Journal of the American College of Surgeons最新文献

{"title":"Challenging Legacy Burn Resuscitation Paradigms with Fluid Restriction and Early Plasma.","authors":"Steven A Kahn, Mallorie L Huff, Justin Taylor, Keisha O'Neill, Ashley B Hink, Rohit Mittal, Andrew Bright, Prabhakar Baliga","doi":"10.1097/XCS.0000000000001339","DOIUrl":"10.1097/XCS.0000000000001339","url":null,"abstract":"<p><strong>Background: </strong>Fresh frozen plasma (FFP) as an adjunct in burn resuscitation to decrease endothelial cell permeability by restoring the glycocalyx is not yet standard of care despite increasing evidence showing benefits. We hypothesize that using an adjusted body weight index (ABWI) and starting resuscitation at a low rate of 2 mL/kg/% total body surface area (TBSA) with early plasma results in less fluid administration and superior clinical outcomes compared with traditional resuscitation methods, such as the Parkland formula.</p><p><strong>Study design: </strong>This was a retrospective comparative study of burn patients (>20% TBSA) resuscitated with 2 mL/kg/%TBSA lactated Ringer's using their ABWI, early FFP, plus rescue FFP as needed for oliguria. ABWI = ideal weight + 0.3 (actual weight - ideal weight). Patients with >30% TBSA were given 1 to 2 units of FFP at admission. Fluids were titrated 10% to 20% per hour based on urine output (UOP). If oliguric for 2 hours, patients received 1 to 2 U \"rescue\" FFP. Legacy groups were resuscitated with Parkland formula (\"4 mL/kg\" group) or a less restrictive 3 mL/kg ABWI group w/rescue FFP only. Demographics, injury characteristics, fluids administered during resuscitation, UOP, outcomes, and death were recorded. Legacy groups were compared with the \"2 mL/kg + FFP\" ABWI group.</p><p><strong>Results: </strong>Patients given 2 mL/kg + FFP received significantly less fluid than the 3 and 4 mL groups (1.7 vs 3.3 [p < 0.05] vs 4.15 mL/kg/%TBSA [p < 0.0001]). UOP was significantly reduced from 1.4 to 1 to 0.7 mL/kg/h (p < 0.0001), approaching the goal of 0.5 mL/kg/h. Mortality, mechanical ventilation, tracheostomy, and hemodialysis were significantly less in the 2 mL/kg + FFP group (p < 0.05).</p><p><strong>Conclusions: </strong>Patients treated with the restrictive 2 mL/kg + FFP formula received less fluid than the 3 mL/kg and Parkland formula controls. With reduced fluids, patients had less mechanical ventilation, less dialysis, fewer tracheostomies, and better survival. Acute kidney injury was minimal despite fluid restriction. Early experience suggests the new protocol is safe and feasible for further study.</p>","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"339-347"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143189712","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Discussion.","authors":"","doi":"10.1097/XCS.0000000000001325","DOIUrl":"10.1097/XCS.0000000000001325","url":null,"abstract":"","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"549-551"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143066508","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Textbook Neoadjuvant Experience: Defining a Novel Composite Outcomes Measure for Patients with Pancreatic Cancer Undergoing Neoadjuvant Therapy.","authors":"Patrick W Underwood, Thomas Leuschner, Aslam Ejaz, Mary Dillhoff, Susan Tsai, Timothy M Pawlik, Ashish Manne, Somashekar G Krishna, Eric D Miller, Syed Ahmad, Jordan M Cloyd","doi":"10.1097/XCS.0000000000001277","DOIUrl":"10.1097/XCS.0000000000001277","url":null,"abstract":"<p><strong>Background: </strong>Neoadjuvant therapy (NT) is increasingly used for patients with pancreatic ductal adenocarcinoma (PDAC). Disease progression, toxicity, and failure to undergo surgical resection are common during NT, yet little research has focused on efforts to optimize care delivery. We sought to define and validate a novel composite outcomes metric that characterizes the successful delivery of NT.</p><p><strong>Study design: </strong>All patients with localized PDAC receiving NT in an intention-to-treat fashion between 2018 and 2023 were retrospectively evaluated. A textbook neoadjuvant experience (TNE) was defined as the absence of mortality, disease progression, or hospital admission during NT as well as the completion of all intended NT and successful surgical resection.</p><p><strong>Results: </strong>Among 306 patients with localized PDAC, the median age was 66 years and 58.5% were men. Overall, only 85 (28%) experienced a TNE which was more common among patients with potentially resectable (45 of 96, 47%) than borderline resectable (33 of 112, 29%) or locally advanced (7 of 98, 7%) disease. Patients with a TNE experienced greater overall survival than those individuals without a TNE (median not reached vs 16.4 months [95% CI 14.9 to 17.9 months], p < 0.001). On multivariable Cox regression analysis, a TNE was the strongest predictor of improved overall survival (hazard ratio 0.33, 95% CI 0.20 to 0.54, p < 0.001).</p><p><strong>Conclusions: </strong>A TNE is infrequently achieved among patients with PDAC undergoing NT but is significantly associated with improved long-term outcomes. Future research aimed at optimizing outcomes of NT delivery should incorporate this novel composite metric that may more accurately reflect patient and provider expectations of treatment.</p>","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"539-548"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142971519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Liver Injury as a Risk Factor for Post-traumatic Venous Thromboembolism.","authors":"Michael D Cobler-Lichter, Jessica M Delamater, Nicole B Lyons, Brianna L Collie, Jonathan P Meizoso, Louis R Pizano, Kenneth G Proctor, Nicholas Namias, Nicholas H Carter","doi":"10.1097/XCS.0000000000001293","DOIUrl":"10.1097/XCS.0000000000001293","url":null,"abstract":"<p><strong>Background: </strong>Venous thromboembolism (VTE) remains a major source of morbidity and mortality in severely injured patients despite current methods of risk stratification and prophylaxis, suggesting incomplete understanding of VTE risk factors. Given the liver's role in coagulation, we hypothesized that liver injury (LI) is associated with increased rates of VTE in severely injured patients.</p><p><strong>Study design: </strong>The American College of Surgeons TQIP 2017 to 2021 was retrospectively reviewed for patients with a maximum abdominal Abbreviated Injury Score 4 or more with or without LI. Transfers, burns, all kinds of death, and patients younger than 18 years of age were excluded. Logistic regression was performed to assess the independent effect of LI on development of pulmonary embolism (PE) and deep venous thrombosis (DVT) while controlling for potential confounding variables.</p><p><strong>Results: </strong>Of 44,506 patients, there were 1,736 (3.9%), 890 (2.0%), and 18,642 (41.9%) with DVT, PE, and LI, respectively. After controlling for potential confounders, LI was independently associated with PE (adjusted odds ratio 1.279, 95% CI 1.088 to 1.504) but was not associated with DVT (adjusted odds ratio 1.011, 95% CI 0.897 to 1.140).</p><p><strong>Conclusions: </strong>In severely injured patients, LI is an independent predictor of PE, but not DVT, suggesting that LI is the source of either emboli or a more complex locally prothrombotic focus leading to downstream thrombi in the lung without causing upstream systemic venous thrombi. Further work should focus on elucidation of mechanisms including the portal venous blood coagulation profile, endothelial injury in the liver, and the potential for stasis of venous blood traversing an injured liver as well as the role for including LI in VTE risk stratification.</p>","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"660-666"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143007167","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Discussion.","authors":"","doi":"10.1097/XCS.0000000000001309","DOIUrl":"https://doi.org/10.1097/XCS.0000000000001309","url":null,"abstract":"","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":"240 4","pages":"347-350"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143674150","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Discussion.","authors":"","doi":"10.1097/XCS.0000000000001311","DOIUrl":"https://doi.org/10.1097/XCS.0000000000001311","url":null,"abstract":"","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":"240 4","pages":"376-377"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143674156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Discussion.","authors":"","doi":"10.1097/XCS.0000000000001333","DOIUrl":"10.1097/XCS.0000000000001333","url":null,"abstract":"","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"645-648"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143066440","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Disease Etiology and Indication for Colectomy on Postoperative Outcomes: NSQIP Colectomy-Targeted Database Study.","authors":"Sourav K Podder, Allison Doermann, George Ibrahim, Matthew Bowen, Scott H Koeneman, Christine Schleider, Kathleen Shindle, Scott W Cowan, Charles J Yeo, Nader Hanna","doi":"10.1097/XCS.0000000000001280","DOIUrl":"10.1097/XCS.0000000000001280","url":null,"abstract":"<p><strong>Background: </strong>The American College of Surgeons (ACS) NSQIP Colectomy-Targeted database provides valuable metrics on surgical outcomes by using clinical data to enhance quality improvement efforts. However, the quality measures offered in the ACS NSQIP semiannual report do not stratify for the indication of colectomy. We aim to compare postoperative outcomes in patients undergoing colectomy for colon cancer, infectious causes, and inflammatory bowel disease (IBD).</p><p><strong>Study design: </strong>A retrospective review of patients undergoing colectomy was performed using the ACS NSQIP Colectomy-Targeted database from 2012 to 2022. Logistic regression models were used to compare the 30-day postoperative outcomes of patients who underwent colectomy for colon cancer, infectious causes, and IBD while adjusting for preoperative risk factors.</p><p><strong>Results: </strong>There were 158,560 patients who underwent colectomy for colon cancer, 90,827 patients for infectious causes, and 30,548 patients for IBD. In unadjusted analysis, patients undergoing colectomy for infectious causes had the highest rates of mortality (2.6%) and morbidity (27.6%). After adjusting for covariates, patients with IBD undergoing colectomy had significantly higher odds of morbidity compared to those undergoing colectomy for colon cancer (odds ratio 1.3, 95% CI [1.1 to 1.4]) and infectious causes (odds ratio 1.3 [1.2 to 1.4]). Patients with IBD had significantly higher odds of experiencing venous thromboembolism, surgical site infections, prolonged ileus, and readmission within 30 days compared to both colon cancer and infectious causes patients.</p><p><strong>Conclusions: </strong>This study demonstrates that the indication for colectomy impacts postoperative outcomes. Reporting risk-adjusted outcomes based on the underlying disease etiology could lead to identifying high-risk patients, improving benchmarking outcomes, and developing targeted quality initiatives.</p>","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"365-376"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142978984","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcomes after Ventral Hernia Repair with Concurrent Panniculectomy: A Large Database Review.","authors":"Amy Gin Gossett, Justin D Leavitt, W Borden Hooks, William W Hope","doi":"10.1097/XCS.0000000000001287","DOIUrl":"10.1097/XCS.0000000000001287","url":null,"abstract":"<p><strong>Background: </strong>Patients with large pannus and ventral hernias may benefit from undergoing panniculectomy performed concurrently with open ventral hernia repair (VHR-PAN). However, there have been concerns related to increased surgical site occurrences (SSOs) when adding a panniculectomy. This study aimed to evaluate outcomes of open VHR with and without panniculectomy using a large hernia-specific database.</p><p><strong>Study design: </strong>The Abdominal Core Health Quality Collective database was queried from 2012 to 2023 for patients who underwent VHR-only vs VHR-PAN. Patient and surgical characteristics were described and compared. Short-term outcomes including surgical site infection, SSO, and SSO requiring procedural intervention were compared. Patient-reported outcomes and hernia recurrence were compared at 1 year. Logistic regression was used to identify risks associated with the above outcomes.</p><p><strong>Results: </strong>A total of 28,140 patients underwent open VHR, with panniculectomy data (yes or no) available for 2,108 patients, including 870 who underwent VHR-PAN. Patients who underwent VHR-PAN were more likely to be female (78.3% vs 64.8%, p < 0.0001), have a BMI greater than 40 (21.0% vs 7.8%, p < 0.0001), and have a larger median hernia width (10.0 [7.0 to 15.0] vs 8.0 [3.0 to 13.0], p < 0.0001). In a matched analysis, there was no significant difference in surgical site infection, SSO, SSO requiring procedural intervention, or 1-year hernia recurrences rates in the VHR-PAN group (p < 0.05).</p><p><strong>Conclusions: </strong>This study demonstrated that VHR with concurrent panniculectomy is not significantly associated with an increased risk of complications. Concurrent panniculectomy can be considered for selected patients needing VHR.</p>","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"530-535"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143007354","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Precision in Stroke Care: Novel Model for Predicting Functional Independence in Urgent Carotid Intervention Patients.","authors":"Hernan A Bazan, Daniel Fort, Larry Snyder, Frank G Opelka, Samuel R Money, W C Sternbergh, Jeffrey Burton","doi":"10.1097/XCS.0000000000001276","DOIUrl":"10.1097/XCS.0000000000001276","url":null,"abstract":"<p><strong>Background: </strong>Stroke requires timely intervention, with carotid endarterectomy (CEA) and carotid artery stenting (CAS) increasingly used in select acute carotid-related stroke patients. We aimed to build a model to predict neurologic functional independence (modified Rankin scale [mRS] ≤ 2) in this high-risk group.</p><p><strong>Study design: </strong>We analyzed data from 302 stroke patients undergoing urgent CEA or CAS between 2015 and 2023 at a tertiary comprehensive stroke center. Predictors included (1) stroke severity (NIH Stroke Scale), (2) time to intervention (≤48 hours), (3) thrombolysis use, and (4) frailty risk score. Two-way interactions were included to enhance generalizability without overfitting. Multiple models were constructed and selected based on the area under the receiver operating characteristic curve. The primary endpoint was discharge neurological functional independence (mRS ≤ 2).</p><p><strong>Results: </strong>Presenting clinical factors and neurological outcomes data from 302 patients undergoing urgent CEA and CAS during the index hospitalization from 2015 to 2023 at a tertiary comprehensive stroke center formed the model's foundation. Most patients (72.8%, 220 of 302) were discharged functionally independent (mRS ≤ 2). The combined 30-day rate of stroke, death, and MI was 8.3% (25 of 302), 6.5% (14 of 214) for CEA alone, and 12.5% (11 of 88) for CAS. The model, incorporating thrombolysis, time to intervention, stroke severity (NIH Stroke Scale), and frailty risk, correctly predicted 93% of functional independence outcomes (area under the receiver operating characteristic curve 0.808).</p><p><strong>Conclusions: </strong>We present a novel model using 4 clinical factors-stroke severity, time to intervention, thrombolysis use, and frailty risk-to predict functional neurologic independence with 93% accuracy in patients undergoing urgent carotid interventions for acute stroke. This high predictive capability can enhance clinical decision-making and improve patient outcomes by identifying those most likely to benefit from timely carotid revascularization.</p>","PeriodicalId":17140,"journal":{"name":"Journal of the American College of Surgeons","volume":" ","pages":"491-504"},"PeriodicalIF":3.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11913246/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143007382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}