This study aimed to evaluate the impact of hospital blunt intestinal injury (BInI) trauma volume on time to surgery in patients with BInI. The diagnosis of BInI is challenging, even for trauma experts, leading to frequent delays in necessary surgical intervention. The 2017-2020 ACS-TQIP database was used to identify patients 18 years or older with full-thickness ileal, jejunal, or colonic perforation secondary to blunt trauma. Hospitals were stratified by the annual volume of BInI. Multivariable logistic regression adjusting for demographics, comorbidities, and injury characteristics/severity was used to study the impact of hospital trauma volume on delayed surgery (>24 hours) and outcomes (eg, mortality, sepsis). Sensitivity analyses were performed classifying hospitals by their volume of (1) blunt trauma and (2) all trauma admissions. Out of a total of 4,005,762 trauma patients, 3954 were included: 1397 (35.3%) in low BInI volume, 1373 (34.7%) in medium BInI volume, and 1184 (30%) in high BInI volume hospitals. The mean time to surgery was 18 ± 46 hours in low-volume compared with 15 ± 45 hours in high-volume hospitals ( P < 0.001). On multivariable analysis, high BInI volume was independently associated with early surgery [adjusted odds ratios (aOR) for delayed surgery: 0.68, 95% CI: 0.53-0.88] and a 42% lower risk of post-injury sepsis (aOR: 0.58, 95% CI: 0.37-0.91) compared with low BInI volume. High blunt trauma and all trauma hospital volumes were similarly associated with early surgery (aOR: 0.65, 95% CI: 0.51-0.84; aOR: 0.66, 95% CI: 0.51-0.85, respectively). High trauma hospital volume is independently associated with prompt surgical intervention and improved outcomes in patients with BInI. These findings highlight the importance of clinical trauma experience and available resources for trauma care in early diagnosis and management of the rare and tricky intestinal injuries.

Characterize the additive value of endoscopic ultrasound (EUS) and fine needle aspiration (FNA) when applying specific surgical thresholds for pancreatic cystic neoplasms (PCNs). When characterizing PCNs, MRI assesses lesion morphology, while EUS can confirm morphology and assess malignant risk through cyst fluid aspiration. Currently there is limited understanding of the additive benefit of sequential testing. An institutional registry was queried for patients with an MRI and EUS for a PCN. Morphologic high-risk features (MHRF): mural nodule, pancreatic duct dilation, thickened/enhanced wall were assessed on both modalities. Clinical courses were assessed for development of high-grade dysplasia/cancer on surgical pathology or surveillance. Diagnostic accuracy was established on surgical pathology. Receiver operating curves and decision-curve analysis were conducted to qualify the benefit afforded by each modality. Of 3,702 registry patients, 1,674 met inclusion criteria. MRI detected MHRF in 462(28%) and EUS in 400(24%), with discordance in 436(26%). Morphologically negative MRI and EUS yielded a +FNA in 5%. MHRF on EUS but not MRI occurred in 187, with a confirmed upgrade rate of 66%. MHRF on MRI but not EUS occurred in 249, with 92% remaining cancer-free on surveillance (median:49 [23-78] months). In 215 surgical patients, EUS following normal MRI improved specificity by 14%, with MRI+EUS+FNA improving specificity to 38%. MRI+EUS+FNA demonstrated superior AUC versus MRI (P=0.022). Decision-curve analysis demonstrated EUS provides greatest clinical benefit in MRIs without MHRF when combined with FNA. EUS and FNA provide a considerable contribution to clinical decision-making in MRIs without MHRF. Retrospective registry cohort study.

International medical graduates (IMGs) play a critical role in the United States physician workforce and are essential to sustaining access to surgical care, particularly in underserved communities. Despite their contributions, IMGs pursuing surgical training continue to face significant systemic, financial, cultural, and institutional barriers. To examine the historical role, workforce contributions, challenges, and future implications of IMGs within the U.S. surgical workforce and identify opportunities to better support their integration into surgical training and practice. IMGs comprise a substantial portion of the U.S. physician workforce but remain underrepresented in many surgical specialties. Persistent barriers include licensing requirements, financial burden, limited access to clinical and research opportunities, visa restrictions, bias within training environments, and reduced match success rates compared with U.S. medical graduates. This article synthesizes presentations from the American Surgical Association Inclusive Excellence Forum and incorporates current literature regarding IMG participation in U.S. surgical education, workforce trends, residency training, and professional advancement. IMGs contribute significantly to clinical care, academic medicine, healthcare leadership, and culturally competent patient care. However, structural barriers within recruitment, credentialing, residency training pathways, and immigration processes continue to limit equitable access to surgical careers. Preliminary surgical positions, visa-related constraints, and cultural bias remain major challenges affecting IMG trainees and practicing surgeons. IMGs are indispensable to the future of the U.S. surgical workforce. Institutional support, mentorship, equitable recruitment practices, expanded residency opportunities, and immigration policy reform are necessary to strengthen IMG integration and ensure continued access to high-quality surgical care.

An endoscopically placed duodenal-jejunal bypass liner (DJBL) may provide a safe adjunctive therapy for those with poorly controlled type 2 diabetes mellitus (T2DM) and obesity. Although some endoscopic therapies have been shown to improve glycemic indices secondary to weight loss, small bowel interventions may have direct metabolic effects. A meta-analysis of observational studies demonstrated reduction in HbA1c by 1.3% at 1 year after DJBL in patients with T2DM and obesity. This was a multicenter, double-blind, randomized, sham-controlled trial comparing DJBL to sham procedure with medical management and lifestyle modification. Primary endpoints included mean difference in changes in HbA1c at 12 months between arms, and device-related serious adverse events (SAEs). Secondary endpoints included percent total weight loss (%TWL) and subjects achieving HbA1c≤7% and TWL≥5% at 12 months. Three hundred twenty subjects were randomized to DJBL (n=212) and sham (n=108). Baseline HbA1c and BMI were 8.79±0.92% and 38.45±5.75kg/m 2 . On modified intent-to-treat analysis, change in HbA1c at 12 months was -1.10±1.45% and -0.28±1.54% for DJBL and sham groups, respectively ( P =0.0004). Rate of device-related SAEs was 9.4% including intolerance (3.7%), hemorrhage (2.8%), and hepatic abscess (2.3% stopping study early). At 12 months, DJBL group experienced greater weight loss compared with sham (7.7±9.6% TWL and 2.1±5.4% TWL, respectively; P <0.0001), with significantly more patients achieving HbA1c ≤ 7% (28.3% vs. 9.4%; P <0.0003) and TWL ≥ 5% (60.4% vs. 21.3%; P <0.0001). DJBL met primary glycemic control efficacy and primary safety endpoints, while providing clinically significant weight loss, and comorbidity improvement.

Ambulatory surgery centers now perform more than 60% of the 60 million elective surgical procedures in the United States, yet artificial intelligence research in surgery has focused almost exclusively on hospital-based implementations. This evidence gap has implications for technology validation, investment decisions, and patient safety as ASCs adopt hospital-validated systems without setting-specific evidence. We conducted a scoping literature review searching PubMed, Scopus, Web of Science, and Cochrane Library from January 2020 through September 2025 for studies explicitly examining AI or machine learning applications in ASCs with quantitative outcomes. A parallel search using hospital-related terminology enabled direct comparison of research volume. After screening 847 potentially relevant articles, fewer than 10 studies specifically examined AI in ASC settings, while more than 500 hospital-based studies were identified during the same period. Existing ASC research focused on predictive analytics for workflow optimization; no studies examined intraoperative AI applications. The limited amount of ASC-specific research makes it unclear if hospital-validated benefits translate across settings to ASCs. A profound evidence gap exists between ASC surgical volume and ASC-focused AI research. The operational characteristics that distinguish ASCs from hospitals position them as ideal research settings for rigorous AI validation. Systematic ASC research is urgently needed to inform implementation decisions and establish data-standardization, technical, and economic frameworks required for the setting where most surgical patients receive care.