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Background The number of units with experience in extended radical resections for advanced pelvic tumours has grown substantially in recent years. The use of complex vascular resections and reconstructive techniques in these units is expected to increase with experience. This review aimed to provide a cutting-edge overview of this evolving surgical approach to complex pelvic tumours with vascular involvement. Methods This was a narrative review of published data on major vascular resection and reconstruction for advanced pelvic tumours, including preoperative evaluation, techniques used, and outcomes. Advice for treatment decisions is provided, and based on current literature and the personal experience of the authors. Current controversies and future directions are discussed. Results Major vascular resection and reconstruction during surgery for advanced pelvic tumours is associated with prolonged operating time (510–678 min) and significant blood loss (median 2–5 l). R0 resection can be achieved in 58–82 per cent at contemporary specialist units. The risk of major complications is similar to that of extended pelvic resection without vascular involvement (30–40 per cent) and perioperative mortality is acceptable (0–4 per cent). Long-term survival is achievable in approximately 50 per cent of patients. Conclusion En bloc resection of the common or external iliac vessels during exenterative pelvic surgery is a feasible strategy for patients with advanced tumours which infiltrate major pelvic vascular structures. Oncological, morbidity, and survival outcomes appear comparable to more central pelvic tumours. These encouraging outcomes, combined with an increasing interest in extended pelvic resections globally, will likely lead to more exenteration units developing oncovascular experience.

Despite population-wide recommendations by the U.S. Dietary Guidelines for Americans and others to encourage health-promoting dietary patterns, the proportion of Americans following dietary recommendations remains low. The gaps in the adoption and integration of evidence-based dietary interventions, practices, programs, and policies (EBIs) into community and clinical settings signal the need to strengthen efforts in implementation science (IS) in nutrition research to understand and alleviate barriers to adopting and sustaining healthy dietary behaviors and practices. Equally important is the translation of this research into practice in a variety of settings and across the diversity of populations. Recognizing this need, the U.S. National Institutes of Health (NIH) 2020-2030 Strategic Plan for NIH Nutrition Research calls for the expansion of IS as a key opportunity to advancing nutrition research. This commentary highlights three scientific opportunities to stimulate IS in nutrition research and provides examples for each opportunity. These include: (a) Advance consideration of implementation and dissemination early in the design of interventions to facilitate opportunities for equitable scale-up and sustainability of EBIs, (b) Develop and test strategies for equitable implementation of nutrition and diet EBIs in health care and community settings, and (c) Build and strengthen the infrastructure, capacity, and expertise needed to increase use of IS in clinical and community nutrition research to swiftly move the research into practice. By advancing the three opportunities identified in this commentary, the scientific community has the potential to advance the field of nutrition research and IS with the ultimate goal of improving public health.While dietary guidelines have proven effective in clinical studies, most Americans do not follow these tested guidelines. More work is needed to bring research into practice so that all populations can benefit from the research. The U.S. National Institutes of Health recognizes this need and highlights it as a key opportunity in its 2020–2030 Strategic Plan for NIH Nutrition Research. This commentary describes three scientific opportunities that can help to stimulate the research needed to move research into practice, toward the ultimate goal of improving public health.

The release of the 2020–2030 Strategic Plan for NIH Nutrition Research (SPNR) and its emphasis on precision nutrition has provided an opportunity to identify future nutrition research that addresses individual variability in response to diet and nutrition across the life span—including those relevant to the Strategic Vision of the National Heart, Lung, and Blood Institute (NHLBI). The SPNR and the NHLBI's Strategic Vision were developed with extensive input from the extramural research community, and both have 4 overarching strategic goals within which are embedded several objectives for research. For the SPNR, these include 1) spur discovery science and normal biological functions (e.g., role of the microbiome in health and disease), 2) population science to understand individual differences (e.g., biomarkers including ’omics that predict disease status), 3) emerging scientific areas of investigation and their application (e.g., data science, artificial intelligence), and 4) cross-cutting themes (e.g., training the scientific workforce and minority health and health disparities). These strategic goals and objectives serve as blueprints for research and training. Nutrition remains important in the prevention and treatment of heart, lung, blood, and sleep (HLBS) disorders and diseases, and the NHLBI has played a pivotal role in supporting nutrition research. In this paper, we report important gaps in the scientific literature related to precision nutrition in HLBS diseases. Research opportunities that could stimulate precision nutrition and their alignment with the SPNR and the NHLBI Strategic Vision Objectives are provided. These opportunities include 1) exploring individual differences in response to varying dietary patterns and nutrients; 2) investigating genetic/epigenetic, biological (e.g., microbiome, biomarkers), social, psychosocial, and environmental underpinnings of individual variability in diet; 3) elucidating the role of circadian rhythm and chrononutrition; and 4) applying implementation science research methods in precision nutrition interventions relevant to HLBS diseases.

Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS).Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery.Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P 0.01) with either major bony (70% vs. 50%; P 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications.Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.

Selection of an open or minimally invasive approach to total mesorectal excision (TME) is generally based on surgeon preference and an intuitive assessment of patient characteristics but there consensus on criteria to predict surgical difficulty. Pelvimetry has been used to predict the difficult surgical pelvis, typically using only bony landmarks. This study aimed to assess the relationship between pelvic soft tissue measurements on preoperative MRI and surgical difficulty. Preoperative MRIs for patients undergoing laparoscopic rectal resection in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were retrospectively reviewed by two blinded surgeons and pelvimetric variables measured. Pelvimetric variables were analyzed for predictors of successful resection of the rectal cancer, defined by clear circumferential and distal resection margins and completeness of TME. There was no association between successful surgery and any measurement of distance, area, or ratio. However, the was a strong association between the primary outcome and the estimated total pelvic volume on adjusted logistic regression analysis (OR = 0.99, P = 0.01). For each cubic centimeter increase in the pelvic volume, there was a 1% decrease in the odds of successful laparoscopic rectal cancer surgery. Intuitive prediction of unsuccessful surgery was correct in 43% of cases, and correlation between surgeons was poor (ICC = 0.18). A surgeon’s intuitive assessment of the difficult pelvis, based on visible MRI assessment, is not a reliable predictor of successful laparoscopic surgery. Further assessment of pelvic volume may provide an objective method of defining the difficult surgical pelvis.

Racial/ethnic disparities in glycemic control—a key diabetes outcome measure—continue to widen, even though the overall prevalence of glycemic control in the United States has improved. Health insurance coverage may be associated with improved glycemic control, but few studies examine effects during a period of policy change. We assessed changes in glycemic control by racial/ethnic groups following the Massachusetts Health Insurance Reform for patients at two urban safety-net academic health systems between January 2005 and December 2013. We analyzed outcomes for three measures of poor glycemic control: 1) lack of a hemoglobin A1C (A1C) measure during a six-month period; 2) A1C ≥8%; 3) A1C >9% before, during, and after implementation of insurance reform. We did not find increased rates of A1C monitoring or control following insurance reform overall or for specific racial/ethnic groups. We found evidence of worsened, not improved, glycemic control in some racial/ethnic groups in the post-reform period. The expansion of affordable insurance coverage was not associated with improved glycemic control in vulnerable populations.

Background Nutrition plays a major role in the prevention and treatment of cardiovascular and other chronic diseases; hence, nutrition research is a priority for the National Heart, Lung, and Blood Institute (NHLBI). The purpose of this analysis is to describe the scope of NHLBI-funded extramural nutrition research grants over the past decade and offer insights into future opportunities for nutrition research relevant to NHLBI's mission. Methods Data were extracted using the Research, Condition, and Disease Categorization spending categories from the publicly available NIH Research Portfolio Online Reporting Tool Expenditures and Results. New 2018 and 2019 grants were coded into categories and mapped to the 2016 NHLBI Strategic Vision priorities. Results Approximately 90% of nutrition research funds supported extramural grants, particularly through investigator-initiated R series grants (69.6%). Of these, 19.8% were classified as clinical trials. Consistent nutrition-related topics, including physical activity, weight loss, fatty acids, metabolic syndrome, childhood obesity, and other topics such as gut microbiota, arterial stiffness, sleep duration, and meal timing, emerged in 2014-2019. Mapping of the NHLBI Strategic Vision objectives revealed that 32% of newly funded grants focused on pathobiological mechanisms important to the onset and progression of heart, lung, blood, and sleep disorders, with opportunities including developing novel diagnostic and therapeutic strategies and clinical and implementation science research. Discussion The findings show the breadth of NHLBI-funded nutrition research and highlight potential research opportunities for nutrition scientists.

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AIM This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy. METHOD Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan-Meier plots. RESULTS Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance (P

The difficulty of performing total mesorectal excision (TME) for rectal cancer partly relies on the surgeon’s subjective assessment of the individual patient’s pelvic anatomy and tumour characteristics, which generally influences the choice of platform used (open, laparoscopic, robotic or trans-anal surgery). Recent studies have found associations between several anatomical pelvic measurements and surgical difficulty. The aim of this study was to systematically review existing data reporting the use of magnetic resonance imaging (MRI)-based pelvic measurements to predict technical difficulty and outcomes of TME, and determine whether pelvimetry could optimise patient-specific selection of a particular surgical approach. MEDLINE, Embase and Cochrane Library databases were systematically searched for studies reporting MRI-based pelvic measurements in patients undergoing surgery for rectal cancer, and the effect of these measurements on surgical difficulty. Eleven studies reporting the association between MRI-pelvimetry measurements and rectal cancer surgical outcomes were included. Indicators for surgical difficulty used in the included studies were involved circumferential resection margin, longer operative time, incomplete TME, higher blood loss, anastomotic leak, conversion to open surgery and overall complications. Bony pelvic measurements which were associated with increased surgical difficulty in more than one study were a smaller interspinous distance, a smaller intertubercle distance, a smaller pelvic inlet and larger pubic tubercle height. Two studies identified larger mesorectal fat area as a predictor of surgical difficulty. Bony pelvic measurements may predict surgical difficulty during TME, however, use of different indicators of difficulty limit comparison between studies. Early data suggest MRI soft tissue measurements may predict surgical difficulty and warrants further investigation.

This study aimed to describe short- and medium-term longitudinal quality-of-life (QoL) outcomes after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Consecutive patients undergoing CRS and HIPEC were recruited. The primary outcome was QoL, measured using the short-form 36 questionnaire and expressed as a physical component score (PCS) and a mental component score (MCS), with higher scores representing better QoL. Data were collected prospectively at baseline and before discharge, then 3, 6, and 12 months postoperatively. Trajectories of the PCS and MCS were described for the study period and grouped according to a peritoneal carcinomatosis index (PCI) (≤ 12 vs. ≥ 13) and a completeness of cytoreduction (CC) score (CC0 vs. CC1–CC3). Overall, 117 patients underwent CRS and HIPEC and 115 (98.3%) of the 117 patients participated in the study. The main primary pathology was colorectal in 52 (45%) of the 115 patients and appendiceal in 27 (23.5%) of the 115 patients. The median baseline PCS [48.16; interquartile range (IQR), 38.6–54.9] had decreased at pre-discharge (35.34; IQR, 28.7–41.8), then increased slightly at 3 months (42.54; IQR, 37.6–51.6), before returning to baseline within 6 months (48.35; IQR, 39.1–52.5) and remaining unchanged 12 months after surgery (48.55; IQR, 40.8–55.5). The MCS remained unchanged during the study period. The patients with a PCI of 13 or higher had worse PCS and MCS during the postoperative period than the patients with a PCI of 12 or lower. The CRS and HIPEC procedures impaired PCS, with scores returning to baseline within 6 months after surgery, whereas MCS remained unchanged. The patients with a lower PCI had better postoperative QoL outcomes. For patients with peritoneal malignancy, CRS and HIPEC can be performed with acceptable short- to medium-term QoL outcomes.

Tumour infiltration of the lateral pelvic compartment has previously been associated with the highest rate of involved resection margins and carries significant risk of morbidity. In this study, consecutive patients undergoing pelvic exenteration at a single centre between 1994 and 2019 who required en bloc resection of the common or external iliac artery or vein were included.The results demonstrate that complete resection of the iliac vascular system, including resection and reconstruction of the common and external iliac vessels, can be performed safely during pelvic exenteration with oncological outcomes comparable to more central tumours.

Objectives To determine what constitutes a clear resection margin (R0) in patients with LRRC. Summary of background data R0 is the most important predictor of survival in patients with LRRC. However, it is not clear what constitutes an R0. A 1-2 mm margin is often used to define R0 but this is based on primary rectal cancer studies. The same definition of R0 is likely inappropriate considering the anatomy and etiology of local recurrences. Methods A prospective maintained database was reviewed. A R2 margin was defined as macroscopic residual disease. R1 was defined as a microscopically involved margin (0 mm margin) and R0 as at least a 0.1 mm margin. Associations between R status and local recurrence was explored using X test. Associations between margins and overall survival and local recurrence free survival were explored using Kaplan-Meier analysis. Results There were 210 patients eligible for inclusion for analysis. Of these, 165 (78.6%), 35 (16.7%), and 10 (4.8%) patients had R0, R1, and R2 margins, respectively. Overall survival was significantly different between patients with R0 versus R1 margins but wider resection margins do not confer a survival benefit [57 months (95% confidence interval 38.5-75.5) vs 33 months (95% confidence interval 20.3-45.7), P = 0.03]. Local recurrence free survival was significantly different between patients with R0 versus R1 margins (2- and 5-year local recurrence free survivals of 53.5% and 20.4% vs 25.9% and 14.8%, respectively, P = 0.001 for both). Margins >0.5 mm were not predictive of local recurrence free survival. Conclusions A microscopically clear resection margin is most important in predicting overall survival. Margins up to 0.5 mm offers a local recurrence benefit but does not confer survival benefit.

Background Anorectal cancer arising in IBD can be challenging to manage. There is a paucity of reports describing locally advanced and recurrent anorectal cancer in this setting. Objective This study aimed to describe patients who underwent extended radical pelvic resection for locally advanced and recurrent IBD-associated anorectal cancer. Design This is a retrospective review of a prospectively maintained database of extended radical pelvic resection. Settings This study was conducted at a quaternary pelvic malignancy referral center. Patients All of the patients who underwent extended radical pelvic resection for IBD-associated anorectal cancer between September 1994 and September 2019 were included. Main outcome measures Demographic, operative, and oncologic outcomes were assessed. Results Ten patients (1.3%) were identified of 765 (6 men; median age = 51 y). The average time from the diagnosis of IBD to cancer was 23 years. Five patients had surgery for primary cancer previously. All of the patients had previous complex abdominal and perineal surgical interventions. There were 7 adenocarcinomas and 3 squamous cell carcinomas. Nine underwent pelvic exenteration and 1 rectal resection with radical vaginectomy. The median operating time, intraoperative blood loss, and blood transfusion were 698 minutes, 1.8 L, and 4.5 units. The median hospital stay was 24 days. The operative mortality and morbidity rates were 0% and 60%. At a median follow-up of 51.3 months, 7 patients remained alive and free of cancer. Limitations This is a retrospective study of a small number of patients. Conclusions Extended radical pelvic resection offers a potential cure for locally advanced and recurrent IBD-associated anorectal cancer with acceptable operative mortality and morbidity rates. A high index of suspicion is required to achieve early diagnosis. Multiple factors need to be considered in the multimodal treatment of such complex patients. See Video Abstract at http://links.lww.com/DCR/B418. Excelentes resultados despus de la reseccin plvica radical extendida por cncer anorrectal recurrente y localmente avanzada, asociada a enfermedad inflamatoria intestinal ANTECEDENTES:Cancer anorrectal surgiendo de la enfermedad inflamatoria intestinal, puede ser dificil de manejar. Hay escasez de informes que describan el cancer anorrectal localmente avanzado y recurrente en este contexto.OBJETIVO:El estudio tiene como objetivo, describir a los pacientes que se sometieron a reseccion pelvica radical extendida por cancer anorrectal recurrente y localmente avanzada, asociada con enfermedad inflamatoria intestinal.DISENO:Esta es una revision retrospectiva, de una base de datos mantenida prospectivamente de reseccion pelvica radical extendida.AJUSTES:El estudio se realizo en un centro de referencia cuaternaria en malignidad pelvica.PACIENTES:Se incluyeron a todos los pacientes sometidos a reseccion pelvica radical ampliada por cancer anorrectal, asociada a enfermedad inflamatoria intestinal entre septiembre de 1994 y septiembre de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los resultados demograficos, quirurgicos y oncologicos.RESULTADOS:Diez pacientes (1.3%) fueron identificados de 765 (seis masculinos; mediana de edad 51 anos). El tiempo promedio desde el diagnostico de la enfermedad inflamatoria intestinal hasta el cancer, fue de 23 anos. Cinco pacientes fueron previamente sometidos a cirugia por cancer primario. Todos los pacientes tuvieron previamente, intervenciones quirurgicas abdominales y perineales complejas. Hubo siete adenocarcinomas y tres carcinomas de celulas escamosas. Nueve se sometieron a exenteracion pelvica y una a reseccion rectal con vaginectomia radical. La mediana del tiempo de operacion, perdida de sangre intraoperatoria y transfusion sanguinea, fueron 698 minutos, 1.8 litros y 4.5 unidades respectivamente. La mediana de la estancia hospitalaria fue de 24 dias. Las tasas de mortalidad y morbilidad operatoria fueron 0% y 60% respectivamente. En una mediana de seguimiento de 51,3 meses, siete pacientes permanecieron vivos y libres de cancer.LIMITACIONES:Es un estudio retrospectivo con numero pequeno de pacientes.CONCLUSIONES:La reseccion pelvica radical extendida, ofrece una cura potencial para el cancer anorrectal recurrente y localmente avanzada, asociada a0 enfermedad inflamatoria intestinal y con tasas aceptables de mortalidad y morbilidad operatoria. Se requiere un alto indice de sospecha para obtener un diagnostico temprano. Se deben considerar multiples factores en el tratamiento multimodal de pacientes tan complejos. Consulte Video Resumen en http://links.lww.com/DCR/B418. (Traduccion-Dr Fidel Ruiz Healy).

Aim There is current debate about the optimal management of lateral pelvic lymph nodes (LPLNs) in rectal cancer between Western and Eastern centres. This paper aims to report the rate of histologically proven positive LPLNs in a group of patients undergoing the conventional Western approach to primary and recurrent rectal cancer. Method A retrospective cohort review of all patients who underwent LPLN dissection at Royal Prince Alfred Hospital in Sydney, Australia. This included patients who underwent pelvic exenteration who had LPLNs excised either en bloc for laterally invasive or recurrent tumours or as part of selective node dissection for suspicious lymph nodes on preoperative imaging. Histopathological results for these patients were compared with node status at preoperative imaging. Results Seventy-one patients satisfied the inclusion criteria. Of those patients with positive nodes on histology, 27% (9/33) with radiologically positive LPLNs were treated with preoperative radiotherapy and 75% (9/12) with radiologically positive LPLNs were not treated with preoperative radiotherapy (P = 0.004). None of the 12 patients with radiologically negative nodes treated with radiotherapy had positive nodes; 25% (3/12) of the patients with radiologically negative nodes who were not treated with radiotherapy had positive nodes. Fifty-three per cent of patients developed postoperative complications. Conclusion Our study suggests that in patients with radiologically positive LPLNs chemoradiotherapy may not be enough to sterilize these extra-mesorectal lymph nodes as a large proportion (27%) will have residual viable adenocarcinoma cells. In patients with radiologically negative LPLNs, however, the addition of chemoradiotherapy may serve to adequately sterilize these lymph nodes without the need for prophylactic LPLN dissection.

Introduction Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has gained traction for the management of peritoneal metastases. The number of specialist units globally offering CRS/HIPEC is increasing. The aim of this survey was to assess current practices and barriers to referral for CRS/HIPEC among colorectal surgeons in Australia and New Zealand (ANZ). Materials and methods An online questionnaire was emailed to members of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). The survey contained 3 sections: namely; demographics, referral patterns and clinical scenarios. Questions on referral patterns included number of peritoneal metastases patients seen per year and referred to a CRS/HIPEC unit, awareness of such a unit and distance from principle place of practice. Different pathologies referred were also explored, as well as investigations performed. Barriers to referral were also surveyed. Results The response rate was 28% (83/296). Twenty-five percent received CRS training. Most surgeons (95%) were aware of a CRS/HIPEC unit and had referred to one previously. Thirty-nine percent would refer all patients. Provision of good service and/or relationship with CRS/HIPEC specialist were the main reasons for referring to the nearest unit, followed by accessibility. Major factors preventing referral included extent of peritoneal disease (48%), patient characteristics and comorbidities (44%) and lack of evidence (20%). The most common pathologies referred included colorectal and appendiceal peritoneal metastases and pseudomyxoma peritonei. Conclusion Colorectal specialist awareness of CRS/HIPEC units and accessibility is high. Strategies to improve referring physician/surgeon knowledge on patient selection and indications for CRS/HIPEC should be investigated and instituted to ensure all appropriate patients are referred to specialist units for discussion of suitability.

Food insecurity, defined as a lack of consistent access to enough food for an active, healthy life, is a major public health concern with 11.8% of U.S. households (15.0 million) estimated to be affected at some point in 2017 according to the United States Department of Agriculture Economic Research Service. While the link between food insecurity, diet quality, and obesity is well documented in the literature, additional research and policy considerations are needed to better understand underlying mechanisms, associated risks, and effective strategies to mitigate the adverse impact of obesity related food insecurity on health. With its Strategic Plan for NIH Obesity Research, the NIH has invested in a broad spectrum of obesity research over the past 10 years to understand the multifaceted factors that contribute to the disease. The issue of food insecurity, obesity and nutrition is cross-cutting and relates to many activities and research priorities of the institutes and centers within the NIH. Several research gaps exist, including the mechanisms and pathways that underscore the complex relationship between food insecurity, diet, and weight outcomes, the impacts on pregnant and lactating women, children, and other vulnerable populations, its cumulative impact over the life course, and the development of effective multi-level intervention strategies to address this critical social determinant of health. Challenges and barriers such as the episodic nature of food insecurity and the inconsistencies of how food insecurity is measured in different studies also remain. Overall, food insecurity research aligns with the upcoming release of the Strategic Plan for NIH Nutrition Research and will continue to be prioritized in order to enhance health, lengthen life, reduce illness and disability and health disparities.

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as 'the biggest unaudited free-for-all in the history of surgery' due to 'a lack of effective centralised control'. Whether a new surgical intervention is considered an acceptable 'minor' variation of an established procedure, or is sufficiently 'novel' to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first-in-human setting. In phase I (first-in-human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the 'first in human' stage.

Heart disease and stroke are the first and fifth leading causes of death in the United States, respectively. Employers have a unique opportunity to promote cardiovascular health, because >60% of US adults are employed, and most spend half of their waking hours at work. Despite the scope of the opportunity

Selection of an open or minimally invasive approach to total mesorectal excision (TME) is generally based on surgeon preference and an intuitive assessment of patient characteristics but there consensus on criteria to predict surgical difficulty. Pelvimetry has been used to predict the difficult surgical pelvis, typically using only bony landmarks. This study aimed to assess the relationship between pelvic soft tissue measurements on preoperative MRI and surgical difficulty.Preoperative MRIs for patients undergoing laparoscopic rectal resection in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were retrospectively reviewed by two blinded surgeons and pelvimetric variables measured. Pelvimetric variables were analyzed for predictors of successful resection of the rectal cancer, defined by clear circumferential and distal resection margins and completeness of TME.There was no association between successful surgery and any measurement of distance, area, or ratio. However, the was a strong association between the primary outcome and the estimated total pelvic volume on adjusted logistic regression analysis (OR = 0.99, P = 0.01). For each cubic centimeter increase in the pelvic volume, there was a 1% decrease in the odds of successful laparoscopic rectal cancer surgery. Intuitive prediction of unsuccessful surgery was correct in 43% of cases, and correlation between surgeons was poor (ICC = 0.18).A surgeon's intuitive assessment of the difficult pelvis, based on visible MRI assessment, is not a reliable predictor of successful laparoscopic surgery. Further assessment of pelvic volume may provide an objective method of defining the difficult surgical pelvis.

OBJECTIVES: Recently, the Director of the National Institutes of Health (NIH) unveiled the first NIH-wide Strategic Plan for Nutrition Research (NIH SPNR), which emphasized cross-cutting and innovative opportunities to advance nutrition research across all NIH Institutes under the theme of precision nutrition. This review provides an assessment of nutrition research gaps and opportunities, and alignment with the NIH SPNR and with the National Heart, Lung, and Blood Institute's (NHLBI) Strategic Vision. The objective is to provide information to investigators and clinicians to stimulate nutrition research discoveries to improve heart, lung, blood, and sleep (HLBS) health. METHODS: We reviewed the scientific literature and summarized seminal peer-reviewed publications of nutrition research in NHLBI cohort studies from 2008–2019 to identify potential areas needing research. We conducted a portfolio analysis of NHLBI funded nutrition research studies and mapped them with the NHLBI Strategic Vision Objectives. To further identify research gaps and opportunities, we engaged NHLBI staff in prioritizing nutrition research as it relates to the NIH SPNR and the NHLBI Strategic Vision. RESULTS: Our findings indicate a strong alignment of the NIH SPNR with the NHLBI Strategic Vision. Nutrition research gaps and potential opportunities as they relate to HLBS include the following: bidirectional translation of nutrition in the basic sciences, epidemiology, clinical, implementation science and dissemination research, inclusion of the lifespan approach, and nutrition disparities in cardiovascular disease (e.g., heart failure). There were relatively fewer studies focused on nutrition across the spectrum of lung diseases (e.g., asthma and acute respiratory distress syndrome), blood diseases (e.g., sickle cell disease) and circadian biology (e.g., chrononutrition). CONCLUSIONS: This review identified marked gaps in our knowledge of nutrition in HLBS diseases and disorders and calls attention to precision nutrition approaches to address research gaps in nutrition to improve cardiovascular, pulmonary, blood and sleep health. FUNDING SOURCES: None.

Objective: This study examined whether health insurance stability was associated with improved type 2 diabetes mellitus (DM) control and reduced racial/ethnic health disparities.Methods: We utilized electronic medical record data (2005-2013) from two large, urban academic health systems with a racially/ethnically diverse patient popula­tion to examine insurance coverage, and three DM outcomes (poor diabetes control, A1c ≥8.0%; very poor diabetes control A1c >9.0%; and poor BP control, ≥ 130/80 mm Hg) and one DM management outcome (A1c monitoring). We used generalized estimating equations adjusting for age, sex, comorbidities, site of care, education, and income. Additional analysis examined if insurance stability (stable public or private insurance over the six-month internal) moderates the impact of race/ethnicity on DM outcomes.Results: Nearly 50% of non-Hispanic (NH) Whites had private insurance cover­age, compared with 33.5% of NH Blacks, 31.5% of Asians, and 31.1% of Hispanics. Overall, and within most racial/ ethnic groups, insurance stability was associated with better glycemic control compared with those with insurance switches or always being uninsured, with uninsured NH Blacks having significantly worse BP control. More NH Black and Hispanic patients had poorly controlled (A1c≥8%) and very poorly controlled (A1c>9%) diabetes across all insurance stability types than NH Whites or Asians. The interaction between insurance instability and race/ethnic groups was statis­tically significant for A1c monitoring and BP control, but not for glycemic control.Conclusion: Stable insurance coverage was associated with improved DM outcomes for all racial / ethnic groups, but did not eliminate racial ethnic disparitiesEthn Dis. 2021;31(1):149-158; doi:10.18865/ed.31.1.149

An 84-year-old man presented to a rural hospital in Australia with haemodynamic instability and abdominal pain. Investigation revealed haemorrhage from a lesion in his liver—an incidental finding of a hepatocellular carcinoma. Initial resuscitation and damage control surgery was performed at the peripheral hospital prior to transfer to a tertiary centre 386 km away for the second stage of management. The second stage of management included interventional radiological embolization of the bleeding liver vessel and subsequent resection of the liver tumour. This was all undertaken with new policies in place to limit the spread of infection at the peak of the COVID-19 epidemic.

In-home and shared meals have been hypothesized to have positive effects. This narrative review examines research on the influence of in-home eating on diet quality, health outcomes, and family relationships. A combination search approach included a search of PubMed, backward searches of previous published reviews, and studies the authors were familiar with. A search identified 118 publications; 54 original studies and 11 review studies were included in this review. Each study was reviewed and summarized. The diverse designs precluded quantitative data synthesis. Relatively strong evidence from cross-sectional research supports the association of shared family meals with favorable dietary patterns in children and adolescents, including consumption of fruits, vegetables, and healthful nutrients. Correlational evidence links shared meals with health and psychosocial outcomes in youth, including less obesity, decreased risk for eating disorders, and academic achievement. Most evidence is cross-sectional, thus, limiting attribution of causality. There is insufficient evidence to conclude that interventions improve the frequency of shared meals, improve diet, or prevent child obesity. Despite the “common wisdom”, the evidence that in-home, shared meals, per se, have positive effects on diet quality, health outcomes, psychosocial outcomes, and family relationships is limited due to weak research designs and single-item measurement of the independent variable. More research, with stronger designs, is warranted.

There have been significant developments in the management of advanced and recurrent colorectal cancer in recent decades. 70% of primary colorectal tumours arise in the colon and for patients with stage I-III disease, the standard of care is surgical resection followed by adjuvant therapy where appropriate. Locoregional recurrence (LR) occurs in 4-11.5% of patients following treatment of primary colon cancer with curative intent, and can be categorised as peri-anastomotic, mesenteric/paracolic (nodal), retroperitoneal and peritoneal. Of these, peritoneal recurrence is usually recognised as the most challenging type of recurrence to manage. Patients with isolated peri-anastomotic or limited nodal recurrence in the mesentery or retroperitoneum may be curable by radical salvage surgery, which often requires en bloc multi-visceral resection, while patients with low volume peritoneal metastases may be candidates for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ensuring complete resection along embryonic mesocolic planes or en bloc resection of contiguously involved structures are best strategies to reduce the likelihood of local recurrence through a R1 resection margin. The role of complete mesocolic excision (CME) with high vascular ligation has been demonstrated to increase nodal yield and improve overall survival although this is more contentious. In patients with T4a disease and serosal surface involvement, peritoneal recurrence represents the greatest threat. Efforts for early diagnosis of peritoneal recurrence in these patients or prophylactic treatment, while intuitive have not demonstrated the survival benefit that would be expected. Other than locoregional recurrence (LR), systemic recurrence may occur in up to 50% of patients who have undergone curative resection for colorectal cancer. In keeping with portal venous outflow, the most common site of systemic recurrence is the liver. Although previously thought to be a fatal condition, liver resection is now the standard of care where liver metastases can be completely resected with clear margins plus leaving an adequate liver remnant with intact vascular inflow, outflow and biliary drainage. This can usually be achieved in 26-45% of patients presenting with liver metastases. Liver surgeons at the forefront of liver resection have also developed techniques to induce liver hypertrophy so as to improve likelihood of resectability. Even where patients have non-resectable disease, ablative techniques have become increasingly common. Naturally, none of these would be possible without the advent of improved chemotherapeutic and biological options in the field of medical oncology. Pulmonary metastasectomy with curative intent may be possible in a small number (10%) of patients with lung metastases, which is associated with an overall survival of up to 40%. Unlike liver metastases, proportionally less patients with pulmonary metastases will be resectable. For these patients, several ablative options are available. For all patients with recurrent colon cancer, patient selection for radical salvage surgery and decisions surrounding treatment strategy (including use of systemic therapy or ablative procedures) should take place in a multidisciplinary team setting.

This review is an assessment of the state of the science on nutrition disparities and their contribution to disparities in cardiovascular health. Nutrition disparities remain pervasive by race/ethnicity, sex/gender, socioeconomic status, and geography. They are rooted in differences in social, cultural, and environmental determinants of health, behavioral and lifestyle factors, and the impact of policy interventions. Systematic differences in diet quality, dietary patterns, and nutrient intakes contribute to cardiovascular disparities and are mediated by microbiota, and CVD risk factors including high levels of blood pressure, low density lipoprotein cholesterol (LDL), and glucose; oxidative stress, pro-inflammatory cytokines, and endothelial dysfunction. Despite the progress made in nutrition research, important gaps persist that signal the need for more effective interventions at multiple levels to reduce cardiovascular disparities. Research opportunities include (1) exploring the gene-nutrient-environment interactions in the context of ancestral diversity; (2) investigating the causal link between diet and gut microbiota and impact of social determinants of health; (3) understanding resilience; (4) testing the effectiveness of multi-level interventions that address social and environmental determinants; and (4) supporting intervention research informed by validated implementation science frameworks.

The evolving coronavirus disease 2019 (COVID‐19) pandemic represents an unprecedented and largely unanticipated challenge to the delivery of surgical care in Australia and New Zealand. The first confirmed COVID‐19 case in Australia occurred on 25 January 2020. Since then, 2675 patients have been diagnosed nationally, resulting in 12 deaths (at the time of writing). New South Wales has been the most affected state based on case volume, with 1219 documented cases. During the initial response in New South Wales, all patients with confirmed COVID‐19 requiring hospitalization were managed at a nominated COVID‐19 centre (Westmead Hospital). As the pandemic evolved and the confirmed cases increased, a second COVID‐19 centre was established at Royal Prince Alfred (RPA) Hospital on 4 March 2020. RPA is a 900‐bed teaching hospital located in metropolitan Sydney, which provides surgical care for the local community but also serves as a quaternary referral centre for complex surgical services including advanced gastrointestinal malignancy, complex cardiovascular and neurosurgery, and renal and liver transplantation. As the third week of the response period at RPA comes to an end, this article aims to share our initial experience as a dedicated COVID‐19 centre by describing the issues faced in providing acute and elective surgical care, the broad impacts on staff and the early strategies adopted to address these challenges.

Aim The aim was to determine whether or not the clinical management of anal fissure in Australia and New Zealand accords with published guidelines. Methods A comprehensive survey based on common clinical scenarios was distributed to 206 colorectal surgeons in Australia and New Zealand. Results The response rate was 44% (91 surgeons). For 19 topic areas, only seven (37%) reached consensus (defined as > 70% majority opinion). Of these, six (86%) agreed with guideline recommendations. Twelve (63%) topic areas demonstrated community equipoise (defined as less than or equal to 70% majority opinion), of which five (42%) agreed with guideline recommendations and seven (58%) disagreed with guidelines. Of the seven topics that disagreed with guidelines, three were based on moderate quality evidence (first line management of acute anal fissure in a young patient, fissure healing and faecal incontinence rates following anocutaneous flap) and four were based on low quality evidence (length of sphincter division during a lateral sphincterotomy in women, management of chronic low-pressure anal fissures postpartum, fissure healing rate following anoplasty with botulinum toxin or sphincterotomy and faecal incontinence rates following repeat sphincterotomy for recurrence). Consensus and/or agreement with guidelines were more prevalent in management when medical therapy failed. Conclusion While areas of consensus mostly agreed with guideline recommendations, there remain many areas of community equipoise which warrant further research.

Background Non-Hispanic blacks in the United States are less likely to not meet national dietary recommendations than non-Hispanic whites; however, most studies do not consider nativity of US blacks. Objective With the use of the Alternative Healthy Eating Index-2010 (AHEI-2010) and the Dietary Approach to Stop Hypertension (DASH) scores, this cross-sectional study compared diet quality between US-born (n = 3,911) and foreign-born (n = 408) non-Hispanic black adults aged 22-79 y, based on pooled nationally representative data (NHANES 2003-2012) as well as by length of US residency. Design The association between nativity and diet quality was determined by using multivariable-adjusted linear regression for the continuous total diet quality scores and their components or multinomial (polytomous) logistic regression for categorical tertiles (low, medium, or high) of the total scores and their components. Results Foreign-born blacks had significantly higher AHEI-2010 (β: 9.3; 95% CI: 7.5, 11.0) and DASH (β: 3.1; 95% CI: 2.5, 3.8) scores compared with US-born blacks and more favorable intakes for many of the score components. Among foreign-born blacks, diet quality did not significantly differ by length of residency. Foreign-born blacks were more likely to be in the high than in the low tertile for vegetables [excluding starchy vegetables; relative risk ratio (RRR): 1.68; 95% CI: 1.24, 2.29], fruit [excluding and including fruit juice-RRR: 2.42 (95% CI: 1.69, 3.47) and RRR: 2.95 (95% CI: 1.90, 4.59), respectively], percentage of whole grains (RRR: 2.39; 95% CI: 1.64, 3.49), and omega-3 (ω-3) fatty acids (RRR: 2.03; 95% CI: 1.38, 2.97). Conclusions Foreign-born blacks have better diet quality than their US-born counterparts. In nutrition research and public health efforts, considering the place of birth among US blacks may improve the accuracy of characterizing dietary intakes and facilitate the development of targeted nutrition interventions to reduce diet-related diseases in the diverse black population in the United States.

Associations between diet, physical activity, parenting, and acculturation among Chinese-American children are understudied. Parents/caregivers of children attending child-care programs in Boston Chinatown completed a self-administered survey on demographics, child's diet, physical activities, anthropometrics, and parenting practices. Associations were evaluated in multivariable regression analysis, stratified by survey language preference, a proxy for acculturation. Responding Asian families = 132; 86.4% were immigrants; 75.8% completed the Chinese-version survey. Children (mean ± SD: 4.9 ± 1.1 years) did not eat vegetables (31.8%), or play actively outside (45.4%) daily, 64.8% watched television/screens daily; 32.6% were overweight/obese (based on parent report). Parenting practices associated with obesity were apparent. Although healthy-living behavioral outcomes were less prevalent among less acculturated parents; multivariable adjustment attenuated the observed significant differences. Findings suggest opportunities for improvement in study children's diet and healthy-living behaviors, and underscore the need for further research on acculturation, and parenting styles in this population.

Considerable progress has been made in the management of patients with locally advanced or recurrent cancers of the pelvis over the past 60 years since the inception of pelvic exenteration. Early progress in pelvic exenteration was marred by the high surgical mortality and morbidity, which drew scepticism from the broader surgical community. Subsequent evolution in the procedure hinged on establishing surgical safety and a better understanding of outcome predictors. Surgical mortality from pelvic exenteration is now comparable to that of elective resection for primary colorectal cancers. The importance of a clear resection margin is also now well established in providing durable local control and predicting long-term survival that, in turn, has driven the development of novel surgical techniques for pelvic side wall resection, en bloc sacrectomy, and pubic bone resection. A tailored surgical approach depending on the location of the tumor with resection of contiguously involved organs, yet preserving uninvolved organs to minimize unnecessary surgical morbidity, is paramount. Despite improved surgical and oncological outcomes, surgical morbidity following pelvic exenteration remains high with reported complication rates ranging between 20% and 80%. Extended antibiotic prophylaxis and preemptive parenteral nutrition in the immediate postoperative period may reduce septic and nutritional complications. A high index of suspicion is needed in the early diagnosis and management of complications that may avoid prolonged duration of hospitalization. An acceptable quality of life has been reported among patients after pelvic exenteration. Further research into novel chemotherapy, immunotherapy, and reconstructive options are currently underway and are needed to further improve outcomes.

BACKGROUND: For rectal cancer with unresectable metastases, current practice favors omitting interventions directed at the primary tumor in asymptomatic patients. OBJECTIVE: To determine the proportion of patients with primary tumor-related complications, characterize salvage outcomes, and measure survival in metastatic rectal cancer patients who did not undergo upfront intervention for their primary tumor. DESIGN: Retrospective analysis. SETTING: Comprehensive cancer center. PATIENTS: Patients who presented between January 1, 2008, and December 31, 2015, with synchronous stage IV rectal cancer, an unresected primary, and no prior primary tumor-directed intervention. MAIN OUTCOME MEASURES: Rate of primary tumor-related complications in the cohort that did not receive any primary tumor directed intervention. The Kaplan-Meier method and Cox regression analysis were used to determine whether complications are associated with survival. RESULTS: The cohort comprised 358 patients with median age of 56 years (22–92). Median follow-up was 26 months (range, 1 to 93 months). Among the 168 patients (46.9%) who eventually underwent elective resection of the primary tumor, the surgery was performed with curative intent in 66 patients (18.4%) and preemptive intent in 102 patients (28.5%). Of the 190 patients who did not undergo an upfront or elective intervention for the primary tumor, 68 (35.8%) experienced complications. Nonsurgical intervention for complications was attempted in 34 patients with an overall success rate of 61.8% (21 out of 34). Surgical intervention was performed in 47 patients (including 13 patients for whom nonsurgical intervention failed): diversion in 26 patients and resection in 21 patients. Of those 47 patients, 42 (89.4%) ended up with a colostomy or ileostomy. LIMITATIONS: Single center. CONCLUSION: A significant proportion of patients with metastatic rectal cancer and untreated primary experience primary tumor-related complications. These patients should be followed closely and preemptive intervention (resection, diversion, or radiation) considered if the primary progresses despite systemic therapy. See Video Abstract at http://links.lww.com/DCR/B400.

Distributive justice refers to the fair and appropriate distribution of benefits, risks and costs within a society. In a medical context, this requires patients with similar cases to be treated in a similar manner, and for there to be overarching equality of access to finite health resources. Distributive justice is a derivative of the broader principle of justice, which is one of the four biomedical ethics pillars described by Beauchamp and Childress as underpinning modern medical practice, along with beneficence, non‐maleficence and autonomy.1 The concept of distributive justice as it relates to the delivery of surgical care requires attention in the context of the coronavirus disease 2019 (COVID‐19) pandemic. Significant measures have been taken by our governments, health ministries and public and private hospitals in an effort to prepare the Australian healthcare system for high volumes of patients with COVID‐19. In the Australian context where a relatively low societal burden of disease has emerged, a question arises about the opportunity cost of these unprecedented interventions and restrictions, which have resulted in significant disruptions to the delivery of emergency and elective medical treatment – are we upholding the principle of distributive justice during the present pandemic?

To determine what constitutes a clear resection margin (R0) in patients with LRRC.R0 is the most important predictor of survival in patients with LRRC. However, it is not clear what constitutes an R0. A 1-2 mm margin is often used to define R0 but this is based on primary rectal cancer studies. The same definition of R0 is likely inappropriate considering the anatomy and etiology of local recurrences.A prospective maintained database was reviewed. A R2 margin was defined as macroscopic residual disease. R1 was defined as a microscopically involved margin (0 mm margin) and R0 as at least a 0.1 mm margin. Associations between R status and local recurrence was explored using X2 test. Associations between margins and overall survival and local recurrence free survival were explored using Kaplan-Meier analysis.There were 210 patients eligible for inclusion for analysis. Of these, 165 (78.6%), 35 (16.7%), and 10 (4.8%) patients had R0, R1, and R2 margins, respectively. Overall survival was significantly different between patients with R0 versus R1 margins but wider resection margins do not confer a survival benefit [57 months (95% confidence interval 38.5-75.5) vs 33 months (95% confidence interval 20.3-45.7), P = 0.03]. Local recurrence free survival was significantly different between patients with R0 versus R1 margins (2- and 5-year local recurrence free survivals of 53.5% and 20.4% vs 25.9% and 14.8%, respectively, P = 0.001 for both). Margins0.5 mm were not predictive of local recurrence free survival.A microscopically clear resection margin is most important in predicting overall survival. Margins up to 0.5 mm offers a local recurrence benefit but does not confer survival benefit.

There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours involving adjacent organs and neurovascular structures, beyond the traditional mesorectal planes, who would have traditionally been considered irresectable at many centres, now undergo surgery routinely at specialised units. While high rates of morbidity and mortality were reported by the pioneers of pelvic exenteration (PE) in early literature, this is now considered historical data. In 2019, patients who undergo PE for advanced or recurrent rectal cancer can expect reasonable rates of long-term survival (up to 60% at 5 years) and acceptable morbidity and quality of life. This article describes the surgical techniques that have been developed for radical multivisceral pelvic resections and reviews contemporary outcomes.

While the endovascular approach has been the treatment of choice for abdominal aortic aneurysm (AAA) repair in the modern era, open AAA repair remains a treatment option and may have a resurgence after the recent release of draft guidelines from the National Institute for Health and Care Excellence (NICE). Incisional hernia is a common long-term complication of open AAA repair and causes significant patient morbidity. As the number of patients undergoing open AAA repair increases, it is imperative that vascular surgeons are aware of and aim to reduce the complications associated with open surgery. This article summarises current evidence, highlighting the risk factors for incisional hernia and the modern surgical techniques that can prevent complications.

Improving advanced colorectal cancer care