American Surgeon最新文献

The early resuscitation of patients with mild to moderate non-exsanguinating trauma has shifted from the conventional use of one to two liters of crystalloids to the use of one to two units of PRBC. This evolution assumes that the transfusion of PRBC is superior to the administration of any volume of crystalloids because of the propensity of crystalloids to migrate from the intravascular to the interstitial space leading to organ dysfunction, organ failure, and worse outcomes. However, the premise of the fluid migration relies on Starling original model of fluid exchange between the hydrostatic and oncotic pressure without considering whether the endothelial surface glycocalyx (ESG) is affected by the degree of traumatic insult and by the duration and depth of hypotension. It fails to account for the changes that occur to the PRBC during storage from the standpoint of off-loading of oxygen and the ability to negotiate the microcirculation. This review explores the impact of the burden of trauma and hemorrhage on the ESG, the changes to the RBCs that occur during storage, particularly their diminished capacity to offload oxygen and to negotiate low-shear microvascular districts, leading to failure to improve oxygen consumption despite the increase in oxygen delivery. We argue that the recent trend toward early resuscitation with one to two units of PRBC rather that low-volume crystalloids, in patients with non-exsanguinating mild to moderate trauma lacks sufficient justification.

IntroductionIschiatic (sciatic) hernias represent one of the rarest forms of pelvic floor herniation, with fewer than 100 documented cases worldwide since first described by Papen in 1750. Their rarity, combined with often-cryptic clinical presentation, contributes to significant diagnostic and therapeutic challenges.MethodsFollowing PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases from 1947 to 2024, identifying 68 relevant articles. Our search strategy combined terms related to ischiatic/sciatic hernias with various publication types. Data extraction focused on patient demographics, clinical presentation, diagnostic methods, hernia contents, surgical approaches, and outcomes.ResultsOur analysis revealed striking female predominance (98.5%), particularly among elderly patients (mean age 71 ± 12.8 years). Ureter was the most commonly herniated structure (58.8%), followed by small intestine (20.6%). Most patients (80.9%) lacked an external gluteal bulge, contributing to diagnostic delays. CT emerged as the primary diagnostic modality (63.2%), with the pathognomonic "curlicue sign" representing a key feature in ureterosciatic herniation. Management approaches were evenly distributed between minimally invasive techniques (35.3%), open surgery (35.3%), and conservative management with ureteral stenting (29.4%). Laparoscopic and robotic approaches demonstrated shorter hospital stays (1-2 days vs 5-14 days for open repairs) and reduced postoperative pain, despite slightly longer operative times. Complication rates were low (5.9% surgical site infections), with no reported mortality.ConclusionIschiatic hernias require a high index of clinical suspicion for timely diagnosis, particularly in elderly females presenting with unexplained pelvic or sciatic pain. The evolution from open to minimally invasive surgical approaches has significantly transformed management outcomes, while ureteral stenting offers an alternative for high-risk patients with ureterosciatic hernias. The optimal approach remains individualized based on patient characteristics, hernia contents, and available surgical expertise.

BackgroundLong-term weight regain affects 20%-30% of patients after laparoscopic sleeve gastrectomy (LSG). We investigated whether single-incision laparoscopic sleeve gastrectomy (SILS) provides superior weight maintenance compared to conventional multi-port LSG.MethodsThis study is a retrospective analysis of prospectively collected data comparing 54 propensity-matched patients (27 SILS and 27 conventional LSG) operated between 2010 and 2017. Primary outcome was weight maintenance at 7 years. Secondary outcomes included safety profile, complications, quality of life, and patient satisfaction.ResultsGroups were comparable except baseline BMI (SILS: 40.17 ± 3.23 vs conventional: 43.71 ± 5.36 kg/m², P = .005). Single-incision laparoscopic sleeve gastrectomy demonstrated safety non-inferiority with no conversions, leaks, or reoperations in either group. Overall complications: 11.1% SILS vs 3.7% conventional (P = .308). At 7 years, SILS patients maintained significantly lower absolute weight (75.56 ± 13.24 vs 85.26 ± 19.78 kg, P = .039) despite similar %EWL (85.2% vs 92.6%, P = .396). Weight regain from nadir was 11.26 ± 9.24 vs 15.04 ± 14.10 kg (P = .250). Enhanced patient satisfaction scores in SILS (9.56 ± 0.93 vs 8.07 ± 1.90, P = 0.001) suggest a potential mediating mechanism.ConclusionsSingle-incision laparoscopic sleeve gastrectomy achieves superior long-term weight maintenance while demonstrating safety non-inferiority compared to conventional LSG. The technique resulted in 10 kg lower absolute weight at 7 years without increased complications. For appropriately selected patients, SILS offers a safe alternative with improved long-term metabolic outcomes.

Background: Previous upper abdominal surgeries (PUAS) hamper the identification and dissection of the common bile duct (CBD) during laparoscopic transductal common bile duct exploration (LCBDE). Indocyanine green (ICG) fluorescence cholangiography enables the real-time identification of extrahepatic bile ducts. However, the tissue penetration of ICG fluorescence is limited. The objective of the study was to evaluate the feasibility and effectiveness of ICG fluorescence-guided LCBDE in patients with PUAS.

Methods: A total of 176 patients who underwent either conventional LCBDE (n = 99) or ICG-guided LCBDE (n = 77) were enrolled in the study. A 1:1 matched, propensity score-matched analysis was performed using the following factors: gender, age, BMI, ASA score, CBD diameter, number of CBD stones, and previous surgical approach. The surgical outcomes of the two groups were compared.

Results: A well-balanced cohort of 122 patients was analyzed (n = 61 in the conventional group and n = 61 in the ICG group). The incidence of positive fluorescence in patients with PUAS was 88.5%. Time of CBD identification and total surgical duration were shorter in the ICG group with less intraoperative blood loss compared to the conventional group. There was no significant difference in the time of drainage tube extraction, conversion rate to open surgery, and intraoperative complication incidence between the two groups. Patients in the ICG group exhibited faster postoperative recovery, milder inflammatory responses, and reduced overall postoperative complication rate.

Conclusions: ICG fluorescence cholangiography contributes to faster identification of CBD, improved postoperative recovery, and fewer postoperative complications in patients with PUAS.

BackgroundPost-pull chest X-rays (ppCXR) are routinely performed after chest tube (CT) removal despite questionable utility. Prior studies suggest that ppCXR rarely alter management, but the impact of timing remains unknown. This study compares early vs delayed ppCXR on radiographic changes and clinical management in asymptomatic trauma patients. We hypothesized ppCXR timing may influence radiographic findings, but not reintervention rates.MethodsA retrospective study of trauma patients undergoing CT placement and removal at a level 1 trauma center from 2019 to 2022. Each ppCXR was classified as early (≤4 h) or delayed (>4 h). Primary outcome was reintervention after CT removal (CT replacement, VATS, or thoracotomy). Secondary outcomes included radiographic changes, unplanned ICU transfer, hospital and ICU LOS, and total CXRs.Results318 patients were included with a mean age of 47.2 years, 25.2% female, and 77.4% with blunt mechanism. Most had delayed ppCXR (78.3%) with mean delay of 7.2 h (2.3 vs 9.5 h, P < .001). No differences were found in radiographic changes (26.1 vs 29.3%, P = .708) or reintervention (4.3 vs 5.6%, P = .999) between groups. Radiographic changes occurred in 28.6% of ppCXR, but these findings display poor sensitivity (65.0%) and specificity (73.4%) for reintervention. Delayed ppCXR had more ICU transfers (0 vs 5.6%, P = .046), but no differences in hospital LOS, ICU LOS, or total CXRs.DiscussionThe timing of ppCXR did not affect detection of radiographic changes or reintervention rates. Our findings support growing evidence questioning routine ppCXR in asymptomatic trauma patients. Future multicenter studies are warranted to establish standardized protocols and reduce unnecessary imaging in trauma care.

BackgroundClinical practice guidelines (CPGs) shape surgical care and outcomes, but concerns persist regarding the diversity and expertise of their authors. Whether U.S. surgical society guidelines reflect inclusive and expert-driven authorship remains unknown.MethodsWe conducted a cross-sectional analysis of 213 CPGs published by 11 national U.S. surgical societies between 2015 and 2024. We assessed author gender, race/ethnicity, and prior publication history using validated name-based algorithms and PubMed queries. Authors were classified as underrepresented in medicine (URiM) if identified as Black and Hispanic/Latino. Trends over time were analyzed using the Jonckheere-Terpstra test.ResultsAmong 2185 authors, 557 (25.5%) were women and 111 (5.1%) were URiM. Over half of guidelines (52.1%) had no URiM authors, and 21.6% had no female authors. Female representation increased over time (P = 0.02), while URiM representation remained unchanged (P = 0.32). Representation varied widely across societies. Among first and corresponding authors, 45% had fewer than 5 topic-specific publications. Additionally, 486 (14.7%) of all authors had no prior guideline authorship experience.DiscussionCPGs published by U.S. surgical societies from 2015 to 2024 demonstrated persistent gaps in gender and racial/ethnic diversity, as well as inconsistent subject-matter expertise among authors. These findings raise concerns about the representativeness and rigor of current guideline development practices. Surgical societies should consider reforms to authorship selection processes to promote more inclusive and expert-driven guidance reflective of the populations they serve.

IntroductionThe optimal diagnostic pathway for pediatric acute appendicitis (AA) following an inconclusive or negative ultrasonography (US) is poorly defined, leading to debate over subsequent computed tomography (CT) use. This systematic review and meta-analysis compared negative appendectomy rates in children managed with a US-only pathway vs a pathway involving CT after a non-diagnostic initial US.MethodsFollowing PRISMA guidelines (PROSPERO: CRD42024568560), we systematically searched 6 databases, including PubMed and Embase, through July 2024 for longitudinal studies comparing the 2 diagnostic pathways. Two reviewers independently selected studies and extracted data. Risk of bias in included studies was assessed using the ROBINS-I and Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the GRADE framework. A fixed-effects meta-analysis was performed to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs).ResultsThe pooled analysis demonstrated that a US-only pathway was associated with significantly lower odds of negative appendectomy compared to the US-followed-by-CT pathway (OR 0.44; 95% CI 0.21-0.90; P = 0.02). This protective association was even more pronounced in the subgroup of patients with an initial inconclusive US (OR 0.22; 95% CI 0.05-0.89; P = 0.03).ConclusionIn children with suspected AA after a non-diagnostic US, a US-only pathway is associated with a significantly lower rate of negative appendectomy. These findings support strategies that prioritize clinical re-evaluation and repeat US to reduce unnecessary surgeries and radiation exposure. However, given the low certainty of evidence, clinical judgment remains paramount.

ObjectiveAs pulmonary segmentectomy becomes increasingly common in the treatment of early-stage lung cancer, providing relevant clinical training for residents is essential. However, understanding pulmonary segment anatomy can be challenging due to its complex and variable structures. This study aimed to evaluate the value of automated three-dimensional CT bronchography and angiography (3D-CTBA) technology in training surgical residents for segmentectomy.MethodsFifty-two surgical residents were randomized into 2 groups: the 3D-CTBA group and the control group. The 3D-CTBA group utilized automated 3D-CTBA technology alongside specific case for segmentectomy training, while the control group relied on traditional teaching methods. After the training sessions, all participants completed a post-training assessment and questionnaires. Additionally, we collected feedback from instructors regarding the residents' performance through a separate questionnaire.ResultsResidents in the 3D-CTBA group achieved significantly higher scores on the post-training assessments than those in the control group (83.46 ± 6.75 vs 68.27 ± 8.12, P < 0.001). Subjective survey results indicated that automated 3D-CTBA technology greatly benefited residents in preoperatively identifying tumor locations, recognizing anatomical variations during surgery, and mastering relevant surgical techniques. Feedback from instructors indicated that residents in the 3D-CTBA group performed better intraoperatively than those in the control group. Furthermore, residents in the 3D-CTBA group expressed greater interest in learning and higher satisfaction with the course.ConclusionsAutomated 3D-CTBA technology significantly improved residents' comprehension of the complex and variable anatomy of pulmonary segments, thereby enhancing their related surgical skills.

BackgroundSmoking is an established risk factor for postoperative complications. There is limited data on characteristics of smokers that increase risk beyond pack-years. This study aims to assess the effect of preoperative smoking duration and intensity, periods of cessation, and concurrent smokeless product use on colorectal surgery outcomes.MethodsA retrospective cohort study was conducted to assess operative details, demographic and smoking factors, and postoperative complications in smokers. The cohort included 239 current and former smokers who underwent colorectal surgery from 2012 to 2022. The primary endpoint was major adverse events 30-days postoperatively, defined as incidence of major bleeding, venous-thromboembolism, acute kidney injury, myocardial infarction, acute respiratory distress syndrome, stroke, infection, mortality, or readmission.ResultsThe most common procedure was colon resection. Average age at procedure was 63.9 ± 0.85 years, smoking duration was 27.0 ± 1.0 years, packs-per-day was 0.94 ± 0.04 packs, and pack-years was 26.0 ± 1.7. It was found that 11% of the patients concurrently used smokeless products (chew, dip, and/or vape). Half of the patients quit smoking prior to surgery. During the follow-up period, 28% had any major adverse event. Independent predictors of increased complications were chronic obstructive pulmonary disease (P = .01), pack-years (P = .02), and concurrent vape use (P = .01). Years of smoking (P = .01) was an independent predictor of complications, whereas packs-per-day (P = .33) was not. Former smokers (P = .03) had fewer complications than current smokers.DiscussionColorectal surgery patients with significant duration of smoking and/or concurrent vape use should be counseled regarding their increased risk of major postoperative complications.

Background: The use of neoadjuvant chemoradiation (NCRT) for upper rectal cancer remains controversial. Our aim was to determine whether NCRT was associated with improved outcomes. Methods: The US Rectal Cancer Consortium was queried for patients who underwent resection of nonmetastatic upper rectal cancer (≥12 cm from anal verge) from 2007-2017. Primary outcomes were recurrence-free (RFS) and overall survival (OS). Secondary outcomes were postoperative complications. Results: 193 pts met inclusion criteria; 100 (52%) did not receive NCRT and 93 (48%) did. Patients in each group had similar age, gender, and pathological stage (non-NCRT: 22% stage I, 32% stage II, 36% stage III; NCRT: 21% stage I, 23% stage II, 33% stage III; P = 0.143). Median follow-up was 31 months (non-NCRT) and 34 months (NCRT). On Kaplan-Meier analysis, NCRT was not associated with improved RFS compared to non-NCRT (3-year RFS 85% vs 80%; P = 0.34) or OS (3-year OS 88% vs 90%; P = 0.49). This finding persisted on multivariable cox regression. R0 resection rate was similar between groups at 99% (non-NCRT) and 97% (NCRT; P = 0.27). Anastomotic leak occurred in 11% of both cohorts. Creation of a diverting loop ileostomy (DLI) was nearly 3 times higher in NCRT (82%) vs non-NCRT patients (29%; P < 0.001). Conclusions: Among patients with nonmetastatic upper rectal cancer, NCRT did not improve survival or recurrence rates, but was associated with a nearly 3-fold higher DLI rate. Although NCRT is a mainstay of treatment for lower rectal cancer, our results do not support its use in upper rectal cancer.