American Surgeon最新文献

Fungal growth is common in intraoperative cultures of patients with perforated peptic ulcer (PPU) leading to the common use of empiric antifungal therapy, with current evidence not clearly supporting this practice. The goal of this updated systematic review and meta-analysis was to synthesize the effect of empiric antifungals in patients with PPU. Eligible studies were identified through a comprehensive literature search in the MEDLINE (PubMed) and EMBASE databases, following the PRISMA 2020 statement. A total of eight studies were identified reporting on 1802 patients. The population consisted of 67.3% males (n = 121/1802), with a mean age of 59.1 ± 13.2 years. Most of the population underwent surgery (n = 1763/1802, 97.8%), which was most frequently omental patch (n = 1169/1411, 82.8%), while 12.8% (n = 140/1096) underwent laparoscopic repair. Intraoperative cultures were obtained in 73.7% (n = 1262/1713); blood cultures were obtained in 54.5% (n = 467/857) and were positive for fungus in 44.1% (n = 558/1262) and in 5.6% (n = 26/467), respectively. Empiric antifungal treatment was administered in 19.6% (n = 353/1802). The most common agent was fluconazole reported in 6 studies. At a mean follow-up of 34.4 ± 9.9 days, 191/1787 (10.7%) patients died. Patients with fungus-positive intraoperative cultures had significantly increased odds of having diabetes mellitus (OR: 1.55; 95% CI: 1.05-2.30), history of malignancy (OR: 2.80; 95% CI: 1.22-6.45), being on steroids (OR: 5.13; 95% CI: 1.37-19.3), and increased mortality (OR: 2.49; 95% CI: 1.67-3.70). Empiric antifungal therapy did not significantly decrease the odds for death (OR: 1.45; 95% CI: 0.33-6.41). The presence of fungi in the peritoneal fluid is associated with increased risk of death, that is not affected by administration of empiric antifungal therapy.

Background/aim: The aim of this study was to investigate the prognostic impact of the inflammatory burden index (IBI), a novel inflammation-based biomarker, in patients with colorectal liver metastases (CRLM) after hepatic resection.

Patients and methods: One hundred fifty patients with CRLM who underwent hepatectomy were retrospectively analyzed. The IBI was defined as C-reactive protein × neutrophil count/lymphocyte count. The relationship of the IBI with overall survival was investigated by univariate and multivariate analyses.

Results: Seventy-three (49%) patients had a high IBI (>3.45). In univariate analysis, overall survival was significantly worse in patients with lymph node metastases (P = 0.048), high NLR (P = 0.03), and high IBI (P < 0.01). In multivariate analysis, high IBI (P = 0.048) was an independent and significant predictor of overall survival. Patients with a high IBI had more postoperative complications compared with those with a low IBI (P < 0.01).

Conclusion: The IBI was a strong predictor for both short- and long-term outcomes in patients who underwent hepatic resection for CRLM.

Today's controversies of gain-of-function virological research and mRNA COVID vaccination policies had an antecedent nearly a century ago in an event often referred to as "the Lübeck disaster." From April through September 1930, 77 newborn infants in Lübeck, Germany, died after receiving oral BCG immunizations tainted with active human Mycobacterium tuberculosis. The tragedy threatened to end BCG immunizations. BCG and its originators, the French scientists Albert Calmette and Camille Guérin, were exonerated from liability. An inquest uncovered careless laboratory practices that contaminated doses of the vaccine with a human pathogen. The calamity underscored the necessity for exacting standards when handling dangerous infective microbes. The physician and bacteriologist responsible for the immunization program in Lübeck were tried and convicted for negligence, a concrete example of the civic responsibility expected of scientists when an experimental venture inflicts harm on an unwitting public. The example of Lübeck stands as an object lesson on the necessity of an informed, measured approach to any novel treatment. Controversies continue whether BCG vaccination is the preferred public health strategy against tuberculosis. Calmette and Guérin's lasting scientific achievement is the creation of a microbe that over a century has kept its essential features of inciting a vigorous immunological reaction that was tolerated by its host and never regaining its pathogenicity. The features form the basis of modern cancer immunotherapy, where intravesical BCG is first-line therapy against non-muscle invasive bladder cancer.

Aims: The aim was to determine the effect of socioeconomic deprivation on operative mortality after emergency laparotomy.

Methods: A PRISMA-compliant systematic review and meta-analysis (random-effects modeling) was performed searching for studies comparing operative mortality between the least and the most socioeconomically deprived patients undergoing emergency laparotomy. Both unadjusted and adjusted odds ratio (OR) were calculated as summary measure. Risk of bias was assessed using the Quality In Prognosis Studies tool, and certainty of evidence was assessed using the GRADE system.

Results: Four studies comprising 87,690 patients were included. There was no difference in the risk of operative mortality between the most and least deprived groups (unadjusted OR: 1.57, 95% CI .92, 2.68, P = .100) and when adjusted for other predictors (adjusted OR: 1.11, 95% CI .93, 1.32, P = .230). Subgroup analysis showed consistency of the findings in the United Kingdom (unadjusted OR: 1.36, 95% CI .92, 2.01, P = .130; adjusted OR: 1.15, 95% CI .92, 1.43, P = .230) and in the United States (unadjusted OR: 1.75, 95% CI .75, 4.06, P = .190; adjusted OR: 1.01, 95% CI .79, 1.29, P = .940). Sensitivity analyses showed inconsistency in favor of higher mortality risk in the most deprived patients. The GRADE certainty was moderate.

Conclusions: Socioeconomic deprivation may have minor effect on operative mortality after emergency laparotomy; however, such effect fades away once adjusted for other predictors of mortality. Although independent research is required, it may be reasonable to predict that incorporation of socioeconomic deprivation into preoperative risk assessment tools may not improve their predictive performance.

Background: The shortage of general surgeons in rural America is well documented. The North Dakota community-based general surgery residency program initiated a unique approach to training for rural practice through a dedicated rural track. The rural track included 9 months of rotations in specialty rotations beneficial for rural practice. This study analyzed practice patterns and satisfaction of residents completing rural track training.

Methods: An anonymous voluntary survey was sent to rural track graduates between 2010 and 2022 via the Qualtrics Web site.

Data collection included: Specialty rotations completed, specialty procedures currently performing, satisfaction with rural track training, and recommended specialty rotations for future rural track graduates.

Results: Twelve of fifteen graduates (80%) responded. Eighty-three percent of respondents chose the rural track because they desired practice in rural areas and/or desired broad-spectrum surgical practice. One hundred percent of the graduates were satisfied with their training. Seventy-five percent of the graduates came from a rural background, and 75% either previously practiced or currently practice in a rural community. Procedural data demonstrated that 67% of the graduates performed endoscopy procedures, 42% performed hand procedures, and 47% performed C-sections. Rural track graduates desired more experience in urology (50%), ENT, OBGYN, and advanced endoscopy (33%). Experience in plastic surgery, GI, hand surgery, dermatology, and IR was cited as beneficial.

Conclusion: The rural track graduates found significant value in their rural track training that benefited them in practice. Three quarters of the graduates entered rural surgery practice, performing a broad spectrum of procedures.

Gossypiboma is a condition that occurs as a result of leaving sterile gauze, surgical sponges, or similar materials inadvertently retained in the body following surgery. The most common localization of gossypibomas is the intraabdominal cavity. Patients with gossypiboma can remain asymptomatic for years. Clinical manifestations and complications vary widely. Gossypibomas can result in significant complications based on the affected organ and its anatomical location. It is difficult to determine the exact incidence due to medicolegal issues. While prevention remains the most effective strategy for protecting against gossypiboma, the preferred treatment for abdominal gossypiboma is typically surgical intervention. This case aims to present a giant 25 × 25 cm textiloma that led to significant fistulization secondary to intraluminal migration and was expelled via the rectum, a phenomenon not previously reported in the literature.

Background: Although existing work has evaluated outcomes associated with care fragmentation (CF), these adverse consequences may be accentuated in patients undergoing bariatric operations. This retrospective study examined the association of CF with clinical and financial outcomes among patients receiving bariatric surgery.

Methods: All adult (≥18 years) records for bariatric operations were tabulated from the 2016-2021 Nationwide Readmissions Database. Patients with nonelective rehospitalization at a non-index facility within 30 days of index discharge comprised the CF cohort (others: No-CF). Multivariable linear and logistic models were developed to assess the association of care fragmentation with outcomes of interest.

Results: Of an estimated 38,842 patients, 5591 (17.0%) comprised the CF cohort. Compared to No-CF, CF was older, less likely to be female, and more frequently insured by Medicare. Following comprehensive risk adjustment, CF demonstrated increased odds of respiratory (adjusted odds ratio [AOR] 1.61, 95% CI 1.37-1.90), renal (AOR 1.56, 95% CI 1.38-1.76), and thromboembolic (AOR 2.03, 95% CI 1.71-2.41) complications. Additionally, those who experienced CF demonstrated increased odds of non-home discharge (AOR 2.03, 95% CI 1.70-2.42).

Conclusions: Care fragmentation is associated with increased mortality, complications, non-home discharge, and hospitalization costs. Initiatives such as patient education, harmonizing postoperative care, and facilitating returns to the index hospitals may minimize the adverse effects of CF to improve the continuation of care following bariatric operations.

Background: Agriculture is a hazardous industry, with tractor-related incidents being among the leading causes of traumatic injury and death. These injuries tend to take place far away from hospitals, thus leading to increased prehospital time to receive care. Understanding the relationship between prehospital time and outcomes such as hospital length of stay and mortality in the state of Nebraska could inform resource allocation for tractor related injuries.

Study design: A 10-year retrospective study abstracting adults involved in tractor injuries using The Nebraska State Trauma Registry was performed. Mortality was evaluated using standard logistic regression, while length of stay outcomes were estimated using the negative binomial distribution. Adjusted model covariates included age, arrived from status, and Injury Severity Score.

Results: A total of 100 tractor-related injuries were included. Extremity injuries made up the largest percentage of injury types (44%). Injury severity scores were considered low in most patients. The majority of injuries were experienced by a party not operating the tractor. After adjusting for age, the scene of patient arrival, and Injury Severity Score, total prehospital time was not a significant predictor of facility length of stay or mortality.

Conclusion: Access to care is an ongoing problem for many communities in the United States, with the Midwest having some of the largest regions with poor access to care. We did not find a significant relationship between prehospital time and outcomes related to length of stay or mortality. Future studies should assess for differences in outcomes among accident types such as roll-over accidents vs collisions.