Importance It is not clear whether laparoscopic and open distal gastrectomy produce similar outcomes among patients with locally advanced gastric cancer. Data from a multicenter, randomized clinical trial (Chinese Laparoscopic Gastrointestinal Surgical Study [CLASS]–01) showed that laparoscopic distal gastrectomy did not result in inferior disease-free survival at 3 years compared with open distal

Importance Previous studies have shown high rates of mistreatment among US general surgery residents, leading to poor well-being. Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) residents represent a high-risk group for mistreatment; however, their experience in general surgery programs is largely unexplored. Objective To determine the national prevalence of

Importance There are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial. Objective To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the

The article by Heiderscheit et al1 is the latest to investigate biases, discrimination, and bullying in surgery. This is an important study that leveraged the captive audience of surgical residents who took the 2019 American Board of Surgery In-Training Examination. The authors concluded that lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) surgical residents

Rosenberg and colleagues1 first proposed the use of nonabsorbable oral antibiotic preparation (OAB) for colorectal surgery in 1971. In a randomized clinical trial, they demonstrated a reduction in surgical site infection and anastomotic leak rates after combined mechanical bowel preparation (MBP) and 1 or 2 nonabsorbable oral antibiotics (phthalylsulphathiazole and phthalylsulphathiazole and neomycin

Liver transplantation is a necessary life-saving procedure for end-stage liver disease. Deceased donors contribute 95% of the organs required for liver transplantation across the US and Europe. However, the scarcity of deceased donors has made live donor liver transplantation (LDLT) the predominant modality (90%) in Asia. Morbidity and mortality of the donor are understandably the most feared repercussions

To the Editor The ICAN trial has provided level 1 evidence favoring intrathoracic anastomosis after a total or hybrid minimally invasive esophagectomy.1 We commend the authors on a robust study design for a purely surgical trial. The quality control of the surgical technique before participation and later during the trial is meticulous and may lay the standard for future surgical trials.

To the Editor With interest we have read the randomized clinical trial by van Workum et al.1 In their article, the authors show a reduction in anastomotic leakage rate from 31.7% to 12.3% with the introduction of an intrathoracic anastomosis. They conclude that “intrathoracic, as opposed to cervical, anastomosis resulted in better outcome for patients treated with transthoracic MIE [minimally invasive

In Reply With great interest we read the Letters from Nittala et al and de Steur et al, and we thank them for their thoughtful comments on our study.1 In the Letter by Nittala et al, the generalizability of the results of the ICAN trial to the subgroup of midesophageal tumors is questioned. For the ICAN trial, we believed it was important that we only included patients in which both types of anastomoses

Overtreatment is medical intervention that is extremely unlikely to help a patient, is misaligned with a patient’s wishes, or both. Its harms to individual patients and families include iatrogenesis, financial burden, anxiety, and time wasted at hospitals and clinics. Overtreatment adds substantially to US health care costs.1 Surgeons have been concerned with reducing overtreatment for decades. Early

Importance Hereditary cancer risk is informed by the presence of a germline gene variant more so than by family history of cancer. Objective To assess gastric cancer risk among patients who received a diagnosis of hereditary lobular breast cancer (HLBC) owing to a germline loss-of-function variant in CDH1 by establishing prevalence of signet ring cell carcinomas among asymptomatic patients. Design

To the Editor Liver transplant (LT) has already become one of the major approaches to manage advanced liver diseases, including colorectal cancer liver metastasis (CRLM). Dueland et al1 reported their single-institutional retrospective cohort analysis on LT for CRLM, which was compared with those who received portal vein embolization (PVE) with intent to undergo liver resection (LR). Their results

In Reply We would like to thank Aini et al for commenting on our article on liver transplant (LT) in colorectal cancer liver metastases.1 Our results were presented as Kaplan-Maier–estimated overall survival (OS) because not all patients were observed for 5 years or until death. According to Aini et al, patients receiving portal vein embolization (PVE) and liver resection (LR) had a 5-year OS of 54

The rapid transformation of the health care delivery system and surgical services across the US as a result of the COVID-19 pandemic was unprecedented. To limit COVID-19 exposure and transmission between patients and clinicians, millions of elective surgical procedures were suspended and necessity compelled surgeons to adopt telemedicine for preoperative, follow-up, and emergent surgical care visits

The COVID-19 pandemic has had profound effects on the health care workforce; more than 130 million cases of COVID-19 and nearly 3 million deaths have been recorded worldwide as of April 1, 2021.1 To reduce health care resource utilization and increase the expected need for critical care capacity as COVID-19 cases surged, surgical care was dramatically interrupted, with more than 28 million elective

Importance While surgeons often delay pregnancy and childbearing because of training and establishing early careers, little is known about risks of infertility and pregnancy complications among female surgeons. Objective To describe the incidence of infertility and pregnancy complications among female surgeons in the US and to identify workplace factors associated with increased risk compared with

Importance The familial aspect of acute appendicitis (AA) has been proposed, but its hereditary basis remains undetermined. Objective To identify genomic variants associated with AA. Design, Setting, and Participants This genome-wide association study, conducted from June 21, 2019, to February 4, 2020, used a multi-institutional biobank to retrospectively identify patients with AA across 8 single-nucleotide

Importance In evaluating the effectiveness of general surgery (GS) training, an unbiased assessment of the progression of residents with attention to individual learner factors is imperative. Objective To evaluate the role of trainee sex in milestone achievement over the course of GS residency using national data from the Accreditation Council for Graduate Medical Education (ACGME). Design, Setting

Importance Image-based deep learning models (DLMs) have been used in other disciplines, but this method has yet to be used to predict surgical outcomes. Objective To apply image-based deep learning to predict complexity, defined as need for component separation, and pulmonary and wound complications after abdominal wall reconstruction (AWR). Design, Setting, and Participants This quality improvement

Importance Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents’ experiences with gender discrimination and sexual harassment may inform solutions. Objective To describe the types, sources, and factors associated with (1) discrimination based

Importance Robotic gastrectomy (RG) for gastric cancer may be associated with decreased incidence of intra-abdominal infectious complications, including pancreatic fistula, leakage, and abscess. Prospective randomized clinical trials comparing laparoscopic gastrectomy (LG) and RG are thus required. Objective To compare the short-term surgical outcomes of RG with those of LG for patients with gastric

Importance There is currently no consensus on the indication for cholecystectomy in patients with uncomplicated gallstone disease. Objective To report on the development and validation of a multivariable prediction model to better select patients for surgery. Design, Setting, and Participants This study evaluates data from 2 multicenter prospective trials (the previously published Scrutinizing (In)efficient

Importance Increasing rates of bilateral mastectomy have been most pronounced in young women with breast cancer, but the association of surgery with long-term quality of life (QOL) remains largely unknown. Objective To examine the association of surgery with longer-term satisfaction and QOL in young breast cancer survivors. Design, Setting, and Participants This multicenter cross-sectional study of

The term lean in became part of US vernacular largely because of Sheryl Sandberg’s influential 2013 book1 encouraging women to claim workplace equality and success in the face of ongoing sexism while philosophically letting go of expectations for perfection at work or home. For many female surgeons, this was not a new concept: to secure and maintain a seat at the table, we often use grit and practicality

Acute appendicitis is a common disease with a causative mechanism that is likely multifactorial. Existing evidence1-4 is suggestive of a familial predisposition to acute appendicitis, with heritability estimates ranging from 27% to 56%. In a multi-institutional genome-wide association study in this issue of JAMA Surgery, Gaitanidis and colleagues5 identified a polymorphism at 18q, located in the NEDD4-like

In 2013, the Accreditation Council for Graduate Medical Education (ACGME) affirmed its commitment to competency-based medical education and introduced semiannual, structured formative assessments using milestone assessments.1 Milestone achievements inform but do not determine high-stakes summative decisions on resident promotion and readiness for independent practice. Yet, as training paradigms shift

Interest in the role of artificial intelligence (AI) in medicine is growing exponentially. Machine learning models have been trained to perform diagnostic and decision support functions, including interpretation of radiographic abnormalities, detection of polyps during endoscopy, and prediction of melanoma from images of skin lesions.1-3 In surgery, AI also has the potential to inform intraoperative

In this issue of JAMA Surgery, Schlick et al1 characterize the gender discrimination and sexual harassment experienced by women vs men in surgical residency programs across the US. Although illuminating this mistreatment is undoubtedly important, there are 2 equally important topics that are missing from this work: (1) an analysis that fully encompasses the community of lesbian, gay, bisexual, transgender

Clinicians generally accept, almost without question, that patients undergoing elective laparoscopic cholecystectomy for symptomatic cholelithiasis will experience improvement in their symptoms after the operation. We believe this with such confidence that it remains one of the so-called safe places in general surgery, away from controversy, drama, or questionable expectations. In this issue of JAMA

A central tenet in the use of local therapy for breast cancer is patient choice. Survival and rates of local recurrence do not differ significantly among patients undergoing breast-conserving therapy (BCT) or mastectomy,1 and the widespread use of adjuvant systemic therapy has led to substantial decreases in the risk of local recurrence and contralateral breast cancer,2 making BCT a more attractive

Importance Cancer is the leading cause of mortality in incarcerated individuals older than 45 years and the fourth leading cause of mortality overall. Health care professionals face increasing challenges to provide high-quality care under the confines of prison regulations and procedures. Observations Adjusted for age, race, sex, and year of diagnosis, the standardized incidence ratio for all cancers

More than 60% of the US population have experienced epistaxis (nosebleeds) in their lifetime, of whom 6% will seek medical attention.1 Depending on the severity, nosebleeds can be costly and heavily affect quality of life.1 The range of interventions for epistaxis includes self-treatment and/or home remedies, moderately invasive (sometimes only temporizing) clinician-based interventions, and surgical

Postoperative kidney failure requiring dialysis significantly increases in-hospital and long-term mortality.1,2 A major challenge in nephrectomy is estimating the probability of postoperative dialysis. Because of its rarity (0.5% to 2.1%),3,4 to our knowledge, there are no validated models to estimate this probability. We developed externally validated nomograms to compute this probability after nephrectomy

Current literature documents significant surgical trainee interest in global surgery rotations, trainees’ motivations for seeking international opportunities,1 and how international experiences shape career aspirations.2 Global surgery rotations have proliferated in residency programs to meet these interests, and studies have documented benefits with these rotations in low-resource settings.3 However

Enhanced recovery pathways (ERPs) have emerged as one of the most effective strategies to improve clinical outcomes and reduce health care utilization in elective colorectal surgery. However, ERP implementation alone does not result in improvement without high pathway component compliance.1,2 Hospital collaboratives have been used to accelerate quality improvement across clinical areas, including ERP

To the Editor We read with great interest the article by Santos et al1 on the opportunity of treating recurrent, complicated, or symptomatic diverticulitis by conservative management or elective sigmoidectomy and related quality of life (QoL). We congratulate the authors for their efforts in conducting this randomized clinical trial. However, we would like to raise concerns and make comments on the

To the Editor We read with great interest the article by Santos et al.1 We would like to congratulate the authors on this important study. A randomized clinical trial with few crossovers during the study period is challenging to perform in this setting and deserves respect. We have the following comments and questions to the authors. We believe that this trial supports the most recent guidelines by

To the Editor In clinical trial design, the minimal clinically important difference (MCID) is used in sample size calculations to ensure enough statistical power to detect the smallest difference needed to justify changing patient treatment. Unfortunately, because these calculations are based on probabilities of hypothetical findings, clinical trials can produce statistically significant results for

To the Editor We write regarding the recent article by Santos et al,1 which was recently discussed at an online journal club based in the UK.2 We enjoyed reading and reviewing the Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) trial and applaud the authors on a well-designed study. We thought that the study was well written and addressed an important clinical issue. We discussed

In Reply We are delighted that the Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) trial1 has generated discussion. First, we would like to thank Schultz et al for their excellent comments. We agree that the premature termination of the trial is a limitation, which was acknowledged in the original publication. The termination of trial followed strictly the prespecified termination

To the Editor We read with great interest the article by Stewart and Fong regarding perioperative cannabis use.1 The authors provided an informative overview of cannabis use and many of the pertinent issues surrounding it. However, we strongly disagree with their recommendation that cannabis products be stopped 10 days prior to a surgical procedure. While succinct guidance is easy to adopt into clinical

To the Editor We read with great interest the Review article by Stewart and Fong.1 We completely agree with the concluding remarks that there is a critical need for additional research on the effects of perioperative cannabis. However, we have some concerns. The authors state after citing very early publications that there is “…no demonstrable association between cannabis use and myocardial infarction

In Reply We thank Ladha et al and Davidson et al for their Letters to the Editor regarding our Review article on perioperative cannabis1 and for bringing some additional published research to the forefront. This includes a recent retrospective study demonstrating the association of cannabis use disorder with perioperative myocardial infarction.2 It should be noted that regular cannabis use is not synonymous

To the Editor Mahoney and colleagues presented the results of an extensive survey (>250 items) administered to more than 25 000 fellows of the American College of Surgeons in summer 2018.1 Their article (with its associated commentary2) is extremely interesting and focuses on the differences between academic and private practice.

In Reply Our data set1 is unique in that it likely represents one of the largest and most comprehensive surveys of surgeon attitudes toward their careers. The extensive demographic data allow for analysis of satisfaction of various subgroups of surgeons. We do feel personal responsibility for maximizing the utility of this data in respect to the gracious efforts of thousands of surgeons who took the

To the Editor We would like to thank Lewit et al for their Research Letter, “Association of Sex and Race/Ethnicity With National Institutes of Health Funding of Surgeon-Scientists”1 for addressing the urgent issue of disparities in National Institutes of Health (NIH) funding. There is a continued need for such investigations to illuminate the unique challenges faced by underrepresented and/or marginalized

In Reply We would like to thank Acuña et al for their Letter to the Editor in response to our recent Research Letter addressing the association of sex, race, and ethnicity with receipt of National Institutes of Health (NIH) funding by surgeon-scientists.1 We wholeheartedly agree with their concerns regarding identification of race and ethnicity, and we would extend their concern to include sex as well

In the article titled “Association of Local Therapy With Quality-of-Life Outcomes in Young Women With Breast Cancer,” published online September 1, 2021, in JAMA Surgery,1 the age of women who participated in the study was given incorrectly in the Abstract as “40 years or older.” The sentence now reads, “Women 40 years or younger enrolled in the Young Women’s Breast Cancer Study were assessed.” The

The Original Investigation titled, “Incidence of Infertility and Pregnancy Complications in US Female Surgeons,”1 published online July 28, 2021, included an error in the Results indicating that 90 female surgeons experienced a pregnancy loss. The text has been corrected and now indicates that 290 female surgeons experienced a pregnancy loss. All other information in the article was correct and is

Mission Statement: To promote the art and science of surgery by publishing relevant peer-reviewed research to assist the surgeon in optimizing patient care. JAMA Surgery will also serve as a forum for the discussion of issues pertinent to surgery, such as diversity, equity, and inclusion; the education and training of the surgical workforce; quality improvement; and the ethics and economics of health

Importance Sleeve gastrectomy is the most widely used bariatric operation; however, its long-term safety is largely unknown. Objective To compare the risk of mortality, complications, reintervention, and health care use 5 years after sleeve gastrectomy and gastric bypass. Design, Setting, and Participants This retrospective cohort study included adult patients in a national Medicare claims database

Importance The role of primary tumor resection (PTR) in synchronous patients with metastatic colorectal cancer (mCRC) who had unresectable metastases and few or absent symptoms of their primary tumor is unclear. Studying subgroups with low postoperative mortality may identify patients who potentially benefit from PTR. Objective To determine the difference in 60-day mortality between patients randomized

Importance Preventing anastomotic leakage (AL) is crucial for colorectal surgery. Some studies have suggested a positive role of transanal drainage tubes (TDTs) in AL prevention after low anterior resection, but this finding is controversial. Objective To assess the effect of TDTs in AL prevention after laparoscopic low anterior resection for rectal cancer. Design, Setting, and Participants This multicenter

Importance The surgical workforce shortage is a threat to promoting health equity in medically underserved areas. Although the Health Resources and Services Administration and the American College of Surgeons have called to increase the surgical pipeline for trainees to mitigate this shortage, the demographic factors associated with students’ intention to practice in underserved areas is unknown. Objective

“Compared to What” was a song composed and recorded in the 1960s by several jazz artists, with 1 rendition by McCann and Harris often mentioned as one of the best jazz live performances ever. The song addressed societal problems of the times, with lyrics “Nobody gives us rhyme or reason/Have one doubt, they call it treason.” So, is it reasonable or treason to consider alternative approaches to a definitive

The role of up-front surgery for primary colorectal cancer (CRC) in patients who have nonresectable metastases has been long debated. Small retrospective studies have demonstrated an association between primary tumor resection (PTR) and longer survival.1 However, without random assignment to resection vs not receiving resection, it is impossible to eliminate patient-selection biases.2 Advocates also

Anastomotic leaks are common in colorectal surgery1 and serve as a significant driver of mortality and cost.2 Efforts at reducing the incidence of leaks have been most successful when nutritional deficits are addressed before surgery and when the construction of an end or diverting stoma is considered in patients perceived to be at higher risk for a leak.3 However, diversion does not prevent a radiographic

Contemporary research suggests that physicians could offer patients with computed tomography (CT)–confirmed uncomplicated acute appendicitis a choice between surgery and antibiotics.1-5 In the recent Appendicitis Acuta (APPAC) II trial2 aiming to optimize antibiotic treatment of uncomplicated acute appendicitis in adults, 70.2% of the patients (207 of 295) randomized to receive oral antibiotic monotherapy

To the Editor We read with interest the results of phase 2 of the CAIRO6 trial that showed the feasibility and safety of perioperative chemotherapy in patients with resectable colorectal peritoneal metastases (CPM).1 The major postoperative morbidity was similar in both arms, although the absolute figures showed a lower morbidity in the experimental arm (22% vs 33% in the control arm).

In Reply We thank Bhatt and colleagues for their interesting comments on our article.1 First, they consider the median baseline peritoneal cancer index (PCI) of 5 to be low. Importantly, the surgical baseline PCI was determined by laparoscopy in 74% of patients. Compared with laparotomy, laparoscopy may underestimate the PCI.2 This potential underestimation is reflected by the higher median PCI of