Safety-net hospitals have demonstrated comparable surgical outcomes to non–safety-net hospitals across various populations, highlighting their potential as regional care centers for diagnosis and treatment of time-sensitive conditions. This study evaluated the impact of safety-net status on clinical and financial outcomes following type A aortic dissection repair.
Methods
The National Inpatient Sample was queried for years 2017 to 2022 to identify adults with a diagnosis of type A aortic dissection. Safety-net hospitals were defined as institutions in the top quartile for the annual proportion of patients with Medicaid or no insurance. Multivariable regression models were used to assess the association of safety-net status with outcomes of interest including in-hospital mortality, perioperative complications, and resource utilization.
Results
Of an estimated 25,936 patients with type A aortic dissection undergoing aortic interventions, 7,055 (27.2%) were managed at safety-net hospitals. Compared with non–safety-net hospitals, patients at safety-net hospitals had a similar distribution of age, sex, and Elixhauser Comorbidity Index. After excluding patients who did not receive aortic surgical interventions, the proportion of cases transferred into safety-net hospitals increased from 27.5% to 48.1%. Following adequate risk adjustment, safety-net hospitals did not alter the odds of in-hospital mortality (adjusted odds ratio 1.15, 95% confidence interval 0.72–1.83, reference: non–safety-net hospitals). Notably, higher type A aortic dissection center volume was linked with reduced odds of death, independent of safety-net status (adjusted odds ratio 0.94, 95% confidence interval 0.91–0.97).
Conclusions
Our findings suggest that safety-net hospitals yield comparable perioperative outcomes to non–safety-net hospitals in management of type A aortic dissection outcomes. Future studies are warranted to further investigate the impact of safety-net status on long-term outcomes, as well as rates of readmission and reoperation.
{"title":"Surgical repair of type A aortic dissection at safety-net hospitals across the United States","authors":"Dariush Yalzadeh BS , Kevin Tabibian BS , Sara Sakowitz MD , Barzin Badiee BS , Jeffrey Balian BS , Giselle Porter BS , Peter Downey MD , Peyman Benharash MD","doi":"10.1016/j.surg.2025.110040","DOIUrl":"10.1016/j.surg.2025.110040","url":null,"abstract":"<div><h3>Background</h3><div>Safety-net hospitals have demonstrated comparable surgical outcomes to non–safety-net hospitals across various populations, highlighting their potential as regional care centers for diagnosis and treatment of time-sensitive conditions. This study evaluated the impact of safety-net status on clinical and financial outcomes following type A aortic dissection repair.</div></div><div><h3>Methods</h3><div>The National Inpatient Sample was queried for years 2017 to 2022 to identify adults with a diagnosis of type A aortic dissection. Safety-net hospitals were defined as institutions in the top quartile for the annual proportion of patients with Medicaid or no insurance. Multivariable regression models were used to assess the association of safety-net status with outcomes of interest including in-hospital mortality, perioperative complications, and resource utilization.</div></div><div><h3>Results</h3><div>Of an estimated 25,936 patients with type A aortic dissection undergoing aortic interventions, 7,055 (27.2%) were managed at safety-net hospitals. Compared with non–safety-net hospitals, patients at safety-net hospitals had a similar distribution of age, sex, and Elixhauser Comorbidity Index. After excluding patients who did not receive aortic surgical interventions, the proportion of cases transferred into safety-net hospitals increased from 27.5% to 48.1%. Following adequate risk adjustment, safety-net hospitals did not alter the odds of in-hospital mortality (adjusted odds ratio 1.15, 95% confidence interval 0.72–1.83, reference: non–safety-net hospitals). Notably, higher type A aortic dissection center volume was linked with reduced odds of death, independent of safety-net status (adjusted odds ratio 0.94, 95% confidence interval 0.91–0.97).</div></div><div><h3>Conclusions</h3><div>Our findings suggest that safety-net hospitals yield comparable perioperative outcomes to non–safety-net hospitals in management of type A aortic dissection outcomes. Future studies are warranted to further investigate the impact of safety-net status on long-term outcomes, as well as rates of readmission and reoperation.</div></div>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":"191 ","pages":"Article 110040"},"PeriodicalIF":2.7,"publicationDate":"2026-01-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145918503","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Although most adrenal incidentalomas are benign, many are identified by single-phase contrast-enhanced computed tomography, which is unreliable for excluding malignancy. Virtual noncontrast computed tomography is a newer modality with the potential to better characterize adrenal nodules.
Methods
Virtual noncontrast computed tomography of adrenal nodules with available reference standard of true noncontrast computed tomography were identified (2016–2024). Images were evaluated for nodule characteristics including Hounsfield unit attenuation and variability. Nodules were classified as benign (≤10 Hounsfield units) or indeterminate/suspicious (>10 Hounsfield units) by true noncontrast computed tomography. Hounsfield units were compared between virtual noncontrast computed tomography and true noncontrast computed tomography. Variability in attenuation measurements was compared by evaluating Hounsfield unit differences 1 slice up and down from the chosen mid-depth image. Receiver operating characteristic analysis was used to define optimal virtual noncontrast computed tomography accuracy thresholds.
Results
After excluding 5 adrenal nodules due to suboptimal imaging, 67 nodules were identified. Based on true noncontrast computed tomography Hounsfield units, 23 nodules (34.3%) were benign, and 44 (65.7%) were indeterminate/suspicious. Hounsfield unit measurements for each nodule exhibited wide variability by both virtual noncontrast computed tomography and true noncontrast computed tomography. Virtual noncontrast computed tomography and true noncontrast computed tomography were significantly correlated with moderate effect size (Pearson coefficient 0.69, P < .001). Conflicting impressions occurred for 6 nodules (9.0%). Overall, virtual noncontrast computed tomography exhibited outstanding discrimination between benign and indeterminate/suspicious nodules (area under the curve 0.94). Maintaining a threshold of ≤10 Hounsfield units achieved 93% sensitivity, 76% specificity, and 84% negative predictive value, whereas ≤7 Hounsfield units achieved 100% negative predictive value. The functional utility of virtual noncontrast computed tomography as a rule-out test applied to 16% of nodules.
Conclusion
Despite wide variability in Hounsfield unit measurements, adrenal nodules are well defined by both virtual noncontrast computed tomography and true noncontrast computed tomography. Well-reconstructed virtual noncontrast computed tomography images can accurately rule out malignancy in selected patients, potentially obviating the need for additional imaging.
{"title":"Can virtual noncontrast computed tomography improve the diagnostic uncertainty of adrenal incidentalomas?","authors":"Likolani Arthurs MD , Max Schumm MD , Paige Curcio BS , Zoran Gajic MD , Robert Petrocelli MD , Myles Taffel MD , Rajam Raghunathan MD, PhD , Olivia McAllister-Nevins BA , Cadence Chan BS , Kepal Patel MD , Rachel Liou MD , Jason Prescott MD, PhD , John Allendorf MD , Insoo Suh MD","doi":"10.1016/j.surg.2025.110038","DOIUrl":"10.1016/j.surg.2025.110038","url":null,"abstract":"<div><h3>Background</h3><div>Although most adrenal incidentalomas are benign, many are identified by single-phase contrast-enhanced computed tomography, which is unreliable for excluding malignancy. Virtual noncontrast computed tomography is a newer modality with the potential to better characterize adrenal nodules.</div></div><div><h3>Methods</h3><div>Virtual noncontrast computed tomography of adrenal nodules with available reference standard of true noncontrast computed tomography were identified (2016–2024). Images were evaluated for nodule characteristics including Hounsfield unit attenuation and variability. Nodules were classified as benign (≤10 Hounsfield units) or indeterminate/suspicious (>10 Hounsfield units) by true noncontrast computed tomography. Hounsfield units were compared between virtual noncontrast computed tomography and true noncontrast computed tomography. Variability in attenuation measurements was compared by evaluating Hounsfield unit differences 1 slice up and down from the chosen mid-depth image. Receiver operating characteristic analysis was used to define optimal virtual noncontrast computed tomography accuracy thresholds.</div></div><div><h3>Results</h3><div>After excluding 5 adrenal nodules due to suboptimal imaging, 67 nodules were identified. Based on true noncontrast computed tomography Hounsfield units, 23 nodules (34.3%) were benign, and 44 (65.7%) were indeterminate/suspicious. Hounsfield unit measurements for each nodule exhibited wide variability by both virtual noncontrast computed tomography and true noncontrast computed tomography. Virtual noncontrast computed tomography and true noncontrast computed tomography were significantly correlated with moderate effect size (Pearson coefficient 0.69, <em>P</em> < .001). Conflicting impressions occurred for 6 nodules (9.0%). Overall, virtual noncontrast computed tomography exhibited outstanding discrimination between benign and indeterminate/suspicious nodules (area under the curve 0.94). Maintaining a threshold of ≤10 Hounsfield units achieved 93% sensitivity, 76% specificity, and 84% negative predictive value, whereas ≤7 Hounsfield units achieved 100% negative predictive value. The functional utility of virtual noncontrast computed tomography as a rule-out test applied to 16% of nodules.</div></div><div><h3>Conclusion</h3><div>Despite wide variability in Hounsfield unit measurements, adrenal nodules are well defined by both virtual noncontrast computed tomography and true noncontrast computed tomography. Well-reconstructed virtual noncontrast computed tomography images can accurately rule out malignancy in selected patients, potentially obviating the need for additional imaging.</div></div>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":"191 ","pages":"Article 110038"},"PeriodicalIF":2.7,"publicationDate":"2026-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145918500","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-05DOI: 10.1016/j.surg.2025.110046
Huizhong Shi MD , Xiaoyu Yang MM , Xie Song MD , Zhengjian Wang MD , Chaoqun Ma MD , Qingqiang Ni MD , Shunzhen Zheng MD , Fangfeng Liu MD , Hong Chang MD
Background
Solid pseudopapillary tumor of the pancreas is a rare low-grade malignant neoplasm. The clinical relevance of lymph node dissection during surgical resection remains controversial due to limited evidence.
Method
We retrospectively reviewed the clinical records of patients with solid pseudopapillary tumor of the pancreas who underwent surgery at Shandong Provincial Hospital between 2005 and 2024. Lymph node status and clinicopathologic characteristics were analyzed. The patients were divided into 2 groups according to whether the lymph nodes were cleared or not, and the association between lymph node dissection and postoperative outcomes was evaluated.
Result
A total of 351 patients were included, with a male to female ratio of 63:288. Among 109 patients who underwent lymph node dissection, no lymph node metastasis was identified. Tumor location, age at diagnosis, and clinical presentation did not differ between sexes; however, female patients had significantly larger tumors than male patients (5.74 ± 3.46 cm vs 4.57 ± 2.82 cm, P = .013). A total of 182 patients were followed up after surgery, with a 41-month median follow-up time, including 60 patients with lymph node dissection and 122 patients without lymph node dissection. No tumor recurrence or metastasis occurred in either group, and the complication rates were comparable.
Conclusion
In the absence of radiologic or intraoperative suspicion of nodal involvement, routine lymph node dissection may be unnecessary in solid pseudopapillary tumor of the pancreas surgery.
背景：胰腺实性假乳头状瘤是一种罕见的低度恶性肿瘤。由于证据有限，手术切除时淋巴结清扫的临床意义仍然存在争议。方法：回顾性分析2005年至2024年在山东省立医院行胰腺实性假乳头状瘤手术治疗的临床资料。分析淋巴结状况及临床病理特征。根据淋巴结清扫情况将患者分为两组，评估淋巴结清扫与术后预后的关系。结果：共纳入351例患者，男女比例为63:288。在109例接受淋巴结清扫的患者中，未发现淋巴结转移。肿瘤的位置、诊断时的年龄和临床表现在性别之间没有差异；女性患者肿瘤明显大于男性患者（5.74±3.46 cm vs 4.57±2.82 cm, P = 0.013）。术后随访182例，中位随访时间41个月，其中淋巴结清扫60例，未淋巴结清扫122例。两组均未发生肿瘤复发或转移，并发症发生率相当。结论：在没有影像学或术中怀疑淋巴结受累的情况下，胰腺实性假乳头状瘤可能不需要常规淋巴结清扫。
{"title":"Necessity of lymph node dissection in solid pseudopapillary tumor of the pancreas: A retrospective analysis","authors":"Huizhong Shi MD , Xiaoyu Yang MM , Xie Song MD , Zhengjian Wang MD , Chaoqun Ma MD , Qingqiang Ni MD , Shunzhen Zheng MD , Fangfeng Liu MD , Hong Chang MD","doi":"10.1016/j.surg.2025.110046","DOIUrl":"10.1016/j.surg.2025.110046","url":null,"abstract":"<div><h3>Background</h3><div>Solid pseudopapillary tumor of the pancreas is a rare low-grade malignant neoplasm. The clinical relevance of lymph node dissection during surgical resection remains controversial due to limited evidence.</div></div><div><h3>Method</h3><div>We retrospectively reviewed the clinical records of patients with solid pseudopapillary tumor of the pancreas who underwent surgery at Shandong Provincial Hospital between 2005 and 2024. Lymph node status and clinicopathologic characteristics were analyzed. The patients were divided into 2 groups according to whether the lymph nodes were cleared or not, and the association between lymph node dissection and postoperative outcomes was evaluated.</div></div><div><h3>Result</h3><div>A total of 351 patients were included, with a male to female ratio of 63:288. Among 109 patients who underwent lymph node dissection, no lymph node metastasis was identified. Tumor location, age at diagnosis, and clinical presentation did not differ between sexes; however, female patients had significantly larger tumors than male patients (5.74 ± 3.46 cm vs 4.57 ± 2.82 cm, <em>P</em> = .013). A total of 182 patients were followed up after surgery, with a 41-month median follow-up time, including 60 patients with lymph node dissection and 122 patients without lymph node dissection. No tumor recurrence or metastasis occurred in either group, and the complication rates were comparable.</div></div><div><h3>Conclusion</h3><div>In the absence of radiologic or intraoperative suspicion of nodal involvement, routine lymph node dissection may be unnecessary in solid pseudopapillary tumor of the pancreas surgery.</div></div>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":"191 ","pages":"Article 110046"},"PeriodicalIF":2.7,"publicationDate":"2026-01-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145913045","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-02DOI: 10.1016/j.surg.2025.109816
Alexandra Z. Agathis MD, Jeanne Wu MPH, Celia M. Divino MD
Background
Since its introduction, the Modified Five-Factor Frailty Index (mFI-5) has been widely applied across subspecialties using the National Surgical Quality Improvement Program (NSQIP) database. Although the mFI-5 index is predictive, it predominantly focuses on comorbidities and does not represent functional frailty aspects. We sought to apply the new Modified Four-Factor Functional Frailty Index (mFF-4) to a colorectal population.
Methods
This retrospective study using NSQIP 2021-2022 includes patients >75 years of age who underwent colon and rectal surgery. The mFF-4 frailty index is scored by adding one point for each present variable including history of falls, dementia, poor nutritional status (body mass index <18.5), and nonindependent functional status. Patients were stratified into frailty groups: mFF-4=0, 1, 2+. Univariate and multivariate regressions were performed to assess 30-day postoperative outcomes. Area under the curve (AUC) and Akaike information criterion (AIC) values assessed predictability of the mFF-4 model, in reference to mFI-5.
Results
Our sample of n=27,875 included 21,573 in the mFF-4=0 (77.4%), 4,601 in mFF-4=1 (16.5%), and 1,701 in mFF-4=2+ (6.1%). The mFF-4 multivariate regressions had less error (lower AICs by >2) and higher AUCs (most >0.7) than the mFI-5 for predicting mortality, pneumonia, ventilator use >48 hours, delirium, length of stay >30 days, and nonhome discharge destination. For these complications, patients with high frailty (mFF-4=2+) had statistically significant odds ratios >2.0.
Conclusion
This new frailty index, focused on functional capabilities, is more encompassing of phenotypical frailty and is more predictive than the mFI-5. This new scale will help risk-stratify our aging colorectal population.
自引入以来，修正五因子衰弱指数（mFI-5）已在国家外科质量改进计划（NSQIP）数据库中广泛应用于亚专科。虽然mFI-5指数具有预测性，但它主要关注合并症，并不代表功能衰弱方面。我们试图将新的修正四因素功能脆弱指数（mFF-4）应用于结直肠人群。方法采用NSQIP 2021-2022进行回顾性研究，纳入75岁接受结肠和直肠手术的患者。mFF-4虚弱指数是通过为每一个当前变量加1分来评分的，这些变量包括跌倒史、痴呆、营养状况不良（体重指数18.5）和非独立的功能状态。将患者分为虚弱组：mFF-4=0、1、2+。采用单因素和多因素回归评估术后30天的预后。曲线下面积（AUC）和赤池信息准则（Akaike information criterion， AIC）值评价了mFF-4模式参考mFI-5的可预测性。结果样本n= 27875例，其中mFF-4=0组21573例（77.4%），mFF-4=1组4601例（16.5%），mFF-4=2+组1701例（6.1%）。与mFI-5相比，mFF-4多变量回归在预测死亡率、肺炎、呼吸机使用时间（48小时）、谵妄、住院时间（30天）和非家庭出院目的地方面的误差更小（AICs低>；2）， auc高>；0.7。对于这些并发症，高虚弱患者（mFF-4=2+）的优势比为2.0，具有统计学意义。结论与mFI-5相比，这一关注功能能力的新脆弱性指数更能涵盖表型脆弱性，并具有更强的预测性。这种新的量表将有助于对结直肠癌老年人群进行风险分层。
{"title":"The new modified four-factor functional frailty index (mFF-4) in colorectal surgery: A retrospective cohort study","authors":"Alexandra Z. Agathis MD, Jeanne Wu MPH, Celia M. Divino MD","doi":"10.1016/j.surg.2025.109816","DOIUrl":"10.1016/j.surg.2025.109816","url":null,"abstract":"<div><h3>Background</h3><div>Since its introduction, the Modified Five-Factor Frailty Index (mFI-5) has been widely applied across subspecialties using the National Surgical Quality Improvement Program (NSQIP) database. Although the mFI-5 index is predictive, it predominantly focuses on comorbidities and does not represent functional frailty aspects. We sought to apply the new Modified Four-Factor Functional Frailty Index (mFF-4) to a colorectal population.</div></div><div><h3>Methods</h3><div>This retrospective study using NSQIP 2021-2022 includes patients >75 years of age who underwent colon and rectal surgery. The mFF-4 frailty index is scored by adding one point for each present variable including history of falls, dementia, poor nutritional status (body mass index <18.5), and nonindependent functional status. Patients were stratified into frailty groups: mFF-4=0, 1, 2+. Univariate and multivariate regressions were performed to assess 30-day postoperative outcomes. Area under the curve (AUC) and Akaike information criterion (AIC) values assessed predictability of the mFF-4 model, in reference to mFI-5.</div></div><div><h3>Results</h3><div>Our sample of n=27,875 included 21,573 in the mFF-4=0 (77.4%), 4,601 in mFF-4=1 (16.5%), and 1,701 in mFF-4=2+ (6.1%). The mFF-4 multivariate regressions had less error (lower AICs by >2) and higher AUCs (most >0.7) than the mFI-5 for predicting mortality, pneumonia, ventilator use >48 hours, delirium, length of stay >30 days, and nonhome discharge destination. For these complications, patients with high frailty (mFF-4=2+) had statistically significant odds ratios >2.0.</div></div><div><h3>Conclusion</h3><div>This new frailty index, focused on functional capabilities, is more encompassing of phenotypical frailty and is more predictive than the mFI-5. This new scale will help risk-stratify our aging colorectal population.</div></div>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":"191 ","pages":"Article 109816"},"PeriodicalIF":2.7,"publicationDate":"2026-01-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145876920","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-24DOI: 10.1016/j.surg.2025.109927
Kyle R Stephens, Megan Wilson, Manting Xu, Kelly M McMasters, Nicolas Ajkay
Background: The Sentinel Node versus Observation after Axillary Ultrasound (SOUND) trial suggested that sentinel lymph node biopsy could be omitted in small breast cancers with negative axillary ultrasound, despite 13.7% of preoperative axillary ultrasound being falsely negative when validated on sentinel lymph node biopsy. Our aim was to evaluate the performance of axillary ultrasound in our patient population using SOUND trial criteria.
Methods: A retrospective review was performed between 2015 and 2023 of SOUND trial-eligible patients. Two subgroup univariate analyses, pathologic T classification group and molecular subgroup, were performed comparing preoperative axillary ultrasound performance metrics, demographics, and tumor characteristics. Multivariate analysis was performed to predict false-negative axillary ultrasound.
Results: 263 patients were SOUND trial-eligible, whereas only 223 had a sentinel lymph node biopsy. Overall, this study was similar to the SOUND trial in terms of demographics and tumor characteristics, as well as false-negative axillary ultrasound (13.5%). The remaining performance metrics of preoperative axillary ultrasound were sensitivity (23%), specificity (94%), positive predictive value (37%), and negative predictive value (88%). There were significant differences in specificity (P = .005) among molecular subgroups (Luminal/HER2-, HER2/neu+, and triple-negative). False-negative axillary ultrasound was significantly different (P value .015) when comparing pathologic T group (31% T2, 13% T1c, 11% T1b, and 0% T1mi/T1a). Multivariate analysis demonstrated that each 1-cm increase in tumor size was associated with 46% higher odds of a false-negative axillary ultrasound (odds ratio 1.46 per cm, P = .018).
Conclusions: The high specificity and negative predictive value of axillary ultrasound suggests that foregoing sentinel lymph node biopsy in small breast cancers with negative preoperative AUS is reasonable, especially in patients with T1mi/T1a and T1b tumors.
背景：前哨淋巴结与腋窝超声后观察（SOUND）试验表明，在腋窝超声阴性的小乳腺癌中，可以省略前哨淋巴结活检，尽管13.7%的术前腋窝超声在前哨淋巴结活检中被证实为假阴性。我们的目的是使用SOUND试验标准评估腋窝超声在我们患者群体中的表现。方法：对2015年至2023年间符合SOUND试验条件的患者进行回顾性分析。两个亚组进行单变量分析，病理T分类组和分子亚组，比较术前腋窝超声表现指标、人口统计学和肿瘤特征。采用多变量分析预测腋窝超声假阴性。结果：263例患者符合SOUND试验条件，而只有223例患者进行了前哨淋巴结活检。总体而言，本研究在人口统计学和肿瘤特征以及腋窝超声假阴性（13.5%）方面与SOUND试验相似。术前腋窝超声的其余性能指标为敏感性（23%）、特异性（94%）、阳性预测值（37%）和阴性预测值（88%）。分子亚组（Luminal/HER2-、HER2/neu+和三阴性）特异性差异有统计学意义（P = 0.005）。腋窝超声假阴性与腋窝超声假阴性差异有统计学意义(P值。病理T组（t1组31%，T1c组13%，T1b组11%，T1mi/T1a组0%）。多因素分析表明，肿瘤大小每增加1厘米，腋窝超声假阴性的几率增加46%（比值比为1.46 / cm, P = 0.018）。结论：腋窝超声的高特异性和阴性预测值提示术前AUS阴性的小乳腺癌前哨淋巴结活检是合理的，特别是对于T1mi/T1a和T1b肿瘤患者。
{"title":"Evaluation of axillary ultrasound performance on Sentinel Node versus Observation after Axillary Ultrasound (SOUND) trial-eligible patients.","authors":"Kyle R Stephens, Megan Wilson, Manting Xu, Kelly M McMasters, Nicolas Ajkay","doi":"10.1016/j.surg.2025.109927","DOIUrl":"https://doi.org/10.1016/j.surg.2025.109927","url":null,"abstract":"<p><strong>Background: </strong>The Sentinel Node versus Observation after Axillary Ultrasound (SOUND) trial suggested that sentinel lymph node biopsy could be omitted in small breast cancers with negative axillary ultrasound, despite 13.7% of preoperative axillary ultrasound being falsely negative when validated on sentinel lymph node biopsy. Our aim was to evaluate the performance of axillary ultrasound in our patient population using SOUND trial criteria.</p><p><strong>Methods: </strong>A retrospective review was performed between 2015 and 2023 of SOUND trial-eligible patients. Two subgroup univariate analyses, pathologic T classification group and molecular subgroup, were performed comparing preoperative axillary ultrasound performance metrics, demographics, and tumor characteristics. Multivariate analysis was performed to predict false-negative axillary ultrasound.</p><p><strong>Results: </strong>263 patients were SOUND trial-eligible, whereas only 223 had a sentinel lymph node biopsy. Overall, this study was similar to the SOUND trial in terms of demographics and tumor characteristics, as well as false-negative axillary ultrasound (13.5%). The remaining performance metrics of preoperative axillary ultrasound were sensitivity (23%), specificity (94%), positive predictive value (37%), and negative predictive value (88%). There were significant differences in specificity (P = .005) among molecular subgroups (Luminal/HER2-, HER2/neu+, and triple-negative). False-negative axillary ultrasound was significantly different (P value .015) when comparing pathologic T group (31% T2, 13% T1c, 11% T1b, and 0% T1mi/T1a). Multivariate analysis demonstrated that each 1-cm increase in tumor size was associated with 46% higher odds of a false-negative axillary ultrasound (odds ratio 1.46 per cm, P = .018).</p><p><strong>Conclusions: </strong>The high specificity and negative predictive value of axillary ultrasound suggests that foregoing sentinel lymph node biopsy in small breast cancers with negative preoperative AUS is reasonable, especially in patients with T1mi/T1a and T1b tumors.</p>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":" ","pages":"109927"},"PeriodicalIF":2.7,"publicationDate":"2025-12-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145834859","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-22DOI: 10.1016/j.surg.2025.110023
Chase J Wehrle, Pranav Kumar, Abby Gross, Breanna Perlmutter, Jenny Chang, Antonio Giusepucci, Robert Naples, Kathryn Stackhouse, John McMichael, Samer Naffouje, Daniel Joyce, Robert Simon, Toms Augustin, R Matthew Walsh
Introduction: Clinical practice guidelines for intraductal papillary mucinous neoplasms are based on expert opinion because of paucity of clinical evidence. We aim to establish the data-driven correlation between worrisome/high-risk/clinically relevant progression features and high-risk pathology on fine needle aspiration or resection.
Design: A prospectively maintained database (1997-2023) of presumed pancreatic cystic neoplasms was queried for intraductal papillary mucinous neoplasm with potentially concerning feature(s) per Fukuoka guidelines. Association and predictive power of specific features was examined via logistic mixed effects modeling and least absolute shrinkage and selection operator regression.
Results: Of the 2,686 patients diagnosed with intraductal papillary mucinous neoplasms, 460 (17.1%) had a feature of clinically relevant progression. Median follow-up was 7.1 years (interquartile range 2.99-11.9). Most (n = 365; 79%) were offered pancreatic resection with 230 (63%) undergoing resection. Sixty-nine (15.6%) developed invasive carcinoma. Endoscopic ultrasonography-guided cytology at diagnosis demonstrated a sensitivity of 28.4% (95% confidence interval 18.0%-40.7%) and specificity 98.9% (97.2%-99.7%) for high-risk pathology. Endoscopic ultrasonography-guided cytology after clinically relevant progression demonstrated a specificity of 100% (95% confidence interval 92.1%-100%) and sensitivity 16.1% (5.5%-33.7%).On mixed effects modeling, enhancing nodule (odds ratio 24.6, 95% confidence interval 6.58-91.74), main pancreatic duct involvement (odds ratio 4.77, 95% confidence interval 1.18-14.05), and symptoms (hazard ratio 12.139, 95% confidence interval 1.786-82.48) predicted high-risk pathology; other features, including size or size growth, did not (conditional pseudo-R2 = 0.218, marginal = 0.243). On least absolute shrinkage and selection operator analysis, enhancing nodule was the strongest predictor of both high-risk pathology and invasive carcinoma followed by main pancreatic duct dilatation and thick cyst wall. Age, body mass index, cyst size, and rate of size growth all had coefficients converging to zero.
Conclusion: Enhancing nodule and any degree of main duct dilatation in an intraductal papillary mucinous neoplasm portend a high risk of malignant pathology, whereas cyst size and growth rate notably did not. These data should aid clinical management and might inform future practice guidelines.
{"title":"Predicting high-risk pathology across the spectrum of resected and surveilled intraductal papillary mucinous neoplasms: A cohort study.","authors":"Chase J Wehrle, Pranav Kumar, Abby Gross, Breanna Perlmutter, Jenny Chang, Antonio Giusepucci, Robert Naples, Kathryn Stackhouse, John McMichael, Samer Naffouje, Daniel Joyce, Robert Simon, Toms Augustin, R Matthew Walsh","doi":"10.1016/j.surg.2025.110023","DOIUrl":"https://doi.org/10.1016/j.surg.2025.110023","url":null,"abstract":"<p><strong>Introduction: </strong>Clinical practice guidelines for intraductal papillary mucinous neoplasms are based on expert opinion because of paucity of clinical evidence. We aim to establish the data-driven correlation between worrisome/high-risk/clinically relevant progression features and high-risk pathology on fine needle aspiration or resection.</p><p><strong>Design: </strong>A prospectively maintained database (1997-2023) of presumed pancreatic cystic neoplasms was queried for intraductal papillary mucinous neoplasm with potentially concerning feature(s) per Fukuoka guidelines. Association and predictive power of specific features was examined via logistic mixed effects modeling and least absolute shrinkage and selection operator regression.</p><p><strong>Results: </strong>Of the 2,686 patients diagnosed with intraductal papillary mucinous neoplasms, 460 (17.1%) had a feature of clinically relevant progression. Median follow-up was 7.1 years (interquartile range 2.99-11.9). Most (n = 365; 79%) were offered pancreatic resection with 230 (63%) undergoing resection. Sixty-nine (15.6%) developed invasive carcinoma. Endoscopic ultrasonography-guided cytology at diagnosis demonstrated a sensitivity of 28.4% (95% confidence interval 18.0%-40.7%) and specificity 98.9% (97.2%-99.7%) for high-risk pathology. Endoscopic ultrasonography-guided cytology after clinically relevant progression demonstrated a specificity of 100% (95% confidence interval 92.1%-100%) and sensitivity 16.1% (5.5%-33.7%).On mixed effects modeling, enhancing nodule (odds ratio 24.6, 95% confidence interval 6.58-91.74), main pancreatic duct involvement (odds ratio 4.77, 95% confidence interval 1.18-14.05), and symptoms (hazard ratio 12.139, 95% confidence interval 1.786-82.48) predicted high-risk pathology; other features, including size or size growth, did not (conditional pseudo-R<sup>2</sup> = 0.218, marginal = 0.243). On least absolute shrinkage and selection operator analysis, enhancing nodule was the strongest predictor of both high-risk pathology and invasive carcinoma followed by main pancreatic duct dilatation and thick cyst wall. Age, body mass index, cyst size, and rate of size growth all had coefficients converging to zero.</p><p><strong>Conclusion: </strong>Enhancing nodule and any degree of main duct dilatation in an intraductal papillary mucinous neoplasm portend a high risk of malignant pathology, whereas cyst size and growth rate notably did not. These data should aid clinical management and might inform future practice guidelines.</p>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":" ","pages":"110023"},"PeriodicalIF":2.7,"publicationDate":"2025-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145820782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-22DOI: 10.1016/j.surg.2025.109974
Meredith Essandoh, Michael Chaney, Alain Elian, Saad Shebrain
Introduction: The ability to operate autonomously is one of the most desirable traits surgical residents seek to obtain by the end of their training. This study assesses the relationship between autonomy and intraoperative teaching as graded by faculty and residents.
Methods: We retrospectively analyzed intraoperative evaluations completed by general and subspecialty surgical faculty for general surgery residents between July 2014 and June 2024 using the Global Rating Scale of Operative Performance and the Zwisch autonomy scale. Both faculty and residents assessed autonomy and intraoperative teaching. Correlation analyses examined the relationship between autonomy scores as rated by faculty and as rated by residents, and the association between intraoperative teaching and autonomy.
Results: A total of 2,338 elective procedures were independently evaluated to assess resident's performance by 53 faculty (faculty evaluation) and 70 residents (self-evaluation) at various postgraduate years. Commonly evaluated procedures included hernia repairs, cholecystectomies, colorectal and anal, breast, and soft tissue. Faculty-assigned teaching and autonomy scores were moderately positively correlated (r = 0.45, P < .001), as were resident self-assessed teaching and autonomy scores (r = 0.37, P < .001). A moderate correlation was found between faculty and resident autonomy scores (r = 0.44, P < .001), whereas the correlation between faculty and resident intraoperative teaching scores was weak (r = 0.13, P < .001). A paired samples t test was used to compare the means of scores as assessed by faculty and residents.
Conclusions: Faculty and resident assessments reveal strong internal correlations between autonomy and teaching, but notable discordance exists in perceived intraoperative teaching, highlighting the need to clarify how both groups assess these skills.
自主操作的能力是外科住院医师在培训结束时寻求获得的最理想的特征之一。本研究评估自主与术中教学之间的关系，并以教师和住院医师为评分标准。方法：回顾性分析2014年7月至2024年6月由普通外科和亚专科外科医师完成的普外科住院医师术中评估，采用全球手术表现评定量表和Zwisch自主量表。教师和住院医师都对自主性和术中教学进行了评估。相关分析检验了教师评分和住院医师评分之间的关系，以及术中教学与自主权之间的关系。结果：共有2,338个选修程序被独立评估，以评估住院医师在各个研究生年的表现，由53名教师（教师评估）和70名住院医师（自我评估）。通常评估的手术包括疝气修补、胆囊切除术、结直肠和肛门、乳房和软组织。教师分配的教学和自主得分呈中度正相关（r = 0.45, P < .001），住院医师自我评估的教学和自主得分也呈中度正相关（r = 0.37, P < .001）。教师与住院医师自主性评分有中等相关性（r = 0.44, P < .001），教师与住院医师术中教学评分相关性较弱（r = 0.13, P < .001）。配对样本t检验用于比较教师和住院医师评估的得分均值。结论：教师和住院医师的评估显示自主与教学之间存在很强的内在相关性，但术中教学存在明显的不一致，强调需要澄清两组如何评估这些技能。
{"title":"Autonomy and intraoperative teaching from faculty and resident perspectives.","authors":"Meredith Essandoh, Michael Chaney, Alain Elian, Saad Shebrain","doi":"10.1016/j.surg.2025.109974","DOIUrl":"https://doi.org/10.1016/j.surg.2025.109974","url":null,"abstract":"<p><strong>Introduction: </strong>The ability to operate autonomously is one of the most desirable traits surgical residents seek to obtain by the end of their training. This study assesses the relationship between autonomy and intraoperative teaching as graded by faculty and residents.</p><p><strong>Methods: </strong>We retrospectively analyzed intraoperative evaluations completed by general and subspecialty surgical faculty for general surgery residents between July 2014 and June 2024 using the Global Rating Scale of Operative Performance and the Zwisch autonomy scale. Both faculty and residents assessed autonomy and intraoperative teaching. Correlation analyses examined the relationship between autonomy scores as rated by faculty and as rated by residents, and the association between intraoperative teaching and autonomy.</p><p><strong>Results: </strong>A total of 2,338 elective procedures were independently evaluated to assess resident's performance by 53 faculty (faculty evaluation) and 70 residents (self-evaluation) at various postgraduate years. Commonly evaluated procedures included hernia repairs, cholecystectomies, colorectal and anal, breast, and soft tissue. Faculty-assigned teaching and autonomy scores were moderately positively correlated (r = 0.45, P < .001), as were resident self-assessed teaching and autonomy scores (r = 0.37, P < .001). A moderate correlation was found between faculty and resident autonomy scores (r = 0.44, P < .001), whereas the correlation between faculty and resident intraoperative teaching scores was weak (r = 0.13, P < .001). A paired samples t test was used to compare the means of scores as assessed by faculty and residents.</p><p><strong>Conclusions: </strong>Faculty and resident assessments reveal strong internal correlations between autonomy and teaching, but notable discordance exists in perceived intraoperative teaching, highlighting the need to clarify how both groups assess these skills.</p>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":" ","pages":"109974"},"PeriodicalIF":2.7,"publicationDate":"2025-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145820717","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-19DOI: 10.1016/j.surg.2025.110022
Jessica M Delamater, Gary H Danton, Larisa Shagabayeva, Luciana Tito Bustillos, Michael D Cobler-Lichter, Brianna L Collie, Nicole B Lyons, Brandon M Parker, Paul J Wetstein, Jonathan P Meizoso, Nicholas Namias, Kenneth G Proctor, Edward B Lineen
Background: Autopsies are the gold standard for determining traumatic deaths causes, but rates have been decreasing. Postmortem computed tomography is an alternative; however, its utility and feasibility in patients who have undergone interventions is unknown. In addition, questions remain about artifacts caused by surgical interventions and postmortem putrefaction. We hypothesized that postmortem computed tomography is a rapid, reliable, and practical alternative to trauma autopsy, even in patients who underwent invasive interventions.
Methods: All postmortem computed tomography scans at our trauma center from March 2023 to April 2024 were retrospectively reviewed and divided into those who received invasive interventions, defined as thoracostomy, thoracotomy, or laparotomy, and those who did not. Injury severity score pre- and postpostmortem computed tomography was compared between groups. postmortem computed tomography scans were reviewed to investigate missed injuries and the presence of ectopic air.
Results: In total, 54 patients received postmortem computed tomography, with a mean age of 42 ± 18 years. Most were male (78%) with blunt injury (82%). The median time from death to postmortem computed tomography was 126 minutes. Among the 25 patients (46%) who underwent invasive interventions, Injury Severity Score increased from 10 to 48 after postmortem computed tomography (P < .001). In the no-intervention group, Injury Severity Score increased similarly after postmortem computed tomography (3 vs 50, P < .001). Hepatic gas was seen in 70% and intracardiac air in 56% of patients. Time from death to postmortem computed tomography was similar in patients with and without hepatic gas and intracardiac air (P > .05).
Conclusions: Postmortem computed tomography increases Injury Severity Score in patients who received invasive interventions and can identify injuries that may be missed on autopsy, such as ectopic air, making it a rapid and reliable alternative to autopsy.
{"title":"A rapid and reliable alternative to autopsy at a level I trauma center.","authors":"Jessica M Delamater, Gary H Danton, Larisa Shagabayeva, Luciana Tito Bustillos, Michael D Cobler-Lichter, Brianna L Collie, Nicole B Lyons, Brandon M Parker, Paul J Wetstein, Jonathan P Meizoso, Nicholas Namias, Kenneth G Proctor, Edward B Lineen","doi":"10.1016/j.surg.2025.110022","DOIUrl":"https://doi.org/10.1016/j.surg.2025.110022","url":null,"abstract":"<p><strong>Background: </strong>Autopsies are the gold standard for determining traumatic deaths causes, but rates have been decreasing. Postmortem computed tomography is an alternative; however, its utility and feasibility in patients who have undergone interventions is unknown. In addition, questions remain about artifacts caused by surgical interventions and postmortem putrefaction. We hypothesized that postmortem computed tomography is a rapid, reliable, and practical alternative to trauma autopsy, even in patients who underwent invasive interventions.</p><p><strong>Methods: </strong>All postmortem computed tomography scans at our trauma center from March 2023 to April 2024 were retrospectively reviewed and divided into those who received invasive interventions, defined as thoracostomy, thoracotomy, or laparotomy, and those who did not. Injury severity score pre- and postpostmortem computed tomography was compared between groups. postmortem computed tomography scans were reviewed to investigate missed injuries and the presence of ectopic air.</p><p><strong>Results: </strong>In total, 54 patients received postmortem computed tomography, with a mean age of 42 ± 18 years. Most were male (78%) with blunt injury (82%). The median time from death to postmortem computed tomography was 126 minutes. Among the 25 patients (46%) who underwent invasive interventions, Injury Severity Score increased from 10 to 48 after postmortem computed tomography (P < .001). In the no-intervention group, Injury Severity Score increased similarly after postmortem computed tomography (3 vs 50, P < .001). Hepatic gas was seen in 70% and intracardiac air in 56% of patients. Time from death to postmortem computed tomography was similar in patients with and without hepatic gas and intracardiac air (P > .05).</p><p><strong>Conclusions: </strong>Postmortem computed tomography increases Injury Severity Score in patients who received invasive interventions and can identify injuries that may be missed on autopsy, such as ectopic air, making it a rapid and reliable alternative to autopsy.</p>","PeriodicalId":22152,"journal":{"name":"Surgery","volume":" ","pages":"110022"},"PeriodicalIF":2.7,"publicationDate":"2025-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145800660","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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