American Surgeon最新文献

BackgroundGastrocardiac syndrome is a condition where digestive issues, particularly in the upper gastrointestinal tract, are linked to heart-related symptoms. Gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are notable causes. The release of cytokines near the damaged esophagus may promote atrial fibrillation (AF). Hiatal hernia may lead to anatomical block and arrhythmias. Our systematic review aims to investigate the relationship between treatment of GERD/HH and improvement/resolution of arrhythmias.MethodsA systematic literature search was conducted following PRISMA guidelines. Databases including PubMed, Embase, and Scopus were searched from January 2005 to February 2024 using specific terms. Two co-authors screened and reviewed records. Exclusion criteria included cases without post-treatment information and conference abstracts. All study types discussing the relationship between GERD/ HH and arrhythmias were included. Data on patient characteristics, arrhythmia types, treatments, and outcomes were extracted. Murad checklist was utilized for quality assessment.Results13 studies in the review included 11 case reports, 1 case series, and 1 pilot study. Hiatal hernia repair (HHR) and proton pump inhibitors (PPIs) resolved arrhythmias in case reports and the case series. Proton pump inhibitor treatment for reflux esophagitis reduced AF symptoms in the pilot study. Arrhythmia resolution usually occurred shortly after treatment began. Patients were mostly around 59-62 years old, with more males. Hypertension and esophagitis were common comorbidities. Paroxysmal atrial fibrillation (PAF) was the most frequent arrhythmia type. Antiarrhythmic medication was stopped in some cases, and anticoagulation varied.ConclusionHiatal hernia and GERD may contribute to arrhythmias, and early management with surgery and PPIs shows promise in resolving symptoms and reducing medication reliance.

Chordomas are a rare malignancy of the axial spine arising from primitive notochordal cells. Optimal management entails en bloc resection with negative margins, with some evidence to support adjuvant radiotherapy. Failure to achieve adequate margins has been shown to result in a higher rate of recurrence. Frequent involvement of major pelvic structures further complicates their surgical management, and multidisciplinary teams are best suited to perform these resections. Here, we present a patient with a large, locally invasive sacral chordoma and review recent literature surrounding the current management of such chordomas. A 52-year-old male was found to have an infiltrating mass after magnetic resonance imaging (MRI) of the prostate for rising prostate-specific antigen (PSA). Computerized tomography (CT)-guided biopsy confirmed diagnosis of sacral chordoma, and the patient underwent excision with a two-stage operation utilizing a combined anterior-posterior approach. After a 49-day hospitalization complicated by small bowel obstruction (SBO), he was discharged to inpatient rehab (IPR), with subsequent receipt of adjuvant radiation therapy and no recurrence at 1 year of follow-up. A narrative review of pertinent literature over the last 20 years (2005-2025) was completed. Our search strategy identified 68 articles, allowing in-depth discussion of topics including tumor workup, surgical approach, emerging operative technologies, prognostic factors contributing to recurrence and survival rates, and the benefit of excision at high-volume centers.

High-energy, blunt force trauma to the abdomen results in an abdominal wall injury (AWI) in up to 9% of patients. In 1% of blunt abdominal trauma, they result in a traumatic abdominal wall hernia (TAWH). Optimal management of these injuries remains unclear. Because they are the result of a high-energy mechanism, concomitant serious abdominal organ injuries are common. This has prompted some to advocate that the presence of a TAWH on physical exam mandates exploratory laparotomy. However, delayed repairs have better outcomes and nontherapeutic celiotomy should be avoided. Similarly debated is the expanding use of minimally invasive techniques and the use of mesh for hernia repairs. Overall, the presence of a TAWH is likely not an absolute indication for emergency surgery. Rather, it is an indicator of high-energy impact and associated with a high rate of visceral injury. These patients require a close observation for clinical decline and development of typical indicators for laparotomy.

IntroductionIntegrated cardiothoracic surgery residency programs were introduced in 2008 in response to a decline in cardiothoracic surgery trainees. Since their inception, the number of integrated programs has grown, while the availability of independent fellowships has diminished. We hypothesize that the rise in integrated residencies will adversely affect the number of general thoracic surgery graduates.MethodsWe reviewed websites and social media pages of all accredited integrated cardiothoracic surgery residency programs and independent fellowships from 2020 to 2024. Programs without graduates or publicly available graduate data during this period were excluded. Data on each graduate's first position after residency was obtained.ResultsSince 2008, the number of traditional cardiothoracic surgery fellowship positions has decreased by 29.2% (130 to 92), while integrated positions have increased 16-fold (3 to 48). Of the 479 alumni, 330 pursued cardiac surgery and 149 pursued thoracic surgery. Among cardiac surgeons, 30.6% (101) completed additional training post-residency, compared to 6.7% (10) of thoracic surgeons. Graduates from 2021 and 2022 were significantly less likely to pursue thoracic surgery compared to 2020 (OR 0.485, 95% CI 0.241-0.974, P = .042; OR 0.491, 95% CI 0.244-0.988, P = .046). Only 5.4% (8) of integrated program alumni entered thoracic surgery, with these graduates having 86.3% lower odds of pursuing thoracic surgery than those from independent fellowships (OR 0.137, 95% CI 0.0610-0.310, P < .001). Program leadership specialty did not significantly impact outcomes.ConclusionThe increasing number of integrated cardiothoracic residency positions and decreasing independent fellowship opportunities contribute to a shrinking general thoracic surgery workforce, as most integrated program graduates enter cardiac surgery.

Incarcerated or threatened bowel obstruction with suspected intestinal ischemia requires prompt surgical intervention. This retrospective case series, involving 8 patients undergoing emergency laparotomy, evaluated the feasibility of combining indocyanine green (ICG) fluorescence and Doppler ultrasound for intraoperative bowel viability assessment. Indocyanine green was injected intravenously. Doppler assessment was performed using a high-frequency linear probe along the antimesenteric border. No patients required bowel resection. In 2 cases, initial ICG findings suggested non-viability, but Doppler ultrasound demonstrated preserved arterial flow. A second ICG injection showed fine granular fluorescence, allowing bowel preservation. The combination of modalities helped avoid unnecessary resections. Indocyanine green is safe and repeatable but limited by reduced signal in edematous tissue and subjectivity. Doppler ultrasound offers objective flow confirmation and may guide delayed reassessment. Despite a small sample size and selection bias, these findings support cautious, stepwise approaches in borderline cases and the need for multicenter prospective trials in emergency surgical settings.

IntroductionCritical care is a core component of resident education across multiple specialties. At this institution, nighttime supervision was previously provided by the on-call acute care surgeon. The CCRI model is a multidisciplinary team of fellowship trained intensivists who provide in-house overnight coverage. A prior study looked at the perceptions of general surgery residents on the impact of the CCRI model on education and patient care. This study expands our inquiry to compare the experience of residents across multiple specialties.MethodsAnonymous surveys were sent to anesthesiology (AN), emergency medicine (EM), internal medicine (IM), and general surgery (GS) residents using the Qualtrics platform. Demographic information included postgraduate year (PGY), specialty, and relationship to implementation of CCRI. 4-Point Likert Scale and free text questions were included.ResultsOf 138 total residents (16 AN, 46 EM, 51 IM, and 25 GS), 82 completed the survey (59.4%). Respondent stratification included 31 PGY-1 (38%), 22 PGY-2 (27%), 17 PGY-3 (21%), 6 PGY-4 (7%), 6 PGY-5 (7%); 11 AN (14%), 18 EM (22%), 29 IM (35%), and 24 GS (29%). Composites of strongly agree/agree show positive perception of attending availability (95%), improved patient care (98%), education (87%), and procedural skill (78%) and disagree/strongly disagree show negative perception of limiting autonomy (79%) or detracting from education (83%).ConclusionsThe CCRI model was implemented to enhance educational and clinical support of residents in the ICU overnight. Across multiple disciplines and training years, residents have indicated a favorable impact of the CCRI on education, clinical support, and procedural skill with no significant impairment to autonomy.

BackgroundWhile numerous studies regarding the need for magnetic resonance imaging (MRI) for evaluation of suspected blunt cervical spine injury (BCSI) exist, the resulting recommendations are often conflicting and are less reliably applicable to non-examinable or National Emergency X-radiography Utilization Study (NEXUS)-positive patients. This study sought to identify the utility of MRI in characterizing BCSI in such patients who had already undergone computed tomography (CT) imaging of the cervical spine.MethodsRecords from 402 unique patients presenting to a Level 1 trauma center were analyzed. Incidence of positive MRI in the setting of negative CT, unstable BCSI on either modality, need for surgical intervention, time in a cervical collar, and hospital readmission rates were calculated.ResultsNon-examinable or NEXUS-positive patients with BCSI identified on both CT and MRI were less likely to have a stable BCSI compared to CT-positive alone (53% vs 88%, P = 0.001). Out of 189 CT-negative patients, 53 (28%) were found to have BCSI on MRI, with 13 (6.8% overall) requiring operative intervention. Out of 100 BCSIs read as "stable" on CT, 28 (23.1%) were deemed "unstable" on subsequent MRI. Patients with negative MRI findings spent less time in a cervical collar than patients with positive findings (median 2 days vs 57 days, P < 0.001) and had lower 180-day readmission rates (12 patients [7.5%] vs 35 [15%], P = 0.031).ConclusionWhile CT remains vital for diagnosing BCSI, non-examinable or NEXUS-positive patients with negative CT should undergo confirmatory MRI prior to cervical collar removal.

BackgroundRecently, the number of older esophageal cancer patients has increased. Thoracoscopic esophagectomy, a minimally invasive surgery, is expected to improve surgical and clinical outcomes. But its outcome in older adults remains unclear. We aim to investigate the feasibility and safety of thoracoscopic esophagectomy in older patients.MethodsWe retrospectively enrolled 132 thoracic esophageal cancer patients who underwent thoracoscopic esophagectomy between January 2014 and January 2024. The patients were divided into 2 groups: non-older (<75 years) and older (≥75 years). A propensity score-matching (PSM) analysis was conducted based on sex, clinical T stage, and clinical N stage, resulting in 30 matched pairs. Patient characteristics, surgical procedures, postoperative complications, changes in nutritional status, and overall survival (OS) were compared between the 2 groups.ResultsPreoperative serum albumin levels were found to be lower in the older group compared to the non-older group (P <.05); nonetheless, the nutritional status of 6 months after esophagectomy was similar between the 2 groups. There were no significant intergroup differences in the incidences of recurrent nerve palsy, pneumonia, and anastomotic leakage (older vs non-older group: 13.3% vs 13.3%, P = 1.0; 16.6% vs 20.0%, P = 0.73; and 13.3% vs 13.3%, P = 1.0, respectively). The in-hospital mortality rate for the older group was 2.9%, showing no significant difference compared with the non-older group (P = 0.14). Overall, the OS was poor in the older group (P <.05); however, it was similar between the 2 groups after PSM (P = 0.36).DiscussionFor older patients, minimally invasive esophageal surgery is a feasible and safe option, offering acceptable short- and long-term outcomes.

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used for hemorrhage control in trauma patients, yet its role in blunt pelvic trauma remains controversial. This study evaluates outcomes in hypotensive patients with blunt pelvic trauma undergoing hemorrhage control surgery, comparing those who received zone 3 REBOA to those who did not.MethodsA retrospective cohort analysis was conducted using the ACS Trauma Quality Programs Participant Use File (TQP-PUF) from 2016 to 2019. Adult patients (≥18 years) with hypotension (SBP <100 mmHg) and blunt pelvic trauma who underwent surgical hemorrhage control were included. Exclusion criteria included traumatic brain injury, preperitoneal packing, resuscitative thoracotomy/sternotomy, and bleeding diatheses. Propensity score matching (1:1) was used to compare patients who received zone 3 REBOA versus those who did not. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes included transfusion volume, acute kidney injury (AKI), and lower extremity amputation.ResultsOf 4453 patients, 139 underwent REBOA. After matching, 121 patients remained per group. REBOA patients had significantly higher in-hospital mortality (50.5% vs 25.0%, P < 0.001) and 24-hour mortality (31.0% vs 14.3%, P = 0.002). The median PRBC transfusion was greater at 4 hours (4000 mL vs 1750 mL) and 24 hours (5600 mL vs 2800 mL) in the REBOA group (both P < 0.001). Acute kidney injury occurred more frequently in REBOA patients (15.7% vs 6.6%, P = 0.025).ConclusionsZone 3 REBOA in hypotensive blunt pelvic trauma was associated with higher mortality and transfusion needs. These findings highlight the need for cautious use and further prospective investigation.

BackgroundHelicopter emergency medical services (HEMS) provide rapid transport for trauma patients to specialized centers, potentially improving outcomes in life-threatening situations. However, HEMS is costly and often overutilized, with limited benefit in low-acuity cases. This study re-evaluates HEMS utilization at our Level I trauma center to assess current appropriateness based on clinical need and validated triage criteria.MethodsWe retrospectively analyzed all trauma patients transported to our institution by helicopter from January 2018-December 2021. Patients were categorized into trauma activation criteria and if any procedural intervention was performed within 1 hour of transport. Of the patients that received a procedure during admission, type of procedure and specialty that performed the procedure were evaluated. Disposition from trauma bay was collected.Results1419 helicopter transports met inclusion criteria during our analyzed time frame. 37.8% (n = 536) required a procedural intervention during their admission. Only 1.5% of patients (n = 21) who received an intervention were treated within 1 hour of arrival. Less than 30% of patients met criteria for helicopter transport when evaluated with current established national guidelines for prehospital triage. 35% of patients required ICU admission, while 8% were discharged to home within 24 hours. 36.3% (n = 515) of patients were activated as a Level I trauma alert upon arrival.ConclusionsMost helicopter transports were not clinically justified based on urgency or national triage guidelines. These findings highlight persistent overuse of HEMS and reinforce the need for standardized, evidence-based criteria to guide both scene and interfacility helicopter transport decisions in trauma care.