Neuroendocrine tumors (NETs) secrete vasoactive hormones that promote hemodynamic instability. This study investigated whether NETs alter vascular responsiveness using a murine model. J:Nu mice received intrasplenic inje...Neuroendocrine tumors (NETs) secrete vasoactive hormones that promote hemodynamic instability. This study investigated whether NETs alter vascular responsiveness using a murine model. J:Nu mice received intrasplenic injections of BON-1 NET cells (BON-1, n = 21) or PBS (VEH, n = 21) and monitored for 10 weeks. Liver metastases were identified by histological analysis, chromogranin A expression, and presence of ALDH1-positive cancer stem cells. Vasomotor function of isolated mesenteric arteries was assessed to acetylcholine, serotonin, vasopressin, and endothelin-1, and with nitric oxide synthase inhibition (L-NAME), 5-HT receptor blockade, or serotonin incubation. BON-1 mice exhibited impaired vasodilation to acetylcholine and serotonin compared with VEH (p < 0.05), specifically in males (p < 0.001). L-NAME and 5-HT receptor blockade attenuated vasodilatory responses to serotonin only in VEH mice. Serotonin incubation reduced vasopressin-mediated vasoconstriction (p < 0.0001). These findings indicate that NET metastases are associated with impaired serotonin-mediated vasodilation, which is associated with reduced nitric oxide bioavailability, altered 5-HT receptor action, and sex-dependent impairment of endothelium-dependent vasodilation. Elevated serotonin levels may further compromise vasopressin-mediated vasoconstriction. The presence of NET metastases alters vascular responsiveness, which may contribute to hemodynamic instability.
INTRODUCTION: Little research exists on whether racial disparities impact trauma activation (TA). This study aimed to compare undertriage (UT) in Black vs. White patients. METHODS: Black and White patients receiving high...INTRODUCTION: Little research exists on whether racial disparities impact trauma activation (TA). This study aimed to compare undertriage (UT) in Black vs. White patients. METHODS: Black and White patients receiving high-intensity time-sensitive interventions (HITS) were selected from trauma registry data, 2017-19. UT was defined as patients receiving HITS without a highest-level TA. Mixed-effects multivariable regressions compared odds of UT and outcomes by race groups. RESULTS: 4734 Black and 11,070 White patients at 37 Level I/II centers had HITS. UT rate was 19% for Black and 31% for White patients (p < 0.001). After adjustment, there was no difference in odds of UT between Black and White patients (aOR 0.97, 95% CI 0.85-1.09, p = 0.58). Among those undertriaged, there was no difference in adjusted odds of mortality between Black and White patients (aOR 0.84, 95% CI 0.62-1.14, p = 0.27). CONCLUSIONS: After adjustment, there was no evidence of racial disparity in UT or outcomes between Black and White patients.
In academic surgery, success has long been defined by titles, leadership roles, productivity, and other visible measures of achievement. Without intentional reflection, these signifiers can become a proxy for self-worth,...In academic surgery, success has long been defined by titles, leadership roles, productivity, and other visible measures of achievement. Without intentional reflection, these signifiers can become a proxy for self-worth, driving surgeons to seek external validation at the expense of what they find most meaningful. This editorial examines how early conditioning shapes the pursuit of achievement and how institutional reward systems reinforce it. A coaching approach is proposed to help surgeons reflect and reconnect with their internal motivation and align it with organizational expectations, creating a definition of success that is both personally meaningful and professionally relevant.
The optimal management of recurrent papillary thyroid carcinoma (PTC) in cervical lymph nodes remains a clinical challenge. Lymphadenectomy is the gold standard, but reoperative procedures have a well-documented increase...The optimal management of recurrent papillary thyroid carcinoma (PTC) in cervical lymph nodes remains a clinical challenge. Lymphadenectomy is the gold standard, but reoperative procedures have a well-documented increase in morbidity. Radiofrequency ablation (RFA) has emerged as a promising alternative for the management of nodal metastases. In this study, nine patients with ten sites of PTC nodal recurrence were treated with RFA. At one month, there was a statistically significant reduction in nodule size (P = .022). By the end of follow-up, all patients achieved a volume reduction ratio (VRR) > 90%, and three-quarters demonstrated complete sonographic resolution. One patient experienced transient voice change. No major complications occurred. These findings support RFA as a safe and effective therapy that can play a complementary role to surgery and radioactive iodine in the management of nodal recurrence of PTC.
BACKGROUND: Laparoscopic hepatectomy (LH) for tumors in complex segments (Couinaud I, IVa, VII, VIII) is technically challenging. This study evaluates an integrated 3D-guided planning system combining preoperative 3D rec...BACKGROUND: Laparoscopic hepatectomy (LH) for tumors in complex segments (Couinaud I, IVa, VII, VIII) is technically challenging. This study evaluates an integrated 3D-guided planning system combining preoperative 3D reconstruction with intraoperative ultrasonography and 3D laparoscopy. METHODS: In this retrospective study of 217 patients undergoing LH, outcomes were compared between a 3D-guided planning group (n = 105) and a routine group (n = 112) using 1:1 propensity score matching (PSM). RESULTS: After PSM (65 pairs), the 3D group had significantly reduced intraoperative blood loss (80 vs. 160 mL, P < 0.001) and bile leakage rate (3.1% vs. 15.4%, P = 0.015). In the special-segment subgroup, the 3D group also demonstrated shorter operative time (180 vs. 250 min, P < 0.001) and lower bile leakage (9.5% vs. 42.9%, P = 0.014). CONCLUSION: The integrated 3D-guided planning system substantially reduces intraoperative blood loss during LH, especially for tumors located in the special segments designated by the Louisville Statement.
INTRODUCTION: Although numerous studies have examined small bowel obstruction (SBO) post-bariatric surgery, they are limited by single center design. There is limited broad epidemiologic data on incidence of SBO after ba...INTRODUCTION: Although numerous studies have examined small bowel obstruction (SBO) post-bariatric surgery, they are limited by single center design. There is limited broad epidemiologic data on incidence of SBO after bariatric surgery. The aim of this study was to comprehensively evaluate the cumulative incidence of SBO. METHODS: The SPARCS database was used to identify patients with previous Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) who required surgery for SBO at the time of first diagnosis. We analyzed the incidence of and prognostic indicators of surgery for SBO. Multivariable Fine-Gray models were utilized to examine the association between each risk factor and subsequent SBO surgery where death was treated as a competing risk event. RESULTS: A total of 38,582 RYGB patients and 91,982 SG patients were included with median follow-up time of 1492 and 1074 days, respectively. The cumulative incidence of surgery for SBO for RYGB was 0.46 % (0.39%-0.53%), 1% (0.89-1.12%), 1.89% (1.71-2.08%) at 1, 3 and 6 years, respectively. The cumulative incidence of surgery for SBO for SG was 0.13% (0.11%-0.16%), 0.55% (0.49%-0.61%), and 2.02% (1.87%-2.18%) at 1, 3 and 6 years, respectively. No significant difference existed in risk of SBO between RYGB and SG (p = 0.72). Other prognostic factors for SBO included female gender, chronic pulmonary disease, phlebitis, black ethnicity and Medicare/Medicaid insurance. CONCLUSION: Bariatric surgery patients have a low risk of needing subsequent surgery for SBO, with comparable rates between RYGB and SG, indicating minimal added risk with RYGB compared to other intra-abdominal procedures.
The Peritoneal Cancer Index (PCI) is widely used to quantify disease extent and guide therapeutic decisions for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) across multiple primary tu...The Peritoneal Cancer Index (PCI) is widely used to quantify disease extent and guide therapeutic decisions for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) across multiple primary tumors. While PCI is a validated prognostic indicator, the use of a single total surgical PCI threshold as a determinant of eligibility for CRS-HIPEC presents significant conceptual and practical limitations. Surgical PCI calculation is subject to inter-surgeon variability, particularly at anatomical region boundaries, where lesion allocation may alter the total score sufficiently to influence treatment decisions. In addition, surgical PCI frequently overestimates disease extent compared with pathological PCI, while laparoscopic assessment may underestimate peritoneal involvement. Increasing evidence indicates that the anatomical distribution of peritoneal metastases, particularly involvement of critical regions such as the hepatoduodenal ligament, small bowel, and mesentery, is more predictive of resectability, morbidity, and oncologic outcome than aggregate PCI alone. Furthermore, the prognostic significance of PCI varies according to primary tumor biology, challenging the applicability of universal threshold values. These considerations suggest that total PCI should not be used in isolation to contraindicate CRS-HIPEC. Decision-making frameworks should instead emphasize regional disease distribution, technical resectability, and tumor-specific behavior to optimize patient selection.
INTRODUCTION: We sought to determine the feasibility of REBOA placement under intravascular ultrasound (IVUS) guidance and to determine flow dynamics while undergoing aortic occlusion of non-compressible torso hemorrhage...INTRODUCTION: We sought to determine the feasibility of REBOA placement under intravascular ultrasound (IVUS) guidance and to determine flow dynamics while undergoing aortic occlusion of non-compressible torso hemorrhage (NCTH) secondary to aortic branch vessel injury. METHODS: Ten Sus scrofa swine underwent laparotomy to create an artificial arteriovenous shunt between a mesenteric vessel and the IVC to simulate ongoing hemorrhage with auto-resuscitation. An IVUS catheter was advanced to the level of injury. A full- or partial-REBOA was then deployed proximally under IVUS guidance. Continuous hemodynamic data were collected. RESULTS: All devices were placed successfully using IVUS. Comparing full- and partial-REBOA, femoral pressures were decreased (34% vs. 95%), and carotid pressures were increased (276% vs. 144%). Shunt flow was 26% of baseline for full-REBOA and 75% for partial-REBOA. CONCLUSION: Endovascular localization and treatment of hemorrhage has potential to advance combat casualty care through delivery of interventional approaches in a mobile technique with IVUS.
BACKGROUND: Disparities in gastrointestinal (GI) cancer care are well-documented but underexplored from the provider's perspective. This study aimed to identify provider-perceived barriers and actionable targets to advan...BACKGROUND: Disparities in gastrointestinal (GI) cancer care are well-documented but underexplored from the provider's perspective. This study aimed to identify provider-perceived barriers and actionable targets to advance equity. METHODS: A cross-sectional survey was conducted among purposively sampled multidisciplinary GI cancer providers. Items assessed practice-based challenges and provider-driven solutions. Quantitative data were analyzed descriptively; qualitative data underwent thematic analysis. RESULTS: Seventy-six out of 120 (63%) providers participated. Barriers were most prominent during initial treatment planning. Two major themes emerged: 1) challenges related to health literacy and insurance, and 2) the substantial time providers spend addressing these barriers, reported by 55% of physicians as 10-30% of their workday and by 38% of nurses as 30-50%. CONCLUSIONS: Providers invest significant time managing non-medical barriers in GI cancer care, particularly around insurance and health literacy. Findings will inform a multidisciplinary care team model aimed at reducing administrative burden and promoting equity.
INTRODUCTION: There are conflicting recommendations surrounding the use of intraoperative wound irrigation (IOWI) to reduce surgical site infections (SSIs) for patients undergoing laparotomy. This study aimed to perform...INTRODUCTION: There are conflicting recommendations surrounding the use of intraoperative wound irrigation (IOWI) to reduce surgical site infections (SSIs) for patients undergoing laparotomy. This study aimed to perform a systematic review and network meta-analysis of randomised clinical trials (RCTs) to elucidate the most appropriate IOWI solution to reduce SSIs following laparotomy. METHODS: A systematic review and network meta-analysis (NMA) was performed as per preferred reporting items for systematic reviews and meta-analysis (PRISMA)-NMA extension. Data analytics were performed using shiny and R. RESULTS: 11 RCTs were included involving 2943 patients. Overall, 1292 patients were randomised to normal saline (NS) (43.9%), 771 to povidone iodine (PI) (26.2%), 519 to polyhexidine (PH) (17.6%), 180 to electrolysed strongly acidic aqueous solution (ESAAS) (6.1%), 102 to none (control) (3.5%) and 79 to olanexidine (O) (2.7%). Non-significant differences in patient age, gender, body mass indices, or American Society of Anaesthesiologist grade were observed for each IOWI group (all P > 0.050). At NMA, IOWI using PH significantly reduced all cause SSIs in patients undergoing laparotomy (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.36 - 0.80). Furthermore, IOWI using PH (OR: 0.54, 95% CI: 0.36 - 0.80) and ESAAS (OR: 0.36, 95% CI: 0.13 - 0.98) significantly reduced superficial SSI (SSSI) in patients undergoing laparotomy. For patients undergoing laparotomy in the elective setting, PH significantly reduced both SSI (OR: 0.41, 95% CI: 0.25 - 0.68) and SSSI (OR: 0.42, 95% CI: 0.22 - 0.82) rates. CONCLUSION: IOWI with PH reduces SSIs in patients undergoing laparotomy and should therefore be considered in patients undergoing this procedure.
OBJECTIVE: Medical device companies rely on surgeons' input to develop safe, effective products. For transparency, industry partners must publicly disclose payments via the Open Payments (OP) program, established through...OBJECTIVE: Medical device companies rely on surgeons' input to develop safe, effective products. For transparency, industry partners must publicly disclose payments via the Open Payments (OP) program, established through the Sunshine Act. We aim to examine the prevalence and factors influencing consulting payments made to academic vascular surgeons. METHODS: Faculty from integrated vascular surgery residencies were identified, and data on clinical experience, training, and research output were collected using OP, program websites, LinkedIn, and Scopus. Univariate linear, univariate logistic, and multivariate linear regression analyses were performed. RESULTS: From 75 programs (25% without consultants), 697 vascular surgeons were identified. Of these, 622 (89.2%) received $5,033,069 in total general payments and 117 (19%) received $2,168,496 (43%) in consulting payments in the 2022 fiscal year. Consultants received a general payment median of $12,966, significantly higher than non-consultants' $506 (p < 0.001). Median total consulting fees were $4400, and consultants had significantly more publications (p < 0.001), higher Hirsch indices (P < 0.001), and were less commonly females (p = 0.002) than non-consultants. There was no statistical association between consulting payments and clinical experience, research productivity, or biological sex. CONCLUSION: Approximately 1 in 5 academic vascular surgeons receive consulting payments. While consultants have significantly more publications and higher H indices than non-consultants, consulting payments received in dollars are not influenced by these factors. Female academic vascular surgeons are underrepresented in consulting, but the payments made to those who do consult do not significantly differ from their male counterparts.
PURPOSE: Recurrence remains a significant challenge following curative resection for hepatocellular carcinoma (HCC). METHODS: To analyze the patterns, and predictive factors of HCC recurrence following liver resection. R...PURPOSE: Recurrence remains a significant challenge following curative resection for hepatocellular carcinoma (HCC). METHODS: To analyze the patterns, and predictive factors of HCC recurrence following liver resection. RESULTS: 398 patients were included. Recurrence occurred in 177 patients (44.5%). 146 patients experienced early recurrence (36.7%) and 31 patients experienced late recurrence (7.8%). Most recurrences occurred inside the remnant liver (75.1%) and were bilobar (39.5%). Lung was the commonest site for extra-hepatic recurrence (9.6%). The 1-, 3-, and 5-years DFS were 71.8%, 47.7%, and 32.1%, respectively. The 1-, 3-, and 5-years OS for were 83.3%, 67.3%, and 47.6%, respectively. Predictive factors for early recurrence included alpha-feto protein, and microvascular invasion. Predictive factors for late recurrence included tumor site and multifocal tumor. CONCLUSION: Early HCC recurrence is linked to aggressive pathological features, whereas late recurrence is due to multicentric carcinogenesis. Identifying patients at higher risk can guide postoperative monitoring and improve survival outcomes.
BACKGROUND: This study aimed to assess the diagnostic ability of routine laboratory biomarkers and develop machine learning (ML) models to improve differentiation between LH and AA. METHODS: A total of 873 patients (209...BACKGROUND: This study aimed to assess the diagnostic ability of routine laboratory biomarkers and develop machine learning (ML) models to improve differentiation between LH and AA. METHODS: A total of 873 patients (209 LH; 664 AA) were retrospectively analyzed. Laboratory parameters, including CRP, WBC, neutrophils, lymphocytes, monocytes, NLR (neutrophil to lymphocyte ratio), LMR (lymphocyte to monocyte ratio), PLR (platelet to lymphocyte ratio), and PIV (pan immune inflammation value), were used to build logistic regression, Naive Bayes, neural network, and gradient boosting models. Diagnostic performance was evaluated using AUC, accuracy, precision, recall, and F1 score. RESULTS: All biomarkers differed significantly between LH and AA (p < 0.001). AA patients exhibited higher CRP, WBC, neutrophil count, NLR, PLR, and PIV, whereas LH demonstrated higher LMR values. Logistic regression yielded the best performance (AUC 0.918; accuracy 0.869), followed closely by Naive Bayes (AUC 0.917) and neural network (AUC 0.914). SHAP-based model interpretability analysis further identified LMR and NLR as the most influential features driving model predictions. CONCLUSION: Routine hematologic biomarkers combined with ML-based modeling provide a robust, non-invasive tool for differentiating LH from AA.
BACKGROUND: Mild Autonomous Cortisol Secretion (MACS) is associated with cardiometabolic comorbidities, but the benefit of adrenalectomy remains controversial. METHODS: We retrospectively reviewed patients undergoing adr...BACKGROUND: Mild Autonomous Cortisol Secretion (MACS) is associated with cardiometabolic comorbidities, but the benefit of adrenalectomy remains controversial. METHODS: We retrospectively reviewed patients undergoing adrenalectomy between October 2019 and October 2024. MACS was defined as post-1 mg dexamethasone suppression test cortisol 1.8-5.0 μg/dL without overt Cushing's syndrome. Pre- and postoperative clinical and biochemical outcomes were analyzed. RESULTS: Thirty-eight patients met inclusion criteria (median age 64 years; 60.5% female). Median post-DST cortisol was 2.9 μg/dL, with a median follow-up of 258 days. Significant postoperative improvements were observed in systolic (p = 0.001) and diastolic (p = 0.004) blood pressure, HbA1c (p = 0.013), and antihypertensive medication burden (p = 0.009). General health status, HbA1c and number of antihypertensive medications improved in 76.3%, 58.4% and 52.8% of the patients, respectively. Clinical outcomes did not differ between patients with cortisol levels <2.5 vs. ≥2.5 μg/dL. CONCLUSION: Adrenalectomy in selected MACS patients is associated with improvements in blood pressure, glycemic control, and overall health, independent of preoperative cortisol levels.
BACKGROUND: Abdominoperineal resection (APR) for low rectal cancer is associated with substantial morbidity and psychosocial burden. This randomized controlled trial evaluated whether integrating resilience-oriented cogn...BACKGROUND: Abdominoperineal resection (APR) for low rectal cancer is associated with substantial morbidity and psychosocial burden. This randomized controlled trial evaluated whether integrating resilience-oriented cognitive behavioral therapy and behavioral sleep regulation into enhanced recovery after surgery (ERAS) improves clinical and oncologic outcomes. METHODS: In this single-center trial, 192 patients undergoing curative APR were randomized to standard ERAS or ERAS plus a structured multidomain behavioral intervention. The primary endpoint was 2-year disease-free survival (DFS). Key secondary outcomes included recovery metrics, clinically significant complications, inflammatory markers, and patient-reported outcomes. RESULTS: The intervention group demonstrated faster bowel recovery, shorter hospitalization, fewer Clavien-Dindo grade ≥ II complications, and lower postoperative CRP, IL-6, and TNF-α levels. Two-year DFS and overall survival favored the intervention. CONCLUSIONS: Integrating resilience- and sleep-based interventions into ERAS was associated with improved recovery, attenuated perioperative inflammation, and superior 2-year DFS after APR.