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William Mitchell,1,* Thomas Roser,1,* Jessica Heard,2 Shankar Logarajah,2 John Ok,1,2 John Jay,2 Houssam Osman,1,2 D Rohan Jeyarajah1,2 1Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA; 2Methodist Richardson Medical Center, Richardson, TX, USA*These authors contributed equally to this workCorrespondence: D Rohan Jeyarajah, Tel +1 972 619 3500, Email rohanjeyarajah@tcu.eduBackground: Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA.Methods: This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission.Results: The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain.Conclusion: The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study’s population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy.Trial Registration: This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R.Keywords: trans-hiatal, esophagectomy, transversus abdominis plane, TAP, quadratus lumborum, QL, block, epidural, ERAS, analgesia

Background: The Whipple procedure for pancreatic adenocarcinoma frequently is referred to surgeons at high-volume centers, which requires that patients travel long distances, potentially impacting patient outcomes. Furthermore, patients with pancreatic cancer from underserved areas often have poor outcomes. There are limited data on Whipple outcomes on the basis of both socioeconomic and distance traveled., Methods: This retrospective cohort study examined patients who underwent the Whipple procedure for pancreatic adenocarcinoma at a tertiary care center from 2019 to 2021. Patients who lived in areas with an Area Deprivation Index national percentile of >50% and ≥100 miles away from the care center were labeled as "at-risk" patients., Results: Seventy-eight patients were included, with 22 (28.2%) patients determined to be at risk. The preoperative characteristics were comparable between the patients in the at-risk and standard-risk groups. Postoperatively, patients in the at-risk group were more likely to require reoperation (13.6% vs 0%; P = .020) and less likely to undergo adjuvant chemotherapy (73.2% vs 50%; P = .034) than patients in the standard-risk group; pathologic staging and frequency of previous use of neoadjuvant chemotherapy were not significantly different between the groups. At-risk status did not influence overall survival or recurrence rate., Conclusions: Through the integration of distance traveled and Area Deprivation Index, we have redefined the characterization of at-risk patients with pancreatic adenocarcinoma, who are at greater risk of undergoing reoperation and not receiving adjuvant chemotherapy. By addressing these intersecting challenges, providers can mitigate disparities and improve the care of these patients with pancreatic adenocarcinoma., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Margin accentuation using irreversible electroporation (MA-IRE) improves recurrence and overall survival (OS) in pancreatic cancer patients; however, there have been limited outcome comparisons to similarly risked patients who did not receive MA-IRE., Methods: Patients with borderline resectable or locally advanced pancreatic adenocarcinoma who underwent a pancreaticoduodenectomy (PD) between 2017 and 2022 were included. Those who did not receive neoadjuvant chemotherapy for major vessel involvement were excluded. One-to-one propensity score matching (PSM) was used to match the MA-IRE group with the corresponding non-MA-IRE control group with similar risk factors., Results: A total of 36 patients were included in this study. Seventeen (47.2%) patients who underwent MA-IRE matched with 19 control patients (52.8%) with similar risk factors who did not have MA-IRE. Before matching, OS and disease-free survival (DFS) were comparable between the MA-IRE and non-MA-IRE groups. After matching, the MA-IRE group showed improved OS (746 vs. 509 days, hazard ratio 0.313; p = 0.034) compared with the non-MA-IRE group. DFS (p = 0.768), negative margin status (p = 0.317), and 30-day complication rates (p = 1.000) remained statistically different between the groups., Conclusions: MA-IRE in PD results in longer OS but does not impact margin status, DFS, or postoperative complication rates in our cohort. These findings suggest that MA-IRE is safe and potentially promotes immune cell activation rather than upfront margin mitigation., (© 2024. Society of Surgical Oncology.)

Hepatocellular carcinoma, historically, has had a poor prognosis with very few systemic options. Furthermore, most patients at diagnosis are not surgical candidates. Therefore, locoregional therapy (LRT) has been widely used, with strong data supporting its use. Over the last 15 years, there has been progress in the available systemic agents. This has led to the updated Barcelona Clinic Liver Cancer (BCLC) algorithm's inclusion of these new systemic agents, with advocacy of earlier usage in those who progress on LRT or have tumor characteristics that make them less likely to benefit from LRT. However, neither the adjunct of LRT nor the specific sequencing of combination therapies is addressed directly. This Research Consensus Panel sought to highlight research priorities pertaining to the combination and optimal sequencing of LRT and systemic therapy, assessing the greatest needs across BCLC stages., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a rare tumor described as a mucosal exophytic neoplastic lesion that projects into the gallbladder lumen. In regards to the size, lesions that did not make the arbitrary 1cm cutoff are described as "incipient" ICPN. Not much is known about these incipient ICPNs, as they are often excluded in ICPN studies, given the attempted adherence to the traditional 1cm cutoff. We present the youngest reported case of incipient, non-mucinous gastric-pylorus type ICPN who underwent cholecystectomy. Resection with negative margin for ICPN appears to be sufficient treatment and post resection imaging surveillance could be of value but further studies are required., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Jeyarajah is a consultant for AngioDynamics, Ethicon, and Sirtex.

Objective: The goals of this study were (1) to assess if examiner ratings in the American Board of Surgery (ABS) General Surgery Cetifying Exam (CE) are biased based on the gender, race, and ethnicity of the candidate or the examiners, and (2) if the format of delivering of the exams, in-person or virtual, affects how examiners rate candidates., Design: We included every candidate-examiner combination for first time takers of the general surgery oral exam. Total scores and pass/fail outcomes based on the 4 scores given by examiners to candidates were analyzed using multilevel models, with candidates as random effects. Explanatory variables included the gender, race, and ethnicity of candidates and examiners, and the format of the exam (in-person or virtual). Candidates' first attempt scores on the ABS General Surgery Qualifying Exam (QE) were also included in the models to control for the baseline knowledge of the candidate. Three sets of models were evaluated for each demographic variable (gender, race, ethnicity) due to missingness in data. p-values and coefficients of determination R 2 were used to quantify the statistical and practical significance of the model coefficients (an existent relationship between the explored variables on CE scores was considered statistically and practically significant if the p-value was lower than 0.01 and R 2 higher than 1%)., Participants: All first-time takers of the American Board of Surgery General Surgery Certifying Exam from 2016 to 2022 that had demographic data, and the examiners that participated in those exams., Results: The number of candidates/examiners for the 3 sets of models was 8665/514 (gender), 5906/465 (race), and 4678/295 (ethnicity). The demographic variables, format of the exam, or their interactions were not found to significantly relate to examiner-candidate ratings or pass/fail outcomes. The only variable that was significantly related to CE scores was candidates' QE scores, which was added to the models as a measure of candidates' initial knowledge; this held for all models for total scores (F[1,8659] = 1069.89, p-value < 0.01, R 2  = 5% [gender models], F(1,5696.3) = 589.13, p-value < 0.01, R 2  = 5% [race models], F(1,4459.5) = 278.33, p-value < 0.01, R 2  = 5% [ethnicity models]), and pass/fail outcomes (CI = 1.61-1.73, p-value < 0.01, R 2  = 3% [gender models], CI = 1.67-1.85, p-value < 0.01, R 2  = 3% [race models], CI = 2.17-2.90, p-value < 0.01, R 2  = 3% [ethnicity models])., Conclusions: This study shows that there is not a relationship between candidate and examiner gender, race, or ethnicity, and exam outcomes based on statistical models looking at examiner-candidate ratings and pass/fail outcomes. In addition, the delivery of the certifying exam in a virtual format appears to have no statistical impact on outcomes compared to in-person delivery. This suggests that the ABS is performing well in both demographic bias and virtual space., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Hiatal hernias are observed in approximately 15% to 20% of the population in Western society. Most patients are diagnosed with a sliding-type hiatal hernia, of which gastroesophageal reflux is the predominant driving symptom. Surgical repair of these types of hernias often involves a wrap procedure during the index operation as standard of care. For type 2, 3, and 4 hernias, also known as paraesophageal hernias (PEHs), the symptom complexes vary and often involve symptoms other than reflux, including dysphagia, anemia, shortness of breath, and chest pain. We sought to evaluate whether patients who underwent PEH repair without fundoplication reported different rates of postoperative symptoms compared with those who did., (Copyright © 2023. Published by Elsevier Inc.)

Background/Objective: Optimal approach for lower anterior resection has been closely debated. The relatively new addition of the robotic approach adds a layer of complexity to this topic. The majority of the literature has compared the possible approaches between two techniques; however, only a few studies have comprehensively compared all 3 approaches at the same time, especially in a non-academic center. Study Design: This is a retrospective cohort study of a prospectively maintained database of data from a large group of private-practice colorectal surgeons in a large metropolitan area. Specifically, rectal resections using open, laparoscopic, and robotic approaches were queried. A total of 130 patients underwent open, laparoscopic, or robotic oncological lower anterior resection from 2016 to January 2020. Results: Statistical significance of length of stay was noted between the three approaches with the mean length of stay for open being 8.08 days, laparoscopic being 7.04 days, and robotic being 4.96 days (P < .005). No statistical significance was noted for estimated blood loss, operating time, or postoperative complications including anastomotic leak, ileus, pneumonia, pulmonary embolism, surgical site infection, and urinary tract infection. When directly comparing any minimally invasive surgery approach to open, estimated blood loss was decreased in addition to the shortened length of stay (P < .05). Conclusions: This study demonstrates that MIS LAR has significant benefit over the open approach. However, finding that robotic surgery had was superior to laparoscopic LAR which was surprising and important. This experience in the private world raises the question as to whether robotic LAR should be considered the standard of care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Burnout has become a prominent topic, yet there are limited data on the manifestation of this phenomenon among surgical fellows. The goal of this study is to elucidate the prevalence of burnout and determine if there are protective or predisposing factors in surgical fellowship training., Methods: A confidential electronic survey was distributed to Fellowship Council accredited fellows during the 2020-2021 academic year. Demographic information and training characteristics were queried. The fellows were then asked to complete the Maslach Burnout Inventory (MBI), Perceived Stress Scale (PSS), Short Grit Scale (SGS), Satisfaction with Life Scale (SLS), and General Self-Efficacy Scale (SE). Data were analyzed using p values of ≤ 0.05 as statistically significant., Results: At the end of the survey period, 92 out of 196 (46.9%) fellowship trainees responded. 69.6% of respondents identified as men, 29.7% as international medical school graduates (IMGs), and 15.3% non-US IMGs. Based on criteria defined by the MBI, there was an 8.4% rate of burnout. Most respondents noted low stress levels (62.3%), good satisfaction with life (58.9%), a moderate amount of grit, and a high level of self-esteem. On comparative analysis, fellows with burnout had significantly higher stress levels, lower levels of satisfaction with life, and less self-esteem., Conclusions: Overall, there was a low rate of burnout among fellows. We suggest this may be reflective of a self-selecting effect, as trainees who choose to undergo additional training may be less likely to experience this syndrome. In addition, there may be a protective factor during fellowship that results from inherent mentoring, increased specialization, and autonomy. Further investigation of the predisposing factors to burnout in fellowship trainees is warranted based on the results of this study., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Development of a post-esophagectomy hiatal hernia (PEHH) is a rare, but problematic, sequela with the current reported prevalence ranging up to 20%. To determine the incidence rate of PEHH at our institution, a retrospective review of all transhiatal esophagectomies performed from 2012 to 2020 was conducted. Demographic, operative, and oncologic data were collected, rates of PEHH were calculated, and characteristics of subsequent repair were reviewed and analyzed. A total of 160 transhiatal esophagectomies were included, of which four patients (2.5%) developed a PEHH at a mean of 12 months postoperatively (range: 3-28 months) with symptomatology driving the diagnosis for three patients. The limited size of our study does not allow for statistically significant determinations regarding risk factors or method of repair. The true prevalence of a hiatal defect is likely higher than reported, as clinically asymptomatic patients are not captured in our current literature.

Background: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the two most common malignant neoplasms of the liver. The objective of this study was to assess outcomes of surgical approaches to liver ablation comparing laparoscopic versus percutaneous microwave ablation (MWA), and MWA versus radiofrequency ablation (RFA) in patients with HCC or CRLM lesions smaller than 5 cm., Methods: A systematic review was conducted across seven databases, including PubMed, Embase, and Cochrane, to identify all comparative studies between 1937 and 2021. Two independent reviewers screened for eligibility, extracted data for selected studies, and assessed study bias using the modified Newcastle Ottawa Scale. Random effects meta-analyses were subsequently performed on all available comparative data., Results: From 1066 records screened, 11 studies were deemed relevant to the study and warranted inclusion. Eight of the 11 studies were at high or uncertain risk for bias. Our meta-analyses of two studies revealed that laparoscopic MW ablation had significantly higher complication rates compared to a percutaneous approach (risk ratio = 4.66; 95% confidence interval = [1.23, 17.22]), but otherwise similar incomplete ablation rates, local recurrence, and oncologic outcomes. The remaining nine studies demonstrated similar efficacy of MWA and RFA, as measured by incomplete ablation, complication rates, local/regional recurrence, and oncologic outcomes, for both HCC and CRLM lesions less than 5 cm (p > 0.05 for all outcomes). There was no statistical subgroup interaction in the analysis of tumors < 3 cm., Conclusion: The available comparative evidence regarding both laparoscopic versus percutaneous MWA and MWA versus RFA is limited, evident by the few studies that suffer from high/uncertain risk of bias. Additional high-quality randomized trials or statistically matched cohort studies with sufficient granularity of patient variables, institutional experience, and physician specialty/training will be useful in informing clinical decision making for the ablative treatment of HCC or CRLM., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The Fellowship Council (FC) is transitioning to a competency-based medical education (CBME) model, including the introduction of Entrustable Professional Activities (EPAs) for training and assessment of Fellows. This study describes the implementation process employed by the FC during a ten-month pilot project and presents data regarding feasibility and perceived value., Methods: The FC coordinated the development of EPAs in collaboration with the sponsoring societies for Advanced GI/MIS, Bariatrics, Foregut, Endoscopy and Hepatopancreaticobiliary (HPB) fellowships encompassing the preoperative, intraoperative, and postoperative phases of care for key competencies. Fifteen accredited fellowship programs participated in this project. The assessments were collected through a unique platform on the FC website. Programs were asked to convene a Clinical Competency Committee (CCC) on a quarterly basis. The pilot group met monthly to support and improve the process. An exit survey evaluated the perceived value of EPAs., Results: The 15 participating programs included 18 fellows and 106 faculty. A total of 655 assessments were initiated with 429 (65%) completed. The average (SD) number of EPAs completed for each fellow was 24(18); range 0-72. Intraoperative EPAs were preferentially completed (71%). The average(SD) time for both the fellow and faculty to complete an EPA was 27(78) hours. Engagement increased from 39% of fellows completing at least one EPA in September to 72% in December and declining to 50% in May. Entrustment level increased from 6% of EPAs evaluated as "Practice Ready" in September to 75% in June. The exit survey was returned by 63% of faculty and 72% of fellows. Overall, 46% of fellows and 74% of program directors recommended full-scale implementation of the EPA framework., Conclusion: A competency-based assessment framework was developed by the FC and piloted in several programs. Participation was variable and required ongoing strategies to address barriers. The pilot project has prepared the FC to introduce CBME across all FC training programs., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Metabolic surgery has been on the rise over the last 2 decades. As more literature has been being published regarding its efficacy in treating metabolic syndrome as well as advancements in surgical training and safety rise with it, metabolic surgery will in no doubt continue to increase in prevalence. Concomitantly, the prevalence of esophageal cancer is increasing. We present two cases of patients who are status post sleeve gastrectomy and require esophagectomy. These patients do not have the availability of a gastric conduit, and colon interposition graft was planned for their reconstructions. We here review the two unique case scenarios as well as an overview of colon interposition technique and workup considerations. The need this reconstruction technique will likely increase in the years to come and metabolic surgery and esophageal cancer both continue to rise., (© 2022. The Society for Surgery of the Alimentary Tract.)

Background: Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM., Methods: Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research., Results: The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence., Conclusions: These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pancreatic-enteric drainage procedures have become standard therapy for symptomatic pancreatic pseudocysts and walled-off pancreatic necrosis. The need for pancreatic resection after cyst-enteric drainage procedure in the event of recurrence is not well studied. This study aimed to quantify the percentage of patients requiring resection due to recurrence after surgical cystogastrostomy and identify predictors of drainage failure., Methods: A single-institution retrospective review was conducted to identify all patients undergoing surgical cystogastrostomy between 2012 and 2020. Demographic, disease, and treatment characteristics were identified. Failure of surgical drainage was defined as the need for subsequent pancreatic resection due to recurrence. Characteristics between failure and nonfailure groups were compared with identifying predictors of treatment failure., Results: Twenty-four cystogastrostomies were performed during the study period. Three patients (12.5%) required a subsequent distal pancreatectomy after surgical drainage. There was no difference in comorbidities between drainage alone and failure of drainage groups. Mean cyst size seemed to be larger in patients that underwent drainage alone versus those that needed subsequent resection (15.2 vs 10.3 cm, P =0.05). Estimated blood loss at initial operation was similar between groups (126 vs 166 mL, P =0.36)., Conclusion: Surgical pancreatic drainage was successful in the initial management of pancreatic fluid collections. We did not identify any predictors of failure of initial drainage. There was a trend suggesting smaller cyst size may be associated with cystgastrostomy failure. Resection with distal pancreatectomy for walled-off pancreatic necrosis and pancreatic pseudocysts can be reserved for cases of failure of drainage., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Primary repair failure rates for hiatal hernias (HH) can reach up to 40%, this is especially high in the morbidly obese patient. There is no clear data on how to manage this patient subset. This paper evaluates the efficacy of Roux-N-Y Gastrojejunostomy (RNY GJ) for treatment of symptomatic HH., Methods: A retrospective analysis of all patients who received a Roux-en-Y Gastrojejunostomy (RNY GJ) for HH at our institution between January 2016 and January 2021 was performed. Patient demographics, symptoms, and post-operative outcomes were recorded and univariate analysis was performed between preoperative and postoperative symptoms., Results: Thirty-seven patients with a mean age of 56.9 years (SD 11.8) underwent RNY GJ. Patients were mostly female (81.1%) with a mean BMI of 36.8 (SD 8.4). An 78.4% reduction in symptoms of either heartburn, dysphagia, or regurgitation was noted at follow up (p < 0.001)., Conclusions: RNY GJ represents a safe procedure for morbidly obese patients with hiatal hernias with no mortalities amongst our patient cohort along with a significant reduction in pre-operative symptoms and no symptomatic recurrences. RNY GJ should be considered as the operation of choice for repair for this patient population., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Neoadjuvant chemoradiotherapy has become the mainstay of treatment for locally advanced esophageal cancer. CALGB 9781 trial established cisplatin and 5-flourouracil (5-Fu) with radiotherapy as superior to surgery alone while the CROSS trial established paclitaxel, carboplatin, and radiotherapy as superior to surgery alone. Previous data has been unclear as to which regimen provides a superior pathologic response. This study aims to look at this. This study aims to look at this., Methods: A retrospective chart review at a single institution of patients who underwent esophagectomies after neoadjuvant chemoradiotherapy with either cisplatin and 5-Fu or carboplatin and paclitaxel between 2012-2020 was performed. Demographics as well as staging, response rates, and modified Ryan scores were collected. Univariate analysis between the two groups was performed., Results: A total of 82 patients were identified between 2012-2020 who underwent esophagectomy after neoadjuvant chemoradiotherapy. In total, 74 (90.2%) received carboplatin and paclitaxel while 8 (9.8%) received 5-Fu and carboplatin. Both groups included patients with squamous cell carcinoma (SCC) and adenocarcinoma. No significant factors were found in terms of patient comorbidities or pathologic staging. There was no significant difference in modified Ryan score between the two groups (P=0.745)., Conclusions: This study evaluates the degree and presence of pathologic response between the two neoadjuvant chemoradiotherapy modalities used for esophageal cancer. Our results, in contrast to other studies, suggest no significant difference with regards to pathologic response rate. Furthermore, our findings suggest that use of the least toxic regimen would make sense., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-22-70/coif). The authors have no conflicts of interest to declare., (2022 Journal of Gastrointestinal Oncology. All rights reserved.)

Background: Surgical intervention in the geriatric population has a higher risk of perioperative morbidity and mortality due to frailty, comorbidities, and lack of compensatory physiologic reserve. The literature on esophagectomy in octogenarians is limited and there is concern about elderly patients being with-held surgery. The purpose of this study is to analyze the outcomes of esophagectomies for esophageal cancer in octogenarians to assess the safety of esophagectomy in this population., Methods: 145 transhiatal esophagectomies performed for esophageal cancer between 2012 and 2020 were retrospectively reviewed in this IRB approved study. Two aborted esophagectomies were excluded. Patient demographics, surgical outcomes, and oncologic outcomes were reviewed. The octogenarian group was analyzed compared to patients younger than 80 years of age., Results: Among 143 esophagectomies, 136 patients were <80 years old while 7 were ≥80 years old. Octogenarians received significantly less neoadjuvant therapy compared to younger patients (42.9% vs 80.2%, p = 0.02). No statistically significant difference was noted in complication rate, length of stay (LOS), estimated blood loss (EBL), or mortality. However, octogenarians were found to have an increase in severity of complications compared to younger patients., Conclusion: This study demonstrates that esophagectomy can be performed in carefully selected octogenarians. This comes at a cost with increased severity of complications without an increase in complication rates or mortality. This data suggests that esophagectomy can be offered selectively to older patients with clear expectations and planning for the high risk of more severe post-operative complications., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s).)

Background: While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor., Methods: PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD)., Results: From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17)., Conclusions: Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Resectability in localized pancreatic ductal adenocarcinoma (PDAC) is deemed through radiological criteria. Despite initial evaluation classifying tumors as "resectable," they often have ill-defined borders that can result in more extensive cancer than predicted on final pathology analysis. We attempt to categorize these tumors radiologically and define them as "infiltrative" and contrast them to more well-defined or "mass-forming" tumors and assess their correlation with surgical oncological outcomes. We hypothesize that mass-forming lesions will result in fewer positive resection margins., Methods: Patients diagnosed with PDAC of the head of the pancreas and who underwent subsequent curative intent resection between 2016 and 2018 were included. A retrospective chart review of patients was conducted and computed tomography images at the time of diagnosis were reviewed by two radiologists and scored as "mass forming" or "infiltrative" using a newly developed classification system. These classifications were then correlated with margin status., Results: Sixty-eight consecutive pancreatoduodenectomies performed for PDAC from 2016 to 2018 were identified. After screening, 54 patients were eligible for inclusion. Radiologically defined mass-forming lesions had a trend toward a lower rate of positive resection margins (35.7% vs. 50.0%; p  = 0.18), specifically the bile duct margin and pancreas margin as well as an overall larger size (4.03 cm vs. 3.25 cm, p  = 0.02) compared with infiltrative lesions., Conclusion: We propose a new radiological definition of PDAC into "mass forming" and "infiltrative," a nomenclature that resonates with other tumor sites. Infiltrative lesions trended toward a higher rate of positive resection margins. This classification may help tailor therapy for infiltrative tumors toward a neoadjuvant approach even if they appear resectable., Competing Interests: No competing financial interests exist., (© Muhammad B. Darwish et al., 2022; Published by Mary Ann Liebert, Inc.)

Purpose: To develop a multidisciplinary consensus for high quality multidisciplinary implementation of brachytherapy using Yttrium-90 ( 90 Y) microspheres transarterial radioembolization ( 90 Y TARE) for primary and metastatic cancers in the liver., Methods and Materials: Members of the American Brachytherapy Society (ABS) and colleagues with multidisciplinary expertise in liver tumor therapy formulated guidelines for 90 Y TARE for unresectable primary liver malignancies and unresectable metastatic cancer to the liver. The consensus is provided on the most recent literature and clinical experience., Results: The ABS strongly recommends the use of 90 Y microsphere brachytherapy for the definitive/palliative treatment of unresectable liver cancer when recommended by the multidisciplinary team. A quality management program must be implemented at the start of 90 Y TARE program development and follow-up data should be tracked for efficacy and toxicity. Patient-specific dosimetry optimized for treatment intent is recommended when conducting 90 Y TARE. Implementation in patients on systemic therapy should account for factors that may enhance treatment related toxicity without delaying treatment inappropriately. Further management and salvage therapy options including retreatment with 90 Y TARE should be carefully considered., Conclusions: ABS consensus for implementing a safe 90 Y TARE program for liver cancer in the multidisciplinary setting is presented. It builds on previous guidelines to include recommendations for appropriate implementation based on current literature and practices in experienced centers. Practitioners and cooperative groups are encouraged to use this document as a guide to formulate their clinical practices and to adopt the most recent dose reporting policies that are critical for a unified outcome analysis of future effectiveness studies., Competing Interests: Conflicts of Interest Dr. Sharma received honoraria, research grant, and is a consultant for SIRTEX Medical Inc. Dr. Kappadath received honoraria and research funding from Boston Scientific, SIRTEX Medical, and ABK Biomedical. Dr. Choung received honoraria from SIRTEX Medical Inc. Dr Jabbour is a consultant for Merck & Co Inc; Syntactx, IMX Medical; and has grant funding from the NIH and Merck & Co, Inc. Dr Jeyarajah is a consultant for Angiodynamics, SIRTEX Medical Inc., Ethicon. Dr. Liu is a consultant for SIRTEX Medical Inc, Eisai Pharmaceuticals, and a speaker for Astra Zeneca and Eisa Pharmaceuticals. Dr. Meyer has a research grant and honorarium from Varian Medical Systems. Dr. Mikell has a research grant funding from Varian. Dr. Patel is a consultant to SIRTEX Medical and Medtronic Inc. and a speaker for Boston Scientific. Drs. Folkert, Kennedey, Gibbs, Yang, and Mourtada report no conflict of interest., (Copyright © 2022 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Background: The Americas Hepato-Pancreato-Biliary Association (AHPBA) Education and Training Committee standardized a Hepatopancreatobiliary (HPB) Surgery Fellowship certification process in 2010. Several classes of fellows have since graduated from HPB, combined Society of Surgical Oncology/AHPBA, and combined American Society of Transplant Surgeons/AHPBA fellowships, but there is little information on their career outcomes. We seek to offer long-term data on the careers of HPB fellowship graduates., Methods: A 26-question anonymous survey was distributed among graduates of accredited programs for the last 10 years. We generated descriptive statistics from the responses., Results: The respondents were evenly distributed in terms of graduation years between 2010 and 2019. Fifty-eight percent of fellows had completed a prior fellowship, 82% received 1 to 3 job offers during the fellowship, and 75% of respondents were still at their first job. The majority of graduates (>60%) were able to secure a job with a >50% HPB practice and >40 HPB cases per year within 3 years of graduation. Overall, >90% candidates rated their satisfaction with fellowship training greater than 8 out of 10., Discussion: This survey helps shed light on the early formative years in the practices of HPB fellowship graduates. These data show that HPB fellowship training is essential and effective in providing job security and helps fellowship graduates develop a gratifying practice.

Background: Gender disparities in surgical leadership have come under increased scrutiny, and in order to better understand why these disparities exist, it is important to study the disparities across surgical fellowship programs., Methods: Data derived from the Fellowship Council (FC) database for fellows completing training from academic years 2015-2019 were analyzed. Available information included institution, fellowship type, program director (PD), associate program director (APD), faculty, and fellow names for all FC Fellowships. Faculty and fellow gender were determined from personal knowledge or publicly available online biographical information., Results: A total of 1023 fellows and 221 programs were analyzed. The advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs included 321 fellows, with a small increase in the percentage of female fellows from 28 to 31% over 5 years. Advanced GI/MIS/bariatric fellowship programs had a total of 262 fellows, also with a small increase in the percent of female fellows, from 29 to 38% in the study period. The gender of program directors, assistant program directors, and faculty for the fellowship programs studied were analyzed as well. Of the 221 programs in the Fellowship Council data, 13.6% of program directors, 18.3% of associate program directors, and 19.9% of faculty were female. Advanced GI/MIS fellowship programs had the lowest percentage of female PDs, with only 9.3% of the program directors being female. Colorectal surgery fellowships had the highest percentage of female PDs, with 33% being female., Conclusions: In conclusion, women are underrepresented in gastrointestinal surgery fellowships among both trainees and educators. It is likely that a significant contributing factor to this underrepresentation of female fellows is the underrepresentation of female program directors and faculty; although neither our study nor any previously published study has proven that statistically., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: A formative hepato-pancreato-biliary (HPB) ultrasound (US) skills practicum is offered annually to graduating HPB fellows, using entrustment assessments for open (IOUS) and laparoscopic (LAPUS) US. It is hypothesized that validity evidence will support the use of these assessments to determine if graduating fellows are well prepared to perform HPB US independently., Methods: Expert faculty were surveyed to set Mastery Entrustment standards for fellow performance. Standards were applied to fellow performances during two annual US skills practicums., Results: 11 faculty questionnaires were included. Mean Entrustment cut scores across all items were 4.9/5.0 and 4.8/5.0 and Global Entrustment cut scores were 5.0/5.0 and 4.8/5.0 for IOUS and LAPUS, respectively. 78.5% (29/37) fellows agreed to have their de-identified data evaluated. Mean fellow Entrustments (across all skills) were 4.1 (SD 0.6; 2.6-4.9) and 3.9 (SD 0.7; 2.7-5), while the Global Entrustments were 3.6 (SD 0.8; 2-5) and 3.5 (SD 1.0; 2-5) for IOUS and LAPUS, respectively., Conclusions: Two cohorts of graduating HPB fellows are not meeting Mastery Standards for HPB US performance determined by a panel of expert faculty., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: SARS-CoV-2 has changed global healthcare since the pandemic began in 2020. The safety of minimally invasive surgery (MIS) utilizing insufflation from the standpoint of safety to the operating room personnel is currently being explored. The aims of this guideline are to examine the existing evidence to provide guidance regarding MIS for the patient with, or suspecting of having, the SARS-CoV-2 as well as the healthcare team involved., Methods: Systematic literature reviews were conducted for 2 key questions (KQ) regarding the safety of MIS in the setting of COVID-19 pandemic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. Evidence-based recommendations were formulated using a narrative synthesis of the literature by subject experts. Recommendations for future research were also proposed., Results: In KQ1, a total of 1361 articles were reviewed, with 2 articles meeting inclusion. In KQ2, a total of 977 articles were reviewed, with 4 articles met inclusions criteria, of which 2 studies reported on the SARS-CoV2 virus specifically. Despite many publications in the field, very little well-controlled and unbiased data exist to inform the recommendations. Of that which is available, it shows that both laparoscopic and open operations in Covid-positive patients had similar rates of OR staff positivity rates; however, patients who underwent laparoscopic procedures had a lower perioperative mortality than open procedures. Also, SARS-CoV-2 particles have been detected in the surgical plume at laparoscopy., Conclusion: With demonstrated equivalence of operating room staff exposure, and noninferiority of laparoscopic access with respect to mortality, either laparoscopic or open approaches to abdominal operations may be used in patients with SARS-CoV-2. Measures should be employed for all laparoscopic or open cases to prevent exposure of operating room staff to the surgical plume, as virus can be present in this plume., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Duodenal adenomas are pre-malignant lesions. Transduodenal resection and pancreaticoduodenectomy remain the only two surgical options. The optimal surgical management remains controversial between these two strategies., Methods: A retrospective review was conducted to identify patients who underwent intervention for duodenal adenomas. Patient were stratified by type of procedure, pancreaticoduodenectomy or transduodenal resection, and their demographic data as well as perioperative outcomes were compared., Results: 26 patients underwent surgery for duodenal adenomas. 11 underwent a pancreaticoduodenectomy (PD) (42.3%) and 15 underwent a transduodenal resection (TDR) (57.7%). Median operative time, median estimated blood loss, and mean length of stay were longer in the PD vs TDR group. Two patients (13.3%) in the TDR group developed recurrent adenomas., Conclusion: Transduodenal resection should be considered in patients who are suspected to harbor benign duodenal tumors. Duodenal tumors with high grade dysplasia or invasive cancer should undergo an oncologic procedure. Endoscopic surveillance appears to be indicated after transduodenal resection., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors.)

Background: The Whipple procedure in its current form owes its evolution to the groundbreaking and innovative work of giants in the field of surgery. From being a multistep procedure with high morbidity and mortality, it is now ubiquitously performed in a single setting, often offered via minimally invasive approaches. Training to perform this procedure is an arduous task, and different training paradigms vary significantly., Objectives/methods: The purpose of this paper is to share a standard method by which the surgeon can perform the Whipple procedure in a systematic manner. Using illustrations to make the steps clearer, the authors will postulate that an improvement in mean operative time can be realistically achieved by most pancreatic surgeons. The focus is also on presenting this complex procedure as reproducible and teachable techniques for trainees., Conclusion: This illustrated review of the Whipple procedure as performed at our institution is intended to help facilitate a streamlined and stepwise progression through what is undoubtedly a challenging surgical procedure. Although the procedure described will not apply to all Whipple operations given the heterogeneity in anatomy and circumstances, our hope is that this will lead to a more efficient procedure and decreased operating room time and costs as well as provide a framework to teach and measure technical progress for surgical trainees., (© 2021 Published by Elsevier Inc.)

The management of colorectal liver metastasis (CRLM) is complicated and benefits from a multidisciplinary team approach. Liver-directed therapy has been emerging as a modality for better progression-free control. In its early years, selective internal radiation therapy (SIRT) with yttrium-90 (Y-90) was confined as an end-of-line therapy. However, literature has supported other roles including: a first-line treatment for CRLM alone or in combination with systemic chemotherapy; an adjunct to second or third-line chemotherapy; and a salvage treatment for chemo-refractory disease. Although future liver remnant (FLR) hypertrophy may take 3-12 months, the SIRT effect on loco-regional disease control has rendered it to be a useful tool in some pathologies with certain strategic goals. This paper reviews the use of SIRT with Y-90 in a surgical treatment pathway. This includes: (I) an element of multidisciplinary treatment of low-volume CRLMs, (II) convert an R1 to R0 resection by sterilizing the margins of tumor near critical structures, and (III) radiation lobectomy to induce contralateral hypertrophy in order to aid in a safer resection. There are many opportunities to validate the role of SIRT as a first-line therapy along with surgical resection including an umbrella clinical trial design., Competing Interests: Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jgo-21-96). Dr. DRJ serves as a consultant for SIRTEX, Ethicon and Angiodynamics. Dr. MAM has no conflicts of interest to declare., (2021 Journal of Gastrointestinal Oncology. All rights reserved.)

Background and Objectives: The primary aim of this study is to assess the necessity of fundoplication for reflux in patients undergoing Heller myotomy for achalasia. The secondary aim is to assess the safety of the robotic approach to Heller myotomy., Methods: This is a single institution, retrospective analysis of 61 patients who underwent robotic Heller myotomy with or without fundoplication over a 4-year period (January 1, 2015 - December 31, 2019). Symptoms were evaluated using pre-operative and postoperative Eckardt scores at < 2 weeks (short-term) and 4 - 55 months (long-term) postoperatively. Incidence of gastroesophageal reflux and use of antacids postoperatively were assessed. Long-term patient satisfaction and quality of life (QOL) were assessed with a phone survey. Finally, the perioperative safety profile of robotic Heller myotomy was evaluated., Results: The long-term average Eckardt score in patients undergoing Heller myotomy without fundoplication was notably lower than in patients with a fundoplication (0.72 vs 2.44). Gastroesophageal reflux rates were lower in patient without a fundoplication (16.0% vs 33.3%). Additionally, dysphagia rates were lower in patients without a fundoplication (32.0% vs 44.4%). Only 34.8% (8/25) of patients without fundoplication continued use of antacids in the long-term. There were no mortalities and a 4.2% complication rate with two delayed leaks., Conclusion: Robotic Heller myotomy without fundoplication is safe and effective for achalasia. The rate of reflux symptoms and overall Eckardt scores were low postoperatively. Great patient satisfaction and QOL were observed in the long term. Our results suggest that fundoplication is unnecessary when performing Heller myotomy., Competing Interests: Conflict of interests: none., (© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons.)

Objective: The goal of the 1-year Advanced Gastrointestinal (AGI) surgery fellowship is to train the general surgeon to perform advanced and complex operations that they had insufficient experience with in residency training. This study examines the case logs of AGI fellows that have completed Society for Surgery of the Alimentary Tract (SSAT)-sponsored Fellowship Council (FC)-accredited AGI fellowships to determine the role of these fellowships in providing complex gastrointestinal operative experience., Design/participants: Institutional Review Board-approved retrospective surgical case log analysis. Case logs of 60 AGI fellows in 12 different AGI fellowships from 2014 to 2019 were requested by the SSAT and provided in a de-identified format from the FC. Cases were categorized as colorectal surgery, anus, hernia-abdomen, hernia inguinal, esophagus-hiatal hernia, esophagus-Heller, pancreas, liver, bile duct, diagnostic/therapeutic esophagogastroduodenoscopy (EGD), diagnostic/therapeutic colonoscopy, thoracic esophagus, thoracic lung, spleen, thyroid, diaphragm, gastric, abdomen, adrenal/kidney, bariatric, diagnostic/therapeutic bronchoscopy, kidney/liver/pancreas transplant, and trauma., Results: AGI fellows performed a mean of 345 cases per year (range: 184-558). Our results showed that 5 programs provided >30 colorectal cases, 6 provided >50 hernia (hernia-abdomen and hernia-inguinal) cases, 8 provided >25 hiatal hernia cases, 2 provided >100 endoscopy cases (diagnostic/therapeutic EGD and diagnostic/therapeutic colonoscopy), 6 provided >30 gastric cases, 3 provided >100 bariatric cases, 6 provided >10 pancreas cases, 3 provided >10 liver cases, and 4 provided >6 biliary cases., Conclusion: SSAT-sponsored FC-accredited AGI fellowship programs provide a wide array of training in complex gastrointestinal surgeries. Most programs provide broad training in hiatal work, colorectal surgery, hepato-pancreato-biliary surgery, and abdominal wall reconstruction. This FC-accredited AGI training paradigm prepares trainees for broad-based complex abdominal surgery, an area that is sorely needed to augment insufficient experience in many general surgical training programs., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The use of neoadjuvant pelvic radiotherapy was a major advance in oncologic care for locally advanced rectal cancer in the twentieth century. The extrapolation of the care of locally advanced rectal cancer to the management of rectal cancer with treatable liver metastases is controversial. The aim of this review is to examine the available data on the role of pelvic radiotherapy and chemoradiation in the setting of treatable metastatic liver disease., Methods: A systematic search of MEDLINE was performed to report the landmark randomized controlled trials between 1993 and 2021., Results: Attaining liver clearance and total mesorectal excision with R0 margin remains the mainstay of cure. There is uncertainty regarding the sequencing of treatment. The literature lacks randomized clinical trials comparing the rectal first, liver first, interval strategy, and simultaneous surgical approaches. A multidisciplinary discussion regarding the utility of radiotherapy is emphasized to achieve the goals of treatment. Short-course radiotherapy has proved comparable disease-control outcomes to long-course chemoradiation with a significantly improved cost-performance. The implementation of short-course radiotherapy in the interval strategy and simultaneous surgical approach is promising. Neoadjuvant pelvic radiotherapy can be omitted in patients with metastatic rectal cancer if adequate margin clearance is achievable., Conclusion: The use of radiotherapy in metastatic rectal cancer is popular but is based on limited data. Treatment should be tailored to the local extent of rectal cancer and priority of liver metastasis management. The optimal treatment strategy in patients with rectal cancer and synchronous liver metastatic disease needs to be studied in randomized trials., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background: Selection biases affecting candidate matches to fellowship programs directly influence diversity within the surgical community. The review of selection bias has never been distinctively investigated in the Hepatopancreatobiliary (HPB) surgery community. This study seeks to (i) evaluate factors affecting selection of candidates to HPB fellowships, (ii) examine explicit biases among program directors and faculty of HPB programs in North America, and (iii) compare the demography of the HPB faculty and recently graduated fellows to general surgery residents., Study Design: An anonymous, self-reported survey consisting of 10 sets of fictional applications was distributed to 52 faculty members, including program directors, of AHPBA-affiliated HPB fellowships in North America. The respondents had to pick a preferred candidate between two abridged, fictional HPB fellow applications and give an open-ended response as to why they picked that candidate. The applications were nearly identical with one notable characteristic of interest. Demographic information of both faculty and their recent fellows was also collected. This survey was administered and collected between February and April, 2020., Results: A total of 29 fully completed responses were received, comprising a 55.7% response rate. Respondents were 72.4% male, 69.0% Caucasian, and 79.3% held US medical degrees (MD). 50.0% of respondents preferred an MD candidate to a DO candidate, and 37% preferred US graduates to foreign-trained candidates. The respondents were unanimous in stating that gender, race, and family status were not a factor in their selection process. 5.0% said they would support an LGBTQ candidate when faced with otherwise similar applicants. Seventy-six HPB fellows from the past 5 years were 76.3% male, 56.6% Caucasian, and 51.3% US graduated Doctor of Medicine (US MD)., Conclusion: This is the first study explicitly exploring the impact of demographic factors in the HPB fellowship selection process. The respondents unanimously and explicitly stated that race and gender do not play any role in their selection process. Yet, there is stark discordance between general surgery resident demographics and HPB fellow demographics. A greater effort to promote a more diverse HPB surgery community may be needed.

Hepato-pancreatico-biliary (HPB) surgery, and the training of HPB surgeons, has evolved significantly over the last several decades. The current state of training in HPB surgery in North America is defined through three main pathways: the Complex General Surgical Oncology (CGSO) ACGME fellowship, the American Society of Transplant Surgeons (ASTS) fellowship, and the Americas Hepatopancreaticobiliary Association (AHPBA) fellowship. These fellowships offer variable experiences in pancreas, liver, and biliary cases, and each pathway offers a unique perspective on HPB surgery. The CGSO ACGME, ASTS, and AHPBA fellowships represent decades of work by the three major surgical leadership stakeholders to improve and ensure quality training of future HPB surgeons. The best care is provided by the HPB surgeon who has been trained to understand the importance of all available treatment options within the context of a multidisciplinary setting. The three fellowship pathways are outlined in this paper with the nuances and variations characteristic of the different training programs highlighted., (© 2021. The Society for Surgery of the Alimentary Tract.)

Purpose: 68Ga-DOTATATE PET is becoming a popular imaging technique for detecting neuroendocrine tumors (NETs). The sensitivity and specificity of 68Ga-DOTATATE PET compared to standard cross-sectional imaging with triple phase CT or MRI with Eovist has not been studied extensively., Methods: 68Ga-DOTATATE PET scans ordered at our institution between 11/2017 and 7/2018 were reviewed. Patients with evidence of liver metastases were sorted and cross-sectional imaging results were reviewed. Specifically, the number of lesions detected by standard cross-sectional imaging versus 68Ga-DOTATATE PET was compared., Results: 32 patients with 68Ga-DOTATATE PET scans and a corresponding MRI or CT were identified. Primary tumors were pancreatic (43.8%), small bowel (25%), hepatic (9.4%), gastric (6.3%), appendiceal (3.1%), and not localized (12.5%). 26/32 (81%) patients had CT scans and 17/32 (53%) had MRI scans. 25/32 (78%) patients had at least equal or increased number of lesions identified on 68Ga-DOTATATE PET when compared with CT or MRI. 7/32 (21.9%) had fewer lesions on 68Ga-DOTATATE PET compared to CT or MRI. However, 3 of these cases had numerous liver lesions. The overall sensitivity and specificity of 68Ga-DOTATATE PET are 92.9% and 75% respectively., Conclusion: 68Ga-DOTATATE PET appears to have superior sensitivity in detecting metastatic NET to the liver. Further studies are needed to determine if it should be considered the test of choice for evaluating patients with metastatic NET to the liver. While standard cross-sectional imaging will be needed for surgical planning, 68Ga-DOTATATE PET will identify lesions that may not be seen on other imaging modalities.

Background/objective: Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single-surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results' implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery., Study Design: This is a retrospective case series of a prospectively maintained database at a non-university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020., Results: Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93 min, respectively. No statistical significance was noted for estimated blood loss or length of stay., Conclusions: Robotic HPB procedures have significantly higher learning curves compared to non-HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non-HPB robotic surgeries with a shorter learning curve-especially foregut procedures such as RHM-into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

Introduction: Several pathophysiologic changes after the Whipple procedure have been well described, but anemia has not. Post-surgical changes can impede micronutrient absorption. We hypothesize that patients post-pancreatoduodenectomy suffer from iron deficiency anemia., Methods: Patients who underwent a pancreatoduodenectomy from 2016 to 2018 were retrospectively evaluated. Preoperative, intraoperative, and postoperative data, including hemoglobin (Hb) levels and mean corpuscular volume (MCV) as well as therapies with chemoradiation, iron, and/or B12 were collected at 1-, 3-, 6-, and 12-months after surgery., Results: The dataset included 74 patients (median age: 64 years). Mean preoperative Hb and MCV were 11.7 ± 1.9 g/dl and 90.1 ± 7.3 fl, respectively. Significant changes in Hb were noted at 1 and 6 months (11.7 vs 10.9, p = 0.01 and 11.7 vs 11.3, p = 0.003, respectively), and in MCV were noted at 6 and 12 months (90.1 vs 94.6, p = 0.008 and 90.1 vs. 93.7, p = 0.02, respectively)., Conclusions: All patients remained anemic after pancreatoduodenectomy. This was not linked to chemotherapy. Iron and vitamin B12 supplementation, given in a minority, did not ameliorate the anemia. Future studies should investigate this lack of aid, as nutrient supplementation may be an important change in the standard of care of these patients.

Objective: The purpose of this study is to identify perceptions of academic surgeons regarding academic productivity and assess its relationship to clinical productivity. We hypothesized that these perceptions would vary based on respondent characteristics including clinical activity and leadership roles., Design: This retrospective, survey-based study was performed from August 26, 2019 to September 26, 2019., Setting: The setting was academic surgical departments across the US., Participants: The survey instrument was administered to faculty members of the Association of Program Directors in Surgery. A total of 105 academic surgeons responded., Results: Most respondents were Program Directors (59%) of general surgery programs. Of the participants, 30% identified as Professor, 36% as Associate Professor, and 15% as Assistant Professor. Respondents agreed that multiple academic pursuits or factors should count towards academic productivity including the following (in descending order): completing a first-authored manuscript (98.8%), completing a senior-authored manuscript (97.7%), chairing a national committee (94.1%), serving on a national committee (88.2%), completing a second-authored manuscript (88.0%), completing a first lecture (83.7%), completing a middle-authored manuscript (71.8%), completing a lecture (whether or not repeated) (70.9%), impact factor of journal (60.7%), and attendance at grand rounds (57.0%). Perspectives did not vary significantly based on surgeon demographics, clinical setting, or leadership role (p > 0.05)., Conclusions: Perceptions regarding what constitutes academic productivity and merit a reduction in clinical expectation are remarkably similar across multiple surgeon characteristics including demographics, academic title, leadership role, and practice environment., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)