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Background: Emerging data suggest women have worse outcomes than men following cardioplegia and cardiopulmonary bypass (CP/CPB). Altered coronary microvascular function affecting myocardial perfusion may contribute, but human translational studies are lacking., Methods: Viable coronary microvessels (<200 μ m) were dissected from human atrial samples collected before and after CP/CPB from a subset of 108 patients enrolled. Ex vivo contractile responses to vasopressin were assessed using video microscopy. RNA deep-sequencing and immunoblotting were used to quantify gene and protein expression, respectively., Results: Coronary microvessels exhibited increased vasopressin-induced contractile responses post-CP/CPB in males and females (p ​< ​0.0001). Females exhibited a decrease in microvascular contractile response versus males pre- (p ​= ​0.1) and post-CP/CPB (p ​= ​0.09) which approached significance. Myocardial vasopressin 1a receptor levels were increased in females versus males (p ​= ​0.001). Vasopressin-induced vasoconstriction predicted postoperative cardiac index., Conclusions: Impaired coronary microvascular contractile responses in females jeopardizing myocardial perfusion may underlie worse outcomes following cardiac surgery., Competing Interests: Declaration of interest statement The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The authors report on a patient who presented with an extremely large presacral schwannoma and subsequent mass effect-induced hydronephrosis and kidney failure. To the authors' knowledge, this case represents the largest radiographically verified spinal schwannoma in the medical literature. The tumor presented here was more than three times as large as a typical giant schwannoma. While smaller presacral schwannomas are usually uncomplicated surgical cases, the supergiant schwannomas described here create significant surgical challenges., Observations: The extremely large size of this nerve sheath tumor introduced a level of surgical complexity not seen in most spinal schwannoma cases. The authors hope that this case informs surgeons regarding the approach to excision of giant spinal schwannomas., Lessons: The resection of giant spinal schwannomas is likely to involve one or more lengthy surgeries, and the resection volume can be limited by excessive bleeding. Physicians approaching these large, benign spinal tumors should be aware of the challenges of surgery duration and hemostasis before approaching a tumor of this kind. https://thejns.org/doi/10.3171/CASE24224.

Palliative surgery is defined as an operation or procedure performed with the primary intention of relieving symptoms or improving quality of life. Gastrostomy tubes are often employed with palliative intent but, like many palliative interventions, there is insufficient data to facilitate surgical decision-making. This can be challenging for healthcare professionals as caring for palliative patients often encompasses end of life care, severe life-altering symptoms, and poor prognosis. Thus, we have gathered available data for the appropriate use of gastrostomy tube in palliative surgery and propose our mini-review as a primer to aid in medical and surgical decision-making. We first provide the background for palliative surgery and the definition, brief history and techniques pertinent to palliative gastrostomy tube (PGT). Then we review the data relevant to two common indications-head/neck cancer and malignant bowel obstruction-for PGT. As our deliverable, we present an effective paradigm for delivering the data to patients and families utilizing known palliative communication and decision-making frameworks such as the Palliative Triangle, Best Case/Worst Case and Defining Value. Moreover, we highlight the necessity of conducting more palliative care research that involves palliative outcome measures in addition to traditional metrics such as overall survival. We end our discussion by emphasizing the importance of multidisciplinary team, individualized decision-making, and relationship-based care for palliative patients.

Objective: Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors' institutional case series., Methods: The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed., Results: The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision., Conclusions: The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.

Gastric adenocarcinoma typically presents with advanced stage when inoperable. Chemotherapy options include non-targeted and toxic agents, leading to poor 5-year patient survival outcomes. Small molecule ONC201/TIC10 (TRAIL-Inducing Compound #10) induces cancer cell death via ClpP-dependent activation of the integrated stress response (ISR) and up-regulation of the TRAIL pathway. We previously found in breast cancer, pancreatic cancer and endometrial cancer that ONC201 primes tumor cells for TRAIL-mediated cell death through ISR-dependent upregulation of ATF4, CHOP and TRAIL death receptor DR5. We investigated the ability of ONC201 to induce apoptosis in gastric adenocarcinoma cells in combination with recombinant human TRAIL (rhTRAIL) or PEGylated trimeric TRAIL (TLY012). AGS (caspase 8-, KRAS-, PIK3CA-mutant, HER2-amplified), SNU-1 (KRAS-, MLH1-mutant, microsatellite unstable), SNU-5 (p53-mutant) and SNU-16 (p53-mutant) gastric adenocarcinoma cells were treated with ONC201 and TRAIL both in cell culture and in vivo . Gastric cancer cells showed synergy following dual therapy with ONC201 and rhTRAIL/TLY012 (combination indices < 0.6 at doses that were non-toxic towards normal fibroblasts). Synergy was observed with increased cells in the sub-G1 phase of the cell cycle with dual ONC201 plus TRAIL therapy. Increased PARP, caspase 8 and caspase 3 cleavage after ONC201 plus TRAIL further documented apoptosis. Increased cell surface expression of DR5 with ONC201 therapy was observed by flow cytometry, and immunoblotting revealed ONC201 upregulation of the ISR, ATF4, and CHOP. We observed downregulation of anti-apoptotic cIAP-1 and XIAP in all cells except AGS, and cFLIP in all cells except SNU-16. We tested the regimen in an organoid model of human gastric cancer, and in murine sub-cutaneous xenografts using AGS and SNU-1 cells. Our results suggest that ONC201 in combination with TRAIL may be an effective and non-toxic option for the treatment of gastric adenocarcinoma by inducing apoptosis via activation of the ISR, increased cell surface expression of DR5 and down-regulation of inhibitors of apoptosis. Our results demonstrate in vivo anti-tumor effects of ONC201 plus TLY012 against gastric cancer that could be further investigated in clinical trials., Competing Interests: W.S.E-D. is a co-founder of Oncoceutics, Inc., a subsidiary of Chimerix. Dr. El-Deiry has disclosed his relationship with Oncoceutics/Chimerix and potential conflict of interest to his academic institution/employer and is fully compliant with NIH and institutional policy that is managing this potential conflict of interest. V.V.P. is an employee and shareholder at Chimerix., (AJCR Copyright © 2023.)

Background: Malignant small bowel obstruction has a poor prognosis and is associated with multiple related symptoms. The optimal treatment approach is often unclear. We aimed to compare surgical versus non-surgical management with the aim to determine the optimal approach for managing malignant bowel obstruction., Methods: S1316 was a pragmatic comparative effectiveness trial done within the National Cancer Trials Network at 30 hospital and cancer research centres in the USA, Mexico, Peru, and Colombia. Participants had an intra-abdominal or retroperitoneal primary cancer confirmed via pathological report and malignant bowel disease; were aged 18 years or older with a Zubrod performance status 0-2 within 1 week before admission; had a surgical indication; and treatment equipoise. Participants were randomly assigned (1:1) to surgical or non-surgical treatment using a dynamic balancing algorithm, balancing on primary tumour type. Patients who declined consent for random assignment were offered a prospective observational patient choice pathway. The primary outcome was the number of days alive and out of the hospital (good days) at 91 days. Analyses were based on intention-to-treat linear, logistic, and Cox regression models combining data from both pathways and adjusting for potential confounders. Treatment complications were assessed in all analysed patients in the study. This completed study is registered with ClinicalTrials.gov, NCT02270450., Findings: From May 11, 2015, to April 27, 2020, 221 patients were enrolled (143 [65%] were female and 78 [35%] were male). There were 199 evaluable participants: 49 in the randomised pathway (24 surgery and 25 non-surgery) and 150 in the patient choice pathway (58 surgery and 92 non-surgery). No difference was seen between surgery and non-surgery for the primary outcome of good days: mean 42·6 days (SD 32·2) in the randomised surgery group, 43·9 days (29·5) in the randomised non-surgery group, 54·8 days (27·0) in the patient choice surgery group, and 52·7 days (30·7) in the patient choice non-surgery group (adjusted mean difference 2·9 additional good days in surgical versus non-surgical treatment [95% CI -5·5 to 11·3]; p=0·50). During their initial hospital stay, six participants died, five due to cancer progression (four patients from the randomised pathway, two in each treatment group, and one from the patient choice pathway, in the surgery group) and one due to malignant bowel obstruction treatment complications (patient choice pathway, non-surgery). The most common grade 3-4 malignant bowel obstruction treatment complication was anaemia (three [6%] patients in the randomised pathway, all in the surgical group, and five [3%] patients in the patient choice pathway, four in the surgical group and one in the non-surgical group)., Interpretation: In our study, whether patients received a surgical or non-surgical treatment approach did not influence good days during the first 91 days after registration. These findings should inform treatment decisions for patients hospitalised with malignant bowel obstruction., Funding: Agency for Healthcare Research and Quality and the National Cancer Institute., Translation: For the Spanish translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests GLA received payments to Fred Hutch for support for the present manuscript. AAS has grants or contracts from AbbVie, Aravive, AstraZeneca, Boehringer, Ingelheim, Clovis, Eisai, Ellipses, Immunogen, Merck, Oncoquest, Roche/Genentech, SeagenInc, TapImmune, Tesaro/GSK, VBL Therapeutics, and National Cancer Trial Network; has received honoraria for educational presentations or lectures from @Point of Care, Clinical Care Optios, Curio Science, Peerview, Bio ASCEND, RTP, and GOG Foundation; has received honorarium from Myriad; and has received support for attending meetings or travel from GOG, Society of Gynecologic Oncology, and NRG. DCF received support for the present manuscript in the form of payments through S1316 to Valley Health for patient enrolment; received payment or honoraria for lectures from Intuitive for the resident lecture programme; and has stock options in Intuitive. JDW has grants or contracts from Merck; receives royalties or licenses from UptoDate; receives payments for expert testimony from Medicolegal for consulting on gynaecological cancer; is a journal editor for the American College of Obstetricians and Gynecologists. BFa received visiting professor honoraria in April, 2022, at the Ohio State University Department of Surgery, October, 2021, at the University of Nebraska Department of Surgery, and December, 2020, at the University of Tennessee Department of Surgery; and has stock or stock options in Align Tech, Biogen, Bristol Myers Squibb, DexCom, Editas Medicine, Fulgent Genetics, GoodRx Holdings, Guardant Health, Globus Medical, Healthequity, HCA Healthcare, IDEXX Laboratories, Illumina, Intuitive Surgical, Invitae, Masimo, Moderna, Neurocrine Bioscience, Novocure, Quidel, Repligen, Seagen, Shockwave Medical, STAAR Surgical, UnitedHealth Group, Veeva Systems, Teladoc Health, and ResMed. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Patient selection for palliative surgery is complex, and appropriate outcomes measures are incompletely defined. We explored the usefulness of a specific outcomes measure "was it worth it" in patients after palliative-intent operations for advanced malignancy., Study Design: A retrospective review of a comprehensive longitudinal palliative surgery database was performed at an academic tertiary care center. All patients who underwent palliative-intent operation for advanced cancer from 2003 to 2022 were included. Patient satisfaction ("was it worth it") was reported within 30 days of operation after palliative-intent surgery., Results: A total of 180 patients were identified, and 81.7% self-reported that their palliative surgery was "worth it." Patients who reported that their surgery was "not worth it" were significantly older and were more likely to have recurrent symptoms and to need reoperation. There was no significant difference in overall, recurrence-free, and reoperation-free survival for patients when comparing "worth it" with "not worth it." Initial symptom improvement was not significantly different between groups. Age older than 65 years (hazard ratio 0.25, 95% CI 0.07 to 0.80, p = 0.03), family engagement (hazard ratio 6.71, 95% CI 1.49 to 31.8, p = 0.01), and need for reoperation (hazard ratio 0.042, 95% CI 0.01 to 0.16, p < 0.0001) were all independently associated with patients reporting that their operation was "worth it.", Conclusions: Here we demonstrate that simply asking a patient "was it worth it" after a palliative-intent operation identifies a distinct cohort of patients that traditional outcomes measures fail to distinguish. Family engagement and durability of an intervention are critical factors in determining patient satisfaction after palliative intervention. These data highlight the need for highly individualized care with special attention paid to patients self-reporting that their operation was "not worth it.", (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being., Study Design: A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort., Results: Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans., Conclusions: Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical culture has shifted to recognize the importance of resident well-being. This is the first study to longitudinally track regional surgical resident well-being over 5 years., Study Design: An anonymous cross-sectional, multi-institutional survey of New England general surgery residents using novel and published instruments to create three domains: health maintenance, burnout, and work environment., Results: Overall, 75% (15 of 20) of programs participated. The response rate was 44% (250 of 570), and 53% (133 of 250) were women, 94% (234 of 250) were 25 to 34 years old, and 71% (178 of 250) were in a relationship. For health maintenance, 57% (143 of 250) reported having a primary care provider, 26% (64 of 250) had not seen a primary care provider in 2 years, and 59% (147 of 250) endorsed being up to date with age-appropriate health screening, but only 44% (109 of 250) were found to actually be up to date. Only 14% (35 of 250) reported exercising more than 150 minutes/week. The burnout rate was 19% (47 of 250), with 32% (81 of 250) and 25% (63 of 250) reporting high levels of emotional exhaustion and depersonalization, respectively. For program directors and attendings, 90% of residents reported that they cared about resident well-being. Eighty-seven percent of residents believed that it was acceptable to take time off during the workday for a personal appointment, but only 49% reported that they would personally take the time., Conclusions: The personal health maintenance of general surgery residents has changed little over the past five years, despite an overwhelming majority of residents reporting that attendings and program directors care about their well-being. Further study is needed to understand the barriers to improvement of resident wellbeing., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

This review focuses on the role of palliative surgery in the care of the palliative care patient, and the appropriate role of the surgeon. The surgeon has much to bring to the palliative care team. The surgeon's role goes beyond the technical requirements of the palliative procedure, which itself must be strictly defined, and has recognized utility for improving quality of life in selected patients. These benefits may be substantial, but come at significant risk; requiring careful balancing of risks and benefits that is most completely understood by the surgeon. The surgeon's judgement can help determine which procedure best meets a patient's goals. The complex dialogue involved in the decision to undergo a palliative operation requires excellent communication between the palliative care team, the patient, and their family. Integrating the surgeon into the palliative care team could help with earlier initiation of those palliative discussions, and assist deliberation of palliative surgery. Surgeons also understand the importance of communication around palliative surgical interventions and have adapted several teaching models to the specifics of this crucial communication. A palliative team combining both surgeons and palliative care physicians may promote goal-concordant decision-making and remove barriers to communication and team engagement. The future of palliative surgery research will involve measures of success that go beyond physiology or mortality, to include more evaluations of communication and patient goals.

No one person has the right or ability to make decisions about to whom or according to which criteria palliative surgery should be offered. Instead, patient and surgeon together must consider symptom severity, goals of care, and the value palliative surgery could add to the patient's health experience or quality of life., (© 2021 American Medical Association. All Rights Reserved.)

Surgical palliation in oncology can be defined as "procedures employed with non-curative intent with the primary goal of improving symptoms caused by an advanced malignancy," and is an important aspect of the end-of-life care of patients with incurable malignancies. Palliative interventions may provide great benefit, but they also carry high risk for morbidity and mortality, which may be minimized with careful patient selection. This can be done by consideration of the patient and his or her indication for the given intervention via open communication, as well as prediction of benefits and risks to define the therapeutic index of the operation or procedure., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Combined cytotoxic T-lymphocyte-associated antigen 4 and programmed death 1 inhibitor blockade is a promising strategy in advanced melanoma and other solid tumors. This pilot study assessed the safety and toxicity of nivolumab plus low-dose ipilimumab in patients with high-risk completely resected melanoma., Patients and Methods: Patients received ipilimumab, 1 mg/kg every 6 weeks, and nivolumab, 3 mg/kg every 2 weeks, for a total of 24 weeks (4 cycles). The primary objective was to assess the toxicity of the combined regimen., Results: Twenty-one patients with resected melanoma were enrolled. One patient was stage IIC, 16 patients were stage III and 4 patients had resected stage 4 disease. Ten of 21 (48%) had grade 3 treatment-related toxicities but there was no grade 4 or grade 5 toxicities. The rate of grade 3 nonhematologic toxicities exceeded the toxicity limits defined by the study. Fifteen of 21 patients (71%) completed all 4 cycles of therapy. The median follow-up is 41 months. The 2-year recurrence-free survival is 85.7% and the 2-year overall survival is 90.5%., Conclusion: A 6-month course of nivolumab and low-dose ipilimumab may be a promising adjuvant treatment for patients with resected melanoma. Further studies of this regimen are indicated., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Backgrounds/aims: Post-operative pancreatic fistulas (POPF) are a major source of morbidity following pancreaticoduodenectomy (PD). This study aims to investigate if persistent lymphopenia, a known marker of sepsis, can act as an additional marker of POPF with clinical implications that could help direct drain management., Methods: A retrospective chart review of all patients who underwent PD in a single hospital network from 2008 to 2018. Persistent lymphopenia was defined as lymphopenia beyond post-operative day #3., Results: Of the 201 patients who underwent PD during the study period 161 patients had relevant laboratory data, 81 of whom had persistent lymphopenia. 17 patients with persistent lymphopenia went on to develop a POPF, compared to 7 patients without. Persistent lymphopenia had a negative predictive value of 91.3%. Multivariate analysis revealed only persistent lymphopenia as being independently associated with POPF (HR 2.57, 95% CI 1.07-6.643, p =0.039). Patients with persistent lymphopenia were more likely to have a complication requiring intervention (56.8% vs 35.0%, p <0.001)., Conclusions: Persistent lymphopenia is a readily available early marker of POPF that holds the potential to identify clinically relevant POPF in patients where no surgical drain is present, and to act as an adjunct of drain amylase helping to guide drain management.

Background: In order to better characterize outcomes of palliative surgery (PS), we evaluated patients that experienced top quartile survival to elucidate predictors of high impact PS., Methods: All PS performed on advanced cancer patients from 2003 to 2017 were identified from a PS database., Results: 167 patients were identified. Multivariate analysis demonstrated the ability to rise from a chair was independently associated with top quartile survival (HR 7.61, 95% CI 2.12-48.82, p=0.008) as was the need for re-operation (HR 2.81, 95% CI 1.26-6.30, p=0.0012). Patients who were able to rise from a chair had significantly prolonged overall survival (320 vs 87 days, p < 0.001)., Conclusions: Although not the primary goal, long-term survival can be achieved following PS and is associated with re-operation and the ability to rise from a chair. These patients experience the benefits of PS for a longer period of time, which in turn maximizes value and positive impact., Summary: Long-term survival and symptom control can be achieved in highly selected advanced cancer patients following palliative surgery. The ability of the patient to independently rise from a chair and the provider to offer a re-operation when indicated are associated with long-term survival following a palliative operation., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

People experiencing homelessness are particularly vulnerable when diagnosed with pancreatic cancer. Patients with lower socioeconomic status have worse outcomes from pancreatic cancer as the result of disparities in access to treatment and barriers to navigation of the health care system. Patients with lower socioeconomic status, or who are vulnerably housed, are less likely to receive surgical treatment even when it is recommended by National Comprehensive Cancer Network guidelines. This disparity in access to surgical care explains much of the gap in pancreatic cancer outcomes. There are many factors that contribute to this disparity in surgical management of pancreatic cancer in people experiencing homelessness. These include a lack of reliable transportation, feeling unwelcome in the medical setting, a lack of primary care and health insurance, and implicit biases of health care providers, including racial bias. Solutions that focus on rectifying these problems include utilizing patient navigators, addressing implicit biases of all health care providers and staff, creating an environment that caters to the needs of patients experiencing homelessness, and improving their access to insurance and regional support networks. Implementing these potential solutions all the way from the individual provider to national safety nets could improve outcomes for patients with pancreatic cancer who are experiencing homelessness.

Regardless of the anatomic site of malignant bowel obstruction leading to the need for palliative intervention, decisions must consider the natural history of the disease, the availability and success of nonsurgical treatments, the individual patient's symptom severity, goals, preferences, quality, and expectancy of life. Therapy for symptoms must remain flexible and individualized because the specific needs of the patient will change as disease progresses. Because strangulation is uncommon, malignant bowel obstruction is usually not a surgical emergency. There is usually time to proceed with deliberate and thoughtful decisions on how best to meet the needs and expectations of the individual patient and family. Providers must be well versed in both surgical and nonsurgical therapeutic options, the natural history of disease, and be active and compassionate providers to foster meaningful ongoing dialogue focused on excellent care even after cure is no longer possible. The palliative triangle not only allows patient, family, and surgeon to effectively utilize the full continuum of care that can be delivered, but also it supports end-of-life decisions when continuity in care matters most. Due to social distancing requirements, the dynamics of communication between patient, family, and surgeon have changed. Zoom, Skype, and FaceTime have become tools in our communication armamentarium.

The neutrophil-to-lymphocyte ratio (NLR) is gaining traction as a biomarker with utility in a variety of malignancies including melanoma. Intact lymphocyte function is necessary for tumor surveillance and destruction, and neutrophils play a role in suppressing lymphocyte proliferation and in the induction of lymphocyte apoptosis. Early research in melanoma indicates that in high-risk localized melanoma, a high NLR is correlated with worse overall and disease-free survival. Similarly, in metastatic melanoma treated with both metastasectomy and immunotherapies, an elevated NLR is predictive of shortened overall survival and progression-free survival. Future studies incorporating NLR into more traditional melanoma prognostic markers while employing more granular outcomes, are needed to realize the full potential of NLR., Competing Interests: Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript., (© 2020 Joshua T. Cohen, Thomas J. Miner, and Michael P. Vezeridis.)

Purpose: A formal 2-year clinical research project in conjunction with a system-based practice and practice-based learning and improvement curriculum was initiated for all residents in our program. Within the structure of this formal clinical research curriculum, residents are required to develop a research hypothesis, develop an appropriate study design, collect and analyze data, and present a completed project., Methods: At the end of the PGY1 year, residents select a project with an emphasis on quality improvement or clinical outcomes. The first 6 months of the 2-year program are dedicated to the identification of a faculty mentor and submission of a formal proposal to both the departmental education committee and to the institutional IRB. Over the following 12 months, residents meet monthly for required group research meetings. The final 6 months are focused on data analysis and project completion., Results: Seventy-five residents have successfully completed the clinical research program since it was initiated in 2002. Completed projects led to abstracts accepted at 33 national or regional meetings and 11 peer reviewed publications to date. In addition, 3 major hospital wide quality improvement measures were initiated based on project findings. Following the first peer reviewed publication associated with these research projects in 2006, there have been significant increases in not only the number of accepted abstracts from these resident projects (3/18 [17%] vs 30/57 [53%], p = 0.008) but also the total number of all accepted resident clinical research (mean accepted abstracts per year 7.9 vs 1.0, p = 0.009 and mean peer reviewed publications per year 6.8 vs 2.0, p = 0.003.) DISCUSSION: Increased academic productivity was observed after a formal resident clinical research program was initiated in our program. Resident research efforts extended beyond the specific initial outcome projects as skills gained allowed for future independent clinical research., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Thick melanomas, defined as ≥4 mm in thickness, represent ~5% of new melanoma diagnoses and have been associated with poor overall survival (OS). Ultrathick melanomas, those lesions ≥8 mm in thickness, have been associated with worse survival. We sought to compare prognostic factors for thick and ultrathick melanoma., Methods: Retrospective analysis of a prospective database of all patients receiving an operation for melanoma, June 2005 to December 2016 was performed. Multivariate Cox proportional hazards regression analyses were performed to identify predictors of progression-free survival (PFS) and OS., Results: Of 95 patients with thick melanoma, 37 (39%) had ultrathick tumors (≥8 mm thick). Thick and ultrathick lesions were not significantly different on the basis of tumor location, ulceration, mitotic rate, lymphovascular invasion, or performance or positivity of sentinel node biopsy or therapeutic lymphadenectomy. Disease recurrence was identified in 38 patients overall (40%), more commonly in ultrathick disease (55% vs. 29%, P=0.008). Serum neutrophil to lymphocyte ratio (NLR) was available for 36 patients, of whom 23 (64%) had high NLR (>3.0). Decreased PFS was independently associated with ultrathick tumors (HR, 2.9; P=0.003), head/neck location (HR, 2.6; P=0.023), and positive lymph nodes (HR, 3.3; P=0.004). Decreased OS was independently associated with high NLR (HR, 5.0; P=0.042)., Conclusions: Disease progression was higher in the ultrathick melanoma group. Thicker tumors, head/neck location, and positive lymph nodes were associated with decreased PFS. High NLR was associated with decreased OS. Ultrathick melanomas represent advanced malignancy; however, patients may derive benefit from surgical treatment to achieve locoregional control.

Proper patient selection for palliative surgery requires a challenging and often complex decision-making process. Optimally, proposed palliative procedures must be undertaken with an intent to provide the greatest possible value to patients at the end of life. This review describes the process of patient selection and identifies psychosocial, biochemical, and functional markers that can complement sound surgical judgment., (© 2019 Wiley Periodicals, Inc.)

Background: Medical student reflection is integral for professional development. Preliminary findings suggest that short-format writing promotes reflection and identifies impactful experiences. We sought to determine whether reflective writing could be used as a clerkship needs assessment., Methods: During their surgical clerkship, medical students submitted "tweet"-format reflections and completed a standardized evaluation. "Tweet" content was analyzed using modified grounded theory methods and coded by valence, content, and reflection. Sub-coding was conducted to compare feedback between "tweets" and evaluations., Results: We analyzed 286 reflections and 214 evaluation comments; 176 "tweets" were reflective (62%). "Tweets" commented on "patient interaction" (53%), "educational experience" (38%), "physician interaction" (26%), and "career decisions" (10%). A significant difference was observed between "tweets" and evaluations with regard to the number that provided feedback on experiences with "critically ill or dying patients.", Conclusions: Reflections provided real-time reactions to impactful clerkship events, notably those involving critically ill or dying patients. This focus on illness may represent an unmet need for discussions related to end of life care. Overall, reflections provided more actionable feedback compared to evaluations., (Copyright © 2018 Elsevier Inc. All rights reserved.)

For women with newly diagnosed ovarian cancer, the goal of surgery is to achieve a maximal, if not complete, cytoreduction. In cases when this is not possible, whether because of the extent of disease or patient-specific reasons, neoadjuvant chemotherapy using a platinum-based combination (on a typical every-2-week schedule) is often recommended. After neoadjuvant therapy and surgery, women proceed with additional adjuvant chemotherapy, which is typically given in a similar fashion to what was done in the preoperative setting. The question remains as to whether this is the optimal strategy, particularly in light of other data suggesting the use of an alternative regimen in the adjuvant context might yield a survival advantage. In this article, we review the outcomes of randomized trials that compared primary debulking to neoadjuvant chemotherapy and contemporary neoadjuvant chemotherapy trials that incorporated a novel schedule or regimen for testing in the adjuvant setting, including both intraperitoneal and heated intraperitoneal chemotherapy. We describe our center's approach to these data, and we conclude that both options should be considered for women with ovarian cancer undergoing neoadjuvant therapy.

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients., Competing Interests: Conflict-of-interest statement: There is no conflict of interest associated with the senior author or other coauthors that contributed their efforts in this manuscript.

Objective: Reflective writing during medical education allows for professional growth through retrospective analysis of experiential knowledge. However, these writing assignments can pose a challenge to millennial medical students who are more likely to assimilate knowledge through the use of innovative technology and who prefer their data in a concise format. Here, we present a novel, tweet-style reflective writing assignment to better engage the unique skill set of today's medical students. We analyzed the written content partway through the year to determine whether or not the format retains the impact of longer, more structured reflective writing assignments., Design: Surgical clerkship students were required to reflect on 3 distinct experiences through a 140-character written reflection, or tweet. Students were able to submit these assignments at any point during their rotation through a platform available on their smartphone or computer. There were no specifications with regard to content. These reflections were analyzed using modified grounded theory methods. Each tweet was analyzed by 2 individuals to ensure intercoder reliability. Codes were created a priori with respect to positive and negative domains, and type of experience., Stetting: Department of Surgery, Warren Alpert School of Medicine, Brown University, Third Year Medical Student Surgical Clerkship., Participants: Third year medical students at the Warren Alpert School of Medicine, Brown University. Fifty-six medical students were included in this study., Results: During the first 4 blocks of the 2016-2017 academic year, 56 students rotated through the third year surgical clerkship. One hundred and sixty-eight tweets were collected and coded. Sixty-nine tweets (42%) had a positive valence. Students reflected on the following experiences: patient interaction (54%), surgical education (34%), physician/resident interaction (27%), and career decisions (11%). Overall, 87 (52%) tweets were reflective. Many tweets included emotional reactions to specific experiences., Conclusions: Using tweet-style reflective writing, students identified and reacted to multiple salient experiences from their surgical clerkship. They reflected on both positive and negative emotions, mostly related to personal interactions with patients, but also associated with their education, their team, and their future career. Based on early analysis of the data, we believe that short format writing can be an effective format for reflection., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: National Comprehensive Cancer Network (NCCN) melanoma treatment guidelines are based on best available literature. We evaluated NCCN excision margin and sentinel lymph node biopsy (SLNB) guideline adherence to identify patient populations at risk for suboptimal care., Methods: Retrospective review of prospectively maintained database of all patients who underwent operation for invasive melanoma from January 2005 to 2015., Results: In total, 865 patients underwent operation for 522 thin (60.3%), 268 intermediate-thickness (31.0%), and 75 thick (8.7%) melanomas. Tumor location was 349 extremity (40.4%), 348 trunk (40.2%), and 168 head/neck (19.4%). SLNB was performed in 422 patients (48.8%); 75 (17.8%) were positive, and 67 (15.9%) underwent therapeutic lymphadenectomy. A total of 154 lesions (17.8%) were ulcerated; 444 had mitotic rate ≥1 (51.3%). In total, 788 patients (91.1%) fulfilled both NCCN guidelines. Recommended surgical margins were achieved in 837 patients (96.8%) and SLNB was performed as appropriate in 806 patients (93.2%); 10 patients (1.2%) were deficient for both. Deficient margins and lack of SLNB were associated with increased invasion depth and head/neck location; deficient SLNB was associated with age 80 and above (P<0.0001). Overall recurrence was 7.1%: 15 local (1.7%), 23 regional (2.7%), and 23 distant (2.7%) failures. Local recurrence was associated with head/neck location (P=0.031); all recurrence types were associated with increased tumor thickness., Conclusions: NCCN excision and SLNB guidelines were almost always met. Patients at risk for not meeting criteria included the elderly and those with head/neck tumors. Failure to meet NCCN criteria was not associated with increased disease recurrence. Surgeons must carefully balance the risks of not pursuing NCCN guidelines with treatment goals.

Aims: The tumour microenvironment is increasingly important in several tumours. We studied the relationship of key players of immune microenvironment with clinicopathological parameters in gastric adenocarcinomas., Methods and Results: Tissue microarrays were constructed from gastrectomy specimens, 2004-13. Immunohistochemistry was performed for programmed cell death ligand 1 (PD-L1), indoleamine 2,3-dioxygenase (IDO), tryptophanyl-tRNA synthetase (WARS), guanylate-binding protein 5 (GBP5), tumour-infiltrating lymphocytes (TIL) expressing CD3/CD8/FoxP3/PD1 and mismatch repair proteins (MMRs) MLH1, PMS2, MSH2 and MSH6. Clinicopathological parameters and clinical follow-up were recorded. The study included 86 patients; median follow-up was 34 months (0-148). Tumour types were 45% tubular, 38% diffuse, 17% mixed. PD-L1 was positive in 70%, epithelial IDO in 58%, stromal IDO in 91%, epithelial WARS in 67%, stromal WARS in 100%, epithelial GBP5 in 53% and stromal GBP5 in 71%. MMR-deficiency was found in 22%. There was no difference in biomarker expression by histological subtype, with the exception of fewer diffuse-type being MMR-deficient. Low stromal IDO was associated with decreased progression-free, overall and disease-specific survival. PD-L1-positive tumours were larger with MMR-deficiency and with increasing TILs, and had significantly higher FoxP3TILs., Conclusions: PD-L1 is expressed in a large proportion of gastric carcinomas, suggesting that therapy targeting this pathway could be relevant to many patients. PD-L1 expression and MMR-deficiency are associated with increased TILs and larger tumour size, emphasising their role in tumour biology. Higher stromal IDO expression is associated with better prognosis. Finally, we observed that immune modulators WARS and GBP5 are expressed highly in gastric adenocarcinomas, suggesting an important role in tumour pathobiology., (© 2018 John Wiley & Sons Ltd.)

Aims: The immune microenvironment is a prognostic factor for various malignancies. The significance of key players of this immune microenvironment, including tumour-infiltrating lymphocytes (TILs) and expression of programmed death-ligand 1 (PD-L1), indoleamine 2,3-dioxygenase (IDO) and tryptophanyl-tRNA synthetase (WARS) in gastrointestinal stromal tumours (GISTs) is largely unknown., Methods and Results: Tissue microarrays were constructed from pathology files, 1996-2016. Immunohistochemistry for PD-L1, IDO and WARS was correlated with tumour size, mitoses and outcomes. TILs expressing CD3, CD4, CD8, FoxP3 and GBP5 were counted. A total of 129 GISTs were analysed. Mean patient age was 62.5 years; 52.0% were male. Tumour location included 89 stomach (69.0%), 33 small bowel (25.6%) and seven other (5.4%). Mean tumour size was 5.6 cm; mean mitoses were 7.2 per 50 high-power field. Nineteen patients (15.0%) developed disease progression, to abdominal wall (n = 8), liver (n = 6) and elsewhere (n = 5). Median progression-free survival was 56.6 months; five patients died of disease. PD-L1 was positive in 88 of 127 tumour samples (69.0%), 114 of 127 tumours were IDO-positive (89.8%) and 60 of 127 were positive for WARS (47.2%). PD-L1 was associated with increased size (P = 0.01), necrosis (P = 0.018) and mitoses (P = 0.006). Disease progression was not associated with PD-L1 (P = 0.44), IDO (P = 0.14) or WARS (P = 0.36) expression. PD-L1-positive GISTs with CD8 + or CD3 + TILs were significantly smaller than tumours with CD8 + or CD3 + TILs., Conclusions: PD-L1 expression was associated with increased size and mitoses. High CD8 + or CD3 + TIL counts were associated with decreased PD-L1/IDO + GIST size. PD-L1 and IDO could be significant in GIST tumour biology, which invites consideration of immunotherapy as a potential treatment option., (© 2017 John Wiley & Sons Ltd.)

Aim: To assess nutritional recovery, particularly regarding feeding jejunostomy tube (FJT) utilization, following upper gastrointestinal resection for malignancy., Methods: A retrospective review was performed of a prospectively-maintained database of adult patients who underwent esophagectomy or gastrectomy (subtotal or total) for cancer with curative intent, from January 2001 to June 2014. Patient demographics, the approach to esophagectomy, the extent of gastrectomy, FJT placement and utilization at discharge, administration of parenteral nutrition (PN), and complications were evaluated. All patients were followed for at least ninety days or until death., Results: The 287 patients underwent upper GI resection, comprised of 182 esophagectomy ( n = 107 transhiatal, 58.7%; n = 56 Ivor-Lewis, 30.7%) and 105 gastrectomy [ n = 63 subtotal (SG), 60.0%; n = 42 total (TG), 40.0%]. 181 of 182 esophagectomy patients underwent FJT, compared with 47 of 105 gastrectomy patients (99.5% vs 44.8%, P < 0.0001), of whom most had undergone TG ( n = 39, 92.9% vs n = 8 SG, 12.9%, P < 0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups (14.7 d vs 17.1 d, P = 0.076). Upon discharge, 87 esophagectomy patients (48.1%) were taking enteral feeds, with 53 (29.3%) fully and 34 (18.8%) partially dependent. Meanwhile, 20 of 39 TG patients (51.3%) were either fully ( n = 3, 7.7%) or partially ( n = 17, 43.6%) dependent on tube feeds, compared with 5 of 8 SG patients (10.6%), all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients (6.4% vs 29.3%, P = 0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy ( n = 11, 23.4% vs n = 7, 3.9%, P = 0.0001). FJT-specific complications requiring reoperation within 30 d of resection occurred more commonly in the gastrectomy group ( n = 6), all after TG, compared to 1 esophagectomy patient (12.8% vs 0.6%, P = 0.0003). Six of 7 patients (85.7%) who experienced tube-related complications required PN., Conclusion: Nutritional recovery following esophagectomy and gastrectomy is distinct. Operations are associated with unique complication profiles. Nutritional supplementation alternative to jejunostomy should be considered in particular scenarios., Competing Interests: Conflict-of-interest statement: The authors declare no conflicts of interest regarding this manuscript.

Gastric outlet obstruction (GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract. Palliative treatment of patients' symptoms who present with GOO is an important aspect of their care. Surgical palliation of malignancy is defined as a procedure performed with the intention of relieving symptoms caused by an advanced malignancy or improving quality of life. Palliative treatment for GOO includes operative (open and laparoscopic gastrojejunostomy) and non-operative (endoscopic stenting) options. The performance status and medical condition of the patient, the extent of the cancer, the patients prognosis, the availability of a curative procedure, the natural history of symptoms of the disease (primary and secondary), the durability of the procedure, and the quality of life and life expectancy of the patient should always be considered when choosing treatment for any patient with advanced malignancy. Gastrojejunostomy appears to be associated with better long term symptom relief while stenting appears to be associated with lower immediate procedure related morbidity.

Background: The impact of early medical school mentorship in students' clerkships performance and career selection is unknown., Methods: We administered Introduction to Surgery, a resident-directed, semester-long, preclinical elective to junior medical students who answered a Likert-type survey after residency application. Elective participants (EPs) were compared with nonparticipant applicants (EAs), medical school class (MS), and national match outcomes (USA)., Results: All 18 EPs (7 M1's, 11 M2's) completed the elective and survey. EP reported more confidence and improved surgical skills, especially attributed to resident mentorship (F(13,237) = 2.3, P = 8*10(-3)). EP "honored" the clerkship more than MS (P = .05); 55.6% of EP, 37.5% of EA, and 27.7% of MS chose surgical fields, yielding a relative risk of 2.0 for EP vs MS (95% confidence interval: 1.3 to 3.2, P = 4*10(-3)). EP "strongly agree" with future mentorship programs (4.6/5), and 1 EP reported the course to be the "main reason" for applying to general surgery., Conclusions: Introduction to Surgery provides a model for a multifaceted junior medical student mentorship program, which has the potential to retain interested students for surgical career selection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Failure to rescue (FTR) is a key metric of perioperative morbidity and mortality. We review perioperative medical comorbidities (MCMs) to determine what factors are associated with complications and rates of FTR., Study Design: A retrospective review of a NSQIP database including general, vascular, and surgical subspecialty patients from a tertiary referral center between March 2008 and March 2013 was performed. Demographics, MCMs, complications, 30-day mortality, and risk of FTR associated with specific complications and MCM were evaluated., Results: A total of 7,763 patients were included; 52.6% had MCMs and 14% (n = 1,099) experienced a complication. Patients with complications were older (64.9 vs 55 years; p < 0.001), more likely male (54% vs 44%; p < 0.001), and had more MCMs per patient (1.6 vs 1.4; p < 0.001). Complications were also associated with renal failure (odds ratio [OR] = 1.4; 95% CI, 1.0-2.0), steroid use (OR = 1.9; 95% CI, 1.4-2.5), CHF (OR = 2.5; 95% CI, 1.2-5.1), and ascites (OR = 9.1; 95% CI, 3.7-21.7), but not diabetes, hypertension, or COPD. There were 117 (11%) deaths among patients with complications. Adjusting for age, sex, American Society of Anesthesiologists class, and number of comorbidities, FTR was associated with postoperative respiratory failure, sepsis, and renal failure, as well as comorbid CHF, renal failure, ascites, and disseminated cancer., Conclusions: Specific comorbidities are associated with higher rates of complications and FTR. Preoperative CHF, renal failure, and ascites, which were associated with FTR, can reflect a physiologic inability to tolerate complication-induced fluid shifts. Postoperative mortality was associated with signs of end organ damage, including sepsis, respiratory failure, and renal failure. Earlier recognition of these complications in at-risk patients should improve rates of FTR., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: One of the challenges for program directors (PDs) is to sort and weight the tidal wave of assessments that training programs create in the modern Milestone era. We evaluated whether the use of a radar plot (RP) would be helpful in sorting data and providing a graphic representation of each resident's progress., Design: Using at least 2 different types of assessments for each of the 16 surgical Milestones, the data were ranked and weighted by a predetermined method embedded in a computerized workbook (Excel). This process created a unique 16-spoked RP for each resident (Fig. below). The RP allowed the faculty to see areas of weakness (shown by concavity) and allowed an overall grade calculated as a ratio of the area of the smooth outer circle (faculty expectations, triangles) and the resident's unique radar shape (resident performance, squares). To help us validate our new tool, we looked at whether residents with recent remedial issues "looked" different from residents without remedial issues., Results: Of our 30 categorical residents, 8 had significant areas of concavities, suggesting possible areas of improvement. Of these 8 residents, 4 had been on a remediation program in the last 18 months. The average ratio of performance/expectations was 0.709. The 4 residents on recent remediation had a ratio of 0.616 when compared with 0.723 for the residents without remedial issues (p < 0.009)., Conclusions: Many exciting challenges await PDs, as we evolve to a competency-based evaluation system. The use of an evaluation summary tool using RPs may aid PDs in leading clinical competency discussions and in monitoring a resident's progress over time., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Multiple studies have shown the significantly increased post-operative morbidity and mortality of patients undergoing palliative operations. It has been proposed by some authors that the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database can be used reliably to develop risk-calculators or as an aid for clinical decision-making in advanced cancer patients. ACS-NSQIP is a population-based database that by design only captures outcomes data for the first 30-day following an operation. We considered the suitability of these data as a tool for decision-making in the advanced cancer patient., Methods: Six-year retrospective review of a single institution's ACS-NSQIP database for cases identified as "Disseminated Cancer". Procedures performed with palliative intent were identified and analyzed., Results: Of 7,763 patients within the ACS-NSQIP database, 138 (1.8%) were identified as having "Disseminated Cancer". Of the remaining 7,625 entries only 4,486 contained complete survival data for analysis. Thirty-day mortality within the "Disseminated Cancer" group was higher when compared to all other surgical patients (7.9% vs. 0.9%, P<0.001). Explicit chart review of these 138 patients revealed that 32 (23.2%) had undergone operations with palliative intent. Overall survival for palliative and non-palliative operations was significantly different (104 vs. 709 days, P<0.001). When comparing palliative to non-palliative procedures using ACS-NSQIP data, we were unable to detect a difference in 30-day mortality (9.4% vs. 7.5%, P=0.72)., Conclusions: Calculations utilizing ACS-NSQIP data fail to demonstrate the increased mortality associated with palliative operations. Patients diagnosed with advanced cancer are not adequately represented within the database due to the limited number of cases collected. Also, more suitable outcomes measures for palliative operations such as pain relief, functional status, and quality of life, are not captured. Therefore, the sole use of thirty-day morbidity and mortality data contained in the ACS-NSQIP database is insufficient to make sound decisions for surgical palliation.

Background: Surgical palliation of cancer is best defined as procedures performed with non-curative intent to improve quality of life or control symptoms of advanced malignancy. Soft tissue involvement of advanced malignancies may produce symptoms such as pain, bleeding, or odor that significantly reduce quality of life. Literature on outcomes of palliative resection of soft tissue malignancy for local or regional control is lacking., Methods: Soft tissue resections performed with palliative intent for locoregional control were identified from a prospectively maintained palliative surgery database at a tertiary care center from January 2004 to July 2013. Tumor type, presenting symptom, procedure performed, and symptom recurrence were recorded. Patients were followed for at least 60 days or until death., Results: Thirty-one patients who underwent palliative soft tissue resection for local control were identified. Primary tumor types included melanoma (n=9, 29.0%), squamous cell carcinoma (n=9, 29.0%), sarcoma (n=5, 16.1%), breast (n=3, 9.7%), and other (n=5, 16.1%). Eighteen of 31 patients (58.1%) underwent resection for pain, two (6.5%) for bleeding, and eleven (35.5%) for local control or other symptoms. Procedures were performed on the trunk (n=17, 54.8%), extremities (n=7, 22.6%), head/neck (n=5, 16.1%), or multiple areas (n=2, 6.5%). Eleven of 31 patients (35.5%) underwent axillary, inguinal, or neck lymph node dissection, seventeen (54.8%) radical resection, and three (9.7%) wound excision. Split-thickness skin graft was performed in 6 of 17 radical resections (35.3%). Five patients (16.1%) had symptom recurrence at the site of the initial palliative procedure, of whom four (12.9%) underwent a second palliative procedure. Seven patients (22.6%) had new disease-related symptoms develop during follow-up. Thirty-day morbidity was 29.0%; mortality was 3.2%, which was associated with progression of disease., Conclusions: Palliative surgery for local control of advanced soft tissue malignancy can provide durable symptom relief and improved quality of life. These procedures positively impact patients regardless of primary tumor type or tumor extent. Careful patient selection is important in order to maximize benefit of surgical palliation and minimize morbidity and mortality.

Background and Objectives: Optimal surgical decision-making and informed consent for palliative procedures is limited by a lack of appropriate outcomes data. Elevated C-reactive protein (CRP) may help guide patient selection for palliative surgery., Methods: Procedures to palliate symptoms of advanced cancer were identified from a prospective palliative surgery database. Patients with a recorded preoperative serum CRP were identified and observed for at least 180 days or until death., Results: Fifty patients were identified who underwent an elective palliative procedure from July 2006 to June 2012. Presenting symptoms included gastrointestinal obstruction (40%), tumor-related pain (38%) or bleeding (12%), and other (10%). Symptom improvement was documented for 37 patients (74%). Palliative procedures were associated with 30-day postoperative morbidity (42%) and mortality (10%). CRP (range 1-144 mg/L, median 9.7 mg/L) was elevated in 27 patients (54%) and was independently associated with developing a major complication (P = 0.005) and decreased overall survival (166 vs. 659 days, P < 0.0001)., Conclusions: Patients with advanced cancer can be afforded symptom improvement and the opportunity for improved quality of life following palliative procedures. Elevated preoperative CRP may help identify patients who are less likely to realize the benefits of palliative operations., (© 2014 Wiley Periodicals, Inc.)

Background: Positron emission tomography/computed tomography (PET/CT) scanning is commonly used for the preoperative staging of patients with at least intermediate thickness (>1 mm) melanomas. Its role in staging at initial diagnosis for clinically asymptomatic patients is not yet established., Methods: We examined records of all patients receiving an operation for at least an intermediate thickness melanoma from June 2005 to June 2011. Results of preoperative PET/CT scans were evaluated in asymptomatic patients with a negative physical exam. Outcome measures included changes in clinical management, as well as incidence of true- and false-positives., Results: PET/CT scans were performed for 149 patients with at least an intermediate thickness melanoma. Positive scans were identified in 28% (41/149) of patients. An invasive procedure to further aid in diagnosis was performed in 44% (18), yet only 6 (15%) patients were diagnosed with metastatic cancer (85% false positive rate). Each of these patients had regional disease subsequently diagnosed by a sentinel lymph node biopsy. No distant metastatic disease was identified., Conclusions: Preoperative PET/CT in asymptomatic patients is of limited benefit in staging asymptomatic melanoma patients with at least an intermediate thickness melanoma and may lead to unnecessary invasive procedures., (© 2013 Wiley Periodicals, Inc.)

Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Continued assessment and redesign of the curriculum is essential for optimal surgical education. For the last 3 y, we have asked the residents to reflect on the previous week and describe "the best thing" they learned. We hypothesize that this statement could be used to assess the weaknesses or strengths of our curriculum., Methods: Starting in 2007, residents filled out surveys approximately 4 times/y at the start of a mandatory conference. They were asked to describe the "best thing" they learned that week, where it was learned, and who taught it. Residents were not asked to classify the item learned by core competency (communication, knowledge, patient care, practice-based learning, professionalism, and systems-based practice). This categorization into core competencies was done as part of our study design. Attending, fellow, resident, or other were used as groups designating who taught each item. Where the item was learned was fit into either clinic, conference, operating room (OR), wards, or self. The impact of postgraduate year (PGY) level on learning was also assessed. χ(2) analysis was used to compare groups., Results: During the study period, 304 surveys were completed and returned by 65 residents. The majority of responses came from PGY 1 residents (134, 43%). Patient care and knowledge were the most common core competencies learned. As PGY level increased, learning of professionalism (P = 0.035) increased. A majority of learning was experiential (wards and OR, P < 0.0125). Self-learning and learning in clinic was a minor component of learning (P < 0.0125). Learning on wards (P < 0.001) decreased as residents progressed and learning from the OR (P = 0.002) had the opposite trend., Conclusions: Patient care and knowledge are the most frequently cited competencies learned by the residents. Self-learning is not a significant source of learning, and the majority of the learning is experiential. It is not known if this was a sign that there was a lack of self-directed learning or that self-directed learning was not an efficient method of learning. In addition, each PGY level learns differently (teacher and location of learning), perhaps reflecting the different needs and/or structure of each PGY. We believe the reflective statement has been and will be a useful tool to assess our curriculum., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, quality of life can be improved through palliative procedures. Selecting the appropriate treatment modality remains a careful process, which should take into account potential risks and benefits and the life expectancy of the patient. Traditional therapies, including paracentesis, peritoneovenous shunt placement and diuretics, are successful and effective in varying degrees. After careful review of the patient's primary tumor origin, tumor biology, tumor stage, patient performance status and comorbidities, surgical debulking and intraperitoneal chemotherapy should be considered if the benefit of therapy outweighs the risk of operation because survival curves can be extended and palliation of symptomatic malignant ascites can be achieved in select patients. In patients with peritoneal carcinomatosis who do not qualify for surgical cytoreduction but suffer from the effects of malignant ascites, intraperitoneal chemotherapy can be safely and effectively administered via laparoscopic techniques. Short operative times, short hospital stays, low complication rates and ultimately symptomatic relief are the advantages of laparoscopically administering heated intraperitoneal chemotherapy, making it not only a valuable treatment modality but also the most successful treatment modality for achieving palliative cure of malignant ascites.

Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Malignant bowel obstruction (MBO), a serious problem in stage IV colorectal cancer (CRC) patients, remains poorly understood. Optimal management requires realistic assessment of treatment goals. This study's purpose is to characterize outcomes following palliative intervention for MBO in the setting of metastatic CRC., Study Design: Retrospective review of a prospective palliative database identified 141 patients undergoing surgical (OR; n = 96) or endoscopic (GI; n = 45) procedures for symptoms of MBO., Results: Median patient age was 58 years, median follow-up 7 months. Most (63%) had multiple sites of metastases. Computed tomography (CT) scan findings of carcinomatosis (p = 0.002), ascites (p = 0.05), and multifocal obstruction with carcinomatosis and ascites (p = 0.03) significantly predicted the need for percutaneous or open gastrostomy tube, or stoma. Procedure-associated morbidity for 81 patients with small bowel obstruction (SBO) was 37%; 7% developed an enterocutaneous fistula/anastomotic leak. Thirty-day mortality was 6%. Most (84%) patients were palliated successfully; some received additional chemotherapy (38%) or surgery (12%). Procedure-associated morbidity for 60 patients with large bowel obstruction (LBO) was 25%; 11 patients (18%) required other procedures for stent failure, with one death at 30 days. Symptom resolution was >97%. Patients with LBO had improved symptom resolution, shorter length of stay (LOS), and longer median survival than patients with SBO., Conclusions: Patients with MBO and stage IV CRC were successfully palliated with GI or OR procedures. Patients with CT-identified ascites, carcinomatosis, or multifocal obstruction were least likely to benefit from OR procedures. CT plays an important role in preoperative planning. Sound clinical judgment and improved understanding are required for optimal management of MBO.

Objectives: To examine the outcomes of patients managed with the palliative triangle method and to evaluate factors associated with effective patient selection., Design: Patients receiving a procedure to palliate symptoms of advanced cancer were identified prospectively from all surgical palliative care consultations and observed for at least 90 days or until death., Setting:   Academic surgical oncology service., Patients: A total of 227 patients symptomatic from advanced incurable cancer., Intervention: The palliative triangle technique was used to select patients for palliative operations., Main Outcome Measures: Symptom resolution, overall survival, and complications., Results: We evaluated 227 patients from July 1, 2004, through June 30, 2009. Reasons cited for not selecting 121 patients (53.3%) for a palliative procedure were low symptom severity (23.9%), decision for nonoperative palliation (19.0%), patient preference (19.8%), concerns about complications (15.7%), and other (21.6%). A palliative operation was performed in 106 patients (46.7%) for complaints of gastrointestinal obstruction (35.8%), local control of tumor-related symptoms (25.5%), jaundice (10.4%), and other (28.3%). Of these 106 patients, 5 required procedures for recurrent symptoms and 6 for additional symptoms; of the 121 patients originally not selected, 12 required procedures for progressive symptoms, for a total of 129 procedures. Patient-reported symptom resolution or improvement was noted in 117 of 129 procedures (90.7%). Palliative procedures were associated with 30-day postoperative morbidity (20.1%) and mortality (3.9%). Median survival was 212 days., Conclusion: Palliative operations performed in these carefully selected patients were associated with significantly better symptom resolution and fewer postoperative complications compared with previously published results.

Objective: To determine whether simply being made continually aware of the hospital costs of daily phlebotomy would reduce the amount of phlebotomy ordered for nonintensive care unit surgical patients., Design: Prospective observational study., Setting: Tertiary care hospital in an urban setting., Participants: All nonintensive care unit patients on 3 general surgical services., Intervention: A weekly announcement to surgical house staff and attending physicians of the dollar amount charged to nonintensive care unit patients for laboratory services during the previous week., Main Outcome Measure: Dollars charged per patient per day for routine blood work., Results: At baseline, the charges for daily phlebotomy were $147.73/patient/d. After 11 weeks of residents being made aware of the daily charges for phlebotomy, the charges dropped as low as $108.11/patient/d. This had a correlation coefficient of -0.76 and significance of P = .002. Over 11 weeks of intervention, the dollar amount saved was $54,967., Conclusion: Health care providers being made aware of the cost of phlebotomy can decrease the amount of these tests ordered and result in significant savings for the hospital.

Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Although systemic therapy for metastatic breast cancer (MBC) continues to evolve, there are scant data to guide physicians and patients when symptoms develop. In this article, the authors report the frequency and durability of palliative procedures performed in the setting of MBC., Methods: From July 2002 to June 2003, 91 patients with MBC underwent 109 palliative procedures (operative, n=76; IR n=39, endoscopic n=3). At study entry, patients had received a mean of 6 prior systemic therapies for metastatic disease. System-specific symptoms included neurologic (33%), thoracic (23%), musculoskeletal (22%) and GI (14%). The most common procedures were thoracostomy with or without pleurodesis (27%), craniotomy with resection (19%) and orthopedic open reduction/internal fixation (19%)., Results: Symptom improvement at 30 days and 100 days was reported by 91% and 81% of patients, respectively, and 70% reported continued benefit for duration of life. At a median interval of 75 days from intervention (range, 8-918 days), 23 patients (25%) underwent 61 additional procedures for recurrent symptoms. The durability of palliation varied with system-specific symptoms. Patients with neurologic or musculoskeletal symptoms were least likely to require additional maintenance procedures (P<.0002). The 30-day complication rate was 18% and there were no procedure-related deaths. At a median survival of 37.4 mos from MBC diagnosis (range, 1.6-164 months) and 8.4 months after intervention (range, 0.2-73 months), 7 of 91 patients remained alive., Conclusions: Palliative interventions for symptoms of MBC are safe and provide symptom control for the duration of life in 70% of patients. Definitive surgical treatment of neurologic or musculoskeletal symptoms provided the most durable palliation; interventions for other symptoms frequently require subsequent procedures. The longer median survival for patients with MBC highlights the need to optimize symptom control to maintain quality of life., (Copyright (c) 2010 American Cancer Society.)

Objective: To obtain prospective outcomes data on patients (pts) undergoing palliative operative or endoscopic procedures for malignant bowel obstruction due to recurrent ovarian cancer., Methods: An institutional study was conducted from July 2002 to July 2003 to prospectively identify pts who underwent an operative or endoscopic procedure to palliate the symptoms of advanced cancer. This report focuses on pts with malignant bowel obstruction due to recurrent ovarian cancer. Procedures performed with an upper or lower gastrointestinal (GI) endoscope were considered "endoscopic." All other cases were classified as "operative." Following the procedure, the presence or absence of symptoms was determined and followed over time. All pts were followed until death., Results: Palliative interventions were performed on 74 gynecologic oncology pts during the study period, of which 26 (35%) were for malignant GI obstruction due to recurrent ovarian cancer. The site of obstruction was small bowel in 14 (54%) cases and large bowel in 12 (46%) cases. Palliative procedures were operative in 14 (54%) pts and endoscopic in the other 12 (46%). Overall, symptomatic improvement or resolution within 30 days was achieved in 23 (88%) of 26 patients, with 1 (4%) postprocedure mortality. At 60 days, 10 (71%) of 14 pts who underwent operative procedures and 6 (50%) of 12 pts who had endoscopic procedures had symptom control. Median survival from the time of the palliative procedure was 191 days (range, 33-902) for those undergoing an operative procedure and 78 days (range, 18-284) for those undergoing an endoscopic procedure., Conclusion: Patients with malignant bowel obstructions due to recurrent ovarian cancer have a high likelihood of experiencing relief of symptoms with palliative procedures. Although recurrence of symptoms is common, durable palliation and extended survival are possible, especially in those patients selected for operative intervention.