Vanguard Health Systems

Acute compartment syndrome (ACS) is a surgical emergency most commonly associated with trauma. A less common variant, acute exercise-induced compartment syndrome (AEICS), occurs without direct injury and is rarely seen in strength athletes. We report a case of a 50-year-old male powerlifter who developed AEICS of the right lower leg following an 815-lb squat. He presented with delayed onset right calf pain, weakness, and creatine kinase (CK) elevation exceeding 93,000 IU/L. Despite an emergent four-compartment fasciotomy, he sustained a persistent right foot drop. This case highlights the diagnostic challenge of AEICS in nontraumatic settings, the potential role of anabolic steroids as a predisposing factor, and the importance of timely recognition and decompression to prevent permanent neurologic deficits.

OBJECTIVES:R1 margins after biliary tract cancer (BTC) resection confer a high recurrence risk. The roles of adjuvant chemoradiotherapy and treatment timing remain incompletely defined. We compared overall survival (OS) with adjuvant chemotherapy (AC) versus adjuvant chemoradiotherapy (ACRT) and assessed whether treatment delay modifies outcomes in R1-resected BTC. METHODS:This retrospective National Cancer Database study included adults with intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), or gallbladder cancer (GBC) diagnosed from 2011 to 2019 who underwent R1 resection and received adjuvant therapy. Treatment was categorized as AC or ACRT and stratified by initiation timing: timely (<60 d) versus delayed (≥60 d). Kaplan-Meier analyses, log-rank tests, and multivariable Cox regression compared OS, adjusting for age, sex, race/ethnicity, facility type, Charlson-Deyo comorbidity score, and stage. RESULTS:Of 87,340 BTC patients, 1182 (1.4%) met inclusion criteria; 616 (52.1%) initiated therapy within 60 days, and 566 (47.9%) had delayed treatment. Groups were: timely AC (29.6%), delayed AC (26.2%), timely ACRT (22.5%), and delayed ACRT (21.7%). Timely ACRT was associated with improved median OS versus timely AC (25.2 vs. 13.7 mo; HR: 0.59, 95% CI: 0.48-0.73; P<0.001). Site-specific analyses demonstrated OS benefit with ACRT in ECC and GBC, but not ICC. In GBC, delayed ACRT remained associated with improved OS. CONCLUSIONS:In R1-resected BTC, ACRT was associated with improved OS over AC alone, particularly in ECC and GBC. In GBC, delayed ACRT still conferred benefit, suggesting radiotherapy may mitigate the adverse impact of treatment delay in high-risk patients.

Postoperative recovery represents a complex, multidimensional process that extends beyond the technical success of surgery, encompassing the restoration of physiologic stability, functional capacity, and patient-centered well-being. Recovery trajectories are highly variable, influenced not only by baseline patient characteristics but also by modifiable determinants spanning physiologic, behavioral, and system-level domains. This narrative review synthesizes current evidence on the interplay among these factors, highlighting mechanistic pathways, contextual modulators, and opportunities for targeted optimization. At the patient level, physiologic reserve, including nutritional status, sarcopenia, frailty, metabolic control, and comorbidities, defines the capacity to tolerate surgical stress and engage in functional recovery. Behavioral determinants, encompassing early mobilization, structured rehabilitation, patient engagement, perioperative education, and multimodal pain management, translate physiologic potential into meaningful postoperative outcomes. These factors operate synergistically, with behavioral interventions mitigating vulnerabilities such as frailty or sarcopenia while amplifying gains from physiologic optimization. System-level determinants, including multidisciplinary perioperative pathways, coordinated surgical home models, telemonitoring platforms, and implementation science-driven frameworks, provide the structural scaffolding necessary to ensure fidelity, adaptability, and scalability of interventions. Digital health technologies and predictive analytics offer additional mechanisms to monitor recovery trajectories, identify deviations early, and personalize care in real time. The integration of patient-level, behavioral, and system-level determinants is nonlinear and context-dependent, with interactions modulated by institutional resources, patient risk profiles, and care culture. Effective perioperative optimization requires a holistic, reproducible framework that aligns physiologic enhancement, behavioral engagement, and system-level support, enabling dynamic adaptation to individual patient needs. This review emphasizes that recovery is not a passive outcome but a mechanistically coherent, modifiable, and measurable process. By conceptualizing postoperative recovery as an integrated, adaptive, and precision-guided continuum, clinicians and health systems can improve functional outcomes, reduce complications, and advance patient-centered surgical care across heterogeneous populations.

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract and is often asymptomatic in adults. When symptomatic, adult presentations frequently involve obstruction or inflammation and can be difficult to diagnose preoperatively due to nonspecific imaging findings. We report a case of a healthy 31-year-old male with progressive abdominal pain, distention, and emesis, ultimately found to have a high-grade small-bowel obstruction refractory to conservative management. Diagnostic laparoscopy identified a Meckel's diverticulum tethered to the retroperitoneum at the transition point, and laparoscopic diverticulectomy relieved the obstruction. Histopathology demonstrated a true diverticulum without ectopic mucosa. This case highlights the importance of maintaining Meckel's diverticulum in the differential diagnosis of unexplained small-bowel obstruction in younger adults and highlights the value of timely operative exploration when conservative therapy fails.

Gallbladder dyskinesia (GBD) is a functional biliary disorder characterized by biliary colic in the absence of cholelithiasis or mechanical obstruction and is identified by reduced gallbladder ejection fraction (EF) on cholecystokinin (CCK)-stimulated hepatobiliary scintigraphy. Patients may experience significant symptoms due to impaired gallbladder contractility and bile stasis despite the absence of gallstones or inflammatory structural abnormalities on imaging. We present a 42-year-old male with a three-month history of episodic right upper quadrant (RUQ) pain triggered by fatty meals. Abdominal ultrasound demonstrated no cholelithiasis, sludge, wall thickening, or pericholecystic fluid. Contrast-enhanced computed tomography (CT) revealed a distended gallbladder without obstructing gallstones or inflammatory changes. CCK-hepatobiliary iminodiacetic acid (HIDA) scintigraphy demonstrated a markedly reduced gallbladder EF of 2%, consistent with severe contractile dysfunction. The patient underwent an uncomplicated laparoscopic cholecystectomy. Histopathology revealed mild chronic cholecystitis and cholesterolosis. At follow-up, he reported complete resolution of symptoms and tolerance of a normal diet. This case highlights the diagnostic value of functional biliary imaging in symptomatic patients without gallstones or inflammatory structural abnormalities. Profound reduction in gallbladder EF may correlate with severe biliary dysmotility and favorable postoperative outcomes.