The American Surgeon™

Lateral 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.

This 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.

The 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).

The 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.

Recently, 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.

We 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.

Preoperative 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).

For older patients, minimally invasive esophageal surgery is a feasible and safe option, offering acceptable short- and long-term outcomes.

Tertiary 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.

In 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.

A 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).

Most 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.

Surgical 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.

This 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.

A 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)).

Cardiovascular 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.

As pulmonary segmentectomy becomes increasingly common in the treatment of early-stage lung cancer, providing relevant clinical training for residents is essential. However, understanding pulmonary segment anatomy can be challenging due to its complex and variable structures. This study aimed to evaluate the value of automated three-dimensional CT bronchography and angiography (3D-CTBA) technology in training surgical residents for segmentectomy.

Fifty-two surgical residents were randomized into 2 groups: the 3D-CTBA group and the control group. The 3D-CTBA group utilized automated 3D-CTBA technology alongside specific case for segmentectomy training, while the control group relied on traditional teaching methods. After the training sessions, all participants completed a post-training assessment and questionnaires. Additionally, we collected feedback from instructors regarding the residents’ performance through a separate questionnaire.

Residents in the 3D-CTBA group achieved significantly higher scores on the post-training assessments than those in the control group (83.46 ± 6.75 vs 68.27 ± 8.12, P < 0.001). Subjective survey results indicated that automated 3D-CTBA technology greatly benefited residents in preoperatively identifying tumor locations, recognizing anatomical variations during surgery, and mastering relevant surgical techniques. Feedback from instructors indicated that residents in the 3D-CTBA group performed better intraoperatively than those in the control group. Furthermore, residents in the 3D-CTBA group expressed greater interest in learning and higher satisfaction with the course.

Automated 3D-CTBA technology significantly improved residents’ comprehension of the complex and variable anatomy of pulmonary segments, thereby enhancing their related surgical skills.

Clinical practice guidelines (CPGs) shape surgical care and outcomes, but concerns persist regarding the diversity and expertise of their authors. Whether U.S. surgical society guidelines reflect inclusive and expert-driven authorship remains unknown.

We conducted a cross-sectional analysis of 213 CPGs published by 11 national U.S. surgical societies between 2015 and 2024. We assessed author gender, race/ethnicity, and prior publication history using validated name-based algorithms and PubMed queries. Authors were classified as underrepresented in medicine (URiM) if identified as Black and Hispanic/Latino. Trends over time were analyzed using the Jonckheere-Terpstra test.

Among 2185 authors, 557 (25.5%) were women and 111 (5.1%) were URiM. Over half of guidelines (52.1%) had no URiM authors, and 21.6% had no female authors. Female representation increased over time (P = 0.02), while URiM representation remained unchanged (P = 0.32). Representation varied widely across societies. Among first and corresponding authors, 45% had fewer than 5 topic-specific publications. Additionally, 486 (14.7%) of all authors had no prior guideline authorship experience.

CPGs published by U.S. surgical societies from 2015 to 2024 demonstrated persistent gaps in gender and racial/ethnic diversity, as well as inconsistent subject-matter expertise among authors. These findings raise concerns about the representativeness and rigor of current guideline development practices. Surgical societies should consider reforms to authorship selection processes to promote more inclusive and expert-driven guidance reflective of the populations they serve.

This study aimed to evaluate the impact of postoperative complications on early recurrence (ER) after pancreaticoduodenectomy (PD) for biliary tract cancer (BTC).

Patients who underwent PD for BTC between 2009 and 2022 were enrolled in this study. Postoperative complications were assessed using the comprehensive complication index (CCI), calculated by summing all the complications. The optimal CCI cutoff value for predicting ER was selected based on the minimum P value from the chi-square test. ER was defined as recurrence within 12 months of resection. Risk factors for ER were identified using multivariate analysis.

A total of 118 patients were analyzed. ER was observed in 34 (28.8 %) patients, indicating a significantly poorer prognosis than those without ER (log-rank, P < .001). No significant differences were observed in the primary tumor site or pathological features between the low CCI (<42.6) and high CCI (≥42.6) groups. The incidence of ER was significantly higher in the high CCI group than in the low CCI group (50.0% vs 24.0%, P = .015). Multivariate analysis revealed that high CCI (odds ratio [OR] 4.43, 95% confidence interval [CI] 1.41-13.97, P = .011) and R1 resection (OR 4.88, 95% CI 1.43-16.70, P = .012) were independent risk factors for ER.

Postoperative complications after PD for BTC were found to be independent risk factors for ER.

There is a known correlation with older age and an increase in both postoperative morbidity and mortality in surgery. However, there is limited postoperative data analysis for older patients undergoing cholecystectomy. Our goal was to compare surgical outcomes of cholecystectomy performed in older adults in comparison to younger adults.

This retrospective cohort study examined patients ages 18 years and older undergoing cholecystectomy from January 2016 to December 2020 from the American College of Surgeons (ACS) National Surgical Quality Improvement Program database. Patients were categorized into 3 age groups: 18-64y, 65-74y, and ≥75y. Thirty-day perioperative outcomes were analyzed using bivariate χ² test and multivariate logistic regression to estimate the risk of outcomes.

Our study identified 175 512 patients who underwent cholecystectomy: 136 793 (77.9%) patients between 18 and 64y, 25 108 (14.3%) patients between 65 and 74y, and 13 608 (7.8%) ≥75y. Compared with younger adults, patient aged ≥75y were 4.03 times more likely to develop a complication (95% confidence interval [CI]: 3.71-4.39, P < 0.001), 2.84 times more likely to be admitted for any reason (95% CI: 2.64-3.05, P < 0.001), 2.66 times more likely to be readmitted for reasons related to cholecystectomy (95% CI: 2.45-2.9, P < 0.001), and 3.81 times more likely to have an extended hospital stay (95% CI: 3.63-3.99, P < 0.001).

The ≥75y cohort has significantly higher rates of overall complications, higher rates of total and cholecystectomy-related readmissions, and extended length of hospital stay.

Virtual 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.

Applicants 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.

Interviews 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).

We 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.

Gastrocardiac 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.

A 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.

13 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.

Hiatal hernia and GERD may contribute to arrhythmias, and early management with surgery and PPIs shows promise in resolving symptoms and reducing medication reliance.

Smoking is an established risk factor for postoperative complications. There is limited data on characteristics of smokers that increase risk beyond pack-years. This study aims to assess the effect of preoperative smoking duration and intensity, periods of cessation, and concurrent smokeless product use on colorectal surgery outcomes.

A retrospective cohort study was conducted to assess operative details, demographic and smoking factors, and postoperative complications in smokers. The cohort included 239 current and former smokers who underwent colorectal surgery from 2012 to 2022. The primary endpoint was major adverse events 30-days postoperatively, defined as incidence of major bleeding, venous-thromboembolism, acute kidney injury, myocardial infarction, acute respiratory distress syndrome, stroke, infection, mortality, or readmission.

The most common procedure was colon resection. Average age at procedure was 63.9 ± 0.85 years, smoking duration was 27.0 ± 1.0 years, packs-per-day was 0.94 ± 0.04 packs, and pack-years was 26.0 ± 1.7. It was found that 11% of the patients concurrently used smokeless products (chew, dip, and/or vape). Half of the patients quit smoking prior to surgery. During the follow-up period, 28% had any major adverse event. Independent predictors of increased complications were chronic obstructive pulmonary disease (P = .01), pack-years (P = .02), and concurrent vape use (P = .01). Years of smoking (P = .01) was an independent predictor of complications, whereas packs-per-day (P = .33) was not. Former smokers (P = .03) had fewer complications than current smokers.

Colorectal surgery patients with significant duration of smoking and/or concurrent vape use should be counseled regarding their increased risk of major postoperative complications.

While 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.

Records 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.

Non-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).

While CT remains vital for diagnosing BCSI, non-examinable or NEXUS-positive patients with negative CT should undergo confirmatory MRI prior to cervical collar removal.

Post-pull chest X-rays (ppCXR) are routinely performed after chest tube (CT) removal despite questionable utility. Prior studies suggest that ppCXR rarely alter management, but the impact of timing remains unknown. This study compares early vs delayed ppCXR on radiographic changes and clinical management in asymptomatic trauma patients. We hypothesized ppCXR timing may influence radiographic findings, but not reintervention rates.

A retrospective study of trauma patients undergoing CT placement and removal at a level 1 trauma center from 2019 to 2022. Each ppCXR was classified as early (≤4 h) or delayed (>4 h). Primary outcome was reintervention after CT removal (CT replacement, VATS, or thoracotomy). Secondary outcomes included radiographic changes, unplanned ICU transfer, hospital and ICU LOS, and total CXRs.

318 patients were included with a mean age of 47.2 years, 25.2% female, and 77.4% with blunt mechanism. Most had delayed ppCXR (78.3%) with mean delay of 7.2 h (2.3 vs 9.5 h, P < .001). No differences were found in radiographic changes (26.1 vs 29.3%, P = .708) or reintervention (4.3 vs 5.6%, P = .999) between groups. Radiographic changes occurred in 28.6% of ppCXR, but these findings display poor sensitivity (65.0%) and specificity (73.4%) for reintervention. Delayed ppCXR had more ICU transfers (0 vs 5.6%, P = .046), but no differences in hospital LOS, ICU LOS, or total CXRs.

The timing of ppCXR did not affect detection of radiographic changes or reintervention rates. Our findings support growing evidence questioning routine ppCXR in asymptomatic trauma patients. Future multicenter studies are warranted to establish standardized protocols and reduce unnecessary imaging in trauma care.

Intravenous glucocorticoids have been suggested as first-line therapy for patients with ulcerative colitis (UC) and megacolon. However, there is no definite consensus regarding the timing of surgical intervention when medical therapy fails.

Data were collected from 56 consecutive patients diagnosed with megacolon UC who underwent surgery between January 2000 and September 2024. Patients who underwent surgery within 48 h of the diagnosis were defined as the early group, and those who underwent surgery after 48 h were defined as the delayed group. The short-term surgical outcomes were compared between the 2 groups, and the factors associated with postoperative complications were investigated.

Among the 56 patients with megacolon, 37 were categorized into the early group and 19 into the delayed group. There was a tendency toward a lower incidence of severe postoperative complications (Clavien-Dindo grade ≥3) in the early group than in the delayed group with statistical significance (P = .043). Furthermore, the risk of colonic perforation significantly increased when more than 48 h had passed since diagnosis (P = .0015). A multivariate analysis identified colonic perforation as a significant risk factor for severe postoperative complications.

We suggest that surgical intervention within 48 h may reduce the incidence of colonic perforation in the treatment of UC complicated by megacolon, thereby potentially decreasing the risk of severe postoperative complications.

Indocyanine green (ICG) near-infrared visualization (NIR) is used in colorectal surgery to evaluate anastomotic limb perfusion and aid sentinel lymph node harvest in oncologic surgeries. Proponents of ICG-NIR claim improved anastomotic and oncologic outcomes, but no large-scale studies are reported. This study aims to evaluate the effect of ICG-NIR on anastomotic and oncologic outcomes after colorectal surgeries on a nationwide scale.

Retrospective cohort analysis of the 2016-2020 ACS-NSQIP colorectal-specific database. Adults who underwent elective minimally invasive colorectal surgeries (low anterior resection (LAR), partial colectomy (PC), or right colectomy (RC)) were stratified into 2 groups based on intraoperative ICG-NIR use. Outcomes measured were operative duration, anastomotic leak, unplanned conversion to open, return to the operating room, perioperative bleeding requiring blood transfusions, survivor-only length of stay (LOS), mortality, and unplanned readmissions. Sub-analysis of lymph node harvest and margin-positive status was performed among patients with colorectal cancer.

95 179 patients were identified (ICG-NIR: 1101 (1.2%); No ICG-NIR: 94 078 (98.8%). There were no differences in 30-day outcomes between groups except for longer OR duration among ICG-NIR group. ICG-NIR was not independently associated with reduced adjusted odds of anastomotic leak (aOR 0.790 (95% CI 0.520-1.201), P = 0.270). There were no differences between subgroups in terms of lymph node harvest or resection margin positive status.

This is a large nationwide study showing leak rates and oncologic outcomes do not improve with ICG-NIR. The utility of ICG-NIR over preoperative bowel preparation, surgical technique, and gross visualization may be overstated warranting further study.

Integrated 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.

We 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.

Since 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.

The 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.

The diagnosis of blunt thoracic aortic injury (BTAI) is challenging. In this study, a prediction model with a simplified scoring system for BTAI was developed for the primary evaluation of trauma patients in the emergency department.

This retrospective cohort study included blunt chest trauma patients. Mediastinal width was measured using supine position X-rays. Other factors that may be associated with BTAI were also evaluated, including hemodynamics, associated hemothorax, sonographic examination results, and troponin I levels. Risk identification was performed using a logistic regression model, which led to establishment of the final model.

A total of 418 patients with thoracic trauma were included in the study. Of them, 52 patients had BTAI. We found that a mediastinal width of >8.5 cm had a better predictive value than the conventional cutoff value of 8 cm. In multivariate logistic regression analysis, significant risk factors for BTAI included shock (odds ratio (OR): 2.12), left hemothorax (OR: 2.86), mediastinum width >8.5 cm (OR: 3.48), elevated troponin I levels (OR: 2.90), and pericardial effusion (OR: 6.03). The receiver operating characteristic curve (ROC) curve yielded an area under the curve (AUC) value of 0.754, demonstrating superior diagnostic accuracy compared with the use of mediastinal widening alone, which had an AUC of 0.632.

In addition to a widened mediastinum alone, a model that combines shock upon admission, elevated troponin I levels, left hemothorax, and pericardial effusion offers a straightforward, feasible, and acceptable screening method for BTAI.

Resuscitative 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.

A 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.

Of 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).

Zone 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.

Laboratory biomarkers have been used as prognostic markers in several solid tumors. This study aims to evaluate 3 preoperatively measured laboratory values: blood neutrophil to lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), as potential prognostic biomarkers in patients with peritoneal carcinomatosis undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

We performed a retrospective review of 156 patients who underwent CRS-HIPEC between 2013 and 2020. Biomarker ratios were calculated based on the preoperative laboratory values closest to the date of CRS-HIPEC. Multivariable Cox regression models were used to evaluate the biomarkers’ associations with survival (OS), recurrence-free survival (RFS), and postoperative outcomes.

Increased MLR was independently associated with worse OS (P < 0.001) and RFS (P = 0.03) in this patient cohort. Additionally, increased MLR was independently associated with increased rate of hospital re-admission within 30 days after discharge (P = 0.04). None of the analyzed biomarkers were associated with increased rate of Clavien-Dindo class III/IV complication or hospital length of stay.

In this retrospective review, increased preoperative MLR was independently associated with worse overall and recurrence-free survival as well as increased rate of hospital re-admission. Preoperative PLR was associated with increased hospital length of stay. Thus, the utilization of preoperative systemic inflammatory biomarkers may aid in preoperative counseling and risk stratification prior to CRS-HIPEC.

Long-term weight regain affects 20%-30% of patients after laparoscopic sleeve gastrectomy (LSG). We investigated whether single-incision laparoscopic sleeve gastrectomy (SILS) provides superior weight maintenance compared to conventional multi-port LSG.

This study is a retrospective analysis of prospectively collected data comparing 54 propensity-matched patients (27 SILS and 27 conventional LSG) operated between 2010 and 2017. Primary outcome was weight maintenance at 7 years. Secondary outcomes included safety profile, complications, quality of life, and patient satisfaction.

Groups were comparable except baseline BMI (SILS: 40.17 ± 3.23 vs conventional: 43.71 ± 5.36 kg/m², P = .005). Single-incision laparoscopic sleeve gastrectomy demonstrated safety non-inferiority with no conversions, leaks, or reoperations in either group. Overall complications: 11.1% SILS vs 3.7% conventional (P = .308). At 7 years, SILS patients maintained significantly lower absolute weight (75.56 ± 13.24 vs 85.26 ± 19.78 kg, P = .039) despite similar %EWL (85.2% vs 92.6%, P = .396). Weight regain from nadir was 11.26 ± 9.24 vs 15.04 ± 14.10 kg (P = .250). Enhanced patient satisfaction scores in SILS (9.56 ± 0.93 vs 8.07 ± 1.90, P = 0.001) suggest a potential mediating mechanism.

Single-incision laparoscopic sleeve gastrectomy achieves superior long-term weight maintenance while demonstrating safety non-inferiority compared to conventional LSG. The technique resulted in 10 kg lower absolute weight at 7 years without increased complications. For appropriately selected patients, SILS offers a safe alternative with improved long-term metabolic outcomes.

Critical 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.

Anonymous 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.

Of 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%).

The 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.

This 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.

3 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.

The 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%).

In 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.

We compared short-term outcomes of laparoscopic surgery and open surgery (OS) for older patients with large (≧ 5 cm) colonic adenocarcinomas.

Patients ≥ 75 years with stage I-III colon cancer were identified in the NCDB (2010-2020). Patients were divided into laparoscopic or OS groups and propensity-score matched, and outcomes were compared. Primary outcomes were 30- and 90-day mortality and secondary outcomes were hospital stay, positive resection margins, and harvested lymph node number.

15,253 patients were included (MIS = 5860; OS = 8486), with 5672 in each group after matching. 68.2% of cancers were right-sided. Laparoscopic surgery was associated with lower 30-day (OR: 0.56, 95% CI: 0.47, 0.66; P < 0.001) and 90-day mortality rates (OR: 0.58, 95% CI: 0.51, 0.66; P < 0.001) compared to OS. Laparoscopic surgery was significantly associated with lower 30- and 90-day mortality and shorter hospital stays for all tumor locations. Laparosscopic surgery for right-sided tumors was more often associated with negative resection margins (94.4% vs 92.8%; P = 0.005), and shorter hospital stays (5.0 [4.0-7.0] vs 6.0 [5.0-9.0] days; P < 0.001). Laparoscopic surgery was associated with more harvested lymph nodes in right colon cancers (median: 20.0 [15.0-26.0] vs 19.0 [15.0-25.0]; P < 0.001) and left colon cancers (18.0 [14.0-23.0] vs 17.0 [13.0-23.0]; P = 0.001) cancers, but not in transverse colon cancers (18.0 [14.0-25.0] vs 19.0 [14.0-25.0]; P = 0.518).

This study highlights the potential for laparoscopic surgery in elderly patients with large colonic adenocarcinomas. Findings were consistent when stratified by tumor location, except transverse colon cancers where resection quality was comparable to OS.

Helicopter 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.

We 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.

1419 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.

Most 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.

The optimal diagnostic pathway for pediatric acute appendicitis (AA) following an inconclusive or negative ultrasonography (US) is poorly defined, leading to debate over subsequent computed tomography (CT) use. This systematic review and meta-analysis compared negative appendectomy rates in children managed with a US-only pathway vs a pathway involving CT after a non-diagnostic initial US.

Following PRISMA guidelines (PROSPERO: CRD42024568560), we systematically searched 6 databases, including PubMed and Embase, through July 2024 for longitudinal studies comparing the 2 diagnostic pathways. Two reviewers independently selected studies and extracted data. Risk of bias in included studies was assessed using the ROBINS-I and Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the GRADE framework. A fixed-effects meta-analysis was performed to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs).

The pooled analysis demonstrated that a US-only pathway was associated with significantly lower odds of negative appendectomy compared to the US-followed-by-CT pathway (OR 0.44; 95% CI 0.21-0.90; P = 0.02). This protective association was even more pronounced in the subgroup of patients with an initial inconclusive US (OR 0.22; 95% CI 0.05-0.89; P = 0.03).

In children with suspected AA after a non-diagnostic US, a US-only pathway is associated with a significantly lower rate of negative appendectomy. These findings support strategies that prioritize clinical re-evaluation and repeat US to reduce unnecessary surgeries and radiation exposure. However, given the low certainty of evidence, clinical judgment remains paramount.

Incisional hernia remains a common complication following abdominal surgery with significant implications for patient quality of life and healthcare costs. This systematic review and meta-analysis aim to evaluate the relationship between various abdominal incision types and the development of hernias, while identifying key risk factors.

A comprehensive literature search was conducted across multiple databases for studies published between January 2000 and January 2025. Studies reporting incisional hernia rates following abdominal surgery with clearly documented incision types and a minimum follow-up of 6 months were included. Data extraction included study characteristics, patient demographics, incision types, hernia rates, and associated risk factors. Random-effects meta-analysis was performed to calculate pooled hernia rates and odds ratios.

Forty studies comprising 183 496 patients were included. Midline incisions were associated with the highest hernia rates (12.8-35%, pooled rate 18.7%) compared to transverse incisions (4.8-10.2%, pooled rate 7.4%; OR 0.38, 95% CI 0.26-0.57). In colorectal surgery specifically, midline incisions carried an odds ratio of 11.7 (95% CI 3.3-42.0) for hernia formation compared to transverse approaches. Paramedian, oblique, and Pfannenstiel incisions demonstrated lower hernia rates (2.1-8.6%). Significant patient-related risk factors included obesity (OR 4.74, 95% CI 1.42-15.55), male gender (HR 2.2), COPD (HR 2.35, 95% CI 1.16-4.75), and wound infection (HR 3.66). Most hernias (54-80%) developed within the first year after surgery, though continued development was observed for up to 10 years.

Transverse, paramedian, and Pfannenstiel incisions offer significant advantages over midline approaches for reducing incisional hernia risk. Patient-specific factors, particularly obesity and pulmonary comorbidities, substantially influence hernia development. A tailored approach to incision selection based on patient risk profile, coupled with meticulous technique and wound management, is recommended to minimize hernia occurrence.

Ischiatic (sciatic) hernias represent one of the rarest forms of pelvic floor herniation, with fewer than 100 documented cases worldwide since first described by Papen in 1750. Their rarity, combined with often-cryptic clinical presentation, contributes to significant diagnostic and therapeutic challenges.

Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases from 1947 to 2024, identifying 68 relevant articles. Our search strategy combined terms related to ischiatic/sciatic hernias with various publication types. Data extraction focused on patient demographics, clinical presentation, diagnostic methods, hernia contents, surgical approaches, and outcomes.

Our analysis revealed striking female predominance (98.5%), particularly among elderly patients (mean age 71 ± 12.8 years). Ureter was the most commonly herniated structure (58.8%), followed by small intestine (20.6%). Most patients (80.9%) lacked an external gluteal bulge, contributing to diagnostic delays. CT emerged as the primary diagnostic modality (63.2%), with the pathognomonic “curlicue sign” representing a key feature in ureterosciatic herniation. Management approaches were evenly distributed between minimally invasive techniques (35.3%), open surgery (35.3%), and conservative management with ureteral stenting (29.4%). Laparoscopic and robotic approaches demonstrated shorter hospital stays (1-2 days vs 5-14 days for open repairs) and reduced postoperative pain, despite slightly longer operative times. Complication rates were low (5.9% surgical site infections), with no reported mortality.

Ischiatic hernias require a high index of clinical suspicion for timely diagnosis, particularly in elderly females presenting with unexplained pelvic or sciatic pain. The evolution from open to minimally invasive surgical approaches has significantly transformed management outcomes, while ureteral stenting offers an alternative for high-risk patients with ureterosciatic hernias. The optimal approach remains individualized based on patient characteristics, hernia contents, and available surgical expertise.