The Impact of a Narcotic-Sparing Enhanced Recovery Protocol on Postoperative Narcotic Use Following Colectomy.

BACKGROUND: In the United States, 37% of all opioids are prescribed in the surgical setting, many of which report initial exposure in the postoperative period. OBJECTIVE: This study aimed to assess the impact of a narcotic-sparing enhanced recovery after surgery protocol on postoperative narcotic use by patients and to assess its impact on the narcotic-prescribing practices of physicians. DESIGN: Data regarding consecutive narcotic-naïve patients who underwent a surgical procedure from January 2013 to August 2017 were retrospectively reviewed. SETTINGS: Patients were divided into 2 cohorts: preimplementation (2013-2015) and postimplementation (2015-2017) of the enhanced recovery after surgery protocol. PATIENTS: This study included patients who underwent elective inpatient abdominal colorectal surgery at the University of Florida Health. MAIN OUTCOME MEASURES: The primary outcome measure was 30-day postoperative narcotic use (inpatient and outpatient). Other outcomes measured included pain scores, time to diet institution, length of hospital stay, cost of hospitalization, and postoperative complications. RESULTS: Baseline characteristics were similar between the preprotocol group (n = 537) and postprotocol group (n = 790). Protocol implementation was associated with a decrease in the total 30-day postoperative narcotic amount used by patients (2481 vs 31 morphine milligram equivalents; p = 0.05), inpatient patient-controlled analgesia use (63% vs 0.5%; p < 0.00001; dosage 1254 vs 5 morphine milligram equivalents), inpatient on-demand oral narcotic use (90% vs 32%; p = 0.001; dosage 47 vs 5 morphine milligram equivalents), and outpatient narcotic amount used (46 vs 6 morphine milligram equivalents; p = 0.001). Average pain scores were similar. LIMITATIONS: Retrospective nature of the study and possible underestimation of pre- and postoperative narcotic use. CONCLUSIONS: Implementation of a narcotic-sparing enhanced recovery after surgery protocol was associated with a decrease in both inpatient and 30-day outpatient postoperative narcotic use. Variation in resident physician prescribing practices suggests the need for ongoing education to accompany these protocols. See Video Abstract at http://links.lww.com/DCR/B936 . EL IMPACTO DE UN PROTOCOLO DE RECUPERACIN MEJORADO CON AHORRO DE NARCTICOS EN EL USO POSTOPERATORIO DE NARCTICOS DESPUS DE UNA COLECTOMA: ANTECEDENTES:En los Estados Unidos, el 37 % de todos los opioides se prescriben en el entorno quirúrgico. Entre los adictos a los narcóticos, muchos reportan una exposición inicial en el período posoperatorio.OBJETIVO:Nuestro objetivo fue evaluar el impacto de un protocolo de recuperación mejorada después de la cirugía que ahorra narcóticos en el uso de narcóticos postoperatorios por parte de los pacientes y evaluar su impacto en las prácticas de prescripción de narcóticos de los médicos.DISEÑO:Se revisaron retrospectivamente los datos de pacientes consecutivos sin tratamiento previo con narcóticos que se sometieron a un procedimiento quirúrgico colorrectal abdominal electivo para pacientes hospitalizados desde enero de 2013 hasta agosto de 2017.AJUSTE:Los pacientes se dividieron en 2 cohortes: antes de la implementación (2013-2015) y después de la implementación (2015-2017) del protocolo de recuperación mejorada después de la cirugía.PACIENTES:Pacientes de cirugía colorrectal abdominal electiva para pacientes internados en University of Florida Health.MEDIDAS DE RESULTADO PRINCIPALES:La medida de resultado primaria fue el uso de narcóticos postoperatorios de 30 días (pacientes hospitalizados y ambulatorios). Otros resultados medidos incluyeron puntuaciones de dolor, tiempo hasta la institución de la dieta, duración de la estancia hospitalaria, costo de la hospitalización y complicaciones postoperatorias.RESULTADOS:Las características iniciales fueron similares entre los grupos antes (n = 537) y después del protocolo (n = 790). La implementación del protocolo se asoció con una disminución en la cantidad total de narcóticos postoperatorios de 30 días utilizada por los pacientes (2481 mg frente a 31 mg de equivalentes de morfina, p = 0,05), uso de analgesia controlada por pacientes hospitalizados (63 % frente a 0,5 %, p < 0,00001; dosis 1254 mg frente a 5 mg), uso de narcóticos orales a demanda en pacientes hospitalizados (90 % frente a 32 %, p = 0,001; dosis de 47 mg frente a 5 mg) y cantidad de narcóticos utilizados en pacientes ambulatorios (46 mg frente a 6 mg, p = 0,001). Las puntuaciones medias de dolor fueron similares.LIMITACIONES:La naturaleza retrospectiva del estudio y la posible sub estimación del uso de narcóticos antes y después de la operación fueron limitaciones de los hallazgos del estudio.CONCLUSIÓN:La implementación de un protocolo de recuperación mejorada después de la cirugía que ahorra narcóticos se asoció con una disminución en el uso de narcóticos en el postoperatorio de pacientes hospitalizados y ambulatorios de 30 días. La variación en las prácticas de prescripción de los médicos residentes sugiere la necesidad de una educación continua que acompañe a estos protocolos. Consulte Video Resumen en http://links.lww.com/DCR/B936 . (Traducción-Dr. Mauricio Santamaria ).

Activity of Sorafenib Plus Capecitabine in Previously Treated Metastatic Colorectal Cancer.

LESSONS LEARNED: Treatment for patients with metastatic colorectal cancer (mCRC) typically involves multiple lines of therapy with eventual development of treatment resistance. In this single-arm, phase II study involving heavily pretreated patients, the combination of sorafenib and capecitabine yielded a clinically meaningful progression-free survival of 6.2 months with an acceptable toxicity profile. This oral doublet therapy is worthy of continued investigation for clinical use in patients with mCRC. BACKGROUND: Capecitabine (Cape) is an oral prodrug of the antimetabolite 5-fluorouracil. Sorafenib (Sor) inhibits multiple signaling pathways involved in angiogenesis and tumor proliferation. SorCape has been previously studied in metastatic breast cancer. METHODS: This single-arm, phase II study was designed to evaluate the activity of SorCape in refractory metastatic colorectal cancer (mCRC). Patients received Sor (200 mg p.o. b.i.d. max daily) and Cape (1,000 mg/m2 p.o. b.i.d. on days 1-14) on a 21-day treatment cycle. Primary endpoint was progression-free survival (PFS) with preplanned comparison with historical controls. RESULTS: Forty-two patients were treated for a median number of 3.5 cycles (range 1-39). Median PFS was 6.2 (95% confidence interval [CI], 4.3-7.9) months, and overall survival (OS) was 8.8 (95% CI, 4.3-12.2) months. One patient (2.4%) had partial response (PR), and 22 patients (52.4%) had stable disease (SD) for a clinical benefit rate of 54.8% (95% CI, 38.7%-70.2%). Hand-foot syndrome was the most common adverse event seen in 36 patients (85.7%) and was grade ≥ 3 in 16 patients (38.1%). One patient (2.4%) had a grade 4 sepsis, and one patient (2.4%) died while on treatment. CONCLUSION: SorCape in this heavily pretreated population yielded a reasonable PFS with manageable but notable toxicity. The combination should be investigated further.

Objective predictors of intern performance.

BACKGROUND: Residency programs select medical students for interviews and employment using metrics such as the United States Medical Licensing Examination (USMLE) scores, grade-point average (GPA), and class rank/quartile. It is unclear whether these metrics predict performance as an intern. This study tested the hypothesis that performance on these metrics would predict intern performance. METHODS: This single institution, retrospective cohort analysis included 244 graduates from four classes (2015-2018) who completed an Accreditation Council for Graduate Medical Education (ACGME) certified internship and were evaluated by program directors (PDs) at the end of the year. PDs provided a global assessment rating and ratings addressing ACGME competencies (response rate = 47%) with five response options: excellent = 5, very good = 4, acceptable = 3, marginal = 2, unacceptable = 1. PDs also classified interns as outstanding = 4, above average = 3, average = 2, and below average = 1 relative to other interns from the same residency program. Mean USMLE scores (Step 1 and Step 2CK), third-year GPA, class rank, and core competency ratings were compared using Welch's ANOVA and follow-up pairwise t-tests. RESULTS: Better performance on PD evaluations at the end of intern year was associated with higher USMLE Step 1 (p = 0.006), Step 2CK (p = 0.030), medical school GPA (p = 0.020) and class rank (p = 0.016). Interns rated as average had lower USMLE scores, GPA, and class rank than those rated as above average or outstanding; there were no significant differences between above average and outstanding interns. Higher rating in each of the ACGME core competencies was associated with better intern performance (p < 0.01). CONCLUSIONS: Better performance as an intern was associated with higher USMLE scores, medical school GPA and class rank. When USMLE Step 1 reporting changes from numeric scores to pass/fail, residency programs can use other metrics to select medical students for interviews and employment.

Associations Between National Board Exam Performance and Residency Program Emphasis on Patient Safety and Interprofessional Teamwork.

OBJECTIVE: Several aspects of medical training may contribute to the ultimate goal of producing excellent physicians whose patients will have the best possible outcomes. However, the relative importance of education, evaluation and feedback, duty hours, practice structure, and program culture in achieving this goal is unclear. This study assessed associations among in-training exam performance, Accreditation Council for Graduate Medical Education (ACGME) Resident Survey responses, and American Board of Medical Specialties (ABMS) national board exam performance. METHODS: Residency training programs at a university teaching hospital were classified as having 5-year first-time ABMS pass rates above (n=12) or below (n=3) the national average for their specialty. These groups were compared by ACGME Resident Survey data and in-training exam performance. RESULTS: Surveys were collected from 484/543 eligible residents (89%), including 177 surveys from programs with below-average board pass rates and 307 surveys from programs with aboveaverage board pass rates. In-training exam performance was similar between groups. Aboveaverage programs had stronger agreement with statements that their culture reinforced patient safety (4.72 vs. 4.30, p=0.006) and that information was not lost during transitions of care (4.14 vs. 3.63, p=0.001). Although the occurrence of interprofessional teamwork was similar between groups, above-average programs had stronger agreement with the statement that interprofessional teamwork was effective (4.60 vs. 4.17, p=0.003). CONCLUSION: Residency programs emphasizing patient safety and effective interprofessional teamwork had above-average first-time national board pass rates.

Rectal cancer patients younger than 50 years lack a survival benefit from NCCN guideline-directed treatment for stage II and III disease.

BACKGROUND: The incidence of rectal cancer in patients younger than 50 years is increasing. To test the hypothesis that the biology in this younger cohort may differ, this study compared survival patterns, stratifying patients according to National Comprehensive Cancer Network (NCCN) guideline-driven care and age. METHODS: The National Cancer Data Base was queried for patients treated with curative-intent transabdominal resections with negative surgical margins for stage I to III rectal cancer between 2004 and 2014. Outcomes and overall survival for patients younger than 50 years and patients 50 years old or older were compared by subgroups based on NCCN guideline-driven care. RESULTS: A total of 43,106 patients were analyzed. Younger patients were more likely to be female and minorities, to be diagnosed at a higher stage, and to have travelled further to be treated at academic/integrated centers. Short- and long-term outcomes were significantly better for patients younger than 50 years, with age-specific survival rates calculated. Younger patients were more likely to receive radiation treatment outside NCCN guidelines for stage I disease. In younger patients, the administration of neoadjuvant chemoradiation for stage II and III disease was not associated with an overall survival benefit. CONCLUSIONS: Age-specific survival data for patients with rectal cancer treated with curative intent do not support an overall survival benefit from NCCN guideline-driven therapy for stage II and III patients younger than 50 years. These data suggest that early-onset disease may differ biologically and in its response to multimodality therapy.

Objective Preoperative Parameters Predict Difficult Pelvic Dissections and Clinical Outcomes.

BACKGROUND: Objective criteria to predict difficult pelvic dissection with prognostic significance are lacking. Previous studies have focused on predicting intraoperative conversion and not evaluated factors specific to pelvic surgery. We aimed to develop an objective, prognostic, preoperative assessment to predict difficult pelvic dissections and clinical outcomes. Such a model is much needed, may facilitate objective comparisons between rectal cancer centers, or may serve as a stratification variable in clinical trials. MATERIALS AND METHODS: Patients who underwent low anterior resection or abdominoperineal resection for rectal cancer within 10 cm of the anal verge (2009-2014) were retrospectively analyzed. Procedures were categorized into "routine" or "difficult" based on predefined criteria. All patients underwent 14 measurements on preoperative imaging. Outcomes were compared between the two groups. Stepwise multivariate logistic regression was used to develop the prediction model, which was validated in an independent data set. RESULTS: Of the 280 patients analyzed, 80 fulfilled the inclusion criteria. Baseline characteristics were similar except for more males having a "difficult" pelvis. "Difficult" patients were significantly more likely to have a narrower pelvis, smaller pelvic volumes, a longer pelvis, more curved sacrum, and more acute anorectal angle. Difficult cases correlated significantly with higher blood loss, hospital costs, longer operative time, and length of stay. A practical model to predict difficult pelvic dissections was created and included male gender, previous radiation, and length from promontory to pelvic floor > 130 mm. Model validation was performed in 40 patients from an independent data set. CONCLUSIONS: An objective, validated model that predicts a difficult pelvic dissection and associated worse clinical outcome is possible.

A novel method of minimally invasive rectus abdominis muscle flap harvest: Laparoscopic surgeons take note.

The rectus abdominis muscle (RAM) is a workhorse flap to fill or repair abdominal defects. A drawback of an open RAM harvest is donor site morbidity, and minimally invasive techniques for flap harvesting have been previously proposed but involve vertical division of the rectus fascia. We present a case of a 52-year-old woman with a recurrent rectovaginal fistula in a radiated field treated with a laparoscopic low anterior resection with simultaneous RAM flap harvest utilising a single Pfannenstiel incision. Our novel modified laparoscopic-assisted RAM harvest technique prevents longitudinal violation of the anterior and posterior rectus sheaths, thereby promoting a quick recovery, improved cosmesis and decreased post-operative morbidity.

Survey results of COVID-19 pandemic on female surgical trainees: New normal work environment.

BACKGROUND: The COVID-19 pandemic has had a profound impact on surgical training globally. We aimed to explore and identify the specific challenges faced by women surgeons during the pandemic and provide recommendations for improvement. METHODS: A survey was conducted among trainee members of the Association of Women Surgeons, assessing various aspects of clinical training, mental well-being, and personal and professional life. RESULTS: The respondents were distributed across the United States, with the majority (28%) from the Midwest and Northeast. Training settings were predominantly academic university hospital programs (85%). The majority (92%) were resident trainees and 32% were in research. General surgery, constituting 86% of the respondents, was the most common specialty. There was a decline in surgical cases, research, mental health, and quality of didactics. Limited learning opportunities and challenges in job search were reported. Although virtual conferences were deemed affordable, the lack of networking was noted to be significant. CONCLUSION: The study highlights the need for ongoing support and adaptation in surgical training programs. These programs include the optimization of virtual platforms, prioritizing mental well-being, and ensuring equal opportunities. Strategies to mitigate the impact of future disruptions and promote gender equality are essential. Further research and workflow changes are warranted for effective capacity building.

Validation of a pelvic surgery difficulty risk model to predict difficult pelvic dissection and poor outcomes.

BACKGROUND: We previously developed the Pelvic Surgery Difficulty Index for predicting intraoperative events and postoperative outcomes associated with rectal mobilization with or without proctectomy ("deep pelvic dissection"). The aim of this study was to validate the scoring system as a prognostic tool for outcomes of pelvic dissection, regardless of the cause of dissection. METHODS: Consecutive patients who underwent elective deep pelvic dissection at our institution from 2009 to 2016 were reviewed. Pelvic Surgery Difficulty Index score (0-3) was calculated from the following parameters: male sex (+1), prior pelvic radiotherapy (+1), and linear distance from sacral promontory to pelvic floor >13 cm (+1). Patient outcomes stratified by Pelvic Surgery Difficulty Index score were compared. The outcomes assessed included operative blood loss, operative time, length of hospital stay, cost, and postoperative complications. RESULTS: A total of 347 patients were included. Higher Pelvic Surgery Difficulty Index scores were associated with significantly more blood loss, operative time, postoperative complications, hospital costs, and hospital stay. The model achieved good discrimination with area under the curve ≥0.7 for most outcomes. CONCLUSION: Preoperative prediction of the morbidity associated with difficult pelvic dissection is possible with an objective, feasible, and validated model. Such a tool may facilitate preoperative preparation and allow for better risk stratification and uniform quality control across centers.

Utility of Restaging MRI Following Neoadjuvant Chemoradiotherapy for Stage II-III Rectal Adenocarcinoma.

Background Magnetic resonance imaging (MRI) is currently utilized for the pretreatment staging of locally advanced rectal cancer; however, there is no consensus regarding the utility of repeat MRI for restaging following neoadjuvant chemoradiotherapy (CRT). In this study, we aimed to investigate the clinical utility of restaging MRI after CRT in patients with clinical stage II-III rectal cancer. Methodology We performed a retrospective observational study at a tertiary care hospital. Our study population included patients with clinical stage II-III rectal cancer treated with neoadjuvant CRT who underwent both pre- and post-CRT MRI followed by surgical resection from 2012 to 2017. MRIs were reviewed by radiologists with an interest in rectal cancer MRI imaging using a standardized template. The utility of post-CRT MRI was evaluated by assessing its impact on change in surgical planning, concordance with pathologic staging, and prediction of surgical margins. Results A total of 30 patients were included in the study; 67% had clinical stage III and 33% had stage II disease based on pre-CRT MRI. Post-CRT MRI findings did not lead to a change in the originally outlined surgical plan in any patient. Compared to pre-CRT MRI, post-CRT MRI was not significantly more accurate in predicting T stage (k = 0.483), N stage (k = 0.268), or positive surgical margins (k = 0.839). Conclusions Due to poor concordance with pathologic staging, inability to more accurately predict surgical margin status and the absence of a demonstrable change in surgical treatment, post-CRT restaging with MRI, in its current form, appears to be of limited clinical utility.

Performance Improvement With Implementation of a Surgical Skills Curriculum.

OBJECTIVE: To assess the efficacy of an intern surgical skills curriculum involving a boot camp for core open and laparoscopic skills, self-guided practice with positive and negative incentives, and semiannual performance evaluations. DESIGN: Longitudinal cohort study. SETTING: Academic tertiary care center. PARTICIPANTS: Intervention group (n = 15): residents who completed the intern surgical skills curriculum and had performance evaluations in fall of intern year, spring of intern year, and fall of second year. Control group (n = 8): second-year residents who were 1 year ahead of the intervention group in the same residency program, did not participate in the curriculum, and had performance evaluations in fall of second year. RESULTS: In fall of second year of residency, the intervention group had better performance (presented as median values with interquartile ranges) than the control group on one-hand ties (left hand: 9.1 [6.3-10.1] vs 14.6 [13.5-15.4] seconds, p = 0.007; right hand: 8.7 [8.5-9.6] vs 11.5 [9.9-16.8] seconds, p = 0.039). The intervention group also had better performance on all open suturing skills, including mattress suturing (vertical: 33.4 [30.0-40.0] vs 55.8 [50.0-67.6] seconds, p = 0.001; horizontal: 28.7 [27.3-39.9] vs 52.7 [40.7-57.8] seconds, p = 0.003), and a water-filled glove clamp, divide, and ligate task (28.0 [25.0-31.0] vs 59.1 [53.0-93.0] seconds, p < 0.001). Finally, the intervention group had better performance on all laparoscopic skills, including peg transfer (66.0 [59.0-82.0] vs 95.2 [87.5-101.5] seconds, p = 0.018), circle cut (82.0 [69.0-124.0] seconds vs 191.8 [155.5-231.5] seconds, p = 0.002), and intracorporeal suturing (195.0 [117.0-200.0] seconds vs 359.5 [269.0-450.0] seconds, p = 0.002). CONCLUSIONS: Implementation of a comprehensive surgical skills curriculum was associated with improved performance on core open and laparoscopic skills. Further research is needed to understand and optimize motivational factors for deliberate practice and surgical skill acquisition.

Prevalence and extent of industry support for program directors of surgical fellowships in the United States.

BACKGROUND: Fellowship program directors have a considerable influence on the future practice patterns of their trainees. Multiple studies have demonstrated that industry can also exert substantial influence on the practice patterns of physicians as a whole. The purpose of this study is to quantify industry support of fellowship program directors across surgical subspecialties and to assess the prevalence of this support within specific subspecialties. METHODS: Fellowship program directors for acute care, breast, burn, cardio-thoracic, critical care, colon and rectal, endocrine, hepato-pancreato-biliary, minimally invasive, plastic, oncologic, pediatric, and vascular surgery for 2017 were identified using a previously described database. The Open Payments Database for 2017 was queried and data regarding general payments, research, associated research payments, and ownership were obtained. The national mean and median payouts to nonfellowship program director surgeons were used to determine subspecialties with substantial industry support. RESULTS: Five hundred and seventy-six fellowship program directors were identified. Of these, 77% of the fellowship program directors had a presence on the Open Payments Database. The subspecialties with the most fellowship program directors receiving any industry payment, regardless of amount, included vascular (93.5%), cardio-thoracic (92.8%), minimally invasive surgery (90.5%), plastics (85.3%), and colon and rectal (81.0%). The subspecialty with the greatest mean payment was minimally invasive surgery (21,175 US dollars); the greatest median payment was vascular (1,871 US dollars). The 3 most common types of payments were for general compensation (31.4%), consulting fees (28.7%), and travel and lodging (14.7%). Vascular surgery had the greatest percentage of fellowship program directors receiving research payments (48%). The greatest amount paid to any individual fellowship program director was 382,368 US dollars. Excluding outliers, fellowship program directors received substantially more payments than those received on average by general surgeons. CONCLUSION: The majority of fellowship program directors receive some industry support. Most payments are for compensation for noncontinuing medical education related services and consulting fees. Certain specialties were more likely to have industry payments than others. Overall, only a minority of fellowship program directors received research support from industry. We advocate for transparent discussions between fellowship program directors and their trainees to help foster healthy academic-industry collaborations.

STAT3 Genotypic Variant rs744166 and Increased Tyrosine Phosphorylation of STAT3 in IL-23 Responsive Innate Lymphoid Cells during Pathogenesis of Crohn's Disease.

Crohn's disease (CD) results from dysregulated immune responses to gut microbiota in genetically susceptible individuals, affecting multiple areas of the gastrointestinal tract. Innate lymphoid cells (ILCs) are tissue-resident innate effector lymphocytes which play crucial roles in mucosal immune defense, tissue repair, and maintenance of homeostasis. The accumulation of IFN-γ-producing ILC1s and increased level of proinflammatory cytokines produced by ILCs has been observed in the inflamed terminal ileum of CD patients. To date, the precise mechanisms of ILC plasticity and gene regulatory pathways in ILCs remain unclear. Signal transducer and activator of transcription 3 (STAT3) regulates gene expression in a cell-specific, cytokine-dependent manner, involving multiple immune responses. This study proposes the positive correlation between the prevalence of STAT3 rs744166 risky allele "A" with the severity of disease in a cohort of 94 CD patients. In addition, the results suggest an increased STAT3 activity in the inflamed ileum of CD patients, compared to unaffected ileum sections. Notably, IL-23 triggers the differentiation of CD117+NKp44- ILC3s and induces the activation of STAT3 in both CD117+NKp44- and CD117-NKp44- ILC subsets, implying the involvement of STAT3 in the initiation of ILC plasticity. Moreover, carriage of STAT3 "A" risk allele exhibited a higher basal level of STAT3 tyrosine phosphorylation, and an increased IL-23 triggered the pSTAT3 level. We also demonstrated that there was no delayed dephosphorylation of STAT3 in ILCs of both A/A and G/G donors. Overall, the results of this study suggest that IL-23-induced activation of STAT3 in the CD117-NKp44- ILC1s involves in ILC1-to-ILC3 plasticity and a potential regulatory role of ILC1 function. Those genetically susceptible individuals carried STAT3 rs744166 risky allele appear to have higher basal and cytokine-stimulated activation of STAT3 signal, leading to prolonged inflammation and chronic relapse.

Sigmoido-rectal intussusception.

Rectal prolapse is usually of benign etiology. Rarely, sigmoido-rectal intussusception results from a malignant lead-point. We report the case of a patient with a partially obstructing sigmoid cancer causing a full thickness rectal prolapse requiring surgical intervention. An 82-year-old woman presented with 1 week of rectal bleeding, fecal incontinence, and weight loss. Computed tomography identified sigmoido-rectal intussusception. Colonoscopic biopsy revealed high-grade dysplasia. Magnetic resonance imaging demonstrated a 6-cm mass forming the lead point of the intussusceptum with epiploic appendages seen within the rectal lumen. She underwent laparoscopic low anterior resection with final pathology consistent with T2N0 adenocarcinoma, and recovered well. Among adult patients with rectal prolapse, suspicion for underlying malignancy should prompt a thorough investigation to inform the decision for resection, which may be safely performed by minimally invasive techniques.

Pre-operative total parenteral nutrition improves post-operative outcomes in a subset of Crohn's disease patients undergoing major abdominal surgery.

BACKGROUND: Despite major advances in the medical management of Crohn's disease (CD), a significant proportion of patients will require surgery within 5 years of diagnosis. Malnutrition is an independent risk factor for adverse post-operative outcomes following gastrointestinal surgery. Data on the value of pre-operative total parenteral nutrition (TPN) in CD patients are mixed and there is a paucity of data in the biologic era. We aimed to define the role of pre-operative TPN in this population. METHODS: This was a retrospective cohort study conducted at a tertiary referral center. CD patients who underwent major abdominal surgery were identified. Patients receiving pre-operative TPN were compared to controls. We compared the incidence of 30-day infectious and non-infectious post-operative complications between the two groups. RESULTS: A total of 144 CD patients who underwent major abdominal surgery between March 2007 and March 2017 were included. Fifty-five patients who received pre-operative TPN were compared to 89 controls. Twenty-one (14.6%) patients developed infectious complications (18.2% in TPN group vs 12.3% in non-TPN group, P = 0.34) and 23 (15.9%) developed non-infectious complications (14.5% in TPN group vs 16.9% in non-TPN group, P = 0.71). In a multivariate analysis, controlling for differences in baseline disease severity and malnutrition between groups, patients receiving pre-operative TPN for ≥60 days had significantly lower odds of developing non-infectious complications (odds ratio 0.07, 95% confidence interval: 0.01-0.80, P = 0.03). Weight loss of >10% in the past 6 months was a significant predictor of post-operative complications. CONCLUSIONS: In a subset of malnourished CD patients, TPN is safe and allows comparable operative outcomes to controls. Pre-operative TPN for ≥60 days reduced post-operative non-infectious complications without associated increase in infectious complications.

Gender differences among surgical fellowship program directors.

BACKGROUND: Although women are increasingly represented in American surgery, data regarding sex and academic rank of the leadership of fellowship programs are lacking. METHODS: Demographics and academic ranks for fellowship program directors were analyzed for 811 surgery fellowship programs across 14 specialties. Associations between academic rank and sex were assessed using a χ2 independence test. Correlation between subspecialty compensation and percentage of female fellowship program directors was assessed using Pearson r. RESULTS: Women represented 18% of all fellowship program directors. Eighteen percent of fellowship program directors were assistant professors (25% women vs 17% men, P = .049), 36% were associate professors (39% women vs 35% men, P = .379), and 46% were full professors (36% women vs 48% men, P = .018). The percentage of women program directors was greatest in breast surgery (65%) and least in minimally invasive surgery (6%). There was a negative correlation between subspecialty compensation and percentage of female fellowship program directors (r = -0.62, P = .04). CONCLUSION: Women are underrepresented among surgery fellowship program directors. Female fellowship program directors had lesser academic ranks compared with males. It remains unclear whether women surgeons achieve program director appointments at lesser academic ranks or if promotion among fellowship program directors is influenced by sex.

Are the kids alright? Review books and the internet as the most common study resources for the general surgery clerkship.

BACKGROUND: To define resources deemed most important to medical students on their general surgery clerkship, we evaluated their material utilization. METHODS: A prospective study was conducted amongst third-year medical students using a 20-item survey. Descriptive statistics were performed on the demographics. Kruskal-Wallis and Mann-Whitney analyses were performed on the Likert responses (α = 0.05). RESULTS: Survey response was 69.2%. Use of review books and Internet was significantly higher compared to all other resources (p < 0.05). Wikipedia was the most used Internet source (39.1%). 56% never used textbooks. Analyses of surgery subject exam (NBME) results or intended specialty with resources used showed no statistical relationship (all p > 0.05). CONCLUSIONS: Resources used by students reflect access to high-yield material and increased Internet use. The Internet and review books were used more than the recommended textbook; NBME results were not affected. Understanding study habits and resource use will help guide curricular development and students' self-regulated learning.

Sigmoid Colon Adenocarcinoma with Isolated Loss of PMS2 Presenting in a Patient with Synchronous Prostate Cancer with Intact MMR: Diagnosis and Analysis of the Family Pedigree.

Lynch syndrome (LS) patients with isolated PMS2 loss in the colon cancer, while intact MMR in the prostate cancer, are exceedingly rare. Herein, we report such a case. A 71-year-old male was found to have increased serum PSA (10 ng/ml) after treatment for his urinary tract infection. Prostate biopsies showed foci of prostate cancer with Gleason score 7 (3+4) (grade grope 2) involving 10% of two cores. Through work up for treatment of the prostate cancer, he was found to have focal thickening of his sigmoid colon with adjacent lymphadenopathy in CT scans. Colon biopsy showed a tubular adenoma with high-grade dysplasia and deep invasive carcinoma could not be excluded. A low anterior resection of the rectosigmoid colon was performed and a sigmoid colon adenocarcinoma (pT2N1b, AJCC 8th edition) was confirmed. Immunostaining showed that the colon cancer was positive for CDX2, SATB2, had a loss of PMS2 and intact expression of MLH1, MSH2 and MSH6, negative for AMACR, while the prostate cancer was positive for AMACR, had intact expression of PMS2, MLH1, MSH2 and MSH6, and negative for CDX2 and SATB2. MSI-H phenotype and PMS2 mutation in the colon cancer were confirmed by microsatellite instability (MSI) PCR and next-generation sequencing (NGS), respectively. Through genetic counseling and analysis of the family pedigree, LS was confirmed with colon cancer present in multiple maternal family members and his brother also had metachronous colon and prostate cancers. To the best of our knowledge, this is the first documented case of synchronous colon and prostate cancers, with isolated PMS2 loss present in the colon cancer while intact DNA mismatch repair (MMR) protein expressions present in the prostate cancer, in the English literature. The pathogenesis, diagnosis and prognosis of this entity are discussed.

Total Neoadjuvant Therapy: A Shifting Paradigm in Locally Advanced Rectal Cancer Management.

Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one-third of newly diagnosed cases, thus representing a major socioeconomic health burden. Although minimally invasive procedures (ie, transanal excision) may be appropriate for a subset of patients with small, superficially invasive tumors, a more comprehensive trimodality approach with neoadjuvant chemoradiotherapy, total mesorectal excision, and systemic chemotherapy is recommended for medically operable patients with nonmetastatic, locally advanced rectal cancer (LARC). Although such multimodality therapy has markedly reduced local recurrence rates, there remains an estimated 5-year distant relapse rate of 35%, representing the leading cause of death in this population. This review critically assesses the literature regarding neoadjuvant therapy for LARC, as well as the available evidence to support selective exclusion of individual modalities from the contemporary therapeutic paradigm, including controversies of nonoperative management, selective radiation sparing, and neoadjuvant systemic therapy. Through the review of existing data and the anticipated results of ongoing clinical trials, we outline the pragmatic opportunities for future investigation into questions of efficacy, safety, and ultimate improvements to the current status quo.

Cecal volvulus caused by internal herniation after roux-en-y gastric bypass surgery.

Cecal volvulus is the rotation of a mobile cecum resulting in a large bowel obstruction. We present the case of a 55-year-old female who underwent a roux-en-y gastric bypass in 2003 and presented to the emergency department with worsening abdominal pain, distention and obstipation. Roentgenogram demonstrated a 14 cm colon suggestive of sigmoid volvulus, but CT scan showed rectal contrast abruptly ending in the distal transverse colon, mesenteric swirling and a distended cecum, consistent with cecal, rather than sigmoid, volvulus. Upon surgical exploration the majority of the small bowel, cecum and ascending colon had herniated through the transverse mesocolon defect created during her prior gastric bypass. The bowel was reduced through the mesenteric defect, and an ileocecectomy was performed. This is, to our knowledge, the first reported case of cecal volvulus caused by an internal hernia through a mesocolon defect created during a prior roux-en-y gastric bypass operation.