Faculty Bibliography

BACKGROUND:Distal pancreatic neuroendocrine tumors (PNET) and pancreatic cystic neoplasms (PCN) are often incidentally found in older adults, requiring careful consideration between operative management and watchful waiting. This study analyzes the short-term complications associated with distal pancreatectomy (DP) for PNET and PCN in older adults to inform clinical decision-making. METHODS:Patients undergoing DP for PNET and PCN were analyzed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and the pancreatectomy procedure-targeted dataset. Associations between decade of age and 30-day outcomes were evaluated. RESULTS:1626 patients were analyzed from 2014 to 2015. 692 (42.6%) were younger than 60 years, 507 (31.2%) were sexagenarians, 342 (21.0%) were septuagenarians, and 85 (5.2%) were octogenarians. Minimally invasive approaches were used in 62.7%. While septuagenarians and octogenarians constituted 26.3% of the cohort, they were affected by 55.6% of reintubations, 66.7% of failures to wean, 82.4% of myocardial infarctions, and 57.1% of septic shock. Septuagenarians and octogenarians had longer hospital stays, as compared to those younger than 60 years. CONCLUSION:Septuagenarians and octogenarians are disproportionately affected by perioperative complications after DP for PNET and PCN. Careful patient selection and thorough counseling should be provided when surgery is considered.

PURPOSE:While there is no level 1 evidence supporting the use of adjuvant radiotherapy (RT) for non-rectal colon cancer in the modern chemotherapy era, there are studies that suggest a local control benefit. This treatment modality is not part of standard treatment recommendations, and we hypothesized that adjuvant RT provides a benefit in locally advanced disease. Due to the limited number who receive post-operative RT, a national database was searched to provide sufficient power. MATERIALS AND METHODS:A retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database was performed. Inclusion criteria were: non-rectal colon cancer, AJCC 6th or 7th edition T4 and M0, oncologic resection, and 1st cancer site. Patients were excluded for RT prior to or during surgery, or if the sequence of RT was unknown. Using a Cox proportional hazard model, the relative risk of cause-specific mortality for "RT after surgery" versus "No RT" was calculated. RESULTS:21,789 patients were identified who met the inclusion criteria. Of these, only 1001 received adjuvant RT, and 64% were node-positive (53% RT vs. 65% no RT). When comparing RT vs. no RT, after adjusting for sex, age, N stage, and grade, we determined the relative risk of death from cancer was 0.8849 (95% CI: 0.8008-0.9779; p = 0.0165), suggesting that only 14 patients with T4 disease need receive adjuvant radiation to spare a cancer-related death. CONCLUSIONS:Adjuvant RT is not routinely utilized for definitive treatment of T4 non-rectal colon cancer, but this analysis shows a significant cause-specific survival benefit.

BACKGROUND:Surgical residents train under immense stress, often manifesting into poor well-being. While recent research identifies methods of coping with stress, few studies empirically investigate the role of the environment on surgical resident well-being. We aimed to assess surgical resident perceptions of workplace climate, organizational support, burnout, and job satisfaction to test a mediation model identifying antecedents to well-being. MATERIALS AND METHODS:A convenience sampling of program directors from general surgery within the Eastern region of the United States were emailed to request either agenda time to collection data via paper survey or to forward an electronic survey link to their residents between March 2016 and June 2016. The survey included scales demonstrating validity evidence on well-being, climate, and perceptions of support. RESULTS:Based on 160 general surgery residents (out of 557; 29% response rate) across 19 training programs, our mediation model found that job satisfaction was significantly predicted by workplace climate directly (direct effect = 0.37, 95% CI [0.19, 0.55]) and indirectly (specific indirect effect = 0.07, 95% CI [0.01, 0.13]) through perceived organizational support and burnout, while controlling for training year and gender, F(5,147) = 53.76, P < 0.001, Rsq. = 0.65. CONCLUSIONS:Medical education requires an additional focus on how the clinical learning environment affects surgical resident well-being. Health systems and training programs will need to collaborate on workplace innovations to improve workplace climate for trainees to address the concerns of well-being with a modern surgical workforce.

PURPOSE/OBJECTIVE:To assess the safety and feasibility of neoadjuvant short-course radiation therapy (RT) concurrent with continuous infusion 5-fluorouracil (5-FU) for the treatment of locally advanced rectal cancer. METHODS AND MATERIALS/METHODS:/d. RESULTS:/d with no dose-limiting toxicity. Thirteen patients received the neoadjuvant mFOLFOX, and only 1 patient went straight to surgery after chemoradiation. Clinical response was 21% complete, 63% partial, 14% stable disease, and no patients had progression. Three patients with cCR had negative biopsies and did not have TME. Pathologic response was 64% partial response and 14% stable disease. No patients had pathologic progression. The most common grade 3 and 4 toxicities were cytopenias. The most common grade 1 and 2 toxicities were cytopenia, fatigue, diarrhea, and nausea. CONCLUSIONS:Our findings suggest that concurrent chemotherapy with neoadjuvant short-course RT is feasible and can be safely given with concurrent continuous infusion 5-FU. This works adds to the growing evidence that short-course RT is not only equivalent to long-course RT, but also may provide additional benefits, such as allowing for a transition to full dose systemic therapy in the neoadjuvant setting, selective organ preservation in complete responders, and providing a more convenient and cost-effective way of delivering pelvic RT.

OBJECTIVES/OBJECTIVE:Surgical ethics has been suggested as a distinct field of study apart from clinical ethics due to a unique practice type and treatment dynamic. At our institution, most if not all teaching of clinical ethics is undertaken by nonsurgical faculty. We introduced a novel online Surgical Ethics Program (SEO) in a pilot form (SEO-P) for initial presentation to learners in our environment. The overall goal of our educational intervention was to enhance knowledge, understanding and appreciation for surgical ethics in medical students and to evaluate our curriculum. SETTING/METHODS:SEO-P was undertaken over a 4-week period in 2018 with 9 fourth-year medical students enrolled in a surgery elective at our institution. These learners all had career plans in general surgery or a surgical subspecialty. There was 3 weeks of content: (1) background in clinical ethics as it applies to surgical practice, (2) surgical consents and autonomy, and (3) the impaired physician. All pilot learners were evaluated with: (1) postprogram final exam assessment (compared to preprogram knowledge base test), (2) self-reflection essay of ethical practice in surgery, (3) evaluation of 2 case studies, and (4) an assessment of participation in online discussion forums. Postprogram survey of the learners was also undertaken in an anonymous fashion. RESULTS:Four of 9 or 44.4% of students scored greater than or equal to 80% on the postprogram knowledge assessment test. A preprogram knowledge-based examination of all learners yielded a mean and standard deviation of 57.1 ± 6.0%. Postprogram knowledge-based test with mean and standard deviation was 78.8 ± 15%. This was a statistically significant increase in scores (p = 0.004; t test). All 9 passed the course with a mean final summative course grade of 95.2 ± 3.2%. From the postprogram evaluation survey, all 7 students who responded felt that the SEO-P would help them become an "ethical" practitioner. Surprisingly, only half of the learners (57.1%) thought "technology used to support the SEO Course (i.e., the chosen curriculum management system) was effective in conducting the course." CONCLUSIONS:We set forth to use "web-based" technology to enhance exposure of medical students in our institution to surgical ethics. Hence, we designed our pilot curriculum to be a completely online offering. We feel that the utilization of the surgical voice, that is a surgical ethics curriculum developed by surgeons to explore surgically related clinical ethical issues, is an essential theme and goal of our program. Future challenges will be to present this voice in an effective manner with either an improved curriculum delivery system or by potentially utilizing a blended approach.

BACKGROUND:Readmissions are a common complication after pancreaticoduodenectomy and are increasingly being used as a performance metric affecting quality assessment, public reporting, and reimbursement. This study aims to identify general and pancreatectomy-specific factors contributing to 30-day readmission after pancreaticoduodenectomy, and determine the additive value of incorporating pancreatectomy-specific factors into a large national dataset. METHODS:Prospective American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) data were retrospectively analyzed for patients who underwent pancreaticoduodenectomy (PD) between 2011 and 2015. Additionally, a subset of patients with pancreatectomy-targeted data between 2014 and 2015 were analyzed. RESULTS:Outcomes of 18,440 pancreaticoduodenectomies were analyzed, and found to have an 18.7% overall readmission rate. Multivariable modeling with pancreatectomy-specific variables increased the predictive value of the model (area under receiver operator characteristic 0.66 to 0.73). Statistically significant independent contributors to readmission included renal insufficiency, sepsis, septic shock, organ space infection, dehiscence, venous thromboembolism, pancreatic fistula, delayed gastric emptying, need for percutaneous drainage, and reoperation. CONCLUSIONS:Large registry analyses of pancreatectomy outcomes are markedly improved by the incorporation of granular procedure-specific data. These data emphasize the need for prevention and careful management of perioperative infectious complications, fluid management, thromboprophylaxis, and pancreatic fistulae.

BACKGROUND:Organizational effects on job satisfaction, burnout, work-life balance, and perceived support have not been studied in the context of the clinical learning environment. We evaluated the relationship between academic resources and resident well-being, the clinical learning environment, and in-service examination performance of surgical residents. MATERIALS AND METHODS:Residents of general surgery and surgical specialty programs were recruited from March 2016 through June 2016 across the Southeast, Mid-Atlantic, and Northeast regions. Program directors were asked to allow distribution of a paper survey or to forward an electronic survey link onto residents. Five dichotomous questions were asked regarding access to academic resources. Validated measures were obtained assessing resident well-being and perceived clinical learning environment. Data were analyzed through t-tests and chi-squared test of independence. RESULTS:We received 276 respondents across 50 programs. Residents perceiving adequate support to succeed had less burnout (P = 0.008), better resilience (P = 0.009), better job satisfaction (P < 0.001), less work/life strain (P = 0.001), better workplace climate (P < 0.001), better organizational support (P < 0.001), and were more likely to have high performance on the in-service examination (P = 0.001). Specific resources including educational stipends, review questions, in-service board prep, and support for poor performers correlated with improved well-being and perceived clinical learning environment. CONCLUSIONS:Provision of academic resources has implications beyond in-service examination performance, correlating with improved resident well-being and perceptions of the clinical learning environment.

BACKGROUND:Historically, management of pancreatic cancer has been determined based on whether the tumor was amenable to resection and all patients deemed resectable received curative intent surgery followed by adjuvant therapy with chemotherapy (CT) ± RT. However, patients who undergo resection with microscopic (R1) positive margins have inferior rates of survival. The purpose of this study is to identify patients who have undergone pancreatectomy for pancreatic cancer, determine the surgical margins, types of adjuvant therapies given and patterns of failure. Our hypothesis was that in patients who have surgery without pre-operative therapy, there is a high rate of R1 resections and subsequent local recurrence, despite adjuvant therapy. METHODS:CT alone, stratified by surgical margin status. RESULTS:13 months, P=0.06), but there was no significant difference in time to death compared to patients with CT alone (P=0.68). CONCLUSIONS:After curative resection, the addition of RT to CT improves PFS in both R0 and R1 settings. However, patients with R1 have significantly worse PFS and OS compared to patients with R0 and even aggressive adjuvant therapy does not make up for the difference. The paradigm has shifted and now for patients with resectable pancreatic cancers we recommend neoadjuvant CT + RT to improve RT targeting and treatment response assessment and most importantly, improve chances of obtaining R0.

INTRODUCTION/BACKGROUND:Desmoplastic melanoma is a rare variant of melanoma that has been reported to demonstrate unique clinical behavior when compared with other histological subtypes. In this study, we present the clinical course of patients with this unusual diagnosis. We hypothesized that desmoplastic melanoma would differ from nondesmoplastic melanoma with regard to its presentation, rate of regional metastasis, and recurrence pattern. METHODS:After institutional review board approval, a retrospective chart review was performed on all patients with a diagnosis of desmoplastic melanoma since 1998. The following data were collected: patient demographics, histopathological details of the lesion, initial treatment, and clinical course. In addition, the available slides were reviewed by a dermatopathologist. RESULTS:Twenty-eight patient charts were reviewed. Mean age at diagnosis was 65 years. Fifty-seven percent of patients were men, and 67% of the lesions originated from the head and neck. Of the 28 patients, 11 had pathology slides that were adequate for evaluation. Pure desmoplastic melanoma, defined by more than 90% of the specimen demonstrating desmoplastic features, was found in only 3 patients. Taking into account all cases, the mean Breslow thickness was 5.09 mm and ulceration was present in 12.5% of lesions. Regional disease was discovered in 18% of patients. The mean follow-up time was 43 months, and the overall recurrence rate was 32%. 66.7% of first recurrences were local. Two of 3 patients with pure desmoplastic melanoma developed regional metastasis. CONCLUSIONS:Our data largely support previous studies that suggest desmoplastic melanoma behaves differently compared with other histological subtypes. However, the incidence of regional disease among patients with pure desmoplastic melanoma appears to be higher in our study than in previous reports. Although this rare variant typically presents with advanced local disease, the rate of regional metastasis is less than what would be expected for similar thickness, nondesmoplastic cutaneous melanoma. The recurrence pattern is different compared with nondesmoplastic melanoma, and the most common site of recurrence is local. Discrepancy in the literature regarding the clinical behavior of this disease may be related to inconsistent pathological criteria for diagnosis. Further research will help clarify the optimal management of desmoplastic melanoma.