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Background: Natural orifice transluminal endoscopic surgery (NOTES), a recent development in the field of minimally invasive surgery, provides theoretical advantages over open and laparoscopic surgery. Challenges with the use of NOTES for colon resections include the need to extract a large specimen and perform an intestinal anastomosis. A transanal single-port laparoscopic proctectomy uses the potential advantages of NOTES yet provides easy specimen extraction and anastomosis.Methods: Fresh frozen then thawed human cadavers were used. Access was obtained via transanal mucosectomy, and a transanal endoscopic microsurgery (TEM) system was used to perform the proctectomy once the procedure was above the pelvic floor. After the peritoneal cavity was entered, a hand port was placed through the sphincter and above the pelvic floor. The left colon was mobilized using two 5-mm working ports and a 10-mm camera port for the flexible-tipped laparoscope that were placed through the hand port. The specimen was removed transanally.Results: The critical steps for an oncologic resection of the rectum were achieved using a combination of TEM and laparoscopic instrumentation transanally. The rectum and mesorectum were mobilized. The left ureter was identified and preserved, the inferior mesenteric artery (IMA) ligated at its origin, the inferior mesenteric vein ligated near the ligament of Treitz, the proximal colon mobilized for transanal extraction, the specimen resected proximal to the ligated IMA, and a hand-sewn coloanal anastomosis performed. Postresection examination showed preservation of the hypogastric nerves and an intact mesorectum. Challenges included maneuverability around the sacral promontory and length of the instruments. However, this was easily overcome by the use of long reticulating instruments and a flexible-tipped laparoscope.Conclusions: Transanal single-port low anterior resection using TEM and laparoscopic techniques is feasible and can maintain the principles of an oncologic resection. [ABSTRACT FROM AUTHOR]

Objective: Leadership is an important competency for surgical trainees but traditionally overlooked in residency programs. Existing leadership curricula are limited by a lack of standardized objectives and validated assessment tools. This project seeks to define the most essential leadership skills for surgical residents leading inpatient teams and to develop an instrument that can be used as a workplace-based assessment., Design: We surveyed the literature to compile a preliminary list of relevant leadership skills. We then recruited national experts in surgical resident leadership to participate in 2 rounds of a modified Delphi process. In the first round, panelists voted to keep, modify, or remove the preliminary items, or to add additional ones. Insufficient agreement to keep a skill necessitated revision. In the second round, panelists rated their agreement with revised items' inclusion, with consensus indicated by content validity index >0.75. Leadership behaviors were mapped onto a quality rating scale., Setting: REDCap online forms., Participants: Sixteen experts including senior surgeons, surgical educators/social psychologists, and advanced practice providers participated in both rounds of the Delphi process., Results: The preliminary list included 26 behaviors grouped into 9 domains. After the first round of the Delphi process, 18 items were modified, 3 were removed, 3 were added, and 2 domains were merged. After the second round, all 27 revised behaviors in 8 domains achieved consensus. We incorporated them into the Inpatient Leadership Assessment Device (I-LEAD)., Conclusions: We used a consensus of national experts to define essential leadership skills for surgical residents and created a workplace-based assessment tool. I-LEAD provides a shared mental model for residents and team members, and clear objectives for educators seeking to develop leadership curricula. These efforts align with current trends toward competency-based education and can underpin the establishment of formal leadership training programs for surgical residents on a wider scale., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Current training methods for surgical trainees are inadequate because they are costly, low-fidelity, or have a low skill ceiling. This work aims to expand available virtual reality training options by developing a VR trainer for straight coloanal anastomosis (SCA), one of the Colorectal Objective Structured Assessment of Technical Skills (COSATS) tasks., Methods: We developed a VR-based SCA simulator to evaluate trainees based on their performance. To increase the immersiveness, alongside the VR headset, we used haptics as the primary method of interaction with the simulation. We also implemented objective performance metrics to evaluate trainee performance throughout the simulation., Results: We presented our performance metrics to 27 participants for an Expert Consensus Survey (5-point Likert scale) and created weights for our metrics. The weighted average scores for the 24 task-specific metrics ranged from 3.5 to 5. Additionally, for the general metrics, the scores spanned from 3.3 to 4.6. In the second phase of our study, we conducted a study with 16 participants (novice n = 9, expert n = 7). Based on the performance, experts outperformed novices by 8.56% when referring to the total score (p = 0.0041). Three of the measurable metrics, purse suture (p = 0.0797), retracting the anvil (p = 0.0738), and inserting the colonoscope (p = 0.0738) showed a significant difference between experts and novices. Experts were smoother with their hand motions by 3.67% per second and took 70.77% longer paths to complete the same tasks., Conclusion: We created a high-fidelity coloanal anastomosis VR simulator. The simulator runs in real-time while allowing high immersion with a VR headset, deformable bodies, and a haptic device while providing objective feedback through performance metrics. Experts obtained higher scores throughout the simulation, including the quiz to demonstrate procedural knowledge, the metrics to demonstrate experience in steps/procedure, and control of their basic surgical skills and hand movements., Competing Interests: Declarations. Conflict of interest: George Westergaard, Jacob Barker, Drs. Alexis Desir, Ganesh Sankaranarayanan, Tansel Halic, Shruti Hegde, Amr Al Abbas, Javier Salgado Pogacnik, James W. Fleshman, Doga Demirel, and Suvranu De have no conflicts of interest or financial ties to disclose. Ethical approval: This study was approved by the University of Texas Southwestern Institutional Review Board (IRB # STU-2021–0202). Informed consent: Informed consent was obtained from all participants included in the study., (© 2024. CARS.)

Background: Perineal proctectomy is a complex procedure that requires advanced skills. Currently, there are no simulators for training in this procedure. As part of our objective of developing a virtual reality simulator, our goal was to develop and validate task-specific metrics for the assessment of performance for this procedure. We conducted a three-phase study to establish task-specific metrics, obtain expert consensus on the appropriateness of the developed metrics, and establish the discriminant validity of the developed metrics., Methods: In phase I, we utilized hierarchical task analysis to formulate the metrics. In phase II, a survey involving expert colorectal surgeons determined the significance of the developed metrics. Phase III was aimed at establishing the discriminant validity for novices (PGY1-3) and experts (PGY4-5 and faculty). They performed a perineal proctectomy on a rectal prolapse model. Video recordings were independently assessed by two raters using global ratings and task-specific metrics for the procedure. Total scores for both metrics were computed and analyzed using the Kruskal-Wallis test. A Mann-Whitney U test with Benjamini-Hochberg correction was used to evaluate between-group differences. Spearman's rank correlation coefficient was computed to assess the correlation between global and task-specific scores., Results: In phase II, a total of 23 colorectal surgeons were recruited and consensus was obtained on all the task-specific metrics. In phase III, participants (n = 22) included novices (n = 15) and experts (n = 7). There was a strong positive correlation between the global and task-specific scores (rs = 0.86; P < 0.001). Significant between-group differences were detected for both global (χ 2  = 15.38; P < 0.001; df = 2) and task-specific (χ 2  = 11.38; P = 0.003; df = 2) scores., Conclusions: Using a biotissue rectal prolapse model, this study documented high IRR and significant discriminant validity evidence in support of video-based assessment using task-specific metrics., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Guidelines are published for referral to genetic counseling and multigene panel genetic testing for colorectal cancer. We hypothesize that these guidelines are not recognized in practice, resulting in the underreferral of patients to genetic counseling. We aimed to investigate the clinical impact of these guidelines., Methods: This was a retrospective cohort study conducted using a single academic-institution colorectal cancer patient registry. The registry included all patients ≥18 years old with a pathologic diagnosis of colon cancer, rectal cancer, or polyposis from January 2018 to January 2020 with complete chart data to determine inclusion into the genetic referral cohort., Results: Out of 225 colon cancer patients, 92 met criteria for referral to genetic testing, but only 56 patients obtained referral and 39 completed testing. For rectal cancer, 29 out of 127 patients met criteria for referral, but only 11 obtained referral and 8 completed testing. Actionable variants, defined as pathogenic or likely pathogenic, were identified in 18 colon cancer and 5 rectal cancer patients. Age made a significant difference in the referral rate for colon cancer ( P  = 0.02) but not rectal cancer ( P  > 0.05)., Conclusion: Our study demonstrates poor adherence to guideline-based genetic testing. These data emphasize the need for more consistent referral to genetic testing for diagnosis of underlying inherited cancer syndromes., Competing Interests: The authors report no funding or conflicts of interest. All data generated or analyzed during this study are readily available upon request. Previously presented at the American Society of Colon and Rectal Surgeons Annual Scientific Meeting in Tampa, Florida, April 28, 2022–May 2, 2022., (Copyright © 2024 Baylor University Medical Center.)

Objective: The leadership team invited surgical team members to participate in educational sessions that created self and other awareness as well as gathered baseline information about these topics: communication, conflict management, emotional intelligence, and teamwork., Design: Each educational session included an inventory that was completed to help participants understand their own characteristics and the characteristics of their team members. The results from these inventories were aggregated, relationships were identified, and the intervention was evaluated., Setting: A level 1 trauma center, Baylor Scott and White Health, in central Texas; a 636-bed tertiary care main hospital and an affiliated children's hospital., Participants: An open invitation for all surgical team members yielded 551 interprofessional OR team members including anesthesia, attending physicians, nursing, physician assistants, residents, and administration., Results: Surgeons' communication styles were individual focused, while other team members were group focused. The most common conflict management mode for surgical team members on average was avoiding, and the least common was collaborating. Surgeons primarily used competing mode for conflict management, with avoiding coming in a close second. Finally, the 5 dysfunctions of a team inventory revealed low accountability scores, meaning the participants struggled with holding team members accountable., Conclusions: Helping team members understand their own and others' strengths and blind spots will help create opportunity for more purposeful and clear communication. Additionally, this knowledge should improve efficiency and safety in the high-stakes environment of the operating room., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs., Methods: We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance., Results: Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated., Conclusions: Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted., (Copyright © 2023. Published by Elsevier Inc.)

Background: Assessing performance automatically in a virtual reality trainer or from recorded videos is advantageous but needs validated objective metrics. The purpose of this study is to obtain expert consensus and validate task-specific metrics developed for assessing performance in double-layered end-to-end anastomosis., Materials and Methods: Subjects were recruited into expert (PGY 4-5, colorectal surgery residents, and attendings) and novice (PGY 1-3) groups. Weighted average scores of experts for each metric item, completion time, and the total scores computed using global and task-specific metrics were computed for assessment., Results: A total of 43 expert surgeons rated our task-specific metric items with weighted averages ranging from 3.33 to 4.5 on a 5-point Likert scale. A total of 20 subjects (10 novices and 10 experts) participated in validation study. The novice group completed the task significantly more slowly than the experienced group (37.67 ± 7.09 vs 25.47 ± 7.82 min, p = 0.001). In addition, both the global rating scale (23.47 ± 4.28 vs 28.3 ± 3.85, p = 0.016) and the task-specific metrics showed a significant difference in performance between the two groups (38.77 ± 2.83 vs 42.58 ± 4.56 p = 0.027) following partial least-squares (PLS) regression. Furthermore, PLS regression showed that only two metric items (Stay suture tension and Tool handling) could reliably differentiate the performance between the groups (20.41 ± 2.42 vs 24.28 ± 4.09 vs, p = 0.037)., Conclusions: Our study shows that our task-specific metrics have significant discriminant validity and can be used to evaluate the technical skills for this procedure., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Task-specific metrics facilitate the assessment of surgeon performance. This 3-phased study was designed to (1) develop task-specific metrics for stapled small bowel anastomosis, (2) obtain expert consensus on the appropriateness of the developed metrics, and (3) establish its discriminant validity., Methods: In Phase I, a hierarchical task analysis was used to develop the metrics. In Phase II, a survey of expert colorectal surgeons established the importance of the developed metrics. In Phase III, to establish discriminant validity, surgical trainees and surgeons, divided into novice and experienced groups, constructed a side-to-side anastomosis on porcine small bowel using a linear cutting stapler. The participants' performances were videotaped and rated by 2 independent observers. Partial least squares regression was used to compute the weights for the task-specific metrics to obtain weighted total score., Results: In Phase II, a total of 45 colorectal surgeons were surveyed: 28 with more than 15 years, 13 with 5 to 15 years, and 4 with less than 5 years of experience. The consensus was obtained on all the task-specific metrics in the more experienced groups. In Phase III, 20 subjects participated equally in both groups. The experienced group performed better than the novice group regardless of the rating scale used: global rating scale (p = 0.009) and the task-specific metrics (p = 0.012). After partial least squares regression, the weighted task-specific metric score continued to show that the experienced group performed better (p < 0.001)., Conclusion: Task-specific metric items were developed based on expert consensus and showed good discriminant validity compared with a global rating scale between experienced and novice operators. These items can be used for evaluating technical skills in a stapled small bowel anastomosis model., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical site infections are a major preventable source of morbidity, mortality, and increased health care expenditures after colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections., Objective: This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures., Design: This is a retrospective observational study., Setting: This study was conducted at a tertiary teaching hospital in Dallas., Patients: Adults undergoing colectomy or proctectomy between July 2012 and July 2019 were included., Main Outcome Measures: The primary outcomes measured were preoperative antibiotic choice and surgical site infection., Results: Among 2198 patients included in the study, 12.26% (n = 307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%; p < 0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics than patients who did not report a penicillin allergy (79.8% vs 96.7%, p < 0.001). Overall, 143 (6.5%) patients had surgical site infections. On multivariable logistic regression, there was no difference in rates of surgical site infection between patients with penicillin allergy vs those without penicillin allergy (adjusted OR 1.14; 95% CI, 0.71-1.82)., Limitations: A limitation of this study was its retrospective study design., Conclusions: Self-reported penicillin allergy among patients undergoing colorectal surgery is common; however, only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non-beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients, and these patients can be safely prescribed non-beta-lactam antibiotics without negatively impacting surgical site infection rates. See Video Abstract at http://links.lww.com/DCR/B838 .IMPACTO DE LA ALERGIA A LA PENICILINA INFORMADA POR EL PACIENTE EN LA PROFILAXIS ANTIBIÓTICA Y LA INFECCIÓN DEL SITIO OPERATORIO ENTRE PACIENTES DE CIRUGÍA COLORECTAL., Antecedentes: Las infecciones del sitio operatorio son una de las principales fuentes prevenibles de morbilidad, mortalidad y aumento del gasto sanitario después de cirugía colorrectal. Es posible que los pacientes con alergia a la penicilina no reciban los antibióticos preoperatorios recomendados, lo que los pone en mayor riesgo de infecciones en el sitio operatorio., Objetivo: Este estudio tuvo como objetivo evaluar el impacto de la alergia a la penicilina informada por el paciente sobre la profilaxis antibiótica preoperatoria y las tasas de infección del sitio operatorio entre pacientes sometidos a procedimientos mayores de colon y recto., Diseo: Estudio observacional retrospectivo., Ajuste: Hospital universitario terciario en Dallas., Pacientes: Adultos sometidos a colectomía o proctectomía entre julio de 2012 a julio de 2019., Principales Medidas De Desenlace: Elección de antibióticos preoperatorios e infección del sitio operatorio., Resultados: Entre los 2198 pacientes incluidos en el estudio, el 12,26% (n = 307) informó alergia a la penicilina. Los pacientes con alergia a la penicilina tenían más probabilidades de ser blancos (82%) y mujeres (54%) ( p < 0,01). El tipo más común de reacción alérgica notificada fue erupción cutánea (36,5%), mientras que el 7,2% de los pacientes notificó anafilaxia. Los pacientes con alergia a la penicilina autoinformada tenían menos probabilidades de recibir antibióticos betalactámicos en comparación con los pacientes que no informaron alergia a la penicilina (79,8% frente a 96,7%, p < 0,001). En general, hubo 143 (6,5%) pacientes con infecciones del sitio operatorio. En la regresión logística multivariable no hubo diferencias en las tasas de infección del sitio operatorio entre los pacientes con alergia a la penicilina frente a los que no tenían alergia a la penicilina (razón de probabilidades ajustada 1,14; intervalo de confianza del 95%, 0,71-1,82)., Limitaciones: Diseño de estudio retrospectivo., Conclusiones: La alergia a la penicilina autoinformada entre los pacientes de cirugía colorrectal es común, sin embargo, solo un pequeño número de estos pacientes informan reacciones adversas graves. Los pacientes con alergia a la penicilina autoinformada tienen menos probabilidades de recibir antibióticos betalactámicos y más probabilidades de recibir antibióticos no betalactámicos. Sin embargo, esto no afecta la tasa de infección del sitio quirúrgico entre estos pacientes y se les puede recetar de forma segura con antibióticos no betalactámicos sin afectar negativamente las tasas de infección del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B838 . (Traducción-Dr. Juan Carlos Reyes )., (Copyright © The ASCRS 2021.)

The surgical treatment of breast cancer has rapidly evolved over the past 50 years, progressing from Halsted's radical mastectomy to a public campaign of surgical options, aesthetic reconstruction, and patient empowerment. Sparked by the research of Dr. Bernard Fisher and the first National Surgical Adjuvant Breast and Bowel Project trial in 1971, the field of breast surgery underwent significant growth over the next several decades, enabling general surgeons to limit their practices to the breast. High surgical volumes eventually led to the development of the first formal breast surgical oncology fellowship in a large community-based hospital at Baylor University Medical Center in 1982. The establishment of the American Society of Breast Surgeons, as well as several landmark clinical trials and public campaign efforts, further contributed to the advancement of breast surgery. In 2003, the Society of Surgical Oncology (SSO), in partnership with the American Society of Breast Surgeons and the American Society of Breast Disease, approved its first fellowship training program in breast surgical oncology. Since that time, the number of American fellowship programs has increased to approximately 60 programs, focusing not only on training in breast surgery, but also in medical oncology, radiation oncology, pathology, breast imaging, and plastic and reconstructive surgery. This article focuses on the happenings in the United States that led to the transition of breast surgery from a subset of general surgery to its own specialized field., Competing Interests: The authors declare that they have no potential conflicts of interest or financial relationships., (Copyright © 2022 Lauren Zammerilla Westcott et al.)

Background: Thousands of cancer surgeries were delayed during the peak of the COVID-19 pandemic. This study examines if surgical delays impact survival for breast, lung and colon cancers., Methods: PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science were searched. Articles evaluating the relationship between delays in surgery and overall survival (OS), disease-free survival (DFS) or cancer-specific survival (CSS) were included., Results: Of the 14,422 articles screened, 25 were included in the review and 18 (totaling 2,533,355 patients) were pooled for meta-analyses. Delaying surgery for 12 weeks may decrease OS in breast (HR 1.46, 95%CI 1.28-1.65), lung (HR 1.04, 95%CI 1.02-1.06) and colon (HR 1.24, 95%CI 1.12-1.38) cancers. When breast cancers were analyzed by stage, OS was decreased in stages I (HR 1.27, 95%CI 1.16-1.40) and II (HR 1.13, 95%CI 1.02-1.24) but not in stage III (HR 1.20, 95%CI 0.94-1.53)., Conclusion: Delaying breast, lung and colon cancer surgeries during the COVID-19 pandemic may decrease survival., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials., Objective: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection., Design: We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years., Settings: This was a multicenter trial., Patients: Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge., Intervention: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy., Main Outcome Measures: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention., Results: This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34)., Limitations: The predetermined sample size to adequately reduce the risk of type II error was not achieved., Conclusions: Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560., Valoracin De La Irrigacin De Lado Izquierdo/reseccin Anterior Baja Pilar Iii Un Estudio Aleatorizado, Controlado, Paralelo Y Multicntrico Que Evala Los Resultados De La Irrigacin Con Pinpoint Imgenes De Fluorescencia Cercana Al Infrarrojo En La Reseccin Anterior Baja: ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero)., (Copyright © The ASCRS 2021.)

Background: Enhancing cognitive load while performing a bimanual surgical task affects performance. Whether repeated training under this condition could benefit performance in an operating room was tested using a virtual reality simulator with cognitive load applied through two-digit math multiplication questions., Method: 11 subjects were randomized to Control, VR and VR + CL groups. After a pre-test, VR and VR + CL groups repeated the peg transfer task 150 times over 15 sessions with cognitive load applied only for the last 100 trials. After training, all groups took a post-test and two weeks later the retention test with and without cognitive load and the transfer task on a pig intestine of 150 cm long under cognitive load., Results and Conclusion: Mixed ANOVA analysis showed significant differences between the control and VR and VR + CL groups (p = 0.013, p = 0.009) but no differences between the VR + CL and the VR groups (p = 1.0). GOALS bimanual dexterity score on transfer test show that VR + CL group outperformed both Control and VR groups (p = 0.016, p = 0.03). Training under cognitive load benefitted performance on an actual surgical task under similar conditions., Competing Interests: Declaration of competing interest Drs. Sankaranarayanan, Wells, Leeds, Chauhan, Fleshman, Jones, De and Mr. Odlozil have no disclosures to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: Conflict of Interest None declared.

Surgical training can be compared with a functioning military unit with chain of command, responsibility/accountability relationship, and graduated leadership assignments. Proficiency, commitment, communication, consistency, ownership, relationships, confidence, humility, feedback and evaluation, exemplary behavior, empathy, and humanity are all aspects of leadership. Leadership skills developed in the protected environment of residency are the basis for a successful career., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Leaders are held to the highest of standards in both performance and ethics. The same is true for leaders in medicine. Thus, medical leaders must give attention to ethical development as well as performance development. Virtue ethics provide a way for the leader to develop ethically. Virtue ethics is the oldest form of ethics. Although other ethical approaches focus on external considerations, virtue ethics focuses on the inward development of character. Following the examples of virtuous people and developing habits of virtue are critical with this approach. The cardinal virtues of prudence, courage, temperance, and justice are considered the most important. Specific virtue lists have also been developed for medical practitioners. All of these virtues can contribute to the enhancement of leadership skills. The virtue approach is especially helpful for leaders because it motivates one to excel in whatever endeavor pursued, whether medicine, leadership, relationships, or life., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

There are few topics of more importance in health care today than surgical leadership. The surgical leader will need to organize and maintain a collective effort if the organization is going to be effective. Health care teams work in a volatile, uncertain, complex, and ambiguous ecosystem. Therefore, surgeons must develop skills beyond the operating room. The facilitative leader will lead from the middle, not the top. They will empower coworkers to participate in creating a vision by building consensus, developing teams, clarifying roles, and earning the loyalty and trust of their colleagues. Surgical leaders will use communication as the vehicle for their success, including intentional listening, asking open-ended questions, and creating dialog instead of argumentative exchanges. The future of health care belongs to the physicians who are investing the time and effort today to become leaders., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

The role of a surgeon is inherently that of a leader and as women become a larger minority in surgical specialties, the next step becomes greater representation of women in positions of surgical leadership. Leadership is a relationship of granting and claiming wherein society must accept that women are deserving of leadership and women must realize their rightfulness to lead. Implicit gender bias undermines this relationship by perpetuating traditional gender norms of women as followers and not as leaders. Though female representation in academia and leadership has increased over the past few decades, this process is unacceptably slow, in part due to manifestations of implicit bias including discrimination within academia, pay inequality, and lack of societal support for childbearing and childcare. The women who have achieved leadership roles are testament to woman's rightfulness to lead and their presence serves to encourage other young professional women that success is possible despite these challenges., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

The surgeon acts as a manager in the operating room, ward, classroom, and in daily life to control time. Skills cross all boundaries of medicine with specific needs in each area. Without leadership skills the nonmedical aspect of practice becomes more difficult and can make the physician less successful. Learning to manage, therefore, becomes critical., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Leadership training is an essential component of faculty development and resident training. Characteristics of leaders include growth mindset, curiosity, humility, selflessness, intrinsic motivation, hunger to achieve, insight, collaboration, harmony, introversion and analytical approach (inherited) and emotional intelligence, empathy, flexibility, adaptability, conflict management, resilience, interpersonal skills, and judgment (learned). Training for each of these characteristics will enhance the leadership abilities of the surgical department., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Research has identified emotional intelligence as the ability to understand and manage emotions. This is especially important for surgical leaders who must interact constructively with teams, administrators, patients, colleagues, and the community. Conventional intelligence emphasizes the rational and analytical brain. When one becomes aware of emotional intelligence, it adds to the repertoire of the surgical leader. It gives them insight into the dynamics of interpersonal relationships. This will allow the surgeon to control the emotional side of communication. Specifically, emotional intelligence focuses on self-awareness, self-management, social skills, and resiliency. With these skills, they are able to modulate their leadership style, allowing for increased conflict management and persuasiveness, more effective change management, and consensus-building. Emotional intelligence is not innate; these are learned skills. With practice and attention, it is possible to acquire the skills to enhance relationships., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Surgery is a very complex, changing, and, sometimes, threatening environment. Emotional intelligence is a key skill for surgical leaders. Authoritarian, hierarchical, transactional, transformational, adaptive, situational, and servant-shepherd leadership can all be used in surgical leadership. Patient care must be the priority for surgical leaders., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Informal leaders in nursing, medical specialties, and administration positively impact the success of an institution. Developing all members of the team as leader then becomes important, especially in the area of nursing. The result is less need for management and control and more individual self-motivated participation in quality improvement., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Leadership in the operating room requires the ability to adopt different styles under specific circumstances. Transformational leadership grows the team. The style used to guide the team can vary; coercive, visionary, affiliative, democratic, pacesetting, and coaching are all important styles in team leadership. The ability to adapt to different needs in the operating room by using the appropriate style is leadership., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Pragmatic clinical research is part of five focus areas of the Challenges in IBD research document, which also includes preclinical human IBD mechanisms, environmental triggers, novel technologies, and precision medicine. The Challenges in IBD research document provides a comprehensive overview of current gaps in inflammatory bowel diseases (IBD) research and delivers actionable approaches to address them. It is the result of multidisciplinary input from scientists, clinicians, patients, and funders, and represents a valuable resource for patient centric research prioritization. In particular, the pragmatic clinical research section is focused on highlighting gaps that need to be addressed in order to optimize and standardize IBD care. Identified gaps include: 1) understanding the incidence and prevalence of IBD; 2) evaluating medication positioning to increase therapeutic effectiveness; 3) understanding the utility of therapeutic drug monitoring (TDM); 4) studying pain management; and 5) understanding healthcare economics and resources utilization. To address these gaps, there is a need to emphasize the use of emerging data sources and real-world evidence to better understand epidemiologic and therapeutic trends in IBD, expanding on existing data to better understand how and where we should improve care. Proposed approaches include epidemiological studies in ethnically and geographically diverse cohorts to estimate incidence and prevalence of IBD and impact of diversity on treatment patterns and outcomes. The implementation of new clinical trial design and methodologies will be essential to evaluate optimal medication positioning, appropriate use of TDM in adults and children, and multidisciplinary approaches to IBD pain management and its impact on healthcare resources., (© 2019 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: SAGES FUSE curriculum provides didactic knowledge on OR fire prevention. The objective of this study is to evaluate the impact of an immersive virtual reality (VR)-based OR fire training simulation system in combination with FUSE didactics., Methods: The study compared a control with a simulation group. After a pre-test questionnaire that assessed the baseline knowledge, both groups were given didactic material that consists of a 10-min presentation and reading materials about precautions and stopping an OR fire from the FUSE manual. The simulation group practiced on the OR fire simulation for one session that consisted of five trials within a week from the pre-test. One week later, both groups were reassessed using a questionnaire. A week after the post-test both groups also participated in a simulated OR fire scenario while their performance was videotaped for assessment., Results: A total of 20 subjects (ten per group) participated in this IRB approved study. Median test scores for the control group increased from 5.5 to 9.00 (p = 0.011) and for the simulation group it increased from 5.0 to 8.5 (p = 0.005). Both groups started at the same baseline (pre-test, p = 0.529) and reached similar level in cognitive knowledge (post-test, p = 0.853). However, when tested in the mock OR fire scenario, 70% of the simulation group subjects were able to perform the correct sequence of steps in extinguishing the simulated fire whereas only 20% subjects in the control group were able to do so (p = 0.003). The simulation group was better than control group in correctly identifying the oxidizer (p = 0.03) and ignition source (p = 0.014)., Conclusions: Interactive VR-based hands-on training was found to be a relatively inexpensive and effective mode for teaching OR fire prevention and management scenarios.

Purpose: Preoperative short-course radiation therapy (SCRT) has rarely been used for rectal cancer in the United States, although 2 randomized phase 3 trials demonstrate equivalence to conventional chemoradiation (CRT), and recent updates to national guidelines include this regimen as a treatment option. We sought to evaluate the efficacy and safety of preoperative SCRT followed by immediate surgery within 1 week to treat rectal cancer in the US setting., Methods and Materials: All patients treated with preoperative SCRT (4 Gy × 5 fractions for total 20 Gy) followed by planned surgery within 1 week at our institution were retrospectively evaluated. Censored cases with ≥2 years of follow-up were included along with any disease failure or death. Patients with cM1 disease were excluded. Patients with yp stage II/III disease typically received adjuvant chemotherapy from the 1990s onwards. The primary outcomes were actuarial (Kaplan-Meier) 5-year locoregional control (LC), disease-free survival (DFS), and overall survival (OS) as well as late severe (greater than or equal to grade 3) toxicity., Results: Our analysis included 202 consecutive patients with clinical stage I-III disease treated from 1977 through 2011. Median follow-up was 6.5 years (range, 2-29.2). Five-year disease outcomes were 95.9% ± 1.5% for LC, 76.4% ± 3.1% for DFS, and 84.6% ± 2.6% for OS. For patients with locally advanced rectal cancer (cT3-4 and/or cN+), 5-year LC, DFS, and OS were 95.1% ± 2.1%, 73.3% ± 4.3%, and 80.6% ± 3.7%, respectively. The late severe toxicity rate was 11.4%., Conclusions: SCRT followed by immediate surgery is a safe and effective treatment for patients with rectal cancer in the United States. Though SCRT has not been widely adopted, recent updates to the national guidelines for rectal cancer as well as financial pressures to reduce healthcare costs may lead to increased utilization of this treatment regimen in the future., (Copyright © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Background and Objectives: The routine use of preoperative bowel preparation (BP) is heavily debated in the colorectal surgery literature. To date, no study has investigated the effect preoperative BP has on patients with an established anastomotic leak. We therefore seek to compare the severity of patient morbidity and mortality in patients with a known anastomotic leak based on type of preoperative BP using the Targeted Colectomy American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP)., Methods: All elective colon cancer operations performed with primary anastomosis were identified within the targeted colectomy database from 2012 to 2013. Patients who experienced a postoperative anastomotic leak were identified and stratified based on preoperative BP. Variables that had an association with mechanical BP at P < 0.10 were included in a multivariate logistic regression model to determine if BP was independently associated with postoperative morbidity and mortality., Results: A total of 6,297 patients underwent elective colon resection with primary anastomosis for colon cancer. Two hundred and nineteen (3.5%) patients experienced an anastomotic leak. Thirty-day wound morbidity and mortality was not worse in patients who underwent preoperative BP., Conclusions: BP is not associated with worse patients outcomes in those patients with an established anastomotic leak following elective colon research with primary anastomosis. J. Surg. Oncol. 2016;114:810-813. © 2016 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: There is excellent evidence that surgical safety checklists contribute to decreased morbidity and mortality., Objective: The purpose of this study was to develop a surgical checklist composed of the key phases of care for patients with rectal cancer., Design: A consensus-oriented decision-making model involving iterative input from subject matter experts under the auspices of The American Society of Colon and Rectal Surgeons was designed., Settings: The study was conducted through meetings and discussion to consensus., Patients: Patient data were extracted from an initial literature review., Main Outcome Measures: The checklist was measured by its ability to improve care in complex rectal surgery cases by reducing the possibility of omission through the division of treatment into 3 distinct phases., Results: The process generated a 25-item checklist covering the spectrum of care for patients with rectal cancer who were undergoing surgery., Limitations: The study was limited by its lack of prospective validation., Conclusions: The American Society of Colon and Rectal Surgeons rectal cancer surgery checklist is composed of the essential elements of preoperative, intraoperative, and postoperative care that must be addressed during the surgical treatment of patients with rectal cancer.

Background: The surgical management of colitis-associated rectal cancer (CARC) is not well defined. This study determines outcomes after surgery for CARC compared with sporadic rectal cancer., Materials and Methods: This is a retrospective cohort study comparing 27 patients with CARC with 54 matched patients with sporadic cancer. Matching criteria included age, gender, neoadjuvant chemoradiation, and American Joint Committee on Cancer stage. Outcome measures were disease-free and overall survival, tumor characteristics, and postoperative morbidity., Results: Compared to those with sporadic rectal cancer, patients with CARC underwent proctocolectomy more frequently (21 [78%] versus 6 [22%] P < 0.001) and were more likely to have mucinous tumors (11 [40.7%] versus 12 [22.3%] P = 0.03). Overall 3-y survival was significantly reduced in CARC patients compared with patients with sporadic rectal cancer. Those with CARC undergoing segmental proctectomy only demonstrated reduced overall and disease-free survival compared to patients with sporadic rectal cancer and to colitis patients undergoing proctocolectomy (P = 0.002)., Conclusions: Patients with CARC undergoing proctectomy demonstrate reduced disease-free survival versus those undergoing proctocolectomy, and versus patients with sporadic rectal cancer undergoing proctectomy. These findings warrant further study and suggest that proctocolectomy should be considered the preferred surgical approach for CARC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Upper intestinal leaks and perforations are associated with high morbidity and mortality rates. Despite the growing experience using endoscopically placed stents, the treatment of these leaks and perforations remain a challenge. Endoluminal vacuum (E-Vac) therapy is a novel treatment that has been successfully used in Germany to treat upper gastrointestinal leaks and perforations. There currently are no reports on its use in the USA., Methods: E-Vac therapy was used to treat 11 patients with upper gastrointestinal leaks and perforations from September 2013 to September 2014. Five patients with leaks following sleeve gastrectomy were excluded from this study. A total of six patients were treated with E-Vac therapy; these included: (n = 2) iatrogenic esophageal perforations, (n = 1) iatrogenic esophageal and gastric perforations, (n = 1) iatrogenic gastric perforation, (n = 1) gastric staple line leak following a surgical repair of a traumatic gastric perforation, and (n = 1) esophageal perforation due to an invasive fungal infection. Four patients had failed an initial surgical repair prior to starting E-Vac therapy., Results: All six patients (100 %) had complete closure of their perforation or leak after an average of 35.8 days of E-Vac therapy requiring 7.2 different E-Vac changes. No deaths occurred in the 30 days following E-Vac therapy. One patient died following complete closure of his perforation and transfer to an acute care facility due to an unrelated complication. There were no complications directly related to the use of E-Vac therapy. Only one patient had any symptoms of dysphagia. This patient had severe dysphagia from an esophagogastric anastomotic stricture prior to her iatrogenic perforations. Following E-Vac therapy, her dysphagia had actually improved and she could now tolerate a soft diet., Conclusions: E-Vac therapy is a promising new method in the treatment of upper gastrointestinal leaks and perforations. Current successes need to be validated through future prospective controlled studies.

Objectives: To identify predictors of positive circumferential resection margin following rectal cancer resection in the United States., Background: Positive circumferential resection margin is associated with a high rate of local recurrence and poor morbidity and mortality for rectal cancer patients. Prior study has shown poor compliance with national rectal cancer guidelines, but whether this finding is reflected in patient outcomes has yet to be shown., Methods: Patients who underwent resection for stage I-III rectal cancer were identified from the 2010-2011 National Cancer Database. The primary outcome was a positive circumferential resection margin. The relationship between patient, hospital, tumor, and treatment-related characteristics was analyzed using bivariate and multivariate analysis., Results: A positive circumferential resection margin was noted in 2859 (17.2%) of the 16,619 patients included. Facility location, clinical T and N stage, histologic type, tumor size, tumor grade, lymphovascular invasion, perineural invasion, type of operation, and operative approach were significant predictors of positive circumferential resection margin on multivariable analysis. Total proctectomy had nearly a 30% increased risk of positive margin compared with partial proctectomy (OR 1.293, 95%CI 1.185-1.411) and a laparoscopic approach had nearly 22% less risk of a positive circumferential resection margin compared with an open approach (OR 0.882, 95%CI 0.790-0.985)., Conclusions: Despite advances in surgical technique and multimodality therapy, rates of positive circumferential resection margin remain high in the United States. Several tumor and treatment characteristics were identified as independent risk factors, and advances in rectal cancer care are necessary to approach the outcomes seen in other countries.

The management of T1 rectal cancers is based on finding the balance between optimal oncologic outcomes and acceptable functional results for the patient. While radical resection involving a proctectomy is considered the most oncologically adequate option, its adverse effects on patient reported outcomes makes this a less than ideal choice in certain circumstances. While local excision can circumvent some of the adverse functional outcomes, its inadequacy in assessing metastatic lymph node disease and the subsequent negative impact of untreated positive lymph nodes on patient prognosis is a cause for concern. As a result, the therapeutic strategy has to be based on patient and disease-related factors in order to identify the best treatment choice that maximizes survival benefit and preserves health-related quality of life. After adequate preoperative staging work up, in selected patients with favorable pathological features, local excision can be considered. These cancers can be removed by transanal local excision or transanal endoscopic microsurgery, depending on the location of the cancer and expertise available. While perioperative morbidity is minimal, close postoperative follow-up is essential.