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SUMMARY The persistence of health care disparities along racial and ethnic lines highlights the complex and multifactorial nature of this national concern. The paucity of physicians ethnically underrepresented in medicine to treat an ever-growing heterogeneous population inherently contributes to these ongoing disparities. The authors proposed an approach to improve the representation of physicians underrepresented in medicine in their plastic surgery residency program. With a renewed commitment to ethnic diversity and inclusion, a multifaceted recruitment and retention approach was implemented at the University of Pennsylvania plastic and reconstructive surgery residency program from 2015 to 2020 (5 academic years). A retrospective review of the demographics of the program's residents was then assessed over the past 9 academic years for comparison (2011 to 2020). The representation of underrepresented-in-medicine residents within the plastic and reconstructive surgery residency program steadily increased with the implementation of this multifaceted approach, reaching an unprecedented high. Currently, 29 percent of all residents are underrepresented in medicine and 29 percent are female, some of whom are also underrepresented in medicine. Although the female representation is on par with the national average, the underrepresented-in-medicine representation is far greater than the national average. As a result of this multifaceted approach, the representation of African American and Latino plastic surgery residents at the University of Pennsylvania now far exceeds current national averages. Unfortunately, the representation of Native American and Alaskan Natives is still lacking, despite the program's broadened recruitment efforts. The success of this experience describes a successful strategy that institutions can implement to enhance underrepresented-in-medicine representation among its plastic surgery trainees.

ImportanceVariation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities.ObjectiveTo simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery.Design, Setting, and ParticipantsThis economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022.ExposuresUsing hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient’s highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity.Main Outcomes and MeasuresThe primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals.ResultsA total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare.Conclusions and RelevanceIn this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.

Objective After COVID-19 rendered in-person meetings for national societies impossible in the spring of 2020, the leadership of the Association of Program Directors in Surgery (APDS) innovated via a virtual format in order to hold its national meeting. Design APDS leadership pre-emptively considered factors that would be important to attendees including cost, value, time, professional commitments, education, sharing of relevant and current information, and networking. Setting The meeting was conducted using a variety of virtual formats including a web portal for entry, pre-ecorded poster and oral presentations on the APDS website, interactive panels via a web conferencing platform, and livestreaming. Participants There were 298 registrants for the national meeting of the APDS, and 59 participants in the New Program Directors Workshop. The registrants and participants comprised medical students, residents, associate program directors, program directors, and others involved in surgical education nationally. Results There was no significant difference detected for high levels of participant satisfaction between 2019 and 2020 for the following items: overall program rating, topics and content meeting stated objectives, relevant content to educational needs, educational format conducive to learning, and agreement that the program will improve competence, performance, communication skills, patient outcomes, or processes of care/healthcare system performance. Conclusions A virtual format for a national society meeting can provide education, engagement, and community, and the lessons learned by the APDS in the process can be used by other societies for utilization and further improvement.

IMPORTANCE: Although men are increasingly involved in childrearing, little is known about paternity leave in surgical residency. Conflict between professional and family duties contribute to burnout and decreased career satisfaction for surgeons of both sexes. With men more likely than women to have children during their clinical years of surgical training, understanding the issues surrounding paternity leave is imperative to ensuring the longevity of our workforce. OBJECTIVE: To explore surgical program directors’ perspectives on the challenges of providing paternity leave. DESIGN, SETTING, AND PARTICIPANTS: This qualitative descriptive study of transcripts collected from semistructured interviews of US surgical program directors was performed from October 2018 to June 2019. Program directors were selected using purposive-stratified criterion-based sampling. Interviews were audio-recorded and transcribed verbatim, with emergent themes identified using content analysis. EXPOSURE: Paternity leave. MAIN OUTCOMES AND MEASURES: Program directors’ perspectives on paternity leave were categorized into common themes. RESULTS: A total of 40 US general surgery program directors were interviewed (28 male [70%]; mean [SD] age, 49.7 [6.8] years; 36 [90%] were university-based programs). Twenty (50%) reported providing paternity leave of 1-week duration. Five major themes were identified: (1) paternity leave policies are poorly defined by many programs and require self-initiation by residents; (2) residents often do not take the full amount of time offered for leave; (3) stigma against male residents taking parental leave is common and may be even greater than that facing women taking maternity leave; (4) paternity leave has little to no impact on colleagues’ workload owing to the brevity of time taken; and (5) men desire longer leave than what they are currently offered and wish to receive equal time off compared with childbearing parents. CONCLUSIONS AND RELEVANCE: Surgical program directors report male residents take brief paternity leave despite a desire for more time off, which may be influenced by fear of stigma and surgical culture that avoids handing off work, even for short periods of time. A cultural shift toward supporting family planning as a normal part of young adult life, rather than a medical condition to be accommodated, is necessary to promote life balance and behaviors that will sustain a long career in surgery. Implementation of defined leave policies at individual programs for the nonchildbearing parent is critical to make parental leave socially acceptable among surgical residents.

Background Hepatopancreatobiliary (HPB) Fellowship training in the Americas consists of 3 distinctive routes with variable curricula: Surgical Oncology Fellowship via the Society of Surgical Oncology (SSO), Abdominal Transplant Surgery Fellowship via the American Society of Transplant Surgeons (ASTS), and HPB Fellowship via the Americas Hepato-Pancreato-Biliary Association (AHPBA). Our objective was to establish a pan-American consensus among HPB surgeons, surgical oncologists, abdominal transplant surgeons, and general surgery residency program directors (GSPDs) on a core knowledge curriculum for HPB fellowship, and to identify topics appropriate for general surgery residency and subspecialty beyond HPB fellowship. Study Design A 3-round modified Delphi process was used. Baseline statements were developed by the Education and Training Committee of the AHPBA, in collaboration with representatives of the SSO, ASTS, and GSPDs. The expert panel, consisting of members of the 3 societies together with GSPDs, rated the statements on a 5-point Likert scale and suggested editing or adding new statements. A statement was included in the final curriculum when Cronbach’s alpha value was ≥ 0.8 and ≥ 80% of the panel agreed on inclusion. Results The response rate was 100% for the first round, and 98% for the second and third rounds. Eighty-nine of 138 proposed statements were included in the final HPB fellowship curriculum. Curricula for general surgery residency and subspecialty beyond HPB fellowship included 50 and 29 statements, respectively. Conclusions A multinational consensus on core knowledge for an HPB fellowship curriculum was achieved via the modified Delphi method. This core curriculum may be used to standardize HPB fellowship training across different pathways in the Americas.

Background The lack of underrepresented minorities has been a persistent issue within the surgical workforce. Equal sex representation has also been a problem in surgery. Underrepresented minorities females face the unique challenge of being a minority in both race and sex. Objective The objective of this retrospective cross-sectional study is to determine the racial and sex demographics of medical trainees and faculty and determine the degree to which minority women are underrepresented at higher ranks and leadership. Methods Race and sex demographic data for all medical students, surgical residents and faculty was extracted from the AAMC data files. This data was compared to the US population using chi squared tests. Race and sex breakdowns of the different surgical subspecialties was also analyzed using chi squared tests. Demographics of surgical faculty at various ranks are also reported. Results White men made up 37% of all surgical residents. Black men made up only 1.9% of all surgical residents whereas Black women made up 2.6%. The subspecialty with the smallest percentage of Black women was Orthopedic Surgery with 0.6%. The specialty with the highest representation of Black women was Ob/Gyn with 6.2%. There was a decrease in representation of Black women with each increase in professional rank, with 2.8%, 1.6%, and 0.7% for assistant, associate, and full professor, respectively, as compared to Black men, who as a percentage, remained stable at the various ranks with 2.1%, 2.4%, and 2.1% for assistant, associate, and full professor, respectively. Conclusions There is a striking lack of minority women in surgery. This trend is amplified as surgeons progress from student, to resident, to attending, and then to leadership positions.

Background Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients. Methods A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011–2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes. Results Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p Conclusions Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.

The preoperative assessment of patients with colorectal cancer (CRC) often requires a multidisciplinary approach, involving a complete endoscopic evaluation as well as both clinical and radiographic staging. In addition to providing a concrete diagnosis, histologic review by the pathologist imparts valuable information about tumor grade and other important prognostic features, which will be discussed in greater detail in this chapter. A thorough history and physical examination rounds out the initial evaluation and provides the surgeon with vital information that may influence operative planning.

In specialties with gender imbalance, such as general surgery, women faculty frequently receive lower teaching evaluation scores compared with men, which can affect academic advancement.We collected 1 year of anonymous resident-derived faculty teaching evaluations from 21 general surgery programs, along with resident, faculty, and department leadership gender complement. A composite evaluation score was calculated for each faculty. After accounting for within-program correlations, we compared male and female scores using the cluster-adjusted t-test to describe the respective mean differences with a 95% CI. Programs were divided into quartiles based on percent female faculty, female residents, and combined total females to detect associations between female representation and faculty teaching evaluation scores.The 21 programs yielded 20,187 teaching evaluations of 1,177 faculty. Women comprised 28% of the faculty, 47% of residents, 43% of program directors, and 19% of department chairs. Overall, women faculty had significantly higher evaluation scores than men (90.6% vs 89.5%, p 0.05). Female gender was associated with higher teaching evaluation scores compared with male faculty in the lowest quartiles for all combinations of women representation.This multi-institutional analysis of general surgical resident evaluations of faculty identified that female gender was associated with higher evaluation scores than men (although the difference was small). This unanticipated finding might reflect the slowly changing gender balance within general surgery and attitudes towards female faculty in a traditionally male-dominated field. Contrary to our hypothesis, female gender was associated with higher faculty evaluation scores at programs with fewer women faculty and fewer women residents.

Background This study compared adhesion reformation after open and laparoscopic adhesiolysis in a rat model. Methods Adhesions were induced by surgically creating ischaemic buttons on the peritoneal side wall. After 7 days the animals underwent laparoscopy with carbon dioxide insufflation or laparotomy to score and lyse adhesions. Peritoneal tissue and fluid were collected after 24 h in a subset of animals, and adhesion reformation was scored 7 days after lysis in the remainder. Tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI) 1, transforming growth factor (TGF) β1 and tumour necrosis factor (TNF) α mRNA, and total fibrinolytic activity were assessed. The abdomen of non-operated animals was insufflated for 7, 15 or 30 min with carbon dioxide, after which tPA and PAI-1 mRNA and total fibrinolytic activity were measured. Results Animals that underwent open adhesiolysis had 60 per cent fewer reformed adhesions than the laparoscopic adhesiolysis group (P < 0·001). There were no differences in tPA activity or tPA, PAI-1 and TNF-α mRNA between groups, but TGF-β1 mRNA levels were significantly increased in the open group. Carbon dioxide insufflation did not affect peritoneal tPA activity. Conclusion Open adhesiolysis may be more beneficial in minimizing adhesion reformation in the management of adhesion-related complications.

Ulcerative colitis (UC) can be treated with surgery or medications. Patients often must choose between long-term immunosuppressant therapy or total colectomy. Whether one of these treatment approaches has a mortality benefit is uncertain.To determine whether patients with advanced UC treated with elective colectomy have improved survival compared with those treated with medical therapy.Retrospective matched cohort study.Data from all 50 states for Medicaid beneficiaries (2000 to 2005), Medicare beneficiaries (2006 to 2011), and dual-eligible persons (2000 to 2011).830 patients with UC pursuing elective colectomy and 7541 matched patients with UC pursuing medical therapy.The primary outcome was time to death. Cox proportional hazards models were used to compare the survival of patients with advanced UC treated with elective colectomy or medical therapy. The models controlled for significant comorbid conditions through matched and adjusted analysis.The mortality rates associated with elective surgery and medical therapy were 34 and 54 deaths per 1000 person-years, respectively. Elective colectomy was associated with improved survival compared with long-term medical therapy (adjusted hazard ratio [HR], 0.67 [95% CI, 0.52 to 0.87]), although this result did not remain statistically significant in all sensitivity analyses. Post hoc analysis by age group showed improved survival with surgery in patients aged 50 years or older with advanced UC (HR, 0.60 [CI, 0.45 to 0.79]; P = 0.032 for age-by-treatment interaction).Retrospective nonrandomized analysis is subject to residual confounding. The source cohort was derived from different databases throughout the study. Sensitivity and secondary analyses had reduced statistical power.Elective colectomy seemed to be associated with improved survival relative to medical therapy among patients aged 50 years or older with advanced UC.National Institutes of Health and Agency for Healthcare Research and Quality.

Colon cancer remains a significant clinical problem worldwide and in the United States it is the third most common cancer diagnosed in men and women. It is generally accepted that most malignant neoplasms of the colon arise from precursor adenomatous polyps. This stepwise progression of normal epithelium to carcinoma, often with intervening dysplasia, occurs as a result of multiple sequential, genetic mutations-some are inherited while others are acquired. Malignant polyps are defined by the presence of cancer cells invading through the muscularis mucosa into the underlying submucosa (T1). They can appear benign endoscopically but the presence of malignant invasion histologically poses a difficult and often controversial clinical scenario. Emphasis should be initially focused on the endoscopic assessment of these lesions. Suitable polyps should be resected en-bloc, if possible, to facilitate thorough evaluation by pathology. In these cases, proper attention must be given to the risks of residual cancer in the bowel wall or in the surrounding lymph nodes. If resection is not feasible endoscopically, then these patients should be referred for surgical resection. This review will discuss the important prognostic features of malignant polyps that will most profoundly affect this risk profile. Additionally, we will discuss effective strategies for their overall management.

Perioperative fluid management of the colorectal surgical patient has evolved significantly over the last five decades. Older notions espousing aggressive hydration have been shown to be associated with increased complications. Newer data regarding fluid restriction has shown an association with improved outcomes. Management of perioperative fluid administration can be considered in three primary phases: In the preoperative phase, data suggests that avoidance of preoperative bowel preparation and avoidance of undue preoperative dehydration can improve outcomes. Although the type of intraoperative fluid given does not have a significant effect on outcome, data do suggest that a restrictive fluid regimen results in improved outcomes. Finally, in the postoperative phase of fluid management, a fluid-restrictive regimen, coupled with early enteral feeding also seems to result in improved outcomes.

Kaposi sarcoma (KS) is a vascular tumor associated with human herpesvirus 8 (HHV8) infections. The iatrogenic variant of KS frequently occurs in human immunodeficiency virus (HIV)-negative patients receiving prolonged immunosuppressive therapy. Isolated intestinal KS in the background of Crohn disease (CD) is exceeding rare, with only 2 reported cases in the literature since 1966. Here we report a case …

Oxidative stress has been implicated in intra-abdominal adhesion formation. Substance P, a neurokinin-1 receptor (NK-1R) ligand, facilitates leukocyte recruitment and reactive oxygen species (ROS) generation. We have shown in a rat model of adhesion formation that intraperitoneal administration of a NK-1R antagonist at the time of abdominal operation reduces postoperative adhesion formation. Thus we determined the effects of NK-1R antagonist administration on peritoneal leukocyte recruitment and oxidative stress within 24 h of surgery. Adhesions were induced in Wistar rats randomly assigned to receive the antagonist or vehicle intraperitoneally. Peritoneal tissue was isolated at 2, 4, 6, and 24 h after surgery for analysis of the oxidative stress biomarkers 8-isoprostane (8-IP), protein carbonyl, NADPH oxidase, myeloperoxidase (MPO), and ICAM-1 and VCAM-1 mRNAs. Total antioxidant capacity of peritoneal fluid was also determined. MPO, NADPH oxidase, 8-IP, and protein carbonyl were elevated ( P < 0.05) by 6 h. ICAM-1 mRNA was elevated ( P < 0.05) by 2 h, whereas VCAM-1 levels decreased ( P < 0.05) at 24 h. The NK-1R antagonist delayed the MPO rise and reduced ( P < 0.05) 8-IP levels by 6 h and ICAM-1 mRNA, VCAM-1 mRNA, and protein carbonyl at 2 h. The antagonist also increased ( P < 0.05) the antioxidant capacity of peritoneal fluid at all time points. These data further support a role for oxidative stress in adhesion formation and suggest that the NK-1R antagonist may limit adhesions, in part, by reducing postoperative oxidative stress through an inhibition of neutrophil recruitment and an increase in peritoneal fluid antioxidant capacity.

Objectives: The aims of this study were to determine if statins reduce adhesion formation in vivo and to identify the mechanism of action in vitro. Background: Intraperitoneal adhesions develop in up to 95% of patients following laparotomy. Adhesions are reduced by mechanisms that up-regulate fibrinolysis within the peritoneum. Statins promote fibrinolysis in the cardiovascular system and may play a role in the prevention of adhesions. Methods: Adhesions were induced in rats (n 102) using our previously described ischemic button model. Rats received vehicle (controls), lovastatin (30 mg/kg), or atorvastatin (30 mg/kg) as a single intraperitoneal dose at the time of laparotomy. Animals were killed and adhesions were quantified at day 7. Peritoneal fluid and tissue were collected at day 1 to measure tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) by real-time PCR and ELISA. To assess the effects of statins on wound healing, burst pressures were measured in anastomoses of the colon. The effects of lovastatin on tPA and PAI-1 production were measured in vitro in human mesothelial cells (HMC) in the presence or absence of mevalonate (MVA), geranylgeranyl-pyrophosphate (GGPP) and farnesylpyrophosphate (FPP), all intermediates in the cholesterol pathway downstream of HMG-CoA. The effect of a Rho protein inhibitor, exoenzyme C3 transferase, on tPA production was also determined. Results: Lovastatin and atorvastatin reduced adhesion formation by 26% and 58%, respectively (P 0.05), without affecting anastomotic burst pressure. At 24 hours, tPA mRNA levels in peritoneal tissue and tPA activity in peritoneal fluid from lovastatin-treated animals were increased by 57% and 379%, respectively (P 0.05), while PAI-1 levels were unchanged. HMC incubated with either lovastatin or atorvastatin showed concentration-dependent increases in tPA production and decreases in PAI-1 production (P 0.05). These lovastatin-induced changes in tPA and PAI-1 production were significantly reversed by the addition of MVA, GGPP, and FPP. The Rho protein inhibitor increased tPA production and rescued tPA production from the inhibitory effect of GGPP. Conclusion: These data suggest that statins administered within the peritoneum can up-regulate local fibrinolysis, while the in vitro studies show that this effect may be mediated, in part, by intermediates of the cholesterol biosynthetic pathway that regulate Rho protein signaling.