This Special Communication reflects of the work of an international panel who developed evidence-based recommendations for the diagnosis, operative strategy, technical conduct, and perioperative management of adult colon and rectal trauma. ImportanceTraumatic colon and rectal injuries generate wide practice variation across diagnosis, operative strategy, technical conduct, and perioperative care. Management has shifted from mandatory fecal diversion toward selective primary repair and physiology-guided reconstruction, but decision-making remains inconsistent.ObjectiveTo develop evidence-based recommendations for the diagnosis, operative strategy, technical conduct, and perioperative management of adult colon and rectal trauma.Evidence ReviewAn international World Society of Emergency Surgery panel prioritized 17 clinical questions in the format Population, Intervention, Comparator, Outcome across 3 domains (colon, rectum, and technical/perioperative considerations). For each question, designated authors performed structured literature reviews through early 2026; evidence was synthesized and recommendations were drafted with an assigned strength (strong or conditional) and certainty (high, moderate, low, or very low) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach and then harmonized by consensus. Reporting followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) conventions.FindingsContrast-enhanced computed tomography (CT) anchors diagnosis but is a sensitive screening tool whose negative result does not exclude injury; specific signs (bowel wall discontinuity, extraluminal air, active mesenteric extravasation) warrant operation. For suspected rectal injury, CT is first-line, with adjunctive rigid or flexible proctoscopy raising combined sensitivity to approximately 97%; routine rectal contrast is not recommended. Primary repair or resection with anastomosis is preferred over routine diversion for most stable patients, including many traditionally deemed high risk; for low-grade injuries, primary repair alone is preferred over resection with anastomosis. Selective diversion is reserved for persistent vasopressor dependence after damage-control laparotomy, inability to achieve fascial closure at the first reoperation, or compounded physiologic derangement. Proximal diversion is the default for extraperitoneal rectal injury, and routine presacral drainage and distal rectal washout are not recommended. Stapled and hand-sewn anastomoses are equivalent; antibiotic prophylaxis should not exceed 24 hours; and early enteral nutrition is advised in selected patients.Conclusions and RelevanceThese recommendations support a selective, physiology-driven approach to colorectal trauma, in which patient physiology, contamination, perfusion, and the ability to achieve fascial closure-rather than the injured organ or any single risk factor-guide management. Much of the supporting evidence remains observational, and prospective study is warranted.
Importance Surgical faculty turnover in academic centers causes interruptions in continuity of patient care, trainee education, and loss of funding from research and clinical revenue, while burdening departments with new recruitment efforts. Objective To identify variables associated with surgical faculty's desire both to leave and to stay in their job. Design, Setting, and Participants A cross-sectional 67-item survey based on the job demands-resources model was administered to 452 surgical faculty at 10 medical centers across the US from February 2025 to September 2025. Demographics and factors related to attrition/intent to leave/retention were queried. Satisfaction was measured on a 5-point Likert scale. Reliability was high (Cronbach alpha > 0.70). chi(2) testing and Mann-Whitney U tests were used for analysis. These data were analyzed from September 2025 through February 2026. Exposures Surgical faculty in full-time practice at 1 of 10 medical centers. Main Outcomes and Measures The primary outcome measure was surgical faculty seriously considering leaving (SCL) their current job. Secondary outcome was attrition from prior faculty position. Results There were 209 respondents (response rate, 46.2% [209 of 452]); 59.4% were in their first job (FJ) after training, with 36.7% serving as assistant professors, 29.4% as associate professors, and 29.4% as full professors. Overall, 41.1% (95% CI, 34.3%-48.1%) reported SCL. SCL was higher for FJ (47.2%; 95% CI, 38.1%-56.4% vs 32.1%; 95% CI, 22.4%-43.2% for non-FJ faculty [P = .03]), those working longer clinical hours (50; 95% CI, 40-58.75 vs 40; 95% CI, 40-50; P = .05), and the university-academic SCL rate (45.5% [55 of 121]) vs university-affiliated SCL (48% [24 of 50]) vs nonprofit independent SCL (16.7% [6 of 36]) (P = .004). The top reasons cited for SCL were unhappiness with current leadership/governance (60% strongly agreed/agreed), lacking work-life balance (51.8%), feeling burnout (51.8%), and seeking new leadership opportunities (48.2%). Age, gender, race and ethnicity, geographic region, and academic rank were not associated with SCL. The most cited reasons for why faculty stayed in their present position were enjoying teaching trainees, relationship with colleagues, and the variety of cases. Conclusions and Relevance These results demonstrated that a significant number of surgical faculty reported seriously considering leaving their positions. The results provide actionable insights for improving retention, including greater engagement from departmental leadership and the creation of a nurturing, collaborative environment with career advancement opportunities.
QuestionIn patients with tubo-ovarian abscess, is transvaginal drainage as effective as laparoscopy in achieving a 6-week posttreatment cure?FindingsIn this randomized clinical trial involving 208 patients, transvaginal drainage was associated with a cure rate (72.5%) similar to that of laparoscopy (77.0%), although noninferiority could not be determined. The duration of hospitalization and postoperative pain were lower in the transvaginal drainage group, whereas surgical complications did not differ between the groups.MeaningConsidering the less invasive nature of transvaginal drainage, this approach should be offered as an alternative to laparoscopy for the treatment of tubo-ovarian abscess. ImportanceThe treatment of tubo-ovarian abscess involves a combination of antibiotic therapy and abscess evacuation, which is usually performed by transvaginal drainage or laparoscopy.ObjectiveTo demonstrate noninferiority of transvaginal drainage compared with laparoscopy for treatment of tubo-ovarian abscess in terms of the cure rate.Design, Setting, and ParticipantsThe PACTOL (Efficacit & eacute; de la Ponction transvaginale pour le traitement des AbC & egrave;s Tubo-Ovariens par rapport & agrave; la Laparoscopie) multicenter, randomized, controlled, open, noninferiority clinical trial included patients aged 18 years or older and planning to undergo tubo-ovarian abscess evacuation who were recruited from 19 French hospitals and randomized between April 30, 2019, and April 29, 2023, with a 6-week follow-up duration. Data analysis was conducted from April 2024 to May 2025.InterventionUltrasound-guided transvaginal drainage or laparoscopy.Main Outcomes and MeasuresThe primary outcome was the cure rate, defined using a composite criterion, evaluated at 6 weeks after tubo-ovarian abscess evacuation. The criteria were (1) no surgical reintervention, (2) no reintroduction of antibiotic therapy, and (3) disappearance of the tubo-ovarian collection. Noninferiority was defined as a difference of 12.5 percentage points or less for the main outcome.ResultsAmong the 208 patients included (mean [SD] age, 34.7 [8.8]; all female), 130 were included in the per-protocol analysis. Six weeks after evacuation, 50 of 69 patients (72.5%) in the transvaginal drainage group and 47 of 61 patients (77.0%) in the laparoscopy group achieved the primary outcome (difference, -4.6 percentage points [95% CI, -19.4 to 10.7 percentage points]). There were no differences in persistence of the tubo-ovarian collection and reintroduction of antibiotic therapy. Reintervention was more frequently necessary in the transvaginal drainage group than in the laparoscopy group (9 of 69 patients [13.0%] vs 2 of 61 patients [3.3%], respectively; P = .046). In the intention-to-treat population, 201 women were included. The duration of hospitalization was significantly longer for laparoscopy than for transvaginal drainage (median [IQR], 3 [2-4] vs 2 [2-3] days, respectively; P = .01). The rates of Clavien-Dindo surgical complications of grade II or higher did not differ between groups. The pain score after tubo-ovarian abscess evacuation decreased more quickly in the transvaginal drainage group.Conclusions and RelevanceIn this randomized clinical trial, the noninferiority of transvaginal drainage compared with laparoscopy for tubo-ovarian abscess evacuation was not established, and transvaginal drainage required reintervention more frequently than laparoscopy. Considering the less invasive nature of transvaginal drainage, this approach should be offered as an alternate to laparoscopy, although patients should be aware that it has a higher probability of reintervention.Trial RegistrationClinicalTrials.gov Identifier: NCT03819309 This randomized clinical trial evaluates whether transvaginal drainage is noninferior to laparoscopy for the treatment of tubo-ovarian abscess.
QuestionWhat is the residual lifetime risk of ovarian cancer for BRCA carriers according to age at the time of bilateral salpingo-oophorectomy (BSO)?FindingsIn this study, we analyzed prospective data from 5713 BRCA carriers and applied the life table approach to estimate the residual ovarian cancer risk according to variant type, current age, and projected age at BSO.MeaningClinical decision support tools can help personalize the risk of ovarian cancer and inform decisions regarding the timing and projected benefit of BSO in BRCA carriers. This study estimates the residual lifetime risk of ovarian cancer among BRCA carriers. ImportanceWomen with a BRCA1 or BRCA2 variant face a high lifetime risk of ovarian cancer and are often advised to undergo preventive surgery (bilateral salpingo-oophorectomy [BSO]) before cancer develops. The recommended age of BSO is 35 years for BRCA1 carriers and is 45 years for BRCA2 carriers, but some women choose to delay surgery until the age of menopause; there is no standard upper age at which surgery is no longer advised.ObjectiveTo estimate the residual lifetime risk of ovarian cancer among BRCA carriers by current age and projected age at BSO.Design, Setting, and ParticipantsThis was a prospective cohort study in an international cohort of BRCA carriers monitored for incident ovarian cancer. A life table analysis used age-specific ovarian cancer incidence rates and competing mortality rates to estimate lifetime risk of ovarian cancer among women with a BRCA1 or BRCA2 pathogenic variant with both ovaries intact and no prior ovarian cancer at baseline. Patients were recruited between 1995 and 2024 across 24 international centers, and the mean (SD) follow-up was 4.4 (3.9) years.ExposureTiming of BSO, defined as immediate BSO, delayed BSO, or no BSO.Main Outcome and MeasuresResidual lifetime risk of ovarian cancer.ResultsThe cohort consisted of 4286 BRCA1 and 1427 BRCA2 carriers between the ages of 30 and 74 years at baseline (mean [SD] age, 42.0 [10.8] years). There were 249 incident ovarian cancers in the follow-up period. The lifetime risk of ovarian cancer was 55.0% (95% CI, 48.8-61.9) for a BRCA1 carrier and 24.1% (95% CI, 15.1-36.6) for a BRCA2 carrier. A 30-year-old BRCA1 carrier with BSO delayed to age 50 years had a projected residual ovarian cancer risk of 23.9% (95% CI, 20.7-27.4). At age 75 years, the residual risk of ovarian cancer was estimated to be 8.4% (95% CI, 1.7-22.7) for a BRCA1 carrier and 3.7% (95% CI, 0.1-22.7) for a BRCA2 carrier.Conclusions and RelevanceThe residual risk of ovarian cancer for older women in good health is sufficiently high to consider preventive surgery. BRCA1 carriers who defer BSO until age 50 years may face a substantial risk of developing ovarian cancer.
Importance Acute cholangitis (AC) is a potentially fatal biliary tract infection most commonly caused by gallstones. While modern-day treatments with antibiotics and biliary decompression have drastically decreased mortality rates, AC still requires prompt intervention. Observations Diagnosis of AC traditionally relied on the presence of the Charcot triad, which has since proven to incompletely capture the complexity of this condition. Modern-day diagnosis, severity grading, and management guidelines provide a more holistic approach. Tokyo Guidelines (TG) are widely used, though newer guidelines, namely the BILE criteria, have recently emerged. These criteria include demonstration of inflammation, cholestasis, and biliary obstruction. Ultrasound is first-line imaging modality with computed tomography or magnetic resonance cholangiopancreatography often used for diagnostic dilemmas. Treatment is dependent on severity, though guidelines generally recommend early decompression (most commonly with endoscopic retrograde cholangiopancreatography [ERCP]) for moderate to severe cases. The optimal timing of biliary drainage remains unclear, with mixed evidence from observational studies and no universal definition of what constitutes “early” vs “urgent” drainage. Laparoscopic cholecystectomy should be performed during index hospitalization, when possible, with multiple studies demonstrating lower morbidity and mortality rates when compared with interval procedures. The prognosis of AC is favorable if treated swiftly and appropriately; in turn, mortality rates increase with severity and delays in diagnosis. Conclusions and Relevance AC can be challenging to diagnose and the precise timing of biliary drainage and cholecystectomy is debated. This comprehensive review reflects the most recent evidence and recommendations on severity grading, resuscitation, and timing of ERCP and cholecystectomy to assist clinicians who manage these complex patients.
