IntroductionThe prognostic significance of high-risk features (HRFs) in stage II colon cancer is established, but the cumulative impact of multiple HRFs and their relation to stage III disease remain unclear. This study...IntroductionThe prognostic significance of high-risk features (HRFs) in stage II colon cancer is established, but the cumulative impact of multiple HRFs and their relation to stage III disease remain unclear. This study evaluated whether patients with stage II colon adenocarcinomas with ≥3 HRFs demonstrate survival outcomes comparable to stage III disease.MethodsA retrospective analysis included 377 patients who underwent curative resection for colon adenocarcinoma between 2016 and 2022. Patients were classified as stage II <3 HRFs (n = 102), stage II ≥3 HRFs (n = 88), and stage III (n = 187). Clinicopathologic variables were compared, and overall (OS) and disease-free survival (DFS) were analyzed.ResultsPatients with stage II ≥3 HRFs demonstrated 5-year OS and DFS rates of 58.9% and 57.8%, significantly worse than stage II <3 HRFs (79.4% and 74.5%) and comparable to stage III (71.2% and 61.3%) ( = .037, = .040). Subgroup analysis confirmed that stage II ≥3 HRFs had worse OS and DFS than <3 HRFs ( = .010, = .017), but outcomes were comparable to stage III ( = .126, = .600). On multivariate analysis, predictors of worse OS included age ≥65, stoma formation, <12 lymph nodes, and elevated CEA, while DFS was adversely influenced by age ≥65, stoma formation, tumor volume >30 cm, <12 lymph nodes, elevated CEA, and stage III disease.ConclusionStage II colon cancers with ≥3 HRFs demonstrate survival outcomes comparable to stage III, emphasizing the cumulative prognostic impact of multiple risk factors. These findings reinforce adjuvant chemotherapy consideration and highlight the need for refined risk stratification.
IntroductionPersonality assessments have been widely used in business to identify leadership potential and enhance team performance; however, their integration into surgical education remains limited. This study evaluate...IntroductionPersonality assessments have been widely used in business to identify leadership potential and enhance team performance; however, their integration into surgical education remains limited. This study evaluated surgeons' personality profiles using the PRISM assessment and compared them with those of other health care professionals to guide the design of leadership development curricula for surgical training.MethodsA total of 199 surgeons (residents, fellows, and faculty) across multiple academic medical centers completed the PRISM personality assessment as part of structured leadership development programs. Data were compared with a normative cohort of 5887 health care professionals from the SurePeople database. Primary and under-pressure personality profiles were analyzed using chi-square and Fisher's exact tests, with significance set at < .05.ResultsNo significant differences were found between surgeons and other health care professionals in primary personality distributions. Under-pressure profiles, however, revealed a greater proportion of surgeons classified as the type (22% vs 14%; = .05), reflecting tendency towards higher decisiveness and structure in stressful conditions. Personality distributions were similar across residents, fellows, and attending surgeons.DiscussionAlthough surgeons' baseline personalities mirror those of other health care professionals, their stress-related behavioral tendencies demonstrate a unique shift toward structured, action-oriented responses. Incorporating personality assessments such as PRISM into leadership curricula may enhance self-awareness, emotional intelligence, and team performance.ConclusionIntegrating structured personality assessment into surgical leadership education provides valuable insight into behavioral responses under stress and supports the development of adaptive, emotionally intelligent leaders who foster effective and collaborative surgical teams.
Wound contraction is a pivotal component of the wound healing cascade, and contractions of moderate intensity and duration can exert a facilitative effect on the healing process to a certain extent. Accumulating evidence...Wound contraction is a pivotal component of the wound healing cascade, and contractions of moderate intensity and duration can exert a facilitative effect on the healing process to a certain extent. Accumulating evidence indicates that α-smooth muscle actin (α-SMA)-positive myofibroblasts act as the primary functional effector cells mediating wound contraction, whose regulatory role in this process depends on their cellular abundance and functional activity, thereby exerting a profound impact on wound healing outcomes. Recent advances in research pertaining to wound contraction and healing have deepened the mechanistic insights into these intertwined biological processes. Against this backdrop, the present review synthesizes current literature on the multifaceted roles of myofibroblasts in wound contraction and healing, with a particular focus on establishing explicit connections to clinical decision-making in surgical practice. It is anticipated that this work will provide valuable insights to advance both basic research and clinical translation in this field.
BackgroundHypoalbuminemia is associated with worse postoperative outcomes, but data is limited in the bariatric population. Patients with BMI ≥50 may represent a higher-risk group for malnutrition.MethodsWe analyzed MBSA...BackgroundHypoalbuminemia is associated with worse postoperative outcomes, but data is limited in the bariatric population. Patients with BMI ≥50 may represent a higher-risk group for malnutrition.MethodsWe analyzed MBSAQIP data (2015-2022) for patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Propensity score matching was used to control for 22 preoperative variables. We compared 30-day outcomes and bariatric-specific complications in patients with albumin <3.5 g/dL vs ≥3.5 g/dL across four groups: SG with BMI ≥50 (analysis 1), RYGB with BMI ≥50 (analysis 2), SG with BMI <50 (analysis 3), and RYGB with BMI <50 (analysis 4).ResultsAmong 728,915 patients, matched cohorts in analyses 1 (n = 17,548), 2 (n = 9459), 3 (n = 16,025), and 4 (n = 6787) had similar preoperative characteristics. Hypoalbuminemia was associated with increased complications across all groups. In patients with BMI ≥50, hypoalbuminemia was significantly associated with increased mortality (SG 0.2% vs 0.1%, = 0.011; RYGB 0.3% vs 0.1%, < 0.001), unplanned ICU admission (SG 1.0% vs 0.7%, = 0.020; RYGB 1.6% vs 1.2%, = 0.034), and non-home discharge (SG 0.8% vs 0.5%, < 0.001; RYGB 0.9% vs 0.6%, = 0.009). These mortality differences were not observed in patients with BMI <50.ConclusionHypoalbuminemia is associated with higher complications rates after bariatric surgery and increased mortality in patients with BMI ≥50. Preoperative nutritional optimization is strongly recommended in this high-risk group.
BackgroundComputed tomography (CT) is the preferred imaging modality for diagnosing acute appendicitis in adults. However, the optimal contrast protocol remains debated, balancing diagnostic accuracy, operational efficie...BackgroundComputed tomography (CT) is the preferred imaging modality for diagnosing acute appendicitis in adults. However, the optimal contrast protocol remains debated, balancing diagnostic accuracy, operational efficiency, and patient safety.ObjectiveTo systematically compare the diagnostic accuracy and operational efficiency of different CT contrast protocols-oral, intravenous (IV), combined oral + IV, and non-contrast-in adult patients with suspected acute appendicitis.MethodsA comprehensive search of MEDLINE, Embase, Cochrane Library, and Web of Science was conducted from inception to April 2025. Eligible studies compared CT contrast protocols in adults (≥18 years) and reported diagnostic or operational outcomes. Two independent reviewers screened articles, extracted data, and assessed risk of bias using the QUADAS-2 tool. Primary outcomes were sensitivity, specificity, positive predictive value, and negative predictive value; secondary outcomes included time to CT completion and emergency department (ED) length of stay.ResultsSeventeen studies involving 5033 patients met inclusion criteria. Non-contrast CT demonstrated sensitivity of 82.4-90.5% and specificity of 75-100%. Oral contrast-only protocols showed sensitivity of 73.5% and specificity of 80%. Combined oral + IV protocols achieved sensitivity of 89.4-100% and specificity of 54.5-98.5%. IV-only protocols provided sensitivity of 77.8-100% and specificity of 87-100%. Across studies, eliminating oral contrast reduced ED length of stay by 29-91 minutes without compromising diagnostic accuracy.ConclusionsIV-only or non-contrast CT protocols offer comparable diagnostic accuracy to oral contrast approaches while significantly improving workflow efficiency. Protocol selection should consider clinical setting and patient factors, reserving oral contrast for select groups such as oncology patients or those with prior abdominal surgery.
IntroductionA "smoker's paradox" has been described in rib fractures for which smokers have demonstrated increased complications but decreased mortality. Alcohol has shown increased mortality risk but the effect of subst...IntroductionA "smoker's paradox" has been described in rib fractures for which smokers have demonstrated increased complications but decreased mortality. Alcohol has shown increased mortality risk but the effect of substance use has not been well evaluated. Given the paucity of data surrounding these outcomes, we evaluated the impact of alcohol use, smoking, and substance use disorders on outcomes after traumatic rib fracture.MethodsWe performed a five-year retrospective review for all adult patients admitted to our level 1 trauma center with rib fractures. Each outcome was evaluated independently in a stepwise backward regression model for potential confounding factors. We then performed multivariable linear and logistic regression to examine the relationship between alcohol, smoking, and substance use to outcomes.ResultsIn total, 3,327 patients were included for review. Smoking was associated with increased morbidity but a paradoxical decreased risk of respiratory failure and a 56% decreased risk of mortality. Substance use disorder had increased risk of respiratory failure and complications but a paradoxical 66% decreased risk of mortality. Alcohol use disorder was associated with increased morbidity with no change in mortality and no paradoxical beneficial outcomes. Both alcohol and substance use disorders were associated with significantly prolonged hospital length of stay.ConclusionDespite increased morbidity, both smoking and substance use disorder demonstrated significantly decreased mortality. These findings could support the expansion to a "smoker's and substance use paradox" in traumatic rib fracture although further study is warranted.
UNLABELLED: The Psychology of Surgery: An Initial Inquiry Into What Practicing Surgeons Think is Important to Know From Psychology. Abstract Background: There is growing interest in potential contributions psychological...UNLABELLED: The Psychology of Surgery: An Initial Inquiry Into What Practicing Surgeons Think is Important to Know From Psychology. Abstract Background: There is growing interest in potential contributions psychological science can make to the practice of surgery. However, as an expansive field, selecting relevant content for education and training can be challenging. We surveyed practicing surgeons to assess their perception of the most relevant psychological topics and their mastery for excellence in a surgical career and care. METHODS: A list of surgery-related psychological topics was generated from content in the surgical literature and from experience. They were then reviewed by subject matter experts. The survey was distributed to attending surgeons who rated each item's importance and also their degree of mastery (from 0 low to 7 high). RESULTS: Twenty-three surgeons of various subspecialties participated. Topics of highest importance had mean scores approaching the highest potential rating of 7. Qualitative analysis suggested 4 categorical themes: coping with difficult events, communication skills, leadership skills, and psychological performance skills. A significant correlation was found between ratings of importance and mastery, but mean ratings of mastery were significantly lower than ratings of importance. DISCUSSION: This study found that practicing surgeons endorse a large number of psychological topics as being of high importance in surgical practice. However, ratings of mastery were significantly lower than ratings of importance. These findings suggest the need for training and education in the psychology of surgery for surgeons and surgical residents and provide potential targets for such training.
BackgroundThe Brain Injuries in Greater East Texas (BIGTEX) criteria were developed to identify patients with mild traumatic brain injury (mTBI) who may be managed at Level IV trauma centers (L4TCs). This study compared...BackgroundThe Brain Injuries in Greater East Texas (BIGTEX) criteria were developed to identify patients with mild traumatic brain injury (mTBI) who may be managed at Level IV trauma centers (L4TCs). This study compared outcomes of mTBI patients treated at a Level I trauma center (L1TC) vs affiliated L4TCs.MethodsA 10-year retrospective review of mTBI admissions was performed. Patients were grouped by location: L1TC or L4TC. Adverse events included neurological deterioration, worsening CT scan, neurosurgical intervention, or death. At L4TCs, patients received routine emergency care with neurological assessments performed by trauma-trained staff. Decisions to transfer were made by the treating emergency physician, independently or in consultation with the affiliated L1TC, using established transfer pathways.ResultsSeventy-four patients were included: 63 treated at the L1TC and 11 at L4TCs. The L1TC group met BIGTEX criteria; several L4TC patients had minor deviations, including low-dose aspirin (n = 5), intraparenchymal hemorrhage 5-7 mm (n = 1), and subarachnoid hemorrhage (focal n = 1; diffuse n = 2). All presented with GCS 14-15, no intoxication, polytrauma, or skull fractures. All remained neurologically stable, with no neurosurgical interventions or deaths. L4TC patients had more CT scans (median 3 vs 2), slightly longer hospital stays (3 vs 2 days), shorter ICU stays (0 vs 2 days), and lower hospital charges ($30,236 vs $38,076).ConclusionSelected mTBI patients, including those with minor BIGTEX deviations, were managed at L4TCs without observed adverse outcomes. These findings support the feasibility of local management in carefully selected patients and warrant prospective validation in broader rural trauma populations.
BackgroundFournier gangrene (FG) remains a life-threatening necrotizing infection with persistently high mortality despite advances in surgical and supportive care. Reliable early prognostic markers are therefore essenti...BackgroundFournier gangrene (FG) remains a life-threatening necrotizing infection with persistently high mortality despite advances in surgical and supportive care. Reliable early prognostic markers are therefore essential. The C-reactive protein-albumin-lymphocyte (CALLY) index, which integrates inflammatory, nutritional, and immune status, has shown prognostic value in several critical illness settings, but its utility in FG has not been adequately evaluated.MethodsThis multicenter retrospective cohort study included 136 adults who underwent surgical treatment for FG between 2015 and 2025. Demographic variables, comorbidities, laboratory parameters, qSOFA scores, and 30-day outcomes were analyzed.ResultsThe 30-day mortality rate was 17% (23/136). Non-survivors had significantly lower albumin and lymphocyte levels, higher CRP levels, and markedly reduced CALLY indices compared with survivors (0.005 vs 0.039, < 0.001). The CALLY index demonstrated strong discriminative performance for 30-day mortality (AUC = 0.886; 95% CI: 0.780-0.991). A cutoff ≤0.012 provided 82.6% sensitivity and 95.6% specificity. In multivariate analysis, CALLY ≤0.012 (OR 42.61; < 0.001) and qSOFA score 2-3 (OR 12.97; = 0.019) emerged as strong independent predictors of mortality, whereas age, sex, uncontrolled diabetes, CAD, immunosuppression, and malignancy were not independently associated with death.DiscussionThe C-reactive protein-albumin-lymphocyte (CALLY) index was independently associated with 30-day mortality in patients with Fournier gangrene and may serve as a simple adjunctive biomarker for early risk stratification when interpreted alongside established clinical scoring systems such as qSOFA. Incorporating the CALLY index into early risk-stratification algorithms may facilitate timely clinical decision-making and more targeted management strategies for high-risk FG patients.
Nipple-sparing mastectomy has been increasingly used for the surgical management of breast cancer. The procedure has been shown to be oncologically safe and improves patient psychosocial and sexual wellbeing outcomes. Th...Nipple-sparing mastectomy has been increasingly used for the surgical management of breast cancer. The procedure has been shown to be oncologically safe and improves patient psychosocial and sexual wellbeing outcomes. This reflection emphasizes that surgical management must consider the subjective patient experience.
BackgroundSurgical costs per procedure may vary by surgeon due to operating time and equipment selection.MethodsCost and materials data were analyzed using an institutional database from a large academic, quaternary care...BackgroundSurgical costs per procedure may vary by surgeon due to operating time and equipment selection.MethodsCost and materials data were analyzed using an institutional database from a large academic, quaternary care center. The analysis included 475 thyroidectomy-coded operations performed by 13 surgeons from department A (n = 6) and department B (n = 7) between 2021 and 2023.ResultsMean time cost of procedures was significantly lower for department A surgeons by $112 compared to department B ( = .03). There was no statistically significant difference between the material cost of procedures between departments ( = .40). The highest average material cost for a single surgeon was $1590 with the lowest being $523, demonstrating the high degree of variability between surgeons.DiscussionExamining cost of materials alone, the highest and lowest-cost-ranked surgeons had a difference of $1067. Standardization of surgical trays and avoidance of outlier materials may be future avenues for research in decreasing costs.
Neuroendocrine tumors of unknown primary (NET-UPs) represent a diagnostically and therapeutically challenging subset of neuroendocrine neoplasms. Despite advances in imaging and molecular profiling, up to 13% of metastat...Neuroendocrine tumors of unknown primary (NET-UPs) represent a diagnostically and therapeutically challenging subset of neuroendocrine neoplasms. Despite advances in imaging and molecular profiling, up to 13% of metastatic NETs lack an identifiable origin at presentation. This review examines the multimodal diagnostic strategies for NET-UPs, highlighting the integration of cross-sectional imaging, receptor-based PET imaging, immunohistochemistry, and surgical exploration. While Ga-DOTATATE PET/CT remains the preferred imaging modality for well-differentiated tumors, intraoperative small bowel palpation offers the highest diagnostic yield when imaging is inconclusive. Immunohistochemical markers, including second generation neuroendocrine stains and transcription factor profiles, aid in classifying tumor origin and differentiation. Management of NET-UPs is largely guided by tumor grade and somatostatin receptor status. Well-differentiated, receptor-positive tumors are treated with somatostatin analogues, with peptide receptor radionuclide therapy used in progressive disease. Despite therapeutic advancements, optimal sequencing and combination strategies remain areas of ongoing investigation. Given the clinical heterogeneity of NET-UPs, sustained multidisciplinary collaboration is critical to optimizing outcomes in this complex and increasingly prevalent disease.
BackgroundFollicular thyroid carcinoma (FTC) behaves differently from papillary thyroid carcinoma. Although early-stage FTC generally has favorable outcomes, risk within AJCC stage I-II is not uniform, and robust evidenc...BackgroundFollicular thyroid carcinoma (FTC) behaves differently from papillary thyroid carcinoma. Although early-stage FTC generally has favorable outcomes, risk within AJCC stage I-II is not uniform, and robust evidence focusing exclusively on this group is limited.MethodsWe identified 4220 patients with AJCC stage I-II FTC in the SEER database (2010-2022). The primary endpoint was disease-specific survival (DSS). We estimated cumulative incidence functions (CIFs) for thyroid cancer-specific and other-cause mortality and evaluated prognostic factors using Fine-Gray competing-risk regression. Multivariable modeling and nomogram construction were not pursued because only one variable met significance in univariable analyses.ResultsAcross follow-up, other-cause mortality exceeded thyroid cancer-specific mortality; at ∼10 years, other-cause death was ∼6% while thyroid cancer-specific death remained <1.5%. In competing-risk regression, AJCC stage II was the sole significant predictor of thyroid cancer-specific mortality vs stage I (SHR 7.76; 95% CI 2.09-28.8; = 0.002). Other demographic, tumor, and treatment variables were not significant or were non-estimable due to sparsity.ConclusionsEarly-stage FTC shows low cancer-specific mortality overall, but risk is concentrated in stage II, underscoring clinically meaningful heterogeneity within "early stage." These findings support stage-attuned counseling and follow-up and highlight the importance of competing-risk methods when interpreting outcomes in FTC.
IntroductionSerous cystadenocarcinoma (SCAc) of the pancreas is the rare malignant counterpart of serous cystadenoma, with fewer than 40 reported cases. Its clinical behavior and optimal management remain poorly defined....IntroductionSerous cystadenocarcinoma (SCAc) of the pancreas is the rare malignant counterpart of serous cystadenoma, with fewer than 40 reported cases. Its clinical behavior and optimal management remain poorly defined. This systematic review summarizes the presentation, diagnosis, treatment, and outcomes of pancreatic SCAc.MethodsA systematic search of PubMed, Scopus, Web of Science, and Embase was performed from inception through December 2025. Thirty-six studies describing 38 histologically confirmed cases met inclusion criteria. Data on demographics, tumor characteristics, imaging, management, and outcomes were extracted and summarized descriptively.ResultsMedian age at diagnosis was 66.5 years (IQR 55.8-71.0), and 71% of patients were female. Abdominal pain and incidental imaging findings were the most common presentations. Tumors were typically large and located in the pancreatic body or tail. Local invasion occurred in 74% of cases. Distant metastases were present in 68% (26 of 38), most commonly to the liver. All patients underwent surgical resection. Chemotherapy use was rare. Recurrence was reported in 26% of cases, with a median disease-free interval of roughly 50 months. Disease-related mortality was infrequently reported.ConclusionsDespite frequent invasion and metastasis, SCAc often demonstrates an indolent course, and long-term survival is common after resection. Surgical management remains central to treatment. Given its rarity and diagnostic limitations, individualized management and prolonged surveillance are warranted.
Requests for major revision generate more anxiety than almost any other editorial decision, in part because authors struggle to interpret what the journal is signaling. Some view major revision as near acceptance and rus...Requests for major revision generate more anxiety than almost any other editorial decision, in part because authors struggle to interpret what the journal is signaling. Some view major revision as near acceptance and rush to make changes, while others interpret it as a softened rejection and respond incompletely. Both approaches miss the central purpose of major revision. A request for major revision represents a conditional investment by editors and reviewers. The topic is relevant and the question appropriate for the journal, but the manuscript is not yet ready for publication. This editorial provides practical guidance on how authors should respond, emphasizing judgment over persistence. Key principles include reading reviews with distance, understanding the structural issues underlying reviewer comments, and avoiding a checklist mentality. The editorial highlights the importance of using the response-to-reviewers form correctly, making revisions easy to identify, and respecting the significant time reviewers devote to thoughtful critique. Guidance is provided on responding without defensiveness, prioritizing core concerns related to framing and contribution, and reassessing whether the manuscript truly advances the field or has become redundant. Situations in which authors may reasonably decline to pursue revision, as well as how to disagree productively with reviewers, are also addressed. Major revision is neither a promise nor a rejection. When approached as collaboration rather than negotiation, it often results in a manuscript that is clearer, stronger, and more valuable to practicing surgeons.
IntroductionChondromanubrial pectus carinatum (PC) is a rare type of pectus deformity in which there is protrusion of the manubrium and superior costal cartilage. Studies have shown that orthotic bracing is successful in...IntroductionChondromanubrial pectus carinatum (PC) is a rare type of pectus deformity in which there is protrusion of the manubrium and superior costal cartilage. Studies have shown that orthotic bracing is successful in correcting chondrogladiolar PC, but surgery has been the primary treatment for the chondromanubrial subtype. Due to the rarity of this type of PC, we aimed to describe our experience and outcomes with the dynamic compression system (DCS) bracing in these patients.MethodsThis is retrospective single center review of all patients with chondromanubrial PC treated with DCS from 2011 to 2021. Data collected included demographics, PC type and location, brace initiation date, pressure of initial correction (PIC), exercise activity, frequency of brace use, and final treatment results. Data are presented with medians with interquartile ranges (IQRs) and frequencies with percentages.Results11 patients had chondromanubrial PC treated with the brace system. There was an equal distribution in gender, with a median age at brace placement of 13 years (IQR 12, 15). The median change in PIC from the first clinic visit to the last was 2.6 psi (IQR 1.6, 3.8). Most of the cohort (80%) exercised and 50% achieved retainer stage at a median time of 121 days (IQR 91, 238). Four patients maintained correction at the last clinic visit, with the remaining achieving partial improvement of the PC deformity.ConclusionDynamic compression system can be an effective initial approach in managing patients with chondromanubrial PC. Although some patients did not achieve total correction, there was an improvement in the chest wall deformity in all cases.
The circumstances surrounding unintentional firearm-related injuries remain relatively unknown. This study aimed to characterize unintentional firearm-related injuries through a retrospective review of 151 patients admit...The circumstances surrounding unintentional firearm-related injuries remain relatively unknown. This study aimed to characterize unintentional firearm-related injuries through a retrospective review of 151 patients admitted to a Level 1 Trauma Center between January 1, 2013, and January 1, 2023. Most patients were non-Hispanic (91%, n = 138), Caucasian (87%, n = 132), and male (92%, n = 139) and primarily aged 18 to 24 years (25%, n = 37). The mean Injury Severity Score was 6 ± 7.5, with most injuries occurring in the extremities. Injuries were mainly self-inflicted (66%, n = 100), often involved a handgun (70%, n = 105), and frequently occurred in the patient's home (45%, n = 68). Circumstances surrounding the injuries included cleaning the gun (27%, n = 41) and engaging in unsafe practices (21%, n = 31). Overall, 2% (n = 3) experienced a fatal injury. Emphasizing safe gun-cleaning practices and addressing firearm malfunctions may help reduce the incidence of unintentional firearm injuries, highlighting this as a critical area for future intervention.