The American Surgeon™

The Brain Injuries in Greater East Texas (BIGTEX) criteria were developed to identify patients with mild traumatic brain injury (mTBI) who may be managed at Level IV trauma centers (L4TCs). This study compared outcomes of mTBI patients treated at a Level I trauma center (L1TC) vs affiliated L4TCs.

A 10-year retrospective review of mTBI admissions was performed. Patients were grouped by location: L1TC or L4TC. Adverse events included neurological deterioration, worsening CT scan, neurosurgical intervention, or death. At L4TCs, patients received routine emergency care with neurological assessments performed by trauma-trained staff. Decisions to transfer were made by the treating emergency physician, independently or in consultation with the affiliated L1TC, using established transfer pathways.

Seventy-four patients were included: 63 treated at the L1TC and 11 at L4TCs. The L1TC group met BIGTEX criteria; several L4TC patients had minor deviations, including low-dose aspirin (n = 5), intraparenchymal hemorrhage 5-7 mm (n = 1), and subarachnoid hemorrhage (focal n = 1; diffuse n = 2). All presented with GCS 14-15, no intoxication, polytrauma, or skull fractures. All remained neurologically stable, with no neurosurgical interventions or deaths. L4TC patients had more CT scans (median 3 vs 2), slightly longer hospital stays (3 vs 2 days), shorter ICU stays (0 vs 2 days), and lower hospital charges ($30,236 vs $38,076).

Selected mTBI patients, including those with minor BIGTEX deviations, were managed at L4TCs without observed adverse outcomes. These findings support the feasibility of local management in carefully selected patients and warrant prospective validation in broader rural trauma populations.

Definitions 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.

Patients 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.

There 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, P < 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).

The 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 IV.

Prognostic and Epidemiological.

The purpose of this descriptive study was to characterize the utilization and outcomes of CPB after trauma.

This 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.

There 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%) (P = .009), higher rate of hypotension (SBP <80 mmHg) 15 (71%) (P = .002) were more common in CPB≤2-hours. Septal (P = .001) and valvular (P = .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 (P = .002), aorta repair was more common in CPB 2-24 hours (P = .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 P > .05). Mortality was 22% with 96% of them undergoing CPB in the first 24 hours (P < .001).

CPB 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 IV; Therapeutic/Care Management.

Fournier gangrene (FG) remains a life-threatening necrotizing infection with persistently high mortality despite advances in surgical and supportive care. Reliable early prognostic markers are therefore essential. The C-reactive protein–albumin–lymphocyte (CALLY) index, which integrates inflammatory, nutritional, and immune status, has shown prognostic value in several critical illness settings, but its utility in FG has not been adequately evaluated.

This multicenter retrospective cohort study included 136 adults who underwent surgical treatment for FG between 2015 and 2025. Demographic variables, comorbidities, laboratory parameters, qSOFA scores, and 30-day outcomes were analyzed.

The 30-day mortality rate was 17% (23/136). Non-survivors had significantly lower albumin and lymphocyte levels, higher CRP levels, and markedly reduced CALLY indices compared with survivors (0.005 vs 0.039, P < 0.001). The CALLY index demonstrated strong discriminative performance for 30-day mortality (AUC = 0.886; 95% CI: 0.780-0.991). A cutoff ≤0.012 provided 82.6% sensitivity and 95.6% specificity. In multivariate analysis, CALLY ≤0.012 (OR 42.61; P < 0.001) and qSOFA score 2-3 (OR 12.97; P = 0.019) emerged as strong independent predictors of mortality, whereas age, sex, uncontrolled diabetes, CAD, immunosuppression, and malignancy were not independently associated with death.

The C-reactive protein–albumin–lymphocyte (CALLY) index was independently associated with 30-day mortality in patients with Fournier gangrene and may serve as a simple adjunctive biomarker for early risk stratification when interpreted alongside established clinical scoring systems such as qSOFA. Incorporating the CALLY index into early risk-stratification algorithms may facilitate timely clinical decision-making and more targeted management strategies for high-risk FG patients.

Computed tomography (CT) is the preferred imaging modality for diagnosing acute appendicitis in adults. However, the optimal contrast protocol remains debated, balancing diagnostic accuracy, operational efficiency, and patient safety.

To systematically compare the diagnostic accuracy and operational efficiency of different CT contrast protocols—oral, intravenous (IV), combined oral + IV, and non-contrast—in adult patients with suspected acute appendicitis.

A comprehensive search of MEDLINE, Embase, Cochrane Library, and Web of Science was conducted from inception to April 2025. Eligible studies compared CT contrast protocols in adults (≥18 years) and reported diagnostic or operational outcomes. Two independent reviewers screened articles, extracted data, and assessed risk of bias using the QUADAS-2 tool. Primary outcomes were sensitivity, specificity, positive predictive value, and negative predictive value; secondary outcomes included time to CT completion and emergency department (ED) length of stay.

Seventeen studies involving 5033 patients met inclusion criteria. Non-contrast CT demonstrated sensitivity of 82.4-90.5% and specificity of 75-100%. Oral contrast-only protocols showed sensitivity of 73.5% and specificity of 80%. Combined oral + IV protocols achieved sensitivity of 89.4-100% and specificity of 54.5-98.5%. IV-only protocols provided sensitivity of 77.8-100% and specificity of 87-100%. Across studies, eliminating oral contrast reduced ED length of stay by 29-91 minutes without compromising diagnostic accuracy.

IV-only or non-contrast CT protocols offer comparable diagnostic accuracy to oral contrast approaches while significantly improving workflow efficiency. Protocol selection should consider clinical setting and patient factors, reserving oral contrast for select groups such as oncology patients or those with prior abdominal surgery.

Umbilical or paraumbilical hernia repair is relatively common in general surgical procedures, including laparoscopic and open repair. However, there is currently insufficient evidence to prove which surgical approach is related to better postoperative outcomes.

The meta-analysis was based on the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The related studies were searched and retrieved from major databases (PubMed, Cochrane, and Web of Science). Both random and fixed-effects models were used to calculate the pooled effect size.

Nine observation studies and four randomized controlled trials (RCTs) involving 5458 patients were finally analyzed. The open group shows a longer duration of hospital stays (MD = −71.01; 95% CI: −108.52, −33.51; P = 0.0002), a higher incidence rate early complications (OR = 0.46; 95% CI: 0.27, 0.77; P = 0.003), and recurrence (OR = 0.14; 95% CI: 0.08, 0.26; P < 0.00001) compared with the laparoscopic group. The subgroup analysis of open repair types showed a higher incidence of recurrence rate (P = 0.008) in the open suture group compared to the open mesh group. Notably, in comparison with the laparoscopic group, early complications (P = 0.01 and P = 0.0003) and recurrence (P = 0.04 and P < 0.00001) were more common in the open repair with and without mesh groups separately.

In umbilical or paraumbilical hernia patients, compared to the laparoscopic repair, hospital stays, early complications, and recurrence were more common in the open repair. Moreover, a higher incidence rate of recurrence was observed in the open suture repair compared with the open mesh repair.

The prognostic significance of high-risk features (HRFs) in stage II colon cancer is established, but the cumulative impact of multiple HRFs and their relation to stage III disease remain unclear. This study evaluated whether patients with stage II colon adenocarcinomas with ≥3 HRFs demonstrate survival outcomes comparable to stage III disease.

A retrospective analysis included 377 patients who underwent curative resection for colon adenocarcinoma between 2016 and 2022. Patients were classified as stage II <3 HRFs (n = 102), stage II ≥3 HRFs (n = 88), and stage III (n = 187). Clinicopathologic variables were compared, and overall (OS) and disease-free survival (DFS) were analyzed.

Patients with stage II ≥3 HRFs demonstrated 5-year OS and DFS rates of 58.9% and 57.8%, significantly worse than stage II <3 HRFs (79.4% and 74.5%) and comparable to stage III (71.2% and 61.3%) (P = .037, P = .040). Subgroup analysis confirmed that stage II ≥3 HRFs had worse OS and DFS than <3 HRFs (P = .010, P = .017), but outcomes were comparable to stage III (P = .126, P = .600). On multivariate analysis, predictors of worse OS included age ≥65, stoma formation, <12 lymph nodes, and elevated CEA, while DFS was adversely influenced by age ≥65, stoma formation, tumor volume >30 cm³, <12 lymph nodes, elevated CEA, and stage III disease.

Stage II colon cancers with ≥3 HRFs demonstrate survival outcomes comparable to stage III, emphasizing the cumulative prognostic impact of multiple risk factors. These findings reinforce adjuvant chemotherapy consideration and highlight the need for refined risk stratification.

Choosing Wisely Guidelines recommend against routine sentinel lymph node biopsy (SLNB) for early-stage, hormone-receptor positive (HR+), clinically node negative (cN0) breast cancer (BC) in elderly women. To determine the applicability of this guideline to men, we evaluated pathologic nodal positivity (pN+) between men and women with low-risk HR+, cN0 BC.

The National Cancer Database was queried for patients ≥70 years who underwent surgical resection for low-risk, HR+, cN0 BC. Low-risk was defined as grade 1, cT1mi-T1c or grade 2, or cT1mi-T1b. pN+ was evaluated and compared by sex.

Of 708 men and 123 855 women, 13.0% of men were pN+ compared to 7.7% of women (P < 0.001). Men presented with older age, more comorbidities, advanced stage, lymphovascular invasion, tumor upstaging, and a higher nodal burden (all P < 0.001). Men were more likely to undergo axillary lymph node dissection (P = 0.002), but there were no differences in adjuvant chemotherapy or endocrine therapy between pN+ men and women. There were no differences in 5-year overall survival (84.0% vs 85.3%, P = 0.80).

Men ≥70 years with low-risk cN0 breast cancer have nearly double the rate of nodal positivity compared with women, indicating that SLNB omission cannot be directly extrapolated from female-based guidelines and should instead be considered on an individualized basis.

To synthesize evidence on outcomes of treatment strategies for management of primary hepatic artery aneurysms (HAAs).

A PRISMA-compliant systematic review was conducted. Due to rarity of the disease, all reported cases which underwent operative or endovascular intervention for true HAA were pooled from case reports and case series to create a single cohort of patients. Descriptive statistics, logistic regression models, and Kaplan-Meier statistics were used for analyses.

62 patients from 41 case reports and one case series were included. The mean age was 60.9 and 77% were male; 66% were symptomatic with pain as the most common symptom (76%). The mean diameter and length of aneurysms were 47.4 mm and 55.8 mm, respectively. The anatomy of aneurysm was hostile in 39% and 11% were ruptured at presentation. In terms of treatment, 74% were treated via operative approach and 26% via endovascular approach. Hostile anatomy was the only predictor for selecting operative approach (OR: 8.72, P = .031). Technical success was achieved in 98%; postoperative mortality and morbidity occurred in 5% and 16%, respectively. The probabilities of graft patency at 60 months were not different between the operative and endovascular approaches (86% vs 90%, P = .961); however, the probability of recurrence-free survival was higher after operative approach (100% vs 85%, P = .046).

Accepting type 2 error and confounding by indication as the limitations, both operative and endovascular techniques seem to be safe and feasible in management of true HAA. Hostile anatomy may be the main determinant of selecting operative approach over the endovascular approach.

Follicular thyroid carcinoma (FTC) behaves differently from papillary thyroid carcinoma. Although early-stage FTC generally has favorable outcomes, risk within AJCC stage I-II is not uniform, and robust evidence focusing exclusively on this group is limited.

We identified 4220 patients with AJCC stage I-II FTC in the SEER database (2010-2022). The primary endpoint was disease-specific survival (DSS). We estimated cumulative incidence functions (CIFs) for thyroid cancer–specific and other-cause mortality and evaluated prognostic factors using Fine-Gray competing-risk regression. Multivariable modeling and nomogram construction were not pursued because only one variable met significance in univariable analyses.

Across follow-up, other-cause mortality exceeded thyroid cancer–specific mortality; at ∼10 years, other-cause death was ∼6% while thyroid cancer–specific death remained <1.5%. In competing-risk regression, AJCC stage II was the sole significant predictor of thyroid cancer–specific mortality vs stage I (SHR 7.76; 95% CI 2.09-28.8; P = 0.002). Other demographic, tumor, and treatment variables were not significant or were non-estimable due to sparsity.

Early-stage FTC shows low cancer-specific mortality overall, but risk is concentrated in stage II, underscoring clinically meaningful heterogeneity within “early stage.” These findings support stage-attuned counseling and follow-up and highlight the importance of competing-risk methods when interpreting outcomes in FTC.

Hypoalbuminemia is associated with worse postoperative outcomes, but data is limited in the bariatric population. Patients with BMI ≥50 may represent a higher-risk group for malnutrition.

We analyzed MBSAQIP data (2015-2022) for patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Propensity score matching was used to control for 22 preoperative variables. We compared 30-day outcomes and bariatric-specific complications in patients with albumin <3.5 g/dL vs ≥3.5 g/dL across four groups: SG with BMI ≥50 (analysis 1), RYGB with BMI ≥50 (analysis 2), SG with BMI <50 (analysis 3), and RYGB with BMI <50 (analysis 4).

Among 728,915 patients, matched cohorts in analyses 1 (n = 17,548), 2 (n = 9459), 3 (n = 16,025), and 4 (n = 6787) had similar preoperative characteristics. Hypoalbuminemia was associated with increased complications across all groups. In patients with BMI ≥50, hypoalbuminemia was significantly associated with increased mortality (SG 0.2% vs 0.1%, P = 0.011; RYGB 0.3% vs 0.1%, P < 0.001), unplanned ICU admission (SG 1.0% vs 0.7%, P = 0.020; RYGB 1.6% vs 1.2%, P = 0.034), and non-home discharge (SG 0.8% vs 0.5%, P < 0.001; RYGB 0.9% vs 0.6%, P = 0.009). These mortality differences were not observed in patients with BMI <50.

Hypoalbuminemia is associated with higher complications rates after bariatric surgery and increased mortality in patients with BMI ≥50. Preoperative nutritional optimization is strongly recommended in this high-risk group.

Personality assessments have been widely used in business to identify leadership potential and enhance team performance; however, their integration into surgical education remains limited. This study evaluated surgeons’ personality profiles using the PRISM assessment and compared them with those of other health care professionals to guide the design of leadership development curricula for surgical training.

A total of 199 surgeons (residents, fellows, and faculty) across multiple academic medical centers completed the PRISM personality assessment as part of structured leadership development programs. Data were compared with a normative cohort of 5887 health care professionals from the SurePeople database. Primary and under-pressure personality profiles were analyzed using chi-square and Fisher’s exact tests, with significance set at P < .05.

No significant differences were found between surgeons and other health care professionals in primary personality distributions. Under-pressure profiles, however, revealed a greater proportion of surgeons classified as the Navigator type (22% vs 14%; P = .05), reflecting tendency towards higher decisiveness and structure in stressful conditions. Personality distributions were similar across residents, fellows, and attending surgeons.

Although surgeons’ baseline personalities mirror those of other health care professionals, their stress-related behavioral tendencies demonstrate a unique shift toward structured, action-oriented responses. Incorporating personality assessments such as PRISM into leadership curricula may enhance self-awareness, emotional intelligence, and team performance.

Integrating structured personality assessment into surgical leadership education provides valuable insight into behavioral responses under stress and supports the development of adaptive, emotionally intelligent leaders who foster effective and collaborative surgical teams.

Surgical costs per procedure may vary by surgeon due to operating time and equipment selection.

Cost and materials data were analyzed using an institutional database from a large academic, quaternary care center. The analysis included 475 thyroidectomy-coded operations performed by 13 surgeons from department A (n = 6) and department B (n = 7) between 2021 and 2023.

Mean time cost of procedures was significantly lower for department A surgeons by $112 compared to department B (p = .03). There was no statistically significant difference between the material cost of procedures between departments (p = .40). The highest average material cost for a single surgeon was $1590 with the lowest being $523, demonstrating the high degree of variability between surgeons.

Examining cost of materials alone, the highest and lowest-cost-ranked surgeons had a difference of $1067. Standardization of surgical trays and avoidance of outlier materials may be future avenues for research in decreasing costs.