Colitis-Associated Colorectal Cancer Survival is Comparable to Sporadic Cases after Surgery: a Matched-Pair Analysis.

BACKGROUND: Inflammatory bowel disease (IBD) confers an increased lifetime risk of colorectal cancer (CRC). The pathogenesis of colitis-associated CRC is considered distinct from sporadic CRC, but existing is mixed on long-term oncologic outcomes. This study aims to compare clinicopathological characteristics and survival between colitis-associated and sporadic CRC. METHODS: Data was retrospectively extracted and analyzed from a single institutional database of patients with surgically resected CRC between 2004 and 2015. Patients with IBD were identified as having colitis-associated CRC. The remainder were classified as sporadic CRC. Propensity score matching was performed. Univariate and survival analyses were carried out to estimate the differences between the two groups. RESULTS: Of 2275 patients included in this analysis, 65 carried a diagnosis of IBD (2.9%, 33 Crohn's disease, 29 ulcerative colitis, 3 indeterminate colitis). Average age at CRC diagnosis was 62 years for colitis-associated CRC and 65 for sporadic CRC. The final propensity score matched cohort consisted of 65 colitis-associated and 130 sporadic CRC cases. Patients with colitis-associated CRC were more likely to undergo total proctocolectomy (p < 0.01) and had higher incidence of locoregional recurrence (p = 0.026) compared to sporadic CRC patients. There were no significant differences in time to recurrence, tumor grade, extramural vascular invasion, perineural invasion, or rate of R0 resections. Overall survival and disease-free survival did not differ between groups. On multiple Cox regression, IBD diagnosis was not a significant predictor of survival. CONCLUSIONS: Patients with colitis-associated CRC who undergo surgical resection have comparable overall and disease-free survival to patients with sporadic CRC.

Facility type is associated with improved perioperative and oncologic outcomes after minimally invasive surgery for pancreatic cancer.

BACKGROUND: This study sought to evaluate outcome differences by facility type in patients who underwent minimally invasive surgery (MIS) for pancreatic ductal adenocarcinoma (PDAC). METHODS: The National Cancer Database was used to identify patients with clinical stage I-III PDAC who underwent MIS from 2010 to 2019 in academic or community facilities. RESULTS: Of 6806 patients who fulfilled inclusion criteria; 1788 (26.3%) were treated at community facilities and 5018 (74.7%) at academic facilities. Patients treated at academic facilities were more likely to receive care at a high-volume facility (62% vs. 32%, p < 0.001), undergo a Whipple (64% vs. 61%, p < 0.001), and be clinical stage II (42% vs. 38%) and III (5.6% vs. 4.9%, p = 0.001). Treatment at academic facilities was predictive of receiving neoadjuvant therapy (OR 2.08, p < 0.001), negative margin resection (OR 0.80, p = 0.004), lower 90-day mortality (OR 0.72, p = 0.02), decreased length of stay (IRR 0.96, p < 0.001), and longer OS (HR 0.88, p = 0.002). CONCLUSION: Patients who underwent MIS for PDAC at academic facilities experienced an association with improved perioperative and oncologic outcomes than those treated in community facilities.

The time Interval Between the End of Radiotherapy and Surgery Does Not Affect Outcomes in Rectal Cancer.

INTRODUCTION: The ideal time interval between the completion of chemoradiotherapy and subsequent surgical resection of advanced stage rectal tumors is highly debated. Our aim is to study the effect of the time interval between the completion of chemoradiotherapy and surgical resection on postoperative and oncologic outcomes in rectal cancer. METHODS: Patients who underwent neoadjuvant chemoradiotherapy for resected locally advanced rectal tumors between 2004 and 2015 were included in this analysis. The time interval was calculated from the date of radiation completion to date of surgery. Patients were split into 2 groups based on the time interval (<8 weeks and >8 weeks). Postoperative outcomes (anastomotic leak, pathologic complete response (pCR), and readmission) and survival were assessed with multivariable logistic regression and Cox regression models while adjusting for relevant confounders. RESULTS: 200 patients (62% male) underwent resection with a median time interval of 8 weeks from completion of radiotherapy. On multivariable logistic regression, there was no significant increase in odds between time interval to surgery and anastomotic leak (aOR = .8 [.27-2.7], P = .8), pCR (aOR = 1.2[.58-2.6] P = .6), or readmission (aOR = 1.02, 95% CI:0.49-2.24, P = .9). Time interval to surgery was not an independent prognostic factor for overall (HR = 1.04 CI = .4-2.65, P = .9) and disease-free survival (HR = 1.2 CI = .5-2.9, P = .6). CONCLUSION: The time interval between neoadjuvant radiotherapy completion and surgical resection does not affect anastomotic leak rate, achievement of pCR, or overall and disease-free survival in patients with rectal cancer. Extended periods of time to surgical resection are relatively safe.

Interprofessional Trauma Team Training: Leveraging Each Specialties' Expertise to Teach Procedural-Based Skills.

OBJECTIVE: The goal of this study was to utilize interprofessional trauma team training to teach procedural-based skills, teamwork, and assess the impact on the procedural comfort and interprofessional collaboration. DESIGN: Interdisciplinary skills sessions were created to focus on chest tube placement and advanced ultrasound techniques. Chest tube sessions were taught by senior general surgery (GS) residents and faculty. Ultrasound sessions were taught by emergency medicine (EM) fellows and faculty. Mock trauma simulations for EM and GS residents and EM nurses, were developed to also focus on improving interprofessional trauma-bay collaboration. Sessions were held throughout the year for 2 consecutive academic years. After completing skills sessions and trauma scenarios, participants were surveyed on skill comfort, session utility, and willingness to collaborate with the other specialty. Likert scale responses were analyzed by specialty cohort and in aggregate. Free-text feedback responses were analyzed for common themes. SETTING: Large, tertiary, urban academic medical center PARTICIPANTS: Forty seven EM residents and 32 GS residents completed instructional chest tube and ultrasound simulations, respectively. Twenty two EM residents, 24 GS residents, and 29 EM nurses participated in interprofessional trauma simulations. RESULTS: For chest tube placement: 71% of EM residents reported feeling uncomfortable with the procedure prior to the session, with 100% reporting improved confidence afterwards. Seventy percent stated the model was realistic. One hundred percent thought it improved their procedural skills. All participants thought it was worthwhile, should be offered again in future years, and planned to incorporate what they learned in their future practice. For the ultrasound sessions: 61% of GS residents felt uncomfortable with the Focused Assessment with Sonography in Trauma prior to the simulation. Ninety four percent reported the improved skill and confidence, and felt the model was realistic. All participants felt sessions were worthwhile, should be offered again, and planned to incorporate what they learned in their future practice. For trauma simulations: 97% of participants felt scenarios were realistic and clinically relevant and planned to incorporate lessons learned in their future clinical practice. All participants thought participation was worthwhile. Ninety seven percent thought it improved their confidence with trauma clinical management and 56% reported it improved their skills. Many participants reported they appreciated learning from the other specialty's perspective, with greater than 95% of all participants reporting improved comfort and willingness to collaborate across disciplines when caring for future trauma patients. All participants requested the simulation sessions continue in future academic years. CONCLUSION: Interprofessional trauma simulation sessions can harness the unique skill sets of different disciplines to teach procedural-based skills and improve interprofessional collaboration within the trauma bay.

Development and validation of the Massachusetts General Hospital/Memorial Sloan Kettering nomogram to predict overall survival of resected patients with pancreatic ductal adenocarcinoma treated with neoadjuvant therapy.

BACKGROUND: Prognostication in patients undergoing resection for pancreatic ductal adenocarcinoma following neoadjuvant therapy remains challenging. In this study, we aimed to develop and validate a nomogram for the prediction of overall survival of these patients. METHODS: Patients who underwent neoadjuvant therapy followed by surgical resection at the Massachusetts General Hospital were analyzed (training cohort). Patients from Memorial Sloan Kettering were included as a validation cohort. A nomogram to predict overall survival was designed, trained, and subjected to internal (bootstrap) validation. RESULTS: A total of 325 patients were identified from Massachusetts General Hospital. Multivariable Cox regression analysis demonstrated that age (hazard ratio 1.828, 95% confidence interval 1.251-2.246; P = .007), serum carbohydrate antigen 19-9 ≥ 37 U/mL (HR 1.602, 95% confidence interval 1.187-3.258; P = .015), tumor size (hazard ratio 2.278, 95% confidence interval 1.405-4.368; P = .003), nodal status (hazard ratio 1.309, 95% confidence interval 1.108-2.439; P = .032), and R1 tumor resection (hazard ratio 1.481, 95% confidence interval 1.049-2.091; P = .026) were independent factors associated with overall survival. A nomogram that incorporated these significant prognostic factors was established. The calibration plots demonstrated high concordance between predictive nomogram values and actual overall survival for 1-year, 3-year, and 5-year overall survival. The model demonstrated excellent discriminatory power in both the Massachusetts General Hospital and Memorial Sloan Kettering cohorts, with adjusted Harrel's concordance index values of 0.729 and 0.712, respectively. CONCLUSION: In this report, we established and validated a novel nomogram for predicting the survival of patients who underwent neoadjuvant therapy followed by pancreatectomy. This model allows clinicians to better estimate the survival of these specific patients.

Improving the financial wellness of general surgery residents: A nationwide survey.

BACKGROUND: Our study evaluated general surgery resident indebtedness and perspectives on financial compensation. METHODS: In May 2020, a survey was distributed nationwide by general surgery program directors in the Association of Program Directors in Surgery on a voluntary basis to their residents. RESULTS: The survey was completed by 419 general surgery residents. Median salary was $60-65 K and median medical educational debt was $200-250 K. Approximately 61% of residents reported that their financial needs were not met by their income. Most residents (76%) believe that for a fair compensation, their salaries should be 30-50% higher. Proposed interventions for improvement in resident compensation included: overtime payment, redirection of GME funds to the residency programs, and compensating residents for billable services. CONCLUSIONS: Residents enter training with significant medical educational debt and feel unfairly compensated for their work. Therefore, comprehensive interventions with input from residents are needed to improve their financial well-being.

Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training.

BACKGROUND: Low first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum. METHODS: Novice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA. RESULTS: Twenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion. CONCLUSION: A VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.

Simulation versus reality: what can interprofessional simulation teach us about team dynamics in the trauma bay?

Purpose: Surgical consultation and the joint management of trauma patients is a common scenario in the emergency department. The goal of this study was to utilize interprofessional trauma team training to understand the role of simulation and its impact on the overall culture of trauma-related care. Methods: Interdisciplinary trauma simulation scenarios were completed by 12 groups of emergency medicine residents, general surgery residents, and emergency medicine nurses across two academic years. Following each simulation, a debriefing session was held to reflect on the scenario, focusing on team interactions. Debriefing sessions were audio-recorded, transcribed, deidentified, and independently, inductively coded by two members of the research team. Using the constant comparative method, a codebook was developed and refined until interrater reliability was confirmed with a kappa of > 0.9. Codes were organized into higher level themes. Results: There were 72 participants, including 23 general surgery residents, 19 emergency medicine residents, and 30 emergency medicine nurses. 214 primary codes were collapsed into 29 coding categories, with 6 emerging themes. Pre-trauma bay impact describes how interactions prior to the trauma scenario can impact how team members communicate, trust one another, and ultimately care for the patient. Role and team identity explores the importance of one knowing their individual role in the trauma bay and how it impacts overall team identity. Resource allocation describes the balance of having appropriate resources to efficiently care for patients while not negatively impacting crowd control or role identity. Impact of the simulation experience highlights the impact of the lower stakes simulation scenario on learning and reflection as well as concerns with simulation fidelity. Trauma leader traits and actions outlines inherent traits and learned actions of trauma leaders that impact how the trauma scenario unfolds. Interprofessional team performance describes the overall performance of the trauma team, including but not limited to the type of communication used, teamwork behaviors, and transition of care of the patient. Conclusions: Interdisciplinary trauma simulations and structured debriefing sessions provide insights into team dynamics and interprofessional relationships. Simulations and debriefing sessions can promote understanding, respect, and familiarity of team members' roles; recognition of key characteristics of high functioning leaders and teams; and discovery of conflict mitigating strategies for future interdisciplinary team improvement. Simulation sessions allow implementation of quality improvement measures and communication and leadership strategy practice in a safe, collaborative learning environment. The lessons learned from these sessions can encourage participants to reexamine how they interact and function as a team within the real-life trauma bay.

Association of age with treatment at high-volume hospitals and distance traveled for care, in patients with rectal cancer who seek curative resection.

BACKGROUND: The association between volume and outcomes has led to recommendations that patients undergo surgery at high-volume centers. We aimed to determine if older patients with rectal cancer are undergoing operations at high-volume centers. METHODS: We identified patients ≥50 years old who underwent rectal cancer resection using the NCDB (2004-2015). Tertiles were used to categorize facility volume and distance traveled. RESULTS: Higher facility volume was associated with improved outcomes. Patients >75 years old were less likely than patients 50-59 years old to be treated at high-volume centers. Traveling >16.8 miles was associated with treatment at high-volume facilities, however patients >75 years old were less likely to travel >16.8 miles. CONCLUSIONS: Higher facility volume is associated with improved outcomes after rectal cancer resection. However, older patients are less likely to be treated at high-volume facilities. Older patients travel shorter distances for care, suggesting that care integration across networks must be optimized.

Zip Code-Related Income Disparities in Patients With Colorectal Cancer.

INTRODUCTION: Screening and early detection reduce morbidity and mortality in colorectal cancer. Our aim is to study the effect of income disparities on the clinical characteristics of patients with colorectal cancer in Massachusetts. METHODS: Patients were extracted from a database containing all surgically treated colorectal cancers between 2004 and 2015 at a tertiary hospital in Massachusetts. We split patients into 2 groups: "above-median income" and "below-median income" according to the median income of Massachusetts ($74,167). RESULTS: The analysis included 817 patients. The above-median income group consisted of 528 patients (65%) and the below-median income group consisted of 289 patients (35%). The mean age of presentation was 64 ± 15 years for the above-median income group and 67 ± 15 years for the below-median income group (P = .04). Patients with below-median income were screened less often (P < .001) and presented more frequently with metastatic disease (P = .02). Patients with above-median income survived an estimated 15 months longer than those with below-median income (P < .001). The survival distribution was statistically significantly different between the groups for stage III disease (P = .004), but not stages I, II, or IV (P = 1, 1, and .2, respectively). For stage III disease, a lower proportion of below-median income patients received chemotherapy (61% vs. 79%, P = .002) and a higher proportion underwent nonelective surgery (5% vs. 2%, P = .007). CONCLUSIONS: In Massachusetts, patients with colorectal cancer residing in lower income areas are screened less, received adjuvant chemotherapy less, and have worse outcomes, especially when analyzing those who present with stage III disease.

Anastomotic Troubleshooting.

Anastomotic leak remains a critical and feared complication in colorectal surgery. The development of a leak can be catastrophic for a patient, resulting in overall increased morbidity and mortality. To help mitigate this risk, there are several ways to assess and potentially validate the integrity of a new anastomosis to give the patient the best chance of avoiding this postoperative complication. A majority of anastomoses will appear intact with no obvious sign of anastomotic dehiscence on gross examination. However, each anastomosis should be interrogated before the conclusion of an operation. The most common method to assess for an anastomotic leak is the air leak test (ALT). The ALT is a safe intraoperative method utilized to test the integrity of left-sided colon and rectal anastomoses and most importantly allows the ability to repair a failed test before concluding the operation. Additional troubleshooting is sometimes needed due to technical difficulties with the circular stapler. Problems, such as incomplete doughnuts and stapler misfiring, do occur and each surgeon should be prepared to address them.

The Impact of Neoadjuvant Treatment on Survival in Patients Undergoing Pancreatoduodenectomy With Concomitant Portomesenteric Venous Resection: An International Multicenter Analysis.

OBJECTIVE: The aim of this study was to evaluate whether neoadjuvant therapy (NAT) critically influenced microscopically complete resection (R0) rates and long-term outcomes for patients with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy (PD) with portomesenteric vein resection (PVR) from a diverse, world-wide group of high-volume centers. SUMMARY OF BACKGROUND DATA: Limited size studies suggest that NAT improves R0 rates and overall survival compared to upfront surgery in R/BR-PDAC patients. METHODS: This multicenter study analyzed consecutive patients with R/BR-PDAC who underwent PD with PVR in 23 high-volume centers from 2009 to 2018. RESULTS: Data from 1192 patients with PD and PVR were collected and analyzed. The median age was 68 [interquartile range (IQR) 60-73] years and 52% were males. Some 186 (15.6%) and 131 (10.9%) patients received neoadjuvant chemotherapy (NAC) alone and neoadjuvant chemoradiotherapy, respectively. The R0/R1/R2 rates were 57%, 39.3%, and 3.2% in patients who received NAT compared to 46.6%, 49.9%, and 3.5% in patients who did not, respectively (P =0.004). The 1-, 3-, and 5-year OS in patients receiving NAT was 79%, 41%, and 29%, while for those that did not it was 73%, 29%, and 18%, respectively (P <0.001). Multivariable analysis showed no administration of NAT, high tumor grade, lymphovascular invasion, R1/R2 resection, no adjuvant chemotherapy, occurrence of Clavien-Dindo grade 3 or higher postoperative complications within 90 days, preoperative diabetes mellitus, male sex and portal vein involvement were negative independent predictive factors for OS. CONCLUSION: Patients with PDAC of the pancreatic head expected to undergo venous reconstruction should routinely be considered for NAT.

Delay to Intervention for Complicated Diverticulitis is Associated with Higher Inpatient Mortality.

BACKGROUND: Patients with diverticular disease complicated by abscess and/or perforation represent the most severely afflicted with the highest mortality and poorest outcomes. This study investigated patient and operative factors associated with poor outcomes from diverticulitis complicated by abscess or perforation. METHODS: We analyzed the National Inpatient Sample to identify inpatient discharges for colonic diverticulitis in the United States from 1/1988 to 9/2015. We identified patients with perforation and/or intestinal abscess based on ICD-9 codes. The primary outcome was inpatient mortality. RESULTS: During the study period, a total of 993,220 patients were discharged with diverticulitis from sampled U.S. hospitals. From this group, 10.7% had an abscess and 1.0% had a perforation associated with diverticular disease. Inpatient mortality of diverticulitis patients with a perforation was 5.4% compared to 1.5% in those without a perforation (p<0.001). Patients with a perforation who underwent surgery had an inpatient mortality of 6.3% vs. 3.0% mortality amongst patients with a perforation who did not undergo an operation (p<0.001). Patients with a perforation that underwent surgery had a 31% increased mortality risk for each day after admission that a procedure was delayed (OR 1.31, CI 1.05-1.78; p=0.03). Mortality risk was increased for patients with either abscess or perforation who underwent surgery if they were female, age ≥65, higher comorbidity, were admitted urgently, underwent peritoneal lavage, or had a post-procedural complication. CONCLUSIONS: Patients with perforated diverticular disease had substantial associated inpatient mortality compared to those with uncomplicated diverticulitis. This increased risk may be associated with performance of peritoneal lavage or because of a delay to procedural intervention.

A Needs Assessment of Video-based Education Resources Among General Surgery Residents.

BACKGROUND: Video-based education (VBE) is an effective tool for knowledge and skill acquisition for medical students, but its utility is less clear for resident physicians. We sought to determine how to incorporate VBE into a general surgery resident operative curriculum. METHODS: We conducted a single-institution, survey-based needs assessment of general surgery residents to determine desired content and format of an operative VBE module. RESULTS: The response rate was 84% (53/63), with 66% senior (postgraduate year ≥3) resident respondents. VBE was the most commonly cited resource that residents used to prepare for an operation (93%) compared with surgical textbooks (89%) and text-based website content (57%). Junior residents were more likely to utilize text-based website content than senior residents (P < 0.01). The three most important operative video components were accuracy, length, and cost. Senior residents significantly preferred videos that were peer-reviewed (P < 0.05) and featured attending surgeons whom they knew (P = 0.03). A majority of residents (59%) believed 5-10 min is the ideal length of an operative video. Across all postgraduate year levels, residents indicated that detailed instruction of each operative step was the most important content of a VBE module. Senior residents believed that the overall indications and details of each step of the operation were the most important contents of VBE for a junior resident. CONCLUSIONS: At this institution, general surgery residents preferentially use VBE resources for operative preparation. A centralized, standardized operative resource would likely improve resident studying efficiency, but would require personalized learning options to work for both junior and senior surgery residents.

Mentoring experience of new surgeons during their transition to independent practice: A nationwide survey.

BACKGROUND: New surgeons are faced with inadequate mentoring when first entering practice. Our study examined challenges faced by young surgeons during their transition in practice and their mentoring experience when entering practice. METHODS: An article-based survey was mailed in August 2019 to general, colorectal, vascular, and cardiothoracic surgeons that became members of the American College of Surgeons within the past 5 years. RESULTS: A total of 853 of 2,915 surveys were completed (29.3% response rate). Both female (38%) and male (62%) surgeons participated. The 3 most common challenges during the transition to practice were confidence building (26.0%), adjusting to a new institutional culture (16.9%), and business and administrative aspects of practice (16.3%). First job attrition rate 44.2%, with the mean duration of the first job being 3.28 ± 0.17 years. Nearly one-third (28.3%) of respondents were not mentored when they first entered practice. The proportion of nonmentored young surgeons leaving their first job (64.3%) was almost twice as that of surgeons who received mentoring (36.3%). Furthermore, the mean duration of the first job was significantly shorter in nonmentored versus mentored surgeons (3.16 ± 0.26 vs 3.76 ± 0.25 years; P < .05). A significant number (43.3%) of respondents reported a desire to be mentored by retired surgeons. CONCLUSION: Our survey highlights the importance of mentoring for young surgeons during their transition into practice. With many young surgeons being enthusiastic about mentoring by retired surgeons, specific programs are necessary to better use their expertise.