American Surgeon最新文献

IntroductionTo assess if performing a high-fidelity simulated laparoscopic cholecystectomy in a teaching case format improves junior residents' operative confidence or senior residents' comfort in coaching.MethodsThis is a prospective observational study including categorical general surgery residents across all postgraduate levels (1-5) from a program based in New York, NY. Randomly paired junior and senior residents performed a laparoscopic cholecystectomy teaching case on a high-fidelity laparoscopic simulator. Residents answered pre- and post-simulation survey questions regarding operative experience, laparoscopic surgery comfort, biliary anatomy knowledge, confidence coaching, and impressions of the exercise.ResultsThe study included n = 30 residents. Juniors reported significant improvements in confidence obtaining a critical view with and without anatomic variants, placing trocars, and detecting their instruments on-screen (P < .05). Seniors experienced non-statistically significant improvements in coaching confidence (P > .05). On a scale of 1-5, seniors felt these exercises should be completed by both seniors (3.47, SD 1.20) and juniors (3.67, SD 0.94) before their first teaching cholecystectomy. There were no significant associations found between survey responses and simulator performance metrics (instrument path length or number of collisions) on regression analysis. In free responses, junior residents emphasized the benefits of having a senior mentor with real-life operative experience to provide nuanced guidance and tailored real-time feedback.DiscussionThese findings suggest that junior residents' technical comfort improved after performing a simulated teaching laparoscopic cholecystectomy. By implementing coached simulation in early training, residents will enter the operating room with enhanced confidence to become more autonomous.

Rejection is a routine and expected part of surgical publishing. Many manuscripts that ultimately reach publication have been declined by at least one journal, most often not because of flawed data or poor execution, but because of misalignment between the work and a journal's scope, audience, or expectations. For many authors, particularly trainees and early-career surgeons, a rejected submission is experienced as an endpoint rather than an opportunity for reassessment. For papers that eventually succeed, the outcome depends less on persistence than on how thoughtfully the manuscript is revised and repositioned. This editorial presents a practical, editor-informed approach to reworking a rejected manuscript for resubmission. Key steps include reading reviews with distance, diagnosing the structural reasons for rejection, and selecting the next journal deliberately based on mission and readership. Successful resubmission usually requires reframing rather than polishing. Authors are encouraged to revise the abstract and discussion to emphasize clinical decision making, strengthen context through comparison with existing literature, and revise the manuscript itself rather than relying on a persuasive cover letter. Attention is also given to reassessing currency, redundancy, and scholarly contribution. When similar titles already exist or recent systematic reviews address the same topic, authors should reconsider scope and identify what the work truly adds or pursue a different scholarly product altogether. When approached with judgment and clarity, rejection often serves as redirection toward a more effective and ultimately successful contribution to surgical practice.

BackgroundHormone receptor-positive (HR+), HER2-negative breast cancer demonstrates limited chemosensitivity, making patient selection for neoadjuvant chemotherapy (NACT) a challenge. The Magee Equation 3 (ME3), derived from routine immunohistochemistry, provides a cost-effective surrogate for genomic assays. This study aimed to evaluate the predictive value of ME3 for both primary tumor and axillary response to NACT in HR+/HER2- breast cancer.MethodsWe retrospectively analyzed 116 patients with HR+/HER2- breast cancer who received NACT between 2018 and 2023. Magee Equation 3 scores, calculated from ER, PR, HER2, and Ki-67 data, were stratified into low (<18), intermediate (18-31), and high (>31) categories. Pathological complete response (pCR) and axillary response were assessed using Residual Cancer Burden criteria. Receiver operating characteristic (ROC) analyses determined optimal ME3 cut-offs.ResultsOverall, 16.4% of patients achieved tumor pCR, and 59.5% achieved axillary response. No patients with ME3 <18 achieved pCR, compared with 7.4% in the intermediate and 46.9% in the high category (P < .001). Axillary response rates were 13.3%, 63.0%, and 96.9% across the low, intermediate, and high groups, respectively (P < .001). Receiver operating characteristic analysis identified ME3 >31.2 as the optimal cut-off for tumor pCR (AUC 0.863, sensitivity 78.9%, and specificity 87.6) and >22.5 for axillary response (AUC 0.887, sensitivity 78.3%, and specificity 85.1).DiscussionMagee Equation 3 is a strong predictor of both tumor and axillary response following NACT in HR+/HER2- breast cancer. By offering a practical and inexpensive alternative to genomic assays, ME3 may support treatment decision-making, particularly for axillary management, and has the potential to expand clinical utility in settings where genomic testing is limited.

Single-center retrospective studies remain a common form of surgical scholarship and often reflect careful clinical work addressing real problems. Despite this, many such studies fail to reach publication. The reason is rarely flawed data or poor execution. More often, the work does not move beyond local experience or articulate why its findings matter to surgeons outside the authors' own institution. This editorial outlines a practical framework for transforming a single-center retrospective study into a publishable article. Key elements include clarifying a focused and clinically relevant research question, defining the study population and time frame transparently, and using standardized outcomes and benchmarks to place results in context. Emphasis is placed on the unique strength of single-center studies: granular detail regarding operative decision making, technical nuance, workflow, and postoperative management that large administrative datasets and multicenter prospective studies often cannot capture. A thorough literature review establishes external validity and scope. When multiple similar retrospective series already exist, authors are encouraged to consider whether a reframed analysis or an updated PRISMA-compliant systematic review would better serve the field. Single-center retrospective studies become publishable when they offer more than results. When thoughtfully framed, they can contribute meaningfully to surgical knowledge and practice. Writing must be directed to practicing surgeons, which is the primary readership of the journal. The submission must emphasize interpretation and application rather than description alone, with a consistent focus on patient care.

BackgroundChoosing Wisely Guidelines recommend against routine sentinel lymph node biopsy (SLNB) for early-stage, hormone-receptor positive (HR+), clinically node negative (cN0) breast cancer (BC) in elderly women. To determine the applicability of this guideline to men, we evaluated pathologic nodal positivity (pN+) between men and women with low-risk HR+, cN0 BC.MethodsThe National Cancer Database was queried for patients ≥70 years who underwent surgical resection for low-risk, HR+, cN0 BC. Low-risk was defined as grade 1, cT1mi-T1c or grade 2, or cT1mi-T1b. pN+ was evaluated and compared by sex.ResultsOf 708 men and 123 855 women, 13.0% of men were pN+ compared to 7.7% of women (P < 0.001). Men presented with older age, more comorbidities, advanced stage, lymphovascular invasion, tumor upstaging, and a higher nodal burden (all P < 0.001). Men were more likely to undergo axillary lymph node dissection (P = 0.002), but there were no differences in adjuvant chemotherapy or endocrine therapy between pN+ men and women. There were no differences in 5-year overall survival (84.0% vs 85.3%, P = 0.80).DiscussionMen ≥70 years with low-risk cN0 breast cancer have nearly double the rate of nodal positivity compared with women, indicating that SLNB omission cannot be directly extrapolated from female-based guidelines and should instead be considered on an individualized basis.

As management of complex gastrointestinal diseases of childhood improves, there are an increasing number of children who are reaching adulthood with a significant abdominal surgical history and need for ongoing surgical care. The transition from pediatric to adult surgical care is nuanced for many reasons and fraught with opportunities for patients to be lost to follow-up. Several studies delineate the severe risk to patients that can ensue. This paper seeks to provide a review of the current literature surrounding transfer of care from the pediatric surgeon to the adult surgeon and provides actionable interventions to optimize success, specific to the rural environment. Some factors to be discussed are patient specific, including condition-specific patient/family education and a focused effort to gradually have the pediatric patient take ownership of their healthcare. Pediatric surgeon factors include early initiation of transition, education of adult colleagues on pediatric conditions, forming strong working relationships with adult surgeons, and participation in multidisciplinary clinics facilitating transition. Adult surgeon factors include a willingness to accept these patients and a desire to understand the unique factors that accompany caring for transitioning patients, as well as similarly participating in multidisciplinary clinics. System-based factors include ensuring that the support staff and financial resources are available to provide extra support to these patients throughout this time. Finally, the unique challenges of rurality as it relates to transitioning rural patients and the surgeons that care for them will be addressed. The end goal of this project is to open a multidisciplinary discussion regarding how each institution can best address the needs of their transitioning surgical patients.

BackgroundScapulothoracic dissociation is a rare, limb-, and potentially life-threatening injury in which the scapula and shoulder girdle are violently detached from the thoracic cage. However, the published data on the condition is mainly composed of case reports and single institution samples, which limits the overall generalizability. The aim of the current investigation was consequently to use a multi-institutional data set to characterize the injuries observed in patients with scapulothoracic dissociation along with the treatment strategies selected.MethodsThe 2016-2021 Trauma Quality Improvement Project (TQIP) database was used to identify cases of scapulothoracic dissociation. Patients were grouped based on the presence of neurovascular injury. The statistical significance of differences between the cohorts was determined using the Mann-Whitney U-test, chi-squared test, or Fisher's exact test, as appropriate.ResultsAfter applying the inclusion criteria, 74 cases of scapulothoracic dissociation were detected in the TQIP database; of these, 20% (N = 15) also suffered a neurovascular injury. The majority of patients with scapulothoracic dissociation without neurovascular injury could be managed non-operatively, while this was only the case for a minority with neurovascular injury (71.2% vs 26.7%, P = 0.004). Among patients who were ≥60 years old without neurovascular injury (N = 13), 92.3% (N = 12) could be managed non-operatively. Of those with neurovascular injury, 46.7% required internal fixation, 40% underwent vascular surgery, and 20% necessitated upper arm or forequarter amputation.ConclusionWhile scapulothoracic dissociation can be a serious, debilitating injury, most cases don't result in neurovascular injury and can often be managed non-operatively, particularly among the elderly.

IntroductionPrevious studies have demonstrated that C¹¹ choline positron emission tomography/computed tomography (Choline-PET/CT) can localize abnormal parathyroid glands in the reoperative setting. This study assesses a large volume of patients with primary hyperparathyroidism (1HPT) who underwent Choline-PET/CT to confirm its utility in the setting of negative or equivocal conventional imaging.MethodsAll patients who underwent Choline-PET/CT for evaluation of 1HPT from July 2017 to July 2024 at a single institution were reviewed. Inclusion criteria were patients who underwent parathyroidectomy and had lab testing to assess for cure (defined as >50% drop from baseline PTH and into normal range, or resolution of hypercalcemia at follow-up). Sensitivity, positive predictive value (PPV), false negative rate (FNR), and accuracy were compared to conventional imaging (neck ultrasound, parathyroid scan, and parathyroid four-dimensional CT (4D-CT)). Subgroup analysis was conducted comparing sensitivity of modalities among index operations and separately in reoperations.Results84 patients were included for analysis. 61 failed to localize on at least one conventional modality, and 15 failed to localize on all conventional studies. 67 patients (80%) achieved cure, of which 53 were reoperations. Choline-PET/CT outperformed conventional modalities across sensitivity, PPV, FNR, and accuracy. Choline-PET/CT also outperformed conventional modalities when comparing sensitivity in both subgroups.ConclusionC¹¹ choline-PET/CT is a valuable imaging modality in the reoperative setting and demonstrates utility for index operations. It provides localization when other modalities fail and allows for a high surgical cure rate. Further investigation into its utility as a primary imaging modality is warranted.

BackgroundThis study aimed to evaluate outcomes of different antibiotic durations in patients with severe diverticulitis.MethodsInitial electronic medical record review identified 2437 adult patients who underwent sigmoid colectomy. Manual chart review identified 133 patients who underwent sigmoid resection and proximal diversion for Hinchey stage 3 or 4 diverticulitis. Patients who received a short antibiotic course (SAC, ≤5 days) were compared with those who received a long antibiotic course (LAC, >5 days). The primary composite outcome included superficial, incisional, organ-space infections or death within 30 days post procedure.ResultsA total of 53 SAC patients and 55 LAC patients were identified. The composite outcome occurred more frequently in LAC patients than in SAC patients (40% vs 15%; P = .005). Organ-space infection occurred more frequently in LAC patients than in SAC patients (31% vs 13%; P = .04).ConclusionsExtended duration of antibiotics after adequate source control does not improve outcomes even in the setting of extensive intra-abdominal contamination.

Situs inversus totalis (SIT) is a rare congenital condition characterized by mirror-image transposition of thoracic and abdominal organs. This anatomical variation often delays diagnosis of abdominal pathologies such as acute cholecystitis and cholelithiasis due to atypical symptom presentation. We conducted a systematic literature review with strict exclusion criteria, including 23 studies focused on benign indications. Our findings suggest that robotic assistance in laparoscopic cholecystectomy reduces risks associated with traditional approaches, improving operative ease and patient outcomes.