American Surgeon最新文献

BackgroundFinancial toxicity can lead to poor outcomes in surgical oncology patients. This study evaluates the impact of financial toxicity on readmissions in surgical oncology patients, including different-hospital readmissions.MethodsThe Nationwide Readmissions Database was queried for patients admitted with a surgically treated malignancy. Financial toxicity was defined by at least two: lack of insurance, household income in the lowest quartile, or index hospitalization cost in the highest quartile.ResultsOf 108,850 patients, the 30-day readmission rate was 17.4% (n = 18,959), with 19.1% (n = 3,611) readmitted to a different hospital. Financial toxicity was identified in 7.3% (n = 7,888), with a readmission rate of 20.1% (n = 1,585; P < .001). On multivariable regression, the strongest risk factors for readmission were more than 3 comorbidities (OR 1.74 [1.68-1.79]; P < .001), and financial toxicity (OR 1.11 [1.05-1.18]; P < .001).ConclusionSurgical oncology patients impacted by financial toxicity are at an increased risk for readmission. Readmission studies from single institutions miss a large portion of these patients with this compounding risk. Outcome improvements can be achieved by reducing financial burdens placed on surgical oncology patients.

The Mpox virus, formerly known as Monkeypox, was declared a Public Health Emergency of International Concern in July 2022 due to its rapid global spread. By 2024, the more virulent and fatal Clade Ib variant had reached the United States. While Mpox typically presents with a self-limited rash, severe manifestations requiring surgical intervention have become increasingly prevalent, necessitating heightened awareness and preparedness among surgeons.This narrative review, specifically targeting surgeons, provides a comprehensive summary of the current data on the epidemiology, pathophysiology, perioperative considerations, and surgical management of Mpox-related conditions. It outlines essential hospital protocols and perioperative precautions to mitigate nosocomial spread, drawing useful parallels with measures established for COVID-19. It also addresses Mpox-related surgical pathologies, including colorectal abscesses, cutaneous scarring, facial lesions, and ocular complications, detailing management strategies for each.Our findings emphasize the need for rigorous infection control measures, early recognition of surgical indications, and interdisciplinary coordination to optimize patient outcomes, especially since Mpox is most readily transmitted among immunocompromised individuals, such as those who have undergone solid organ transplants. The virus primarily spreads through sexual transmission and contact with infected skin lesions, necessitating standardized hospital protocols to minimize its spread, particularly in operating rooms. Colorectal manifestations often require surgical drainage, with colostomy being necessary in severe cases, while ophthalmic manifestations demand prompt and aggressive management to preserve vision. Airway management and anesthetic planning are also critical considerations in cases involving oropharyngeal Mpox lesions.This review highlights the urgent need for ongoing documentation and research to refine surgical management protocols for Mpox, enhancing preparedness for future outbreaks. The complexity and severity of Mpox-related surgical pathologies underscore the necessity for further studies to refine management strategies, develop innovative treatments, and improve patient outcomes. Future research should aim to deepen our understanding of Mpox pathophysiology and optimize protocols to ensure safe and effective care for affected patients. This is essential in an era marked by the threat of emerging infectious diseases and the lessons learned from recent global health crises.

Neurogenic Thoracic Outlet Syndrome (nTOS), the most prevalent type of thoracic outlet syndrome, results from compression of the compression of the brachial plexus as it traverses the scalene triangle and rectopectoralis minor space. It typically presents with upper extremity pain, hand weakness, paresthesia, and muscle atrophy that is often exacerbated by arm elevation or overhead activity. Etiology commonly includes congenital anatomical variants, trauma, and repetitive overhead activity. Diagnosis remains challenging as a result of significant symptom overlap with cervical radiculopathy, brachial plexopathies, and entrapment neuropathies. Work up involves a combination of thorough history and physical with electrophysiologic testing, diagnostic injections and imaging such as MRI or duplex ultrasonography. Initial therapy indicates physical therapy with a focus on decompression and postural correction. In patients with persistent symptoms, motor deficits or failed conservative management, surgical decompression using transaxillary, supraclavicular or minimally invasive techniques is indicated. Rib-sparing surgical decompression is increasingly favored given lower complication rates. Postoperative rehabilitation focuses on restoring range of motion and shoulder girdle strength. This review serves to outline clinical presentation, diagnostic strategies and operative options for nTOS while emphasizing an individualized, stepwise approach to optimize outcomes and minimize risk.

BackgroundDriving pressure (ΔP), the difference between peak inspiratory pressure (PIP) or plateau pressure (Pplat) and positive end-expiratory pressure (PEEP), has been proposed as a better target for avoiding ventilator-induced lung injury (VILI) in mechanically ventilated patients. This study aimed to determine if lower dynamic ΔP would correlate with reduced mortality and lower incidences of VILI.MethodsA single-center retrospective analysis identified 237 trauma patients admitted in 2020 who underwent ≥48 hours of mechanical ventilation and survived ≥72 hours. The primary outcomes were 30-day hospital mortality and development of acute hypoxic VILI. Univariate and multivariate analyses assessed variables associated with 30-day mortality and VILI incidence.ResultsThe cohort had a median age of 45 years, predominantly male (83.1%), with most admitted for blunt trauma (62.4%). The median ventilation duration was 6 days. Mortality was 20% for patients with ΔP ≤ 15 cm H₂O and 32% for those with higher ΔP (P = 0.04). Ventilator-induced lung injury incidence was higher in patients with ΔP ≥ 15 cm H₂O (34% vs 19%; P = 0.01). Multivariate analysis, adjusting for age, Injury Severity Score (ISS), and presence of intracranial bleed, indicated that an average ΔP ≥ 15 cm H₂O was associated with an increased risk of 30-day mortality (OR 2.4; 95% CI 1.2-4.8, P = 0.02) and higher VILI incidence (OR 2.2; 95% CI 1.2-4.0, P = 0.01).ConclusionsAmong trauma patients requiring at least 48 hours of mechanical ventilation, employing strategies to limit dynamic ΔP to less than 15 cm H₂O may reduce 30-day mortality and the incidence of acute VILI.

BackgroundThere has been a shift in the management of choledocholithiasis from laparoscopic common bile duct exploration to endoscopic retrograde cholangiopancreatography. This has led to an increase in hospital length of stay, costs, and specifically for rural hospitals, transfer to a tertiary center for ERCP. Given this shift of choledocholithiasis management to advanced GI endoscopists, general surgery residents are rarely performing laparoscopic transcystic common bile duct explorations.MethodsA retrospective study of 69 consecutive laparoscopic transcystic common bile duct explorations (LCBDE) performed by 2 general surgeons in a rural community over 5 years between 2017 and 2022. Primary outcomes included successful duct cannulation, successful stone clearance, instruments used, operative time, and significant complications (pancreatitis, bile leak, bleeding, bile duct injury). Specific technique for laparoscopic transcystic common bile duct exploration is outlined in Appendix 1.ResultsThere was a median age of 54 years (Range 17-91). There was successful cannulation in 97% and successful stone clearance in 82% of cases. In the vast majority of cases only a guide wire and biliary balloon dilation catheter were utilized to perform the procedure. Median operative time for laparoscopic cholecystectomy with cholangiogram was 40 minutes. Median operative time for laparoscopic cholecystectomy with cholangiogram and transcystic common bile duct explorations was 64 minutes (Range 39-168). Therefore, the median time added by performing LCBDE was 24 minutes There were no complications during laparoscopic transcystic common bile duct explorations.ConclusionsLaparoscopic transcystic common bile duct exploration can be safely, efficiently, and successfully performed with 0.035-inch Roadrunner PC guidewire, TAUT intraducer and an Advance Biliary Balloon Catheter. In order to shift the management of choledocholithiasis back to the general surgeon to decrease the length of stay and cost, there needs to be a change at the residency training level.

BackgroundLaparoscopic colectomy is standard for uncomplicated diverticulitis (UD) but has higher conversion and morbidity rates in complicated diverticulitis (CD). Robotic colectomy (RC) is increasingly used for both UD and CD. This study compared outcomes of RC for CD and UD and evaluated factors contributing to adverse outcomes.MethodsUsing 2014-2021 NSQIP data, we identified patients with CD or UD who underwent RC. The primary endpoint was textbook outcome (TO), defined as absence of prolonged length of stay (LOS), major morbidity, readmission, anastomotic leak, or mortality within 30 days. Regression analyses were used to assess outcomes and associated factors.ResultsAmong 6829 patients, 4604 (67.4%) had UD, and 2225 (32.6%) had CD. Complicated diverticulitis patients were more often male (50.3% vs 41.0%; P < 0.001) and had smoking history (21.0% vs 16.1%; P < .001), preoperative sepsis (3.1% vs 0.8%; P < .001), and delayed surgery >1 day after admission (8.8% vs 1.9%; P < .001). Textbook outcome was achieved in 48.5% of CD vs 62.9% of UD patients (P < .001), and major morbidity occurred in 12.5% vs 5.4% (P < .001). On regression analyses, CD patients had lower odds of achieving TO (OR 0.754 [95% CI 0.673-0.846]) and higher odds of major morbidity (1.949 [1.610-2.360]), conversion (1.577 [1.262-1.972]), prolonged LOS (1.280 [1.137-1.440]), iatrogenic complication (2.134 [1.561-2.918]), postoperative sepsis (2.653 [2.020-3.486]), and organ/space infection (1.751 [1.374-2.232]). Factors associated with TO achievement were identified separately in UD and CD cohorts.ConclusionRobotic colectomy is a safe and feasible option for both UD and CD, with anticipated variations in complication rates reflecting differences in disease complexity.

Mesenchymal hamartomas are rare benign liver tumors located in the embryonic mesenchymal tissue, most frequently affecting male infants and young children. While clinical presentation is typically asymptomatic, rupture, hemorrhage, infection, and malignant transformation are possible. Biliary hamartomas are benign lesions most frequently in patients >35 years. Imaging for both entities is typically nonspecific; a broad differential between solid and cystic lesions of the liver makes histologic evaluation critical. Both hamartomas are treated by liver resection, with most patients recovering fully with no further treatment. Here, we report a rare case of a mesenchymal hamartoma in an adult and provide a systematic review of mesenchymal and biliary hamartomas utilizing PRISMA guidelines; this review highlights the reported diagnostic and treatment paradigms and utilizes these to develop a diagnostic algorithm to assist in the definitive identification of these benign lesions with the potential to avoid surgical resection in appropriately selected patients.

IntroductionColorectal cancer is the third leading cause of cancer incidence and mortality in the U.S. Screening has contributed to a 2% annual decline in incidence and deaths. The Cologuard test is approved for average-risk patients 45 and older and, when positive, mandates follow-up colonoscopy. However, false positives range from 13% to 40%. There is ongoing debate about the utility of adding upper gastrointestinal (UGI) endoscopy to the workup of a positive Cologuard test, despite its utility in diagnosing conditions like peptic ulcer disease. This study explores the potential benefits of including UGI endoscopy to the work up of positive Cologuard patients in an Appalachian population.Methods100 consecutive patients with positive Cologuard tests underwent bidirectional endoscopy by the same surgeon. The study was conducted in an Appalachian region with high levels of tobacco and alcohol use. Positive findings included severe UGI inflammation, erosions, ulcers, and colon polyps or tumors larger than 5 mm.ResultsThe study analyzed endoscopic findings on 100 consecutive patients. Only 52% of positive Cologuard patients had positive findings on colonoscopy. 70% of patients had significant findings on UGI endoscopy. 28% had positive findings on both upper and lower endoscopy and 6% had normal upper and lower endoscopy.ConclusionThis study suggests that UGI endoscopy may be a beneficial component of the workup for positive Cologuard tests in certain high-risk populations. This practice could identify significant pathology and improve early detection of conditions like peptic ulcers and early cancers, thereby enhancing patient outcomes.

Early oral feeding (EOF), a key component of enhanced recovery after surgery (ERAS), has been proven to be safe and associated with a significant reduction in overall complications, but the safe volume for EOF remains ambiguous, and rare complications have been reported in recent years. We report a case of 68-year-old male, who underwent laparoscopic total gastrectomy, voluntarily consumed 1500 mL of enteral nutrition formula due to hunger on postoperative day 1. Within 3 hours, he developed fever, abdominal distension, palpitations, and nausea. Computed tomography (CT) revealed hepatic portal venous gas and pneumatosis intestinalis. Mechanical obstruction, anastomotic leakage, and necrosis were excluded, avoiding surgical intervention. Conservative management (intestinal decompression, antibiotics, and fluid resuscitation) led to a full recovery. Although rare, this case highlights potential risks of aggressive EOF regimens, emphasizing the need for individualized postoperative protocols, patient education, and vigilant monitoring to mitigate complications.

IntroductionBlunt trauma patients (BTPs) with cirrhosis are at an elevated risk for hemorrhagic complications, including traumatic brain injury (TBI). This study assessed whether BTPs with cirrhosis experience higher rates of TBI and severe TBI compared to those without cirrhosis and whether alcohol use disorder (AUD) further impacts these outcomes.MethodsWe analyzed data from the 2017-2022 Trauma Quality Improvement Program (TQIP) for BTPs aged ≥18 years. Patients were grouped by cirrhosis status, and those with cirrhosis were further stratified by AUD. Severe TBI was defined as an Abbreviated Injury Scale (AIS) > 5. The primary outcome was the incidence and adjusted risk of severe TBI in cirrhotic BTPs.ResultsAmong 4 182 335 BTPs, 53 190 (1.3%) had cirrhosis. Cirrhotic patients had higher rates of TBI (26.3% vs 17.8%, P < .001), severe TBI (7.2% vs 3.2%, P < .001), complications (11.9% vs 4.6%, P < .001), longer hospital stay (6 vs 4 days, P < .001), and mortality (9.7% vs 2.9%, P < .001) compared to non-cirrhotics. After adjusting for age and injury severity, on multivariable analysis, cirrhotic patients were independently associated with an increased risk of severe TBI (OR 2.02, 95% CI 1.88-2.17, P < .001). Among cirrhotics, those with AUD had higher rates of TBI (31.4% vs 23.1%, P < .001), severe TBI (10.6% vs 5.3%, P < .001), and increased adjusted mortality risk (OR 1.18, 95% CI 1.11-1.27, P < .001).ConclusionCirrhosis is associated with a significantly increased risk of TBI and severe TBI among BTPs, AUD further amplifies these risks. Awareness of these associations is essential for risk stratification and management in trauma care.Level of EvidenceIV.