Introduction: Pancreatic neuroendocrine tumors (pNETs) are slow growing, malignant tumors that show different survival outcomes by race. Current size-based guidelines were largely developed in White patients. Our aim was to investigate tumor size and incidence of lymph node metastasis (LNM) between White and Asian pNET patients to evaluate generalizability of established guidelines. Methods: Using the National Cancer Database (NCDB), we conducted a multi-institutional analysis of patients with low grade, resected, nonfunctional, sporadic, non-metastatic pNETs. Chi-squared tests were implemented to determine correlation between PTS and LMN incidence as well as race and LMN incidence. A logistic regression model was utilized to determine correlation between LMN, tumor size, and race. Overall survival was assessed using the Kaplan-Meier method. Results: A total of 4977 pNET patients (205 Asian and 4772 White) were included in our analysis. Asian patients presented with smaller tumors (3.0 cm vs 3.9 cm, p = 0.029) but when grouped by size, there was no difference in the distribution (p = 0.77). White patients demonstrated a higher incidence of lymph node metastasis at presentation compared to Asian patients (27% vs 19%, p = 0.013), a higher likelihood of an R0 resection (95.3% vs. 89.3 %, p < 0.0001). Within both populations, tumor size (<2 cm, 2-3 cm, and >3 cm) positively correlated with incidence of LNM (11.5 %, 24.6 %, and 39.1 %). No difference of LNM was seen between racial cohorts at PTS <3 cm, however, Asian patients were less likely to exhibit LNM at PTS >3 cm (28.2 % and 39.5 %, p = 0.04). Overall survival was not significantly different between racial groups (p = 0.92). Conclusion: Size based surgical resection guidelines for pancreatic neuroendocrine tumors based on a predominantly White patient population may not be generalizable to the Asian population. Within this population, we found the risk of lymph node metastasis did not increase at similar rates with increasing primary tumor size.

BACKGROUND:The surgical decision making for pancreatic adenocarcinoma is complex. Although practice guidelines exist for many scenarios, these do not cover many common eventualities that may be encountered during these cases. We sought to identify the practice pattern variations amongst pancreatic surgeons in response to commonly experienced clinical scenarios. METHODS:A multiple-choice questionnaire was distributed to all full members of the IHPBA. Participant demographics, training history, and clinical practice information were obtained. The survey provided various operative scenarios and participants were asked how they would likely proceed. Responses were collected and stored anonymously in a secure database. Statistical analysis was performed using Stata 16.0. RESULTS:164 responses were submitted. Most of the respondents were male and had been in practice for over 10 years. The median age range was 40-50 years old. When asked about staging laparoscopy, the majority performed it selectively. For most respondents a pathological aorto-caval nodes was a reason to abort the procedure but most would have continued in the setting of a positive hepatic artery node. When encountering a single Segment 2 liver metastasis, participants who practiced in Europe were significantly more likely to resect and proceed compared to those in Asia and North America. Participants who had undergone only a Surgical Oncology fellowship were most likely to abort. With respect to direct colonic invasion, most participants would resect the specimen en bloc. Respondents who participated in fewer that 20 PDAC operations/year were most likely to abort. CONCLUSIONS:Surgical decision making in PDAC surgery is complex and there is significant disagreement on the correct management. While formal guidelines cannot exist for all situations, this survey highlights the need for consensus on commonly encountered operative scenarios.

With an increasingly diverse patient population, efforts to enhance the ethnic and racial representation of the surgeon workforce are critically important. Unfortunately, ethnic representation in academic surgery is regressively disproportionate with Black and Latino physicians representing 4.7% and 3.1% of surgical residents and 2.9% and 5.6% of surgical faculty, respectively. 1 Butler P.D. Longaker M.T. Britt L.D. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg. 2008 Nov; 248 (PMID: 18948795): 704-711https://doi.org/10.1097/SLA.0b013e31817f2c30 Crossref PubMed Scopus (108) Google Scholar Recognizing that not all US minority groups are underrepresented in the physician workforce, the Association of American Medical Colleges (AAMC) coined the terminology ethnically underrepresented in medicine (URiM), amplifying the lack of physicians from Black, Latino, and indigenous backgrounds. 2 Association of American Medical CollegesUnderrepresented in medicine definition. https://www.aamc.org/initiatives/urm/Date accessed: March 25, 2023 Google Scholar The historical void of ethnically diverse provider representation has been implicated in suboptimal patient-provider interactions. For example, Black patients who reported provider racial discordance, rated their clinical experiences as poorer in communication quality, information-giving, and participatory decision making as compared to White patients with racially concordant providers. 3 Shen M.J. Peterson E.B. Costas-Muñiz R. et al. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities. 2018 Feb; 5 (Epub 2017 Mar 8. PMID: 28275996; PMCID: PMC5591056): 117-140https://doi.org/10.1007/s40615-017-0350-4 Crossref PubMed Scopus (411) Google Scholar Increasing URiM surgeon prevalence bolsters culturally sensitive healthcare, invigorates investigative studies highlighting minority specific health care needs, and provides culturally concordant role models and mentors to train future generations. 1 Butler P.D. Longaker M.T. Britt L.D. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg. 2008 Nov; 248 (PMID: 18948795): 704-711https://doi.org/10.1097/SLA.0b013e31817f2c30 Crossref PubMed Scopus (108) Google Scholar ,3 Shen M.J. Peterson E.B. Costas-Muñiz R. et al. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities. 2018 Feb; 5 (Epub 2017 Mar 8. PMID: 28275996; PMCID: PMC5591056): 117-140https://doi.org/10.1007/s40615-017-0350-4 Crossref PubMed Scopus (411) Google Scholar (see Fig. 1)

Background: To encourage progression of surgeon scientists amongst increasingly limited funding, academic interest, training institutions are supporting mid-training academic development time (ADT). We propose that supporting ADT with a full funding mechanism will improve ADT participation at minimal institutional cost. Materials and methods: From 2017 to 2022, our surgery department proposed a full funding mechanism for a post-graduate year three (PGY-3) resident to encourage ADT participation. Residents were required to submit at least two external grants. Annual funding sources and total stipend supplementation was calculated by prevalence of ADT residents. Results: From 2017 to 2022, 30 residents opted to participate in 1-4 years of ADT with increasing prevalence. 5 funding sources were utilized with similar to$530,000 in total annual funding. Departmental contribution was minimal compared to external (9% vs. 91% ($48,102 vs. $485,573, p < 0.001)). Conclusions: With commitment of full salary supplementation, residents choosing ADT increased at marginal institutional cost, suggesting a solution to combating the declining number of academic surgeons.

Background: The knowledge required to manage surgical patients has expanded considerably over the past 40 years. Simultaneously, the cost of medical education has increased substantially. Surgical trainees are at particular disadvantage due to the time demands of training. We aim to determine whether surgeon compensation over time has adequately accounted for increasing student debt burden. Study Design: We conducted a retrospective review of data on surgeon salaries and medical education debt from the Medical Group Management Association and Association of American Medical Colleges (2014-2019). Inflation adjustment was performed using the consumer price index calculator from the United States Bureau of Labor and Statistics. Outcomes of interest included trends in debt, salaries, and the debt:income ratio. Results: The median salary for a general surgeon in 1984 was $111,287 and median medical school debt was $22,000, corresponding to a salary of $274,900 and $54,344 in 2019 dollars, respectively, representing a 147% increase. The reported median salary for a general surgeon in 2019 was $350,000 (214.5% increase) and medical school debt was $200,000 (809% increase). The debt:income ratio increased from 0.2 in 1984 to 0.57 in 2012 and has remained stable since that time. Direct comparison of loan burden and salary reveals that while medical school debt has increased by 268% in the past 40 years, surgeon salaries have increased as well, but not nearly to the same degree (27.3%). Conclusions: The rate of debt accumulation has outpaced the rate of salary growth for general surgeons to a significant degree.