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In the Halstedian era (1920-1970s), women with breast cancer were treated with mastectomy and full axillary dissection, usually without radiotherapy or chemotherapy. Thus, the lymphedema of the arm that occurred during this period was primarily and appropriately blamed on the surgeon. In the current non-Halstedian era of multimodality therapy, lymphedema can be blamed on everyone.
To the Editor We read with great interest the article by Chen et al reporting a prediction model based on collagen architecture and morphology to estimate the risk of lymph node metastasis (LNM) in patients with early gastric cancer (EGC). The newly developed tools were suggested to be useful in decision-making in the choice of surgical or endoscopic submucosal dissection (ESD) treatment in patients with T1 gastric cancer. However, we have some concerns about this study from the perspective of endoscopists.
How should a surgeon’s time in the operating room be compensated? Based on the complexity of the procedure? The risk? The length of the operation? What if the procedure is extremely complex or high risk but is of short duration? Should such a case have a higher relative value than a long but low-risk procedure? These are but a few of the controversies related to relative value units (RVUs), the current basis for payment for surgeons’ services by Medicare and other third-party payers.
Older adults account for more than 30% of trauma admissions in the United States, and as Americans live longer, this number will continue to grow. In response, the trauma community has increased research and programmatic efforts toward improving care and outcomes of older trauma patients. For trauma surgeons and systems, the trauma registry is the foundational data source for measurement, quality improvement, and research. These trusted registries are used to identify gaps in care and track process improvements. In this issue of JAMA Surgery, a study by Newgard et al beautifully demonstrates that nearly 3 in 4 older patients were left out of a sample of trauma registries. This article also reiterates the National Academies of Science, Engin.
In this issue of JAMA Surgery, Juo et al have presented a study on a US trend in treating fulminant Clostridium difficile colitis with loop ileostomy as an organ-preserving procedure vs performing total abdominal colectomy. With a retrospective cohort study design, Juo et al examined a US national administrative database, the National Inpatient Sample database, with a weighted sampling of treatment choices for C difficile colitis in approximately 20% of associated hospitalizations in nonfederal acute care hospitals in the sampled US states from 2011 through 2015. The study includes 3021 adult patients who underwent surgery for severe C difficile colitis during the study period, of whom 2408 had subtotal colectomies and 613 had loop ileostom.
The management of locally advanced rectal cancer has been a topic of debate between surgical schools in the East and the West, and to date, there is still no formal consensus or mutually agreed-on guidelines. While in Western countries, neoadjuvant chemoradiation therapy followed by total mesorectal excision has been the standard of care for 2 decades now, 2 recent studies have demonstrated that this approach does not prevent lateral lymph node recurrence. On the contrary, prophylactic lateral lymph node dissection has been the standard of care for locally advanced rectal cancer in Eastern countries, with predominance in Japan. Pelvic magnetic resonance imaging (MRI) has become an invaluable instrument to establish local disease extension a.
In Reply We appreciate the interest in our study expressed by Gachabayov et al, and we welcome their comments. First, our study methodology indeed shares similarities with the before-after design as referred to. However, the current design remains that of a cohort study, given the fact that the cohort includes patients that all share the same characteristics (ie, patients 18 years or older undergoing elective laparoscopic colorectal cancer surgery) apart from the intervention (systematic video recording). It is our belief that in the example of decreased length of hospital stays, sample size is a more substantial part to acknowledge. Therefore, regarding this outcome, we have suggested specifically to interpret this particular result discre.
To the Editor We read with great interest the study comparing systematic video documentation with narrative operative report in colorectal cancer surgery by van de Graaf et al and would like to congratulate the authors for a good study. Although we appreciate the work behind the study, we feel that we will be contributing to the overall message of the study with the following methodological comments.
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 the education and training of the surgical workforce, quality improvement, and the ethics and economics of health care delivery.
Task shifting is a process whereby specific duties are moved to health care workers with shorter training times and fewer qualifications. The process may also involve delegation of clearly delineated responsibilities to newly created cadres of health care workers after completion of specific competency-based training. In high-income countries, successful, sometimes controversial, examples of task shifting include donor lung procurements by physician assistants, midlevel clinicians performing diagnostic and therapeutic endoscopy, and hernia repairs performed by general practitioners. In resource-limited countries, multiple studies report safe outcomes for procedures performed by nonsurgeons, including those done even by nonphysicians. Depend.
To the Editor I read the article by Perry et al with interest. Several other molecular mechanisms and factors may also play a role in how anesthesia may influence cancer outcomes. First, it is important to distinguish the difference between certain fluoridated anesthesia, such as sevoflurane, from their contribution to higher plasma fluoride levels. For example, it is known that sevoflurane can provide 20-fold the total daily dietary fluoride intake from all sources of fluoridated food and water combined, resulting in peak ionic fluoride levels in the range of 50 μmol/L. Hence, fluoridated anesthesia can result in extremely high plasma fluoride levels. Second, it is important to point out that chronic fluoride exposure has been found to dec.
In Reply We thank Waugh for the interest he has shown in our article and the Editor for the opportunity to reply to his comments. It is true that serum fluoride levels are elevated during anesthesia with sevoflurane, which occurs as a result of its metabolism by hepatic cytochrome P450 enzymes to yield hexafluoroisopropanol and inorganic fluoride. Indeed, there were well-documented concerns about the potential toxicity of these metabolites when sevoflurane first came into clinical use in the 1990s, although it rapidly transpired that reported cases of nephrotoxicity in rats were actually caused by compound A (fluoromethyl 2,2-difluoro-1-[trifluoromethyl]vinyl ether), a degradation product formed by the interaction of sevoflurane with carbon.

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