Pub Date : 2025-02-05DOI: 10.1001/jamasurg.2024.6817
Traci L Hedrick, Christopher A Campbell
{"title":"The Morbidity of a Perineal Wound.","authors":"Traci L Hedrick, Christopher A Campbell","doi":"10.1001/jamasurg.2024.6817","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6817","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143188710","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-05DOI: 10.1001/jamasurg.2024.6818
Saskia I. Kreisel, Sarah Sharabiany, Jurriaan Tuynman, Eric H. J. Belgers, Baljit Singh, Sanjay Chaudhri, Anna A. W. van Geloven, Ronald J. C. L. M. Vuylsteke, Johannes H. W. de Wilt, Jarno Melenhorst, Jeroen W. A. Leijtens, Maarten Vermaas, Joost Rothbarth, Cornelis Verhoef, Johannes W. A. Burger, Fatih Polat, Hans F. J. Fabry, Arend G. J. Aalbers, Jan H. Wijsman, Bas Lamme, Jarmila D. W. van der Bilt, Oren Lapid, Susan van Dieren, Roel Hompes, Pieter J. Tanis, Gijsbert D. Musters
ImportancePerineal wound complications are common following abdominoperineal resection for rectal cancer and might have substantial and long-lasting implications for patients’ recovery.ObjectiveTo evaluate the superiority of gluteal turnover flap closure compared to primary closure in patients with rectal cancer undergoing abdominoperineal resection.Design, Setting, and ParticipantsThe BIOPEX-2 study was an investigator-initiated, parallel-group, multicenter randomized clinical trial conducted at 19 centers in the Netherlands and the UK between June 2019 and November 2023, including 12 months of follow-up. Data analysis was performed from October 2023 to December 2023. Independent perineal wound assessors were masked to the type of closure. Eligibility criteria were resection of rectal cancer by abdominoperineal resection, aged 18 years or older, and ability to complete follow-up. In modified intention-to-treat analyses, patients were assigned to either primary closure or gluteal turnover flap closure.InterventionGluteal turnover flap closure started with a half-moon–shaped perineal skin island that was incised and deepithelialized. Subsequently, the subcutaneous fat was dissected toward the gluteal fascia, after which the dermis was sutured to the contralateral levator remnant, followed by midline closure.Main Outcomes and MeasuresThe primary outcome was uncomplicated wound healing at 30 days postoperatively, defined as a Southampton wound score less than 2. Secondary outcomes included presacral abscess formation and wound-related readmissions.ResultsA total of 175 patients were randomized, but 7 did not undergo abdominoperineal resection and 3 withdrew consent. In the modified intention-to-treat analyzes, 86 patients were assigned to primary closure and 79 patients to gluteal turnover flap closure. Of these 165 patients, mean (SD) patient age was 67 (10) years, and 57 patients (34.5%) were female. Uncomplicated perineal wound healing was present in 49 of 82 patients (60%) after primary closure, which did not significantly differ from flap closure (42 of 76 patients [55%]). Presacral abscess developed significantly more often after primary closure than flap closure (19 of 86 patients [22%] vs 7 of 78 patients [9%]; <jats:italic>P</jats:italic> = .02), and more percutaneous presacral abscess drainage was performed in the control group (primary closure) (7 patients [8%] vs 1 patient [1%]; <jats:italic>P</jats:italic> = .04). Perineal wound–related readmission occurred in 18 patients (21%) after primary closure and in 10 patients (13%) after gluteal flap closure (<jats:italic>P</jats:italic> = .17).Conclusion and RelevanceIn this parallel-group, multicenter randomized clinical trial, gluteal turnover flap closure did not show superiority over primary closure in 30-day perineal wound healing after abdominoperineal resection for rectal cancer. However, flap closure significantly reduced presacral abscess formation.Trial RegistrationClinicalTrials.gov
{"title":"Perineal Wound Closure Using Gluteal Turnover Flap After Abdominoperineal Resection for Rectal Cancer","authors":"Saskia I. Kreisel, Sarah Sharabiany, Jurriaan Tuynman, Eric H. J. Belgers, Baljit Singh, Sanjay Chaudhri, Anna A. W. van Geloven, Ronald J. C. L. M. Vuylsteke, Johannes H. W. de Wilt, Jarno Melenhorst, Jeroen W. A. Leijtens, Maarten Vermaas, Joost Rothbarth, Cornelis Verhoef, Johannes W. A. Burger, Fatih Polat, Hans F. J. Fabry, Arend G. J. Aalbers, Jan H. Wijsman, Bas Lamme, Jarmila D. W. van der Bilt, Oren Lapid, Susan van Dieren, Roel Hompes, Pieter J. Tanis, Gijsbert D. Musters","doi":"10.1001/jamasurg.2024.6818","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6818","url":null,"abstract":"ImportancePerineal wound complications are common following abdominoperineal resection for rectal cancer and might have substantial and long-lasting implications for patients’ recovery.ObjectiveTo evaluate the superiority of gluteal turnover flap closure compared to primary closure in patients with rectal cancer undergoing abdominoperineal resection.Design, Setting, and ParticipantsThe BIOPEX-2 study was an investigator-initiated, parallel-group, multicenter randomized clinical trial conducted at 19 centers in the Netherlands and the UK between June 2019 and November 2023, including 12 months of follow-up. Data analysis was performed from October 2023 to December 2023. Independent perineal wound assessors were masked to the type of closure. Eligibility criteria were resection of rectal cancer by abdominoperineal resection, aged 18 years or older, and ability to complete follow-up. In modified intention-to-treat analyses, patients were assigned to either primary closure or gluteal turnover flap closure.InterventionGluteal turnover flap closure started with a half-moon–shaped perineal skin island that was incised and deepithelialized. Subsequently, the subcutaneous fat was dissected toward the gluteal fascia, after which the dermis was sutured to the contralateral levator remnant, followed by midline closure.Main Outcomes and MeasuresThe primary outcome was uncomplicated wound healing at 30 days postoperatively, defined as a Southampton wound score less than 2. Secondary outcomes included presacral abscess formation and wound-related readmissions.ResultsA total of 175 patients were randomized, but 7 did not undergo abdominoperineal resection and 3 withdrew consent. In the modified intention-to-treat analyzes, 86 patients were assigned to primary closure and 79 patients to gluteal turnover flap closure. Of these 165 patients, mean (SD) patient age was 67 (10) years, and 57 patients (34.5%) were female. Uncomplicated perineal wound healing was present in 49 of 82 patients (60%) after primary closure, which did not significantly differ from flap closure (42 of 76 patients [55%]). Presacral abscess developed significantly more often after primary closure than flap closure (19 of 86 patients [22%] vs 7 of 78 patients [9%]; <jats:italic>P</jats:italic> = .02), and more percutaneous presacral abscess drainage was performed in the control group (primary closure) (7 patients [8%] vs 1 patient [1%]; <jats:italic>P</jats:italic> = .04). Perineal wound–related readmission occurred in 18 patients (21%) after primary closure and in 10 patients (13%) after gluteal flap closure (<jats:italic>P</jats:italic> = .17).Conclusion and RelevanceIn this parallel-group, multicenter randomized clinical trial, gluteal turnover flap closure did not show superiority over primary closure in 30-day perineal wound healing after abdominoperineal resection for rectal cancer. However, flap closure significantly reduced presacral abscess formation.Trial RegistrationClinicalTrials.gov","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"79 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143125102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-05DOI: 10.1001/jamasurg.2024.6729
Richard Sassun, Annaclara Sileo, Jyi Cheng Ng, Tommaso Violante, Ibrahim Gomaa, Jay Mandrekar, Kristen K. Rumer, Nicholas P. McKenna, David W. Larson
ImportanceTumor deposits have prognostic value in colon cancer, but the current American Joint Committee on Cancer (AJCC) staging only considers them if there are no concurrent positive lymph nodes.ObjectiveTo devise a staging system for colon cancer by integrating counts of tumor deposits with positive lymph nodes while retaining the current AJCC staging framework.Design, Setting, and ParticipantsThis retrospective cohort study examines data from a large-volume, tertiary care center database (January 2010 through March 2023 with follow-up until December 2023) and the population-based National Cancer Database (January 2010 through December 2020 with follow-up until December 2021). Participants were adults (age 18-75 years) with stage III colon adenocarcinoma who underwent chemotherapy, and had a specified positive lymph node count and tumor deposit count were selected.ExposureA real positive lymph nodes count was developed and used to derive Sassun-Mayo N/tumor, lymph node, and metastasis (TNM) stages that were compared with the AJCC N/TNM stages.Main Outcomes and MeasuresReceiver operating characteristic (ROC) curves and Kaplan-Meier analyses for 3-year overall survival were performed to assess the efficiency of the 2 staging systems. The concordance index was used for validation using the National Cancer Database.ResultsFrom a total patient number of 11 162 (institutional) and 848 704 (national), the final patient numbers were 788 and 77 790, respectively. The institutional database patients had a mean (SD) age of 58.5 (11.5) years; there were 433 male patients (54.9%) and 355 female (45.1%). The national database patients had a mean (SD) age of 59.3 (10.6) years; there were 40 315 male patients (51.8%) and 37 475 female (48.2%). ROC curve areas were improved using the Sassun-Mayo stages (3-year death for AJCC TMN, 0.63 [95% CI, 0.57-0.69] vs 0.66 [95% CI, for 0.60-0.72] for Sassun-Mayo TNM). Kaplan-Meier curves revealed visible overlaps among AJCC N stages, which were absent in the Sassun-Mayo N stages. The concordance index in the Sassun-Mayo N/TNM stages was 0.611 and 0.616, respectively, while in the AJCC N/TNM stages, it was 0.598 and 0.606, respectively. Patients upstaged from N1 to N2 (n = 10 307; 13.2%) had a 3-year overall survival rate nearly identical to that of AJCC N2a patients. Additionally, 3001 patients (3.9%) were upstaged from N2a to N2b, indicating that 13 308 patients (17.1%) with stage III colon cancer across cohorts were understaged.Conclusions and RelevanceThis study found that Sassun-Mayo N/TNM staging provided superior overall survival stratification compared with the current AJCC staging, suggesting that their implementation could improve prognostication in colon cancer.
{"title":"Validated Integration of Tumor Deposits in N Staging for Prognostication in Colon Cancer","authors":"Richard Sassun, Annaclara Sileo, Jyi Cheng Ng, Tommaso Violante, Ibrahim Gomaa, Jay Mandrekar, Kristen K. Rumer, Nicholas P. McKenna, David W. Larson","doi":"10.1001/jamasurg.2024.6729","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6729","url":null,"abstract":"ImportanceTumor deposits have prognostic value in colon cancer, but the current American Joint Committee on Cancer (AJCC) staging only considers them if there are no concurrent positive lymph nodes.ObjectiveTo devise a staging system for colon cancer by integrating counts of tumor deposits with positive lymph nodes while retaining the current AJCC staging framework.Design, Setting, and ParticipantsThis retrospective cohort study examines data from a large-volume, tertiary care center database (January 2010 through March 2023 with follow-up until December 2023) and the population-based National Cancer Database (January 2010 through December 2020 with follow-up until December 2021). Participants were adults (age 18-75 years) with stage III colon adenocarcinoma who underwent chemotherapy, and had a specified positive lymph node count and tumor deposit count were selected.ExposureA real positive lymph nodes count was developed and used to derive Sassun-Mayo N/tumor, lymph node, and metastasis (TNM) stages that were compared with the AJCC N/TNM stages.Main Outcomes and MeasuresReceiver operating characteristic (ROC) curves and Kaplan-Meier analyses for 3-year overall survival were performed to assess the efficiency of the 2 staging systems. The concordance index was used for validation using the National Cancer Database.ResultsFrom a total patient number of 11 162 (institutional) and 848 704 (national), the final patient numbers were 788 and 77 790, respectively. The institutional database patients had a mean (SD) age of 58.5 (11.5) years; there were 433 male patients (54.9%) and 355 female (45.1%). The national database patients had a mean (SD) age of 59.3 (10.6) years; there were 40 315 male patients (51.8%) and 37 475 female (48.2%). ROC curve areas were improved using the Sassun-Mayo stages (3-year death for AJCC TMN, 0.63 [95% CI, 0.57-0.69] vs 0.66 [95% CI, for 0.60-0.72] for Sassun-Mayo TNM). Kaplan-Meier curves revealed visible overlaps among AJCC N stages, which were absent in the Sassun-Mayo N stages. The concordance index in the Sassun-Mayo N/TNM stages was 0.611 and 0.616, respectively, while in the AJCC N/TNM stages, it was 0.598 and 0.606, respectively. Patients upstaged from N1 to N2 (n = 10 307; 13.2%) had a 3-year overall survival rate nearly identical to that of AJCC N2a patients. Additionally, 3001 patients (3.9%) were upstaged from N2a to N2b, indicating that 13 308 patients (17.1%) with stage III colon cancer across cohorts were understaged.Conclusions and RelevanceThis study found that Sassun-Mayo N/TNM staging provided superior overall survival stratification compared with the current AJCC staging, suggesting that their implementation could improve prognostication in colon cancer.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"27 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143125380","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-05DOI: 10.1001/jamasurg.2024.6708
Alizeh Abbas, Daniel I Chu
{"title":"Tumor Deposits-A Blind Spot in Colon Cancer Staging.","authors":"Alizeh Abbas, Daniel I Chu","doi":"10.1001/jamasurg.2024.6708","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6708","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143188717","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-05DOI: 10.1001/jamasurg.2024.6446
Ben Li, Ahmed Kayssi, Lianne J. McLean
This Viewpoint discusses the role of generative artificial intelligence in surgical publishing, including idea generation, study conduct, manuscript preparation, and manuscript review.
{"title":"Generative Artificial Intelligence in Surgical Publishing","authors":"Ben Li, Ahmed Kayssi, Lianne J. McLean","doi":"10.1001/jamasurg.2024.6446","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6446","url":null,"abstract":"This Viewpoint discusses the role of generative artificial intelligence in surgical publishing, including idea generation, study conduct, manuscript preparation, and manuscript review.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"130 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143125376","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-29DOI: 10.1001/jamasurg.2024.6312
Annie M Q Wang
{"title":"Adversity as Privilege-Poverty Has Made Me a Better Surgeon.","authors":"Annie M Q Wang","doi":"10.1001/jamasurg.2024.6312","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6312","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"36 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143056904","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-29DOI: 10.1001/jamasurg.2024.6602
Jessica Spence,P J Devereaux,Shun-Fu Lee,Frédérick D'Aragon,Michael S Avidan,Richard P Whitlock,C David Mazer,Nicolas Rousseau-Saine,Raja Ramaswamy Rajamohan,Kane O Pryor,Rael Klein,Edmund Tan,Matthew J Cameron,Emily Di Sante,Erin DeBorba,Mary E Mustard,Etienne J Couture,Raffael Pereira Cezar Zamper,Michael W Y Law,George Djaiani,Tarit Saha,Stephen Choi,Peter Hedlin,D Ryan Pikaluk,Wing Lam,Alain Deschamps,Chinthanie F Ramasundarahettige,Jessica Vincent,William F McIntyre,Simon J W Oczkowski,Braden J Dulong,Christopher Beaver,Shelley A Kloppenburg,Andre Lamy,Eric Jacobsohn,Emilie P Belley-Côté,
ImportanceDelirium is common after cardiac surgery and associated with adverse outcomes. Intraoperative benzodiazepines may increase postoperative delirium but restricting intraoperative benzodiazepines has not yet been evaluated in a randomized trial.ObjectiveTo determine whether an institutional policy of restricted intraoperative benzodiazepine administration reduced the incidence of postoperative delirium.Design, Setting, and ParticipantsThis pragmatic, multiperiod, patient- and assessor-blinded, cluster randomized crossover trial took place at 20 North American cardiac surgical centers. All adults undergoing open cardiac surgery at participating centers during the trial period were included through a waiver of individual patient consent between November 2019 and December 2022.InterventionInstitutional policies of restrictive vs liberal intraoperative benzodiazepine administration were compared. Hospitals (clusters) were randomized to cross between the restricted and liberal benzodiazepine policies 12 to 18 times over 4-week periods.Main Outcomes and MeasuresThe primary outcome was the incidence of delirium within 72 hours of surgery as detected in routine clinical care, using either the Confusion Assessment Method-Intensive Care Unit or the Intensive Care Delirium Screening Checklist. Intraoperative awareness by patient report was assessed as an adverse event.ResultsDuring the trial, 19 768 patients (mean [SD] age, 65 [12] years; 14 528 [73.5%] male) underwent cardiac surgery, 9827 during restricted benzodiazepine periods and 9941 during liberal benzodiazepine periods. During restricted periods, clinicians adhered to assigned policy in 8928 patients (90.9%), compared to 9268 patients (93.2%) during liberal periods. Delirium occurred in 1373 patients (14.0%) during restricted periods and 1485 (14.9%) during liberal periods (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.01; P = .07). No patient spontaneously reported intraoperative awareness.Conclusions and RelevanceIn intention-to-treat analyses, restricting benzodiazepines during cardiac surgery did not reduce delirium incidence but was also not associated with an increase in the incidence of patient-reported intraoperative awareness. Given that smaller effect sizes cannot be ruled out, restriction of benzodiazepines during cardiac surgery may be considered. Research is required to determine whether restricting intraoperative benzodiazepines at the patient level can reduce the incidence of postoperative delirium.Trial RegistrationClinicalTrials.gov Identifier: NCT03928236.
{"title":"Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium: A Cluster Randomized Crossover Trial.","authors":"Jessica Spence,P J Devereaux,Shun-Fu Lee,Frédérick D'Aragon,Michael S Avidan,Richard P Whitlock,C David Mazer,Nicolas Rousseau-Saine,Raja Ramaswamy Rajamohan,Kane O Pryor,Rael Klein,Edmund Tan,Matthew J Cameron,Emily Di Sante,Erin DeBorba,Mary E Mustard,Etienne J Couture,Raffael Pereira Cezar Zamper,Michael W Y Law,George Djaiani,Tarit Saha,Stephen Choi,Peter Hedlin,D Ryan Pikaluk,Wing Lam,Alain Deschamps,Chinthanie F Ramasundarahettige,Jessica Vincent,William F McIntyre,Simon J W Oczkowski,Braden J Dulong,Christopher Beaver,Shelley A Kloppenburg,Andre Lamy,Eric Jacobsohn,Emilie P Belley-Côté,","doi":"10.1001/jamasurg.2024.6602","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6602","url":null,"abstract":"ImportanceDelirium is common after cardiac surgery and associated with adverse outcomes. Intraoperative benzodiazepines may increase postoperative delirium but restricting intraoperative benzodiazepines has not yet been evaluated in a randomized trial.ObjectiveTo determine whether an institutional policy of restricted intraoperative benzodiazepine administration reduced the incidence of postoperative delirium.Design, Setting, and ParticipantsThis pragmatic, multiperiod, patient- and assessor-blinded, cluster randomized crossover trial took place at 20 North American cardiac surgical centers. All adults undergoing open cardiac surgery at participating centers during the trial period were included through a waiver of individual patient consent between November 2019 and December 2022.InterventionInstitutional policies of restrictive vs liberal intraoperative benzodiazepine administration were compared. Hospitals (clusters) were randomized to cross between the restricted and liberal benzodiazepine policies 12 to 18 times over 4-week periods.Main Outcomes and MeasuresThe primary outcome was the incidence of delirium within 72 hours of surgery as detected in routine clinical care, using either the Confusion Assessment Method-Intensive Care Unit or the Intensive Care Delirium Screening Checklist. Intraoperative awareness by patient report was assessed as an adverse event.ResultsDuring the trial, 19 768 patients (mean [SD] age, 65 [12] years; 14 528 [73.5%] male) underwent cardiac surgery, 9827 during restricted benzodiazepine periods and 9941 during liberal benzodiazepine periods. During restricted periods, clinicians adhered to assigned policy in 8928 patients (90.9%), compared to 9268 patients (93.2%) during liberal periods. Delirium occurred in 1373 patients (14.0%) during restricted periods and 1485 (14.9%) during liberal periods (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.01; P = .07). No patient spontaneously reported intraoperative awareness.Conclusions and RelevanceIn intention-to-treat analyses, restricting benzodiazepines during cardiac surgery did not reduce delirium incidence but was also not associated with an increase in the incidence of patient-reported intraoperative awareness. Given that smaller effect sizes cannot be ruled out, restriction of benzodiazepines during cardiac surgery may be considered. Research is required to determine whether restricting intraoperative benzodiazepines at the patient level can reduce the incidence of postoperative delirium.Trial RegistrationClinicalTrials.gov Identifier: NCT03928236.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"28 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143056967","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-29DOI: 10.1001/jamasurg.2024.6520
Michelle C. Nguyen, Chi Zhang, Yu-Hui Chang, Xingjie Li, Stephanie Y. Ohara, Kayla R. Kumm, Christopher P. Cosentino, Bashar A. Aqel, Blanca C. Lizaola-Mayo, Peter E. Frasco, Raphael Nunez-Nateras, Winston R. Hewitt, Jack W. Harbell, Nitin N. Katariya, Andrew L. Singer, Adyr A. Moss, Kunam S. Reddy, Caroline Jadlowiec, Amit K. Mathur
ImportanceNormothermic machine perfusion (NMP) has been shown to reduce peritransplant complications. Despite increasing NMP use in liver transplant (LT), there is a scarcity of real-world clinical experience data.ObjectiveTo compare LT outcomes between donation after brain death (DBD) and donation after circulatory death (DCD) allografts preserved with NMP or static cold storage (SCS).Design, Setting, and ParticipantsThis single-center, retrospective observational cohort study included all consecutive adult LTs performed between January 2019 and December 2023 at the Mayo Clinic in Arizona. Data analysis was performed between February 2024 and June 2024. Outcomes of DBD-SCS, DBD-NMP, DCD-SCS, and DCD-NMP transplants were compared.ExposureDBD and DCD livers preserved on NMP or SCS.Main Outcomes and MeasuresThe primary outcomes were early allograft dysfunction (EAD), intraoperative transfusion, and post-LT hospital resource use, including length of stay (LOS) and readmissions. Secondary outcomes included acute kidney injury (AKI) and 1-year graft and patient survival.ResultsA total of 1086 LTs were included in the following 4 groups: DBD-SCS (n = 480), DBD-NMP (n = 63), DCD-SCS (n = 264), and DCD-NMP (n = 279). Among LT recipients, median (IQR) age was 60.0 years (52.0-66.0); 399 LT recipients (36.7%) were female. DCD-NMP had the lowest EAD rate (17.5%), followed by DCD-SCS (50.0%), DBD-NMP (36.8%), and DBD-SCS (27.3%) (P &lt; .001). DCD-NMP had the lowest intraoperative transfusion requirement compared to all other groups. Hospital and intensive care unit (ICU) LOS were shortest in DCD-NMP (median [IQR] hospital LOS, 5.0 days [4.0-7.0]; P = .01; median [IQR] ICU LOS, 1.5 days [1.2-3.1]; P = .01). One-year cumulative readmission probability was 86% lower for DCD-NMP vs DCD-SCS (95% CI, 0.09-0.22; P &lt; .001) and 53% lower for DBD-NMP vs DBD-SCS (95% CI, 0.26-0.87; P &lt; .001). AKI events were lower in DCD-NMP (31.1%) vs DCD-SCS (47.4%) (P = .001). Compared to SCS, the NMP group had a 78% overall reduction in graft failure (hazard ratio [HR], 0.22; 95% CI, 0.10-0.49; P &lt; .001). For those receiving DCD allografts, the risk reduction was even more pronounced, with an 87% decrease in graft failure (HR, 0.13; 95% CI, 0.05-0.33; P &lt; .001). NMP was significantly protective from patient mortality vs SCS (HR, 0.31; 95% CI, 0.12-0.80; P = .02).Conclusions and RelevanceIn this observational high-volume cohort study, NMP significantly improved LT clinical outcomes and reduced hospital resource use, especially in DCD allografts. NMP may enhance access to LT by addressing the challenges historically linked with DCD liver use.
{"title":"Improved Outcomes and Resource Use With Normothermic Machine Perfusion in Liver Transplantation","authors":"Michelle C. Nguyen, Chi Zhang, Yu-Hui Chang, Xingjie Li, Stephanie Y. Ohara, Kayla R. Kumm, Christopher P. Cosentino, Bashar A. Aqel, Blanca C. Lizaola-Mayo, Peter E. Frasco, Raphael Nunez-Nateras, Winston R. Hewitt, Jack W. Harbell, Nitin N. Katariya, Andrew L. Singer, Adyr A. Moss, Kunam S. Reddy, Caroline Jadlowiec, Amit K. Mathur","doi":"10.1001/jamasurg.2024.6520","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6520","url":null,"abstract":"ImportanceNormothermic machine perfusion (NMP) has been shown to reduce peritransplant complications. Despite increasing NMP use in liver transplant (LT), there is a scarcity of real-world clinical experience data.ObjectiveTo compare LT outcomes between donation after brain death (DBD) and donation after circulatory death (DCD) allografts preserved with NMP or static cold storage (SCS).Design, Setting, and ParticipantsThis single-center, retrospective observational cohort study included all consecutive adult LTs performed between January 2019 and December 2023 at the Mayo Clinic in Arizona. Data analysis was performed between February 2024 and June 2024. Outcomes of DBD-SCS, DBD-NMP, DCD-SCS, and DCD-NMP transplants were compared.ExposureDBD and DCD livers preserved on NMP or SCS.Main Outcomes and MeasuresThe primary outcomes were early allograft dysfunction (EAD), intraoperative transfusion, and post-LT hospital resource use, including length of stay (LOS) and readmissions. Secondary outcomes included acute kidney injury (AKI) and 1-year graft and patient survival.ResultsA total of 1086 LTs were included in the following 4 groups: DBD-SCS (n = 480), DBD-NMP (n = 63), DCD-SCS (n = 264), and DCD-NMP (n = 279). Among LT recipients, median (IQR) age was 60.0 years (52.0-66.0); 399 LT recipients (36.7%) were female. DCD-NMP had the lowest EAD rate (17.5%), followed by DCD-SCS (50.0%), DBD-NMP (36.8%), and DBD-SCS (27.3%) (<jats:italic>P</jats:italic> &amp;lt; .001). DCD-NMP had the lowest intraoperative transfusion requirement compared to all other groups. Hospital and intensive care unit (ICU) LOS were shortest in DCD-NMP (median [IQR] hospital LOS, 5.0 days [4.0-7.0]; <jats:italic>P</jats:italic> = .01; median [IQR] ICU LOS, 1.5 days [1.2-3.1]; <jats:italic>P</jats:italic> = .01). One-year cumulative readmission probability was 86% lower for DCD-NMP vs DCD-SCS (95% CI, 0.09-0.22; <jats:italic>P</jats:italic> &amp;lt; .001) and 53% lower for DBD-NMP vs DBD-SCS (95% CI, 0.26-0.87; <jats:italic>P</jats:italic> &amp;lt; .001). AKI events were lower in DCD-NMP (31.1%) vs DCD-SCS (47.4%) (<jats:italic>P</jats:italic> = .001). Compared to SCS, the NMP group had a 78% overall reduction in graft failure (hazard ratio [HR], 0.22; 95% CI, 0.10-0.49; <jats:italic>P</jats:italic> &amp;lt; .001). For those receiving DCD allografts, the risk reduction was even more pronounced, with an 87% decrease in graft failure (HR, 0.13; 95% CI, 0.05-0.33; <jats:italic>P</jats:italic> &amp;lt; .001). NMP was significantly protective from patient mortality vs SCS (HR, 0.31; 95% CI, 0.12-0.80; <jats:italic>P</jats:italic> = .02).Conclusions and RelevanceIn this observational high-volume cohort study, NMP significantly improved LT clinical outcomes and reduced hospital resource use, especially in DCD allografts. NMP may enhance access to LT by addressing the challenges historically linked with DCD liver use.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"14 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143056251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-29DOI: 10.1001/jamasurg.2024.6603
Amanda M Kleiman,Michael P Calgi,John S McNeil
{"title":"Benzodiazepines Not Main Suspect in Cardiac Surgery Delirium.","authors":"Amanda M Kleiman,Michael P Calgi,John S McNeil","doi":"10.1001/jamasurg.2024.6603","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.6603","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"23 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143056907","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}