American Surgeon最新文献

Access to surgical care represents a significant and widespread issue that impacts millions of Americans across varying demographics. It is estimated that nearly 100 million Americans-approximately 1 in 3-lack access to quality surgical care. Additionally, the financial implications of this lack of access lead to an estimated annual cost of $1 billion in preventable healthcare spending, coupled with increased morbidity and mortality rates. Reliable access to care includes sufficient and affordable health insurance and the ability to easily locate and receive care that meets the patient's health needs. The barriers to timely, affordable, quality surgical care are complex and multifaceted. They include population-based factors such as rural geography, the repercussions of hospital closures, access challenges faced by justice-involved individuals, LGBTQ+ patients, and other marginalized groups, language and cultural barriers as well as the impact of natural disasters on supply and health system infrastructure, bias and discrimination, and policy.

BackgroundBile duct injuries (BDI) occur in 0.2%-0.6% of cholecystectomies. Early definitive repair prevents clinical deterioration, reduces hospital stays, and cuts costs, while delayed repairs may reduce postoperative stricture rates. Currently, there are no guidelines to support early vs delayed repair. Using our institution's risk stratification, we hypothesize that low-risk patients can undergo early repair without increased postoperative complications.MethodsThis retrospective study reviewed 53 patients with BDI treated surgically from January 2014 to September 2023 at a non-university tertiary care center. Patients were classified as low-risk (score ≤2) or high-risk (score ≥3) based on four factors: index surgical approach, vascular injury, biloma, and sepsis.ResultsThe mean age was 58.3 years, with 49.1% women. Most BDI were diagnosed within one week (median 3 days) following laparoscopic cholecystectomy (83.6%). Biloma was present in 46% of cases, and 3.8% were septic. The majority (88.7%) of patients were classified as low-risk. Strasberg-Bismuth E2 (27.3%) and E3 (20%) injuries were the most common. Additionally, 92.7% of patients underwent end-to-side hepaticojejunostomy. Early (9 of 29; 31.0%) and late repairs (8 of 18; 44%) showed no significant difference in complication rates for low-risk patients (P = 0.35).DiscussionThis study proposes a scoring system to identify low-risk patients who can safely undergo early repair without increased complications. These findings highlight the potential for stratified decision-making to optimize outcomes, but prospective validation is needed to establish evidence-based guidelines for BDI management.

Introduction: Near-hanging injuries are a significant cause of morbidity and mortality worldwide. These injuries result in complex clinical presentations due to the combination of mechanical asphyxia and potential neck and cervical spine trauma. The primary objectives of this narrative review include assessing the incidence, sex distribution, pathophysiology, prognostic indicators, neurologic outcomes, and treatment strategies.Methods: Review performed using Medline in English from 1946 to 2023. Excluded: articles of accidental, sex-related, auto-asphyxiation, cancer-related, and pediatric near-hanging, review articles, and case reports.Results: 53 articles were first reviewed; 30 articles encompassing 4712 patients had complete demographic and neck injuries data. Sixteen articles reported the presence and absence of ligature markings in 1778 patients. Ligature markings were present in 1103 (73.5%). Median Age: 33 (29-38) 75.7% male distribution. Suicide attempt: 97.3%. Neck vascular injuries, aerodigestive, and neck bony injuries occurred in 83 (1.8%), 123 (2.6%), and 125 (2.7%), respectively. Cardiac arrest: 1195 (25.3%) and GCS<9-2125 (45%) were the major contributors to the mortality: 26.9%. Glasgow Outcome Score>3 or by a Cerebral Performance Category score of 1-2 was documented in 35.2% of patients. Hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management did not appear to be useful from the standpoint of survival in patients who suffered a cardiac arrest.Conclusions: Near-hanging as an attempt to suicide is more frequent in young male patients. The incidence of associated neck injuries is low; mortality is likely to occur in patients with cardiac arrest with an associated neurologic injury. There is insufficient evidence to support the use of hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management in patients who have suffered a cardiac arrest and severe neurologic injury after near-hanging.

Pleural space diseases are a significant cause of morbidity in the United States with a reported 25% mortality rate within a year of diagnosis. Pleural space diseases, including intrapleural infections, retained hemothorax (RH), and malignant pleural effusions (MPE), often indicate advanced disease. Despite options like video-assisted thoracoscopy (VATS), tube thoracostomy, and intrapleural fibrinolytic therapy (IPFT), treatment remains a significant clinical challenge. IPFT, which describes a combination of administrating tissue plasminogen activator (tPA) and DNase through a chest tube, has shown effectiveness in improving fluid drainage and reducing surgery frequency in a large, randomized control trial and is widely used. However, the success of IPFT varies based on infection severity, patient health, and treatment timing, with a failure rate around 20-25%. This highlights the need for further research to enhance the therapy's efficacy, investigating both disease mechanisms and optimizing treatment protocols. This review seeks to provide a comprehensive overview of IPFT, highlighting recent advancements, current trends, and existing research gaps.

BackgroundBreast conserving surgery represents the preferred surgical treatment option for patients with early-stage breast cancer. Reexcision rates are generally higher for patients undergoing lumpectomies for ductal carcinoma in situ (DCIS) compared to invasive breast cancer, as the microscopic extent of disease is difficult to assess during excision. This study investigated the clinicopathological characteristics of patients undergoing BCS for pure DCIS and reexcision rates over time, including the effect of the MarginProbe™ device.MethodsWe queried our prospectively maintained Institutional Breast Cancer Database for patients diagnosed with DCIS and treated with BCS as their primary procedure from 2010-2021. The primary endpoint was the rate of reexcision. Variables of interest included age at diagnosis, race/ethnicity, mode of diagnostic imaging, mammographic breast density, method of core biopsy, nuclear grade, size of DCIS, multifocality, DCIS subtype, and MarginProbe™ use.ResultsPapillary DCIS (P < 0.004) and larger size (P < 0.001) was associated with an increased reexcision rate. There were also differences in the method of core biopsy (P < 0.001), with stereotactic core biopsy predominating among patients who did not require reexcision (71.3% vs 49.5%). In an unadjusted estimate for the odds ratio for association, patients who had MarginProbe™ used were 81% less likely to require reexcision (OR = 0.19, 95% CI = 0.12, 0.31, P < 0.0001).ConclusionYounger age, papillary DCIS, larger DCIS size, and non-stereotactic core biopsy method were found to be associated with higher reexcision rates. Additionally, patients whose primary procedures included intraoperative margin assessment with the MarginProbe™ were significantly less likely to require reexcision.

BackgroundCutaneous head and neck melanoma (cHNM) has a high rate of false-negative sentinel lymph node biopsy (SLNB) and up to a 25% risk of recurrence despite negative SLNB. The aim of this study was to investigate the pattern of melanoma recurrence in patients with cHNM with negative SLNB.MethodsA retrospective cohort study of consecutive cHNM patients at a tertiary care centre from 2014-2022. We included all cHNM patients with negative SLNB. All patients were categorized into Breslow thickness >2 mm and ≤2 mm and extracted information pertaining to histopathological characteristics and the presence and type of disease recurrences. We performed multivariable analysis using logistic and cox regression. We used an alpha of 0.05 and all statistical analyses were performed using R software.ResultsOverall, 167 patients met eligibility criteria and of these, 53.5% patients had cHNM ≤2 mm thick and 46.7% had lesions >2 mm thick. The overall recurrence rate was 29.3%. Multivariable analysis demonstrated that Breslow thickness [aOR: 5.89 (95% CI: 1.37, 32.3), P = 0.02] was associated with distant recurrence. Multivariable cox regression also identified that pathological ulceration [aHR: 3.17 (95% CI: 1.61, 7.66), P = 0.01] predicted time to distant recurrence. The SLNB false omission rate was 3.6% (95% CI: 1.3%, 7.7%).ConclusionSLNB-negative cHNM patients with high-risk pathological features may benefit from adjuvant immunotherapy.

IntroductionThe COVID-19 pandemic led to nationwide stay at home orders, leading to delays in medical care. We sought to identify if the severity of appendicitis changed during the pandemic due to these delays and if there were differences in appendicitis severity in patients with simultaneous COVID-19 infection. We hypothesized that pandemic-related restrictions led to more severe cases of appendicitis.MethodsWe performed a retrospective study (4/2018-4/2022) of all patients ≥ 5y with appendicitis. Patients with a malignant appendiceal specimen were excluded. Clinical outcomes and characteristics were compared in those with appendicitis prior to the COVID-19 (PC) era to those in the COVID-19 (C) era, as well as between COVID-19 positive (C+) and negative (C-) individuals. Univariate analyses were conducted. A P-value <0.05 was considered to be statistically significant.ResultsA total of 1665 patients met inclusion criteria, 806 (48.4%) in PC era, and 859 (51.6%) in C era. Age and gender did not differ from PC era to C era, nor did they differ from the C- group to the C+ group. The C era had significantly higher 30-day readmissions than the PC era (C 6.29% (n = 54) v. PC 2.73% (n = 22), P = 0.001). The C era also had more greater than 30-day readmissions than the PC era (C 3.26% (n = 28) v. PC 1.74% (n = 14), P = 0.048). There was no significant difference in the reason for 30-day or greater than 30-day readmissions for the PC vs C eras. Of the C era, 833 (97.0%) were C- and 26 (3.0%) were C+. Rates of nonoperative management at index admission were not different between groups. The white blood cell (WBC) count was significantly lower in C+, 11.9 (8.55-13.35 IQR), vs C- group, 12.85 (9.9-15.3 IQR), P = 0.0336. There was no significant difference in the severity of appendicitis nor readmission status in C+ vs C- groups during the C era.ConclusionOur data indicates that the PC era had more severe cases of appendicitis as shown by higher rates of perforated and gangrenous appendicitis on pathology reports compared to the C era. Interestingly, readmissions were more prevalent in the C era as opposed to the PC era, which coincided with an increase in complications requiring readmission following laparoscopic appendectomies. In evaluating appendicitis patients according to COVID-19 status, we saw no significant differences in the severity of appendicitis in C- and C+ individuals.

BackgroundVenous thromboembolism (VTE) is a well-established risk of inpatient surgery, but VTEs among ambulatory surgical patients are comparatively understudied.MethodsThis review assesses VTE risk after outpatient general surgeries. PubMed and Embase were queried for studies mentioning deep venous thrombosis or pulmonary embolism (PE) and outpatient or ambulatory surgery published between January 2000 and February 2022. Results were restricted to peer-reviewed English articles reporting postoperative VTE incidence or risk factors in adults undergoing elective, outpatient general surgery. Bariatric, oncologic, orthopedic, vascular, and plastic surgeries were excluded.ResultsA total of 678 unique articles were retrieved from PubMed (n = 198) and Embase (n = 480) with 12 articles meeting inclusion and exclusion criteria. Of the articles included, 3 articles focused on cholecystectomy and 2 on hernia repair. Reported risk factors for VTE included older age, higher BMI, prolonged operative duration, Trendelenburg positioning, and pneumoperitoneum. Reported postoperative VTE/PE incidence ranged from 0.0% to 0.5% regardless of procedure, comparable to the baseline annual VTE incidence in the general population.DiscussionThis study is the first review of recent literature on outpatient surgery VTEs. Limitations included patients presenting to different facilities for VTE evaluation, no standardized definition for ambulatory surgery, and short follow-up periods. Whether VTE/PE prophylaxis benefit outweighs associated risks should be addressed in future research.

BackgroundThe use of lymph node (LN) tracers can help obtain a complete dissection of the LNs and increase the detection rate of metastatic LNs. Carbon nanoparticle suspension injection (CNSI) has become increasingly used in radical gastrectomy procedures. This study is designed to evaluate the quality of LN dissection in gastric cancer patients with laparoscopic distal gastrectomy under the guidance of CNSI lymphography.MethodThis was a retrospective cohort study including patients with a pathological biopsy diagnosis of resectable gastric cancer who underwent laparoscopic distal gastrectomy. Data was focused on patients at [Renji Hospital of Shanghai Jiaotong University] from July 2023 to January 2024. Patients were divided into the CNSI group and control group after 1:1 propensity score matching analysis. The median number of LNs harvested was compared between groups. Perioperative status and any complications that arose within 30 days were also analyzed.ResultAfter 1:1 propensity matching analysis, there were 49 patients each in the CNSI group and control group. The median number of harvested LNs was larger in the CNSI group than the control group (P = 0.01). A significant difference between 2 groups was observed in surgery time (P = 0.008). The morbidity of any short-term postoperative complications within 30 days after surgery revealed a similar outcome (P > 0.05).DiscussionCNSI-guided laparoscopic distal gastrectomy is less time-consuming and harvests more LNs. For laparoscopic distal gastrectomy, CNSI-guided lymphography can be an excellent adjuvant.

BackgroundSolid pseudopapillary neoplasms (SPNs) arising in the body or tail of the pancreas can be amenable to laparoscopic distal pancreatectomy with or without concomitant splenectomy. The purpose of this study was to evaluate laparoscopic distal pancreatectomy for SPN using the Warshaw technique as a means to preserve spleens in children.MethodsWe reviewed our database of SPN patients 19 years and younger (January 2006-December 2023). Five had a laparoscopic Warshaw procedure. Using the volumetric analysis tool in Sectra, a pediatric radiologist calculated preoperative tumor, pancreas, and spleen volumes (including postoperative organ volumes) on computed tomography. Descriptive statistics were performed.ResultsAll five spleens were salvaged, although small infarcts occurred centrally in four patients. Splenic volumes on first imaging after Warshaw averaged 93.9% of preoperative size. Splenic volumes were preserved over time, as the most recent scans averaged 110.6% of the preoperative spleen volume. Collateral flow through the short gastric arteries, inferred from dilation on scans, increased in all patients. Median tumor volume was 85.2 mL, and all SPN were resected with negative margins. No relapse occurred (median follow up: 407 days). Median estimated blood loss was 100 mL, median length of procedure was 4.9 hours, and median inpatient length of stay was 3 days. A multimodal pain regimen, including preoperative TAP blocks, non-opiate, and opiate medications, resulted in a median 81 Morphine Milligram Equivalents (MMEs) administered during the hospital stay.ConclusionLaparoscopic Warshaw for SPN in children appears highly effective at preserving splenic volume without compromising oncologic fidelity or consuming excess inpatient resources.