Pub Date : 2025-10-15DOI: 10.1001/jamasurg.2025.4195
Karlynn Holland,Patrycja Lis,Steven Medvedovsky,Claire Ferguson,Dewi Sihaloho,Panos Kougias,Sherene E Sharath
{"title":"Preoperative Social Support and Impact on Outcomes After Elective Surgery in Older Adults.","authors":"Karlynn Holland,Patrycja Lis,Steven Medvedovsky,Claire Ferguson,Dewi Sihaloho,Panos Kougias,Sherene E Sharath","doi":"10.1001/jamasurg.2025.4195","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4195","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"54 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145288464","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 : 2025-10-15DOI: 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":"https://doi.org/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":""},"PeriodicalIF":14.9,"publicationDate":"2025-10-15","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 : 2025-10-15DOI: 10.1001/jamasurg.2025.4320
Avinash Maganty,Xiu Liu,Christopher Dall,Preeti Chachlani,Sarah Leick,Arnav Srivastava,Samuel R Kaufman,Vahakn B Shahinian,Brent K Hollenbeck
ImportanceEnrollment in Medicare Advantage (MA) accounts for more than half of Medicare beneficiaries. Despite this growth, its impact on access to high-quality cancer surgery remains unclear.ObjectiveTo evaluate the association between MA enrollment and receipt of surgery at high-quality hospitals among Medicare beneficiaries undergoing major cancer surgery.Design, Setting, and ParticipantsThis national retrospective cohort study uses Medicare Provider Analysis and Review (MedPAR) data from January 1, 2016, to November 30, 2022. The study included 567 770 Medicare beneficiaries undergoing elective surgery for esophageal, pancreatic, liver, gastric, bladder, colon, kidney, or prostate cancer at hospitals across the United States. Data analysis was performed from August 2024 to July 2025.ExposureEnrollment in Medicare Advantage plan.Main Outcomes and MeasuresThe primary outcome was surgery at a high-quality hospital, defined by procedure-specific mortality, risk-adjusted for patient characteristics and reliability-adjusted for differences in case volume using mixed-effects logistic regression models. Adjusted hospital mortality was rank ordered and sorted into quintiles. High quality was defined as hospitals in the quintile with the lowest mortality rates. The secondary outcome was likelihood of bypassing the nearest hospital of lower quality to undergo surgery at a high-quality hospital.ResultsAmong 567 770 beneficiaries undergoing surgery, 351 447 were enrolled in traditional Medicare (TM; 231 104 [65.8%] male, 120 343 [34.2%] female; mean [SD] age, 72.5 [8.0] years) and 216 323 in MA (138 554 [64.0%] male, 77 769 [36.0%] female; mean [SD] age, 72.7 [7.6] years). MA enrollment increased from 32% in 2016 to 46% in 2022. Compared with beneficiaries in TM, MA enrollees were more likely to be from socially vulnerable areas, have more comorbidities, and undergo surgery at nonteaching hospitals across all cancer types. Compared with those in TM, MA beneficiaries were less likely to undergo surgery at a high-quality hospital. For example, 21.7% (95% CI, 20.7%-22.8%) of patients enrolled in TA had an esophagectomy at a high-quality hospital vs 17.3% (95% CI, 16.1%-18.5%) of MA beneficiaries, and 22.6% (95% CI, 22.1%-23.2%) of patients enrolled in TA had a pancreatectomy at a high-quality hospital vs 16.2% (95% CI, 15.6%-16.8%) of those in MA. TM beneficiaries were more likely to bypass a lower-quality hospital to receive surgery at a high-quality hospital for all procedures.Conclusions and RelevanceThis study found that MA enrollees were less likely to receive cancer surgery at high-quality hospitals and less likely to bypass lower-quality hospitals. These findings suggest that current MA plan networks may limit access to optimal surgical care, raising concerns about the adequacy of cancer care delivery under privatized Medicare.
{"title":"Surgery at High-Quality Hospitals Among Medicare Advantage Beneficiaries Undergoing Cancer Surgery.","authors":"Avinash Maganty,Xiu Liu,Christopher Dall,Preeti Chachlani,Sarah Leick,Arnav Srivastava,Samuel R Kaufman,Vahakn B Shahinian,Brent K Hollenbeck","doi":"10.1001/jamasurg.2025.4320","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4320","url":null,"abstract":"ImportanceEnrollment in Medicare Advantage (MA) accounts for more than half of Medicare beneficiaries. Despite this growth, its impact on access to high-quality cancer surgery remains unclear.ObjectiveTo evaluate the association between MA enrollment and receipt of surgery at high-quality hospitals among Medicare beneficiaries undergoing major cancer surgery.Design, Setting, and ParticipantsThis national retrospective cohort study uses Medicare Provider Analysis and Review (MedPAR) data from January 1, 2016, to November 30, 2022. The study included 567 770 Medicare beneficiaries undergoing elective surgery for esophageal, pancreatic, liver, gastric, bladder, colon, kidney, or prostate cancer at hospitals across the United States. Data analysis was performed from August 2024 to July 2025.ExposureEnrollment in Medicare Advantage plan.Main Outcomes and MeasuresThe primary outcome was surgery at a high-quality hospital, defined by procedure-specific mortality, risk-adjusted for patient characteristics and reliability-adjusted for differences in case volume using mixed-effects logistic regression models. Adjusted hospital mortality was rank ordered and sorted into quintiles. High quality was defined as hospitals in the quintile with the lowest mortality rates. The secondary outcome was likelihood of bypassing the nearest hospital of lower quality to undergo surgery at a high-quality hospital.ResultsAmong 567 770 beneficiaries undergoing surgery, 351 447 were enrolled in traditional Medicare (TM; 231 104 [65.8%] male, 120 343 [34.2%] female; mean [SD] age, 72.5 [8.0] years) and 216 323 in MA (138 554 [64.0%] male, 77 769 [36.0%] female; mean [SD] age, 72.7 [7.6] years). MA enrollment increased from 32% in 2016 to 46% in 2022. Compared with beneficiaries in TM, MA enrollees were more likely to be from socially vulnerable areas, have more comorbidities, and undergo surgery at nonteaching hospitals across all cancer types. Compared with those in TM, MA beneficiaries were less likely to undergo surgery at a high-quality hospital. For example, 21.7% (95% CI, 20.7%-22.8%) of patients enrolled in TA had an esophagectomy at a high-quality hospital vs 17.3% (95% CI, 16.1%-18.5%) of MA beneficiaries, and 22.6% (95% CI, 22.1%-23.2%) of patients enrolled in TA had a pancreatectomy at a high-quality hospital vs 16.2% (95% CI, 15.6%-16.8%) of those in MA. TM beneficiaries were more likely to bypass a lower-quality hospital to receive surgery at a high-quality hospital for all procedures.Conclusions and RelevanceThis study found that MA enrollees were less likely to receive cancer surgery at high-quality hospitals and less likely to bypass lower-quality hospitals. These findings suggest that current MA plan networks may limit access to optimal surgical care, raising concerns about the adequacy of cancer care delivery under privatized Medicare.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"1 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145288388","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 : 2025-10-15DOI: 10.1001/jamasurg.2025.4328
Can Deniz Deveci,Jason Joe Baker,Jacob Rosenberg
ImportancePrevious studies on mesh weights have focused on the definitions of lightweight and heavyweight meshes, which were not based on clinical outcomes.ObjectiveTo investigate which mesh weight would be associated with the lowest reoperation rate for recurrence in laparoscopic inguinal hernia repair.Design, Setting, and ParticipantsThis nationwide cohort study was based on prospectively collected data on eligible patients aged 18 years or older who had undergone a primary transabdominal preperitoneal laparoscopic inguinal hernia repair in Denmark between January 1998 and July 2023 from the Danish Inguinal Hernia Database, obtained through population-based sampling. The final grouping included patients who received a mesh with a weight of <45 g/m2, 45-65 g/m2, or >65 g/m2. The database linkage to the Danish National Patient Registry made it possible to follow-up patients until the date of data extraction, death, emigration, or reoperation. Sequential explorative analyses were conducted to compare all mesh weight intervals to find the weight interval that resulted in the lowest risk of reoperation for recurrence.Main Outcomes and MeasuresThe main outcome was reoperation for recurrence using a Cox proportional hazards regression model.ResultsA total of 43 986 inguinal hernias from 36 446 patients were included: 16 949 in the less than 45-g/m2 group, 16 531 in the 45- to 65-g/m2 group, and 10 506 in the greater than 65-g/m2 group. A total of 1910 (4.34%) inguinal hernias underwent reoperation for recurrence. The mesh weight interval of 45 to 65 g/m2 had the lowest risk of reoperation for recurrence. Compared with a mesh weight of 45 to 65 g/m2, a mesh weight of less than 45 g/m2 had a hazard ratio for reoperation of 2.6 (95% CI, 2.2-2.8; P < .001), and a mesh weight of greater than 65 g/m2 had a hazard ratio of 2.4 (95% CI, 2.1-2.8; P < .001) for reoperation.Conclusions and RelevanceThis nationwide cohort study found that a mesh weight of 45 to 60 g/m2 resulted in the lowest risk of reoperation for recurrence compared with other mesh weights in laparoscopic inguinal hernia repair. These findings suggest that selecting a mesh within 45 to 60 g/m2 can optimize outcomes and reduce the need for reoperation.
{"title":"Mesh Weight in Reoperation for Recurrence After Laparoscopic Inguinal Hernia Repair.","authors":"Can Deniz Deveci,Jason Joe Baker,Jacob Rosenberg","doi":"10.1001/jamasurg.2025.4328","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4328","url":null,"abstract":"ImportancePrevious studies on mesh weights have focused on the definitions of lightweight and heavyweight meshes, which were not based on clinical outcomes.ObjectiveTo investigate which mesh weight would be associated with the lowest reoperation rate for recurrence in laparoscopic inguinal hernia repair.Design, Setting, and ParticipantsThis nationwide cohort study was based on prospectively collected data on eligible patients aged 18 years or older who had undergone a primary transabdominal preperitoneal laparoscopic inguinal hernia repair in Denmark between January 1998 and July 2023 from the Danish Inguinal Hernia Database, obtained through population-based sampling. The final grouping included patients who received a mesh with a weight of <45 g/m2, 45-65 g/m2, or >65 g/m2. The database linkage to the Danish National Patient Registry made it possible to follow-up patients until the date of data extraction, death, emigration, or reoperation. Sequential explorative analyses were conducted to compare all mesh weight intervals to find the weight interval that resulted in the lowest risk of reoperation for recurrence.Main Outcomes and MeasuresThe main outcome was reoperation for recurrence using a Cox proportional hazards regression model.ResultsA total of 43 986 inguinal hernias from 36 446 patients were included: 16 949 in the less than 45-g/m2 group, 16 531 in the 45- to 65-g/m2 group, and 10 506 in the greater than 65-g/m2 group. A total of 1910 (4.34%) inguinal hernias underwent reoperation for recurrence. The mesh weight interval of 45 to 65 g/m2 had the lowest risk of reoperation for recurrence. Compared with a mesh weight of 45 to 65 g/m2, a mesh weight of less than 45 g/m2 had a hazard ratio for reoperation of 2.6 (95% CI, 2.2-2.8; P < .001), and a mesh weight of greater than 65 g/m2 had a hazard ratio of 2.4 (95% CI, 2.1-2.8; P < .001) for reoperation.Conclusions and RelevanceThis nationwide cohort study found that a mesh weight of 45 to 60 g/m2 resulted in the lowest risk of reoperation for recurrence compared with other mesh weights in laparoscopic inguinal hernia repair. These findings suggest that selecting a mesh within 45 to 60 g/m2 can optimize outcomes and reduce the need for reoperation.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"78 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145288432","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 : 2025-10-08DOI: 10.1001/jamasurg.2025.4142
John T Simpson,Krista L Haines,Suresh Agarwal
{"title":"Reducing Missed Doses of VTE Prophylaxis.","authors":"John T Simpson,Krista L Haines,Suresh Agarwal","doi":"10.1001/jamasurg.2025.4142","DOIUrl":"https://doi.org/10.1001/jamasurg.2025.4142","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"9 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2025-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145246429","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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