Surgical Consultation Research Articles

The Association Between Perinatal Pharmacologic Treatments and Spontaneous Intestinal Perforation in Extremely Preterm Infants: A Propensity Score Matching Study

Background: The impact of perinatal pharmacologic agents on spontaneous intestinal perforation (SIP) in extremely low-birthweight (ELBW, <1000 g) preterm infants remains inconclusive based on findings from retrospective cohort or case–control studies. This study aims to address this uncertainty by using propensity score matching (PSM) to reduce bias. Methods: We retrospectively reviewed ELBW infants in our unit between 2014 and 2023 to identify SIP cases. Confirmed through medical notes, surgical consultation, and author review, each SIP case was matched at a 1:3 ratio using propensity scores on factors including the gestational age (GA), birthweight, gender, and birth year. Pharmacologic agents commonly given antenatally and postnatally were analyzed. Only medications that were started 24 h before the onset of SIP or the corresponding age (PSM-controls) were included. Results: A total of 858 ELBW infants were reviewed, 28 SIP cases (GA 25.3 ± 2.1 weeks, BW 735 ± 167 g) were identified, and 84 PSM-controls were matched. The SIP cases received hydrocortisone (25% (7/28) vs. 9.5% (8/84), p = 0.037) and combined inotropic agents (17.9% (5/28) vs. 2.4% (2/84), p = 0.020) to a significantly greater extent. No differences were observed in the use of other medications. In logistic regression, the use of hydrocortisone and combined inotropes remained independent risks for SIP, with ORs (95% CIs) of 3.4 (1.1–10.9) and 2.1 (1.2–3.8), respectively. Conclusions: This first PSM-based study supported postnatal hydrocortisone and combined inotrope use as independent risks for SIP in ELBW infants. Clinicians should be aware of these risks and remain vigilant for SIP when administering hydrocortisone and inotropes.

A Framework to Optimize Primary Care of Older Surgical Patients: A Qualitative Study of Geriatricians.

An increasing number of older adults are undergoing surgery. Older adults face significant challenges throughout the spectrum of perioperative care. No frameworks exist to support primary care clinicians in helping older adults navigate perioperative care beyond preoperative medical clearance. We aimed to develop a framework to assist primary care clinicians in surgical care navigation for older patients. This qualitative study used semistructured interviews with a sample of geriatricians from across the US between January and June 2022. Interviews were conducted one on one via an online video conferencing platform without observers present. Demographics of participants were analyzed using descriptive statistics. Directed content analysis of interview data was used to examine how primary care clinicians can optimally support older patients throughout the perioperative process. This qualitative study included 24 geriatricians, 16 (67%) women, with median time in practice of 12.4 years (IQR, 5.0-24.5 years). Of those, 11 (46%) worked at an academic or tertiary referral center. Qualitative analysis identified 7 actions that geriatricians perform when caring for patients through the surgical continuum: conduct risk-benefit analysis of surgical referral, elicit and communicate patient goals, prepare patient and family for surgical consultation, set realistic expectations, assist with decision about surgery, advocate for patient and family, and coordinate postoperative care. In this qualitative study of geriatricians, 7 key domains of perioperative care for older adults were identified. The resulting framework can be used by primary care clinicians as they help their older patients navigate surgical care.

P1022 ChatGPT in the management of Inflammatory Bowel Disease, a future or a present reality?

Abstract Background The management of inflammatory bowel disease (IBD) involves complex clinical scenarios, especially when complications arise. Traditionally guided by clinical expertise and established guidelines, artificial intelligence (AI) is now being explored as an adjunct in medical care. This study assesses ChatGPT’s ability to provide IBD management recommendations in both initial and complex cases. By comparing ChatGPT’s responses to both, real-world decisions and medical treatment in European Crohn’s and Colitis Organisation (ECCO) guidelines, the study aims to evaluate AI’s alignment, reliability, and potential in IBD management. Methods A retrospective analysis was conducted of the electronic medical records of IBD patients in both initial and complicated phases. Management recommendations for 19 cases were generated using ChatGPT-4o and then compared with actual treatments and the ECCO guidelines. A gastroenterologist certified by the Mexican Association of Gastroenterology oversaw evaluations across 7 categories: 5-ASA, steroids, antibiotics, thiopurines, anti-TNF agents, anti-integrins, and anti-IL23. Cohen’s Kappa test was used to assess agreement. Results ChatGPT showed perfect agreement (Kappa = 1.000) with healthcare providers and ECCO guidelines for antibiotics, diagnostic workups, symptom management, surgical consultations, monitoring, and anti-IL-23 recommendations. Substantial agreement (Kappa ~0.6–0.8) was observed for 5-ASA and steroids, with minor variations but overall strong alignment. Moderate to fair agreement (Kappa ~0.3–0.5) was noted for anti-TNF and anti-integrins, reflecting variability in complex cases. For thiopurines, agreement was minimal, suggesting differences due to varying thresholds or interpretations (Figure 1). Conclusion ChatGPT displayed a perfect agreement with providers and guidelines in areas such as antibiotics, diagnostic workups, symptom management, surgical consultations, monitoring, and anti-IL-23 therapies, indicating its potential for standardising IBD care. However, discrepancies arise in complex cases involving anti-TNF and anti-integrins, possibly due to the inclusion of newer treatments not yet covered by ECCO guidelines. This underscores the necessity for AI systems to evolve alongside advancing treatment modalities. Differences in thiopurine recommendations highlight the enduring importance of clinical judgement. Notably, there is currently no standardisation in the management of IBD. This study illustrates ChatGPT’s promise as a decision-support tool for standardising IBD care. Future efforts should focus on validating AI to further apply it as an adjuvant in clinical decision-making and tailoring recommendations to individual patients.

Impact of Earthquakes During COVID-19 Lockdown on the Pediatric Injury Pattern in the Zagreb Urban Area.

Background/Objectives: Previous works on the epidemiology of pediatric trauma during the COVID-19 lockdown observed a decrease in pediatric surgical emergency consultations and fracture referrals. None of those works describes a unique situation in which there is the coexistence of another opposing factor, like an earthquake, that influences the number of injured children's referrals. Therefore, this study aimed to investigate the influence of earthquakes during the COVID-19 lockdown on pediatric injury pattern referrals at a tertiary care hospital in a urban setting. Methods: A retrospective single-center case-control study comprised a time interval at the time of the COVID-19 lockdown, starting with a day when the biggest earthquake happened and finishing at the end of the confinement period in Zagreb, Croatia (22 March-27 April 2020). The control group comprised the identical time interval in 2019. We identified all successive pediatric trauma patients referred to the Pediatric Emergency Department. Demographics and leading injury characteristics were analyzed. Results: We analyzed data from 1166 patients. In the case group, the median age was lower than in the control group but without gender differences. We detected a decrease in Pediatric Emergency Department referrals and a reduced proportion of pediatric trauma patients in the case group. Additionally, the proportion of shoulder/elbow injuries and head injuries was higher, and the proportion of foot/ankle injuries was lower in the case period than in the control period. Conclusions: Earthquakes during the COVID-19 lockdown changed the pattern of pediatric injuries. These data can be used to restructure health resources during similar conditions to provide optimal health care to children.

Mild acute biliary pancreatitis: still a surgical disease. A post-hoc analysis of the MANCTRA-1 international study

BackgroundThe current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) to reduce the risk of recurrence. The MANCTRA-1 project revealed a knowledge-to-action gap and higher recurrence rates in patients admitted to medical wards, attributable to fewer ELCs being performed. The project estimated a 35% to 70% probability of narrowing this gap by 2025. This study evaluates the safety of suboptimal ELC implementation and identifies risk factors for recurrent acute biliary pancreatitis (RAP) in patients not undergoing ELC after an MABP episode.MethodsWe conducted a post-hoc analysis of the MANCTRA-1 registry, including MABP patients who did not undergo ELC during the index hospitalization, excluding those with related complications. The primary outcome was the 30-day hospital readmission rate due to RAP. We performed multivariable logistic regression to find risk factors associated with the primary outcome.ResultsBetween January 2019 and December 2020, 1920, MABP patients from 150 centers were included in the study. The 30-day readmission rate due to RAP was 6%. Multivariable logistic regression found the admission to a medical ward (internal medicine or gastroenterology) (OR = 1.95, p = 0.001) and a positive COVID-19 test (OR = 3.08, p = 0.029) as independent risk factors for RAP.ConclusionOur analysis offers valuable insights into the management of MABP, particularly in centers where ELC cannot be fully implemented due to logistical and clinical constraints, worsened by the COVID-19 pandemic. Regardless of the admitting ward, prompt access to surgical care is crucial in reducing the risk of early recurrence, highlighting the need to implement surgical consultation pathways within MABP care bundles.

Early Reinitiation of Obesity Pharmacotherapy Post Laparoscopic Sleeve Gastrectomy in Youth: A Retrospective Cohort Study.

Bariatric surgery is the most effective intervention for severe pediatric obesity, but a subset of youth experience suboptimal weight loss and/or recurrent weight gain. Early re-initiation ofobesity pharmacotherapy postoperatively may improve outcomes, though this has not been evaluated in pediatric populations. A retrospective cohort study at a tertiary care children's hospital evaluated the safety and efficacy of reintroducing obesity pharmacotherapy within six weeks afterlaparoscopic sleeve gastrectomy (LSG). Youth were offered obesity pharmacotherapy reinitiation at their 2-week postoperative visit. The study compared outcomes between 25 youth who chose early obesity pharmacotherapy reinitiation and 21 who received standard care without restarting medication. Primary outcomes included weight trajectory, eating behaviors, complications, readmissions, and reoperation rates, analyzed using independent t-tests, Chi-squared tests, and logistic regressions. Between November 2023 and July 2024, 53 youth had surgical consults, and 46 (86% conversion rate; mean age 16.5 ± 1.9years, mean BMI 53 ± 9.7kg/m2; 70% (32/46) female, 80% (37/46) Hispanic, 87% (40/46) publicly insured) underwent LSG, with 93% (43/46) using obesity pharmacotherapy preoperatively. Mixed-effects multivariate regression, adjusting for baseline BMI, age, and sex, revealed that early reinitiation (5.1weeks [IQR 3.7, 8.4]) significantly reduced BMI, percent BMI, percent total weight loss (TWL), and percent excess weight loss (EWL) at 3 and 6months compared to standard care, with no significant differences in complications or readmissions. At 6months, the mean differences were: %BMI: -6.5% (95% CI: -9.13, -3.86), p < 0.001; %TWL: -5.9% (95% CI: -8.52, -3.25), p < 0.001; %EWL: Reinitiators: -45.5% vs. standard care: -39.4%; meandifference: -8.2% (95% CI: -14.69, -1.63), p < 0.001. Early reinitiation also resulted in a significant reduction in emotional overeating at 3 and 6months compared to standard care, with mean differences of -2.5points (95% CI: -3.29, -1.76), p < 0.001, and -3.5points (95% CI: -4.38, -2.69), p < 0.001, respectivelyon self-reported eating behavior questionnaires. Early obesity pharmacotherapy reinitiation after LSG was safe and well tolerated, improving weight outcomes without negatively impacting complication or readmission rates.

Machine Learning to Detect Cervical Spine Fractures Missed by Radiologists on CT: Analysis Using Seven Award-Winning Models from the RSNA 2022 Cervical Spine Fracture AI Challenge.

Background: Available data on radiologists' missed cervical spine fractures are based primarily on studies using human reviewers to identify errors on re-evaluation; such studies do not capture the full extent of missed fractures. Objective: To use machine-learning (ML) models to identify cervical spine fractures on CT missed by interpreting radiologists, characterize the nature of these fractures, and assess their clinical significance. Methods: This retrospective study included all cervical spine CT examinations performed in adult patients in the emergency department between January 1, 2018 and December 31, 2022. Examinations reported as negative for cervical spine fracture were processed by seven award-winning ML models from the 2022 RSNA Cervical Spine Fracture AI Challenge; examinations classified as positive by at least four of seven models were considered to have ML-detected fractures. Two neuroradiologists independently reviewed examinations with ML-detected fractures, using ML-derived heat maps, to identify those representing true missed fractures. The neuroradiologists further assessed fractures' extent. Two spine surgeons independently assessed whether missed fractures were clinically significant (i.e., warranting at least one of surgical consultation, MRI, CTA, or collar immobilization). Results: The study included 6671 patients (2414 female, 4257 male; mean age, 54.6±22.1 years) who underwent a total of 6979 cervical spine CT examinations. Interpreting radiologists reported 6378 examinations as negative for fracture. Of these, 356 had ML-detected fractures (i.e., positive by ≥4 of 7 models). The neuroradiologists classified 40 of these examinations, in 39 unique patients, as having true fractures. ML-detected missed true fractures involved 51 unique sites, most commonly the C7 transverse process (n=12), C5 spinous process (n=12), and C6 spinous process (n=8). The surgeons considered missed fractures clinically significant in 15/40 examinations [MRI and collar immobilization (n=7), MRI and surgical evaluation (n=1), CTA (n=9)]. Interobserver agreement, expressed as kappa, was 0.88 between neuroradiologists for true fracture classification and 0.94 between surgeons for clinical significance classification. Conclusion: ML models identified cervical spine fractures missed by radiologists. These fractures were further characterized to systematically highlight radiologists' common misses. Clinical Impact: This ML-based framework can be applied in quality improvement efforts, to help refine radiologists' search patterns based on prone-to-miss findings.

A collaborative interdisciplinary approach for trigger finger management.

Stenosing tenosynovitis, or trigger finger, is a common cause of hand disability. This study outlines a trigger finger management protocol that redirects referrals for surgical consultations to conservative management first. The primary outcome variable was the protocol endpoint based on the resolution of trigger finger symptoms (i.e. pain and triggering). Secondary outcome measures were to identify which patient characteristics were associated with an increased need for (i) surgical management and (ii) corticosteroid injections. Retrospective chart review. The study sample included all patients referred for surgical consultation for trigger finger who were redirected to physical therapy first between the dates of August 2018 and January 2023 (n=72). Participants initially received a physical therapy assessment and three treatment sessions. Further management was determined based on patient presentation following our protocol. Descriptive analysis involved frequency calculations of studied variables. Comparison of patient characteristics and treatment modalities across different sub-groups was examined as well as associations between various patient characteristics and increased need for (i) surgical management and (ii) corticosteroid injection. Seventy-two patients were included in the study, and 60 patients completed the protocol. Of these patients, 22% (n=16) resolved with physical therapy (PT) alone, 48.5% (n=35) resolved with 1-2 corticosteroid injections following initial PT management and 12.5% (n=9) were referred back for surgical consult. Sub-group comparisons revealed no significant differences in patient characteristics and treatment modalities across patients who resolved with physical therapy alone, physical therapy plus 1-2 injections, or in cases referred back for surgical consults. The interdisciplinary care protocol in this study demonstrated that conservative management was successful in a majority of cases; facilitating timely access to evidence-based care, including corticosteroid injections and surgical management if necessary. Physical therapy treatment provides self-management and education strategies to those requiring further interventions, potentially reducing recurrence rates.

Peri-Implant Enhancement of the Breast: Imaging Features, Significance, and Management Strategies.

Peri-implant enhancement can be seen on contrast-enhanced breast MRI, but its association with malignancy has not been described, leading to considerable variability in assessment and recommendations by radiologists. This study evaluated imaging features, management, and outcomes of implant-related enhancement. This multisite IRB-approved retrospective review queried all breast MRI reports for keywords describing peri-implant enhancement, fluid, and/or masses (plus synonymous descriptions) and implant-associated malignancies, with subsequent imaging and chart review. Peri-implant enhancement and implant features were characterized. Assessments and outcomes were evaluated via clinical and imaging follow-up, aspiration/biopsy, and/or capsulectomy to evaluate for association of peri-implant enhancement with implant-related malignancy. A total of 100 patients had peri-implant enhancement. Uniform thin peripheral enhancement was most common (79/100, 79%). Capsulectomy was performed in 31/100 (31%), with benign capsular fibrosis/inflammation discovered in 26/31 (83.9%). Breast implant-associated anaplastic large cell lymphoma was present in 2/100 (2%), both with textured implants, while 98/100 (98%) had no implant-related malignancy. MRI recommendations varied: resume routine imaging (26/100, 26%), clinical management (18/100, 18%), follow-up MRI (17/100, 17%), MRI-directed US (17/100, 17%), aspiration/biopsy (11/100, 11%), and surgical consultation (10/100, 10%). Peri-implant enhancement is a nonspecific imaging finding with a low malignant association, especially when seen in isolation (no associated effusion, mass, or adenopathy). Implant surface texture should be considered in management recommendations; diagnostic capsulectomy is not recommended in patients with smooth implants. Additional studies are encouraged to validate nonoperative management recommendations.

Associations between (pharmaco-)genetic markers and postoperative pain after inguinal hernia repair – a prospective study protocol

BackgroundPostoperative pain is a common complication following surgery, with severity and duration varying between patients. Chronic postoperative pain after inguinal hernia surgery has an incidence rate of approximately 10%. Risk factors for acute and chronic pain following hernia surgery include age, sex, psychosocial factors, and demographic background. Additionally, genetic polymorphisms in enzymes involved in pain mechanisms, as well as the metabolism of analgesics might influence pain perception, pain development, and response to pain medications. Key enzymes include the catechol-o-methyltransferase (COMT), the µ-opioid receptor 1 (OPRM1), and the cytochrome P450 2D6 (CYP2D6).CYP2D6 plays a crucial role in metabolizing analgesics such as tramadol, codeine, and oxycodone. It is also suspected to be involved in the synthesis of catecholamines and endogenous morphines suggesting a potential role in pathophysiology of pain. We hypothesize that the CYP2D6 activity influences the development of postoperative pain after hernia surgery.MethodsThis study is a prospective, observational, multicenter association study investigating adult patients scheduled for inguinal hernia surgery using a robotic-assisted (rTAPP) approach. Patients are enrolled during the preoperative surgical consultation. A buccal swab is collected for genetic testing at this time. Pain at the site of the hernia is assessed using the validated EuraHSQoL score preoperatively and at 2, 4, and 6 weeks postoperatively. Additionally, information on co-medication and details of the surgery will be collected. The planned number of participants is 350 patients. The primary objective is to analyze the association between different genotype-predicted CYP2D6 phenotypes and patient-reported pain intensity 6 weeks after surgery. Secondary objectives include the association between further genetic variants, such as the COMT rs4680 and OPRM1 rs1799971 genotype, and pain severity. Additionally, the potential of pharmacogenetic panel testing to optimize analgesic therapy in hernia surgery patients will be explored.DiscussionThe findings of this study are expected to provide valuable insights into identifying patients at higher risk for postoperative pain before surgery. This knowledge could pave the way for tailored interventions during and after surgery for these specific patients.Trial registrationDeutsches Register Klinischer Studien https://www.drks.de/DRKS00034796 Registered on August 07, 2024.

Optimizing the Use of Computed Tomography for Appendicitis Diagnosis in the Pediatric Emergency Department Through the Quality Improvement Methodology.

Acute appendicitis is one of the most common causes of an acute abdomen among pediatric patients. The diagnosis of appendicitis is challenging due to the nonspecific presentation. Diagnosis is based on historical, physical, and serologic information as well as right lower quadrant ultrasound (RLQ US). In equivocal patients, or those with a high degree of suspicion, computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast can be utilized to rule in appendicitis. However, optimizing diagnostic protocols to minimize ionizing radiation exposure while maintaining diagnostic accuracy is important. We performed a monthly retrospective analysis of CT usage among pediatric patients with suspected acute appendicitis presenting to the pediatric emergency department (ED) from June 2023 to December 2023. We used quality improvement methodology to decrease CT use with monthly Plan-Do-Study-Act (PDSA) cycles with an aim to decrease CT use by 50%. The main intervention was coordination between the ED and surgical providers to require surgical consult before ordering a CT. We quantified the number of patients who received a surgical consult before CT, the number of RLQ US performed, the number of CTs performed, and the number of appendectomies, specifically the number with perforation. A total of 249 patients under 18 years of age presented to the pediatric ED with symptoms of acute appendicitis during the study period. All 249 patients underwent an initial RLQ US.The number of CTs performed decreased from a baseline of 14 in June to a nadir of four in September (71% decrease, p=0.029). There was a decrease in the percentage of patients who underwent a CT scan after an RLQ US from 36.5% in June to 11.8% in September after our intervention. In June, a total of 38 RLQ USwere performed and 14 patients underwent additional CT (36.5%) and in September a total of 34 US were performed and 14 patients underwent additional CT (11.8%).There was an increase in the surgical consults rate from a baseline of seven surgical consults with 14 total CTs in June 2023 (50%) to seven consults with a total of seven CTs performed(100%) in December 2023. There was no increase in appendiceal perforation rates. Multidisciplinary discussions between pediatric ED physicians and pediatric surgeons reduced CT usage, and corresponding radiation exposure and cost, in the evaluation of appendicitis.

What do patients with lumbar spinal stenosis think is physical therapy’s best card? A survey of perceived message strength

ABSTRACT Objectives Rising surgical rates for lumbar spinal stenosis (LSS) and underutilization of physical therapist services for this condition may increase patient risks and healthcare costs. Patient beliefs may also contribute to this problem. Therefore, our objective was to determine which messages about physical therapy were perceived as strongest by patients with LSS and whether those messages were influenced by patient factors. Methods The study used a cross-sectional survey design, and participants were patients of outpatient physical therapy clinics with imaging or clinical evidence of LSS. Participants completed an electronic survey containing different messages about physical therapist services for LSS. Messages were designed using the health belief model. Perceived message strength was scored using the perceived argument strength scale (PASS). Pain catastrophizing and pain self-efficacy were measured to determine whether they influenced participant perceptions. Occurrence of magnetic resonance imaging and surgical consultations were also measured. Results Of 189 potential participants, 101 were included in the study. The message perceived as strongest emphasized physical therapists as listeners who would customize a plan (PASS 36.1 [5.0]) Similar scores were seen for messages that emphasized benefits of education and self-management and de-emphasized severity. The message that emphasized research findings was rated the least strong. Participants who had high levels of pain catastrophizing were more likely to have had imaging and perceived arguments as less strong. Discussion/Conclusion Results of the current study suggested patients with LSS preferred a message that emphasized physical therapists as listeners who would customize a plan. The message about research outcomes was perceived as the least strong. Therefore, awareness campaigns intended to influence the beliefs or behavior of patients with LSS should emphasize the individualized nature of physical therapy more than research evidence.

Characteristics of Intravenous Fluid Infiltration and Factors Associated With Adverse Events: A Multicenter Retrospective Study.

Peripheral intravenous (PIV) infiltration and extravasation are common complications of intravenous fluid administration. Here, we aim to investigate risk factors associated with major adverse events following PIV infiltration, which may help risk stratify those who require early surgical consultation. Retrospectively, patients were identified who had a documented PIV infiltration or extravasation event at 3 academic hospitals between 2015 and 2022. A major adverse advent was defined as a full-thickness injury requiring operative management (deep infection, compartment syndrome). A minor adverse event was defined as superficial injury (cellulitis, superficial thrombosis). In total, 160 patients with PIV infiltration events were included (37.5% men), with an average age of 64.1 years. A surgical consult for a hand specialist was placed 35% of the time: orthopedic surgery in 46.4% of cases and plastic surgery in 42.9%. Among these consults, 87.5% recommended supportive treatment (elevation, warm/cold compresses, serial examinations). Major adverse events occurred in 4.4% (n = 7) of patients, and minor adverse events occurred in 11.3% (n = 18). Both intensive care unit (ICU) admission and current intubation status (ie, intubated, sedated, and nonexaminable) at the time of infiltration were significantly associated with adverse events (P = .02 and P = .03, respectively). Current intubation status was significantly associated with operative management (P = .001). Robust characterization of PIV infiltration events may facilitate early identification of patients at risk of serious complications. We found ICU admission and current intubation both to be associated with adverse events following PIV infiltration. Further work should be done to evaluate the risk of infiltration with different fluid types (vesicant, nonvesicant).

Shared decision-making during surgical thyroid consultation

INTRODUCTION. Shared decision-making (SDM) enables individually tailored treatment plans. This survey explored patients’ and surgeons’ perceptions of SDM in consultations on thyroid nodules. Furthermore, we aimed to explore possible discrepancies between the groups, identify factors influencing patients’ perceived levels of SDM and evaluate decisional regret. METHODS. A prospective survey study was conducted among patients attending surgical consultations for thyroid nodules. Patients and surgeons completed SDM questionnaires to measure perceived levels of SDM. Six-month decisional regret was assessed by the Decisional Regret Scale. RESULTS. The median SDM scores were 86.7 (interquartile range (IQR) = 20) and 80.0 (IQR = 28.9) for patients and doctors, respectively, showing a significant mean difference of 7.9 (95% confidence interval: 4.0-11.8; p &lt; 0.001) with higher scores for patients than surgeons. A high SDM score was positively associated with preliminary examinations (p = 0.04) but not with other consultation types or sociodemographic factors (SDF). A total of 12.2% of patients showed decisional regret. Regret was not correlated with the patient’s SDM score (Spearman's rank correlation coefficient = −0.06; p = 0.6). CONCLUSIONS. Patients and surgeons reported high levels of perceived SDM. Perceived levels of SDM and decisional regret were not associated with SDF, except for the consultation type. Factors affecting the perceived SDM level remain largely unknown and could be identified by adding objective SDM measures in future studies. FUNDING. None. TRIAL REGISTRATION. Not relevant.

Blunt Force Trauma

Purpose. This case report describes the evidence-based work-up of blunt force ocular trauma that resulted in a zygomaticomaxillary fracture. Sequelae of blunt trauma, management, and referral for surgical consultation will be reviewed. Material and Methods. A patient presented for an eye examination following a referral from dentistry after receiving a computerized tomography (CT) scan that confirmed orbital fracture to rule out globe injury prior to maxillofacial surgery. The patient underwent a comprehensive dilated examination to evaluate vision, anterior and posterior segment structures. Results. The examination revealed a sub conjunctival hemorrhage and eyelid edema, with no other signs of ocular trauma. After the comprehensive examination, the patient was educated on the finding of a subconjunctival hemorrhage and was reassured regarding the self-limiting and benign nature of the condition. The patient was cleared for maxillofacial surgery and instructed to return to the clinic for refraction and to rule out any delayed sequelae of ocular trauma. Conclusion. Blunt force trauma to the eye can cause a host of ocular sequelae that may present as acute or delayed signs and symptoms. These sequelae can be managed by optometrists in hospital and outpatient settings. It is important to be aware of the potential long-term sequelae and how to treat, manage, or refer these patients. Reassurance is important when patients present with ocular signs that appear more alarming than they are. Education is imperative to preventing reoccurrence of trauma and to motivate the patient to remain compliant with the treatment plan.

Spontaneous Rupture of Splenic Artery Aneurysm: A Case Report and Review of the Literature

Introduction: Splenic artery aneurysms are uncommon and typically asymptomatic. However, they pose a high risk of mortality if they rupture. Case Report: This case report describes the occurrence of a spontaneous rupture of a splenic artery aneurysm in a 55-year-old man with no known previous diseases, no trauma history, and no risk factors for developing an aneurysm who applied to the emergency department with abdominal pain. The diagnosis was determined with an urgent abdominal computed tomography angiography scan. The patient received urgent surgical intervention consisting of splenectomy and excision of the splenic artery aneurysm. Conclusion: The rupture of a spontaneous splenic artery aneurysm is a rare and fatal disease that necessitates urgent diagnosis and treatment. Spontaneous splenic artery aneurysm usually develops without any noticeable symptoms and is frequently discovered by chance. In the event of a rupture, it can lead to abrupt abdominal pain and hypovolemic shock and the mortality rate is high. Ultrasound, Computed Tomography, Magnetic Resonance Imaging, and abdominal aortic arteriography are the methods of imaging that are used to diagnose splenic artery aneurysms. The key elements in patient management include prompt resuscitation, diagnostic imaging, surgical consultation, and subsequently performing a laparotomy. In our case, the diagnosis was determined using emergency contrast-enhanced Computed Tomography and was treated with open surgery, specifically splenectomy and excision of the splenic artery aneurysm.

Comparison between pancreatojejunostomy and pancreaticogastrostomy in pancreaticoduodenectomy in a gastroenterology and hepatology teaching hospital

Background: Pancreatoduodenectomy (PD) is a surgical procedure used to treat diseases of the pancreatic Head, the distal common bile duct (CBD), and the duodenum, as well as trauma to the head of the pancreas. Once the pancreatic head and the duodenum are resected, the surgeon needs to reconnect the stomach, the biliary tract, and the pancreatic stump. The technique for reconstructing the biliary tract is fairly standard, represented by the anastomosis of the CBD to the jejunum, but the reconstruction of the pancreatic stump is a matter of debate. In general, two procedures can be used: pancreaticojejunostomy (PJ), which is an anastomosis between the pancreatic stump and the jejunum, and pancreaticogastrostomy (PG), which is an anastomosis between the pancreatic stump and the stomach. Aim: The objective of this study was to compare the impact of PJ and PG on the occurrence of postoperative pancreatic fistula (POPF), morbidity, and mortality following PD. Patients and Methods: This study took place between April 1, 2021 and April 1, 2023 at Gastroenterology and Hepatology Teaching Hospital in Baghdad Medical City. The cases in the study were designed prospectively. It is a comparison between PG and PJ after undergoing Whipple surgery. A total of 30 patients were selected and divided into two groups. The first group consisted of 16 patients who underwent PJ, while the second group consisted of 14 patients who underwent PG. The cases were prepared in the surgical consultation clinic. On the one hand, through PG, it was determined whether the texture of the pancreas was soft and the size of the main pancreatic duct (MPD) was less than 3 mm. On the other hand, through PJ, it was determined whether the texture of the pancreas was firm or hard and the size of the MPD was more than 3 mm. Results: The age group of males and females ranged from 11 to 68 (median 57) years. There were a total of 16 males and 14 females. The ampullary tumor was present in 11 patients of the PJ group and 7 patients of the PG group. Histopathology of tumors showed adenocarcinoma in 13 patients of the PJ group and in 6 patients of the PG group. POPF occurred in 3 patients of the PJ group, type A in 1 patient and type B in 2 patients, and no POPF was observed in the PG group. Hemorrhage occurred in 1 patient of the PG group and 2 patients of the PJ group. Delayed gastric emptying occurred in 5 patients: 3 patients of the PJ group (type A) and 2 patients of the PG group. SSI (surgical site infection) occurred in 7 patients: 5 patients of the PJ and 2 patients of the PG group. Finally, mortality occurred in 3 patients of the PJ group. Conclusion: Pancreatic intestinal anastomosis must be tailored to the surgeon's preferences and experience level, and any innovative technique that reduces the prevalence of POPF is welcome in pancreatic surgery. PG seems to be associated with less POPF, morbidity, and mortality than PJ after undergoing Whipple surgery, especially given the soft texture of the pancreas and the size of the MPD &lt; 3 mm. Recommendations: 1. Because our study included a limited number of samples, further prospective randomized studies with larger samples are required to confirm that PG had fewer complications. 2 Surgeons should be encouraged to use PG more frequently in the future.

Ensuring goal-aligned care in a busy surgical practice

The US population is aging. Accordingly, older adults with multiple comorbidities and geriatric syndromes will present in increasing numbers for surgical consultation. Incorporating patient goals into surgical treatment decisions is recommended by a joint guideline from the American Geriatrics Society and American College of Surgeons, the American Society of Colon and Rectal Surgeons, the Geriatric Surgery Verification program, and the Institute for Healthcare Improvement as part of building Age-Friendly Health Systems, however uptake has been slow. The aim of this review is to provide a framework for how patient goals can be elicited and used in real-world surgical practices to achieve goal-aligned care.

Evaluating the Importance of Return to Sports and Hamstring Strength in a Discrete Choice Experiment for Anterior Cruciate Ligament Injury.

With emerging treatments for anterior cruciate ligament (ACL) injury, analysis of patient preferences is lacking to align clinical care and research with patient priorities. To identify patient priorities for outcomes after surgical intervention if they were to sustain an ACL tear, analyze what outcome measures influenced preferences, and determine whether patient demographics influenced preferences. Cross-sectional study. The authors screened patients aged 18 to 30 years who presented for upper extremity complaints to a single institution in 2023. Patients were excluded for current lower extremity injury or history of a knee injury requiring surgical consultation. The authors designed a discrete choice experiment through literature review of outcome measures for bridge-enhanced ACL restoration (BEAR) and ACL reconstruction (ACLR) with hamstring tendon autograft. Measures included return to sports, risk of arthritis, risk of reinjury, and hamstring strength. Patients chose surgery A (ACLR with hamstring tendon autograft) or surgery B (BEAR) and then rated the importance of each outcome measure on their selection. In total, 100 participants (36 female; mean age, 25.1 ± 4.0 years) completed the discrete choice experiment. Overall, 56.0% participated in sports and 80.0% were employed. Based on surgery choice group, there were no significant differences in sex, age, Marx Activity Scale score, sports participation, or employment status between patients who selected BEAR or ACLR with hamstring tendon autograft (all P > .361). Return to sports and hamstring strength were significant priorities for patients in procedure selection (P ≤ .011). Of the patients who selected ACLR with hamstring tendon autograft, 31.6% would not elect to undergo this procedure. In this discrete choice experiment of adults without prior ACL injury, return to sports and hamstring strength were identified as patient priorities when selecting a procedure for ACL injury. Risk of reinjury, however, was not a significant factor in procedure selection. Importantly, these priorities were maintained regardless of patient characteristics, activity level, or employment status.

A rare case of acute colonic pseudo-obstruction leading to colonic perforation in a ventilated patient with cerebrovascular accident

Acute pseudo-colonic obstruction in a patient with a functioning ileocecal valve can be risky, resulting in closed-loop obstruction, significant distention of the colon, and increased chances of colon perforation and ischemia if diagnosis and timely non-operative treatments are delayed. We report a case of acute pseudo-colonic obstruction with closed-loop obstruction, resulting in colon perforation in a ventilated patient with a cerebrovascular incident. The situation was promptly identified during the first assessment with a surgical consultation and imaging study, resulting in timely surgical intervention which included removing the diseased section of the right colon, creating an end ileostomy, and colostomy. The postoperative contrast study of the remaining colon and colonoscopy confirmed the pseudo-obstruction without finding any blockages in the distal colon and rectum. After the operation, the patient recovered well and was sent home. In conclusion, early clinical suspicion, diagnosis, and prompt management of a complicated ACPO result in a good patient outcome.