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Background: Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs., Methods: We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance., Results: Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated., Conclusions: Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted., (Copyright © 2023. Published by Elsevier Inc.)

The surgical treatment of breast cancer has rapidly evolved over the past 50 years, progressing from Halsted's radical mastectomy to a public campaign of surgical options, aesthetic reconstruction, and patient empowerment. Sparked by the research of Dr. Bernard Fisher and the first National Surgical Adjuvant Breast and Bowel Project trial in 1971, the field of breast surgery underwent significant growth over the next several decades, enabling general surgeons to limit their practices to the breast. High surgical volumes eventually led to the development of the first formal breast surgical oncology fellowship in a large community-based hospital at Baylor University Medical Center in 1982. The establishment of the American Society of Breast Surgeons, as well as several landmark clinical trials and public campaign efforts, further contributed to the advancement of breast surgery. In 2003, the Society of Surgical Oncology (SSO), in partnership with the American Society of Breast Surgeons and the American Society of Breast Disease, approved its first fellowship training program in breast surgical oncology. Since that time, the number of American fellowship programs has increased to approximately 60 programs, focusing not only on training in breast surgery, but also in medical oncology, radiation oncology, pathology, breast imaging, and plastic and reconstructive surgery. This article focuses on the happenings in the United States that led to the transition of breast surgery from a subset of general surgery to its own specialized field., Competing Interests: The authors declare that they have no potential conflicts of interest or financial relationships., (Copyright © 2022 Lauren Zammerilla Westcott et al.)

Background: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials., Objective: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection., Design: We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years., Settings: This was a multicenter trial., Patients: Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge., Intervention: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy., Main Outcome Measures: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention., Results: This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34)., Limitations: The predetermined sample size to adequately reduce the risk of type II error was not achieved., Conclusions: Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560., Valoracin De La Irrigacin De Lado Izquierdo/reseccin Anterior Baja Pilar Iii Un Estudio Aleatorizado, Controlado, Paralelo Y Multicntrico Que Evala Los Resultados De La Irrigacin Con Pinpoint Imgenes De Fluorescencia Cercana Al Infrarrojo En La Reseccin Anterior Baja: ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero)., (Copyright © The ASCRS 2021.)

Background: Thousands of cancer surgeries were delayed during the peak of the COVID-19 pandemic. This study examines if surgical delays impact survival for breast, lung and colon cancers., Methods: PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science were searched. Articles evaluating the relationship between delays in surgery and overall survival (OS), disease-free survival (DFS) or cancer-specific survival (CSS) were included., Results: Of the 14,422 articles screened, 25 were included in the review and 18 (totaling 2,533,355 patients) were pooled for meta-analyses. Delaying surgery for 12 weeks may decrease OS in breast (HR 1.46, 95%CI 1.28-1.65), lung (HR 1.04, 95%CI 1.02-1.06) and colon (HR 1.24, 95%CI 1.12-1.38) cancers. When breast cancers were analyzed by stage, OS was decreased in stages I (HR 1.27, 95%CI 1.16-1.40) and II (HR 1.13, 95%CI 1.02-1.24) but not in stage III (HR 1.20, 95%CI 0.94-1.53)., Conclusion: Delaying breast, lung and colon cancer surgeries during the COVID-19 pandemic may decrease survival., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Evidence suggests a relationship between dietary fat intake, obesity, and colorectal cancer, implying a role for fatty acid metabolism in intestinal tumorigenesis that is incompletely understood. Liver fatty acid-binding protein (L-Fabp), a dominant intestinal fatty acid-binding protein, regulates intestinal fatty acid trafficking and metabolism, and L-Fabp deletion attenuates diet-induced obesity. Here, we examined whether changes in intestinal fatty acid metabolism following L-Fabp deletion modify adenoma development in Apc(Min)(/+) mice. Compound L-Fabp(-/-)Apc(Min)(/+) mice were generated and fed a 10% fat diet balanced equally between saturated, monounsaturated, and polyunsaturated fat. L-Fabp(-/-)Apc(Min)(/+) mice displayed significant reductions in adenoma number and total polyp area compared with Apc(Min)(/+)controls, reflecting a significant shift in distribution toward smaller polyps. Adenomas from L-Fabp(-/-)Apc(Min)(/+) mice exhibited reductions in cellular proliferation, high-grade dysplasia, and nuclear β-catenin translocation. Intestinal fatty acid content was increased in L-Fabp(-/-)Apc(Min)(/+) mice, and lipidomic profiling of intestinal mucosa revealed significant shifts to polyunsaturated fatty acid species with reduced saturated fatty acid species. L-Fabp(-/-)Apc(Min)(/+) mice also showed corresponding changes in mRNA expression of enzymes involved in fatty acid elongation and desaturation. Furthermore, adenomas from L-Fabp(-/-)Apc(Min)(/+) mice displayed significant reductions in mRNA abundance of nuclear hormone receptors involved in cellular proliferation and in enzymes involved in lipogenesis. These findings collectively implicate L-Fabp as an important genetic modifier of intestinal tumorigenesis, and identify fatty acid trafficking and metabolic compartmentalization as an important pathway linking dietary fat intake, obesity, and intestinal tumor formation.

The workup and management of squamous cell anal carcinoma, which represents the most common histologic form of the disease, are addressed in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Anal Carcinoma. These NCCN Guidelines Insights provide a summary of major discussion points of the 2012 NCCN Anal Carcinoma Panel meeting. In summary, the panel made 4 significant changes to the 2012 NCCN Guidelines for Anal Carcinoma: 1) local radiation therapy was added as an option for the treatment of patients with metastatic disease; 2) multifield technique is now preferred over anteroposterior-posteroanterior (AP-PA) technique for radiation delivery and the AP-PA technique is no longer recommended as the standard of care; 3) PET/CT should now be considered for radiation therapy planning; and 4) a section on risk reduction was added to the discussion section. In addition, the panel discussed the use of PET/CT for the workup of anal canal cancer and decided to maintain the recommendation that it can be considered in this setting. They also discussed the use of PET/CT for the workup of anal margin cancer and for the assessment of treatment response. They reaffirmed their recommendation that PET/CT is not appropriate in these settings.

Background: Process and outcome measures for quality assessment of colorectal surgical care are poorly defined., Objective: The aim of this study was to develop candidate end points for use in surgeon-specific registries designed for case reporting and quality improvement program development., Design: The study design was based on modified Delphi-based development of consensus quality end points., Setting: This study was undertaken by the American Society of Colon and Rectal Surgeons Executive Council, Quality Committee, and by the ColoRectal Education System Template Committee, American Board of Colon and Rectal Surgery., Patients: No patients were included in this study., Interventions: Six areas of colorectal surgery were defined by members of the American Society of Colon and Rectal Surgeons' Executive Council and the American Board of Colon and Rectal Surgery to cover areas of importance for colorectal surgeons. These included colectomy, rectal cancer, hemorrhoidectomy, anal fistula and abscess, colonoscopy, and rectal prolapse. Relevant American Society of Colon and Rectal Surgeons' committee members through a series of 4 panel discussions identified important demographic, process, and outcome measures in each of these 6 areas that might be suitable for the American College of Surgeons case log. Panel size was sequentially expanded from 8 members to 28 members to include all active committee members. Panelists contributed additional process and outcome measures for inclusion during each discussion. Modified Delphi methodology was used to generate consensus, and, after each panel discussion, members rated the relative importance of each end point from 1 (least important) to 4 (most important)., Main Outcome Measures: The mean rating for each process and outcome measure after each round was recorded with the use of standardized definitions for relevant variables., Results: Eighty-nine process and outcome measures were compiled and rated. Mean scores following the final round ranged from a low of 1.3 (anal fistula/abscess, preoperative imaging) to a high of 4.0 (colectomy-anastomotic leak)., Limitations: The limitations of this study involved the use of consensus, small study size, and the fact that no end points were excluded., Conclusions: With the use of modified Delphi methodology, a consensus-derived ranked list of 89 process and outcome measures was developed in 6 key areas of colorectal surgery. These data provide a framework for development of guideline standards for case-reporting program development initiatives for colon and rectal surgery.

Clinical research is an important part of an academic surgery practice. To be successful, it is important to understand the multiple regularity committees and organizations that impact research. The author briefly reviews these groups and provides guidance on how to initiate and conduct research.

Retained foreign body is a recognized complication of abdominal, pelvic, and thoracic surgery and a cause of medical malpractice. Efforts to reduce its incidence include safe exposure and the use of fewer laparotomy pads. The EZ DASH is an absorbent 12-thickness laparotomy pad covering a malleable stainless steel mesh, providing both the needed retraction and a reduction in the use of individual pads. EZ DASH has been introduced into clinical use in 183 consecutive cases by specialty surgeons (colorectal, gynecology, and gynecologic oncology services) at multiple medical centers. The retractor may be shaped to the individual needs of an operating field, eg, the pelvis, and the small bowel secured behind the retractor, held in place by the tension of its mesh and the security of the abdominal wall. Positioning has been intuitive and secure, and the intraoperative use of sponges and of operating time have both been noticeably reduced. Among 183 cases, 91% of uses were felt to reduce OR time by or=10 minutes. Ninety-three percent of EZ DASH cases used fewer individual laparotomy pads for small bowel retraction. Ninety-five percent of uses suggested a value added to the case by the operating surgeon with an expressed desire to use the product repeatedly. The EZ DASH is a simple method of obtaining small bowel retraction and laparotomy pad absorption with a reduction in the need for individual pads, providing excellent exposure for the operative field and reducing the risk of retained foreign body.

Background: Surgical outcome and quality of life (QOL) following perineal proctectomy for rectal prolapse remain poorly documented., Methods: From 1994 to 2004, patients with full-thickness rectal prolapse were treated exclusively with perineal proctectomy independent of age or comorbidities. Subjective patient assessments and recurrences were determined retrospectively from hospital and clinic records. Consenting patients completed the gastrointestinal quality of life index (GIQLI)., Results: Perineal proctectomy was performed in 103 consecutive patients with a median age of 75 years (range 30-94). Most patients underwent concurrent levatorplasty (anterior 85.8%, posterior 67.9%). Durable results were obtained in all patients; the recurrence rate was 8.5% over a mean follow-up of 36 months. Preoperatively, 75.5% of patients reported fecal incontinence, and 32.1% had obstructed defecation. Incontinence significantly improved post-proctectomy (41.5%, p < 0.001), as did constipation (10.4%, p < 0.001). GIQLI respondents reported satisfaction following proctectomy with 63% scoring within one standard deviation of healthy controls. Patients with recurrent prolapse reported a lower QOL. Risk factors for recurrence included duration of prolapse, need for posterior levatorplasty, and prior anorectal surgery., Conclusions: Perineal proctectomy provides significant relief from fecal incontinence and obstructive symptoms caused by rectal prolapse, with an acceptable recurrence rate and low morbidity.

Between 1979 and 1988, 33 patients with squamous cell carcinoma of the anal canal were treated with chemoradiation. There were 24 women and 9 men, from 37 to 90 years of age (median: 63 years). Complete tumor regression occurred in 29 of the 33 patients (88%), only one of whom later developed recurrence. In the other four patients, there was persistent tumor after 3 months; three of these patients died within 2 years; and one is alive with distant metastases 2 years later. During the first 5 years of the study, seven patients with complete tumor regression underwent planned abdominoperineal resection following chemoradiation. Four of the abdominoperineal resection specimens were free of tumor, but three were not. These three patients, who had abdominoperineal resection within 3 months of chemoradiation, are disease-free. Ten of the 29 patients who had complete tumor regression had biopsies of the primary site 3 months after treatment. All biopsies were negative for residual carcinoma. At present, 26 patients (79%) are alive and disease-free from 2 to 10 years post-treatment (median: 4 years). Two patients died of unrelated causes, four of cancer, and one is alive with cancer. Complications of the chemoradiation required surgical intervention in two patients, and two others developed severe hematologic toxicity, for a complication rate of 12% (4 of 33 patients). There was no treatment-related mortality. These results support the efficacy of chemoradiation treatment for carcinoma of the anal canal. They suggest that abdominoperineal resection no longer need be part of the planned initial management, and that posttreatment biopsy of the primary site is unnecessary, unless palpable or visible abnormalities are present 3 months after treatment.

1. Morphological and electrophysiological data on the electrotonic structure of six triceps surae alpha-motoneurons and on the number and location of 202 Group Ia synapses making contact with ankle extensor motoneurons, previously obtained in this laboratory, were used to construct computer models to examine the generation of composite monosynaptic Group Ia excitatory postsynaptic potentials (EPSPs). 2. A total of 300 active synapses, each generating conductance transients based on voltage-clamp data and having activation times temporally dispersed (range approximately 1.3 ms) according to the conduction velocity profile of Group Ia-afferents, were used to generate composite EPSPs. 3. The shape indexes (foot-to-peak rise times and half widths) of simulated EPSPs matched those of experimentally observed Ia EPSPs reasonably well, although the rise times were, on average, approximately 0.25 ms longer in the simulated EPSPs. This may indicate that the effective temporal dispersion of actual Group Ia monosynaptic EPSPs is less than that the temporal asynchrony used in the simulations. 4. The peak amplitudes of simulated composite EPSPs (6-14 mV), as well as EPSPs produced by single somatic synapses (80-300 microV), were comparable to those found in experimental data. 5. Simulated EPSPs in motoneuron models with two forms of nonuniform Rm distribution ("step" increase from low values of Rm on the soma to much higher but uniform values in the dendrites, versus gradual monotonic "sigmoidal" increases from soma to distal dendrites) were similar in shape and amplitude. This prevented choosing one or the other Rm model as more "correct." 6. Transmembrane voltages at synaptic sites in motoneuron dendrites during generation of composite Ia EPSPs had peak amplitudes less than twice those of the somatic EPSP. The amount of nonlinearity during EPSP production was assessed by making the delivery of synaptic current independent of the local transmembrane voltage. This non-linearity was modest (less than 10%) during composite EPSP generation, consistent with previous experimental evidence. 7. The local voltages produced in various parts of different dendrites during composite EPSP generation depended on the number and location of active synapses and on the electrotonic structure of the particular dendrite. The results show that dendrites that project in different directions away from the motoneuron soma could, in principle, exhibit different degrees of interaction between Ia and other synaptic inputs. 8. Although produced by the same number of active synapses, the simulated composite Ia EPSPs varied over a two-fold range of peak amplitude in relation to motor-unit type, cell input resistance, and cell size (total membrane area).(ABSTRACT TRUNCATED AT 400 WORDS)

From 1980 to 1983, 20 patients had abdominal colectomy with primary ileorectal anastomosis. Fourteen operations were elective and six were emergency. Elective indications included familial polyposis (five), inflammatory bowel disease (four), colon cancer associated with multiple polyps (four), and colon cancer associated with diverticulosis and a history of massive hemorrhage (one). Emergency operations were performed for obstructing sigmoid or rectosigmoid cancer (three), massive lower gastrointestinal hemorrhage (two), and right colon cancer associated with obstructing diverticulitis (one). All patients survived the operation; in three patients complications developed in the immediate postoperative period for a morbidity of 15%. Our experience suggests that abdominal colectomy with primary ileorectal anastomosis can be safely performed in carefully selected cases.

Prenatal administration of cytotoxic drugs during proliferation of precursor cells of neurons in granular and supragranular layers of the rat cerebral cortex prevents these layers from forming and causes malformations of some cells in the surviving layers. But it does not prevent the surviving layers from establishing normal efferent connections, nor does it prevent afferent fibers from colonizing the cortex and establishing a bilaminar pattern of synaptic connections, partly in an abnormal position.

Pregnant rats were injected on the 14th day of gestation with the cytotoxic drug methylazoxymethanol acetate. This compound causes the death of neural precursor cells that were synthesizing DNA at the time of injection. After birth, the progeny of treated mothers grew to maturity with a neocortex that was greatly reduced in area by the death of all cells, particularly at the frontal and occipital poles but at medial and lateral margins of neocortex as well. In the remaining cortex layers II through IV failed to develop. The experiment deprived growing thalamocortical axons, which innervate the somatic sensory cortex late in development, of part of their normal target area and of a substantial number of their definitive target cells. It also deprived them of any cues they might have received from these target cells migrating through them as the axons accumulate beneath the cortical plate. Anatomical experiments indicated that, despite these defects, thalamocortical axons could still colonize the sensorimotor areas and form synapses in their typically bilaminar pattern, though the outer, denser lamina of terminations occurred abnormally at the level of the apices of layer V pyramidal cell bodies. Receptive field mapping of single and multiunit responses in the somatic sensory region showed brisk responses and receptive fields of normal size. It also indicated the formation of a body map that was topographically intact except for deletions at its periphery; that is, a total map was not compressed into a smaller area. This suggests that somatic sensory thalamocortical fibers recognize only remaining cortical target cells in appropriate fields. Moreover, successful ones among them seem to recognize neighborhood relations and conserve synaptic space at the expense of those that would have innervated the deleted peripheral parts of the area. Pyramidal neurons in the remaining cortical layers and in ectopic islands of cells that had incompletely migrated from the neuroepithelium, probably on account of destruction of radial glial cell precursors, were shown by retrograde labeling to send their axons only to appropriate subcortical targets. Pyramidal neurons, though recognized as such, also adopted a variety of abnormal orientations, such as inversion, apparently in an attempt to grow apical dendrites toward major zones of synaptic terminations.