Rural settings can be challenging with regard to the level of resources and general support of surgery. Effective advocacy is the means to deal with barriers to good surgical care. While advocating for more support for rural health care can appear daunting, it can be accomplished. This article gives concrete examples of tools for rural surgeons to participate in strong advocacy as well as success stories. This article can serve as a primer to begin or amplify a surgeon's advocacy journey.
BACKGROUND:Leadership can be succinctly defined as influencing behavior to achieve desired results. Physicians influence the behavior of patients, team members, and colleagues many times each day to achieve desired outcomes, yet leadership is rarely framed or taught as a core clinical competency. In practice, physicians routinely lead patients through complex decisions, guide interprofessional teams, support families during times of uncertainty, and model professional behavior for trainees. METHODS:This article reframes physician leadership as an essential function of clinical care and presents a practical, longitudinal framework for leadership development across the medical profession. A concentric circles model describes leadership growth across four interdependent domains: leading self, leading another, leading teams, and leading organizations. Complementing this individual framework, four institutional lines of effort are proposed: developing interest, providing foundational education, refining leadership through apprenticeship, mentorship, and coaching, and building a pipeline of future leaders. RESULTS:The proposed framework provides a scalable approach for embedding leadership development across medical education, clinical practice, and health care systems. Recognizing leadership as a core clinical competency aligns with existing accreditation standards and creates a unifying framework for strengthening communication, professionalism, teamwork, and systems-based practice. The model also links individual leadership development with institutional strategies that can support progressive growth across the continuum of a physician's career. CONCLUSION:Leadership is an essential component of everyday clinical practice rather than a competency reserved for physicians in formal administrative roles. It is a fact that all physicians are leading every day; the question is whether we recognize it and train for it. Integrating structured leadership development throughout medical training and professional practice represents a meaningful opportunity to strengthen physician effectiveness, enhance team performance, and improve patient outcomes.
BACKGROUND:In treating obesity and related comorbidities, novel glucagon-like peptide-1 receptor agonists have risen in popularity. Among patients with glucagon-like peptide-1 receptor agonist exposure, there is a subset that opts to undergo metabolic and bariatric surgery. We aimed to understand patient motivations to transition to metabolic and bariatric surgery following glucagon-like peptide-1 receptor agonist utilization. METHODS:This was a qualitative single-institution study that recruited adult patients planning to undergo primary metabolic and bariatric surgery with prior or current use of novel glucagon-like peptide-1 receptor agonists. Semistructured interviews were conducted to elucidate factors that impacted patient decision-making to pursue metabolic and bariatric surgery. A comprehensive codebook was continually developed, and interview data were analyzed using conventional content analysis. RESULTS:Fourteen patients with a history of glucagon-like peptide-1 receptor agonist use were recruited prior to undergoing primary metabolic and bariatric surgery and underwent semistructured interviews. Six themes emerged from the interview data: preference for a long-term, durable treatment option; desire to reduce comorbidities and health risks; adverse aspects of prior treatment modalities; barriers to treatment access; social influences; and differences in health care support systems. CONCLUSION:Despite the efficacy and growing appeal of glucagon-like peptide-1 receptor agonists, some patients with obesity continue to opt for metabolic and bariatric surgery because of multifactorial considerations. The themes identified in this study suggest that this is driven by a complex interplay of the perceived durability of surgery, limitations and adverse aspects of glucagon-like peptide-1 receptor agonists, access and insurance constraints, as well as the desire for a robust, comprehensive improvement in health. These findings underscore the patient-centered benefits of discussing multimodal therapies, including metabolic and bariatric surgery, among patients taking glucagon-like peptide-1 receptor agonists.
BACKGROUND:The Functional Status Scale has been proposed for assessing functional outcomes after pediatric injury. The Functional Status Scale was developed in critically ill children with a score of 6 defined as normal and Functional Status Scale ≥8 as "abnormal." Previous work using this definition has shown that 51% of injured children with disability at follow-up did not have disability at hospital discharge, suggesting that defining Functional Status Scale ≥8 as "abnormal" may underestimate impairment in children with mild single-system disability (Functional Status Scale = 7). We aimed to determine appropriate classification of Functional Status Scale = 7 in injured children. We hypothesized that a Functional Status Scale = 7 at discharge would (1) correlate with previously established disability measures and (2) have higher rates of long-term disability than those with no disability (Functional Status Scale = 6) at discharge. METHODS:Data from the "Assessment of Health-Related Quality of Life and Functional Outcomes after Pediatric Trauma" prospective multicenter study were analyzed. Agreement was assessed between Functional Status Scale and Pediatric Overall Performance Category. Detectable disability at 6-month follow-up using Functional Status Scale and Pediatric Overall Performance Category was compared between children with discharge Functional Status Scale of 6, 7, or 8. RESULTS:Data from 427 children with available long-term follow-up were analyzed. Children with Functional Status Scale = 7 had detectable disability by Pediatric Overall Performance Category in 48% (55/114) at discharge and in 50% (20/40) at follow-up. Disability measured by Functional Status Scale and Pediatric Overall Performance Category at follow-up was higher among patients with discharge Functional Status Scale = 7 (26% and 19%) than those with discharge Functional Status Scale = 6 (13% and 3.8%; P ≤ .01). CONCLUSION:Classifying Functional Status Scale = 7 as "good" underestimates long-term injury-related disability. These findings support obtaining follow-up functional assessments on injured children with Functional Status Scale ≥7 at discharge.
BACKGROUND:In complex anal fistulas, treatment should achieve healing while preserving continence and quality of life. However, direct comparative evidence across sphincter-preserving, sphincter-dividing/reconstructive, and seton-based approaches remains limited. We compared these techniques for postoperative fecal incontinence, pain, quality of life, and recurrence. METHODS:We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Network Meta-Analysis checklist to report our study. We searched PubMed, Embase, and CENTRAL until August 2025. We included randomized controlled trials and nonrandomized controlled trials in adults with complex cryptoglandular anal fistulas. We extracted data via Research Electronic Data Capture and performed risk-of-bias evaluation via Risk of Bias 2/ROBINS-I. We performed data analysis using MetaXL with setonas the reference technique. We used Grading of Recommendations Assessment, Development, and Evaluation to rate the certainty of our evidence. RESULTS:We included 2,972 patients across 43 studies. For fecal incontinence, adipose-derived stem cells plus fibrin glue and video-assisted anal fistula treatment combined with ligation of the intersphincteric fistula tract showed the most consistent reductions compared with seton (moderate-high certainty). For pain, the JUMP seton technique (described by Khoshnevis et al) and video-assisted anal fistula treatment combined with ligation of the intersphincteric fistula tract were associated with lower pain scores (moderate certainty). Soluble N-ethylmaleimide-sensitive factor attachment protein receptor, video-assisted anal fistula treatment combined with ligation of the intersphincteric fistula tract, and ligation of the intersphincteric fistula tract plus platelet-rich plasma showed higher quality-of-life scores compared with seton (moderate certainty). Recurrence was lower with adipose-derived stem cells plus fibrin glue (relative risk, 0.02) and acellular dermal matrix (relative risk, 0.08) compared with seton. Randomized controlled trial-only sensitivity analyses were consistent with low inconsistency. CONCLUSIONS:Ligation and adhesive-based approaches showed an advantage over seton-based techniques in terms of fecal incontinence, pain, and quality-of-life results with comparable recurrence rates. These results highlight the importance of careful patient selection and choosing specific surgical approaches to improve patients' outcomes.
BACKGROUND:Robotic-assisted surgery is increasingly used for early stage non-small cell lung cancer resection, yet its impact on time to surgery and outcomes remains unclear. METHODS:Using the National Cancer Database (2010-2022), adults with clinical stage I-II non-small cell lung cancer who underwent initial resection by open, video-assisted thoracoscopic surgery, or robotic-assisted surgery were identified for a retrospective cohort study. Prolonged time to surgery was defined as surgery >8 weeks after diagnosis. Multivariable logistic regression identified factors associated with longer time to surgery and short-term outcomes, such as length of hospital stay, 30-day readmission, and 30-/90-day mortality. Overall survival was assessed using Kaplan-Meier analysis, and Cox hazards regression evaluated adjusted hazard of death in robotic cases. RESULTS:Among 173,170 patients, 22.9% experienced longer time to surgery. Robotic-assisted surgery, academic centers, non-White race, nonprivate insurance, and lower socioeconomic status were independently associated with increased time to surgery. Across all patients, increased time was independently associated with higher 30-day mortality and 90-day mortality. While robotic-assisted surgery was associated with higher odds of longer time to surgery, it was independently associated with lower 30-day and 90-day mortality. Within the robotic subgroup, longer time to surgery was independently associated with increased 90-day mortality and worse overall survival. CONCLUSION:Robotic resection is associated with favorable short-term outcomes but more frequent longer time-to-surgery intervals and worse overall survival. Targeted strategies to reduce time to surgery in robotic-assisted surgery are warranted.
BACKGROUND:Palliative care skills are essential in surgical practice, but time constraints and lack of faculty expertise are barriers to implementing palliative care education in surgical training. This study describes and assesses a 5-hour palliative care curriculum designed to fit within demanding residency programs. METHODS:The palliative care curriculum was delivered to general surgery residents at a single institution by faculty surgeons over the course of five 1-hour sessions. Palliative care competence was assessed by a palliative care competence survey completed by residents at baseline and after completion of the palliative care curriculum. The palliative care curriculum survey assessed 3 domains (attitudes, knowledge, and behavior) on a 5-point Likert scale to create a composite score and domain subscores reported as mean (standard deviation). RESULTS:The study included 62 survey respondents, most of whom were in their first year of training (n = 32, 59.7%). Overall survey scores were significantly higher after palliative care curriculum participation (3.92 [0.43]) when compared with baseline (3.56 [0.61]), P = .008; this was also demonstrated in the knowledge domain (3.73 [0.55] vs 3.32 [0.69], P = .011) and the behavior domain (3.44 [0.7] vs 3.28 [0.78], P = .023). The improvement in scores was demonstrated in both univariate and multivariate analyses (P < .05). CONCLUSION:Participation in this 5-hour palliative care curriculum for surgical residents is associated with improved attitudes, knowledge, and behaviors in palliative care. This palliative care curriculum provides a framework for palliative care education across a variety of residency programs based on available time and faculty resources.
BACKGROUND:Predicting hypothyroidism after thyroid lobectomy is important for treatment selection, patient counseling, and postoperative management. Although thyroiditis is a recognized risk factor, the predictive value of ultrasound strain elastography remains unclear. METHODS:We conducted a retrospective cohort study based on prospectively collected elastography data from consecutive adults undergoing thyroid lobectomy between January 2023 and December 2024. Biochemical hypothyroidism was defined as an elevated thyroid-stimulating hormone level at the final assessment within 1 year after surgery or before initiation of levothyroxine therapy. Multivariable logistic regression, restricted cubic spline analysis, and 3 machine learning models were used to identify predictors of postoperative hypothyroidism. RESULTS:Among the 269 patients included, 86 (32%) developed biochemical hypothyroidism. In multivariable logistic regression, preoperative thyroid-stimulating hormone level and thyroid parenchymal strain ratio were independent predictors of postoperative hypothyroidism (both P < .001). Restricted cubic spline analysis demonstrated a positive nonlinear association between strain ratio and predicted risk without an apparent threshold. Across all machine learning models, preoperative thyroid-stimulating hormone level and strain ratio consistently ranked as the 2 most influential predictors based on SHapley Additive exPlanations. The elastic net model achieved the highest discrimination (area under the receiver operating characteristic curve, 0.800), whereas the random forest model demonstrated the best calibration. CONCLUSION:Thyroid parenchymal strain ratio measured by ultrasound elastography and preoperative thyroid-stimulating hormone level are independent predictors of biochemical hypothyroidism after thyroid lobectomy. Incorporating quantitative assessment of thyroid stiffness into preoperative risk stratification may provide incremental predictive value beyond conventional clinicopathologic factors and facilitate individualized surgical counseling, treatment selection, and postoperative surveillance.
BACKGROUND:Postoperative outcomes after curative colorectal cancer surgery vary widely, even among patients with comparable tumor characteristics and treatment pathways. Conventional clinicopathologic factors and circulating tumor DNA predominantly characterize tumor-related risk but provide limited information regarding the dynamic host response to surgical stress. We investigated whether distinct perioperative immunocircadian recovery trajectories could be identified and whether these trajectories were associated with postoperative circulating tumor DNA-based minimal residual disease and long-term oncologic outcomes. METHODS:This prospective observational cohort study included 1,000 patients with stage II-III colorectal cancer who underwent curative-intent resection between June 2017 and December 2019 and were scheduled for oncologic follow-up through 60 months. Perioperative immunocircadian recovery phenotypes were derived by integrating longitudinal wearable-based sleep, rest-activity rhythm, and heart-rate measures with serial inflammatory and immune markers collected from the preoperative period through postoperative day 30. Associations with postoperative circulating tumor DNA-minimal residual disease positivity were assessed using multivariable logistic regression, whereas associations with disease-free survival and overall survival were assessed using multivariable Cox regression and a postoperative day 30 landmark analysis. RESULTS:Three distinct recovery phenotypes were identified: rapid recovery (382/1,000; 38.2%), intermediate recovery (401/1,000; 40.1%), and delayed immunocircadian recovery (217/1,000; 21.7%). Postoperative circulating tumor DNA-minimal residual disease positivity increased from 8.9% (34/382) in the rapid-recovery group to 17.0% (68/401) in the intermediate-recovery group and 30.0% (65/217) in the delayed-recovery group. Compared with rapid recovery, delayed recovery was associated with greater odds of postoperative circulating tumor DNA-minimal residual disease positivity (adjusted odds ratio, 3.94; 95% confidence interval, 2.45-6.33). At 60 months, estimated disease-free survival was 82.1%, 76.4%, and 63.8%, respectively, and estimated overall survival was 90.0%, 86.9%, and 77.2%, respectively. In models adjusted for clinicopathologic factors but not circulating tumor DNA-minimal residual disease, delayed recovery was associated with worse disease-free survival (adjusted hazard ratio, 2.21; 95% confidence interval, 1.64-2.98) and overall survival (adjusted hazard ratio, 2.03; 95% confidence interval, 1.45-2.85). After additional adjustment for postoperative circulating tumor DNA-minimal residual disease, the corresponding adjusted HRs were 1.90 (95% confidence interval, 1.40-2.57) and 1.80 (95% confidence interval, 1.28-2.53), respectively. Addition of the recovery phenotype to a clinicopathologic model that included circulating tumor DNA-minimal residual disease increased the optimism-corrected C-index for disease-free survival from 0.754 to 0.781. CONCLUSION:Distinct perioperative immunocircadian recovery phenotypes were associated with postoperative circulating tumor DNA-minimal residual disease positivity and long-term oncologic outcomes after colorectal cancer surgery. The recovery phenotype provided information complementary to clinicopathologic factors and circulating tumor DNA-minimal residual disease within the study cohort. However, this investigational phenotype requires independent external validation before it can be used to guide postoperative clinical management.
BACKGROUND:Postpancreatectomy hemorrhage complicates 3%-10% of pancreaticoduodenectomies and is associated with mortality rates up to 20%. Clinically relevant postoperative pancreatic fistula is a major risk factor. This study aimed to characterize bleeding sources and identify predictors of severe hemorrhage in patients with clinically relevant postoperative pancreatic fistula. METHODS:We retrospectively analyzed 1,722 consecutive pancreaticoduodenectomies performed between January 2013 and December 2024 at a high-volume tertiary center. Bleeding sources were systematically classified, and microbiological profiles of peripancreatic collections were reviewed. Multivariable logistic regression identified independent predictors of grade B/C postpancreatectomy hemorrhage in patients with clinically relevant postoperative pancreatic fistula. Cryptogenic postpancreatectomy hemorrhage was defined as grade B/C hemorrhage without an identifiable source despite comprehensive evaluation. RESULTS:Postpancreatectomy hemorrhage occurred in 135 patients (7.8%), including 89 cases (5.2%) of grade B/C hemorrhage. The pancreaticojejunal anastomosis was the most frequent bleeding source (15.6%), followed by branches of the superior mesenteric (9.6%) and hepatic (8.1%) arteries; the gastroduodenal artery accounted for only 3.7%. Independent predictors of severe hemorrhage were bile leak (odds ratio, 4.50; 95% confidence interval, 2.01-10.07; P < .001) and gram-negative infection, predominantly Klebsiella pneumoniae (odds ratio, 2.55; 95% confidence interval, 1.18-5.51; P = .017). A nomogram incorporating these factors showed acceptable discrimination (area under the curve, 0.701) with good internal validation (area under the curve, 0.791). Cryptogenic postpancreatectomy hemorrhage occurred in 24.7% of grade B/C cases and was associated with lower mortality than source-identified hemorrhage. CONCLUSION:In clinically relevant postoperative pancreatic fistula patients, bile leak and K pneumoniae infection independently predict severe postpancreatectomy hemorrhage. The pancreaticojejunal anastomosis was the most common bleeding site, whereas cryptogenic postpancreatectomy hemorrhage appears to represent a lower-mortality subgroup once arterial bleeding is excluded.
BACKGROUND:Traditional postoperative prognostic indicators rely primarily on objective measures, such as patient characteristics and operative indices, potentially missing important clinical insights that surgeons develop through experience. We investigated whether surgeons' subjective perceptions quantified using a visual analog scale serve as valuable predictors of postoperative outcomes. METHODS:This prospective cohort study was conducted at a tertiary hospital over 2 consecutive periods (2023 and 2024). Patients undergoing general surgical procedures were enrolled, with the 2023 cohort (n = 296) serving as the development data set and the 2024 cohort (n = 171) serving as the validation cohort. Primary and assistant surgeons completed visual analog scale assessments (0-100 scale) for multiple aspects of the surgical case both preoperatively and postoperatively. The primary outcome was the occurrence of Clavien-Dindo grade III or higher complications (≥Clavien-Dindo grade III). RESULTS:In the 2023 cohort, 10.1% of patients experienced ≥Clavien-Dindo grade III complications, and 12.3% in the 2024 validation cohort. Surgeons' preoperative assessment of the patient's basic general condition (Q4) emerged as the strongest independent predictor of severe complications in the multivariable analysis (odds ratio, 1.35 per 10-unit increase; 95% confidence interval, 1.12-1.63; P = .002). A risk prediction model incorporating age, emergency status, blood loss, and the surgeon's Q4 assessment demonstrated good discrimination (area under the curve, 0.777). The model maintained a similar performance in the validation cohort (area under the curve, 0.774). CONCLUSION:Surgeons' subjective assessments, particularly their preoperative evaluation of patients' general condition, provide valuable prognostic information. These assessments may capture important clinical insights not reflected in conventional scoring systems and enhance perioperative risk stratification.
BACKGROUND:Pancreaticoduodenectomy remains a technically demanding procedure associated with substantial postoperative morbidity. The PD-ROBOSCORE was developed to quantify procedural difficulty using preoperative variables, but external validation and its clinical relevance across different surgical approaches remain limited. This study aimed to validate PD-ROBOSCORE and assess its prognostic performance in predicting major postoperative complications. METHODS:We conducted a retrospective single-center study including consecutive patients undergoing open or robotic pancreaticoduodenectomy between 2020 and 2025. PD-ROBOSCORE was calculated using the original weighted formula and analyzed as a continuous variable, by quartiles, and using the predefined high-difficulty threshold (≥9). The primary end point was major postoperative complications (Clavien-Dindo ≥3). Associations were evaluated using logistic regression. Discrimination was assessed using receiver operating characteristic analysis. Incremental predictive value was examined by comparing a baseline clinical model with and without PD-ROBOSCORE. RESULTS:A total of 381 patients were included; 36.5% developed major complications. Higher PD-ROBOSCORE values were independently associated with increased odds of major morbidity (odds ratio, 1.12; 95% confidence interval, 1.01-1.15; P = .02), with a significant trend across quartiles (P = .011). The score demonstrated good discrimination (area under the curve, 0.727), with similar performance in open and robotic pancreaticoduodenectomy (P = .91). Among high-difficulty cases (n = 98), no statistically significant difference in major postoperative complications was observed between robotic and open pancreaticoduodenectomy. Addition of PD-ROBOSCORE improved predictive accuracy compared with the clinical model alone (area under the curve, 0.748 vs 0.673; P = .003). CONCLUSION:PD-ROBOSCORE is an effective predictor of major postoperative morbidity after pancreaticoduodenectomy and provides incremental prognostic value beyond patient-related factors. It may support preoperative risk stratification and surgical decision-making, particularly in technically complex cases.
BACKGROUND:Adolescent and young adult women (ages 18-39) with breast cancer face distinct clinical and psychosocial challenges, yet national perioperative data specific to this group remain scarce. This study characterizes surgical patterns and short-term outcomes in adolescent and young adult women with breast cancer compared with outcomes in older women using a large multi-institutional data set. METHODS:Women with a diagnosis of breast cancer undergoing lumpectomy or mastectomy with or without axillary surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2013 to 2023. Patients were stratified by age (adolescent and young adult 18-39 vs ≥40). Baseline demographics, comorbidities, operative characteristics, and 30-day outcomes were compared using χ2 and t tests. RESULTS:Of 241,885 patients identified, 11,544 (4.8%) were in the adolescent and young adult group. The racial and ethnic makeup of these 2 groups was distinct, with 11.6% of young women identifying as Hispanic and 13.2% as Black, compared with 6.6% and 10.6% of older women, respectively (P < .001). Adolescent and young adult patients were healthier at baseline than older patients; however, a higher percentage of patients in the adolescent and young adult group had disseminated cancer (3.2% vs 1.8%, P < .001). Adolescent and young adult patients were more likely to undergo mastectomy, including modified radical mastectomy, than their older counterparts (72.1% and 20.2% vs 42.5% and 10.6%, P < .001), resulting in longer operative times (177 ± 108 vs 110 ± 83 min) and longer hospital stays (median, 1.0 vs 0.6 days; P < .001). Despite this, 30-day complication rates were low and comparable between younger and older women (4.0% vs 3.9%, P = .69); reoperation was slightly higher in adolescent and young adult patients (4.0% vs 2.8%, P < .001), whereas mortality remained <0.1% in both groups. CONCLUSION:Adolescent and young adult women constitute a demographically distinct minority of breast-surgical patients who overwhelmingly undergo mastectomy for surgical management of their disease. Adolescent and young adult women were also more likely to undergo surgical resection in the metastatic setting. Despite this, perioperative outcomes for adolescent and young adult women are comparable to those of older women. These data provide the largest contemporary benchmark for counseling young patients and support the safety of aggressive surgical management in this patient population.
BACKGROUND:After gastrointestinal surgery, assessing gastric content provides insight in the recovery of gastrointestinal function. Gastric point-of-care ultrasound is a quick and noninvasive technique that enables objective bedside assessment of gastric content. This pilot study introduces gastric point-of-care ultrasound into routine postoperative care, evaluating the feasibility from nurses', patients', and quality perspectives. METHODS:Trained nurses performed gastric point-of-care ultrasound in patients after gastrointestinal surgery. Feasibility outcomes included nurses' perspectives on acceptability, measured with the theoretical framework of the acceptability questionnaire; nurses' self-confidence (questionnaire); usability measured with the Dutch-System Usability Scale; patients' perspectives on tolerance by measuring pain and comfort before, during, and after gastric point-of-care ultrasound; and quality perspectives, including gastric point-of-care ultrasound indications, technical success, length of a gastric point-of-care ultrasound assessment, accuracy, and qualitative (empty, fluids, and solids) and quantitative (volume of fluid) gastric point-of-care ultrasound results. RESULTS:A total of 52 gastric point-of-care ultrasound assessments were performed in 34 postoperative patients, mostly because of clinical signs of disturbed gastrointestinal function (n = 40, 81%), and mostly conclusive (n = 48, 92%). Reasons for nonconclusive gastric point-of-care ultrasound assessment included abdominal air, antrum not identified, or discomfort. Fluid content was found in 22 (46%) cases, with a median volume of 248 mL. Gastric point-of-care ultrasound was well accepted by nurses who also felt confident employing it. During the procedure, patients' pain and comfort levels did not change. The intraclass correlation coefficient for interpretation accuracy was 0.537, indicating moderate reliability. CONCLUSION:Ultrasound assessment of gastric content in patients recovering from major gastrointestinal surgery is feasible from nursing and patient perspectives. Examinations employed by nurses were successful, with acceptable inter-rater agreement in the interpretation.
BACKGROUND:Early adoption of new surgical technologies represents a critical period for acquiring operative experience that may influence surgeons' careers. However, whether access to operative opportunities during the introduction of robot-assisted surgery differs according to the surgeon's sex remains unclear. METHODS:This retrospective observational study used data from the National Clinical Database, a multicenter database covering more than 95% of all surgeries in Japan. Male and female gastroenterological surgeons who performed distal gastrectomy or low anterior resection between January 1, 2023 and December 31, 2024 were included. The primary outcome was the number of operations performed per surgeon, stratified by sex and years since medical registration. RESULTS:A total of 47,934 distal gastrectomies and 38,230 low anterior resections were included in the analysis. For both procedures, the proportion of operations performed by female surgeons was lowest for robot-assisted surgery. For distal gastrectomy, the proportions were 4.32%, 9.47%, and 11.86% and for low anterior resection, 5.41%, 8.41%, and 8.57% (robot-assisted, laparoscopic, and open, respectively). For robot-assisted procedures, the number of operations performed per surgeon increased with years since medical registration among male surgeons, whereas no comparable increase was observed among female surgeons. Sex differences became apparent at approximately 10 years after medical registration. CONCLUSION:Substantial sex-based disparities in operative opportunities were observed during the early adoption phase of robot-assisted surgery. These disparities were most pronounced for robot-assisted procedures compared with laparoscopic and open surgery. Inequities in access to newly introduced surgical technologies may contribute to persistent sex disparities in surgical careers.
BACKGROUND:Assessing peritoneal cytology status is essential for determining the optimal treatment strategy in patients with pancreatic cancer. This study aimed to evaluate the safety and technical feasibility of percutaneous abdominal lavage cytology screening and its clinical utility in identifying patients unlikely to benefit from resection, thereby reducing nontherapeutic laparotomy. METHODS:We retrospectively analyzed 225 consecutive patients with pancreatic cancer referred for potential curative-intent resection who underwent percutaneous abdominal lavage cytology screening between May 2022 and February 2026. Percutaneous abdominal lavage cytology screening was performed under local anesthesia with ultrasound and fluoroscopic guidance using 100 mL of saline. Recovery of less than 10 mL of lavage fluid was defined as technical failure. Cytology was classified from class I to V, with classes IV and V considered positive for malignancy. RESULTS:A total of 315 procedures were performed, with a technical success rate of 99.7% and 1 procedure-related complication (0.3%). Percutaneous abdominal lavage cytology screening identified positive cytology in 16 patients (7.1%). Overall, 39 patients (17.3%) were deemed ineligible for surgery owing to newly identified unresectable disease during the preoperative period. Excluding 8 patients awaiting surgery, 178 underwent laparotomy, among whom 12 (6.7%) were found to have unresectable disease intraoperatively; R0/1 resection was achieved in 166 patients. Intraoperative cytology positivity was observed in 1 patient (0.6%). CONCLUSION:Percutaneous abdominal lavage cytology screening is a safe, technically feasible, and repeatable method for preoperative cytology assessment in patients with pancreatic cancer considered for curative-intent resection. Integration of percutaneous abdominal lavage cytology screening into preoperative evaluation may improve surgical selection and reduce the rate of nontherapeutic laparotomy.
BACKGROUND:Studies in patients with advanced cancer have shown that earlier palliative care involvement can improve quality of life, caregiver burden, resource utilization, and even survival. However, 2 recent clinical trials failed to show similar benefit at 90 days postoperatively among patients undergoing curative surgery for abdominal cancer. The impact of palliative care on end-of-life outcomes in these patients has not been examined. This study presents an exploratory analysis of the end-of-life outcomes from one of these randomized controlled trials. METHODS:The Surgery with Option of Palliative Care Expert trial was an assessor-blind randomized controlled trial performed at an urban academic hospital. Patients undergoing curative surgery for 1 of 8 different abdominal cancer types were randomized to usual care or early involvement of a specialist palliative provider. Patients were followed for a 3-year period, and caregivers were contacted for patients who died to complete the end-of-life assessment. Outcomes included 3-year mortality, receipt of chemotherapy within the last 2 weeks of life, hospice length of stay, days at home without an emergency department visit in the last 30 days of life, death outside a health care facility, and the Family Assessment of Treatment at End of Life-Short Version survey, a measure of caregivers' perception of the quality of support received at the end of the patient's life. To evaluate 3-year mortality, a Cox proportional hazards model was fit, adjusting for type of cancer. Unadjusted proportional odds logistic regression models were utilized to analyze continuous outcomes, and unadjusted logistic regression models were used for binary outcomes. RESULTS:Two hundred thirty-five eligible patients were randomized in the trial, with 117 in the intervention group and 118 in the usual care group. Ninety-three (40%) patient deaths were recorded in the study database, with 61 of those patients' caregivers (66%) completing part or all the end-of-life assessments (32 in the intervention group and 29 in the usual care group). Comparing the intervention group to the usual care group, no statistically significant differences were seen in mortality (hazard ratio, 1.14; 95% confidence interval, 0.85-1.51; P = .39), receipt of chemotherapy in the last 2 weeks of life (odds ratio, 5.19; 95% confidence interval, 0.57-47.32; P = .14), hospice length of stay (odds ratio, 0.67; 95% confidence interval, 0.27-1.66; P = .38), days at home without an emergency department visit (odds ratio, 0.96; 95% confidence interval, 0.39-2.36; P = .93), death outside a health care facility (odds ratio, 0.82; 95% confidence interval, 0.30-2.25; P = .71), or Family Assessment of Treatment at End of Life-Short Version scores (odds ratio, 0.81; 95% confidence interval, 0.32-2.03; P = .65). CONCLUSION:This study did not show the benefit of early palliative care on end-of-life outcomes in patients undergoing surgery for cancer. This finding is in keeping with the trial's original conclusion that routine specialist palliative involvement may not be warranted among these patients, and limited palliative care resources can best be allocated elsewhere or on a case-by-case basis.
