Pub Date : 2025-11-12DOI: 10.1001/jamasurg.2025.4941
Philip C Müller,Caroline Berchtold,Christoph Kuemmerli,Eva Breuer,Zhihao Li,Alessia Vallorani,Carsten Hansen,Cristiano Guidetti,Janina Eden,Brady A Campbell,Pengfei Wu,Sara Nicole Cecchetto,Hallbera Gudmundsdottir,Michael Kendrick,Patrick P Starlinger,Nicolò Pecorelli,Giovanni Guarneri,Waqas Farooqui,Christoph Tschuor,Stefan Kobbelgaard Burgdorf,Julia Mühlhäusser,Jörn-Markus Gass,Brian K P Goh,Ye-Xin Koh,Artur Rebelo,Jörg Kleeff,Tomas Seip,Martin Santibanes,Letizia Todeschini,Giovanni Marchegiani,Nadiya Belfil,Mickaël Lesurtel,Marcel Machado,Ugo Boggi,Emanuele Kauffmann,Marie Cappelle,Bas Groot Koerkamp,Fabrizio Di Benedetto,Keith Roberts,Avinoam Nevler,Harish Lavu,Philipp Dutkowski,Felix Nickel,Thilo Hackert,Jin He,Massimo Falconi,Mark Truty,Adrian T Billeter,Beat P Müller, ,James Halle-Smith,Valentina Valle,Pier Giulianotti,Fabio Giannone,Patrick Pessaux,Patricia Sánchez-Velázquez,Prabin Bikram Thapa,Dhiresh Maharjan,Orlando Torres,Matta Kuzman,Sanjay Pandanaboyana
ImportanceTotal pancreatectomy (TP) is indicated for advanced pancreatic cancer or multifocal tumors. Furthermore, TP may be performed to avoid the risk of pancreatic fistula in selected patients to improve the perioperative risk profile.ObjectiveTo define reference values for TP based on a low-risk cohort treated at expert centers.Design, Setting, and ParticipantsThis multicenter study analyzed outcomes from patients undergoing primary TP for malignant or benign lesions from 25 international expert centers from January 2017 to November 2023. Low-risk patients undergoing TP (LR-TP) were without vascular resections or significant comorbidities.ExposuresTP.Main Outcomes and MeasuresTwenty reference values were derived from the 75th or the 25th percentile of the median values of all centers. Outcomes of LR-TP were compared with a cohort of TP with vascular resection, TP due to high-risk pancreatic anastomosis, and the benchmark values for low-risk pancreatoduodenectomy.ResultsOf 994 patients, 333 (33.5%; median [IQR] age, 66 [58-72] years; 171 male [51.4%]) qualified as the LR-TP cohort. Reference values included blood loss (≤1000 mL), major complications (≤37%), 3-month postoperative mortality (<6%), and retrieved lymph nodes (≥29). Compared with TP with vascular resections, reference cutoffs were not met for major complications (51% vs LR-TP ≤37%) and 90-day mortality (11% vs LR-TP ≤6%). For TP due to high-risk anastomosis, failure to rescue rate (38% vs ≤6%) and 90-day mortality (11% vs LR-TP ≤6%) were not met. Compared with pancreatoduodenectomy, reference values for postoperative mortality were 3 times higher for LR-TP (≤2% vs ≤6%) and less for resected lymph nodes (≥16 vs ≥29).Conclusions and RelevanceThis case-control study provided global reference values for TP, indicating significantly higher postoperative morbidity and mortality compared with pancreatoduodenectomy. Perioperative morbidity of TP was especially increased in patients with vascular resections. These reference values can serve for quality control of pancreatic surgery.
重要性全胰腺切除术（TP）适用于晚期胰腺癌或多灶性肿瘤。此外，在特定的患者中，TP可以避免胰瘘的风险，以改善围手术期的风险概况。目的根据专家中心治疗的低危队列确定TP的参考值。设计、环境和参与者本多中心研究分析了2017年1月至2023年11月25个国际专家中心因恶性或良性病变接受原发性TP治疗的患者的结果。接受TP （LR-TP）的低危患者无血管切除或显著合共病。主要结局和测量方法20个参考值来自所有中心中位数的第75或第25百分位。将低风险胰十二指肠切除术的预后与胰十二指肠切除术合并血管切除术的预后、胰十二指肠吻合术的预后以及低风险胰十二指肠切除术的预后进行比较。结果994例患者中，333例（33.5%；中位[IQR]年龄66[58-72]岁；171例男性[51.4%]）符合LR-TP队列。参考值包括出血量（≤1000ml）、主要并发症（≤37%）、术后3个月死亡率（<6%）和淋巴结清扫（≥29）。与TP +血管切除术相比，主要并发症（51% vs LR-TP≤37%）和90天死亡率（11% vs LR-TP≤6%）均未达到参考截止值。对于吻合术高危的TP，未达到抢救失败率（38% vs≤6%）和90天死亡率（11% vs LR-TP≤6%）。与胰十二指肠切除术相比，LR-TP的术后死亡率参考值高出3倍（≤2% vs≤6%），而切除淋巴结的死亡率参考值更低（≥16 vs≥29）。结论与意义本病例对照研究为TP提供了全球参考价值，表明TP术后发病率和死亡率明显高于胰十二指肠切除术。围手术期TP的发病率在血管切除患者中尤为明显。这些参考值可为胰腺手术质量控制提供参考。
{"title":"International Reference Values for Surgical Outcomes of Total Pancreatectomy.","authors":"Philip C Müller,Caroline Berchtold,Christoph Kuemmerli,Eva Breuer,Zhihao Li,Alessia Vallorani,Carsten Hansen,Cristiano Guidetti,Janina Eden,Brady A Campbell,Pengfei Wu,Sara Nicole Cecchetto,Hallbera Gudmundsdottir,Michael Kendrick,Patrick P Starlinger,Nicolò Pecorelli,Giovanni Guarneri,Waqas Farooqui,Christoph Tschuor,Stefan Kobbelgaard Burgdorf,Julia Mühlhäusser,Jörn-Markus Gass,Brian K P Goh,Ye-Xin Koh,Artur Rebelo,Jörg Kleeff,Tomas Seip,Martin Santibanes,Letizia Todeschini,Giovanni Marchegiani,Nadiya Belfil,Mickaël Lesurtel,Marcel Machado,Ugo Boggi,Emanuele Kauffmann,Marie Cappelle,Bas Groot Koerkamp,Fabrizio Di Benedetto,Keith Roberts,Avinoam Nevler,Harish Lavu,Philipp Dutkowski,Felix Nickel,Thilo Hackert,Jin He,Massimo Falconi,Mark Truty,Adrian T Billeter,Beat P Müller, ,James Halle-Smith,Valentina Valle,Pier Giulianotti,Fabio Giannone,Patrick Pessaux,Patricia Sánchez-Velázquez,Prabin Bikram Thapa,Dhiresh Maharjan,Orlando Torres,Matta Kuzman,Sanjay Pandanaboyana","doi":"10.1001/jamasurg.2025.4941","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4941","url":null,"abstract":"ImportanceTotal pancreatectomy (TP) is indicated for advanced pancreatic cancer or multifocal tumors. Furthermore, TP may be performed to avoid the risk of pancreatic fistula in selected patients to improve the perioperative risk profile.ObjectiveTo define reference values for TP based on a low-risk cohort treated at expert centers.Design, Setting, and ParticipantsThis multicenter study analyzed outcomes from patients undergoing primary TP for malignant or benign lesions from 25 international expert centers from January 2017 to November 2023. Low-risk patients undergoing TP (LR-TP) were without vascular resections or significant comorbidities.ExposuresTP.Main Outcomes and MeasuresTwenty reference values were derived from the 75th or the 25th percentile of the median values of all centers. Outcomes of LR-TP were compared with a cohort of TP with vascular resection, TP due to high-risk pancreatic anastomosis, and the benchmark values for low-risk pancreatoduodenectomy.ResultsOf 994 patients, 333 (33.5%; median [IQR] age, 66 [58-72] years; 171 male [51.4%]) qualified as the LR-TP cohort. Reference values included blood loss (≤1000 mL), major complications (≤37%), 3-month postoperative mortality (<6%), and retrieved lymph nodes (≥29). Compared with TP with vascular resections, reference cutoffs were not met for major complications (51% vs LR-TP ≤37%) and 90-day mortality (11% vs LR-TP ≤6%). For TP due to high-risk anastomosis, failure to rescue rate (38% vs ≤6%) and 90-day mortality (11% vs LR-TP ≤6%) were not met. Compared with pancreatoduodenectomy, reference values for postoperative mortality were 3 times higher for LR-TP (≤2% vs ≤6%) and less for resected lymph nodes (≥16 vs ≥29).Conclusions and RelevanceThis case-control study provided global reference values for TP, indicating significantly higher postoperative morbidity and mortality compared with pancreatoduodenectomy. Perioperative morbidity of TP was especially increased in patients with vascular resections. These reference values can serve for quality control of pancreatic surgery.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"101 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145491708","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 : 2025-11-12DOI: 10.1001/jamasurg.2025.4917
Amélie Cambriel, Amy Tsai, Benjamin Choisy, Maximilian Sabayev, Julien Hedou, Elizabeth Shelton, Kreeti Singh, Jonas Amar, Valentin Badea, Serena Bruckman, Ed Ganio, Jakob Einhaus, Dorien Feyaerts, Ina Stelzer, Masaki Sato, Olivier Langeron, T. Adam Bonham, Dyani Gaudillière, Andrew Shelton, Cindy Kin, Brice Gaudillière, Franck Verdonk
Importance Prehabilitation programs are increasingly recognized for their potential to improve surgical outcomes. However, their efficacy remains debated, largely due to a lack of pathophysiologically driven implementation and limited personalization. Objective To determine the impact of personalized vs standard prehabilitation on preoperative physical, cognitive, and immune function and postoperative outcomes. Design, Setting, and Participants In this prospective, single-blinded, randomized interventional trial conducted from June 2020 to September 2022 in a single academic medical center, 58 patients undergoing major elective surgery were randomized to standard (n = 30) or personalized prehabilitation (n = 28) using block randomization. Those with contraindication to exercise, an American Society of Anesthesiologists score 4 or higher, in palliative care, less than 14 days between screening and surgery were excluded. Data were analyzed from April 2023 to May 2025. Intervention The personalized group received 2 weekly one-on-one remote coaching sessions tailored to individual progress in 4 domains (physical activity, nutrition, cognitive training, and mindfulness), whereas the standard group followed a paper-based program, including the same domains, without individualized support. Main Outcomes and Measures Primary clinical outcomes included cognitive assessments and physical performance measures, including the wall squat test, timed-up-and-go test, and 6-minute walk test (6MWT). The primary immunological outcomes included major innate and adaptive immune cell frequencies and intracellular signaling responses measured using a 47-plex mass cytometry immunoassay. Results Of 58 patients (median [IQR] age, 57 [45-67] years; 31 [57%] female) enrolled, 54 completed the study (n = 27 per group). The personalized group exhibited significant improvements in physical measures (eg, median [IQR] 6MWT: 496 [340-619] minutes before prehab versus 546 [350-728] minutes after; <jats:italic>P</jats:italic> = .03) and fewer moderate-to-severe postoperative complications (4 vs 11 Clavien-Dindo grade &gt;1; <jats:italic>P</jats:italic> = .04). Multivariable modeling identified profound and cell-type specific immune alterations postprehabilitation compared to baseline (area under the receiver operating characteristic curve [AUROC], 0.88; 0.79-0.97; <jats:italic>P</jats:italic> &lt; .001; leave-one-out cross-validation), including dampened phosphorylated protein kinase R-like endoplasmic reticulum kinase 1/2 signaling in classical monocytes and myeloid-derived suppressor cells after interleukin 2, 4, and 6 stimulation, and reduced phosphorylated cyclic adenosine monophosphate response–element binding protein signaling in Th1 cells. In contrast, the standard group showed only moderate clinical improvements and no immune changes (AUROC = 0.63; 95% CI, 0.48-0.78; <jats:italic>P</jats:italic> = .12). Conclusions and Relevance In this study, personalized p
重要性康复计划因其改善手术结果的潜力而日益得到认可。然而，它们的功效仍然存在争议，主要是由于缺乏病理生理学驱动的实施和有限的个性化。目的探讨个性化康复与标准康复对术前身体、认知、免疫功能及术后预后的影响。这项前瞻性、单盲、随机介入性试验于2020年6月至2022年9月在一个学术医疗中心进行，58名接受重大择期手术的患者采用块随机法随机分为标准组（n = 30）和个性化康复组（n = 28）。那些有运动禁忌症、美国麻醉医师学会评分4分或更高、姑息治疗、筛查和手术间隔少于14天的患者被排除在外。数据分析时间为2023年4月至2025年5月。干预：个性化组每周接受2次一对一远程辅导课程，针对4个领域（体育活动、营养、认知训练和正念）的个人进步进行量身定制，而标准组则遵循基于纸张的计划，包括相同的领域，没有个性化的支持。主要临床结果包括认知评估和体能测试，包括蹲墙测试、计时起跑测试和6分钟步行测试（6MWT）。主要免疫学结果包括主要的先天和适应性免疫细胞频率和细胞内信号反应，使用47-plex细胞计数免疫分析法测量。结果入组的58例患者（中位[IQR]年龄57[45-67]岁，31例[57%]女性）中，54例完成了研究（每组27例）。个性化组在身体测量方面有显著改善（例如，术前中位[IQR] 6MWT: 496[340-619]分钟，术前546[350-728]分钟，P = 0.03），中重度术后并发症较少（4 vs 11 Clavien-Dindo分级&；amp;gt;1; P = 0.04）。与基线相比，多变量模型确定了康复后深刻的细胞类型特异性免疫改变(受试者工作特征曲线下面积[AUROC]， 0.88; 0.79-0.97; P < .001；留一交叉验证)，包括在白细胞介素2、4和6刺激后，经典单核细胞和髓源性抑制细胞中磷酸化蛋白激酶r样内质网激酶1/2信号的抑制，以及Th1细胞中磷酸化环磷酸腺苷反应元件结合蛋白信号的减少。相比之下，标准组只有中度临床改善，无免疫变化（AUROC = 0.63; 95% CI, 0.48-0.78; P = 0.12）。在这项研究中，个性化的康复治疗在手术前显著改变了免疫组，抑制了先前涉及关键手术结果病理生理学的炎症信号反应，包括手术部位感染和术后神经认知能力下降。这些变化伴随着术前身体和认知功能的改善，以及术后并发症的减少。这些发现支持了个性化康复的使用，并为生物学驱动的康复疗效监测和个性化定制方案提供了途径，以优化手术准备和康复。临床试验注册ClinicalTrials.gov标识符：NCT04498208
{"title":"Immune Modulation by Personalized vs Standard Prehabilitation Before Major Surgery","authors":"Amélie Cambriel, Amy Tsai, Benjamin Choisy, Maximilian Sabayev, Julien Hedou, Elizabeth Shelton, Kreeti Singh, Jonas Amar, Valentin Badea, Serena Bruckman, Ed Ganio, Jakob Einhaus, Dorien Feyaerts, Ina Stelzer, Masaki Sato, Olivier Langeron, T. Adam Bonham, Dyani Gaudillière, Andrew Shelton, Cindy Kin, Brice Gaudillière, Franck Verdonk","doi":"10.1001/jamasurg.2025.4917","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4917","url":null,"abstract":"Importance Prehabilitation programs are increasingly recognized for their potential to improve surgical outcomes. However, their efficacy remains debated, largely due to a lack of pathophysiologically driven implementation and limited personalization. Objective To determine the impact of personalized vs standard prehabilitation on preoperative physical, cognitive, and immune function and postoperative outcomes. Design, Setting, and Participants In this prospective, single-blinded, randomized interventional trial conducted from June 2020 to September 2022 in a single academic medical center, 58 patients undergoing major elective surgery were randomized to standard (n = 30) or personalized prehabilitation (n = 28) using block randomization. Those with contraindication to exercise, an American Society of Anesthesiologists score 4 or higher, in palliative care, less than 14 days between screening and surgery were excluded. Data were analyzed from April 2023 to May 2025. Intervention The personalized group received 2 weekly one-on-one remote coaching sessions tailored to individual progress in 4 domains (physical activity, nutrition, cognitive training, and mindfulness), whereas the standard group followed a paper-based program, including the same domains, without individualized support. Main Outcomes and Measures Primary clinical outcomes included cognitive assessments and physical performance measures, including the wall squat test, timed-up-and-go test, and 6-minute walk test (6MWT). The primary immunological outcomes included major innate and adaptive immune cell frequencies and intracellular signaling responses measured using a 47-plex mass cytometry immunoassay. Results Of 58 patients (median [IQR] age, 57 [45-67] years; 31 [57%] female) enrolled, 54 completed the study (n = 27 per group). The personalized group exhibited significant improvements in physical measures (eg, median [IQR] 6MWT: 496 [340-619] minutes before prehab versus 546 [350-728] minutes after; <jats:italic>P</jats:italic> = .03) and fewer moderate-to-severe postoperative complications (4 vs 11 Clavien-Dindo grade &amp;gt;1; <jats:italic>P</jats:italic> = .04). Multivariable modeling identified profound and cell-type specific immune alterations postprehabilitation compared to baseline (area under the receiver operating characteristic curve [AUROC], 0.88; 0.79-0.97; <jats:italic>P</jats:italic> &amp;lt; .001; leave-one-out cross-validation), including dampened phosphorylated protein kinase R-like endoplasmic reticulum kinase 1/2 signaling in classical monocytes and myeloid-derived suppressor cells after interleukin 2, 4, and 6 stimulation, and reduced phosphorylated cyclic adenosine monophosphate response–element binding protein signaling in Th1 cells. In contrast, the standard group showed only moderate clinical improvements and no immune changes (AUROC = 0.63; 95% CI, 0.48-0.78; <jats:italic>P</jats:italic> = .12). Conclusions and Relevance In this study, personalized p","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"5 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145492693","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 : 2025-11-12DOI: 10.1001/jamasurg.2025.4938
Arto Kokkola,Johanna Louhimo,Pauli Puolakkainen
{"title":"Laparoscopic Surgery in Patients With Distal T4a Gastric Cancer.","authors":"Arto Kokkola,Johanna Louhimo,Pauli Puolakkainen","doi":"10.1001/jamasurg.2025.4938","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4938","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"16 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145491713","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 : 2025-11-12DOI: 10.1001/jamasurg.2025.4929
Tran Quang Dat,Dang Quang Thong,Doan Thuy Nguyen,Nguyen Viet Hai,Tran Duy Phuoc,Nguyen Vu Tuan Anh,Nguyen Hoang Bac,Vo Duy Long
ImportanceNo prospective trial on laparoscopy has been specifically designed for clinical T4a gastric cancer (GC); evidence of the safety and efficacy of laparoscopy for T4a GC is currently insufficient.ObjectiveTo compare the short-term surgical outcomes between laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) with D2 lymph node dissection for patients with clinical T4a GC.Design, Setting, and ParticipantsThe UMC-UPPERGI-01 randomized clinical trial (RCT) was a single-center, open-label, noninferiority RCT conducted at a tertiary hospital in Ho Chi Minh City, Vietnam, among patients with clinical T4a GC. The study was conducted from June 2020 to April 2025. Interim and short-term results analyses were conducted in October 2023 and June 2025, respectively.InterventionsPatients were randomly assigned 1:1 to undergo LDG or ODG with D2 lymph node dissection as the full analysis set of the UMC-UPPERGI-01 trial. The procedures were performed exclusively by qualified surgeons.Main Outcomes and MeasuresShort-term outcomes included surgical results, pathological characteristics, 30-day postoperative morbidity and mortality (Clavien-Dindo classification), and postoperative recovery parameters.ResultsA total of 208 patients who underwent curative-intent distal gastrectomy with D2 lymphadenectomy were included in the full analysis set, with 104 patients in each group. There was no crossover between the 2 groups. Patients in the LDG group had a mean (SD) age of 61.1 (10.0) years and included 25 female patients (24.0%). Patients in the ODG group had a mean (SD) age of 60.0 (10.7) years and included 29 female patients (27.9%). No significant differences were found between the LDG and ODG groups in 30-day morbidity and mortality, including rates of any postoperative complication (22.1% vs 21.2%; P = .87) and severe complications (2.9% vs 3.8%; P > .99). The LDG group showed nonsignificant differences regarding surgical complications (21.2% vs 16.4%; P = .37) and general complications (3.9% vs 10.6%; P = .11) compared to the ODG group. The LDG group had significantly longer mean (SD) operative time (220.0 [42.4] minutes vs 153.7 [36.7] minutes; P < .001) and higher median (IQR) blood loss (80 [50-145] mL vs 50 [30-100] mL; P = .003). There were no significant differences in terms of time to the first flatus, time to oral tolerance, length of postoperative hospital stay, and time from surgery to initiation of adjuvant chemotherapy. Comorbidity was identified as an independent risk factor for postoperative complications in multivariate analysis (odds ratio, 2.42; 95% CI, 1.11-5.30; P = .03).Conclusions and RelevanceIn the UMC-UPPERGI-01 noninferiority RCT, LDG showed comparable short-term outcomes to ODG for T4a GC. The results suggest that LDG can be recommended as an alternative to ODG by qualified surgeons for clinical T4a GC; ongoing follow-up will determine long-term oncologic outcomes.Trial RegistrationClinicalTrials.gov Identifier: NC
没有一项腹腔镜前瞻性试验是专门为临床T4a胃癌（GC）设计的；目前，腹腔镜治疗T4a胃癌的安全性和有效性证据不足。目的比较腹腔镜胃远端切除术（LDG）与开放式胃远端切除术（ODG）联合D2淋巴结清扫治疗临床T4a型胃癌的近期手术效果。设计、环境和参与者UMC-UPPERGI-01随机临床试验（RCT）是一项单中心、开放标签、非劣效性随机对照试验，在越南胡志明市的一家三级医院进行，患者为临床T4a GC。该研究于2020年6月至2025年4月进行。中期和短期结果分析分别于2023年10月和2025年6月进行。干预：作为UMC-UPPERGI-01试验的完整分析集，患者按1:1随机分配接受LDG或ODG伴D2淋巴结清扫。手术只由合格的外科医生进行。短期结果包括手术结果、病理特征、术后30天发病率和死亡率（Clavien-Dindo分类）和术后恢复参数。结果208例以治愈为目的的胃远端切除术合并D2淋巴结切除术纳入完整分析集，每组104例。两组之间没有交叉。LDG组患者平均（SD）年龄为61.1（10.0）岁，其中女性25例（24.0%）。ODG组患者平均（SD）年龄为60.0（10.7）岁，其中女性29例（27.9%）。LDG组和ODG组在30天的发病率和死亡率（包括任何术后并发症的发生率）方面无显著差异(22.1% vs 21.2%; P =。87)和严重并发症（2.9% vs 3.8%; P < 0.99）。LDG组手术并发症差异无统计学意义(21.2% vs 16.4%; P =。37)和一般并发症(3.9% vs 10.6%; P =。11)与ODG组比较。LDG组平均（SD）手术时间（220.0 [42.4]min vs 153.7 [36.7] min）明显延长；001)和更高的中位（IQR）失血量（80 [50-145]mL vs 50 [30-100] mL; P = 0.003）。两组在首次放屁时间、口服耐受时间、术后住院时间以及从手术到开始辅助化疗时间方面无显著差异。多因素分析发现合并症是术后并发症的独立危险因素（优势比为2.42；95% CI为1.11-5.30;P = 0.03）。在UMC-UPPERGI-01非劣效性随机对照试验中，LDG治疗T4a GC的短期疗效与ODG相当。结果表明，合格的外科医生可以推荐LDG作为临床T4a GC的替代方案；持续的随访将确定长期的肿瘤预后。临床试验注册号：NCT04384757。
{"title":"Laparoscopic vs Open Distal Gastrectomy With D2 Lymphadenectomy for Clinical T4a Gastric Cancer: The UMC-UPPERGI-01 Randomized Clinical Trial.","authors":"Tran Quang Dat,Dang Quang Thong,Doan Thuy Nguyen,Nguyen Viet Hai,Tran Duy Phuoc,Nguyen Vu Tuan Anh,Nguyen Hoang Bac,Vo Duy Long","doi":"10.1001/jamasurg.2025.4929","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4929","url":null,"abstract":"ImportanceNo prospective trial on laparoscopy has been specifically designed for clinical T4a gastric cancer (GC); evidence of the safety and efficacy of laparoscopy for T4a GC is currently insufficient.ObjectiveTo compare the short-term surgical outcomes between laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) with D2 lymph node dissection for patients with clinical T4a GC.Design, Setting, and ParticipantsThe UMC-UPPERGI-01 randomized clinical trial (RCT) was a single-center, open-label, noninferiority RCT conducted at a tertiary hospital in Ho Chi Minh City, Vietnam, among patients with clinical T4a GC. The study was conducted from June 2020 to April 2025. Interim and short-term results analyses were conducted in October 2023 and June 2025, respectively.InterventionsPatients were randomly assigned 1:1 to undergo LDG or ODG with D2 lymph node dissection as the full analysis set of the UMC-UPPERGI-01 trial. The procedures were performed exclusively by qualified surgeons.Main Outcomes and MeasuresShort-term outcomes included surgical results, pathological characteristics, 30-day postoperative morbidity and mortality (Clavien-Dindo classification), and postoperative recovery parameters.ResultsA total of 208 patients who underwent curative-intent distal gastrectomy with D2 lymphadenectomy were included in the full analysis set, with 104 patients in each group. There was no crossover between the 2 groups. Patients in the LDG group had a mean (SD) age of 61.1 (10.0) years and included 25 female patients (24.0%). Patients in the ODG group had a mean (SD) age of 60.0 (10.7) years and included 29 female patients (27.9%). No significant differences were found between the LDG and ODG groups in 30-day morbidity and mortality, including rates of any postoperative complication (22.1% vs 21.2%; P = .87) and severe complications (2.9% vs 3.8%; P > .99). The LDG group showed nonsignificant differences regarding surgical complications (21.2% vs 16.4%; P = .37) and general complications (3.9% vs 10.6%; P = .11) compared to the ODG group. The LDG group had significantly longer mean (SD) operative time (220.0 [42.4] minutes vs 153.7 [36.7] minutes; P < .001) and higher median (IQR) blood loss (80 [50-145] mL vs 50 [30-100] mL; P = .003). There were no significant differences in terms of time to the first flatus, time to oral tolerance, length of postoperative hospital stay, and time from surgery to initiation of adjuvant chemotherapy. Comorbidity was identified as an independent risk factor for postoperative complications in multivariate analysis (odds ratio, 2.42; 95% CI, 1.11-5.30; P = .03).Conclusions and RelevanceIn the UMC-UPPERGI-01 noninferiority RCT, LDG showed comparable short-term outcomes to ODG for T4a GC. The results suggest that LDG can be recommended as an alternative to ODG by qualified surgeons for clinical T4a GC; ongoing follow-up will determine long-term oncologic outcomes.Trial RegistrationClinicalTrials.gov Identifier: NC","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"1 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145491712","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 : 2025-11-05DOI: 10.1001/jamasurg.2025.4716
Tamara Byrd,Sebastian Boland,Liling Lu,David Silver,Joshua B Brown
ImportanceThe Air Medical Prehospital Triage (AMPT) score may attenuate disparities observed in recent data that demonstrated significantly lower odds of prehospital air medical transport (AMT) use among injured patients of minoritized race and ethnicity groups compared to non-Hispanic White patients.ObjectiveTo evaluate if using the AMPT score is associated with a reduction in racial and ethnic disparities in prehospital AMT use or a mortality benefit in patients who meet AMPT criteria.Design, Setting, and ParticipantsThis was a retrospective cohort study of the Pennsylvania Trauma Outcomes Study database from January 2000 to December 2020. Participants included injured patients aged 16 years and older who underwent ground or helicopter emergency medical service transport from the scene of injury, excluding those with transport distances less than 5 miles from the trauma center. Race and ethnicity were reported as per the dataset, which used patient self-report. Data were analyzed from February to August 2025.ExposureAMPT-assigned transport mode.Main Outcomes and MeasuresActual prehospital transport mode (air vs ground) and AMPT-assigned transport mode were evaluated; in-hospital mortality was assessed by AMPT triage assignment. Socioenvironmental context was evaluated using the Area Deprivation Index (ADI), Social Deprivation Index (SDI), and Distressed Communities Index (DCI).ResultsThe study cohort included 307 831 patients (mean [SD] age, 50.0 [25.3] years; 185 288 [60.2%] male; 2727 [0.9%] non-Hispanic Asian, 30 570 [10.2%] non-Hispanic Black, 8471 [2.8%] Hispanic/Latino, 253 491 [84.5%] non-Hispanic White, 4643, and [1.6%] other [including Alaskan Native, American Indian, and Asian, and Pacific Islander]). Non-Hispanic Asian, Non-Hispanic Black, and Hispanic/Latino patients were significantly less likely to undergo prehospital AMT compared to White patients. When assigning prehospital transport mode based on the AMPT score, no significant associations were observed between race and ethnicity and AMT use. Prehospital air vs ground transport was associated with 24% lower odds of mortality among patients who had an AMPT score of 2 or greater (adjusted odds ratio [aOR], 0.76; 95% CI, 0.58-0.99; P = .40). As ADI, DCI, and SDI scores increased, AMT use varied by race and ethnicity. Causal mediation analyses demonstrated that 38% (mediation effect, 0.38; 95% CI, 0.35-0.42), 40% (mediation effect, 0.40; 95% CI, 0.38-0.43), and 13% (mediation effect, 0.13; 95% CI, 0.11-0.18) of the effect of race and ethnicity on prehospital transport mode were explained by ADI, DCI, and SDI scores, respectively.Conclusions and RelevanceThe results of this cohort study indicate that standard use of the AMPT score during air medical triage may improve equity in prehospital AMT use.
{"title":"Air Medical Prehospital Triage Score and Racial and Ethnic Disparities in Air Transport After Injury.","authors":"Tamara Byrd,Sebastian Boland,Liling Lu,David Silver,Joshua B Brown","doi":"10.1001/jamasurg.2025.4716","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4716","url":null,"abstract":"ImportanceThe Air Medical Prehospital Triage (AMPT) score may attenuate disparities observed in recent data that demonstrated significantly lower odds of prehospital air medical transport (AMT) use among injured patients of minoritized race and ethnicity groups compared to non-Hispanic White patients.ObjectiveTo evaluate if using the AMPT score is associated with a reduction in racial and ethnic disparities in prehospital AMT use or a mortality benefit in patients who meet AMPT criteria.Design, Setting, and ParticipantsThis was a retrospective cohort study of the Pennsylvania Trauma Outcomes Study database from January 2000 to December 2020. Participants included injured patients aged 16 years and older who underwent ground or helicopter emergency medical service transport from the scene of injury, excluding those with transport distances less than 5 miles from the trauma center. Race and ethnicity were reported as per the dataset, which used patient self-report. Data were analyzed from February to August 2025.ExposureAMPT-assigned transport mode.Main Outcomes and MeasuresActual prehospital transport mode (air vs ground) and AMPT-assigned transport mode were evaluated; in-hospital mortality was assessed by AMPT triage assignment. Socioenvironmental context was evaluated using the Area Deprivation Index (ADI), Social Deprivation Index (SDI), and Distressed Communities Index (DCI).ResultsThe study cohort included 307 831 patients (mean [SD] age, 50.0 [25.3] years; 185 288 [60.2%] male; 2727 [0.9%] non-Hispanic Asian, 30 570 [10.2%] non-Hispanic Black, 8471 [2.8%] Hispanic/Latino, 253 491 [84.5%] non-Hispanic White, 4643, and [1.6%] other [including Alaskan Native, American Indian, and Asian, and Pacific Islander]). Non-Hispanic Asian, Non-Hispanic Black, and Hispanic/Latino patients were significantly less likely to undergo prehospital AMT compared to White patients. When assigning prehospital transport mode based on the AMPT score, no significant associations were observed between race and ethnicity and AMT use. Prehospital air vs ground transport was associated with 24% lower odds of mortality among patients who had an AMPT score of 2 or greater (adjusted odds ratio [aOR], 0.76; 95% CI, 0.58-0.99; P = .40). As ADI, DCI, and SDI scores increased, AMT use varied by race and ethnicity. Causal mediation analyses demonstrated that 38% (mediation effect, 0.38; 95% CI, 0.35-0.42), 40% (mediation effect, 0.40; 95% CI, 0.38-0.43), and 13% (mediation effect, 0.13; 95% CI, 0.11-0.18) of the effect of race and ethnicity on prehospital transport mode were explained by ADI, DCI, and SDI scores, respectively.Conclusions and RelevanceThe results of this cohort study indicate that standard use of the AMPT score during air medical triage may improve equity in prehospital AMT use.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"341 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145440580","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 : 2025-11-05DOI: 10.1001/jamasurg.2025.4706
Thomas Schaschinger,Tobias Niederegger,Jule Brandt,Samuel Knoedler,Leonard Knoedler,Dany Y Matar,Wilson Alobuia,Giovanni M Perottino,George A Poultsides,Mohammad Sabagh,Dennis P Orgill,Johann Pratschke,Adriana C Panayi,Gabriel Hundeshagen
ImportanceDysglycemia is increasingly recognized as a major contributor to adverse surgical outcomes. However, the clinical utility of preoperative hemoglobin A1C (HbA1c) screening in general surgery remains unclear.ObjectiveTo determine whether elevated HbA1c is associated with increased 30-day postoperative complications, readmissions, and mortality in patients undergoing general surgery procedures.Design, Setting, and ParticipantsThis retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from 2021 to 2023. Multivariable logistic regression was used to evaluate associations between glycemic status and complications within 30 days after surgery. The multicenter database comprised more than 700 participating institutions worldwide, predominantly in the US. Participants included adult patients (18 years or older) undergoing general surgery procedures with available HbA1c data.ExposuresGlycemic status categorized by documented diabetes diagnosis and HbA1c levels, ranging from normoglycemia to very poor glycemic control. Patients without a diagnosis but HbA1c levels higher than 6.4% (to convert to proportion of total hemoglobin, multiply by 0.01) were considered to have undiagnosed diabetes.Main Outcomes and MeasuresMain outcomes included occurrence of any, surgical, and medical complications, as well as readmissions, reoperations, and mortality within 30 days after surgery.ResultsAmong 282 131 patients (mean [SD] age, 60 [15] years), 36% had diagnosed diabetes, whereas 6.4% had HbA1c values in the diabetes range but no diagnosis. In those patients with diabetes, risk of any complication increased progressively from near normal (HbA1c level <6.0%; odds ratio [OR], 1.06; 95% CI, 1.00-1.11) to very poor glycemic control (HbA1c level >9.0%; OR, 1.32; 95% CI, 1.25-1.39). Undiagnosed diabetes was also associated with higher risks of medical complications (OR, 1.11; 95% CI, 1.04-1.18) and mortality (OR, 1.24; 95% CI, 1.07-1.42).Conclusions and RelevanceDysglycemia-both diagnosed and undiagnosed-is highly prevalent among general surgery patients and independently associated with increased risks of complications, readmissions, or mortality. A significant proportion of patients had HbA1c levels in the diabetes range, despite lacking a diabetes diagnosis. These findings support routine preoperative HbA1c screening and the adoption of individualized glycemic management strategies to optimize surgical risk assessment, reduce complications, and improve perioperative outcomes.
{"title":"Preoperative Hemoglobin A1C, Glycemic Status, and Postoperative Outcomes in General Surgery.","authors":"Thomas Schaschinger,Tobias Niederegger,Jule Brandt,Samuel Knoedler,Leonard Knoedler,Dany Y Matar,Wilson Alobuia,Giovanni M Perottino,George A Poultsides,Mohammad Sabagh,Dennis P Orgill,Johann Pratschke,Adriana C Panayi,Gabriel Hundeshagen","doi":"10.1001/jamasurg.2025.4706","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4706","url":null,"abstract":"ImportanceDysglycemia is increasingly recognized as a major contributor to adverse surgical outcomes. However, the clinical utility of preoperative hemoglobin A1C (HbA1c) screening in general surgery remains unclear.ObjectiveTo determine whether elevated HbA1c is associated with increased 30-day postoperative complications, readmissions, and mortality in patients undergoing general surgery procedures.Design, Setting, and ParticipantsThis retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from 2021 to 2023. Multivariable logistic regression was used to evaluate associations between glycemic status and complications within 30 days after surgery. The multicenter database comprised more than 700 participating institutions worldwide, predominantly in the US. Participants included adult patients (18 years or older) undergoing general surgery procedures with available HbA1c data.ExposuresGlycemic status categorized by documented diabetes diagnosis and HbA1c levels, ranging from normoglycemia to very poor glycemic control. Patients without a diagnosis but HbA1c levels higher than 6.4% (to convert to proportion of total hemoglobin, multiply by 0.01) were considered to have undiagnosed diabetes.Main Outcomes and MeasuresMain outcomes included occurrence of any, surgical, and medical complications, as well as readmissions, reoperations, and mortality within 30 days after surgery.ResultsAmong 282 131 patients (mean [SD] age, 60 [15] years), 36% had diagnosed diabetes, whereas 6.4% had HbA1c values in the diabetes range but no diagnosis. In those patients with diabetes, risk of any complication increased progressively from near normal (HbA1c level <6.0%; odds ratio [OR], 1.06; 95% CI, 1.00-1.11) to very poor glycemic control (HbA1c level >9.0%; OR, 1.32; 95% CI, 1.25-1.39). Undiagnosed diabetes was also associated with higher risks of medical complications (OR, 1.11; 95% CI, 1.04-1.18) and mortality (OR, 1.24; 95% CI, 1.07-1.42).Conclusions and RelevanceDysglycemia-both diagnosed and undiagnosed-is highly prevalent among general surgery patients and independently associated with increased risks of complications, readmissions, or mortality. A significant proportion of patients had HbA1c levels in the diabetes range, despite lacking a diabetes diagnosis. These findings support routine preoperative HbA1c screening and the adoption of individualized glycemic management strategies to optimize surgical risk assessment, reduce complications, and improve perioperative outcomes.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"39 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145440643","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 : 2025-11-05DOI: 10.1001/jamasurg.2025.4701
Mikayla Hurwitz,Quynh-Anh Dang,Salvatore Scali,Nina Bowens,Karen Woo,Christian de Virgilio
ImportanceMore than 100 000 patients in the US begin hemodialysis each year. While arteriovenous fistulas (AVFs) have been the preferred dialysis access due to their durability and lower complication rates, contemporary guidelines now emphasize achieving a functional access tailored to individual patient needs. Prosthetic arteriovenous grafts (AVGs) remain a critical alternative for patients with suboptimal autogenous options. Given the essential role of hemodialysis access in patient survival, both surgeons and nonsurgeons must be familiar with the unique challenges of placing and maintaining AVFs and AVGs. This review highlights common complications associated with each access type and evidence-based management strategies.ObservationsComplications of arteriovenous (AV) access can manifest at varying time points, ranging from the immediate postoperative period to months or years later due to long-term sequelae of altered hemodynamics and repeated cannulation. Determining whether symptoms, such as pain, weakness, paresthesia, and hand dysfunction, are due to the AV access or simply due to outcomes of kidney failure can be extremely challenging, emphasizing the importance of a detailed patient history, comprehensive physical examination, and duplex imaging. Certain complications, including access-related hand ischemia (ie, steal syndrome), carpal tunnel syndrome, ulnar neuropathy, aneurysms, and pseudoaneurysms, have multiple treatment options that span conservative management, open surgery, and endovascular procedures. Treatment decisions should consider patient comorbidities, anatomical factors, the risk of access site loss, and the availability of alternate access sites. Other complications, such as ischemic monomelic neuropathy, persistent bleeding, and high-output heart failure, require urgent intervention to prevent loss of limb or life.Conclusions and RelevancePatients with upper-extremity AVF and AVG can face a number of access-related complications. Understanding the diagnostic evaluation and treatment options is essential to balance preserving access longevity while minimizing the risk of short and long-term morbidity and mortality.
{"title":"Diagnosis and Management of Hemodialysis Access Complications: A Review.","authors":"Mikayla Hurwitz,Quynh-Anh Dang,Salvatore Scali,Nina Bowens,Karen Woo,Christian de Virgilio","doi":"10.1001/jamasurg.2025.4701","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4701","url":null,"abstract":"ImportanceMore than 100 000 patients in the US begin hemodialysis each year. While arteriovenous fistulas (AVFs) have been the preferred dialysis access due to their durability and lower complication rates, contemporary guidelines now emphasize achieving a functional access tailored to individual patient needs. Prosthetic arteriovenous grafts (AVGs) remain a critical alternative for patients with suboptimal autogenous options. Given the essential role of hemodialysis access in patient survival, both surgeons and nonsurgeons must be familiar with the unique challenges of placing and maintaining AVFs and AVGs. This review highlights common complications associated with each access type and evidence-based management strategies.ObservationsComplications of arteriovenous (AV) access can manifest at varying time points, ranging from the immediate postoperative period to months or years later due to long-term sequelae of altered hemodynamics and repeated cannulation. Determining whether symptoms, such as pain, weakness, paresthesia, and hand dysfunction, are due to the AV access or simply due to outcomes of kidney failure can be extremely challenging, emphasizing the importance of a detailed patient history, comprehensive physical examination, and duplex imaging. Certain complications, including access-related hand ischemia (ie, steal syndrome), carpal tunnel syndrome, ulnar neuropathy, aneurysms, and pseudoaneurysms, have multiple treatment options that span conservative management, open surgery, and endovascular procedures. Treatment decisions should consider patient comorbidities, anatomical factors, the risk of access site loss, and the availability of alternate access sites. Other complications, such as ischemic monomelic neuropathy, persistent bleeding, and high-output heart failure, require urgent intervention to prevent loss of limb or life.Conclusions and RelevancePatients with upper-extremity AVF and AVG can face a number of access-related complications. Understanding the diagnostic evaluation and treatment options is essential to balance preserving access longevity while minimizing the risk of short and long-term morbidity and mortality.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"38 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145440861","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 : 2025-11-05DOI: 10.1001/jamasurg.2025.4806
James Whitbread,Allen Kachalia,Peter A Najjar
{"title":"Responsible Development of Artificial Intelligence in Surgery.","authors":"James Whitbread,Allen Kachalia,Peter A Najjar","doi":"10.1001/jamasurg.2025.4806","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4806","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"19 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145440644","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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