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Aim: The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts. Method: A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed. Results: Seventy‐three patients were identified (81% female) with a mean age of 45 years. Thirty‐nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty‐day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow‐up greater than 1 year, the median follow‐up was 39 months (range 1.0–11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient. Conclusion: The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months. [ABSTRACT FROM AUTHOR]

Background: The rampant, disturbing, and dismal unrestricted use of topical corticosteroids on face results in steroid-induced dermatitis termed topical steroid-dependent face (TSDF). It is an embarrassing and irritating condition for a patient. There is paucity of data from India regarding the effect of TSDF on the quality of life (QoL) of such patients. Aims: The aim of this study was to study the effect of TSDF on the QoL of patients with the help of a validated, easy-to-use, and reproducible dermatology life quality index (DLQI). Methods: A cross-sectional study was done among the outpatients seeking treatment for TSDF at a tertiary care hospital of a medical college. Patients were administered Hindi questionnaire version of DLQI. Controls were apparently healthy age- and sex-matched individuals. Results: DLQI scores revealed that TSDF had some effect on QoL in 98.11% of study patients. Study group had a mean DLQI score of 11.49. Statistically significant higher DLQI scores were recorded among females, patients aged <20 years and those who had no formal education/illiterate. Conclusions: TSDF affects QoL in majority of patients and it has a very large effect on the QoL in more than one-third of the patients. [ABSTRACT FROM AUTHOR]

Background: Concerns persist regarding the effectiveness of robotic proctectomy compared with open proctectomy for locally advanced rectal cancer with a high risk of circumferential resection margin involvement., Objective: Comparison of surrogate cancer outcomes after robotic versus open proctectomy in this subpopulation., Design: Retrospective cohort study., Setting: Three academic hospitals (Mayo Clinic Arizona, Florida, and Rochester) with data available through the Mayo Data Explorer platform., Patients: Patients at high risk of circumferential resection margin involvement were selected on the basis of the MRI-based definition from the MERCURY I and II trials., Main Outcome Measures: Rate of pathologic circumferential resection margin involvement (≤1 mm), mesorectal grading, and rate of distal margin involvement., Results: Out of 413 patients, 125 (30%) underwent open and 288 (70%) underwent robotic proctectomy. Open proctectomy was significantly associated with a greater proportion of cT4 tumors (39.3% vs 24.8%, p = 0.021), multivisceral/concomitant resections (40.8% vs 18.4%, p < 0.001), and less frequent total neoadjuvant therapy use (17.1% vs 47.1%, p = 0.001). Robotic proctectomy was less commonly associated with pathologic circumferential resection margin involvement (7.3% vs 17.6%, p = 0.002), including after adjustment for cT stage, neoadjuvant therapy, and multivisceral resection (OR 0.326; 95% CI, 0.157-0.670, p = 0.002). Propensity score matching for 66 patients per group and related multivariable analysis no longer indicated any reduction of circumferential positive margin rate associated with robotic surgery ( p = 0.86 and p = 0.18). Mesorectal grading was comparable (incomplete mesorectum in 6% robotic proctectomy patients vs 11.8% open proctectomy patients, p = 0.327). All cases had negative distal resection margins., Limitation: Retrospective design., Conclusions: In patients with locally advanced rectal cancer at high risk of circumferential resection margin involvement, robotic proctectomy is an effective approach and could be pursued when technically possible as an alternative to open proctectomy. See Video Abstract ., Resultados Comparativos Entre La Proctectoma Robtica Y La Proctectoma Abierta En Casos De Cncer De Recto Con Alto Riesgo De Mrgen De Reseccin Circunferencial Positivo: ANTECEDENTES:Persisten preocupaciones con respecto a la efectividad de la proctectomía robótica en comparación con la proctectomía abierta en casos de cáncer de recto localmente avanzado con un alto riesgo de margen de resección circunferencial positivo.OBJETIVO:Comparar los resultados en la subpoblación de portadores de cáncer luego de una proctectomía robótica versus una proctectomía abierta.DISEÑO:Estudio retrospectivo de cohortes.AJUSTE:Realizado en tres hospitales académicos (Mayo Clinic de Arizona, Florida y Rochester) a través de la plataforma Mayo Data Explorer.PACIENTES:Fueron seleccionados aquellos pacientes con alto riesgo de compromiso sobre el margen de resección circunferencial, según la definición de los Estudios Mercury I-II basada en la Imágen de Resonancia Magnética.MEDIDAS DE RESULTADO PRINCIPALES Y SECUNDARIAS:La tasa de compromiso patológico sobre el margen de resección circunferencial (≤1 mm), la clasificación mesorrectal y la tasa del compromiso del margen distal.RESULTADOS:De 413 pacientes, 125 (30%) fueron sometidos a una proctectomía abierta y 288 (70%) a proctectomía robótica. La proctectomía abierta se asoció significativamente con una mayor proporción de tumores cT4 (39,3% frente a 24,8%, p = 0,021), las resecciones multiviscerales/concomitantes fueron de 40,8% frente a 18,4%, p < 0,001 y una adminstración menos frecuente de terapia neoadyuvante total (17,1). % vs 47,1%, p = 0,001).La proctectomía robótica se asoció con menos frecuencia con la presencia de una lesión sobre el margen de resección circunferencial patológico (7,3% frente a 17,6%, p = 0,002), incluso después del ajuste por estadio cT, de la terapia neoadyuvante y de resección multivisceral (OR 0,326, IC 95% 0,157-0,670, p = 0,002). El apareado de propensión por puntuación en 66 pacientes por grupo y el análisis multivariable relacionado, no mostraron ninguna reducción en la tasa de margen positivo circunferencial asociado con la cirugía robótica ( p = 0,86 y p = 0,18). La clasificación mesorrectal fue igualmente comparable (mesorrecto incompleto en el 6% de los pacientes con RP frente al 11,8% de los pacientes con OP, p = 0,327). Todos los casos tuvieron márgenes de resección distal negativos.LIMITACIÓN:Diseño retrospectivo.CONCLUSIÓN:En pacientes con cáncer de recto localmente avanzado con alto riesgo de compromiso del margen de resección circunferencial, la proctectomía robótica es un enfoque eficaz y podría realizarse cuando sea técnicamente posible como alternativa a la proctectomía abierta. (Traducción-Dr. Xavier Delgadillo )., (Copyright © The ASCRS 2024.)

Neutrophils are the most abundant leukocytes in humans and play an important early role in the innate immune response against microorganisms. Neutrophil phagosomes contain high concentrations of antibacterial enzymes, including myeloperoxidase (MPO) and the neutrophil serine proteases (NSPs). These antibacterial enzymes can also be released extracellularly upon degranulation or as a component of neutrophil extracellular traps (NETs). Due to host/pathogen coevolution, S. aureus expresses a diverse arsenal of innate immune evasion proteins that target many aspects of the neutrophil antibacterial response. In the last decade, two new classes of staphylococcal innate immune evasion proteins that act as potent, selective inhibitors of MPO and NSPs, respectively, have been discovered. The Staphylococcal Peroxidase INhibitor (SPIN) is a small ∼8.3 kDa α-helical bundle protein that blocks MPO activity by interfering with substrate and product exchange with the MPO active site. The Extracellular Adherence Protein (EAP) family consists of three unique proteins comprised of one or more copies of an ∼11 kDa β-grasp domain capable of high-affinity, selective, non-covalent inhibition of NSPs. This brief review article summarizes recent advances in understanding the structural and functional properties of SPIN and EAP family members and outlines some potential avenues for future investigation of these enzyme inhibitors., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest with the contents of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Staphylococcus aureus expresses three high-affinity neutrophil serine protease (NSP) inhibitors known as the extracellular adherence protein domain (EAPs) proteins. Whereas EapH1 and EapH2 are comprised of a single EAP domain, the modular extracellular adherence protein (Eap) from S. aureus strain Mu50 consists of four EAP domains. We recently reported that EapH2 can simultaneously bind and inhibit cathepsin-G (CG) and neutrophil elastase (NE), which are the two most abundant NSPs. This unusual property of EapH2 arises from independent CG and NE-binding sites that lie on opposing faces of its EAP domain. Here we used X-ray crystallography and enzyme assays to show that all four individual domains of Eap (i.e. Eap1, Eap2, Eap3, and Eap4) exhibit an EapH2-like ability to form ternary complexes with CG and NE that inhibit both enzymes simultaneously. We found that Eap1, Eap2, and Eap3 have similar functional profiles insofar as NSP inhibition is concerned but that Eap4 displays an unexpected ability to inhibit two NE enzymes simultaneously. Using X-ray crystallography, we determined that this second NE-binding site in Eap4 arises through the same region of its EAP domain that also comprises its CG-binding site. Interestingly, small angle X-ray scattering data showed that stable tail-to-tail dimers of the NE/Eap4/NE ternary complex exist in solution. This arrangement is compatible with NSP-binding at all available sites in a two-domain fragment of Eap. Together, our work implies that Eap is a polyvalent inhibitor of NSPs. It also raises the possibility that higher-order structures of NSP-bound Eap may have unique functional properties., Competing Interests: Conflict of interest The authors declare that they have no conflicts of interest with the contents of this article., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Staphylococcus aureus secretes an array of small proteins that inhibit key enzyme-catalyzed reactions necessary for proper function of the human innate immune system. Among these, the Staphylococcal Peroxidase Inhibitor, SPIN, blocks the activity of myeloperoxidase (MPO) and thereby disrupts the HOCl-generating system of neutrophils. Previous studies on S. aureus SPIN have shown that it relies on a C-terminal α-helical bundle domain to mediate initial binding to MPO, but requires a disordered N-terminal region to fold into a β-hairpin conformation to inhibit MPO activity. To further investigate the structure/function relationship of SPIN, we introduced two cysteine residues into its N-terminal region to trap SPIN in its MPO-bound conformation and characterized the modified protein, which we refer to here as SPIN-CYS. Although control experiments confirmed the presence of the disulfide bond in SPIN-CYS, solution structure determination revealed that the N-terminal region of SPIN-CYS adopted a physically constrained series of lariat-like structures rather than a well-defined β-hairpin. Nevertheless, SPIN-CYS exhibited a gain in inhibitory potency against human MPO when compared to wild-type SPIN. This gain of function persisted even in the presence of deleterious mutations within the C-terminal α-helical bundle domain. Surface plasmon resonance studies showed that the gain in potency arose through an increase in apparent affinity of SPIN-CYS for MPO, which was driven primarily by an increased association rate with MPO when compared to wild-type SPIN. Together, this work provides new information on the coupled binding and folding events required to manifest biological activity of this unusual MPO inhibitor., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest with the contents of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cardiovascular diseases continue to challenge global health, demanding innovative therapeutic solutions. This review delves into the transformative role of mesenchymal stem cells (MSCs) in advancing cardiovascular therapeutics. Beginning with a historical perspective, we trace the development of stem cell research related to cardiovascular diseases, highlighting foundational therapeutic approaches and the evolution of cell-based treatments. Recognizing the inherent challenges of MSC-based cardiovascular therapeutics, which range from understanding the pro-reparative activity of MSCs to tailoring patient-specific treatments, we emphasize the need to refine the pro-regenerative capacity of these cells. Crucially, our focus then shifts to the strategies of the fourth generation of cell-based therapies: leveraging the secretomic prowess of MSCs, particularly the role of extracellular vesicles; integrating biocompatible scaffolds and artificial sheets to amplify MSCs' potential; adopting three-dimensional ex vivo propagation tailored to specific tissue niches; harnessing the promise of genetic modifications for targeted tissue repair; and institutionalizing good manufacturing practice protocols to ensure therapeutic safety and efficacy. We conclude with reflections on these advancements, envisaging a future landscape redefined by MSCs in cardiovascular regeneration. This review offers both a consolidation of our current understanding and a view toward imminent therapeutic horizons.

Background: Venous thromboembolism occurs in approximately 2% of patients undergoing abdominal and pelvic surgery for cancers of the colon, rectum, and anus and is considered preventable. The American Society of Colon and Rectal Surgeons recommends extended prophylaxis in high-risk patients, but there is low adherence to the guidelines., Objective: This study aims to analyze the impact of venous thromboembolism risk-guided prophylaxis in patients undergoing elective abdominal and pelvic surgeries for colorectal and anal cancers from 2016 to 2021., Design: This was a retrospective analysis., Setting: The study was conducted at a multisite tertiary referral academic health care system., Patients: Patients who underwent elective abdominal or pelvic surgery for colon, rectal, or anal cancer., Main Outcome Measures: Receipt of Caprini-guided venous thromboembolism prophylaxis, 90-day postoperative rate of deep vein thrombosis, pulmonary embolism, venous thromboembolism, and bleeding events., Results: A total of 3504 patients underwent elective operations, of whom 2224 (63%) received appropriate thromboprophylaxis in the inpatient setting. In the postdischarged cohort of 2769 patients, only 2% received appropriate thromboprophylaxis and no thromboembolic events were observed. In the group receiving inappropriate thromboprophylaxis, at 90 days postdischarge, the deep vein thrombosis, pulmonary embolism, and venous thromboembolism rates were 0.60%, 0.40%, and 0.88%, respectively. Postoperative bleeding was not different between the 2 groups., Limitations: Limitations to our study include its retrospective nature, use of aggregated electronic medical records, and single health care system experience., Conclusion: Most patients in our health care system undergoing abdominal or pelvic surgery for cancers of the colon, rectum, and anus were discharged without appropriate Caprini-guided venous thromboembolism prophylaxis. Risk-guided prophylaxis was associated with decreased rates of inhospital and postdischarge venous thromboembolism without increased bleeding complications. See Video Abstract ., Margen De Mejora El Impacto De La Tromboprofilaxis Recomendada Por Las Directrices En Pacientes Sometidos a Ciruga Abdominal Por Cncer Colorrectal Y Anal En Un Centro De Referencia Terciario: ANTECEDENTES:El tromboembolismo venoso ocurre en aproximadamente el 2% de los pacientes sometidos a cirugía abdominal y pélvica por cánceres de colon, recto y ano, y se considera prevenible. La Sociedad Estadounidense de Cirujanos de Colon y Recto recomienda una profilaxis prolongada en pacientes de alto riesgo, pero el cumplimiento de las directrices es bajo.OBJETIVO:Este estudio tiene como objetivo analizar el impacto de la profilaxis guiada por el riesgo de tromboembolismo venoso (TEV) en pacientes sometidos a cirugías abdominales y pélvicas electivas por cáncer colorrectal y anal entre 2016 y 2021.DISEÑO:Este fue un análisis retrospectivo.AJUSTE:El estudio se llevó a cabo en un sistema de salud académico de referencia terciaria de múltiples sitios.PACIENTES:Pacientes sometidos a cirugía abdominal o pélvica electiva por cáncer de colon, recto o ano.PRINCIPALES MEDIDAS DE RESULTADO:Recepción de profilaxis de tromboembolismo venoso guiada por Caprini, tasa postoperatoria de 90 días de trombosis venosa profunda, embolia pulmonar, tromboembolismo venoso y eventos de sangrado.RESULTADOS:Un total de 3.504 pacientes se sometieron a operaciones electivas, de los cuales 2.224 (63%) recibieron tromboprofilaxis adecuada en el ámbito hospitalario. En el cohorte de 2.769 pacientes después del alta, solo el 2% recibió tromboprofilaxis adecuada en la que no se observaron eventos tromboembólicos. En el grupo que recibió tromboprofilaxis inadecuada, a los 90 días después del alta, las tasas de trombosis venosa profunda, embolia pulmonar y tromboembolia venosa fueron del 0,60%, 0,40% y 0,88%, respectivamente. El sangrado posoperatorio no fue diferente entre los dos grupos.LIMITACIONES:Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva, el uso de registros médicos electrónicos agregados y la experiencia de un solo sistema de atención médica.CONCLUSIÓN:La mayoría de los pacientes en nuestro sistema de salud sometidos a cirugía abdominal o pélvica por cánceres de colon, recto y ano fueron dados de alta sin una profilaxis adecuada de TEV guiada por Caprini. La profilaxis guiada por el riesgo se asoció con menores tasas de tromboembolismo venoso hospitalario y dado de alta sin un aumento de las complicaciones de sangrado. (Traducción-Dr. Aurian Garcia Gonzalez )., (Copyright © The ASCRS 2024.)

Extrapulmonary involvement of coronavirus-19 disease (COVID-19) is being documented and studied at an increasing frequency. Specifically, gastrointestinal involvement is hypothesized to occur due to cellular entry via the ACE2 receptor found in gastrointestinal epithelial cells, causing inflammation and symptoms such as abdominal pain, nausea/vomiting, and diarrhea. We present the case of a 45-year-old female with recent severe COVID-19 infection and early gastrointestinal symptoms who later presented with worsening abdominal pain, nausea, vomiting, and constipation after initial discharge. She was diagnosed with a large bowel obstruction and underwent urgent exploratory laparotomy, which revealed a stricture of the distal transverse colon. Following segmental resection, the patient experienced resolution of symptoms. We hypothesize that this patient's colonic stricture arose secondary to severe COVID-19-induced bowel inflammation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Extracellular adherence protein domain (EAP) proteins are high-affinity, selective inhibitors of neutrophil serine proteases (NSP), including cathepsin-G (CG) and neutrophil elastase (NE). Most Staphylococcus aureus isolates encode for two EAPs, EapH1 and EapH2, that contain a single functional domain and share 43% identity with one another. Although structure/function investigations from our group have shown that EapH1 uses a globally similar binding mode to inhibit CG and NE, NSP inhibition by EapH2 is incompletely understood due to a lack of NSP/EapH2 cocrystal structures. To address this limitation, we further studied NSP inhibition by EapH2 in comparison with EapH1. Like its effects on NE, we found that EapH2 is a reversible, time-dependent, and low nanomolar affinity inhibitor of CG. We characterized an EapH2 mutant which suggested that the CG binding mode of EapH2 is comparable to EapH1. To test this directly, we used NMR chemical shift perturbation to study EapH1 and EapH2 binding to CG and NE in solution. Although we found that overlapping regions of EapH1 and EapH2 were involved in CG binding, we found that altogether distinct regions of EapH1 and EapH2 experienced changes upon binding to NE. An important implication of this observation is that EapH2 might be capable of binding and inhibiting CG and NE simultaneously. We confirmed this unexpected feature by solving crystal structures of the CG/EapH2/NE complex and demonstrating their functional relevance through enzyme inhibition assays. Together, our work defines a new mechanism of simultaneous inhibition of two serine proteases by a single EAP protein., Competing Interests: Conflict of interest The authors declare that they have no conflicts of interest with the contents of this article., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: There is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA)., Methods: Patients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR)., Results: One-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01-1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7-5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76-20.82, p < 0.001) were predictive of mortality., Conclusions: Short and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The S. aureus extracellular adherence protein (Eap) and its homologs, EapH1 and EapH2, serve roles in evasion of the human innate immune system. EapH1 binds with high-affinity and inhibits the neutrophil azurophilic granule proteases neutrophil elastase, cathepsin-G and proteinase-3. Previous structural studies using X-ray crystallography have shown that EapH1 binds to neutrophil elastase and cathepsin-G using a globally similar binding mode. However, whether the same holds true in solution is unknown and whether the inhibitor experiences dynamic changes following binding remains uncertain. To facilitate solution-phase structural and biochemical studies of EapH1 and its complexes with neutrophil granule proteases, we have characterized EapH1 by multidimensional NMR spectroscopy. Here we report a total of 100% of the non-proline backbone resonance assignments of EapH1 with BMRB accession number 50,304., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Acute diverticulitis in immunocompromised patients is associated with high morbidity and mortality rates with either medical or surgical treatment. Thus, management approach is controversial, especially for patients presenting with nonperforated disease., Objective: This study aimed to report the Mayo clinic experience of acute diverticulitis management in immunocompromised patients., Design: This design is based on a retrospective cohort study., Setting: This study was conducted with institutional data composed from 3 tertiary referral centers., Patients: Immunocompromised patients presenting with acute diverticulitis at 3 Mayo clinic sites between 2016 and 2020 were included., Main Outcome Measures: The main outcome measures were the management algorithm and short-term outcomes., Results: Immunocompromised patients presenting with acute uncomplicated diverticulitis (86) were all managed nonoperatively at presentation with a success rate of 93% (80/86). Two patients (2.3%, 2/86) required surgery during the same admission, and 4 patients (4.8%, 4/84) had 30-day readmission. Complicated diverticulitis patients with abscess (22) were all managed nonoperatively first with a success rate of 95.4% (21/22). One patient (4.6%, 1/22) required surgery during the same admission. All the patients who presented with obstruction (2), fistula (1), or free perforation (11) underwent surgery except one who chose hospice. Overall, the major complication rate was 50% (8/16) and mortality rate was 18.8% (3/16) among patients who underwent surgery during the same admission. For patients who presented with perforated diverticulitis, the mortality rate was 27.3% (3/11), compared with 0% (0/111) for patients who presented with nonperforated disease., Limitations: This cohort was limited by its retrospective nature and heterogeneity of the patient population., Conclusions: Nonoperative management was safe and feasible for immunocompromised patients with colonic diverticulitis without perforation at our center. Perforated colonic diverticulitis in immunocompromised patients was associated with high morbidity and mortality rate. See Video Abstract at http://links.lww.com/DCR/B988 .MANEJO DE LA DIVERTICULITIS AGUDA EN PACIENTES INMUNOCOMPROMETIDOS: EXPERIENCIA DE LA CLINICA MAYOANTECEDENTES:La diverticulitis aguda en pacientes inmunocomprometidos se asocia con una alta tasa de morbilidad y mortalidad con el tratamiento médico o quirúrgico. Por lo tanto, el enfoque de manejo es controvertido, especialmente para pacientes que presentan enfermedad no perforada.OBJETIVO:El propósito fue informar la experiencia de la clínica Mayo en el manejo de la diverticulitis aguda en pacientes inmunocomprometidos.DISEÑO:Este es un estudio de cohorte retrospectivoENTORNO CLÍNICO:Este estudio se realizó con datos institucionales compuestos de tres centros de referencia terciarios.PACIENTES:Se incluyeron pacientes inmunocomprometidos que presentaron diverticulitis aguda en tres sitios de la clínica Mayo entre 2016 y 2020.RESULTADO PRINCIPAL:Algoritmo de gestión y resultados a corto plazo.RESULTADOS:Los pacientes inmunocomprometidos que presentaban diverticulitis aguda no complicada (86) fueron tratados de forma no quirúrgica en la presentación inicial con una tasa de éxito del 93 % (80/86). Dos pacientes (2,3%, 2/86) requirieron cirugía durante el mismo ingreso y cuatro pacientes (4,8%, 4/84) tuvieron reingreso a los 30 días. Todos los pacientes con diverticulitis complicada con absceso (22) fueron tratados primero de forma no quirúrgica con una tasa de éxito del 95,4 % (21/22). Un paciente (4,6%, 1/22) requirió cirugía durante el mismo ingreso. Todos los pacientes que presentaron obstrucción (2), fístula (1) o perforación libre (11) fueron intervenidos excepto uno que optó por hospicio. La tasa global de complicaciones mayores fue del 50 % (8/16) y la tasa de mortalidad fue del 18,8 % (3/16) entre los pacientes que se sometieron a cirugía durante el mismo ingreso. Para los pacientes que presentaban diverticulitis perforada, la tasa de mortalidad fue del 27,3 % (3/11), en comparación con el 0 % (0/111) de los pacientes que presentaban enfermedad no perforada.LIMITACIONES:Esta cohorte estuvo limitada por su naturaleza retrospectiva y la heterogeneidad de la población de pacientes., Conclusines: El manejo no quirúrgico fue seguro y factible para pacientes inmunocomprometidos con diverticulitis colónica sin perforación en nuestro centro. La diverticulitis colónica perforada en pacientes inmunocomprometidos se asoció con una alta tasa de morbilidad y mortalidad. Consulte Video Resumen en http://links.lww.com/DCR/B988 . (Traducción- Dr. Ingrid Melo )., (Copyright © The ASCRS 2022.)

Objective: General surgery residency programs have increased their social media presence to educate and recruit prospective residents. This study aims to understand the impact of general surgery residency program social media on the 2020-2021 applicants' evaluation of prospective programs, particularly during the COVID-19 pandemic., Design: An optional 20-item online survey regarding specialty choice, sub-internship rotation completion, social media resource use, social media impact, and general demographic information., Setting: Large academic medical center, United States., Participants: A total of 1191 Participants to our general surgery residency program were sent a survey. Six hundred thirteen completed the survey., Results: Surveys were sent to all general surgery residency applicants of a single program (1,191) and 613 (51.4%) responded. Overall, social media resources use included official residency program website (92.4%), Doximity (36.5%), and Twitter (35.6%). The most frequently relied upon resources by applicants were the official residency program website (64.9%) Twitter (10.9%) and Instagram (10.8%). Most respondents agreed that social media was an effective means to inform applicants (70.9%) and that it positively impacted their perception of the program (62.6%). The most commonly cited benefits were helping the program exhibit its culture and comradery among residents, faculty, and staff (79.2%), with posts of social events and camaraderie as being the most helpful in learning about residency programs. Of all applicants, 71.3% noted that social media had a significant impact on perceptions of programs during the application cycles that were limited by COVID-19 safety and travel restrictions. However, most applicants disagree with (35.3%) or are neutral toward (32.1%) the statement that social media will have less of an impact on future cycles not limited by COVID-19., Conclusion: During the 2020-2021 application cycle, the majority of applicants utilized social media to inform and educate themselves about the general surgery programs they applied to. Residency-based social media had a positive impact on the majority of applicants, especially in terms of allowing a program to demonstrate its culture and camaraderie. Investing time and resources into residency social media accounts appears to be a meaningful pursuit for general surgery programs and is an important aspect in today's recruitment effort., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Intraoperative frozen-section analysis provides real-time margin resection status that can guide intraoperative decisions made by the surgeon and radiation oncologist. For patients with locally recurrent rectal cancer undergoing surgery and intraoperative radiation therapy, intraoperative re-resection of positive margins to achieve negative margins is common practice., Objective: This study aimed to assess whether re-resection of positive margins found on intraoperative frozen-section analysis improves oncologic outcomes., Design: This is a retrospective cohort study., Settings: This study was an analysis of a prospectively maintained multicenter database., Patients: All patients who underwent surgical resection of locally recurrent rectal cancer with intraoperative radiation therapy between 2000 and 2015 were included and followed for 5 years. Three groups were compared: initial R0 resection, initial R1 converted to R0 after re-resection, and initial R1 that remained R1 after re-resection. Grossly positive margin resections (R2) were excluded., Main Outcome Measures: The primary outcome measures were 5-year overall survival, recurrence-free survival, and local re-recurrence., Results: A total of 267 patients were analyzed (initial R0 resection, n = 94; initial R1 converted to R0 after re-resection, n = 95; initial R1 that remained R1 after re-resection, n = 78). Overall survival was 4.4 years for initial R0 resection, 2.7 years for initial R1 converted to R0 after re-resection, and 2.9 years for initial R1 that remained R1 after re-resection ( p = 0.01). Recurrence-free survival was 3.0 years for initial R0 resection and 1.8 years for both initial R1 converted to R0 after re-resection and initial R1 that remained R1 after re-resection ( p ≤ 0.01). Overall survival did not differ for patients with R1 and re-resection R1 or R0 ( p = 0.62). Recurrence-free survival and freedom from local re-recurrence did not differ between groups., Limitations: This study was limited by the heterogeneous patient population restricted to those receiving intraoperative radiation therapy., Conclusions: Re-resection of microscopically positive margins to obtain R0 status does not appear to provide a significant survival advantage or prevent local re-recurrence in patients undergoing surgery and intraoperative radiation therapy for locally recurrent rectal cancer. See Video Abstract at http://links.lww.com/DCR/B886 ., La Rereseccin De Los Mrgenes Microscpicamente Positivos Encontrados De Manera Intraoperatoria Mediante La Tcnica De Crioseccin, No Da Como Resultado Un Beneficio De Supervivencia En Pacientes Sometidos a Ciruga Y Radioterapia Intraoperatoria Para El Cncer Rectal Localmente Recidivante: ANTECEDENTES:El análisis de la ténica de criosección para los margenes positivos encontrados de manera intraoperatoria proporciona el estado de la resección del margen en tiempo real que puede guiar las decisiones intraoperatorias tomadas por el cirujano y el oncólogo radioterapeuta. Para los pacientes con cáncer de recto localmente recurrente que se someten a cirugía y radioterapia intraoperatoria, la re-resección intraoperatoria de los márgenes positivos para lograr márgenes negativos es una práctica común.OBJETIVO:Evaluar si la re-resección de los márgenes positivos encontrados en el análisis de la ténica por criosecciónde manera intraoperatorios mejora los resultados oncológicos.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Análisis de una base de datos multicéntrica mantenida de forma prospectiva.POBLACIÓN:Todos los pacientes que se sometieron a resección quirúrgica de cáncer de recto localmente recurrente con radioterapia intraoperatoria entre 2000 y 2015 fueron incluidos y seguidos durante 5 años. Se compararon tres grupos: resección inicial R0, R1 inicial convertido en R0 después de la re-resección y R1 inicial que permaneció como R1 después de la re-resección. Se excluyeron las resecciones de márgenes macroscópicamente positivos (R2).PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia global a cinco años, supervivencia sin recidiva y recidiva local.RESULTADOS:Se analizaron un total de 267 pacientes (resección inicial R0 n = 94, R1 inicial convertido en R0 después de la re-resección n = 95, R1 inicial que permaneció como R1 después de la re-resección n = 78). La supervivencia global fue de 4,4 años para la resección inicial R0, 2,7 años para la R1 inicial convertida en R0 después de la re-resección y 2,9 años para la R1 inicial que permaneció como R1 después de la re-resección ( p = 0,01). La supervivencia libre de recurrencia fue de 3,0 años para la resección inicial R0 y de 1,8 años para el R1 inicial convertido en R0 después de la re-resección y el R1 inicial que permaneció como R1 después de la re-resección ( p ≤ 0,01). La supervivencia global no difirió para los pacientes con R1 y re-resección R1 o R0 ( p = 0,62). La supervivencia libre de recurrencia y la ausencia de recurrencia local no difirieron entre los grupos.LIMITACIONES:Población de pacientes heterogénea, restringida a aquellos que reciben radioterapia intraoperatoria.CONCLUSIONES:La re-resección de los márgenes microscópicamente positivos para obtener el estado R0 no parece proporcionar una ventaja de supervivencia significativa o prevenir la recurrencia local en pacientes sometidos a cirugía y radioterapia intraoperatoria para el cáncer de recto localmente recurrente. Consulte Video Resumen en http://links.lww.com/DCR/B886 . (Traducción-Dr. Daniel Guerra )., (Copyright © The ASCRS 2022.)

Objective: Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes., Design: ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant., Setting: Mayo Clinic, Rochester, Minnesota (quaternary referral center)., Participants: Colon and rectal surgery resident year-end ACGME reports (2011-2019)., Results: ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs., Conclusions: At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes., Competing Interests: Declarations of Interest None for all authors., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Anorectal neuroendocrine carcinomas (NECs) are uncommon malignancies with poor prognosis. Consensus guidelines exist for treating extrapulmonary NEC. However, limited data is available to guide treatment for anorectal NEC. In this study, we sought to review the clinical characteristics and outcomes of patients with NEC of the rectum and/or anus at Mayo Clinic., Patients and Methods: This is a retrospective study of all patients with the diagnosis of NEC of the anus and/or rectum treated across Mayo Clinic sites since 2000. Baseline patient characteristics, tumor pathology, imaging profiles, treatment strategies utilized, and survival outcomes were analyzed. Kaplan-Meier analysis was used with a significance level of P < .05., Results: The study included a total of 38 patients with primary NEC of the anus and/or rectum. The median age at diagnosis was 55.5 years. The median follow-up was 18.8 months. Fifteen patients had locoregional disease (LRD) at diagnosis. The remaining 23 had metastatic disease. Overall survival was significantly shorter in patients with LRD compared with those with metastatic disease at diagnosis (18.1 vs. 13.8 months; P = .039). The majority (n = 11) of patients with LRD were treated with concurrent chemoradiation therapy, and 10 underwent surgical resection of the primary tumor. The majority (13/15) of patients with LRD progressed, with the majority (11/15) of progressions being distant. The median progression-free survival for patients with LRD was 5.7 months (1-year progression-free survival, 26.7%)., Conclusion: Anorectal NEC is an aggressive malignancy with poor prognosis requiring multidisciplinary discussion. In addition, the systemic nature of anorectal NEC with distant recurrences in LRD and poor outcomes in metastatic disease emphasizes the need to further develop better systemic treatment options that can potentially improve outcomes in NEC., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The Extracellular Adherence Protein (Eap) from Staphylococcus aureus is a potent inhibitor of the classical and lectin pathways of the complement system. Previous studies have shown that Eap binds with nanomolar affinity to complement component C4b and prevents C4b binding the pro-protease, C2, thereby inhibiting formation of the pro-C3 convertase shared by the classical and lectin pathways (Woehl et al. in J Immunol 193:6161-6171, 2014). The C4b-binding and complement-inhibitory properties of Eap from S. aureus strain Mu50 lie within the two C terminal-most Eap domains (i.e. Eap34) (Woehl et al. J Immunol 193:6161-6171, 2014). Interestingly, Eap34 binds C4b with an apparent K D that is nearly 100-fold tighter than that of either Eap3 or Eap4 alone (Woehl et al. in Protein Sci 26:1595-1608, 2017). This suggests that linking these two domains into a single molecule is a significant determinant of Eap function. To better understand this property at the structural level, we undertook a solution NMR study of the ~ 23 kDa Eap34 protein. In this communication, we report that greater than 98% of the total non-proline backbone residues have been assigned. These data have been deposited in the BMRB database under the accession number 50210.

Introduction: As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits., Technique: After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect., Results: After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap., Conclusions: This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.

Background: Primary colorectal lymphoma is rare, representing 0.2% to 0.6% of all colorectal cancers. Because of its low incidence and histologic variety, no treatment guidelines exist., Objective: The purpose was to report the experience of primary colorectal lymphoma in an institutional and a national cohort., Design: This was a retrospective cohort study., Settings: The study was conducted with institutional data composed of 3 tertiary referral centers and national data., Patients: Patients with primary colorectal lymphoma were identified within the Mayo Clinic (1990-2016) and the Surveillance, Epidemiology, and End Results database (1990-2014)., Main Outcome Measures: Primary outcomes were overall and 5-year survival., Results: For the institutional cohort (N = 82), 5-year survival was 79.9%. Five-year survival was higher for rectal (88.4%) than for colon tumors (77.2%; p = 0.004). On multivariable analysis, age <50 years was associated with higher overall survival (p = 0.04). Left-sided colon masses and aggressive histological subtypes were associated with worse survival (0.04 and 0.03). No effect of treatment modality on survival was noted. For the national cohort (N = 2942), 5-year survival was 58.4%. Five-year survival for rectal tumors was 61.0% and 57.8% for colon tumors. On multivariable analysis, factors associated with improved survival were age <70 y, (p < 0.0001), female sex (p = 0.005), right-sided masses (p = 0.02), and diagnoses after 2000 compared with 1990-1999 (p < 0.0001). Aggressive pathology (p < 0.0001) and stage III or stage IV presentation compared with stage I (p = 0.02 and p < 0.0001) were associated with worse survival., Limitations: The institutional cohort was limited by sample size to describe treatment effect on survival. A major limitation of the national cohort was the ability to describe treatment modalities other than surgery, including chemotherapy and/or no additional treatment., Conclusions: Poorer survival was noted in elderly patients and in those with aggressive pathology. An overall survival advantage was seen in women in the national cohort. Currently, optimal strategies should follow a patient-centered multidisciplinary approach. See Video Abstract at http://links.lww.com/DCR/A807., Linfoma Colorectal Primario: EXPERIENCIA INSTITUCIONAL Y REVISIÓN DE UNA BASE DE DATOS NACIONAL: El linfoma colorectal primario es poco frecuente, representando del 0.2% al 0.6% de todos los cánceres colorectales. Debido a su baja incidencia y variedad histológica, no existen guías de tratamiento., Objetivo: El propósito fue reportar la experiencia en linfoma colorectal primario en una cohorte institucional y una nacional. DISEÑO:: Este fue un estudio de cohorte retrospectivo., Escenario: El estudio se realizó con datos institucionales provenientes de 3 centros de referencia terciarios y datos nacionales., Pacientes: Se identificaron pacientes con linfoma colorectal primario en la base de datos de la Clínica Mayo (1990-2016) y en la base de datos de vigilancia, epidemiología y resultados finales [Surveillance, Epidemiology, and End Results database (1990-2014)]., Principales Medidas De Resultado: Los resultados primarios fueron la sobrevida general y a 5 años., Resultados: Para la cohorte institucional (N = 82), la sobrevida a 5 años fue de 79.9%. La sobrevida a cinco años fue mayor en tumores rectales (88.4%) que en los de colon (77.2%; p = 0.004). En el análisis multivariable, la edad <50 años se asoció con una mayor sobrevida general (p = 0,04). Las masas de colon izquierdo y los subtipos histológicos agresivos se asociaron con una peor sobrevida (0.04 y 0.03). No se observó ningún efecto según la modalidad de tratamiento en la sobrevida. Para la cohorte nacional (N = 2942), la sobrevida a 5 años fue del 58.4%. La sobrevida a cinco años fue de 61.0% para los tumores rectales y 57.8% para los tumores de colon. En el análisis multivariable, los factores asociados con una mayor sobrevida fueron edad <70 años, (p <0.0001), sexo femenino (p = 0.005), masas derechas (p = 0.02) y los casos diagnósticados después del año 2000 comparados con los de 1990-1999 (p <0.0001). Histopatología agresiva (p <0.0001) y presentación en estadio III o estadio IV en comparación con estadio I (p = 0.02 y p <0.0001) se asociaron con una peor sobrevida., Limitaciones: La cohorte institucional estuvo limitada por el tamaño de la muestra para describir el efecto del tratamiento en la sobrevida. Una limitación mayor en la cohorte nacional fue la habilidad para describir modalidades de tratamiento distintas a la cirugía, incluyendo quimioterapia y/o ningún tratamiento adicional., Conclusiones: Una menor sobrevida fue documentada en pacientes de edad avanzada y en aquellos con histopatología agresiva. Se observó ventaja en cuanto a sobrevida general en las mujeres de la cohorte nacional. Actualmente, las estrategias óptimas deben de seguir un abordaje multidisciplinario centrado en cada paciente. Vea el abstract en video en http://links.lww.com/DCR/A807.

Objective: To characterize reasons for discordance between administrative data and registry data in the determination of postoperative infectious complications., Background: Data regarding the occurrence of postoperative surgical complications are identified through either administrative or registry data. Rates of complications vary significantly between these two types of data; the reasons for this are not well-understood., Methods: The occurrence of 30-day inpatient infectious complications (pneumonia, sepsis, surgical site infection, and urinary tract infection) was compared between the NSQIP and administrative mechanisms at 4 academic hospitals between 2012 and 2014. In each situation where the NSQIP and administrative data were discordant regarding the occurrence of a specific complication, a 2-clinician chart abstraction was performed to characterize the reasons for discordance as (i) administrative coding error, (ii) NSQIP coding error, (iii) "question of criteria", where the discordance was the result of differences in criteria, or (iv) "dually incorrect", where both data sources coded the complication incorrectly., Results: The cohort included 19,163 patients undergoing surgery in 4 different academic hospitals. Rates of infectious complications varied up to 5-fold between the two data sources. A total of 717 discordant complications were identified. Of these, the greatest portion (43%) was due to "question of criteria," followed by administrative coding error (37%), NSQIP error (15%), and dually incorrect (5%)., Conclusions: With a goal of improving existing mechanisms for measuring surgical quality, definitions for the occurrence of a postoperative complication need to be developed and applied consistently. Progress toward this goal will enable patients and payers to better take advantage of recent advances in healthcare data transparency.

Colonoscopy is the gold standard for colon cancer screening. It has led to a decrease in the incidence of colorectal cancer mortality. Colon perforation is a feared complication of this procedure with high morbidity and substantial mortality. Due to the high volume of colonoscopies performed, the absolute number of colonoscopic perforations is relatively high. It leads to a substantial cost to the patient and the health system. Understanding the mechanisms and the risk factors may help in preventing perforation. Traditionally, a laparotomy with creation of a stoma was used to address this complication. However, minimally invasive techniques such as laparoscopy and endoluminal repairs are being used more commonly now. More surgeons are favoring primary anastomosis (with or without a diverting loop ileostomy) than a Hartmann procedure.

A 40-year-old man presented for diagnosis with nodules and plaques of the nose and upper lip, progessive over 1(1/2) years.