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Background: Use of artificial intelligence to generate personal statements for residency is currently not permitted but is difficult to monitor. This study sought to evaluate the ability of surgical residency application reviewers to identify artificial intelligence-generated personal statements and to understand perceptions of this practice., Methods: Three personal statements were generated using ChatGPT, and 3 were written by medical students who previously matched into surgery residency. Blinded participants at a single institution were instructed to read all personal statements and identify which were generated by artificial intelligence; they then completed a survey exploring their opinions regarding artificial intelligence use., Results: Of the 30 participants, 50% were faculty (n = 15) and 50% were residents (n = 15). Overall, experience ranged from 0 to 20 years (median, 2 years; interquartile range, 1-6.25 years). Artificial intelligence-derived personal statements were identified correctly only 59% of the time, with 3 (10%) participants identifying all the artificial intelligence-derived personal statements correctly. Artificial intelligence-generated personal statements were labeled as the best 60% of the time and the worst 43.3% of the time. When asked whether artificial intelligence use should be allowed in personal statements writing, 66.7% (n = 20) said no and 30% (n = 9) said yes. When asked if the use of artificial intelligence would impact their opinion of an applicant, 80% (n = 24) said yes, and 20% (n = 6) said no. When survey questions and ability to identify artificial intelligence-generated personal statements were evaluated by faculty/resident status and experience, no differences were noted (P > .05)., Conclusion: This study shows that surgical faculty and residents cannot reliably identify artificial intelligence-generated personal statements and that concerns exist regarding the impact of artificial intelligence on the application process., Competing Interests: Conflict of Interest/Disclosure The authors have no relevant financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Surgery is the mainstay of therapy for thyroid cancer. A rising number of patients decline recommended surgical intervention. This study aimed to identify factors associated with the decision to decline surgery for well-differentiated thyroid cancer., Methods: Patients with papillary or follicular thyroid cancer diagnosed between 2004 and 2017 were identified from the National Cancer Database. Patients were grouped based on patient-documented refusal of recommended surgery and patients who successfully completed surgery. Baseline characteristic comparison, univariable and multivariable logistic regression, and survival analyses were performed., Results: A total of 221,664 patients met inclusion criteria: 565 (0.3%) patients declined and 221,099 (99.7%) underwent recommended surgery. Patients who declined surgery were older, male, Black or Asian, and not privately insured. They more frequently had Charlson-Deyo scores ≥3, were diagnosed at academic centers, and presented with larger tumors and advanced clinical stage. Multivariable modeling demonstrated that older age, Black or Asian race, diagnosis at an academic center, no insurance or lack of private insurance, clinical N stage ≥1a, and clinical M stage >0 were associated with higher odds of declining surgery (P < .001). A mean survival of 10 years was found among patients who declined surgery versus 16 years among patients who underwent surgery (P < .0001)., Conclusion: Most patients diagnosed with well-differentiated thyroid cancer undergo physician-recommended surgical intervention. Declining surgery is associated with worse overall survival and is more likely in older, male, Black, or Asian patients with socioeconomic disadvantage. This study underscores the importance of understanding barriers to thyroid cancer surgery and opportunities to optimize outcomes and reduce disparities for these populations., Competing Interests: Conflict of Interest/Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: In 2016, the Choosing Wisely campaign published guidelines recommending omission of sentinel lymph node biopsy in clinically node-negative women ≥70 years with early-stage (cT1-2), hormone receptor-positive, and human epidermal growth factor receptor 2-negative breast cancers. This study aimed to evaluate the implementation of this guideline., Methods: The National Cancer Database was queried from 2017 to 2020. All patients who met criteria for lymph node surgery omission were included and compared with those who underwent lymph node surgery., Results: Of 138,648 patients who met criteria for lymph node surgery omission, 26,070 (21.0%) had lymph node surgery omission and 109,482 (79.0%) underwent lymph node surgery. Those who had lymph node surgery omission were older (median 79 [75-84] vs 75 [72-79] years, P < .01) and had increased comorbidities (28.3% with Charlson/Deyo score ≥3 had lymph node surgery omission vs 20.2% with score 0, P < .01). Academic/research institutions most frequently practiced lymph node surgery omission (25.8% vs 16.5% community cancer programs, 19.3% comprehensive community cancer programs, and 20.6% integrated network cancer programs, P < .01). A greater percentage of lymph node surgery omission was noted with ductal carcinoma (21.4% vs 17.6% lobular and 19.4% mixed, P < .01) and lower-grade tumors (21.7% of grade 1 vs 19.4% of grade 2 and 17.8% of grade 3, P < .01). Throughout the period studied, the overall rate of lymph node surgery omission increased from 17.7% in 2017 to 23.1% in 2020 (P < .01)., Conclusion: Despite the evidence-based Choosing Wisely guideline recommending lymph node surgery omission in selected patients with breast cancer, more than 75% of patients meeting criteria were still being subjected to lymph node surgery as of 2020. Future work is warranted to determine factors affecting implementation of the Choosing Wisely guideline., Competing Interests: Conflict of Interest/Disclosure Dr Alicia Heelan is a consultant for Elucent, and Dr Jaime Lewis is a consultant for Elucent and ProvePharm, although these disclosures are not applicable to our work. There are no other conflicts to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Recent studies have evaluated patient perception of physician attire; however, few studies have considered physician perceptions of workplace attire. This study aimed to assess current trends regarding attire preferences among surgeons., Methods: A national, population-based survey was distributed via email and "X" (Twitter). Participants were asked to complete an online questionnaire regarding their perception of the white coat, preferred attire in clinical settings, and reasons for choice of attire., Results: Of 481 participants, 172 (36%) were attendings, 164 (34%) were residents, 125 (26%) were medical students, and 20 (4%) were fellows. Those who practiced in the Midwest region were more likely to wear a white coat daily (35.1% versus 28.5% South, 23.5% Northeast, 20.0% West, P < 0.05). Late career surgeons (practicing >20 y) were more likely to wear a white coat in the hospital and wear it daily (56% versus 36% of middle-career surgeons, 34% early-career surgeons, and 26% in training, P < 0.05). Women surgeons more frequently wore a white coat in clinic (64% versus 54% men, P < 0.05), reported that wearing a white coat was influenced by their program's culture (61% versus 46% of men surgeons, P < 0.05), that they would stop wearing a white coat if other members of their department stopped (50% versus 35% of men, P < 0.05), and that they believe the white coat helps distinguish female doctors from nurses (61% versus 50% of men surgeons, P < 0.05)., Conclusions: This study demonstrates generational, regional, and gender differences among surgeons in their perception of the white coat at a national level., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Surgery followed by pathology-guided adjuvant therapy is standard treatment for colon cancer. Data from the FOxTROT clinical trial showed potential benefit of a 6-wk neoadjuvant chemotherapy (NACT) in T3/T4 patients. The present study evaluated real-world outcomes of neoadjuvant therapy in a national cohort of patients with resectable colon cancer., Methods: 169,120 patients with clinical stage I, II, or III colon cancer from the National Cancer Database registry were included. Patients were categorized as having received neoadjuvant therapy followed by surgery (NACT), surgery then adjuvant chemotherapy (AC), or surgery alone. Factors associated with treatment sequencing and outcomes were assessed., Results: Of identified patients, 1.4% received NACT including 0.5% of stage I, 1.8% of stage II, and 3.0% of stage III. For stage I, 5-y overall survival (OS) was 74.7% after AC, 62.2% after NACT, and 76.4% after SA. For stage II, 5-y OS was 73.2% after AC, 66.8% after NACT, and 64.3% after SA. For stage III, 5-y OS was 67.3% after AC, 67.7% after NACT, and 42.4% after SA. Cox proportional-hazards model suggested NACT had worse outcomes versus AC in clinical stages I (hazard ratio [HR] = 1.59, 95% confidence interval [CI] 1.39-1.85, P < 0.01) and II (HR = 1.37, 95% CI 1.23-1.52, P < 0.01). In stage III, there was no difference in OS between NACT and AC (HR = 1.1, 95% CI 0.99-1.22, P = 0.05)., Conclusions: In a real-world national cohort of patients with resectable colon cancer, NACT had no OS benefit over AC. Future studies should examine which subset of patients might benefit from neoadjuvant approaches., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The Choosing Wisely ® (CW) campaign recommended de-implementation of surgical management of axillary nodes in specified patients. This study aimed to assess trends in the application of CW guidelines for lymph node (LN) surgery in males with breast cancer., Methods: The National Cancer Database was queried for males diagnosed with breast cancer from 2017 to 2020. Patients were categorized into two cohorts based on CW criteria. Cohort 1 included all T1-2, clinically node-negative patients who underwent breast-conserving therapy and with ≤ 2 positive nodes, and Cohort 2 included all T1-2, node-negative, hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative patients aged ≥ 70 years. In Cohort 1, patients who underwent sentinel LN biopsy (SLNB) alone were compared with axillary LN dissection (ALND) or no LN surgery, while in Cohort 2, patients who underwent LN surgery were compared with those with no LN surgery., Results: Of 617 patients who met the criteria for Cohort 1, 73.1% underwent SLNB alone compared with ALND (11.8%) or no LN surgery (15.1%). Those who received SLNB alone were younger (65 vs. 68 vs. 73 years; p < 0.001). The annual proportion of males who underwent SLNB alone remained stable from 2017 to 2020. Overall, 1565 patients met the criteria for Cohort 2, and 84.9% received LN surgery. LN surgery was omitted in older patients (81 vs. 77; p < 0.001). The proportion of elderly males with early-stage breast cancer who underwent LN surgery increased from 2017 to 2020., Conclusion: This study demonstrates that CW recommendations are not being routinely applied to males. These findings reinforce the need for additional studies and subsequent recommendations for optimal application of axillary surgery de-implementation for males diagnosed with breast cancer., (© 2024. The Author(s).)

Introduction: Prior work has demonstrated utility in using operative time to measure surgeon learning for surgical stabilization of rib fractures (SSRF); however, no studies have used operative time to evaluate the benefit of proctoring in subsequent generations of surgeons. We sought to evaluate whether there is a difference in learning between an original series (TOS) of self-taught surgeons versus the next generation (TNG) of proctored surgeons using cumulative summation (CUSUM) analysis. We hypothesized that TNG would have a comparatively accelerated learning curve., Methods: A single-center retrospective review of all SSRF at a level 1 trauma center was performed. Data were collected from the beginning of an operative chest injury program to include at least 2 y of TNG experience. Operative time was used to determine success and misstep based on prior methods. Learning curves using CUSUM analysis were calculated based on an anticipated success rate of 90% and compared between TOS and TNG groups., Results: Over 7 y, 163 patients with a median Injury Severity Score of 24 underwent SSRF. Median operative time was 165 min with a 0.5 plate-to-fracture ratio. All three TOS surgeons experienced a positive slope indicative of early missteps for their first 15-20 cases. By contrast, all three TNG surgeons demonstrated a series of early successes resulting in negative CUSUM slopes which coincided with a period of proctoring. By the end of TNG series, the composite cumulative score was less than half of the TOS surgeon' scores., Conclusions: Operative time continues to be a useful surrogate for observing SSRF learning curves. In a mature institutional program, proctored novice surgeons appear to have an accelerated learning curve compared to novice surgeons developing a new operative rib program., (Published by Elsevier Inc.)

Introduction: Residency interviews have traditionally been conducted in person; however, COVID-19 forced programs to shift to virtual interviewing. This study delineated the nationwide trends observed after virtual interviewing across multiple application cycles on both surgical residency applicant competitiveness and program workload., Methods: Publicly available National Residency Matching Program applicant and program data were retrospectively reviewed. Applicant competitiveness was assessed using a validated competitive index (# positions ranked/match rate). Interview types included in-person (2010-2020) or virtual (2021-2023), and programs were classified as general surgery (GS), surgical subspecialty (SS) - orthopedics, otolaryngology and neurosurgery, and integrated specialty (IS) - plastic, thoracic, and vascular surgery., Results: When comparing in-person to virtual cohorts, the competitive index has increased in GS (0.97 ± 0.00 to 1.05 ± 0.01, P < 0.001), SS (0.97 ± 0.02 to 1.06 ± 0.01 P < 0.001), and IS (0.93 ± 0.06 to 1.12 ± 0.03, P = 0.001). United Sates Medical Licensing Examination Step scores and research experiences increased over time in GS and SS (P < 0.05). Program workload, represented by number of applications received per program increased in GS, IS, and SS (P < 0.05), as well as the number of interviews conducted in GS and SS (P < 0.05). Importantly, match rate remained stable in GS and IS, with a decrease in SS (0.69 ± 0.03 to 0.63 ± 0.02, P = 0.04)., Conclusions: The residency application process has been irrevocably changed due to COVID-19. The rise in applicant volume and competitiveness places unique strains on applicants and programs. Additional modifications such as signaling and ACGME guidance are needed to help alleviate strain and ensure that residents and programs alike find their best fit., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The demand for liver transplants (LT) in the United States far surpasses the availability of allografts. New allocation schemes have resulted in occasional difficulties with allograft placement and increased intraoperative turndowns. We aimed to evaluate the outcomes related to use of late-turndown liver allografts., Methods: A review of prospectively collected data of LTs at a single center from July 2019 to July 2023 was performed. Late-turndown placement was defined as an open offer 6 h prior to donation, intraoperative turndown by primary center, or post-cross-clamp turndown., Results: Of 565 LTs, 25.1% (n = 142) received a late-turndown liver allograft. There were no significant differences in recipient age, gender, BMI, or race (all p > 0.05), but MELD was lower for the late-turndown LT recipient group (median 15 vs 21, p < 0.001). No difference in 30-day, 6-month, or 1-year survival was noted on logistic regression, and no difference in patient or graft survival was noted on Cox proportional hazard regression. Late-turndown utilization increased during the study from 17.2% to 25.8%, and median waitlist time decreased from 77 days in 2019 to 18 days in 2023 (p < 0.001)., Conclusion: Use of late-turndown livers has increased and can increase transplant rates without compromising post-transplant outcomes with appropriate selection., Competing Interests: Conflict of interest None declared., (Copyright © 2024 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Introduction: Many patients suffering from isolated severe traumatic brain injury (sTBI) receive blood transfusion on hospital arrival due to hypotension. We hypothesized that increasing blood transfusions in isolated sTBI patients would be associated with an increase in mortality., Methods: We performed a trauma quality improvement program (TQIP) (2017-2019) and single-center (2013-2021) database review filtering for patients with isolated sTBI (Abbreviated Injury Scale head ≥3 and all other areas ≤2). Age, initial Glasgow Coma Score (GCS), Injury Severity Score (ISS), initial systolic blood pressure (SBP), mechanism (blunt/penetrating), packed red blood cells (pRBCs) and fresh frozen plasma (FFP) transfusion volume (units) within the first 4 h, FFP/pRBC ratio (4h), and in-hospital mortality were obtained from the TQIP Public User Files., Results: In the TQIP database, 9257 patients had isolated sTBI and received pRBC transfusion within the first 4 h. The mortality rate within this group was 47.3%. The increase in mortality associated with the first unit of pRBCs was 20%, then increasing approximately 4% per unit transfused to a maximum mortality of 74% for 11 or more units. When adjusted for age, initial GCS, ISS, initial SBP, and mechanism, pRBC volume (1.09 [1.08-1.10], FFP volume (1.08 [1.07-1.09]), and FFP/pRBC ratio (1.18 [1.08-1.28]) were associated with in-hospital mortality. Our single-center study yielded 138 patients with isolated sTBI who received pRBC transfusion. These patients experienced a 60.1% in-hospital mortality rate. Logistic regression corrected for age, initial GCS, ISS, initial SBP, and mechanism demonstrated no significant association between pRBC transfusion volume (1.14 [0.81-1.61]), FFP transfusion volume (1.29 [0.91-1.82]), or FFP/pRBC ratio (6.42 [0.25-164.89]) and in-hospital mortality., Conclusions: Patients suffering from isolated sTBI have a higher rate of mortality with increasing amount of pRBC or FFP transfusion within the first 4 h of arrival., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Blunt cardiac injury (BCI) can be challenging diagnostically, and if misdiagnosed, can lead to life-threatening complications. Our institution previously evaluated BCI screening with troponin and electrocardiogram (EKG) during a transition from troponin I to high sensitivity troponin (hsTnI), a more sensitive troponin I assay. The previous study found an hsTnI of 76 ng/L had the highest capability of accurately diagnosing a clinically significant BCI. The aim of this study was to determine the efficacy of the newly implemented protocol., Methods: Patients diagnosed with a sternal fracture from March 2022 to April 2023 at our urban level-1 trauma center were retrospectively reviewed for EKG findings, hsTnI trend, echocardiogram changes, and clinical outcomes. The BCI cohort and non-BCI cohort ordinal measures were compared using Wilcoxon's two-tailed rank sum test and categorical measures were compared with Fisher's exact test. Youden indices were used to evaluate hsTnI sensitivity and specificity., Results: Sternal fractures were identified in 206 patients, of which 183 underwent BCI screening. Of those screened, 103 underwent echocardiogram, 28 were diagnosed with clinically significant BCIs, and 15 received intervention. The peak hsTnI threshold of 76 ng/L was found to have a Youden index of 0.31. Rather, the Youden index was highest at 0.50 at 40 ng/L (sensitivity 0.79 and specificity 0.71) for clinically significant BCI., Conclusions: Screening patients with sternal fractures for BCI using hsTnI and EKG remains effective. To optimize the hsTnI threshold, this study determined the hsTnI threshold should be lowered to 40 ng/L. Further improvements to the institutional protocol may be derived from multicenter analysis., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The implementation of acuity circles (AC) in 2020 and the COVID-19 pandemic increased the use of local surgeons to recover livers for transplant; however, the impact on liver transplant (LT) outcomes is unknown., Methods: Deceased donor adult LT recipients from the UNOS database were identified.  Recipients were grouped by donor surgeon: local versus primary recovery.  Patient and graft survival as well as trends in local recovery in the 2 years pre-AC and post-AC were assessed., Results: The utilization of local recovery in LT increased from 22.3% to 37.9% post-AC (p < 0.01).  LTs with local recovery had longer cold ischemia times (6.5 h [5.4-7.8] vs. 5.3 h [4.4-6.5], p < 0.01) and traveled further (210 miles [89-373] vs. 73 miles [11-196], p < 0.01) than those using primary recovery. Multivariate analyses revealed no differences in patient or graft survival between local and primary recovery, and between OPO and local surgeon. There was no difference in survival when comparing simultaneous liver-kidney, donation after circulatory death, MELD ≥ 30, or redo-LT by recovery team.  Recovery and utilization rates were also noted to be higher post-AC (51.4% vs. 48.6% pre-AC, p < 0.01) as well as when OPO surgeons recovered the allografts (72.5% vs. 66.0%, p < 0.01)., Conclusion: Nearly 40% of LTs are performed using local recovery, and utilization rates and trends continue to change with changing organ-sharing paradigms such as AC.  This practice appears safe with outcomes similar to recovery by the primary team in appropriately selected recipients and may lead to increased access and the ability to transplant more livers., (© 2024 The Author(s). Clinical Transplantation published by Wiley Periodicals LLC.)

Purpose of Review: While liver transplant for unresectable colorectal cancer liver metastases (CRLM) has been demonstrated to be a promising treatment in selected patients, the typically low MELD score of these patients and lack of exception points may lead to challenges in receiving a deceased donor liver for transplant., Recent Findings: Several studies have shown improved outcomes in select patients with CRLM who undergo liver transplant, and several trials are ongoing and will conclude in the next several years. MELD exception points have recently been proposed in qualifying patients with CRLM to help this group obtain more timely quality allografts. Under the current proposal, patients with CRLM would receive a score of the median MELD at transplant (MMaT) for their center minus 20 with a minimum score of 15 in cases where MMaT minus 20 would be less than 15. This would allow them to receive transplants faster without competing unnecessarily with those with greater medical need., Summary: Giving MELD exception points to patients with colorectal cancer liver metastases in need of transplant may decrease time on the waitlist and improve outcomes for these patients., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Limited data exist regarding the optimal locoregional approach for males with ductal carcinoma in situ (DCIS). This study examined trends in management and survival for males with DCIS., Methods: The National Cancer Database (NCDB) was queried for males with a diagnosis of DCIS from 2006 to 2017. Patients were categorized by locoregional management. Continuous variables were evaluated by Kruskal-Wallis and categorical variables by chi-square or Fisher's exact test. Univariable and multivariable logistic regressions were performed to evaluate for predictors of patients receiving partial mastectomy (PM) with radiation. Survival was analyzed by Kaplan-Meier., Results: Between 2006 and 2017, 711 males with DCIS were identified. Most received mastectomy alone (57.1%). No change was observed in management approach from 2006 to 2017. Patients who underwent mastectomy alone were mostly hormone-positive (95.9% were estrogen-positive, 90.9% were progesterone-positive), although this cohort was least likely to receive hormone therapy (17.2%). Among those who underwent PM with radiation, only 61% of those who were hormone-positive received hormone therapy. Univariable analysis demonstrated that those of black race had lower odds of receiving PM with radiation (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.36-0.84), which persisted in the multivariable analysis with control for age and tumor size (OR, 0.32; 95% CI, 0.15-0.67). Overall survival did not differ significantly between the four treatment methods (p = 0.08)., Conclusions: The management approach to male DCIS did not change from 2006 to 2017. Survival did not differ between treatment methods. Demographic and clinicopathologic features, including race, may influence locoregional treatments received, and further studies are needed to further understand this., (© 2023. Society of Surgical Oncology.)

Background: Robotic pancreaticoduodenectomy (RPD) is a safe and efficacious procedure in appropriately selected patients, though frequently with increased operative times compared to open pancreaticoduodenectomy (OPD)., Methods: From 2014 to 2019, patients who underwent elective, low-risk, RPDs and OPDs in the NSQIP database were isolated. The operative time threshold (OTT) for safety in RPD patients was estimated by identifying the operative time at which complication rates for RPD patients exceeded the complication rate of the benchmark OPD control., Results: Of 6270 patients identified, 939 (15%) underwent RPD and 5331 (85%) underwent OPD. The incidence of major morbidity or mortality for the OPD cohort was 35.1%. The OTT was identified as 7.7 h. Patients whose RPDs were above the OTT experienced a higher incidence of major morbidity (42.5% vs. 35.0%, p < 0.01) and 30-day mortality (2.7% vs. 1.2%, p = 0.03) than the OPD cohort. Preoperative obstructive jaundice (OR: 1.47, [95% CI: 1.08-2.01]) and pancreatic duct size <3 mm (OR: 2.44, [95% CI: 1.47-4.06]) and 3-6 mm (OR: 2.15, [95% CI: 1.31-3.52]) were risk factors for prolonged RPDs on multivariable regression., Conclusion: The operative time threshold for safety, identified at 7.7 h, should be used to improve patient selection for RPDs and as a competency-based quality benchmark., (Copyright © 2023 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Axillary management for node-positive breast cancer continues to evolve. Data further supporting targeted axillary dissection after neoadjuvant chemotherapy was published in 2016 and may have induced changes in practice., Methods: Patients included in the National Cancer Database from 2014 to 2017 with clinical T1 to T4 and node-positive disease who underwent neoadjuvant chemotherapy before surgical axillary management were evaluated. Patients were divided into the following 3 groups: selective axillary dissection, minimal axillary dissection, and maximal axillary dissection, according to surgical axillary management and pathological node status., Results: Patients who underwent selective axillary dissection were younger (52.4 years ± 12.4, P < .0001) compared to maximal axillary dissection (55.1 ± 12.7) and minimal axillary dissection (54.6 ± 12.7). Patients with higher clinical stage more frequently underwent maximal axillary dissection, and those with lower tumor grade more frequently underwent minimal axillary dissection (P < .0001). Community cancer programs were more likely to perform maximal axillary dissection compared to all other types of programs and had the slowest rate of adoption of selective axillary dissection. Integrated Network Cancer Programs had the lowest proportion of maximal axillary dissection performed and the highest proportion of selective axillary dissection. Uninsured patients were more likely to receive maximal axillary dissection, and those with private insurance were more likely to undergo selective axillary dissection (P < .0001). Selective axillary dissection rates increased from 29.8% of procedures in 2016 to 41.5% in 2017, and MaxAD rates decreased from 62.4% in 2016 to 47.9% in 2017., Conclusion: Utilization of selective axillary dissection has increased since 2016; however, discrepancies in surgical axillary management after neoadjuvant chemotherapy still exist., (Copyright © 2023. Published by Elsevier Inc.)

Colorectal cancer is one of the most common malignancies worldwide. Approximately half of the patients diagnosed will develop colorectal liver metastases (CRLM). Liver resection has a 50% 5-year survival; however, only a fourth of cases are resectable. Unresectable CRLM has poor prognosis despite improved systemic and local ablative treatments. Liver transplantation (LT) has demonstrated a survival benefit in initial prospective clinical trials. Current use of LT for CRLM is limited to several randomized trials and high-performing centers. Improving patient selection criteria and perioperative management, LT will likely become an important part of the multidisciplinary approach to managing the metastatic disease., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Hilar cholangiocarcinoma is considered a biologically aggressive disease for which surgical resection remains the only curative treatment. Preoperative evaluation for resectability is challenging given tumor proximity to the porta hepatis, but minimal benefit and increased morbidity precludes recommendation for margin positive resection. This article reviews the determination of unresectability in hilar cholangiocarcinoma through discussion of the preoperative assessment, the intraoperative assessment, and key steps of surgical resection, as well as treatment options for unresectable tumors. Overall, evaluating patients preoperatively for resectability requires a multidisciplinary, holistic, and individualized approach to accurately determine resectability and optimize clinical outcomes for patients with hilar cholangiocarcinoma., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Temporary abdominal closure is commonly employed in liver transplantation when patient factors make primary fascial closure challenging. However, there is minimal data evaluating long-term survival and patient outcomes after temporary abdominal closure., Methods: A single-center, retrospective review of patients undergoing liver transplantation from January 2013 through December 2017 was performed with a 5-year follow-up. Patients were characterized as either requiring temporary abdominal closure or immediate primary fascial closure at the time of liver transplantation., Results: Of 422 patients who underwent 436 liver transplantations, 17.2% (n = 75) required temporary abdominal closure, whereas 82.8% (n = 361) underwent primary fascial closure. Patients requiring temporary abdominal closure had higher Model for End-Stage Liver Disease scores preoperatively (27 [22-36] vs 23 [20-28], P = .0002), had higher rates of dialysis preoperatively (28.0% vs 12.5%, P = .0007), and were more likely to be hospitalized within 90 days of liver transplantation (64.0% vs 47.5%, P = .0093). On univariable analysis, survival at 1 year was different between the groups (90.9% surviving at 1 year for primary fascial closure versus 82.7% for temporary abdominal closure, P = .0356); however, there was no significant difference in survival at 5 years (83.7% vs 76.0%, P = .11). On multivariable analysis, there was no difference in survival after adjusting for multiple factors. Patients requiring temporary abdominal closure were more likely to have longer hospital stays (median 16 days [9.75-29.5] vs 8 days [6-14], P < .0001), more likely to be readmitted within 30 days (45.3% vs 32.2%, P = .03), and less likely to be discharged home (36.5% vs 74.2%, P < .0001)., Conclusions: Temporary abdominal closure after liver transplantation appears safe and has similar outcomes to primary fascial closure, though it is used more commonly in complex patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Colorectal cancer with liver metastases is a condition with significant morbidity and mortality that affects many people around the world. Many treatments exist to target liver metastases, including surgical resection, chemotherapy, nonsurgical liver-directed therapies, and liver transplantation. The field of transplant oncology is emerging as a promising alternative to palliative chemotherapy alone in appropriately selected patients. Though few clinical trials have been completed to evaluate safety of liver transplant for colorectal cancer metastases, there are several ongoing trials to hopefully make transplant a viable option for more patients with limited options., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Colorectal cancer with unresectable liver metastases has significant mortality when treated with chemotherapy alone. In appropriately selected patients, liver transplant is emerging as a treatment alternative for this population. Some key clinical trials, including SECA-I and SECA-II, have shown promising survival results: more trials are being conducted to evaluate safety of this practice., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Objective: The importance of the profunda femoris for aortoiliac inflow procedure patency is well-recognized. We aim to quantify the characteristics of the profunda femoris and its relation to patency following aortoiliac inflow procedures., Methods: Patients undergoing aortoiliac inflow procedures between 2009 and 2019 were identified. These were classified into aorto-bifemoral bypass (ABF), extra-anatomic bypass (EAB), femoral endarterectomy (FEA), and iliac stenting. Preoperative imaging characteristics of the profunda femoris were reviewed as well as outcomes., Results: We performed 269 procedures in 202 patients. Of these, 162 were men (59.8%), with a mean age of 61 years (standard deviation, 11.45 years). A total of 123 patients (45.3%) presented with claudication, 69 (25.9%) with critical limb ischemia, and 30 (11.2%) with acute limb ischemia. Fifty patients (18.6%) underwent ABF, 44 (16.4%) underwent EAB, 57 (21.2%) underwent FEA, and 158 (58.7%) underwent iliac stenting. Fourteen patients (5.2%) underwent FEA plus iliac stenting. Fifty-two patients (19.2%) had an occluded superficial femoral artery. Twenty-four patients (8.9%) had additional outflow procedures performed during the index operation, including infrainguinal endovascular intervention in 10 patients (3.7%), infrainguinal bypass in 10 patients (3.7%), and femoropopliteal thrombectomy in 5 patients (1.9%). The mean follow-up was 17.5 months with overall 2-year primary patency (PP) of 79%. Two-year PP was 94.7% for FEA, 85.6% for ABF, 79.8% for iliac stents, and 62.5% for EAB. Unadjusted analysis revealed that loss of primary assisted patency was associated with active smoking (67.6% vs 48.6%; P = .035), lower creatinine (mean, 0.84 vs 1.06 mg/dL; P = .003), critical limb ischemia vs claudication (37.8% vs 21.4%; P = .037), and profunda femoris with fewer than five branches >2 mm in size (88.2% vs 68.5%; P = .011). Multivariate analysis confirmed that a profunda with five or more branches >2 mm in diameter was significantly associated with a lower risk of thrombosis (odds ratio, 0.30; P = .034). Size of the profunda greater than 6 mm approached statistical significance on univariate analysis (35% of the non-thrombosed vs 21% in the thrombosed; P = .073), but did not significantly affect risk of thrombosis on the multivariate analysis (odds ratio, 0.58; P = .25). The 2-year PP when all operations were considered was 76% compared with 72% for profunda with fewer than five branches > 2 mm., Conclusions: Anatomic characteristics of the profunda are associated with patency of inflow procedures. Care should be taken to assess the main profunda and branch diameters on preoperative imaging. A concomitant infrainguinal procedure should be considered in cases of profunda with inadequate large branches, to ensure long-term patency of the inflow operation., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)