Surgical Decision-Making in Familial Adenomatous Polyposis.

Familial adenomatous polyposis (FAP) is an autosomal dominant disorder affecting patients with germline mutations of the adenomatous polyposis coli (APC) tumor suppressor gene. The surgical treatment of colorectal disease in FAP, which has the goal of colorectal cancer prevention, varies based on both patient and disease factors but can include the following: total colectomy with ileorectal anastomosis, proctocolectomy with stapled or hand-sewn ileal pouch-anal anastomosis, or total proctocolectomy with end ileostomy. The operative options and extent of resection, as well as the use of endoscopy and chemoprevention for the management of polyposis, will be discussed in detail in this article. In addition, commonly debated management decisions related to the treatment of patients with FAP, including the timing of prophylactic colorectal resections for patients with FAP and management of the polyp burden in the rectum, will be discussed. Finally, genotype considerations and the impact of desmoid disease on operative decisions in the setting of FAP will also be reviewed.

Underemployment of Female Surgeons?

OBJECTIVE: To compare the complexity of operations performed by female versus male surgeons. BACKGROUND: Prior literature has suggested that female surgeons are relatively underemployed when compared to male surgeons, with regards to operative case volume and specialization. METHODS: Operative case records from a large academic medical center from 1997 to 2018 were evaluated. The primary end point was work relative value unit (wRVU) for each case with a secondary end point of total wRVU per month for each surgeon. Multivariate linear analysis was performed, adjusting for surgeon race, calendar year, seniority, and clinical subspecialty. RESULTS: A total of 551,047 records were analyzed, from 131 surgeons and 13,666 surgeon-months. Among them, 104,424 (19.0%) of cases were performed by female surgeons, who make up 20.6% (n = 27) of the surgeon population, and 2879 (21.1%) of the surgeon months. On adjusted analysis, male surgeons earned an additional 1.65 wRVU per case, compared to female surgeons (95% confidence interval 1.57-1.74). Subset analyses found that sex disparity increased with surgeon seniority, and did not improve over the 20-year study period. CONCLUSIONS: Female surgeons perform less complex cases than their male peers, even after accounting for subspecialty and seniority. These sex differences are not due to availability from competing professional or familial obligations. Future work should focus on determining the cause and mitigating this underemployment of female surgeons.

Pathologic discordance to clinical management decisions suggests overtreatment in pediatric benign breast disease.

PURPOSE: Breast masses in pediatric patients are often managed similarly to adult breast masses despite significant differences in pathology and natural history. Emerging evidence suggests that clinical observation is safe. The purpose of this study was to quantify the clinical appropriateness of the management of benign breast disease in pediatric patients. METHODS: A multi-institutional retrospective cohort study was completed between 1995 and 2017. Patients were included if they had benign breast disease and were 19 years old or younger. A timeline of all interventions (ultrasound, biopsy, or excision) was generated to quantify the number of patients who were observed for at least 90 days, deemed appropriate care. To quantify inappropriate care, the number of interventions performed within 90 days, and the pathologic concordance to clinical decisions was determined by reviewing the radiology reports of all ultrasounds and pathology reports of all biopsies and excisions. RESULTS: A total of 1,909 patients were analyzed. Mean age was 16.4 years old (± 2.1). The majority of masses were fibroadenomas (60.4%). Only half of patients (54.3%) were observed for 90 or more days. 81.1% of interventions were unnecessary, with pathology revealing masses that would be safe to observe. The positive predictive value (PPV) of clinical decisions made based on suspicious ultrasound findings was 16.2%, not different than a PPV of 21.9% (p < 0.25) for decisions made on clinical suspicion alone. CONCLUSION: Despite literature supporting an observation period for pediatric breast masses, half of patients had an intervention within three months with one out of ten patients undergoing an invasive procedure within this time frame. Furthermore, 81.1% of invasive interventions were unnecessary based on final pathologic findings. A formal consensus clinical guideline for the management of pediatric benign breast disease including a standardized clinical observation period is needed to decrease unnecessary procedures in pediatric patients with breast masses.

A Longitudinal Population Analysis of Cumulative Risks of Circumcision.

BACKGROUND: Circumcision is widely accepted for newborns in the United States. However, circumcision carries a risk of complications, the rates of which are not well described in the contemporary era. METHODS: We performed a longitudinal population analysis of the California Office of Statewide Health Planning and Development database between 2005 and 2010. Using International Classification of Procedures, Ninth Revision, Clinical Modification and Current Procedural Terminology codes, we calculated early and late complication rates by Kaplan-Meier survival estimates. Late complications were defined as those that occurred between 30 d and 5 y after circumcision. Descriptive analysis of complications was obtained by analysis of variance, chi-square test, or log-rank test. On adjusted analysis, a Cox proportional hazard model was performed to determine the risk of early and late complications, adjusting for patient demographics. RESULTS: A total of 24,432 circumcised children under age 5 y were analyzed. Overall, cumulative complication rates over 5 y were 1.5% in neonates, 0.5% of which were early, and 2.9% in non-neonates, 2.2% of which were early. On adjusted analysis, non-neonates had a higher risk of early complications (OR 18.5). In both neonates and non-neonates, the majority of patients with late complications underwent circumcision revision. CONCLUSIONS: Circumcision has a complication rate higher than previously recognized. Most patients with late complications after circumcision received an operative circumcision revision. Clinicians should weigh the surgical risks against the reported medical benefits of circumcision when counseling parents about circumcision.

Heller myotomy is the optimal index procedure for esophageal achalasia in adolescents and young adults.

BACKGROUND: There is limited and conflicting data on the optimal intervention for the treatment of achalasia in adolescents and young adults (AYA), Heller myotomy (HM), esophageal dilation (ED) or botulinum toxin injection (botox). The goal of this study is to determine the most appropriate index intervention for achalasia in the AYA population. METHODS: We completed a longitudinal, population-based analysis of the California (2005-2010) and New York (1999-2014) statewide databases. We included patients 9-25 years old with achalasia who underwent HM, ED or botox. Comparisons were made based on the patients' index procedure. Rates of 30-day complications, long-term complications, and re-intervention up to 14 years were calculated. Cox regression was performed to determine the risk of re-intervention, adjusting for patient demographics. RESULTS: A total of 442 AYAs were analyzed, representing the largest cohort of young patients with this disease studied to date. Median follow-up was 5.2 years (IQR 1.8-8.0). The overall rate of re-intervention was 29.3%. Rates of re-intervention for ED and botox were equivalent and higher than HM (65.0% for ED, 47.4% for botox and 16.4% for HM, p < 0.001). Ultimately, 46.9% of ED and botox patients underwent HM. The overall short-term complication rate was 4.3% and long-term, 1.9%. There was no difference in the short-term and long-term complication rates between intervention groups (p > 0.05). On adjusted analysis, ED and botox were associated with increased risks of re-intervention when compared to HM (HR 5.9, HR 4.8, respectively, p < 0.01). Black patients were found to have a risk of re-intervention twice that of white patients (HR 2.0, p = 0.05). CONCLUSIONS: HM has a similar risk of complications but a significantly lower risk of re-intervention when compared to ED and botox. Based on our findings, we recommend HM as the optimal index procedure for AYAs with achalasia.

Pediatric enteric neuropathies: diagnosis and current management.

PURPOSE OF REVIEW: Neurointestinal diseases are increasingly recognized as causes of significant gastrointestinal morbidity in children. This review highlights the most common pediatric enteric neuropathies and their diagnosis and management, emphasizing insights and discoveries from the most recent literature available. RECENT FINDINGS: The embryologic and histopathologic causes of enteric neuropathies are varied. They range from congenital aganglionosis in Hirschsprung disease, to autoimmune-mediated loss of neuronal subtypes in esophageal achalasia and Chagas disease, to degenerative neuropathies in some cases of chronic intestinal pseudo-obstruction and gastroparesis. Increased awareness of the clinical presentation and diagnostic evaluation of these conditions is essential as it allows for earlier initiation of treatment and improved outcomes. Most current therapies, which include medical management, neurostimulation, and operative intervention, aim to minimize the symptoms caused by these conditions. The evidence base for many of these treatments in children is poor, and multiinstitutional prospective studies are needed. An innovative therapy on the horizon involves using neuronal stem cell transplantation to treat the underlying disorder by replacing the missing or damaged neurons in these diseases. SUMMARY: Although recent advances in basic and clinical neurogastroenterology have significantly improved our awareness and understanding of enteric neuropathies, the efficacy of current treatment approaches is limited. The development of novel therapies, including pharmacologic modulators of neurointestinal function, neurostimulation to enhance gut motility, and neuronal cell-based therapies, is essential to improve the long-term outcomes in children with these disorders.

Implementation, Feasibility, and Perception of Facilitated Process Groups in Surgical Residency.

OBJECTIVE: Recent studies have demonstrated burnout in surgeons, with trainees affected at alarming levels. However, few studies have focused on specific wellbeing initiatives in surgical residency. We implemented facilitated process groups at our residency program and aimed to understand the feasibility and perception of this program. DESIGN: We recruited a psychologist to conduct weekly process groups. Each postgraduate year (PGY) class was scheduled for a rotating 1-hour session every 6 weeks during protected didactic time. A presurvey was conducted shortly following program commencement for PGY1-5 residents (11/2020-1/2021) and a postsurvey conducted after 9 to 10 months of implementation for PGY2-5 residents. Surveys included demographics, a 2-item Maslach Burnout Inventory, and questions about stress, lifestyle, and perception of the process groups, including qualitative feedback. SETTING: The study took place at within the General Surgery Residency at Massachusetts General Hospital, a tertiary-care institution in Boston, Massachusetts. PARTICIPANTS: Participants in process groups were all General Surgery residents during the timeframe of the study. Participation in the presurvey and postsurvey was voluntary for residents. RESULTS: A total of 32 and 35 residents completed the presurveys and postsurveys, respectively. Groups were similar with regards to gender and race. A total of 97% and 57% of postsurvey respondents attended ≥1 and ≥3 process groups, respectively, with 95% citing clinical/other obligations as the cause of missing sessions. Perception of process groups was highly positive and persisted across both surveys. There were no significant differences in perception or burnout questions, except for a slight decrease in "I think process groups might help me process personal challenges" on postsurvey. Of 15 qualitative postsurvey responses, 73% were positive and the remainder were neutral. CONCLUSIONS: Based on current measures, it is feasible to implement facilitated process groups for surgical residents. Resident perception of these groups was persistently positive.

Disparity in prehospital scene time for geriatric trauma patients.

BACKGROUND: Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults. METHODS: Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity. RESULTS: Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29. CONCLUSIONS: Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.

Do surgeons adjust clinical productivity after maternity leave?

BACKGROUND: It has been speculated that women's productivity decreases after maternity leave. In this study, we measured if surgeon clinical productivity decreases after a maternity leave or other types of leave. METHODS: Data from a large medical center was used to measure surgeon productivity before (pre) and after (post) a leave of absence. Post-to-pre productivity ratios were calculated for each leave based on operative volumes and Relative Value Units (RVUs). Multivariate linear regression analysis was performed for the post/pre productivity ratios, adjusting for surgeon characteristics. RESULTS: Fifty leaves of absence, from 30 surgeons, were analyzed. There was no significant difference between post and pre leave productivity for maternity leave or other types of leave. There was also no significant difference when comparing post/pre productivity ratios between maternity leaves versus other types of leave (volume: 0.06, p = 0.52; RVU: 0.08, p = 0.58). CONCLUSION: Surgeons do not significantly reduce clinical productivity after maternity or other types of leaves.

Optimal timing for Soave primary pull-through in short-segment Hirschsprung disease: A meta-analysis.

BACKGROUND: The optimal age for endorectal pull-through (ERPT) surgery in infants with short-segment Hirschsprung disease varies, with a trend toward earlier surgery. However, it is unclear if the timing of surgery impacts functional outcomes. We undertook the present study to determine the optimal timing of ERPT in infants with short-segment Hirschsprung disease. METHODS: The NCBI PubMed database was searched for English-language manuscripts published between 2000 and 2019 analyzing functional outcomes for patient following the initial Soave ERPT for short-segment Hirschsprung disease. Raw data from these studies was obtained from the corresponding author for each manuscript. We combined data from these papers with our own institutional data and performed a meta-analysis. RESULTS: A total of 780 infants were included in our meta-analysis. Constipation occurred in 1.0-31.7%, soiling 1.3-26.0%, anastomotic stricture 0.0-14.6%, and anastomotic leak 0.0-3.4%. Regarding age at ERPT, younger infants at the time of initial corrective surgery had higher rates of soiling, stricture, and leak. On sub-group analysis, patients <2.5 months at their initial corrective surgery had higher rates of soiling (25.9% vs. 11.4%, p<0.01), as well as stricture (10.0% vs 1.7%, p<0.01) and leak (5.5% vs 1.3%, p<0.01). CONCLUSION: While age at Soave endorectal pull-through for short-segment Hirschsprung disease has decreased over time, functional outcomes associated with this trend have only recently been examined. Our findings suggest that patients <2.5 months old at the time of endorectal pull-through may have worse functional outcomes, emphasizing the need to consider further study of the timing of surgery in this population.

Contribution of unequal new patient referrals to female surgeon under-employment.

BACKGROUND: The literature shows that female surgeons have lower operative volumes than male surgeons. Since volume is dependent on new patient referrals for most surgeons, inequities in referrals may contribute to this employment disparity. METHODS: Using 1997-2018 data from a large medical center, we examined the number of new patient referrals for surgeons. Multivariate linear analysis was performed, adjusting for surgeon race, calendar year, seniority, and clinical subspecialty. RESULTS: A total of 121 surgeons across 12,410 surgeon-months were included. Overall, surgeons had a median of 14 new patient referrals per month (interquartile range (IQR) = 7, 27). On adjusted analysis, female surgeons saw 5.4 fewer new patient referrals per month (95% CI -6.4 to -4.5). CONCLUSION: Female surgeons, with equal training and seniority, received fewer new patient referrals than their male peers, and this may contribute to female surgeon under-employment. Surgeon gender may be one of the factors contributing to this differential referral pattern.

Annual Incidence of Hospitalization for Nonfatal Firearm-Related Injuries in New York From 2005 to 2016.

Importance: In the US, approximately 40 000 people die due to firearm-related injuries annually. However, nonfatal firearm-related injuries are less precisely tracked. Objectives: To assess the annual incidence of hospitalization for nonfatal firearm-related injuries in New York and to compare the annual incidence by sex, race/ethnicity, county of residence, and calendar years. Design, Setting, and Participants: This retrospective cross-sectional study used data from the New York Statewide Planning and Research Cooperative System for patients aged 15 years or older who presented to an emergency department in New York with nonfatal firearm-related injuries from January 1, 2005, to December 31, 2016. Data were analyzed from January 15, 2019, to April 21, 2021. Exposure: A nonfatal firearm-related injury, defined by International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Main Outcomes and Measures: The annual incidence of nonfatal firearm-related injuries was calculated by determining the number of patients with a nonfatal firearm-related injury each year divided by the total population of New York. Results: The study included 31 060 unique patients with 35 059 hospital encounters for nonfatal firearm-related injuries. The mean (SD) age at admission was 28.5 (11.9) years; most patients were male (90.6%) and non-Hispanic Black individuals (62.0%). The overall annual incidence was 18.4 per 100 000 population. Although decreasing trends of annual incidence were observed across the state during the study period, this trend was not present in all 62 counties, with 32 counties (51.6%) having an increase in the incidence of injuries between 2005 and 2010 and 29 (46.8%) having an increase in the incidence of injuries between 2010 and 2015. In 19 of the 30 counties (63.3%) that had a decrease in incidence in earlier years, the incidence increased in later years. Conclusions and Relevance: The annual incidence of hospitalization for nonfatal firearm-related injuries in New York during the study period was 18.4 per 100 000 population. Reliable tracking of nonfatal firearm-related injury data may be useful for policy makers, hospital systems, community organizers, and public health officials as they consider resource allocation for trauma systems and injury prevention programs.

Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults.

STUDY OBJECTIVE: Current literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers. DESIGN AND SETTING: We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016. PARTICIPANTS: We included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded. INTERVENTIONS AND MAIN OUTCOME MEASURES: Trends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics. RESULTS: A total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital. CONCLUSION: There is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.

Practice patterns and work environments that influence gender inequality among academic surgeons.

BACKGROUND: Practice pattern and work environment differences may impact career advancement opportunities and contribute to the gender gap within highly competitive surgical specialties. METHODS: Using a 2000-2015 New York statewide dataset, we compared board-certified pediatric surgeons by specialist case volume and Herfindahl-Hirschman Index (HHI), which quantifies surgeon focus within specialist case mix. RESULTS: 51 pediatric surgeons were analyzed for 461 surgeon-years. Female surgeons had lower case volume (159 cases/year versus 214, p < 0.01), lower shares of specialist cases (14.1% versus 16.7%, p = 0.04), and less focused practices (HHI 0.16 versus 0.20, p = 0.03). Female surgeons' networks had fewer colleagues (7.2 versus 12.1, p < 0.01), and lower annual total (388 versus 726, p < 0.01) and specialist case volume (83 versus 159, p < 0.01), even after accounting for career length. However, female surgeons performed more cases within their networks (49% versus 36%, p = 0.04) and worked at major teaching hospitals as often as men (76% versus 76%, p = 0.97). CONCLUSION: The challenges that female surgeons face may be reflective of organizational inequities that necessitate intentional scrutiny and change.

Beyond insurance: race-based disparities in the use of metabolic and bariatric surgery for the management of severe pediatric obesity.

BACKGROUND: It is unknown whether previously noted racial disparities in the use of metabolic and bariatric surgery (MBS) for the management of pediatric obesity could be mitigated by accounting for primary insurance. OBJECTIVES: To examine utilization of pediatric MBS across race and insurance in the United States. SETTING: Retrospective cross-sectional study. METHODS: The National Inpatient Sample was used to identify patients 12 to 19 years old undergoing MBS from 2015 to 2016, and these data were combined with national estimates of pediatric obesity obtained from the 2015 to 2016 National Health and Nutrition Examination Survey. Severe obesity was defined as class III obesity, or class II obesity plus hypertension, dyslipidemia, or type 2 diabetes. RESULTS: A total of 1,659,507 (5.0%) adolescents with severe obesity were identified, consisting of 35.0% female, 38.0% white, and 45.0% privately insured adolescents. Over the same time period, 2535 MBS procedures were performed. Most surgical patients were female (77.5%), white (52.8%), and privately insured (57.5%). Black and Hispanic adolescents were less likely to undergo MBS than whites (odds ratio .50, .46, respectively; P < .001 both), despite adjusting for primary insurance. White adolescents covered by Medicaid were significantly more likely to undergo MBS than their privately insured counterparts (odds ratio 1.66; P < .001), while the opposite was true for black and Hispanic adolescents (odds ratio .29, .75, respectively; P < .001 both). CONCLUSIONS: Pediatric obesity disproportionately affects racial minorities, yet MBS is most often performed on white adolescents. Medicaid insurance further decreases the use of MBS among nonwhite adolescents, while paradoxically increasing it for whites, suggesting expansion of government-sponsored insurance alone is unlikely to eliminate this race-based disparity.

A population-based analysis of pediatric breast cancer.

PURPOSE: The purpose of this study was to evaluate trends in demographics and outcomes of pediatric breast cancer in a United States population-based cohort. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify all pediatric patients with malignant breast tumors between 1973 and 2014. Analysis was performed using Stata Statistical Software version 13.1. Associations between categorical variables were made using X2 test. Log-rank test was used for univariate survival analysis. Kaplan-Meier analysis investigated five-year survival rates across several variables. Adjusted analysis was performed using a Cox Proportional-Hazards regression. RESULTS: 134 patients with breast malignancies were identified. Carcinoma was the most prevalent histology (48.5%), followed by fibroepithelial tumors (FETs) (35.1%), and sarcoma (14.2%). FETs were twice as common in black compared to nonblack patients (56.3% vs. 29.0%, p < 0.01). Analyzing histology by stage revealed that 100% of FETs were early stage disease (p < 0.0001). 46.7% of the tumors tested were ER/PR negative, more than twice as many compared to the published adult estimate of 20.0%. Unadjusted survival analysis revealed worse survival for patients with adenocarcinoma/sarcomas, advanced stage, and high grade disease, without a survival difference between races. CONCLUSION: Breast cancer remains a rare malignancy among pediatric patients. Although black patients were found to have more noncarcinomatous tumors with less advanced disease, this did not confer a survival advantage. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level III.

"Yes, I'm the Doctor": One Department's Approach to Assessing and Addressing Gender-Based Discrimination in the Modern Medical Training Era.

While gender-based bias and discrimination (GBD) is known to exist in medical training, there is limited guidance for training programs on how to understand and combat this issue locally. The Massachusetts General Hospital Department of Surgery established the Gender Equity Task Force (GETF) to address GBD in the local training environment. In 2017, members of the GETF surveyed residents in surgery, anesthesia, and internal medicine at 2 academic hospitals to better understand perceived sources, frequency, forms, and effects of GBD. Overall, 371 residents completed the survey (60% response rate, 197 women). Women trainees were more likely to endorse personal experience of GBD and sexual harassment than men (P < .0001), with no effect of specialty on rates of GBD or sexual harassment. Patients and nursing staff were the most frequently identified groups as sources of GBD. While an overwhelming majority of both men (86%) and women (96%) respondents either experienced or observed GBD in the training environment, less than 5% of respondents formally reported such experiences, most frequently citing a belief that nothing would happen. Survey results served as the basis for a variety of interventions addressing nursing staff and patients as sources of GBD, low confidence in formal reporting mechanisms, and the pervasiveness of GBD, including sexual harassment, across specialties. These results reproduce other studies' findings that GBD and sexual harassment disproportionately affect women trainees while demonstrating how individual training programs can incorporate local GBD data when planning interventions to address GBD.