American Surgeon最新文献

Dedifferentiated liposarcoma with leiomyosarcomatous differentiation is a rare, aggressive subtype of soft tissue sarcoma with limited treatment options. Histotripsy is a novel, non-invasive, non-thermal ablative therapy that uses focused ultrasound to induce mechanical tissue destruction through acoustic cavitation. We report a case of a 72-year-old female with metastatic dedifferentiated liposarcoma who underwent histotripsy for 2 large hepatic metastases after progression on other therapies. Partial liquefaction of tumors was observed on post-procedural imaging. Following a second histotripsy session targeting additional hepatic lesions, imaging demonstrated significant tumor destruction, and a concurrent reduction in the size of an untreated pelvic metastasis was noted. No other therapy was administered during this period. Symptomatic improvement with reduction in abdominal pain and pressure was achieved. However, tumor regrowth was observed at 5 months post-treatment. This case demonstrates the potential of histotripsy to achieve local tumor control and symptomatic relief, with a possible systemic effect on distant metastases.

The early resuscitation of patients with mild to moderate non-exsanguinating trauma has shifted from the conventional use of one to two liters of crystalloids to the use of one to two units of PRBC. This evolution assumes that the transfusion of PRBC is superior to the administration of any volume of crystalloids because of the propensity of crystalloids to migrate from the intravascular to the interstitial space leading to organ dysfunction, organ failure, and worse outcomes. However, the premise of the fluid migration relies on Starling original model of fluid exchange between the hydrostatic and oncotic pressure without considering whether the endothelial surface glycocalyx (ESG) is affected by the degree of traumatic insult and by the duration and depth of hypotension. It fails to account for the changes that occur to the PRBC during storage from the standpoint of off-loading of oxygen and the ability to negotiate the microcirculation. This review explores the impact of the burden of trauma and hemorrhage on the ESG, the changes to the RBCs that occur during storage, particularly their diminished capacity to offload oxygen and to negotiate low-shear microvascular districts, leading to failure to improve oxygen consumption despite the increase in oxygen delivery. We argue that the recent trend toward early resuscitation with one to two units of PRBC rather that low-volume crystalloids, in patients with non-exsanguinating mild to moderate trauma lacks sufficient justification.

Cancer survivors newly diagnosed with second primary colorectal cancer (SPCRC) is rapidly growing. However, the impact of different prior cancers on survival of patients who underwent surgery for SPCRC remains unclear; therefore, we conducted an analysis to investigate the influence of prior cancer history. In this study, the data of patients diagnosed with CRC between 2004 and 2013 were extracted from the Surveillance, Epidemiology, and End Results database. The bias was minimized by Propensity Score Matching, and the Kaplan-Meier method as well as Cox proportional hazards models were used to analyze the impact of different prior cancer histories on overall survival (OS) and colorectal cancer-specific survival (CCSS) in patients undergoing surgery for SPCRC. Subgroup analyses were further conducted based on the time since first cancer diagnosis, age at SPCRC diagnosis, and SPCRC stage.Here, we included 68,410 patients who underwent surgery for FPCRC and 12,010 patients for SPCRC. KM curves showed that the OS and CCSS of patients with a history of prior thyroid cancer undergoing surgery for SPCRC were similar to those undergoing surgery for FPCRC (P ≥ 0.05). Patients with a history of prior colorectal cancer, prostate cancer, breast cancer, uterine cancer, bladder cancer, skin cancer, lung cancer, kidney cancer, or stomach cancer undergoing surgery for SPCRC had inferior OS compared to those undergoing surgery for FPCRC (P < 0.05). Taken together, our findings demonstrate that the history of prior cancers, except for prior thyroid cancer, might adversely influence the OS of patients who underwent surgery for SPCRC.

Platelet inhibition is known to occur after traumatic brain injury (TBI) and is predictive of bleed progression. The relationship between platelet inhibition and modified brain injury guideline (mBIG) score, however, is unknown. We hypothesize that patients with higher mBIG scores are more likely to have platelet inhibition and bleed progression.

Methods: A practice management guideline was established calling for a thromboelastography with platelet mapping (TEG-PM) on all adult trauma patients with an intracranial hemorrhage. Patients were then categorized per the mBIG as 1, 2, or 3. Data was retrospectively collected from December 2019 to December 2021. Patients were considered to have platelet inhibition if the percent arachidonic acid (AA) or percent adenosine diphosphate (ADP) inhibition was ≥60% on TEG-PM.

Results: Between December 2019 and December 2021, 768 patients underwent TEG-PM. AA inhibition was more likely to occur in mBIG 3 patients (26.3%) compared to mBIG 1 or mBIG 2 patients (P = 0.08),. ADP and combined AA/ADP inhibition were similar between mBIG scores. Modified BIG 3 patients were more likely to experience bleed progression compared to mBIG 1 or 2 (46.4%; P < 0.001) and to require neurosurgical intervention (16.5%; p < 0.001).

Discussion: Our study suggests that the higher the mBIG scores, the more likely patients will have worse outcomes regardless of platelet inhibition. Patients with TBI who experience worse outcomes is multifactorial in nature. TEG-PM should be used in conjunction with clinical judgement for treatment guidance.

BackgroundThe diagnosis of blunt thoracic aortic injury (BTAI) is challenging. In this study, a prediction model with a simplified scoring system for BTAI was developed for the primary evaluation of trauma patients in the emergency department.MethodsThis retrospective cohort study included blunt chest trauma patients. Mediastinal width was measured using supine position X-rays. Other factors that may be associated with BTAI were also evaluated, including hemodynamics, associated hemothorax, sonographic examination results, and troponin I levels. Risk identification was performed using a logistic regression model, which led to establishment of the final model.ResultsA total of 418 patients with thoracic trauma were included in the study. Of them, 52 patients had BTAI. We found that a mediastinal width of >8.5 cm had a better predictive value than the conventional cutoff value of 8 cm. In multivariate logistic regression analysis, significant risk factors for BTAI included shock (odds ratio (OR): 2.12), left hemothorax (OR: 2.86), mediastinum width >8.5 cm (OR: 3.48), elevated troponin I levels (OR: 2.90), and pericardial effusion (OR: 6.03). The receiver operating characteristic curve (ROC) curve yielded an area under the curve (AUC) value of 0.754, demonstrating superior diagnostic accuracy compared with the use of mediastinal widening alone, which had an AUC of 0.632.ConclusionIn addition to a widened mediastinum alone, a model that combines shock upon admission, elevated troponin I levels, left hemothorax, and pericardial effusion offers a straightforward, feasible, and acceptable screening method for BTAI.

Prehospital interventions, used individually or in combination, can have better patient outcomes; however, rural areas have limited resources. Shock index (SI) has been found to predict resource utilization, hospital outcomes, and mortality. Reducing SI through utilization of prehospital interventions could benefit patient outcomes. A total of 274 trauma activation patients between January 2017 and March 2024 were brought directly from the scene to a level 1 trauma center with a SI >1.0. Demographics, prehospital interventions (transfusions, tranexamic acid (TXA), and tourniquet use), transportation time, change in SI, and patient outcomes were analyzed. Reducing SI correlated with better patient outcomes (P < 0.05) and combining TXA with blood or TXA with tourniquet reduced SI and LOS (P < 0.05). Optimization of prehospital interventions in rural areas may improve a patient's condition prior to hospital arrival, ultimately benefiting patients and minimizing hospital costs through reduced resource utilization.

IntroductionIschiatic (sciatic) hernias represent one of the rarest forms of pelvic floor herniation, with fewer than 100 documented cases worldwide since first described by Papen in 1750. Their rarity, combined with often-cryptic clinical presentation, contributes to significant diagnostic and therapeutic challenges.MethodsFollowing PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases from 1947 to 2024, identifying 68 relevant articles. Our search strategy combined terms related to ischiatic/sciatic hernias with various publication types. Data extraction focused on patient demographics, clinical presentation, diagnostic methods, hernia contents, surgical approaches, and outcomes.ResultsOur analysis revealed striking female predominance (98.5%), particularly among elderly patients (mean age 71 ± 12.8 years). Ureter was the most commonly herniated structure (58.8%), followed by small intestine (20.6%). Most patients (80.9%) lacked an external gluteal bulge, contributing to diagnostic delays. CT emerged as the primary diagnostic modality (63.2%), with the pathognomonic "curlicue sign" representing a key feature in ureterosciatic herniation. Management approaches were evenly distributed between minimally invasive techniques (35.3%), open surgery (35.3%), and conservative management with ureteral stenting (29.4%). Laparoscopic and robotic approaches demonstrated shorter hospital stays (1-2 days vs 5-14 days for open repairs) and reduced postoperative pain, despite slightly longer operative times. Complication rates were low (5.9% surgical site infections), with no reported mortality.ConclusionIschiatic hernias require a high index of clinical suspicion for timely diagnosis, particularly in elderly females presenting with unexplained pelvic or sciatic pain. The evolution from open to minimally invasive surgical approaches has significantly transformed management outcomes, while ureteral stenting offers an alternative for high-risk patients with ureterosciatic hernias. The optimal approach remains individualized based on patient characteristics, hernia contents, and available surgical expertise.

BackgroundLong-term weight regain affects 20%-30% of patients after laparoscopic sleeve gastrectomy (LSG). We investigated whether single-incision laparoscopic sleeve gastrectomy (SILS) provides superior weight maintenance compared to conventional multi-port LSG.MethodsThis study is a retrospective analysis of prospectively collected data comparing 54 propensity-matched patients (27 SILS and 27 conventional LSG) operated between 2010 and 2017. Primary outcome was weight maintenance at 7 years. Secondary outcomes included safety profile, complications, quality of life, and patient satisfaction.ResultsGroups were comparable except baseline BMI (SILS: 40.17 ± 3.23 vs conventional: 43.71 ± 5.36 kg/m², P = .005). Single-incision laparoscopic sleeve gastrectomy demonstrated safety non-inferiority with no conversions, leaks, or reoperations in either group. Overall complications: 11.1% SILS vs 3.7% conventional (P = .308). At 7 years, SILS patients maintained significantly lower absolute weight (75.56 ± 13.24 vs 85.26 ± 19.78 kg, P = .039) despite similar %EWL (85.2% vs 92.6%, P = .396). Weight regain from nadir was 11.26 ± 9.24 vs 15.04 ± 14.10 kg (P = .250). Enhanced patient satisfaction scores in SILS (9.56 ± 0.93 vs 8.07 ± 1.90, P = 0.001) suggest a potential mediating mechanism.ConclusionsSingle-incision laparoscopic sleeve gastrectomy achieves superior long-term weight maintenance while demonstrating safety non-inferiority compared to conventional LSG. The technique resulted in 10 kg lower absolute weight at 7 years without increased complications. For appropriately selected patients, SILS offers a safe alternative with improved long-term metabolic outcomes.