Behind The Knife: The Surgery Podcast

Join the Behind the Knife Surgical Oncology Team as we discuss the MATTERHORN trial and the addition of perioperative immunotherapy to FLOT for resectable gastric and gastroesophageal junction adenocarcinoma!

Hosts:

Timothy Vreeland, MD, FACS (@vreelant) is an Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at Brooke Army Medical Center.

Daniel Nelson, DO, FACS (@usarmydoc24) is an Associate Professor of Surgery and Surgical Oncologist at the University of Tennessee Health Science Center, Chattanooga.

Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a Surgical Oncologist at Brooke Army Medical Center.

Joe (Joseph) Broderick, MD, MA (@joebrod5) is a General Surgery research resident between his second and third year at Brooke Army Medical Center.

Galen Gist, MD (@gistgalen) is a third-year General Surgery resident at Brooke Army Medical Center.

Learning Objectives:
In this episode, we review the evolution of perioperative therapy for resectable gastric and gastroesophageal junction adenocarcinoma, from the MAGIC and FLOT4 trials to the MATTERHORN trial, a phase III randomized controlled trial investigating the addition of perioperative durvalumab to FLOT. We discuss the mechanism of checkpoint inhibition, the trial design, the event-free and overall survival results, the pathologic and nodal response data, and the open questions this trial raises for surgeons.
References used in the making of this episode:

Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11-20. doi:10.1056/NEJMoa055531

Al-Batran SE, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-1957. doi:10.1016/S0140-6736(18)32557-1

Janjigian YY, Al-Batran SE, Wainberg ZA, et al. Perioperative durvalumab in gastric and gastroesophageal junction cancer. N Engl J Med. 2025;393(3):217-230. doi:10.1056/NEJMoa2503701

Tabernero J, Al-Batran SE, Wainberg ZA, et al. Final overall survival and the association of pathological outcomes with event-free survival in MATTERHORN: a randomised, phase III study of durvalumab plus FLOT in resectable gastric/gastroesophageal junction adenocarcinoma. Presented at: European Society for Medical Oncology (ESMO) Congress 2025; October 17, 2025; Berlin, Germany. Abstract LBA81.

Shitara K, Rha SY, Wyrwicz L, et al. Pembrolizumab plus chemotherapy versus chemotherapy as perioperative therapy in locally advanced gastric and gastroesophageal junction cancer: final analysis of the randomized, phase III KEYNOTE-585 study. J Clin Oncol. 2025;43(29):3152-3159. doi:10.1200/JCO-25-00486

Kang YK, Terashima M, Kim YW, et al. Adjuvant nivolumab plus chemotherapy versus placebo plus chemotherapy for stage III gastric or gastro-oesophageal junction cancer after gastrectomy with D2 or more extensive lymph-node dissection (ATTRACTION-5): a randomised, multicentre, double-blind, placebo-controlled, phase 3 trial. Lancet Gastroenterol Hepatol. 2024;9(8):705-717. doi:10.1016/S2468-1253(24)00156-0

André T, Tougeron D, Piessen G, et al. Neoadjuvant nivolumab plus ipilimumab and adjuvant nivolumab in localized deficient mismatch repair/microsatellite instability-high gastric or esophagogastric junction adenocarcinoma: the GERCOR NEONIPIGA phase II study. J Clin Oncol. 2023;41(2):255-265. doi:10.1200/JCO.22.00686

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In this episode of the Behind the Knife Global Surgery Series, we explore what it actually takes to build a meaningful career in global surgery. Global surgery is not a single specialty or job title—it is a broad field that intersects with clinical care, education, research, policy, advocacy, implementation science, and health-system strengthening. So how do trainees and early-career surgeons find their place in it?

Host Mike M. Mallah is joined by Dr. Barnabas Alayande and Dr. Lacey LaGrone for a candid discussion about the personal and professional paths that brought them into global surgery. Dr. Alayande shares how experiences with limited access to healthcare in Nigeria shaped his decision to pursue medicine and ultimately global surgery, while Dr. LaGrone discusses her focus on translating evidence into clinical practice and building scalable approaches to knowledge dissemination.

Together, they discuss why purpose matters, why global surgery should be viewed as a field rather than a job title, and why aspiring global surgeons should first become excellent at something that allows them to add real value. The conversation also examines mentorship, the difference between visibility and impact, the importance of integrity in partnerships, and the personal sacrifices that can accompany a career devoted to this work.

For medical students, residents, fellows, and junior faculty interested in global surgery, this episode offers practical advice: develop meaningful expertise, seek mentors who are genuinely invested in your growth, focus less on recognition and more on impact, and keep doing the next right thing—excellently.

Hosts/Guests:
Mike M. Mallah, MD, FACS, FICS
Director of Global Surgery, Medical University of South Carolina
@MikeMMallahMD
@MUSCGlobalSurg
mallahm@musc.edu

Barnabas Alayande, MD
Chair, Center for Equity and Global Surgery
University of Global Health Equity, Rwanda
General Surgeon, Surgical Educator, and Global Surgery Leader
@DrBarnabasAlay

Lacey LaGrone, MD
Associate Director of Research, Medical Center of the Rockies
Associate Clinical Faculty, University of Colorado
Co-Founder, Together Made
Acute Care Surgeon, Surgical Intensivist, and Global Surgery Leader

Papers noted:
·   Abimbola S. The foreign gaze: authorship in academic global health. BMJ Global Health. 2019;4:e002068. https://doi.org/10.1136/bmjgh-2019-002068
·   Essentialism: The Disciplined Pursuit of Less by Greg McKeown https://gregmckeown.com/books/essentialism/

Topics discussed: Career pathways in global surgery; finding your “why”; global surgery as a field rather than a specialty; developing expertise; implementation science; mentorship; visibility versus impact; ethical partnerships; professional sacrifice; work-life balance; and advice for the next generation of global surgeons.
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Open the capsule, quit the cigarettes, and know when to cut: the essentials of managing marginal ulcers after bypass.
Marginal ulcers are among the most common complications after Roux-en-Y gastric bypass, with a pooled prevalence around 4.6%, and they span everything from mild postprandial pain to perforation with peritonitis. In this episode, our expert panel works through three clinical scenarios (an uncomplicated early ulcer, a refractory ulcer with recurrent stricture, and a perforated ulcer with peritonitis) to build a practical framework for prevention, workup, medical therapy, and surgical escalation.
Hosts

Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California)

Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio)

Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida)

Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) 

Learning objectives
1.     Identify the established and debated risk factors for marginal ulcers. Recognize smoking, diabetes, NSAIDs, and larger pouch size as key contributors. Appreciate that the role of H. pylori remains unsettled because of heavy heterogeneity across meta-analyses.
2.     Perform a complete etiologic workup for a new marginal ulcer. Assess NSAID and immunosuppressant use, smoking (including cotinine test), H. pylori status, and visible suture or staple material at the anastomosis, and know that endoscopy, not CT, is the diagnostic tool of choice unless perforation is suspected.
3.     Optimize first-line medical management. Use PPI therapy with instructions to open the capsules for faster healing, understand the limited evidence for adding sucralfate, confirm healing with repeat endoscopy, and individualize treatment duration, including when lifelong prophylaxis is reasonable.
4.     Define and evaluate the refractory ulcer. Apply the 6- to 12-month definition of refractory disease, rule out gastrogastric fistula, hypersecretory states (serum gastrin), and PPI rapid metabolism (CYP2C19), and recognize ulcer-related gastrojejunal stricture and the perforation risk of serial dilation.
5.     Weigh escalation options for refractory disease. Compare endoscopic suturing and stenting, truncal vagotomy, and GJ revision, including their mixed durability data, and address nutritional optimization and remnant access before reoperation.
6.     Manage a perforated marginal ulcer. Prioritize resuscitation, antibiotics, and IV PPI; take unstable patients straight to the OR, use primary repair with omental patch as the default approach, and reserve revision or damage control for select patients based on physiology, tissue quality, and expertise.
7.     Counsel patients on long-term recurrence risk. Communicate substantial recurrence rates after both repair and revision and emphasize that quitting smoking early (more than a year before surgery) meaningfully lowers reoperation risk.
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It’s 2 a.m. and a patient with a GSW to the thigh is rolling into the trauma bay. He’s hypotensive, tachycardic, and has a tourniquet in place. Do you get a CTA or go straight to the OR? What do you do with the tourniquet?
Join us as we work through this and two other cases of extremity vascular trauma and break down the literature to answer these questions and discuss how we should approach these challenging injuries.
Hosts:
·      Christian Hadeed - PGY 5 General Surgery, Brookdale Hospital Medical Center
·      Paul Haser -Division Chief, Vascular Surgery, Brookdale Hospital Medical Center
·      Andrew Harrington – Division Chief, Vascular surgery, Richmond University Medical Center
·      Lucio Flores - Vascular surgery, Brookdale Hospital Medical Center
Learning Objectives:
·      Apply the X-ABCDE approach to patients with extremity vascular trauma, including the role of early hemorrhage control and tourniquets.
·      Recognize the hard and soft signs of extremity arterial injury and determine when additional vascular imaging is indicated.
·      Describe the role of the ankle-brachial index, CT angiography, and conventional angiography in the evaluation of suspected extremity vascular injury.
·      Discuss the principles of operative management of extremity vascular injuries, including temporary shunting, vascular repair, and restoration of limb perfusion.
·      Briefly discuss mangles extremities and when saving the limb may not be appropritate
References:
·      American College of Surgeons Committee on Trauma. (2025). Advanced trauma life support (ATLS®) student course manual (11th ed.). American College of Surgeons.
·      Lynch, K., & Johansen, K. (1991). Can Doppler pressure measurement replace “exclusion” arteriography in the diagnosis of occult extremity arterial trauma? Annals of Surgery, 214(6), 737–741. https://doi.org/10.1097/00000658-199112000-00016
·      Inaba, K., Branco, B. C., Reddy, S., Park, J. J., Green, D., Plurad, D., Talving, P., Lam, L., & Demetriades, D. (2011). Prospective evaluation of multidetector computed tomography for extremity vascular trauma. Journal of Trauma, 70(4), 808–815. https://doi.org/10.1097/TA.0b013e3182118384
·      Polcz, J. E., White, J. M., Ronaldi, A. E., Dubose, J. J., Grey, S., Bell, D., White, P. W., & Rasmussen, T. E. (2021). Temporary intravascular shunt use improves early limb salvage after extremity vascular injury. Journal of Vascular Surgery, 73(4), 1304–1313. https://doi.org/10.1016/j.jvs.2020.08.137
·      Asensio, J. A., Kessler, J. J., Miljkovic, S. S., Kotaru, T. R., Dabestani, P. J., Kalamchi, L. D., Wenzl, F. A., Sanford, A. P., & Rowe, V. L. (2020). Brachial artery injuries: Operative management and predictors of outcome. Annals of Vascular Surgery, 69, 146–157. https://doi.org/10.1016/j.avsg.2020.05.049
·      Barnes, C. J., Pietrobon, R., & Higgins, L. D. (2002). Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. Journal of Trauma, 53(6), 1109–1114. https://doi.org/10.1097/00005373-200212000-00013
·      Mills, W. J., Barei, D. P., & McNair, P. (2004). The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: A prospective study. Journal of Trauma, 56(6), 1261–1265. https://doi.org/10.1097/01.TA.0000068995.63201.0B
·      Weinberg, D. S., Scarcella, N. R., Napora, J. K., & Vallier, H. A. (2016). Can vascular injury be appropriately assessed with physical examination after knee dislocation? Clinical Orthopaedics and Related Research, 474, 1453–1458. https://doi.org/10.1007/s11999-016-4730-6

Sponsor URL: https://www.goremedical.com/
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This mini-series on Behind the Knife will discuss the technical aspects of the Operative Standards for Cancer Surgery, developed through the American College of Surgeons Cancer Research Program and Cancer Surgery Standards Program. This episode highlights total mesorectal excision for rectal cancer.
Host:

Jason Lizalek, MD (@JasonLizalekMD) is a Surgical Oncology fellow at Moffitt Cancer Center in Tampa, FL.
Guests:

Sean J Langenfeld, MD, FACS, FASCRS (@seanlangenfeld) is a professor of surgery and the chief of the division of colon and rectal surgery at the University of Nebraska Medical Center in Omaha, NE

Larissa Temple, MD, FACS, FASCRS is a professor of surgery and the chief of colon and rectal surgery at the University of Rochester in Rochester, NY.

Learning Objectives: 
-       Understand the relevant pelvic anatomy that makes TME challenging.
-       Develop a step-by-step approach to TME that avoids major pitfalls and allows for a sfe low pelvic anastomosis.
-       Learn tips and tricks for exposure and progress in the more difficult cases.
Links to Papers Referenced in this Episode:

Operative Standards for Cancer Surgery, Volume 1: Breast, Lung, Pancreas, Colon
https://www.facs.org/quality-programs/cancer-programs/cancer-surgery-standards-program/operative-standards-for-cancer-surgery/purchase/

Kindle edition:
https://www.amazon.com/Operative-Standards-Cancer-Surgery-Section-ebook/dp/B07MWSNFSB

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement
https://pubmed.ncbi.nlm.nih.gov/37647138/

NCCN Guidelines for Rectal Cancer
https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1461
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