Faculty Bibliography

BACKGROUND:Portomesenteric venous thrombosis (PMVT) is a rare complication of bariatric surgery that can lead to cavernous transformation of the portal vein. There are no established treatment algorithms regarding anticoagulation (AC) only vs. catheter-directed thrombolysis in this population. METHODS:Medical records at 4 urban bariatric surgery centers were queried for patients diagnosed with PMVT between 2012 and 2025. Patient characteristics, perioperative details, imaging at PMVT diagnosis, treatment course, and follow-up imaging were reviewed. Fisher's exact testing was conducted to identify correlations between extent of thrombosis, treatment course (anticoagulation vs. interventional radiology [IR] thrombolysis), and the outcome of cavernous transformation. RESULTS:71 patients were diagnosed with PMVT following bariatric surgery (68 LSG, 3 RYGB) at 4 centers between 2012 and 2025. Median time from surgery to PMVT diagnosis was 13 days. Three patients (4%) required reoperation for small bowel resection, of whom 2 underwent open thrombectomy and 1 underwent subsequent IR thrombolysis. Of the remaining patients, 6/68 (9%) underwent IR catheter-directed thrombolysis, and 62/68 (91%) received AC only. Of 53 patients with long-term data, 18 (34%) developed cavernous transformation. Among patients who had a main portal vein + intrahepatic portal vein + inflow (superior mesenteric vein or splenic vein) thrombosis, treatment with AC only was strongly associated with cavernous transformation (13/17, 76%) vs IR (1/5, 20%, p < 0.05). There were no deaths related to PMVT. CONCLUSIONS:In this largest known case series of postbariatric surgery PMVT treated with anticoagulation vs. IR, we found that the PMVT clot pattern with the highest risk of developing cavernous transformation was the extensive type involving the main portal vein, an intrahepatic portal vein, and an inflow vein, whether the main portal vein clot was occlusive or nonocclusive. Early IR intervention was associated with decreased cavernous transformation.

BACKGROUND:Minimally invasive surgical techniques have improved outcomes in colorectal surgery, but comparative data on their use in total abdominal colectomy with end ileostomy for inflammatory bowel disease remain limited. This study aimed to compare postoperative outcomes among patients undergoing robotic, laparoscopic, or open total abdominal colectomy for inflammatory bowel disease. METHODS:We performed a retrospective cohort analysis using propensity score matching to control for baseline differences across patients. Data were obtained from the 2022 American College of Surgeons National Surgical Quality Improvement Program, a national surgical outcomes registry. Adult patients who underwent total abdominal colectomy with end ileostomy for ulcerative colitis or Crohn's disease were included. Patients were treated with robotic-assisted, laparoscopic, or open total abdominal colectomy with end ileostomy. The primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included operative time, conversion to open surgery, length of hospital stay, 30-day readmission, and other specific postoperative complications such as surgical site infection and renal insufficiency. RESULTS:A total of 581 matched patients were analyzed, including 83 robotic, 415 laparoscopic, and 83 open cases. There were no significant differences in overall 30-day morbidity across groups. Robotic surgery had significantly longer operative time than laparoscopic but not open surgery. Organ space infections and renal complications were more common in the robotic group compared with laparoscopic. Although robotic surgery was associated with shorter hospital stay, it also had the highest 30-day readmission rate. CONCLUSIONS:Robotic total abdominal colectomy demonstrated similar overall morbidity and conversion rates compared with other approaches but was associated with longer operative time, increased complications, and higher readmissions. Further refinement of perioperative protocols and patient selection may improve outcomes.

BACKGROUND:Endoscopic sleeve gastroplasty (ESG) is increasingly utilized for treating obesity, but some patients may subsequently present for conversion to a surgical procedure. Foreign material or distorted anatomy may make conversion more challenging. The preoperative evaluation, intraoperative findings, and postoperative outcomes of converting ESG to bariatric surgery are not well described. METHODS:Bariatric surgery patients at a single center with history of ESG were identified by review of electronic medical records from 2016 to 2026. Background characteristics, preoperative imaging, endoscopic findings, intraoperative details, and outcomes were obtained by chart review. Intraoperative videos were obtained when possible. RESULTS:. Most patients (19/20, 95%) underwent preoperative esophagram, which showed a tubularized stomach in half of cases (10/19, 53%) but no radiopaque materials precluding conversion to surgery. Preoperative endoscopy (n = 5) and intraoperative endoscopy (n = 3), when performed, revealed no apparent gastroplasty. Intraoperative findings included mild adhesions around the stomach, with sutures sometimes visible, but an otherwise native stomach not requiring any changes to the staple line. Mean total weight loss was 29.1% at 1 year postoperatively. No stapler misfires occurred, and none of the postoperative complications were related to the gastric staple line. There were no gastric staple line leaks or bleeds. CONCLUSION/CONCLUSIONS:In our experience, sleeve gastrectomy and gastric bypass were both technically feasible and relatively straightforward to perform in patients with a history of ESG.

The loss of Royal Mail Ship (RMS) Titanic has been examined extensively through the lenses of engineering failure, maritime law, and social history, yet little attention has been paid to the conduct and professional identity of her medical officers. This surgical history examines the lives and final hours of the ship's 2 surgeons, Dr. William Francis Norman O'Loughlin and Dr. John Edward "Jack" Simpson, situating their actions within the evolving practice of maritime medicine in the early 20th century. Drawing on contemporary newspaper accounts, official inquiries, archival records, personal correspondence, and genealogical sources, this article reconstructs their careers, responsibilities, and conduct during the disaster. O'Loughlin, a senior surgeon with decades of maritime experience, and Simpson, a younger assistant surgeon at the outset of his career, represented 2 generations united by a shared professional ethic. Both remained at their posts, assisting passengers and crew, maintaining calm, and declining opportunities for self-preservation. Their actions exemplify the unwritten code of the surgeon: composure under pressure, disciplined and methodical judgment, and a steadfast respect for the dignity of every human life. Beyond documenting individual bravery, this article demonstrates that their conduct reflects enduring principles of surgical professionalism that transcend era, technology, and setting. In a tragedy remembered primarily for its scale, the surgeons' story highlights how judgment, humanity, and moral responsibility remain central to the identity of the surgeon, whether practiced in a modern operating room or a rolling hospital at sea.

BACKGROUND:Redo/revisional ileal pouch-anal anastomosis (IPAA) surgery is technically challenging and more likely to require mesenteric lengthening maneuvers, largely due to mesenteric reach issues, which may affect the perfusion of the critical sites in the pouch. Indocyanine green fluorescence angiography (ICG-FA) offers real-time assessment of tissue perfusion and may reduce the risk of complications, such as anastomotic leak. We aimed to evaluate the impact of intraoperative ICG-FA on surgical outcomes in patients undergoing redo/revisional IPAA surgery. METHODS:This is a retrospective case-control study with 1:1 propensity score matching based on data from a high-volume quaternary inflammatory bowel disease center. Patients who underwent redo/revisional IPAA surgery between September 2016 and December 2023 were included. The primary objective was to evaluate the direct impact of ICG-FA on intraoperative decision-making, measured by the rate of change in surgical plan. Secondary objectives included an exploratory comparison of short- and long-term outcomes, such as anastomotic leak and major complications. RESULTS:A total of 46 patients were included, with 23 patients in each of the ICG and non-ICG groups. ICG-FA led to intraoperative changes in surgical management in 2 patients (8.7%), including one pouch augmentation with resection of the tip of the J pouch and one pouch excision. The 30-day major complication rate was lower in the ICG group (11.1%) compared to non-ICG (18.2%), though not statistically significant (p = 1.00). No significant difference was found in long-term complication rates after adjusting for a marked disparity in follow-up duration between the groups. No adverse reactions related to ICG-FA were observed. CONCLUSIONS:ICG-FA is a safe and feasible adjunct during redo/revisional IPAA surgery. Its use may guide intraoperative decision-making, leading to timely revisions.

OBJECTIVE:This study reports patient outcomes and predictors of outcomes after total contact casting (TCC) for diabetic stump ulceration in patients with partial-foot amputations. METHODS:Retrospective review of patients treated with TCC for diabetic stump ulcerations with ipsilateral partial-foot amputation at a tertiary center from 2015 to 2022 was performed. Patients lost to follow-up, those unable to tolerate TCC, and those with partial amputations of digits 2 to 5 were excluded. Patient demographics, outcomes, and complication rates of TCC were collected and compared. Multivariable linear regression was performed to identify demographic predictors of time to ulcer closure. RESULTS:Forty-three patients were included in this study, with a 93.5% rate of primary ulcer closure, 46.5% rate of re-ulceration, and 9.3% rate of re-amputation. Patients without re-ulceration were significantly more likely to be nonsmokers. Regression analysis also found that smoking history trended toward a longer delay to ulcer closure (P=.097). Age, body mass index, presence of contralateral amputation, and type of amputation did not affect patient outcomes or complication rates. CONCLUSIONS:TCC effectively promotes ulcer closure in diabetic patients with high comorbidity burden and partial-foot amputation, although smoking history increases re-ulceration rates.

Merkel cell carcinomas (MCC) typically arise from the clonal integration of the Merkel cell polyomavirus. Immunogenic viral oncoproteins then lead to tumorigenesis. Oncoprotein-specific T cells are essential for anti-MCC immunity, but it is unclear whether B cells promote tumor control. In this study, we analyzed the frequency and phenotype of viral oncoprotein-specific and total B cells in blood samples from 47 patients with MCC and tumor samples from another 19 patients with MCC. The phenotype of blood B cells did not correlate with the outcomes of patients with MCC. In contrast, all 11 patients with robust oncoprotein-specific antibody-secreting and/or germinal center B cells in tumors experienced long-term MCC control. In vitro, B cells engineered to be specific for viral oncoproteins increased the sensitivity of oncoprotein-specific CD4+ T cells by more than 50-fold. Together, our findings suggest that cancer-specific B cells promote antitumor immunity via increased responses by T cells and that cancer-specific augmentation of B cells could be therapeutically relevant. See related Spotlight, p. 716.

INTRODUCTION/BACKGROUND:Minimally invasive surgery (MIS) is widely considered to be the standard of care for paraesophageal hernia (PEH) repairs, yet a subset of cases still require unplanned conversion to open surgery due to factors such as poor visualization and intraoperative complications. Although both laparoscopic and robotic approaches are routinely used, few studies have compared conversion rates as a primary outcome. This study aims to evaluate conversion to open surgery and associated short-term outcomes between surgical approaches for PEH repairs. METHODS:This retrospective cohort study used the 2022-2023 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) registry to identify elective laparoscopic and robotic PEH repairs in patients aged 18-90 years. Concomitant procedures were excluded and 1:1 propensity score matching was performed to control for baseline characteristics and comorbidities. The primary outcome was unplanned conversion to open surgery. Secondary outcomes included 30-day postoperative complications, return to OR, readmission, and hospital length of stay. RESULTS:A total of 8325 patients met inclusion criteria, of which 40% (n=3364) underwent robotic repair. After matching, 3335 patients were included in each group with balanced covariates (standardized mean difference < 0.05). The robotic group had zero conversions to open, while the laparoscopic group had a conversion rate of 0.2% (p = 0.031). Operative times were longer in the robotic group (133 vs 115 minutes, p < 0.001). No differences were observed in 30-day postoperative complications, readmission, return to OR, or median length of stay. Rates of specific complications including infections, thromboembolic events, and cardiopulmonary issues were comparable between groups. CONCLUSION/CONCLUSIONS:In this large national cohort, there was a growing trend of robot usage for elective PEH repair. Additionally, robotic repairs were associated with fewer conversions to open but longer operative time. Further studies are needed.

Humankind's historical footprint on the continent of Antarctica now spans nearly 130 years. Since the first expedition, surgical care has remained both a necessity and a challenge. Residence in Antarctica is made difficult by unforgiving terrain and a long, isolating winter season. Survival requires strategic allocation of resources and personnel. Surgical emergencies and consultations on residential bases arise in the forms of traumatic injuries and atraumatic illnesses. Medical evacuation is considered dangerous and therefore reserved for critical cases. As such, medical professionals (both surgeons and non-surgeons) must be prepared to provide life-saving surgical care.