American Surgeon最新文献

Background: Frailty is increasingly recognized as a perioperative risk for numerous surgical diseases. We applied the modified frailty index (mFI-11) to the National Inpatient Sample (NIS) for patients undergoing surgery for colorectal cancer (CRC).

Methods: We performed a retrospective analysis of the NIS (2015-2019) including CRC patients undergoing surgery. We classified patients into frail (ie, mFI ≥0.27) and robust (ie, mFI <0.27) categories. Primary outcomes were in-hospital postoperative morbidity and mortality. The secondary outcomes included system-specific postoperative morbidity and length of stay (LOS). Multivariable regression models were fit.

Results: Within the 53,652 identified patients undergoing surgery for CRC, 19.1% were frail. Frail patients were at higher risk of postoperative mortality (3.1% vs 1.0%, odds ratio [OR] 1.96, 95% confidence intervals [CIs] 1.68-2.30, P < 0.001), morbidity (41.3 % vs 23.1%, OR 1.75, 95% CI 1.66-1.83, P < 0.001), and LOS (mean difference [MD] 1.46, 95% CI 0.29-1.62, P < 0.001). Significant differences existed between groups in system-specific postoperative morbidity, with the largest effect estimates seen in cardiovascular morbidities (OR 4.07, 95% CI 3.36-4.93, P = 0.001), followed by respiratory (OR 1.75, 95% CI 1.66-1.83, P = 0.001).

Conclusion: Frail patients undergoing CRC surgery are at risk of increased postoperative complications. Preoperative frailty screening may allow for individualized preoperative counseling.

Background: Cholangiography for visualization of the biliary tree during laparoscopic cholecystectomy is an important diagnostic roadmap in the context of suspected choledocholithiasis (CDL). The renewed interest in transcystic laparoscopic common bile duct exploration (LCBDE) necessitates a general description of the range of CDL presentations. Our aim was to establish a novel classification system of intraoperative cholangiograms (IOCs) to advance research efforts in this field.

Methods: A novel cholangiogram classification system, featuring 8 distinct presentations of choledocholithiasis, was applied to a data set of 80 preintervention IOCs for suspected choledocholithiasis. The classification system is as follows: A (no common bile duct stones, duodenal filling present, and concern for air bubbles), B (no common bile duct stones, no duodenal filling, and concern for sludge), C1 (stone(s) < 2x size of cystic duct with duodenal filling), C2 (stone(s) < 2x size of cystic duct without duodenal filling), D1 (stone(s) ≥ 2x size of cystic duct with duodenal filling), D2 (stone(s) ≥ 2x size of cystic duct without duodenal filling), E1 (congenital anatomical variant and/or common duct stricture), and E2 (surgically altered biliary anatomy).

Results: Cholangiogram review yielded preintervention classifications for 6 of 8 variants (A-E): A (7.5%), B (3.75%), C1 (23.75%), C2 (42.5%), D1 (15%), and D2 (7.5%). Analysis of cystic duct diameter yielded no significant differences among classification groups, indicating no predominant pattern of cystic duct anatomy within a given classification.

Discussion: An IOC classification system for suspected choledocholithiasis is foundational to answering key clinical questions for transcystic laparoscopic common bile duct exploration.

Background: There is currently no standardized treatment for Mirizzi's syndrome (MS). We aim to explore the surgical treatment strategy for MS by analyzing its clinical characteristics and treatment outcomes.

Methods: This retrospective study analyzed the clinical data of 130 patients with MS who underwent surgery at our hospital from April 2013 to April 2020.

Results: The study population comprised 130 patients with MS, with an approximately balanced sex ratio and a median age of 58.5 years. The preoperative diagnostic rate was 82.3%. The diagnostic accuracy of ERCP was 92.5%, higher than that of MRCP and ultrasound. All patients underwent surgical treatment, with 74 cases of laparoscopic surgery, 43 cases of laparotomy, and 13 cases of laparoscopic surgery converted to laparotomy. A total of 23 patients experienced short-term and long-term complications after surgery, with a complication rate of 17.7%. There was no statistical difference between laparoscopic surgery and open surgery in terms of intraoperative hemorrhage, operative time, and postoperative complication rate. However, the length of hospital stay was shorter in the laparoscopic surgery compared to the open surgery, which was statistically different from each other.

Conclusion: ERCP is the gold standard for the diagnosis of MS, especially for identifying the type of MS. ERCP plays an important role in both the preoperative and postoperative phases of MS. Our study demonstrated that laparoscopic surgery was a safe and feasible option for MS treatment, even requires less hospitalization than open surgery.

Pyoderma gangrenosum (PG) is a rare, chronic, ulcerative disease characterized by non-healing wounds that worsen with debridement, a phenomenon called pathergy. No consensus regarding pathogenesis, diagnosis, or treatment exists for PG. A previous pilot study using dehydrated human amniotic/chorionic membrane (dHACM), following excisional debridement, augmented PG wound healing and allowed for subsequent wound closure through split-thickness skin grafting (STSG). In this clinical trial (NCT05120726), four patients with an established PG diagnosis were enrolled to undergo treatment with dHACM and characterize the pre- and post-treatment transcriptome profiles. RNA sequencing was used to isolate the total RNA from specimens. Genes of particular interest were quantified through real-time quantitative reverse transcription polymerase chain reaction. We observed varied changes to the local expression of inflammatory response, positive regulators of cellular proliferation, and extracellular matrix disassembly cytokines. All PG wounds produced granulation tissue following treatment and were closed using split-thickness skin grafts.

Background: This study aimed to identify postoperative recurrence and prognostic factors, including osteosarcopenia for borderline resectable (BR) and unresectable locally advanced (UR-LA) pancreatic cancer and to examine the impact of postoperative pancreatic enzyme replacement therapy (PERT).

Methods: We retrospectively examined 32 resected patients with BR and UR-LA pancreatic cancer. We investigated independent factors in the disease-free survival and overall survival. The relation of osteosarcopenia with the clinicopathological factors was investigated. Additionally, the association of the administration of a standard dose of pancrelipase, the amount of lipase required for patients with pancreatic exocrine insufficiency, for ≥6 months postoperatively with improvement of sarcopenia, osteopenia, and osteosarcopenia and completion rate of adjuvant chemotherapy was investigated.

Results: Multivariate analyses identified osteosarcopenia (P = 0.049) and lymph node metastasis (P = 0.01) as independent recurrence predictors, and osteosarcopenia (P = 0.002), maximum tumor diameter ≥40 mm (P = 0.006), and no adjuvant therapy (P = 0.01) as independent prognostic predictors. In the osteosarcopenia group, serum CA19-9 levels were higher (P = 0.03). The administration of a standard dose of pancrelipase for ≥6 months postoperatively was none in the osteosarcopenia group (0% vs 42.9%, P = 0.01), while significantly improved postoperative sarcopenia (33% vs 0%, P = 0.004), increased number of cycles of adjuvant chemotherapy (n = 6 vs n = 3, P = 0.03), and the completion rate of adjuvant chemotherapy in excluding cases interrupted because of recurrence (86% vs 25%, P = 0.007).

Conclusions: Osteosarcopenia was an independent recurrent and prognostic factor in patients after pancreatectomy for locally advanced pancreatic cancer. Appropriate postoperative PERT may contribute to a better prognosis by improving sarcopenia and increasing the completion rate of adjuvant chemotherapy.

Purpose: Parathyroidectomy is beneficial in tertiary hyperparathyroidism (THPT) consequent to chronic renal failure. The craniofacial morphology of patients who undergo total parathyroidectomy and autologous transplantation (tPTX + AT) has not been widely studied. This study assessed the efficacy of tPTX + AT in THPT and evaluated possible improvements in craniofacial features.

Methods: This retrospective analysis included patients who were diagnosed with medically refractory THPT and had undergone tPTX + AT between September 2013 and May 2021. The VAS was used to evaluate improvements in various symptoms including bone pain and pruritus. Changes in serum calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone (iPTH) levels were also assessed. The impact of the procedure was assessed by comparing two-photon X-ray bone mineral density measurements obtained 1 year before and after surgery.

Results: The VAS of pain and pruritus decreased significantly on the first postoperative day (P < 0.05). Calcium levels changed significantly (from 2.50 ± 0.22 mmol/L to 2.10 ± 0.26 mmol/L) on postoperative day 1 (P = 0.0000); iPTH levels also declined substantially on this day, reducing from 211.00 (122.10, 252.80) to 5.04 (2.96, 9.40) pmol/L. Bone mineral density increased significantly across various regions including the greater trochanter of the femur, intertrochanteric area, total hip, and third lumbar vertebra (P < 0.05). The angles between the upper incisor and mandibular plane and the lower lip and Ricketts E line (drawn from the tip of the nose to the soft tissue area) also improved (P = 0.043, P = 0.001).

Conclusion: Total parathyroidectomy and autologous transplantation can rapidly alleviate bone pain and skin itching in THPT. It may also improve bone density and facial soft tissue.

Background: Open fractures have been associated with a higher risk of infection if antibiotics are not administered within 1 h of presentation in adult trauma patients. Time to antibiotic administration for open fractures is frequently used as a quality metric for trauma centers, but there have been no large studies evaluating this topic for pediatric patients.

Methods: The 2019 Trauma Quality Improvement Program dataset was queried for patients ≤ 16 years old with isolated open femur or tibia fractures undergoing operative intervention after blunt trauma. Patients transferred from another hospital were excluded. Pediatric patients receiving early antibiotics (EA) within 1 h were compared to patients receiving delayed antibiotics (DA) greater than or equal to 1 h from arrival. Multivariate logistic regression was used to evaluate risk of surgical site infection (SSI).

Results: There were 150 patients with open lower extremity fractures: 98 (64.9%) EA vs 52 (34.4%) DA. There was no difference in the rate of SSI between the 2 groups (EA: 1.0% vs DA: 1.9%, P = 0.65). There remained similar associated risk of infection after adjusting for lower extremity abbreviated injury scale >3, blood transfusion requirement, and vital signs on arrival (OR 0.62, 95% CI 0.04-10.24, P = 0.74).

Conclusions: Most pediatric trauma patients with open lower extremity fracture received antibiotics within 1 h of presentation. However, SSI was rare and the risk of SSI was not associated with antibiotic administration within 1 h. Therefore, timing of antibiotic administration for pediatric open lower extremity fractures should be re-evaluated as a quality metric.Level of Evidence: Level III.

Background: Surgeons face intense stress, causing hormonal imbalances that harm their health, leading to burnout, chronic illness, and shorter lifespans due to their demanding careers.

Purpose: This study explores self-care strategies focusing on sleep, nutrition, and exercise to help surgeons reduce stress and improve their overall well-being and quality of life.

Research design: A thorough literature review of physiological, metabolic, and psychological principles informed the development of a structured self-care approach.

Data collection and/or analysis: We reviewed existing research on brain-body interactions, highlighting hormonal balance, nutrition, and exercise to mitigate chronic stress.

Results: The review underscores the importance of quality sleep for hormonal balance and overall health. Proper nutrition, emphasizing balanced macronutrients and meal timing, supports health. Exercise should be 80% low-intensity aerobic activities, with 20% high-intensity. Combining these elements strengthens resistance to chronic stress and enhances health.

Conclusions: A structured self-care approach, prioritizing sleep, followed by nutrition and exercise, effectively reduces stress among surgeons. This sequence improves well-being and quality of life. Surgeons should focus on consistent sleep, balanced nutrition, and regular low-intensity exercise to enhance resilience and achieve a fulfilling professional life.