American Surgeon最新文献

Intensive care unit (ICU) admissions are the standard of care (SOC) for coronary artery bypass graft (CABG) and are reserved for highly complicated appendectomy cases. Therefore, they are uniquely positioned to examine racial disparities in the likelihood of receiving SOC and suffering complications. Using a US national database, we studied Black or White adults (≥18 years old) undergoing emergent, urgent, or elective inpatient CABG or appendectomy. The primary outcome was ICU admission stratified by procedure and was measured using mixed-effects models. A sensitivity analysis controlled for hospital. Black patients had higher odds of ICU admission post-CABG (OR 1.35 95% CI 1.27-1.42, P < 0.001) and post-appendectomy (OR 1.11 95% CI 1.05-1.17, P < 0.001). However, no significant racial disparities were observed in our sensitivity analysis. This shows that while racial disparities exist due to cultural, disease-related, and socioeconomic reasons, these may be driven by hospital-related variability, likely in familiarity with the patients' different needs, and not provider-level bias.

Machine learning (ML), a branch of artificial intelligence, is rapidly transforming surgical complication and outcome prediction. Unlike traditional statistical approaches, ML can learn complex, nonlinear relationships across multiple variables, enabling more accurate and adaptable prognostication. Emerging ML-based tools have demonstrated strong performance across diverse surgical specialties, often surpassing conventional risk models. However, challenges remain, including opaque "black box" outputs, diminished performance during external validation, difficulty modeling rare events, and dependence on tabular data. These limitations can be mitigated but demand thoughtful design and rigorous validation. Importantly, ML introduces distinct methodological considerations unfamiliar to many surgeons. Successful clinical integration requires robust external validation and transparent sharing of trained models to ensure reproducibility and generalizability across diverse cohorts. By enhancing the precision of risk prediction, ML holds the potential to guide patient selection, optimize perioperative care, and strengthen shared decision-making between patients and surgeons.

BackgroundCytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is well established for mucinous cancers with peritoneal dissemination. Its role for non-mucinous tumors is less defined. This study compares outcomes between mucinous and non-mucinous cancer patients undergoing CRS-HIPEC to better understand therapeutic impact.MethodsA prospectively maintained database of CRS-HIPEC patients at an academic tertiary referral center from 2011-2023 was analyzed, including patients with appendiceal, colorectal, gastric, ovarian tumors, and soft tissue sarcomas. Survival outcomes were assessed using Kaplan Meier curves and multivariate Cox-proportional hazards models.ResultsAmong 195 patients, 55 (28%) had non-mucinous cancers and 140 (72%) mucinous tumors. The non-mucinous group had lower PCI (median 9 vs 14, P < 0.0001) was more frequently high grade (43.6% vs 22.9%, P = 0.004) with lymph node metastases (65.5% vs 17.1%, P < 0.0001). Length of stay, 30-day readmissions, and Clavien Dindo scores were similar between groups. There was no significant difference in overall (aHR 1.67, 95% CI 0.84-3.33) or cancer-specific survival (aHR 1.34, 95% CI 0.60-3.00) between groups. Non-mucinous patients did have a higher risk of cancer progression (aHR 2.50 95% CI 1.43-4.36), although this was primarily driven by differences in the appendiceal subgroup and was not seen in colorectal cancer patients.DiscussionDespite differential loco-regional features, non-mucinous cancer patients had similar survival after CRS-HIPEC. Differences in progression were primarily seen in those with appendiceal cancers, not colorectal tumors. These findings support the use of CRS-HIPEC across histologic subtypes, contributing to prognostication and risk-stratification for patients with differing cancer histopathology.

BackgroundSevere lower extremity injuries in pediatric patients present significant challenges for surgeons deciding between repair and amputation. A novel scoring system, the MangLE score, has been developed to identify adult patients who are unlikely to require amputation after severe lower extremity injury. This study sought to evaluate the predictive ability of the MangLE score in pediatric patients.MethodsA retrospective analysis was conducted using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Pediatric patients (≤17 years) with mangled lower extremities were included. Patients were stratified into age groups (0-3, 4-9, 10-13, and 14-17 years), and the predictive ability of the MangLE score for lower extremity amputation was assessed based on the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.ResultsA total of 7959 patients met the inclusion criteria. The MangLE score demonstrated an excellent predictive capability in patients aged 10-13 (AUC (95% CI): 0.87 (0.79-0.94)) and 14-17 (AUC (95% CI): 0.83 (0.79-0.86)). At the cutoff of ≥8, this resulted in an NPV of 99.7% for 10-13-year-olds and 99.4% for 14-17-year-olds. However, the MangLE score was ineffective in discriminating between those who did and did not require a lower extremity amputation in patients between 0 and 9 years old.DiscussionThe MangLE score maintains an excellent predictive ability for identifying those unlikely to require lower extremity amputation in pediatric mangled extremity patients aged 10-17; however, it fails to accurately predict this outcome in younger patients.Level of EvidenceLevel IV.

BackgroundMild traumatic brain injuries (TBI) are often overmanaged, resulting in an inefficient use of time and resources. The Brain Injury Guidelines was developed and subsequently improved as the modified Brain Injury Guidelines (mBIG) to help standardize TBI management. This study evaluates how adopting the mBIG criteria could improve TBI management at our institution.Materials and MethodsThis retrospective observational study included patients aged 18 to 89 admitted for isolated TBI to our Level 1 trauma center ICU between January 2021 and December 2023. Patients were categorized into 3 groups using the mBIG guidelines-mBIG 1, 2, and 3; mBIG 3 were excluded. Data were collected through the institutional trauma registry and chart review.ResultsThe study included 46 mBIG 1 and 44 mBIG 2 patients, who were comparable in terms of characteristics, clinical presentation, and procedures. Both groups had similar clinical outcomes, including in-hospital complications, mortality, discharge disposition, and 30-day readmission, and utilized hospital resources. All patients had a neurosurgery consult, with 49 repeat head CTs in the mBIG 1 group and 50 in the mBIG 2 group. The total combined cost for repeat head computer tomography (RHCTs) scans, magnetic resonance imaging (MRIs), computed tomography angiography (CTAs), neurosurgical consultations, and ICU stay in both groups was $337,637.4.DiscussionThe overutilization of imaging, ICU admissions, and neurosurgeon consultations can strain institutional resources and may not benefit patients with mild TBI. By adopting the mBIG criteria, institutions can implement a more efficient and safe management strategy, allowing these valuable resources to be better allocated to more severely injured patients who require them.

BackgroundAppendicitis in children can be treated with operative management (OM) or non-operative management (NOM) depending on patient risk factors. Our goal was to evaluate for differences in being offered NOM before and after the implementation of a standardized clinical pathway among patients of different demographic backgrounds.MethodsThis was a single center retrospective study of patients under the age of 18 years with appendicitis. Univariate regression was used to assess for associations between demographic factors and patients who were offered NOM.ResultsThere were 730 unique patient encounters for appendicitis during the study period. Qualified patients had significantly increased odds of being offered NOM in the post-pathway period than in the pre-pathway period (OR = 2.21, 95^th CI 1.28-3.82). In the post-pathway period, Hispanic/Latino patients (OR = 0.47, 95^th CI 0.28-0.78) and patients in the 4^th social vulnerability index quartile (OR = 0.46, 95^th CI 0.23-0.94) had decreased odds of being offered NOM. Patients with private insurance (OR = 2.25, 95^th CI 1.33-3.79) had increased odds of being offered NOM. When restricted to patients who qualified for NOM, female patients (OR = 2.66, 95^th CI 1.02-6.93) and patients with private insurance (OR = 3.26 95^th CI 1.31-8.15) were more likely to be offered NOM.ConclusionA clinical pathway for appendicitis increased the odds that qualified patients were offered NOM. However, differences in who was offered NOM based on demographic features were seen. More research on the effect of clinical pathways and factors impacting differential care is needed.

BackgroundThe relationship between the number of revascularization procedures and the level of major lower extremity amputation in chronic limb-threatening ischemia (CLTI) remains unclear. We aim to determine whether the revascularization frequency is associated with the level of amputation and whether procedural burden influences postoperative outcomes.MethodsWe performed a retrospective chart review of 252 patients who underwent major lower extremity amputations for CLTI from 2014 to 2022. The primary outcome was the association between revascularization frequency and amputation level, categorized into above-knee amputation (AKA) or non-AKA (through-knee and below-knee). Secondary outcomes included the association of revascularization level and type (open, endovascular, or hybrid) with AKA risk. Other outcomes were postoperative complications, readmission, reamputation, and mortality. Multivariable logistic regression adjusted for age, diabetes, and disease level.ResultsThe mean age was 55.9 years, with 61.9% male patients, and 58.3% identifying as Black. Most had hypertension (86.5%) and diabetes (62.3%). Among the cohort, 45% of the patients had no revascularizations. 47.6% underwent 1-2 procedures, and 7.5% underwent three or more procedures. Undergoing ≥3 revascularizations was significantly associated with increased odds of above-knee amputation (AKA) (OR: 6.33, 95% CI: 2.00-20.00, P = 0.002). Disease level and type of revascularization were not significantly associated with amputation level. There were no significant differences in postoperative complications, readmissions, reamputations, or mortality between AKA and non-AKA groups.ConclusionPatients undergoing three or more revascularization procedures were significantly more likely to undergo an AKA, suggesting a threshold effect where additional interventions may diminish patient benefits.

Burn injuries over previously grafted tissue present a formidable challenge for excision and debridement, particularly when there are critical underlying structures such as bowel. Enzymatic debridement with the recently approved anacaulase-bcdb, a bromelain-based enzymatic debridement gel (Nexobrid^®), presents an additional method of burn excision that may be useful in such a situation. This brief report presents the management of a complex third-degree burn over a remotely skin-grafted bowel mass using anacaulase-bcdb gel. This report is written with documented patient consent and approval by the Human Research Protection Program office in compliance with institutional policy. A 52-year-old man presented to our level I burn center with a third-degree 3% total body surface area contact burn to a remotely skin-grafted bowel mass. The patient was admitted with the decision to proceed with anacaulase-bcdb debridement of his wound to minimize the risk of compromising his underlying bowel. The patient underwent the debridement without any sign of succus emanating from the wound. Post-debridement, he was transitioned to a negative pressure wound dressing and discharged home. He continued receiving wound care at clinic follow-ups and eventually underwent complex open ventral hernia repair. This brief report provides a safe alternative to operative excision of wounds with underlying critical structures.

BackgroundWhistal (Whipple + Distal) is a rare parenchyma-preserving technique for select patients with disease in both the pancreatic head and tail, sparing a disease-free middle segment. It may also be used after prior partial pancreatectomy. Surgical resection remains the cornerstone of treatment for pancreatic diseases such as PDAC, RCC metastasis, and multifocal IPMN. Whistal may balance oncologic control with pancreatic function preservation. Though infrequent, it is practiced and reported in literature.MethodsWith IRB approval, a retrospective review of a prospective database (Aug 1999-Mar 2024) identified Whistal cases, categorized as staged Whistal (SW) or concomitant whistal (CW). Perioperative outcomes were assessed via Clavien-Dindo and ISGPS. A PubMed search identified reported middle segment pancreatectomy (Whistal) cases.ResultsOf 2008 resections (Aug 1999-Mar 2024), 5 were Whistals (3 CW, 2 SW) for PDAC (n = 3), RCC (n = 1), IPMN (n = 1), and bile duct stricture (n = 1). Rates for major morbidity, POPF, and DGE were each 40%. Literature review found 26 papers reporting 52 additional Whistal cases.ConclusionWhistal is safe for select patients, but wider adoption and long-term data are needed to confirm its efficacy.

BackgroundAugmented reality offers multiple enhanced diagnostic imaging visualization opportunities. The objective of this pilot study was to assess the applicability of HoloLens augmented reality in resident education.Methods34 categorical general surgery residents, postgraduate years (PGY) 1-5, reviewed a CTA and 3D hologram on Intravision XR using the Microsoft HoloLens 2 of the renal anatomy of 2 donor nephrectomy patients. Residents were randomized into 2 groups altering which modality was visualized first then described their findings and answered a device usability questionnaire.Results45.5% PGY-1s, 75% PGY-2s, and 86.7% PGY-3-5s correctly identified the pathology on the HoloLens compared with 45.5%, 50%, and 86.7%, respectively, on the CTA. 84% of participants appreciated improved visualization of the illustrated pathology with AR. 82% of participants stated an improved view of the vasculature using the HoloLens model. 25% of residents preferred using the HoloLens to traditional CT imaging.ConclusionsDespite being unable to obtain statistically significant results due to sample size, we observed that HoloLens renderings were non-inferior to conventional CT scans when it came to residents detecting pathology on an imaging study and superior at the PGY-2 level with an increasing preference towards use of the HoloLens with more senior PGY levels. This technology may assist residents in getting a fresh perspective on imaging studies and anatomical variations and improve resident education.