American Surgical Association Research Articles

The First Aortic Endoaneurysmorrhaphy: Ricardo Lozano Monzón (1872-1934).

In 1888, Rudolph Matas described and performed a procedure (endoaneurysmorrhaphy) that revolutionized the treatment of aneurysms, which for centuries had been untreatable or simply involved treatment by ligation and other marginal techniques. In 1940, during the annual meeting of the American Surgical Association, Matas presented the excellent results he had obtained with 98 endoaneurysmorrhaphies, although none of these cases involved an aortic aneurysm. On November 4, 1904, a Spanish surgeon called Ricardo Lozano Monzón was the first person in the world to perform an endoaneurysmorrhaphy on a patient suffering from an abdominal aortic aneurysm. The case was reported in a local journal called La Clínica Moderna in 1905. Despite the journal's limited circulation, Matas and others acknowledged that Lozano was the practitioner of the first, although admittedly unsuccessful, endoaneurysmorrhaphy on an abdominal aorta. Lozano's attempt was followed by other equally unsuccessful ones until Isaac A. Bigger performed the first successful procedure in 1938. The different kinds of endoaneurysmorrhaphy that Matas used, which proved to be effective in the treatment of peripheral aneurysms, did not perform in the same way in aortic aneurysms. Nonetheless, the procedure paved the way for new ideas and contributions (Creech technique).

Reassessing career pathways of surgical leaders: An examination of surgical leaders’ early accomplishments

BackgroundThe American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and Society of Black Academic Surgeons (SBAS) partnered to gain insight into whether inequities found in surgical society presidents may be present earlier. MethodsACS, ASA, AWS, and SBAS presidents’ CVs were assessed for demographics and scholastic achievements at the time of first faculty appointment. Regression analyses controlling for age were performed to determine relative differences across societies. Results66 of the 68 presidents’ CVs were received and assessed (97% response rate). 50% of AWS future presidents were hired as Instructors rather than Assistant professors, compared to 29.4% of SBAS, 25% of ASA and 29.4% of ACS. The future ACS, ASA, and SBAS presidents had more total publications than the AWS presidents, but similar numbers of 1st and Sr. author publications. ConclusionGender inequities in academic surgeon hiring practices and perceived scholastic success may be present at first hire.

Discrepancies in decision making preferences between parents and surgeons in pediatric surgery

BackgroundLittle data exists regarding decision-making preferences for parents and surgeons in pediatric surgery. Here we investigate whether parents and surgeons have similar decision-making preferences as well as which factors influence those preferences. Specifically, we compare parents’ and surgeons’ assessments of the urgency and complexity of pediatric surgical scenarios and the impact of their assessments on decision-making preferences.MethodsA survey was emailed to parents of patients evaluated in a university-based pediatric surgery clinic and surgeons belonging to the American Pediatric Surgical Association. The survey asked respondents to rate 6 clinical vignettes for urgency, complexity, and desired level of surgeon guidance using the Controlled Preferences Scale (CPS).ResultsRegarding urgency, parents were more likely than surgeons to rate scenarios as emergent when cancer was involved (parents: 68.8% cancer vs. 29.5% non-cancer, p < .001; surgeons: 19.2% cancer vs. 25.4% non-cancer, p = .051). Parents and surgeons were more likely to rate a scenario as emergent when a baby was involved (parents: 45.2% baby vs. 36.2% child, p = .001; surgeons: 28.0% baby vs. 14.0% child, p < .001). Regarding decision-making preferences, parents and surgeons had similar CPS scores (2.56 vs. 2.72, respectively). Multivariable analysis showed parents preferred more surgeon guidance when scenarios involved a baby (OR 1.22; 95% CI 1.08–1.37; p < 0.01) or a cancer diagnosis (OR 1.29; 95% CI 1.11–1.49; p < 0.01), and that both parents and surgeons preferred more surgeon guidance when a scenario was considered emergent (parents: OR 1.81; 95% CI 1.37–2.38, p < 0.001; surgeons: OR 2.48 95% CI 1.76–3.49, p < 0.001).ConclusionsWhen a pediatric patient is a baby or has cancer, parents are more likely then surgeons to perceive the clinical situation to be emergent, and both parents and surgeons prefer more surgeon guidance in decision-making when a clinical scenario is considered emergent. More research is needed to understand how parents’ decision-making preferences depend on clinical context.

The Surgical Legacy of Randolph Lee Clark, Jr, MD: First Director and Surgeon-in-Chief of University of Texas MD Anderson Cancer Center II. Surgical Practice and Leadership at University of Texas MD Anderson Cancer Center (1946-1978).

Dr. R. Lee Clark Jr brought a broad-based cancer surgery experience to MD Anderson Hospital for Cancer Research when he became its first Surgeon-in-Chief and full-time salaried physician in 1946. He performed major surgery until 1971 including major head and neck operations, thyroidectomy, mastectomy, radical melanoma and sarcoma surgery, gastric and abdominal-perineal resection, and even hemipelvectomy. He initiated major programs in radiation therapy and mammography breast screening, and organized teams of specialists in a group practice providing multidisciplinary cancer care. Dr. Clark was elected into membership by the James Ewing Society (currently the Society of Surgical Oncology), the Southern Surgical Association, and the American Surgical Association, and was a founding member of the Society of Head and Neck Surgery. The Society of Surgical Oncology honored him with the Lucy Wortham James Award in 1965 and the James Ewing Lecture Award in 1977. Dr. Clark also provided invaluable leadership in the American College of Surgeons, leading a fledgling Committee on Cancer into a robust organization that became the Commission on Cancer. The College of Surgeons honored him with their Distinguished Service Award in 1969. Dr. Clark recruited major surgical leaders and personally designed the new hospital that opened in 1954, described in Time magazine as "the most modern, most ingeniously designed hospital in the U.S." R. Lee Clark, Jr. was an accomplished and busy clinical surgeon, a visionary and charismatic leader, and an organizational genius. Indeed, he was one of the first pioneers in the specialty of surgical oncology.

American Surgical Association Statement in Support of Science and on Keeping Politics Out of Science.

American Surgical Association Statement in Support of Science and on Keeping Politics Out of Science.

Multiplexed Plasma Immune Mediator Signatures Can Differentiate Sepsis From NonInfective SIRS: American Surgical Association 2020 Annual Meeting Paper.

Sepsis and sterile both release "danger signals' that induce the systemic inflammatory response syndrome (SIRS). So differentiating infection from SIRS can be challenging. Precision diagnostic assays could limit unnecessary antibiotic use, improving outcomes. After surveying human leukocyte cytokine production responses to sterile damage-associated molecular patterns (DAMPs), bacterial pathogen-associated molecular patterns, and bacteria we created a multiplex assay for 31 cytokines. We then studied plasma from patients with bacteremia, septic shock, "severe sepsis," or trauma (ISS ≥15 with circulating DAMPs) as well as controls. Infections were adjudicated based on post-hospitalization review. Plasma was studied in infection and injury using univariate and multivariate means to determine how such multiplex assays could best distinguish infective from noninfective SIRS. Infected patients had high plasma interleukin (IL)-6, IL-1α, and triggering receptor expressed on myeloid cells-1 (TREM-1) compared to controls [false discovery rates (FDR) <0.01, <0.01, <0.0001]. Conversely, injury suppressed many mediators including MDC (FDR <0.0001), TREM-1 (FDR <0.001), IP-10 (FDR <0.01), MCP-3 (FDR <0.05), FLT3L (FDR <0.05), Tweak, (FDR <0.05), GRO-α (FDR <0.05), and ENA-78 (FDR <0.05). In univariate studies, analyte overlap between clinical groups prevented clinical relevance. Multivariate models discriminated injury and infection much better, with the 2-group random-forest model classifying 11/11 injury and 28/29 infection patients correctly in out-of-bag validation. Circulating cytokines in traumatic SIRS differ markedly from those in health or sepsis. Variability limits the accuracy of single-mediator assays but machine learning based on multiplexed plasma assays revealed distinct patterns in sepsis- and injury-related SIRS. Defining biomarker release patterns that distinguish specific SIRS populations might allow decreased antibiotic use in those clinical situations. Large prospective studies are needed to validate and operationalize this approach.

The Right Child/Right Surgeon initiative: A position statement on pediatric surgical training, sub-specialization, and continuous certification from the American Pediatric Surgical Association

The past 50 years have witnessed profound changes in the specialty of pediatric surgery in North America. There has been a marked increase in the number of both pediatric surgical training programs and practicing pediatric general and thoracic surgeons. Despite this trend, the population of children in the United States and the birth rate have recently remained relatively flat. Some pediatric surgeons have become “super specialists”, concentrating their practices in oncology or colorectal surgery. This has the potential to result in a dilution of experience for both pediatric surgical trainees and practicing pediatric surgeons, thus limiting their ability to acquire and maintain expertise, respectively. Coincident with this, there has been a relative paradigm shift in recognition that “quality of life” is based more on maintaining a creative balance in lifestyle and is not “all about work”. There has been a parallel growth in the number of practicing pediatric general and thoracic surgeons in urban settings, but we have not appreciated as much growth in rural and underserved areas, where access to pediatric surgical care remains limited and fewer pediatric general and thoracic surgeons practice. This is a complex issue, as some underserved areas are economically depressed and geographically sparse, but others are just underserved with adult providers taking care of children in settings that are often under resourced for pediatric surgical care. This problem may extend beyond the boundaries of pediatric general and thoracic surgery to other specialties. As the premier association representing all pediatric surgeons in the United States, the American Pediatric Surgical Association (APSA) has concluded that the quality of pediatric surgical care will likely decline should the status quo be allowed to continue. Therefore, APSA has initiated a Right Child/Right Surgeon initiative to consider these issues and propose some potential solutions. What follows is a brief statement of intent.

Benchmarking Accomplishments of Leaders in American Surgery and Justification for Enhancing Diversity and Inclusion

To comprehensively assess the level of achievement and demographics of national surgical society presidents. Data on the accomplishments needed to rise to positions of national surgical leadership is scarce and merit alone does not always yield such opportunities. Recognizing the shortcomings of sex and ethnic diversity within academic surgical leadership, the American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and the Society of Black Academic Surgeons (SBAS) partnered to address these challenges by performing a comprehensive assessment of their presidents over the last 16 years. ACS, ASA, AWS, and SBAS presidents' CVs, at the time of their presidential term, were assessed for demographics and scholastic achievements. Regression analyses controlling for age were performed to determine relative differences across societies. A total of 62 of the 64 presidents' CVs were received and assessed (97% response rate). There was a large discrepancy in the average age in years of ACS (70) and ASA (66) presidents compared to the AWS (51) and SBAS (53) presidents. For the ACS and ASA cohort, 87% were male and 83% were White, collectively. After controlling for age (52), the AWS and SBAS presidents' scholastic achievements were comparable to the ACS (and ASA) cohort in 9 and 12 of the 15 accessed metrics, respectively. The ACS and ASA presidents' CVs displayed unsurpassed scholastic achievement, and although not equivalent, both the AWS and the SBAS presidents had comparable attainment. These findings further substantiate that women and ethnic minority surgeons are deserving of additional national leadership consideration as organized medicine pursues a more diverse and reflective physician workforce.

American Surgical Association Statement of Solidarity on Condemning and Eliminating Racism

The American Surgical Association Council prepared the submitted statement in response to the George Floyd killing and our responsibility as leaders in academic surgery to condemn and eliminate racism.

Standardized Discharge Antibiotics May Reduce Readmissions in Pediatric Perforated Appendicitis

BackgroundBased on limited evidence, the American Pediatric Surgical Association recommends 5-7 d of postoperative antibiotics in perforated appendicitis for preventing intra-abdominal abscess (IAA). In 2015, our institutional clinical practice guideline was modified to standardize prescription for 7 additional days of oral antibiotics after discharge. We hypothesized that prescribing oral antibiotics after discharge would be associated with fewer complications in perforated appendicitis. Materials and methodsA retrospective cohort study was conducted of pediatric (younger than 18 y) patients who underwent laparoscopic appendectomy for perforated appendicitis (August 1, 2012-April 30, 2019). Patients diagnosed with IAA before discharge or with a postoperative length of stay ≥8 d were excluded. Patient outcomes were compared prestandardization and poststandardization of discharge antibiotics. ResultsOf 617 patients, 212 (34.5%) were admitted prestandardization and 404 (65.5%) poststandardization. Overall, 409 patients (66.3%) received discharge antibiotics. The median total postoperative antibiotic duration was 4 d (interquartile range, 3-5) prestandardization versus 11 d (interquartile range, 10-12) poststandardization (P < 0.001). Prestandardization patients had a higher rate of IAA (8.9% versus 4.5%, P = 0.03) and were readmitted more frequently (13.1% versus 6.4%, P = 0.005). On adjusted analysis, admission poststandardization was associated with reduced odds of IAA (odds ratio, 0.51; 95% confidence interval, 0.25-1.06), but the relationship was imprecise. Admission poststandardization was significantly associated with reduced adjusted odds of readmission (odds ratio, 0.46; 95% confidence interval, 0.25-0.85). ConclusionsPrescription for seven additional days of oral antibiotics after discharge was associated with reduced odds of readmission in pediatric perforated appendicitis. This population may benefit from a longer postoperative antibiotic course than currently recommended.

Does academic authorship reflect gender bias in pediatric surgery? An analysis of the Journal of Pediatric Surgery, 2007–2017

BackgroundGender representation in academic publications has been considered a surrogate for gender equity in medicine, although this concept has not been evaluated in pediatric surgery. MethodsFirst and last author genders for Journal of Pediatric Surgery articles from United States and/or Canadian institutions (2007, 2012, 2017) were identified. These data were compared to gender proportions for applicants to and matriculants in pediatric surgery fellowships as well as among American Pediatric Surgical Association (APSA) members. ResultsAuthorship gender was identified for 632/640 primary articles (98.8%). From 2007 to 2017, the proportion of women as first authors increased from 33.0% to 53.9% (p < 0.001) and as last authors from 16.2% to 26.4% (p = 0.01). The proportion of women fellowship applicants rose from 35.9% to 57.6% (p < 0.001); among those who successfully matched the rise was nonlinear (20.5%–34.0%, p = 0.16). APSA junior and senior women membership proportions rose during the study period [from 28.1% to 43.4% (p = 0.06 for linear trend) and 17.9% to 24.4% (p = 0.005 for linear trend), respectively]. ConclusionsOver the past decade, the overall proportion of women authors in a leading academic pediatric surgery journal has increased significantly, although representation among last authors remains disproportionately low. The numbers of women applicants to pediatric surgery fellowship increased but there was not a concordant rise in the number of women accepted into training positions. Type of studyBibliometric analysis. Level of evidencen/a

The 100 Most Cited Papers in the History of the American Surgical Association.

The aim of this study was to determine characteristics of the most cited publications in the history of the American Surgical Association (ASA). The Annals of Surgery has served as the journal of record for the ASA since 1928, with a special issue each year dedicated to papers presented before the ASA Annual Meeting. The top 100 most cited ASA publications in the Annals of Surgery were identified from the Scopus database and evaluated for key characteristics. The 100 most cited papers from the ASA were published between 1955 and 2010 with an average of 609 citations (range: 333-2304) and are included among the 322 most cited papers in the Annals of Surgery. The most common subjects of study included clinical cancer (n = 43), gastrointestinal (n = 13), cardiothoracic/vascular (n = 9), and transplant (n = 9). Ninety-three institutions were included lead by Johns Hopkins University (n = 9), University of Pittsburgh (n = 8), Memorial Sloan-Kettering (n = 7), John Wayne Cancer Institute (n = 7), University of Texas (n = 7), and 5 each from Brigham and Women's Hospital, Mayo Clinic, and University of Chicago. The majority of manuscripts came from the United States (n = 85), followed by Canada (n = 7), Germany (n = 5), and Italy (n = 5). Study design included randomized controlled trials (n = 19), retrospective matched cohort studies (n = 11), retrospective nonmatched studies (n = 46), and other (n = 24). The top 100 most cited publications from the ASA are highly impactful, landmark studies representing a diverse array of subject matter, investigators, study design, institutions, and countries. These influential publications have immensely advanced surgical science over the decades and should serve as inspiration for all surgeons and surgical investigators.

Academic Partnerships in Global Surgery: An Overview American Surgical Association Working Group on Academic Global Surgery.

: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.

First person profile: Sir Murray Brennan, MD: A legendary surgical oncologist, Dr. Brennan's research on soft tissue sarcomas and his willingness to mentor others have left a mark on the field.

First person profile: Sir Murray Brennan, MD: A legendary surgical oncologist, Dr. Brennan's research on soft tissue sarcomas and his willingness to mentor others have left a mark on the field.

The adherence of adult trauma centers to American Pediatric Surgical Association guidelines on management of blunt splenic injuries

BackgroundNonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC). MethodsThis was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00–865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS). Results5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ± 0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001). ConclusionsPTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend. Level of evidenceII Type of studyRetrospective.

Academic Advancement in Global Surgery: Appointment, Promotion, and Tenure: Recommendations From the American Surgical Association Working Group on Global Surgery.

: There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrative roles, or other activities that are conducted at low- and middle-income partner institutions and promote the partnerships upon which other global surgery activities depend); and (3) should not be considered (eg, mission trips or other clinical work, if not otherwise linked to funding, training, research, or building partnerships).

Faculty Diversity at Academic Surgical Meetings—Opportunity for Action?

BackgroundThe American Surgical Association delineated deficiencies of diversity, equity, and inclusion within academic surgery. Opportunities to increase diversity are membership in surgical societies and leadership development. We hypothesized that surgical society meetings represent additional opportunities, using gender diversity as an example. MethodsPublished programs from annual meetings of three large surgical societies were reviewed. Participants’ gender was classified by first name. Online search was used for equivocal names. We used JMP Pro 14.1.0 for univariate and multivariate logistic regression. ResultsDuring six meetings (2016–2018), 415 sessions with 4078 participants were included, 61% educational panels with invited faculty and 39% abstract sessions. Across all meetings, 32% of abstracts were presented by women, 22% of panel chairs or invited faculty were women. Fifty-four percent of male meeting participants were invited by their societies as moderator or speaker, and 41% of female participants were invited faculty. Fifty-nine percent of all panel chairs had no woman participant. In both univariate and multivariate regression, women had more than threefold the odds of presenting an abstract than presenting on a panel (p < 0.0001). Women were three times more likely to present in a session that was co-chaired by a woman (< 0.0001). ConclusionsOne in three abstract presenters in national surgery meetings was a woman, demonstrating engagement in the societies. Historically, men are more likely invited as faculty than women. The presence of a woman co-chair on a panel correlated with increased female participation. Similar scenarios may apply to other underrepresented groups.

A Call to Action for Male Surgeons in the Wake of the #MeToo Movement: Mentor Female Surgeons.

A Call to Action for Male Surgeons in the Wake of the #MeToo Movement: Mentor Female Surgeons.

Surgical or endovascular management of ruptured intracranial aneurysms: an agreement study.

Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA. The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non-middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage patients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0-10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics. Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158-0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within subgroups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (ability to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred. Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.

The Ochsner Legacy

One of the iconic families in American surgery is the Ochsners. The youngest son of Swiss immigrants, Henry Ochsner (1877-1902) was the first to enter the medical profession. His promising internship at the Johns Hopkins Hospital ended when he died of cholera, a tragedy deeply felt by his mentor William Osler. On another branch of the family tree, Albert Ochsner (1858-1925) wrote authoritative textbooks on surgery and became president of the ACS and the American Surgical Association. His most significant achievement may have been his mentorship of his cousin's son Alton (1896-1981), guiding his medical education and training in surgery. The younger Ochsner succeeded Rudolph Matas as chair of surgery at Tulane University at the age of only 31 years. Under his leadership, Charity Hospital in New Orleans became a leading program for surgical training and Tulane earned a reputation for clinical excellence. Ochsner and four partners from the Tulane faculty created a multidisciplinary clinic to attract patients from a wider area, a facility that would become today's Ochsner Clinic. His son John (1927-2018) followed him in the profession and received specialty training in cardiovascular surgery under Michael DeBakey in Houston, a Tulane graduate and an Ochsner trainee. John Ochsner returned to the Ochsner Clinic to establish a major cardiothoracic and vascular surgery program. Further generations of the Ochsner family continued the family legacy in surgery and medicine, exemplified by M. Gage Ochsner (1954-2013), Alton's grandson and John's nephew, who became a leading traumatologist and surgical educator in Savannah.