American Surgeon最新文献

BackgroundMost studies demonstrating efficacy of surgical stabilization of rib fractures (SSRF) are in patients with isolated severe chest wall injury. Recent evidence suggests SSRF may reduce mortality in polytrauma patients. The present study examines SSRF outcomes in severe polytrauma patients.MethodsThe 2013-2021 Trauma Quality Improvement Project database was used to identify severe polytrauma patients, defined as Injury Severity Score (ISS) ≥15 and abbreviated injury scale (AIS) ≥2 in 2 or more regions, with rib fractures. Exclusion criteria included AIS 6 in any region, death ≤72 hours, or SSRF >72 hours after admission. Outcomes of interest were in-hospital mortality, pneumonia, acute respiratory distress syndrome (ARDS), and length of mechanical ventilation. Adjustment for confounding was achieved using inverse probability of treatment weighting, Poisson regression models and quantile regression models.ResultsA total of 388 091 patients met inclusion criteria, of which 1.3% (N = 5020) underwent SSRF. SSRF was associated with a 57% decreased risk of mortality (P < 0.001) and 53% lower risk of ARDS (P < 0.001). Patients who underwent SSRF also required approximately 1 day less of mechanical ventilation (P < 0.001). Patients with ISS 15-19 exhibited an association between SSRF and a 55% (P = 0.023) lower rate of pneumonia.ConclusionSSRF within 72 hours of admission in severe polytrauma patients is associated with a lower rate of mortality and acute respiratory distress syndrome, along with shorter duration of mechanical ventilation. A reduction in the rate of pneumonia was only observed among patients with ISS 15-19.

BackgroundDefinitions of massive transfusion following injury help identify patients at the greatest risk of death. However, these definitions primarily use blood component therapy. The use of whole blood (WB) transfusion protocols has seen a resurgence, with evidence of improved outcomes compared to component therapy. Therefore, our aim was to define and stratify patients into low, intermediate, and high risk for death based on volume of blood products transfused utilizing a WB-first resuscitation strategy.MethodsPatients that received at least 1 unit of whole blood following injury between January 2016 and November 2021 were identified. Receiver operating characteristic (ROC) curves to predict death based on volume of blood products transfused were constructed. Patients were stratified to low, intermediate, and high risk of death based on positive likelihood ratios.ResultsThere were 785 patients identified to have received at least 1 unit of WB following injury during the study period. Based on ROC curve analysis, the best predictor of death was volume of whole blood plus packed red blood cells (PRBC) in the first hour (AUC 0.66, P < 0.001). Low risk of mortality was defined as WB + PRBC volume <3400 cc in the first hour (14.9% mortality), intermediate risk 3400-5100 cc in the first hour (39.1% mortality), and high risk >5100 mL in the first hour (66.7% mortality).DiscussionThe combination of WB + PRBC volume within the first hour following injury is the best predictor of death. Further, volumes of WB + PRBC transfused within the first hour can be used to stratify patients' risk of death.Level of EvidenceLevel IV.Study TypePrognostic and Epidemiological.

IntroductionPersonality assessments have been widely used in business to identify leadership potential and enhance team performance; however, their integration into surgical education remains limited. This study evaluated surgeons' personality profiles using the PRISM assessment and compared them with those of other health care professionals to guide the design of leadership development curricula for surgical training.MethodsA total of 199 surgeons (residents, fellows, and faculty) across multiple academic medical centers completed the PRISM personality assessment as part of structured leadership development programs. Data were compared with a normative cohort of 5887 health care professionals from the SurePeople database. Primary and under-pressure personality profiles were analyzed using chi-square and Fisher's exact tests, with significance set at P < .05.ResultsNo significant differences were found between surgeons and other health care professionals in primary personality distributions. Under-pressure profiles, however, revealed a greater proportion of surgeons classified as the Navigator type (22% vs 14%; P = .05), reflecting tendency towards higher decisiveness and structure in stressful conditions. Personality distributions were similar across residents, fellows, and attending surgeons.DiscussionAlthough surgeons' baseline personalities mirror those of other health care professionals, their stress-related behavioral tendencies demonstrate a unique shift toward structured, action-oriented responses. Incorporating personality assessments such as PRISM into leadership curricula may enhance self-awareness, emotional intelligence, and team performance.ConclusionIntegrating structured personality assessment into surgical leadership education provides valuable insight into behavioral responses under stress and supports the development of adaptive, emotionally intelligent leaders who foster effective and collaborative surgical teams.

IntroductionThe prognostic significance of high-risk features (HRFs) in stage II colon cancer is established, but the cumulative impact of multiple HRFs and their relation to stage III disease remain unclear. This study evaluated whether patients with stage II colon adenocarcinomas with ≥3 HRFs demonstrate survival outcomes comparable to stage III disease.MethodsA retrospective analysis included 377 patients who underwent curative resection for colon adenocarcinoma between 2016 and 2022. Patients were classified as stage II <3 HRFs (n = 102), stage II ≥3 HRFs (n = 88), and stage III (n = 187). Clinicopathologic variables were compared, and overall (OS) and disease-free survival (DFS) were analyzed.ResultsPatients with stage II ≥3 HRFs demonstrated 5-year OS and DFS rates of 58.9% and 57.8%, significantly worse than stage II <3 HRFs (79.4% and 74.5%) and comparable to stage III (71.2% and 61.3%) (P = .037, P = .040). Subgroup analysis confirmed that stage II ≥3 HRFs had worse OS and DFS than <3 HRFs (P = .010, P = .017), but outcomes were comparable to stage III (P = .126, P = .600). On multivariate analysis, predictors of worse OS included age ≥65, stoma formation, <12 lymph nodes, and elevated CEA, while DFS was adversely influenced by age ≥65, stoma formation, tumor volume >30 cm³, <12 lymph nodes, elevated CEA, and stage III disease.ConclusionStage II colon cancers with ≥3 HRFs demonstrate survival outcomes comparable to stage III, emphasizing the cumulative prognostic impact of multiple risk factors. These findings reinforce adjuvant chemotherapy consideration and highlight the need for refined risk stratification.

Wound contraction is a pivotal component of the wound healing cascade, and contractions of moderate intensity and duration can exert a facilitative effect on the healing process to a certain extent. Accumulating evidence indicates that α-smooth muscle actin (α-SMA)-positive myofibroblasts act as the primary functional effector cells mediating wound contraction, whose regulatory role in this process depends on their cellular abundance and functional activity, thereby exerting a profound impact on wound healing outcomes. Recent advances in research pertaining to wound contraction and healing have deepened the mechanistic insights into these intertwined biological processes. Against this backdrop, the present review synthesizes current literature on the multifaceted roles of myofibroblasts in wound contraction and healing, with a particular focus on establishing explicit connections to clinical decision-making in surgical practice. It is anticipated that this work will provide valuable insights to advance both basic research and clinical translation in this field.

BackgroundHypoalbuminemia is associated with worse postoperative outcomes, but data is limited in the bariatric population. Patients with BMI ≥50 may represent a higher-risk group for malnutrition.MethodsWe analyzed MBSAQIP data (2015-2022) for patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Propensity score matching was used to control for 22 preoperative variables. We compared 30-day outcomes and bariatric-specific complications in patients with albumin <3.5 g/dL vs ≥3.5 g/dL across four groups: SG with BMI ≥50 (analysis 1), RYGB with BMI ≥50 (analysis 2), SG with BMI <50 (analysis 3), and RYGB with BMI <50 (analysis 4).ResultsAmong 728,915 patients, matched cohorts in analyses 1 (n = 17,548), 2 (n = 9459), 3 (n = 16,025), and 4 (n = 6787) had similar preoperative characteristics. Hypoalbuminemia was associated with increased complications across all groups. In patients with BMI ≥50, hypoalbuminemia was significantly associated with increased mortality (SG 0.2% vs 0.1%, P = 0.011; RYGB 0.3% vs 0.1%, P < 0.001), unplanned ICU admission (SG 1.0% vs 0.7%, P = 0.020; RYGB 1.6% vs 1.2%, P = 0.034), and non-home discharge (SG 0.8% vs 0.5%, P < 0.001; RYGB 0.9% vs 0.6%, P = 0.009). These mortality differences were not observed in patients with BMI <50.ConclusionHypoalbuminemia is associated with higher complications rates after bariatric surgery and increased mortality in patients with BMI ≥50. Preoperative nutritional optimization is strongly recommended in this high-risk group.

BackgroundComputed tomography (CT) is the preferred imaging modality for diagnosing acute appendicitis in adults. However, the optimal contrast protocol remains debated, balancing diagnostic accuracy, operational efficiency, and patient safety.ObjectiveTo systematically compare the diagnostic accuracy and operational efficiency of different CT contrast protocols-oral, intravenous (IV), combined oral + IV, and non-contrast-in adult patients with suspected acute appendicitis.MethodsA comprehensive search of MEDLINE, Embase, Cochrane Library, and Web of Science was conducted from inception to April 2025. Eligible studies compared CT contrast protocols in adults (≥18 years) and reported diagnostic or operational outcomes. Two independent reviewers screened articles, extracted data, and assessed risk of bias using the QUADAS-2 tool. Primary outcomes were sensitivity, specificity, positive predictive value, and negative predictive value; secondary outcomes included time to CT completion and emergency department (ED) length of stay.ResultsSeventeen studies involving 5033 patients met inclusion criteria. Non-contrast CT demonstrated sensitivity of 82.4-90.5% and specificity of 75-100%. Oral contrast-only protocols showed sensitivity of 73.5% and specificity of 80%. Combined oral + IV protocols achieved sensitivity of 89.4-100% and specificity of 54.5-98.5%. IV-only protocols provided sensitivity of 77.8-100% and specificity of 87-100%. Across studies, eliminating oral contrast reduced ED length of stay by 29-91 minutes without compromising diagnostic accuracy.ConclusionsIV-only or non-contrast CT protocols offer comparable diagnostic accuracy to oral contrast approaches while significantly improving workflow efficiency. Protocol selection should consider clinical setting and patient factors, reserving oral contrast for select groups such as oncology patients or those with prior abdominal surgery.

IntroductionA "smoker's paradox" has been described in rib fractures for which smokers have demonstrated increased complications but decreased mortality. Alcohol has shown increased mortality risk but the effect of substance use has not been well evaluated. Given the paucity of data surrounding these outcomes, we evaluated the impact of alcohol use, smoking, and substance use disorders on outcomes after traumatic rib fracture.MethodsWe performed a five-year retrospective review for all adult patients admitted to our level 1 trauma center with rib fractures. Each outcome was evaluated independently in a stepwise backward regression model for potential confounding factors. We then performed multivariable linear and logistic regression to examine the relationship between alcohol, smoking, and substance use to outcomes.ResultsIn total, 3,327 patients were included for review. Smoking was associated with increased morbidity but a paradoxical decreased risk of respiratory failure and a 56% decreased risk of mortality. Substance use disorder had increased risk of respiratory failure and complications but a paradoxical 66% decreased risk of mortality. Alcohol use disorder was associated with increased morbidity with no change in mortality and no paradoxical beneficial outcomes. Both alcohol and substance use disorders were associated with significantly prolonged hospital length of stay.ConclusionDespite increased morbidity, both smoking and substance use disorder demonstrated significantly decreased mortality. These findings could support the expansion to a "smoker's and substance use paradox" in traumatic rib fracture although further study is warranted.