Pub Date : 2026-02-01DOI: 10.1001/jamasurg.2025.5366
Shawn J Rangel
{"title":"Refining CPT Codes to Reflect the Complexity of Pediatric Appendicitis.","authors":"Shawn J Rangel","doi":"10.1001/jamasurg.2025.5366","DOIUrl":"10.1001/jamasurg.2025.5366","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":"207-208"},"PeriodicalIF":14.9,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145714378","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 : 2026-02-01DOI: 10.1001/jamasurg.2025.6516
{"title":"Errors in Figure 2 and the Discussion.","authors":"","doi":"10.1001/jamasurg.2025.6516","DOIUrl":"10.1001/jamasurg.2025.6516","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"161 2","pages":"211"},"PeriodicalIF":14.9,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12895276/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146157045","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1001/jamasurg.2025.4199
Vincenzo Villani, Lilian S Kao, Yuman Fong
Importance: Difficult cholecystectomies are associated with a higher risk of severe bilio-vascular injuries.
Observations: Obesity, cirrhosis, high American Society of Anesthesiologists score, previous abdominal operations, and presence of acute cholecystitis or common bile duct stones are associated with difficult cholecystectomies. On imaging, thickened gallbladder wall, pericholecystic fluid, and an impacted gallstone are associated with difficult cholecystectomies. In challenging operations, the use of imaging (intraoperative cholangiography, intraoperative ultrasound, near-infrared cholangiography) is recommended. If the critical view of the hepatocystic triangle cannot be safely achieved, bailout strategies, such as tube cholecystostomy, subtotal cholecystectomy, or an anterograde approach, should be considered. Conversion to open surgery should be considered for significant bleeding, cholecystoenteric fistula, Mirizzi syndrome, or malignancy. Seeking advice or assistance from another surgeon is recommended when conditions are challenging.
Conclusions and relevance: Knowledge of perioperative and intraoperative adjuncts and alternative surgical options aid surgeons in performing difficult cholecystectomies safely.
{"title":"The Difficult Cholecystectomy.","authors":"Vincenzo Villani, Lilian S Kao, Yuman Fong","doi":"10.1001/jamasurg.2025.4199","DOIUrl":"10.1001/jamasurg.2025.4199","url":null,"abstract":"<p><strong>Importance: </strong>Difficult cholecystectomies are associated with a higher risk of severe bilio-vascular injuries.</p><p><strong>Observations: </strong>Obesity, cirrhosis, high American Society of Anesthesiologists score, previous abdominal operations, and presence of acute cholecystitis or common bile duct stones are associated with difficult cholecystectomies. On imaging, thickened gallbladder wall, pericholecystic fluid, and an impacted gallstone are associated with difficult cholecystectomies. In challenging operations, the use of imaging (intraoperative cholangiography, intraoperative ultrasound, near-infrared cholangiography) is recommended. If the critical view of the hepatocystic triangle cannot be safely achieved, bailout strategies, such as tube cholecystostomy, subtotal cholecystectomy, or an anterograde approach, should be considered. Conversion to open surgery should be considered for significant bleeding, cholecystoenteric fistula, Mirizzi syndrome, or malignancy. Seeking advice or assistance from another surgeon is recommended when conditions are challenging.</p><p><strong>Conclusions and relevance: </strong>Knowledge of perioperative and intraoperative adjuncts and alternative surgical options aid surgeons in performing difficult cholecystectomies safely.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":"189-196"},"PeriodicalIF":14.9,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145292121","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 : 2026-02-01DOI: 10.1001/jamasurg.2025.5507
Thomas S Helling
{"title":"General Surgeons and Tranexamic Acid.","authors":"Thomas S Helling","doi":"10.1001/jamasurg.2025.5507","DOIUrl":"10.1001/jamasurg.2025.5507","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":"188"},"PeriodicalIF":14.9,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145774602","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}
ImportanceFrailty is associated with functional decline and increased postoperative morbidity. Prehabilitation may complement Enhanced Recovery After Surgery (ERAS) care to improve patient outcomes.ObjectiveTo evaluate the effect of a multimodal prehabilitation program on functional capacity and clinical outcomes in older patients with frailty undergoing radical gastrectomy.Design, Setting, and ParticipantsThis randomized clinical trial was conducted at 15 centers in China. Participants aged 65 to 85 years with frailty (Geriatric 8 screening tool score ≤14) scheduled for elective gastrectomy or neoadjuvant chemotherapy prior to elective gastrectomy were randomized 1:1 to ERAS care either with or without prehabilitation. Recruitment for the study began in September 2022 and was completed in April 2024; data analysis was completed from September 2024 to April 2025.InterventionsThe prehabilitation group (PG) underwent multimodal prehabilitation for at least 2 weeks in combination with ERAS care, while the standard ERAS group (SG) followed a well-defined ERAS pathway.Main Outcomes and MeasuresThe primary outcome was the proportion of patients with postoperative complications within 30 days after surgery. Secondary outcomes included functional capacity, surgical resilience, and other short-term postoperative outcomes.ResultsA total of 368 participants were randomized to either the PG or SG group. In the modified intention-to-treat population of 347 participants (PG: n = 169; SG: n = 178), overall compliance with prehabilitation was 93.75%; median (IQR) participant age was 70 (68-73) years, and 95 participants (27.4%) were female. The rate of complications was lower in PG compared to SG (17.2% vs 28.7%; P = .01). In particular, significant benefits were observed in minor complications (PG: 18 of 169 patients [10.7%]; SG: 36 of 178 patients [20.2%]; P = .01) and medical complications (PG: 14 of 169 patients [8.3%]; SG: 30 of 178 patients [16.9%]; P = .02). The PG showed increased functional capacity before surgery compared to baseline (mean [SD] 6-minute walk test change, +24 [12.5] m; P < .001). Four weeks after surgery, the mean walking distance of the PG remained above baseline levels. Moreover, secondary parameters, such as chronic low-grade inflammation, preoperative physical quality of life, length of intensive care unit stay, mechanical ventilation time, and length of hospital stay, generally favored prehabilitation compared with standard ERAS care.Conclusions and RelevancePer the results of this randomized clinical trial, a multimodal prehabilitation program may enhance physiological reserve, reduce morbidity, and promote surgical resilience in older patients with frailty undergoing radical gastrectomy.Trial RegistrationClinicalTrials.gov Identifier: NCT05352802.
虚弱与功能下降和术后发病率增加有关。预康复可以补充术后增强恢复（ERAS）护理，以改善患者的预后。目的评价多模式康复方案对行根治性胃切除术的老年虚弱患者功能能力和临床预后的影响。设计、环境和参与者本随机临床试验在中国的15个中心进行。年龄在65 ~ 85岁之间，体弱者（Geriatric 8筛查工具评分≤14）计划择期胃切除术或择期胃切除术前新辅助化疗的参与者按1:1的比例随机分配到有或没有预适应的ERAS治疗组。该研究的招募于2022年9月开始，并于2024年4月完成；数据分析于2024年9月至2025年4月完成。干预措施：预康复组（PG）在ERAS护理的同时进行至少2周的多模式预康复，而标准ERAS组（SG）则遵循明确的ERAS途径。主要结局和措施主要结局是术后30天内出现术后并发症的患者比例。次要结局包括功能能力、手术恢复力和其他短期术后结局。结果共有368名参与者被随机分为PG组和SG组。在347名受试者（PG: n = 169; SG: n = 178）的改良意向治疗人群中，总体康复依从性为93.75%；参与者年龄中位数（IQR）为70（68-73）岁，95名参与者（27.4%）为女性。PG组并发症发生率低于SG组（17.2% vs 28.7%; P = 0.01）。特别是，在轻微并发症方面观察到显著的益处(PG: 169例患者中有18例[10.7%]；SG: 178例患者中有36例[20.2%];P =。01)和医学并发症（169例患者中PG: 14例[8.3%]；178例患者中SG: 30例[16.9%];P = 0.02）。与基线相比，PG术前功能能力增加（平均[SD] 6分钟步行测试变化，+24 [12.5]m; P < .001）。术后4周，PG的平均步行距离仍高于基线水平。此外，次要参数，如慢性低度炎症、术前身体生活质量、重症监护病房住院时间、机械通气时间和住院时间，与标准ERAS护理相比，普遍倾向于康复治疗。结论和相关性根据这项随机临床试验的结果，多模式的康复计划可以增强接受根治性胃切除术的老年虚弱患者的生理储备，降低发病率，并提高手术恢复能力。临床试验注册号：NCT05352802。
{"title":"Supervised Multimodal Prehabilitation and Clinical Outcomes in Older Patients With Frailty and Gastric Cancer: The GISSG+2201 Randomized Clinical Trial.","authors":"Yuqi Sun,Yulong Tian,Shougen Cao,Leping Li,Wenbin Yu,Yinlu Ding,Xixun Wang,Ying Kong,Xinjian Wang,Hao Wang,Xizeng Hui,Jianjun Qu,Hongbo Wang,Quanhong Duan,Daogui Yang,Huanhu Zhang,Shaofei Zhou,Xiaodong Liu,Zequn Li,Qi Liu,Yanbing Zhou","doi":"10.1001/jamasurg.2025.6256","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.6256","url":null,"abstract":"ImportanceFrailty is associated with functional decline and increased postoperative morbidity. Prehabilitation may complement Enhanced Recovery After Surgery (ERAS) care to improve patient outcomes.ObjectiveTo evaluate the effect of a multimodal prehabilitation program on functional capacity and clinical outcomes in older patients with frailty undergoing radical gastrectomy.Design, Setting, and ParticipantsThis randomized clinical trial was conducted at 15 centers in China. Participants aged 65 to 85 years with frailty (Geriatric 8 screening tool score ≤14) scheduled for elective gastrectomy or neoadjuvant chemotherapy prior to elective gastrectomy were randomized 1:1 to ERAS care either with or without prehabilitation. Recruitment for the study began in September 2022 and was completed in April 2024; data analysis was completed from September 2024 to April 2025.InterventionsThe prehabilitation group (PG) underwent multimodal prehabilitation for at least 2 weeks in combination with ERAS care, while the standard ERAS group (SG) followed a well-defined ERAS pathway.Main Outcomes and MeasuresThe primary outcome was the proportion of patients with postoperative complications within 30 days after surgery. Secondary outcomes included functional capacity, surgical resilience, and other short-term postoperative outcomes.ResultsA total of 368 participants were randomized to either the PG or SG group. In the modified intention-to-treat population of 347 participants (PG: n = 169; SG: n = 178), overall compliance with prehabilitation was 93.75%; median (IQR) participant age was 70 (68-73) years, and 95 participants (27.4%) were female. The rate of complications was lower in PG compared to SG (17.2% vs 28.7%; P = .01). In particular, significant benefits were observed in minor complications (PG: 18 of 169 patients [10.7%]; SG: 36 of 178 patients [20.2%]; P = .01) and medical complications (PG: 14 of 169 patients [8.3%]; SG: 30 of 178 patients [16.9%]; P = .02). The PG showed increased functional capacity before surgery compared to baseline (mean [SD] 6-minute walk test change, +24 [12.5] m; P < .001). Four weeks after surgery, the mean walking distance of the PG remained above baseline levels. Moreover, secondary parameters, such as chronic low-grade inflammation, preoperative physical quality of life, length of intensive care unit stay, mechanical ventilation time, and length of hospital stay, generally favored prehabilitation compared with standard ERAS care.Conclusions and RelevancePer the results of this randomized clinical trial, a multimodal prehabilitation program may enhance physiological reserve, reduce morbidity, and promote surgical resilience in older patients with frailty undergoing radical gastrectomy.Trial RegistrationClinicalTrials.gov Identifier: NCT05352802.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"87 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2026-01-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146056868","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 : 2026-01-28DOI: 10.1001/jamasurg.2025.6255
Liane S Feldman,Franco Carli,Janius Tsang
{"title":"Expanding the Prehabilitation Team Beyond the Clinic.","authors":"Liane S Feldman,Franco Carli,Janius Tsang","doi":"10.1001/jamasurg.2025.6255","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.6255","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"12 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2026-01-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146056860","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}
ImportanceAcute appendicitis is the most common abdominal surgical emergency worldwide and a leading cause of emergency hospital admissions and operations. Despite its frequency, substantial variability persists in diagnosis and management across patient populations and health care settings.ObjectiveTo provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis in adults, children, pregnant women, older patients (aged ≥65 years), immunocompromised individuals, and patients with obesity (body mass index ≥30), developed by the World Society of Emergency Surgery (WSES) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.Evidence ReviewA systematic literature search was performed in MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library to identify relevant studies published until May 2025. Eligible designs included randomized clinical trials, observational studies, systematic reviews, and meta-analyses. Risk of bias was assessed with design-appropriate tools (RoB-2, ROBINS-I, QUADAS-2). Evidence profiles and evidence-to-decision frameworks were generated for each of 19 key clinical questions. The certainty of evidence was rated as high, moderate, low, or very low. Recommendations were classified as strong or conditional (weak) according to GRADE.FindingsSix key clinical domains were addressed across 19 questions. Thirty-five recommendations were formulated. Key findings include: (1) clinical risk scores and imaging improve diagnostic accuracy and reduce negative appendectomy rates; (2) nonoperative management with antibiotics is safe and effective in selected patients with uncomplicated appendicitis, with recommendations tailored for specific populations; (3) appendectomy for uncomplicated appendicitis may be safely delayed within 24 hours without increased risk of adverse outcomes; (4) laparoscopic appendectomy remains the standard surgical approach; (5) postoperative antibiotic therapy should be limited to short courses (2-3 days) in complicated disease; and (6) follow-up strategies are essential after nonoperative management of complicated appendicitis with abscess to detect neoplasms.Conclusions and RelevanceThe 2025 WSES Jerusalem Guidelines provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis with the aim to standardize practice, reduce unwarranted variability, and support safe, effective, and patient-centered care across diverse populations and health care systems. Their implementation should be adapted to local resources.
急性阑尾炎是世界范围内最常见的腹部外科急症，也是急诊住院和手术的主要原因。尽管发病率很高，但在不同的患者群体和卫生保健机构中，诊断和管理仍然存在很大的差异。目的：为成人、儿童、孕妇、老年患者（≥65岁）、免疫功能低下个体和肥胖患者（体重指数≥30）急性阑尾炎的诊断和治疗提供最新的循证建议，该建议由世界急诊外科学会（WSES）采用分级建议评估、发展和评价（GRADE）方法制定。在MEDLINE、Embase、Scopus、Web of Science和Cochrane Library中进行系统的文献检索，以确定2025年5月之前发表的相关研究。符合条件的设计包括随机临床试验、观察性研究、系统评价和荟萃分析。采用设计合适的工具（rob2、robins - 1、QUADAS-2）评估偏倚风险。为19个关键临床问题中的每一个问题生成证据概要和证据到决策框架。证据的确定性分为高、中、低和极低。根据GRADE将推荐分为强推荐和有条件推荐（弱推荐）。六个关键的临床领域涉及19个问题。提出了35项建议。主要发现包括：(1)临床风险评分和影像学提高了诊断准确性，降低了阑尾切除术阴性率；(2)对于非复杂性阑尾炎患者，非手术治疗抗生素是安全有效的，可针对特定人群提出针对性的建议；(3)无并发症的阑尾炎患者可以在24小时内安全延迟阑尾切除术，而不会增加不良后果的风险；(4)腹腔镜阑尾切除术仍是标准手术方式；(5)并发症术后抗生素治疗应限于短期疗程（2-3天）；(6)复杂阑尾炎合并脓肿非手术治疗后的随访策略是发现肿瘤的关键。2025年WSES耶路撒冷指南为急性阑尾炎的诊断和治疗提供了最新的循证建议，旨在规范实践，减少不必要的可变性，并支持在不同人群和医疗保健系统中安全、有效和以患者为中心的护理。它们的执行应适应当地资源。
{"title":"Diagnosis and Treatment of Acute Appendicitis: 2025 Edition of the World Society of Emergency Surgery Jerusalem Guidelines.","authors":"Mauro Podda,Marco Ceresoli,Belinda De Simone,Paola Fugazzola,Francesco Pata,Andrea Balla,Chiara Gerardi,Eleonora Allocati,Paulina Salminen,Raul Coimbra,Michael Kelly,Marja Boermeester,Helmut Segovia Lohse,Edward Tan,Adolfo Pisanu,Fikri Abu-Zidan,David Flum,Boris Sakakushev,Luca Ansaloni,Carlos Augusto Gomes,David Talan,Giovanni Domenico Tebala,Vishal Shelat,Cino Bendinelli,Zsolt Balogh,Panu Mentula,Isidoro Di Carlo,Yoram Kluger,Matti Tolonen,Henna Sammalkorpi,Dimitrios Damaskos,Walter Biffl,Baohong Yang,Ville Sallinen,Justin Davies,Carlo Vallicelli,Francesco Amico,Goran Augustin,Eugenio Cucinotta,Andrey Litvin,Andrew Kirkpatrick,Nicola de'Angelis,Dieter Weber,Ari Leppaniemi,Matthew Lee,Luis Felipe Cabrera Vargas,Massimo Sartelli,Federico Coccolini,Salomone Di Saverio,Fausto Catena","doi":"10.1001/jamasurg.2025.6218","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.6218","url":null,"abstract":"ImportanceAcute appendicitis is the most common abdominal surgical emergency worldwide and a leading cause of emergency hospital admissions and operations. Despite its frequency, substantial variability persists in diagnosis and management across patient populations and health care settings.ObjectiveTo provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis in adults, children, pregnant women, older patients (aged ≥65 years), immunocompromised individuals, and patients with obesity (body mass index ≥30), developed by the World Society of Emergency Surgery (WSES) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.Evidence ReviewA systematic literature search was performed in MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library to identify relevant studies published until May 2025. Eligible designs included randomized clinical trials, observational studies, systematic reviews, and meta-analyses. Risk of bias was assessed with design-appropriate tools (RoB-2, ROBINS-I, QUADAS-2). Evidence profiles and evidence-to-decision frameworks were generated for each of 19 key clinical questions. The certainty of evidence was rated as high, moderate, low, or very low. Recommendations were classified as strong or conditional (weak) according to GRADE.FindingsSix key clinical domains were addressed across 19 questions. Thirty-five recommendations were formulated. Key findings include: (1) clinical risk scores and imaging improve diagnostic accuracy and reduce negative appendectomy rates; (2) nonoperative management with antibiotics is safe and effective in selected patients with uncomplicated appendicitis, with recommendations tailored for specific populations; (3) appendectomy for uncomplicated appendicitis may be safely delayed within 24 hours without increased risk of adverse outcomes; (4) laparoscopic appendectomy remains the standard surgical approach; (5) postoperative antibiotic therapy should be limited to short courses (2-3 days) in complicated disease; and (6) follow-up strategies are essential after nonoperative management of complicated appendicitis with abscess to detect neoplasms.Conclusions and RelevanceThe 2025 WSES Jerusalem Guidelines provide updated, evidence-based recommendations for the diagnosis and treatment of acute appendicitis with the aim to standardize practice, reduce unwarranted variability, and support safe, effective, and patient-centered care across diverse populations and health care systems. Their implementation should be adapted to local resources.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"64 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2026-01-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146056867","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}
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