The American Surgeon[JOURNAL]
Sun
200 papers
Bypass Thrombosis is the Most Common Reason for Unplanned Return to Operating Room After Lower Extremity Bypass for Chronic Limb-Threatening Ischemia.
Paracha AW, Zil-E-Ali A, Tall AA … +3 more , Soucy JW, Dogbe L, Aziz F
Am Surg · 2026 Aug · PMID 41739976 · Publisher ↗
BackgroundReturn to operating room (ROR) is an important quality metric reflecting surgical outcomes. This study aimed to identify risk factors associated with ROR after lower extremity bypass (LEB) for chronic limb-thre...
BackgroundReturn to operating room (ROR) is an important quality metric reflecting surgical outcomes. This study aimed to identify risk factors associated with ROR after lower extremity bypass (LEB) for chronic limb-threatening ischemia (CLTI).MethodsA retrospective analysis was performed using the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) database for patients undergoing LEB for CLTI between 2007 and 2020. Patients were divided into two groups: Group I (ROR) and Group II (No ROR). Univariate and multivariate regression analyses were conducted to identify risk factors, with significance set at < .05.ResultsAmong 10 800 patients, 1443 (14%) required ROR. Factors significantly associated with increased ROR risk included African American race (OR 1.39, CI [1.18-1.63]), Medicaid insurance (OR 1.36, CI [1.06-1.75]), ambulatory with assistance (OR 1.21, CI [1.05-1.41]), discharge to rehabilitation (OR 2.98, CI [2.58-3.44]), transfer to other hospitals (OR 4.06, CI [2.38-6.93]), concomitant bypass (OR 1.46, CI [1.05-2.03]), infrageniculate graft insertion (OR 1.39, CI [1.15-1.67]), non-autologous biologic conduit (OR 1.71, CI [1.25-2.33]), and general anesthesia (OR 2.58, CI [1.25-5.33]). Female sex (OR 0.82, CI [0.71-0.95]) and aspirin use (OR 0.85, CI [0.73-0.99]) were protective. Bypass thrombosis was the most common reason for ROR. No significant trend in ROR reduction was observed over the study period.ConclusionMultiple clinical and operative factors increase ROR risk after LEB for CLTI. Risk stratification and targeted interventions are essential to minimize complications and improve patient outcomes.
The Difficult Gallbladder: Practical Considerations for Performing Safe Cholecystectomy.
Arthur B, Anderson N, Gallimore J … +1 more , Richmond BK
Am Surg · 2026 Aug · PMID 41739886 · Publisher ↗
The management of the difficult gallbladder remains one of the most significant challenges in general surgery. As many as 16% of gallbladders can be classified as "difficult," which also makes the difficult gallbladder o...
The management of the difficult gallbladder remains one of the most significant challenges in general surgery. As many as 16% of gallbladders can be classified as "difficult," which also makes the difficult gallbladder one of the most common challenges facing the general surgeon in practice. Despite emphasis on a culture of safety surrounding the performance of laparoscopic cholecystectomy, bile duct injury remains a major problem, occurring anywhere from 0.15 to 0.36% of all laparoscopic cholecystectomies. Many of these cases are frequently litigated successfully, and the long-term quality of life in patients who suffer major bile duct injury is reduced. The following review addresses several key aspects related to the management of the difficult gallbladder. These will include a review of the significance of the problem as well as its associated epidemiology and impact on the health care system. Also, the clinical circumstances that serve to make a gallbladder difficult will be discussed. These include aberrant biliary anatomy, the presence of cholecystitis (either acute or chronic), and cirrhosis. Ways to approach these conditions in a safe manner will be reviewed. Finally, the management of biliary injuries in the acute setting will be reviewed, with special attention to the most appropriate management strategy to adopt in the context of available resources and expertise.
Association Between Post-Cholecystectomy Gut Microbiota Dysbiosis and Adverse Clinical Outcomes: A Single-Center Retrospective Case-Control Study.
Li Z, Zhang F, Sun X
Am Surg · 2026 Aug · PMID 41738993 · Publisher ↗
BackgroundAlterations in gut microbiota are recognized modulators of gastrointestinal and metabolic health, but the clinical relevance of dysbiosis after cholecystectomy remains unclear.MethodsA retrospective case-contro...
BackgroundAlterations in gut microbiota are recognized modulators of gastrointestinal and metabolic health, but the clinical relevance of dysbiosis after cholecystectomy remains unclear.MethodsA retrospective case-control study included adults who underwent cholecystectomy (2020-2023) and developed persistent gastrointestinal/metabolic symptoms postoperatively with fecal microbiota testing. Patients were divided into dysbiosis or eubiosis groups using a predefined scoring system. Baseline characteristics, microbial profiles, and outcomes were compared. Correlations and multivariate regression assessed associations. 75 patients were included (35 dysbiosis, 40 eubiosis).ResultsThe dysbiosis group had significantly reduced , and spp, and increased , , Firmicutes-to-Bacteroidetes (F/B) ratio, spp., spp., and spp. (all < .05). Alpha diversity analysis revealed lower Shannon index and Chao1 index (all < .05). Dysbiosis was associated with higher rates of diarrhea (51.4% vs 22.5%, = .010), abdominal distension (42.9% vs 17.5%, = .018), and ALT elevation (40.0% vs 17.5%, = 0.031). The F/B ratio positively correlated with ALT (ρ = 0.46, = .005), while inversely correlated with triglycerides (ρ = -0.41, = 0.011). Dysbiosis was independently associated with a higher risk of postoperative diarrhea (adjusted OR = 2.87; 95% CI: 1.02-8.05; = 0.046).ConclusionGut microbiota dysbiosis is common post-cholecystectomy and associated with increased risks of postoperative diarrhea and metabolic disturbances. Microbiota profiling may aid risk stratification and guide interventions targeting the gut-liver axis.
A Novel Approach to Complex Splenic Hilar Aneurysms: ICG-Guided Partial Spleen Preservation Combined With Distal Pancreatectomy.
Song X, Du F, Wang W … +4 more , Shi H, Wang Z, Zheng S, Chang H
Am Surg · 2026 Feb · PMID 41736514 · Publisher ↗
BackgroundSplenic hilar aneurysms exceeding 2 cm in diameter typically warrant surgical intervention given their elevated risk of fatal rupture. While complete splenectomy has historically been the conventional approach...
BackgroundSplenic hilar aneurysms exceeding 2 cm in diameter typically warrant surgical intervention given their elevated risk of fatal rupture. While complete splenectomy has historically been the conventional approach to mitigate operative complexity, this procedure carries significant postoperative concerns including compromised immune function and increased thrombotic risks associated with splenic absence.Case presentationIn two cases of splenic artery aneurysms (SAAs) deeply embedded within the pancreatic tail at the splenic hilar region, we performed laparoscopic resection of the splenic artery aneurysm and distal pancreas. Intraoperative indocyanine green (ICG) fluorescence imaging was employed to map perfusion patterns of the spleen, demonstrating sequential greening and subsequent fading of the splenic upper pole. This confirmed preserved arterial inflow and venous drainage, thus confirming maintained vascularization following splenic artery ligation. The patients achieved an uneventful recovery and were discharged without complications.ConclusionsWe described the first use of a technique that integrates distal pancreatectomy with ICG-guided partial splenic preservation for complex splenic hilar aneurysms. This strategy facilitates precise resection of the aneurysm and non-viable spleen, thereby maximizing functional preservation and establishing itself as a promising option for managing these challenging lesions.
A Safe Step Toward Opioid Stewardship: Standardized Low-Dose Discharge Opioid Prescriptions After Minimally Invasive Outpatient Appendectomy and Cholecystectomy.
Maidenberg CT, Samuel K, Porras H … +10 more , Roberts M, Ferre A, Coleoglou Centeno AA, VanDerPloeg D, Morton A, Brooke M, Thomas S, Moore EE, Pieracci FM, Yeh DD
Am Surg · 2026 Aug · PMID 41734037 · Publisher ↗
BackgroundOpioid stewardship aims to balance effective pain control with minimizing overprescription. We hypothesized that a discharge prescription of 5 oxycodone 5 mg tablets for minimally invasive outpatient appendecto...
BackgroundOpioid stewardship aims to balance effective pain control with minimizing overprescription. We hypothesized that a discharge prescription of 5 oxycodone 5 mg tablets for minimally invasive outpatient appendectomy and cholecystectomy would be associated with low rates of prescription refill and emergency department (ED) utilization for inadequate pain control.MethodsThis single-center retrospective study enrolled outpatient appendectomies and cholecystectomies between 1/25 and 6/25. Patients with oxycodone allergy or chronic opioid therapy were excluded. Primary outcome was patient-reported number of tablets taken by the first postoperative visit. Secondary outcomes included proportion of patients who utilized the NurseLine or ED for postoperative pain, proportion who requested prescription refills, and timing of contact after discharge.ResultsA total of 364 patients were included. Six patients met exclusion criteria and 90 were lost to follow-up. The median [IQR 0-5] and mode of tablets taken were 3 and 5, respectively. Fifty-six patients (21%) reported taking zero tablets. Fifteen (4%) requested prescription refills. Thirty-two patients (9% of 358) contacted the NurseLine due to inadequately treated pain. Among those, 16 (50% of 32) presented to the ED, 3 of whom received a dose of opioids. The median number of days until NurseLine contact for postoperative pain was 4 [2-8].DiscussionA standardized opioid discharge regimen for outpatient appendectomy and cholecystectomy was associated with low ED utilization (<5%) and rare need for additional opioids (4%). The median number of oxycodone tablets taken postoperatively was 3, suggesting further room for optimization in our opioid stewardship. NurseLine counseling may further reduce ED use.
Mesh Safety Under Contamination Across Incarcerated Hernias: A Single-Center Cohort Analysis With a Systematic Review of Adult Bochdalek Hernia Complicated by Gastric Pathologies.
Gao J, Xu M, Chen J … +2 more , Zheng Y, Huang X
Am Surg · 2026 Aug · PMID 41725243 · Publisher ↗
BackgroundWhether prosthetic mesh increases infection in contaminated fields remains controversial, particularly in incarcerated hernias and adult Bochdalek hernia (BH) with gastric pathology.MethodsWe combined a PRISMA-...
BackgroundWhether prosthetic mesh increases infection in contaminated fields remains controversial, particularly in incarcerated hernias and adult Bochdalek hernia (BH) with gastric pathology.MethodsWe combined a PRISMA-guided systematic review of adult BH with gastric pathology (14 cases, 1981-2025) with a single-center retrospective cohort of incarcerated hernias treated laparoscopically or laparoscopy-assisted (n = 313; inguinal 177, incisional 111, diaphragmatic 10 [4 BH, 1 Morgagni], and hiatal 15). Pure open repairs were excluded. Intraoperative findings were stratified as clean, mild, or severe contamination. Primary endpoint: 3-month infectious outcomes (surgical site infection, intra-abdominal abscess, and mesh infection) comparing mesh vs non-mesh repair. A representative BH case with gastric antral perforation managed by one-stage gastric repair and mesh-reinforced diaphragmatic closure is presented.ResultsAmong clean cases receiving mesh, the 3-month infection rate was 1.5% (3/198). In mild contamination, mesh did not increase infection compared with non-mesh repair (10.0% [4/40] vs 6.7% [3/45]; RR 1.50, 95% CI 0.36-6.30; = .702). In severe contamination, infection rates were also similar (21.4% [3/14] vs 18.8% [3/16]; RR 1.14, 95% CI 0.27-4.78; = 1.000). The BH review showed 57.1% gastric volvulus and 42.9% perforation/necrosis; mesh was used selectively (21.4%) in staged or clean settings, and 37.5% of female cases occurred during pregnancy.ConclusionsIn this laparoscopic-dominant cohort, mesh repair after meticulous lavage was not associated with higher 3-month infection across contamination strata and appeared safe in selected severely contaminated cases. These findings support a contamination-aware, selective mesh strategy within a CT-first, laparoscopy-first pathway and warrant prospective validation, particularly for open repairs and longer follow-up.
Bypass of Local Surgical Care in North Carolina: Patient-Directed Care Destination and Utilization.
Abid M, Malone T, Holmes M … +1 more , Charles A
Am Surg · 2026 Aug · PMID 41725154 · Full text
BackgroundAlthough frequent, patient bypass of local surgical care (bypass) remains understudied. No prior work has evaluated the association between bypass and local surgeon workforce density.MethodsThis is a retrospect...
BackgroundAlthough frequent, patient bypass of local surgical care (bypass) remains understudied. No prior work has evaluated the association between bypass and local surgeon workforce density.MethodsThis is a retrospective cohort study of North Carolina patient bypass (receiving care at a hospital ≥ 10 miles farther from the nearest surgery-capable hospital) from 2016 to 2019 for urgent/emergent surgery. The association between bypass and clinical, sociodemographic, and NSH characteristics was estimated using logistic regression.Results23.7% of patients (n = 9864) bypassed local surgical care. These patients traveled further for care (median miles 25.8 vs 7.4). Living in counties with the lowest general surgeon workforce density (aOR: 1.58, 95% CI: 1.16, 2.16) and second lowest workforce density (aOR: 1.55, 95% CI: 1.26, 1.90) was associated with bypass.DiscussionApproximately 25% of patients undergoing urgent/emergent general surgeries bypassed their nearest surgical care. Patients in counties with lower workforce density were more likely to bypass the nearest surgical hospital.
Techniques for Mesoappendix Division and Appendiceal Stump Closure: A Comparative Review.
Ekestubbe L, Forssten MP, Forssten SP … +3 more , Bass GA, AlHussaini Y, Mohseni S
Am Surg · 2026 Aug · PMID 41723596 · Publisher ↗
Acute appendicitis is a leading cause of emergency abdominal surgery, with laparoscopic appendectomy (LA) established as the gold standard treatment. Notwithstanding its extensive utilization, there is no agreement on th...
Acute appendicitis is a leading cause of emergency abdominal surgery, with laparoscopic appendectomy (LA) established as the gold standard treatment. Notwithstanding its extensive utilization, there is no agreement on the most effective method for closing the appendiceal stump and dividing the mesoappendix. This review sought to assess existing treatments in terms of surgical duration, hospital length of stay (LOS), complications, and cost-effectiveness. A comprehensive review of 53 studies was performed. Eligible studies included adult patients undergoing appendectomy and examined various procedures for appendiceal stump closure and mesoappendix division. The primary outcomes were surgical duration and LOS; the secondary objectives were postoperative complications and cost-effectiveness. For appendiceal stump closure, clips and staples were frequently linked to decreased surgical duration in comparison to ligatures or sutures, although outcomes varied. Clips were also associated with a reduced length of hospital stay. Cost-effectiveness analyses consistently found clips to be the most economical option for stump closure, with staples the most expensive. Complication rates were largely comparable, though loop ligatures were linked to more organ/space infections, and clips showed higher rates of surgical site infections in some studies. For mesoappendix division, electrocautery and energy devices generally shortened operative time compared with mechanical methods. Electrocautery was the least costly for mesoappendix division, while energy devices tended to increase costs. Division of the mesoappendix and appendiceal stump closure can be achieved with a wide range of techniques and tools. The optimal treatment strategy varies significantly based on the outcome investigated.
Cell Phone Measured Population Mobility and Interactions as a Predictor of Trauma Volume and Trauma Center Need.
Mathew PJ, Graetz E, Maung A … +5 more , Keating J, Moutinho MA, Schneider E, Davis K, Schuster KM
Am Surg · 2026 Aug · PMID 41723595 · Publisher ↗
BackgroundPredicting trauma center need is imprecise with current population-based models. Population activity level may help to estimate trauma demand. We compared daily trauma admissions (TA) and population-level cellu...
BackgroundPredicting trauma center need is imprecise with current population-based models. Population activity level may help to estimate trauma demand. We compared daily trauma admissions (TA) and population-level cellular mobility patterns during large fluctuations caused by the COVID-19 pandemic.MethodsTA from all level I trauma centers in one state (January 2020 to August 2021) were aggregated and compared to the Device Exposure Index (DEX), a standardized measure of daily cellular device interactions per county. Mean, standard deviation and range for daily DEX and TA were calculated. Spearman's rank correlation was calculated, followed by regression adjusted for autocorrelation and seasonality. Chi-square test assessed associations between categorized DEX and categorized TA. A 7-day moving average was utilized to smooth values.ResultsThe combined average TA was 17.8 per day (SD 5.5, range 4-38). Mean DEX was 73.6 (SD 32.5, range 6.8-188.4). Both measures declined sharply following pandemic lockdowns and demonstrated parallel trends across centers. TA and DEX were correlated (Spearman's rho = 0.2, < .001). In regression, DEX remained significantly associated with TA ( < .05). In Chi-square analysis, nearly half (48.2%) of low DEX days (DEX <70) were also low TA days (<17), whereas just over one-third (37.2%) of high DEX days (DEX ≥ 70) were low TA days ( = .008).DiscussionChanges in TA at the onset of the COVID-19 pandemic corresponded with DEX patterns, suggesting DEX may serve as an additional tool to inform trauma system planning, especially during periods of rapid behavioral change. Daily DEX may also provide short-term insight into fluctuations in TA.
Holding the Scalpel: Scientific Authorship and Responsibility in the Era of Generative Artificial Intelligence.
Arredondo Montero J
Am Surg · 2026 Aug · PMID 41723594 · Publisher ↗
Scientific writing and authorship are fundamentally acts of professional judgment and responsibility. This essay examines these principles in the era of increasingly fluent generative artificial intelligence (AI), arguin...
Scientific writing and authorship are fundamentally acts of professional judgment and responsibility. This essay examines these principles in the era of increasingly fluent generative artificial intelligence (AI), arguing that scientific integrity-much like surgical mastery-depends on a level of earned comprehension and accountability that no algorithm can simulate. Drawing on a surgical experience in a resource-limited setting to illustrate the nature of judgment under uncertainty, the piece explores how the rise of AI risks replacing genuine expertise with hollow fluency. The essay concludes that judgment and responsibility must remain irreducibly human in both surgical practice and scientific authorship.
Treatment Sequencing and Survival in Octogenarians With Pancreatic Ductal Adenocarcinoma: A SEER Analysis.
Gupta P, Radkani P, Moris D
Am Surg · 2026 Jun · PMID 41721780 · Publisher ↗
Pancreatic ductal adenocarcinoma (PDAC) in patients aged 80 years and older poses a significant therapeutic dilemma, as evidence supporting aggressive multimodality treatment in this population is limited. Using the Surv...
Pancreatic ductal adenocarcinoma (PDAC) in patients aged 80 years and older poses a significant therapeutic dilemma, as evidence supporting aggressive multimodality treatment in this population is limited. Using the Surveillance, Epidemiology, and End Results database, we evaluated overall survival in patients aged ≥80 years with localized or regional PDAC treated with surgery alone versus neoadjuvant chemoradiation followed by surgery. Kaplan-Meier analysis, multivariable Cox regression, and inverse probability of treatment weighting were used to adjust for demographic and disease-related factors. Among 3,806 eligible patients, surgery alone and neoadjuvant therapy plus surgery yielded identical median survival of 2.0 years in both localized and regional disease. No statistically significant survival advantage was observed with neoadjuvant therapy in adjusted analyses. These findings suggest that, in carefully selected octogenarians, upfront surgical resection provides survival outcomes comparable to more intensive neoadjuvant strategies, supporting individualized treatment approaches in this growing patient population.
A Short "Scrubbing" Prayer as a Potentially Valuable Addition to Preoperative Preparation.
Linos D, Angelos P, Papazoglou AS
Am Surg · 2026 Jul · PMID 41721561 · Publisher ↗
Surgeon well-being and patient safety remain central priorities in contemporary surgical practice. Many surgeons endorse spirituality-broadly defined-as an important component of personal resilience and professional purp...
Surgeon well-being and patient safety remain central priorities in contemporary surgical practice. Many surgeons endorse spirituality-broadly defined-as an important component of personal resilience and professional purpose. We propose a brief moment of private reflective practice, adaptable to diverse belief systems, during the preoperative hand-scrubbing period. This "scrubbing reflection", which may include silent prayer for those who choose, could promote focused attention, reduce stress, and cognitively reinforce essential information such as patient identity, diagnosis, and the planned procedure. As this pause occurs during an already standard process, it adds no operational delay while potentially supporting improved human performance and surgical safety. This perspective encourages consideration of simple, voluntary practices that may strengthen both caregiver well-being and patient protection.
Preoperative Prediction of Hiatal Hernia Based on the American Foregut Society (AFS) Endoscopic Classification in Bariatric Surgery.
Dalkılıç MS, Gençtürk M, Yılmaz M … +1 more , Şişik A
Am Surg · 2026 Jun · PMID 41719477 · Publisher ↗
Abstract loading — click title to view on PubMed.
Comparative Analysis of Surgical Stabilization of Traumatic Rib Fractures in Patients With Morbid Obesity: A Retrospective Review of the Nationwide Readmissions Database.
Aalberg J, Ricard C, Brown A … +5 more , Johnson B, Kim WC, Hojman H, Bawazeer M, Bugaev N
Am Surg · 2026 Aug · PMID 41717726 · Publisher ↗
BackgroundThe effectiveness of surgical stabilization of rib fractures (SSRF) in patients with obesity is unknown.MethodsThe Nationwide Readmissions Database 2015-2019 was used to identify adult patients with obesity and...
BackgroundThe effectiveness of surgical stabilization of rib fractures (SSRF) in patients with obesity is unknown.MethodsThe Nationwide Readmissions Database 2015-2019 was used to identify adult patients with obesity and rib fractures (RF). The outcomes of those with Obesity who underwent SSRF were compared to non-operative management (NOM) and also to non-obese participants who underwent SSRF. Patient demographics and outcomes were characterized with univariate, multivariate, and inverse-propensity score (IWPS) analyses adjusting for confounding variables and selection bias. Primary outcomes included 30-day readmission, hospital length of stay (LOS), and mortality.Results39 177 patients were included Obese with NOM 86% (n = 33,516), Obese SSRF 1.8% (n = 707), and non-Obese SSRF 13% (n = 4954). While comparing between Obese NOM vs Obese with SSRF, no significant differences in all-cause 30-day-readmission rates between groups were identified through multivariate analysis (odds ratio (OR) 1.16, 95% confidence interval (CI) 0.91-1.48), or IWPS analysis (OR 0.81, CI 0.50-1.31). Patients undergoing SSRF vs NOM had increased median (IQR) LOS (12 (8-20) vs 6 (3-12) days, < 0.001), but lower rates of in-hospital mortality (1.7% vs 6.2%, < 0.001; OR 0.16, CI 0.09-0.28). While comparing SSRF in Obese vs non-Obese using a multivariate analysis, obesity did not confer greater odds of readmission (OR = 1.17, 95% CI 0.92-1.5) or death (OR = 0.74, 95% CI 0.4-1.35), and obesity did not contribute to a clinically significant increase in LOS (43 additional minutes, < 0.05).DiscussionIn patients with obesity and rib fractures, SSRF is a valuable treatment option given its association with decreased rates of in-hospital mortality and comparable outcomes to their non-obese counterparts.Level of EvidenceIII.Study typetherapeutic/Care management.
Overcoming Adversity: Its Impact in Advancing Health Care.
Gosain AK, Reisner KR, Haydon KL … +3 more , Arcelona CN, Melendez CN, Rodriguez GC
Am Surg · 2026 May · PMID 41711357 · Publisher ↗
Adversity is an inherent and recurring feature in health care, impacting patient care, clinical training, and professional careers. This editorial describes the senior author's (AKG) perception as to how patients, traine...
Adversity is an inherent and recurring feature in health care, impacting patient care, clinical training, and professional careers. This editorial describes the senior author's (AKG) perception as to how patients, trainees, and he have transformed adversity into sustained positive impact. Patients undergoing reconstructive surgery frequently confront prognostic uncertainty, fragmented care, social isolation from peers, and insurance barriers. Health care trainees may experience negative or discouraging feedback that can lead to alteration or even complete change in their career ambitions. We demonstrate how patients have used these experiences towards initiating health care advocacy, how medical students have used these experiences towards refocusing their careers, and how the senior author has used these experiences towards building platforms to facilitate the career development of current trainees. Ultimately, the responsibility of educators, practitioners, and leaders in health care is to leverage adversity by analyzing circumstances that may have led to it and helping to either alter conditions such that others are not subject to the same conditions, or in guiding those who may follow towards a path that will reward them, rather than punish them, for their efforts. While adversity is unavoidable in all facets of health care, its impact can be shaped to serve as a foundation for growth and meaningful impact on others.
Cranial Access in Preperitoneal Pretransversalis eTEP (PeTEP) for Primary Midline Hernias: Technical Description of a Novel Approach.
Gómez-López JR, Trujillo-Díaz J, Concejo-Cutoli P … +4 more , Benítez Riesco A, Schenone F, Bennazar Nin R, Martín-Del Olmo JC
Am Surg · 2026 Jun · PMID 41711126 · Publisher ↗
Minimally invasive abdominal wall surgery continues to evolve, and the cranial approach to the PeTEP (preperitoneal/pretransversalis enhanced-view totally extraperitoneal) technique represents a meaningful addition to ou...
Minimally invasive abdominal wall surgery continues to evolve, and the cranial approach to the PeTEP (preperitoneal/pretransversalis enhanced-view totally extraperitoneal) technique represents a meaningful addition to our armamentarium. In this report, we present a 62-year-old obese male (BMI 34.3) with a combined umbilical and epigastric hernia (EHS M2-M3 W1) managed using the cranial PeTEP approach. The procedure is detailed step-by-step to highlight technical nuances. The operation was completed without complications in 150 minutes, and the patient was discharged within 24 hours with no postoperative pain. Follow-up at 1 week, 1 month, 3 months and 6 months showed no adverse events or recurrence. Based on this experience, the cranial PeTEP approach appears to be a safe, effective, and reproducible option for primary midline hernia repair in appropriately selected patients, enabling wide preperitoneal mesh placement without entering the retromuscular space. Larger studies with longer follow-up are warranted to further validate these findings.
Utilization of Cardiopulmonary Bypass in Trauma Patients: A Multi-Institutional Study of the American Association for the Surgery of Trauma.
Karamchandani MM, Nahmias J, Alvarez C … +59 more , Callcut RA, Stadeli KM, Park C, Kost M, Bruce N, Biffl WL, Al-Dulaimi H, Wood FC, Gushing JD, Taghavi S, Ghio M, Kirsch JM, Staszak JK, Collier B, Jordan MB, Sciarretta JD, Chow K, Evans DC, Rady EW, Mukherjee K, Winchell RJ, Hsu CY, Brasel K, Henry R, Doles B, Smith B, Williams JB, Udekwu PO, Bhattacharya B, Jones T, Byrne J, Haut E, Jacobson LE, Williams JM, Brat G, Beaulieu-Jones BR, Harfouche MN, Rao AS, Bauman ZM, Goodman M, Craugh L, Winfield RD, Rakhit S, Maiga AW, Blay E, Fernández LG, Pero B, Brown CVR, Weresh H, Wilson CT, Miles TJ, Barmparas G, Margulies DR, Ra J, O'Keeffe T, Fickle J, Draper B, Barbosa R, Bugaev N
Am Surg · 2026 Jul · PMID 41689481 · Publisher ↗
BackgroundThe purpose of this descriptive study was to characterize the utilization and outcomes of CPB after trauma.MethodsThis is an AAST-sponsored retrospective (2011-2021) multicenter (32 centers) study of all adult...
BackgroundThe purpose of this descriptive study was to characterize the utilization and outcomes of CPB after trauma.MethodsThis is an AAST-sponsored retrospective (2011-2021) multicenter (32 centers) study of all adult trauma patients undergoing CPB. Univariate analysis comparing demographics, clinical characteristics and the study outcomes were performed between those who required CPB≤2 hours, >2-24 hours, and >24 hours from the arrival. The primary outcome was mortality.ResultsThere were 113 patients, 63% sustained blunt trauma. The most common injuries were cardiac (42%), thoracic aorta (42%), and pericardial tamponade (25%). The three most common reasons to use CPB were aortic repair (32%), cardiopulmonary resuscitation (20%), and cardiac repair (15%). CPB was performed within 2 hours in 44(39%), and 21(19%) underwent CPB after 24-hours. Penetrating mechanisms of injury 24 (55%) ( = .009), higher rate of hypotension (SBP <80 mmHg) 15 (71%) ( = .002) were more common in CPB≤2-hours. Septal ( = .001) and valvular ( = .002) injuries were more frequent in CPB >24 hours, otherwise there were no differences in injury patterns among CPB ≤2 hours, >2-24 hours, and >24 hours. Cardiac repair was the most common indications for CPB ≤2 hours ( = .002), aorta repair was more common in CPB 2-24 hours ( = .03). Complications were not different between CPB ≤2 hours, >2-24 hours, and >24 hours. Among survivors, no differences in terms of discharge disposition, hospital LOS were found (all > .05). Mortality was 22% with 96% of them undergoing CPB in the first 24 hours ( < .001).ConclusionsCPB is rarely used for traumatic injuries. The true impact of CPB is unknown and should be studied in comparison to patients with cardiovascular injuries that are repaired without CPB.Level of EvidenceLevel IV; Therapeutic/Care Management.
Instant Answers, Enduring Responsibility: Teaching Judgment in the Age of Artificial Intelligence.
Nakayama DK
Am Surg · 2026 Jun · PMID 41672484 · Publisher ↗
Artificial intelligence (AI) has become embedded in medical practice and education. In today's digital world, medical learners use AI tools to arrive at plausible diagnoses with speed and accuracy that can equal those of...
Artificial intelligence (AI) has become embedded in medical practice and education. In today's digital world, medical learners use AI tools to arrive at plausible diagnoses with speed and accuracy that can equal those of experienced clinicians. This shift challenges a long-standing assumption in medical education that clinical error primarily reflects gaps in factual knowledge. Digital information and AI now make facts immediately accessible. Errors arise when AI is misapplied, when users accept outputs with unwarranted confidence, and when clinicians fail at the therapeutic judgment required to act. Two brief outpatient encounters involving a third-year medical student illustrate the gap between technology-assisted diagnosis and the human decision to act. In both cases, the student used AI and digital resources to reframe the clinical problem in a useful way. The responsibility to verify the diagnosis, assess risk, and accept the consequences of action remained with the attending physician. AI collapses the distance between presentation and diagnosis. It leaves untouched the distance between knowledge and responsibility an intersection that defines medical professionalism and now focuses explicit attention in medical education.
Surgical Stabilization of Rib Fractures in Severe Polytrauma: A Potential Indication.
Matecki M, Forssten MP, Cao Y … +2 more , Sarani B, Mohseni S
Am Surg · 2026 Aug · PMID 41667081 · Publisher ↗
BackgroundMost studies demonstrating efficacy of surgical stabilization of rib fractures (SSRF) are in patients with isolated severe chest wall injury. Recent evidence suggests SSRF may reduce mortality in polytrauma pat...
BackgroundMost studies demonstrating efficacy of surgical stabilization of rib fractures (SSRF) are in patients with isolated severe chest wall injury. Recent evidence suggests SSRF may reduce mortality in polytrauma patients. The present study examines SSRF outcomes in severe polytrauma patients.MethodsThe 2013-2021 Trauma Quality Improvement Project database was used to identify severe polytrauma patients, defined as Injury Severity Score (ISS) ≥15 and abbreviated injury scale (AIS) ≥2 in 2 or more regions, with rib fractures. Exclusion criteria included AIS 6 in any region, death ≤72 hours, or SSRF >72 hours after admission. Outcomes of interest were in-hospital mortality, pneumonia, acute respiratory distress syndrome (ARDS), and length of mechanical ventilation. Adjustment for confounding was achieved using inverse probability of treatment weighting, Poisson regression models and quantile regression models.ResultsA total of 388 091 patients met inclusion criteria, of which 1.3% (N = 5020) underwent SSRF. SSRF was associated with a 57% decreased risk of mortality ( < 0.001) and 53% lower risk of ARDS ( < 0.001). Patients who underwent SSRF also required approximately 1 day less of mechanical ventilation ( < 0.001). Patients with ISS 15-19 exhibited an association between SSRF and a 55% ( = 0.023) lower rate of pneumonia.ConclusionSSRF within 72 hours of admission in severe polytrauma patients is associated with a lower rate of mortality and acute respiratory distress syndrome, along with shorter duration of mechanical ventilation. A reduction in the rate of pneumonia was only observed among patients with ISS 15-19.
Stratifying Early Risk of Death From Hemorrhage in the Era of Whole Blood.
Conner J, Nunn AM, Avery M … +6 more , Goldstein C, Carroll H, McCullough MA, Mowery N, Hoth J, Stettler GR
Am Surg · 2026 Jul · PMID 41666287 · Publisher ↗
BackgroundDefinitions of massive transfusion following injury help identify patients at the greatest risk of death. However, these definitions primarily use blood component therapy. The use of whole blood (WB) transfusio...
BackgroundDefinitions of massive transfusion following injury help identify patients at the greatest risk of death. However, these definitions primarily use blood component therapy. The use of whole blood (WB) transfusion protocols has seen a resurgence, with evidence of improved outcomes compared to component therapy. Therefore, our aim was to define and stratify patients into low, intermediate, and high risk for death based on volume of blood products transfused utilizing a WB-first resuscitation strategy.MethodsPatients that received at least 1 unit of whole blood following injury between January 2016 and November 2021 were identified. Receiver operating characteristic (ROC) curves to predict death based on volume of blood products transfused were constructed. Patients were stratified to low, intermediate, and high risk of death based on positive likelihood ratios.ResultsThere were 785 patients identified to have received at least 1 unit of WB following injury during the study period. Based on ROC curve analysis, the best predictor of death was volume of whole blood plus packed red blood cells (PRBC) in the first hour (AUC 0.66, < 0.001). Low risk of mortality was defined as WB + PRBC volume <3400 cc in the first hour (14.9% mortality), intermediate risk 3400-5100 cc in the first hour (39.1% mortality), and high risk >5100 mL in the first hour (66.7% mortality).DiscussionThe combination of WB + PRBC volume within the first hour following injury is the best predictor of death. Further, volumes of WB + PRBC transfused within the first hour can be used to stratify patients' risk of death.Level of EvidenceLevel IV.Study TypePrognostic and Epidemiological.
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