American Surgeon最新文献

America once again has an immigration problem stoked by fear and political opportunism. This review revisits the Japanese American experience in the first half of the 20th century-not because the events are identical to the issues today but because the underlying dynamics are strikingly familiar: the rise of an Asian power perceived as a threat to U.S. global influence; the arrival of immigrants deemed "unassimilable" through racialized stereotypes; and the amplification of public anxiety by irresponsible politicians and media. In the case of the Japanese experience, the rule of law bent to popular will over 40 years to culminate in the mass incarceration of 110 000 Japanese in concentration camps in the American interior. It took another 40 years for Congress and the courts to return to constitutional principles and rectify the irreversible decisions that history would come to condemn.

IntroductionIndocyanine green (ICG) near-infrared visualization (NIR) is used in colorectal surgery to evaluate anastomotic limb perfusion and aid sentinel lymph node harvest in oncologic surgeries. Proponents of ICG-NIR claim improved anastomotic and oncologic outcomes, but no large-scale studies are reported. This study aims to evaluate the effect of ICG-NIR on anastomotic and oncologic outcomes after colorectal surgeries on a nationwide scale.MethodsRetrospective cohort analysis of the 2016-2020 ACS-NSQIP colorectal-specific database. Adults who underwent elective minimally invasive colorectal surgeries (low anterior resection (LAR), partial colectomy (PC), or right colectomy (RC)) were stratified into 2 groups based on intraoperative ICG-NIR use. Outcomes measured were operative duration, anastomotic leak, unplanned conversion to open, return to the operating room, perioperative bleeding requiring blood transfusions, survivor-only length of stay (LOS), mortality, and unplanned readmissions. Sub-analysis of lymph node harvest and margin-positive status was performed among patients with colorectal cancer.Results95 179 patients were identified (ICG-NIR: 1101 (1.2%); No ICG-NIR: 94 078 (98.8%). There were no differences in 30-day outcomes between groups except for longer OR duration among ICG-NIR group. ICG-NIR was not independently associated with reduced adjusted odds of anastomotic leak (aOR 0.790 (95% CI 0.520-1.201), P = 0.270). There were no differences between subgroups in terms of lymph node harvest or resection margin positive status.ConclusionThis is a large nationwide study showing leak rates and oncologic outcomes do not improve with ICG-NIR. The utility of ICG-NIR over preoperative bowel preparation, surgical technique, and gross visualization may be overstated warranting further study.

BackgroundThere is a known correlation with older age and an increase in both postoperative morbidity and mortality in surgery. However, there is limited postoperative data analysis for older patients undergoing cholecystectomy. Our goal was to compare surgical outcomes of cholecystectomy performed in older adults in comparison to younger adults.MethodsThis retrospective cohort study examined patients ages 18 years and older undergoing cholecystectomy from January 2016 to December 2020 from the American College of Surgeons (ACS) National Surgical Quality Improvement Program database. Patients were categorized into 3 age groups: 18-64y, 65-74y, and ≥75y. Thirty-day perioperative outcomes were analyzed using bivariate χ² test and multivariate logistic regression to estimate the risk of outcomes.ResultsOur study identified 175 512 patients who underwent cholecystectomy: 136 793 (77.9%) patients between 18 and 64y, 25 108 (14.3%) patients between 65 and 74y, and 13 608 (7.8%) ≥75y. Compared with younger adults, patient aged ≥75y were 4.03 times more likely to develop a complication (95% confidence interval [CI]: 3.71-4.39, P < 0.001), 2.84 times more likely to be admitted for any reason (95% CI: 2.64-3.05, P < 0.001), 2.66 times more likely to be readmitted for reasons related to cholecystectomy (95% CI: 2.45-2.9, P < 0.001), and 3.81 times more likely to have an extended hospital stay (95% CI: 3.63-3.99, P < 0.001).ConclusionsThe ≥75y cohort has significantly higher rates of overall complications, higher rates of total and cholecystectomy-related readmissions, and extended length of hospital stay.

BackgroundLaboratory biomarkers have been used as prognostic markers in several solid tumors. This study aims to evaluate 3 preoperatively measured laboratory values: blood neutrophil to lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), as potential prognostic biomarkers in patients with peritoneal carcinomatosis undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).MethodsWe performed a retrospective review of 156 patients who underwent CRS-HIPEC between 2013 and 2020. Biomarker ratios were calculated based on the preoperative laboratory values closest to the date of CRS-HIPEC. Multivariable Cox regression models were used to evaluate the biomarkers' associations with survival (OS), recurrence-free survival (RFS), and postoperative outcomes.ResultsIncreased MLR was independently associated with worse OS (P < 0.001) and RFS (P = 0.03) in this patient cohort. Additionally, increased MLR was independently associated with increased rate of hospital re-admission within 30 days after discharge (P = 0.04). None of the analyzed biomarkers were associated with increased rate of Clavien-Dindo class III/IV complication or hospital length of stay.ConclusionsIn this retrospective review, increased preoperative MLR was independently associated with worse overall and recurrence-free survival as well as increased rate of hospital re-admission. Preoperative PLR was associated with increased hospital length of stay. Thus, the utilization of preoperative systemic inflammatory biomarkers may aid in preoperative counseling and risk stratification prior to CRS-HIPEC.

BackgroundIncisional hernia remains a common complication following abdominal surgery with significant implications for patient quality of life and healthcare costs. This systematic review and meta-analysis aim to evaluate the relationship between various abdominal incision types and the development of hernias, while identifying key risk factors.MethodsA comprehensive literature search was conducted across multiple databases for studies published between January 2000 and January 2025. Studies reporting incisional hernia rates following abdominal surgery with clearly documented incision types and a minimum follow-up of 6 months were included. Data extraction included study characteristics, patient demographics, incision types, hernia rates, and associated risk factors. Random-effects meta-analysis was performed to calculate pooled hernia rates and odds ratios.ResultsForty studies comprising 183 496 patients were included. Midline incisions were associated with the highest hernia rates (12.8-35%, pooled rate 18.7%) compared to transverse incisions (4.8-10.2%, pooled rate 7.4%; OR 0.38, 95% CI 0.26-0.57). In colorectal surgery specifically, midline incisions carried an odds ratio of 11.7 (95% CI 3.3-42.0) for hernia formation compared to transverse approaches. Paramedian, oblique, and Pfannenstiel incisions demonstrated lower hernia rates (2.1-8.6%). Significant patient-related risk factors included obesity (OR 4.74, 95% CI 1.42-15.55), male gender (HR 2.2), COPD (HR 2.35, 95% CI 1.16-4.75), and wound infection (HR 3.66). Most hernias (54-80%) developed within the first year after surgery, though continued development was observed for up to 10 years.ConclusionsTransverse, paramedian, and Pfannenstiel incisions offer significant advantages over midline approaches for reducing incisional hernia risk. Patient-specific factors, particularly obesity and pulmonary comorbidities, substantially influence hernia development. A tailored approach to incision selection based on patient risk profile, coupled with meticulous technique and wound management, is recommended to minimize hernia occurrence.

Requests for major revision generate more anxiety than almost any other editorial decision, in part because authors struggle to interpret what the journal is signaling. Some view major revision as near acceptance and rush to make changes, while others interpret it as a softened rejection and respond incompletely. Both approaches miss the central purpose of major revision. A request for major revision represents a conditional investment by editors and reviewers. The topic is relevant and the question appropriate for the journal, but the manuscript is not yet ready for publication. This editorial provides practical guidance on how authors should respond, emphasizing judgment over persistence. Key principles include reading reviews with distance, understanding the structural issues underlying reviewer comments, and avoiding a checklist mentality. The editorial highlights the importance of using the response-to-reviewers form correctly, making revisions easy to identify, and respecting the significant time reviewers devote to thoughtful critique. Guidance is provided on responding without defensiveness, prioritizing core concerns related to framing and contribution, and reassessing whether the manuscript truly advances the field or has become redundant. Situations in which authors may reasonably decline to pursue revision, as well as how to disagree productively with reviewers, are also addressed. Major revision is neither a promise nor a rejection. When approached as collaboration rather than negotiation, it often results in a manuscript that is clearer, stronger, and more valuable to practicing surgeons.

The circumstances surrounding unintentional firearm-related injuries remain relatively unknown. This study aimed to characterize unintentional firearm-related injuries through a retrospective review of 151 patients admitted to a Level 1 Trauma Center between January 1, 2013, and January 1, 2023. Most patients were non-Hispanic (91%, n = 138), Caucasian (87%, n = 132), and male (92%, n = 139) and primarily aged 18 to 24 years (25%, n = 37). The mean Injury Severity Score was 6 ± 7.5, with most injuries occurring in the extremities. Injuries were mainly self-inflicted (66%, n = 100), often involved a handgun (70%, n = 105), and frequently occurred in the patient's home (45%, n = 68). Circumstances surrounding the injuries included cleaning the gun (27%, n = 41) and engaging in unsafe practices (21%, n = 31). Overall, 2% (n = 3) experienced a fatal injury. Emphasizing safe gun-cleaning practices and addressing firearm malfunctions may help reduce the incidence of unintentional firearm injuries, highlighting this as a critical area for future intervention.

IntroductionChondromanubrial pectus carinatum (PC) is a rare type of pectus deformity in which there is protrusion of the manubrium and superior costal cartilage. Studies have shown that orthotic bracing is successful in correcting chondrogladiolar PC, but surgery has been the primary treatment for the chondromanubrial subtype. Due to the rarity of this type of PC, we aimed to describe our experience and outcomes with the dynamic compression system (DCS) bracing in these patients.MethodsThis is retrospective single center review of all patients with chondromanubrial PC treated with DCS from 2011 to 2021. Data collected included demographics, PC type and location, brace initiation date, pressure of initial correction (PIC), exercise activity, frequency of brace use, and final treatment results. Data are presented with medians with interquartile ranges (IQRs) and frequencies with percentages.Results11 patients had chondromanubrial PC treated with the brace system. There was an equal distribution in gender, with a median age at brace placement of 13 years (IQR 12, 15). The median change in PIC from the first clinic visit to the last was 2.6 psi (IQR 1.6, 3.8). Most of the cohort (80%) exercised and 50% achieved retainer stage at a median time of 121 days (IQR 91, 238). Four patients maintained correction at the last clinic visit, with the remaining achieving partial improvement of the PC deformity.ConclusionDynamic compression system can be an effective initial approach in managing patients with chondromanubrial PC. Although some patients did not achieve total correction, there was an improvement in the chest wall deformity in all cases.

Single case reports remain a common form of scholarly submission, particularly from residents, students, and clinician-educators. Many are thoughtfully written and describe interesting clinical problems, yet most do not reach publication. The reason is rarely a lack of effort or clinical insight. More often, it is a problem of scope. Over the past several years, The American Surgeon has worked with authors to transform narrowly focused case reports into case-based reviews that contribute meaningfully to the literature. When this succeeds, a clinical observation shifts from description to synthesis, and from recounting an individual event to offering guidance that informs practice and is cited by others. Making this transition requires a deliberate change in framing. A practical approach begins with defining a broader clinical question and grounding it in current literature. A structured review-particularly of articles and reviews published in the last three to five years-helps focus the discussion on contemporary standards and areas of debate. When the literature includes multiple reports or collected series, an updated systematic review may be a more appropriate strategy. Successful reviews are organized around how surgeons approach clinical problems and make decisions. They address a knowledge gap not yet resolved by existing literature and use an illustrative case to anchor a broader discussion. A case report describes one patient. A publishable paper must speak to many surgeons.

BackgroundColorectal cancer is a common and deadly form of cancer. Sigmoid colon cancer is the most prevalent type of colon cancer. Robotic-assisted surgical systems, like the Senhance Digital Laparoscopy System, have attracted considerable attention in recent years. The purpose of this study was to confirm the non-inferiority of Senhance-assisted surgery regarding its short-term safety compared with conventional laparoscopic surgery for sigmoid colon cancer.MethodsThis retrospective single-center study analyzed data from patients undergoing a sigmoidectomy between March 2020 and 2025. Propensity score matching was employed to create comparable groups. Patient characteristics, short-term surgical outcomes, and pathological data were assessed. Postoperative complications were graded using the Clavien-Dindo system.ResultsPrior to propensity score matching, there were differences in cancer stage between groups. After matching, two groups comprising 45 patients each were comparable across various factors. The operative time was significantly longer in the Senhance-assisted group compared with the conventional laparoscopic surgery group (236 min vs 204 min, P = .001), underscoring the importance of optimizing surgical techniques. Postoperative Numerical Rating Scale pain scores were significantly lower in the Senhance-assisted group on day 1 (3 [1-5] vs 4 [2-6], P = .03) and day 3 (2 [0-4] vs 3 [2-5], P = .02). However, no there were no significant differences in blood loss, complications, or pathological characteristics between the groups.ConclusionsThis study demonstrated that Senhance-assisted sigmoidectomy was non-inferior to conventional laparoscopic surgery in terms of short-term safety outcomes.