American Surgeon最新文献

IntroductionPancreatic ductal adenocarcinoma (PDAC) is considered one of the most aggressive malignancies, with approximately 90% of patients presenting with advanced disease. Despite advances in the treatment therapies over the last 30 years, the 5-year survival rate for Stage IV disease is approximately 3%. Understanding patterns of metastatic burden may refine staging and guide treatment goals and outcomes. This study evaluates metastatic distribution and site-specific survival among patients with PDAC using a large, recent nationwide cohort.MethodsData on all patients with metastatic PDAC were abstracted from the Nationwide Inpatient Sample (NIS) database (1998-2018). Patterns of metastases were identified using ICD-9 codes. Sites and rates of metastatic patterns were recorded. Standard statistical methods were used, and binary logistic regression was performed to assess the influence of metastatic site(s) on mortality.ResultsIn total, 119,620 patients were analyzed with a diagnosis of metastatic PDAC. The most common sites of metastases included liver (31%), regional abdominal lymph nodes (10%), peritoneum (8.5%), and respiratory tract (6%). The small intestine (4.1%) was more frequently involved than the large intestine (0.9%). The least common nodal site was the axillary nodes (0.05%). Less than 1% of patients had metastases in the head/neck and pelvic lymph nodes (0.2%), thoracic and mediastinal nodes (0.5%), or inguinal nodes (0.5%). Bone metastases (2.4%) were more common than ovarian (0.2%), renal (0.3%), and adrenal (0.7%) metastases. Brain metastases occurred in 0.4% of patients, and skin (0.1%) and CNS not otherwise classified (0.1%) were rarely involved. Metastases to lung (OR = 1.5), liver (OR = 1.7), brain and spinal cord (OR = 1.8), and bone (OR = 1.3), and presence of malignant ascites (OR = 2.03) independently influenced mortality, P = 0.01.ConclusionBased on NIS data, PDAC predominantly metastasizes to the liver, regional nodes, peritoneum, lung, and small intestine. Metastases to atypical sites are rare and suggest advanced burden of disease. Mortality was independently influenced by metastases to lung, liver, brain and spinal cord, bone, and peritoneum. Increased knowledge of metastatic patterns and site-specific survival may help guide decision-making regarding the treatment plan in terms of palliative care or adjuvant therapy.

BackgroundUnplanned ICU admissions (UA-ICU) is a TQIP metric associated with increased morbidity, mortality, and resource utilization. Despite identification of certain predictive factors in prior publications, gaps remain in identifying patients at-risk, particularly once in-hospital and outside the emergency room setting. Our study investigates novel predictors and emphasizes outcomes in UA-ICU for trauma.MethodsRetrospective cohort study. Single ACS-verified Level 1 Trauma Center (2019-2023). N = 140 UA-ICU after initial non-ICU hospital ward admission and 140 controls never admitted to ICU propensity-matched for age, gender, mechanism of injury (MOI), ISS, and top two highest abbreviated injury values (AIS). We compared variables including demographic, injuries, comorbidities, laboratory, and pharmacology. Statistical analysis was performed utilizing SPSS-28 (Armok, NY) software.ResultsUA-ICU patients demonstrated higher mortality (22.1% vs 1.4%, P < 0.001), longer length of stay (LOS) (10 vs 3 days, P < 0.001), and fewer discharges home (33.6%, P < 0.001). Comorbidity predictors included cirrhosis, active cancer diagnosis, CHF, and home medication for seizure and loop diuretics. Between 48-72 h post-admission, UA-ICU had higher heart rates (107 vs 96 P < 0.001), lower hemoglobin (11 vs 13, P < 0.001), lower platelets (193 vs 229, P = 0.002) and supplemental oxygen requirements (2L vs 0, P < 0.001).DiscussionOur study affirms established predictors and introduces novel indicators for UA-ICU. Length of stay, discharge other than home, and mortality outcomes are consistent with research linking UA-ICU to prolonged hospitalization and adverse outcomes. Early detection, dynamic monitoring, and interdisciplinary interventions should coalesce to mitigate preventable UA-ICU and conserve resources. We proposed integration of additional predictors into clinical practice/scoring systems to optimize patient outcomes.

ObjectiveThe objective of this study was to compare in-hospital outcomes and mortality in patients with and without a psychiatric comorbidity that presented to a trauma center with isolated blunt chest trauma and multiple traumatic rib fractures.Materials and MethodsThis is retrospective analysis using the American College of Surgeons Trauma Quality Improvement Program database (2014-2016). Patients ≥18 years with ≥3 traumatic rib fractures were stratified based on the presence or absence of a psychiatric comorbidity. In-hospital complications, length of stay, intensive care unit (ICU) admission, and mortality were assessed. Variables significant (P < 0.05) on univariate analysis were entered into logistic regression models to determine the independent effect of a psychiatric comorbidity on outcomes.ResultsAmong the 56,558 patients meeting inclusion criteria, 10.6% (n = 6022) had a psychiatric comorbidity. On univariate analysis, patients with a psychiatric comorbidity demonstrated significantly worse in-hospital outcomes, including higher rates of acute respiratory distress syndrome (ARDS) (1.0% vs 0.7%), deep vein thrombosis (DVT) (1.5% vs 1.2%), pulmonary embolism (PE) (0.8% vs 0.5%), pneumonia (4.2% vs 3.1%), urinary tract infection (2.4% vs 1.7%), and decreased mortality (2.2% vs 3.5%). After controlling for comorbidities, substance use, and demographic factors, psychiatric comorbidity was an independent predictor of ARDS (aOR 1.15, P < 0.01), DVT (OR 1.32, P = 0.017), PE (aOR 1.40, P = 0.004), pneumonia (aOR 1.36, P < 0.001), and decreased mortality (aOR 0.71, P < 0.001).ConclusionsThe presence of a psychiatric comorbidity increases in-hospital complications independent of patient characteristics, comorbidities, and trauma burden in patients presenting with multiple traumatic rib fractures.

Wound management in hidradenitis suppurativa (HS) patients is often challenging due to worsening infections and impaired circulation, which can lead to prolonged hospitalization and poorer quality of life. Traditionally, autografting-a leading option in skin grafting-exhibits risks, including donor site morbidity. However, xenograft products, such as Kerecis^TM, derived from North Atlantic Cod fish, offer a novel solution for conditions with chronic wounds by promoting natural tissue regeneration. This case report presents a 35-year-old woman with HS who presented with persistent abscesses and fistulas in bilateral axillary regions. Following multiple surgical incisions and drainage procedures, the patient was treated with intact fish skin grafting, which resulted in significant granulation tissue deposition and wound edge approximation. The successful outcome in this case suggests that intact fish skin grafting is a viable option for non-healing wounds, particularly HS wounds, and can be integrated into surgical and wound care practices.

Requests for major revision generate more anxiety than almost any other editorial decision, in part because authors struggle to interpret what the journal is signaling. Some view major revision as near acceptance and rush to make changes, while others interpret it as a softened rejection and respond incompletely. Both approaches miss the central purpose of major revision. A request for major revision represents a conditional investment by editors and reviewers. The topic is relevant and the question appropriate for the journal, but the manuscript is not yet ready for publication. This editorial provides practical guidance on how authors should respond, emphasizing judgment over persistence. Key principles include reading reviews with distance, understanding the structural issues underlying reviewer comments, and avoiding a checklist mentality. The editorial highlights the importance of using the response-to-reviewers form correctly, making revisions easy to identify, and respecting the significant time reviewers devote to thoughtful critique. Guidance is provided on responding without defensiveness, prioritizing core concerns related to framing and contribution, and reassessing whether the manuscript truly advances the field or has become redundant. Situations in which authors may reasonably decline to pursue revision, as well as how to disagree productively with reviewers, are also addressed. Major revision is neither a promise nor a rejection. When approached as collaboration rather than negotiation, it often results in a manuscript that is clearer, stronger, and more valuable to practicing surgeons.

BackgroundInformed consent is a cornerstone of ethical and legal medical practice, ensuring patients understand treatment benefits, risks, and alternatives. Patients often forget key details, potentially compromising decision-making. This study evaluates whether incorporating an informative video into the standard consent process enhances patient comprehension, retention, and satisfaction for laparoscopic cholecystectomy.MethodsThis single-center, parallel-group, superiority randomized controlled trial was conducted in a hospital setting in Turkey. It included 264 patients, evenly divided. The control group underwent standard verbal consent; the video-consent group received an informative video additionally. Both groups completed an 8-question knowledge test and the 32-point Client Satisfaction Questionnaire (CSQ-8) post-consent. Scores were compared statistically. Harms were assessed via patient self-report of adverse events or discomfort related to the consent process or video.ResultsThe video-consent group achieved significantly higher scores in the surgery and complications categories (P = 0.032 and P = 0.048). Significant differences were found for Questions 5 and 7 (P = 0.021 and P = 0.043). Satisfaction scores were higher in the video-consent group (P = 0.044), and satisfaction correlated with comprehension scores (P < 0.001). Older age negatively correlated with comprehension (P = 0.041), and secondary-educated patients in the video-consent group scored significantly higher (P = 0.039).ConclusionIncorporating video into the consent process improves patient comprehension and satisfaction, particularly for surgery and complications. Video-assisted consent is a valuable adjunct to traditional methods, enhancing patient understanding and engagement. Further studies are needed to explore its broader applicability.

The Accreditation Council for Graduate Medical Education (ACGME) conducts an annual trainee survey to evaluate program quality, but many institutions also use internal surveys to identify concerns earlier. This study examined resident and fellow perceptions of graduate medical education at one institution, particularly the effects of the COVID-19 pandemic on training and satisfaction. From 2018 to 2023, approximately 225-250 residents and fellows across multiple ACGME-accredited programs participated in annual surveys covering duty hours, faculty engagement, evaluations, wellness, scholarship, and quality improvement. Surveys were distributed via institutional email, responses captured on a 5-point Likert scale, and data analyzed with descriptive statistics and chi-square tests. Completion rates improved significantly from 78% in 2018-2019 to 99% in 2022-2023. Key improvements included compliance with the 80-hour workweek (84.4%-91.7%), faculty supervision (72.3%-84.5%), and wellness initiatives (68%-79%). Faculty effectiveness and educational interest also improved. Evaluation accessibility and feedback showed positive but non-significant trends. Participation in quality improvement declined during the pandemic but rebounded afterward. Overall, institutional responses to survey findings, supported by structured feedback, the House Staff Association, and wellness committees, enhanced satisfaction, compliance with ACGME standards, and educational outcomes. Internal surveys effectively complemented the national ACGME survey, providing a proactive tool to adapt programs and strengthen resident wellness, particularly during the challenges of the COVID-19 pandemic.