The American Surgeon™

Alterations in gut microbiota are recognized modulators of gastrointestinal and metabolic health, but the clinical relevance of dysbiosis after cholecystectomy remains unclear.

A 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).

The dysbiosis group had significantly reduced Bifidobacterium, Lactobacillus and Bacillus spp, and increased Escherichia coli, Clostridium perfringens, Firmicutes-to-Bacteroidetes (F/B) ratio, Enterococcus spp., Klebsiella spp., and Streptococcus spp. (all P < .05). Alpha diversity analysis revealed lower Shannon index and Chao1 index (all P < .05). Dysbiosis was associated with higher rates of diarrhea (51.4% vs 22.5%, P = .010), abdominal distension (42.9% vs 17.5%, P = .018), and ALT elevation (40.0% vs 17.5%, P = 0.031). The F/B ratio positively correlated with ALT (ρ = 0.46, P = .005), while Bifidobacterium inversely correlated with triglycerides (ρ = −0.41, P = 0.011). Dysbiosis was independently associated with a higher risk of postoperative diarrhea (adjusted OR = 2.87; 95% CI: 1.02-8.05; P = 0.046).

Gut 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.

Accurately predicting perforated appendicitis (PA) preoperatively remains challenging.

We retrospectively studied appendectomy patients with histopathologically confirmed acute appendicitis (2022-2023) to identify predictors of perforation. The primary outcome was histopathologically confirmed perforated appendicitis. Bayesian univariate analysis and Bayesian logistic regression were performed to estimate risk probabilities, with frequentist analyses conducted for confirmation. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.

Of 770 patients with histologically confirmed appendicitis, 155 (20%) had PA. Bayesian univariate analysis demonstrated decisive evidence (BF₁₀ > 100) for several predictors, with C-reactive protein (CRP) (BF₁₀ = 251 079), age (BF₁₀ = 828), and lymphocyte percentage (BF₁₀ = 352) showing the strongest associations. Multivariate Bayesian modeling identified a parsimonious three-variable model comprising CRP, age, and lymphocyte percentage. This model demonstrated good discrimination (AUC 0.78) with high specificity (95.4%) and modest sensitivity (29%). Frequentist analyses confirmed these findings.

A predictive model incorporating CRP, age, and lymphocyte percentage provides a highly specific tool for ruling in perforated appendicitis. This approach may aid in prioritizing surgical urgency and optimizing perioperative management. Prospective validation is warranted.

To evaluate the effect of obesity on postoperative mortality after trauma laparotomies.

A PRISMA-compliant meta-analysis with meta-regression using random-effects modeling was conducted (last search: August 01, 2025). All studies comparing the risk of postoperative mortality in adult patients with and without obesity (BMI ≥30) undergoing trauma laparotomies were included. The certainty of evidence was evaluated using GRADE system.

Nine studies comprising 19,780 patients were included (obesity group: 6474; no obesity group: 13,306). The obesity and no obesity groups were comparable in terms of male sex (RD: −0.03, 95% CI −0.06, 0.00, P = .090), injury severity score (MD: 0.96, 95% CI −0.36, 2.29, P = .160), penetrating mechanism of injury (RD: −0.01, 95% CI −0.03, 0.00, P = .150), and blunt mechanism of injury (RD: 0.01, 95% CI −0.00, 0.03, P = .150). The patients in the obesity group were older (MD: 4.18 years; 95% CI 2.19, 6.18, P < .0001). The risk of postoperative mortality was higher in patients with obesity (OR: 1.33, 95% CI 1.09, 1.64. P = .006). Injury severity score (coefficient: 0.017, P = .004) and blunt mechanism (coefficient: 0.263, P = .017) were associated with an increased risk of mortality; penetrating mechanism (coefficient: −0.263, P = .017) was associated with a reduced risk of mortality; and age (coefficient: −0.004, P = .779) and male sex (coefficient: −0.055, P = .908) did not affect the mortality.

Obesity is associated with increased postoperative mortality in patients undergoing trauma laparotomies (moderate certainty). Injury severity score and blunt mechanism of injury may increase the risk of mortality in obese patients undergoing trauma laparotomies.

HER2-positive (HER2+) invasive breast cancer is more prevalent among Asian American and Pacific Islander (AAPI) women. We evaluated response to neoadjuvant chemotherapy (NAC) to identify disparities among disaggregated AAPI subgroups.

Women with HER2+ breast cancer in the 2018-2020 National Cancer Database who received NAC followed by surgical excision were identified. Patients were categorized as White, AAPI, or Non-White Non-Asian (NWNA), followed by analysis of AAPI subgroups. The primary outcome was pathologic complete response (pCR).

Of 14,110 women, 10,603 (75.1%) were White, 964 (6.8%) AAPI, and 2543 (18.0%) NWNA. Asian American and Pacific Islander patients had the highest overall pCR rate at 43.3% compared with 42.5% in White and 36.1% in NWNA patients (P < .001). Disaggregation revealed heterogeneity: Pacific Islander patients had the lowest pCR rate (35.6%), below both White and NWNA cohorts, while Korean patients had the highest pCR rate (54.6%) (both P < .001). Pacific Islander patients were more likely to present with comorbidities, advanced clinical stage, lymphovascular invasion, and experienced the longest time to chemotherapy. Korean patients were least likely to present with advanced disease, nodal involvement, or lymphovascular invasion and had the shortest time to chemotherapy. On multivariable analysis, nodal positivity, lymphovascular invasion, and increasing time to chemotherapy—not race/ethnicity—were independent negative predictors of pCR.

Disaggregated AAPI data are essential to identify vulnerable subgroups, prioritize timely neoadjuvant therapy, and inform targeted interventions that may reduce disparities in treatment response.

Diverticulitis with abscess (Hinchey Ib or II) is often initially managed nonoperatively with antibiotics and/or percutaneous drainage (PCD). For patients who respond successfully to this approach, it remains controversial whether an elective colectomy (EC) should routinely follow. This systematic review and meta-analysis evaluate and compare the outcomes of two strategies in this population: EC vs continued observation after successful nonoperative management.

We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library through August 15, 2024, for studies comparing EC to continued observation in patients with Hinchey Ib/II diverticulitis who achieved initial successful nonoperative management. Outcomes assessed included recurrence of diverticulitis. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model.

We included four studies comprising 7236 patients. Among these, 1719 patients (24%) underwent EC following initial successful nonoperative treatment, while 5517 (76%) did not undergo elective surgery. The average patient age was 58.5 years, with a mean follow-up of 3.22 years. The mean time to EC ranged from 2 to 6 months. Elective colectomy was associated with a significantly lower recurrence rate (OR 0.14; 95% CI 0.11-0.17; P < .001; I² = 0%) but a higher frequency of stoma formation (OR 1.83; 95% CI 1.51-2.23; P < .001; I² = 0%).

In patients with Hinchey Ib or II diverticulitis who initially underwent successful nonoperative management, subsequent EC was associated with lower odds of recurrence but higher odds of stoma formation.

PROSPERO CRD42024582759.

Although frequent, patient bypass of local surgical care (bypass) remains understudied. No prior work has evaluated the association between bypass and local surgeon workforce density.

This 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.

23.7% 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.

Approximately 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.

This study was performed to determine the amount of waste produced in breast operations in the ambulatory surgery center (ASC) as well as the hospital setting and where potential improvements could be made.

The study was performed at two hospitals and one ASC in Arizona from January 1, 2025 to September 30, 2025. 60 patients at the ASC and 20 patients were included at each hospital. All the disposable items that were opened were documented. All reusable surgical equipment and instruments were documented. At the conclusion of each case, the weight of the waste bags were recorded.

The study included 100 patients who had breast conserving operations. The surgeons used 14/70 (20%) and 14/74 (19%) of the instruments at the two hospitals and 14/50 (28%) of the instruments at ASC. A significantly lower percentage of surgical equipment went unused at ASC vs hospitals (P < 0.01). The average weight of the waste produced was 13.8 lbs and 14.0 lbs at the two hospitals, and ASC 7.97 lbs. The amount of waste produced at the ASC was significantly lower (P < 0.01). The costs of the unused items per case at the two hospitals were $183.78 and $252.07, while the cost at the ASC was $52.35.

Even in small operations, there is significant waste of valuable resources. More specific trays would lessen waste. Waste was greater in hospitals vs the ASC. This may be another cost saving measure of ambulatory surgery center compared to hospital based surgery.

This study aimed to evaluate the association between computed tomography (CT) findings and the development of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) in patients with a hard pancreas.

The medical records of 96 patients who underwent PD and had a hard pancreas were retrospectively reviewed. The estimated functional remnant pancreatic volume (eFRPV), which is a composite preoperative CT-derived parameter reflecting both pancreatic volume and attenuation, was evaluated. Additionally, pancreatic attenuation value (PAV), remnant pancreatic volume (RPV), and main pancreatic duct (MPD) were also assessed. Variables, including eFRPV, were compared between patients with and those without POPF after PD.

Clinically relevant POPF was observed in seven (7.3%) patients. In the preoperative evaluable factors, only the eFRPV (33.3 HU·mL vs 70.8 HU·mL, P = .021) and PAV (32.6 HU vs 40.2 HU, P = .013) were associated with clinically relevant POPF. Remnant pancreatic volume and MPD were not significantly different between two groups. The area under the curve (AUC) was 0.764 for eFRPV and 0.783 for PAV. Although the AUCs for eFRPV and PAV were not significantly different (P = .785), eFRPV showed higher specificity at the point corresponding to 100% sensitivity (62.5% vs 38.2%).

In patients with a hard pancreas, POPF following PD can be predicted using eFRPV assessed by preoperative CT.

Whether prosthetic mesh increases infection in contaminated fields remains controversial, particularly in incarcerated hernias and adult Bochdalek hernia (BH) with gastric pathology.

We 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.

Among 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; P = .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; P = 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.

In 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.

Opioid 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.

This 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.

A 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].

A 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.

Gastric neuroendocrine tumors (gNETs) are rare malignancies with distinct biological behavior compared with gastric adenocarcinoma. Data directly comparing surgical and oncologic outcomes, including lymph node yield, recurrence pattern, and survival, remain limited.

A retrospective review of 285 gastrectomies (2014-2024) identified 20 gNET and 265 adenocarcinoma cases. After excluding palliative procedures and mixed histology, propensity-score matching (1:2.5; age, sex, BMI, and comorbidities) yielded 18 gNET and 45 adenocarcinoma patients. Outcomes included lymph node harvest, nodal metastasis, lymph node ratio (LNR), recurrence pattern, disease-free survival (DFS), and overall survival (OS).

Median lymph node yield was lower in gNET than in adenocarcinoma (18 vs 28; P = 0.004), and the overall rate of nodal metastasis did not differ between groups (44.4% vs 44.4%; P = 1.00), although the nodal metastatic burden was significantly lower in gNET as reflected by a lower median number of positive nodes and lymph node ratio (LNR 0.05 vs 0.17; P = 0.008), with no gNET patient exhibiting pN3 disease. DFS was comparable (21.4 vs 18.7 months; P = 0.617), whereas OS favored gNET (45.3 vs 27.4 months; P = 0.045). Peritoneal recurrence was markedly less frequent in gNET (16.7% vs 81.3%; P = 0.003), while hepatic relapse predominated. Perioperative morbidity and 90-day mortality were similar.

Compared with adenocarcinoma, gastric neuroendocrine tumors show reduced nodal metastatic burden, lower peritoneal dissemination, and improved overall survival. These findings support biology-adapted lymphadenectomy and surveillance for gNET, although validation in larger cohorts is required.

A “smoker’s paradox” has been described in rib fractures for which smokers have demonstrated increased complications but decreased mortality. Alcohol has shown increased mortality risk but the effect of substance use has not been well evaluated. Given the paucity of data surrounding these outcomes, we evaluated the impact of alcohol use, smoking, and substance use disorders on outcomes after traumatic rib fracture.

We performed a five-year retrospective review for all adult patients admitted to our level 1 trauma center with rib fractures. Each outcome was evaluated independently in a stepwise backward regression model for potential confounding factors. We then performed multivariable linear and logistic regression to examine the relationship between alcohol, smoking, and substance use to outcomes.

In total, 3,327 patients were included for review. Smoking was associated with increased morbidity but a paradoxical decreased risk of respiratory failure and a 56% decreased risk of mortality. Substance use disorder had increased risk of respiratory failure and complications but a paradoxical 66% decreased risk of mortality. Alcohol use disorder was associated with increased morbidity with no change in mortality and no paradoxical beneficial outcomes. Both alcohol and substance use disorders were associated with significantly prolonged hospital length of stay.

Despite increased morbidity, both smoking and substance use disorder demonstrated significantly decreased mortality. These findings could support the expansion to a “smoker’s and substance use paradox” in traumatic rib fracture although further study is warranted.

Most 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.

The 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.

A 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 (P < 0.001) and 53% lower risk of ARDS (P < 0.001). Patients who underwent SSRF also required approximately 1 day less of mechanical ventilation (P < 0.001). Patients with ISS 15-19 exhibited an association between SSRF and a 55% (P = 0.023) lower rate of pneumonia.

SSRF 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.

The effectiveness of surgical stabilization of rib fractures (SSRF) in patients with obesity is unknown.

The 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.

39 177 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, P < 0.001), but lower rates of in-hospital mortality (1.7% vs 6.2%, P < 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, P < 0.05).

In 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.

III.

therapeutic/Care management.

Predicting 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.

TA 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.

The 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, P < .001). In regression, DEX remained significantly associated with TA (P < .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 (P = .008).

Changes 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.

Return 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).

A 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 P < .05.

Among 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.

Multiple 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.