The Association Between Low Preoperative Phosphate Levels and Postliver Surgery Outcomes-A Single Center Experience.

INTRODUCTION: Previous research has demonstrated the impact of postoperative phosphate levels on liver regeneration and outcomes after liver resection surgeries, a potential predictor for regenerative success and liver failure. However, little is known about the association between low preoperative serum phosphate levels and outcomes in liver resections. METHODS: We performed a retrospective analysis of liver resections performed at our institution. Patients were categorized based on preoperative phosphate levels (low versus normal). Our primary outcome measure was posthepatectomy liver failure. RESULTS: A total of 265 cases met the study criteria. 71 patients (26.7%) had low preoperative phosphate levels. The incidence of posthepatectomy liver failure was higher in the low preoperative phosphate group (19.2% versus 12.4%). However, after propensity score matching, rates of posthepatectomy liver failure were similar between low and normal preoperative phosphate cohorts (13% versus 14%, P = 0.83). CONCLUSIONS: Low preoperative phosphate levels were not associated with worse postoperative outcomes in this study. Further studies are warranted to investigate this association and its relevance as a clinical prognostic factor for postoperative liver failure.

Liver resection is superior to tumor ablation in patients with multifocal hepatocellular carcinoma.

INTRODUCTION: The management of T2 multifocal hepatocellular carcinoma (MHCC) is controversial, and the comparative impact of liver resection (LR) versus tumor ablation (TA) on survival continues to be debated. The aim of our study was to examine short- and long-term survival for LR and TA in a nationally representative cohort. We hypothesized that patients who underwent LR would have improved survival. METHODS: We utilized the National Cancer Database (2004-2015) to identify patients diagnosed with non-metastatic T2 MHCC. Kaplan-Meier survival curves were generated to compare 10-year overall survival (OS) between LR and TA patients. Kaplan-Meier analysis with stratification was also performed based on lymphovascular invasion, resection margin status, and Charlson-Deyo score. Cox proportional hazard models were used in multivariable analyses. RESULTS: A total of 1225 patients met the inclusion criteria. 991 patients received LR, and 234 received TA. The majority of patients were male, White, and older than ≥60 years old. Clinicodemographic characteristics were generally similar between LR and TA patients. Among patients who underwent LR, 84% had negative margins, and 17% had lymphovascular invasion. Mortality at 30 days was significantly higher among LR patients compared to TA patients (5.4% vs 0.0%, p < 0.001), with those having a Charlson-Deyo score ≥2 facing the highest risk at 7.3%. Nevertheless, 10-year OS for the LR cohort was 27.5% (95% confidence interval [CI]: 24.4%-30.8%) versus 14.7% (95% CI: 9.8%-20.7%, p < 0.001) for TA patients. In stratified analysis, survival benefit was statistically significant only among those with negative resection margin, no lymphovascular invasion, and Charlson-Deyo score ≤1. In multivariable Cox analysis, LR was independently associated with improved survival compared to TA (hazard ratio: 0.80; 95% CI = 0.67-0.95). CONCLUSION: LR poses a higher long-term survival benefit than TA. Prospective studies are warranted to confirm these findings. Although our study patients are a highly selected group of multifocal T2 patients, it gives us a good insight into the fact that LR provides better outcomes if a transplant option is unavailable.

Program Website Evaluation Regarding Dedicated Research Years Offered in General Surgery Residency Programs in the United States.

INTRODUCTION: Research is a vital component in the advancements of surgical sciences due to the reliance of treatment options on innovations and outcomes of patient care. This study aimed to identify research pathways, opportunities, and academic productivities of different general surgery residency programs in the United States. MATERIALS AND METHODS: A web-based review was conducted concerning accredited US general surgery residency programs. Each program's official website was assessed for the availability of research year, compulsory status, duration, type, structure, and location. The study also identified faculty supervision, research day, funding, output, and opportunities to obtain an advanced degree. RESULTS: Data were collected from all 313 general surgery programs in the United States, out of which 127 (41%) offered a dedicated research year to their residents. The research year was deemed mandatory in 27 programs (8%) and optional in 100 programs (32%). Seventy-two programs (23%) offered to start the dedicated research year after postgraduate year 2 or postgraduate year 3. Twenty-two programs (7.02%) provided examples of resident publications and presentations. Resident research day was cited by 42 programs (13.41%). On campus research opportunity was mentioned by nine programs (2.8%), while the off campus chance was provided by 10 programs (3.19%). Furthermore, 36 programs (11.5%) demonstrated potential funding sources. Finally, 38 (12.14%) programs mentioned receiving advanced degrees after the research year. CONCLUSIONS: Although dedicated research time is provided to trainees for some research programs, there is a lack of structure and the need to expand the available content and information regarding research opportunities for the various general surgery residency programs.

Association Between Preoperative Angioembolization and Bleeding Complications in Patients With Benign Liver Tumors: Analysis of a National Database.

INTRODUCTION: The role of angioembolization (AE) in patients with benign liver diseases is an area of active research. This study aims to assess any difference in liver resection outcomes in patients with benign tumors dependent on utilization of preoperative AE. METHODS: A retrospective cohort study of patients undergoing elective liver resections for benign liver tumors was performed using the National Surgical Quality Improvement Program database (2014-2019). Only tumors of 5 cm in size or more were included in the analysis. We categorized the patients based on preoperative AE (AE + versus AE -). The primary outcome measured included bleeding complications within 72 h. The secondary outcomes were to determine predictors of bleeding. RESULTS: After propensity score matching, there were 103 patients in both groups. There was no difference in intraoperative or postoperative blood transfusions within 72 h of surgery (14.6% versus 12.6%; P = 0.68), reoperation (1.9% versus 1.9%; P = 1), or mortality (1.0% versus 0.0%; P = 1) between the two groups. Multivariate regression analysis revealed an open surgical approach (odds ratio [OR]: 4.59 confidence interval [CI]: 2.94-7.16), use of Pringle maneuver (OR: 1.7, CI: 1.26-2.310), preoperative anemia (OR: 2.79, CI: 2.05-3.80), and preoperative hypoalbuminemia (OR: 1.53 [1.14-2.05]) were associated with the need for intraoperative or postoperative blood transfusions within 72 h of surgery. CONCLUSIONS: Preoperative AE was not associated with reducing intraoperative or postoperative bleeding complications or blood transfusions within 72 h after surgery.

Perceptions of General Surgery Program Leadership and Residents on Research Sabbatical.

INTRODUCTION: The incorporation of a 1-y- or 2-y research period during general surgery residency is increasingly common in many academic programs, yet often, it is heterogeneously structured and ill-defined. This survey-based observational study aimed to characterize the perceptions of general surgery program directors (PDs) and residents regarding an in-training, dedicated research sabbatical. METHODS: Two surveys were conducted using Qualtrics software. One survey was sent to general surgery residency PDs, and the other was sent to general surgery residents currently on a research sabbatical. The primary aim of the survey was to assess the PDs' and research residents' perceptions of the research sabbatical. RESULTS: Seven hundred and fifty-two surveys were analyzed, of which 120 were from PDs and 632 from research residents. Among the residents, 44.1% felt that the research time delayed their surgical training. Regarding research funding, 46.7% of the responding residents said that their residency program funded their research, 30.9% said they acquired funding independently, and 19.1% said that it came from a combination of residency program and independent funding. Finally, regarding how residents found their research opportunity, 42.7% said they found it independently and 53.3% said their program provided it. CONCLUSIONS: Research sabbaticals during residency may be considered essential to academic development. However, in this survey-based study, perceptions of research time and its structure varied greatly between PDs and residents. An intentional push toward developing guidelines for research sabbaticals may benefit residency program leadership and residents.

Outcomes in elderly patients undergoing hepatic resection compared to ablative therapy for hepatocellular carcinoma.

BACKGROUND AND OBJECTIVES: Hepatic resection is an excellent option in the care of patients with hepatocellular carcinoma (HCC). Elderly patients often forego hepatic resection in favor of liver-directed ablative therapies due to the increased likelihood of adverse postoperative outcomes due to age. We sought to determine long-term outcomes in patients who underwent hepatic resection compared to liver-directed ablative therapy in this patient population. METHODS: We queried the National Cancer Database for elderly patients (≥70 years) diagnosed with HCC between 2004 and 2018. The primary outcome was overall survival (OS) computed using the Kaplan-Meier method and Cox proportional hazard regression. RESULTS: A total of 10 032 patients were included in this analysis. On unadjusted analysis (p < 0.001) as well as multivariable analysis (hazard ratio: 0.65, 95% confidence interval: 0.57-0.73), hepatic resection was associated with improved OS. The protective association between hepatic resection and OS persisted after 1:1 propensity score matching. CONCLUSIONS: Hepatic resection is associated with improved survival for well-selected elderly patients with HCC. While age is often thought of as influencing the decision to offer surgery, our study, in combination with others, demonstrates that it should not. Instead, other objective indicators of performance and functional status may be considered.

Outcomes in elderly patients undergoing hepatic resection compared to liver transplant for hepatocellular carcinoma.

BACKGROUND: Hepatic resection (HR) is an excellent option for patients with hepatocellular carcinoma (HCC). For patients meeting the Milan criteria, a liver transplant (LT) is also a viable option for patients with HCC, especially those with end-stage liver disease. With increasing rates of LTs amongst the elderly, we sought to determine long-term outcomes in patients who underwent HR compared to LTs in this patient population. METHODS: We queried the national cancer database for elderly patients (≥70 years) diagnosed with HCC between 2004 and 2020. The primary outcome was overall survival (OS) computed using the Kaplan-Meier method and Cox proportional hazard regression. One-to-one propensity score matching was conducted on the basis of clinicodemographic features to account for baseline differences between patients undergoing each procedure. RESULTS: Of the 5090 patients included, 4674 (91.8%) and 416 (8.2%) patients underwent HR and LT, respectively. Compared with HR patients, patients receiving LT had better OS (p < 0.001) and greater median survival time (65.6 months HR vs. 97.9 months LT, p < 0.001). On multivariable analysis, a LT was independently associated with improved survival (adjusted hazard ratio: 0.61, 95% confidence interval: 0.50-0.76, p < 0.001). CONCLUSIONS: LT is associated with improved survival for well-selected elderly patients with HCC. Age alone should not be used as the sole parameter for the candidacy of LT in elderly patients.

Synthesis and In Silico Study of Some New bis-[1,3,4]thiadiazolimines and bis-Thiazolimines as Potential Inhibitors for SARS-CoV-2 Main Protease.

A novel series of bis-[1,3,4]thiadiazolimines, and bis-thiazolimines, with alkyl linker, were synthesized through general routes from cyclization of 1,1'-(hexane-1,6-diyl)bis(3-phenylthiourea) and hydrazonoyl halides or α-haloketones, respectively. Docking studies were applied to test the binding affinity of the synthesized products against the Mpro of SARS-CoV-2. The best compound, 5h, has average binding energy (-7.50 ± 0.58 kcal/mol) better than that of the positive controls O6K and N3 (-7.36 ± 0.34 and -6.36 ± 0.31 kcal/mol). Additionally, the docking poses (H-bonds and hydrophobic contacts) of the tested compounds against the Mpro using the PLIP web server were analyzed.

Should Radiological Assessment be Part of Core General Surgery Competency? A Survey of the General Surgery Residents.

BACKGROUND: Radiological assessment is an important skill to develop in general surgery training. Therefore, we aimed to determine general surgery residents' points of view on receiving formal radiology didactics. METHODS: We performed an anonymous survey of general surgery residents throughout the USA. The survey queried the residents' postgraduate year, training program type, diagnostic radiology education in their training program, as well as the residents' comfort level in interpreting various imaging modalities, followed by a series of images to assess the residents' ability to interpret images showing various surgical disease processes. RESULTS: A total of 365 residents responded to the survey. In total, 76.6% of the respondent states that there is no structured didactic session in their program on radiological studies. However, 66.3% felt that interpretation of radiological images should be used to determine surgical competency and promotion to the next academic year. In terms of accurately reading images-68.7% of the residents were able to read an X-ray showing cecal volvulus correctly, 51.9% were able to read a cholangiogram correctly, and 95.3% were correctly read an X-ray showing free under the diaphragm. CONCLUSION: Most residents favored having radiological assessments as part of the competency evaluation. Furthermore, a curriculum and inbuilt training structure that aims to ensure residents develop competent clinical image interpretation abilities may enhance the development and retention of such skills, ultimately influencing patient outcomes.

National Trends in Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography During Index Hospitalization for Mild Gallstone Pancreatitis.

BACKGROUND: Guidelines call for cholecystectomy during the index hospitalization for patients with gallstone pancreatitis. Therefore, the study sought to determine the trends for cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) for mild gallstone pancreatitis. METHODS: A retrospective analysis of the 2010-2018 Nationwide Readmission Database (NRD) was performed to identify patients with mild gallstone pancreatitis. The primary aim was to identify the trends in the use of cholecystectomy in these patients, and the secondary aim was to assess if ERCP alone was protective against readmission. RESULTS: A total of 510,470 patients with mild gallstone pancreatitis were identified. There has been an increasing trend in ERCP use (25% in 2018 vs. 22% in 2010; p-0.001) and a decline in cholecystectomy (37% in 2018 vs. 46% in 2010; p-0.001) prior to discharge. Multivariate analysis revealed higher 30-day readmission for patients who underwent ERCP without cholecystectomy (odds ratio1.3; 95% confidence interval, 1.1-3.5) during the index admission. CONCLUSIONS: There has been a decline in the use of cholecystectomy during index hospitalization for mild gallstone pancreatitis. In addition, ERCP was not protective against 30-day readmission from mild gallstone pancreatitis.

Selecting the Next Generation of Surgeons: General Surgery Program Directors and Coordinators Perspective on USMLE Changes and Holistic Approach.

INTRODUCTION: The United States Medical Licensing Examination (USMLE) was designed as a universal assessment tool for states to determine physician's medical licensure's candidacy. Recent changes in the USMLE exam have changed the way future surgical residency candidate applications will be reviewed. The survey aimed to assess the effect of changes in USMLE exams-USMLE Step 1 pass/fail, complete dissolution of USMLE clinical skills exam, and the role of holistic review in future surgical residency candidacy selection. METHODS: An anonymous online survey was created and distributed to general surgery program directors and coordinators across the USA. The survey aimed to assess attitudes toward changes to USMLE exams and the potential changes with a holistic review of candidate applications. RESULTS: The response rate was 63.7%. Most program directors and coordinators disagree with changing USMLE Step 1 to a pass/fail scoring system. The majority felt that contacts, the medical school's name, and performance in clinical electives and sub-internships would hold more significance. They also believe that a holistic review of application will decrease socioeconomic discrepancies and promote a more diverse and inclusive resident cohort. CONCLUSION: Step 2 clinical knowledge (CK) will gain more importance in future residency matches because of the change in the scoring system of Step 1. The medical school's name, personal contacts, and clinical performance in rotations will hold more significance.

Survival Benefits and Disparities in Adjuvant Radiation Therapy for Patients with Pancreatic Cancer.

BACKGROUND: The effects of adjuvant radiation therapy on pancreatic cancer outcomes after resection are not well defined in the literature. METHODS: We abstracted data from the Surveillance, Epidemiology, and End Result (SEER) database to explore the impact of adjuvant radiation on cancer-specific survival in pancreatic cancer patients who received surgical resection. RESULTS: A total of 10,224 patients met our inclusion criteria with 6768 (66.2%) patients treated with surgery only and 3456 (33.8%) treated with surgery plus adjuvant radiation. Surgery followed by adjuvant radiation was associated with significantly improved survival (HR: 0.753, CI: 0.718-0.789, p<0.001). Additionally, female gender and married status were both independently associated with better survival (p<0.05), while advanced age, Caucasian race, higher TNM stage, and higher grade had worse survival outcomes (p<0.05) Asian and Spanish-Hispanic-Latino patients were less likely to receive adjuvant radiotherapy (p<0.05). CONCLUSION: Adjuvant radiation was associated with significantly improved survival after resection for pancreatic cancer. There are significant differences in the patient populations who receive adjuvant radiation.

Global experience and perspective on anonymous nondirected live donation in living donor liver transplantation.

Anonymous nondirected living liver donation (ANLLD), sometimes referred to as "altruistic" donation, occurs when a biologically unrelated person comes forward to donate a portion of his/her liver to a transplant candidate who is unknown to the donor. Here, we explore the current status of ANLLD with special consideration of published reports; US experience; impact on donor psychosocial outcomes; barriers to donation; and current global trends with respect to ethical considerations. Between 1998 and 2019, 105 anonymous nondirected living liver donor (ND-LLD) transplants have been documented in the US Scientific Registry of Transplant Recipients. Sixteen donors (15%) were reported to experience a postoperative complication. Currently, 89 donors remain alive (85%), 16 (15%) have unknown status, and none are confirmed deceased. Although there are only a handful of case series, these data suggest that ANLLD is a feasible option. While there are no liver-specific data, studies involving anonymous nondirected kidney donors suggest that anonymous donation does not adversely impact psychosocial outcomes in donors or recipients. There are substantial financial burdens and ethical considerations related to ANLLD. Further studies are required to assess donor demographics, psychosocial motivations, long-term health-related quality of life, and financial impact of ANLLD.

Research priorities in Fontan-associated liver disease.

PURPOSE OF REVIEW: Fontan-associated liver disease (FALD) is an emerging condition in patients who have undergone surgical correction of univentricular congenital heart disease. There is little known about the epidemiology of FALD, including risk factors for end-organ failure or hepatocellular carcinoma nor a consensus on surveillance guidelines. Furthermore, there is a need to understand the role of heart versus combined heart-liver transplantation in this population. Research is limited by systemic barriers hindering the ability to track longitudinal FALD outcomes. RECENT FINDINGS: Nearly all patients post-Fontan develop histological features of FALD as a function of time post-Fontan, regardless of Fontan hemodynamics. In cases of end-organ disease, single-center studies have shown promising outcomes of combined heart-liver transplant in this population, with decreased rates of acute rejection. However, despite the burden of disease, it is not currently possible to identify the population of patients with FALD using existing clinical databases and registries due to a lack of diagnostic codes. SUMMARY: Strategies proposed to address barriers to understanding FALD include developing appropriate diagnostic and transplant-related codes for existing registries. Efforts should also be targeted at initiating prospective studies to understand recognized comorbidities related to Fontan physiology, guided by a team of multidisciplinary subspecialists.

Current state of kidney utilization in multiorgan transplants.

PURPOSE OF REVIEW: In the United States, the leading indication for kidney transplant is primary kidney dysfunction arising from chronic hypertension and diabetes. However, an increasing indication for kidney transplantation is secondary kidney dysfunction in the setting of another severe organ dysfunction, including pancreas, liver, heart, and lung disease. In these settings, multiorgan transplantation is now commonly performed. With the increasing number of multiorgan kidney transplants, an assessment of guidelines and trends for in multiorgan kidney is necessary. RECENT FINDINGS: Although the utilization of kidney transplants in combined liver-kidney transplant was sharply rising, following the introduction of the 'safety net' policy, combined liver-kidney transplant numbers now remain stable. There is an increasing trend in the utilization of kidney transplantation in heart and lung transplantation. However, as these surgeries were historically uncommon, guidelines for patients who require simultaneous heart or lung transplants are limited and are often institution specific. SUMMARY: Strict guidelines need to be established to assess candidacy for kidney transplantation in multiorgan failure patients, particularly for combined heart-kidney and lung-kidney patients.

RETINAL DETACHMENT SURGERY IN A PEDIATRIC POPULATION: Visual and Anatomic Outcomes.

PURPOSE: Pediatric retinal detachments (RDs) are unique in etiology, anatomy, and prognosis compared with the adult population. The mechanisms of pediatric RD include tractional (TRD), rhegmatogenous retinal detachment, traumatic, and other types, such as exudative or hemorrhagic. This study examined visual and anatomical outcomes of pediatric RD undergoing surgical repair at a single university referral center. METHODS: A retrospective consecutive case series of patients clinically diagnosed and undergoing surgery for RD between birth and 15 years of age from 2002 to 2013 at a single academic institution. RESULTS: A total of 206 patients (231 eyes) were included in this study, of which 25 (12%) had bilateral RD. Of those patients, 67 (29%) had TRD (retinopathy of prematurity, persistent fetal vasculature, or familial exudative vitreoretinopathy), 51 (22%) had rhegmatogenous retinal detachment (myopia, X-linked retinoschisis, or Stickler syndrome), 60 (26%) had traumatic RD, and 53 (23%) were due to other types of RD, such as Coats disease or coloboma. Presenting best-corrected visual acuity better than 20/200 correlated with better final best-corrected visual acuity (P < 0.0001). Anatomical success was strongly correlated with visual acuity outcome (P < 0.00001) and was significantly more likely in rhegmatogenous retinal detachment versus TRD (78% vs. 39%, P < 0.05). The rates of obtaining a final best-corrected visual acuity > 20/200 were poorer in TRD (10%) compared with rhegmatogenous retinal detachment (39%, P < 0.01) or traumatic RD (28%, P < 0.05). CONCLUSION: Visual and anatomical outcomes varied among categories of RD. Rhegmatogenous retinal detachments were associated with the best outcomes (anatomical success and globe conservation), whereas TRDs generally had poorer visual and anatomical outcomes.