American Surgeon最新文献

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.

The Psychology of Surgery: An Initial Inquiry Into What Practicing Surgeons Think is Important to Know From Psychology. Abstract Background: There is growing interest in potential contributions psychological science can make to the practice of surgery. However, as an expansive field, selecting relevant content for education and training can be challenging. We surveyed practicing surgeons to assess their perception of the most relevant psychological topics and their mastery for excellence in a surgical career and care.

Methods: A list of surgery-related psychological topics was generated from content in the surgical literature and from experience. They were then reviewed by subject matter experts. The survey was distributed to attending surgeons who rated each item's importance and also their degree of mastery (from 0 low to 7 high).

Results: Twenty-three surgeons of various subspecialties participated. Topics of highest importance had mean scores approaching the highest potential rating of 7. Qualitative analysis suggested 4 categorical themes: coping with difficult events, communication skills, leadership skills, and psychological performance skills. A significant correlation was found between ratings of importance and mastery, but mean ratings of mastery were significantly lower than ratings of importance.

Discussion: This study found that practicing surgeons endorse a large number of psychological topics as being of high importance in surgical practice. However, ratings of mastery were significantly lower than ratings of importance. These findings suggest the need for training and education in the psychology of surgery for surgeons and surgical residents and provide potential targets for such training.

BackgroundLateral neck lymph node dissection (LLND) for thyroid carcinoma can result in chylous fistula, a complication with limited preventative surgical techniques. This study aimed to evaluate the impact of a novel surgical technique, reverse-sequence dissection and protection of the thoracic duct or right lymphatic duct, in reducing chylous fistula incidence post-LLND.MethodsThis study included 989 patients who underwent LLND between October 2019 and February 2024. Patients were divided into two groups based on the surgical technique: Group A (reverse-sequence dissection and protection of the thoracic duct and/or right lymphatic duct; n = 494) and Group B (prophylactic ligation of tissue around the venous angle; n = 495). The primary outcome was postoperative chylous fistula incidence.ResultsThe chylous fistula rate in group A (0.81%) was significantly lower compared to group B (5.05%, P = .0001). Group A had a significantly lower median peak output of 24-hour chylous fistula (32.50 [30.00, 36.25] ml/day vs 67.00 [55.00, 75.00] ml/day, P = .0188).ConclusionThe reverse-sequence dissection technique, combined with protection of the thoracic duct and/or the right lymphatic duct, effectively reduces the occurrence of chylous fistula following LLND for thyroid carcinoma.

PurposeVirtual General Surgery residency interviews remain common despite the easing of travel restrictions and health risks associated with the spread of COVID-19. The primary benefits of virtual interviews include time and cost savings for applicants and programs alike. Despite these benefits, many have advocated for a return to the in-person setting, citing improved ability for applicants to assess the intangibles of a program. In the 2022-2024 application cycles, our institution offered general surgery applicants the choice to interview virtually or in-person.MethodsApplicants who received an interview invitation for a categorical general surgery residency position at our institution could schedule either an in-person or virtual interview. Four in-person interview dates and 4 virtual interview dates were offered and filled. Applicants were ranked daily, compared only to those interviewed in the same modality. Conglomerate scores were then used to generate the overall rank list.ResultsInterviews were filled in a first-come first-serve manner with 55% of interview slots offered being in-person. A comparison of top-ranked and bottom-ranked individuals over 2 years demonstrates a near even split of their interviewing modality (60% of top-ranked candidates interviewed in person while 46.7% of bottom-ranked candidates interviewed in person, in the past 2 years). Matched candidates were also from both interview modalities (62% in-person).ConclusionWe describe the successful implementation of a hybrid interview system that allowed applicants to choose their interview modality. Prior data has demonstrated that when afforded the choice, most applicants elect to complete at least one interview in person and attend in-person post-interview events. This preference should not be ignored. Our study demonstrates that an individualized interview process can be offered with a successful Match of candidates from both interview types, allowing candidates the power and choice of their desired modality.

Esophageal cancer is a malignancy of the digestive tract characterized by high aggressiveness and poor prognosis. The two main histological subtypes are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma. Traditional treatment strategies for esophageal cancer include surgery, radiotherapy, and chemotherapy. For patients with locally advanced esophageal cancer, surgery remains the preferred approach; however, surgery alone often yields unsatisfactory outcomes. Meanwhile, the clinical efficacy of chemotherapy is limited by drug resistance and adverse effects. With the advent of immune checkpoint inhibitors, neoadjuvant immunotherapy combined with chemotherapy (nICT) has emerged as a novel therapeutic strategy. In recent years, an increasing number of clinical trials have been conducted in this field. This narrative review summarizes current clinical trials involving nICT in resectable or potentially resectable ESCC, and provides an overview of cutting-edge immunotherapeutic strategies and the unresolved challenges that remain.

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.