American Surgeon最新文献

BackgroundMild traumatic brain injuries (TBI) are often overmanaged, resulting in an inefficient use of time and resources. The Brain Injury Guidelines was developed and subsequently improved as the modified Brain Injury Guidelines (mBIG) to help standardize TBI management. This study evaluates how adopting the mBIG criteria could improve TBI management at our institution.Materials and MethodsThis retrospective observational study included patients aged 18 to 89 admitted for isolated TBI to our Level 1 trauma center ICU between January 2021 and December 2023. Patients were categorized into 3 groups using the mBIG guidelines-mBIG 1, 2, and 3; mBIG 3 were excluded. Data were collected through the institutional trauma registry and chart review.ResultsThe study included 46 mBIG 1 and 44 mBIG 2 patients, who were comparable in terms of characteristics, clinical presentation, and procedures. Both groups had similar clinical outcomes, including in-hospital complications, mortality, discharge disposition, and 30-day readmission, and utilized hospital resources. All patients had a neurosurgery consult, with 49 repeat head CTs in the mBIG 1 group and 50 in the mBIG 2 group. The total combined cost for repeat head computer tomography (RHCTs) scans, magnetic resonance imaging (MRIs), computed tomography angiography (CTAs), neurosurgical consultations, and ICU stay in both groups was $337,637.4.DiscussionThe overutilization of imaging, ICU admissions, and neurosurgeon consultations can strain institutional resources and may not benefit patients with mild TBI. By adopting the mBIG criteria, institutions can implement a more efficient and safe management strategy, allowing these valuable resources to be better allocated to more severely injured patients who require them.

BackgroundAppendicitis in children can be treated with operative management (OM) or non-operative management (NOM) depending on patient risk factors. Our goal was to evaluate for differences in being offered NOM before and after the implementation of a standardized clinical pathway among patients of different demographic backgrounds.MethodsThis was a single center retrospective study of patients under the age of 18 years with appendicitis. Univariate regression was used to assess for associations between demographic factors and patients who were offered NOM.ResultsThere were 730 unique patient encounters for appendicitis during the study period. Qualified patients had significantly increased odds of being offered NOM in the post-pathway period than in the pre-pathway period (OR = 2.21, 95^th CI 1.28-3.82). In the post-pathway period, Hispanic/Latino patients (OR = 0.47, 95^th CI 0.28-0.78) and patients in the 4^th social vulnerability index quartile (OR = 0.46, 95^th CI 0.23-0.94) had decreased odds of being offered NOM. Patients with private insurance (OR = 2.25, 95^th CI 1.33-3.79) had increased odds of being offered NOM. When restricted to patients who qualified for NOM, female patients (OR = 2.66, 95^th CI 1.02-6.93) and patients with private insurance (OR = 3.26 95^th CI 1.31-8.15) were more likely to be offered NOM.ConclusionA clinical pathway for appendicitis increased the odds that qualified patients were offered NOM. However, differences in who was offered NOM based on demographic features were seen. More research on the effect of clinical pathways and factors impacting differential care is needed.

BackgroundThe relationship between the number of revascularization procedures and the level of major lower extremity amputation in chronic limb-threatening ischemia (CLTI) remains unclear. We aim to determine whether the revascularization frequency is associated with the level of amputation and whether procedural burden influences postoperative outcomes.MethodsWe performed a retrospective chart review of 252 patients who underwent major lower extremity amputations for CLTI from 2014 to 2022. The primary outcome was the association between revascularization frequency and amputation level, categorized into above-knee amputation (AKA) or non-AKA (through-knee and below-knee). Secondary outcomes included the association of revascularization level and type (open, endovascular, or hybrid) with AKA risk. Other outcomes were postoperative complications, readmission, reamputation, and mortality. Multivariable logistic regression adjusted for age, diabetes, and disease level.ResultsThe mean age was 55.9 years, with 61.9% male patients, and 58.3% identifying as Black. Most had hypertension (86.5%) and diabetes (62.3%). Among the cohort, 45% of the patients had no revascularizations. 47.6% underwent 1-2 procedures, and 7.5% underwent three or more procedures. Undergoing ≥3 revascularizations was significantly associated with increased odds of above-knee amputation (AKA) (OR: 6.33, 95% CI: 2.00-20.00, P = 0.002). Disease level and type of revascularization were not significantly associated with amputation level. There were no significant differences in postoperative complications, readmissions, reamputations, or mortality between AKA and non-AKA groups.ConclusionPatients undergoing three or more revascularization procedures were significantly more likely to undergo an AKA, suggesting a threshold effect where additional interventions may diminish patient benefits.

Burn injuries over previously grafted tissue present a formidable challenge for excision and debridement, particularly when there are critical underlying structures such as bowel. Enzymatic debridement with the recently approved anacaulase-bcdb, a bromelain-based enzymatic debridement gel (Nexobrid^®), presents an additional method of burn excision that may be useful in such a situation. This brief report presents the management of a complex third-degree burn over a remotely skin-grafted bowel mass using anacaulase-bcdb gel. This report is written with documented patient consent and approval by the Human Research Protection Program office in compliance with institutional policy. A 52-year-old man presented to our level I burn center with a third-degree 3% total body surface area contact burn to a remotely skin-grafted bowel mass. The patient was admitted with the decision to proceed with anacaulase-bcdb debridement of his wound to minimize the risk of compromising his underlying bowel. The patient underwent the debridement without any sign of succus emanating from the wound. Post-debridement, he was transitioned to a negative pressure wound dressing and discharged home. He continued receiving wound care at clinic follow-ups and eventually underwent complex open ventral hernia repair. This brief report provides a safe alternative to operative excision of wounds with underlying critical structures.

BackgroundWhistal (Whipple + Distal) is a rare parenchyma-preserving technique for select patients with disease in both the pancreatic head and tail, sparing a disease-free middle segment. It may also be used after prior partial pancreatectomy. Surgical resection remains the cornerstone of treatment for pancreatic diseases such as PDAC, RCC metastasis, and multifocal IPMN. Whistal may balance oncologic control with pancreatic function preservation. Though infrequent, it is practiced and reported in literature.MethodsWith IRB approval, a retrospective review of a prospective database (Aug 1999-Mar 2024) identified Whistal cases, categorized as staged Whistal (SW) or concomitant whistal (CW). Perioperative outcomes were assessed via Clavien-Dindo and ISGPS. A PubMed search identified reported middle segment pancreatectomy (Whistal) cases.ResultsOf 2008 resections (Aug 1999-Mar 2024), 5 were Whistals (3 CW, 2 SW) for PDAC (n = 3), RCC (n = 1), IPMN (n = 1), and bile duct stricture (n = 1). Rates for major morbidity, POPF, and DGE were each 40%. Literature review found 26 papers reporting 52 additional Whistal cases.ConclusionWhistal is safe for select patients, but wider adoption and long-term data are needed to confirm its efficacy.

BackgroundAugmented reality offers multiple enhanced diagnostic imaging visualization opportunities. The objective of this pilot study was to assess the applicability of HoloLens augmented reality in resident education.Methods34 categorical general surgery residents, postgraduate years (PGY) 1-5, reviewed a CTA and 3D hologram on Intravision XR using the Microsoft HoloLens 2 of the renal anatomy of 2 donor nephrectomy patients. Residents were randomized into 2 groups altering which modality was visualized first then described their findings and answered a device usability questionnaire.Results45.5% PGY-1s, 75% PGY-2s, and 86.7% PGY-3-5s correctly identified the pathology on the HoloLens compared with 45.5%, 50%, and 86.7%, respectively, on the CTA. 84% of participants appreciated improved visualization of the illustrated pathology with AR. 82% of participants stated an improved view of the vasculature using the HoloLens model. 25% of residents preferred using the HoloLens to traditional CT imaging.ConclusionsDespite being unable to obtain statistically significant results due to sample size, we observed that HoloLens renderings were non-inferior to conventional CT scans when it came to residents detecting pathology on an imaging study and superior at the PGY-2 level with an increasing preference towards use of the HoloLens with more senior PGY levels. This technology may assist residents in getting a fresh perspective on imaging studies and anatomical variations and improve resident education.

This perspective examines recent legislation in multiple U.S. states that allows foreign-trained physicians (FTPs) to obtain medical licensure without completing an ACGME-accredited residency or fellowship. While these laws aim to address physician shortages, they raise important concerns for surgical education and patient care. The article outlines how current licensure pathways lack mechanisms to verify equivalence of international training and may disrupt residency and fellowship training. Moreover, although the policies are framed as rural workforce solutions, most provisional license placements occur in urban academic centers, with no mandate for rural service. Further, the article highlights risks to informed consent, noting that patients may unknowingly receive surgical care from providers who did not complete U.S.-based training, a fact not currently subject to mandatory disclosure. Ultimately, the article calls for greater oversight, transparency, and alignment of these policies with educational and ethical standards to ensure they do not compromise the quality of surgical care.

BackgroundComponent separation technique (CST) has emerged as a novel surgical strategy in the management of large and complex hernia defects. Although prior work has associated CST with decreased hernia recurrence and improved clinical outcomes, the impact of hospital-level variation in component separation utilization remains understudied.MethodsThis retrospective cohort study investigated the impact of operative volume on outcomes in patients undergoing CST. All adult (≥18 years) records for elective CST procedures were tabulated using the 2016-2021 Nationwide Readmissions Database. Hospitals ranked in the top quartile of annual CST volume were defined as high-volume hospitals (HVH; others LVH, MVH, and MHVH). Multivariable regression models were developed to characterize the association between HVH status and outcomes of interest.ResultsOf an estimated 12 720 patients undergoing component separation, 3359 (26.3%) underwent treatment at HVH. Although CST utilization increased significantly over the study period, the total number of high-volume centers remained relatively stable. Additionally, Medicaid recipient status, lowest income quartile, and treatment at rural hospitals were all associated with lower odds of component separation use. Following comprehensive risk adjustment, HVH status was associated with decreased odds of major adverse events (AOR [adjusted odds ratio] 0.75, 95% CI [0.61, 0.91], P = 0.003). However, the HVH cohort had similar resource utilization compared to their LVH, MVH, and MHVH counterparts.DiscussionHigher CST hospital volume was linked with improved clinical outcomes without increased resource utilization. Persistent disparities in component separation utilization highlight the need for protocol standardization and expanded access to specialized surgical care nationally.

Background: Primary surgery in metastatic breast cancer (MBC) has been a subject of debate in part due to the heterogeneity of the results of individual studies. We synthesized evidence from the existing randomized clinical trials (RCTs) to evaluate the effect of primary surgery on health-related quality of life (HRQoL) in MBC. Methods: We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and ClinicalTrials.gov and gray literature till January 2025. Included were RCTs among patients with MBC for whom outcome data on HRQOL was reported. Results: Of the 1019 records screened, four RCTs (961 patients) were included. The risk of bias was high in one RCT and moderate in three. Four HRQoL tools were deployed. Three moderate-quality RCTs measured HRQoL specifically at 18 months: One was in favor of surgery (BR23 18.7 vs. 10.0, P = 0.009), one showed no difference (BR23 10.4 vs. 12.0, P = 0.45), and one was in favor of avoiding surgery (FACT-B 74.2 vs. 68.0, P = 0.005). Two moderate-quality RCTs measured HRQoL generically at 18 months: None showed any difference (C30 64.7 vs. 60.0, P = 0.3 and C30 63.5 vs 68.7, P = 0.2). One low-quality RCT measured HRQoL generically at 36 months: It showed no difference (SF-12 40.8 vs. 43.4, P = 0.34). Primary surgery improved specific HRQoL at 18 months in one study and deteriorated in another, compared to non-surgical treatment, among moderate-quality trials. Conclusion: The pros and cons of surgery as a palliative option should be considered in shared decision-making for improving life quality among individual patients.

BackgroundPulmonary benign metastasizing leiomyoma (PBML), characterized by histologically benign lung metastases from uterine leiomyomas, represents a rare hormone-dependent entity with enigmatic pathogenesis. The aim of the study was to define the clinical-radiological features and therapeutic management of pulmonary benign metastasizing leiomyoma.MethodsA total of 115 cases of PBML in women were reviewed, including 105 cases selected from PubMed and 10 cases treated at our institution from 2014 to 2025. Data encompassed clinical history, imaging findings, pathological diagnosis, treatments, and follow-up outcomes. A comprehensive literature review was undertaken. No prospective interventions were performed.ResultsA systematic review identified 105 published PBML cases. Combined with our institutional cohort (n = 10), analysis of 115 patients revealed a median age of 46 years, with bilateral pulmonary nodules present in 68.7% of cases and a history of uterine surgery in 92.1%. Immunohistochemistry consistently showed positivity for smooth muscle markers (90%), estrogen receptor (86.3%), and progesterone receptor (88.2%). Surgical resection of pulmonary lesions was performed in 42.6% (49/115) of patients and was associated with a favorable prognosis, with 85.2% (41/48) of surgically managed patients achieving disease-free status during follow-up.ConclusionPulmonary benign metastasizing leiomyoma is a rare hormone-dependent neoplasm linked to uterine leiomyoma. Pathological verification remains essential for diagnosis. Surgical resection may correlate with favorable outcomes, necessitating long-term recurrence surveillance.