Journal of Gastrointestinal Surgery最新文献

Background: Management of pregnancy-associated cancers (PACs)-malignancies diagnosed during pregnancy or within 1 year postpartum-poses unique clinical challenges. Treatment decisions must balance maternal cancer control with fetal safety, yet little is known about how cancer treatment timing varies between pregnant and nonpregnant individuals or how PACs affect obstetric and neonatal outcomes. Understanding these associations is critical to improve care strategies for this vulnerable population.

Methods: We conducted a retrospective cohort study using Epic Cosmos, a large multicenter United States electronic health record database. The primary "cancer" cohort included individuals aged 18 to 49 years diagnosed as having cancer between January 2018 and December 2022. These individuals were categorized by pregnancy status at diagnosis: gestational PAC, postpartum PAC, or nonpregnant. A secondary "maternal" cohort comprised individuals with viable deliveries during the same period; gestational PAC pregnancies were matched 1:4 with cancer-unexposed pregnancies. Primary outcomes were time from cancer diagnosis to initiation of surgery, radiotherapy, and chemotherapy. Secondary outcomes included 30-day surgical complications, mortality, readmissions, and obstetric and neonatal outcomes such as cesarean delivery, preterm birth, low birth weight, and 5-min appearance, pulse, grimace, activity, and respiration (Apgar) scores.

Results: Among 38,345 individuals in the cancer cohort (median age, 43 years; IQR, 38-47), most were White (n = 26,594; 71.3%) and married (n = 19,230; 51.5%). Gestational PAC was associated with 15% longer time to surgery (adjusted rate ratio [aRR], 1.15; 95% CI, 1.13-1.17), 28% longer time to radiotherapy (aRR, 1.28; 95% CI, 1.27-1.29), and 29% shorter time to chemotherapy initiation (aRR, 0.71; 95% CI, 0.70-0.72) than nonpregnant controls. Postpartum PAC was associated with 13% shorter time to surgery (aRR, 0.87; 95% CI, 0.86-0.88) and 30% shorter time to chemotherapy (aRR, 0.70; 95% CI, 0.70-0.71). In the maternal cohort, gestational PAC was associated with higher odds of cesarean delivery (adjusted odds ratio [aOR], 1.21; 95% CI, 1.04-1.41), preterm birth (aOR, 3.79; 95% CI, 3.15-4.56), low birth weight (aOR, 3.08; 95% CI, 2.50-3.77), and low 5-min Apgar scores (aOR, 1.86; 95% CI, 1.20-2.82).

Conclusion: PAC was associated with delays in locoregional treatment and increased maternal and neonatal morbidity, underscoring the need for coordinated multidisciplinary care to optimize outcomes for women with PACs.

Background: Recent literature suggests that volume-outcome associations for pancreatectomy have attenuated over time, leading some researchers to question the continued relevance of volume thresholds. However, this perceived attenuation may reflect the methodological limitations of single, binary cutoffs rather than a true weakening of the underlying relationship. Stratum-specific likelihood ratios (SSLRs) generate multiple empirically derived volume strata that may detect persistent gradients that are obscured by binary stratification. The objectives of this study were to (i) define volume strata for pancreatectomy using SSLR, (ii) assess the robustness of these strata across multiple outcomes, and (iii) examine whether the association persists in modern cohorts.

Methods: Patients who underwent pancreatectomy between 2004 and 2021 were identified using the National Cancer Database. The volume strata were defined by SSLR based on the 90-day postoperative mortality. The temporal threshold stability was assessed by stratified outcome analysis (chi-squared test).

Results: Overall, 61,920 patients underwent pancreatectomy at 982 facilities with a 90-day mortality rate of 5.4%. SSLR analysis yielded 6 volume strata: ≤3, 4 to 9, 10 to 20, 21 to 47, 48 to 120, and ≥121 procedures/year with decreasing 90-day mortality (≤3: 11%; 4-9: 7.3%; 10-20: 6.1%; 21-47: 4.2%; 48-120: 3.3%; ≥121: 2.3%; P <.001). The optimized threshold of 21 procedures/year was identified based on SSLR. Temporal stratification into 5-year periods (2006-2010, 2011-2015, and 2016-2020) demonstrated persistent volume-outcome associations across volume strata (P <.001).

Conclusion: SSLR reveals persistent volume-outcome associations for pancreatectomy across multiple empirically derived strata, even in contemporary data. These findings suggest that reports of an attenuated volume-outcome relationship may reflect limitations of single, static cutoffs rather than true weakening of this association.

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: Laparoscopic choledocholithotripsy (or laparoscopic common bile duct exploration [LCBDE]) with laparoscopic cholecystectomy (LC) and preoperative endoscopic sphincterotomy (EST) followed by LC are established treatment strategies for concomitant choledocholithiasis and cholelithiasis. However, the comparative efficacy, safety, and cost-effectiveness of these 1-stage vs 2-stage approaches remain uncertain, particularly with recent advances in minimally invasive interventions.

Methods: A systematic search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted between January 2000 and December 2024. Randomized controlled trials (RCTs) comparing LCBDE + LC with EST + LC in patients with confirmed or suspected common bile duct (CBD) stones were included. Of note, 2 reviewers independently extracted data and assessed the risk of bias using the Cochrane Collaboration tool. Meta-analyses were performed using Review Manager software (version 5.4.1; Cochrane Informatics and Knowledge Management Department, Nordic Cochrane Centre) with random-effects models to calculate odds ratios (ORs) or mean differences (MDs) with 95% CIs. The study protocol was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42024610284).

Results: Overall, 16 RCTs involving 1576 patients were included (778 in the LCBDE + LC group and 798 in the EST + LC group). EST + LC achieved a higher CBD stone clearance rate (OR, 1.72 [95% CI, 1.14-2.60]; P =.01). No significant differences were observed in the overall complications (OR, 0.66 [95% CI, 0.42-1.03]; P =.07) or mortality (OR, 0.22 [95% CI, 0.02-1.93]; P =.17). LCBDE + LC resulted in lower recurrence (OR, 0.27 [95% CI, 0.11-0.69]; P =.006) and reduced costs (MD, -2059.35 United States dollar [95% CI, -2720.55 to -1398.16]; P <.00001). Hospital stay and residual stone rates were comparable between the 2 groups.

Conclusion: EST + LC provides a higher rate of CBD stone 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.