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Purpose In the midst of a pandemic, residency interviews transitioned to a virtual format for the first time. Little is known about the effect this will have on the match process. The study aim is to evaluate resident application processes and perceived outcomes. Methods An electronic survey was distributed to 142 colon and rectal surgery residency applicants (95% of total). Results A total of 77 applicants responded to the survey (54% response rate). Applicants reported high levels of satisfaction with virtual interviews but less comfort. Utilizing the mute button and using notes in a different way from face-to-face interviews were significantly associated with applicant confidence that they ranked the right program highest. A majority of applicants (73%) would recommend virtual interviews next year even if COVID-19 is not a factor. Conclusion While applicants appear generally satisfied with virtual interviews, they also reported less comfort. Applicant confidence was predicted by utilizing the unique technological affordances offered by the virtual platform.

Medical school admissions committees are tasked with fulfilling the values of their institutions through careful recruitment. Making accurate predictions regarding the enrollment behavior of admitted students is critical to intentionally formulating class composition and impacts long-term physician representation.

The COVID-19 pandemic has uncovered disparities for allopathic and osteopathic surgical applicants for the upcoming 2021 residency application cycle. It has provided an opportunity for change to the current paradigm in surgical resident selection. This study seeks to quantify the disproportionality of opportunities between allopathic and osteopathic students and provides solutions to level the playing field for all applicants.

Surgical resident autonomy is an essential element of the transition from supervised training to independent practice. However, in an age of duty hour restrictions, legislative constraints, increased litigation, and heightened societal expectations, training an autonomous resident proves increasingly difficult. To tackle these barriers to training successful surgeons, the American College of Surgeons Committee on Resident Education initiated the Resident Mentored Autonomy Project. As a subdivision of this project, the Empowered Learner research team here presents a framework for training the self-directed and empowered surgical resident learner. There are many strategies by which surgical faculty, program directors and chairs, and residents themselves may engage to improve resident operative autonomy.

Appendicular mucinous neoplasms are a collection of rare tumors with diverse clinical presentations and pathologic potential, which can cause diagnostic and therapeutic challenges. Traditionally, they are diagnosed by radiologic imaging or identified intraoperatively; however, rarely, they may be diagnosed during an endoscopic procedure. In this unusual case, we present the case of a 62-year-old Caucasian male undergoing routine surveillance colonoscopy due to a history of colonic neoplasia. During the colonoscopy, a submucosal, non-bleeding 1cm mass of benign appearance was found in the appendix. Further workup determined the mass was likely a mucocele, and surgical consultation was recommended. The patient denied any symptoms suggestive of a mucinous neoplasm prior to and during evaluation. A laparoscopic appendectomy was subsequently performed, and the histopathology report confirmed the diagnosis of a low-grade appendiceal mucinous neoplasm. The patient recovered without complications and continued to deny any symptoms during his postoperative course and follow-up care. Given their rare incidence and unpredictable nature, appendiceal mucinous neoplasms remain difficult to identify. Discovering a low-grade mucinous neoplasm in an asymptomatic patient via colonoscopy illustrates the spectrum of unique presentations and modalities for diagnosis.

Background Ligation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented. Methods Retrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016. Results 53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment. Conclusion Patients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.

Constipation and fecal incontinence can result from increased, paradoxical or decreased tone of the pelvic floor. Abnormal pelvic floor activity can result from anatomic and neurogenic injury or unlearned function. Biofeedback, which compliments a physical therapy program, is an effective therapy for the malfunctioning pelvic floor and represents the main therapy for dyssynergic defecation and one of the first line therapies for many patients with fecal incontinence. Biofeedback allows visualization of pelvic floor muscle activity and facilitates reproducibility of the correct maneuvers to mitigate deranged function. Biofeedback facilitates return of normal pelvic floor function with minimal risk or side effects.

Controversy exists regarding the optimal surveillance strategy following local excision of T1NX rectal adenocarcinoma. This study aims to determine the cost-effectiveness of surveillance strategies for locally excised T1NX rectal adenocarcinoma based on histopathologic and local staging risk factors. A Markov model with 10-year follow-up was developed for cost-effectiveness analysis of high-, medium-, and low-intensity surveillance strategies after local excision of T1NX rectal adenocarcinoma. Literature review and expert consensus were utilized to populate state/transition probabilities and rewards. Based on this data, 87% of T1NX patients undergoing local excision were low risk. Healthcare utilization costs were based on Centers for Medicare and Medicaid Services data. The primary outcomes were costs in 2018 US dollars and effectiveness in life-years presented as net monetary benefit and incremental cost-effectiveness ratios. One-way sensitivity and probabilistic sensitivity analyses were performed. Net monetary benefit for low-, medium-, and high-intensity surveillance strategies ($393,117.00, $397,978.80, and $397,290.00) shows medium-intensity surveillance to be optimal. One-way sensitivity analysis shows medium-intensity surveillance to be optimal when the cohort is 73–94% low risk. High-intensity surveillance is preferred when less than 73% of the cohort is low risk. Low-intensity surveillance is preferred when greater than 94% is low risk. Probabilistic sensitivity analysis of the base-case shows medium-intensity surveillance is the optimal strategy for 51.5% of the iterations performed. Medium-intensity surveillance is the most cost-effective surveillance strategy for locally excised T1NX rectal adenocarcinoma in a clinically representative population model.

Definitive surgery with total mesorectal excision is the mainstay of treatment for locally advanced rectal cancer. Multimodality therapy improves long-term survival. Current standards advise neoadjuvant chemoradiation followed by radical surgery and adjuvant chemotherapy. Nationally, compliance with adjuvant chemotherapy is only 32%. New research evaluates the effectiveness of total neoadjuvant therapy: complete chemotherapy and chemoradiation before surgery.The aim of this study is to determine the favored treatment for locally advanced rectal cancer by comparing the cost-effectiveness of total neoadjuvant therapy and the current standard of care.Decision analytical modeling using long-term costs and 5-year disease-free survival was performed to determine the cost-effectiveness after total neoadjuvant therapy and the current standard of care. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.Centers for MedicareMedicaid Services billing data perspective was adopted and outcomes modeled according to local and national databases and literature consensus.Adult patients with stage II or III rectal cancer were selected.Cost-effectiveness in disease-free life-years, incremental cost-effectiveness ratio, and net monetary benefit were determined over a 5-year posttreatment period. The favored strategy was determined based on cost-effectiveness and sensitivity analyses.Cost-effectiveness for total neoadjuvant therapy was 40,708 $/life-year, and, for conventional therapy, cost-effectiveness was 44,248 $/life-year. Sensitivity analysis showed that, for an estimated total neoadjuvant therapy completion rate of 90%, total neoadjuvant therapy would remain the dominant strategy for any adjuvant chemotherapy completion rate of less than 93%.The samples used to calculate completion rates are small, and survival probabilities are based on existing literature, local database values, and consensus estimates. The model encompasses a 5-year time period from diagnosis.Cost-effectiveness analysis shows that a strategy of total neoadjuvant therapy followed by radical surgery is favored over the current standard of care for locally advanced rectal cancer. Sensitivity analysis shows that a low rate of adjuvant chemotherapy administration plays a key role in decreasing the cost-effectiveness of the current standard of care. See Video Abstract at http://links.lww.com/DCR/A942.

The need for reoperation for diverticulitis may become necessary for a range of conditions. Surgeons will most commonly encounter these conditions in an elective setting with planned cases for ostomy reversal, however, recurrence of acute disease after sigmoid resection also occurs with a degree of regularity. A suspected recurrence should prompt a workup for alternative conditions, such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). Reoperation in the emergent setting may be necessary for both recurrent diverticulitis as well as complications from earlier procedures. Attention to technical details improves outcome of both elective and emergent reoperations. The operative plan should be individualized to optimize patient outcomes. This discussion will review necessary details to enhance the chance of successful outcomes. Details for the management of some of these issues (problems common to colon and rectal surgery in general, e.g., anastomotic leaks, stoma complications, and fistulas) are discussed elsewhere in this publication. Some conclusions are based on the extrapolation of data from more generalized reviews because the literature on reoperative diverticular surgery is limited.

Background The aim of this study was to assess the rate of permanent diversion in patients undergoing coloanal anastomosis after neoadjuvant therapy for rectal cancer. Methods We performed a retrospective review of patients with rectal cancer who underwent a total mesorectal excision of a tumor within 9 cm of the anal verge. Results There were 201 patients who underwent resection with coloanal anastomosis, with a mean follow-up period of 51 months. The average tumor distance from the anal verge was 7 cm (range, 4–9 cm). Neoadjuvant therapy was administrated in 145 patients, 47 had no radiation, and 9 received radiation postoperatively. Thirty-two patients (16%) had long-term complications including incontinence, fistulas, and strictures. Twenty-five patients (12%) had recurrent disease, 16 of these were local recurrence. The total rate of permanent diversion was 29 (14%). Reasons for diversion included local recurrence in 12 patients (6%), complications in 10 patients (5%), and poor function in 7 patients (3%). Conclusions Poor bowel function, late complications, and local recurrence all contribute to permanent diversion after a coloanal anastomosis. Neoadjuvant therapy in conjunction with a total mesorectal excision and coloanal anastomosis leads to acceptably low permanent diversion rates in the vast majority of patients.