American Surgeon最新文献

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.

BackgroundThis study reported on cadaveric surgical training (CST) focusing on the anatomical knowledge necessary for transanal total mesorectal excision (TaTME) and educational perspective on our experiences.Methods3 CSTs were conducted with a total of 6 male cadavers between 2018 and 2020. Anatomical findings were collected from CSTs. All steps of the TaTME process were timed. Specimens were transanally or transabdominally extracted. The trainer rated the total mesorectal excision (TME) quality as complete, near complete, or incomplete.ResultsThe number of trainees were 6 surgeons. Their number of years since graduation was 9 (6-19), their experience with conventional TME on live patients was 46 cases (27-202), and their experience with TaTME on live patients was 0 case (0-4). Their set up of the transanal platform was 14 min (7-21), time to resect the anococcygeal ligament was 17 min (6-29), time to resect the retrourethral muscle was 23 min (9-41), time to spare fourth pelvic splanchnic nerves was 11 min (4-28), and total completion of the TaTME was 84 min (59-122). The grade of TME was incomplete in 1 case (11.1%), nearly complete in 1 case (11.1%), and complete in 7 cases (77.8%).ConclusionIn this study, the anatomical structures necessary for TaTME were identified. We believe that CST for TaTME is a promising educational method for overcoming and performing the characteristic anatomical challenges safely.

BackgroundTertiary hyperparathyroidism (3HPT) occurs when hypercalcemia and elevated parathyroid hormone (PTH) persist after renal transplantation. Our study aims to identify gaps in the diagnosis and treatment of patients with 3HPT.MethodsIn a single-center retrospective analysis, we identified renal transplant patients with 3HPT based on the history of secondary hyperparathyroidism, preserved renal allograft function, and persistent serum PTH elevations (12-88 pg/mL) during postoperative follow-up.ResultsA total of 1556 patients were biochemically diagnosed with 3HPT. Median age was 57 (IQR = 47-65). Most were male (n = 888, 61%), black (n = 801, 55%), and did not undergo parathyroidectomy (n = 1388, 95.4%). Of these, 29.4% (n = 429) of the patients were diagnosed and treated, 23.4% (n = 354) were diagnosed and not treated, and 46.2% (n = 672) remained undiagnosed. Predictive factors for diagnosis and treatment included elevated pre-kidney transplantation PTH levels ≥ 600 pg/mL, postoperative PTH levels ≥ 300 pg/mL, and elevated postoperative calcium (≥10.4 mg/dL).ConclusionMost patients with biochemical 3HPT remain undiagnosed. This highlights gaps in patient care and the need for clearer guidelines on timing for PTH assessment and surgical referral in patients with 3HPT.

BackgroundSurgical stabilization of rib fractures (SSRF) remains controversial as studies search for the patient population who would benefit most from SSRF. This study aimed to identify the predictive risk factors in patients with chest wall injuries who underwent SSRF and sustained in-hospital complications.MethodsThis study is a retrospective review of the 2016-2019 Trauma Quality Improvement Program database. Data included age, sex, comorbidities, Abbreviated Injury Score (AIS), injury pattern, interventions, and complications. All adult patients who suffered ≥1 rib fracture following an isolated thoracic injury (AIS ≥2 but < 6 and AIS ≤ 1 in all other regions) and underwent SSRF were eligible for inclusion.ResultsA total of 1823 patients were included in this study of whom 4.8% (N = 87) of patients suffered an in-hospital complication. Patients who suffered a complication were generally older, male, had a higher cardiac risk, were more severely injured, and tended to have a longer time to SSRF (3.8 vs 2.5 days, P < 0.001). The top 5 predictors of in-hospital complications were RCRI, thorax AIS, time to SSRF, age, and sex. These variables were sufficient for achieving an acceptable discriminative ability for complications (AUC (95% CI): 0.78 (0.73-0.83)).DiscussionCardiovascular risk, thoracic injury severity, and delayed SSRF were correlated with elevated risk of complications. As time to surgery constitutes the sole changeable factor, prompt intervention may substantially diminish postoperative morbidity. These findings can enhance risk classification and assist therapeutic decision making for SSRF.

Colonoscopy-associated rectal perforation is rare but serious. Although a colostomy or laparotomy is frequently required, primary repair may suffice in selected cases. A 70-year-old woman with prior laparoscopic low anterior resection underwent surveillance colonoscopy and EMR. During retroflexion, a 3 cm perforation was noted 10 cm from the anal verge, which was located 7 cm proximal to the previous anastomosis at 3 cm from the anal verge. Endoscopic clipping failed due to the size and location of the lesion. No intraperitoneal contamination was evident. A transanal endoscopic approach (TAMIS) was employed using an Alexis® wound protector and insufflation. The defect was closed using 3-0 Vicryl under direct intraluminal visualization. Laparoscopic inspection confirmed no leakage. A transanal drain was left in place.The postoperative course was uneventful. Inflammatory marker levels remained stable, and the patient was discharged on postoperative day 9 without complications. Transanal endoscopic repair is a viable, minimally invasive alternative for iatrogenic rectal perforations without gross contamination, potentially avoiding colostomy and improving the postoperative quality of life.