American Surgeon最新文献

BackgroundRobotic surgery may lend several advantages to the rural surgeon such as improved visualization, ergonomics, mobility, and decreased conversions to open. This study evaluated the growth of robotic surgery across the state of Kansas in regard to urban vs rural use.MethodsA retrospective review of surgical cases performed on da Vinci robotic systems from 2018 to 2022 throughout the state of Kansas. The information is grouped together based on the Rural Urban Commuting Codes (RUCA) for the location of procedure. The cases were divided by type (general surgery, cardiothoracic, urology, and gynecology).ResultsGeneral surgery was the fastest growing procedure type over the 5-year span increasing in proportion from 45.7% to 64.2%. This was followed by gynecology initially at 36.4% to 24.5%. Urology ranged from 16.6% to 9.5% and thoracic remained at 1% for the 5-year span. RUCA 1 facilities maintained a steady growth of cases per robot over the 5-year span initially at 225 cases per robot and increasing to 375 cases per robot. RUCA 4 centers illustrated a slower growth initially down trending the first 2 years then showing steady growth ending around 250 cases per robot. RUCA 7 centers had the fastest growth curve starting at 175 cases per robot and increasing to 360 cases per robot finishing just behind RUCA 1 centers.DiscussionThe robot may be an effective tool in a rural facility to generate caseload, revenue, recruit physicians, and provide health equity.

BackgroundColorectal cancer (CRC) remains a leading cause of cancer-related mortality worldwide, underscoring the need for reliable prognostic biomarkers. Emerging evidence suggests that body composition parameters may influence cancer outcomes. This study aimed to evaluate whether low skeletal muscle mass, high visceral fat, and their coexistence predict long-term outcomes in patients with CRC.MethodsThis retrospective study included 103 patients with pathological stage III CRC who underwent curative resection. Skeletal mass index (SMI) and visceral fat index (VFI) were calculated from preoperative CT images at the L3 level by dividing skeletal muscle and visceral fat areas by height squared. Overall survival (OS) and recurrence-free survival (RFS) were analyzed using Kaplan-Meier and Cox regression models.ResultsLow-SMI and high-VFI were present in 52.4% and 28.2% of patients, respectively. In Cox regression, low-SMI independently predicted poor OS (HR 5.14, P = 0.004), while high-VFI was an independent predictor of RFS (HR 2.72, P = 0.012). In the four-group analysis, for OS, both the coexistence of low-SMI and high-VFI (low-SMI-high-VFI, P = 0.021) and low-SMI-only (P = 0.023) had worse survival than controls, with no difference between them (P = 0.77). For RFS, high-VFI alone was associated with worse prognosis compared with controls (P = 0.040). Low-SMI-high-VFI patients had significantly poorer prognosis than both controls (P < 0.001) and low-SMI alone (P = 0.024).ConclusionsLow skeletal muscle mass and high visceral fat are associated with poorer OS and RFS, respectively. The coexistence of them may have an additive adverse association with recurrence risk in patients with low skeletal muscle mass. Preoperative body composition assessment may facilitate risk stratification in CRC, and improving these parameters could potentially contribute to better oncologic outcomes.

BackgroundAccurately predicting perforated appendicitis (PA) preoperatively remains challenging.MethodsWe retrospectively studied appendectomy patients with histopathologically confirmed acute appendicitis (2022-2023) to identify predictors of perforation. The primary outcome was histopathologically confirmed perforated appendicitis. Bayesian univariate analysis and Bayesian logistic regression were performed to estimate risk probabilities, with frequentist analyses conducted for confirmation. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.ResultsOf 770 patients with histologically confirmed appendicitis, 155 (20%) had PA. Bayesian univariate analysis demonstrated decisive evidence (BF₁₀ > 100) for several predictors, with C-reactive protein (CRP) (BF₁₀ = 251 079), age (BF₁₀ = 828), and lymphocyte percentage (BF₁₀ = 352) showing the strongest associations. Multivariate Bayesian modeling identified a parsimonious three-variable model comprising CRP, age, and lymphocyte percentage. This model demonstrated good discrimination (AUC 0.78) with high specificity (95.4%) and modest sensitivity (29%). Frequentist analyses confirmed these findings.ConclusionA predictive model incorporating CRP, age, and lymphocyte percentage provides a highly specific tool for ruling in perforated appendicitis. This approach may aid in prioritizing surgical urgency and optimizing perioperative management. Prospective validation is warranted.

BackgroundGastric neuroendocrine tumors (gNETs) are rare malignancies with distinct biological behavior compared with gastric adenocarcinoma. Data directly comparing surgical and oncologic outcomes, including lymph node yield, recurrence pattern, and survival, remain limited.MethodsA retrospective review of 285 gastrectomies (2014-2024) identified 20 gNET and 265 adenocarcinoma cases. After excluding palliative procedures and mixed histology, propensity-score matching (1:2.5; age, sex, BMI, and comorbidities) yielded 18 gNET and 45 adenocarcinoma patients. Outcomes included lymph node harvest, nodal metastasis, lymph node ratio (LNR), recurrence pattern, disease-free survival (DFS), and overall survival (OS).ResultsMedian lymph node yield was lower in gNET than in adenocarcinoma (18 vs 28; P = 0.004), and the overall rate of nodal metastasis did not differ between groups (44.4% vs 44.4%; P = 1.00), although the nodal metastatic burden was significantly lower in gNET as reflected by a lower median number of positive nodes and lymph node ratio (LNR 0.05 vs 0.17; P = 0.008), with no gNET patient exhibiting pN3 disease. DFS was comparable (21.4 vs 18.7 months; P = 0.617), whereas OS favored gNET (45.3 vs 27.4 months; P = 0.045). Peritoneal recurrence was markedly less frequent in gNET (16.7% vs 81.3%; P = 0.003), while hepatic relapse predominated. Perioperative morbidity and 90-day mortality were similar.ConclusionCompared with adenocarcinoma, gastric neuroendocrine tumors show reduced nodal metastatic burden, lower peritoneal dissemination, and improved overall survival. These findings support biology-adapted lymphadenectomy and surveillance for gNET, although validation in larger cohorts is required.

BackgroundThis study aimed to evaluate the association between computed tomography (CT) findings and the development of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) in patients with a hard pancreas.MethodsThe medical records of 96 patients who underwent PD and had a hard pancreas were retrospectively reviewed. The estimated functional remnant pancreatic volume (eFRPV), which is a composite preoperative CT-derived parameter reflecting both pancreatic volume and attenuation, was evaluated. Additionally, pancreatic attenuation value (PAV), remnant pancreatic volume (RPV), and main pancreatic duct (MPD) were also assessed. Variables, including eFRPV, were compared between patients with and those without POPF after PD.ResultsClinically relevant POPF was observed in seven (7.3%) patients. In the preoperative evaluable factors, only the eFRPV (33.3 HU·mL vs 70.8 HU·mL, P = .021) and PAV (32.6 HU vs 40.2 HU, P = .013) were associated with clinically relevant POPF. Remnant pancreatic volume and MPD were not significantly different between two groups. The area under the curve (AUC) was 0.764 for eFRPV and 0.783 for PAV. Although the AUCs for eFRPV and PAV were not significantly different (P = .785), eFRPV showed higher specificity at the point corresponding to 100% sensitivity (62.5% vs 38.2%).ConclusionsIn patients with a hard pancreas, POPF following PD can be predicted using eFRPV assessed by preoperative CT.

Introduction/PurposeDiverticulitis with abscess (Hinchey Ib or II) is often initially managed nonoperatively with antibiotics and/or percutaneous drainage (PCD). For patients who respond successfully to this approach, it remains controversial whether an elective colectomy (EC) should routinely follow. This systematic review and meta-analysis evaluate and compare the outcomes of two strategies in this population: EC vs continued observation after successful nonoperative management.MethodsWe systematically searched PubMed, Embase, Web of Science, and the Cochrane Library through August 15, 2024, for studies comparing EC to continued observation in patients with Hinchey Ib/II diverticulitis who achieved initial successful nonoperative management. Outcomes assessed included recurrence of diverticulitis. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model.ResultsWe included four studies comprising 7236 patients. Among these, 1719 patients (24%) underwent EC following initial successful nonoperative treatment, while 5517 (76%) did not undergo elective surgery. The average patient age was 58.5 years, with a mean follow-up of 3.22 years. The mean time to EC ranged from 2 to 6 months. Elective colectomy was associated with a significantly lower recurrence rate (OR 0.14; 95% CI 0.11-0.17; P < .001; I² = 0%) but a higher frequency of stoma formation (OR 1.83; 95% CI 1.51-2.23; P < .001; I² = 0%).ConclusionsIn patients with Hinchey Ib or II diverticulitis who initially underwent successful nonoperative management, subsequent EC was associated with lower odds of recurrence but higher odds of stoma formation.RegistrationPROSPERO CRD42024582759.

BackgroundIncidence of Pancreatic Neuroendocrine Tumors (PNET) has increased in recent decades. In navigating health diagnoses like pNETs, patients are increasingly turning to the internet for information. This study aims to provide a comprehensive overview of Patient Education Materials (PEMs) specific to pNETs using 6 primary criteria for evaluation: Quality, Understandability, Actionability, Readability, Comprehensiveness/Adherence to clinical guidelines, and Accountability.Methods36 unique web pages were selected using 9 different web browser/search engine combinations. Quality was evaluated using the DISCERN instrument, understandability and actionability with the PEMAT-P tool, readability with the Flesch-Kincaid Reading Ease algorithm, and comprehensiveness/adherence to clinical guidelines and accountability with author generated criteria. Scores were categorized based on affiliation to either a foundation, academic, or commercial publishing source, and by search position.ResultsOf the 36 web pages evaluated, 8 were published by foundations, 23 by academic sources and 5 by commercial sources. The mean understandability score for all sources using PEMAT-P was 75.45% (SD 10.89%), and actionability was 19.44% (SD 25.25%). The mean Flesch-Kincaid Reading Ease Score for all sources was 46.11 (SD 12.71), equivalent to a college reading level. Additionally, significant differences were found between the accountability scores for foundation (mean 1.75, SD 1.75), academic (mean 0.87, SD 1.49), and commercial (mean 3.2, SD 0.82) categories.DiscussionThis study reveals many shortcomings of online PEMs for PNETs, including average reading grade level and PEMAT-P actionability scores well below recommended standards. Academic web pages also demonstrated the lowest accountability scores to a statistically significant degree, indicating a need for that category of sources to increase transparency on author information and sources.

Dr. John Jeffries (1744-1819) twice became one of the most prominent surgeons in Boston. His career was interrupted by the American Revolution. Having chosen the Loyalist side, from 1776 to 1790, he left his native city and served with the British Army in Nova Scotia and the Carolinas. After the war, he established a successful practice in London and made the first flight across the English Channel. Able to return in 1790, he resettled in Boston and again became a leading figure in the city's medical community. This essay gives a short synopsis of his extraordinary life and of the death of his friend Dr. Joseph Warren.

BackgroundIn HER2-positive breast cancer, response to neoadjuvant chemotherapy (NAC) is a key prognostic factor. While complete response (CR) is associated with improved survival, non-complete responses are typically treated as a homogeneous group in prognostic models. However, this binary classification may obscure clinically relevant differences, particularly for patients achieving partial response (PR).MethodsWe conducted a retrospective cohort study using a large national cancer registry to evaluate outcomes of HER2-positive female patients treated with NAC. Patients were classified into three groups based on treatment response: CR, PR, and no response (NR). Overall survival (OS) and disease-specific survival (DSS) were assessed using Kaplan-Meier analysis and multivariable Cox regression models adjusted for demographic, clinical, and treatment-related variables.ResultsAmong 4711 patients, 72.4% achieved CR, 24.9% PR, and 2.8% NR. Both OS and DSS were significantly higher in the PR group compared to the NR group (10-year OS: 74.7% vs 35.5%, P < .001). In multivariate analysis, PR was independently associated with better survival than NR (HR for OS: 2.51; HR for DSS: 2.75; both P < .001). Other independent predictors of poor survival included older age, higher T/N stage, unmarried status, and absence of surgery.ConclusionA tripartite classification of treatment response-CR, PR, and NR-provides improved prognostic discrimination in HER2-positive breast cancer compared to the conventional binary model. Recognizing partial responders as a distinct clinical group may improve risk stratification and guide individualized treatment planning in the post-neoadjuvant setting.

BackgroundRobotic-assisted surgery is increasingly available in rural Michigan, but outcomes in these populations remain unclear. National data suggest robotic colectomies are associated with improved outcomes compared with open procedures, but evidence for rural patients is limited. This study compared postoperative outcomes of open, laparoscopic, and robotic right colectomies among rural and urban Michigan residents.MethodsThe HCUP State Inpatient Sample (2016-2018) identified adults undergoing right colectomy. Rural and urban residence was classified using Urban Influence Codes (UIC); rural residence was defined as codes 3-12. Complications included prolonged ileus, pneumonia, surgical site infection, abscess, septicemia, hemorrhage/hematoma, urinary tract infection, in-hospital death, and length of stay ≥5 days. ICD-10 codes identified surgical approach. Logistic regression estimated adjusted odds ratios (aORs), controlling for demographic and clinical covariates.ResultsAmong rural residents, minimally invasive approaches were associated with lower odds of complications than open surgery, with robotic procedures showing the lowest odds. Urban residents undergoing robotic colectomies experienced greater reductions in odds of pneumonia and urinary tract infections than rural residents.DiscussionMinimally invasive right colectomy was associated with lower odds of complications compared with open surgery. Robotic techniques showed the most favorable outcomes, though benefits appeared greater among urban residents. These disparities may reflect institutional experience, infrastructure, or access to robotic platforms. Given the limitations of administrative data and observational design, results should be interpreted as associations rather than causation. Further studies incorporating hospital- and surgeon-level data and post-discharge outcomes are needed to clarify rural-urban differences and guide equitable surgical care.