American Surgeon最新文献

Objective: To assess the diagnostic value of joint detection of serum TK1, TSGF, CA199, and CA724 for gastric cancer and its relationship with clinicopathologic features and prognosis.

Methods: The 105 gastric cancer patients were enrolled. The diagnostic value of serum TK1, TSGF, CA199, and CA724 for gastric cancer and the relationship between these indicators and the clinicopathologic characteristics of gastric cancer patients were evaluated. During the follow-up period, recurrence, metastasis, and death were considered as poor prognosis. The relationships between serum TK1, TSGF, CA199, and CA724 levels and poor prognosis and factors affecting the poor prognosis of gastric cancer patients were analyzed.

Results: TK1, TSGF, CA199, and CA724 levels in the gastric cancer group were higher; serum TK1, TSGF, CA199, and CA724 levels were higher in gastric cancer patients with tumor diameters ≥3 cm, TNM stages III and IV, low/moderate degree of differentiation, infiltration depths of the muscular or plasma layer, and lymphatic metastases; AUC of combined TK1, TSGF, CA199, and CA724 (0.894) was higher than that of the four indicators alone; the percentage of gastric cancer patients with poor prognosis in patients with low serum TK1, TSGF, CA199, and CA724 levels was lower; serum TK1, TSGF, CA199, and CA724 levels were factors influencing poor prognosis of gastric cancer patients (all P < 0.05).

Conclusion: Elevated serum levels of TK1, TSGF, CA199, and CA724 are associated with clinicopathologic features and poor prognosis of gastric cancer and may be used as serum biomarkers for prognostic evaluation of gastric cancer patients.

Cardiac injuries pose challenging diagnostic and management dilemmas. Cardiac trauma can be classified by mechanism into blunt and penetrating injuries. Penetrating trauma has an overall higher mortality and is more likely to require operative intervention. Due to the lethality of any cardiac injury, prompt diagnosis and treatment is critical for survival. The initial management of suspected cardiac injury should start with Advanced Trauma Life Support (ATLS) protocols followed shortly by directed diagnosis and management, which usually begins with a focused assessment with sonography in trauma (FAST) examination. In contrast to traditional ATLS protocols, some centers have adopted an assessment of "circulation before "airway" and "breathing"; however, this is an evolving concept. In this article, we provide an overview on the management of penetrating and blunt cardiac injuries, including use of physical exam, laboratory tests, imaging, and surgery.

Background: High output is a common cause for readmission after new ileostomy creation. The loss of sodium leads to compensatory activation of the renin-angiotensin-aldosterone system (RAAS). Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are first-line therapy for hypertension in the United States. We hypothesized that concurrent use of ACEI/ARB increases the risk of readmission following new ileostomy creation due to the loss of this compensatory mechanism.

Methods: Patients undergoing ileostomy creation between 2009-2022 at an integrated managed health care system were included in this retrospective study. Primary outcomes were hospital readmission and ED visit within 30-days. Additional variables included ACEI/ARB use, ileostomy type, Charlson Comorbidity Index, additional antihypertensives at discharge (furosemide, hydrochlorothiazide, spironolactone, amlodipine, nifedipine, and diltiazem), and readmission diagnosis. Descriptive and advanced statistical analysis was completed with SPSS.

Results: Of 540 patients, 41.9% were readmitted or visited an ED within 30 days. There was no difference in readmission or ED visit based on age, gender, or ileostomy type. Patients discharged with ACEI/ARB (37.4% vs 25.5%, P = .005) and additional antihypertensives (37.2% vs 17.3%, P = .006) were at a higher risk for readmission.

Conclusions: Inhibition of RAAS is associated with increased risk for hospital readmission. In patients with hypertension undergoing ileostomy creation, individualized care plans are needed with earlier antimotility agent use or intravenous rehydration plans.

Background: Patients residing in rural and frontier areas experience worse thyroid cancer outcomes than those in urban areas. This novel qualitative study sought the perspectives of rural surgeons to identify practical measures that could mitigate the disparities in thyroid cancer care between rural and urban contexts.

Methods: We contacted general and head and neck surgeons at all of California's Critical Access Hospitals (n = 35), which are remote, rural hospitals, and requested self-referral to our study through the American College of Surgeons. We performed semi-structured qualitative interviews with surgeons at rural hospitals to understand the assets and vulnerabilities of rural hospitals in providing the highest quality care to patients with thyroid cancer. Responses were coded and analyzed using mixed-methods qualitative analysis methodology.

Results: Rural surgeons (n = 13) from a geographically diverse sample of states and regions (AK, AR, CA, NE, NC, NM, TX, UT, WY, and Newfoundland) participated. All initially trained in general surgery; 46% had fellowship training (15% in endocrine surgery) and performed a median of 8.5 thyroidectomies annually.Rural surgeons from all training backgrounds felt adequately trained to treat thyroid cancer and reported a strong desire to provide comprehensive thyroid cancer care. Most reported patients' strong preference to be treated near home. Key challenges to local, comprehensive thyroid cancer care included limited or no access to medical endocrinology, lack of continuing education on thyroid cancer management, and professional isolation in decision-making. Interviewed rural surgeons identified connections with university health systems, expert colleagues, and telemedicine consultations as valuable assets in treating thyroid cancer in geographically isolated hospitals.

Discussion: This study identified key challenges and clear avenues for interventions in treating rural thyroid cancer patients. Interviewed rural surgeons specifically suggest improving access to endocrinology specialists, developing educational initiatives on thyroid cancer management, and fostering connections and collaborations with urban colleagues to reduce professional isolation.

Background: While minimally invasive pancreaticoduodenectomy (MIPD) has historically demonstrated benefits over open pancreaticoduodenectomy (OPD), recent advances in perioperative care and surgical techniques may have impacted the relative advantages of these two approaches. This contemporary analysis examines national trends to assess potential differences in resource utilization metrics along with perioperative outcomes between the two approaches. Methods: We analyzed the Nationwide Inpatient Sample database for cancer patients who underwent pancreaticoduodenectomies from 2016 through 2020. We compared socio-demographics, length of stay (LOS), total charges, and perioperative complications between MIPD and OPD. Results: In this observational study, MIPD was associated with lower total charges ($97,470 vs $126,586), shorter LOS (5.05 vs 7.37 days), and lower odds of perioperative complications (OR 1.40, 95% CI 1.18-1.65) compared to OPD. While total charges increased similarly in both groups over time, a declining trend in LOS was observed for OPD (11.49 to 10.36 days). Non-white race and private/other insurance correlated with longer stays, higher charges, and more complications regardless of surgical approach. Conclusions: Despite the gradual improvements in LOS observed with OPD, MIPD demonstrated advantages in resource utilization metrics, indicating potential for reduced healthcare utilization and costs compared to the open surgical approach during the study period. Continued prospective investigation is warranted to comprehensively evaluate MIPD's value proposition.

Background: Rectal cancer surgery is technically demanding, especially in males. Robotic assistance may help overcome these challenges. This study aimed to identify factors associated with robotic-assisted proctectomy in rectal cancer.

Methods: Retrospective case-control analysis of patients with clinical stage I-III rectal adenocarcinoma who underwent proctectomy from the National Cancer Database (2010-2019) was conducted. Univariable and multivariable binary logistic regression analyses were conducted to determine predictive factors of robotic-assisted proctectomy in rectal cancer.

Results: 67 145 patients (60.9% male; mean age: 61.15 ± 12.49 years) were included. 44.7% had stage III disease and 66.2% received neoadjuvant radiation. The surgical approach was laparotomy (n = 29 725), laparoscopy (n = 21 657), and robotic-assisted proctectomy (n = 15 763). Independent predictors for the use of robotic-assisted proctectomy were age <50 years (OR: 1.06; P = .032), male sex (OR: 1.07, P < .001), Asian race (OR: 1.25; P < .001), private insurance (OR: 1.25; P < .001), rectal cancer treatment between 2015 and 2019 (OR: 3.52; P < .001), stage III disease (OR: 1.06; P = .048), neoadjuvant radiation (OR: 1.26; P < .001), and pull-through coloanal anastomosis (OR: 1.15; P < .001). Robotic-assisted surgery was less often used in Black (OR: .857, P < .001) and American Indian patients (OR: .62, P = .002) and those with a Charlson score = 3 (OR: .818, P = .002), living in rural areas (OR: .865, P = .033), who were uninsured (OR: .611, P < .001), and undergoing pelvic exenteration (OR: .461, P < .001).

Conclusions: Demographic and insurance disparities of robotic-assisted proctectomy are Black and American Indian patients and those with higher Charlson comorbidity index scores and uninsured patients were less likely to undergo robotic-assisted proctectomy. While patients with advanced disease and/or received neoadjuvant radiation were more likely to undergo robotic-assisted proctectomy, robotic-assisted surgery was less often performed in pelvic exenteration.

It is not every day that true scientific pioneers come along. Fortunately, the early 20^th century gifted us with immensely talented professionals like Dr Eugene Opie, who set the groundwork for Dr Juan Acosta and his associates to make revolutionary advancements on the pathophysiologic origin and proper management of acute biliary pancreatitis. Amidst a modest hospital in the city of Rosario, Argentina, Dr Acosta pioneered numerous studies to validate his hypothesis that transient gallstone obstruction of the lumen was the true source of acute biliary pancreatitis. His findings, along with his mentorship within his residency program, and his dedication to improving patient outcomes, have cemented his name into patient care as we know it today. The goal of this paper is to outline the relentless dedication of Dr Acosta to the improvement of patient care and pancreatitis management.

Background: Traumatic brain injury (TBI) due to single-level falls (SLF) are frequent and often require interhospital transfer. This retrospective cohort study aimed to assess the safety of a criteria for non-transfer among a subset of TBI patients who could be observed at their local hospital, vs mandatory transfer to a level 1 trauma center (L1TC).

Methods: We conducted a 7-year review of patients with TBI due to SLF at a rural L1TC. Patients were classified as transfer/non-transfer according to the Brain Injuries in Greater East Texas (BIGTEX) criteria. The primary outcome measure was the occurrence of a critical event defined as deteriorating repeat head computed tomography (CT) scan or neurological status, neurosurgical intervention, or death.

Results: Of the 689 included patients, 63 (9.1%) were classified as non-transfer. Although there were 4 cases with a neurological change and one with a head CT change among the non-transfer group, there were no neurosurgical procedures or deaths. The Cox Proportional Hazard model showed a near 3-fold increased risk of experiencing a critical event if classified as a non-transfer. The multivariable regression model showed patients with an Abbreviated Injury Scale (AIS) of 3 was twice as likely to experience a critical event, with an AIS of 4, three times, and 3 times more likely to be classified to transfer.

Discussion: The BIGTEX criteria identify a subset of patients who can safely be observed at their local hospital. To confirm the safety and efficacy of this transfer criteria recommendation, a prospective study is warranted.

Objective: To evaluate the safety study of percutaneous gastroscopic gastrostomy in patients after ventriculoperitoneal shunt.

Methods: We conducted a retrospective analysis of neurosurgical patients who underwent VPS and PEG at our hospital between January 2012 and November 2023. Patients were divided into 2 groups: VPS group and VPS followed by PEG gruop. Patients received routine antibiotic prophylaxis before the procedure, continued for 48 hours. Follow-up included monitoring immediate complications, particularly wound infection, intracranial infection, neurologic status deterioration, and shunt dysfunction. Routine follow-up visits were conducted post-discharge.

Results: In the VPS group (n = 778), the incidence of intracranial infection was 3.08%. Among patients with PEG after VPS, the time interval between procedures ranged from 13 to 685 days. The mean follow-up period was 22 (1-77) months, with no deaths or further complications.

Conclusion: Performing PEG more than 13 days after VPS does not significantly increase the risk of intracranial infections or PEG-associated infections, making it a relatively safe procedure.