The American Surgeon[JOURNAL]
Sun
200 papers
Complete Response of Merkel Cell Carcinoma to Immunotherapy and Single-Fraction Radiotherapy Following Severe COVID-19 Infection: A Case Report and Review of Immune Mechanism.
Swilling AC, Caraway J, Irwin TM … +6 more , McCracken TJ, Bodenhamer WS, Lominska CE, Akhavan D, Doolittle GC, Selby LV
Am Surg · 2026 Jul · PMID 42389872 · Publisher ↗
Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine form of skin cancer. This case report describes a 70-year-old Hispanic male with stage IIA MCC of the upper back which rapidly progressed during hospitaliz...
Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine form of skin cancer. This case report describes a 70-year-old Hispanic male with stage IIA MCC of the upper back which rapidly progressed during hospitalization for severe COVID-19 infection requiring ventilatory support. After resolution of his severe acute illness, he received one dose of anti-PD-1 therapy and single-fraction radiotherapy to his primary lesion for local control. His tumor then underwent a rapid regression and he completed 17 cycles of immunotherapy with a complete clinical and radiologic response sustained more than 4 years. This case illustrates a possible synergistic effect of radiation therapy and immune checkpoint inhibition after rebounding immune-system hyperactivation from infection with COVID-19.
Perioperative Acute Myocardial Infarction in Non-Cardiac Operations: A National Analysis.
Mahrokhi S, Ali K, Kropp R … +5 more , Gao Z, Desai K, Justo M, Sanaiha Y, Benharash P
Am Surg · 2026 Jul · PMID 42383337 · Publisher ↗
BackgroundPerioperative acute myocardial infarction (POMI) complicates 1-5% of non-cardiac operations, influenced by patient risk factors and surgical complexity. The present study used a contemporary, nationally represe...
BackgroundPerioperative acute myocardial infarction (POMI) complicates 1-5% of non-cardiac operations, influenced by patient risk factors and surgical complexity. The present study used a contemporary, nationally representative cohort of non-cardiac operation patients to characterize current trends in the incidence and impact of POMI. We hypothesized that POMI remains associated with increased mortality, complications, and resource utilization.MethodsAll adult (>18 years) hospitalizations entailing non-cardiac surgical procedures were identified from the 2016-2022 Nationwide Readmissions Database. Non-cardiac operations included intraabdominal, vascular, orthopedic, thoracic, urinary, gynecology, and otolaryngology procedures. Those experiencing POMI comprised the cohort (others: ). Multivariable logistic and linear regression models were developed to evaluate the association of POMI with outcomes of interest including in-hospital mortality, postoperative complications, and non-elective readmissions.ResultsOf an estimated 8 633 451 non-cardiac operations, 66% were elective and 0.92% experienced POMI. Relative to others, were older and had a greater burden of chronic medical conditions. Following comprehensive risk-adjustment, POMI was associated with greater in-hospital mortality. Furthermore, POMI was linked with increased hospitalization duration by 4.25 days and costs by $23 710. Additionally, POMI was associated with increased odds of 30-day non-elective readmissions. A modest increase in POMI incidence was observed over time across operative categories.ConclusionThe incidence of perioperative acute myocardial infarction following non-cardiac operations remains low (∼1%), with modest increases observed across select operative categories. This complication remains associated with substantial mortality, increased resource utilization, and higher rates of non-elective readmissions, underscoring the critical importance of perioperative cardiac risk stratification and optimization.
Outcomes of Completion Cholecystectomy: Association With Patient Comorbidity in a National Database.
Stega MS, Katuwal B, Jacobs MJ … +2 more , Patil SV, Mittal VK
Am Surg · 2026 Jul · PMID 42383329 · Publisher ↗
IntroductionCholecystectomy is considered the gold standard treatment for symptomatic gallstone disease. In certain cases, due to technical difficulties, a subtotal cholecystectomy may be performed. Between 1998 and 2015...
IntroductionCholecystectomy is considered the gold standard treatment for symptomatic gallstone disease. In certain cases, due to technical difficulties, a subtotal cholecystectomy may be performed. Between 1998 and 2015, a total of 1 423 080 laparoscopic cholecystectomies were performed. 10 162 patients who underwent completion cholecystectomy were identified and stratified by age (<50 vs. ≥50 years). This study examines outcomes and risk factors associated with completion cholecystectomy following partial (subtotal) cholecystectomy, with a focus on age and comorbidity burden.ResultsOlder patients demonstrated significantly higher comorbidity burdens, as reflected by Charlson Comorbidity Index scores. Overall complication rates were substantial (26.3%), including gastrointestinal, infectious, and cardiopulmonary events. Mortality was 2.5% overall but markedly higher in patients aged ≥50 years (3.3% vs 0.6%). Length of stay was also longer in older patients.ConclusionsWorse outcomes in older individuals correlated strongly with increased comorbidities rather than age alone. Completion cholecystectomy is frequently performed in complex surgical settings with distorted anatomy, contributing to higher complication rates. However, variability in outcomes across studies suggests that patient selection, operative approach, and baseline health status are key determinants. The study highlights the diagnostic challenge of post-subtotal cholecystectomy cholecystitis and underscores the importance of clinical vigilance. It concludes that careful preoperative risk stratification and patient selection are critical to improving outcomes, as procedural risk is closely tied to underlying health status and case complexity rather than the surgery itself.
Building the Conversation: Editorial Stewardship in Contemporary Surgical Publishing.
Nakayama DK
Am Surg · 2026 Jun · PMID 42380801 · Publisher ↗
Academic publishing in surgery has undergone profound change during the past several decades. Expansion of medical schools, residency programs, international academic centers, and digital publishing platforms has produce...
Academic publishing in surgery has undergone profound change during the past several decades. Expansion of medical schools, residency programs, international academic centers, and digital publishing platforms has produced unprecedented growth in manuscript submissions and intensified competition for professional attention. Journals are judged both by readership, as measured by article downloads, and by scientific influence, as reflected in scholarly citation. At , these changes prompted development of editorial frameworks designed to identify contributions most likely to matter to practicing surgeons and subsequent investigators. Many manuscripts contained observations whose significance was underrecognized by their authors. This observation led to the Hidden Publishable Idea (HPI), a framework for identifying contributions most useful to readers. Once identified, the HPI often revealed methodological limitations that imposed an evidentiary ceiling, preventing definitive conclusions while suggesting new hypotheses for future investigation. Analysis of downloads and citations suggested that readership and scholarly adoption are related but distinct outcomes. This observation led to development of the CitDL matrix, a two-by-two framework based on high and low download and citation performance. The editorial objective was not simply manuscript acceptance, but identification and development of contributions that could move manuscripts toward greater readership, greater scholarly engagement, or both. These concepts represent adaptive responses to the contemporary challenge of helping useful ideas find their audience and contribute to the advancement of surgical practice and science.
Musculoskeletal Pain in Surgeons on Operating Days.
Panuccio A, Webb T, Jiangliu Y … +1 more , Haigh PI
Am Surg · 2026 Jun · PMID 42375122 · Publisher ↗
UNLABELLED: Work-related musculoskeletal (MSK) pain is frequent in surgeons, but factors associated with it are not well studied. METHODS: Repeat surveys were sent to general and subspecialty surgeons in the evening of t...
UNLABELLED: Work-related musculoskeletal (MSK) pain is frequent in surgeons, but factors associated with it are not well studied. METHODS: Repeat surveys were sent to general and subspecialty surgeons in the evening of their operating room (OR) days in one month. Age, sex, BMI, weekly exercise, NASA Task Load Index (NASA-TLX: a composite measure of workload), and pain scores were collected. Operating room case length and approach were collected from a registry. All variables were analyzed for their independent association with mean pain score changes in 12 body regions (with 95% CI). RESULTS: There were 29 surgeons who performed a total of 537 operative cases on 228 OR days. Increases in NASA-TLX by 100 were associated with increased pain in neck +0.23 (0.10-0.35), hands/fingers +0.22 (0.11-0.33), upper back +0.22 (0.10-0.34), lower back +0.31 (0.18-0.44), buttocks +0.07 (0.02-0.13), hips +0.10 (0.03-0.18), legs +0.14 (0.06-0.21), and feet +0.15 (0.05-0.24). Longer total case length increased pain in neck and upper back (+0.15 and +0.13 for every increase in 4 hours, respectively). An OR day with higher proportion of robotic time was associated with increased pain in wrists +0.32 (0.10-0.54) and lower back +0.36 (0.02-0.70). Higher proportion of lap/endo time was associated with increased pain in upper back +0.33 (0.08-0.58). CONCLUSION: Workload was the strongest contributor to musculoskeletal pain during operating days, with associations seen across most body regions. Case length and approach contributed to pain in a smaller number of regions. Targeted ergonomic strategies may reduce the burden of MSK pain among surgeons.
Splenectomy During Cytoreductive Surgery: Marker of Surgical Burden or Independent Predictor of Morbidity?
Erdem O, Canbak T, Acar A … +3 more , Kılıç A, Yalçınkaya C, Başak F
Am Surg · 2026 Jun · PMID 42374715 · Publisher ↗
BackgroundCytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) is a cornerstone treatment for peritoneal metastases but carries substantial morbidity. Splenectomy is frequently pe...
BackgroundCytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) is a cornerstone treatment for peritoneal metastases but carries substantial morbidity. Splenectomy is frequently performed during CRS, yet it remains uncertain whether it independently increases postoperative risk or merely reflects greater surgical complexity.MethodsWe retrospectively analyzed 124 CRS procedures performed between 2014 and 2023 at a tertiary center, including 20 splenectomy cases. Operative characteristics, morbidity, and mortality were compared between splenectomy and non-splenectomy groups. Propensity score matching (PSM; 1:2 nearest-neighbor) and inverse probability of treatment weighting (IPTW; average treatment effect on the treated) were applied to adjust for baseline imbalances across age, ASA score, PCI, blood loss, primary tumor type, sex, and number of anastomoses.ResultsPatients undergoing splenectomy exhibited higher PCI scores (median 18.5 vs 9; < .001), greater blood loss (775 vs 450 mL; = .037), longer operative times (9 vs 6 hours; = .007), and more visceral resections (median 4.5 vs 2; < .001). Severe complications occurred in 60% of splenectomy vs 27% of non-splenectomy cases ( = .007), while mortality did not differ significantly (15% vs 8.7%; = .408). After adjustment, splenectomy was not an independent risk factor for morbidity (PSM: OR 2.69, = .193; IPTW: OR 1.76, = .37). Higher ASA score, perioperative fluid replacement, and blood loss remained significant predictors.ConclusionsSplenectomy during CRS correlates with higher observed morbidity but not with independently increased risk after controlling for surgical complexity. These findings suggest splenectomy reflects procedural burden rather than a direct hazard, underscoring the importance of contextual interpretation and vigilant perioperative management.
Predictors of a Long Hospital Stay After Abdominoperineal Resection of Rectal Cancer: Analysis of the National Cancer Database.
Shustak AG, Oosenbrug M, Horesh N … +5 more , Emile SH, Garoufalia Z, Gefen R, Salama E, Wexner SD
Am Surg · 2026 Jun · PMID 42372118 · Publisher ↗
BackgroundIt is difficult to predict which patients will have longer postoperative hospital stays after rectal cancer surgery. We aimed to determine the predictors of a long hospital stay following abdominoperineal resec...
BackgroundIt is difficult to predict which patients will have longer postoperative hospital stays after rectal cancer surgery. We aimed to determine the predictors of a long hospital stay following abdominoperineal resection (APR) for rectal cancer.MethodsRetrospective cohort analysis of patients diagnosed with rectal adenocarcinoma in the National Cancer Database between 2015 and 2019 with clinical stage I-IV cancers who underwent APR. Multiple linear regression analysis was conducted to determine the predictors of a long hospital stay. A statistical calculator was created to predict the in-hospital length of stay.Results7470 patients (63.2% males; mean age: 62.3 years) were included. Median hospital stay was 6 (IQR: 4-8) days. Black patients stayed nearly two days longer compared to other patients (1.9; 95% CI: 1.33-2.49, < 0.001). Patients with a Charlson Deyo Score of 3 also had a longer length of stay (1.96, 95% CI: 1.02-2.91, < .001). Robotic surgery was associated with shorter hospital stays (-0.7 days, 95% CI - 1.1, -0.4, < .001), while conversion from minimally invasive to open surgery was associated with a longer hospital stay (1.1 days, 95% CI: 0.55-1.68, < .001).ConclusionOlder age, black race, male sex, and severe comorbidities were associated with longer hospital stays, while minimally invasive surgery was associated with decreased length of stay.
Robotic Resection of Right Perihilar Intrahepatic Cholangiocarcinoma: Practical Technique of Major Hepatic Resection for Biliary Tract Cancer.
Kumar S, Christodoulou M, Sucandy I
Am Surg · 2026 Jun · PMID 42363663 · Publisher ↗
Intrahepatic juxtahilar cholangiocarcinoma frequently necessitates major hepatic resection with radical regional lymphadenectomy to achieve oncologic clearance and accurate staging; however, standardized easy-to-follow r...
Intrahepatic juxtahilar cholangiocarcinoma frequently necessitates major hepatic resection with radical regional lymphadenectomy to achieve oncologic clearance and accurate staging; however, standardized easy-to-follow robotic techniques for centrally located tumors remain limited. Herein, we present a fully robotic right hepatectomy with formal portal lymphadenectomy in a 76-year-old woman with a 5.5-cm centrally located intrahepatic cholangiocarcinoma with underlying hepatic steatosis. Preoperative evaluation included cross-sectional imaging and volumetric assessment to ensure adequate future liver remnant, consistent with contemporary recommendations for minimally invasive major hepatectomy. The procedure was performed using a structured, stepwise approach emphasizing early hilar dissection, inflow-first control, parenchymal transection under low central venous pressure <5mmHg, and systematic portal lymphadenectomy. The operation was completed in 6 hours with an estimated blood loss of 150 mL without Pringle maneuver. The patient was discharged on postoperative day 5 without perioperative complications. Final pathology demonstrated a poorly differentiated intrahepatic cholangiocarcinoma with negative margins (R0) and no lymph node metastases (0/6), consistent with current staging recommendations. At one year, the patient remains disease free. Beyond technical feasibility, this report illustrates a reproducible operative framework informed by cumulative institutional experience, including prior analyses of robotic hepatectomy outcomes, learning-curve progression, and preoperative difficulty stratification. This approach may support incremental expansion of robotic indications for selected centrally located tumors within established hepatobiliary programs.
Application of the Heidelberg Prognostic Pancreatic Cancer Score for Survival Risk Stratification in Stage II/III Colorectal Cancer.
Urabe M, Hiyoshi M, Suzuki M … +7 more , Fukai T, Hasegawa Y, Terai E, Kiya Y, Morizono G, Watanabe T, Hashiguchi Y
Am Surg · 2026 Jun · PMID 42362199 · Publisher ↗
BackgroundReliable and broadly applicable tools for survival risk stratification in stage II/III colorectal cancer (CRC) remain limited. The Heidelberg prognostic pancreatic cancer (HELPP) score is a multidimensional ind...
BackgroundReliable and broadly applicable tools for survival risk stratification in stage II/III colorectal cancer (CRC) remain limited. The Heidelberg prognostic pancreatic cancer (HELPP) score is a multidimensional index integrating tumor burden, systemic inflammation, nutritional status, and host physiological condition, and has been well validated for prognostication in pancreatic cancer. We hypothesized that this score would also be applicable to CRC and investigated its prognostic utility.MethodsA consecutive cohort of 481 patients with pathological stage II/III CRC undergoing curative resection was retrospectively interrogated. The prognostic impact of the HELPP score was assessed using Kaplan-Meier estimates and Cox proportional hazards modeling.ResultsWith a median follow-up of 65 months, 129 patients died. Kaplan-Meier analyses demonstrated clear and consistent stratification of both overall survival (OS) and relapse-free survival (RFS) according to the HELPP score. In univariate analyses, a HELPP score >3 was significantly associated with worse OS and RFS. Importantly, this association remained robust after adjustment for clinically relevant covariates, with HELPP score >3 independently predicting OS (hazard ratio [HR] 1.99, 95% confidence interval [CI] 1.25-3.18, P = 0.004) and RFS (HR 1.78, 95% CI 1.19-2.66, = 0.005).DiscussionThe HELPP score delivers robust, independent prognostic stratification in stage II/III CRC and represents a practical, clinically actionable tool for refined risk assessment. Its integration into clinical practice may enable more precise tailoring of adjuvant therapy and surveillance, advancing individualized management in CRC.
Upfront Total Mesorectal Excision for MRI-Defined Low-Risk cT3 Rectal Cancer: A Systematic Review and Meta-Analysis.
Pompeu BF, Baptista CH, Abud TH … +7 more , Trindade MLU, de Paiva MECB, Barone GL, Delgado LM, Theis C, Poli de Figueiredo SM, Formiga FB
Am Surg · 2026 Jun · PMID 42360989 · Publisher ↗
BackgroundContemporary rectal cancer management increasingly relies on MRI-based risk stratification to identify low-risk cT3 tumors that may avoid neoadjuvant therapy. This meta-analysis compared upfront total mesorecta...
BackgroundContemporary rectal cancer management increasingly relies on MRI-based risk stratification to identify low-risk cT3 tumors that may avoid neoadjuvant therapy. This meta-analysis compared upfront total mesorectal excision with neoadjuvant therapy in MRI-defined low-risk cT3 rectal cancer.MethodsPubMed, Scopus, and Cochrane Central were systematically searched through June 2025. Pooled odds ratios (ORs), mean differences (MDs), and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed with the I statistic. Analyses were performed using R (version 4.4.2). A complementary Bayesian random-effects meta-analysis was performed to explore posterior uncertainty and potential equivalence between strategies.ResultsFive studies, including 1447 patients, were analyzed. Upfront surgery was associated with shorter operative time (MD -25.7 min; 95% CI -38.6 to -12.7) and more lymph nodes retrieved (MD 6.6; 95% CI 6.0-7.3). No significant differences were observed in perioperative complications, including anastomotic leaks, intra-abdominal abscesses, or reoperations. Oncologic outcomes were comparable, including circumferential resection margin positivity (CRM+) (OR 1.05; 95% CI 0.49-2.26), local recurrence (OR 0.99; 95% CI 0.58-1.70), and distant recurrence (OR 1.03; 95% CI 0.64-1.65). Survival outcomes were also similar, with no differences in disease-free (DFS) or overall survival (OS). Bayesian analyses supported these findings, with effect estimates centered around the null and probabilities of superiority close to equipoise, indicating inconclusive evidence.ConclusionIn MRI-defined low-risk cT3 rectal cancer, upfront TME may provide oncologic outcomes comparable to neoadjuvant therapy. However, the available evidence remains exploratory and insufficient to support definitive treatment recommendations.
Atypical Presentation of Metastatic Prostate Adenocarcinoma in the Presacral Space: A Case Report of Diagnostic Resection via the Kraske Approach.
Tran A, Rasheid S
Am Surg · 2026 Jun · PMID 42360889 · Publisher ↗
Prostate adenocarcinoma most commonly metastasizes to bone and lymph nodes; isolated soft-tissue presacral metastasis without a known primary is exceedingly rare and poorly characterized. We report a 69-year-old man pres...
Prostate adenocarcinoma most commonly metastasizes to bone and lymph nodes; isolated soft-tissue presacral metastasis without a known primary is exceedingly rare and poorly characterized. We report a 69-year-old man presenting with hematuria and an incidental 4-cm presacral mass. MRI demonstrated a solid, heterogeneously enhancing lesion within the right mesorectal compartment without intraluminal involvement, most consistent with a primary neurogenic tumor. Serum PSA was not obtained preoperatively, as symptoms were attributed to chronic suprapubic catheter irritation and imaging did not suggest a prostatic origin. Preoperative biopsy was not pursued given the lesion's deep posterior location at the S4 level-proximity to sacral nerve roots precluded safe percutaneous access, and transrectal biopsy is contraindicated. The mass was resected via a posterior transsacral (Kraske) approach for presumed primary presacral neoplasm. Histopathology revealed metastatic prostatic adenocarcinoma with positive PSA and prostatic acid phosphatase immunostaining, identifying an occult primary tumor. This case illustrates an atypical diagnostic scenario in which resection was undertaken for a presumed primary lesion; the metastatic diagnosis was an unexpected pathologic finding that would have substantially altered management had it been established preoperatively. This case underscores the importance of including serum PSA in the standard workup of solid presacral masses in older male patients and demonstrates that the Kraske approach can provide adequate exposure for selected posteriorly situated extrarectal masses when diagnosis remains uncertain and resection is clinically indicated.
Evaluation of an Artificial Intelligence-Based System for Standardized Hand Hygiene Monitoring Among Operating Room Personnel.
Wang F, Bian DM, Wang Q
Am Surg · 2026 Jun · PMID 42360860 · Publisher ↗
ObjectiveThis study developed an artificial intelligence (AI)-based hand hygiene assessment system to improve low-supervision monitoring, enhance compliance in operating rooms, standardize procedures, and reduce the risk...
ObjectiveThis study developed an artificial intelligence (AI)-based hand hygiene assessment system to improve low-supervision monitoring, enhance compliance in operating rooms, standardize procedures, and reduce the risk of intraoperative infections.MethodsThis system installed high-definition cameras, faucets, and hand sanitizer sensors in the operating room handwashing area to collect real-time data on handwashing videos, water flow sounds, duration of water usage, and hand sanitizer consumption. The system automatically identified health care personnel and monitors compliance with surgical handwashing protocols step-by-step, assessing whether procedures were standardized and duration requirements were met. Upon detecting omissions, sequence errors, or insufficient duration, immediate corrections were provided through visual and auditory prompts on the screen. The system automatically recorded all data throughout the process without requiring on-site supervision, ensuring stable adaptation to both routine operating room scenarios and emergency surgical procedures.ResultsExperimental findings demonstrated that the system achieved a handwashing step recognition rate of 94.57%, an assessment accuracy rate of 93.25%, and a handwashing duration compliance rate of 92.68%. When deployed in clinical environments, including surgical and emergency departments, the system significantly improved handwashing compliance, increasing the adherence rate to 94.2%. Additionally, the average handwashing duration was reduced to 45.7 seconds, accompanied by a substantial decrease in non-compliant behaviors.ConclusionThe AI-based hand hygiene assessment system substantially enhanced the standardization and efficiency of handwashing procedures in operating rooms, significantly improved hand hygiene compliance and standardized practice, and demonstrated strong clinical applicability. Future research should focus on optimizing the model and incorporating feedback mechanisms to further improve the accuracy and user experience of the system.
Medicaid Expansion and Stage-Specific Colorectal Cancer Survival.
Akinyemi O, Gordon K, Fasokun M … +4 more , Nnorom S, Cornwell E, Hughes K, Nembhard C
Am Surg · 2026 Jun · PMID 42358182 · Publisher ↗
BackgroundMedicaid expansion under the Affordable Care Act has been associated with improved colorectal cancer (CRC) outcomes, predominantly attributed to earlier diagnosis and stage migration. However, it remains unclea...
BackgroundMedicaid expansion under the Affordable Care Act has been associated with improved colorectal cancer (CRC) outcomes, predominantly attributed to earlier diagnosis and stage migration. However, it remains unclear whether survival benefits vary across disease stages.ObjectiveTo evaluate cancer-specific survival (CSS) after Medicaid expansion across disease stages among working-age adults with CRC, comparing the expansion state of California with the non-expansion state of Texas.MethodsWe conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER) registry data (2007-2021) for patients aged 18-64 years with primary CRC. A difference-in-differences design compared pre-ACA (2007-2013) and post-ACA (2015-2021) periods between California and Texas. CSS was modeled using Cox proportional hazards regression adjusting for demographics, tumor characteristics, and treatments. Analyses were stratified by disease stage (localized, regional, distant) and race/ethnicity.ResultsAmong 122,543 patients, CSS improved after Medicaid expansion in California relative to Texas. Stage-stratified difference-in-differences models showed a modest reduction in cancer-specific mortality for localized disease 0.985 (0.974-0.996), a larger reduction for regional disease 0.941 (0.900-0.983), and the greatest reduction for distant metastatic disease 0.689 (0.525-0.903). Improvements were consistent across racial/ethnic groups, with the largest relative reduction among non-Hispanic Black patients 0.855 (0.763-0.958).ConclusionMedicaid expansion was associated with stage-dependent improvements in CRC survival, with the most pronounced benefit for patients with metastatic disease. These findings suggest that enhanced access to systemic therapy, multidisciplinary care, and financial protection may yield survival gains beyond those mediated by stage shift alone.
Occult Pulmonary Adenosquamous Carcinoma Presenting With Synchronous Colonic Metastases.
Hyche MH, Lopez I, Schammel CM … +3 more , Devane AM, Schammel DP, Yurko YY
Am Surg · 2026 Jun · PMID 42357822 · Publisher ↗
BackgroundGastrointestinal metastases from primary lung malignancies occur in 0.2-11.9% of autopsy series; symptomatic colonic involvement is exceedingly rare (0.1%), portending a dismal prognosis with a reported median...
BackgroundGastrointestinal metastases from primary lung malignancies occur in 0.2-11.9% of autopsy series; symptomatic colonic involvement is exceedingly rare (0.1%), portending a dismal prognosis with a reported median survival of approximately 2 months.Case PresentationA 60-year-old woman with a 40 pack-year smoking history, chronic obstructive pulmonary disease, and prior cervical malignancy presented with a refractory acute exacerbation. In the absence of a discrete pulmonary parenchymal lesion, computed tomography pulmonary angiography incidentally identified mass-like left upper lobe bronchial wall thickening. Bronchoscopic evaluation revealed high-grade endobronchial stenosis. Mediastinal fine-needle aspiration confirmed non-small cell lung carcinoma; colonic metastases identified on staging PET-CT demonstrated TTF-1/Napsin-A positivity with a CK7+/CK20-/CDX2- immunophenotype, consistent with pulmonary adenocarcinoma. Sequential adrenal resection revealed divergent squamous differentiation (p40+/CK5/6+; TTF-1-/Napsin-A-) with KRAS/MYC and NF-1 amplification, supporting a final diagnosis of pulmonary adenosquamous carcinoma-an aggressive NSCLC variant comprising 0.4-4% of lung malignancies.Management and OutcomeTreatment followed evidence-based, histology-guided sequencing: concurrent carboplatin-pemetrexed chemoradiation, nivolumab upon platinum resistance, and cytotoxic salvage with docetaxel followed by vinorelbine. Palliative adrenalectomy addressed refractory pain. The patient survived 42 months from diagnosis, the clinical course was shaped by adequate tissue sampling, diagnostic challenges, and multidisciplinary histology-guided treatment acquisition.ConclusionThis case underscores the diagnostic and therapeutic complexity of lung adenocarcinoma presenting with synchronous colonic metastases without a discrete parenchymal mass, compounded by intratumoral heterogeneity and phenotypic divergence across metastases. Comprehensive tissue sampling enabling serial immunohistochemical and molecular characterization, coupled with coordinated multidisciplinary management, is essential to optimize diagnostic accuracy and therapeutic sequencing in this rare and clinically challenging disease entity.
When Wrong Answers Matter: Consequence-Weighted Evaluation of Large Language Models for ERCP Triage.
Çalışkan YK
Am Surg · 2026 Jun · PMID 42348911 · Publisher ↗
BackgroundLarge language models (LLMs) increasingly generate clinical recommendations, but their ability to translate biliary guidelines into safe procedural triage remains uncertain. We evaluated next-generation LLMs fo...
BackgroundLarge language models (LLMs) increasingly generate clinical recommendations, but their ability to translate biliary guidelines into safe procedural triage remains uncertain. We evaluated next-generation LLMs for ERCP indication in suspected choledocholithiasis and tested whether errors could affect workflow.MethodsA cross-sectional in-silico diagnostic accuracy study was conducted from May 14 to May 18, 2026. One hundred locked synthetic vignettes were mapped to ASGE/ESGE-based standards: 45 ERCP-indicated and 55 nonindicated cases. GPT-5.5, Gemini 3.0 Pro, and Claude 4 Opus were queried with an identical zero-shot prompt at temperature 0.0. Outcomes included accuracy, sensitivity, specificity, kappa, error phenotype, and simulated under-triage delay.ResultsGPT-5.5 achieved the highest accuracy (96.0%; 95% CI, 90.2%-98.4%), followed by Gemini 3.0 Pro (90.0%; 95% CI, 82.6%-94.5%) and Claude 4 Opus (84.0%; 95% CI, 75.6%-89.9%). Agreement was near-perfect for GPT-5.5 (kappa = 0.92), substantial for Gemini 3.0 Pro (kappa = 0.80), and weaker for Claude 4 Opus (kappa = 0.68). GPT-5.5 outperformed Claude 4 Opus (McNemar = .004). Claude 4 Opus produced the most under-triage errors (n = 9) and the largest simulated delay burden (163.8 hours per 100 vignettes; Kruskal-Wallis = .007).ConclusionNext-generation LLMs can approximate guideline-based ERCP triage, but clinically meaningful differences emerge when errors are weighted by procedural delay and safety. GPT-5.5 showed the most balanced profile; conservative under-triage remains the key hazard requiring supervision.
Artificial Intelligence, Cognitive Aging, and the Late-Career Surgeon: A Narrative Review.
McElveen K, Nakayama DK
Am Surg · 2026 Jun · PMID 42343662 · Publisher ↗
BackgroundThe surgical workforce in the United States is aging while artificial intelligence (AI) tools are increasingly integrated into clinical practice. These developments raise questions about cognitive aging, profes...
BackgroundThe surgical workforce in the United States is aging while artificial intelligence (AI) tools are increasingly integrated into clinical practice. These developments raise questions about cognitive aging, professional longevity, and patient safety within the cognitive domains of surgical performance. This review situates these issues within the broader context of surgeon competency, cognitive aging, and the integration of emerging technologies into clinical practice.MethodsThis narrative review synthesizes literature published between 2000 and 2026 addressing cognitive reserve, cognitive offloading, automation bias, surgeon aging, fatigue, and contemporary AI applications relevant to surgical decision-making. Emphasis was placed on human studies, clinically applicable cognitive science, and AI tools currently used in perioperative care.ResultsCognitive aging is associated more consistently with reduced processing speed and endurance than with deterioration in clinical judgment. Sustained engagement in complex surgical practice may contribute to cognitive reserve. Current AI systems primarily offload documentation, information retrieval, and organizational tasks, thereby reducing extraneous cognitive load without replacing clinical reasoning. Overreliance on automated systems introduces risk of automation bias and diminished vigilance.ConclusionsAI does not restore technical dexterity and does not substitute for surgical judgment. When implemented deliberately, it may reduce peripheral cognitive burden and support reliable decision-making. For late-career surgeons, AI functions as augmentation rather than replacement.
Primary Hepatic Neuroendocrine Tumors: A Stepwise Decision-Making Framework for Diagnosis and Surgical Management.
Li L, Ling K, Hua S … +4 more , Liu Y, Zhou G, Hu Y, Yang L
Am Surg · 2026 Jun · PMID 42331343 · Publisher ↗
Primary hepatic neuroendocrine tumors (PHNETs) are exceptionally rare, posing significant challenges in diagnosis and management. To address these challenges, this study establishes an actionable, surgeon-facing decision...
Primary hepatic neuroendocrine tumors (PHNETs) are exceptionally rare, posing significant challenges in diagnosis and management. To address these challenges, this study establishes an actionable, surgeon-facing decision framework that transforms clinical evidence into a stepwise management algorithm. By synthesizing evidence from the Surveillance, Epidemiology, and End Results (SEER) program (n = 446) and clinical series, we propose a structured pathway that explicitly links diagnostic confirmation, biological characteristics, and therapeutic strategy. The framework first necessitates the definitive exclusion of extrahepatic primary lesions through functional imaging (eg, PET-CT) and origin-specific markers to confirm the diagnosis. Subsequent operative decision-making is guided by biological assessment; higher tumor grades (G3: HR 2.94; G4: HR 3.04) are strong independent predictors of poorer survival, warranting a shift toward systemic control for high-grade disease. For localized disease, surgical resection remains the cornerstone of management, offering 5-year survival rates of 60-80%, whereas liver transplantation is prioritized as a viable curative strategy for unresectable, liver-confined G1/G2 tumors (5-year survival 70-80%). In advanced or multifocal stages, locoregional approaches provide effective palliation. This structured decision framework enables practicing surgeons to determine the optimal intervention-whether resection, transplantation, or palliation-based on individualized tumor grade, burden, and distribution, thereby optimizing long-term outcomes for this rare malignancy.
Postoperative Transthoracic Echocardiography Following Penetrating Cardiac Injury: Moving From Routine Use to a Risk-Stratified Approach.
French JT, Lemon NT, Capasso TJ … +11 more , Mbaka MI, Polite NM, Deci RT, Miller SG, Kinnard CM, Bright AC, Williams AY, Simmons JD, Lee YL, Park C, Butts CC
Am Surg · 2026 Jun · PMID 42318598 · Publisher ↗
BackgroundPatients undergoing surgical repair of penetrating cardiac injury are routinely evaluated postoperatively with a transthoracic echocardiogram (TTE). We hypothesized that patients undergoing a single operation f...
BackgroundPatients undergoing surgical repair of penetrating cardiac injury are routinely evaluated postoperatively with a transthoracic echocardiogram (TTE). We hypothesized that patients undergoing a single operation for penetrating cardiac injuries without the need for cardiopulmonary bypass (CPB), coronary artery bypass grafting (CABG), or additional staged procedures do not benefit from routine postoperative TTEs.MethodsA retrospective chart review of patients presenting with cardiac injuries to a level I trauma center from January 2018 to March 2025 was performed. Patients with a blunt mechanism, age <18 years, or no identifiable penetrating cardiac injury were excluded. Demographic data, injury characteristics, postoperative care and complications, and TTE findings were analyzed.ResultsThirty-eight patients with penetrating cardiac injuries were identified. Twenty-one patients died within 4 hours of arrival, and 2 patients underwent advanced procedures (ie, CPB and CABG), leaving 15 patients for analysis. Thirteen (87%) were male with an average age of 36. The Median Injury Severity Score (ISS) was 26, with a median American Association for the Surgery of Trauma (AAST) heart injury grade of 3. Fourteen (93%) patients survived to discharge. Eight (53%) of the fifteen patients underwent postoperative TTEs, none of which revealed clinically significant findings relative to their procedure.DiscussionRoutine postoperative TTE demonstrated low clinical utility in this cohort. These findings support a selective approach to TTE based on injury complexity and clinical indicators. Postoperative TTE may be deferred in asymptomatic patients following uncomplicated repair but remains indicated in patients with new cardiac symptoms, higher-risk injury patterns, or complex operative repair.
Gender Disparities in Thyroid Cancer Diagnosis: Evaluating Detection Bias and Clinical Implications.
Brosnihan P, Creighton CJ, Yu B … +1 more , Chen KT
Am Surg · 2026 Jun · PMID 42316468 · Publisher ↗
BackgroundDespite a female preponderance in clinical diagnoses, meta-analyses of autopsy studies demonstrate similar rates of subclinical thyroid cancer between sexes. This study examines granular demographic, clinical,...
BackgroundDespite a female preponderance in clinical diagnoses, meta-analyses of autopsy studies demonstrate similar rates of subclinical thyroid cancer between sexes. This study examines granular demographic, clinical, and pathologic data to evaluate this discordance.MethodsA single-center retrospective review (2015-2021) identified 195 thyroid cancer patients. Logistic regression models assessed demographics, presenting symptoms, pathology, recurrence, and mortality as factors in stage of presentation.ResultsMen presented with significantly larger nodules than women (median 4.45 cm vs 3.2 cm, ), particularly when symptomatic (). However, nodule size did not differ in asymptomatic patients (). No significant differences were observed in BMI, age, prior radiation history, or ethnicity. Primary care status approached significance, with 42.5% of men lacking a documented primary care physician vs 24.5% of women (). Women were more likely to have small, localized tumors (), T1 disease (), and stage 1 disease (), while metastatic disease was more common in men (22.5% vs 5%, ). Women were also more likely to be diagnosed with an incidental thyroid cancer when undergoing thyroidectomy for non-cancer indication. No differences in recurrence or mortality were found. Multivariate logistic regression revealed that visiting a PCP within 1 year of diagnosis was protective against advanced disease (OR:0.59, 95% CI:0.41-0.84, ).ConclusionWomen are more frequently diagnosed with subclinical and incidentally identified early-stage thyroid cancer and smaller thyroid nodules, whereas men present with larger nodules and more advanced disease. Men were also less likely to have had routine primary care visits. These findings suggest that diagnostic bias and healthcare access disparities may contribute to gender differences in thyroid cancer detection.
Postoperative Inflammatory and Nutritional Biomarkers for Predicting Anastomotic Leakage After Ovarian Cancer Surgery: A Multicenter Study.
Miao L, Ding B, Qiu S … +6 more , Zhang J, Zhou Y, Shen Z, Zhang Y, Wang Y, Shen Y
Am Surg · 2026 Jun · PMID 42308010 · Publisher ↗
BackgroundUltra-radical cytoreductive surgery is frequently performed for patients with advanced ovarian cancer (OC). However, anastomotic leakage (AL) is a serious complication of such surgeries and the risk factors rem...
BackgroundUltra-radical cytoreductive surgery is frequently performed for patients with advanced ovarian cancer (OC). However, anastomotic leakage (AL) is a serious complication of such surgeries and the risk factors remain unclear. This study identified early postoperative C-reactive protein (CRP) and albumin were the strongest predictors of leakage.MethodsThis multicenter retrospective study involved 305 patients with ovarian cancer who underwent primary anastomosis following enterectomy, spanning January 2018 to June 2023. Comprehensive clinical and demographic data were used to develop predictive models. Feature selection was performed using LASSO and univariate logistic regression. Machine learning algorithms were subsequently applied, with model interpretability assessed using SHapley Additive explanations (SHAP).ResultsThe study revealed an AL prevalence of 14.1%, with 46.5% of affected patients requiring reoperation. Five predictors were identified, including postoperative CRP, serum albumin levels, Eastern Cooperative Oncology Group score, N stage, and blood urea nitrogen. The Lasso-Logistic model demonstrated the best predictive performance with an area under the curve of 0.828 (0.119). SHAP analysis highlighted early postoperative CRP, albumin, and N stage as major contributing factors. Economic analysis revealed a significant correlation between AL and hospital stay, hospital costs, and time to chemotherapy.DiscussionEarly postoperative inflammatory and nutritional biomarkers, particularly CRP and albumin, demonstrated significant predictive value for anastomotic leakage, providing an early warning for risk stratification and intervention. The investigation also bolstered the evidence supporting the restrictive surgical scope approach advocated in clinical guidelines.
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