American Surgeon最新文献

The management of primary hyperparathyroidism (PHPT) has evolved with increased recognition of asymptomatic and normocalcemic disease, improved imaging, and greater understanding of multiglandular involvement. Parathyroidectomy remains the only definitive cure and is now recommended for all symptomatic and asymptomatic patients meeting guideline criteria. Focused parathyroidectomy guided by dual-modality imaging and intraoperative PTH monitoring is effective for single-gland disease, while bilateral exploration is essential for in cases of multiglandular disease. Cure rates exceed 97% in experienced hands, with low complication rates. Surgery leads to improvements in bone mineral density, quality of life, and long-term survival. Ongoing research is needed to optimize localization strategies and define outcomes in emerging disease variants.

Artificial intelligence (AI) is rapidly transforming surgical care, with growing integration across all phases from preoperative planning to postoperative recovery. The role of AI in postoperative care represents a particularly promising frontier. Applications such as AI-generated discharge instructions, conversational chatbots, and computer vision-based wound monitoring have the potential to improve comprehension, enhance patient satisfaction, and reduce unnecessary health care utilization. While the economic impact remains underexplored, these innovations could substantially lower health care costs through safe, responsible implementation. This review explores current and emerging uses of AI in surgical aftercare, emphasizing its capacity to simplify complex information, provide accessible guidance beyond clinician availability, and enable early detection of complications. Thoughtful adoption of these tools may help bridge health literacy gaps, advance equitable care delivery, and optimize outcomes, particularly for underserved and marginalized populations.

Artificial intelligence (AI) and machine learning (ML) are rapidly transforming surgery, moving beyond traditional risk prediction to real-time clinical support and intraoperative assistance. However, successful integration requires clinicians to understand key methodological challenges, including overfitting, data bias, and the "black box" nature of many models, which can obscure interpretability and limit generalizability. Recent advances demonstrate AI's growing ability to process text and audiovisual data to streamline documentation, enhance intraoperative decision-making, and even perform basic operative tasks through robotic automation. This review outlines core ML principles relevant to surgical applications, discusses data modalities and evaluation metrics, and highlights emerging models that exemplify the evolving role of AI in the operating room. As these systems progress from experimental to practical use, understanding both their potential and limitations will be essential to ensure safe, effective, and ethically sound adoption in surgical practice.

ObjectiveTo develop and validate a nomogram for predicting the risk of postoperative prolonged ileus (PPOI) in patients undergoing gastric cancer (GC) surgery, providing a personalized risk assessment tool for early identification and optimized postoperative management.MethodsA retrospective cohort (January 2019-December 2023) was used to develop and internally test the nomogram, while a prospective cohort (January-December 2024) was used for external validation. Univariate and multivariate logistic regression with backward stepwise selection identified independent predictors. Model performance was assessed through receiver operating characteristic (ROC) curves, calibration curves, decision-curve analysis (DCA), and clinical impact curve analysis (CICA). Patients were stratified into low, medium, and high-risk groups based on nomogram scores for further analysis.ResultsA total of 780 patients in the training cohort and 294 in the validation cohort were included, with postoperative prolonged ileus rates of 11.54% and 16.33%, respectively (χ² = 4.371, P =.037). Independent predictors included electroacupuncture, pain self-efficacy questionnaire (PSEQ) score, preoperative serum albumin (Alb), body fat, postoperative day 1 Visual Analog Scale (Pod1 VAS), and intensive care unit (ICU) admission. The nomogram demonstrated strong discriminatory ability and calibration, with clinical utility confirmed through DCA and CICA. Higher nomogram scores correlated with increased PPOI incidence.ConclusionsThe developed nomogram is a valuable tool for early identification of PPOI in GC patients, supporting clinicians and nurses in implementing personalized preventive strategies.

Optimal timing for surgical intervention in small bowel obstruction remains controversial, with traditional guidelines recommending 48-72 h of conservative management before considering surgery. We conducted a systematic review and meta-analysis to determine whether early surgical intervention improves clinical outcomes and to identify predictors of failed conservative management. We searched PubMed, Embase, Cochrane Library, and Web of Science from January 2010 to October 2024 for studies comparing surgical timing in adults with small bowel obstruction. Primary outcomes included mortality, bowel resection rates, and complications. Random-effects models were used to calculate pooled risk ratios and odds ratios with 95% confidence intervals. Among 47 studies comprising 12 486 patients, early surgery within 24 h significantly reduced mortality (RR 0.53, 95% CI 0.34-0.82, P = 0.004), bowel resection rates (RR 0.56, 95% CI 0.43-0.73, P < 0.001), and overall complications (RR 0.62, 95% CI 0.48-0.79, P < 0.001) compared to delayed intervention. Time-stratified analysis revealed a progressive increase in complications from 18% at less than 6 h to 52% beyond 48 h (P < 0.001). Conservative management succeeded in 73% of patients overall. Significant predictors of failure included absence of flatus (OR 3.3), fever (OR 2.8), complete obstruction (OR 4.1), and free fluid on CT (OR 3.7). A risk score combining three or more factors predicted failure with 84% sensitivity and 78% specificity. This meta-analysis provides robust evidence that early surgical intervention within 24 h significantly improves outcomes in appropriately selected patients with small bowel obstruction. Risk stratification using clinical and radiological predictors enables individualized decision-making rather than adherence to arbitrary waiting periods.

Although rare, popliteal artery entrapment syndrome (PAES) should be considered in every young patient presenting with unexplained leg ischemia or exercise-induced claudication. Failure to recognize this condition can lead to delayed diagnosis, inappropriate treatment, and even limb-threatening complications. Symptoms such as calf pain, cramping, and paresthesia often overlap with musculoskeletal or vascular conditions, underscoring the need for a high index of suspicion. Diagnosis requires dynamic imaging with provocative maneuvers; while angiography remains the gold standard, Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography are increasingly used for both vascular and soft-tissue assessment. Conservative therapies rarely achieve durable results, and surgical intervention, ranging from myofascial decompression to arterial reconstruction, remains the definitive treatment, with early recognition and timely surgery being essential to prevent arterial damage and irreversible ischemia. This review summarizes the most relevant advances in the understanding of PAES, its anatomy, pathophysiology, clinical presentation, diagnostic strategies, classification, and management, with the goal of providing practical guidance for surgeons.

IntroductionFirearm-related injuries are a major public health concern in the United States, contributing to significant Emergency Department (ED) visits. Understanding the impact of neighborhood socioeconomic status (SES) on these injuries is crucial for prevention. The Area Deprivation Index (ADI) has traditionally been the gold standard for assessing neighborhood SES, while the Distressed Communities Index (DCI) is a newer alternative.ObjectiveThis study compares the predictive accuracy of the DCI and ADI in identifying ED visits due to firearm-related injuries using Maryland ED data (2019-2020).MethodsThis retrospective study analyzed firearm-related ED visits in Maryland from January 2019 to December 2020. Three logistic regression models were constructed: one using DCI, one using ADI (stratified into three deprivation levels), and one incorporating both indices. Covariates included age, sex, race, insurance, and comorbidities. Model performance was assessed using Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and Receiver Operating Characteristic (ROC) curves.ResultsOf the 2 392 813 injury-related ED visits, 2504 (0.1%) were firearm-related, predominantly affecting Black individuals (84.7%) and males (88.2%), with a mean age of 29.8 ± 9.9 years. The most deprived neighborhoods (per both indices) had the highest firearm injury incidence. The DCI-only model (AIC = 12 703.88) performed comparably to the ADI-only model (AIC = 12 748.6), with no significant improvement when combined.ConclusionDCI and ADI are comparable predictors of firearm-related ED visits.

IntroductionHypocalcemia is a common side effect of massive transfusion protocols (MTPs) after traumatic injury. The relationship between hypocalcemia severity and transfusion volume has been investigated, but the physiologic impact is not well understood. The aim of this study was to investigate calcium levels in MTP patients, hypothesizing that patients with hypocalcemia would experience an increased risk of mortality.MethodsA retrospective review of trauma patients undergoing MTP (≥10 units of blood within 24 hours) from 2018 to 2023 was conducted at a single institution. Ionized calcium (iCal) levels were collected on admission and after MTP. Calcium was administered with every four units of red blood cell products. Patients were stratified by 6- and 24-hour mortality. Logistic regression analysis was performed to assess for risk factors associated with mortality.Results153 patients underwent MTP with 39 (26%) patients dying within 6 hours and 52 (34%) within 24 hours. The median admission iCal was 0.97 mmol/L and 1.23 mmol/L after MTP. A median of 4 g of calcium was given during MTP. Patients who died within 6 hours had a lower median post-MTP iCal (0.84 vs 1.27 mmol/L, P < 0.001) and higher total grams calcium given (6 vs 4 g, P = 0.026). Higher post-MTP iCal was associated with decreased odds of mortality (OR 0.013) and remained significant in a multivariable model (Table 1) with similar results for 24-hour mortality (Table 2).ConclusionHypocalcemia after MTP is associated with increased 6- and 24- hour mortality. Aggressive and early correction may reduce mortality in MTP patients.

Background: Enterocutaneous fistula (ECF) management remains a complex clinical problem. Prehabilitation (prehab) protocols are becoming more popular. The prehabilitation protocol used in this paper was adopted in 2017 at the University of Florida. The Fistula Registry at University of Florida has captured the efforts of the UFAIR (University of Florida Abdominal Wall Reconstruction and Intestinal Rehab) service. We analyzed if the prehabilitation program is successful in reducing deaths, length of stay, recurrence of fistula, and readmissions to the hospital in our database.Methods: Charts were queried for patients with ECF/EAF from the UFAIR database from January 1, 2017, until present day. Several factors were recorded including: cause of fistula, recurrence of fistula, wound infection, postoperative sepsis, hospital length of stay, postoperative ICU length of stay, postoperative length of stay, death, discharge disposition, and if taken back to surgery.Results: 31 patients underwent prehabilitation while 30 patients underwent standard nutritional therapy. No deaths were reported in the prehab group, compared to 7 deaths in the standard group (P = .006). The prehab population had an average hospital stay of 15.19 days while the standard group had an average stay of 21.16 days (P = .045). 2/31 in the prehab protocol had a recurrence of ECF while 10/30 in the standard protocol recurred (P = .01). Conclusions: Our study showed promising data for the effects of prehabilitation protocol for patients with ECF. The outcomes of those in the prehab protocol surpassed historical outcomes. Our patients had no deaths, shorter hospital stays, and lower rates of recurrence.

BackgroundEmergency general surgery (EGS) patients who undergo interfacility transfer (IFT) experience higher rates of complications and mortality compared to those directly admitted (DA) to a hospital. However, their failure-to-rescue (FTR) rates-defined as mortality following a major complication-remain less studied. Given the increased burden of adverse outcomes in this population, we hypothesized that IFT patients would have higher risk-adjusted FTR rates than DA patients.MethodsWe performed a 5-year (2016-2020) retrospective analysis using the National Surgical Quality Improvement Program (NSQIP) database, focusing on patients aged 18 years and older undergoing high-risk EGS procedures, including enterectomy, colectomy, peptic ulcer surgery, and laparotomy. To assess the impact of IFT, we employed multivariable logistic regression models, adjusting for demographic factors, comorbidities, and procedure type.ResultsAmong 70 028 patients (52% female, 66% white, median age 66), 15 032 (21.4%) underwent IFT. After risk adjustment, IFT patients demonstrated significantly higher odds of major complications (OR 1.09, 95% CI 1.04-1.14), mortality (OR 1.23, 95% CI 1.16-1.31), and FTR (OR 1.12, 95% CI 1.04-1.19), suggesting that transferred patients are at a distinct disadvantage compared to DA patients.Discussion: Interfacility transfer is independently associated with worse outcomes in EGS patients, including higher FTR rates. These findings identify a vulnerable subpopulation of EGS patients that are readily identified by clinicians and highlights the need for future research to identify modifiable risk factors contributing to this disparity.