Objective To evaluate senior General Surgery residents’ performance in the teaching assistant (TA) role during inguinal hernia repair (IHR) and examine relationships among technical skills, teaching effectiveness, and operative autonomy. Design Observational study using an explanatory correlational design. Setting John Cochran Veterans Affairs Medical Center training General Surgery residents from Washington University in St. Louis and St. Louis University. Participants PGY-4 and PGY-5 General Surgery residents serving as TA or in Chief Resident role during IHR performed between July 2023 and March 2024. Results Evaluations were completed for 16 of the 47 eligible IHRs (34% response rate). Case distribution was 63% open and 37% robotic. The mean technical score was 16.6 (±1.8, out of 20), and the mean teaching score was 17.2 (±1.9). Technical and teaching scores were strongly correlated (r = 0.81, p = 0.002). Technical scores demonstrated a strong correlation with the Zwisch autonomy score (rho = 0.60, p = 0.05), whereas teaching scores showed a more modest association that did not meet statistical significance (rho = 0.54, p = 0.085). Conclusions Senior residents perform well in the teaching role for open IHR, which were the primary context in which formal TA activity occurred. Technical performance strongly correlates with teaching performance. Future work should explore strategies to enhance teaching skills prior to independent practice.

OBJECTIVE:To collect validity evidence for the use of the Anastomosis Objective Structured Assessment of Technical Skills (A-OSATS) instrument, which has been developed to evaluate performance of a minimally invasive side-to-side bowel anastomosis with hand-sewn common enterotomy. DESIGN:Residents performed a robotic ileocolic anastomosis simulation on an ex vivo porcine model. Faculty scored each resident with the A-OSATS and performed a provocative leak test on the completed anastomoses. Residents were reassessed on the sewing sub-score 1 month later. Data were compared with parametric and nonparametric analysis. SETTING:Single academic general surgery residency PARTICIPANTS: PGY-4 and -5 general surgery residents (n = 17) RESULTS: PGY-5s performed better than PGY-4s in repeat A-OSATS sewing sub-score (mean 55/55 ± 0 vs 43 ± 4.9, p < 0.001) and time to complete (minutes, mean 14.5 ± 4.9 vs 21.2 ± 3.9, p = 0.01). There was a strong correlation between A-OSATS score and time (r = -0.67, p = 0.005). For the initial assessment, there was no significant difference in mean A-OSATS score between anastomoses that leaked and those that did not leak (137.3 ± 14.5 vs 150.1 ± 11.2, p = 0.098), but on repeat assessment, intact anastomoses had a higher mean A-OSATS sewing sub-score than those that leaked (52.2 ± 4.7 vs 39 ± 3.5, p = 0.007). There was no significant difference between initial A-OSATS score and repeat score (p = 0.14). CONCLUSIONS:We provide extrapolative validity evidence for the A-OSATS instrument by comparing A-OSATS score to time to sew, provocative leak test, and discrimination between PGY-4s and PGY-5s. Generalizability validity evidence is provided by test-retest reliability. Further refinement is needed for the A-OSATS tool to be used for high-stakes entrustment decisions in resident-performed robotic ileocolic anastomoses.

ObjectiveSimulation training for minimally invasive colorectal procedures is in developing stages. This study aims to assess the impact of simulation on procedural knowledge and simulated performance in laparoscopic low anterior resection (LLAR) and robotic right colectomy (RRC).DesignLLAR and RRC simulation procedures were designed using human cadaveric models. Resident case experience and simulation selfassessments scores for operative ability and knowledge were collected before and after the simulation. Colorectal faculty assessed resident simulation performance using validated assessment scales (OSATS-GRS, GEARS). Paired t-tests, unpaired t-tests, Pearson's correlation, and descriptive statistics were applied in analyses.SettingBarnes-Jewish Hospital/Washington University School of Medicine in St. Louis, Missouri.ParticipantsSenior general surgery residents at large academic surgery program.ResultsFifteen PGY4/PGY5 general surgery residents participated in each simulation. Mean LLAR knowledge score increased overall from 10.0 ±  2.0 to 11.5  ±  1.6 of 15 points (p = 0.0018); when stratified, this increase remained significant for the PGY4 cohort only. Mean confidence in ability to complete LLAR increased overall from 2.0 ±  0.8 to 2.8  ± 0.9 on a 5-point rating scale (p = 0.0013); when stratified, this increase remained significant for the PGY4 cohort only. Mean total OSATS GRS score was 28  ±  6.3 of 35 and had strong positive correlation with previous laparoscopic colorectal experience (r = 0.64, p = 0.0092). Mean RRC knowledge score increased from 9.4 ±  2.2 to 11.1 ±  1.5 of 15 points (p = 0.0030); when stratified, this increase again remained significant for the PGY4 cohort only. Mean confidence in ability to complete RRC increased from 1.9 ±  0.9 to 3.2  ±  1.1 (p = 0.0002) and was significant for both cohorts.ConclusionsSurgical trainees require opportunities to practice advanced minimally invasive colorectal procedures. Our simulation approach promotes increased procedural knowledge and resident confidence and offers a safe complement to live operative experience for trainee development. In the future, simulations will target trainees on the earlier part of the learning curve and be paired with live operative assessments to characterize longitudinal skill progression.

Supplemental Figure S1. Perinatal deletion of intestinal HuR in the Apc min/+ background does not alter tumorigenesis.

Percutaneous endoscopic colostomy (PEC) tube placement is a minimally invasive procedure used to treat recurrent colonic pseudo-obstruction, sigmoid volvulus, chronic intractable constipation, and neurogenic bowel. PEC is a viable treatment alternative for patients who have failed conservative therapies and are deemed high risk for surgical management. We present a case of acute colonic pseudo-obstruction after Clostridioides difficile infection that was unresponsive to medical treatment or endoscopic decompression. A PEC tube was placed into the transverse colon with successful resolution of the colonic distension.

Legend for Supplemental Figures S1-S3.

Supplemental Figure S3. mRNA expression of apoptosis-related factors in AOM-DSS-treated Hur IKO and Hur f/f mice.

Immunosuppressed patients are more likely to fail nonoperative management of acute diverticulitis and have more postoperative complications than the immunocompetent. Transplant recipients form a subcategory among the immunosuppressed with unique challenges. The aim of this work is to report 30‐day postoperative complications after colectomy for acute diverticulitis and success rates of nonoperative management in pre‐ and post‐transplant patients.

Supplemental Figure S2. Intestinal HuR deletion does not influence ASBT expression or bile acid homeostasis.

Introduction: Data regarding inter-regional colectomy rates in patients with ulcerative colitis (UC) remains largely unknown. Herein, we sought to systematically review the global variation in the rates of colectomy in patients with UC. Methods: A comprehensive search analysis was performed using the electronic databases MEDLINE/PubMed, EMBASE, and Cochrane through May 2020, to identify all full-text, randomized controlled trials (RCTs) and cohort studies pertaining to colectomy rates in adult patients with UC. We followed PRISMA and AMSTAR 2 guidance for conducting our systematic review. Outcomes included continent based demographic data and variation in colectomy rates. All articles were screened for bias using the Newcastle-Ottawa Scale. To identify the region-specific proportion of patients undergoing colectomy, data were plotted and median overall proportions were generated. Results: Our literature search identified 1249 articles, of which 77 studies met inclusion criteria and were eligible for review. The median overall proportion of persons with UC whom underwent a colectomy in studies was 17% (range: 1.6%-71%). Median age at UC diagnosis was scarcely reported and could not be adequately assessed. While the median proportion of persons with UC whom underwent colectomy was 38%, 31%, and 14% in Oceania, North America, and Europe respectively; Africa, Asia, and South America saw median colectomy rates as low as 10%, 8%, and 3%, respectively (Table). Conclusion: Considerable inter-regional differences were observed regarding colectomy rates in patients with UC. As such, the development of homogenous evidence-based guidelines accounting for the geographic differences in managing patients with UC is needed. Additionally, as a paucity of data on colectomy exists outside the North American and European continents, future studies—particularly in less studied locales—are warranted. Table 1. - Continent based Ulcerative Colitis (UC) colectomy rates Region N studies N sample size (median, range) Proportion males (median, range) N colectomy (median, range) Proportion colectomy (median, range) North America 20 429 (26-443,043) 51% (39%-66%) 176 (9-19,208) 31% (4%-58%) Europe 41 474 (30-76,129) 53% (0%-88%) 37 (10-9118) 14% (2%-71%) Asia 10 175.5 (62-1013) 54% (49%-59%) 20 (3-61) 8% (16%-47%) Oceania 3 71 (15-225) 61% (55%-67%) 22 (9-86) 38% (31%-60%) Africa 2 125 (115-135) 45% (44%-47%) 12 (4-20) 10% (3%-17%) South America 1 267 33% 9 3%

Introduction: Acute colonic pseudo-obstruction (ACPO) is a colonic distention without obstruction that can lead to catastrophic complications. Supportive care until spontaneous resolution is often successful whereas surgery in the acute setting is reserved for emergencies such as ischemia and/or rupture. We present a case of refractory ACPO successfully treated with a percutaneous endoscopic colostomy (PEC) tube. Case Description/Methods: A 72-year-old male presented with cellulitis. He was treated with antibiotics, during which time he developed colonic distention and a diagnosis of toxic megacolon was considered. Surgery was consulted and recommended non-operative management due to his stable clinical status and significant co-morbidities including a BMI of 53. He was started on oral vancomycin and intravenous metronidazole with overall improvement clinically. After discharge, the patient continued to have diarrhea and persistent colonic distention. Readmission occurred and the Gastroenterology team performed colonoscopic decompression twice without sustained resolution of colonic distention. The decision was made to proceed with a cecostomy tube by interventional radiology. Unfortunately, despite a patent 8.5Fr cecostomy tube, the colonic distention continued to worsen mainly in the transverse colon with the diameter reaching 22 cm. The decision was made to place a higher caliber 24 Fr PEC tube in the operation room under monitored anesthesia care. The PEC tube was successfully placed endoscopically in the transverse colon without any acute complications [Figure 1]. Fortunately, the patient’s colonic distention improved to less than 10 cm on follow-up abdominal x-rays. Discussion: Patients with ACPO are often medically complex with multiple comorbidities. Non-interventional, supportive care, including removal of offending agents, correction of fluid and electrolyte imbalances and ambulation remains the preferred treatment. Should medical therapy be contraindicated or fail, endoscopic decompression is recommended with a success rate of up to 95%. Emergent surgical management is usually only reserved for those with perforation or presumed ischemia and is associated with high rates of morbidity and mortality. In challenging cases such as this, a multidisciplinary approach is needed, which can facilitate collective decision-making regarding less well-established and less invasive treatment modalities, such as PEC.Figure 1.: Percutaneous Endoscopic Colostomy tube in the transverse colon.

Introduction: Percutaneous endoscopic colostomy (PEC) is a minimally invasive procedure used to treat recurrent colonic pseudo-obstruction, sigmoid volvulus, chronic intracTable constipation, and neurogenic bowel. Traditional management of these conditions involving surgical colostomy or bowel resection in many cases has been replaced by percutaneous approaches under imaging or endoscopic guidance due to high rates of technical success and low morbidity rates. We conducted a systematic literature review to summarize the use, indications, and complications of PEC in adult patients. Methods: A systematic literature review was conducted using PubMed, Medline, Google Scholar, and Embase to identify patients who had undergone PEC for any indication. The search terms used were “percutaneous endoscopic colostomy”, “percutaneous endoscopic cecostomy”, “percutaneous cecostomy”, and “percutaneous colostomy”. Exclusion criteria were colostomy tubes that were not placed endoscopically. Results: A total of 11 observational studies (3 prospective, 8 retrospective), 18 case reports, and 7 case series between 1998 and 2022 were identified. A total of 318 patients who underwent PEC were identified. The mean age was 66.4 ± 23.5 and 64% were male. The most common indication was sigmoid volvulus (n= 131) followed by pseudo-obstruction (n=43), chronic intrac table constipation (n=83), neurogenic bowel (n=45), and others (n=9). The procedure was technically successful in 311 patients (97.7%). The total complication rate was 37.6%, 83.5% (n=66) of which were minor complications such as pain, bleeding, infection, leakage, and 16.4% (n=13) of which were major complications such as peritonitis, pneumoperitoneum, and sepsis. PEC-related mortality was 1.3% (n=4). The most common locations for tube placement were the left colon (59%) followed by right colon (13%), the rest of the cases the location was not reported. The number of tubes removed was 57, 8 due to symptom resolution, 3 for planned colostomy, and 1 for pain. (Figure) Conclusion: PEC is an underutilized procedure that offers a viable treatment alternative for select patients who are deemed high risk for surgical intervention and in whom conservative therapy is unsuccessful. It can lead to durable relief of symptoms with good technical success and low risk of major complications. Further prospective studies are needed to establish the optimal placement technique, long-term efficacy, and safety.Figure 1.: Percutaneous Endoscopic Colostomy tube indications

BACKGROUND: Lymph node ratio (LNR), the ratio of tumor-positive lymph nodes (+LN) to the total number of resected lymph nodes (rLN), predicts recurrence and survival in colon cancer. Variations in colonic resection length (RL) may influence rLN, +LN, or both, thereby potentially impacting LNR and its prognostic value in colon cancer.METHODS: All colon cancer patients treated surgically at our center from 2004 to 2011 were included in an institutional review board-approved data repository (n = 1,039).RESULTS: Larger RL was associated with increased rLN (rho = .22; P < .001) but not with +LN (P = .21). In node-positive patients (n = 411), RL-adjusted LNR had weaker correlations with death (rho = .338 vs .373, both P < .001) or metastatic disease (rho = .303 vs .345; both P < .001) and a smaller area under the curve (death: .695 vs .715, metastasis: .675 vs .699). Findings were similar in segmental, extended segmental, and total colectomy subgroups.CONCLUSIONS: Provided that resections are performed following standard oncologic principles, our analysis shows that RL does not significantly impact the prognostic value of LNR in colon cancer. Correcting LNR for RL seems redundant and may even act as noise distorting LNR values. (C) 2016 Elsevier Inc. All rights reserved.

BACKGROUND:The surgical management of colitis-associated rectal cancer (CARC) is not well defined. This study determines outcomes after surgery for CARC compared with sporadic rectal cancer.MATERIALS AND METHODS:This is a retrospective cohort study comparing 27 patients with CARC with 54 matched patients with sporadic cancer. Matching criteria included age, gender, neoadjuvant chemoradiation, and American Joint Committee on Cancer stage. Outcome measures were disease-free and overall survival, tumor characteristics, and postoperative morbidity.RESULTS:Compared to those with sporadic rectal cancer, patients with CARC underwent proctocolectomy more frequently (21 [78%] versus 6 [22%] P < 0.001) and were more likely to have mucinous tumors (11 [40.7%] versus 12 [22.3%] P = 0.03). Overall 3-y survival was significantly reduced in CARC patients compared with patients with sporadic rectal cancer. Those with CARC undergoing segmental proctectomy only demonstrated reduced overall and disease-free survival compared to patients with sporadic rectal cancer and to colitis patients undergoing proctocolectomy (P = 0.002).CONCLUSIONS:Patients with CARC undergoing proctectomy demonstrate reduced disease-free survival versus those undergoing proctocolectomy, and versus patients with sporadic rectal cancer undergoing proctectomy. These findings warrant further study and suggest that proctocolectomy should be considered the preferred surgical approach for CARC.

The genetic events involved in the transformation of normal colonic epithelium to neoplastic polyps to invasive carcinoma, as initially proposed by Fearon and Vogelstein, form the foundation of our understanding of colorectal cancer. The identification of the polyp as the precursor lesion to colorectal cancer is the basis of many of our current practices for screening, surveillance, and prevention. The last three decades have seen a veritable explosion in our understanding of the molecular events involved in the pathogenesis of colorectal cancer. It is now clear that there are multiple genetic pathways in the polyp to carcinoma sequence. Some polyps previously thought to be nonneoplastic have now been shown to have malignant potential. Finally, increased understanding of the sequence of genetic events has led to the development of targeted therapeutics. The clinical translation of these scientific advances has made a significant impact on the management of patients with colorectal cancer. Accordingly, it is imperative that all clinicians caring for these patients have an understanding of the genetics of colorectal polyps and cancer. In this article, we review the etiology and genetic pathways to carcinoma associated with a range of polyps of the colon and rectum.