Joseph D. Bozzay

Background: Choledocholithiasis complicates 10–15% of patients undergoing cholecystectomy. While endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy is common, access to ERCP is inconsistent in rural and military hospitals, highlighting the role for single-stage laparoscopic common bile duct exploration (LCBDE). Methods: We describe a technical approach for fluoroscopy-guided, wire-based transcystic LCBDE using standardized endovascular tools, the “Biliary Endovascular Toolkit”. We performed a retrospective review of five patients undergoing cholecystectomy and transcystic LCBDE at our military hospital between May 2024 and October 2025. The operative technique employed percutaneous micropuncture sheath access, fluoroscopy-guided transcystic wire cannulation of the ampulla, and balloon dilation with sphincteroplasty for stone clearance. Results: Five patients (mean age 35.4 years) underwent single-stage cholecystectomy with transcystic LCBDE. Transcystic cannulation, duodenal wire access, and ductal clearance were successful in all cases (100%), without conversion or postoperative ERCP (0%). Mean operative time was 208 min (range 161–275). No patient experienced postoperative pancreatitis, pleural complications, or other 30-day adverse events. Conclusions: The Biliary Endovascular Toolkit offers a standardized, wire-guided workflow for transcystic LCBDE using off-the-shelf equipment. This technical note provides a practical framework for general surgeons managing choledocholithiasis, particularly in resource-limited settings.

Introduction: Hemorrhage from traumatic injuries remains the leading cause of preventable death on the battlefield, with the majority of fatalities occurring before patients reach surgical care. Acoustic Gunshot Detection (AGD) technology, such as SoundThinking (formerly ShotSpotter) in civilian settings and Boomerang III in military applications, offers the potential to reduce prehospital time intervals through rapid detection and localization of gunfire. This narrative review examines the current evidence regarding AGD’s impact on time to treatment, prehospital transport, and potential applications in future large-scale combat operations (LSCO). Materials and Methods: A narrative review was conducted of published civilian and military literature evaluating the performance and outcomes associated with AGD technology. Key studies assessing AGD impact on prehospital time metrics, injury severity, resource utilization, and patient outcomes were analyzed. Additionally, the review explores the tactical and operational relevance of AGD systems for modern and future military engagements, particularly in austere and contested environments anticipated during LSCO. Results: Civilian studies suggest AGD systems may reduce response times by police and Emergency Medical Services (EMS), with some demonstrating shortened scene and transport intervals. However, the evidence remains inconsistent regarding improved patient survival or clinical outcomes. Acoustic Gunshot Detection-related patients often presented with more severe injuries and required greater resource utilization, yet mortality outcomes were not consistently different from non-AGD counterparts. In the military context, AGD systems like Boomerang have proven useful for threat localization but are not yet integrated into medical evacuation workflows. The utility of AGD in LSCO may lie in its potential to cue earlier Tactical Combat Casualty Care (TCCC) and point-of-injury interventions, rather than simply reducing transport times. Key challenges include system survivability, false positive rates, and vulnerability to electronic warfare. Conclusions: Acoustic Gunshot Detection technology shows promise for enhancing prehospital care by potentially accelerating recognition of gunfire events and initiating earlier medical responses. Although time-saving benefits have been demonstrated in some civilian studies, translation into improved outcomes remains unclear. For military medicine, AGD may offer enhanced battlefield awareness and support for earlier intervention during prolonged casualty care scenarios in LSCO. Rigorous testing in operationally relevant military environments, outcome-focused research, and integration into medical command and control systems are critical next steps for validating AGD’s role in improving trauma care and reducing preventable battlefield deaths.

An abstract is unavailable. This article is available as a PDF only.

Mini abstract US military assets have been integral to the response to global pandemics, natural disasters, civilian casualties, and combat care. Strategies are being implemented to strengthen the military health care system and curtail the erosion of relevant surgical skills and knowledge during periods of low combat intensity. However, additional challenges remain. We describe these strategies and obstacles but also explore potential solutions that may strengthen the readiness of military surgeons and combat trauma teams.

Background: Systemic inflammatory response remains a poorly understood cause of morbidity and mortality after traumatic injury. Recent nonhuman primate (NHP) trauma models have been used to characterize the systemic response to trauma, but none have incorporated a critical care phase without the use of general anesthesia. We describe the development of a prolonged critical care environment with sedation and ventilation support, and also report corresponding NHP biologic and inflammatory markers. Methods: Eight adult male rhesus macaques underwent ventilation with sedation for 48–96 hours in a critical care setting. Three of these NHPs underwent “sham” procedures as part of trauma control model development. Blood counts, chemistries, coagulation studies, and cytokines/chemokines were collected throughout the study, and histopathologic analysis was conducted at necropsy. Results: Eight NHPs were intentionally survived and extubated. Three NHPs were euthanized at 72–96 hours without extubation. Transaminitis occurred over the duration of ventilation, but renal function, acid-base status, and hematologic profile remained stable. Chemokine and cytokine analysis were notable for baseline fold-change for Il-6 and Il-1ra (9.7 and 42.7, respectively) that subsequently downtrended throughout the experiment unless clinical respiratory compromise was observed. Conclusions: A NHP critical care environment with ventilation support is feasible but requires robust resources. The inflammatory profile of NHPs is not profoundly altered by sedation and mechanical ventilation. NHPs are susceptible to the pulmonary effects of short-term ventilation and demonstrate a similar bioprofile response to ventilator-induced pulmonary pathology. This work has implications for further development of a prolonged care NHP model.

Purpose The advantages of minimally invasive inguinal hernia repair (MIHR) over open hernia repair (OHR) continue to be debated. We compared MIHR to OHR by utilizing the Army Physical Fitness Test (APFT) as an outcome measure. Methods The APFT is a three-component test scored on a normalized 300 point scale taken semiannually by active-duty military. We identified 1119 patients who met inclusion criteria: 588 in the OHR group and 531 in the MIHR group. Changes in APFT scores, time on post-operative duty restrictions (military profile), and time interval to first post-operative APFT were compared using regression analysis. Results Postoperatively, no APFT score change difference was observed between the OHR or MIHR groups (− 7.3 ± 30 versus − 5.5 ± 27.7, p = 0.2989). Service members undergoing OHR and MIHR underwent their first post-operative APFT at equal mean timeframes (6.6 ± 5 months versus 6.7 ± 5.1, p = 0.74). No difference was observed for time in months spent on an official temporary duty restriction (military profile) for either OHR or MIHR (0.16 ± 0.16 versus 0.15 ± 0.17, p = 0.311). On adjusted regression analysis, higher pre-operative APFT scores and BMI ≥ 30 were independently associated with reduction in post-operative APFT scores. Higher-baseline APFT scores were independently associated with less time on a post-operative profile, whereas higher BMI (≥ 30) and lower rank were independently associated with longer post-operative profile duration. Higher-baseline APFT scores and lower rank were independently associated with shorter time intervals to the first post-operative APFT. Conclusion Overall, no differences in post-operative APFT scores, military profile time, or time to first post-operative APFT were observed between minimally invasive or open hernioplasty in this military population.

Functional data as part of clinical outcomes such as Activities of Daily Living and Quality of Life (QOL) frequently depend on surveys and are thus inherently limited by self-reporting and patient subjectivity. Specifically, the 12-Item Short Form Survey (SF-12), 36-Item Short Form Survey (SF-36), and Carolinas Comfort Scale are validated instruments for assessing medical and surgical QOL outcomes. However, performance-based measures of disability are lacking. We propose the Army Physical Fitness Test (APFT) as a novel clinical measure of function following surgical intervention. We believe that studies using the APFT as a surgical outcome can potentially provide novel, relevant insights that may guide the utilization of specific surgical interventions and that the use of APFT data in surgical research will meet contemporary ethical standards.

BACKGROUND: Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties. METHODS: Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included. Log-binominal regression was used to identify SSI risk factors. RESULTS: Of 4,304 combat casualties, 341 patients underwent a total of 1,053 laparotomies. Abdominal SSIs were diagnosed in 49 patients (14.4%): 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p < 0.001), small bowel (p = 0.010), duodenum (p = 0.006), pancreas (p = 0.032), and abdominal vascular injuries (p = 0.040), as well as prolonged open abdomen (p = 0.004) and more infections diagnosed before the SSI (or final exploratory laparotomy) versus non-SSI patients (p < 0.001). Sustaining colorectal injuries (risk ratio [RR], 3.20; 95% confidence interval [CI], 1.58–6.45), duodenum injuries (RR, 6.71; 95% CI, 1.73–25.58), and being diagnosed with prior infections (RR, 10.34; 95% CI, 5.05–21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non–intra-abdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device was associated with reduced likelihood compared with penetrating nonblast (e.g., gunshot wounds) injuries. Non–intra-abdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood. CONCLUSION: Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14%, with similar risk factors and rates reported following severe civilian trauma. LEVEL OF EVIDENCE: Epidemiological, level III.

Accidental ingestion of a grill brush wire bristle is a rare event. Retrieval rarely requires surgical intervention as the wire typically causes symptoms above the gastro-oesophageal junction and can frequently be removed endoscopically. There are few reported cases of gastrointestinal injury due to ingestion of wire bristles lodging past the gastro-oesophageal junction in adults. We present four cases of wire brush bristle ingestion that required operative intervention. Our case series illustrates how the commonly used wire grill brush may cause a serious injury. This diagnosis should be considered in patients who present with abdominal pain, non-specific symptoms and normal labs, with liner radio-opaque imaging findings and a history of grill use. Education as to the dangers of grill wire brushes to clean grills should be provided commercially.