Background Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. Methods Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. Results The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 ( P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program ( P < .0001). Conclusions There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.

The purpose of this study is to update the available literature with information on the current use of robotic assisted surgery (RAS) in the Department of Defense (DoD) compared to the civilian world, and how the coronavirus disease 2019 (COVID-19) pandemic impacted RAS in the DoD. A total of 9,979 RAS cases between 01st October 2017 and 31st December 2020 were reviewed from every DoD Military Treatment Facility (MTF) that meets our inclusion criteria and employs various models of da Vinci robotic surgical systems (Intuitive Surgical). Specialty, number, and facility were recorded for each case. These data were then compared to previously known trends about RAS use in the DoD as well as with civilian trends. Before COVID-19, the use of RAS had increased over time, but not at the same rate as in the civilian sector. General surgery cases constituted most RAS cases in both the DoD and the civilian sector. The arrival of COVID-19 in the United States significantly decreased the use of RAS in the DoD as well as in the civilian sector in all surgical specialties because it led to postponement or cancellation of many non-emergent surgical procedures. In conclusion, the use of RAS has continued to increase, and general surgery cases continue to constitute most of these cases. However, since the COVID-19 pandemic began, there was a significant decline in both DoD and civilian RAS cases, with a more pronounced decline in the DoD.

Department of Colon and Rectal Surgery, The Hospitals of Providence, El Paso, Texas Funding/Support: None reported. Financial Disclosure: None reported. Correspondence: Avery Walker, M.D., 18511 Highlander Medics St. El Paso, TX. E-mail: [email protected]il.mil

The laser-driven generation of relativistic electron beams in plasma and their acceleration to high energies with GV/m-gradients has been successfully demonstrated. Now, it is time to focus on the application of laser-plasma accelerated (LPA) beams. The "Accelerator Technology HElmholtz iNfrAstructure" (ATHENA) of the Helmholtz Association fosters innovative particle accelerators and high-power laser technology. As part of the ATHENAe pillar several different applications driven by LPAs are to be developed, such as a compact FEL, medical imaging and the first realization of LPA-beam injection into a storage ring. The latter endeavour is conducted in close collaboration between Deutsches Elektronen-Synchrotron (DESY), Karlsruhe Institute of Technology (KIT) and Helmholtz Institute Jena (HIJ). In the cSTART project at KIT, a compact storage ring optimized for short bunches and suitable to accept LPA-based electron bunches is in preparation. In this conference contribution we will introduce the 50 MeV LPA-based injector and give an overview about the project goals. The key parameters of the plasma injector will be presented. Finally, the current status of the project will be summarized.

Nonoperative management (NOM) of acute appendicitis is becoming more popular, especially in resource-strapped locations, to minimize hospital system costs. In uncomplicated cases of appendicitis, NOM can effectively treat the patient. It does carry a 39.1% risk of recurrence in 5 years, and operative management (OM) does not increase morbidity or risk of complication, so the authors recommend laparoscopic OM for uncomplicated appendicitis. For complicated cases of appendicitis, the authors recommend initial NOM with interval appendectomy in all patients. All appendicitis patients should undergo surveillance endoscopy if older than 40 years to rule out a contributing neoplasm.

BACKGROUND The management of battlefield trauma requires a specific skill set, which is optimized by regular trauma experience. As military casualties from the prolonged conflicts in the Middle East decrease, challenges exist to maintain battlefield trauma readiness. Military surgeons must therefore depend on the Military Health System. The purpose of the study was to evaluate the frequency of surgical cases relevant to deployed combat casualty care performed at military treatment facilities (MTFs). METHODS Combat casualty care relevant cases (CCC-RCs) were defined as emergent, open surgical cases in which the patient required a blood transfusion. Case logs from four military treatment centers with surgical residency training programs were used. Twenty-four months of case records between January 1, 2017, and January 1, 2019, were included to determine total numbers of CCC-RCs at each institution. The results were compared with San Antonio Military Medical Center’s, the Department of Defense’s only American College of Surgeons–verified level 1 trauma center. RESULTS Fifty-one trauma/general surgeons and six vascular surgeons case logs were examined. Thirty (0.3%) of 10,529 cases performed by trauma/general and vascular surgeons over the 2-year study period were considered CCC-RCs. These results were in contrast to San Antonio Military Medical Center, which had a significantly higher proportion of CCC-RCs (113 of 320 cases, 35.3%, p < 0.0001). CONCLUSION A cross-section of MTF surgical case complexity demonstrates a lack of cases considered to be CCC-RCs. At the MTFs evaluated, surgical case surrogates for combat trauma and combat casualty care is close to zero. These data are potentially representative of other military treatment centers, which focus on beneficiary care. For readiness purposes, MTFs that care primarily for Tricare beneficiaries without a significant trauma population should not be considered meaningful sources of CCC-RCs for trauma/general and vascular surgeons. LEVEL OF EVIDENCE Therapeutic/care management study, level V.

Benjamin Hall, Andrew MD, FACS; Davis, Elizabeth MD; Scott Walker, Avery MD, FACS; Umberger, Jaime DO; Qureshi, Iram MPH; Jackson Glaser, Jacob MD, FACS; McClendon, Hampton MD; Margaret Gurney, Jennifer MD, FACS Author Information

Background: Despite a lack of supporting data, routine splenic flexure mobilization (SFM) during colectomy has been thought to reduce anastomotic leak (AL). We evaluated the impact of SFM on outcomes in distal colectomy. Study design: The 2005-2016 NSQIP database identified 66,068 patients undergoing distal colectomy with anastomosis. Cohorts were stratified by addition of SFM. Postoperative outcomes were compared between groups. Regression analysis identified factors affecting odds of developing AL. Results: SFM was performed in 27,475 patients (41.6%). There was no difference in overall complications between cases with SFM and those without (p = 0.55). SFM had longer operative times (220 min vs. 184 min; p < 0.0001). SFM was not associated with any difference in AL rate (3.6% vs. 3.7%; p = 0.86). Factors most associated with AL were lack of oral antibiotic preparation (OR 1.93; p < 0.001), chemotherapy (OR 1.91; p < 0.001), and weight loss (OR 1.68; p = 0.0005). Operative indication and approach did not affect leak. Conclusions: SFM in distal colectomy increased operative time without decreasing overall complications or AL. Routine splenic flexure mobilization may add risk without significant benefit. Published by Elsevier Inc.

INTRODUCTION Since inception of robotic-assisted surgery (RAS) in 1999, there has been an exponential rise in RAS in both number and complexity of surgical cases performed. The majority of these cases are gynecologic surgery in nature, with only a quarter of them labeled as general surgery. The purpose of this study is to determine if RAS in the Department of Defense (DoD) mirrors these trends. METHODS A total of 6,204 RAS cases from across the DoD were reviewed between 01 January 2015 and 30 September 2017 from every Military Treatment Facility (MTF) that employs a robotic surgical device (various models of the da Vinci robotic surgical system by Intuitive Surgical). Specialty, number, and surgeon were recorded for each case. These end points were also examined for trends overtime and compared to similar civilian data. RESULTS The number of MTFs performing robotic surgery and the number of cases performed increased significantly. An average of 373 cases per quarter-year were performed in 2015, 647 in 2016, and 708 in 2017. The number of RAS cases increased by about 10% every quarter-year during this time period. RAS was most commonly performed by general surgery in 10 of the 14 MTFs examined. CONCLUSIONS MTFs implemented RAS much later than the civilian world. However, since its implementation, the frequency of RAS use has increased at a faster rate in the DoD than in the civilian world. Possible reasons for this are a younger pool of surgeons in the military and less demands on cost-effective productivity, allowing these younger surgeons to focus on emerging technology rather than maximizing surgical cost efficiency. General surgery constitutes the majority of RAS cases in the DoD. It is unclear why this difference from the civilian world exists.

Citation: Baste LM, Walker A (2018) Colonic Phytobezoar Caused by Popcorn Kernels Resulting in a High Grade Large Bowel Obstruction. Int J Surg Res Pract 5:071. doi.org/10.23937/2378-3397/1410071 Received: April 07, 2018: Accepted: May 21, 2018; Published: May 23, 2018 Copyright: © 2018 Baste LM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. International Journal of Surgery Research and Practice Open Access ISSN: 2378-3397

Introduction: Great advances have been made in screening for and treatment of colorectal cancer (CRC), but recurrence rates remain high and additional therapies are needed. There is great excitement around the field of immunotherapy and many attempts have been made to bring immunotherapy to CRC through a cancer vaccine.Areas covered: This is a detailed review of the last decade's significant CRC vaccine trials.Expert commentary: Monotherapy with a CRC vaccine is likely best suited for adjuvant therapy in disease free patients. Vaccine therapy elicits crucial tumor infiltrating lymphocytes, which are lacking in microsatellite-stable tumors, and therefore may be better suited for these patients. The combination of CRC vaccines with checkpoint inhibitors may unlock the potential of immunotherapy for a much broader range of patients. Future studies should focus on vaccine monotherapy in correctly selected patients and combination therapy in more advanced disease.

Multiple studies have been performed demonstrating the benefits of an enhanced recovery program following a wide breadth of surgical disciplines, including more recent reports showing significant benefits of enhanced recovery protocols for patients undergoing a laparoscopic colectomy. This has held true in both comparisons of an open versus minimally invasive approach, as well as when comparing enhanced recovery pathways to traditional perioperative care strategies. While most providers are now well versed in the concept of enhanced recovery, the individual practice and components often vary in number and nature. However, the basic principles of ensuring this program spans the preoperative, intraoperative, and postoperative settings, along with a multidisciplinary mandated “buy-in”, are necessary to ensure maximal effectiveness regardless of the institution or procedure.

BACKGROUND:Modern 64- to 128-slice computed tomography (CT) scanners have questioned the need for routine colonoscopy after hospital admission for presumed uncomplicated diverticulitis. METHODS:This is a retrospective review of all patients (>18 years) who underwent planned colonoscopy after admission for Hinchey I or II acute diverticulitis (January 2009 to January 2014). The findings on the final radiologist report were then correlated with the colonoscopy results. RESULTS:In total, 110 patients (mean age, 55.2 ± 16; 46.4% female) underwent a subsequent colonoscopy (median, 60 days) after admission for diverticulitis. Overall, 102 patients (92.7%) had CT findings consistent with definitive diverticulitis, 6 patients had a diagnosis suggestive of diverticulitis on CT scan, and 2 patients had masses on their admission CT scans. Within the group with definitive diverticulitis, follow-up colonoscopy identified diverticulosis in 99 (97.0%), whereas the other 3 had normal findings. Of the patients with CT scans suggestive of diverticulitis, follow-up colonoscopy showed 3 with diverticulosis, 2 with malignancies, and 1 with nonspecific inflammation. The reliability of CT scans for diverticulitis compared with colonoscopy was found to have a kappa = .829 (P < .001; 95% confidence interval, .629, 1.21). CONCLUSIONS:Follow-up colonoscopy should be performed when a CT scan suggests malignancy, nonspecific inflammatory findings, or the patient is otherwise due for routine screening or surveillance. In this study, there was no benefit of follow-up colonoscopy in patients with CT-confirmed diverticulitis in the absence of other concerning or indeterminate findings.

Robotic surgery began approximately 30 years ago, growing steadily, and has now become one of the mainstream topics within the surgical literature across multiple surgical disciplines. More recently, robotic use has expanded to colorectal surgery, demonstrating increased usage in the more difficult operations involved. As competition in the marketplace and technology increase and improve, the size and cost of these systems may progressively decrease, and their presence will likely grow. With that, innovative and novel concepts are being introduced at a rapid pace. The enhanced performance gained by the surgeon with these devices will hopefully enable the difficult operations to become more feasible and potentially even safer. We present a brief history of the instruments related to robotic colorectal surgery and discuss some of the robotic instruments that may be seen in a future robotic-enabled operating room.

BACKGROUND: Intraoperative laser fluorescence angiography is a relatively new tool that can be used by colorectal surgeons to ensure adequate perfusion to bowel that remains after resection. It has been used mostly to determine an appropriate point of transection of the proximal bowel, as well as to ensure perfusion after the anastomosis has been constructed. We propose a different use of the technology in complex cases to ensure the ability to safely transect a major vascular pedicle and to ensure that perfusion will remain adequate.OBJECTIVE: The purpose of this article is to describe a new use for fluorescence angiography technology.DESIGN: This is a technical note.SETTINGS: The work was conducted at a tertiary care military medical center.PATIENTS: Patients included individuals requiring oncologic colorectal resection where the status of 1 major vascular pedicle was unknown or impaired.MAIN OUTCOME MEASURES: We assessed perfusion after occlusion of a major vascular pedicle for the short term in hospital outcomes.RESULTS: Adequate studies were obtained, and perfusion was maintained in both patients. Oncologic resections were performed, and short-term outcomes were comparable with any individual undergoing these procedures.LIMITATIONS: This study was limited because it is early experience that was not performed in the setting of a scientific investigation.CONCLUSIONS: Application of intraoperative fluorescence angiography in this setting appears to be safe and may assist the surgeon in estimating reliable vascular perfusion in patients such as these who require oncologic colorectal resection.

ABSTRACT Introduction: Great advances have been made in screening for and treatment of colorectal cancer (CRC), but recurrence rates remain high and additional therapies are needed. There is great excitement around the field of immunotherapy and many attempts have been made to bring immunotherapy to CRC through a cancer vaccine. Areas covered: This is a detailed review of the last decade’s significant CRC vaccine trials. Expert commentary: Monotherapy with a CRC vaccine is likely best suited for adjuvant therapy in disease free patients. Vaccine therapy elicits crucial tumor infiltrating lymphocytes, which are lacking in microsatellite-stable tumors, and therefore may be better suited for these patients. The combination of CRC vaccines with checkpoint inhibitors may unlock the potential of immunotherapy for a much broader range of patients. Future studies should focus on vaccine monotherapy in correctly selected patients and combination therapy in more advanced disease.

Listeria monocytogenes is a pathogen associated with meningitis in the immunosuppressed patient. The pathogen is usually found in soft cheeses and raw milk. We present a case of an infected popliteal artery stent graft with Listeria monocytogenes. The report focuses on the diagnosis and treatment with surgical explantation and vascular reconstruction.

AIMS:To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction.METHODS:A retrospective database review was carried out, covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004-2011.RESULTS:A total of 404 patients met the inclusion criteria. One hundred and thirty-nine were admitted during the day, 93 at night and 172 on the weekend. Overall 30.2% of the patients were managed operatively with no significant difference between the groups (P = 0.89); however, of patients taken to the operating room, patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend, 0.79 days vs 1.90 days, respectively (P = 0.05). Overall mortality was low at 1.7%, with no difference noted between the groups (P = 0.35). Likewise there was no difference in morbidity rates between the three groups (P = 0.90).CONCLUSIONS:Despite a faster time to operative intervention in those patients admitted during the day, our study revealed that time of admission does not appear to correlate to patient outcome or mortality.