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Background: Patients with diverticular disease complicated by abscess and/or perforation represent the most severely afflicted with the highest mortality and poorest outcomes. This study investigated patient and operative factors associated with poor outcomes from diverticulitis complicated by abscess or perforation. Methods: We analyzed the National Inpatient Sample to identify inpatient discharges for colonic diverticulitis in the United States from 1/1988 to 9/2015. We identified patients with perforation and/or intestinal abscess based on ICD-9 codes. The primary outcome was inpatient mortality. Results: During the study period, a total of 993,220 patients were discharged with diverticulitis from sampled U.S. hospitals. From this group, 10.7% had an abscess and 1.0% had a perforation associated with diverticular disease. Inpatient mortality of diverticulitis patients with a perforation was 5.4% compared to 1.5% in those without a perforation (p<0.001). Patients with a perforation who underwent surgery had an inpatient mortality of 6.3% vs. 3.0% mortality amongst patients with a perforation who did not undergo an operation (p<0.001). Patients with a perforation that underwent surgery had a 31% increased mortality risk for each day after admission that a procedure was delayed (OR 1.31, CI 1.05–1.78; p=0.03). Mortality risk was increased for patients with either abscess or perforation who underwent surgery if they were female, age ≥65, higher comorbidity, were admitted urgently, underwent peritoneal lavage, or had a post-procedural complication. Conclusions: Patients with perforated diverticular disease had substantial associated inpatient mortality compared to those with uncomplicated diverticulitis. This increased risk may be associated with performance of peritoneal lavage or because of a delay to procedural intervention. [ABSTRACT FROM AUTHOR]

The microbiome plays a major role in human physiology by influencing obesity, inducing inflammation, and impacting cancer therapies. During the 60th Annual Meeting of the Society of the Alimentary Tract (SSAT) at the State-of-the-Art Conference, experts in the field discussed the influence of the microbiome. This paper is a summary of the influence of the microbiome on obesity, inflammatory bowel disease, pancreatic cancer, cancer therapies, and gastrointestinal optimization. This review shows how the microbiome plays an important role in the development of diseases and surgical complications. Future studies are needed in targeting the gut microbiome to develop individualized therapies. [ABSTRACT FROM AUTHOR]

Outpatient adrenalectomy has the potential to decrease costs, improve inpatient capacity, and decrease patient exposure to hospital-acquired conditions. Still, the practice has yet to be widely adopted and current studies demonstrating the safety of outpatient adrenalectomy are limited by sample size, extensive exclusion criteria, and no comparison to inpatient cases. We aimed to study the characteristics and safety of outpatient adrenalectomy using the largest such sample to date across 2 academic medical centers and 3 minimally invasive approaches. All minimally invasive adrenalectomies were identified, starting from the time outpatient adrenalectomy was initiated at each institution. Cases involving removal of other organs, bilateral adrenalectomies, and cases in which a patient was admitted to the hospital before the day of surgery were excluded. Patient, tumor, and case characteristics were compared between outpatient and inpatient cases, and multivariable regression analysis was used to assess odds of 30-day readmission and/or complication. Of 203 patients undergoing minimally invasive adrenalectomy, 49% (n = 99) were performed on an outpatient basis. Outpatient disposition was more likely in the setting of lower estimated blood loss, case completion before 3 pm, and for surgery performed in the setting of nodule/mass and primary hyperaldosteronism versus Cushing's syndrome, pheochromocytoma, and metastasis (P <.05). There were no significant differences in patient age, body mass index, American Society of Anesthesiologists class, procedure performed, or total time under anesthesia between inpatient and outpatient cases. On adjusted analysis, outpatient adrenalectomy was not associated with increased 30-day readmission rate (odds ratio 0.23 [confidence interval 0.04–1.26] P =.09) or 30-day complication rate (odds ratio 0.21 [confidence interval 0.06–0.81] P =.02). Outpatient adrenalectomy can be performed safely without increased risk of 30-day complications or readmission in appropriately selected candidates. [ABSTRACT FROM AUTHOR]

1 Axial CT image of the pelvis showing a presacral mass with sharp margins and central calcification concerning for ganglioneuroma Graph: Fig. Chemotherapy and radiation are not indicated.[3] Our patient presented with a growing ganglioneuroma in the pelvis and eventually with mass effect symptoms of urinary dribbling and incontinence. A CT-guided core needle biopsy was performed, and pathologic examination revealed bland spindle cells and ganglion cells. [Extracted from the article]

Diverticulitis has become increasingly more common in the 20th century and is now one of the most frequent indications for gastrointestinal tract-related hospitalizations. The spectrum of clinical presentation can vary widely from mild, uncomplicated disease that can be managed as an outpatient, to complicated diverticulitis with peritonitis and sepsis. Historically, all patients with diverticulitis were managed with, at a minimum, a course of antibiotics, with many patients undergoing urgent or emergent surgery with a sigmoid colectomy, end colostomy, and oversewn rectosigmoid "Hartmann's" stump. However, the treatment paradigm has shifted away from more aggressive surgical management over the years, with recent literature supporting the notion that nonoperative management may lead to equivalent or even superior outcomes in many circumstances. Therefore, the purpose of this review is to summarize and interpret the existing literature on the management of uncomplicated and complicated left-sided diverticulitis in 2017. [ABSTRACT FROM AUTHOR]

Background Previous associations between surgeon volume with adrenalectomy outcomes examined only a sample of procedures. We performed an analysis of all adrenalectomies performed in New York state to assess the effect of surgeon volume and specialty on clinical outcomes. Methods Adrenalectomies performed in adults were identified from the New York Statewide Planning and Research Cooperative System from 2000–2014. Surgeon specialty, volume, and patient demographics were assessed. High volume was defined using a significance threshold at ≥4 adrenalectomies per year. Outcome variables included in-hospital mortality, duration of stay, and in-hospital complications. Results A total of 6,054 adrenalectomies were included. Median patient age was 56 years; 41.9% were men and 68.3% were white. Urologists (n = 462) performed 46.8% of adrenalectomies, general surgeons (n = 599) performed 35.0%, and endocrine surgeons (n = 23) performed 18.1%. Significantly more endocrine surgeons were high-volume compared with urologists and general surgeons (65.2% vs 10.2% and 6.7%, respectively, P < .001). High-volume surgeons had significantly lower mortality compared with low-volume surgeons (0.56% vs 1.25%, P = .004) and a lower rate of complications (10.2% vs 16.4%, P = < .001). Endocrine surgeons were more likely to perform laparoscopic procedures (34.8% vs 22.4% general surgeons and 27.7% US, P < .001) and had the lowest median hospital duration of stay (2 days vs 4 days general surgeons and 3 days urologists, P < .001). After risk adjustment, low surgeon volume was an independent predictor of inpatient complications (odds ratio = 0.96, P = .002). Conclusion Patients with adrenal disease should be referred to surgeons based on adrenalectomy volume regardless of specialty, but most endocrine surgeons that perform adrenalectomy are high-volume for the procedure. [ABSTRACT FROM AUTHOR]

Background: The brush-border enzyme intestinal alkaline phosphatase (IAP) functions as a gut mucosal defense factor and detoxifies different toll-like receptor ligands. This study aimed to determine the therapeutic effects of locally administered calf IAP (cIAP) in a cecal ligation and puncture (CLP) model of polymicrobial sepsis.Methods: C57BL/6 mice underwent CLP followed by intraperitoneal injection of cIAP or normal saline. Blood leukocyte counts, levels of cytokines and liver enzymes, and lung myeloperoxidase activity were determined. Peritoneal lavage fluid (PLF) was assayed for neutrophil infiltration and both aerobic and anaerobic bacterial counts.Results: After intraperitoneal injection, cIAP activity in PLF decreased 50% within 15 min with minimal activity evident at 4 h. Compared with irrigation with normal saline, cIAP irrigation increased the 7-day survival rate in mice undergoing CLP, with maximal effects seen at 25 units of cIAP (0% vs. 46% survival rate, respectively; p < 0.001). cIAP treatment reduced lung inflammation, liver damage and levels of tumor necrosis factor alpha and interleukin-6.Conclusions: Peritoneal irrigation with cIAP significantly enhances survival in a mouse model of peritonitis, likely through reduction of local inflammation and remote organ damage. We suggest that intraperitoneal cIAP irrigation could be a novel therapy for intra-abdominal sepsis. [ABSTRACT FROM AUTHOR]

Fibrosis and tissue stiffening are hallmarks of inflammatory bowel disease (IBD). We have hypothesized that the increased stiffness directly contributes to the dysregulation of the epithelial cell homeostasis in IBD. Here, we aim to determine the impact of tissue stiffening on the fate and function of the intestinal stem cells (ISCs). We developed a long-term culture system consisting of 2.5-dimensional intestinal organoids grown on a hydrogel matrix with tunable stiffness. Single-cell RNA sequencing provided stiffness-regulated transcriptional signatures of the ISCs and their differentiated progeny. YAP-knockout and YAP-overexpression mice were used to manipulate YAP expression. In addition, we analyzed colon samples from murine colitis models and human IBD samples to assess the impact of stiffness on ISCs in vivo. We demonstrated that increasing the stiffness potently reduced the population of LGR5+ ISCs and KI-67+–proliferating cells. Conversely, cells expressing the stem cell marker, olfactomedin-4, became dominant in the crypt-like compartments and pervaded the villus-like regions. Concomitantly, stiffening prompted the ISCs to preferentially differentiate toward goblet cells. Mechanistically, stiffening increased the expression of cytosolic YAP, driving the extension of olfactomedin-4+ cells into the villus-like regions, while it induced the nuclear translocation of YAP, leading to preferential differentiation of ISCs toward goblet cells. Furthermore, analysis of colon samples from murine colitis models and patients with IBD demonstrated cellular and molecular remodeling reminiscent of those observed in vitro. Collectively, our findings highlight that matrix stiffness potently regulates the stemness of ISCs and their differentiation trajectory, supporting the hypothesis that fibrosis-induced gut stiffening plays a direct role in epithelial remodeling in IBD. [Display omitted] Intestinal tissue stiffening, due to fibrosis, in inflammatory bowel disease reduces the population and stemness of the intestinal stem cells and promotes their differentiation toward goblet cells. [ABSTRACT FROM AUTHOR]

Summary Cachexia is a wasting syndrome associated with elevated basal energy expenditure and loss of adipose and muscle tissues. It accompanies many chronic diseases including renal failure and cancer and is an important risk factor for mortality. Our recent work demonstrated that tumor-derived PTHrP drives adipose tissue browning and cachexia. Here, we show that PTH is involved in stimulating a thermogenic gene program in 5/6 nephrectomized mice that suffer from cachexia. Fat-specific knockout of PTHR blocked adipose browning and wasting. Surprisingly, loss of PTHR in fat tissue also preserved muscle mass and improved muscle strength. Similarly, PTHR knockout mice were resistant to cachexia driven by tumors. Our results demonstrate that PTHrP and PTH mediate wasting through a common mechanism involving PTHR, and there exists an unexpected crosstalk mechanism between wasting of fat tissue and skeletal muscle. Targeting the PTH/PTHrP pathway may have therapeutic uses in humans with cachexia. [ABSTRACT FROM AUTHOR]

Background Although laparoscopic transperitoneal adrenalectomy (LTA) has become a standard operative approach to patients with benign adrenal masses, some authors have suggested that LTA should be avoided in obese patients, patients who have had previous abdominal surgery, and in cases of bilateral adrenalectomy. We sought to determine whether LTA in these clinical situations is associated with worse outcomes. Methods Consecutive patients who underwent LTA at a tertiary care center (1/2002–8/2014) were reviewed retrospectively. Study endpoints included operative time, duration of stay, conversion to open procedure, and postoperative complications. Statistical analyses were performed by use of Wilcoxon rank sum test, Kruskal–Wallis test, Fisher exact test, χ 2 test, and binary logistic regression analyses. Results A total of 365 patients had a planned LTA, 6 of whom were converted to an open adrenalectomy. Obesity, history of previous abdominal surgery, and bilateral adrenalectomy were not associated with greater conversion rates or postoperative complications. Male sex, tumor size ≥4 cm and obesity (body mass index ≥30 kg/m 2 ) were significant factors associated with increased operative time. Bilateral adrenalectomy, age, and pheochromocytomas were associated with increased hospital stays. Conclusion Obesity, history of prior abdominal surgery and bilateral adrenalectomy should not be used to discourage experienced adrenal surgeons from performing LTA. [ABSTRACT FROM AUTHOR]

Introduction Hypocalcemia is a common complication following thyroid surgery. We seek to report on our experience in pediatric thyroidectomy in a high volume thyroid surgery center and accurately assess the incidence of postoperative hypocalcemia. Materials and methods A retrospective review of patients aged 18 and younger who underwent thyroid surgery between 1992 and 2013. The primary endpoints were the occurrence of postoperative hypocalcemia as by defined as a nadir calcium < 8.0 mg/dL and being discharged on oral calcium supplementation, need for intravenous calcium and the occurrence of permanent hypoparathyroidism. Results 171 patients who underwent 186 thyroid operations were analyzed. The average age was 15.4 years with 82.3% female. The most common indications for surgery were nodular disease (74.7%) and hyperthyroidism (12.4%). 24 patients (12.9%) experienced postoperative hypocalcemia with 13 (7.0%) requiring intravenous calcium infusion. One patient (0.9%) experienced permanent hypoparathyroidism. Risk factors for postoperative hypocalcemia included total thyroidectomy (OR 7.39, p < 0.01), central and bilateral lateral neck dissection (OR 22.26, p = 0.01), Graves’ disease (OR 3.99, p = 0.02), and malignancy (OR 2.96, p = 0.03). Conclusions Pediatric patients who undergo total thyroidectomy for underlying malignancy or Graves’ disease and those who have more extensive nodal dissections are at increased risk of developing this postoperative hypocalcemia. These patients may benefit from more vigilant preoperative preparation and postoperative calcium and vitamin D supplementation. [ABSTRACT FROM AUTHOR]

Background Hypoglycemia after resection of pheochromocytoma is a rare and poorly understood complication thought to be secondary to rebound hyperinsulinemia and increased peripheral glucose uptake. We examined the incidence of this complication and aimed to identify predisposing risk factors. Methods Patients who underwent pheochromocytoma resection between 1993 and 2013 at 2 large academic medical centers were identified retrospectively from a research patient data registry. The primary end point was postoperative hypoglycemia defined as blood glucose <55 mg/dL. Results A total of 213 patients underwent resection of pheochromocytoma for a total of 215 operations. Nine patients (4.2%) experienced postoperative hypoglycemia, with 8 of 9 episodes occurring in the first 24 hours. Patients who developed hypoglycemia were more likely to have greater preoperative 24-hour urinary metanephrine (4,726 vs 2,461 μg/24 h, P = .05) and experienced longer operative times (270 vs 142 minutes, P < .01) with larger neoplasms (7.6 vs 4.6 cm, P = .02). Postoperatively, patients with hypoglycemia required intensive care level monitoring more frequently (88.9% vs 34.5%, P < .01), but there was no difference in duration of hospital stay (5 vs 3 days, P = .10). Conclusion Our data demonstrate that hypoglycemia is a rare complication after resection of pheochromocytoma and may be more common in patients with epinephrine-predominant neoplasms and longer operative times. [ABSTRACT FROM AUTHOR]

BACKGROUND: Proctectomy for ulcerative colitis (UC) can be performed via intramesorectal (IME) or total mesorectal excision (TME). METHODS: We compared patient-reported bowel and sexual function among IME versus TME UC patients (September 2000 to March 2011) using the Memorial Sloan-Kettering Cancer Center Bowel Function scale, Fecal Incontinence Quality of Life, Fecal Incontinence Severity Index, Female Sexual Function Instrument, and International Index of Erectile Dysfunction surveys. RESULTS: Eighty-nine IME versus TME patients (35 ± 2 years, 57% male, 62% IME) had similar baseline characteristics, although IME patients had more open procedures (P % .03). IME patients reported better fecal continence (P = .009) but similar fecal incontinence-related quality of life (P > .44). For sexual function, there were no differences for either women (Female Sexual Function Instrument; P > .20) or men (International Index of Erectile Dysfunction; P > .22). CONCLUSIONS: IME appears to be associated with better fecal continence but no difference in overall bowel or sexual function compared with TME in patients with UC. © 2014 Elsevier Inc. All rights reserved. [ABSTRACT FROM AUTHOR]

Introduction: Proctectomy for ulcerative colitis (UC) can be performed via intramesorectal proctectomy with concomitant rectal eversion (IMP/RE) or total mesorectal excision (TME). No data exists comparing the outcomes of the two techniques. Methods: All UC patients undergoing J-pouch surgery at a single institution over 10.5 years were included. Postoperative complications with IMP/RE vs. TME were analyzed using univariable and multivariable statistics. Results: One hundred nineteen of 201 (59 %) patients underwent IMP/RE. Demographic and disease characteristics were similar between groups. On univariable analysis, IMP/RE had fewer total perioperative complications than TME ( p = 0.02), but no differences in postoperative length of stay or readmissions. Multivariable regression accounting for patient age, comorbidities, disease severity, preoperative medications, operative technique, and follow-up time (mean 5.5 ± 0.2 years) suggested that both anastomotic leak rate (OR 0.32; p = 0.04) and overall postoperative complications (2.10 ± 0.17 vs. 2.60 ± 0.20; p = 0.05) were lower in the IMP/RE group. Conclusions: IMP/RE may be associated with fewer overall postoperative complications compared to TME. However, further studies on functional and long-term outcomes are needed. [ABSTRACT FROM AUTHOR]

BACKGROUND: Surgeons frequently discourage patients with ulcerative colitis from having surgery in the midst of an acute flare for fear of complications and poor long-term outcomes. METHODS: Outcomes of patients undergoing urgent versus elective surgery for ulcerative colitis were compared via retrospective review. RESULTS: Patients undergoing urgent (n =80) versus elective (n = 99) surgery were younger, were more malnourished, had more severe active disease, and had higher steroid use (P ≤ .05). During surgery, hemodynamic stability was similar, but urgent patients underwent more subtotal colectomies (5.1% vs 29%, P < .0001) and fewer laparoscopic procedures (8.8% vs 18%, P = .07). Multivariate regression suggested that short-term complications were increased with higher body mass index and urgency status (P ≤ .05). Anastomotic leaks and long-term complications were similar between groups. Surgeon inexperience and use of immunomodulators other than infliximab were associated with increased odds of long-term fistula/abscess (odds ratio, 5.56; P = .05] and pouch failure (odds ratio, 13.3; P = .01). CONCLUSIONS: Surgery in patients with acute ulcerative colitis flares is associated with more shortterm complications than elective procedures but does not appear to affect risk for anastomotic leak or long-term complications when performed by an expert. [ABSTRACT FROM AUTHOR]

Background: Hypocalcemia is a potential complication after thyroidectomy. Patients with previous roux-en-Y gastric bypass (RYGBP) may be at increased risk for recalcitrant symptomatic hypocalcemia after thyroidectomy. This complication is poorly described and there is no current consensus on optimal management in this unique population. Methods: All patients from 2000 to 2012 who underwent thyroidectomy with history of preceding RYGBP were identified retrospectively. Each of the 19 patients meeting inclusion criteria were matched 2:1 for age, gender, and body mass index (BMI) to a cohort who underwent thyroidectomy without previous RYGBP. The study cohort and matched controls were compared for incidence of symptomatic postoperative hypocalcemia, requirement of intravenous (IV) calcium supplementation, and duration of hospital stay. Results: Age, proportion of female patients, and BMI were equivalent between cases (n = 19) and controls (n = 38). Comparison of primary outcomes demonstrated that the study group had a significantly higher incidence of symptomatic hypocalcemia (42% vs 0%; P < .01), administration of IV calcium (21% vs 0%; P < .01), and duration of hospital stay (2.2 vs 1.2 days, P = .02). Conclusion: Patients with previous RYGBP have a greater incidence of recalcitrant symptomatic hypocalcemia after thyroidectomy, resulting in prolonged duration of hospital stay. In this patient population, calcium levels should be closely monitored and early calcium and vitamin D supplementation initiated preemptively. [Copyright &y& Elsevier]

Background: Papillary thyroid cancer (PTC) recurrence risk is difficult to predict. No current risk classification system incorporates BRAF mutational status. Here, we assess the incremental value of BRAF mutational status in predicting PTC recurrence relative to existing recurrence risk algorithms. Methods: Serial data were collected for a historical cohort having undergone total thyroidectomy for papillary thyroid carcinoma (PTC) during a 5-year period. Corresponding BRAF V600E testing was performed and Cox proportional hazard regression modeling, with and without BRAF status, was used to evaluate existing recurrence risk algorithms. Results: The 5-year cumulative PTC recurrence incidence within our 356 patient cohort was 15%. A total of 205 (81%) of associated archived specimens were successfully genotyped, and 110 (54%) harbored the BRAF V600E mutation. The 5-year cumulative recurrence incidence among BRAF V600E patients was 20% versus 8% among BRAF wild type. BRAF V600E was significantly associated with time to recurrence when added to the following algorithms: AMES (hazard ratio [HR] 2.43 [confidence interval 1.08–5.49]), MACIS category (HR 2.46 [1.09–5.54]), AJCC-TNM (HR 2.51 [1.11–5.66]), and ATA recurrence-risk category (HR 2.44 [1.08–5.50]), and model discrimination improved (incremental c-index range 0.046–0.109). Conclusion: The addition of BRAF mutational status to established risk algorithms improves the discrimination of risk recurrence in patients undergoing total thyroidectomy for PTC. [ABSTRACT FROM AUTHOR]

Background: The optimal initial operative management of medullary thyroid cancer (MTC) and the use of biomarkers to guide the extent of operation remain controversial. We hypothesized that preoperative serum levels of calcitonin and carcinoembryonic antigen (CEA) correlate with extent of disease and postoperative levels reflect the extent of operation performed. Methods: We assessed retrospectively clinical and pathologic factors among patients with MTC undergoing at least total thyroidectomy; these factors were correlated with biomarkers using regression analyses. Results: Data were obtained from 104 patients, 28% with hereditary MTC. Preoperative calcitonin correlated with tumor size (P < .001) and postoperative serum calcitonin levels (P = .01) after multivariable adjustment for lymph node positivity, extent of operation, and hereditary MTC. No patient with a preoperative calcitonin level of <53 pg/mL (n = 20) had lymph node metastases. TNM stage (P = .001) and preoperative calcitonin levels (P = .04), but not extent of operation, independently correlated with the failure to normalize postoperative calcitonin. Postoperative CEA correlated with positive margins (adjusted P = 04). Neither preoperative nor postoperative CEA was correlated with lymph node positivity or extent of surgery. Conclusion: Preoperative serum calcitonin and TMN stage, but not extent of operation, were independent predictors of postoperative normalization of serum calcitonin levels. Future studies should evaluate preoperative serum calcitonin levels as a determinate of the extent of initial operation. [Copyright &y& Elsevier]

Background: Studies have not established the optimal role for prophylaxis after surgery for Crohn''s disease. Some suggest treatment should be initiated within the first month after surgery, whereas others advocate targeted treatment after endoscopic recurrence. In the present study, we compared the efficacy of these competing approaches. Methods: One hundred and ninety-nine Crohn''s disease patients who underwent ileocecectomy between September 1993 and April 2008 were retrospectively divided into 3 groups based on treatment timing: immediate, tailored, and none. Groups were compared for differences in demographics, pathology, and surgical technique (Chi-square, ANOVA). Rate of symptomatic recurrence (Chi-square), and time to symptomatic recurrence were analyzed (log rank, multivariate Cox proportional hazards). Results: Sixty-nine (34.7%) received immediate prophylaxis, 32 (16.1%) received tailored prophylaxis, and 98 (49.3%) did not receive any prophylaxis. The groups were similar, though patients receiving immediate prophylaxis were younger and less likely to be lost to follow-up. At 5 years, 62 (31.2%) patients had endoscopic, 46 (23.1%) had symptomatic, and 22 (11%) had surgical recurrences. On simple univariate analysis, patients treated in a tailored fashion at time of endoscopic recurrence appeared more likely than patients treated with immediate prophylaxis to have symptomatic recurrence (43.7% vs 28.9%; P = .02), However, when censored for length of follow-up on multivariate analysis, the only enduring predictor of symptomatic recurrence was Charlson Comorbidity Index (P = .048). Timing of treatment, medicine used for immunoprophylaxis, age, history of prior resection, presence of active disease, and type of anastomosis were not predictive of symptomatic recurrence. Conclusion: Patients offered prophylaxis tailored to endoscopic recurrence have a similar time to symptomatic recurrence as those offered prophylaxis immediately. This suggests that a tailored treatment within a strict protocol of preemptive endoscopic surveilance may be reasonable. [Copyright &y& Elsevier]

Background: Historically, a high percentage of endocrine surgical procedures are performed by general surgeons in nonteaching environments. With the institution of accredited fellowships, we sought to determine whether that dynamic is changing. Materials and Methods: The American College of Surgeons—National Surgeons Quality Improvement Program was queried for all thyroid, parathyroid, and adrenal operations performed during 2005–2008. Resident assistance was classified as none, junior (postgraduate years 1–3), senior (postgraduate years 4 and 5) or fellow (≥ postgraduate year 6). Data were also examined for associations between resident/fellow assistance and surgical outcomes. Results: In all, 24.7% of endocrine operations (7,140/29,161) were performed by an attending surgeon operating alone (17.1% adrenals, 27.4% thyroids, and 20.6% parathyroids). Fellows assisted in 6.6% of operations (18.3% adrenals, 4.7% thyroids, and 8.2% parathyroids; 2006: 586 operations, 2007: 629 operations, and 2008: 720 operations). Comparing attending surgeons operating alone with those assisted by residents/fellows, they had shorter operative times (P < .001), longer surgical duration of stay (parathyroid: 1.73 days, thyroid: 1.80 days, P < .001), and a higher prevalence of obese, diabetic, or octogenarian patients. However, no significant difference was found in the rates of wound infections, medical complications, return to the operating room, or overall morbidity. Conclusion: Even with the increase in endocrine surgery fellowships, almost one fourth of all endocrine operations are still performed by attending surgeons operating alone. Although operations assisted by residents/fellows took longer and patients had a greater duration of stay, there were no significant differences in measured outcomes. [ABSTRACT FROM AUTHOR]

Background: B-RafV600E is a frequent mutation in anaplastic thyroid cancers and is a novel therapeutic target. We hypothesized that PLX4720 (an inhibitor of B-RafV600E) and thyroidectomy would extend survival and would decrease tumor burden in a mouse model. Methods: Orthotopic anaplastic thyroid tumors were induced in severe combined immunodeficient mice. Mice were treated with PLX4720 or vehicle after 7 days of tumor growth, and thyroidectomy or sham surgery was performed at day 14. The neck space was re-explored, and tumor volume was measured at day 35. Mice were sacrificed when they lost >25% of their initial weight. Results: All 5 mice that received the vehicle developed cachexia, had invasive tumors (average 61 mm3)and were sacrificed by day 35. All 6 mice receiving PLX4720 + sham had small tumors (average 1.3 mm3) and maintained their weight. Three out of 6 mice receiving PLX4720+thyroidectomy had no evidence of tumor at 35 days; the other 3 mice had small tumors (average 1.4 mm3) and showed no signs of metastatic disease. All mice treated with PLX4720 were alive and well-appearing at 50 days. Conclusion: Thyroidectomy with neoadjuvant PLX4720 could be an effective therapeutic strategy for early anaplastic thyroid cancers that harbor the B-RafV600E mutation and are refractory to conventional therapeutic modalities. [ABSTRACT FROM AUTHOR]

Background: Four-dimensional computed tomography (4D-CT) utilizes multiplanar images and perfusion characteristics to identify abnormal parathyroid glands. We assessed the role of 4D-CT in patients with inconclusive preoperative ultrasound and sestamibi localization studies. Methods: Adult patients with primary hyperparathyroidism with negative or discordant standard imaging who underwent both localization with 4D-CT and operative intervention for curative intent were included. Patient characteristics, 4D-CT scan results compared with operative findings, and curative proportion were assessed. Results: Of the 60 patients, 4D-CT accurately lateralized 73% and localized 60% of abnormal glands found at operation. Single candidate lesions (46/60) were confirmed at operation in 70%. When multiple lesions were identified on 4D-CT (14/60), accuracy dropped to 29% (P = .03). The accuracy of 4D-CT was not different between primary and reoperative cases (P = .79). Of the 8 patients with multigland disease diagnosed perioperatively, 5 had multiple candidate lesions noted on 4D-CT. In 94% (48/51) of patients, a >50% drop in intraoperative parathormone (IOPTH) level was achieved after resection and 87% (48/55) had long-term cure with a median follow-up of 221 days. Conclusion: 4D-CT identifies the more than half of abnormal parathyroids missed by traditional imaging and should be considered in cases with negative or discordant sestamibi and ultrasound. Bilateral exploration is warranted when multiple candidate lesions are reported on 4D-CT. Multigland disease remains a challenging entity. [ABSTRACT FROM AUTHOR]

This manuscript describes our technique for a minimally invasive ileoanal J-pouch procedure utilizing hand-assisted laparoscopy. We detail several important maneuvers that may be helpful to the surgeon faced with the challenge of a difficult laparoscopic pouch. [ABSTRACT FROM AUTHOR]

Background: The incidence of thyroid nodules increases with age and little information is available regarding the risks of thyroid surgery in elderly patients. The aim of this study was to determine whether thyroid surgery in patients ≥80 is associated with higher complication rates. Methods: Out of 3,568 patients undergoing thyroid surgery between July 2001 and October 2007 at a single institution, the records of 90 consecutive patients ≥80 years were reviewed retrospectively and compared with a cohort of 242 randomly selected patients aged 18–79, who underwent thyroid surgery during the same time period. Clinical variables included age, gender, pre-operative diagnosis, substernal component, previous surgery, final pathology, length of stay, comorbidities, American Society of Anesthesiologists (ASA) score, body mass index, postoperative complications, and mortality. Results: Preoperative indications for surgery included benign disease in 51% vs 39%, suspected malignancy in 19% vs 26%, and suspected follicular neoplasms in 30% vs 35% in the octogenarian patient group (≥80 years old) vs the younger patient cohort (P = NS). Octogenarians had 20% significant malignancy on final pathology vs 27% in the younger cohort (P = NS). The overall complication rate in the octogenarian group was 24% vs 9% in the younger cohort (P < .001). Male gender and ASA ≥3 were found to be independent risk factors for perioperative complications after thyroid surgery, while age alone was not. Conclusion: Age ≥80 is associated with higher morbidity after thyroid surgery, although not independently. Earlier operative intervention may be advised in those at high risk for disease progression, whereas follow-up strategies without operation may be advised for others. [Copyright &y& Elsevier]

Purpose: The impact of infliximab (IFX) on postoperative complications in surgical patients with Crohn's disease (CD) and ulcerative colitis (UC) is unclear. We examined a large patient cohort to clarify whether a relationship exists between IFX and postoperative complications.Methods: A total of 413 consecutive patients--188 (45.5%) with suspected CD, 156 (37.8%) with UC, and 69 (16.7%) with indeterminate colitis--underwent abdominal surgery at the Massachusetts General Hospital between January 1993 and June 2007. One hundred one (24.5%) had received preoperative IFX < or = 12 weeks before surgery. These patients were compared to those who did not receive IFX with respect to demographics, comorbidities, presence of preoperative infections, steroid use, and nutritional status. We then compared the cumulative rate of complications for each group, which included deaths, anastomotic leak, infection, thrombotic complications, prolonged ileus/small bowel obstruction, cardiac, and hepatorenal complications. Potential risk factors for infectious complications including preexisting infection, pathological diagnosis, and steroid or IFX exposure were further evaluated using logistic regression analysis.Results: Patients were similar with respect to gender (IFX = 40.6% men vs. non-IFX = 51.9%, p = 0.06), age (36.1 years vs. 37.8, p = 0.43), Charlson Comorbidity Index (5.3 vs. 5.7, p = 0.25), concomitant steroids (75.3% vs. 76.9%, p = 0.79), preoperative albumin level (3.3 vs. 3.2, p = 0.36), and rate of emergent surgery (3.0% vs. 3.5%, p = 1.00). IFX patients had higher rates of CD (56.4% vs. 41.9%, p = 0.02), concomitant azathioprine/6-mercaptopurine use (34.6% vs. 16.6%, p < 0.0001), and lower rates of intra-abdominal abscess (3.9% vs. 11%, p < 0.05). After surgery, the two groups had similar rates of death (2% vs. 0.3% p = 0.09), anastomotic leak (3.0% vs. 2.9%, p = 0.97), cumulative infections (5.97% vs. 10.1%, p = 1), thrombotic complications (3.6% vs. 3.0%, p = 0.06), prolonged ileus/small bowel obstructions (3.9 vs. 2.8, p = 0.59), cardiac complications (1% vs. 0.6%, p = 0.42), and hepatic or renal complications (1.0 vs. 0.6% p = 0.72). A logistic regression model was then created to assess the impact of IFX, as well as other potential risk factors, on the rates of cumulative postoperative infections. We found that steroids (odds ratio [OR] = 1.2, p = 0.74), IFX (OR 2.5, p = 0.14), preoperative diagnosis of CD (OR = 0.7, p = 0.63) or UC (OR = 0.6, p = 0.48), and preoperative infection (OR = 1.2, p = 0.76) did not affect rates of clinically important postoperative infections.Conclusions: Preoperative IFX was not associated with an increased rate of cumulative postoperative complications. [ABSTRACT FROM AUTHOR]

Background & Aims: Postoperative morbidity and mortality following a colectomy for ulcerative colitis (UC) has been primarily reported from tertiary care referral centers that perform a high volume of operations; however, the postoperative outcomes among nonselected hospitals are not known. We set out to evaluate postoperative morbidity and mortality using a nationally representative database and to determine the factors that influenced outcomes. Methods: We analyzed the 1995–2005 Nationwide Inpatient Sample to identify 7108 discharges for UC patients who underwent a total abdominal colectomy. The effects of hospital volume on postoperative morbidity and mortality were evaluated in logistic regression models adjusting for demographic and clinical factors. Results: Postoperative mortality and morbidity rates were 2.3% and 30.8%, respectively. Most operations were performed in low-volume hospitals that had an increased risk of death (adjusted odds ratio [aOR], 2.42; 95% confidence interval [CI]: 1.26–4.63). In-hospital mortality was increased in patients who were admitted emergently (aOR, 5.40; 95% CI: 3.48–8.40), aged 60–80 years (aOR, 8.70; 95% CI: 3.30–22.92), and those with Medicaid (aOR, 4.29; 95% CI: 2.13–8.66). Emergently admitted UC patients whose surgery was performed 6 days after their admission had significantly increased likelihood of in-hospital death (aOR, 2.12; 95% CI: 1.13–3.97). Conclusions: Postoperative mortality was lowest in hospitals that performed the highest volume of operations. Increasing the proportion of total colectomies performed in high-volume hospitals may improve clinical outcomes for patients with UC. [Copyright &y& Elsevier]

The timing and appropriateness of surgical treatment of sigmoid diverticular disease remain a topic of controversy. We have reviewed the current literature on this topic, focusing on issues related to the indications and types of surgery. Current evidence would suggest that elective surgery for diverticulitis can be avoided in patients with uncomplicated disease, regardless of the number of recurrent episodes. Furthermore, the need for elective surgey should not be influenced by the age of the patient. Operation should be undertaken in patients with severe attacks, as determined by their clinical and radiological evaluation. [ABSTRACT FROM AUTHOR]

The gut-enriched Krüppel-like factor (KLF4) and the ligand-bound thyroid hormone receptor (TR) have each been shown to play a critical role in mammalian gut development and differentiation. We investigated an interrelationship between these two presumably independent pathways using the differentiation marker gene, intestinal alkaline phosphatase (IAP). Transient transfections were performed in Cos-7 cells using luciferase reporter plasmids containing a 2.5 kb segment of the proximal human IAP 5′ regulatory region, as well as multiple deletions. Cells were cotransfected with TR and/or KLF4 expression vectors and treated±100 nmol/L thyroid hormone (T3). IAP reporter gene transactivation was increased independently by KLF4 (ninefold) and ligand-bound TRβ1 (sevenfold). Cells cotransfected with KLF4 and TRβ1 in the presence of T3 showed synergistic activation (70-fold). A similar pattern was seen with the other T3 receptor isoform, TRα1. The synergistic effect was lost with deletions of the T3 and KLF4 response elements in the IAP promoter and was completely or partially abolished in the case of mutant KLF4 expression vectors. The thyroid hormone receptor complex and KLF4 synergistically activate the enterocyte differentiation marker gene IAP, suggesting a previously unrecognized interrelationship between these two transcription factor pathways. [Copyright &y& Elsevier]

Enterocyte differentiation is thought to occur through the transcriptional regulation of a small subset of specific genes. A recent growing body of evidence indicates that post-translational modifications of chromatin proteins (histones) play an important role in the control of gene transcription. Previous work has demonstrated that one such modification, histone acetylation, occurs in an in vitro model of enterocyte differentiation, butyrate-treated HT-29 cells. In the present work, we sought to determine if the epigenetic signal of histone acetylation occurs in an identifiable pattern in association with the transcriptional activation of the enterocyte differentiation marker gene intestinal alkaline phosphatase (IAP). HT-29 cells were maintained under standard culture conditions and differentiated with sodium butyrate. The chromatin immunoprecipitation (ChIP) assay was used to compare the acetylation state of histones associated with specific regions of the IAP promoter in the two cell populations (undifferentiated vs. differentiated). Chromatin was extracted from cells and cleaved by sonication or enzymatic digestion to obtain fragments of approximately 200 to 600 base-pairs, as confirmed by polymerase chain reaction using primers designed to amplify the IAP segments of interest. The ChIP assay selects DNA sequences that are associated with acetylated histones by immunoprecipitation. Unbound segments represent DNA sequences whose histones are not acetylated. After immunoprecipitation, sequences were detected by radiolabeled polymerase chain reaction, and the relative intensity of the bands was quantified by densitometry. The relative acetylation state of histones at specific sites was determined by comparing the ratios of bound/unbound segments. We determined that in a segment of the IAP promoter between −378 and −303 base-pairs upstream from the transcriptional start site, the acetylation state of histone H3 increased twofold in the differentiated, IAP expressing cells, whereas that of histone H4 remained essentially constant. Additionally, at a distant site, between −1378 and −1303 base-pairs, the acetylation state of H3 and H4 did not change appreciably between the undifferentiated and differentiated cells. We conclude that butyrate-induced differentiation is associated with specific and localized changes in the histone acetylation state within the IAP promoter. These changes within the endogenous IAP gene may underlie its transcriptional activation in the context of the enterocyte differentiation program. ( J Gastrointest Surg 2003;7:237–245.) [Copyright &y& Elsevier]

The short-chain fatty acid (SCFA) butyrate is produced via anaerobic bacterial fermentation within the colon and is thought to be protective in regard to colon carcinogenesis. Although butyrate (C4) is considered the most potent of the SCFA, a variety of other SCFA also exist in the colonic lumen. Butyrate is thought to exert its cellular effects through the induction of histone hyperacetylation. We sought to determine the effects of a variety of the SCFA on colon carcinoma cell growth, differentiation and apoptosis. HT-29 or HCT-116 (wild-type and p21-deleted) cells were treated with physiologically relevant concentrations of various SCFA, and histone acetylation state was assayed by acid-urea-triton-X gel electrophoresis and immunoblotting. Growth and apoptotic effects were studied by flow cytometry, and differentiation effects were assessed using transient transfections and Northern blotting. Propionate (C3) and valerate (C5) caused growth arrest and differentiation in human colon carcinoma cells. The magnitude of their effects was associated with a lesser degree of histone hyperacetylation compared with butyrate. Acetate (C2) and caproate (C6), in contrast, did not cause histone hyperacetylation and also had no appreciable effects on cell growth or differentiation. SCFA-induced transactivation of the differentiation marker gene, intestinal alkaline phosphatase (IAP), was blocked by histone deacetylase (HDAC), further supporting the critical link between SCFA and histones. Butyrate also significantly increased apoptosis, whereas the other SCFA studied did not. The growth arrest induced by the SCFA was characterized by an increase in the expression of the p21 cell-cycle inhibitor and down-regulation of cyclin B1 (CB1). In p21-deleted HCT-116 colon cancer cells, the SCFA did not alter the rate of proliferation. These data suggest that the antiproliferative, apoptotic and differentiating properties of the various SCFA are linked to the degree of induced histone hyperacetylation. Furthermore, SCFA-mediated growth arrest in colon carcinoma cells requires the p21 gene. [ABSTRACT FROM AUTHOR]

Enterocytes at the tips of microvilli are more sensitive to an ischemic insult than those cells residing in the crypts, an effect thought to be due to a relative lack of collateral flow. We speculated that this increased cellular sensitivity to ischemia might be an intrinsic feature of the cells related to their differentiated phenotype. To test this hypothesis, enterocyte response to ischemia was determined using both in vivo and in vitro models. For the in vivo studies, male Sprague-Dawley rats underwent laparotomy, and small intestinal ischemia was induced by clamping the superior mesenteric artery for 30 or 60 minutes, after which reperfusion was allowed for various time points up to 4 days. Injury was assessed histologically, as well as with Northern blots, probing for the enterocyte differentiation markers intestinal alkaline phosphatase and lactase, as well as the gut-epithelial marker villin. Mucosal changes consistent with ischemia/reperfusion injury were evident—that is, a rapid inflammatory response followed by progressive villus cell loss beginning at the tips and progressing to the crypts, depending on the degree of insult, with an eventual return to normal microanatomy. Intestinal alkaline phosphatase and lactase were lost immediately after ischemia and returned with reperfusion, confirming that the differentiated cells are particularly sensitive to ischemic injury. The in vitro studies employed two separate models of enterocyte differentiation: sodium butyrate–treated HT-29 cells and Caco-2 cells maintained for 7 days after confluence. In both models, undifferentiated and differentiated cells were subjected to treatment with 2-deoxyglucose and oligomycin-A (in vitro model of ischemia) and apoptosis was assessed by fluorescence-activated cell sorting analysis. Differentiation of both cell lines resulted in a significantly greater apoptotic response to ischemia compared to undifferentiated cells exposed to an identical insult. We conclude that differentiated enterocytes may be inherently more sensitive to ischemia-induced injury than their undifferentiated counterparts. These findings call into question the popularly held belief that villus tip cells are more susceptible to ischemia because of their location relative to the microvascular anatomy. ( J Gastrointest Surg 2002;6:403–409.) [ABSTRACT FROM AUTHOR]

Thyroid hormone (T3) is an important regulator of gut mucosal development and differentiation, inducing intestinal alkaline phosphatase (IAP) and repressing lactase gene transcription. In contrast, cyclin D1 (CD1) appears to be a growth promoter in the gut, functioning to maintain the undifferentiated state. The present studies were designed to examine the effects of CD1 on T3 action within intestinal epithelia. Caco-2 cells were maintained in hypothyroid medium and transiently transfected with either rat lactase (3.0 kb) or human IAP (2.4 kb) luciferase (Luc) reporter plasmids. Coaansfections were carried out using two T3 receptor (TR) isoforms, TRW1 and TRβ-1, as well as plasmids expressing CDl, CD3, CA, or CB1. Cells were then treated ±10 nmol/L T3 for 24 hours and luciferase activity was determined. with T3 treatment, IAP-Luc activity was induced (TRα-1 = eightfold, TRβ-1 = ninefold), but these effects were dramatically inhibited (>50%) by CD1 and CD3. In contrast, CA and CBl did not alter T3-mediated IAP gene activation. The ability of CD1 and CD3 to inhibit T3 action was also tested in the context of the lactase gene, which is negatively regulated by T3. As expected, lactase reporter gene activity was repressed by T3 treatment in the case of both receptor isoforms, TRW1 = 30% and TRP-1 = 40%. In contrast to its effects on the IAP gene, CD1 did not inhibit T3-mediated changes in lactase reporter gene activity. The D-type cyclins (CD1 and CD3), but not CA or CB1, specifically inhibit T3-mediated activation of the IAP gene. In contrast, the D-type cyclins do not inhibit T3-mediated repression of the lactase gene. These studies have identified a novel molecular interaction that exists between the pathways of growth and differentiation within intestinal epithelia. [ABSTRACT FROM AUTHOR]

In the acute setting, patients with periappendiceal masses generally improve with broad-spectrum antibiotics with or without percutaneous catheter drainage, but whether or not to perform an interval appendectomy remains controversial. We have analyzed our experience over the past decade, comparing results from interval laparoscopic appendectomy (ILA) and interval open appendectomy (IOA). Medical records were reviewed for 56 patients who initially presented with the diagnosis of periappendiceal mass or abscess and who subsequently underwent interval appendectomy. Data were accumulated for both the initial hospitalization and interval appendectomy. Comparisons were made between period 1 (1987 to 1993) and period 2 (1994 to 1997). Follow-up data were obtained via telephone conversations with the patients. Patient characteristics with regard to age, sex, and comorbidities did not differ between the ILA and IOA groups. The number of patients undergoing CAT scan increased from 33% to 55%, whereas the initial hospital stay decreased from 7.42 to 4.61 days (P <0.001). The percentage of interval appendectomies performed by the laparoscopic method increased from 30% to 85%. The total operating room time did not differ (95 vs. 103 minutes), but die hospital stay was much shorter in the ILA group (0.55 vs. 3.07 days, P <0.001). There were no instances of intra-abdominal or wound infections in either group. In the later time period the mean hospital stay decreased to 0.38 days, with 59% of the operations performed on an outpatient basis. Following ILA, narcotic pain medication was used for an average of 1.3 days and the reported "time to return to full activities" was 2.5 days. ILA is a simple and safe procedure that can usually be performed on an outpatient basis. Given the minimal morbidity of the procedure, we believe that ILA should be considered for most patients who initially present with periappendiceal masses. [ABSTRACT FROM AUTHOR]

The role of laparoscopic appendectomy remains controversial since many authors have suggested that overall morbidity is primarily a function of the degree of appendicitis rather than the operative approach. We have reviewed our appendectomy experience to determine the advantages and/or disadvantages of the laparoscopic technique in cases of acute appendicitis, and furthermore to ascertain whether the extent of disease should affect the surgical approach used. Data were accumulated for all 1158 patients who underwent appendectomy at a single institution during the following three time periods that span the pre- and postlaparoscopic eras: period I (1987 to 1990), period II (1991 to 1993), and period III (1994 to 1997). Cases were categorized with regard to pathologic findings and operative approach (i.e., open or laparoscopic appendectomy). The percentage of appendectomies performed laparoscopically increased with time (0%, 27%, and 79% for periods I, II, and III, respectively). Overall, the total operating room time was slightly shorter for laparoscopic compared to open appendectomy (99 vs. 102 minutes; P <0.05). Operating room times for open appendectomy remained unchanged, but the times for laparoscopic appendectomy decreased from period II to period III (119 to 94 minutes; P <0.001). In cases of gangrenous/perforated appendicitis, the times for laparoscopic appendectomy were significantly shorter than those for open appendectomy (98/115 vs. 120/125 minutes; P <0.001 for both). Overall, the hospital stay was shorter for patients undergoing laparoscopic appendectomy (1.63 vs. 4.21 days; P <0.001), and the difference was maintained in all three time periods. The differences in length of hospital stay for laparoscopic vs. open appendectomy were most dramatic in gangrenous/perforated cases (1.8/3.0 vs. 4.0/9.0 days; P <0.001), whereas there was only a slight difference in cases of simple appendicitis, for example, 1.6 vs. 2.1 days (laparoscopic vs. open appendectomy, period III). There was a significant decrease in the percentage of perforated cases in which surgical treatment had been delayed (>8 hours) (21%, 5%, and 5%) over the three time periods, but the rate of "negative" appendectomies was similar (10%, 8%, and 8%). The complication rates following laparoscopic and open appendectomies during period II were 5.4% and 7.5%, respectively ( P >0.05). Laparoscopic appendectomy results in a marked decrease in the length of hospital stay and similar postoperative morbidity compared to open appendectomy. In cases of gangrenous or perforated appendicitis, laparoscopic appendectomy appears to be especially worthwhile in regard to both operating room time and hospital stay. [ABSTRACT FROM AUTHOR]

Enterocyte differentiation occurs along the crypt-villus axis and is generally thought to involve the transcriptional activation of cell-specific genes, among which is the brush-border structural protein villin. We have examined the molecular mechanisms of villin induction using both in vivo and in vitro systems. Total RNA was purified from rat tissues or cultured cells by the guanidinium thiocyanate method and Northern blot analyses carried out using radiolabeled complementary DNA probes specific for villin or the actin control. Transient transfection (calcium/phosphate method) assays were performed using a luciferase reporter gene containing 2 kb of the human villin gene 5'-flanking region. We have found that the villin mRNA was expressed at high levels in the small intestine, to a lesser degree in the colon, and was not detected in the brain or liver. In HT-29 cells, villin mRNA levels increased 2.5-fold (P<0.001) after 24 hours of sodium butyrate treatment, consistent with the process of enterocyte differentiation. Similarly, villin gene expression was induced in Caco-2 cells during postconfluence differentiation. Transient transfection assays demonstrated marked reporter gene activation (fourfold, P<0.001) in response to sodium butyrate in HT-29 cells, but no activation in the liver cell line HepG2. The effects of sodium butyrate were dose dependent, reaching a maximum at a concentration of 5 mmol/L. We conclude that a 2 kb region of the human villin gene is able to mediate its transcriptional activation during HT-29 cell differentiation. This DNA regulatory region appears to function in a cell type-specific (gut) manner. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has presented enormous societal challenges, and we in the health care field have found ourselves at the forefront of this crisis. A recent webinar that took place under the auspices of the SSAT Resident and Fellow Education Committee attracted over 400 registrants and provided both practical and important updates related to the impact of COVID-19 on surgery in the USA. In this manuscript, Fong et al. focus on a variety of challenges that we face in surgery and more broadly in health care, including those related to hospital operations, technology, and education. [Extracted from the article]

On behalf of the Editorial team of I The Journal of Gastrointestinal Surgery (JOGS) i , we are pleased to announce a new article type: Research Communications. We believe that this new article type will help serve our readership and reflects our mission to keep surgeons updated on the latest research in gastrointestinal surgery. Importantly, the findings suggest that adjuvant chemotherapy may not be needed in all T3N0 rectal cancer patients. [Extracted from the article]