jingyi Huang, Zhenglun Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7682552/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: This study aimed to evaluate the effectiveness of incorporating acute abdominal syndrome (AAS) diagnosis and treatment into the standardized training of surgical resident physicians. Specifically, it examines how this curriculum impacts residents' diagnostic abilities regarding postoperative complications in gastric tumor surgeries, considering their background and the perioperative aspects of gastrointestinal surgery. Methods: A total of 449 resident physicians from the Gastrointestinal Surgery Department at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, who participated in standardized training from August 2012 to August 2024, were included in this study. The residents were divided into four groups: surgical specialties, general surgery subspecialties, gastrointestinal surgery within general surgery subspecialties, and non-surgical specialties. Chi-square tests were applied to assess medical licensure status differences between the groups. Diagnostic scores for postoperative complications in gastric tumor surgeries were compared between residents who received systematic teaching focused on AAS and those who did not using a t-test. Results: No significant differences (p>0.05) in medical licensure status were found across the groups. The stratified analysis showed that residents who received systematic teaching on AAS demonstrated significantly higher diagnostic accuracy for postoperative complications in gastric tumor surgeries (p<0.05) during exit evaluations, regardless of their medical licensure status. Conclusion: AAS is a critical and rapidly progressing condition requiring surgical intervention. Incorporating AAS-focused clinical teaching into gastrointestinal surgery training is an effective way to improve residents' diagnostic capabilities in identifying postoperative complications in gastric tumor surgeries. Standardized Training for Resident Physicians Acute Abdominal Syndrome Postoperative Complications in Gastric Surgery Clinical Competence What is already known on this topic Acute Abdominal Syndrome (AAS) is a critical condition that poses significant diagnostic challenges, especially for residents in surgical training. Previous studies have highlighted gaps in the diagnostic proficiency of resident physicians in identifying postoperative complications, particularly in gastric tumor surgeries. There has been a need to integrate focused teaching on AAS to improve diagnostic accuracy. What this study adds: This study demonstrates that incorporating AAS-focused teaching into standardized surgical residency training significantly enhances residents' diagnostic accuracy for postoperative complications in gastric tumor surgeries. The improvement was observed across multiple specialty backgrounds, with residents showing better proficiency in identifying complications. How this study might affect research, practice, or policy: The findings suggest that focused clinical teaching on AAS can be an effective approach to improving diagnostic skills in surgical residency programs. This could lead to the adoption of similar teaching models in other surgical specialties to enhance the diagnostic accuracy of residents, potentially reducing complications and improving patient outcomes. Introduction Surgical training is a multifaceted process that requires technical proficiency, clinical decision-making, patient management, and integration of basic and clinical sciences. Surgical residents refine their skills through hands-on experience, which has been the core of surgical education for over a century. Since the late 19th century, visionary surgeons have emphasized the need for structured training programs offering clinical practice, research, and mentorship in diverse environments. These early proponents argued that residency programs should foster not only technical skills but also critical thinking, clinical reasoning, and the ability to manage complex cases [ 1 ]. In 2010, Shanghai introduced a standardized residency training system designed to develop highly skilled surgeons who would advance surgery and educate future generations [ 2 ]. The system aims to provide surgeons with comprehensive clinical knowledge, improving diagnostic and procedural skills while also fostering research capabilities [ 3 ]. A critical area in surgical training is the diagnosis and management of acute abdominal syndrome, a condition characterized by sudden, severe abdominal pain due to various underlying causes. This syndrome includes multiple emergency conditions, many of which require immediate surgical intervention. These conditions, such as bowel obstruction, perforated viscus, and ischemic bowel disease, present diagnostic challenges due to their varied causes and overlapping symptoms. Prompt diagnosis is crucial, as delays can lead to serious complications or death [ 4 ]. Residents must develop strong diagnostic acumen and clinical judgment to manage these dynamic conditions effectively [ 5 ]. Recognizing its importance, our department integrated acute abdominal syndrome diagnosis and treatment into the standardized curriculum for gastrointestinal surgery residents. Since 2017, a structured teaching program focused on acute abdominal syndrome has been implemented to enhance residents' diagnostic and decision-making abilities. This program includes detailed teaching on clinical presentation, differential diagnosis, and management strategies, emphasizing timely surgical intervention [ 6 ]. The goal is to improve diagnostic skills, particularly for postoperative complications in gastric tumor surgeries, where issues like infection, hemorrhage, and anastomotic leaks are common [ 7 ]. This study evaluates the impact of acute abdominal syndrome-directed teaching on residents’ diagnostic accuracy for complications following gastric tumor surgery. We analyzed data from residents trained at Ruijin Hospital between 2012 and 2024, comparing the diagnostic performance of those who received AAS-focused training with those who did not. We hypothesize that specialized training will improve diagnostic accuracy, highlighting its effectiveness in enhancing clinical competence [ 8 ]. Materials and Methods 1. Clinical Data 1.1 Selection of Residents In accordance with national guidelines set by the Shanghai Municipal Health Commission, surgical residents are required to complete a 13-month rotation in general surgery, while non-surgical residents, including those in obstetrics and gynecology, undergo a 2-month rotation. This study includes 449 residents who completed standardized residency training in the Gastrointestinal Surgery Department at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, from August 2012 to August 2022. Among them, 352 were male and 97 were female. All residents completed the mandatory gastrointestinal surgery rotation as part of their training. Since 2017, acute abdominal-oriented clinical teaching has been incorporated into the residency program. Residents were divided into two groups based on whether they received this specific training. Case analysis scores for postoperative complications related to gastrectomy were recorded for residents of different specialties in each group. Residents were categorized into four groups based on their educational background: (1) surgical base residents, (2) general surgery subspecialty residents, (3) gastrointestinal surgery-focused residents, and (4) non-surgical residents. Medical licensure status was also noted. The residents’ backgrounds included clinical, scientific, and long-cycle clinical programs, with some specializing in general or gastrointestinal surgery, and others from non-surgical disciplines like pediatrics and anesthesiology [ 9 ]. 1.2 Selection of Postoperative Complications Cases We conducted a retrospective review of data from 2257 gastric tumor patients who underwent transabdominal gastrectomy in the Gastrointestinal Surgery Department at Ruijin Hospital between August 2012 and August 2022. The cohort included 1457 males (64.5%) and 800 females (35.5%), with a median age of 60 years (range: 27–90). Among all patients, 1937 (85.8%) were diagnosed with gastric cancer, while 320 (14.2%) had other types of gastric tumors. Of the total cohort, 1727 patients (76.5%) underwent distal gastrectomy, and 530 patients (23.5%) underwent total gastrectomy. All diagnoses were confirmed using postoperative paraffin pathology [ 10 ]. Postoperative complications were categorized according to the Chinese Expert Consensus on the Diagnosis and Registration of Postoperative Complications in Gastrointestinal Cancer Surgery (2018 edition) [ 11 ]. These complications included gastrointestinal, incision-related, respiratory, cardiovascular, urinary, infection-related, embolism-related, and other complications. To create a comprehensive case discussion collection, we supplemented clinical data, including patient histories, physical exams, lab results, pathology reports, imaging data, and references for cases relevant to the clinical teaching of acute surgical abdomen [ 12 ]. 1.3 Inter-group Analysis of Clinical Case Analysis Assessment We constructed a question bank for clinical case analysis based on postoperative complication data and in line with the national and Shanghai residency training program exit exam requirements. During the exit assessments, each resident presented with 10 cases: four from gastrointestinal-related complications and one from each of the other categories (i.e., incision-related, respiratory, cardiovascular, urinary, infection, and embolism complications). Each case was worth 10 points for a total of 100 points. The assessment focused on four key areas: clinical diagnosis (two points), diagnostic reasoning (two points), differential diagnosis (two points), and clinical management principles (four points). Since 2017, acute abdominal-oriented clinical teaching has been implemented in the Gastrointestinal Surgery Department for residents of gastrointestinal surgery. Therefore, residents who underwent standardized training between August 2012 and August 2022 were categorized based on whether they had received systematic acute abdominal-focused clinical teaching. Clinical case analysis scores for residents with different professional backgrounds were recorded and compared [ 13 ]. 2. Data Analysis Descriptive statistics were used to analyze the demographic and professional background distribution s of residents from different specialties. A chi-square test was performed to determine whether there were significant differences in the proportion of residents who obtained a medical practitioner qualification certificate upon entering the program. A t-test was used to compare the diagnostic scores between two groups of residents: those who had received acute abdomen-oriented clinical teaching and those who had not. Data are presented as the mean ± standard deviation. Statistical analysis was performed using SAS 'PROCGLM' 8.0, with a p-value of < 0.05 considered statistically significant [ 14 ]. Results 1. Demographic and Professional Background of Residents in the Gastrointestinal Surgery Department Between August 2012 and August 2024, 449 residents underwent standardized residency training in the Department of Gastrointestinal Surgery at Ruijin Hospital, affiliated with Shanghai Jiao Tong University School of Medicine. The cohort included 352 males (78.3%) and 97 females (21.7%). Of these, 310 residents (69%) came from surgical specialties, while 139 residents (31%) were from non-surgical fields such as pediatrics, anesthesiology, obstetrics and gynecology, and general practice. In the surgical specialty group, 174 residents (38.8%) specialized in general surgery subspecialties, and 87 (19.4%) specialized in gastrointestinal surgery. The residents had diverse educational backgrounds, including clinical and scientific postgraduates, long-cycle clinical postgraduates, 4 + 4 clinical postgraduates, and those holding the "Four-in-One Certificates" for clinical professional masters. The remaining 139 non-surgical residents rotated through the gastrointestinal surgery department from other medical fields. 2. Distribution of Medical Licensure Status and Acute Abdomen-Oriented Training The distribution of residents with and without medical practitioner qualifications at the time of entry was analyzed (Table 1 ). Of the surgical residents, 168 (54.2%) had medical qualifications, while 142 (45.8%) did not. Among the qualified residents, 50% (84/168) received acute abdomen-oriented clinical training, whereas the remaining 50% did not. Similarly, of the 142 residents without medical licensure, 77 (54.2%) received training, while 65 (45.8%) did not. Among the general surgery specialty residents, 48 (53.3%) received acute abdomen training, while 42 (46.7%) did not. Among gastrointestinal surgery residents, 24 (52.2%) received training. Non-surgical residents were similarly split, with 40 (44.4%) with a medical qualification receiving training, and 20 (40.8%) without a medical qualification receiving it. Chi-square tests showed no significant differences in licensure status across the subgroups (p > 0.05). Table 1 The relationship between the residents of different specialties who have obtained the medical license or not when they enter the standardized residency training in Shanghai Residents with different background Practitioner Qualification Certificate or not P-value (Chi-square value) Yes (%) No (%) Residents in Surgery Base 168 (54.2%) 142 (45.8%) 0.458 (0.550) Received systematic acute abdomen clinical training 84 77 Nor received systematic acute abdomen clinical training 84 65 Residents Majoring in General Surgery in Surgery Base 90 (51.7%) 84 (48.3%) 0.850 (0.036) Received systematic acute abdomen clinical training 48 46 Nor received systematic acute abdomen clinical training 42 38 Residents Majoring in Gastrointestinal Surgery in Surgery Base 46 (57.4%) 41 (42.6%) 0.890 (0.019) Received systematic acute abdomen clinical training 24 22 Nor received systematic acute abdomen clinical training 22 19 Residents in Other Bases except Surgery 90 (64.7%) 49 (35.3%) 0.680 (0.170) Received systematic acute abdomen clinical training 40 20s Nor received systematic acute abdomen clinical training 50 29 3. Postoperative Complications in Gastric Tumor Surgery Patients From August 2012 to August 2024, 2257 gastric tumor patients who underwent transabdominal gastrectomy at the Department of Gastrointestinal Surgery were retrospectively analyzed. The cohort consisted of 1457 males (64.5%) and 800 females (35.5%) with a median age of 60 years (range: 27–90 years). Among the patients, 1937 (85.8%) had gastric cancer, whereas 320 (14.2%) had other gastric tumors. A total of 1727 patients (76.5%) underwent distal gastrectomy and 530 patients (23.5%) underwent total gastrectomy. All diagnoses were confirmed using postoperative paraffin pathology. The analysis of postoperative complications revealed the following common issues: anastomotic leakage (1.55%), pelvic and abdominal infections (3.94%), postoperative bleeding (1.15%), mechanical bowel obstruction (1.6%), paralytic ileus (4.39%), and delayed wound healing (1.82%). In cases in wh ich secondary surgeries were required, the primary causes included abdominal and pelvic infections (1.82%), mechanical bowel obstruction (1.37%), paralytic ileus (1.82%), and postoperative bleeding (0.67%). Mortality due to complications was relatively low, with severe infections (0.31%) being the leading cause of death, followed by anastomotic leakage, pelvic and abdominal infections, respiratory complications, and embolism complications (0.09%) each [ 15 ]. 4. Clinical Case Analysis Scores for Postoperative Complications As shown in Table 2 , the mean clinical case analysis scores for diagnosing postoperative complications in gastric tumors were significantly higher for residents who had received acute abdomen-oriented clinical training than for those who had not. Specifically: Among 310 surgical residents, those who had received training (n = 168) had a mean score of 48.5 ± 7.4, while those who had not received training (n = 142) scored 40.7 ± 7.5. Among the 90 residents majoring in general surgery, those who received acute abdomen-oriented teaching (n = 48) had a mean score of 63.2 ± 10.1, while those who did not (n = 42) scored 55.5 ± 10.1. Among 46 residents specializing in gastrointestinal surgery, those who received the teaching (n = 24) scored 76.4 ± 7.6, while those who did not (n = 22) scored 65.3 ± 7.8. Among 139 non-surgical residents, those who received acute abdomen-oriented training (n = 60) scored 41.2 ± 8.5, while those who did not (n = 79) scored 24.1 ± 9.8. All comparisons between the groups were statistically significant (p < 0.05). 5. Impact of Medical License Status on Diagnostic Accuracy Further analysis was conducted to assess whether having a medical license at the time of entry into the residency program influenced the diagnostic performance. The results showed that residents who received acute abdomen-oriented teaching consistently demonstrated higher diagnostic accuracy for postoperative complications irrespective of whether they had a medical license upon entering the program. This trend was particularly evident among gastrointestinal surgery-focused residents, who showed the most significant improvement in diagnostic scores after completing acute abdomen-oriented training [ 16 ]. Table 2 Analysis of clinical case analysis scores of residents with different professional backgrounds for postoperative complications of gastric cancer Residents with different background Score of gastric cancer postoperative complications Diagnosis T-value Residents who had received systematic acute abdomen clinical training Residents who hadn’t received systematic acute abdomen clinical training Residents in Surgery Base With Practitioner Qualification Certificate (n = 168) 50.2 ± 8.0 43.0 ± 6.7 *4.423 Without Practitioner Qualification Certificate (n = 142) 46.4 ± 6.2 37.3 ± 7.4 *5.051 Residents Majoring in General Surgery in Surgery Base With Practitioner Qualification Certificate (n = 90) 69.4 ± 8.0 62.3 ± 8.2 *2.873 Without Practitioner Qualification Certificate (n = 84) 56.3 ± 7.2 48.9 ± 7.0 *3.306 Residents Majoring in Gastrointestinal Surgery in Surgery Base With Practitioner Qualification Certificate (n = 46) 79.5 ± 7.1 66.7 ± 8.3 *5.465 Without Practitioner Qualification Certificate (n = 41) 72.9 ± 6.9 63.7 ± 7.1 *4.137 Residents in Other Bases except Surgery With Practitioner Qualification Certificate (n = 90) 41.3 ± 8.5 23.6 ± 9.6 *9.080 Without Practitioner Qualification Certificate (n = 49) 41.0 ± 8.5 24.8 ± 10.2 *5.814 Note: "*" means P < 0.05 Discussion 1. The Critical Role of Accurate Diagnosis in Acute Abdominal Syndrome and Its Challenges Acute abdominal syndrome refers to a collection of clinical conditions characterized by sudden severe abdominal pain and tenderness, often indicating serious underlying surgical issues. These conditions necessitate urgent evaluation and intervention by an attending surgeon to determine whether surgery is required. The diagnosis of acute abdominal syndrome is particularly challenging owing to its broad range of potential causes, many of which extend beyond the abdominal cavity and can involve non-surgical or systemic diseases [ 17 ]. One of the greatest hurdles in diagnosing acute abdominal syndrome is the need for rapid and accurate decision making in a high-pressure, time-sensitive environment. The diagnostic approach involves detailed medical history, thorough physical examination, laboratory investigations, and imaging studies. However, the most critical component remains clinical history and physical examination, both of which must be methodical and comprehensive. Although laboratory and imaging studies have significantly enhanced diagnostic capabilities, they should not overshadow the importance of clinical skills [ 18 ]. Surgeons, particularly residents, must develop proficiency in history taking and physical examination, as these are the foundation of effective surgical practice and are frequently tested in clinical examinations. 2. Differential Diagnosis and Varied Presentations of Acute Abdominal Syndrome The differential diagnosis of acute abdominal syndrome is broad, influenced by factors such as age, sex, medical history, and presenting symptoms. For instance, appendicitis is common in younger patients [ 19 ], while older adults are more likely to have conditions like biliary diseases, bowel obstruction, ischemic bowel disease, or diverticulitis [ 20 ]. This highlights the need for a comprehensive diagnostic approach that considers both common and rare causes. Acute abdominal syndrome causes can be categorized as surgical or nonsurgical. Surgical causes, such as perforated ulcers, bowel obstructions, and abdominal trauma, typically require surgery. Non-surgical causes include systemic medical conditions like metabolic disorders (e.g., diabetic ketoacidosis), hematologic conditions (e.g., sickle cell crises), and toxin-induced illnesses (e.g., drug overdoses) [21–22]. While nonsurgical causes may not need surgery, they can mimic surgical emergencies, making their exclusion essential. Distinguishing these causes requires high clinical suspicion and a thorough evaluation of patient demographics, clinical presentation, and physical findings. 3. Surgical Causes of Acute Abdominal Syndrome: Understanding the Five Major Categories The surgical causes of acute abdominal syndrome often require urgent surgical intervention and can be classified into five broad categories: Hemorrhagic Conditions Includes solid organ injuries (e.g., liver or spleen trauma), ruptured abdominal aortic aneurysms, ectopic pregnancies, gastrointestinal vascular malformations, and hemorrhagic pancreatitis. These conditions cause internal bleeding, leading to hemodynamic instability and often necessitate immediate surgery to prevent fatal outcomes. Infectious Conditions Conditions such as appendicitis, cholecystitis, diverticulitis, and abscesses often present with fever, localized tenderness, and signs of systemic infection, requiring surgical drainage or resection. Perforation Perforated ulcers, diverticulitis, or bowel perforation lead to peritonitis, which requires prompt surgery to prevent sepsis and organ failure. Obstructive Conditions Includes bowel obstruction, volvulus, and adhesions from prior surgeries. If untreated, these can lead to ischemia, necrosis, or perforation. Ischemic Conditions Conditions like mesenteric ischemia, testicular torsion, and ovarian torsion require immediate surgical intervention to preserve organ function. Understanding these categories is vital for surgical residents, as they are commonly encountered in the emergency department, accounting for about 25% of surgical cases in general hospitals. This knowledge is a key focus in surgical training. 4. The Diagnostic Workflow: Prioritizing Clinical History, Physical Examination, and Imaging Given the urgency of many surgical conditions associated with acute abdominal syndrome, the diagnostic workflow must be expeditious and thorough. The typical workflow begins with history taking, followed by physical examination, laboratory tests, and imaging studies [23]. Although imaging tools such as CT scans, X-rays, and ultrasound have significantly enhanced diagnostic accuracy, clinical history and physical examination remain the most important elements in evaluating acute abdominal syndrome. For example, a sudden onset of right lower quadrant pain accompanied by fever and leukocytosis strongly suggests appendicitis, whereas diffuse abdominal tenderness and signs of sepsis might point to perforation or peritonitis. Although imaging studies are invaluable for confirming a diagnosis, clinical judgment based on the patient’s symptoms, physical exam ination findings, and history remains the cornerstone in guiding treatment. Surgeons must rely on their clinical acumen to determine which tests are necessary to ensure that the diagnostic process does not delay the initiation of urgent treatment. 5. Impact of Acute Abdomen-Oriented Training on Surgical Residents' Competence This study highlights the diverse backgrounds of residents in the Gastrointestinal Surgery Department, with many lacking prior experience in general surgery or gastrointestinal surgery. Despite this, our findings indicate that residents who received acute abdomen-oriented clinical teaching demonstrated significantly higher diagnostic accuracy in identifying postoperative complications of gastric tumors. This improvement was particularly notable among residents without prior surgical experience, reinforcing the effectiveness of targeted acute abdominal training in enhancing clinical competence. Such training provides residents with a foundational understanding of surgical emergencies, which is essential for handling high-stake situations in clinical practice [24]. 6. The Relationship Between Postoperative Complications and Acute Abdominal Syndrome in Gastrointestinal Surgery The strong correlation between common postoperative complications and acute abdominal syndrome in gastrointestinal surgery is another benefit of acute abdominal training. In this study, anastomotic leakage, infection, postoperative bleeding, and bowel obstruction were the most prevalent complications observed in gastric tumor surgery. These complications are often associated with acute abdominal syndrome, and provide excellent teaching opportunities for residents. National data support this with a high incidence of serious postoperative complications, particularly anastomotic leakage and severe infections, which are frequently associated with increased morbidity and mortality. According to 2016 data from the Chinese Gastrointestinal Oncology Surgical Alliance, the incidence of grade 3 or higher postoperative complications in gastric cancer surgeries was 3.8%, with hemorrhage, severe infections, and anastomotic leakage leading to morbidity and mortality [25]. 7. The Role of Multidisciplinary Teams in Managing Acute Abdominal Syndrome As healthcare continues to shift towards multidisciplinary team (MDT) models, the management of acute abdominal syndrome increasingly involves collaboration across various specialties. Surgeons, anesthesiologists, radiologists, pathologists, and critical care teams all contribute d to the comprehensive management of these patients. This multidisciplinary approach improves diagnostic accuracy and patient outcomes by addressing all facets of patient care such as pain management, nutritional support, and infection control [26]. For surgical residents, it is essential to understand how to work within MDTs, as this collaborative approach is becoming standard in acute care settings. Therefore , training in acute abdominal syndrome should not only emphasize surgical techniques, but also include training in working effectively with other healthcare professionals. This prepares the residents to develop the communication and teamwork skills necessary for modern clinical practice. Strengths and Limitations This study's strengths include a large cohort of 449 residents undergoing standardized gastrointestinal surgery training over 12 years, providing robust data. Statistical methods like chi-square and t-tests enabled comparisons of diagnostic performance between residents with and without acute abdomen-oriented teaching. The study demonstrates how targeted teaching improves diagnostic accuracy, particularly for those without prior surgical experience, addressing a critical issue in surgical education [27]. Including residents from both surgical and non-surgical backgrounds highlights how structured training can enhance clinical competence across specialties, offering valuable insights for residency programs [28]. However, the study's retrospective design introduces potential recall bias and uncontrolled confounding factors, limiting the ability to account for all variables affecting diagnostic performance, such as teaching methods or resident experience [29]. The single-institution setting at Ruijin Hospital limits generalizability, and multi-center studies would strengthen these findings [30]. Future studies should include real-world data or longitudinal follow-up to assess the long-term effects of acute abdomen-oriented training [31–32]. Conclusion Acute abdominal syndrome is a rapidly progressing condition that, if not diagnosed and treated promptly, can lead to serious complications or death. Its fast clinical course provides immediate feedback on residents' clinical skills. Surgical residents must recognize the urgency of diagnosing and managing this condition and use each case to refine their diagnostic and decision-making abilities. Given its time-sensitive nature and broad impact, comprehensive training in acute abdominal syndrome management is essential. Incorporating this into standardized residency programs equips residents to handle these emergencies, improving patient outcomes and surgical care quality [33]. Declarations Ethics Approval and Consent to Participate This study was reviewed and approved by the Ruijin Hospital Ethics Committee, Shanghai Jiao Tong University School of Medicine (Ethics Committee Reference Number: [2017] Lin Lun Di No. 6), in compliance with the Helsinki Declaration. Written informed consent was obtained from all participants prior to inclusion in the study. Consent for Publication Written informed consent was obtained from all participants for the publication of their data. Availability of Data and Materials The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. All the materials used in this study are available upon request. Competing Interests The authors declare that they have no competing interests related to this study. Clinical trial number Not applicable. Funding This study received funding support by Shanghai Jiao Tong University Medical-Engineering Interdisciplinary Research Fund (YG2025QNA14) and Shanghai Jiao Tong University School of Medicine Faculty Development Training Program (JFXM202508). Authors' Contributions A.R. contributed to the study design, data collection, data analysis, and manuscript writing. S.Y. assisted with the data collection, analysis, and manuscript drafting. L.Z. provided critical insights into the data analysis and manuscript revision. J.H. contributed to the interpretation of findings and manuscript revision. 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Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review. Cureus. 2023 Sep 4;15(9):e44654. doi: 10.7759/cureus.44654. PMID: 37799263; PMCID: PMC10549779. Su H, Bu Z. Research progress of minimally invasive surgery for gastric cancer. Chin J Cancer Res. 2023 Aug 30;35(4):343-353. doi: 10.21147/j.issn.1000-9604.2023.04.02. PMID: 37691896; PMCID: PMC10485916. Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. J Am Coll Surg. 2018 Sep;227(3):382-386. doi: 10.1016/j.jamcollsurg.2018.06.006. Epub 2018 Jul 25. PMID: 30055849. Rowe DG, Dalton JC, Ladowski JM, Soto AL, Rhodin KE, Migaly J, Greenberg JA, Tracy ET. Prior Teaching Experience and Barriers to Effective Resident Teaching: A Cross-Sectional Study. J Surg Res. 2024 Sep;301:371-377. doi: 10.1016/j.jss.2024.06.008. Epub 2024 Jul 18. PMID: 39029259. Régo P, Peterson R, Callaway L, Ward M, O'Brien C, Donald K. Using a structured clinical coaching program to improve clinical skills training and assessment, as well as teachers' and students' satisfaction. Med Teach. 2009 Dec;31(12):e586-95. doi: 10.3109/01421590903193588. PMID: 19995160. Hajjaj FM, Salek MS, Basra MK, Finlay AY. Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice. J R Soc Med. 2010 May;103(5):178-87. doi: 10.1258/jrsm.2010.100104. PMID: 20436026; PMCID: PMC2862069. Omerovic E, Petrie M, Redfors B, Fremes S, Murphy G, Marquis-Gravel G, Lansky A, Velazquez E, Perera D, Reid C, Smith J, van der Meer P, Lipsic E, Juni P, McMurray J, Bauersachs J, Køber L, Rouleau JL, Doenst T. Pragmatic randomized controlled trials: strengthening the concept through a robust international collaborative network: PRIME-9-Pragmatic Research and Innovation through Multinational Experimentation. Trials. 2024 Jan 23;25(1):80. doi: 10.1186/s13063-024-07935-y. PMID: 38263138; PMCID: PMC10807265. Laurell H, Hansson LE, Gunnarsson U. Impact of clinical experience and diagnostic performance in patients with acute abdominal pain. Gastroenterol Res Pract. 2015;2015:590346. doi: 10.1155/2015/590346. Epub 2015 Jan 22. PMID: 25685146; PMCID: PMC4320905. Légaré F, Adekpedjou R, Stacey D, Turcotte S, Kryworuchko J, Graham ID, Lyddiatt A, Politi MC, Thomson R, Elwyn G, Donner-Banzhoff N. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2018 Jul 19;7(7):CD006732. doi: 10.1002/14651858.CD006732.pub4. PMID: 30025154; PMCID: PMC6513543. Leigh S. Hamby, Thomas A. Colacchio, Eugene C. Nelson,Application of quality improvement to surgical practice,Surgery,Volume 128, Issue 5,2000,Pages 836-844,ISSN 0039-6060,https://doi.org/10.1067/msy.2000.109116. Additional Declarations No competing interests reported. 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Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIie3PsQrCMBCA4SuByxJ0jQitjxApWH2biNAu7eBW50ImcXbSt3BuEepSJxfBpcWX6CBqJ1dvFMw33XA/3AFY1g9SDJxapugiz3JywtS06vk9UWpiAoByZdz5TsYjWhJwflFXnEQGYoA2PXxPZplYNlsRJgbOubOuboTDjmLhS1kmxtlo5hhaEg4f6hUhE4qa8FJKjRqRmnS/MCVzHBuBuiD9EvRPTT14ouft70XdpoQEQKjPmFP2O7wmLlqWZf2tN7ISOCbxajPwAAAAAElFTkSuQmCC","orcid":"","institution":"Ruijin Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zhenglun","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2025-09-22 22:53:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7682552/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7682552/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96503368,"identity":"61cef30d-ca0d-4963-9548-0f2a861e3800","added_by":"auto","created_at":"2025-11-22 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09:08:33","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96458,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7682552/v1/9ee1ded158c7710fbc55ebbd.html"},{"id":106948100,"identity":"1d25b3cb-367f-4811-8e50-ecdd2e93b0b2","added_by":"auto","created_at":"2026-04-15 06:58:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1255983,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7682552/v1/ec949db4-3a65-44d6-b3ab-269fefabb54f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Directed Teaching on Acute Abdominal Syndrome Effectively Improves Resident Physicians' Diagnostic Skills in Postoperative Complications of Gastric Tumor Surgery","fulltext":[{"header":"What is already known on this topic","content":"\u003cp\u003eAcute Abdominal Syndrome (AAS) is a critical condition that poses significant diagnostic challenges, especially for residents in surgical training. Previous studies have highlighted gaps in the diagnostic proficiency of resident physicians in identifying postoperative complications, particularly in gastric tumor surgeries. There has been a need to integrate focused teaching on AAS to improve diagnostic accuracy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study demonstrates that incorporating AAS-focused teaching into standardized surgical residency training significantly enhances residents' diagnostic accuracy for postoperative complications in gastric tumor surgeries. The improvement was observed across multiple specialty backgrounds, with residents showing better proficiency in identifying complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHow this study might affect research, practice, or policy:\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings suggest that focused clinical teaching on AAS can be an effective approach to improving diagnostic skills in surgical residency programs. This could lead to the adoption of similar teaching models in other surgical specialties to enhance the diagnostic accuracy of residents, potentially reducing complications and improving patient outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eSurgical training is a multifaceted process that requires technical proficiency, clinical decision-making, patient management, and integration of basic and clinical sciences. Surgical residents refine their skills through hands-on experience, which has been the core of surgical education for over a century. Since the late 19th century, visionary surgeons have emphasized the need for structured training programs offering clinical practice, research, and mentorship in diverse environments. These early proponents argued that residency programs should foster not only technical skills but also critical thinking, clinical reasoning, and the ability to manage complex cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2010, Shanghai introduced a standardized residency training system designed to develop highly skilled surgeons who would advance surgery and educate future generations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The system aims to provide surgeons with comprehensive clinical knowledge, improving diagnostic and procedural skills while also fostering research capabilities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA critical area in surgical training is the diagnosis and management of acute abdominal syndrome, a condition characterized by sudden, severe abdominal pain due to various underlying causes. This syndrome includes multiple emergency conditions, many of which require immediate surgical intervention. These conditions, such as bowel obstruction, perforated viscus, and ischemic bowel disease, present diagnostic challenges due to their varied causes and overlapping symptoms. Prompt diagnosis is crucial, as delays can lead to serious complications or death [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Residents must develop strong diagnostic acumen and clinical judgment to manage these dynamic conditions effectively [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecognizing its importance, our department integrated acute abdominal syndrome diagnosis and treatment into the standardized curriculum for gastrointestinal surgery residents. Since 2017, a structured teaching program focused on acute abdominal syndrome has been implemented to enhance residents' diagnostic and decision-making abilities. This program includes detailed teaching on clinical presentation, differential diagnosis, and management strategies, emphasizing timely surgical intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The goal is to improve diagnostic skills, particularly for postoperative complications in gastric tumor surgeries, where issues like infection, hemorrhage, and anastomotic leaks are common [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study evaluates the impact of acute abdominal syndrome-directed teaching on residents\u0026rsquo; diagnostic accuracy for complications following gastric tumor surgery. We analyzed data from residents trained at Ruijin Hospital between 2012 and 2024, comparing the diagnostic performance of those who received AAS-focused training with those who did not. We hypothesize that specialized training will improve diagnostic accuracy, highlighting its effectiveness in enhancing clinical competence [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and Methods","content":"\n\u003ch3\u003e1. Clinical Data\u003c/h3\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Selection of Residents\u003c/h2\u003e\u003cp\u003e In accordance with national guidelines set by the Shanghai Municipal Health Commission, surgical residents are required to complete a 13-month rotation in general surgery, while non-surgical residents, including those in obstetrics and gynecology, undergo a 2-month rotation. This study includes 449 residents who completed standardized residency training in the Gastrointestinal Surgery Department at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, from August 2012 to August 2022. Among them, 352 were male and 97 were female. All residents completed the mandatory gastrointestinal surgery rotation as part of their training.\u003c/p\u003e\u003cp\u003eSince 2017, acute abdominal-oriented clinical teaching has been incorporated into the residency program. Residents were divided into two groups based on whether they received this specific training. Case analysis scores for postoperative complications related to gastrectomy were recorded for residents of different specialties in each group.\u003c/p\u003e\u003cp\u003eResidents were categorized into four groups based on their educational background: (1) surgical base residents, (2) general surgery subspecialty residents, (3) gastrointestinal surgery-focused residents, and (4) non-surgical residents. Medical licensure status was also noted. The residents\u0026rsquo; backgrounds included clinical, scientific, and long-cycle clinical programs, with some specializing in general or gastrointestinal surgery, and others from non-surgical disciplines like pediatrics and anesthesiology [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Selection of Postoperative Complications Cases\u003c/h2\u003e\u003cp\u003e We conducted a retrospective review of data from 2257 gastric tumor patients who underwent transabdominal gastrectomy in the Gastrointestinal Surgery Department at Ruijin Hospital between August 2012 and August 2022. The cohort included 1457 males (64.5%) and 800 females (35.5%), with a median age of 60 years (range: 27\u0026ndash;90). Among all patients, 1937 (85.8%) were diagnosed with gastric cancer, while 320 (14.2%) had other types of gastric tumors. Of the total cohort, 1727 patients (76.5%) underwent distal gastrectomy, and 530 patients (23.5%) underwent total gastrectomy. All diagnoses were confirmed using postoperative paraffin pathology [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePostoperative complications were categorized according to the Chinese Expert Consensus on the Diagnosis and Registration of Postoperative Complications in Gastrointestinal Cancer Surgery (2018 edition) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These complications included gastrointestinal, incision-related, respiratory, cardiovascular, urinary, infection-related, embolism-related, and other complications. To create a comprehensive case discussion collection, we supplemented clinical data, including patient histories, physical exams, lab results, pathology reports, imaging data, and references for cases relevant to the clinical teaching of acute surgical abdomen [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Inter-group Analysis of Clinical Case Analysis Assessment\u003c/h2\u003e\u003cp\u003eWe constructed a question bank for clinical case analysis based on postoperative complication data and in line with the national and Shanghai residency training program exit exam requirements. During the exit assessments, each resident presented with 10 cases: four from gastrointestinal-related complications and one from each of the other categories (i.e., incision-related, respiratory, cardiovascular, urinary, infection, and embolism complications). Each case was worth 10 points for a total of 100 points. The assessment focused on four key areas: clinical diagnosis (two points), diagnostic reasoning (two points), differential diagnosis (two points), and clinical management principles (four points).\u003c/p\u003e\u003cp\u003eSince 2017, acute abdominal-oriented clinical teaching has been implemented in the Gastrointestinal Surgery Department for residents of gastrointestinal surgery. Therefore, residents who underwent standardized training between August 2012 and August 2022 were categorized based on whether they had received systematic acute abdominal-focused clinical teaching. Clinical case analysis scores for residents with different professional backgrounds were recorded and compared [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e2. Data Analysis\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics were used to analyze the demographic and professional background distribution\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003es of residents from different specialties. A\u003c/span\u003e chi-square test was performed to determine whether there were significant differences in the proportion of residents who obtained a medical practitioner qualification certificate upon entering the program. A t-test was used to compare the diagnostic scores between two groups of residents: those who had received acute abdomen-oriented clinical teaching and those who had not. Data are presented as \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe\u003c/span\u003e mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Statistical analysis was performed using SAS 'PROCGLM' 8.0, with a p-value of \u0026lt;\u0026thinsp;0.05 considered statistically significant [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Demographic and Professional Background of Residents in the Gastrointestinal Surgery Department\u003c/h3\u003e\n\u003cp\u003eBetween August 2012 and August 2024, 449 residents underwent standardized residency training in the Department of Gastrointestinal Surgery at Ruijin Hospital, affiliated with Shanghai Jiao Tong University School of Medicine. The cohort included 352 males (78.3%) and 97 females (21.7%). Of these, 310 residents (69%) came from surgical specialties, while 139 residents (31%) were from non-surgical fields such as pediatrics, anesthesiology, obstetrics and gynecology, and general practice.\u003c/p\u003e\u003cp\u003eIn the surgical specialty group, 174 residents (38.8%) specialized in general surgery subspecialties, and 87 (19.4%) specialized in gastrointestinal surgery. The residents had diverse educational backgrounds, including clinical and scientific postgraduates, long-cycle clinical postgraduates, 4\u0026thinsp;+\u0026thinsp;4 clinical postgraduates, and those holding the \"Four-in-One Certificates\" for clinical professional masters. The remaining 139 non-surgical residents rotated through the gastrointestinal surgery department from other medical fields.\u003c/p\u003e\n\u003ch3\u003e2. Distribution of Medical Licensure Status and Acute Abdomen-Oriented Training\u003c/h3\u003e\n\u003cp\u003eThe distribution of residents with and without medical practitioner qualifications at the time of entry was analyzed (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of the surgical residents, 168 (54.2%) had medical qualifications, while 142 (45.8%) did not. Among the qualified residents, 50% (84/168) received acute abdomen-oriented clinical training, whereas the remaining 50% did not. Similarly, of the 142 residents without medical licensure, 77 (54.2%) received training, while 65 (45.8%) did not.\u003c/p\u003e\u003cp\u003eAmong the general surgery specialty residents, 48 (53.3%) received acute abdomen training, while 42 (46.7%) did not. Among gastrointestinal surgery residents, 24 (52.2%) received training. Non-surgical residents were similarly split, with 40 (44.4%) with a medical qualification receiving training, and 20 (40.8%) without a medical qualification receiving it. Chi-square tests showed no significant differences in licensure status across the subgroups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe relationship between the residents of different specialties who have obtained the medical license or not when they enter the standardized residency training in Shanghai\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResidents with different background\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePractitioner Qualification Certificate or not\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP-value (Chi-square value)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents in Surgery Base\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e168 (54.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142 (45.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.458 (0.550)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReceived systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNor received systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents Majoring in General Surgery in Surgery Base\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (51.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (48.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.850 (0.036)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReceived systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNor received systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents Majoring in Gastrointestinal Surgery in Surgery Base\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (57.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (42.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.890 (0.019)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReceived systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNor received systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents in Other Bases except Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (64.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (35.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.680 (0.170)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReceived systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNor received systematic acute abdomen clinical training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e3. Postoperative Complications in Gastric Tumor Surgery Patients\u003c/h3\u003e\n\u003cp\u003eFrom August 2012 to August 2024, 2257 gastric tumor patients who underwent transabdominal gastrectomy at the Department of Gastrointestinal Surgery were retrospectively analyzed. The cohort consisted of 1457 males (64.5%) and 800 females (35.5%) with a median age of 60 years (range: 27\u0026ndash;90 years). Among the patients, 1937 (85.8%) had gastric cancer, whereas 320 (14.2%) had other gastric tumors. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA total of\u003c/span\u003e 1727 patients (76.5%) underwent distal gastrectomy and 530 patients (23.5%) underwent total gastrectomy. All diagnoses were confirmed using postoperative paraffin pathology.\u003c/p\u003e\u003cp\u003eThe analysis of postoperative complications revealed the following common issues: anastomotic leakage (1.55%), pelvic and abdominal infections (3.94%), postoperative bleeding (1.15%), mechanical bowel obstruction (1.6%), paralytic ileus (4.39%), and delayed wound healing (1.82%). In cases \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ein wh\u003c/span\u003eich secondary surgeries were required, the primary causes included abdominal and pelvic infections (1.82%), mechanical bowel obstruction (1.37%), paralytic ileus (1.82%), and postoperative bleeding (0.67%). Mortality due to complications was relatively low, with severe infections (0.31%) being the leading cause of death, followed by anastomotic leakage, pelvic and abdominal infections, respiratory complications, and embolism complications (0.09%) each [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003e4. Clinical Case Analysis Scores for Postoperative Complications\u003c/h3\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the mean clinical case analysis scores for diagnosing postoperative complications in gastric tumors were significantly higher for residents who had received acute abdomen-oriented clinical training than for those who had not. Specifically:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAmong 310 surgical residents, those who had received training (n\u0026thinsp;=\u0026thinsp;168) had a mean score of 48.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4, while those who had not \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ereceived training (n\u0026thinsp;=\u0026thinsp;142) scored\u003c/span\u003e 40.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAmong \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe\u003c/span\u003e 90 residents majoring in general surgery, those who received acute abdomen-oriented teaching (n\u0026thinsp;=\u0026thinsp;48) had a mean score of 63.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1, while those who did not (n\u0026thinsp;=\u0026thinsp;42) scored 55.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAmong 46 residents specializing in gastrointestinal surgery, those who received the teaching (n\u0026thinsp;=\u0026thinsp;24) scored 76.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6, while those who did not (n\u0026thinsp;=\u0026thinsp;22) scored 65.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAmong 139 non-surgical residents, those who received acute abdomen-oriented training (n\u0026thinsp;=\u0026thinsp;60) scored 41.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5, while those who did not (n\u0026thinsp;=\u0026thinsp;79) scored 24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eAll comparisons between the groups were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003ch3\u003e5. Impact of Medical License Status on Diagnostic Accuracy\u003c/h3\u003e\n\u003cp\u003eFurther analysis was conducted to assess whether having a medical license at the time of entry into the residency program influenced \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe diagnostic performance. The results showed that residents who received acute abdomen-oriented teaching consistently demonstrated higher diagnostic accuracy for postoperative complications\u003c/span\u003e irrespective of whether they had a medical license upon entering the program. This trend was particularly evident among gastrointestinal surgery-focused residents, who showed the most significant improvement in diagnostic scores after completing acute abdomen-oriented training [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of clinical case analysis scores of residents with different professional backgrounds for postoperative complications of gastric cancer\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResidents with different background\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eScore of gastric cancer postoperative complications Diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eT-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResidents who had received systematic acute abdomen clinical training\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eResidents who hadn\u0026rsquo;t received systematic acute abdomen clinical training\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents in Surgery Base\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWith Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;168)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*4.423\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWithout Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e46.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e37.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*5.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents Majoring in General Surgery in Surgery Base\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWith Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e69.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*2.873\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWithout Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e56.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e48.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*3.306\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents Majoring in Gastrointestinal Surgery in Surgery Base\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWith Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e79.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e66.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*5.465\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWithout Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e72.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e63.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*4.137\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidents in Other Bases except Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWith Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e41.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*9.080\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWithout Practitioner Qualification Certificate (n\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e41.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e*5.814\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: \"*\" means P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\n\u003ch3\u003e1. The Critical Role of Accurate Diagnosis in Acute Abdominal Syndrome and Its Challenges\u003c/h3\u003e\n\u003cp\u003eAcute abdominal syndrome refers to a collection of clinical conditions characterized by sudden severe abdominal pain and tenderness, often indicating serious underlying surgical issues. These conditions necessitate urgent evaluation and intervention by an attending surgeon to determine whether surgery is required. The diagnosis of acute abdominal syndrome is particularly challenging owing to its broad range of potential causes, many of which extend beyond the abdominal cavity and can involve non-surgical or systemic diseases [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne of the greatest hurdles in diagnosing acute abdominal syndrome is the need for rapid and accurate decision making in a high-pressure, time-sensitive environment. The diagnostic approach involves detailed medical history, thorough physical examination, laboratory investigations, and imaging studies. However, the most critical component remains clinical history and physical examination, both of which must be methodical and comprehensive. Although laboratory and imaging studies have significantly enhanced diagnostic capabilities, they should not overshadow the importance of clinical skills [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Surgeons, particularly residents, must develop proficiency in history taking and physical examination, as these are the foundation of effective surgical practice and \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eare frequently tested in clinical examinations.\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003e2. Differential Diagnosis and Varied Presentations of Acute Abdominal Syndrome\u003c/h3\u003e\n\u003cp\u003eThe differential diagnosis of acute abdominal syndrome is broad, influenced by factors such as age, sex, medical history, and presenting symptoms. For instance, appendicitis is common in younger patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], while older adults are more likely to have conditions like biliary diseases, bowel obstruction, ischemic bowel disease, or diverticulitis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This highlights the need for a comprehensive diagnostic approach that considers both common and rare causes.\u003c/p\u003e\u003cp\u003eAcute abdominal syndrome causes can be categorized as surgical or nonsurgical. Surgical causes, such as perforated ulcers, bowel obstructions, and abdominal trauma, typically require surgery. Non-surgical causes include systemic medical conditions like metabolic disorders (e.g., diabetic ketoacidosis), hematologic conditions (e.g., sickle cell crises), and toxin-induced illnesses (e.g., drug overdoses) [21\u0026ndash;22]. While nonsurgical causes may not need surgery, they can mimic surgical emergencies, making their exclusion essential. Distinguishing these causes requires high clinical suspicion and a thorough evaluation of patient demographics, clinical presentation, and physical findings.\u003c/p\u003e\n\u003ch3\u003e3. Surgical Causes of Acute Abdominal Syndrome: Understanding the Five Major Categories\u003c/h3\u003e\n\u003cp\u003eThe surgical causes of acute abdominal syndrome often require urgent surgical intervention and can be classified into five broad categories:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHemorrhagic Conditions\u003c/strong\u003e\u003cp\u003eIncludes solid organ injuries (e.g., liver or spleen trauma), ruptured abdominal aortic aneurysms, ectopic pregnancies, gastrointestinal vascular malformations, and hemorrhagic pancreatitis. These conditions cause internal bleeding, leading to hemodynamic instability and often necessitate immediate surgery to prevent fatal outcomes.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInfectious Conditions\u003c/strong\u003e\u003cp\u003eConditions such as appendicitis, cholecystitis, diverticulitis, and abscesses often present with fever, localized tenderness, and signs of systemic infection, requiring surgical drainage or resection.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePerforation\u003c/strong\u003e\u003cp\u003ePerforated ulcers, diverticulitis, or bowel perforation lead to peritonitis, which requires prompt surgery to prevent sepsis and organ failure.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObstructive Conditions\u003c/strong\u003e\u003cp\u003eIncludes bowel obstruction, volvulus, and adhesions from prior surgeries. If untreated, these can lead to ischemia, necrosis, or perforation.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIschemic Conditions\u003c/strong\u003e\u003cp\u003eConditions like mesenteric ischemia, testicular torsion, and ovarian torsion require immediate surgical intervention to preserve organ function.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eUnderstanding these categories is vital for surgical residents, as they are commonly encountered in the emergency department, accounting for about 25% of surgical cases in general hospitals. This knowledge is a key focus in surgical training.\u003c/p\u003e\n\u003ch3\u003e4. The Diagnostic Workflow: Prioritizing Clinical History, Physical Examination, and Imaging\u003c/h3\u003e\n\u003cp\u003eGiven the urgency of many surgical conditions associated with acute abdominal syndrome, the diagnostic workflow must be expeditious and thorough. The typical workflow begins with history taking, followed by physical examination, laboratory tests, and imaging studies [23].\u003c/p\u003e\u003cp\u003eAlthough imaging tools such as CT scans, X-rays, and ultrasound have significantly enhanced diagnostic accuracy, clinical history and physical examination remain the most important elements in evaluating acute abdominal syndrome. For example, a sudden onset of right lower quadrant pain accompanied by fever and leukocytosis strongly suggests appendicitis, whereas diffuse abdominal tenderness and signs of sepsis might point to perforation or peritonitis.\u003c/p\u003e\u003cp\u003eAlthough imaging studies are invaluable for confirming a diagnosis, clinical judgment based on the patient\u0026rsquo;s symptoms, physical exam\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eination findings, and history\u003c/span\u003e remains the cornerstone in guiding treatment. Surgeons must rely on their clinical acumen to determine which tests are necessary to ensure that the diagnostic process does not delay the initiation of urgent treatment.\u003c/p\u003e\n\u003ch3\u003e5. Impact of Acute Abdomen-Oriented Training on Surgical Residents' Competence\u003c/h3\u003e\n\u003cp\u003eThis study highlights the diverse backgrounds of residents in the Gastrointestinal Surgery Department, with many lacking prior experience in general surgery or gastrointestinal surgery. Despite this, our findings indicate that residents who received acute abdomen-oriented clinical teaching demonstrated significantly higher diagnostic accuracy in identifying postoperative complications of gastric tumors. This improvement was particularly notable among residents without prior surgical experience, reinforcing the effectiveness of targeted acute abdominal training in enhancing clinical competence. Such training provides residents with a foundational understanding of surgical emergencies, which is essential for handling high-stake situations in clinical practice [24].\u003c/p\u003e\n\u003ch3\u003e6. The Relationship Between Postoperative Complications and Acute Abdominal Syndrome in Gastrointestinal Surgery\u003c/h3\u003e\n\u003cp\u003eThe strong correlation between common postoperative complications and acute abdominal syndrome in gastrointestinal surgery is another benefit of acute abdominal training. In this study, anastomotic leakage, infection, postoperative bleeding, and bowel obstruction were the most prevalent complications observed in gastric tumor surgery. These complications are often associated with acute abdominal syndrome, \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eand provide excellent teaching opportunities for residents.\u003c/span\u003e\u003c/p\u003e\u003cp\u003eNational data support this with a high incidence of serious postoperative complications, particularly anastomotic leakage and severe infections, which are frequently associated with increased morbidity and mortality. According to 2016 data from the Chinese Gastrointestinal Oncology Surgical Alliance, the incidence of grade 3 or higher postoperative complications in gastric cancer surgeries was 3.8%, with hemorrhage, severe infections, and anastomotic leakage leading to morbidity and mortality [25].\u003c/p\u003e\n\u003ch3\u003e7. The Role of Multidisciplinary Teams in Managing Acute Abdominal Syndrome\u003c/h3\u003e\n\u003cp\u003eAs healthcare continues to shift towards multidisciplinary team (MDT) models, the management of acute abdominal syndrome increasingly involves collaboration across various specialties. Surgeons, anesthesiologists, radiologists, pathologists, and critical care teams all contribute\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ed to the\u003c/span\u003e comprehensive management of these patients. This multidisciplinary approach improves diagnostic accuracy and patient outcomes by addressing all facets of patient care such as pain management, nutritional support, and infection control [26].\u003c/p\u003e\u003cp\u003eFor surgical residents, it is essential to understand how to work within MDTs, as this collaborative approach is becoming standard in acute care settings. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTherefore\u003c/span\u003e, training in acute abdominal syndrome should not only emphasize surgical techniques, but also include training in working effectively with other healthcare professionals. This prepares \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ethe residents to develop the\u003c/span\u003e communication and teamwork skills necessary for modern clinical practice.\u003c/p\u003e"},{"header":"Strengths and Limitations","content":"\u003cp\u003eThis study's strengths include a large cohort of 449 residents undergoing standardized gastrointestinal surgery training over 12 years, providing robust data. Statistical methods like chi-square and t-tests enabled comparisons of diagnostic performance between residents with and without acute abdomen-oriented teaching. The study demonstrates how targeted teaching improves diagnostic accuracy, particularly for those without prior surgical experience, addressing a critical issue in surgical education [27]. Including residents from both surgical and non-surgical backgrounds highlights how structured training can enhance clinical competence across specialties, offering valuable insights for residency programs [28].\u003c/p\u003e\u003cp\u003eHowever, the study's retrospective design introduces potential recall bias and uncontrolled confounding factors, limiting the ability to account for all variables affecting diagnostic performance, such as teaching methods or resident experience [29]. The single-institution setting at Ruijin Hospital limits generalizability, and multi-center studies would strengthen these findings [30]. Future studies should include real-world data or longitudinal follow-up to assess the long-term effects of acute abdomen-oriented training [31\u0026ndash;32].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAcute abdominal syndrome is a rapidly progressing condition that, if not diagnosed and treated promptly, can lead to serious complications or death. Its fast clinical course provides immediate feedback on residents' clinical skills. Surgical residents must recognize the urgency of diagnosing and managing this condition and use each case to refine their diagnostic and decision-making abilities. Given its time-sensitive nature and broad impact, comprehensive training in acute abdominal syndrome management is essential. Incorporating this into standardized residency programs equips residents to handle these emergencies, improving patient outcomes and surgical care quality [33].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study was reviewed and approved by the Ruijin Hospital Ethics Committee, Shanghai Jiao Tong University School of Medicine (Ethics Committee Reference Number: [2017] Lin Lun Di No. 6), in compliance with the Helsinki Declaration. Written informed consent was obtained from all participants prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Written informed consent was obtained from all participants for the publication of their data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. All the materials used in this study are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study received funding support by Shanghai Jiao Tong University Medical-Engineering Interdisciplinary Research Fund (YG2025QNA14) and Shanghai Jiao Tong University School of Medicine Faculty Development Training Program (JFXM202508).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A.R. contributed to the study design, data collection, data analysis, and manuscript writing. S.Y. assisted with the data collection, analysis, and manuscript drafting. L.Z. provided critical insights into the data analysis and manuscript revision. J.H. contributed to the interpretation of findings and manuscript revision. Z. supervised the study, provided guidance on the direction of the study, and critically revised the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMundschenk MB, Odom EB, Ghosh TD, Kleiber GM, Yee A, Patel KB, Mackinnon SE, Tenenbaum MM, Buck DW 2nd. Are Residents Prepared for Surgical Cases? Implications in Patient Safety and Education. J Surg Educ. 2018 Mar-Apr;75(2):403-408. doi: 10.1016/j.jsurg.2017.07.001. Epub 2017 Jul 18. PMID: 28733171.\u003c/li\u003e\n \u003cli\u003eZhang K., Fang L. The Standardized Training of Resident Physicians Boosting the New Medical Reform: Based on the Three Years Practice Effect of Shanghai. 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Observation of the Effectiveness of a Diagnostic Model for Acute Abdominal Pain Based on the Etiology Checklist and Process Thinking. Risk Manag Healthc Policy. 2021 Feb 26;14:835-845. doi: 10.2147/RMHP.S295142. PMID: 33664605; PMCID: PMC7924112.\u003c/li\u003e\n \u003cli\u003eJ. Matthew Fields, Anthony J. Dean,Systemic Causes of Abdominal Pain,Emergency Medicine Clinics of North America,Volume 29, Issue 2,2011,Pages 195-210,ISSN 0733-8627,https://doi.org/10.1016/j.emc.2011.01.011.\u003c/li\u003e\n \u003cli\u003eDatta A. Clinical Skill: The Ebbing Art of Medicine. Malays J Med Sci. 2021 Feb;28(1):105-108. doi: 10.21315/mjms2021.28.1.13. Epub 2021 Feb 24. PMID: 33679226; PMCID: PMC7909357.\u003c/li\u003e\n \u003cli\u003eLEE JA. The influence of sex and age on appendicitis in children and young adults. Gut. 1962 Mar;3(1):80-4. doi: 10.1136/gut.3.1.80. PMID: 14463503; PMCID: PMC1413298.\u003c/li\u003e\n \u003cli\u003eDumic I, Nordin T, Jecmenica M, Stojkovic Lalosevic M, Milosavljevic T, Milovanovic T. Gastrointestinal Tract Disorders in Older Age. Can J Gastroenterol Hepatol. 2019 Jan 17;2019:6757524. doi: 10.1155/2019/6757524. PMID: 30792972; PMCID: PMC6354172.\u003c/li\u003e\n \u003cli\u003eThachil J, Owusu-Ofori S, Bates I. Haematological Diseases in the Tropics. Manson\u0026apos;s Tropical Infectious Diseases. 2014:894\u0026ndash;932.e7. doi: 10.1016/B978-0-7020-5101-2.00066-2. Epub 2013 Oct 21. PMCID: PMC7167525.\u003c/li\u003e\n \u003cli\u003eAbstracts of the 27th Annual Meeting of the Society of General Internal Medicine. Chicago, Illinois, USA, 12-15 May, 2004. J Gen Intern Med. 2004 Apr;19 Suppl 1(Suppl 1):23-260. doi: 10.1111/j.1525-1497.2004.S1002.x. PMID: 15107043; PMCID: PMC1492602.\u003c/li\u003e\n \u003cli\u003eDavis JL, Murray JF. History and Physical Examination. Murray and Nadel\u0026apos;s Textbook of Respiratory Medicine. 2016:263\u0026ndash;277.e2. doi: 10.1016/B978-1-4557-3383-5.00016-6. Epub 2015 Apr 3. PMCID: PMC7152492.\u003c/li\u003e\n \u003cli\u003eCardoso SA, Suyambu J, Iqbal J, Cortes Jaimes DC, Amin A, Sikto JT, Valderrama M, Aulakh SS, Ramana V, Shaukat B, Patel T. Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review. Cureus. 2023 Sep 4;15(9):e44654. doi: 10.7759/cureus.44654. PMID: 37799263; PMCID: PMC10549779.\u003c/li\u003e\n \u003cli\u003eSu H, Bu Z. Research progress of minimally invasive surgery for gastric cancer. Chin J Cancer Res. 2023 Aug 30;35(4):343-353. doi: 10.21147/j.issn.1000-9604.2023.04.02. PMID: 37691896; PMCID: PMC10485916.\u003c/li\u003e\n \u003cli\u003eCooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. J Am Coll Surg. 2018 Sep;227(3):382-386. doi: 10.1016/j.jamcollsurg.2018.06.006. Epub 2018 Jul 25. PMID: 30055849.\u003c/li\u003e\n \u003cli\u003eRowe DG, Dalton JC, Ladowski JM, Soto AL, Rhodin KE, Migaly J, Greenberg JA, Tracy ET. Prior Teaching Experience and Barriers to Effective Resident Teaching: A Cross-Sectional Study. J Surg Res. 2024 Sep;301:371-377. doi: 10.1016/j.jss.2024.06.008. Epub 2024 Jul 18. PMID: 39029259.\u003c/li\u003e\n \u003cli\u003eR\u0026eacute;go P, Peterson R, Callaway L, Ward M, O\u0026apos;Brien C, Donald K. Using a structured clinical coaching program to improve clinical skills training and assessment, as well as teachers\u0026apos; and students\u0026apos; satisfaction. Med Teach. 2009 Dec;31(12):e586-95. doi: 10.3109/01421590903193588. PMID: 19995160.\u003c/li\u003e\n \u003cli\u003eHajjaj FM, Salek MS, Basra MK, Finlay AY. Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice. J R Soc Med. 2010 May;103(5):178-87. doi: 10.1258/jrsm.2010.100104. PMID: 20436026; PMCID: PMC2862069.\u003c/li\u003e\n \u003cli\u003eOmerovic E, Petrie M, Redfors B, Fremes S, Murphy G, Marquis-Gravel G, Lansky A, Velazquez E, Perera D, Reid C, Smith J, van der Meer P, Lipsic E, Juni P, McMurray J, Bauersachs J, K\u0026oslash;ber L, Rouleau JL, Doenst T. Pragmatic randomized controlled trials: strengthening the concept through a robust international collaborative network: PRIME-9-Pragmatic Research and Innovation through Multinational Experimentation. Trials. 2024 Jan 23;25(1):80. doi: 10.1186/s13063-024-07935-y. PMID: 38263138; PMCID: PMC10807265.\u003c/li\u003e\n \u003cli\u003eLaurell H, Hansson LE, Gunnarsson U. Impact of clinical experience and diagnostic performance in patients with acute abdominal pain. Gastroenterol Res Pract. 2015;2015:590346. doi: 10.1155/2015/590346. Epub 2015 Jan 22. PMID: 25685146; PMCID: PMC4320905.\u003c/li\u003e\n \u003cli\u003eL\u0026eacute;gar\u0026eacute; F, Adekpedjou R, Stacey D, Turcotte S, Kryworuchko J, Graham ID, Lyddiatt A, Politi MC, Thomson R, Elwyn G, Donner-Banzhoff N. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2018 Jul 19;7(7):CD006732. doi: 10.1002/14651858.CD006732.pub4. PMID: 30025154; PMCID: PMC6513543.\u003c/li\u003e\n \u003cli\u003eLeigh S. Hamby, Thomas A. Colacchio, Eugene C. Nelson,Application of quality improvement to surgical practice,Surgery,Volume 128, Issue 5,2000,Pages 836-844,ISSN 0039-6060,https://doi.org/10.1067/msy.2000.109116.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Standardized Training for Resident Physicians, Acute Abdominal Syndrome, Postoperative Complications in Gastric Surgery, Clinical Competence","lastPublishedDoi":"10.21203/rs.3.rs-7682552/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7682552/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eThis study aimed to evaluate the effectiveness of incorporating acute abdominal syndrome (AAS) diagnosis and treatment into the standardized training of surgical resident physicians. Specifically, it examines how this curriculum impacts residents' diagnostic abilities regarding postoperative complications in gastric tumor surgeries, considering their background and the perioperative aspects of gastrointestinal surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A total of 449 resident physicians from the Gastrointestinal Surgery Department at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, who participated in standardized training from August 2012 to August 2024, were included in this study. The residents were divided into four groups: surgical specialties, general surgery subspecialties, gastrointestinal surgery within general surgery subspecialties, and non-surgical specialties. Chi-square tests were applied to assess medical licensure status differences between the groups. Diagnostic scores for postoperative complications in gastric tumor surgeries were compared between residents who received systematic teaching focused on AAS and those who did not using a t-test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e No significant differences (p\u0026gt;0.05) in medical licensure status were found across the groups. The stratified analysis showed that residents who received systematic teaching on AAS demonstrated significantly higher diagnostic accuracy for postoperative complications in gastric tumor surgeries (p\u0026lt;0.05) during exit evaluations, regardless of their medical licensure status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e AAS is a critical and rapidly progressing condition requiring surgical intervention. Incorporating AAS-focused clinical teaching into gastrointestinal surgery training is an effective way to improve residents' diagnostic capabilities in identifying postoperative complications in gastric tumor surgeries.\u003c/p\u003e","manuscriptTitle":"Directed Teaching on Acute Abdominal Syndrome Effectively Improves Resident Physicians' Diagnostic Skills in Postoperative Complications of Gastric Tumor Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-22 01:27:52","doi":"10.21203/rs.3.rs-7682552/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ead697c6-6303-48f8-854f-edb646874199","owner":[],"postedDate":"November 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T06:56:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-22 01:27:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7682552","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7682552","identity":"rs-7682552","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}