The American Surgeon[JOURNAL]
Sun
200 papers
Ten Years of National Data on Chronic Diaphragmatic Hernia: Does Surgical Approach Matter?
Hosseinpour H, Garrett HE, Weiman D … +1 more , Behrman SW
Am Surg · 2026 Jun · PMID 42223370 · Publisher ↗
BackgroundThe optimal surgical approach for chronic diaphragmatic hernia (CDH) remains unclear. This study aimed to compare outcomes of thoracotomy vs laparotomy vs laparoscopic repair of CDH.MethodsWe conducted a retros...
BackgroundThe optimal surgical approach for chronic diaphragmatic hernia (CDH) remains unclear. This study aimed to compare outcomes of thoracotomy vs laparotomy vs laparoscopic repair of CDH.MethodsWe conducted a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) 2013-2022. Adult patients (≥18 years) with non-congenital non-hiatal CDH (with or without obstruction) who underwent thoracotomy, laparotomy, or laparoscopy were included. Outcomes assessed included postoperative complications, unplanned return to the operating room (OR), 30-day readmissions, and unfavorable discharge disposition.ResultsA total of 610 patients underwent CDH repair: 156 thoracotomies, 275 laparotomies, and 179 laparoscopies. Chronic diaphragmatic hernia complicated by obstruction was present in 35.2% of patients. On univariate analysis, rates of complications ( = 0.248), readmissions ( = 0.971), unplanned return to OR ( = 0.068), and discharge disposition ( = 0.937) did not differ significantly among groups. On multivariable regression analysis, among patients presenting with obstruction symptoms, laparoscopy was associated with higher odds of unplanned return to OR (aOR: 3.91, 95% CI: 1.91-5.57) and unfavorable discharge (aOR: 1.50, 95% CI: 1.13-4.71), whereas laparotomy was associated with lower odds of both unplanned return to OR (aOR: 0.17, 95% CI: 0.01-0.36) and unfavorable discharge disposition (aOR: 0.41, 95% CI: 0.15-0.84), compared with thoracotomy.ConclusionAcross a decade of national data, outcomes were similar among thoracotomy, laparotomy, and laparoscopy for uncomplicated CDH. In patients with obstruction, however, laparoscopy, used in nearly one in five cases, was associated with increased risks of reoperation and unfavorable discharge disposition. These findings emphasize the importance of careful patient selection and surgical expertise in tailoring operative approach to CDH.
Explant and Bypass for Polymicrobial Mycotic Pseudoaneurysm Following Renal Transplant.
Sun HD, Lain WJ, Buchanan E … +1 more , Tracci MC
Am Surg · 2026 May · PMID 42218646 · Publisher ↗
Mycotic pseudoaneurysms in renal transplant patients are rare but serious complications associated with significant morbidity, graft loss, and mortality. They present a critical management challenge between endovascular...
Mycotic pseudoaneurysms in renal transplant patients are rare but serious complications associated with significant morbidity, graft loss, and mortality. They present a critical management challenge between endovascular salvage and definitive surgical explant. While contemporary reports suggest endovascular techniques can successfully treat this condition, their role as definitive treatment in fungal fields is controversial. We report a case where repeated endovascular stent treatment of a polymicrobial fungal and bacterial pseudoaneurysm perpetuated biofilm formation and polymicrobial colonization, enabling ongoing infection and ultimately requiring explant and femoral-femoral bypass for definitive source control and revascularization. This case highlights an important decision threshold: in the setting of angioinvasive molds, endovascular salvage is often futile, with recent series showing a high failure rate for allograft preservation. Recognition of persistent pain and recurrent fluid collections following endovascular therapy should trigger early surgical source control with infection-resistant conduits, such as autologous or cryopreserved allografts, rather than endovascular temporization.
Infrahepatic IVC Resection and Prosthetic Reconstruction for Renal Cell Carcinoma.
Sun HD, Lain WJ, McCarthy P … +1 more , Farivar BS
Am Surg · 2026 May · PMID 42216575 · Publisher ↗
Renal cell carcinoma (RCC) may result in venous tumor thrombus (VTT) extension into the inferior vena cava (IVC) in 4-36% of cases, with 20-25% requiring IVC resection or reconstruction. Here, we report a case of a 50-ye...
Renal cell carcinoma (RCC) may result in venous tumor thrombus (VTT) extension into the inferior vena cava (IVC) in 4-36% of cases, with 20-25% requiring IVC resection or reconstruction. Here, we report a case of a 50-year-old man with right RCC and level II VTT who underwent radical nephrectomy and en bloc infrahepatic IVC resection for unexpected lateral wall invasion in the setting of clinically silent pulmonary tumor emboli (PTE). Despite the low embolic risk of level I-II thrombi (<3%), this patient presented with a significant burden of PTE. This case challenges the assumption that lower-level tumors as currently imaged and classified imply minimal risk of tumor embolism or venous wall invasion. Our experience underscores the necessity of pre-operative chest imaging to detect occult PTE, the limitations of imaging for assessing tumor vessel wall invasion, and the need to adequately prepare for unexpected circumstances when resecting RCC with VTT.
Rouvière's Sulcus: An External Landmark for Safe Dissection when the Critical View Cannot Be Achieved.
Cawich SO, Pearce NW, Kluger M … +7 more , Dapri G, Alseidi A, Johnson S, Ramkissoon SC, Gardner MT, Cawich IK, Shetty R
Am Surg · 2026 May · PMID 42215020 · Publisher ↗
BackgroundIntraoperative identification of Rouvière's sulcus is a proposed strategy to prevent bile duct injuries. Since it marks the plane at which the extra-hepatic ducts lie, limiting surgical dissection ventral to Ro...
BackgroundIntraoperative identification of Rouvière's sulcus is a proposed strategy to prevent bile duct injuries. Since it marks the plane at which the extra-hepatic ducts lie, limiting surgical dissection ventral to Rouvière's sulcus should protect the ducts from injury. This is an important adjunct when the critical view of safety cannot be achieved during difficult cholecystectomies.MethodsThis was an observational study of all consecutive elective laparoscopic cholecystectomies between January 1, 2017 and May 30, 2024. Intraoperatively, Rouvière's sulcus was identified by surgeons, with correlation by an independent observer. The relationship between the sulcus and the right hepatic pedicle was confirmed by laparoscopic ultrasound. Comparisons were made using SPSS.ResultsOver 7 years, 356 laparoscopic cholecystectomies were performed, and Rouvieré's sulcus could be identified in 296 (83.2%) patients. When a well-defined sulcus was present, it correlated reliably to the right portal triad in all cases. However, the reliability of this relationship significantly reduced in the absence of a well-defined sulcus (100% vs 5%; < 0.0001).ConclusionsWhen present, Rouvieré's sulcus is a valuable asset to surgeons, who can use it as a landmark for safe dissection planes during cholecystectomies. When a well-defined sulcus is absent, surgeons should employ alternative means of bile duct protection, such as indocyanine green or operative cholangiography.
LLM-Generated Transplant Algorithms: Comparing GPT and Gemini in Producing Step-Wise Diagnostic and Management Pathways.
Kudaş İ
Am Surg · 2026 May · PMID 42213872 · Publisher ↗
BackgroundSolid organ transplantation relies on dynamic, evidence-based clinical algorithms. This study evaluates the educational reliability and feasibility of large language models (LLMs) for rapid protocol drafting by...
BackgroundSolid organ transplantation relies on dynamic, evidence-based clinical algorithms. This study evaluates the educational reliability and feasibility of large language models (LLMs) for rapid protocol drafting by comparing GPT-4 and Gemini 2.5 Pro in generating step-wise diagnostic and management algorithms for common post-transplant scenarios. We assess LLMs as tools for synthesizing existing guidance rather than proposing new clinical practice guidelines.MethodsTen high-stakes post-transplant scenarios (eg, acute cellular rejection and unexplained graft dysfunction) were evaluated. Both LLMs received identical, structured prompts. Three transplant specialists independently scored each algorithm using a 5-point rubric for Clinical Concordance (primary outcome), Logical Flow, and Completeness. Inter-rater reliability was assessed with weighted kappa, and median scores were compared using non-parametric tests. Model identifiers, access dates, and prompting procedures were reported to support reproducibility.ResultsInter-rater agreement was high (κ = 0.81). Gemini 2.5 Pro achieved a higher median Clinical Concordance score than GPT-4 (4.5 vs 3.8, < .01) and higher Logical Flow and Completeness scores. Performance differences were most apparent in high-complexity scenarios requiring sequential differentiation of infectious vs alloimmune causes of graft dysfunction.ConclusionGemini 2.5 Pro outperformed GPT-4 in generating clinically concordant, structured, and complete transplant algorithms. LLM outputs remain model- and version-dependent and require expert validation prior to any clinical use. In practice, LLMs should be used only within a governance framework (specialist review, institutional oversight, and periodic revalidation after model updates), not as autonomous clinical tools.
Identifying Low-Risk Trauma Patients for Blunt Cerebrovascular Injury: Evidence From the North Carolina Trauma Registry.
Gallaher J, Winslow J, Portelli-Tremont J … +3 more , Schiro SE, Avery M, Udekwu P
Am Surg · 2026 May · PMID 42213865 · Publisher ↗
BackgroundBlunt cerebrovascular injury (BCVI) is a serious complication of blunt trauma with high rates of morbidity and mortality. There is evidence to support universal screening, but this raises concerns about cost, r...
BackgroundBlunt cerebrovascular injury (BCVI) is a serious complication of blunt trauma with high rates of morbidity and mortality. There is evidence to support universal screening, but this raises concerns about cost, radiation exposure, and system burden. This study examined the connection between clinical factors at initial presentation and BCVI risk to identify opportunities to improve imaging utilization.MethodsWe analyzed patients with blunt injury from the North Carolina Trauma Registry (2016-2021). Blunt cerebrovascular injury was identified using ICD-10 codes. Clinical risk factors evaluated were low Glasgow Coma Score (GCS), significant supraclavicular injury (above-the-clavicle (ATC) injury), and trauma activation level. Logistic regression was used to identify predictors of BCVI.ResultsAmong 198 211 blunt trauma patients, 1336 (0.70%) were diagnosed with BCVI. The highest prevalence was among patients with both a low GCS and significant ATC injury (4.0%), followed by those with only ATC injury (1.5%). Only two cases (0.001%) occurred in patients with neither indicator. The adjusted odds ratios for BCVI were 3.0 (95% CI: 2.6-3.5) for low GCS and 2.8 (95% CI: 2.4-3.2) for level 1 trauma activation. Above-the-clavicle injury was nearly a perfect predictor of BCVI.ConclusionsPatients without altered mental status or significant injuries above the clavicle had an extremely low risk of BCVI. Although liberal screening strategies remain important to prevent missed injuries, our findings suggest that a clearly defined low-risk subgroup may not require routine CTA screening. Prospective, multicenter validation of contemporary screening criteria is needed to refine risk stratification and optimize cross-sectional imaging utilization.Level of EvidenceLevel III, Prognostic/Epidemiological.
Are We Back to Normal After COVID? Emergency to Elective Surgery Ratio in a Tertiary Care Hospital.
Shu-Yip S, Berki L, Miller J … +3 more , Jebbia M, Love B, Kazi A
Am Surg · 2026 May · PMID 42213605 · Publisher ↗
BackgroundThe COVID pandemic significantly affected surgical care by postponing many elective interventions. The consequences were seen in patients' clinical presentation and cost of care. The purpose of this article is...
BackgroundThe COVID pandemic significantly affected surgical care by postponing many elective interventions. The consequences were seen in patients' clinical presentation and cost of care. The purpose of this article is to evaluate changes in the emergency-to-elective surgery ratio at a tertiary hospital across pre-pandemic, pandemic, and early post-pandemic periods.MethodsWe conducted a retrospective review at a community tertiary care hospital in southern California. We analyzed emergency and elective surgeries from January 2019 to December 2023 based on three time periods: Pre-pandemic (Jan 2019-March 2020), pandemic (April 2020-December 2021), and post-pandemic periods (Jan 2022-Dec 2023). In-hospital complication rates and costs of surgery were collected and compared between the groups.ResultsA total of 20,409 patients were included in the analysis. 14,361 (70.4%) underwent emergency surgery while 6,048 (29.6%) had elective surgery. The emergency to elective surgery ratio pre-pandemic, pandemic, and post-pandemic were 1.5, 3.1, and 2.9 (<0.001), respectively. Complications rates pre-pandemic, pandemic, and post-pandemic were 4.5%, 3.2%, and 4.6% (<0.001). Across all 3 time periods, elective general surgery offered a higher net revenue compared to emergency general surgery cases (<0.001).ConclusionAt this tertiary hospital, elective surgical volume demonstrated only partial recovery following the COVID-19 pandemic, resulting in a persistently elevated emergency-to-elective surgery ratio through the end of 2023. This represents an opportunity to direct quality improvement efforts to promote surgical access to elective surgery to potentially reduce complication rates and decrease costs of care.
Predictive Value of Intraoperative Parathyroid Hormone Levels via Central vs Peripheral Sampling.
Paz SI, Rabinowitz S, Turner DJ … +1 more , Hu Y
Am Surg · 2026 May · PMID 42207012 · Publisher ↗
Intraoperative parathyroid hormone (ioPTH) predicts adequate resection during parathyroidectomy and can be sampled peripherally or via the internal jugular vein (IJ). Several criteria for ioPTH monitoring exist. This stu...
Intraoperative parathyroid hormone (ioPTH) predicts adequate resection during parathyroidectomy and can be sampled peripherally or via the internal jugular vein (IJ). Several criteria for ioPTH monitoring exist. This study compared the Miami and Rome criteria as well as IJ and peripheral sampling. This retrospective cohort study comprised parathyroidectomy patients from 2023 to 2025. We included 201 patients with primary hyperparathyroidism, of which 139 underwent IJ sampling and 62 underwent peripheral sampling. At 6 months, 186 (92.5%) patients were normocalcemic (131 in IJ subgroup vs 55 in peripheral subgroup). The proportions of cases meeting the criteria were 85.6% for Miami and 92.8% for Rome in the IJ subgroup, and 83.9% for Miami and 91.9% for Rome in the peripheral subgroup. Specificity was moderately higher in the IJ subgroup for Miami criterion (45.8% IJ vs 32.7% peripheral). While both sampling sites performed similarly across the criteria, Rome criteria exhibited superior diagnostic properties.
Preoperative Memorial Sloan Kettering Prognostic Score and Long-Term Survival After Surgery for Early-Stage Gastric Cancer.
Urabe M, Suzuki M, Fukai T … +7 more , Hasegawa Y, Terai E, Kiya Y, Morizono G, Hiyoshi M, Watanabe T, Hashiguchi Y
Am Surg · 2026 May · PMID 42198953 · Publisher ↗
BackgroundIn early-stage gastric cancer (GC), survival is frequently determined not by tumor biology but by competing non-cancer-related risks, yet robust prognostic markers for this setting are lacking. We sought to det...
BackgroundIn early-stage gastric cancer (GC), survival is frequently determined not by tumor biology but by competing non-cancer-related risks, yet robust prognostic markers for this setting are lacking. We sought to determine whether the Memorial Sloan Kettering prognostic score (MPS) provides clinically meaningful prognostic information in patients with early GC.MethodsWe retrospectively analyzed 108 consecutive patients with pathological stage I GC who underwent curative surgical resection. The prognostic impact of preoperative MPS on overall survival (OS) was examined using Cox proportional hazards modeling.ResultsOver a median follow-up of 58 months, 26 deaths occurred, only one of which was cancer-related. Patients were stratified as MPS 0 (n = 56), MPS 1 (n = 45), and MPS 2 (n = 7). Preoperative MPS correlated significantly with age, sex, performance status, and Glasgow prognostic score (GPS). Preoperative MPS, but not GPS, significantly predicted OS on univariate analysis. On multivariate analysis, MPS emerged as a powerful, independent predictor of OS (MPS 1 vs 0: hazard ratio [HR] 3.64, 95% confidence interval [CI] 1.22-10.85; MPS 2 vs 0: HR 7.18, 95% CI 1.43-36.08; = .031).DiscussionPreoperative MPS robustly stratified mortality risk in patients undergoing curative surgery for early-stage GC. This finding may reposition MPS as a marker of global vulnerability and highlight its potential role in guiding risk-adapted surgical decision-making in GC population.
Robotic Liver Resection for Intrahepatic Cholangiocarcinoma: Perioperative and Oncologic Outcomes From a Single-Institution Experience.
Vanterpool G, Odorizzi R, Ross SB … +3 more , Zhang H, Covilo KM, Sucandy I
Am Surg · 2026 May · PMID 42186986 · Publisher ↗
BackgroundRobotic liver resection (RLR) for intrahepatic cholangiocarcinoma (ICC) remains a newly adopted approach with limited data supporting its oncologic validity. We aimed to evaluate perioperative outcomes and earl...
BackgroundRobotic liver resection (RLR) for intrahepatic cholangiocarcinoma (ICC) remains a newly adopted approach with limited data supporting its oncologic validity. We aimed to evaluate perioperative outcomes and early oncologic metrics following RLR for ICC at a single hepatobiliary center.MethodsA retrospective analysis was conducted on patients undergoing RLR for histologically confirmed ICC between January 2018 and December 2024. Data were collected and analyzed using descriptive statistics.ResultsThirty-five patients underwent RLR for ICC. Mean age was 69 years, with 66% male and a mean ASA grade of III. Major resections comprised 54% of cases, with no conversions to open surgery or intraoperative complications. Mean operative time was 321 years and mean estimated blood loss was 239 mL. R0 resection was achieved in 97% of cases. Mean lymph node harvested was 5, with 37% of patients having ≥6 nodes retrieved. Mean tumor size was 6 cm, with 94% of patients harboring tumors >2 cm and 60% staged as N0. Postoperative complication rate was 34%, with Clavien-Dindo ≥III at 14%. No reoperation occurred. 90-day mortality was 6%. Mean length of stay was 6 days. At a mean follow-up of 21 months, recurrence was observed in 25% of patients, with a mean disease-free survival of 17 months.ConclusionRobotic liver resection for ICC is safe and feasible, yielding high rates of R0 resection, low conversion and complication rates, with acceptable oncological outcomes. These findings support the continued integration of robotics in complex liver oncology.
Complex Blunt Traumatic Abdominal Wall Hernias: A Review of Contemporary Management.
Kearns PW, Smoker SB, Harrell KN
Am Surg · 2026 May · PMID 42178821 · Publisher ↗
Traumatic abdominal wall hernias (TAWHs) present diagnostic and therapeutic challenges to trauma surgeons. Although rare, these injuries are frequently associated with high-energy mechanisms and underlying injuries. This...
Traumatic abdominal wall hernias (TAWHs) present diagnostic and therapeutic challenges to trauma surgeons. Although rare, these injuries are frequently associated with high-energy mechanisms and underlying injuries. This review synthesizes contemporary evidence by integrating the Dennis grading criteria with the Harrell anatomic classification and subsequent management options. The Dennis classification stratifies injuries from grades I to VI, with low-grade injuries (I-III) managed non-operatively. High-grade injuries (IV-VI) rely on Harrell anatomic modifiers for management. Anterior and lateral defects carry high risk of intra-abdominal injury, often necessitating early surgical repair. Posterior lumbar defects exhibit lower visceral injury association, allowing safe observation or delayed repair. Grade VI injuries universally require emergent laparotomy. This combined severity and anatomic grading creates a unified management algorithm to guide the nuance of early, delayed, or minimally invasive repair. This structured approach differentiates candidates for urgent surgery from those suitable for non-operative management, optimizing outcomes in polytrauma patients.
Outcomes of Response-Based Watch-and-Wait and Surgical Management After Total Neoadjuvant Therapy for Rectal Cancer: A Systematic Review and Meta-analysis.
Pompeu BF, Pigossi BD, de Moraes Alves LEB … +6 more , Barone GL, Delgado LM, Guedes LSSP, Theis C, Poli de Figueiredo SM, Formiga FB
Am Surg · 2026 May · PMID 42178612 · Publisher ↗
BackgroundTotal neoadjuvant therapy (TNT) increases clinical complete response rates in locally advanced rectal cancer (RC), allowing response-based management strategies such as watch-and-wait (WW) as an alternative to...
BackgroundTotal neoadjuvant therapy (TNT) increases clinical complete response rates in locally advanced rectal cancer (RC), allowing response-based management strategies such as watch-and-wait (WW) as an alternative to total mesorectal excision (TME). Outcomes associated with WW after TNT remain incompletely defined. This study aimed to compare oncologic and organ-preservation outcomes between WW and surgical management following TNT.MethodsA systematic search was conducted in PubMed, Scopus, and Cochrane Central up to April 2025. Observational studies comparing WW and TME following TNT were included. Pooled odds ratios (ORs), hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was assessed with I statistics. Secondary outcomes included tumor regrowth, salvage surgery, and permanent stoma. Risk of bias was evaluated using ROBINS-I.ResultsSix studies comprising 793 patients were analyzed. WW showed no significant difference compared with TME regarding local recurrence (OR 1.36, 95% CI 0.07-26.17; I = 80%), distant metastases (OR 0.62, 95% CI 0.29-1.33; I = 49%), 5-year disease-free survival (HR 0.97, 95% CI 0.71-1.31; I = 51.7%), or overall survival (HR 1.03, 95% CI 0.81-1.30; I = 27.9%). Permanent stoma rates were lower with WW (OR 0.12, 95% CI 0.01-1.23; I = 71%), becoming significant after sensitivity analysis (OR 0.04, 95% CI 0.01-0.19).ConclusionWW after TNT offers oncologic outcomes comparable to TME, with high organ preservation and reduced surgical morbidity in highly selected patients.
Nighttime Transfer out of Surgical ICU Are Associated With Higher Readmission.
Perez C, Krishna V, Brahmbhatt T … +2 more , Alban RF, Brownlee AR
Am Surg · 2026 May · PMID 42175796 · Publisher ↗
INTRODUCTION: Surgical intensive care unit (SICU) beds are a limited resource. We hypothesized that nighttime transfers from the SICU are associated with higher rates of SICU readmission. METHODS: All patients who underw...
INTRODUCTION: Surgical intensive care unit (SICU) beds are a limited resource. We hypothesized that nighttime transfers from the SICU are associated with higher rates of SICU readmission. METHODS: All patients who underwent thoracic surgery between 2022 and 2024 were included. Patients were grouped based on time of transfer. Nighttime transfers occurred between 5:30 PM and 5:30 AM. Risk-adjusted multivariable logistic regression was used to assess the association between transfer timing and SICU readmission, complications, and mortality. RESULTS: A total of 216 patients were analyzed, including 169 Day Transfer patients and 47 Night Transfer patients. Baseline characteristics were similar between groups. The Day Transfer group experienced significantly longer transfer times compared with the Night Transfer group (564.1 minutes [IQR 474.3-653.9] vs. 324.1 minutes [IQR 203.4-444.7], p = 0.002). Complication rates were comparable between groups (12.8% Day vs. 14.9% Night, p = 0.71). However, Night Transfer patients had higher SICU readmission rates within 24 hours (10.6% vs. 1.2%, p = 0.001), within 7 days (19.2% vs. 5.2%, p = 0.002), and during the overall readmission rates (27.7% vs. 6.4%, p < 0.001). Nighttime transfer was independently associated with increased odds of SICU readmission at all measured time points. There were no significant differences in mortality or complication odds between groups. Conclusion Nighttime SICU transfers were associated with a significantly increased risk of readmission, indicating a potential opportunity to improve patient safety through optimized transfer timing and post-transfer care.
Early Postanesthesia Recovery Room Markers Associated With Delayed Respiratory Depression.
Deljou A, Ghafouri K, Sprung J … +2 more , Schroeder DR, Weingarten TN
Am Surg · 2026 May · PMID 42175723 · Publisher ↗
BackgroundPostoperative respiratory depression (PRD) is potentially preventable yet remains difficult to preemptively detect. We evaluated whether three post anesthesia care unit (PACU) events-oversedation, caffeine admi...
BackgroundPostoperative respiratory depression (PRD) is potentially preventable yet remains difficult to preemptively detect. We evaluated whether three post anesthesia care unit (PACU) events-oversedation, caffeine administration for impaired arousal, and naloxone administration-can serve as early markers of delayed PRD requiring naloxone administration on wards.MethodsWe retrospectively identified patients who underwent general anesthesia between 2018 and 2023 at a quaternary care academic medical center. From electronic medical records, we retrieved PACU naloxone and caffeine treatments, scores of sedation assessments using the Richmond Agitation-Sedation Scale (RASS), and ward naloxone administrations within 24 hours after PACU discharge.ResultsAmong 95 870 patients, 186 (0.19%, 95% CI 0.17-0.22) required naloxone for respiratory depression after PACU discharge. Ward naloxone administration was independently associated with naloxone (OR 9.11, 95% CI 4.69-17.71, < 0.001) and caffeine (OR 2.00, 95% CI 1.21-3.32, = 0.007) administrations, and with PACU RASS scores ≤ -3 (OR 2.16, 95% CI 1.56-2.99, < 0.001).ConclusionsNaloxone administration in PACU was the strongest predictor of delayed PRD, followed by oversedation and PACU caffeine administration, indicating that information routinely collected during PACU recovery may offer insight into delayed respiratory risk before transition to hospital wards. In light of the overall low incidence of ward naloxone use, these findings support selective, risk-based vigilance for patients exhibiting these PACU events rather than broad adjustments to existing monitoring practices.
Comorbidity Burden as a Determinant of Treatment Pathway After Percutaneous Cholecystostomy Tube Placement for Acute Cholecystitis: Experience From an Appalachian Tertiary Referral Center.
Johnson H, Donovan T, Smith G … +7 more , Byrd O, Powell J, Roche K, Collins H, King S, Devecki K, Burns JB
Am Surg · 2026 May · PMID 42175599 · Publisher ↗
Comorbidity burden in patients with acute cholecystitis (AC) managed by percutaneous cholecystostomy tube (PCT) placement may determine whether patients progress to cholecystectomy (CCY) or require ongoing non-operative...
Comorbidity burden in patients with acute cholecystitis (AC) managed by percutaneous cholecystostomy tube (PCT) placement may determine whether patients progress to cholecystectomy (CCY) or require ongoing non-operative management. This retrospective observational case series examined 139 patients admitted with PCT placement for AC at a rural Appalachian tertiary referral center between October 2020 and March 2025. The most prevalent comorbidities among these patients were hypertension (79.9%), smoking (61.2%), and hyperlipidemia (47.5%). Of the 139 patients, 31.7% (n = 44) underwent subsequent CCY and had 78.7% lower 6-month mortality compared to those managed non-operatively ( < .001). Patients progressing to CCY had significantly lower Charlson Comorbidity Index (CCI) scores (3.89 vs. 5.57, = .05) and were significantly less likely to have active cancer ( = .002), COPD ( = .001), or CHF ( = 0.032). In resource-constrained environments where advanced endoscopic alternatives are unavailable, these comorbidity profiles can guide preoperative risk stratification and inform individualized counseling regarding anticipated treatment pathways after PCT.
Association of Non-infectious Aortitis With Acute Outcomes of Open Thoracic Aortic Aneurysm Repair.
Tabibian K, Tabibian D, Yalzadeh D … +5 more , Chaturvedi A, Porter G, Badiee B, Aguayo E, Benharash P
Am Surg · 2026 May · PMID 42175556 · Publisher ↗
Non-infectious aortitis is encountered in a meaningful subset of patients undergoing open thoracic aortic aneurysm repair (TAAR) and may plausibly worsen perioperative risk through inflammatory tissue friability, impaire...
Non-infectious aortitis is encountered in a meaningful subset of patients undergoing open thoracic aortic aneurysm repair (TAAR) and may plausibly worsen perioperative risk through inflammatory tissue friability, impaired wound integrity, and systemic immune dysregulation. Prior perioperative evidence is largely derived from single-center series with limited sample sizes, leaving uncertainty regarding whether aortitis independently confers excess early mortality, morbidity, or resource utilization after open repair. All adults undergoing open TAAR were identified from the 2016-2022 Nationwide Readmissions Database and stratified by concomitant aortitis diagnosis. Following LASSO-guided variable selection, multivariable regression models were developed to examine the association between aortitis and outcomes of interest. Of an estimated 88,938 patients, 4,404 (5.0%) had non-infectious aortitis. Patients with aortitis were older (69 vs 63 years), more frequently female (36.3 vs 28.0%), and exhibited greater comorbidity burden and frailty prevalence (all < .001). Following multivariable adjustment, aortitis was independently associated with increased odds of in-hospital mortality (AOR: 1.45, 95% CI: 1.14-1.84), major adverse cardiac and cerebrovascular events (AOR: 1.40, 95% CI: 1.15-1.70), neurologic complications (AOR: 1.33, 95% CI: 1.05-1.70), and nonhome discharge (AOR: 1.38, 95% CI: 1.19-1.60). Aortitis was further linked with $6,790 in additional hospitalization costs (95% CI: $4,100-$9,470). Aortitis is independently associated with increased perioperative mortality, morbidity, and resource utilization following open TAAR. The elective nature of most repairs in this population provides an opportunity for regionalization to high-volume aortic centers with expertise in managing inflammatory aortic pathology. Future studies should explore preoperative optimization strategies for this vulnerable population.
Impact of Socioeconomic Status on Failure to Rescue Following Elective Cardiac Surgery.
Tabibian K, Balian J, Chaturvedi A … +6 more , Yalzadeh D, Tabibian D, Badiee B, Aguayo E, Sanaiha Y, Benharash P
Am Surg · 2026 May · PMID 42171470 · Publisher ↗
BackgroundFailure to rescue (FTR), defined as mortality following a major postoperative complication, has emerged as a key quality metric in cardiac surgery. While socioeconomic disparities in surgical outcomes are well-...
BackgroundFailure to rescue (FTR), defined as mortality following a major postoperative complication, has emerged as a key quality metric in cardiac surgery. While socioeconomic disparities in surgical outcomes are well-documented, the relationship between socioeconomic status (SES) and FTR remains insufficiently characterized, particularly regarding which SES components most strongly drive this risk.MethodsAll adults experiencing a Society of Thoracic Surgeons-defined major complication following cardiac surgery were identified from the 2016-2022 Nationwide Readmissions Database. Patients were stratified into low-, middle-, and high-SES groups using a composite metric integrating payer status, neighborhood income quartile, and ICD-10-coded social determinants. Multivariable regression models were developed to examine the association between SES and FTR.ResultsOf an estimated 67,982 patients with major complications, 10,793 (15.9%) experienced FTR. FTR rates increased from 16.0% in 2016 to 18.4% in 2022 (nptrend<0.05), while complication incidence correspondingly declined. Following multivariable adjustment, low- and middle-SES were independently associated with increased odds of FTR compared to high-SES (AOR 1.33, 95% CI 1.19-1.48; AOR 1.18, 95% CI 1.07-1.30, respectively). Upon stratification by individual SES factors, the lowest income quartile consistently demonstrated increased FTR risk, whereas Medicaid status was not significantly associated with FTR.DiscussionSocioeconomic status was independently associated with FTR in a dose-dependent manner. The stronger association with neighborhood income rather than insurance status suggests FTR disparities represent a geographically localized phenomenon. Targeted interventions focusing on communities where low-income patients are concentrated may yield greater impact than population-wide strategies.
Frailty, Comorbid Burden, and Physiologic Factors Associated With Intensive Care Unit-Level Respiratory Complications in Older Adults With Rib Fractures: A Retrospective Trauma Quality Improvement Program Study.
Prado LM, Vasak R
Am Surg · 2026 May · PMID 42170822 · Publisher ↗
BackgroundTraditional intensive care unit (ICU) triage criteria for older trauma patients with rib fractures emphasize age and rib fracture count but do not account for physiologic vulnerability, pre-injury frailty, and...
BackgroundTraditional intensive care unit (ICU) triage criteria for older trauma patients with rib fractures emphasize age and rib fracture count but do not account for physiologic vulnerability, pre-injury frailty, and comorbid burden. We aimed to develop a risk score incorporating these variables to identify ICU-level respiratory complications in older adults with rib fractures.MethodsWe conducted a retrospective cohort study using the 2022 American College of Surgeons Trauma Quality Improvement Program (TQIP) dataset. Patients aged 65-89 years with blunt trauma and ICD-10-identified rib fractures were included after exclusion of patients with major physiologic instability or confounding injuries. The primary outcome was a composite of unplanned ICU admission, unplanned intubation, acute respiratory distress syndrome, or mechanical ventilation. Multivariable logistic regression was used to derive a risk score based on frailty, comorbid conditions, and physiologic variables, with discrimination assessed using the area under the receiver operating characteristic curve.ResultsThe final analytic cohort included 35 341 patients, among whom ICU-level respiratory complications occurred in 1523 (4.3%). A rib fracture-only model demonstrated poor discrimination (AUROC 0.51), while a model based on frailty, comorbid conditions and physiologic variables showed improved discriminatory performance (AUROC 0.66). Complication rates increased stepwise across FRAIL-ICU score categories, from 2.3% in low-risk patients to 9.5% in high-risk patients.DiscussionThe FRAIL-ICU score outperforms rib fracture count alone in predicting ICU-level respiratory complications and provides meaningful risk stratification that may assist in risk stratification to inform ICU triage decisions beyond traditional age- and injury-based criteria.
Access to Surgery and Outcomes for Papillary Thyroid Cancer Following the 2015 American Thyroid Association Guideline Changes.
Cogua LM, Tupper CJ, Silberstein PT … +2 more , Coan KE, Jategaonkar AA
Am Surg · 2026 May · PMID 42169488 · Publisher ↗
BackgroundThe extent of surgical treatment for intermediate-sized (1.0-4.0 cm) papillary thyroid cancer (PTC) has been widely debated. This study evaluates the impact of the 2015 ATA guidelines on the surgical treatment...
BackgroundThe extent of surgical treatment for intermediate-sized (1.0-4.0 cm) papillary thyroid cancer (PTC) has been widely debated. This study evaluates the impact of the 2015 ATA guidelines on the surgical treatment trends of intermediate-sized PTC tumors.MethodsUsing the Surveillance, Epidemiology, and End Results (SEER) database, patients with intermediate-sized PTC tumors were separated into pre-ATA guideline changes (2000-2015) or post-ATA changes (2016-2020) groupings. Lobectomy or total thyroidectomy usage was compared with logistic regression analyses.ResultsThe rate of lobectomy increased from a mean usage rate of 10.0% pre-ATA updates to 18.6% post-guideline changes ( < 0.001). Logistic regression showed the rate of thyroidectomy decreased post-ATA changes ( < 0.001, odds ratio (OR) = 0.607). Additionally, total thyroidectomy was associated with improved survival ( < 0001, HR = 0.624) and); tumors sized 2.1 cm-3.0 cm ( < 0001, HR = 1.824) and 3.1 cm-4.0 cm ( < 0001, HR = 2.927) were associated with worse survival.ConclusionsAfter the 2015 ATA guideline changes there has been a significant increase in the rate of lobectomy for intermediate-sized PTC tumors occurred after the 2015 ATA guideline changes, reflecting the guidelines supporting less aggressive surgical management in low-risk cases.
Perioperative Outcomes of Emergency Cholecystectomy for Grade II-III Acute Cholecystitis in Elderly and Comorbid Patients at a Tertiary Center.
Harada K, Fujikawa T, Uemoto Y … +2 more , Nagata K, Yamana I
Am Surg · 2026 May · PMID 42165405 · Publisher ↗
PurposeThis study aimed to describe perioperative outcomes associated with emergency cholecystectomy (EC) in elderly/high-risk patients based on Tokyo Guidelines 2018 (TG18).MethodsA single-center retrospective surgical...
PurposeThis study aimed to describe perioperative outcomes associated with emergency cholecystectomy (EC) in elderly/high-risk patients based on Tokyo Guidelines 2018 (TG18).MethodsA single-center retrospective surgical database included 2189 patients who underwent cholecystectomy between 2005 and 2025, and the study population included 550 patients who underwent EC for AC, excluding patients with elective cholecystectomy. The patients were divided into Grade I and II-III groups by AC severity. The patient characteristics and perioperative outcomes were compared between groups, and risk factors of severe postoperative complications were assessed using logistic multivariate analysis. Multiple linear regression analysis was performed to identify factors independently associated with the length of postoperative hospital stay.ResultsThe patients with Grade I (n = 355) and those with Grade II-III (n = 195) were included. As a subgroup analysis, the Grade II-III group was divided into 2 groups: surgically low-risk patients (Low-risk, n = 82) and high-risk patients (High-risk, n = 113). The overall complication rate was approximately 15%. The rate of severe postoperative complications was 5.3%, and the 30-day mortality was zero in the entire cohort. The Grade II-III group had significantly more severe postoperative complications than the Grade I group (8.2% vs 3.7%, = 0.028). There were no statistically significant differences in perioperative outcomes between the low-risk and high-risk groups, except for hospital stay. Multivariate analysis showed that LC (odds ratio = 0.414, = 0.037) was associated with lower rates of severe postoperative complications.ConclusionsEC may be a feasible option in selected elderly or comorbid patients with Grade II-III AC, with acceptable short-term outcomes.
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