American Surgeon最新文献

This manuscript uses two personal surgical cases to explore hansei, the Japanese discipline of structured self-reflection, as a framework for technical and professional growth. The first case illustrates the limits of technical perfection and the inevitability of some complications. The second reveals the cost of acting on overcaution. Together, they trace the difficult boundary between error, prudence, and inherent surgical risk. The discussion contrasts hansei's explicit, disciplined acknowledgment of shortcomings with the Western tendency to obscure responsibility through passive language and fear of reputational harm. The manuscript argues that adopting hansei in surgical culture can transform regret into actionable improvement, enhance morbidity and mortality reviews, and strengthen training by normalizing open discussion of fallibility. Ultimately, hansei is presented not as self-punishment but as a technical and ethical tool to refine judgment, maintain integrity, and improve patient care.

BackgroundExtracorporeal membrane oxygenation (ECMO) is a critical life-sustaining intervention for patients with severe cardiac or respiratory failure. Predicting outcomes for ECMO patients remains challenging due to the dynamic and complex nature of ECMO therapy. Machine learning (ML) has emerged as a powerful tool for improving prognostication in critical care by integrating large volumes of clinical data to identify complex, nonlinear relationships between variables. Its ability to model complex interactions holds promise for more accurate and personalized risk assessments in ECMO patients.MethodsThis retrospective study utilized data from the MIMIC-IV v3.1 database, including 162 ECMO-treated patients, to develop machine learning models for predicting 28-day mortality. LASSO regression was first used for feature selection, after which machine learning algorithms, such as logistic regression, Random Forest, XGBoost, decision tree, and support vector machine (SVM), were applied. Model performance was evaluated using area under the curve (AUC), calibration curves, and decision curve analysis (DCA).ResultsThe Random Forest model achieved the highest performance with an AUC of 0.852 (95% CI: 0.745-0.959), outperforming other models. Key predictors identified through LASSO included ACT, age, and MAP, all of which were significantly associated with 28-day mortality. DCA indicated that the Random Forest model provided substantial net clinical benefit, supporting its utility in real-world decision-making.ConclusionMachine learning models, particularly Random Forest, demonstrate substantial potential for improving the prediction of mortality in ECMO patients. By integrating dynamic clinical variables, ML offers a more accurate and individualized approach to risk stratification in this critically ill population. Future research should focus on multi-center validation, the inclusion of genomic data, and the development of time-series models to further enhance predictive performance and clinical applicability.

IntroductionA component of trauma-informed care (TIC) is providing opportunities for patients to share their stories and access healing resources. We introduced a "Trauma Survivor Rounds" (TSR) initiative to provide trauma patients an opportunity to discuss and receive individualized assistance. We evaluated whether they reported improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores, hypothesizing increased hospital recommendation rates following TSR implementation.MethodsA single-center retrospective (2021-2023) analysis of admitted trauma patients with HCAHPS survey responses was conducted. The HCAHPS survey measures patient experience, satisfaction, and health care quality. Pre-TSR (1/1/2021-12/31/2021) (PRE) and post-TSR (1/1/2022-12/31/2023) (POST) cohorts were compared. In TSR, a medical student discussed trauma and assisted patients obtain resources. The primary outcome was whether patients recommended the hospital on the HCAHPS survey.ResultsOf 348 patients, 133 (38.2%) were in the POST cohort. Hospital recommendation rates were statistically similar: "definitely yes" (POST: 82.9% vs PRE: 78.3%), "probably yes" (POST: 15.4% vs PRE: 14.0%), "probably no" (POST: 1.7% vs PRE: 4.3%), and "definitely no" (POST: 0% vs PRE: 3.4%) (P = 0.12). No significant difference was found in the overall hospital ratings. Notably, more POST patients reported receiving help "as soon as wanted" (61.4% vs 54.7%, P < 0.001).ConclusionsImplementation of a TIC-based TSR program showed no statistically significant difference in hospital recommendations or ratings; however, it was associated with more patients reporting receiving help "as soon as wanted." Larger sample size studies are needed to determine whether this approach improves HCAHPS scores or other quality metrics.

BackgroundPrehospital tourniquet (PHT) use has become widespread. However, whether it improves outcomes after penetrating proximal extremity trauma in urban settings remains unknown. We hypothesized that PHT improves mortality in this setting.Materials and MethodsThis was a post hoc analysis of a multicenter study of adults (18+ years) with penetrating torso and/or proximal extremity trauma from 25 urban trauma centers. Subjects were allocated via nearest neighbor propensity matching (chest, abdominal, or extremity injury, GSW vs stab, and vascular injuries) to compare similarly-injured PHT and non-PHT patients.ResultsAmong 2352 patients, 117 (4.9%) received PHT. Prehospital tourniquet patients had 22 (18.84%) arterial injuries, 8 (6.8%) venous injuries, and 92 (78.6%) non-vascular injuries. Most PHTs (86, 73.5%) were placed on-scene, and 22 (18.8%) en-route. Admission of systolic blood pressure was not different between PHT and non-PHT patients. Prehospital tourniquet did not impact survival on regression analysis. After propensity matching, 218 patients remained, who were primarily male (n = 182, 83.9%) with median (IQR) age 30 (23-39) years and new injury severity score 9 (3-17). Mortality was similar between PHT and non-PHT groups (6.4% vs 7.3%; P = 1.0). Matched comparison of patients with vascular injury showed similar mortality for PHT vs non-PHT (3.7% vs 3.7%, P = 1.00). The same was true for isolated extremity trauma (4.1% vs 0.0%, P = 0.25).ConclusionsPHT use for urban, penetrating proximal extremity trauma was not associated with decreased mortality or complications. Further research may determine whether modified tourniquet training improves outcomes, or whether immediate transport to a trauma center is more beneficial for these patients.

In 2008, the Centers for Medicare and Medicaid Services formally described "Never Events" as hospital-acquired conditions for which a hospital would not be reimbursed under the inpatient prospective payment system. While provisions have been created to prevent never events at hospitals, periodically, a never event is discovered incidentally. In the case of an incidentally discovered never event, the steps by which those discovered events are reported and disclosed are not clearly defined. In this discussion, we review methods by which one should discuss incidentally discovered never events and the steps to take in order to prevent future events from occurring.

Skin flaps are an important skill set for the general surgeon. Knowledge and technical skill in basic advancement and pivotal flaps allows general surgeons to close complex wounds effectively. The basic flaps discussed in this article include 3 advancement flaps (V to Y, double V to Y, and keystone) and 4 pivotal flaps (rotation, hurricane, trapezoid, and bilobe).

BackgroundAn appropriately sized tracheostomy is essential to minimizing risk for complications in critically ill patients requiring prolonged ventilator support; however, there are a few recognized guidelines to assist surgeons in selecting appropriate tracheostomy tube length. Advanced imaging studies can be beneficial in evaluating patients with challenging airway anatomy. We aim to determine anthropomorphic factors that can assist in identifying patients who are at increased risk for tracheostomy complications in the adult trauma population.MethodsWe performed a retrospective review of trauma patients who received an open tracheostomy at a level-1 trauma center from August 2021 through March 2023. Criteria for inclusion were a preoperative computed tomography scan of the chest and postoperative chest x-ray. Eighty-seven patients met these criteria.ResultsThere were 17 (19.5%) supraclavicular placements, 22 (25.3%) infraclavicular placements (of which 5 (5.7%) were right mainstem intubations requiring immediate surgical revision, and 11 inadvertent dislodgements (12.6%). The overall average skin-to-trachea (STT) distance was 4.0 cm. Patients with STT >4 cm had 0.280 [0.115-0.680] times lower odds of ETT termination between the clavicles (P = 0.004). Patients with supraclavicular termination depth were 3.667 times more likely to have STT >4 cm (P = 0.024). Infraclavicular placement did not achieve statistical significance for STT >4 cm (P = 0.061).DiscussionPatients with pre-tracheal soft tissue >4 cm have greater odds of suboptimal tracheostomy placement and inadequate tracheostomy tube termination depth. Measuring STT on preoperative neck/chest computed tomography (CT) may be useful in identifying adult trauma patients who will present additional challenges in determining the appropriate tracheostomy tube length.

BackgroundUnplanned ICU admission (UP-ICU), a benchmark of the ACS Trauma Quality Improvement Program, is linked to increased mortality and is used to accredit trauma centers. However, it is unclear whether this reflects a causal relationship or confounding by patient physiology. We hypothesized that UP-ICU, when adjusted for patient and injury factors, would not be independently associated with higher mortality.MethodsWe conducted a retrospective case-control study of adult trauma patients admitted to a level 1 trauma center (2016-2020) with hospital length of stay (LOS) > 24 hours. Controls were selected using 1:1 propensity score matching based on injury severity (RTS, GCS, BMI, base deficit) and medical comorbidities (vascular, cardiac, respiratory, renal, and substance use disorders). The primary outcome was in-hospital mortality. The secondary outcomes included discharge to rehabilitation and LOS.ResultsAmong 7618 patients, the UP-ICU rate was 3.3% (254 patients). In the unmatched cohort, UP-ICU was associated with higher mortality than non-UP-ICU (8.6% vs 2.3%, P < 0.001). However, in the matched cohort, mortality was similar between groups (8.6% vs 7.4%, P = 0.745). Common reasons for UP-ICU included delayed intracranial hemorrhage, cardiac arrhythmia or ischemia, and respiratory distress.DiscussionIn a matched cohort, UP-ICU was not independently associated with mortality after adjustment for patient physiology, injury severity, and comorbidities. As such, UP-ICU is a quality metric that may have a role in reducing failure to rescue, as early escalation of care may allow patients to survive acute deterioration.

Gastroesophageal biliary reflux is a common complication after esophagectomy with gastric pull-up. Symptomatic relief focuses on dietary/lifestyle modifications and acid suppression, and possibly bile-binding medications. Rarely, patients with medically refractory bile reflux may need a surgical intervention. Reoperation in these patients is challenging as injury to the gastroduodenal artery could lead to graft ischemia. To avoid vascular injury, we treated three patients with refractory biliary reflux using a retro-colic Roux-en-Y hepaticojejunostomy. Two patients reported complete resolution of bile reflux symptoms, and the third reported minimal bile reflux after biliary diversion. Follow-up endoscopy in two patients showed improvement of esophagitis, no bile in their grafts, and no recurrent Barrett's esophagus. The Roux-en-Y hepaticojejunostomy, a common and safe operation for biliary diversion, provides the advantage of reducing the risk of conduit vascular injury by avoiding a previous operative field. This surgical strategy provides symptomatic relief and endoscopically confirmed improvement of esophagitis.

IntroductionBetween 2005 and 2009, Black women in Memphis had the highest breast cancer mortality rate in the United States as compared to their White counterparts. This study assesses current breast cancer outcomes for Black women in Memphis with hopes of finding improvement.MethodsPatients with breast cancer were identified in the tumor registry of a large health care system in Memphis, TN. Patients were stratified by race. Associations between race, clinical characteristics, and treatments were determined using chi-square tests. Associations between race, recurrence, and mortality were determined using logistic regression. The study sample was divided into period 1 (2002-2012) and period 2 (2013-2020) for comparison.ResultsIn period 2, 36.5% of Black women and 48.8% of White women presented with stage 1 disease (P < 0.001). 11.4% less Black women were diagnosed with stage 2-4 disease in period 2 as compared to period 1. Treatment regimens are stratified per race in Table 1. In both periods, the median time to surgery (TTS) was higher for Black vs White women with stages 0-3 disease. In period 2, Black women were 42% more likely to experience recurrence and 36% more likely to die when compared to White women vs findings in period 1 of 100% and 50%, respectively (P < 0.05).ConclusionAlbeit improved over the past decade, there continues to be significant racial disparity in breast cancer treatment in Memphis. Our next steps will be to evaluate specific social and medical interventions currently existing while identifying areas for improvement.