Journal of Surgical Research最新文献

Introduction: Overprescribing of opioid pain medications can lead to adverse outcomes and contributes to the opioid crisis. We previously reported eliminating opioids in select patients. This retrospective study aimed to compare outcomes in pediatric patients undergoing laparoscopic cholecystectomy (LC) who were and were not prescribed opioid pain medications.

Methods: A retrospective review of pediatric patients <18 ys of age who underwent LC from 2016 to 2022 was performed. Patients who underwent open cholecystectomy or additional surgical procedures performed simultaneously were excluded. Patient demographics, operative details, medication usage, and postoperative complications were recorded. Patients prescribed opioid pain medication at discharge were compared to those who were treated with nonopioid pain medications (i.e., acetaminophen, ibuprofen, and ketorolac).

Results: In total, 511 patients were included, of which 76.9% were prescribed opioids. Patients who were not prescribed opioids more commonly received intravenous ketorolac (81.4% versus 35.6%, P < 0.001), used less postoperative morphine milligram equivalents per kilogram (MME) (0.3 versus 0.4 MME/kg, P = 0.044), had lower rates of postoperative phone calls for pain (6.8% versus 18.8%, P = 0.002), and reported less pain at follow-up (6.8% versus 18.8%, P = 0.002). There were no differences in emergency department visits or hospital readmissions within 30 ds of discharge. Institutional rates of opioid prescriptions following LC decreased over the study duration (97.8% in 2016 to 28.4% in 2022, P < 0.001).

Conclusions: Nonopioid postoperative pain control in pediatric patients undergoing LC is well-tolerated and may be effective in reducing opioid use. In this cohort, nonopioid and opioid pain management modalities had similar postoperative hospital resource utilization. Therefore, opioid use and its resultant complications may potentially be able to be reduced.

Introduction: Recognizing the need for end-of-life care is a critical aspect of health care. Delayed recognition leads to undue patient suffering and nonvaluable health-care expenditures. Care of patients with surgical diseases is often focused on curative intent despite the presence of significant comorbidities and discrepant patient and family wishes. We hypothesized that surgical patients with clear end-of-life needs may not receive goals of care (GoC) conversations, with variations in frequency by provider level and specialty.

Methods: Providers caring for critically ill patients at an urban, academic, quaternary care center reviewed five case vignettes of critically ill surgical patients. The blinded providers were asked to list at least three care priorities for the patients. Responses were analyzed using Stata/BE 17.0 for inclusion of GoC.

Results: A total of 123 participants responded to at least one scenario (24.1% response rate). In total, 95 participants (77.2%) prioritized GoC at least once for any scenario, and GoC prioritization ranged from 9.7% (scenario 1) to 73.7% (scenario 5) for individual scenarios. Surgical providers prioritized GoC more often than nonsurgical providers (83.1% versus 67.4%, P = 0.044). Critical care specialty training was not found to increase prioritization of GoC (83.3% versus 71.4%, P = 0.12). Increasing post-graduate year (PGY) levels were correlated with increased likelihood of prioritizing GoC; 60.9% of PGY1-4's prioritized GoC as compared to 90.9% of PGY5-9's (P = 0.007).

Conclusions: Providers demonstrated ranging abilities to identify GoC as a priority. For housestaff, increasing PGY level correlates with prioritizing GoC. Surgical providers more often prioritized GoC as compared to nonsurgical providers, suggesting familiarity with surgical pathologies may result in increased prioritization.

Introduction: Utilizing the marginal livers for transplantation has gained more attention recently, but there are still some doubts regarding the outcomes. This study focuses on the outcomes of extended criteria donor liver transplants (LTs) in the United States, in order to assess the feasibility of these types of livers utilization.

Materials and methods: A retrospective registry analysis of the Organ Procurement and Transplantation Network/United Network for Organ Sharing database was done for LTs that were performed in the United States from January 2001 to April 2020.

Results: The study divided into two subgroups, based on the transplantation year; patients who received an LT from January 2001 until the end of December 2010 (n = 50,928), and those who received an LT, from January 2011 to April 2020 (n = 59,643). The data analysis showed a significant overall 10-y graft survival improvement in the 2011-2020 group compared to the 2001-2010 group, from a mean of 58% in 2001-2010 to a mean of 68% in 2011-2020 (P < 0.001). Not only the overall 10-y graft survival has improved in the 2011-2020 group but also the graft survival has significantly improved in the extended criteria donors (ECDs) group compared to the 2001-2010 cohort, in which the 10-y graft survival is even higher in the 2011-2020 ECD group than non-ECD group in 2001-2010.

Conclusions: With all the surgical techniques and postoperation improvements, ECD livers can prove to be a meaningful solution to overcome long waiting times and current underutilization in order to improve the short- and long-term quality of life in the patients who are in need of liver transplant.

Introduction: A robust system for classifying the technical complexity of surgical procedures has many applications, including optimization of hospital and surgeon-level surgical performance evaluations, reimbursement, and hospital resource utilization. However, little work has been done to distinguish surgical complexity from patient- and disease-associated surgical risk.

Methods: Through a scoping review of the literature, we identified surgical subspecialty complexity classification systems which were purposed to quantify the technical complexity of a procedure and were validated with prospective or retrospective patient data.

Results: We identified six validated surgical complexity classification systems and determined the methodology which most accurately determines surgical complexity is the level of training or expertise necessary to perform a procedure as determined by expert consensus. However, the existing literature largely validates complexity classification systems by their ability to predict morbidity and mortality which are measures of surgical risk.

Conclusions: A surgical complexity classification system distinct from, but used in parallel with, surgical risk has significant potential for process improvement. While the technical demands of a surgical procedure may be associated with measures of surgical risk, we propose that surgical complexity is a process measure, best represented in the literature by the level of training/expertise necessary to perform a procedure as determined through expert consensus.

Introduction: In order to clarify the optimal strategy regarding conversion surgery (CS) for gastric cancer (GC) patients, we focused on clinicopathological findings, including immunological factors, related to the favorable prognosis in patients with stage IV GC who underwent CS.

Materials and methods: A total of 25 patients with Stage IV GC who underwent induction chemotherapy (IC) and CS at our hospital between 2010 and 2021 were enrolled in this study. Biopsy specimens before IC and surgical specimens were collected. Immunohistochemical staining was performed using programmed death-ligand 1 (PD-L1) antibody, translationally controlled tumor protein (TCTP) antibody, and CD20 antibody. Prognostic factors were investigated using clinicopathological factors as well as immunological factors such as PD-L1, TCTP, and CD20 expression.

Results: cN0, ycStage1-2, R0-1 surgery, D2 lymph node dissection, ypN0, and ypStage1-2 were significantly associated with favorable overall survival. Among patients who underwent R0/1 surgery, only histological type was a significant prognostic factor for recurrence-free survival. Low PD-L1 expression before IC and high TCTP expression after IC were significantly associated with favorable recurrence-free survival.

Conclusions: In addition to clinical factors, high TCTP expression after IC was identified as a significant favorable prognostic factor, which could help in identifying candidates for CS in the future.

Introduction: To clarify the prognostic significance of the C-reactive protein to prealbumin ratio (CRP or PALB) in patients with pancreatic cancer after radical resection.

Methods: A total of 432 patients with pathologically confirmed pancreatic ductal adenocarcinoma were enrolled in this retrospective study. The predictive capacity of various inflammatory indices was analyzed and compared using the area under the time-dependent receiver operating characteristic curve, including CRP or PALB, CRP-to-albumin ratio, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio. The univariate and multivariate Cox hazard models were employed to analyze the effects of CRP or PALB on overall survival (OS) and recurrence-free survival (RFS).

Results: The optimal cut-off value for preoperative CRP or PALB was 5.94, which was derived from the receiver operating characteristic curve. In comparison with traditional inflammatory indices, CRP or PALB had the highest area under the time-dependent receiver operating characteristic curve (0.693 for 3-y OS, 0.664 for 3-y RFS, 0.662 for 5-y OS, and 0.670 for 5-y RFS), all with P < 0.05. However, when compared with neutrophil-to-lymphocyte ratio, the predictive power of CRP or PALB was not significant for 3-y RFS (P = 0.085). Based on the results of the univariate and multivariate survival analyses, patients in the high CRP or PALB group (HCP: CRP or PALB >5.94) exhibited significantly poorer OS and RFS (median OS: 20.0 versus. 38.0 mo, P = 0.003; median RFS: 10.0 versus. 22.0 mo, P < 0.001) than those in the low CRP or PALB group (CRP or PALB ≤5.94). The multivariate analysis indicated that the HCP was independently associated with poor OS (hazard ratio (HR): 1.556, 95% confidence interval (CI) [1.089-2.222], P = 0.015) and RFS (HR: 1.551, 95% CI [1.135-2.119], P = 0.006).

Conclusions: The predictive capacity of preoperative CRP or PALB in pancreatic ductal adenocarcinoma patients exceeds that of traditional inflammatory indices. HCP levels are significantly correlated with a poor prognosis.

Introduction: Delirium is a common issue following liver transplantation (LT), but research has mainly focused on single-center cohorts.

Methods: We studied delirium in a national cohort of adult LT recipients transplanted October, 2015-December, 2020 using the MarketScan database. Claims data were used to identify LT recipients with delirium. Characteristics and outcomes of LT recipients with and without delirium were compared using descriptive statistics.

Results: Among 2051 LT recipients, only 32 (1.6%) had a delirium claim. Recipients with versus without delirium were more likely to have a history of encephalopathy (21.9% versus 8.2%, P = 0.006) but were of similar age and sex. Recipients with versus without delirium were more likely to be discharged to skilled care or rehabilitation facilities (37.5% versus 14.3%, P = 0.003) and had longer median hospital stays (24 versus 14 ds, P = 0.03). Delirium claims were not associated with median hospitalization costs (P = 0.15) or 30-d (P = 0.32) and 60-d (P = 0.99) readmission.

Conclusions: Overall, only 1.6% of adult LT recipients had delirium claims, despite prevalence estimates of up to 47% in single-center studies. This underreporting-which is likely limited to the most severe cases-limits our ability to assess associated outcomes and highlights the need for better delirium recognition and reporting.

Introduction: Thoracic surgery patients are among the least likely to be on opioids before surgery but have the highest rate of new persistent opioid use after surgery compared to other surgical cohorts. Nearly 27% of opioid-naïve lung cancer resection patients become new persistent opioid users. We aimed to identify risk factors for postdischarge opioid prescription refill within 90 ds of surgery for lung cancer resection patients.

Methods: Retrospective cohort study of all opioid-naïve patients undergoing lung cancer resection from July 2018 to May 2021 at an academic medical center. Multivariable logistic regression was used to identify risk factors for opioid prescription refill between discharge and 90 ds after surgery.

Results: The cohort included 152 patients, 100 (65.8%) women with a median (IQR) age of 71 (65 - 75) and 115 (75.7%) of whom lived with family or friends (versus. alone). Twenty-nine (19.1%) patients had an opioid prescription refill after discharge. Risk factors for opioid prescription refill included living with others (adjusted odds ratio [aOR] 5.31, 95% CI 1.06-26.64), thoracotomy (4.31, 1.37-13.52), chest tube duration (days) (1.14, 1.02-1.27), age (1.08, 1.01-1.16), and morphine milligram equivalents (MME) on the day before discharge (1.07, 1.02-1.11).

Conclusions: We identified risk factors for opioid prescription refill after lung cancer resection: living with family or friend (versus alone), thoracotomy, chest tube duration, increasing age, and MME on the day before discharge. Some of these, namely thoracotomy, chest tube duration, and MME on the day before discharge, may aid patient-centered opioid prescribing.