Nathan W. Bronson

The General Surgery Job Market: Analysis of Current Demand for General Surgeons and Their Specialized Skills

BACKGROUND The majority of general surgery residents pursue fellowships. However, the relative demand for general surgical skills vs more specialization is not understood. Our objective was to describe the current job market for general surgeons and compare the skills required by the market with those of graduating trainees. STUDY DESIGN Positions for board eligible/certified general surgeons in Oregon and Wisconsin from 2011 to 2012 were identified by review of job postings and telephone calls to hospitals, private practice groups, and physician recruiters. Data were gathered on each job to determine if fellowship training or specialized skills were required, preferred, or not requested. Information on resident pursuit of fellowship training was obtained from all residency programs within the represented states. RESULTS Of 71 general surgery positions available, 34% of positions required fellowship training. Rural positions made up 46% of available jobs. Thirty-five percent of positions were in nonacademic metropolitan settings and 17% were in academic metropolitan settings. Fellowship training was required or preferred for 18%, 28%, and 92% of rural, nonacademic, and academic metropolitan positions, respectively. From 2008 to 2012, 67% of general surgery residents pursued fellowship training. CONCLUSIONS Most general surgery residents pursue fellowship despite the fact that the majority of available jobs do not require fellowship training. The motivation for fellowship training is unclear, but residency programs should tailor training to the skills needed by the market with the goal of improving access to general surgical services.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios can Predict Treatment Response to Neoadjuvant Therapy in Esophageal Cancer.

IntroductionWe hypothesized that serum neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios may predict pathologic complete response to neoadjuvant chemoradiotherapy in esophageal cancer patients. The ability to predict favorable treatment response to therapy may aid in determining optimal treatment regimens.Materials and MethodsA retrospective review of a prospective esophageal disease registry was conducted. Neutrophil-to-lymphocyte ratio was defined as the pre-chemoradiotherapy serum neutrophil count divided by lymphocyte count. Platelet-to-lymphocyte ratio was similarly defined. Logistic regression was applied to analyze these ratios and their effect on pathologic complete response. A Cox proportional-hazards model was used to analyze survival.ResultsSixty patients were included. Elevated neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were both negative predictors of pathologic complete response (odds ratio: 0.62; 95% confidence interval: 0.37–0.89, P = 0.037 and odds ratio: 0.91; 95% confidence interval: 0.82–0.98, P = 0.028, respectively). Only platelet-to-lymphocyte ratio was predictive of decreased overall survival (hazard ratio: 1.05, 95% confidence interval: 0.94–1.16, P = 0.40).ConclusionElevated neutrophil and platelet-to-lymphocyte ratios were significant predictors of a poor treatment response to neoadjuvant therapy. Only elevated platelet-to-lymphocyte ratio was predictive of worse overall survival. Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios may offer a simple serum test to assess the likelihood of a pathologic complete response after neoadjuvant therapy in esophageal cancer.

Molecular Marker Expression Is Highly Heterogeneous in Esophageal Adenocarcinoma and Does Not Predict a Response to Neoadjuvant Therapy

A reliable method to identify pathologic complete responders (pCR) or non-responders (NR) to neoadjuvant chemoradiation therapy (NAT) would dramatically improve therapy for esophageal cancer. The purpose of this study is to investigate if a distinct profile of prognostic molecular markers can predict pCR after neoadjuvant therapy. Expression of p53, Her-2/neu, Cox-2, Beta-catenin, E-cadherin, MMP-1, NFkB, and TGF-B was measured by immunohistochemistry in pre-treatment biopsy tissue and graded by an experienced pathologist. A pCR was defined as no evidence of malignancy on final pathology. Molecular profiles comparing responders to non-responders were analyzed using classification and regression tree analysis to investigate response to NAT and overall survival. Nineteen patients were pCRs and 34 were NRs. pCRs were more likely to be alive at follow-up than NRs (p < 0.01). Thirty-seven distinct profiles were identified. Expression of molecular markers was highly heterogeneous between patients and did not correlate with a response to NAT, survival (p = 0.47) or clinical stage (p = 0.39) when evaluated either as individual markers or in combination with other expression patterns. NAT dramatically impacts survival through a mechanism independent of known molecular markers of esophageal cancer, which are expressed in a highly heterogeneous fashion and do not predict response to NAT or survival.

Tailoring Esophageal Cancer Surgery

Esophageal cancer is a significant source of major mortality worldwide and is increasing dramatically in incidence. Without treatment this disease leads rapidly to death, but intervention also carries significant risk, so a carefully tailored approach must be used to maximize oncological efficacy while minimizing the negative consequences of intervention. Careful patient selection based on histologic and anatomic staging, consideration of each patients clinical variables, appropriately timing chemo- and radiation therapy, and minimizing the morbidity of surgical intervention may significantly improve a patients chances of surviving this disease, but each must be carefully orchestrated with a tailored approach to treatment. This review will serve as a guide to tailoring surgery for esophageal cancer.

Indications for Antireflux Surgery

Patients with frequent GERD symptoms cost the healthcare system billions of dollars annually—significantly more than non-GERD patients. Medical therapy (PPI) and antireflux surgery are the two accepted treatment options for these patients. Patients who respond to PPI therapy, at least partially, and have objective evidence of GERD demonstrated on upper endoscopy or pH study have better outcomes after surgery than those who do not. The objective of this chapter is to review the indications for surgical treatment in patients with GERD.

Neutrophil to lymphocyte ratios and pathologic response to neoadjuvant therapy in esophageal cancer.

44 Background: Esophageal cancer (EC) is increasing in incidence dramatically, and is associated with suboptimal outcomes despite the widespread adoption of neoadjuvant multimodality therapy (NAT) as a de-facto standard-of-care for clinically resectable disease. Between one-quarter and one-third of patients (pts) are found to have no evidence of tumor (pCR) at the time of surgical resection, a prognostic indicator of superior survival benefit. However, we currently lack a method to prospectively identify pts who will respond to (NAT). Identifying complete responders could reduce the number of patients requiring esophagectomy. The specific aim of this study was to determine if the pre-operative neutrophil to lymphocyte ratio (NLR), which has been reported as a prognosticator of mortality, is prognostic of pCR to NAT. METHODS A prospectively collected database was queried for all pts that have undergone esophagectomy for EC, including both squamous cell carcinoma and adenocarcinoma. Records were evaluated for preoperative complete blood count (CBC) with differential from which a NLR was calculated as the absolute neutrophil count divided by the absolute lymphocyte count. A NLR greater than 5 was considered elevated. Pts were classified as pCR if they had no residual tumor on final pathology, partial responders (PR) if they demonstrated down staging after neoadjuvant therapy, or non-responders (NR) if they did not show any improvement in their stage on final pathology. RESULTS Of 114 pts who underwent both NAT and esophagectomy for EC, 41 had a pre-operative CBC with differential from which a NLR could be calculated. There were 19 NR, 14 PR and 8 CR. These groups were demographically similar. The average NLR was 5.92 for NR, 6.56 for PR, and 4.89 among CR, with no statistically significant difference between groups. Overall survival at 5 years was 33%. By multivariate analysis NLR>5 did not correlate with pathologic response (p=0.78), and NLR >5 did not correlate with survival (p=0.33). CONCLUSIONS Elevated neutrophil to lymphocyte ratios are not predictive of pathologic response to NAT in esophageal cancer.