Tracheal Stenosis in Open Versus Percutaneous Tracheostomy.

OBJECTIVE: This study aims to investigate if there is an increased risk of developing tracheal stenosis after tracheostomy with an open versus percutaneous tracheostomy. METHODS: The patient cohort included patients receiving open or percutaneous tracheostomies at Catholic Health Initiatives Midwest facilities from January 2017 to June 2023. The primary aim was to compare the differences in the risk of developing tracheal stenosis between open and percutaneous tracheostomy techniques. Between-technique differences in the risk of developing tracheal stenosis were assessed via a Cox proportional hazard model. To account for death precluding patients from developing tracheal stenosis, death was considered a competing risk. RESULTS: A total of 828 patients met inclusion criteria (61.7% open, 38.3% percutaneous); 2.5% (N = 21) developed tracheal stenosis. The median number of days to develop tracheal stenosis was 84 (interquartile range: 60 to 243, range: 6 to 739). Tracheal stenosis was more frequent in patients who received a percutaneous tracheostomy (percutaneous: 3.5% vs. open: 2.0%); however, the risk of developing tracheal stenosis was statistically similar between open and percutaneous techniques (HR: 2.05, 95% CI: 0.86-4.94, p = 0.108). CONCLUSIONS: This study demonstrates no significant difference in the development of tracheal stenosis when performing an open versus a percutaneous tracheostomy. Tracheal stenosis is a long-term complication of tracheostomy and should not influence the decision about the surgical technique used.

Frequency and Characteristics of Social Media Use among General Surgery Trainees.

INTRODUCTION: With increased social isolation due to COVID-19, social media has been increasingly adopted for communication, education, and entertainment. We sought to understand the frequency and characteristics of social media usage among general surgery trainees. MATERIALS AND METHODS: General surgery trainees in 15 American training programs were invited to participate in an anonymous electronic survey. The survey included questions about demographics, frequency of social media usage, and perceptions of risks and benefits of social media. Univariate analysis was performed to identify differences between high users of social media (4-7 h per week on at least one platform) and low users (0-3 h or less on all platforms). RESULTS: One hundred fifty-seven of 591 (26.6%) trainees completed the survey. Most respondents were PGY3 or lower (75%) and high users of social media (74.5%). Among high users, the most popular platforms were Instagram (85.7%), YouTube (85.1%), and Facebook (83.6%). YouTube and Twitter were popular for surgical education (77.3% and 68.2%, respectively). The most reported benefits of social media were improving patient education and professional networking (85.0%), where high users agreed more strongly about these benefits (P = 0.002). The most reported risks were seeing other residents (42%) or attendings (17%) with unprofessional behavior. High users disagreed more strongly about risks, including observing attendings with unprofessional behavior (P = 0.028). CONCLUSIONS: Most respondents were high users of social media, particularly Instagram, YouTube, and Facebook. High users incorporated social media into their surgical education while perceiving more benefits and fewer risks of social media.

APDS Consensus Statement: Ideal Senior Medical Student Experiences for Preparedness for General Surgery Internship.

OBJECTIVE: Guide optimal standards on ideal senior medical student experiences for preparedness for general surgery internship DESIGN: Work product of task force, approved by the Association of Program Directors in Surgery CONCLUSION: General surgery rotations should mirror the learning and working environment of a surgical intern. Opportunities should mimic the next phase of learning to help guide informed decisions regarding entrustability for entry into residency training. These opportunities will also help identify students who may have an aptitude for pursuing a general surgery internship. Students should achieve entrustability in Association of American Medical Colleges Core Entrustable Professional Activities (EPAs); curricula should align Core EPAs and modified American Board of Surgery EPAs to guide essential general surgery components. Experiences should include required night, holiday, and/or weekend shifts, a dedicated critical care experience, and a resident preparatory curriculum focusing on nontechnical and essential technical skills. We encourage the opportunity for additional surgical mentorship and subspecialty experience through Surgical Interest Groups or Surgical Honors or Specialty Tracks.

Partial anomalous pulmonary venous return in a patient undergoing left upper lobectomy for adenocarcinoma of the lung: A case report.

INTRODUCTION: Partial anomalous pulmonary venous return (PAPVR) is a rare congenital heart disease that complicates surgical management of pulmonary pathology. CASE PRESENTATION: This case describes the successful management of a 73-year-old female with a left upper lobe adenocarcinoma and pre-operative discovery of left superior anomalous pulmonary venous return into the innominate vein. This patient presented to our clinic for evaluation regarding her newly discovered adenocarcinoma of the lung. Here, we also discuss findings in the literature for management of these patients regarding the importance of preoperative evaluation to determine the extent to which a lobectomy will alter pulmonary function with special emphasis on identifying patients at risk of increased shunting leading to cardiopulmonary failure. CONCLUSION: Consideration should focus on the extent of the shunting, the presence of symptoms, and underlying right heart strain or pulmonary hypertension.

Cytoreduction with hyperthermic intra peritoneal and intra thoracic chemotherapy for metastatic Sertoli-Leydig cell tumor of the ovary.

Sertoli Leydig cell tumor (SLCT) is a rare sex-cord stromal tumor of the ovary that generally has a benign course. Here, we report an unusual case of recurrent, metastatic SLCT and its unique management with a combination of cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, hyperthermic intrathoracic chemotherapy, and systemic chemotherapy.

Malignant Degeneration of Biopsy-Proven Hamartoma to Chondrosarcoma.

Pulmonary hamartomas are benign lesions that are often managed conservatively in the absence of respiratory symptoms. Increasing reports of malignant transformation question if a more aggressive treatment or surveillance practice for these lesions is warranted in adult patients. Herein, we describe a case of a 67-year-old man with a long history of pulmonary hamartoma that demonstrated malignant degeneration into spindle cell malignancy with chondromatous differentiation. This case illustrates the aggressive nature of sarcomatous disease arising from hamartomas and, with a handful of other cases in the literature, points to the question of whether pulmonary hamartomas arising in late adulthood should follow a more intensive treatment or surveillance algorithm given increased concern for malignant potential.

Burnout and its relationship with perceived stress, self-efficacy, depression, social support, and programmatic factors in general surgery residents.

BACKGROUND: Burnout affects surgical residents' well-being. OBJECTIVE: We sought to identify factors associated with burnout among surgery residents. METHODS: An electronic/anonymous survey was sent to surgical residents at 18 programs, consisting of demographic/programmatic questions and validated scales for burnout, depression, perceived stress, self-efficacy, and social support. Residents were grouped into quartiles based off burnout, and predictors were assessed using univariate and multivariate analyses. RESULTS: 42% of residents surveyed completed it. Burnout was associated with depression, higher perceived stress/debt, fewer weekends off, less programmatic social events, and residents were less likely to reconsider surgery if given the chance. Low burnout was associated with lower depression/stress, higher social support/self-efficacy, more weekends off per month, program mentorship, lower debt, and residents being more likely to choose surgery again if given the chance. On multivariate analysis, higher depression/perceived stress were associated with burnout, and lower burnout scores were associated with lower stress/higher self-efficacy. CONCLUSIONS: Burnout in surgery residents is associated with higher levels of depression and perceived stress. The addition of programmatic social events, limiting weekend work, and formal mentoring programs may decrease burnout.

Pulmonary Atypical Adenomatous Hyperplasia: Diagnostic and Therapeutic Implications.

Lung cancer still remains one of the most common cancers throughout the world, especially in smokers. Adenocarcinoma is now the predominant histological type in many western countries. The etiology of adenocarcinoma is unknown, but evidence suggests that atypical adenomatous hyperplasia (AAH) may act as a precursor lesion. Here we present two case reports of patients diagnosed with AAH on biopsy, highlighting 1) available treatment strategies and 2) AAH's progression to adenocarcinoma. A review of AAH is warranted as little literature is currently available regarding its treatment strategies, especially in light of its role as a precursor to adenocarcinoma. In this review, we will address the following topics: 1. What is the pathophysiology of AAH? 2. What is the natural history of AAH and its risk of malignant transformation? 3. When is surgery recommended? 4. What is the role of stereotactic body radiotherapy (SBRT) in the rare patient who refuses surgery?

Factors IX, XI, and XII: potential therapeutic targets for anticoagulant therapy in atherothrombosis.

Atherosclerosis is a leading cause of cardiovascular and neurological ischemic events. Plaque rupture leads to the exposure of highly thrombogenic material with blood and results in the activation of the coagulation cascade, thrombus formation, and embolic events. Although antiplatelets and anticoagulants are used to prevent thromboembolic episodes, bleeding episodes remain the major adverse effect. Decreased ischemic events have been reported while comparing oral rivaroxaban and apixaban with aspirin to improve the therapeutic outcome in several clinical trials, including Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects with Acute Coronary Syndrome-Thrombolysis in Myocardial Infarction 51, Apixaban for Prevention of Acute Ischemic and Safety Events, and GEMINI-ACS-1 phase II clinical trials. However, there were bleeding episodes. Thus, there is an unmet need for better therapeutic strategies. Therefore, the current focus is to target Factors IX, XI, and XII to develop safer and efficient strategies. In this article, we critically reviewed and discussed the limitations of current therapies and the potential of targeting Factors IX, XI, and XII for anticoagulant therapy in atherothrombosis.

Perioperative nutrition.

Perioperative nutrition is a vitally important yet often overlooked aspect of surgical care. Significant disparity exists between evidenced-based recommendations and practices encouraged by traditional surgical teaching. The metabolic response to surgical stress is complex. Poor nutrition has been demonstrated to correlate with adverse surgical outcomes. Perioperative nutrition encompasses preoperative, intraoperative, and postoperative care. Preoperative nutritional assessment identifies at-risk patients who benefit from supplementation before surgery. Prehabilitation seeks to prepare patients for the impending surgical stress. Immunonutrition seems to provide a benefit, although its precise mechanisms are unknown. This article provides a review of the current state of perioperative nutrition.

Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations.

OBJECTIVE: The objective of this study was to assess the impact of preoperative anemia (hematocrit <39%) on postoperative 30-day mortality and adverse cardiac events in patients 65 years or older undergoing elective vascular procedures. BACKGROUND: Preoperative anemia is associated with adverse outcomes after cardiac surgery, but its association with postoperative outcomes after open and endovascular procedures is not well established. Elderly patients have a decreased tolerance to anemia and are at high risk for complications after vascular procedures. METHODS: Patients (N = 31,857) were identified from the American College of Surgeons' 2007-2009 National Surgical Quality Improvement Program-a prospective, multicenter (>250) database maintained across the United States. The primary and secondary outcomes of interest were 30-day mortality and a composite end point of death or cardiac event (cardiac arrest or myocardial infarction), respectively. RESULTS: Forty-seven percent of the study population was anemic. Anemic patients had a postoperative mortality and cardiac event rate of 2.4% and 2.3% in contrast to the 1.2% and 1.2%, respectively, in patients with hematocrit within the normal range (P < 0.0001). On multivariate analysis, we found a 4.2% (95% confidence interval, 1.9-6.5) increase in the adjusted risk of 30-day postoperative mortality for every percentage point of hematocrit decrease from the normal range. CONCLUSIONS: The presence and degree of preoperative anemia are independently associated with 30-day death and adverse cardiac events in patients 65 years or older undergoing elective open and endovascular procedures. Identification and treatment of anemia should be important components of preoperative care for patients undergoing vascular operations.

Conservative management of traumatic lung hernia.

Traumatic lung hernia is a rare entity. The majority of cases reported in the literature have been treated surgically with early thoracotomy to prevent strangulation of pulmonary tissue. We report the case of a 63-year-old patient who experienced a 20-foot fall, causing multiple rib fractures with a lung hernia that was managed conservatively for 48 hours followed by spontaneous resolution of the herniated pulmonary segment. There is a need to review the indications for surgical versus conservative approach in the management of posttraumatic lung hernia.

Duodenocaval fistula from inferior vena cava filter penetration masquerading as lower gastrointestinal bleeding.

Asymptomatic penetration of the inferior vena cava (IVC) wall with retrievable filters is not uncommon. Occasionally, this can be a cause for morbidity, and rarely for mortality. We present a case of duodenocaval fistula, secondary to penetration from a strut of retrievable IVC filter that presented as lower gastrointestinal bleeding and discuss the subsequent management. Although newer generation retrievable filters provide a longer time for retrieval, they are associated with an increased incidence of IVC wall penetration, caudal migration, and occasionally symptomatic presentation, thereby necessitating surgical intervention. Close follow-up is warranted, and prompt retrieval of such devices should be done when their use is no longer indicated.