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ImportanceCharacteristics of outstanding graduating surgical residents are currently undefined. Identifying these qualities may be important in guiding resident selection and resident education.ObjectiveTo determine characteristics that are most strongly associated with being rated as an outstanding graduating surgical resident.Design, Setting, and ParticipantsThe multi-institutional study had 3 phases. First, an expert panel developed a list of characteristics embodied by top graduating surgical residents. Second, groups of faculty from 14 US general-surgery residency programs ranked 2017 through 2020 graduates into quartiles of overall performance. Third, faculty evaluated their graduates on each characteristic using a 5-point Likert scale. Data were analyzed using Spearman rank-order correlation to identify which individual characteristics were associated with overall graduate performance. A least absolute shrinkage and selection operator (LASSO) ordinal regression was performed to select a parsimonious model to predict the outcome of overall performance rating from individual characteristic scores.Main Outcome and MeasuresSurgical educators’ rankings of general surgery residency graduates’ overall performance.ResultsFifty faculty from 14 US residency programs with a median of 13 (range, 5-30) years of surgical education experience evaluated 297 general surgery residency graduates. Surgical educators identified 21 characteristics that they believed outstanding graduating surgical residents possessed. Two hundred ninety-seven surgical residency graduates were evaluated. Higher scores in every characteristic correlated with better overall performance. Characteristics most strongly associated with higher overall performance scores were surgical judgment (r = 0.728; P r = 0.726; P r = 0.715; P r = 0.707; P Conclusions and RelevanceAll individual characteristics identified by surgical educators as being qualities of outstanding graduating surgical residents were positively associated with overall graduate performance. Surgical judgment and leadership skills had the strongest individual associations. Assessment of only 3 qualities (surgical judgment, leadership, and medical knowledge) were required to predict overall resident performance ratings. These findings highlight the importance of developing specific surgical judgment and leadership skills curricula and assessments during surgical residency.

Background Consensus on the best surgical strategy for the management of synchronous colorectal liver metastases (sCRLM) has not been achieved. This study aimed to assess the attitudes of surgeons involved in the treatment of sCRLM. Methods Surveys designed for colorectal, hepato-pancreato-biliary (HPB), and general surgeons were disseminated through representative societies. Subgroup analyses were performed to compare responses between specialties and continents. Results Overall, 270 surgeons (57 colorectal, 100 HPB and 113 general surgeons) responded. Specialist surgeons more frequently utilized minimally invasive surgery (MIS) than general surgeons for colon (94.8% vs. 71.7%, p p p = 0.005). In patients with an asymptomatic primary, the liver-first two-stage approach was preferred in most respondents’ centres (59.3%), while the colorectal-first approach was preferred in Oceania (83.3%) and Asia (63.4%). A substantial proportion of the respondents (72.6%) had personal experience with minimally invasive simultaneous resections, and an expanding role for this procedure was foreseen (92.6%), while more evidence was desired (89.6%). Respondents were more reluctant to combine a hepatectomy with low anterior (76.3%) and abdominoperineal resections (73.3%), compared to right (94.4%) and left hemicolectomies (90.7%). Colorectal surgeons were less inclined to combine right or left hemicolectomies with a major hepatectomy than HPB and general surgeons (right: 22.8% vs. 50% and 44.2%, p = 0.008; left: 14% vs. 34% and 35.4%, p = 0.002, respectively). Conclusion The clinical practices and viewpoints on the management of sCRLM differ between continents, and between and within surgical specialties. However, there appears to be consensus on a growing role for MIS and a need for evidence-based input. Graphical abstract

Background: Major bile duct injuries (BDIs) are hazardous complications after laparoscopic cholecystectomy (0.4%-0.6% of all laparoscopic cholecystectomies) [1, 2-4]. Major BDIs usually require surgery, ideally either within one week or after 3 three months after index surgery [1]. We describe the case of iatrogenic transection of the common bile duct (CBD) complicated by a complex full midline abdominal evisceration presented on day 12 after emergency laparotomy for biliary peritonitis. Case Presentation: A 65-year-old male underwent laparoscopic cholecystectomy in a district general hospital and was discharged on the same day, following apparently uneventful surgery. He, however, re-presented two days later with biliary peritonitis when emergency ERCP showed full CBD transection. The local surgical team performed midline exploratory laparotomy, washout, and external drainage aside the leaking CBD and referred the case to our tertiary HPB service. While awaiting transfer (due to bed shortage), full wound dehiscence occurred. On transfer arrival at our HPB service on postoperative day 11, the patient presented extensive evisceration with loss of domain and persisting high-volume biliary spillage aside bowels. Following assessment and fast literature review, we considered operation undeferrable and planned multi-stage surgeries, including primary Roux-en-Y hepaticojejunostomy (HJ) and progressive abdominal wall closure in multiple sessions under general anaesthesia, aided by vacuum-assisted wound closure and intraperitoneally mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh. Discussion and Conclusion: The complexity of our case lies in the coexistence of 2-weeks biliary peritonitis following early BDI with massive midline evisceration, in combination, both representing over 40% mortality risk, requiring immediate, simultaneous repair. Roux-en-Y HJ and VAWCM have proven safe and effective.

Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk.We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh.The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.

The operative technique for Spigelian hernia (SH) continues to evolve over the last few decades. The primary endpoint of this systematic review was to evaluate the evolution of surgical technique for the management of SH in adults, and to identify the optimum technique for easy identification of anatomical landmarks. The secondary outcome was to evaluate the operative management of bilateral SH. A systematic search using Cochrane, Medline, and Google Scholar databases was performed to identify all studies from 1989 to 2019 investigating the management of SH. Of 535 articles identified, 29 studies reporting on 619 patients (389 open repair and 230 laparoscopic repair) were included, out of which 25 studies (469 patients) described complication and recurrence rate. Five additional studies reporting on five patients with bilateral SH were identified for a total of 19 cases (3.1%) of bilateral SH. There has been a gradual transition from open to laparoscopic SH repair over the last three decades. Overall complication and recurrence rates after SH repair were 5.5% and 2.8% respectively, with higher rates in open repair (complication 7.7% and recurrence 4.2%). The laparoscopic transabdominal preperitoneal repair (TAPP) has the lowest recurrence and complication rate reported in the literature. The choice of SH repair should be based on the need for abdominal wall reconstruction, any associated intra-abdominal pathology, and the experience of the surgeon. Laparoscopic TAPP with mesh appears to have the lowest complication and recurrence rate.

Liver venous deprivation (LVD) is an emerging, minimally invasive strategy to induce rapid liver hypertrophy of the future liver remnant (FLR) before a major hepatectomy. LVD (aka “double vein embolization”) entails same-session percutaneous embolization of the portal and hepatic veins of the planned liver resection. This report discusses LVD’s utilization and technical challenges in managing a 49-year-old male with recurrent multifocal colorectal liver metastases (CRLM). The patient initially underwent neoadjuvant FOLFOX chemotherapy followed by a simultaneous laparoscopic sigmoid colectomy and liver surgery (microwave ablation of segment V and wedge resections of segment one and IVb), followed by completion of chemotherapy. The patient had an R0 resection with clear colon and liver surgical margins. Nine months after the initial surgery, the patient had a rise in tumor markers, and surveillance imaging demonstrated recurrence of liver metastases in segments I and V. LVD was performed by interventional radiology, which led to a 28% increase in FLR (segments II, III, and IV); initially measuring 464 cm3 before LVD and measuring 594 cm3 on post-procedure day 21. The patient underwent right hemi-hepatectomy and caudate resection on post-procedure day 29. The patient did not have any complications and was discharged on postoperative day 6. The patient remains disease-free with no evidence of recurrence at 12 months follow-up.

e16228 Background: Previous data have established that patients with pancreatic surgical specimens showing lymphovascular invasion (LVI) and positive surgical resection margins are associated with poor survival outcomes. However, there are no biomarkers to identify these high-risk patients preoperatively. In this study, we hypothesized that increased carbohydrate antigen 19-9 (CA 19-9) levels could be used to predict high-risk resectable pancreatic cancer features, including LVI and positive residual margins, thereby guiding the surgical decision-making process. Methods: We sampled the National Cancer Database for patients undergoing pancreatic cancer resection between 2004-2018. Logistic regression analysis was performed to analyze sociodemographic and disease characteristics associated with elevated CA 19-9 levels (> 98 U/ml) versus low CA 19-9 levels (< 98 U/ml). Additionally, Cox regression analyses were used to compare hazard ratios for demographic and disease characteristics. A p < 0.05 was considered statistically significant. Results: 12208 patients (50.76% males) with pancreatic cancer were sampled. Pathological findings of LVI (n = 5963), microscopic residual tumor margins (R1) (n = 1547), and residual margins (R), not otherwise specified (NOS) (n = 885) had a stronger association with high preoperative CA 19-9 levels when compared to those with low CA 19-9 levels (LVI: OR 1.212, 95% CI 1.125–1.305, p < 0.001, R1: OR 1.260, 95% CI 1.129–1.408, p = 0.001 and R NOS: OR 1.212, 95% CI 1.052–1.395, p = 0.008). Macroscopic residual margins (R2) (n = 85) were also associated with high CA 19-9 but statistically not significant (OR 1.242, 95% CI 0.802–1.924, p = 0.332) probably due to the low sample size for this subpopulation. Furthermore, all the factors listed below were independently associated with poor prognosis: (A) Elevated CA 19-9 levels: HR 1.411, 95% CI 1.350–1.475, p < 0.001, (B) LVI: HR 1.333, 95% CI 1.275–1.394, p < 0.001, (C) R NOS: HR = 1.517, 95% CI = 1.401–1.643, p < 0.001, (D) R1: HR 1.594, 95% CI 1.499–1.695, p < 0.001, (E) R2: HR 2.015, 95% CI 1.597–2.543, p < 0.001. Conclusions: Elevated CA 19-9 can be used as a biomarker to identify a subset of pancreatic cancer patients with high-risk surgical pathological features such as LVI or residual tumor margins. In these patients, perhaps neoadjuvant chemotherapy can facilitate downstaging and provide superior surgical and oncological outcomes.

Contrast in fluorescence microscopy images allows for the differentiation between different structures by their difference in intensities. However, factors such as point-spread function and noise may reduce it, affecting its interpretability. We identified that fluctuation of emitters in a stack of images can be exploited to achieve increased contrast when compared to the average and Richardson-Lucy deconvolution. We tested our methods on four increasingly challenging samples including tissue, in which case results were comparable to the ones obtained by structured illumination microscopy in terms of contrast.

Tocilizumab, a monoclonal antiinterluekin-6 receptor antibody, has been empirically used in the treatment of cytokine release syndrome associated with severe coronavirus disease 2019 infections. The efficacy and safety of these medications for these patients is unknown. The purpose of this report was to present a case of acute large bowel perforation in a morbidly obese patient with coronavirus disease 2019 pneumonia who received empiric Tocilizumab. This case report analyzes the risks of acute large bowel perforation after using this medication empirically and discusses the appropriate management of this adverse event.

This chapter discusses technical aspects of laparoscopic pancreaticoduodenectomy (Whipple procedure), including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of laparoscopic unroofing of hepatic cyst, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of laparoscopic right hepatectomy, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

Fluorescence imaging of the biliary tree with indocyanine green (ICG) during gallbladder surgery is slowly becoming a routine practice amongst surgeons around the world. Some of the unique advantages offered by near-infrared fluorescent (NIFR) cholangiography have made it a valuable tool for general surgeons. Low cost and the ability to operate in real time with NIFR cholangiography give this technique an edge over intraoperative cholangiography. The indications for its use continue to increase, though the appropriate dose and timing of injection of ICG continue to be debated and researched amongst clinicians. However, multiple studies, including a randomized control trial, have demonstrated improved biliary imaging with a potential to reduce bile duct injury with the technique.

This chapter discusses technical aspects of laparoscopic pancreatic cystogastrostomy, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

Mental training is defined as the cognitive rehearsal of a task in the absence of overt physical movement, in which the systematic use of mental imagery is used to rehearse an action or skill symbolically without any physical movement. This technique results in an activation of similar neural pathways to those used in the actual physical activity.

This chapter discusses technical aspects of open pancreatoduodenectomy (Whipple procedure), including instrumentation and equipment, patient positioning, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of open longitudinal pancreaticojejunostomy, including instrumentation and equipment, patient positioning, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of laparoscopic distal pancreatectomy with splenectomy, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of laparoscopic central pancreatectomy, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of laparoscopic left hepatectomy, including instrumentation and equipment, patient positioning and trocar placement, and surgical steps. The authors also offer pearls and pitfalls.

This chapter discusses technical aspects of open distal pancreatectomy with splenectomy, including instrumentation and equipment, patient positioning, and surgical steps. The authors also offer pearls and pitfalls.

Surgical training has changed at a rapid rate over the last few decades. Introduction of minimally invasive surgery has bought new dimensions but simultaneously has introduced new challenges, including tactile feedback, haptics, and two-dimensional vision. Surgical training has moved toward competency-based assessment both outside and inside the operating room. Several standard-setting, competency-based curricula focusing on cognitive knowledge, surgical skills, and nontechnical skills have been launched.

Ureters can be accidentally severed during pelvic surgeries, significantly prolonging the times in the operating room to allow for complete repair of damaged ureters and leading to significant morbidities associated with consequent ureter obstruction and possible kidney dysfunction. In an effort to prevent these complications, light-emitting stents and urine-excreted dyes have been introduced to illuminate the ureter during surgery. However, problems with mechanical insertion, ureter spasm, image contrast, and localized injection have limited interest in their clinical applications. We report here the synthesis and characterization of a new near-infrared (NIR) fluorescent dye (UreterGlow) that can be injected systemically but is excreted primarily through the renal system, allowing ureter imaging with an NIR fluorescence camera. Following intravenous injection of 0.1 mg/kg UreterGlow, we have monitored the flow of UreterGlow through the proximal, medial, and distal segments of the ureter. The timing of ureter visualization was calculated from the time of injection of the drug. The null hypothesis was that "Visualization of the ureter in pigs is possible 60 min after administration of UreterGlow using an NIR camera". UreterGlow displayed excitation and emission maxima of λex = 800 nm and λem = 830 nm in phosphate buffered saline, pH 7.4, and could be imaged in the urinary tract in mice. Shortly after injection of UreterGlow into Yorkshire pigs, peristalsis of the ureter could be observed. The distal ureter could be visualized under NIR illumination after 60 min with constant fluorescence in all five pigs for >2 h. The same ureters could not be seen using visible light ( X2, p = 0.0001). Because both excitation and emission of UreterGlow occurs at >30 nm longer wavelength than most tumor-imaging fluorescent dyes, it should be possible to distinguish ureter fluorescence from tumor fluorescence with this dye.

p53 protein coded by the Tp53 gene is considered as one of the most intensively researched protein and mainly due to its role as a tumor suppressor, it acts as a tumor suppressor by carrying out two biologically complex processes namely Cell cycle arrest and apoptosis, In the oncogenic Y220C mutant p53, tyrosine is replaced by cysteine at 220th residue of the DNA binding Domain which causes the formation of a surface crevice, this specific mutation is responsible for approx. 100,000 cancer cases per year due to the destabilization and denaturation of the protein, as a result, the protein degrades at room temperature. In this work we carry out intensive Molecular Dynamic Simulations and Molecular Docking Studies to understand the structural dynamics of wild type p53 and changes the occurs in the mutant protein and also try to design lead against the druggable crevice and at the end of our study we used fragment-based optimization to come up with lead molecules which can act as scaffold for further drug development process

OBJECTIVE: To evaluate the factors affecting the length of hospital stay (LOS) after percutaneous transhepatic biliary drainage (PTBD). METHODS: A retrospective review of all patients who had undergone PTBD with or without stenting at a UK specialist centre between 2005 and 2016 was conducted. RESULTS: 692 patients underwent 1976 procedures over 731 clinical episodes for which, the median age was 65 (range 18–100) years, and the median Charlson Index was 3. PTBD was performed for malignant (n = 563) and benign strictures (n = 60), stones (n = 62), and bile leaks (n = 46). The median LOS was 13 (range 0–157) days, and the median interprocedure duration was 9 (range 0–304) days. The median number of procedures per patient was 2 and the median number of days required to complete a set of procedures for a patient (TBID) ranged from 0 to 557 days, with a median of 16 (interquartile range: 8–32) days. Patients with biliary leak had the highest LOS. Biliary stents were mostly placed at the second stage at a median of 6 (range 0–120) days from the first procedure day. Placement of a biliary stent in the first stage of the procedure was associated with shorter LOS (p < 0.001). CONCLUSIONS: Biliary stenting at index procedure reduces LOS, although it is not always technically possible. Patients with bile leak managed with PTBD have longer LOS. ADVANCES IN KNOWLEDGE: This study provides data which can help in appropriate consenting, better planning, and efficient resource utilization for patients undergoing PTBD.

Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC. An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th International Congress of Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices. Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution’s laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit. Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.

Supplemental material, Appendix1 for Smartphone Application as an Education Platform in Hepato-Pancreato-Biliary Surgery by Mayank Roy, Fernando Dip, Armando Rosales, Matthew Roche and Robert R. Hutchins in Surgical Innovation

The digital world has opened up a new realm of involvement for people from ages eight to eighty. Online social media and news articles are both vital parts of the modern digital world, where users tend to spend most of their time. Users post comments in online social platforms on various topics and create user engagement through discussions and conversations with other users on a topic in the online platform. User engagement is one of the most important revenue factors of online publishing houses. But, discussion and conversational flow of the topic tends to change and even drift to out-of-topic contexts as different users post in these social platforms. Topic drift can have a significant effect on future user engagement in terms of ‘comments' or ‘likes' and subsequently the revenue metric. In one direction, topic drift towards a totally different area may significantly reduce future user engagement on that article but on the other hand topic drift towards any ‘controversial’ or ‘hot’ topic in that particular time frame can increase future engagement. Thus topic drift is an important phenomena in the online world. In this paper, our aim is to identify how topic flow changes and explore the various characteristics of topic drift and user behavior in online forums.

Desmoplastic small round cell tumor (DSRCT) is a rare mesenchymal tumor usually affecting young patients. Local dissemination is common, and liver is the most common site for extraperitoneal metastases. Multimodal management has been shown to be the most effective treatment. Some authors consider liver metastases especially bi-lobar disease as a contraindication for surgical resection. We present a case of a DSRCT with bi-lobar metastases in an adult patient who underwent multi-modal management along with hepatectomy. A 51-year-old man was found to have a large intraperitoneal mass with bi-lobar liver metastases during work up for new onset reflux and abdominal pain. Biopsy confirmed it as DSRCT. The patient was treated with multi-modal therapy including cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), two-stage hepatectomy (TSHP) combined with (90Y) Yittrium-90 radioembolization of the right hepatic lobe and systemic chemotherapy. The patient had a right-sided pleural empyema one month after the surgery for which he required right-sided video-assisted thoracoscopy and decortication. He remains disease free at 2 years follow-up. DSRCT with bi-lobar liver metastases are best managed with multimodal therapy. TSHP seems to be a feasible and safe option in selected cases, with a potentially good outcome.