American Surgeon最新文献

BackgroundEmergent paraesophageal hernia repair (emPEHR) may be required due to complications such as incarceration or gastric volvulus. However, data regarding changes in management and outcomes of emPEHR is limited. Our objective was to evaluate national trends in emPEHR over an 8-year period.MethodsThe 2015-2022 ACS-NSQIP databases were queried for cases of emPEHR using Current Procedural Terminology (CPT) codes. Trends in patient demographics, operative characteristics, and 30-day postoperative outcomes were evaluated.ResultsA total of 42 476 cases of PEHR were performed during the study period. Of these, 1583 (3.7%) were emergent. The proportion of emPEHR cases has increased from 2015 to 2022 (3.1% to 5.6%, P < 0.001). Utilization of laparoscopy has increased from 60.3% to 79.1% (P < 0.001). Emergent cases had a higher likelihood of wound (OR 4.0, P < 0.001), pulmonary (OR 4.5, P < 0.001), neurovascular (OR 3.9, P < 0.001), renal (OR 2.5, P < 0.001), and cardiac (OR 2.0, P < 0.001) complications, sepsis (OR 6.4, P < 0.001), reoperation (OR 1.9, P < 0.001), readmission (OR 1.5, P < 0.001), and mortality (OR 4.5, P < 0.001) compared to elective cases. However, between, there was a decrease in renal complications (6.9% to 1.7%, P = 0.004) and bleeding requiring transfusions (6.9% to 3.7%, P < 0.001) following emPEHR.DiscussionThere has been an increase in rates of emergent PEHR since 2015. Emergent cases have poorer outcomes compared to elective cases, with only a minimal decrease in certain postoperative complications over time. This data highlights the importance of elective repair for PEHs and the need to proactively identify patients who will benefit from elective repair or specialist referral.

BackgroundTraumatic rib fractures can lead to respiratory complications necessitating unplanned intubation, but predictors have been inadequately delineated. We used interpretable machine learning to predict unplanned intubations in rib fracture patients while identifying predictors.MethodsTQIP 2017-2022 was queried for adult patients admitted to the hospital following a rib fracture injury. An XGBoost model was developed to predict unplanned intubation using variables that can be known on admission. A 70/10/20 train/validation/test split was used. SHapley Additive exPlanations (SHAP) were used for interpretation. SHAP allows individualized interpretation of predictors for each patient.ResultsThe cohort had 905 615 patients; 2.3% had unplanned intubations. Model metrics at the F1 maximizing threshold (0.78) included AUROC = 0.83, F1 score = 0.17, accuracy = 0.94, precision = 0.12, recall = 0.29, specificity = 0.95, and Brier score = 0.17. The most influential variables, as determined by mean absolute SHAP values, were admission location (0.62), Injury Severity Score (0.40), age (0.37), absence of comorbidities (0.18), pulse rate (0.14), pneumothorax (0.13), oxygen saturation (0.15), chronic obstructive pulmonary disease (0.11), respiratory rate (0.10), and sex (0.10). ICU admission was the location most influential in predicting an unplanned intubation. SHAP dependency plots determined the directional relationship between variables' values and SHAP values.DiscussionPatients above the F1 maximizing threshold had a 7.4-fold increase in unplanned intubations compared to those below. Nearly 30% of all unplanned intubations were captured at this threshold. Our model's identification of these high-risk patients and influential factors not previously considered in the literature could guide closer monitoring and early interventions.

Stop the Bleed™, the education program created by the American College of Surgeons to address life-threatening bleeding, came from concepts of combat casualty care in tactical settings in the US military. Tourniquet control of exsanguinating extremity injuries dates from its first recorded use in the French military in the 17th century and its general issue to ships of the Royal Navy during the Napoleonic Wars. Wound packing and pressure dressings, specifically in junctional sites and head and neck, also date from the 16th century, illustrating the priority of hemorrhage control throughout the history of military medicine.

Inattentional Blindness (IB) is a cognitive phenomenon where individuals fail to notice both obvious and unexpected stimuli while focused on other tasks. It can have significant implications for performance, especially in healthcare. This study investigated the prevalence and nature of IB among surgical and internal medicine (IM) residents. Results indicated that IM residents more frequently identified a relevant stimulus, a lung nodule (81.3%) compared to surgical residents (57.1%), though the difference was not statistically significant. However, surgical residents more often noted an irrelevant stimulus, a gorilla, compared to IM residents (85.7% vs 50.0%, P < 0.02). The study documents the existence of IB among residents with differences in detection between specialties. The findings suggest the potential importance of teaching residents to recognize and address perceptual flaws in clinical work. Future research should explore strategies to mitigate IB, optimizing clinical performance and patient safety.

Background: During colorectal cancer (CRC) surveillance, tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), play important roles in the diagnosis, prediction, and monitoring of tumors. Herein, we devised a novel combined index comprising the CA19-9-to-CEA ratio and investigated its prognostic value in patients with stage I-III CRC after resection. Methods: This retrospective study included 306 patients who underwent radical resection between 2011 and 2020. CA19-9 and CEA levels were evaluated preoperatively. The CA19-9-to-CEA ratio cutoff value was determined via receiver-operating characteristic analysis using the survival status at the 5-year follow-up evaluation. Multivariate Cox proportional hazard models were used to assess disease-free survival (DFS) and overall survival (OS). Results: According to the multivariate analysis, T3 or T4 tumor (P = 0.041; hazard ratio [HR], 2.54), pathological stage III (P = 0.001; HR, 3.07), serum CEA level ≥5.0 ng/mL (P = 0.018; HR, 2.11), and high CA19-9-to-CEA ratio (P = 0.015; HR, 2.89) were independently associated with DFS. Age 65≥ years (P = 0.03; HR, 2.86), pathological stage III (P = 0.001; HR, 2.00), high neutrophil-to-lymphocyte ratio (P = 0.003; HR, 2.27), and high CA19-9-to-CEA ratio (P = 0.009; HR, 3.16) were independent prognostic factors for OS. Patients with high CA19-9-to-CEA ratios had significantly worse DFS (P < 0.001) and OS (P < 0.001). Discussion: A high CA19-9-to-CEA ratio can be used for detailed risk prediction in patients with CRC.

IntroductionVerification by the American College of Surgeons and state designation of trauma centers improve outcomes in trauma care. In regions where participation in trauma systems is optional, legislation requiring inclusion may need evidence of outcome differences. Given the distinct populations treated at trauma centers vs non-trauma centers, validated risk adjustment is essential for fair comparison. The International Classification of Diseases, 10th Revision injury severity score (ICISS) has been validated for such assessments.MethodsWith institutional review board approval, data from the state Healthcare Cost and Utilization Project from 2018 to 2020 was analyzed. Using ICISS for risk adjustment, outcomes were compared across overall, age-specific, and diagnosis-specific groups.ResultsAmong 3,316,016 discharges, 245,404 (7.4 percent) included at least one injury diagnosis. After excluding transfers out, 151,855 cases remained. Patients at trauma centers had lower risk-adjusted mortality and fewer occurrences of acute kidney injury and pulmonary embolism but higher rates of ventilator-associated pneumonia and surgical site infections. Subgroup analyses revealed that pediatric patients and those with traumatic brain injuries or shock were predominantly treated at trauma centers. Increased age, higher injury severity, male gender, and non-trauma center treatment were associated with lower survival rates. Among geriatric patients with proximal femur fractures, 63 percent were treated at non-trauma centers, with no observed mortality benefit from trauma center care.ConclusionsTrauma center care is associated with improved outcomes supporting the development of more inclusive trauma systems.

Nasal bone fractures represent the most common facial skeletal injury, challenging both function and aesthetics. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-based review analyzed 23 studies published within the past 5 years, selected from 998 records retrieved from PubMed, Embase, and Web of Science. Data from 1780 participants were extracted, focusing on diagnostic methods, surgical techniques, anesthesia protocols, and long-term outcomes. Ultrasound and artificial intelligence-based algorithms improved diagnostic accuracy, while telephone triage streamlined necessary encounters. Navigation-assisted reduction, ballooning, and septal reduction with polydioxanone plates improved outcomes. Anesthetic approaches ranged from local nerve blocks to general anesthesia with intraoperative administration of lidocaine, alongside techniques to manage pain from nasal pack removal postoperatively. Long-term follow-up demonstrated improved quality of life, breathing function, and aesthetic satisfaction with timely and individualized treatment. This review highlights the trend toward personalized, technology-assisted approaches in nasal fracture management, highlighting areas for future research.

BackgroundSurgical society membership and meeting attendance are critical for academic success. Studies demonstrate an association between society membership and greater publication numbers, NIH grants, and departmental leadership positions. Despite this, another study revealed a 68% lapse in membership status by faculty respondents due to costs. Understanding these costs is essential to structuring institutional investments in faculty development.MethodsMembership dues, meeting registration fees, and meeting attendance costs for 23 national, regional, and subspecialty societies from 2022 to 2024 were analyzed. Meeting costs were estimated assuming a 3-day attendance model. Membership dues and meeting registration fees were trended over a 3-year period.ResultsSubspecialty and national societies had the highest meeting attendance cost ($2638 and $2492, respectively). Regional societies had the lowest cost ($2252). Overall average membership dues were the highest for subspecialty societies ($474) and lowest for regional societies ($327). National societies' average membership dues were $431 and had the highest average increase over the 3-year period ($47). Subspecialty societies had the highest average meeting registration fees ($684) and the highest increases in fees over the study ($61). National societies' meeting registration averaged $581 with an average increase of $49. Regional societies had the lowest registration fees ($445) with no increases.DiscussionSubspecialty societies have the highest overall costs and had the greatest increases in meeting registration fees. National societies had the greatest increases in membership dues. Regional society costs are lowest and remained unchanged. An understanding of how faculty and departments finance these costs is needed.

BackgroundThe study of poorly differentiated adenocarcinoma of the rectosigmoid junction (RSJ) remains underexplored. This study aims to develop a postoperative nomogram to accurately predict cancer-specific survival (CSS) in patients afflicted with this form of cancer.MethodsThe study utilized data from the Surveillance, Epidemiology, and End Results database, focusing on patients diagnosed with RSJ cancer between 2004 and 2017. Participants were divided into a training cohort and a validation cohort at a 7:3 ratio. Initially, the training cohort was analyzed using Cox univariate analysis to identify significantly impactful factors. These factors were then examined through Cox multivariate analysis to isolate the best predictors for CSS, which were used to construct the nomogram. The validity of this nomogram was subsequently tested using the validation cohort.ResultsThe study enrolled a total of 2668 patients, with 1867 in the training cohort and 801 in the validation cohort. The 1-, 3-, and 5-year CSS rates were 86.5%, 67.9%, and 57.8%, respectively. Significant predictors identified included race, age, and stage. The constructed nomogram was validated through receiver operating characteristic analysis, calibration, and decision curve analysis, confirming its reliability and accuracy in predicting CSS.ConclusionRace, age, and staging have been affirmed as significant prognostic indicators for CSS. This study has successfully developed a postoperative nomogram that effectively predicts the 1-, 3-, and 5-year CSS for these patients. This predictive model holds substantial clinical value, providing essential guidance for therapeutic decision-making and patient counseling.

BackgroundCholedocholithiasis is a common biliary tract disease that requires effective intervention. This study aimed to evaluate the effectiveness of transduodenal choledochoscopy stone extraction and analyze its impact on postoperative complications in a prospective cohort of patients.MethodsA prospective study was conducted on 186 patients with choledocholithiasis who underwent transduodenal choledochoscopy stone extraction between January 2022 and December 2023. Patients were evaluated for operative success rate, stone clearance rate, and postoperative complications. Stone characteristics, technical aspects, quality of life outcomes, and cost-effectiveness were assessed. Follow-up was conducted for 6 months post-procedure.ResultsThe overall stone clearance rate was 94.6% (176/186), with complete stone removal achieved in a single session in 82.8% of cases (154/186). Mean operation time was 45.3 ± 15.7 min. Basket extraction was the primary method (52.7%), followed by balloon extraction (24.2%) and mechanical lithotripsy (23.1%). Postoperative complications occurred in 11.8% of patients, including pancreatitis (3.2%), cholangitis (2.7%), bleeding (1.6%), and minor complications (4.3%). The stone recurrence rate during the 6-month follow-up period was 4.3%, with a mean time to recurrence of 4.2 ± 1.3 months. Multivariate analysis revealed that stone size >15 mm (OR: 2.34, 95% CI: 1.45-3.78, P < 0.001), multiple stones (OR: 1.89, 95% CI: 1.23-2.91, P = 0.003), and intrahepatic location (OR: 1.76, 95% CI: 1.12-2.77, P = 0.014) were independent risk factors for procedural failure. Quality of life scores showed significant improvement across all SF-36 domains (P < 0.001). Mean procedure-related costs were $2845 ± 625, with additional costs of $986 ± 423 for managing complications.ConclusionsTransduodenal choledochoscopy stone extraction demonstrates high effectiveness with acceptable complication rates. The technique proves particularly suitable for patients with stones smaller than 15 mm and shows advantages in terms of single-session success rates and long-term stone clearance. While initial costs and operator experience may pose challenges, reduced radiation exposure and lower need for re-intervention highlight its clinical value. While associated with higher initial costs, the procedure may be cost-effective due to reduced need for repeat interventions and improved quality of life outcomes. Careful patient selection based on stone characteristics and anatomical factors is crucial for optimal outcomes.