American Surgeon最新文献

IntroductionAppendiceal adenocarcinoma is a rare and heterogeneous malignancy with management strategies historically mirroring those of colorectal cancer. The role of adjuvant chemotherapy (AC) in stage II disease remains poorly studied, particularly in stage IIB/IIC. We evaluated the impact of AC on overall survival (OS) in stage IIB/IIC appendiceal adenocarcinoma using the National Cancer Database (NCDB).MethodsThe NCDB was queried to identify adults diagnosed with stage IIB/IIC appendiceal adenocarcinoma from 2010 to 2021. Patients with carcinoid, goblet cell, or neuroendocrine histologies were excluded. Patients were stratified into surgery alone (S) or surgery plus adjuvant chemotherapy (S+). Kaplan-Meier and log-rank tests estimated survival distributions, and multivariable Cox proportional hazards regression with Firth's correction assessed independent predictors of OS.Results2082 patients met inclusion criteria. Adequate lymph node evaluation (≥12 nodes) was independently associated with improved survival (aHR: 0.62, P < .0001). Adjuvant chemotherapy conferred a significant survival benefit, with a 26% reduction in risk of death (aHR: 0.74, 95% CI: 0.62-0.89, P = .0016). Five-year OS was 78.9% for S+ vs 68.7% for S (P < .001). Patients receiving both AC and adequate nodal harvest demonstrated the greatest survival benefit. Non-mucinous histology was associated with superior outcomes compared to mucinous disease (aHR: 0.62, P < .0001).ConclusionAdjuvant chemotherapy is independently associated with improved survival in patients with stage IIB/IIC appendiceal adenocarcinoma, particularly when combined with adequate lymph node evaluation. These findings challenge current treatment paradigms that extrapolate from colorectal cancer and support consideration of AC as standard therapy in this high-risk patient subset.

Background: The American Society of Anesthesiologists (ASA) Physical Status classification is widely used as a proxy for perioperative risk, yet its relationship to contemporary ventral hernia repair (VHR) case mix and patient-centered outcomes remains incompletely defined.MethodsWe performed an unadjusted retrospective cohort study of adult VHRs in the Abdominal Core Health Quality Collaborative, comparing ASA I-II versus ASA III-IV patients. Analyses emphasized clinically interpretable effect sizes (Cohen's d and h) with conventional P values reported for completeness.ResultsWe analyzed 28,779 ASA I-II and 26,436 ASA III-IV repairs. ASA III-IV patients were older (60.65 ± 12.42 vs 52.38 ± 13.92 years; d = 0.63), had higher BMI (33.52 ± 7.41 vs 30.19 ± 5.83 kg/m²; d = 0.50), and greater comorbidity burden (hypertension 61.2% vs 30.9%; h = 0.62). Hernias were larger in ASA III-IV patients (width 7.91 ± 6.59 vs 3.93 ± 4.07 cm; d = 0.73), and operative complexity markers were higher, including dirty/infected wounds (2.1% vs 0.6%; h = 0.14) and longer operations (≥240 min: 21.0% vs 7.4%; h = 0.40). ASA III-IV patients had longer length of stay (3.72 ± 12.06 vs 1.44 ± 12.14 days; d = 0.19) and higher 30-day mortality (0.361% vs 0.035%; OR = 10.42). Among cases with non-missing 1-year outcome fields, 1-year recurrence (12.1% vs 10.4%; P = .10) and 1-year reoperation (7.0% vs 7.1%; P = .86) were similar. Higher-risk patients demonstrated greater 6-month quality-of-life improvement (ΔHerQLes 29.99 ± 30.35 vs 24.40 ± 28.45; d = 0.19).DiscussionAlthough ASA class stratifies physiological risk and complexity, it does not imply diminished reconstructive benefit, supporting individualized, risk-informed decision-making rather than exclusion based on ASA status alone.

Cloud computing has revolutionized analysis of large datasets. This tutorial provides a comprehensive, practical guide for research groups seeking to leverage cloud platforms for data analysis. The tutorial covers the foundations of cloud computing, including its history, rationale, and use cases for research, followed by detailed comparisons of the 3 major platforms: Google Cloud Platform (GCP), Amazon Web Services (AWS), and Microsoft Azure. Side-by-side comparisons of services, costs, ease of use, and selection guidelines assist researchers in choosing the most appropriate platform. A complete step-by-step example using hospital price transparency data demonstrates the entire workflow from account creation through results retrieval, enabling researchers to begin productive cloud-based analysis within hours.

BackgroundTransplant recipients represent a growing population with unique medical complexities, yet trauma outcomes remain poorly characterized. We investigated mortality and complications in kidney transplant (KT) and liver transplant (LT) patients following blunt trauma.MethodsThe Healthcare Cost and Utilization Project National Inpatient Sample (2019-2022) was queried for adults admitted following blunt trauma. ICD-10 codes identified KT/LT patients. Propensity score matching controlled for confounders.Results1,117,744 patients were included 2237 (0.20%) KT and 1250 (0.11%) LT. No mortality differences were observed. After matching, KT patients had lower renal failure risk (OR 0.83, 95% CI: 0.72-0.95, P = .007) and higher risk of pneumonia (OR 1.41, 95% CI: 1.09-1.82, P = .009). LT patients had higher renal failure risk (OR 1.56, 95% CI: 1.31-1.87, P < .001).ConclusionTransplant recipients experienced mortality rates comparable to matched controls after controlling for hospital characteristics and patient-level confounders. However, organ-specific specific vulnerabilities were identified: KT recipients demonstrated significantly increased pneumonia risk (OR 1.41), while LT recipients had 56% increased odds of renal failure. These associations may inform future investigation into targeted monitoring strategies and interventions for this population.

ObjectiveThis study aimed to preliminarily evaluate the impacts of narrative-based palliative care on psychological stress, end-of-life acceptance, and quality of life in elderly terminally ill cancer patients and their family caregivers.MethodsThis single-center, small-sample randomized controlled study enrolled 50 elderly terminal cancer patients. Patients were randomly assigned to either the observation group or the control group (n = 25 each). The observation group received narrative-based palliative care, while the control group received routine standard care. Family psychological stress was assessed using the Relative Stress Scale (RSS), and patients' perceived stress was evaluated with the Perceived Stress Scale-10 (PSS-10). Caregiver satisfaction was measured using a hospital-developed questionnaire. Patients' quality of life was evaluated using the SF-36, Chinese Version of the Death Attitude Profile (DAP-C), and Pittsburgh Sleep Quality Index (PSQI), respectively.ResultsBaseline characteristics did not differ significantly between the two groups (P > .05). Post-intervention, the observation group demonstrated significantly lower psychological stress among family members and higher caregiver satisfaction (P < .05). Patients in the observation group reported better quality of life, improved sleep, and greater acceptance of death than those in the control group (P < .05).ConclusionAs a small-sample, single-center study, these findings offer preliminary evidence that narrative-based palliative care may reduce psychological stress in elderly terminal cancer patients and caregivers while enhancing patients' quality of life, sleep quality, and acceptance of death. However, the limited sample size, single-site design, and narrow inclusion criteria restrict generalizability. Larger multicenter trials are needed to confirm these results.

PurposeKetorolac is commonly cautioned with a possible effect of bleeding. The safety and efficacy of Ketorolac has not been examined in children who have undergone general surgery procedures.MethodsA single institution retrospective cohort study examining children ages 0-18 from 2017-2022 with and without Ketorolac <24 hours after the following operations: laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic or open inguinal hernia repair, umbilical hernia repair, and ventral hernia repair. Demographics were reported using bivariate inferential statistics. A Cox proportional hazards model identified associations between Ketorolac and time to pain score ≤3. Logistic regression measured odds of opioid use in morphine equivalents 24-hour after surgery.Results5455 patients were identified. Children who received Ketorolac after surgery were more likely to be older (11.5 vs 7.0 years, P < .0001). Compared to Whites, Asian Americans (OR .50, CI .36-.63, P < .0001) and African Americans (OR .22, CI .13-.37, P < .0001) were less likely to receive Ketorolac. Patients receiving Ketorolac were more likely to have a high pain score (>5) after surgery (40% vs 23%, P < .0001) when receiving Ketorolac vs opioid alone (P < .0001). Patients receiving Ketorolac had 40% decreased odds of receiving opioid after surgery (OR .90, 95% CI: .87-.94, P < .0001). Blood transfusions were less common in patients that received Ketorolac (0.2% vs 0.7%, P = 0.005).ConclusionKetorolac does not increase the risk of bleeding requiring transfusion and decreases opioid administration. Ketorolac is efficacious in this patient population either alone or in combination with opioids and improves pain control compared to opioids alone.

BackgroundsThis study aimed to evaluate the prognostic value of the cholinesterase-prognostic nutritional index (ChE-PNI) score in patients undergoing curative colorectal resection for colorectal cancer.MethodsThis retrospective study included 628 patients who underwent curative colorectal resection for stage II/III CRC. Preoperative serum ChE levels and PNI were used to calculate the ChE-PNI score, and patients were categorized into 3 groups (score 0, 1, or 2). We investigated the association between the ChE-PNI score and survival outcomes.ResultsAmong all patients, 88 (14%) were classified as the ChE-PNI score of 2. Multivariate analysis revealed that American Society of Anesthesiologists physical status ≥3 (P = .009), T stage 3-4 (P = .004), N stage 1-3 (P < .001), ChE-PNI = 2 (P = .031), and serum carcinoembryonic antigen ≥5.0 ng/ml (P = .002) were independent predictors of disease-free survival. While, age ≥65 (P = .027), Anesthesiologists physical status ≥3 (P < .001), N stage 1-3 (P = .013), and ChE-PNI = 2 (P = .005) were independent predictors of overall survival.ConclusionThe ChE-PNI score is a novel, simple, and effective marker that independently predicts postoperative prognosis in patients with colorectal cancer.

The optimal timing of repair after common bile duct injury (CBDI) during cholecystectomy remains controversial. We evaluated outcomes after early versus late repair and examined associated malpractice litigation.

Methods: We retrospectively reviewed patients who underwent surgical repair of CBDI between January 2012 and December 2023. Collected data included demographics, operative indication, timing of injury recognition and repair, preoperative assessment, operative classification (primary repair, single anastomosis, multiple anastomoses), and postoperative outcomes. Early repair was defined as intraoperative or ≤3 days after injury and late repair as >3 days. Malpractice claims were identified via the Westlaw database and institutional release-of-information requests.

Results: Fifty-four patients met inclusion criteria: 12 primary repairs, 37 single anastomoses, and 5 multiple anastomoses. 23 patients underwent early repair and 31 underwent late repair. Groups were comparable in demographics and baseline laboratory values. Median time from diagnosis to repair was 0 days in the early repair group versus 10 days in the late repair group (P < 0.001). All strictures (n = 5) occurred in the late repair group (P = 0.023); one required partial hepatectomy and the remainder were managed with dilation. Bile leaks were managed with percutaneous drainage in 1 early-repair and 4 late-repair cases. One death occurred in the late-repair group. Three patients filed malpractice suits; one plaintiff verdict occurred.

Conclusion: Early repair of CBDI yielded excellent clinical outcomes in our series. The incidence of malpractice litigation after CBDI is uncommon. Early definitive intervention by experienced hepatobiliary surgeons should be considered when feasible.

BackgroundChronic anastomotic leaks following low anterior resection (LAR) with primary anastomosis and diverting loop ileostomy (DLI) pose a complex management challenge. Optimal strategies for evaluating and managing chronic leaks remain poorly defined, particularly regarding the timing and safety of stoma reversal.MethodsWe conducted a retrospective study of patients with stage I-III rectal cancer who underwent LAR with DLI between 2011-2022 and subsequently developed a chronic anastomotic leak, defined as a defect persisting beyond 30 days on imaging or endoscopy. Demographic, procedural, and outcome data were abstracted from the electronic medical record. Patterns of imaging and procedural evaluation, time to clinical disposition (defined as DLI reversal, conversion to colostomy, or decision to maintain DLI), and clinical decision-making factors were analyzed.ResultsNineteen patients met inclusion criteria. During their clinical course, 68.4% of patients underwent percutaneous drainage, with management guided by serial abdominopelvic computed tomography (CT). Gastrografin enemas and endoscopies were performed for anastomotic assessments but demonstrated limited predictive value, as one patient with a normal study developed postoperative pelvic sepsis, while three patients with persistent defects achieved successful reversal. The median time to clinical disposition was 367 days. Ten patients remained with a permanent ostomy, while nine underwent attempted reversal, of whom seven (36.8%) achieved durable bowel continuity.DiscussionManagement of chronic anastomotic leaks was individualized, influenced by imaging findings, patient preferences, and surgeon judgment. These findings highlight the limitations of relying solely on structural assessments and underscore the need for integrated, patient-centered frameworks to guide evidence-based reversal decisions.