ObjectiveTo systematically evaluate the efficacy and safety of ultrasound-guided thrombin injection (UGTI) for the treatment of femoral pseudoaneurysms, analyze the technical factors influencing treatment success, and provide evidence-based guidance for clinical practice.MethodsA systematic search of the PubMed database was conducted to identify clinical studies on UGTI for femoral pseudoaneurysms. Original studies with clearly defined efficacy outcome measures were included. Key data, including technical success rates and complication rates, were extracted. Technical details of the procedure (eg, thrombin concentration, injection dose, and neck management strategies) were summarized and analyzed.ResultsMultiple relevant studies were included. The technical success rate of UGTI for femoral pseudoaneurysms exceeded 90%. The commonly used thrombin concentration ranged from 100 to 1000 U/mL, with a single total injection dose typically between 150 and 750 U (equivalent to an injection volume of 1-5 mL). The overall complication rate was approximately 2%, with distal thromboembolism being the most frequent. For wide-necked or anatomically complex pseudoaneurysms, balloon-assisted UGTI further enhanced treatment safety by effectively preventing limb ischemia resulting from thrombin extravasation. Compared to traditional treatment methods, UGTI demonstrated significant advantages in terms of procedure time, patient comfort, and therapeutic stability.ConclusionUGTI for the treatment of femoral pseudoaneurysms offers the benefits of being a simple, rapid, minimally invasive procedure with definitive efficacy and a low recurrence rate. It has become the first-line treatment option, replacing traditional compression therapy and surgery. Strict adherence to indications, precise ultrasound guidance, and individualized thrombin dosing are crucial for successful treatment. For complex cases, balloon-assisted techniques serve as an important adjunctive strategy.

Most hernia recurrence literature records follow-up periods from one to five years and focus on hernia recurrence. More recent data suggest many ventral hernia repairs have long-term consequences related not only to hernia recurrence but also reoperation and mesh-related complications. The purpose of this project was to evaluate long-term outcomes of ventral hernia repair and compare outcomes between non-recurrent and recurrent hernias repairs. An IRB approved retrospective review of consecutive patients undergoing ventral hernia repair from August 2008 to July 2014 from a prospectively collected database was performed to allow for long-term follow-up. Demographic and surgical characteristics were recorded as well as short-term outcomes. Long-term outcomes including recurrences, mesh-related complications, and hernia reoperation were obtained by retrospective chart review. Recurrence was defined as documentation of a hernia by physical exam or CT imaging. A total of 200 patients were included. The median follow-up was 4322 [2959, 4787] days. Mesh-related complications occurred in 9%, recurrence 21%, and reoperation 19%. In comparing non-recurrent to recurrent hernia repairs, recurrent hernia repairs had a higher rate of mesh complications mesh complications (2.0% vs 16.0% (P < 0.001)), hernia recurrence (16.0% vs 42.0% (P < 0.001)), and reoperation rate (9.0% vs 29.0% (P < 0.001)) Long-term outcomes associated with ventral hernia repair are less than ideal with a high rate of recurrence, reoperation, and mesh-related complications. Recurrent hernia repair was shown to have worse long-term outcomes compared to primary hernias and represent a high clinical burden to surgeon and patient.

Burnout and mistreatment remain persistent challenges in surgical residency, with wide-ranging consequences for both resident well-being and patient care. Much of the existing literature describes the prevalence and causes of resident burnout, but fewer studies provide practical insight into how programs can effectively address it. In 2019, our program enrolled in the Surgical Education Culture Optimization through Targeted Interventions based on National Comparative Data (SECOND) Trial, a national benchmarking initiative that measures resident wellness, work environment, and mistreatment relative to institutions nationwide. Initial SECOND Trial benchmarking demonstrated lowest-quartile (Q4) performance in burnout, emotional exhaustion, suicidal thoughts, and work-life integration, with outlier-level mistreatment across multiple domains relative to national peers. These findings prompted targeted organizational interventions led by residents with sustained faculty partnership. Interventions were centered around three domains: (1) structural and culture-focused initiatives through an inclusive excellence committee that promoted belonging, education on healthcare disparities, and anonymous reporting of mistreatment; (2) wellness initiatives including retreats, family-inclusive social events, protected wellness days, and peer mentorship; and (3) mentorship and professional development through faculty workshops, invited speakers, and resident and faculty recognition programs. By 2024, SECOND Trial benchmarking demonstrated improvement to mid-quartile (Q2) performance in burnout-related domains, including burnout, emotional exhaustion, work-life integration, and suicidal thoughts. Mistreatment measures no longer met outlier criteria, although gender disparities persisted. Our experience provides real-world evidence that structured, organizational interventions can produce measurable improvement in resident well-being and residency culture, while highlighting the continued need to address persistent disparities in surgical training.

BackgroundEffects of preoperative weight loss on bariatric surgery outcomes have been previously studied, but the true association remains unclear. We aim to determine whether duration of a standardized preoperative liquid diet has significant effects on postoperative outcomes.MethodsA retrospective analysis was conducted on 576 patients categorized by preoperative diet duration (2-week vs 4-week). Differences in characteristics were assessed using Pearson Chi-square test for categorical variables and Student's t-test for independent groups for continuous data. Least squares multivariable linear regression modeling was used to assess predictors of total body weight loss percentage (TBWL%) at 1 year with TBWL% at 30 days and 1 year as primary endpoints.ResultsFive-hundred and seventy-six patients were analyzed, with 516 undergoing initial bariatric surgery. Ninety-three patients were enrolled in the 2-week liquid diet; 419 patients were enrolled in the 4-week diet. Patients in the 4-week group lost significantly more weight during the preoperative phase (P < 0.001). There was no difference between 2-week and 4-week diets on TBWL% at 30 days or 1 year. Five-hundred and twelve patients had follow-up at 1 year with age (P = 0.001) and race (P < 0.001) of the only significant predictors of TBWL% at 1 year.ConclusionIn this retrospective, non-randomized cohort, extending the preoperative liquid diet from 2 to 4 weeks did not result in improved postoperative weight loss at 30 days or 1 year. Age and race were the only significant predictors of TBWL% at 1 year in our cohort, underscoring the importance of patient-level biologic and social determinants.

BackgroundSmall intestinal neuroendocrine tumors (SiNETs) are rare tumors with propensity to cause bulky fibrotic mesenteric masses by hematogenous and lymphatic invasion. They exhibit variable oncological behavior and reliable prognostic markers remain elusive. The 8[th] edition American Joint Commission on Cancer introduced mesenteric mass ≥2 cm to improve prognostication. The clinical utility in prognostication remains unknown. We reviewed outcomes of resected SiNETs to determine if computed tomography (CT) size is associated with oncological outcomes.MethodsRetrospective review of resected SiNET patients at two tertiary centers with evaluable preoperative CT scans. Measured the largest diameter of the mesenteric mass and the cutoff of 2 cm used to correlate with oncological outcomes.ResultsSeventy-three patients operated for SiNET with preoperative CT were included. The largest mesenteric mass was <2 cm in 28 and ≥2 cm in 45 patients. Cohorts were similar in demographic and clinical characteristics. Median follow-up was 47 months. Overall survival (OS) and progression free survival (PFS) were similar. No significant differences in estimated mean OS (136 vs 139 months, P = 0.981) or median PFS (90 vs 71 months, P = 0.126) for the <2 cm and >2 cm cohorts, respectively. Univariable analysis failed to show an association between mesenteric size as a continuous variable, and at the ≥2 cmcutoff. Age, cardiac comorbidities, and palliative intent surgery were the only factors that correlated with survival.DiscussionMesenteric mass size on preoperative CT was not correlated with oncological outcomes and by itself showed little utility in preoperative decision-making.

Serous cystadenomas (SCAs) are benign pancreatic cystic neoplasms for which surveillance can be safely discontinued once the diagnosis is established with confidence. However, distinguishing SCAs from premalignant or malignant pancreatic cystic lesions remains challenging despite advances in cross-sectional imaging and endoscopic ultrasound (EUS), resulting in unnecessary pancreatic resection. We performed a retrospective review of all pancreatic resections performed at a single tertiary referral center between January 2010 and December 2022 to identify patients with a final pathological diagnosis of SCA. Demographic, radiographic, operative, and postoperative outcomes were analyzed. Among 556 pancreatic resections, 20 patients (4%) had pathologically confirmed SCAs. The median age was 62 years, 55% were women, and the median cyst size was 3.0 cm. Surgery was performed because malignancy could not be excluded in 40% of patients, concern for a mucinous cystic neoplasm in 35%, and interval cyst growth in 25%. Sixteen patients (80%) underwent preoperative EUS with fine-needle aspiration, but cytology was frequently nondiagnostic and neither confirmed SCA nor reliably excluded a mucinous lesion. Seven patients underwent pancreaticoduodenectomy and 13 underwent distal pancreatectomy. Postoperative morbidity occurred in 50% of patients, including clinically relevant postoperative pancreatic fistula in 30%, with no disease-specific mortality. These findings demonstrate that pancreatic resection for SCAs is driven primarily by persistent diagnostic uncertainty rather than symptoms or malignant potential. Despite contemporary imaging and EUS, confidently differentiating SCAs from premalignant or malignant pancreatic cystic neoplasms remains difficult. Improved diagnostic strategies, including molecular testing and enhanced risk stratification, may reduce unnecessary pancreatic resection while preserving oncologic safety.

BackgroundCurrent post-polypectomy surveillance guidelines rely primarily on baseline polyp pathology, lacking integration of metabolic factors and quantitative growth estimation for individualized interval stratification. This study sought to translate cancer growth modeling concepts into clinically actionable insights for surgical practice.MethodsThis retrospective cohort study enrolled 795 patients who underwent polypectomy and at least one follow-up colonoscopy. Independent prognostic factors were identified and a nomogram was constructed using Cox proportional hazards regression and LASSO Cox regression with 10-fold cross-validation. Interval-based polyp progression was quantified via multivariable linear regression (ordinary least squares, robust regression, and log-transformed models). Model performance was evaluated by receiver operating characteristic (ROC), calibration and decision curve analyses with internal validation.ResultsOver a median follow-up of 13 months, the crude recurrence rate was 80.8%. Abnormal HDL-C, baseline polyp count, and baseline polyp volume were independently associated with shorter time to recurrence in the multivariable Cox model. The model showed moderate and consistent discrimination, with good calibration and positive net benefit across moderate-to-high-risk thresholds. In exploratory progression analyses, baseline polyp count and surveillance interval were robustly positively associated with recurrent polyp number and maximum diameter across all model specifications, while associations of abnormal HDL-C were inconsistent and not significant for diameter outcomes in log-transformed models.ConclusionsIntegrating metabolic biomarkers with endoscopic data may modestly improve recurrence risk stratification, though this added value is limited by inconsistent associations and potential confounding. Prospective studies with adjustment for medication use and metabolic syndrome components are needed for validation.

IntroductionMalignant bowel obstruction secondary to peritoneal carcinomatosis (PC) is a challenging end-stage complication in which operative palliation must balance symptom relief against perioperative burden and limited survival. This study evaluated palliative stoma creation not only as an outcome-based intervention, but as a practical decision-making strategy integrating patient selection, hospitalization burden, and individualized operative planning in anatomically hostile abdomens.MethodsWe retrospectively reviewed 46 patients with PC who developed mechanical intestinal obstruction refractory to conservative management between 2016 and 2025 at a tertiary academic referral center. Demographic characteristics, tumor origin, peritoneal carcinomatosis index (PCI), operative strategy, stoma type, incision location, postoperative outcomes, complications, and survival were analyzed. Hospitalization burden was descriptively assessed as the proportion of median remaining survival spent during the index admission.ResultsThe study included 24 (52.2%) female and 22 (47.8%) male patients with a mean age of 61.5 ± 14.4 years (range 29-91). The mean PCI score was 14.9 ± 4.3; 67.4% of the cases underwent loop ileostomy; and the mean operative time was 95 minutes. Mean time to oral intake was 2.7 days, and median length of hospitalization was 11 days. The overall complication rate was 23.9%, and 30-day mortality was 13.0%. Median survival was 60 days, making the index hospitalization approximately 18.3% of median remaining survival. No significant correlation was observed between PC index and duration of hospitalization (r = 0.071, P = .658) or survival (r = ‒0.242, P = .128), although these negative findings should be interpreted cautiously given the limited sample size.ConclusionPalliative stoma creation provides rapid symptom relief in selected patients with PC and mechanical intestinal obstruction. Its value should be judged less by survival extension than by whether the procedure can restore oral intake, allow discharge, and preserve meaningful time outside the hospital. Individualized surgical planning may facilitate safe palliation when standard stoma construction is limited by hostile abdominal conditions.

The American Joint Committee on Cancer (AJCC) TNM staging system, grounded in morphologic assessment of tumor invasion depth, remains the cornerstone of surgical decision-making and prognostication for colorectal cancer (CRC). However, marked prognostic heterogeneity among patients at identical T stages represents a longstanding clinical challenge that cannot be fully accounted for by conventional morphologic evaluation alone. Epithelial-mesenchymal transition (EMT), the core biological process driving tumor cell invasion and metastasis, may provide a unifying biologic framework to interpret this stage-specific variability. From a surgical perspective, this review summarizes the established clinical and prognostic significance of routinely reported pathologic features-tumor budding, lymphovascular invasion (LVI), and perineural invasion (PNI)-and explores how EMT biology may explain their underlying biological basis. We outline how EMT activation may underpin the aggressive behavior associated with these histologic findings, and how it may account for prognostic heterogeneity in stage II disease. Finally, we outline emerging investigational applications of EMT biology, including biomarker testing, biologically informed margin assessment, and integrated staging systems, and discuss their potential future role in surgical practice.

BackgroundAnastomotic leakage remains one of the most serious complications after esophagectomy and is associated with increased morbidity, mortality, and impaired long-term outcomes. Although various technical modifications have been proposed to reduce leakage, the potential role of standardizing the entire reconstructive procedure has received less attention. We evaluated outcomes after a standardized reconstruction protocol using a narrow gastric conduit and triangular stapled cervical esophagogastrostomy.MethodsWe retrospectively reviewed 115 consecutive patients who underwent subtotal esophagectomy followed by gastric conduit reconstruction with cervical anastomosis at 2 institutions between March 2018 and November 2024. The standardized protocol emphasized preservation of a well-perfused conduit segment, optimization of the reconstruction route, and triangular stapled cervical esophagogastrostomy. Anastomotic leakage was defined and classified according to the Esophagectomy Complications Consensus Group (ECCG) criteria.ResultsAnastomotic leakage was identified in 2 patients (1.7%; exact 95% confidence interval, 0.2%-6.1%), both classified as ECCG Type II. No Type III leaks occurred. Anastomotic stricture developed in 10 patients (8.7%), recurrent laryngeal nerve palsy in 12 (10.4%), and Clavien-Dindo grade IIIa or higher complications in 21 (18.3%). Thirty-day and 90-day mortality were 1.7% and 2.6%, respectively, with no deaths related to anastomotic leakage.DiscussionA standardized narrow gastric conduit reconstruction protocol was associated with a low observed rate of clinically identified anastomotic leakage. Because of the retrospective design, small number of events, and absence of a contemporaneous control group, superiority over historical benchmarks cannot be established.

Prolonged chest tube (CT) duration in traumatic pneumothorax (PTX) is associated with increased complications and greater patient discomfort. This retrospective study characterized clinical and procedural factors associated with prolonged CT duration (>48 hours) in adult patients presenting at a level I trauma center undergoing tube thoracostomy for traumatic PTX between January 2020 and June 2023. Among 203 patients (mean age 46 years; 75% male; 86.7% blunt trauma), the mean CT duration was 77.6 hours. There was no significant difference in initial PTX size between patients who had a normal CT duration and patients who had prolonged CT duration. Prolonged CT duration occurred more frequently with open CT, bilateral CT, ICU admission, mechanical ventilation, supplemental oxygen on arrival, and longer hospital stay. Chest tube duration correlated significantly with higher injury severity score (ISS), higher chest AIS, larger tube size, lower presenting blood pressure, and higher heart rate. These findings suggest that systemic injury burden, rather than PTX characteristics like size, identifies patients likely to require prolonged CT duration.

BackgroundBlunt cardiac injury (BCI) after motor vehicle collisions (MVCs) is potentially life-threatening yet easily missed. We evaluated whether airbag deployment, an observation readily available in the trauma bay, can heighten suspicion for BCI and lower the threshold for cardiac screening.MethodsWe performed a retrospective analysis of the ACS-TQIP database (2017-2021). Adult patients (≥16 years) involved in MVCs were stratified by airbag deployment status (AB vs NoAB). Multivariable logistic regression was used to assess the association between airbag deployment and BCI.ResultsAirbag deployment occurred in 424,912 patients (81.5%). AB was independently associated with an increased likelihood of BCI (OR 1.16, 95% CI 1.07-1.26; p < 0.001). Sternal fracture (OR: 3.23; 95% CI: 3.03-3.44; p < 0.001), sternal contusion without fracture (OR: 2.67; 95% CI: 1.71-4.14; p < 0.001), congestive heart failure (OR 1.24, 95% CI 1.05-1.46; p = 0.013), and prior myocardial infarction (OR 1.40, 95% CI 1.02-1.92; p = 0.039) were associated with increased risk of BCI.DiscussionAirbag deployment was independently associated with BCI, including in low-severity trauma. Although the effect size was modest, airbag deployment is a known on arrival finding that, together with sternal injury, physiologic derangement, and cardiac biomarkers, may help identify patients who warrant BCI screening even when overall injury severity appears low.Level of evidenceLevel III retrospective study.

BackgroundOptimal surgical extent for cT1-2N0 papillary thyroid carcinoma (PTC) remains debated.MethodsThis study included 400 consecutive low-risk cT1-2N0 PTC patients (tumor ≤4 cm, clinically node-negative) who underwent initial total thyroidectomy (TT, n = 250) or lobectomy (LT, n = 150) between 2020 and 2024. The primary descriptive outcome was completion thyroidectomy rate in the LT group; the primary oncologic outcome was recurrence-free survival (RFS). Multivariable regression and propensity score matching identified predictors and adjusted comparisons.ResultsTT was associated with longer operative time, hospital stay, and drainage volume (all P < 0.001). Temporary and permanent hypoparathyroidism were significantly higher after TT (25.2% vs 3.3%; 6.0% vs 0.7%, both P < 0.01), with TT as independent risk factor. At median 36.2 months, RFS favored TT (adjusted HR = 0.37, P = 0.012); however, given only 21 recurrence events, this finding is exploratory. Among LT patients, 34.7% (52/150) ultimately required completion thyroidectomy due to pathologic upgrade. Independent predictors were tumor size (OR = 3.19/cm), multifocality (OR = 4.81), and positive lymph node count (OR = 2.61/node) (all P < 0.01). While tumor size is preoperatively assessable, multifocality and nodal burden are predominantly postoperative findings guiding risk stratification.ConclusionsThe oncologic safety of lobectomy for low-risk PTC is well-established. The key tradeoff is clear: lobectomy markedly reduces permanent hypoparathyroidism (0.7% vs 6.0%) but carries a one-in-three reoperation risk, predicted by tumor size, multifocality, and nodal burden. Although TT showed an exploratory RFS benefit, this finding requires confirmation. These tradeoffs must be explicitly discussed during preoperative counseling to enable informed, preference-sensitive decision-making.

This video demonstrates the use of the single-port (SP) robotic system for ileostomy takedown through the existing stoma site in an 82-year-old female with hypertension, hyperlipidemia, and type 2 diabetes. Four months earlier, she underwent exploratory laparotomy, right hemicolectomy, and ileostomy for bowel ischemia. After an uneventful recovery, she was scheduled for ileostomy reversal using the SP robotic platform. The video demonstrates platform setup with execution of the single-port access port. The key procedural shows the benefits of the SP approach, including reduced invasiveness and enhanced recovery. The patient was discharged on postoperative day one and recovered smoothly. This video is intended to illustrate the applicability of SP robotic platform to ileostomy reversal through the stoma site, with attention to technical strategy, instrument limitations, and operative decision-making relevant surgeons adopting this approach.