JAMA surgery最新文献

Importance: There is sparse literature on whether routine cholangiography (RC) vs selective cholangiography (SC) during cholecystectomy is associated with improved perioperative outcomes, regardless of whether an intraoperative cholangiogram (IOC) is performed.

Objective: To compare perioperative outcomes of cholecystectomy between surgeons who routinely vs selectively perform IOC.

Design, setting, and participants: This retrospective cohort study was conducted from January 2015 through June 2023 and took place within the Cleveland Clinic Enterprise, which includes 18 hospitals and 9 ambulatory surgery centers in 2 states (Ohio and Florida). Participants included adult patients who underwent cholecystectomy for benign biliary disease. Data analysis was conducted between July 2023 and August 2024.

Exposure: Routine cholangiography, defined as more than 70% of cholecystectomies performed with IOC per surgeon over the study period.

Main outcome(s) and measure(s): The primary outcome was major bile duct injury (BDI). Hierarchical mixed-effects models with patients nested in hospitals adjusted for individual- and surgeon-level characteristics were used to assess the odds of major BDI and secondary outcomes (minor BDI, operative duration, and perioperative endoscopic retrograde cholangiopancreatography [ERCP]).

Results: A total of 134 surgeons performed 28 212 cholecystectomies with 10 244 in the RC cohort (mean age, 52.71 [SD, 17.78] years; 7102 female participants [69.33%]) and 17 968 in the SC cohort (mean age, 52.33 [SD, 17.72] years; 12 135 female participants [67.54%]). Overall, 26 major BDIs (0.09%) and 105 minor BDIs (0.34%) were identified. Controlling for patient and surgeon characteristics nested in hospitals, RC was associated with decreased odds of major BDI (odds ratio [OR], 0.16; 95% CI, 0.15-0.18) and minor BDI (OR, 0.83; 95% CI, 0.77-0.89) compared with SC. Major BDIs were recognized intraoperatively more often in the RC cohort than the SC cohort (76.9% vs 23.0%; difference, 53.8%; 95% CI, 15.9%-80.2%). Lastly, RC was not significantly associated with increased perioperative ERCP utilization (OR, 1.01; 95% CI, 0.90-1.14) or negative ERCP rate (RC, 27 of 844 [3.2%] vs SC, 57 of 1570 [3.6%]; difference, -0.3%; 95% CI, -1.9% to 1.0%).

Conclusions and relevance: In this study, RC was associated with decreased odds of major and minor BDI, as well as increased intraoperative recognition of major BDI when it occurred. RC could be considered as a health systems strategy to minimize BDI, acknowledging the overall low prevalence but high morbidity from these injuries.

Importance: Originally developed for use in contaminated fields, there is growing evidence against the use of biologic and biosynthetic mesh in ventral hernia repair. However, its prevalence and patterns of use in current practice are largely unknown.

Objectives: To describe the prevalence of biologic and biosynthetic mesh use in ventral hernia repair and to identify factors associated with its use.

Design, setting, and participants: This retrospective cohort study used a statewide clinical registry in Michigan to identify adults who underwent mesh-based ventral hernia repair between January 1, 2021, and December 31, 2023. Data analysis was performed from February to May 2024.

Exposures: Use of biologic or biosynthetic mesh vs synthetic mesh.

Main outcomes and measures: The main outcome was use of biologic or biosynthetic mesh, abstracted directly from the operative report. Multivariable logistic regression was used to identify factors associated with use of biologic or biosynthetic mesh.

Results: A total of 10 838 patients (mean [SD] age, 55.7 [14.0] years; 4619 [42.6%] female) who underwent mesh-based ventral hernia repair were identified, among whom 1174 repairs (10.8%) were performed with biologic or biosynthetic mesh and 9664 (89.2%) were performed with synthetic mesh. Of the 1174 cases using biologic or biosynthetic mesh, 1023 (87.1%) had a clean wound classification and 1039 (88.5%) were performed electively. In multivariable logistic regression, wound contamination was associated with increased odds of biologic or biosynthetic mesh use (clean-contaminated: adjusted odds ratio [aOR], 2.17 [95% CI, 1.62-2.89]; contaminated: aOR, 2.95 [95% CI, 1.63-5.34]; dirty or infected: aOR, 36.22 [95% CI, 12.20-107.56]). Other operative factors associated with increased odds of biologic or biosynthetic mesh use included urgent or emergent surgical priority (aOR, 1.69 [95% CI, 1.33-2.16]), laparoscopic or robotic approach (aOR, 1.31 [95% CI, 1.15-1.50]), larger hernia width (aOR, 1.03 [95% CI, 1.01-1.04] per centimeter), and use of myofascial release (aOR, 2.10 [95% CI, 1.64-2.70]).

Conclusions and relevance: In this large cohort of patients undergoing ventral hernia repair, 1 in 10 mesh-based repairs was performed with biologic or biosynthetic mesh. Although urgent or emergent repair and wound contamination were associated with increased odds of biologic or biosynthetic mesh use, nearly 90% of biologic and biosynthetic mesh use occurred in elective repairs with clean wound classifications. These results raise questions regarding the appropriateness of its application in current practice.