OBJECTIVE:In this study, the cumulative sum analysis was used to examine the learning curve of laparoscopic and open pancreaticoduodenectomy, excluding the first 100 cases. We hypothesized cumulative sum analysis would demonstrate continued evolution after the first learning curve. Cumulative sum analysis is an effective tool to understand the evolution of an individual surgeon or surgical procedure over an experience. The analysis represents a continuous summation of the differences between individual data points of a performance variable and the variable's overall mean. Most studies use operative time and analyze the early experience (ie, first 100 cases). METHODS:This is a retrospective, single-institution study of consecutive patients from 2012 to 2023. The learning curve was evaluated not only for operative time, but also conversion rate, postoperative pancreatic fistula rate, blood loss, and length of stay using the cumulative sum method. RESULTS:This study included 381 patients with 324 (85%) planned laparoscopic and only 57 (15%) planned open surgeries. Of the laparoscopic cases, 29% were converted to open. The median operative time was 277 minutes, median estimated blood loss was 350 mL, and median length of stay was 8 days. Learning curves are separated into 3 phases: initial learning phase, consolidation phase, and proficiency phase. Operative time (P ≤ .00001), estimated blood loss (P ≤ .00001), length of stay (P ≤ .00001), and postoperative pancreatic fistula rate (P ≤ .0001) demonstrated improved outcomes across all 3 phases. Improved results continued to evolve, and proficiency was observed between 313 and 373 cases for operative time, 159 and 294 cases for estimated blood loss, 155 and 237 cases for length of stay, and 171 and 250 for postoperative pancreatic fistula. The conversion rate declined from phase 1 to 2 (P = .0104) but then increased from phase 2 to 3 (P = .0013). CONCLUSION:In a large experience of laparoscopic pancreaticoduodenectomies in which cumulative sum analysis is applied, we demonstrate that mastery continues to evolve past the initial learning curve.

We are excited to introduce a special series of articles that address how surgical leaders build and maintain excellence and growth across all missions in an academic department. In this series of 11 articles, you will benefit from the insights and reflections of thought leaders about important concepts in building an integrated clinical practice, establishing and cultivating a robust research program, and managing human capital in a department. Notably, you also will be enriched by reading about pressing and salient topics, including strategic development, financial stability, communication within and outside the department, establishing a national brand, supporting yourself and faculty through philanthropy and coaching, and, finally, compensating faculty.

Social media has morphed from an interesting phenomenon to an essential part of surgical publishing. This contribution, “What Is Next for Social Media for Surgery,” reviews how we arrived at this point, how we are currently engaged in Surgery in social media, and where we, as editors-in-chief, envision social media heading over the next several years.

Surgical journals and the articles within understandably focus on operative techniques, patient outcomes, and innovative developments in the discipline. The theme of “patients first” has become a global initiative. Recently attention has been focused on surgeon well-being and health. These topics tend to include work life balance, exercise, and family. Infrequently, the surgical literature highlights surgeon-focused needs in the operating theater. In this month’s Surgery, two papers emphasize surgeon needs in the operating room.

As scientists and academics, we teach, conduct research and write scientific research papers [ 1 Rosengart T.K. Mason M.C. LeMaire S.A. Brandt M.L. Coselli J.S. Curley S.A. Mattox K.L. Mills J.L. Sugarbaker D.J. Berger D.A. The seven attributes of the academic surgeon: Critical aspects of the archetype and contributions to the surgical community. Am J Surg. 2017; 214: 165-179 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar ]. Whenever we try to determine whether an outcome, an exposure, or a difference between two or more variables, is meaningful, we perform a statistical test to determine the probability of our finding being due just to chance, or, of our finding having the property of being “statistically significant”, using the “p value”, or some alternative such as confidence, credibility, or prediction intervals.

As our readers are aware, the impact of surgical journals may be quite broad and not readily measured by a single numerical value such as the impact factor. A more holistic view provides a broader context for evaluation of the journal and readership needs. Firstly, one can look at the number of subscriptions, secondly perhaps at the number of pages published, or certainly at the impact factor. Each year Clarivate analytics determines journal impact factors based upon data from the prior two years which include assessment of the number of times that journal articles are cited and the number of citable articles published in that journal. The July 2023 Clarivate journal index factor from the science citation index expanded (SCIE)™ and social science citation index (SSCI)™ began to include journals from arts and humanities citation index (AHCI)™, and multidisciplinary emerging sources citation index (ESCI)™. Therefore, the number of journals assessed rose from more than 3,000 to almost 9,000 journals. In addition, there was an 8% increase in gold open access journals assigned a journal impact factor. Furthermore, the journal citation reports began to display the journal impact factor with to only tenths rather thousandths as had been the case through 2022. This decrease by two decimal places was undertaken to encourage users to consider other indicators and descriptive data when comparing journals. Perhaps the largest change was that the journal impact factor began to be calculated based on the date of electronic publication rather than, as had traditionally been the case, the date of print publication. This change in analytics led to substantial decreases in the impact factors of many surgical journals. Surgery’s impact factor decreased from 4.3 to 3.8. We are, however, very fortunate that our rank within surgical journals rose from the 36th most cited journal out of 213 surgical journals in 2022 to the 32nd most cited surgical journal out of 212 surgical journals in 2023.

Peer-reviewed literature is the foundation of science since the process entails scrutiny of the submitted manuscripts by experts. The standardized structure of published manuscripts includes many sections such as introduction, methods, results, discussion and conclusion. The abstract is an essential component as it provides a quick overview of the entire study hopefully enticing the reader to delve into the full text article. Therefore, well-written abstracts may increase the visibility and access to the published articles. 1 5 Reasons why your abstract is important. https://www.aje.com/arc/why-your-abstract-is-important/Date accessed: September 15, 2023 Google Scholar

Artificial intelligence applications continue to accelerate the development of novel solutions to enduring challenges in surgery by accurately representing the complex, non-linear nature of surgical care. These developments occur alongside substantial progress made in other healthcare fields, fueled by technological advances and increasing federal funding for artificial intelligence research. While artificial intelligence healthare applications are evolving incrementally, industries outside healthcare are being transformed rapidly by artificial intelligence. Surgeons face the reality that artificial intelligence will transform surgical care. In fulfilling our professional responsibility to steer this process, we must improve our efficiency and effectiveness in generating, evaluating, and disseminating high-quality surgical artificial intelligence research.

Supplemental Figure S1. Tumor-associated stromal response to pattern recognition receptor ligands. Supplementary Figure S2. Pancreatic cancer cell conditioned media and TLR4 ligation induces expression of antigen presentation machinery and negative co-stimulatory ligands on TAS. Supplemental Figure S3. TAS-mediated T cell suppression is enhanced by neutralization of either IL6 or IL8 and unaffected by TLR4 knockdown in TAS.

I am grateful to our editor, Dr. Raul Rosenthal, M. D., and my partner as Editor-In-Chief, Dr. Steven Wexner, M. D., Ph. D., for conceptualizing, organizing, enlisting top-notch authors, and writing a series of manuscripts that assess the current use of fluorescence imaging in surgery.

As opportunities for artificial intelligence to augment surgical care expand, the accompanying surge in published literature has generated both substantial enthusiasm and grave concern regarding the safety and efficacy of artificial intelligence in surgery. For surgeons and surgical data scientists, it is increasingly important to understand the state-of-the-art, recognize knowledge and technology gaps, and critically evaluate the deluge of literature accordingly. This article summarizes the experiences and perspectives of a global, multi-disciplinary group of experts who have faced development and implementation challenges, overcome them, and produced incipient evidence thereof. Collectively, evidence suggests that artificial intelligence has the potential to augment surgeons via decision-support, technical skill assessment, and the semi-autonomous performance of tasks ranging from resource allocation to patching foregut defects. Most applications remain in preclinical phases. As technologies and their implementations improve and positive evidence accumulates, surgeons will face professional imperatives to lead the safe, effective clinical implementation of artificial intelligence in surgery. Substantial challenges remain; recent progress in using artificial intelligence to achieve performance advantages in surgery suggests that remaining challenges can and will be overcome.

The intersection of art and surgery is considerable, overlapping in technique, inspiration, and evolution. The surgical field is one that erupts with color, creativity, and intrinsic art. It’s true essence lies far from the algorithmic strait-laced perception that non-surgeons may unfortunately bestow upon it. It’s artistic foundations root in originality, critical thinking, and ingenuity from both innate and acquired sources; there is art in surgery and art of surgery. Two distinct yet inextricable entities that can enable a cumulative masterpiece of sorts. What surgeon has not said, heard, or thought: ‘what beautiful technique,’ ‘what a graceful approach,’ ‘will you look at those planes!’? Art in surgery can be all-encompassing; if looked for, it is ubiquitous… For the art of and in surgery exists within the body, within the operating room, and within the profession -- through music, literature, and visual arts.

Ischemia/reperfusion (I/R) injury unavoidably occurs during hepatic resection and transplantation. Aged livers poorly tolerate I/R during surgical treatment. Although livers have a powerful endogenous inhibitor of calpains, calpastatin (CAST), I/R activates calpains, leading to impaired autophagy, mitochondrial dysfunction, and hepatocyte death. It is unknown how I/R in aged livers affects CAST. Human and mouse liver biopsies at different ages were collected during in vivo I/R. Hepatocytes were isolated from 3-month- (young) and 26-month-old (aged) mice, and challenged with short in vitro simulated I/R. Cell death, protein expression, autophagy, and mitochondrial permeability transition (MPT) between the two age groups were compared. Adenoviral vector was used to overexpress CAST. Significant cell death was observed only in reperfused aged hepatocytes. Before the commencement of ischemia, CAST expression in aged human and mouse livers and mouse hepatocytes was markedly greater than that in young counterparts. However, reperfusion substantially decreased CAST in aged human and mouse livers. In hepatocytes, reperfusion rapidly depleted aged cells of CAST, cleaved autophagy-related protein 5 (ATG5), and induced defective autophagy and MPT onset, all of which were blocked by CAST overexpression. Furthermore, mitochondrial morphology was shifted toward an elongated shape with CAST overexpression. In conclusion, CAST in aged livers is intrinsically short-lived and lost after short I/R. CAST depletion contributes to age-dependent liver injury after I/R.

The exponential growth of health sciences research has allowed many new avenues of investigation through the queries of large datasets. These studies serve as a reflection of the real world of outcomes, in contrast to the highly artificial, tightly controlled, randomized controlled trial conducted at a single center or the multicenter trials conducted in academic referral centers. Indeed, the studies of large, statewide or national databases, although they have their limitations, serve as an important mirror of the real world—and herein lies their strength. The data are readily available in well-designed clinical databases, clinical registries, and administrative databases. These databases include large numbers of patients, often thousands or even hundreds of thousands of patients, and their outcomes are reflective of what actually goes on in the real world.

T hank you, Dr. Britt, for the kind and warm introduction. I appreciate your friendship, service to, and leadership in the Southeastern Surgical Congress. I want to welcome all of you to the 87th meeting of the Southeastern Surgical Congress in the beautiful city of Charlotte. You are 576 attendees strong! Welcome! First, I want to disclose my conflict of interest as the coeditor of Surgery, a position for which I receive compensation. This presentation, however, has no commercial interest or bias relative to my position with this journal. My goals for this presentation are to discuss the strengths of the Southeastern Surgical Congress, outline an inclusive, decision-making strategy, and discuss how self-awareness and bias affect decision-making. I also want to spend some time discussing how inviting conversation with those who offer dissenting opinions improves the decision-making process.

Ischemia/reperfusion (I/R) injury is a causative factor contributing to morbidity and mortality during liver resection and transplantation. Livers from elderly patients have a poorer recovery from these surgeries, indicating reduced reparative capacity with aging. Mechanisms underlying this age-mediated hypersensitivity to I/R injury remain poorly understood. Here, we investigated how sirtuin 1 (SIRT1) and mitofusin 2 (MFN2) are affected by I/R in aged livers. Young (3 months) and old (23-26 months) male C57/BL6 mice were subjected to hepatic I/R in vivo. Primary hepatocytes isolated from each age group were also exposed to simulated in vitro I/R. Biochemical, genetic, and imaging analyses were performed to assess cell death, autophagy flux, mitophagy, and mitochondrial function. Compared to young mice, old livers showed accelerated liver injury following mild I/R. Reperfusion of old hepatocytes also showed necrosis, accompanied with defective autophagy, onset of the mitochondrial permeability transition, and mitochondrial dysfunction. Biochemical analysis indicated a near-complete loss of both SIRT1 and MFN2 after I/R in old hepatocytes, which did not occur in young cells. Overexpression of either SIRT1 or MFN2 alone in old hepatocytes failed to mitigate I/R injury, while co-overexpression of both proteins promoted autophagy and prevented mitochondrial dysfunction and cell death after reperfusion. Genetic approaches with deletion and point mutants revealed that SIRT1 deacetylated K655 and K662 residues in the C-terminus of MFN2, leading to autophagy activation. The SIRT1-MFN2 axis is pivotal during I/R recovery and may be a novel therapeutic target to reduce I/R injury in aged livers.