Journal of Surgical Research最新文献

{"title":"Effects of Local and Systematic Administration of Adipose Tissue–Derived Stem Cells to Intestinal Anastomosis in Intestinal Ishemic Rerfusion Injury: Ani̇mal Experi̇ment Model","authors":"İbrahim Doğan MD ,&nbsp;Bahar Kartal PhD ,&nbsp;Bülent Cavit Yüksel MD ,&nbsp;Umut Fırat Turan MD ,&nbsp;Metin Bozkaya MD ,&nbsp;Gökçe Yağmur Summak ,&nbsp;Ömür Besbinar PhD ,&nbsp;Açelya Yilmazer PhD ,&nbsp;Sadettin Er MD","doi":"10.1016/j.jss.2025.12.023","DOIUrl":"10.1016/j.jss.2025.12.023","url":null,"abstract":"<div><h3>Introduction</h3><div>Intestinal ischemia-reperfusion (IR) injury compromises anastomotic healing and may weaken anastomotic integrity. Adipose tissue–derived stem cells (AD-SCs) have been shown to enhance tissue regeneration through angiogenic and anti-ischemic effects. This study aimed to evaluate the impact of local and systemic AD-SC administration on anastomotic healing and strength following intestinal IR injury using histopathological parameters and bursting pressure measurements.</div></div><div><h3>Methods</h3><div>Thirty male Wistar Albino rats were randomly assigned to three groups (<em>n</em> = 10 each): control, local AD-SC, and systemic AD-SC. IR injury was induced by clamping the superior mesenteric artery, followed by intestinal resection and anastomosis. Local or systemic AD-SCs (1 × 10⁶ cells in 1.5 mL phosphate-buffered saline) were administered according to group allocation. On postoperative day 7, serum hydroxyproline levels, bursting pressures, and semiquantitative histological scores (ischemic necrosis, vascular proliferation, re-epithelialization, and collagen density) were assessed. Ordinal histological outcomes were analyzed using Kruskal–Wallis tests with Dunn's post hoc comparisons.</div></div><div><h3>Results</h3><div>Six animals died before the end point, leaving 24 rats for analysis. Bursting pressures and serum hydroxyproline levels did not differ significantly among groups. However, systemic AD-SC administration significantly improved all histological parameters compared with the control group, exhibiting lower ischemic necrosis and higher vascular proliferation, re-epithelialization, and collagen density (<em>P</em> &lt; 0.05 for each). Local AD-SCs produced intermediate improvements but did not differ significantly from controls in some parameters. Effect sizes indicated moderate to very large differences favoring systemic administration.</div></div><div><h3>Conclusions</h3><div>Systemic AD-SC administration enhanced multiple histological markers of anastomotic healing following intestinal IR injury, whereas local administration produced more modest effects. Although bursting pressures and serum hydroxyproline levels did not significantly differ, the histopathological findings suggest that systemic AD-SCs may provide a broader therapeutic benefit in promoting anastomotic integrity in ischemic bowel conditions. Further experimental studies incorporating direct leak outcomes are warranted.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 290-299"},"PeriodicalIF":1.7,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146030165","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Efficacy of the Traditional Chinese Medicine “Seven-Step Method” With Sleep Support Braces in Managing Postoperative Upper Limb Lymphedema After Breast Cancer Surgery: A Randomized Trial","authors":"Chengwen Shao MMed ,&nbsp;Hongmei LV MMed ,&nbsp;Hengchang Liu MD ,&nbsp;Liangyou Zhao MD ,&nbsp;Na Zhang MD","doi":"10.1016/j.jss.2025.12.031","DOIUrl":"10.1016/j.jss.2025.12.031","url":null,"abstract":"<div><h3>Background</h3><div>Postoperative upper limb lymphedema affects 32%-55% of breast cancer patients and impairs quality of life. Standard treatments, including education and exercise, are often insufficient. In 2014, the U.S. NIH recommended complex decongestive therapy. Recently, integrating traditional Chinese medicine (TCM) meridian theory into complex decongestive therapy has led to the “Seven-Step Method,” which shows encouraging outcomes. The objective of this study was to evaluate the efficacy of the TCM Seven-Step Method combined with sleep braces compared to conventional care in improving limb function and quality of life in breast cancer patients with postoperative upper limb lymphedema.</div></div><div><h3>Methods</h3><div>One hundred thirty-six patients randomized (<em>n</em> = 68 per arm) to conventional care or TCM “Seven-Step Method” + sleep braces applied daily over 6 wks. Outcomes included limb circumference, DASH, VRS pain, QOL-BREF scores, and satisfaction.</div></div><div><h3>Results</h3><div>At weeks 2, 4, and 6, the intervention group showed significantly greater reductions in limb circumference. DASH, VRS pain, and QOL-BREF scores also improved significantly, with higher satisfaction than controls.</div></div><div><h3>Conclusions</h3><div>The TCM Seven-Step Method combined with sleep braces significantly improves limb function, reduces pain, and enhances quality of life in breast cancer patients with lymphedema, offering an effective complementary therapy.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 272-280"},"PeriodicalIF":1.7,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146030114","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Long-term Particulate Matter Exposure and Prolonged Length of Stay After Surgery—A Novel Association","authors":"Wendelyn M. Oslock MD, MBA, MSPH ,&nbsp;Lauren Wood MPH ,&nbsp;Arundhati Sawant MBBS ,&nbsp;Nathan C. English MBChB ,&nbsp;Bayley A. Jones MD, MSPH ,&nbsp;Victor Perim MD ,&nbsp;Colin Martin MD ,&nbsp;Daniel I. Chu MD, MSPH ,&nbsp;Ruzmyn Vilcassim MS, PhD","doi":"10.1016/j.jss.2025.12.035","DOIUrl":"10.1016/j.jss.2025.12.035","url":null,"abstract":"<div><h3>Introduction</h3><div>Air pollution negatively impacts health outcomes for chronic conditions and has been linked to the development of surgically managed diseases. Its impact on surgical outcomes, however, is not well understood.</div></div><div><h3>Methods</h3><div>In this cross-sectional study, we linked institutional American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data to publicly available air pollutant data from 2006 to 2021. We compared the length of stay (LOS), 30-day complications, and readmission for patients undergoing colorectal surgery based on patient home county exposure to particulate matter &lt;2.5 μm in diameter (PM_2.5) during the year of their operation. Patient demographics, comorbidities, procedural characteristics, as well as social vulnerability were included. Statistical analysis included chi-square tests, Kruskal–Wallis rank sum, Pearson correlation, as well as logistical and linear regression modeling.</div></div><div><h3>Results</h3><div>A total of 1892 surgical encounters were linked to PM_2.5. Overall, patients were a median 58.7 years of age, 53% female, 35% Black, 45% had private insurance, and 71% came from areas with a high Social Vulnerability Index. Most procedures were elective (77%) and open (54%). The median LOS was 5 days (interquartile range, 3-9) with a 30-day readmission rate of 12% and 30% of patients experiencing at least one complication. On multivariable analysis, PM_2.5 exposure was associated with LOS. Compared to patients from areas with low PM_2.5, those from moderately elevated and high PM_2.5 had an incidence rate ratio of 1.08 [95% confidence interval: 1.04-1.13] and 1.08 [1.02-1.15], respectively.</div></div><div><h3>Conclusions</h3><div>Air pollution is associated with longer LOS following colorectal surgery. Although readmission and complication rates were not found to be statistically significant, the limited sample size warrants larger study populations.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 281-289"},"PeriodicalIF":1.7,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146030161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond the Basics of Cost-effectiveness Methods: Advanced Methods for Surgical Decision-making","authors":"Yang Zhang MScPH,&nbsp;Grace E. Ratcliff MPH,&nbsp;Jinyi Zhu PhD","doi":"10.1016/j.jss.2025.11.073","DOIUrl":"10.1016/j.jss.2025.11.073","url":null,"abstract":"<div><h3>Introduction</h3><div>As the scope and goals of health care evaluation expand, traditional cost-effectiveness analysis (CEA) methods, which typically evaluate interventions based on their cost per quality-adjusted life year gained, often fall short in capturing the real-world complexities of surgical decision-making. Building on our companion article on foundational CEA, there is an increasing need for advanced analytic tools that incorporate uncertainty, system constraints, and equity considerations.</div></div><div><h3>Methods</h3><div>In this article, we explain a curated set of advanced methods building on our companion introductory article. These include value of information analysis, discrete event simulation, and equity-informative economic evaluations (including distributional and extended CEA). For each method, we describe the underlying analytic framework, explain its relevance to real-world surgical decision-making, and illustrate its application using published examples from surgical or health policy contexts.</div></div><div><h3>Results</h3><div>These methods enhance the relevance and interpretability of economic evaluations by enabling analysts to quantify the value of future research, simulate care delivery in resource-constrained systems, and incorporate equity concerns into economic decision-making. A summary table compares the full suite of methods across both explainers for ease of reference.</div></div><div><h3>Conclusions</h3><div>Advanced CEA methods provide important tools for addressing challenges in modern surgical and policy decision-making. This explainer aims to equip surgeons and surgical health services researchers with practical insight into when and how to apply these approaches to improve the rigor, realism, and ethical relevance of economic evaluations.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 255-263"},"PeriodicalIF":1.7,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146018133","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing Racial Bias Within American Society of Anesthesiologists Classification","authors":"Michael A. Jacobs MS ,&nbsp;Brenna N. McKaig BS ,&nbsp;Susanne Schmidt PhD ,&nbsp;Paula K. Shireman MD, MBA, MS ,&nbsp;James W. Ibinson MD, PhD ,&nbsp;Jessica H. Maxwell MD, MPH ,&nbsp;Daniel E. Hall MD, MDiv, MHSc","doi":"10.1016/j.jss.2025.12.040","DOIUrl":"10.1016/j.jss.2025.12.040","url":null,"abstract":"<div><h3>Introduction</h3><div>The American Society of Anesthesiologists (ASA) classification system is widely used to evaluate surgical risk, make patient care decisions, and determine reimbursement. However, race/ethnicity bias in ASA class is largely unexplored, with potential ramifications for healthcare disparities.</div></div><div><h3>Methods</h3><div>In a retrospective cohort study of 350,187 Veterans Health Administration surgical cases and 4,051,185 non–Veterans Health Administration cases, race/ethnicity groups were matched on the components of the Risk Analysis Index, a surgical frailty measure, and preoperative acute serious conditions, conditions associated with urgent/emergent surgeries, to evaluate differences in ASA class.</div></div><div><h3>Results</h3><div>After matching, Black cases had higher ASA class <em>versus</em> White cases (adjusted odds ratios = 1.37 and 1.07, 95% confidence intervals = 1.37-1.38 and 1.04-1.09, <em>P</em> &lt; 0.001). Hispanic cases had lower ASA class <em>versus</em> White cases (adjusted odds ratios = 0.96 and 0.96, 95% confidence intervals = 0.96-0.97 and 0.93-0.99, <em>P</em> &lt; 0.001 and 0.008), though the effect changed sign in a sensitivity analysis.</div></div><div><h3>Conclusions</h3><div>ASA class varies by race/ethnicity, representing bias that could drive health disparities. Given the matching strategy used, such bias may have practical implications for patient outcomes and quality improvement. For Black patients, a higher ASA class may drive increased preoperative testing, surgical delays, and increased costs. For Hispanic patients, a lower ASA class may drive reduced preoperative screening and riskier outpatient procedures. For some purposes, the ASA class may need to be replaced with other measures of patient morbidity. For others, ASA class may need to be revised and assigned by automated systems with safeguards against race/ethnicity bias.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 264-271"},"PeriodicalIF":1.7,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146018938","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter Regarding: \"Impact of Etiology on Predictive Models for Acute Pancreatitis Severity: A Retrospective Study\".","authors":"Xingyu Huang","doi":"10.1016/j.jss.2025.11.070","DOIUrl":"https://doi.org/10.1016/j.jss.2025.11.070","url":null,"abstract":"","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146018548","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Spontaneous Splenic Ruptures: A Contemporary Systematic Review","authors":"Marti Pastak ,&nbsp;Sten Saar MD, PhD ,&nbsp;Edgar Lipping MD, PhD ,&nbsp;Peep Talving MD, PhD","doi":"10.1016/j.jss.2025.12.029","DOIUrl":"10.1016/j.jss.2025.12.029","url":null,"abstract":"<div><h3>Introduction</h3><div>Spontaneous splenic rupture (SSR) is a rare, life-threatening condition. The current study aims to provide a comprehensive recent overview of SSR.</div></div><div><h3>Methods</h3><div>A comprehensive search was performed in PubMed (MEDLINE), Google Scholar, and Scopus to identify relevant case reports and case series published during the last decade (January 1, 2015-July 1, 2025).</div></div><div><h3>Results</h3><div>We identified 351 eligible studies with 400 cases of SSR. The two most common etiologies for SSR were infectious (25.6%) and neoplastic (22.9%) conditions. Drug- or treatment-related etiologies were reported in 19% of cases, and noninfectious inflammatory conditions in 14.6%. Idiopathic SSRs accounted for 4.1% of the cases. Other less frequent, noncategorized etiologies accounted for the remaining 13.7% of the cases. Abdominal pain was the most common symptom, reported in 94.6% of the patients. Overall, 74.4% of the patients were subjected to splenectomy, followed by conservative management in 12.3%, angioembolization in 10.8%, and spleen-preserving surgery in 1.3%. The overall SSR-related mortality rate was 8.7% (95% confidence interval: 6.2%–12.1%).</div></div><div><h3>Conclusions</h3><div>Infectious and neoplastic causes comprise the most common etiologies of SSR. Compared with previous studies the rate of drug- or treatment-related etiologies has evolved, which may be related to the wider use of antiplatelet and anticoagulant drugs, particularly novel direct oral anticoagulants. The rate of angioembolization has significantly increased, whereas splenectomy numbers have declined. Neoplastic etiology and age over 50 years were associated with higher mortality on multivariate analysis. Overall, SSR-related mortality has decreased.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 249-254"},"PeriodicalIF":1.7,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146018592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond the Injury - Exploring the Foundations of Health-Related Quality of Life in Older Adults and Their Caregivers","authors":"Krista L. Haines DO, MA ,&nbsp;Carrie Dombeck MA ,&nbsp;Gi Jung Shin BA ,&nbsp;Rachel Morris MD ,&nbsp;Suresh Agarwal MD ,&nbsp;Christopher Cox MD, MPH ,&nbsp;Bryce Reeve PhD ,&nbsp;Kenneth Schmader MD ,&nbsp;Amy Corneli PhD","doi":"10.1016/j.jss.2025.12.033","DOIUrl":"10.1016/j.jss.2025.12.033","url":null,"abstract":"<div><h3>Background</h3><div>Older adults (aged ≥65 years) represent 21% of the trauma admissions in the United States, yet little is known about their health-related quality of life at baseline prior to injury. This study aimed to describe the pre-injury daily activities and social engagement of older adult trauma patients and their caregivers.</div></div><div><h3>Materials and Methods</h3><div>We conducted a longitudinal mixed-methods study including critically injured older adult trauma patients (aged ≥60) and their self-identified caregivers (aged ≥55). This manuscript reports qualitative findings from baseline semi-structured interviews with 16 patient-caregiver dyads enrolled at a single academic trauma center. Interviews were transcribed and analyzed using applied thematic analysis.</div></div><div><h3>Results</h3><div>Two themes emerged: (1) older adults maintained active and socially engaged routines before injury and (2) family relationships were a consistent source of connection and support. Prior to injury, most participants reported involvement in physically and cognitively engaging tasks, including exercise, volunteering, spiritual activities, and caregiving responsibilities. Family interactions, irrespective of frequency, provided comfort and meaning for participants.</div></div><div><h3>Conclusions</h3><div>Older adult trauma patients and caregivers engaged in a wide range of meaningful daily activities and social roles prior to injury. These findings underscore the importance of contextualizing health-related quality of life following injury within the lived experiences of older trauma patients.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 241-248"},"PeriodicalIF":1.7,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146018566","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Frailty Index Predicts Withdrawal of Life-Sustaining Therapy in Geriatric Patients With Rib Fractures","authors":"Reid Bartholomew MD ,&nbsp;Jeffery Nelson MD ,&nbsp;Saskya Byerly MD ,&nbsp;Dina M. Filiberto MD","doi":"10.1016/j.jss.2025.12.028","DOIUrl":"10.1016/j.jss.2025.12.028","url":null,"abstract":"<div><h3>Introduction</h3><div>Geriatric patients with rib fractures have a high morbidity and mortality. The 5-item–modified frailty index (mFI-5) is associated with increased complications and mortality in trauma patients. We aim to determine predictors of withdrawal of life-sustaining therapy (WDLST) in geriatric patients with rib fractures.</div></div><div><h3>Materials and methods</h3><div>Patients were stratified by WDLST and compared. We conducted a multivariable logistic regression (MLR) to determine predictors of WDLST.</div></div><div><h3>Results</h3><div>A total of 4707 patients were included, 92 (2%) patients underwent WDLST. MLR found history of advanced directive and injury severity score are associated with WDLST. On MLR, mFI-5 score of &gt;0.4 (adjusted odds ratio = 2.55, 95% confidence interval 1.31-4.96, <em>P</em> = 0.006), which is equivalent to having &gt;2 risk factors, was associated with WDLST. The WDLST cohort had higher mortality (88% <em>versus</em> 1%, <em>P</em> &lt; 0.0001).</div></div><div><h3>Conclusions</h3><div>The severity of injury and older age are associated with WDLST. The mFI-5 is a tool that may be useful to obtain earlier palliative care intervention.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 225-229"},"PeriodicalIF":1.7,"publicationDate":"2026-01-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146010137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Structured Guide to Univariate Test Selection Based on Normality, Variance Homogeneity, and Graphical Data Exploration","authors":"Javier Arredondo Montero MD, PhD","doi":"10.1016/j.jss.2025.10.053","DOIUrl":"10.1016/j.jss.2025.10.053","url":null,"abstract":"<div><h3>Introduction</h3><div>The credibility of surgical research depends on appropriate statistical methodology. However, univariate statistical tests are frequently applied inconsistently, and key assumptions—particularly normality and variance homogeneity—are often misunderstood or inadequately assessed. These methodological shortcomings can distort inference, undermine internal validity, and compromise the clinical interpretability of research findings.</div></div><div><h3>Methods</h3><div>This article presents a structured, assumption-based framework to guide univariate statistical test selection in surgical research. The approach integrates visual data exploration (histograms, Q–Q plots, violin plots) with formal assumption testing, including the Shapiro-Wilk test for normality and Levene’s test for variance homogeneity, explicitly addressing the sample-size dependence of normality tests, which may lack power in small samples and overdetect trivial deviations in large datasets. The framework addresses common pitfalls related to distributional shape (including bimodality), outliers, data transformation, and the treatment of ordinal variables. When standard assumptions are violated, the framework discusses robust alternatives—such as Welch’s tests, nonparametric approaches, and modern robust estimators—to preserve valid and interpretable statistical inference.</div></div><div><h3>Results</h3><div>The proposed framework yields a practical decision algorithm, supported by summary tables and illustrative figures, that links data characteristics to appropriate univariate tests and summary measures. By emphasizing combined visual and statistical assessment, the framework clarifies when parametric, robust parametric, or nonparametric methods are most suitable and highlights frequent sources of misinterpretation in the surgical literature.</div></div><div><h3>Conclusions</h3><div>An assumption-driven approach to univariate test selection enhances statistical rigor, transparency, and reproducibility in surgical research. By aligning test choice and data summarization with underlying distributional properties, this framework supports more reliable statistical inference and clinically meaningful interpretation of univariate analyses.</div></div>","PeriodicalId":17030,"journal":{"name":"Journal of Surgical Research","volume":"318 ","pages":"Pages 230-240"},"PeriodicalIF":1.7,"publicationDate":"2026-01-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146010210","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}