Systematic Review of Neoadjuvant Immunotherapy for Mismatch Repair Deficient Locally Advanced Colon Cancer: An Emerging Strategy.

BACKGROUND: In April 2023, the National Comprehensive Cancer Network endorsed neoadjuvant immunotherapy for select patients with nonmetastatic mismatch repair deficient colon cancer. Approximately 15% of incident colon cancers are mismatch repair deficient, resulting in a distinct molecular subtype with high microsatellite instability that is responsive to immune checkpoint inhibition. OBJECTIVE: To describe the existing evidence supporting neoadjuvant immunotherapy for mismatch repair deficient, microsatellite unstable nonmetastatic colon cancer. DATA SOURCES: A medical librarian performed PubMed, Embase, and Web of Science searches most recently on April 24, 2023. The PubMed search was re-run on September 26, 2023, to identify any additional studies published between April 24 and September 26, 2023. STUDY SELECTION: Two authors screened titles and abstracts in the published studies. The inclusion criteria were 1) English language, 2) adults with primary cancer of the colon, 3) nonmetastatic disease, 4) neoadjuvant immunotherapy, and 5) reporting on 10 or more cases. INTERVENTION: Neoadjuvant immunotherapy. MAIN OUTCOME MEASURES: Safety (grade 3+ treatment-related adverse events) and efficacy (complete pathologic responses). RESULTS: From 7691 studies identified, 6370 were screened and 8 were included. Various agents, dosing regimens, and treatment durations were used, with durations of immunotherapy ranging from 1 to 16 cycles. Complete R0 resections were consistently achieved in 98% to 100% of resections. Of patients who received neoadjuvant immunotherapy and underwent resection, 50% to 91% had ypT0N0 pathology. The safety profiles were generally favorable, with grade 1 to 2 treatment-related adverse events (mostly immune-related) during immunotherapy reported in 22.2% to 70% of patients. Postoperative complications after neoadjuvant immunotherapy were reassuring, with no severe complications reported. LIMITATIONS: Small number of heterogeneous and uncontrolled studies precluding a meta-analysis. CONCLUSIONS: Neoadjuvant immune checkpoint inhibition is associated with high rates of pathologic complete responses in locally advanced colon cancer. The literature is limited, particularly for postoperative outcomes, and more studies are needed to understand the safety and positioning of these regimens in the neoadjuvant context.

Sex Disparities in Academic Productivity and Rank Among Abdominal Transplant Faculty in the United States.

BACKGROUND: The aim of this study was to examine sex differences in academic rank and productivity among members of the American Society of Transplant Surgeons in the United States. METHODS: Cross-sectional, focusing on current board-certified abdominal transplant surgeons in the United States. Demographic factors such as sex, region, and faculty rank were collected from institutional websites. Academic metrics, including H-index, total publications, and relative citation ratio, were collected from Scopus and iCite. RESULTS: We identified 536 surgeon members of the American Society of Transplant Surgeons with an academic institution. The majority were men (83%). Men were in practice longer than women (17.9 ± 11 vs 11.7 ± 9 years, P < .0001) and had higher academic metrics, including H-index (25.6 ± 20 vs16.4 ± 14, P < .0001) and total publications (110 ± 145 vs 58.8 ± 69, P < .0001). There was a significant difference in faculty appointments by sex (P < .05), with men showing evidence of increased academic advancement. After adjusting for academic rank, PhD status, and location of medical school and residency, women remained associated with a lower H-index on multivariate analysis (P < .01). CONCLUSION: Sex disparities in academic rank and achievement are present among transplant surgical faculty in the United States, and future efforts are needed to promote sex equity in transplant surgery academia.

Breast infections: A review of current literature.

Breast infections are common, affect women of all ages, and are associated with significant morbidity. Despite overall prevalence, treatment varies significantly based on provider or institution and no central treatment guidelines exist to direct the management of breast infections. This article provides a summary of the current trends in management of breast infections. The etiology, epidemiology, risk factors, presentation, diagnosis, and treatment of mastitis and breast abscesses (and their relative subdivisions) are explored based on the current literature. Trends in microbiology are reviewed and an approach to antibiotic coverage is proposed. Overall, there is a lack of randomized-controlled trials focused on the treatment of breast infections. This has resulted in an absence of clinical practice guidelines for the management of breast abscesses and variable practice patterns. The development of best-care protocols or pathways could provide more uniformity in care of breast infections.

PROTECTIVE EFFECTS OF HUMANIN-G IN HEMORRHAGIC SHOCK IN FEMALE MICE VIA AMPKα1-INDEPENDENT MECHANISMS.

ABSTRACT: Introduction: Despite therapeutic advances in hemorrhagic shock, mortality from multiple organ failure remains high. We previously showed that the α1 subunit of AMP-activated protein kinase (AMPK), a crucial regulator of mitochondrial function, exerts a protective role in hemorrhagic shock. Humanin is a mitochondrial peptide with cytoprotective properties against cellular stress. Here, we investigated whether AMPKα1 influences systemic levels of endogenous humanin in hemorrhagic shock and whether treatment with the synthetic analog humanin-G affords beneficial effects. Methods: AMPKα1 wild-type (WT) and knockout (KO) female mice were subjected to hemorrhagic shock followed by resuscitation with blood and lactated Ringer's solution. In short-term studies, mice were treated with humanin-G or vehicle and sacrificed at 3 h after resuscitation; in survival studies, mice were treated with PEGylated humanin-G and monitored for 7 days. Results: Compared with the vehicle WT group, KO mice exhibited severe hypotension, cardiac mitochondrial damage, and higher plasma levels of Th17 cytokines but had similar lung injury and similar plasma elevation of endogenous humanin. Treatment with humanin-G improved lung injury, mean arterial blood pressure, and survival in both WT and KO mice, without affecting systemic cytokine or humanin levels. Humanin-G also ameliorated cardiac mitochondrial damage and increased adenosine triphosphate levels in KO mice. Beneficial effects of humanin-G were associated with lung cytoplasmic and nuclear activation of the signal transducer and activator of transcription-3 (STAT3) in AMPKα1-independent manner with marginal or no effects on mitochondrial STAT3 and complex I subunit GRIM-19. Conclusions: Our data indicate that circulating levels of humanin increase during hemorrhagic shock in AMPKα1-independent fashion as a defense mechanism to counteract metabolic derangement and that administration of humanin-G affords beneficial effects through STAT3 activation even in the absence of a functional AMPKα1.

Blood component resuscitative strategies to mitigate endotheliopathy in a murine hemorrhagic shock model.

BACKGROUND: Resuscitation with plasma components has been shown to improve endotheliopathy induced by hemorrhagic shock, but the optimal resuscitation strategy to preserve the endothelial glycocalyx has yet to be defined. The aim of this study was to determine if resuscitation with lactated Ringer's (LR), whole blood (WB), packed red blood cells (RBCs), platelet-rich plasma (PRP), platelet poor plasma, balanced RBC:PRP (1:1), or day 14 (d14) RBC would best minimize endothelial damage following shock. METHODS: Male C57BL/6 mice were hemorrhaged to a goal mean arterial pressure of 25 mm Hg for 1 hour. Unshocked sham mice served as controls. Mice were then resuscitated with equal volumes of LR, WB, RBC, PRP, platelet poor plasma, 1:1, or d14 RBC and then sacrificed at 1, 4, or 24 hours (n = 5). Serum was analyzed for syndecan-1, ubiquitin C-terminal hydrolase L1, and cytokine concentrations. Lungs underwent syndecan-1 immunostaining, and lung injury scores were calculated after hematoxylin and eosin. Proteolytic cleavage of the endothelial glycocalyx was assessed by serum matrix metalloprotease 9 levels. RESULTS: Serum syndecan-1 and ubiquitin C-terminal hydrolase L1 levels were significantly increased following resuscitation with d14 RBC compared with other groups. Early elevation in lung syndecan-1 staining was noted in LR-treated mice, while d14 mice showed decreased staining compared with sham mice following shock. Lung injury scores were significantly elevated 4 hours after resuscitation with LR and d14 RBC compared with WB. Serum matrix metalloprotease 9 levels were significantly increased at 1 and 4 hours in d14 mice compared with sham mice. Systemic inflammation was increased in animals receiving LR, 1:1, or d14 RBC. CONCLUSION: Resuscitation with WB following hemorrhagic shock reduces endothelial syndecan-1 shedding and mitigates lung injury. Aged RBC and LR fail to attenuate endothelial injury following hemorrhagic shock. Further research will be necessary to determine the effect of each of these resuscitative fluids in a hemorrhagic shock model with the addition of tissue injury.

General Surgery Residency Virtual Recruitment During the Pandemic: An Analysis of Applicant Surveys.

INTRODUCTION: The COVID-19 pandemic forced a sudden change from in-person to virtual interviews for the general surgery residency match. General surgery programs and applicants adopted multiple strategies to best mimic in-person recruitment. The purpose of this study was to evaluate applicant opinions of the virtual recruitment format. MATERIALS AND METHODS: Postinterview survey responses for applicants interviewing at a single general surgery residency program in the 2020-2021 and 2021-2022 cycles were evaluated. All interviewed applicants were sent an anonymous survey assessing the virtual interview structure, their impression of the program, and their opinions on recruitment in the future. RESULTS: The response rate was 31.2% (n = 60). Most (88.4%) respondents reported a more favorable view of the program after a virtual interview. Factors that were most likely to create a favorable impression were residents (89.6%) and culture (81.0%). 50.8% of applicants favored virtual-only interviews. The majority of applicants (60.3%), however, preferred the virtual interview remain a component of the application process, 34.4% recommended that virtual interviews be used as an initial screen before in-person invites, while 19.0% suggested applicants should interview in-person or virtually without penalty. 62.1% favored capping the number of interviews offered by programs and accepted by applicants. CONCLUSIONS: The virtual interview format for general surgery residency allows applicants to effectively evaluate a residency program. Applicants are in favor of a combination of virtual and in-person interviews in the future. Innovation in the recruitment process, including limiting the number of applications and incorporating virtual events, is supported by applicants.

Biophysiological stress and sleep deprivation among abdominal transplant surgery fellows: A prospective multi-institutional study using a wearable device.

BACKGROUND: Transplant surgery fellowship is physically and emotionally demanding. The objective of this study was to characterize biophysiological stress and sleep patterns among transplant surgery fellows. METHODS: Participating fellows wore a biophysical monitor over a 28-day period and completed biweekly surveys. Sleep patterns were dichotomized as normal or sleep deprived, and heart rate variability (HRV) was used to assess stress. RESULTS: Seventeen fellows participated. Fellows were frequently sleep deprived (43.9% of nights) and stress was near universal (87.2% of days). Burnout was reported by 2 fellows (11.8%). Only 4 fellows (23.5%) reported compliance with the Transplant Accreditation and Certification Council managed time policy; these fellows experienced fewer days of stress than non-compliant fellows (79.8% vs 89.2% p = 0.02). CONCLUSIONS: This is the first study to quantify sleep deprivation and stress among transplant fellows. Future work is needed to evaluate the effects of sleep deprivation, and stress on burnout and patient outcomes.

The national rate of malignancy among Bethesda III, IV, and V thyroid nodules is higher than expected: A NSQIP analysis.

BACKGROUND: The Bethesda System for Reporting Thyroid Cytopathology was formalized in 2007 to stratify cytologic specimens based on their risk of malignancy. Several studies have reported significant variations between their institutional rate of malignancy compared to the Bethesda System for Reporting Thyroid Cytopathology. The objective of this study was to determine the national rate of malignancy for Bethesda III, Bethesda IV, and Bethesda V thyroid nodules. METHODS: From 2016 to 2019, patients with preoperative thyroid cytopathology and pathology results in National Surgical Quality Improvement database were included. The rate of malignancy was compared to the median the Bethesda System for Reporting Thyroid Cytopathology 2017, and risk factors associated with malignancy were identified for Bethesda III, Bethesda IV, and Bethesda V specimens. RESULTS: In total, 13,121 patients with preoperative cytopathology and postresection pathology were identified. The national rate of malignancy was significantly higher than the Bethesda System for Reporting Thyroid Cytopathology 2017 for Bethesda III (36.2% vs 12.0%, P < .01), Bethesda IV (36.7% vs 25.0%, P < .01), and Bethesda V (91.1% vs 52.5%, P < .01) specimens. Male sex was significantly associated with malignancy in Bethesda III, Bethesda IV, and Bethesda V nodules (Bethesda III, odds ratio: 1.20, [1.01-1.42]; Bethesda IV, odds ratio: 1.47, [1.27-1.71]; Bethesda V, odds ratio: 1.28, [1.03-1.58]). Younger age was associated with malignancy in Bethesda III patients under 55 (odds ratio: 1.23, [1.06-1.42]), Bethesda IV patients under 42 (odds ratio: 1.23, [1.06-1.43]), and Bethesda V patients aged less than 47 (odds ratio: 1.38, [1.15-1.67]). CONCLUSIONS: This is the largest cohort study to describe the national rate of malignancy for Bethesda III, IV, and V specimens in the United States. These results reveal the national rate of malignancy is higher than the implied rate of malignancy reported to patients based on the Bethesda System for Reporting Thyroid Cytopathology. We recommend counseling patients regarding this increased rate of malignancy to set appropriate expectations after surgical intervention.

Incidence of attrition among early-career abdominal transplant surgeons.

BACKGROUND: The prevalence of burnout and depression among abdominal transplant surgeons has been well described. However, the incidence of early-career transplant surgeons leaving the field is unknown. The objective of this study was to quantify the incidence of attrition among early-career abdominal transplant surgeons. METHODS: A custom database from the Organ Procurement and Transplantation Network with encrypted surgeon-specific identifiers was queried for transplant surgeons who entered the field between 2008 and 2019. Surgeons who experienced attrition, defined as not completing a subsequent transplant after a minimum of 5, were identified. Surgeon-specific case volumes, case mix, and recipient outcomes were modeled to describe their association with attrition. RESULTS: Between 2008 and 2018, 496 abdominal transplant surgeons entered the field and performed 76,465 transplant procedures. A total of 24.4% (n = 121) experienced attrition, with a median time to attrition of 2.75 years. Attrition surgeons completed fewer kidney (7 vs 21, P < .01), pancreas (0.52 vs 1.43, P < .01), and liver transplants (1 vs 4, P < .01) in their first year of practice. Attrition surgeons completed a smaller proportion of their transplant center's volume (9% vs 18%, P < .01) and were less likely to participate in pediatric transplants (26.5% vs 52.5%, P < .01) and living donor kidney transplants (64.5% vs 84.5%, P < .01). On multivariable analysis, performing fewer kidney (odds ratio: 0.98, 95% confidence interval: 0.98-0.99) and liver transplants (odds ratio: 0.98, 95% confidence interval: 0.97-0.98) by year 5 and completing a smaller proportion of their centers' volume (odds ratio: 0.96, 95% confidence interval: 0.94-0.98) were associated with attrition. Furthermore, attrition surgeons had worse allograft and patient survival for liver transplant recipients (both log-rank P < .01). CONCLUSION: This investigation was the first to quantify the high incidence of attrition experienced by early-career abdominal transplant surgeons and its association with surgeon-specific case volumes, case mix, and worse recipient outcomes. These findings suggested the abdominal transplant workforce is struggling to retain their fellowship-trained surgeons.

A method for identifying the learning curve for the surgical stabilization of rib fractures.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is an accepted efficacious treatment modality for patients with severe chest wall injuries. Despite increased adoption of SSRF, surgical learning curves are unknown. We hypothesized intraoperative duration could define individual SSRF learning curves. METHODS: Consecutive SSRF operations between January 2017 and December 2021 at a single institution were reviewed. Operative time, as measured from incision until skin closure, was evaluated by cumulative sum methodology using a range of acceptable "missteps" to determine the learning curves. Misstep was defined by extrapolation of accumulated operative time data. RESULTS: Eighty-three patients underwent SSRF by three surgeons during this retrospective review. Average operative times ranged from 135 minutes for two plates to 247 minutes for seven plates. Using polynomial regression of average operative times, 75 minutes for general procedural requirements plus 35 minutes per plate were derived as the anticipated operative times per procedure. Cumulative sum analyses using 5%, 10%, 15%, and 20% incident rates for not meeting expected operative times, or "missteps" were used. An institutional learning curve between 15 and 55 SSRF operations was identified assuming a 90% performance rate. An individual learning curve of 15 to 20 operations assuming a 90% performance rate was observed. After this period, operative times stabilized or decreased for surgeons A, B, and C. CONCLUSION: The institutional and individual surgeon learning curves for SSRF appears to steadily improve after 15 to 20 operations using operative time as a surrogate for performance. The implementation of SSRF programs by trauma/acute care surgeons is feasible with an attainable learning curve. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Minimally Invasive Surgery for Resectable Adrenocortical Carcinoma: A Nationwide Analysis.

INTRODUCTION: The utilization of minimally invasive surgery (MIS) for adrenocortical carcinoma (ACC) remains controversial due to concerns regarding the quality of surgical resection and subsequent oncologic risks. Current guidelines recommend open resections for all cases of suspected ACC independent of size; however, there has been increased adoption of MIS for ACC over time. We sought to determine whether the rise in the utilization of MIS is associated with worse survival outcomes for ACC. METHODS: The National Cancer Database was queried for patients with ACC who underwent surgical resection between 2010 and 2017. Patient selection, oncologic outcomes, and overall survival were compared among patients who received an MIS approach (laparoscopic or robotic) versus an open approach. RESULTS: A total of 1483 patients underwent ACC resection with 982 (66.2%) patients undergoing an open approach and 501 (33.8%) receiving an MIS operation. The overall utilization of MIS for ACC increased significantly after 2013 (37.7% versus 29.5%, P < 0.01). There was no difference in overall survival between MIS and open resections on univariable (log-rank P = 0.12) analysis. On multivariable analysis, survival was improved in MIS patients versus open resection (Hazard ratio: 0.83, 95% CI: [0.70-0.99]). Notably, survival remained comparable among patients who underwent resection for large ACCs (6-10 cm, log-rank P = 0.66) and giant ACCs (>10 cm, log-rank P = 0.24), irrespective of operative approach. CONCLUSIONS: Our findings suggest that in appropriately selected patients with ACC, MIS can be performed safely without a significant decrease in overall survival, independent of size. We recommend consideration of a minimally-invasive approach for adrenal masses despite size >6 cm.

Low Volume Blood Product Transfusion Patterns And Ratios After Injury.

BACKGROUND: The benefit of a balanced resuscitation in low volume transfusions remains unclear This study is aimed at characterizing blood product ratios in this cohort. METHODS: A retrospective analysis (2017-2019) of the ACS TQIP was performed to identify adult trauma patients who received ≥1 unit of packed red blood cells (pRBCs) 4 and 24 h after admission. Blood products received were used to calculate plasma and platelet ratios. RESULTS: Plasma and platelet ratios were closer to the target 1:1 ratio for ≤4 units pRBCs. Plasma and platelet ratios increased for those receiving ≤10 units pRBCs, demonstrating increasingly unbalanced resuscitation. Transfusion ratios were unbalanced for those receiving ≥5 units pRBC. CONCLUSION: Transfusion ratios were closer to the desired transfusion ratio for low volume blood product resuscitation. In those receiving ≥5 units pRBC, plasma and platelet ratios were not balanced. The optimal transfusion ratio in low volume trauma resuscitation is unknown.

Gender Disparities in Academic Productivity and Promotion Among Endocrine Surgery Faculty.

INTRODUCTION: Academic rank and metrics such as total publications (pubs) and H-index are indicators to measure academic achievement. This study aims to determine whether there are gender differences in academic productivity or faculty appointments among endocrine surgeons in the United States. METHODS: A database was generated from the American Association of Endocrine Surgeons (AAES) website. Community or academic practice was designated by institution affiliation and faculty appointment. Academic metrics, including pubs, H-index, and weighted-RCR (relative citation ratio), were obtained from public databases. RESULTS: A total of 258 AAES members were affiliated with an academic institution. The majority were men (58%). Overall, men in endocrine surgery had higher academic metrics: pubs (56.0 [26-134], 23.0 [11-56], P < 0.0001), H-index (19.0 [11-35], 9.0 [5-21], P < 0.0001), weighted-RCR (63.5 [22-193], 24.1 [8-74], P < 0.005) and rank (associate professor or professor, P < 0.0001). Subgroup analysis accounting for time in practice found no difference in total publications, weighted RCR, or faculty appointments between genders in practice for 0-5 y. However, among surgeons in practice for 6-10 y, men had higher academic metrics (pubs: 31.0 [16-79], 18.5 [9-33]; RCR: 46.0 [14-102], 13.3 [9-34]) and faculty appointments (all P < 0.05). CONCLUSIONS: There are gender disparities in academic productivity and faculty appointment among US endocrine surgeons. While junior faculty show no gender differences in most indicators of academic productivity or rank, men with 6-10 y in practice have higher average academic metrics and rank. Whether the absence of gender disparities among junior faculty is a sustainable reflection of recent efforts to encourage equal mentorship and professional opportunities or whether disparities will manifest as faculty progress remains to be determined.

Is There a Benefit to Adjuvant Chemotherapy in Resected, Early Stage Pancreatic Ductal Adenocarcinoma?

BACKGROUND: The role of systemic therapy for Stage IA pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim of our study was to evaluate the impact of adjuvant chemotherapy (AC) on survival in patients with early stage disease. METHODS: The National Cancer Database was queried from 2006 to 2017 for resected pT1N0M0 (Stage 1A) PDAC. Exclusion criteria included neoadjuvant therapy, radiation, or those who suffered a 90-day mortality. RESULTS: Of the 1526 patients included in the study, 42.2% received AC and 57.8% underwent surgery alone. Patients who received AC were younger, had fewer comorbidities, and were more likely to have private insurance, compared with those treated with surgery alone. Patients who received AC had longer median overall survival (OS) compared with those who underwent surgery alone (105.7 months vs 72.0 months, p < 0.01). Subset analyses based on individual "good" prognostic features (size ≤ 1.0 cm, lymphovascular invasion negative, well/moderately differentiated, margin negative resection) demonstrated improved OS with AC. Following propensity score matching based on key clinicopathologic features, AC remained associated with improved median OS (83.7 months vs 59.8 months, p < 0.01). However, in the cohort with body/tail tumors (101.2 months vs 95.0 months, p = 0.19) and those with all "good" prognostic features (95.9 months vs 90.6 months, p = 0.15), AC was not associated with improved survival. CONCLUSIONS: In resected, Stage IA PDAC, AC is associated with improved overall survival in the vast majority of patients; however, in select cohorts the role of AC is unclear. Further study is needed to tailor treatment to individual patients with PDAC.

Avoiding delays in time to renal transplantation: Pretransplant thyroid malignancy does not affect patient or graft survival after renal transplantation.

BACKGROUND: Pretransplant malignancy is associated with decreased patient and graft survival. Current US guidelines recommend a 2- to 5-year, tumor-free waiting period before transplantation. No large studies have examined the specific, modern day risk of pretransplant thyroid malignancy on patient and graft survival after renal transplant. METHODS: The United Network for Organ Sharing database was queried for all adult isolated renal transplant recipients between 2003 and 2019. Patient characteristics, rates of post-transplant malignancy, and survival were compared between patients with pretransplant thyroid malignancy and without pretransplant thyroid malignancy. RESULTS: Eighty-six patients had pretransplant thyroid malignancy diagnosed after listing and before renal transplantation. Both overall and graft survival were similar between cohorts (P > .05). There was no significant association between pretransplant thyroid malignancy and patient (hazard ratio: 0.66; P = .31) or graft (hazard ratio:0.32; P = .11) survival on multivariate analysis. Waitlist duration for pretransplant thyroid malignancy patients was significantly increased (1,444 vs 438 days; P < .01), which translated to increased dialysis duration (2,234 vs 1,201 days, P < .01). Pretransplant thyroid malignancy patients did not experience increased post-transplant malignancy (P = .21). CONCLUSION: Given no association with decreased patient or allograft survival, our findings suggest that pretransplant thyroid malignancy patients are unnecessarily subjected to increased wait-list duration before transplant. We recommend an individualized approach for pretransplant thyroid malignancy patients diagnosed before or after listing.

Examining the impact of COVID-19 restrictions on the operative volumes of US general surgery residents.

BACKGROUND: In March 2020, the COVID-19 virus global pandemic forced healthcare systems to institute regulations including the cancellation of elective surgical cases, which likely decreased resident operative experience. The objective of this study was to determine whether the COVID-19 pandemic affected operative experiences of US general surgery residents. METHODS: The operative experience of general surgery residents was examined nationally and locally. Aggregate Accreditation Council for Graduate Medical Education (ACGME) case logs for 2018 to 2019 (pre-COVID) and 2019 to 2020 (COVID) graduates were compared using national mean cumulative operative volume for total major and surgeon chief cases. Locally, ACGME case logs were used to analyze the operative experience among residents at a single, academic center. Average operative volumes per month per resident during peak COVID-19 quarantine months were compared with those the previous year. RESULTS: Compared with 2019 graduates, 2020 graduates completed 1.5% fewer total major cases (1055 ± 155 vs 1071 ± 150, P = .011). This was most evident during chief year, with 8.4% fewer surgeon chief cases logged in 2020 compared with 2019 (264 ± 67 vs 289 ± 69, P < .001). Institutional data revealed that during the peak of the pandemic, residents across all levels completed 42.5% fewer total major operations (12 ± 11 vs 20 ± 14, P < .001). This effect was more pronounced among junior residents compared with senior and chief residents. CONCLUSION: The COVID-19 pandemic was associated with decreased resident case volume. The ramifications of the COVID-19 pandemic for operative competency and autonomy should be carefully examined.

Who is Committed to Education? An Analysis of Surgical Education Research Publications.

OBJECTIVE: Advances in surgical training have led to the recent emergence of surgical education research. While the importance of surgical education research is well recognized, not all surgical journals are publishing these works. The objective of this study was to analyze the volume and types of surgical education publications in general surgery and surgical subspecialty journals. DESIGN: A PubMed search string was developed to identify surgical education publications in general surgery (GS, n = 10) and surgical subspecialty (SS, n = 16) journals from 2015 to 2019. Publications were catalogued into 7 categories: curriculum and/or teaching, trainee assessment, program evaluation, wellness and/or burnout, resident research, case outcomes with resident involvement, and other. Journals were also categorized by impact factor into 3 groups. Statistical analysis was performed using linear regression and Wilcoxon rank-sum to analyze differences in education publication number and percent between GS and SS journals, as well as between different impact factor groups. RESULTS: The median proportion of surgical education publications was 1.2% (IQR 0.3-2.8%) of total publications for journals queried. The highest proportion of surgical education publications by a journal was 13.9%. All other journals had median ≤ 5.5%. GS journals had a significantly higher median percent of surgical education publications than SS journals (2.9% [IQR 1.7-4.8%] vs 0.5% [IQR 0.0-1.4%] p < 0.01). Additionally, no significant differences were found for number of surgical education publications when journals were categorized by IF (p > 0.05). CONCLUSIONS: Education research is an important component of the surgical literature, with similar publication rates among journals of different impact factors. Publication volume is higher among general surgery than surgical subspecialty journals. With the ever-changing paradigm of surgical training, a rigorous scientific approach is needed to ensure effective training of future surgeons. Subspecialty journals should promote surgical education research to further understand and develop training in their field.

A narrative review of socioeconomic disparities in the treatment of esophageal cancer.

The persistent challenges of disparities in healthcare have led to significantly distinct outcomes among patients from different racial, ethnic, and underserved populations. Esophageal Cancer, not unlike other surgical diseases, has seen significant disparities in care. Esophageal cancer is currently the 6th leading cause of death from cancer and the 8th most common cancer in the world. Surgical disparities in the care of patients with Esophageal Cancer have been described in the literature, with a prevailing theme associating minority status with worse outcomes. The goal of this review is to provide an updated account of the literature on disparities in Esophageal Cancer presentation and treatment. We will approach this task through a conceptual framework that highlights the five main themes of surgical disparities: patient-level factors, provider-level factors, system and access issues, clinical care and quality, and postoperative outcomes, care and rehabilitation. All five categories play a complex role in the delivery of high-quality, equitable care for patients with Esophageal Cancer. While describing disparities in care is the first step to correcting them, moving forward, we should focus on developing effective interventions to mitigate disparities, policies linking disparities to quality-of-care metrics, and delivery system change to enable minority patients to more easily access high volume centers.

Case Report of Foreign Body Stuck in Esophagus with Failure of Endoscopic Management in a Man with a History of Pica.

This is a case report of foreign body ingestion in a 55-year-old intellectually disabled man with a history of pica and previous removal of ten plastic gloves from his rectum four months prior to this presentation. The patient presented after ingesting plastic gloves which formed large, rigid esophageal and gastric bezoars that were not amenable to endoscopic removal. An exploratory laparotomy and gastrostomy was performed, and a 10 × 4.5 × 2 cm gastric bezoar consisting of rigid plastic gloves was removed without complication. Special considerations must be taken when considering the ingestion of nonfood items in the intellectually disabled population as these cases may not present classically with symptoms of a gastric bezoar.