Objective:To understand how surgeons improve the quality of breast cancer surgery.Background:Between 2007 and 2021, breast cancer surgeons in Manitoba, Canada, participated in national initiatives to build a local capacity for quality improvement (QI) in cancer surgery. Key aspects of these initiatives include audit and feedback reports using data from synoptic operative reports and communities of practice. Surgeon engagement in breast cancer surgery QI in Manitoba has not been evaluated since the initiatives were concluded in 2021.Methods:We conducted 60-minute virtual semi-structured qualitative interviews with surgeons who performed breast cancer surgery in Manitoba, Canada, between 2021 and 2024. The interviews were guided by the theoretical domain framework. The thematic analyses were performed by 2 independent researchers.Results:Twelve surgeons were interviewed. Surgeons were motivated to ensure timely care close to home, with excellent oncological, surgical, and aesthetic outcomes. They felt capable of monitoring and improving their surgical quality by tracking their own metrics, collaborating with multidisciplinary colleagues, engaging in continuous professional development, and advocating for improvement. Audit and feedback reports were not perceived to improve the quality of surgery. They felt limited opportunities to sustain improvement strategies. Resource constraints and leadership support within the healthcare system were major barriers to achieving their ideal quality of care.Conclusion:Surgeons performing breast cancer surgery in Manitoba were motivated and capable of improving the quality of breast cancer surgery. However, they perceive limited opportunities and barriers within the healthcare systems to doing so. Future research will provide information on broader contextual factors affecting breast cancer surgery QI.

Objective:This study aimed to characterize SureForm stapler usage trends in robotic sleeve gastrectomy (RSG) and compare associated outcomes, accounting for staple height used.Background:The proportion of sleeve gastrectomy cases done robotically is increasing, but uncertainty remains about optimal stapler choice, reload height and reinforcement, and the impact of these choices on perioperative outcomes.Methods:Elective laparoscopic and robotic SG performed from January 1, 2019, to February 28, 2023, were identified in the PINC AI Healthcare Database. Patients who underwent RSG were included. RSG with no stapler type/height information was excluded. The incidences of complications such as bleeding, leak, and sepsis in the perioperative period were evaluated using International Classification of Diseases/Current Procedure Terminology codes. Hospital resource utilization data such as length of stay, operative time, intensive care unit utilization, and readmission were also analyzed. Propensity score matching (PSM) analysis was used to compare outcomes.Results:A total of 35,795 RSG were analyzed with 23,904 documenting use of SureForm stapler. Use of at least one SureForm white reload increased from 19.2% to 52.7% in the study period; use of 3 or more white reloads per case increased from 6% to 71%. PSM analysis compared 5795 RSG with any white reload versus 5795 RSG with non-white reloads, showing equivalent complication rates, marginally shorter length of stay, and longer operative time with white reloads.Conclusions:There is a trend toward downsizing to white stapler reloads in RSG without significant changes in perioperative outcomes and minor differences in hospital resource utilization. These findings suggest that white stapler reload use is safe in RSG.

Objective:To understand how surgeons perceive risk calculators in emergency general surgery (EGS).Background:EGS involves complex decision-making of operative and nonoperative management. Risk calculators can aid in shared decision-making and informed consent.Methods:We performed semi-structured interviews among emergency surgeons within 1 healthcare system to explore perceptions of risk calculators in EGS. Interviews were completed until thematic saturation, transcribed, coded in duplicate, and analyzed using inductive analysis within a modified grounded theory framework to generate theory regarding surgeon perceptions of risk calculators in EGS.Results:Among 20 interviewees, the mean age was 45. We identified dominant themes related to the concerns of and benefits of using risk calculators within EGS, both in situations of clear and unclear best treatment options. Surgeons questioned risk calculator validity and noted that a lack of health numeracy can limit their use. Risk calculators were seen as helpful for communication, consensus building, informed consent, and litigation mitigation. The ideal risk calculator should have low activation energy for use, incorporate relevant data and accurate prognostication, and provide actionable, easily interpretable output. Education for providers and patients on risk calculator availability and use is necessary.Conclusions:Although surgeons may initially question the data produced by risk calculators in EGS, they identify several potential virtues to their bedside use when optimal treatment options are and are not clear. The ideal risk calculator for use in EGS should be convenient and relevant. Future studies are needed to explore patient perceptions and to directly observe patterns of risk calculator use.

Objective:In a randomized, embedded, multifactorial, adaptive platform (REMAP) trial, we hypothesized that perioperative metformin would improve postoperative time alive and out of the hospital, defined by 90-day hospital-free days (HFD-90), among nondiabetic aged adults.Background:As our population ages, patients are increasingly frail requiring an emphasis on treatments to counteract their diminished resilience, especially following the stress of surgery. Growing literature supports metformin as an antiaging and anti-inflammatory therapy with beneficial effects extending into the perioperative period.Methods:At-risk adults (≥60 years) scheduled for elective surgical interventions were randomized to placebo (N = √3) or metformin (N = 1:1:1; 500 mg:1000 mg:1500 mg) for short (7–28 days), intermediate (29–90 days), or long (>90 days) preoperative durations. An adaptive sample size of (N = 1000–2500) would identify at least a 15% improvement in HFD-90 for >1 metformin doses. Using intention-to-treat analysis, Bayesian ordinal logistic regression compared HFD-90 and frequentist logistic regression compared 90-day reoperation and readmission.Results:Before trial closure, we randomized 302 (N = 106 placebo, N = 196 metformin [N = 64, 500 mg; N = 66, 1000 mg; and N = 66, 1500 mg]) patients without differences in baseline demographics (age 68 ± 6 years, 45% females, and 92% White race) or interventions (spine [29%], general [38%], colorectal [13%], and other [20%]). The odds of HFD-90 did not significantly differ between all doses and duration of metformin or placebo. There were no differences in the odds of reintervention (OR = 1.1 [95% CI, 0.6–2.0]) or readmission (OR = 1.5 [95% CI, 0.7–2.8]).Conclusions:Pretreatment with metformin did not improve postoperative outcomes in this REMAP trial, although trial enrollment was markedly limited by the COVID-19 pandemic and is underpowered.

Objective:Our objective was to assess potential racial bias within the Risk Analysis Index (RAI).Background:Patient risk measures are rarely tested for racial bias. Measures of frailty, like the RAI, need to be evaluated for poor predictive performance among Black patients.Methods:Retrospective cohort study using April 2010–March 2019 Veterans Affairs Surgical Quality Improvement Program and 2010–2019 National Surgical Quality Improvement Program data. The performance of the RAI and several potential variants were compared between Black and White cases using various metrics to predict mortality (180-day for Veterans Affairs Surgical Quality Improvement Program, 30-day for National Surgical Quality Improvement Program).Results:Using the current, clinical threshold, the RAI performed as good or better among Black cases across various performance metrics versus White. When a higher threshold was used, Black cases had higher true positive rates but lower true negative rates, yielding 2.0% higher balanced accuracy. No RAI variant noticeably eliminated bias, improved parity across both true positives and true negatives, or improved overall model performance.Conclusions:The RAI tends to predict mortality among Black patients better than it predicts mortality among White patients. As existing bias-reducing techniques were not effective, further research into bias-reducing techniques is needed, especially for clinical risk predictions. We recommend using the RAI for both statistical analysis of surgical cohorts and quality improvement programs, such as the Surgical Pause.

Founded by Dr Samuel Gross of Philadelphia and colleagues in 1880, the American Surgical Association, the oldest surgical society in the United States,1 honors its societal traditions. At the opening of the annual President’s Banquet, 3 traditions are observed: A toast to the Crown of the United Kingdom (in 2024, a King rather than a Queen was saluted for the first time since 1952) A toast to the President of the United States or, rarely, the people of the United States An invocation Over the past decade or so, I have been privileged to deliver the invocation (or prayer) on 3 occasions. President Steve Stain of the Lahey Clinic asked me to deliver the prayer for the 2024 banquet. This prayer utilizes the acronym ACTS: Adoration, Confession, Thanksgiving, Supplication. INVOCATION, AMERICAN SURGICAL ASSOCIATION, FRIDAY, APRIL 5, 2024 A: Dear God, we come together as individuals from many faith backgrounds including some Nones. We invite You, Your Spirit to be among us tonight and going forward. C: We confess we are not all we can or should be, individually and collectively. Please keep working on and with us. “True Religion” includes taking care of the widows and orphans plus immigrants, the poor, etc. T: We thank you for meaningful work, our health, those who abetted our education, our families, plus the infrastructure, technologies, colleagues, utilities we enjoy. We thank you for the American Surgical Association with its focus on and support for science, education, safety, and quality, plus the chance to network, learn, and self-reflect. S: We pray for our world which is in a mess whether Russia/Ukraine. Israel/Palestine-Gaza, the Sahel, NW Cameroon, Sudan, and on and on. We pray for our country which is in a mess and as polarized as countries and regions globally. We pray for our US medical non-system which is also in a mess – access, affordability, anti-science and fake news re: immunizations, etc. and the ever-present threat of individual bankruptcy. Help us to address our challenges and not accept the status quo. We ask for wellness, health, and peace. Let us walk toward-- not tangentially nor away from-- the Light. Give us the strength and the will to do the requisite heavy lifting and to persevere. May we leave the world better, cleaner, and greener for our descendants. Amen.

Western armies have relied on surgical field manuals to help physicians deal with unfamiliar combat medical conditions from the Napoleonic wars to the present day, but there has been little discussion of whether these handbooks have been used or improved outcomes. Recent research shows that the Union Army’s American Civil War (1861–1865) surgical case fatality rates improved as the war progressed, much like the US Army’s experience in later wars, and were generally superior to comparable European results. These positive Civil War outcomes have been attributed to field experience, adoption of best practices, and enhanced communication, without consideration of New York surgeon Stephen Smith’s widely-used Hand-Book of Surgical Operations. The Army of the Potomac added Smith’s pocket-sized Hand-Book to its supply table in 1862. Northern medical journals applauded it, and Smith’s contemporaries documented its wide use. Smith’s handbook explained and demonstrated surgical techniques that were adopted as the war progressed, such as the use of general anesthesia and limb-sparing resection (debridement) of gunshot wounds. It offered pithy, well-documented advice from recognized experts along with numerous illustrations, which allowed untrained physicians to visualize anatomical relationships and see contemporary best practices in a way that no other wartime publication provided, making it an exemplar of a mass-media surgical improvement change agent.

Following the publication of the article by Dr Balzano et al,1 several members of the International Study Group of Pancreatic Surgery have been informed that this method has now been proposed to patients with pancreatic adenocarcinoma as a possible alternative to Whipple surgery in European centers. This novel approach proposes to perform a total pancreatectomy to avoid the high-risk pancreaticojejunostomy and to isolate the islets of Langerhans from the body and tail of the pancreas to perform an autotransplantation into the liver to prevent the consequences of severe diabetes. During the recent congress of the International Pancreas and Islet Transplantation Association in San Diego (October 25th to October 29th, 2023), the indications and contraindications for total pancreatectomy with islet autotransplantation were discussed by Dr Ty Dunn who mentioned that pancreatic cancer remained a contraindication for islet autotransplantation in the United States (personal communication). Indeed, does the risk of postoperative pancreatic fistula and diabetes mellitus override that of cancer? We therefore propose to limit this new approach for patients with pancreatic malignant tumoral diseases to specialized centers using regulated prospective protocols with Institutional Review Board approval as no clear conclusions have been reported regarding the safety and efficacy of this approach. Two of the cosignatories (LB and AF) have previously commented on some limitations of this published study, such as the low sample size and its lack of statistical power.2 We would like to add several comments regarding any further widespread application of this method: The quoted number of clinically relevant postoperative pancreatic fistula in the Whipple surgery group was close to 60%,1 twice as high than the 30% rate reported by the international study group on pancreatic surgery.3 Furthermore, the overall complication rate reached 90%,1 whereas other multicenter data have evaluated this to be around 60%.3 For patients with an extremely high-risk of a postoperative pancreatic fistula, most cases are of Grade B and can be treated with conservative care and time. Grade C postoperative fistula represent only 6% of all patients undergoing Whipple surgery.3 Finally, many patients who undergo total pancreatectomy are not able to receive adjuvant therapy such as chemo or radiotherapy, even in the absence of diabetes.4 This will also influence the outcome of this method and should be tested in strictly monitored clinical trials. In conclusion, we recommend that total pancreatectomy combined with islet autotransplantation be proposed as treatment for patients with pancreatic adenocarcinoma only within controlled trials with Institutional Review Board approval and informed consent in specialized centers. Extreme precaution must be taken to rule out any possible malignant cells in the islet transplant lot, that the frozen section histology is negative. Of note, 2 prospective multicenter trials have been initiated, one in France in 2022, and the other in Germany in 2023, with the aim to test the safety and efficacy of this approach and are currently ongoing.5,6

To compare the performance of the ACS NSQIP "universal" risk calculator (N-RC) to operation-specific RCs. Resources have been directed toward building operation-specific RCs because of an implicit belief that they would provide more accurate risk estimates than the N-RC. However, operation-specific calculators may not provide sufficient improvements in accuracy to justify the costs in development, maintenance, and access. For the N-RC, a cohort of 5,020,713 NSQIP patient records were randomly divided into 80% for machine learning algorithm training and 20% for validation. Operation-specific risk calculators (OS-RC) and OS-RCs with operation-specific predictors (OSP-RC) were independently developed for each of 6 operative groups (colectomy, whipple pancreatectomy, thyroidectomy, abdominal aortic aneurysm (open), hysterectomy/myomectomy, and total knee arthroplasty) and 14 outcomes using the same 80%/20% rule applied to the appropriate subsets of the 5M records. Predictive accuracy was evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), and Hosmer-Lemeshow (H-L) P values, for 13 binary outcomes, and mean squared error for the length of stay outcome. The N-RC was found to have greater AUROC (P = 0.002) and greater AUPRC (P < 0.001) compared to the OS-RC. No other statistically significant differences in accuracy, across the 3 risk calculator types, were found. There was an inverse relationship between the operation group sample size and magnitude of the difference in AUROC (r = -0.278; P = 0.014) and in AUPRC (r = -0.425; P < 0.001) between N-RC and OS-RC. The smaller the sample size, the greater the superiority of the N-RC. While operation-specific RCs might be assumed to have advantages over a universal RC, their reliance on smaller datasets may reduce their ability to accurately estimate predictor effects. In the present study, this tradeoff between operation specificity and accuracy, in estimating the effects of predictor variables, favors the N-R, though the clinical impact is likely to be negligible.