Journal of Gastrointestinal Surgery最新文献

Background: In the US, perceived discrimination in healthcare settings (PDHS) has been linked with delayed care due to nervousness. Surgery represents a high-stakes, vulnerable period leaving lasting impressions on future utilization. We aimed to assess the association between PDHS and delayed care, and evaluate mediating and moderating roles of patient-clinician communication (PCC) and sociodemographic factors, respectively.

Methods: We included adults who underwent gastrointestinal (GI) procedures before completing the Healthcare Access & Utilization survey in the All of Us Research Program. Associations were examined using structural equation modeling (SEM); variance decomposition quantified contributions of sociodemographic moderators.

Results: Among 1,866 participants (46.4% hepatopancreatobiliary; 41.6% colorectal; 12.0% esophagogastric), median age was 62.0 years (IQR 52.0-70.0); the majority was female (n=1,306, 70.3%,) and non-Hispanic White (n=1,571, 84.2%). Participants who delayed care were more often 18-44 years (39.0% vs. 11.6%) and less frequently married (55.5% vs. 63.5%) (both p<0.05). In adjusted SEM, higher PDHS was associated with worse PCC (β -0.46, 95%CI -0.56-0.36) and greater odds of delayed care (aOR 1.55, 95%CI 1.20,2.01). PCC mediated 14.8% of the PDHS-delayed care association. PDHS (57.9%), age (9.6%), and income (4.3%) contributed most to PCC variance. Delayed care was associated with higher odds of poor quality of life (aOR 2.65), poor mental health (aOR 2.65), and poor physical health (aOR 2.24) (all p<0.001).

Conclusion: PCC mediated the relationship between discrimination and healthcare delays due to nervousness, with sociodemographic factors moderating this effect. Higher PDHS and worse PCC increased odds of delayed care, leading to worse health and quality of life.

Background: Enhanced recovery after surgery (ERAS) protocols aim to optimize perioperative care, accelerate recovery, and reduce length of hospital stay (LOS). This study evaluates the implementation and evolution of an ERAS protocol for esophageal resection in a Western a high-volume tertiary center.

Methods: This retrospective cohort study analyzed all consecutive patients who underwent esophagectomy for esophageal cancer in the University Medical Center Utrecht between May 2015 and December 2023, divided into four cohorts based on protocol changes. Robot assisted minimally invasive esophagectomy with cervical esophagogastrostomy and epidural pain management was the standard of care. An ERAS protocol, focused on preoperative optimization of nutritional and physical fitness, intrathoracic anastomosis, and multidisciplinary postoperative support, was implemented in October 2016. The first cohort served as the pre-ERAS baseline, with subsequent cohorts indicating a change in protocol. Data was extracted from a prospectively maintained database. The primary outcome was median LOS. Secondary outcomes included perioperative dietary, surgical, clinical, and physiotherapeutic measures.

Results: A total of 526 patients were included. Median LOS decreased from 16 (IQR 11-25) days pre-ERAS to 13 (IQR 9-21),11 (IQR 8-15) and 11 (IQR 8-18) days in successive cohorts (p<0.001; HR 0.68, 95%CI 0.52-0.90, p=0.007). This reduction remained significant after adjusting for covariates (HR 0.58, 95%CI 0.44-0.77, p<.001). Median LOS of patients with textbook outcome decreased from 11 days (IQR 11-14) pre-ERAS to 10 (IQR 8-13), 10 (IQR 8-12), and 8 (IQR 7-11) days in subsequent cohorts (P<.001). Several secondary ERAS outcomes improved over the years (dietitian involvement, surgical approach, extubation in the operating room, drain/line management). A reduction in postoperative complications was observed (from 81% to 74%, P=0.033), while mortality and readmission rates remained stable.

Conclusion: Following ERAS implementation for esophagectomy, median LOS decreased from 16 to 11 days over 7 years, with stable readmission rates. These results support ERAS as a valuable tool to optimize perioperative care leading to a significant reduction in length of postoperative hospital stay.

Background: Patients with cirrhosis face increased surgical risk. This study aimed to characterize real-world perioperative outcomes following cholecystectomy in patients with cirrhosis and to identify independent predictors of post-operative liver decompensation events (POLDEs) and mortality.

Methods: We conducted a population-based, retrospective cohort study using administrative health data from Ontario, Canada. Patients with cirrhosis who underwent cholecystectomy between January 2009 and December 2018 were included. Perioperative outcomes were described, including POLDEs and mortality. Modified Poisson regression identified independent predictors of POLDEs and 90-day mortality, while accounting for clustering at the institutional level.

Results: A total of 4,769 patients were analyzed. The leading etiology of cirrhosis was metabolic dysfunction-associated steatotic liver disease (66%). Most (69%) underwent elective surgery. Mean hospital stay was 3.6 days, with a 13% complication rate. Within 90 days, 27% returned to the emergency department, 10% required re-admission, 83 patients (1.7%) experienced POLDEs, and 91 (1.9%) died. Higher MELD-Na scores were associated with both postoperative decompensation and mortality. Independent predictors of POLDEs included older age, alcohol-related cirrhosis, and prior decompensation. Predictors of 90-day mortality included advanced age, comorbidities, emergent surgery, and postoperative decompensation.

Conclusions: Although early liver-related complications and mortality remain low overall, patients with advanced age, co-morbidity, history of decompensation, and emergent surgery have significantly worse outcomes. Moreover, High rates of emergency visits and readmissions highlight substantial healthcare utilization in this population.

Background: Thoracic epidural analgesia (EA) has historically been a key component of multimodal analgesia after open thoracotomy, but its use has decreased over time and peripheral nerve blocks (PNB) are increasingly used as alternatives. We compared outcomes of EA versus PNB among patients undergoing lung and esophageal resections.

Methods: Adult patients receiving EA or PNB after lung or esophageal resections from 2016-2020 were identified in the Nationwide Readmissions Database (NRD). Outcomes included complications, 90-day readmissions, mortality, length of stay (LOS), and hospitalization costs. Patients were stratified by analgesia type, and 1:2 propensity score matching (PSM) adjusted for patient, surgical, and hospital characteristics. Multivariable regression addressed residual confounding.

Results: Of 8,668 patients, 738 (8.5%) received EA and 7,930 (91.5%) received PNB. After propensity score matching (n=2,110; EA 721 vs. PNB 1,389), EA remained associated with longer LOS (β=+1.12 days, 95%CI[+0.85,+1.39]) and higher index admission (β=+$3,630, 95%CI[$2,061-$5,199]) and total 90-day costs (β=+$4,808, 95%CI[$3,230-$6,386]; all p<0.001). In site-stratified multivariable models, EA was associated with higher median 90-day costs after esophageal resection (+$12,487) and lung resection (+$2,970), and longer LOS (esophagus β=+1.93; lung β=+1.00days). EA was also associated with higher odds of ileus after esophageal resection (aOR 18.47). Other complications, readmissions, and 90-day mortality did not differ between groups (all p>0.05).

Conclusion: EA was associated with a longer hospital stay and higher median costs compared with PNB with no differences in clinical outcomes. These findings support PNB as an equally safe and more cost-conscious analgesic strategy in thoracic surgery.

Background: Both laparoscopic choledocholithotripsy with laparoscopic cholecystectomy (LCBDE+LC) and preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy (EST+LC) are established treatment strategies for concomitant choledocholithiasis and cholelithiasis. However, the comparative efficacy, safety, and cost-effectiveness of these one-stage versus two-stage approaches remain uncertain, particularly with recent advances in minimally invasive interventions.

Methods: A systematic search of MEDLINE, EMBASE, and CENTRAL was conducted from January 2000 to December 2024. Randomized controlled trials (RCTs) comparing LCBDE+LC with EST+LC in patients with confirmed or suspected common bile duct stones were included. Two reviewers independently extracted data and assessed risk of bias using the Cochrane Collaboration tool. Meta-analyses were performed using RevMan 5.4.1 with random-effects models to calculate odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs). The protocol was registered in PROSPERO (CRD42024610284).

Results: Sixteen RCTs involving 1,576 patients (778 LCBDE+LC; 798 EST+LC) were included. EST+LC achieved a higher common bile duct (CBD) clearance rate (OR 1.72; 95% CI 1.14-2.60; p=0.01). No significant differences were observed in overall complications (OR 0.66; 95% CI 0.42-1.03; p=0.07) or mortality (OR 0.22; 95% CI 0.02-1.93; p=0.17). LCBDE+LC resulted in lower recurrence (OR 0.27; 95% CI 0.11-0.69; p=0.006) and reduced costs (MD -2059.35 USD; 95% CI -2720.55 to -1398.16; p<0.00001). Hospital stay and residual stone rates were comparable between the two groups.

Conclusion: EST+LC provides a higher rate of CBD clearance, whereas LCBDE+LC offers advantages in reducing recurrence and overall costs. Both approaches are safe and effective. Treatment choice should be individualized based on institutional expertise, resource availability, and patient-specific considerations.

Objectives: Colorectal cancer is the fourth most common cancer in the U.S., and early detection decreases mortality. We evaluated recent trends in colon cancer incidence and changes in rates of presentation with bowel obstruction before and during the COVID-19 pandemic.

Methods: Longitudinal study of U.S. Veterans from 2017-2023. The primary exposure was time-period: pre-pandemic (01/01/2017-02/29/2020) compared to pandemic (03/01/2020-10/31/2023). The primary outcome was new colon cancer diagnoses. We compared observed to expected diagnoses during the pandemic period. Malignant bowel obstruction at index diagnosis date, AJCC tumor stage, and tumor size at time of diagnosis were compared by period using standardized differences and bootstrapped confidence intervals.

Results: There were 22,256 new colon cancer diagnoses made in the VA: mean age 71±11 years old, 96% male, and 72% White. Comparing the pandemic to pre-pandemic periods, the proportion of tumors >4cm increased from 48.9% to 57.3% and the proportion with malignant bowel obstruction at presentation doubled from 2.7% to 5.3%. An estimated 619 cases were 'missed' during the pandemic: they were expected but not observed diagnoses. There were greater observed than expected large cancers, and fewer observed than expected small cancers during the pandemic according to forecast analyses.

Conclusions: Interruptions in care following the onset of the COVID-19 pandemic had measurable consequences among U.S. Veterans through the end of 2023. Among those diagnosed, median size was larger and more presented with bowel obstruction. This may be because decreased screening activity combined with lower healthcare utilization changed the distribution of cancer size at diagnosis to be larger - underlining the importance of encouraging engagement or re-engagement of Veterans in colorectal cancer screening.