American Surgeon最新文献

BackgroundIncidence of Pancreatic Neuroendocrine Tumors (PNET) has increased in recent decades. In navigating health diagnoses like pNETs, patients are increasingly turning to the internet for information. This study aims to provide a comprehensive overview of Patient Education Materials (PEMs) specific to pNETs using 6 primary criteria for evaluation: Quality, Understandability, Actionability, Readability, Comprehensiveness/Adherence to clinical guidelines, and Accountability.Methods36 unique web pages were selected using 9 different web browser/search engine combinations. Quality was evaluated using the DISCERN instrument, understandability and actionability with the PEMAT-P tool, readability with the Flesch-Kincaid Reading Ease algorithm, and comprehensiveness/adherence to clinical guidelines and accountability with author generated criteria. Scores were categorized based on affiliation to either a foundation, academic, or commercial publishing source, and by search position.ResultsOf the 36 web pages evaluated, 8 were published by foundations, 23 by academic sources and 5 by commercial sources. The mean understandability score for all sources using PEMAT-P was 75.45% (SD 10.89%), and actionability was 19.44% (SD 25.25%). The mean Flesch-Kincaid Reading Ease Score for all sources was 46.11 (SD 12.71), equivalent to a college reading level. Additionally, significant differences were found between the accountability scores for foundation (mean 1.75, SD 1.75), academic (mean 0.87, SD 1.49), and commercial (mean 3.2, SD 0.82) categories.DiscussionThis study reveals many shortcomings of online PEMs for PNETs, including average reading grade level and PEMAT-P actionability scores well below recommended standards. Academic web pages also demonstrated the lowest accountability scores to a statistically significant degree, indicating a need for that category of sources to increase transparency on author information and sources.

Dr. John Jeffries (1744-1819) twice became one of the most prominent surgeons in Boston. His career was interrupted by the American Revolution. Having chosen the Loyalist side, from 1776 to 1790, he left his native city and served with the British Army in Nova Scotia and the Carolinas. After the war, he established a successful practice in London and made the first flight across the English Channel. Able to return in 1790, he resettled in Boston and again became a leading figure in the city's medical community. This essay gives a short synopsis of his extraordinary life and of the death of his friend Dr. Joseph Warren.

BackgroundIn HER2-positive breast cancer, response to neoadjuvant chemotherapy (NAC) is a key prognostic factor. While complete response (CR) is associated with improved survival, non-complete responses are typically treated as a homogeneous group in prognostic models. However, this binary classification may obscure clinically relevant differences, particularly for patients achieving partial response (PR).MethodsWe conducted a retrospective cohort study using a large national cancer registry to evaluate outcomes of HER2-positive female patients treated with NAC. Patients were classified into three groups based on treatment response: CR, PR, and no response (NR). Overall survival (OS) and disease-specific survival (DSS) were assessed using Kaplan-Meier analysis and multivariable Cox regression models adjusted for demographic, clinical, and treatment-related variables.ResultsAmong 4711 patients, 72.4% achieved CR, 24.9% PR, and 2.8% NR. Both OS and DSS were significantly higher in the PR group compared to the NR group (10-year OS: 74.7% vs 35.5%, P < .001). In multivariate analysis, PR was independently associated with better survival than NR (HR for OS: 2.51; HR for DSS: 2.75; both P < .001). Other independent predictors of poor survival included older age, higher T/N stage, unmarried status, and absence of surgery.ConclusionA tripartite classification of treatment response-CR, PR, and NR-provides improved prognostic discrimination in HER2-positive breast cancer compared to the conventional binary model. Recognizing partial responders as a distinct clinical group may improve risk stratification and guide individualized treatment planning in the post-neoadjuvant setting.

BackgroundRobotic-assisted surgery is increasingly available in rural Michigan, but outcomes in these populations remain unclear. National data suggest robotic colectomies are associated with improved outcomes compared with open procedures, but evidence for rural patients is limited. This study compared postoperative outcomes of open, laparoscopic, and robotic right colectomies among rural and urban Michigan residents.MethodsThe HCUP State Inpatient Sample (2016-2018) identified adults undergoing right colectomy. Rural and urban residence was classified using Urban Influence Codes (UIC); rural residence was defined as codes 3-12. Complications included prolonged ileus, pneumonia, surgical site infection, abscess, septicemia, hemorrhage/hematoma, urinary tract infection, in-hospital death, and length of stay ≥5 days. ICD-10 codes identified surgical approach. Logistic regression estimated adjusted odds ratios (aORs), controlling for demographic and clinical covariates.ResultsAmong rural residents, minimally invasive approaches were associated with lower odds of complications than open surgery, with robotic procedures showing the lowest odds. Urban residents undergoing robotic colectomies experienced greater reductions in odds of pneumonia and urinary tract infections than rural residents.DiscussionMinimally invasive right colectomy was associated with lower odds of complications compared with open surgery. Robotic techniques showed the most favorable outcomes, though benefits appeared greater among urban residents. These disparities may reflect institutional experience, infrastructure, or access to robotic platforms. Given the limitations of administrative data and observational design, results should be interpreted as associations rather than causation. Further studies incorporating hospital- and surgeon-level data and post-discharge outcomes are needed to clarify rural-urban differences and guide equitable surgical care.

BackgroundDespite rising rates of contralateral prophylactic mastectomy (CPM), little is known about how surgeons and patients communicate about the procedure. This study is among the first to use real-time audio recordings of CPM discussions, link conversations to treatment choice, and include multiple institutions. We assessed surgeon-patient discussions, focusing on how often CPM was addressed, who initiated it, and how decisions were made.MethodsWe recruited surgeons and patients from three academic centers and audio-recorded the first surgical consultation for patients with (1) early-stage unilateral breast cancer or ductal carcinoma in situ and (2) no strong family history or BRCA mutation. Transcripts were analyzed using an inductive, qualitative approach to generate themes and detect patterns.ResultsTwenty-seven patients and eight surgeons participated. In 14 cases, neither patient nor surgeon mentioned CPM. In the remaining 13, surgeons initiated the topic in 10, typically while introducing surgical options. Of the four patients who received CPM, each had a strong initial preference for CPM and was undeterred by the surgeon's cautionary statements against it. When patients lacked strong preferences for CPM, they generally followed surgeon recommendations to forego CPM or to delay the decision until tests (eg, genetics and MRI) were complete.DiscussionSurgeons, not patients, most commonly initiated CPM discussions. Initial patient preference strongly influenced surgical decisions. Surgeon recommendations to wait for additional information shaped decision making only when patients were initially undecided. Future research should explore how patients form preferences prior to consultation and how best to address them during clinical conversations.

Through new and astonishing capabilities of artificial intelligence, the editors of The American Surgeon have been able to step back in time and conduct a virtual interview with the most eponymous surgeon in history: Allen Oldfather Whipple. We caught up with Dr. Whipple on September 2nd, 1946, shortly after completing the final operation of his surgical career; not surprisingly, a pancreaticoduodenectomy.

BackgroundEmergency general surgery (EGS) patients require surgical intervention and often critical care. Current literature suggests that interfacility transfer potentially face worse outcomes including increased mortality and complications. This study aims to evaluate patient transfers on mortality and the utilization of damage control laparotomy (DCL) in EGS.MethodsRetrospective cohort study of patients undergoing emergent exploratory laparotomy at an academic institution from 2013 to 2023. Patients were included if they were ≥18 years old and underwent emergent nontraumatic laparotomy. Or primary outcome was mortality. Secondary outcomes included the usage of DCL, complications, intensive care unit admission, postoperative ventilation, and hospital length of stay.ResultsA total of 1249 patients were included with 745 (59.6%) direct admissions and 504 (40.4%) transfers. Transferred patients had higher PESAS scores (5 vs 3, P < 0.0001) and ASA classifications (ASA 4: 31% vs 22%, P = 0.0004). They also had higher rates of DCL (52% vs 42%, P = 0.0008), ICU admissions (52% vs 40%, P < 0.0001), and increased ventilation in transfers (47% vs 37%, P = 0.0004). While overall complications were higher in transferred patients (50% vs 39%, P = 0.0002), mortality rates were not significantly different (18% vs 14%, P = 0.1479).ConclusionsTransferred EGS patients presented with greater preoperative severity and required DCL at higher rates. Transferred patients had increased complications, ICU, and ventilation needs. They also had an increase in complications however no difference in mortality. This suggests that while transferred patients are at increased preoperative acuity effective transfer systems and utilization of DCL may mitigate mortality risk in these patients.

IntroductionPatients undergoing major cancer surgery face an increased risk of venous thromboembolism. Despite guidelines recommending extended pharmacologic prophylaxis for 30 days after surgery, adoption remains low. Differences in adherence to guidelines for extended prophylaxis based on social and structural determinants of health have not been examined, but if present, may contribute to observed disparities in cancer surgery outcomes.MethodsA single-center retrospective cohort study was performed to identify patients undergoing major gastrointestinal, gynecologic, or urologic cancer resections between 2014 and 2021. Extended prophylaxis was assessed via outpatient low molecular weight heparin prescriptions on hospital discharge and analyzed by demographic factors (age, sex, race, poverty status, and insurance), and procedural factors (organ category, surgical approach, and year) using chi-squared tests and multivariable logistic regression.ResultsOf 5246 patients, 17.1% received extended prophylaxis, varying by specialty. Extended prophylaxis was higher with increasing age, female sex, and Medicare or Medicaid insurance, but lower among below poverty level (14.3% vs 18.1%), Black (14.5% vs 18.2%), and minimally invasive surgery patients (7.9% vs 23.9%). Multivariable regression showed lower odds of receiving extended prophylaxis for below poverty level (adjusted odds ratio 0.73, 95% CI: 0.60-0.88) and Black patients (0.72, 95% CI: 0.58-0.89).DiscussionOverall utilization of extended prophylaxis is low (17.1%) while differences in use based on income and race suggest potentially modifiable factors related to social and structural determinants of health. A planned randomized trial (NCT6451003) will test patient and provider education interventions and a decision-support tool to improve guideline adherence and potentially address cancer disparities.

BackgroundCritical limb ischemia (CLI) is an advanced stage of peripheral arterial disease (PAD) often requiring major amputation. Frailty influences surgical outcomes but remains underexplored in CLI. This study evaluates the 5-item Modified Frailty Index (mFI-5) as a predictor of 1-year mortality and contralateral amputation following major amputation for CLI.Materials and MethodsA retrospective analysis was conducted on 327 patients who underwent primary above- or below-knee amputation (AKA or BKA) for CLI. Patients were stratified into 2 groups based on frailty: mFI-5 <3 (less frail) and mFI-5 ≥3 (severely frail). Binomial logistic regression was used to assess associations between frailty and outcomes, with significance set at P < .05.ResultsWhen analyzed as a continuous variable, mFI-5 did not significantly predict 1-year mortality or contralateral amputation (P = .059, .693). When stratified by frailty status, severe frailty (mFI-5 ≥3) was associated with increased odds of 1-year mortality (OR 1.815, P = .030). Among patients undergoing index AKA, severely frail individuals had the highest risk of mortality (OR 2.67; 95% CI 1.52-4.78; P < .001). Contralateral amputation was also linked to increased 1-year mortality compared to similarly frail patients without a second amputation (P = .010).ConclusionSevere frailty is associated with worse outcomes, particularly 1-year mortality, following amputation for CLI. While frailty did not independently predict contralateral amputation, its occurrence was linked to increased mortality in frail patients. These findings support incorporating frailty assessment into CLI surgical decision-making and postoperative care.