American Surgeon最新文献

IntroductionDuring the newborn period, circumcision is performed under local anesthesia, but for older infants it is typically performed by general surgeons or urologists under general anesthesia. Recent literature debates over a concern for neurotoxicity associated with general anesthesia in the developing brain, and it is important to create techniques to decrease exposure to neurotoxic agents while still allowing safe performance of procedures. We performed a prospective feasibility study performing circumcision with use of caudal block as the primary anesthetic with a natural airway under dexmedetomidine sedation.MethodsThis is a single-institution, prospective comparative study of male patients undergoing outpatient circumcision ages 2 to 24 months. A 1:3 case-control match was utilized. Patients underwent circumcision with natural airway, caudal block, and dexmedetomidine sedation compared to patients performed under general anesthesia. The primary endpoint was successful performance of the operation and secondarily assessed operative times, total-OR times, and intra- and postoperative medication use.Results27 patients were enrolled in the study. Of the 27 patients, 23 (85%) successfully tolerated the procedure after caudal block was performed. Four patients required conversion to placement of an LMA for deeper sedation. Patients had similar OR and operative times, with significantly less Sevoflurane exposure time and less postoperative fentanyl use compared to control.ConclusionCaudal block with intravenous sedation is a feasible alternative to maintaining general anesthesia during circumcision in young patients. It avoids prolonged airway instrumentation and provides adequate intra- and postoperative analgesia without increased postoperative pain or change in expected recovery time.Level of EvidenceLevel 2; prospective comparative study.

IntroductionThe role of elevated shock index is increasingly recognized as a vital indicator in the assessment of mortality rates in trauma patients. Its role in combination with other parameters is crucial yet underexplored in predicting outcomes. We hypothesized that qualitative assessment of elevated admission shock index, elevated base deficit/excess, and elevated lactate in combination would best predict mortality after blunt trauma.MethodsThis study was a retrospective review of trauma registry data on blunt trauma patients from 2012 to 2021 at a level 1 trauma center to evaluate the impact of elevated SI (>0.7), elevated lactate 2 mmol/L to 5 mmol/L, and elevated base deficit ≤-2 mmol/L at admission on predicting mortality. We used these parameters as qualitative and categorical predictors rather than continuous measures. A multivariate logistic regression model was developed, with shock index severity stratification and mortality as primary outcomes.ResultsA total of 4794 patients (151 non-survivors) were included in the analysis. Non-survivors had higher rates of elevated SI + elevated lactate + elevated BD (13.9% vs 5.8%, P < 0.001) with highest overall OR (11.7, P < 0.001) compared to other parameters (age 5.5, severe ISS 9.5, and GCS <8 10.3). When stratified by severity, patients with moderate SI (1.0 < SI <1.4) had a significantly increased risk of mortality in combination with elevated lactate and elevated base deficit (OR 21.1, P < 0.001).ConclusionWe previously reported a qualitative model predicting blunt trauma mortality rates using elevated lactate and elevated base deficit. Combining admission SI, whether mild and moderate, with elevated lactate and elevated base deficit as qualitative "elevated" biomarkers yielded a more robust predictive model and highest OR for predicting mortality in blunt trauma non-survivors, with an 11.7-fold increase compared to survivors. This was higher than the individual parameters or other combinations.

BackgroundDiverticular disease affects over half of individuals over 60, with 25% developing diverticulitis. While Hartmann's procedure has traditionally been the standard for unstable patients, resection with primary anastomosis and diverting loop ileostomy (PADLI) is associated with higher stoma reversal rates and improved long-term outcomes. Despite evidence supporting PADLI, socioeconomic factors may influence procedural selection, contributing to persistent disparities in care.MethodsA retrospective cohort study was conducted using the 2015-2021 National Inpatient Sample (NIS) to identify patients undergoing emergent surgery for acute diverticulitis. Patients who received left colectomy or sigmoidectomy were classified by procedure type (Hartmann's vs PADLI) using ICD-10 codes. Demographic and socioeconomic factors were analyzed including age, sex, race, insurance type, income quartile, in-hospital mortality, length of stay, discharge disposition, and urban vs rural residency. The impact of these factors on procedure choice was assessed using multivariate logistic regression.ResultsAmong 14 551 patients, 85.5% underwent Hartmann's procedure and 14.5% received PADLI. Older age (OR 1.014/year, P < 0.001), female sex (OR 1.129, P = 0.011), white race (OR 1.128, P = 0.041), and lower income (OR 1.223, P < 0.001) were associated with higher odds of receiving Hartmann's procedure. Private insurance reduced this likelihood (OR 0.747, P < 0.001). Primary anastomosis and diverting loop ileostomy was more common in metropolitan areas, younger patients, those with private insurance, and those discharged routinely.DiscussionSocioeconomic disparities significantly influence surgical management of acute diverticulitis. Lower-income and publicly insured patients are more likely to undergo Hartmann's procedure, while PADLI is more common in wealthier, urban populations. Addressing these disparities could promote more equitable care and improve patient outcomes.

Introduction: Patients are commonly discharged to either home health care (HHC), skilled nursing facility (SNF), or inpatient rehabilitation facility (IRF) following surgical stabilization of rib fractures (SSRF) to assist with recovery. This study explores demographic and surgical factors that may be associated with discharge disposition to a transitional care setting (HHC, SNF, and IRF) relative to routine discharge (self-care) following SSRF. Methods: Patients who underwent SSRF between 2017 and 2021 were included using retrospective data from the National Trauma Data Bank. Patients were stratified by discharge status: routine, HHC, SNF, or IRF. Multinomial logistic regression models were estimated to assess the association between discharge disposition and patient demographic and clinical factors. Results: We abstracted approximately 10, 000 SSRF patients between 2017 and 20. Older age, private insurance, and female sex were associated with greater odds of discharge to either HHC, SNF, or IRF than routine discharge. Compared to white patients, black patients were associated with lower odds of discharge to SNF and IRF. Injury severity score, hospital length of stay, time on ventilator, and experiencing a pulmonary embolism were associated with greater odds of discharge to HHC, SNF, and IRF relative to routine. However, the number of ribs fractures and plated were not significantly associated with discharge to HHC or SNF (P > 0.05). Conclusion: This study indicates several patient characteristics and surgical factors to consider when forming a transitional care plan for patients following SSRF, which may help guide patient counseling and improve postoperative outcomes.

The goal of this study is to evaluate whether patients with body mass index (BMI) greater than 35 who undergo hiatal hernia repair are at an increased risk of recurrence and postoperative complications when compared to their counterparts with a BMI less than 35. This retrospective study evaluated patients who underwent elective hiatal hernia repair between 2017 and 2022 at a tertiary care center. Patients were stratified into 2 groups based on BMI: those 35 or greater (BMI-H) and those less than 35 (BMIL). Propensity score matching was performed. BMI-H had 103 patients and BMI-L had 200 patients. The rates of recurrence at 1, 3, and 5 years postoperatively were not significant between the groups nor were the secondary outcomes. We should not exclude patients with a BMI equal to or greater than 35 from undergoing hiatal hernia repair on the basis of BMI alone.

Respecting patient wishes regarding resuscitation is fundamental to providing patient-centered care. Despite best practice guidelines for code status management for patients undergoing invasive procedures with existing Do Not Resuscitate (DNR) orders, compliance is low. Our interdisciplinary team created a workflow for code status management of inpatients with active DNR orders undergoing cardiac catheterization (CC) or electrophysiology (EP) procedures. Representatives from nursing, cardiology, surgery, palliative care, internal medicine, and information technology (IT) were involved. We used the workflow for 32 inpatients to temporarily rescind DNR orders for cardiology procedures. Average patient age was 76.6 years. Code status discussion was documented preprocedurally for 78% of patients; however, the documenting clinician varied. Over one third (37.5%) of cases were done with the primary goal of extending the patient's life. Four patients died during the same hospitalization as the procedure. The workflow was well received by stakeholders who appreciated the efficiency and clarity of the process. Interdisciplinary collaboration with key stakeholders and IT support were integral to the success of this intervention.

BackgroundApproximately 20% of the U.S. population resides in rural areas where health care access is limited by physician shortages. This presents a disparity in emergency general surgery where timely intervention is essential. This study aims to evaluate the impact of rurality on outcomes of emergency general surgery patients transferred to a metropolitan center.MethodsA retrospective single-center cohort study of 1189 patients who underwent non-traumatic emergent exploratory laparotomies. Patient rurality was determined by Rural-Urban Commuting Area (RUCA) codes which categorize patients as metropolitan, micropolitan, small town, or rural. The primary outcome was in-hospital mortality.ResultsRural (n = 369) and small-town (n = 135) patients had similar preoperative comorbidities, Physiological Emergency Surgery Acuity Scores (PESAS), utilization of damage control laparotomies, ICU metrics, and outcomes compared to those that presented to a metropolitan center (n = 508). In contrast, micropolitan (n = 177) patients had higher PESAS scores (5 vs 3, P < 0.0001) and underwent more damage control laparotomies (62% vs 40%-49%, P < 0.0001) with higher use of intraoperative vasopressors (57% vs 37%-39%, P < 0.001) and higher overall mortality (23% vs 13%-15%, P = 0.027).DiscussionOur findings suggest that a mature and centralized transfer system promotes equity of outcomes between rural and metropolitan emergency general surgery patients. Micropolitan patients were more acuity ill than patients of other degrees of rurality, which suggests that low acuity micropolitan patients were more likely to be managed within their own communities.

PurposeBomb blast injuries in non-combat settings have seen a surge in the last two to three decades. Third-world countries like Pakistan have been at the receiving end of these attacks. However, the extent of the damage inflicted in these regions is not fully understood due to gross underreporting. We aim to assist radiologists in identifying common abdominopelvic injuries in bomb blast victims and highlighting specific injury patterns to guide more effective management.MethodsThis was a retrospective observational study designed to analyze abdominopelvic injuries among bomb blast victims treated at our institution. Data were retrieved from the hospital's electronic health records and included demographic information (age and sex), injury classification, imaging results, treatment received, and clinical outcomes.ResultsChi-square and t-tests showed no statistically significant difference in the gender or mean age distribution between patients who underwent abdominopelvic surgery and those who did not. The most common single injury category among the patients analyzed was secondary injury, while the most common combination of injuries observed was a combination of secondary and tertiary injuries. CT was the most frequently requested first-line radiological investigation, while US was most frequently requested as a second-line modality. Injuries to the liver were the most frequently observed solid-organ injury.ConclusionEfficient practices are essential in radiology departments to manage the surge in patient numbers seen after bomb blast incidents. Our study emphasizes the role of radiology scans and details the types of abdominopelvic injury patterns observed in bomb blast victims.

BackgroundPancreatoduodenectomy (PD) is the only curative treatment for pancreatic cancer. Neoadjuvant therapy (NAT) has enhanced survival, especially for downstaging advanced tumors, while also introducing complexities and new complications. Despite surgical advances, some PD attempts remain unsuccessful. The management of these cases is not well defined. This study analyzes outcomes of repeat PD performed by two high-volume surgeons following previously unsuccessful attempts.MethodsWe retrospectively analyzed patients with pancreatic neoplasm undergoing successful pancreaticoduodenectomy (2013-2024) at two high-volume centers under two experienced surgeons. Only cases with prior aborted PD attempts for non-metastatic disease were included. Data from institutional records provided outcomes on failure reasons, procedure timing, surgical details, and 90-day complications.ResultsOf the 858 PD cases, 18 patients (2.1%; 12 males, 6 females; median age 69 years) had prior unsuccessful PD attempts at other institutions. Initial tumors were borderline resectable (33.3%), resectable (22.2%), or locally advanced (22.2%). Main causes for initial failure were vascular involvement (41.2%) and tumor infiltration (17.6%). Median time between attempts was 246 days, with 77.8% receiving chemotherapy before the second attempt. The second procedure achieved R0 resection in 94.4% of cases. Major 90-day complications occurred in 23.5% of patients, with no perioperative mortality. Disease recurrence occurred in 38.9% within the first year.ConclusionRepeat PD after an aborted attempt is feasible in select patients at specialized centers. However, complication and recurrence rates emphasize the need for careful patient selection. Further research is needed to optimize management strategies.