American Surgeon最新文献

Background: Although existing work has evaluated outcomes associated with care fragmentation (CF), these adverse consequences may be accentuated in patients undergoing bariatric operations. This retrospective study examined the association of CF with clinical and financial outcomes among patients receiving bariatric surgery.

Methods: All adult (≥18 years) records for bariatric operations were tabulated from the 2016-2021 Nationwide Readmissions Database. Patients with nonelective rehospitalization at a non-index facility within 30 days of index discharge comprised the CF cohort (others: No-CF). Multivariable linear and logistic models were developed to assess the association of care fragmentation with outcomes of interest.

Results: Of an estimated 38,842 patients, 5591 (17.0%) comprised the CF cohort. Compared to No-CF, CF was older, less likely to be female, and more frequently insured by Medicare. Following comprehensive risk adjustment, CF demonstrated increased odds of respiratory (adjusted odds ratio [AOR] 1.61, 95% CI 1.37-1.90), renal (AOR 1.56, 95% CI 1.38-1.76), and thromboembolic (AOR 2.03, 95% CI 1.71-2.41) complications. Additionally, those who experienced CF demonstrated increased odds of non-home discharge (AOR 2.03, 95% CI 1.70-2.42).

Conclusions: Care fragmentation is associated with increased mortality, complications, non-home discharge, and hospitalization costs. Initiatives such as patient education, harmonizing postoperative care, and facilitating returns to the index hospitals may minimize the adverse effects of CF to improve the continuation of care following bariatric operations.

Background: Agriculture is a hazardous industry, with tractor-related incidents being among the leading causes of traumatic injury and death. These injuries tend to take place far away from hospitals, thus leading to increased prehospital time to receive care. Understanding the relationship between prehospital time and outcomes such as hospital length of stay and mortality in the state of Nebraska could inform resource allocation for tractor related injuries.

Study design: A 10-year retrospective study abstracting adults involved in tractor injuries using The Nebraska State Trauma Registry was performed. Mortality was evaluated using standard logistic regression, while length of stay outcomes were estimated using the negative binomial distribution. Adjusted model covariates included age, arrived from status, and Injury Severity Score.

Results: A total of 100 tractor-related injuries were included. Extremity injuries made up the largest percentage of injury types (44%). Injury severity scores were considered low in most patients. The majority of injuries were experienced by a party not operating the tractor. After adjusting for age, the scene of patient arrival, and Injury Severity Score, total prehospital time was not a significant predictor of facility length of stay or mortality.

Conclusion: Access to care is an ongoing problem for many communities in the United States, with the Midwest having some of the largest regions with poor access to care. We did not find a significant relationship between prehospital time and outcomes related to length of stay or mortality. Future studies should assess for differences in outcomes among accident types such as roll-over accidents vs collisions.

Background: The 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.

Method: This 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.

Result: After 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).

Discussion: CNSI-guided laparoscopic distal gastrectomy is less time-consuming and harvests more LNs. For laparoscopic distal gastrectomy, CNSI-guided lymphography can be an excellent adjuvant.

Objective: This study was aimed at ascertaining the application value of abnormal prothrombin (PIVKA-II) and carbohydrate antigen 125 (CA125) in gallbladder cancer (GBC) diagnosis.

Methods: A total of 70 GBC patients, 70 patients with benign gallbladder diseases (gallbladder stones and gallbladder polyps), and 70 normal health examination people were selected as the malignant, benign, and normal groups, respectively. The differences in serum levels and positive rates of PIVKA-II and CA125 were compared. The correlation between serum PIVKA-II and CA125 levels and different clinicopathological characteristics (TNM stage and differentiation degree) of GBC patients was analyzed. The receiver operating characteristic curve was plotted to evaluate the diagnostic value of serum PIVKA-II and CA125 for GBC, and sensitivity, specificity, and Youden's index were calculated.

Results: Serum PIVKA-II and CA125 levels and positive rates of patients in the malignant group were higher vs those in the benign and normal groups. Gallbladder cancer patients at stages III-IV had higher serum PIVKA-II and CA125 levels than those at stages I-II, and poorly differentiated GBC patients had higher serum PIVKA-II and CA125 levels than moderately differentiated and well-differentiated GBC patients. The AUC of serum PIVKA-II and CA125 alone and in combination were 0.771, 0.789, and 0.866, respectively, and the AUC of the two combined was higher vs that of the two alone.

Conclusion: Serum PIVKA-II and CA125 levels in GBC patients are increased and have significant clinical application value in the diagnosis of GBC.

The goal of our study is to evaluate the safest, efficient, and most cost-effective way to manage suspected choledocholithiasis. This retrospective study evaluated adult patients with suspected choledocholithiasis based on labs and imaging at a single institution between 2017 and 2022 and characterized them into 1 of 3 groups based on their management pathway: (1) ERCP-first, (2) MRCP-first, or (3) surgery-first with possible intraoperative cholangiogram pending laboratory trend. Our primary outcome was hospital length of stay. 34 patients (25%) had MRCP-first, 60 patients (45%) had ERCP-first, and 39 patients (30%) received surgery first. There was no statistically significant difference in the length of stay with respect to the management pathway utilized (P > .05); however, those admitted to a surgical service were discharged on average one day before those admitted to the medicine service (P = .01).

Background: Solid 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.

Methods: We 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.

Results: All 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.

Conclusion: Laparoscopic Warshaw for SPN in children appears highly effective at preserving splenic volume without compromising oncologic fidelity or consuming excess inpatient resources.

The Appalachian region consists of over 26 million Americans, of whom almost 2.5 million live in rural areas. Various social determinants of health including but not limited to rural living conditions and geographic isolation, food insecurity, and low income contribute to disparate health outcomes compared to the rest of the country. Obesity, hypertension, diabetes, stroke, and chronic heart diseases are all more prevalent in Appalachia. These comorbidities, combined with the aforementioned social vulnerabilities, place the Appalachian population at increased risk of higher cancer incidence and poorer outcomes. Lung, cervical, breast, penile, prostate, colorectal, and head and neck cancers are all shown to have higher rates and poorer outcomes within Appalachia relative to the country. Advanced staged colorectal cancer patients are a unique population that may be even further impacted by the social inequities in Appalachia, given the resource-intensive and multi-disciplinary approach required for effective treatment. Unfortunately, there is a dire lack of investigation into the incidence and outcomes of advanced stage colorectal cancer in Appalachian residents. This review summarizes the existing literature on disparate cancer outcomes in the Appalachian population, with a focus on advanced stage colorectal cancer. We also propose various approaches that could decrease malignancy rates and improve outcomes, such as dietary adjustments, screening tools, and public educational endeavors. We also acknowledge the role high-volume centers can play in working towards accessible care and the potential for collaborations between large institutions within Appalachian regions to spur the change that is greatly needed.

Minimally invasive surgery (MIS) has demonstrated significant clinical and economic benefits that have been consistently validated and reproduced in practice and the literature for the past few decades. These benefits include improved patient outcomes, reduced complications, shorter hospital stays, decreased narcotic use, quicker recovery times, and lower rates of wound infections. However, safety-net hospitals, which historically serve a larger percentage of underserved and marginalized populations, often lack the resources to invest in high capital equipment. This limitation decreases access for these marginalized groups to the advantages of MIS, particularly robotic surgery and a wider range of surgical operations. This disparity in access to care highlights a critical shortfall in the delivery of health care for these patients and other vulnerable populations.

Introduction: Artificial Intelligence (AI) has emerged as a promising tool in the delivery of health care. ChatGPT-4.0 (OpenAI, San Francisco, California) and Llama 2 (Meta, Menlo Park, CA) have each gained attention for their use in various medical applications.

Objective: This study aims to evaluate and compare the effectiveness of ChatGPT-4.0 and Llama 2 in assisting with complex clinical decision making in the diagnosis and treatment of thyroid carcinoma.

Participants: We reviewed the National Comprehensive Cancer Network® (NCCN) Clinical Practice Guidelines for the management of thyroid carcinoma and formulated up to 3 complex clinical questions for each decision-making page. ChatGPT-4.0 and Llama 2 were queried in a reproducible manner. The answers were scored on a Likert scale: 5) Correct; 4) correct, with missing information requiring clarification; 3) correct, but unable to complete answer; 2) partially incorrect; 1) absolutely incorrect. Score frequencies were compared, and subgroup analysis was conducted on Correctness (defined as scores 1-2 vs 3-5) and Accuracy (scores 1-3 vs 4-5).

Results: In total, 58 pages of the NCCN Guidelines® were analyzed, generating 167 unique questions. There was no statistically significant difference between ChatGPT-4.0 and Llama 2 in terms of overall score (Mann-Whitney U-test; Mean Rank = 160.53 vs 174.47, P = 0.123), Correctness (P = 0.177), or Accuracy (P = 0.891).[Formula: see text].

Conclusion: ChatGPT-4.0 and Llama 2 demonstrate a limited but substantial capacity to assist with complex clinical decision making relating to the management of thyroid carcinoma, with no significant difference in their effectiveness.