BACKGROUND: ACNES is a pain syndrome caused by entrapment of distal branches of the intercostal nerves. Literature is heterogeneous in the management of this condition, and no standard of care is available. This study ai...BACKGROUND: ACNES is a pain syndrome caused by entrapment of distal branches of the intercostal nerves. Literature is heterogeneous in the management of this condition, and no standard of care is available. This study aims to provide a systematic review and meta-analysis of available treatments for ACNES, propose standardized nomenclature and a management algorithm. METHODS: We systematically searched PubMed, Embase, and Cochrane Library from inception to August 2024 for studies analyzing interventions for ACNES. We analyzed non-operative and surgical outcomes, primary outcomes including treatment success, recurrence, and need for re-intervention, as well as complication rates, and proposed a standardized nomenclature and management flowchart. Our robotic approach was described. RESULTS: Non-operative success rate was 35%. Surgery success rate was 94.45%, and recurrence after first surgery was 34.6%. Significant heterogeneity was observed in the definitions of different neurectomies, and our proposed definition incorporates the relationship of the dissection with the anterior sheath, and includes a robotic approach. CONCLUSIONS: Non-operative therapy for ACNES can provide both symptom relief and diagnostic clarity, but recurrence rate remains high. Despite surgery presented a superior efficacy, no direct comparative superiority between treatment modalities can be established based on the available evidence. Patients might fare better when care is individualized according to symptom severity, expectations, and predicted disability.
INTRODUCTION: The purpose was to evaluate the association between AC use and vessel recanalization, thrombus progression, and bleeding complications in patients with pancreatitis-induced splanchnic vein thrombosis(SVT)....INTRODUCTION: The purpose was to evaluate the association between AC use and vessel recanalization, thrombus progression, and bleeding complications in patients with pancreatitis-induced splanchnic vein thrombosis(SVT). METHODS: Retrospective review of patients with necrotizing pancreatitis between 2015 and 2021. Demographics, pancreatitis extent and etiology, thrombus location (splenic vein(SV) vs portomesenteric vein(PMV)), AC use, and bleeding complications were collected. All imaging within one year of SVT diagnosis were reviewed. Predictors of recanalization, progression and bleeding were identified. RESULTS: Of 529 pancreatitis patients, 73(13.8%) developed SVT(47.9% SV, 52.1% PMV). PMV thrombosis was associated with higher AC use(50%vs.17.1%,p = 0.01) and bleeding interventions(24.3%vs.5.9%,p = 0.005). SV thrombosis had low rates of progression and bleeding regardless of AC, though AC increased recanalization. In PMV thrombosis, progression and bleeding were driven by disease severity (pseudocyst, BISAP, necrosis), with AC playing a secondary role. CONCLUSION: Outcomes in pancreatitis-induced SVT are driven by disease severity rather than AC alone, supporting a selective, risk-stratified treatment approach.
OBJECTIVE: To evaluate the impact of high and low Body mass index (BMI) on 90-day postoperative outcomes in patients with Crohn's disease (CD). METHODS: This retrospective cohort study (2017-2019) included 271 patients u...OBJECTIVE: To evaluate the impact of high and low Body mass index (BMI) on 90-day postoperative outcomes in patients with Crohn's disease (CD). METHODS: This retrospective cohort study (2017-2019) included 271 patients undergoing abdominal surgery, categorized as underweight (BMI <18.5), normal/overweight (18.5-30), and obese (>30). Primary outcomes were 90-day overall and severe (Clavien-Dindo >2) complications and total length of stay (LOS). RESULTS: The cohort comprised 64 underweight, 189 normal/overweight, and 18 obese patients. Multivariable analysis revealed that underweight status was independently associated with higher overall complications (OR = 2.0, p = 0.045), severe complications (OR = 3.05, p = 0.018), and increased total LOS (beta = 3.43, p = 0.003). While obesity showed a trend toward higher morbidity in univariable analysis, it did not maintain independent significance after adjustment (p = 0.159). CONCLUSION: Underweight status is a significant independent predictor of poor 90-day postoperative outcomes in patients with CD, necessitating targeted preoperative nutritional optimization.
INTRODUCTION: Female firearm injury is rising yet remains understudied, particularly among survivors. We examined factors associated with mortality and the circumstances surrounding firearm injury in women. METHODS: We p...INTRODUCTION: Female firearm injury is rising yet remains understudied, particularly among survivors. We examined factors associated with mortality and the circumstances surrounding firearm injury in women. METHODS: We performed a retrospective multicenter mixed-methods study of 208 women with firearm injuries from five trauma centers (2012-2016), using regression and qualitative thematic analysis. RESULTS: Crude mortality was 14.4%; most patients were Black (70%) and injured by assault (72%). White women had higher unadjusted mortality than Black women (25.5% vs 9.9%; p = 0.008). In Firth-penalized multivariable analysis addressing complete separation, no variable independently predicted mortality; self-harm showed the strongest association but did not reach significance (OR 3.08, 95% CI 0.91-10.39; p = 0.07). Self-harm was far more common among white than Black women (31% vs 1%; p < 0.001) and predicted longer hospitalization. Qualitative themes included intimate partner violence, neighborhood violence, and self-harm. CONCLUSIONS: Self-harm was race-patterned and associated with morbidity and mortality, though no factor independently predicted mortality after adjustment. Prospective multicenter study with injury-severity data is needed.
INTRODUCTION: Sex-based differences in the presentation of primary hyperparathyroidism (PHPT) remain poorly understood. A comprehensive understanding of how PHPT manifests and progresses in male versus female patients in...INTRODUCTION: Sex-based differences in the presentation of primary hyperparathyroidism (PHPT) remain poorly understood. A comprehensive understanding of how PHPT manifests and progresses in male versus female patients in the U.S. is still lacking. This study aims to evaluate sex-based differences in the preoperative presentation and postoperative outcomes of patients undergoing parathyroidectomy (PTX). METHODS: A multi-institutional research network, comprising data from 58 U S. institutions, was retrospectively queried for patients presenting with PHPT (ICD-10 E21.0) and PTX (CPT 60500). The follow-up period was 3 ± 2 years. Cox regression analysis was employed to assess differences in pre-operative presentations and post-operative outcomes. RESULTS: This study included 39,216 females and 11,101 males. Females presented with PHPT at an older age (62 ± 13 vs. 60 ± 14, p < 0.01). Males presented with higher levels of pre-operative calcium (10.8 ± 0.9 vs. 10.7 ± 0.8, p < 0.001) and parathyroid hormone (136 ± 151 vs. 125 ± 139, p < 0.001). Females were more likely to present with osteoporosis (26% vs. 11%, p < 0.001), fatigue (16% vs. 12%, p < 0.01), and vitamin D deficiency (29% vs. 24%, p < 0.001). In comparison, males were more likely to present preoperatively with chronic kidney disease (11% vs. 8%, p < 0.001) and nephrolithiasis (21% vs. 13%, p < 0.001). No significant differences were observed in re-operation rates or recurrent laryngeal nerve injury. CONCLUSIONS: Females make up most cases of PHPT and are more likely to experience musculoskeletal disorders and fatigue, while males are more prone to renal complications. These sex-based differences in clinical presentation underscore the importance of timely surgical intervention.
BACKGROUND: Research defining a Full Time Equivalent (FTE) in Acute Care Surgery (ACS) has drawn attention to the stress of ACS work, however variability of the intensity of different shifts is less understood. STUDY DES...BACKGROUND: Research defining a Full Time Equivalent (FTE) in Acute Care Surgery (ACS) has drawn attention to the stress of ACS work, however variability of the intensity of different shifts is less understood. STUDY DESIGN: A daily 10-point assessment measured work-intensity in 6 domains: physical, mental, temporal, effort, frustration, performance (NASA-TLX), and burnout via Single Item Burnout Question (SIBO). RESULTS: The highest levels of burnout: Emergency General Surgery (EGS), backup, and 24hr call (p < 0.01). Highest physical demand: 24hr call (13, p < 0.01); mental load: EGS (13, p < 0.01), Surgical Intensive Care Unit (13, p < 0.01), and 24hr call (13, p < 0.01); EGS demanded highest effort (13.5, p < 0.01) and temporal load (10, p < 0.01). CONCLUSION: ACS Surgeons perceived differences in intensity of various shifts. FTE data is applicable to inform workforce planning, but a nuanced approach considering workload intensity is needed.
Saad M, Gifford CG, Christopher A
… +10 more, Hayes D, Rodriguez A, Robinson N, Piantino J, Meade L, Czaplewski T, Whybrew D, Chang T, Robles JA, Slater ED
Delays in operating room start times lead to inefficiencies, decreased patient satisfaction, and significant hospital costs. FCOTS (first case on-time start) is a widely used performance metric, yet interventions to impr...Delays in operating room start times lead to inefficiencies, decreased patient satisfaction, and significant hospital costs. FCOTS (first case on-time start) is a widely used performance metric, yet interventions to improve it remain understudied in VA settings. The 4 Disciplines of Execution (4DX) model was implemented to target an 85% on-time start rate. Weekly FCOTS data from January to December 2023 were analyzed using statistical process control charts, and causes of delays were reviewed by a multidisciplinary panel. Among 1467 first-start cases, baseline FCOTS rates averaged 76% (weeks 1-19), declined to 68% during the early intervention period (weeks 20-45), and improved to 87% (weeks 46-52). Control chart analysis demonstrated special-cause variation late in the study period. Mean weekly delay-related costs decreased from approximately $5000 to $3000 (p < 0.05), corresponding to an estimated annual savings of $200,000. Structured multidisciplinary approaches can significantly improve operating room efficiency and reduce costs.
INTRODUCTION: Neoadjuvant chemotherapy (NAC) is increasingly utilized in the management of intrahepatic cholangiocarcinoma (IHC), yet its impact on postoperative outcomes remains unclear. This study evaluates the surgica...INTRODUCTION: Neoadjuvant chemotherapy (NAC) is increasingly utilized in the management of intrahepatic cholangiocarcinoma (IHC), yet its impact on postoperative outcomes remains unclear. This study evaluates the surgical outcomes of hepatectomy following NAC compared to upfront resection in patients with IHC. METHODS: We analyzed data from the ACS-NSQIP database (2019-2021), including all patients who underwent hepatectomy for IHC. The patients were stratified into two groups: those who received NAC and those who underwent upfront resection. Outcomes were assessed separately for minor and major hepatectomy. The primary outcomes were 30-day mortality and liver-specific complications, including bile leakage and post-hepatectomy liver failure (PHLF). The secondary outcomes included overall complications. Propensity score matching using nearest-neighbor methodology was performed to ensure balanced comparisons. RESULTS: A total of 1317 patients underwent hepatectomy for IHC. Overall, 285 patients (21.6%) received NAC. After propensity score matching, in major hepatectomy, patients who received NAC had no significant differences in mortality (2.6% vs. 3.6%, p = 0.70) or bile leakage (17.8% vs. 20.6%, p = 0.69) compared with those who underwent upfront surgery. However, NAC was associated with a significantly higher incidence of PHLF (19.1% vs. 10.3%; p = 0.01). Similarly, in minor hepatectomy, NAC was not associated with differences in mortality (2.2% vs. 2.7%, p = 0.92) or bile leakage (11% vs. 7.7%, p = 0.06) but was associated with an increased risk of PHLF (8.8% vs. 2.3%, p = 0.01). CONCLUSIONS: Approximately one in five patients undergoing hepatectomy for IHC received NAC. While NAC was not associated with increased mortality or overall complications, it was associated with a significantly higher risk of post-hepatectomy liver failure in both major and minor hepatectomies. These findings highlight the need for careful patient selection and perioperative optimization in patients undergoing liver resection after NAC.
AIM: To compare patient-reported outcomes and recurrence between permanent and slowly absorbable sutures in sutured repair of small primary ventral hernias. METHODS: Nationwide Danish survey and registry study of adults...AIM: To compare patient-reported outcomes and recurrence between permanent and slowly absorbable sutures in sutured repair of small primary ventral hernias. METHODS: Nationwide Danish survey and registry study of adults undergoing open sutured repair of small (0-2 cm) primary ventral hernias (2014-2024). Patient-reported outcomes from the AFTERHERNIA Project using the Abdominal Hernia-Q (AHQ) were linked to the Danish Ventral Hernia Database and the Danish National Patient Register. RESULTS: Among 6329 eligible patients, 4933 responded (78%), comprising 4095 permanent and 838 slowly absorbable suture repairs. Mean AHQ physical functioning sum scores were identical (23.3 points). Prevalence of chronic pain (9.3% vs 10.3%), foreign body sensation (20.2% vs 19.7%), and self-reported recurrence (16.3% vs 18.0%) was similar between suture groups. CONCLUSION: Permanent and slowly absorbable sutures showed similar patient-reported outcomes and prevalence of self-reported recurrence. Slowly absorbable sutures may represent an alternative that avoids permanent foreign material without compromising outcomes.
INTRODUCTION: Preoperative imaging is widely advocated for and often routinely ordered for patients undergoing parathyroidectomy. Yet its actual benefit in contributing to surgical safety considering high rates of non-di...INTRODUCTION: Preoperative imaging is widely advocated for and often routinely ordered for patients undergoing parathyroidectomy. Yet its actual benefit in contributing to surgical safety considering high rates of non-diagnostic imaging remain debated. This study aims to evaluate if imaging before parathyroidectomy contributes to improving post operative outcomes in hyperparathyroidism. METHODS: We conducted a retrospective cohort study of patients who underwent parathyroidectomy (PTx) for hyperparathyroidism between 2000 and 2023 at our institution. Patients with prior thyroid or parathyroid surgery were excluded. Data collected included demographics, clinical features, biochemical parameters, and outcomes. Localization status was determined by ultrasound, sestamibi, or 4D-CT. Patients without imaging were 1:1 propensity-matched to those with imaging by age, gender, preop calcium, and PTH. Assessed complications included transient and permanent hypocalcemia, hoarseness, and persistent hyperparathyroidism. RESULTS: Of 2,287 eligible patients, 349 (15.3%) underwent PTx without preoperative imaging, while 1,938 (84.7%) had at least one imaging study. We matched 311 imaging-naive patients to counterparts with imaging. Among those imaged, 13.1% (n = 253) had negative localizing studies; 17.4% of these had undergone multiple imaging tests. Negative imaging was significantly associated with normocalcemic or normohormonal disease (OR 1.6, 95% CI 1.2 - 2.2, p = 0.003), double adenomas (OR 2.5, p < 0.001), and hyperplasia (OR 1.5, p = 0.06). Complication rates were similar between imaging and non-imaging groups as were cure rates based on normocalcemia at 6 months (94.5% vs 97.1%, p = 0.2). CONCLUSION: Preoperative imaging is not essential for successful parathyroidectomy performed by experienced surgeons as outcomes remain comparable even without localization.
INTRODUCTION: Constipation following bariatric surgery decreases patient satisfaction and quality of life while increasing healthcare utilization. We evaluate the impact of a preoperative educational handout on constipat...INTRODUCTION: Constipation following bariatric surgery decreases patient satisfaction and quality of life while increasing healthcare utilization. We evaluate the impact of a preoperative educational handout on constipation-related communication (CRC) and emergency department (ED) visit frequency. METHODS: Adult patients who underwent bariatric surgery between 2022 and 2023 who either received or did not receive the handout were analyzed. Baseline demographics, medical comorbidities, and rates of CRC and ED visits within 180 days postoperatively were compared using inferential statistics. Number needed-to-treat (NNT) analyses were performed. RESULTS: 400 patients were included (n = 176 No Handout, n = 224 Handout). Baseline characteristics were comparable. CRCs decreased from 18.8% to 9.4% (p = 0.006), and ED visits decreased from 5.7% to 1.8% (p = 0.035). The NNT for CRC and ED visits were 11 and 26 handouts, respectively. CONCLUSIONS: Implementation of a low-cost preoperative educational handout significantly reduced postoperative healthcare use, representing a high-value intervention to improve patient outcomes and reduce system burden.
Effective communication during laparoscopic procedures is frequently undermined by spatial disorientation and inconsistent terminology between instructors and trainees. This study examined whether standardized visual ove...Effective communication during laparoscopic procedures is frequently undermined by spatial disorientation and inconsistent terminology between instructors and trainees. This study examined whether standardized visual overlays on endoscopic monitors could enhance communication and learning. We conducted a three-phase mixed-methods study: qualitative observation of 20 laparoscopic teaching cases; a randomized trial of 63 second-year medical students assigned to control, clock, or alphanumeric grid (AG) overlays during three trials of a standardized transfer task; and intraoperative implementation in 44 cases (30 AG, 14 clock) with post-case surveys and qualitative feedback. In simulation, the clock overlay produced the fastest completion times, whereas the AG yielded the lowest error scores, and both overlays outperformed the control. Intraoperatively, the AG was rated higher than the clock for communication clarity, spatial orientation, perceived operative efficiency, and trainee confidence. Standardized visual overlays, particularly the AG, appear to support intraoperative teaching by providing a shared spatial frame of reference.
Dana F, Sebio-García R, González-Colom R
… +9 more, Tena B, Capitan D, Momblan D, Campero B, García E, Rivas E, Zabalegui A, Martínez-Pallí G, Hospital Clinic of Barcelona Prehabilitation Group (+)
BACKGROUND: Unplanned healthcare utilization after elective surgery remains a relevant quality indicator; discharge decision support remains limited. This study evaluated whether the Quality of Recovery-15 (QoR-15) score...BACKGROUND: Unplanned healthcare utilization after elective surgery remains a relevant quality indicator; discharge decision support remains limited. This study evaluated whether the Quality of Recovery-15 (QoR-15) score at hospital discharge is associated with unplanned healthcare utilization within 30 days. METHODS: A prospective observational study (2024-2025) included patients undergoing elective general surgery. Unplanned healthcare utilization within 30 days was analyzed using multivariable logistic regression models including QoR-15 and the Comprehensive Complication Index (CCI), and clinical covariates. RESULTS: Among 372 patients, 20% required post-discharge emergency care and 10% were readmitted within 30 days. Lower QoR-15 scores at discharge were associated with emergency department visits. Multivariable models including QoR-15 and CCI demonstrated discriminative performance for emergency visits (AUC 0.69) and readmissions (AUC 0.78), surgical reinterventions were infrequent (3%). CONCLUSIONS: QoR-15 assessed at hospital discharge provides information that complements complication-based metrics and may support postoperative risk stratification for discharge planning after elective general surgery.
OBJECTIVE: Primary hyperparathyroidism (PHPT) affects 1% of adults, but fewer than one-third of screen-eligible patients are tested. We developed and evaluated two new non-interruptive, clinician-facing alerts to increas...OBJECTIVE: Primary hyperparathyroidism (PHPT) affects 1% of adults, but fewer than one-third of screen-eligible patients are tested. We developed and evaluated two new non-interruptive, clinician-facing alerts to increase appropriate PHPT screening. MATERIALS AND METHODS: We designed process changes to facilitate guideline-informed patient identification via electronic phenotyping, laboratory test ordering, result interpretation, and follow-up. The computable phenotype was retrospectively validated. Clinician-facing alerts were built atop existing workflows for health maintenance (HM) and pended orders (PO) and evaluated in separate primary care clinics. RESULTS: Screening laboratory orders were more frequent in PO (81%; n = 30/37; p < 0.001) and HM (57%; n = 51/90; p < 0.001) than in control (19%; n = 373/1945) clinics. Increased screening appeared to yield higher detection of likely PHPT in PO (43%; 16/37; p < 0.001) and HM (8%; 7/90; p = 0.01) than in control (2%; 48/1945) clinics. CONCLUSION: Non-interruptive alerts demonstrate potential to substantially increase PHPT screening among appropriate patients.