The American Surgeon[JOURNAL]
Sun
200 papers
Managing Bariatric Surgical Emergencies: Evidence-Based Approaches for General Surgical Practice.
Tan DK, Jawed AE, Merchant AM
Am Surg · 2026 May · PMID 42160232 · Publisher ↗
With the rising prevalence of obesity and the increasing utilization of bariatric surgery, general surgeons are increasingly encountering patients presenting with acute postoperative complications. While bariatric proced...
With the rising prevalence of obesity and the increasing utilization of bariatric surgery, general surgeons are increasingly encountering patients presenting with acute postoperative complications. While bariatric procedures are generally safe and effective, they carry a unique profile of surgical and metabolic emergencies due to altered anatomy, nutritional vulnerability, and technical complexity. Given that many patients present to non-bariatric centers, it is essential for general surgeons to be equipped to recognize and manage these emergencies. This narrative review aims to provide a comprehensive, procedure-specific guide for general surgeons on the diagnosis and management of bariatric surgical emergencies. It emphasizes timely recognition, key diagnostic principles, and tailored operative and nonoperative strategies, while also highlighting system-level challenges and disparities affecting outcomes. We reviewed the clinical presentation, pathophysiology, and evidence-based management of major categories of bariatric emergencies, including anastomotic leaks, internal hernias, bowel obstruction, bleeding, marginal ulcers, band-related complications, thrombotic events, and nutritional crises. We also examined the distinct challenges posed by revisional surgery. Consideration was given to disparities in access to care, delayed diagnosis, and the role of structured referral systems and enhanced recovery pathways. General surgeons play a critical frontline role in the management of bariatric emergencies. Familiarity with altered anatomy, procedure-specific risks, and atypical presentations is essential. Early imaging, prompt intervention, and multidisciplinary collaboration can significantly improve outcomes. In parallel, addressing systemic barriers and improving access to specialized care are necessary to ensure equitable and high-quality care for the growing population of bariatric surgery patients.
Age-Related Mortality in Trauma Patients Requiring Massive Transfusion.
Gonzalez S, Maneval A, Brahmbhatt T … +3 more , Margulies DR, Barmparas G, Hashim Y
Am Surg · 2026 May · PMID 42141834 · Publisher ↗
BackgroundMassive transfusion (MT) protocols improve survival in trauma patients. Elderly trauma patients requiring MT represent a high-risk population, yet outcome data remain limited. Understanding age-related differen...
BackgroundMassive transfusion (MT) protocols improve survival in trauma patients. Elderly trauma patients requiring MT represent a high-risk population, yet outcome data remain limited. Understanding age-related differences is critical to guide resuscitation and resource allocation.ObjectiveTo characterize the association between MT and mortality in elderly vs younger trauma patients.ParticipantsTrauma patients at a Level I trauma center (1/2013-09/2024) who required MT (≥10 units of whole blood (WB) and/or packed red blood cells (pRBC) within 24 h) were included. Patients ≥65 (elderly) were compared to <65 (non-elderly). The primary outcome was 30-day mortality. Secondary outcomes included ICU and hospital length of stay (LOS), and ventilator days.ResultsOf 368 patients meeting inclusion criteria, 30 (8%) were elderly. Elderly patients were equally likely to be male (70% vs 83%, = 0.06), but were significantly less likely to present with GCS ≤8 (20% vs 45%, < 0.01) despite a significantly higher incidence of severe head trauma (AIS head >3 [53% vs 32%, = 0.02]). There was no difference in median blood products transfused within the first 24 hours (23 vs 22 units, = 0.95). Overall mortality was 51%, higher in elderly patients (73% vs 49%, < 0.01), with shorter time to death (median 14 vs 34 days, < 0.01). Adjusted Cox regression confirmed significantly higher adjusted mortality in the elderly (HR 1.25, = 0.04).ConclusionElderly trauma patients requiring MT experience earlier and significantly higher mortality than younger patients, highlighting the need for improved risk stratification and tailored resuscitation strategies.
Disaggregating AANHPI Patients With NSCLC Reveals Survival Disparities in Stage, Treatment Delays, and Mortality.
Saleh Z, Lou J, Syed H … +5 more , Ghanem Y, Kooragayala K, Dibato JE, Hong YK, Shersher D
Am Surg · 2026 May · PMID 42139449 · Publisher ↗
BackgroundAsian American Native Hawaiian Pacific Islander (AANHPI) patients are generally studied together despite diverse social, cultural, and economic backgrounds. We investigated survival disparities in disaggregated...
BackgroundAsian American Native Hawaiian Pacific Islander (AANHPI) patients are generally studied together despite diverse social, cultural, and economic backgrounds. We investigated survival disparities in disaggregated AANHPI lung cancer patients.MethodsThis retrospective cohort study identified 1,093,916 White, African American, and AANHPI non-small cell lung cancer (NSCLC) patients from the National Cancer Database (2010-2019). AANHPI subgroups included Chinese, Japanese, Filipino, Korean, Vietnamese, Indian, and "other." Multivariate analyses assessed disparities in stage at presentation, time to surgery, and survival.ResultsAggregate data demonstrated AANHPI patients have superior survival than Whites and African Americans (median survival 31.8 vs 19.2 vs 16.2 months, respectively). Disaggregation revealed disparities: Chinese patients have the best outcomes (46.2 months) while Japanese patients have the worst (17.7 months) with a 68% higher mortality risk than Whites (HR 1.68). Filipino patients demonstrated a 27% increased likelihood of stage IV presentation (HR 1.27), a 50% higher surgical delay risk (HR 1.50), and a 33% increased mortality risk (HR 1.33). Vietnamese patients have similar stage IV presentation and surgical delay risks, reducing survival. Of the AANHPI subgroups, Chinese patients had the best survival.DiscussionWhile AANHPI patients generally demonstrate better survival than Whites and African Americans, heterogeneity exists within AANHPI subgroups. Chinese patients experienced the best outcomes, while Japanese, Filipino, and Vietnamese patients faced poor survival due to increased risk of late diagnosis and surgical delay. This underscores the importance of disaggregating AANHPI populations in cancer outcomes research and the need for culturally tailored strategies to improve screening, timely treatment, and survival.
Accessibility of and Engagement With Videos of Colorectal Cancer Surgery Patients' Treatment Experiences: A Multi-Platform Analysis Comparing Videos Produced by Patients and Medical Institutions.
Jernigan A, Hinkle N, Monroe J … +2 more , Shibata D, Solsky I
Am Surg · 2026 May · PMID 42119033 · Publisher ↗
IntroductionVideos of colorectal cancer surgery patients sharing their treatment experiences have been produced by both patients and the medical community, underscoring their perceived value. Since patients and medical i...
IntroductionVideos of colorectal cancer surgery patients sharing their treatment experiences have been produced by both patients and the medical community, underscoring their perceived value. Since patients and medical institutions likely have different motivations for creating these videos, it is important to study the characteristics of these videos to assess what value they have to efforts to better understand and enhance the patient experience.MethodsA formal search strategy was employed to identify videos on YouTube and TikTok wherein colorectal cancer surgery patients shared their experiences. Statistical analyses, including Fisher's Exact Test and the Mann-Whitney U test, were performed to compare the characteristics of videos produced by patients (P-videos) and the medical community (M-videos).Results491 videos were reviewed. Of these, 52.1% were classified as patient experience videos and 89.8% were created postoperatively. P-videos (n = 135) vs M-videos (n = 108) were more prevalent on TikTok (85.2% vs 18.5%) than YouTube (14.8% vs 81.5%). P-videos compared to M-videos also had more comments (median 92 (IQR 30-301) vs 12 (2-81.85), < 0.001)), and were more often created during active cancer therapy (eg, adjuvant chemotherapy) (66.7% vs 14.8%, < 0.001). These differences between groups remained statistically significant when stratifying by TikTok/YouTube.ConclusionThe accessibility of P-videos and M-videos differs by social media platform, which has implications for the type of content viewed by patients with different online habits. P-videos more often featured patients undergoing active treatment and garnered higher engagement, possibly suggesting that the public is drawn more to unfiltered patient narratives than the messaging of medical institutions.
Risk Factors for the Progression of Pyogenic Liver Abscess to Sepsis and Development of a Predictive Model.
Cheng X, Wang J, Zhang H … +4 more , Liang J, Cong J, Wang B, Zeng X
Am Surg · 2026 May · PMID 42114024 · Publisher ↗
AimsThis study aimed to examine risk factors associated with the progression of pyogenic liver abscess (PLA) to sepsis and to evaluate their predictive value.MethodsA retrospective analysis was conducted on patients diag...
AimsThis study aimed to examine risk factors associated with the progression of pyogenic liver abscess (PLA) to sepsis and to evaluate their predictive value.MethodsA retrospective analysis was conducted on patients diagnosed with PLA at a single institution between January 2019 and December 2024. Demographic data and laboratory parameters were collected. Based on the occurrence of sepsis, patients were categorized into a sepsis group (n = 73) and a non-sepsis group (n = 103). Multivariate logistic regression analysis was used to determine independent risk factors for progression to sepsis. Receiver operating characteristic (ROC) curve analysis was conducted to assess the predictive performance of the identified factors.ResultsMultivariate logistic regression identified uric acid (UA), total bilirubin (TBIL), and platelet count (PLT) as independent risk factors for the progression of PLA to sepsis. ROC analysis yielded the following results: (1) Sensitivity: UA 0.589, TBIL 0.753, PLT 0.726; (2) Specificity: UA 0.806, TBIL 0.913, PLT 0.704; (3) Threshold: UA 306.5 μmol/L, TBIL 26.75 μmol/L, PLT 155 × 10/L.ConclusionMultivariate analysis identified elevated UA (per 1 μmol/L increase: OR 1.006, 95% CI 1.000-1.012) and TBIL (per 1 μmol/L increase: OR 1.301, 95% CI 1.183-1.478), and decreased PLT (per 1 ×10/L decrease: OR 0.982, 95% CI 0.972-0.989) as independent risk factors for sepsis progression. Threshold values of UA ≥306.5 μmol/L, TBIL ≥26.75 μmol/L, and PLT ≤155 × 10/L may serve as clinical indicators for identifying patients at high risk of progression to sepsis.
Can Duodenal Derotation With Duodenoduodenostomy Be Performed Safely Robotically, and Is It the Optimal Surgical Intervention for SMAS?
Lozano GV, Chen SC, Shouhed D
Am Surg · 2026 May · PMID 42112896 · Publisher ↗
BackgroundSuperior mesenteric artery syndrome (SMAS) is a rare disorder with 33% mortality. The Cleveland Clinic reported one of the largest series including 18 patients treated with duodenojejunostomy (DDJ), with 33% sh...
BackgroundSuperior mesenteric artery syndrome (SMAS) is a rare disorder with 33% mortality. The Cleveland Clinic reported one of the largest series including 18 patients treated with duodenojejunostomy (DDJ), with 33% showing improvement at 3 years. Alvear et al reported 94.7% improvement in 19 patients treated with duodenal derotation, though 7 later required duodenoduodenostomy (DDD). Ang et al reported 12 patients treated with duodenal derotation with DDD, and 84% experienced improvement and increased BMI at 3 years. While duodenal derotation with DDD shows promising results, case series are limited and surgical treatment with a robotic approach has not been described.MethodsThirty three patients who underwent duodenal derotation with DDD for SMAS by a single surgeon between June 2023 and July 2025 were retrospectively identified. Preoperative, intraoperative, and postoperative data were collected.ResultsMean operative time was 346.9 min. Average length of stay was 8.7 days. Nineteen patients underwent concurrent surgery for Median Arcuate Ligament Syndrome (MALS). There was one conversion to open surgery. There were no intraoperative complications and no mortalities. There were 6 postoperative complications. Follow-up ranged from 3.9 weeks to 2 years. One patient was lost to follow-up. Of the remaining patients, 90.6% experienced significant pain relief, 81.3% no longer required supplemental nutrition, and 84.4% experienced significant weight regain.DiscussionDespite the increased risk for postoperative complications due to severe malnutrition and deconditioning in this patient population, duodenal derotation can be performed safely robotically and offers improved results in carefully selected patients when compared to DDJ.
Off-Road Vehicle Trauma in Southern California: Association With the Social Vulnerability Index.
Kenney R, Magner K, Yau K … +10 more , Kim H, Ayoade P, Wah SL, McRae J, Javid A, Soltani T, Rosenthal M, Ji L, Wiafe S, Tabrizi MB
Am Surg · 2026 May · PMID 42104863 · Publisher ↗
BackgroundOff-road vehicles' (ORVs) inherently unstable design lends to higher injury rates compared to motorcycles. California has ranked among the top five states for ORV-related injuries and deaths for the past decade...
BackgroundOff-road vehicles' (ORVs) inherently unstable design lends to higher injury rates compared to motorcycles. California has ranked among the top five states for ORV-related injuries and deaths for the past decade. Because ORVs are frequently used in rural areas with greater social vulnerability, concerns exist that injuries disproportionately affect disadvantaged populations. This study evaluates whether ORV injury rates and severity are associated with the Centers for Disease Control and Prevention's Social Vulnerability Index (SVI) in Southern California.MethodsWe performed a retrospective cohort study of 574 adult ORV trauma patients treated at a single level 1 trauma center between 2019 and 2024. Home ZIP codes determined patient classification into Low (0-0.249), Low-Medium (0.25-0.49), Medium-High (0.5-0.749), and High (0.75-1) SVI groups. The Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Abbreviated Injury Scale (AIS) assessed injury severity.ResultsThe cohort was predominantly male (88%) with a median age of 32 years (IQR 21.25). 388 (67%) patients reported helmet use. Extremity injuries were the most common (upper: 66% and lower: 52%), followed by thoracic injuries (42.3%). Most patients resided in High SVI ZIP codes (54.3%), with 25.5% in Medium-High, 15.1% in Low-Medium, and 5.1% in Low SVI areas ( < .001). Injury severity did not differ across SVI categories based on ISS, GCS, or AIS.ConclusionOff-road vehicle-related injuries disproportionately affect highly vulnerable communities, despite similar injury severity across all SVI categories in Southern California. This highlights the need for targeted injury-prevention programs and provides a foundation for future investigations into SVI and ORV-related morbidity.
Core Needle Biopsy and Preoperative Risk Factors as Predictors of Upstaging Atypical Ductal Hyperplasia on Surgical Excision.
Rahim R, Yuen S, Esmail M … +7 more , Jackson J, Boyle M, Chung A, Dang C, Karlan S, Giuliano A, Amersi F
Am Surg · 2026 May · PMID 42101436 · Publisher ↗
BackgroundPatients with atypical ductal hyperplasia (ADH) diagnosed on core needle biopsy (CNB) are recommended for surgical excision. However, the rate of upstaging to malignancy on final pathology varies widely. This s...
BackgroundPatients with atypical ductal hyperplasia (ADH) diagnosed on core needle biopsy (CNB) are recommended for surgical excision. However, the rate of upstaging to malignancy on final pathology varies widely. This study sought to determine the rate of upstaging for ADH diagnosed on CNB and to evaluate risk factors associated with upstaging.MethodsPatients diagnosed with ADH by CNB from 1/2014 to 9/2024 were identified from a prospectively maintained database. Pathology, imaging, demographics, family history of breast cancer, genetic testing, and risk of future malignancy were collected. Univariate and multivariable analysis were performed to evaluate predictors of upstaging.Results456 patients with ADH on CNB met inclusion criteria. Median age was 53 years (range 19-89 years). Overall, 110 (24.1%) patients were upstaged on surgical excision. The highest risk of upstaging was observed in patients with multifocal ADH (71.4%). Upstaged patients were older ( < .001), more likely to have a mammographic mass or architectural distortion ( = .03), abnormal MRI ( = .001), ADH bordering on DCIS or multifocal ADH on biopsy ( < .001). Multivariable analysis identified abnormal MRI as an independent predictor of higher risk ( = .046) and focal ADH as a predictor of lower upstage risk ( = .03). At a median follow-up of 52.5 months, 21 (4.6%) patients developed subsequent DCIS, and 20 (4.4%) patients developed subsequent invasive cancer.ConclusionADH on CNB was upstaged on surgical excision in 24.1% of patients. Multifocal ADH and abnormal MRI findings strongly predict upstaging to malignancy. The 9.6% rate of subsequent malignancy necessitates long-term surveillance for all patients with ADH.
Contrast Induced Nephropathy in Trauma: A Real Phenomenon?
Lewis RH, McIntosh B, Talebinejad S … +2 more , Shaw B, Davis GR
Am Surg · 2026 May · PMID 42101284 · Publisher ↗
BackgroundThe goal of this study was to evaluate the impact of contrast administration on the subsequent development of acute kidney injury (AKI) in trauma patients.MethodsTrauma patients at a level one trauma center wer...
BackgroundThe goal of this study was to evaluate the impact of contrast administration on the subsequent development of acute kidney injury (AKI) in trauma patients.MethodsTrauma patients at a level one trauma center were identified and stratified by administration of contrast during their initial diagnostic evaluation. Outcomes including mortality, AKI, and need for renal replacement therapy were collected and compared. Multivariable logistic regression analysis was performed to determine the impact of contrast administration on the development of AKI in trauma patients.Results839 patients were identified: 551 who received contrast and 288 who did not. Only 58 (6.9%) developed AKI and 3 (0.3%) required new renal replacement therapy (RRT). Those exposed to contrast had a higher injury severity score (10 vs 9, < .001), admission serum creatinine (1.02 vs 0.91, < .001), initial vasopressor requirements (3.8% vs 0.3%, = .003), and 24-hour packed red blood cell transfusions (PRBC) (4 vs 2 units, < .001). Despite this, those exposed to intravenous contrast had lower rates of acute kidney injury (9.4% vs 5.6%, = .042) and no difference in the need for new RRT (0.5% vs 0%, = .2). Multivariable logistic regression identified age, 24-hour PRBC transfusions, admission SBP, and admission serum creatinine as the only independent predictors of acute kidney injury.DiscussionIn the diagnostic evaluation of trauma patients, the administration of intravenous contrast was not associated with the subsequent development of acute kidney injury.
National Changes in Timing and Rates of Surgical Stabilization of Rib Fractures (SSRF): SSRF Occurring Early and More Often.
de Virgilio MJ, Grigorian A, Nguyen PD … +6 more , Schubl S, Jebbia M, Kirkorowicz J, Salamah H, Kuza C, Nahmias J
Am Surg · 2026 May · PMID 42101005 · Publisher ↗
Surgical stabilization of rib fractures (SSRF) has garnered increased attention recently for treatment of blunt chest trauma (BCT). This study evaluated temporal trends in rates and timing of SSRF in isolated BCT patient...
Surgical stabilization of rib fractures (SSRF) has garnered increased attention recently for treatment of blunt chest trauma (BCT). This study evaluated temporal trends in rates and timing of SSRF in isolated BCT patients, hypothesizing increased rates of early SSRF and SSRF overall. The 2017-2023 Trauma Quality Improvement Program (TQIP) database was queried for patients with ≥2 rib fractures and abbreviated injury scale <2 in non-chest regions to delineate an isolated BCT cohort. Patients were stratified by timing of SSRF from arrival: early (≤72 h), intermediate (>72-≤ 120 h), and late (>120 h). The primary outcome was annual rate of SSRF. Of 371,193 isolated BCT patients, 17 966 (4.8%) underwent SSRF from 2017 to 2023. The median age of patients undergoing SSRF increased from 58 years in 2017 to 61 years in 2023 ( < 0.001). There was an increased rate of SSRF performed from 2017 to 2023 (n = 1,594, 3.5% vs n = 3,435, 5.5%, < 0.001). When stratified by timing, early (1.8% [2017]; 3.4% [2023], < 0.001) and intermediate SSRF (0.9% [2017]; 1.3% [2023], < 0.001) increased over time, whereas late SSRF remained similar across 2017 to 2023 (late: 0.8%; 0.8%, = 0.25). For all SSRF patients, median overall length of stay (LOS) decreased over time (12 [IQR: 8-17] days [2017]; 11 [IQR: 8-16] days [2023]; < 0.001). This study demonstrates a nearly 60% relative national increase in SSRF from 2017 to 2023, with a progressively older patient cohort and shorter LOS. This was predominantly attributable to increased early (≤72 h) and intermediate (>72-≤120 h) SSRF cases, aligning with existing guidelines.
Clinical Impact of Preoperative Sarcopenia on the Outcome of Patients With Right-Sided Colon Cancer.
Erginöz E, Güldağ MA, Nakashidze M … +9 more , Sak K, Ergün S, Uludağ SS, Demiryas S, Zengin K, Batur Ş, Kepil N, Tutar O, Dulundu E
Am Surg · 2026 May · PMID 42095424 · Publisher ↗
IntroductionSarcopenia is recognized as a predictor of adverse outcomes in colorectal cancer, but evidence regarding its impact specifically in right-sided colon cancer remains limited. This study aimed to evaluate the p...
IntroductionSarcopenia is recognized as a predictor of adverse outcomes in colorectal cancer, but evidence regarding its impact specifically in right-sided colon cancer remains limited. This study aimed to evaluate the prognostic significance of sarcopenia in patients undergoing colectomy for right-sided colon cancer.MethodsWe retrospectively analyzed 228 patients with right-sided colon adenocarcinoma who underwent curative-intent colectomy between 2016 and 2021 in a single institution. Sarcopenia was diagnosed using the psoas muscle index (PMI) on preoperative CT scans. Clinicopathologic variables, postoperative complications, overall survival (OS), and disease-free survival (DFS) were compared between sarcopenic and non-sarcopenic groups.ResultsAmong sarcopenic patients (34.2%), postoperative complications occurred in 46.2% compared with 23.3% of non-sarcopenic patients ( < .001). Sarcopenia was significantly associated with intra-abdominal infection ( = 0.040), pulmonary infection ( = .011), cardiac complications ( = .013), urinary tract infection ( = .013), and postoperative hypoalbuminemia ( < .022). Logistic regression identified postoperative hypoalbuminemia ( = .026) and prolonged hospital stay ( = .002) as independent predictors of complications. The 5-year OS was 19.7% in sarcopenic patients vs 43.0% in non-sarcopenic patients ( = .597), and 5-year DFS was 43.1% vs 51.7% ( = .154). Multivariate Cox analysis identified age ≥65 years ( = .015), male sex ( = .007), stage IV disease ( = .016), and elevated CEA ( = .021) as independent predictors of OS, and age ≥65 years ( = .046) and stage IV disease ( = .001) as independent predictors of DFS, while sarcopenia was not an independent predictor of either outcome.ConclusionSarcopenia was strongly associated with postoperative complications but not with OS or DFS. These findings suggest sarcopenia reflects perioperative risk rather than long-term prognosis in this subgroup.
Traumatic Intrapericardial Diaphragmatic Hernia: Diagnostic Challenges and the Role of Multimodal Evaluation.
Bandi M, Schuetz CR, Cordova AC … +3 more , Diaz JJ, Kuo PC, Sujka J
Am Surg · 2026 May · PMID 42095294 · Publisher ↗
Intrapericardial diaphragmatic hernia (IPDH) is a rare condition that commonly occurs after trauma, in which abdominal contents herniate through the central tendon of the diaphragm into the pericardial sac. Diagnosis is...
Intrapericardial diaphragmatic hernia (IPDH) is a rare condition that commonly occurs after trauma, in which abdominal contents herniate through the central tendon of the diaphragm into the pericardial sac. Diagnosis is frequently delayed due to nonspecific cardiopulmonary symptoms and subtle imaging findings. We performed a narrative review of cases of traumatic IPDH to identify diagnostic challenges and operative strategies and present a case of a 71-year-old woman who developed IPDH following a motor vehicle collision. Initial imaging demonstrated rib, liver, and pelvic fractures without evidence of diaphragmatic injury. After orthopedic surgery, the patient developed chest pain and dyspnea, prompting repeat imaging suggesting IPDH. Robotic-assisted repair revealed a 9-cm anterior diaphragmatic defect containing stomach and omentum, which was repaired with mesh. Postoperatively, the patient developed pericarditis confirmed by cardiac evaluation. This review highlights the diagnostic challenges of IPDH, limitations of imaging, and the importance of multimodal evaluation and timely surgical intervention.
Neurologic Presentations of Pediatric Intussusception Lead to Diagnostic Delay and Increased Need for Surgery.
Seçilmiş Y, Gümüştekin Bilgin S, Doğan AB
Am Surg · 2026 May · PMID 42092742 · Publisher ↗
BackgroundNeurological presentations of pediatric intussusception lead to delayed diagnosis, higher rates of surgical intervention, and worse outcomes compared with classic presentations. These atypical manifestations, i...
BackgroundNeurological presentations of pediatric intussusception lead to delayed diagnosis, higher rates of surgical intervention, and worse outcomes compared with classic presentations. These atypical manifestations, including lethargy, altered mental status, and rarely movement disorders, may predominate and redirect evaluation toward primary neurological etiologies, delaying recognition of this reversible surgical emergency.Case PresentationA previously healthy 2-year-old boy presented with clustered orofacial dyskinesias and irregular upper-extremity jerks without exposure to dopamine-receptor antagonists. He was initially misdiagnosed with tardive dyskinesia and treated with biperiden without improvement. Neurologic examination and brain magnetic resonance imaging were normal. During observation, he developed bilious vomiting. Abdominal imaging revealed ileocolic intussusception. Pneumatic reduction was unsuccessful, and surgical exploration demonstrated an invaginated Meckel diverticulum with ischemic bowel requiring resection. Abnormal movements resolved completely following surgery.MethodsWe conducted a systematic case-based review of published pediatric cases of intussusception presenting with neurological manifestations.ResultsNeurological symptoms-most commonly lethargy and altered mental status-frequently dominated the initial presentation and contributed to significant diagnostic delay (median 12 hours vs 5 hours in classic presentations, < 0.001). Critically, patients with neurological presentations required surgical intervention in 60% of cases compared with 18% of classic presentations ( < 0.001), with approximately one-quarter of surgical patients requiring bowel resection, reflecting more advanced disease at diagnosis.ConclusionIntussusception should be considered in infants and young children with unexplained acute neurological symptoms, particularly when initial neurologic evaluation is unrevealing. Early abdominal imaging may prevent diagnostic delay in this reversible surgical emergency.
Examining the Utility of Point-of-Care Capillary Hemoglobin Testing and Transfusion Decisions in the Trauma Bay.
Wee EC, Cooper CK, Nahmias J … +1 more , Barrios C
Am Surg · 2026 May · PMID 42090604 · Publisher ↗
BackgroundThis study evaluated a point-of-care capillary hemoglobin assay compared to physiologic indicators, such as systolic blood pressure (SBP), heart rate (HR), and Focused Assessment with Sonography in Trauma (FAST...
BackgroundThis study evaluated a point-of-care capillary hemoglobin assay compared to physiologic indicators, such as systolic blood pressure (SBP), heart rate (HR), and Focused Assessment with Sonography in Trauma (FAST) imaging, in predicting transfusion outcomes for trauma patients.MethodsThis retrospective cohort study evaluated adult trauma patients presenting to a single Level I trauma center with an initial point-of-care capillary hemoglobin (POC-Hb; HemoCue®) obtained in the trauma bay. Patients were stratified by receipt of blood transfusion within 24 hours of arrival. Prehospital and emergency department vital signs, FAST results, transfusion timing, and volume were analyzed. Multivariable logistic regression identified variables independently associated with transfusion. Nonparametric tests (Mann-Whitney U, Kruskal-Wallis with post-hoc testing) and Spearman's rank correlation assessed associations between POC-Hb values and transfusion timing and volume.ResultsOf 1552 included patients, 552 received blood transfusions and had significantly lower POC-Hb values compared to non-transfused patients (11.5 vs 13.5 g/dL; < 0.001). POC-Hb was not associated with transfusion on multivariable analysis, and showed no correlation with time to transfusion. Positive FAST results (OR 19.4, 95% CI 8.1-46.2, < 0.001) and SBP on arrival (OR 48.5, 95% CI 15.0-156.7, < 0.001) were associated with transfusion.ConclusionLower initial POC-Hb was associated with transfusion and weakly correlated with blood product volume on unadjusted analyses, but was not independently associated with transfusion or with time to transfusion after adjustment. SBP and FAST demonstrated stronger associations with transfusion outcomes and intensity. These findings support prioritizing physiologic indicators and FAST results over point-of-care hemoglobin when assessing transfusion need in trauma patients.
A Hidden Hurdle: The Plastic Surgery Bottleneck in Breast Cancer Care.
Orosco E, Jensen B, Giglio RS … +2 more , Anderson S, Haji F
Am Surg · 2026 May · PMID 42089447 · Publisher ↗
Timely surgical intervention is critical in breast cancer, with consensus supporting surgery within eight weeks of diagnosis to optimize survival. Immediate breast reconstruction (IBR) has been associated with delays rel...
Timely surgical intervention is critical in breast cancer, with consensus supporting surgery within eight weeks of diagnosis to optimize survival. Immediate breast reconstruction (IBR) has been associated with delays related to insurance status, socioeconomic factors, race, and reconstructive intent. While barriers to accessing IBR have been studied, few investigations have quantified their impact on surgical timing and outcomes. A literature review was conducted using PubMed to identify studies published between 2015 and 2025 that examined time to definitive breast cancer surgery in relation to reconstructive intent, access to IBR, or barriers to reconstruction. Eligible studies included randomized controlled trials, cohort studies, and meta-analyses involving human participants and published in English. Data extracted included study design, patient population, and reported outcomes. Twelve studies met inclusion criteria representing over 1.69 million patients. Across studies, IBR was associated with increased time to definitive surgery compared with mastectomy alone, with reported delays ranging from several days to a few weeks. These delays were statistically significant but generally clinically modest. Patient-, institutional-, and system-level barriers to IBR were identified, including reconstructive surgeon availability, geographic disparities, insurance status, and socioeconomic factors, though operative timing was infrequently evaluated as a primary outcome. IBR is associated with delays in definitive breast cancer surgery, yet the mechanisms remain poorly defined. Identifying and addressing these barriers could reduce surgical delays and potentially impact survival. Our review highlights current gaps in the literature and emphasizes the need for targeted research to optimize timely, equitable access to reconstruction without compromising oncologic outcomes.
Artificial Intelligence in the Trauma Bay: A Pilot Comparison With Surgical Trainees.
Pandya S, Romo M, Bresler T … +6 more , Burrough C, Gheissari R, Ko T, Mauch A, Calero T, DeFreese M
Am Surg · 2026 May · PMID 42085544 · Publisher ↗
BackgroundLarge language models (LLMs) have demonstrated strong performance on general medical knowledge assessments; however, their accuracy within high-acuity, guideline-driven surgical environments such as the trauma...
BackgroundLarge language models (LLMs) have demonstrated strong performance on general medical knowledge assessments; however, their accuracy within high-acuity, guideline-driven surgical environments such as the trauma bay remains incompletely characterized.ObjectiveTo compare the accuracy of a contemporary LLM, Google Gemini, with junior general surgery residents on trauma knowledge questions derived from national practice management guidelines.MethodsThirty multiple-choice questions were developed from current trauma guidelines issued by nationally recognized professional organizations and independently validated by faculty trauma surgeons. Six junior general surgery residents (PGY-1-2) completed the assessment, generating 180 total responses. The LLM was tested on the same questions under standardized conditions. Accuracy was calculated with 95% confidence intervals and compared using a two-proportion z-test.ResultsResidents answered 157 of 180 questions correctly (87.2%, 95% CI 81.6-91.3). The LLM answered 27 of 30 questions correctly (90.0%, 95% CI 74.4-96.5). There was no statistically significant difference in accuracy between groups ( = .67).ConclusionIn this pilot study, a LLM demonstrated accuracy comparable to junior surgical residents when evaluated on trauma guideline-based questions. Although no significant difference was found, the findings of our exploratory study support cautious exploration of guideline-grounded artificial intelligence as an adjunct in surgical education while underscoring the need for broader validation. Further power studies are required to confirm these preliminary findings.
Breslow Thickness and Microsatellite Detection in Primary Cutaneous Melanoma: Implications for Oncologic Surgeons and Patients.
Saravanan A, Parker EL, Pham PV … +7 more , Peery GB, Googe PB, Al-Rohil RN, Miedema JR, Meyers MO, Tyler DS, Ollila DW
Am Surg · 2026 May · PMID 42084393 · Publisher ↗
BackgroundMicrosatellites are an adverse prognostic feature in melanoma that upstages node-negative disease to N1c in the AJCC 8th edition staging system. While Breslow thickness and microsatellites are established progn...
BackgroundMicrosatellites are an adverse prognostic feature in melanoma that upstages node-negative disease to N1c in the AJCC 8th edition staging system. While Breslow thickness and microsatellites are established prognostic markers, their relationship in primary cutaneous melanoma has not been well examined.Materials and MethodsWe conducted a single-institution retrospective review of an IRB-approved prospective database of patients with primary cutaneous melanoma (January 2016-January 2026), excluding those with metastatic disease at diagnosis. Microsatellites are microscopic foci of melanoma cells discontinuous from the primary tumor and located in the dermis, subcutis, separated from the main tumor by normal tissue with no fibrosis or inflammation. Breslow thickness was measured from the granular layer (or the base of ulceration) to the deepest invasive melanoma cell. Patients were grouped by Breslow-based T-stage, and microsatellite frequency was calculated for each group. Fisher's exact test evaluated the association between T-stage and microsatellite presence.ResultsAmong 1,904 patients, 87 (4.6%) had microsatellites, with one patient having two separate microsatellite-positive tumors. Microsatellite frequency increased progressively with T-stage: 0.1% of T1 tumors (1/924), 2.4% of T2 tumors (14/579), 9.1% of T3 tumors (28/309), and 17.8% of T4 tumors (45/253) (Fisher's exact p<0.0001). Within the microsatellite-positive cohort, T-stage distribution was 1.1% for T1, 15.9% for T2, 31.8% for T3, and 51.1% for T4.DiscussionWe found that microsatellite frequency increases with Breslow thickness. Since microsatellites upstage tumors to N1c with implications for immunotherapy decisions, surgeons and dermatopathologists must be diligent in performing and assessing oncology wide excision specimens.
Evolution of the Morbidity and Mortality Conference in Surgery: From Codman to Contemporary Practice.
Torres-Landa S, Farrell TM
Am Surg · 2026 May · PMID 42084021 · Publisher ↗
The morbidity and mortality (M&M) conference is a foundational tradition in surgery, serving as a forum for education, accountability, and patient safety for more than a century. Originally rooted in early efforts to tra...
The morbidity and mortality (M&M) conference is a foundational tradition in surgery, serving as a forum for education, accountability, and patient safety for more than a century. Originally rooted in early efforts to track outcomes and improve hospital efficiency, M&M has evolved alongside major developments in surgical education, quality improvement, and patient safety science. This review traces the historical evolution of the M&M conference from Ernest Codman's end-result system to its institutionalization by the American College of Surgeons and formalization in graduate medical education. It examines the cultural shift from individual blame toward systems-based learning, highlights the influence of the patient safety movement, educational theory, and human factors science, and reviews contemporary approaches incorporating data analytics, multidisciplinary participation, and technology. Persistent challenges including variability in structure, underreporting, and medicolegal concerns along with future opportunities to strengthen M&M as a driver of continuous improvement are discussed. Despite ongoing evolution, the core purpose of honest reflection in service of safer and higher-quality surgical care in M&M remains unchanged.
Declining Incidence of Large Cell Lung Carcinoma in the United States: Effects of WHO Reclassification in a SEER Analysis.
Li F, Yang J, Zhang J … +6 more , Zhao M, Qie S, Wang G, Hu M, Li H, Qi X
Am Surg · 2026 May · PMID 42083517 · Publisher ↗
BackgroundLarge cell lung cancer (LCLC) is an aggressive, undifferentiated subtype of non-small cell lung cancer (N-SCLC) and is now a rare subtype in clinical practice.MethodsData were retrieved from the SEER database,...
BackgroundLarge cell lung cancer (LCLC) is an aggressive, undifferentiated subtype of non-small cell lung cancer (N-SCLC) and is now a rare subtype in clinical practice.MethodsData were retrieved from the SEER database, with two analytical cohorts established. Joinpoint regression quantified LCLC incidence trends. Propensity score matching (PSM) balanced baseline characteristics of the survival cohort. Cox regression determined independent overall survival (OS) predictors, restricted cubic spline (RCS) explored non-linear associations between continuous factors and outcomes, and Kaplan-Meier curves with Log-rank tests compared survival differences.ResultsFrom 1992 to 2022, the incidence of LCLC exhibited a significant downward trend (annual percent change [APC] = -12.690%, 95% CI: -13.788 to -11.577, < 0.001). The most rapid decline was observed during 2005-2015, with an APC of -19.624% (95% CI: -21.955 to -17.224, < 0.001). Finally, a significant decreasing trend persisted from 2015 to 2022, albeit with a slightly slowed rate (APC = -13.995%, 95% CI: -21.303 to -6.008, = 0.002). Multivariate analysis identified advanced age, male sex and advanced AJCC stage as independent predictors. Lobectomy and extended lobectomy were associated with improved OS, while no chemotherapy was a risk factor.Conclusions1992-2022 US LCLC incidence decline is attributable to diagnostic drift rather than reduced actual disease burden; our study identified sex, age, AJCC stage, surgical resection extent and chemotherapy as OS predictors for LCLC patients. Notably, SEER lacks modern systemic therapy data, precluding unrigorous extrapolation of its chemoradiotherapy findings to current regimens.
Utilization of Tumor Markers for Intraoperative Specimen Radiography Does Not Decrease the Rate of Margin Positivity in Breast Conservation Surgery (BCS).
Prasad R, Brainerd M, Ortega C … +6 more , Gabra JN, Mangira C, Brett-Morris A, Mamone C, Fenton A, Murray M
Am Surg · 2026 May · PMID 42080622 · Publisher ↗
IntroductionMargin status after lumpectomy is crucial in determining risk of local recurrence. Current guidelines recommend "no ink on tumor" as adequate negative margins for invasive breast carcinoma. Still, up to 20% o...
IntroductionMargin status after lumpectomy is crucial in determining risk of local recurrence. Current guidelines recommend "no ink on tumor" as adequate negative margins for invasive breast carcinoma. Still, up to 20% of patients may have positive margins and need re-excision. This study explored the use of a commercially available tumor marking system during specimen radiography and its effect on re-excision rates in breast conservation surgery.MethodsWith IRRB approval, a review was conducted of a prospectively collected cohort of 105 study patients and a retrospectively collected cohort of 92 control patients with invasive breast carcinoma undergoing breast conservation surgery. In the study group, lumpectomy specimens were labeled with clips from a commercial tumor marking system, followed by two-view radiography to assess the need for shave margins. The surgeon interpreted the radiograph, and, at their discretion, excised additional margins. A control group was managed by the same surgeons without the tumor marking system. Categorical variables were compared using Chi-Squared or Fisher's exact tests and continuous variables were compared using t-tests or Wilcoxon Rank Sum tests depending on their distribution.ResultsA total of 197 patients were divided into a study group (n = 105) and a control group (n = 92). The types of margin excision rates differed significantly between groups ( ≤ 0.0105). In the study group, the rates of selective and complete margin excisions were 39% and 7%, respectively, while 53% had no margins excised, as determined using the tumor marking system. In the control group, rates of selective and complete margin excisions were 42% and 21%, respectively, and 37% had no margins excised. Final pathology showed positive margins in 24% (study) vs 21% (control), with no significant difference between the groups ( ≤ 0.0810).ConclusionsThe tumor marking system did not decrease the rate of margin positivity compared to the control group. However, the study group demonstrated a significant decrease in the number of patients requiring selective or complete margin excision.
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