Journal of Surgical Research最新文献

Introduction: Esophagectomy is a lifesaving procedure plagued by an anastomotic leak rate of 11%-35%. Ischemia is widely accepted to be the most significant risk factor for anastomotic leak. We hypothesized that the injection of adipose-derived stem cells (ASCs) into an ischemic esophagogastric anastomosis would prevent leakage.

Methods: We developed a leaking ischemic esophagogastric anastomosis model in pigs using indocyanine green and the Elevision device to quantify perfusion. Anastomoses created using a gastric conduit with a relative perfusion of 50%-60% produced an anastomosis that consistently leaked (n = 3) compared to nonischemic controls (n = 3). We then injected either human (n = 2) or porcine (n = 2) ASCs around an ischemic anastomosis. We analyzed clinical outcomes including postoperative sepsis, weight loss, and disruption of the anastomosis and histopathology as well as immunohistochemistry.

Results: All of the ischemic controls (3/3, 100%), as well as the xenograft human ASC-injected experimental group (2/2, 100%), became septic postoperatively and were found to have an anastomotic breakdown or disruption on necropsy. However, in the porcine allograft ASC-injected experimental group, the animals did well, with none of the subjects experiencing postoperative sepsis, and none were found to have disrupted anastomoses on necropsy. Histopathology revealed improved apposition of the anastomosis and immunohistochemistry revealed improved epithelization and submucosal fibrosis of the porcine ASC group compared to ischemic and human ASC groups.

Conclusions: Allogenic ASCs prevented anastomotic leakage of esophagogastric anastomosis in a porcine ischemic esophagectomy model.

Introduction: C-reactive protein (CRP) is the most widely used marker of the systemic inflammatory response. An association between preoperative elevated levels and prognosis has been demonstrated for numerous tumors. The aim of this study was to investigate the association between preoperative CRP levels and survival in early-stage nonsmall cell lung cancer.

Methods: Data from 915 consecutive patients who underwent complete resection for stage I and II nonsmall cell lung cancer were retrospectively analyzed. Recurrence-free survival (RFS) and overall survival (OS) according to preoperative CRP levels were evaluated by the Kaplan-Meier method. The Cox proportional hazards model and logistic regression analysis were used for multivariate analysis.

Results: Five-year RFS and OS were 61.0% and 70.3% in the low CRP group (<4 mg/L) and 41.8% and 49.4% in the high CRP group (≥4 mg/L), respectively (P < 0.001). In univariate analysis, CRP levels were correlated with indicators of tumor burden and pulmonary comorbidity. In multivariate analysis, CRP levels were identified as an independent predictor of RFS and OS.

Conclusions: Elevated preoperative CRP is associated with poor prognosis in patients with early-stage lung cancer. CRP may guide risk-adapted follow-up and adjuvant therapy decisions. As CRP elevation is also associated with nontumor related conditions patients need to be screened for coexisting comorbidities.

Introduction: Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a frequent complication, and its pathogenesis remains unclear, with various patient and procedural factors proposed as potential contributors. This study aimed to assess the predictive value of pancreatic to splenic density ratio on computed tomography (CT) for PEP in patients with inadvertent pancreatic duct cannulation.

Methods: This retrospective study involved 2556 patients undergoing ERCP from January 2014 to December 2020. Inclusion criteria comprised patients with choledocholithiasis, preprocedural CT imaging, and inadvertent pancreatic duct cannulation during ERCP. Demographics, preprocedural laboratory values, pancreatic to splenic density ratios from CT scans, and pancreatic stent usage were analyzed in relation to the development of PEP.

Results: A total of 90 patients were included in the study. Of all patients, 51.1% were female (n = 46), and 48.9% were male (n = 44). The mean (±standard deviation) age was 58.93 (±17.01). Significant differences in sodium levels and the pancreatic to splenic density ratio were noted between the PEP and non-PEP groups. Pancreatic to splenic density ratio <0.74 (odds ratio: 8.253; P = 0.020) was identified as an independent risk factor for PEP.

Conclusions: Pancreas to spleen density ratio on CT imaging serves as a potential predictive marker for PEP, offering insights into risk stratification and guiding prophylactic measures in high-risk patients.

Introduction: Opioid-related morbidity and mortality continue to rise with surgery often serving as the first exposure to opioids for patients. Few interventions focus on real-time education in the outpatient setting while patients are experiencing pain. The effect of short-messaging service (SMS) surveys with real-time opioid-use education (SMSE) and without (SMS) on outpatient postoperative opioid use was studied.

Methods: A double-blinded randomized controlled trial enrolled adults (≥18 y) who underwent outpatient general surgery procedures from January 1, 2020, to January 2, 2021. Participants received an automated daily SMS or SMSE for 10 d postoperatively. Primary outcomes included total opioid use in oral morphine equivalents (OMEs) and total pain scores. Data were gathered via real-time SMS patient responses.

Results: One hundred sixty patients were randomized to SMS (n = 82) or SMSE (n = 78). Patient demographic/clinical characteristics and surgery type were similar. Between SMS and SMSE, there were no differences in total pain scores (25 [interquartile range (IQR): 25.0] versus 31 [IQR: 35.7], P = 0.291) or total OME used (15.5 mg [IQR: 37.5] versus 15.8 mg [IQR: 45.6], P = 0.762). Increased total OME correlated with younger age (P = 0.001), opioids prescribed (P = 0.001), and preoperative opioid use (P = 0.018). Higher patient satisfaction was observed in patients with lower total pain scores and OME used, with no difference in opioids prescribed (P = 0.352). Subgroup analysis revealed open hernia repair patients in the SMSE group had lower OME used (0 mg [IQR: 0] versus 14.2 mg [IQR: 11.6], P = 0.004).

Conclusions: Real-time opioid-use education via SMS did not lead to a difference in opioid use, but demonstrated a high acceptance rate as a mode of communication and feedback. This finding should encourage further optimization of the SMS tool to rapidly identify patients with inadequate pain control while promoting appropriate opioid use and disposal.

Introduction: Thoracobiliary fistula (TBF) is a rare and highly morbid complication of hepatic trauma. There is a paucity of literature regarding incidence, disease course, and treatment. This study identifies etiologic factors and outcome patterns in patients at risk for TBF.

Methods: A retrospective review of patients presenting with concern for trans-diaphragmatic bile leak over an 8-y period was performed at an urban level 1 trauma center. Early postinjury deaths were excluded. Records were reviewed for presence of a delayed bile leak. Patient characteristics with concern for (No-TBF) and confirmed fistula (TBF) were compared using Fisher's exact and Mann-Whitney U-tests. The disease courses of patients with TBF were further examined.

Results: Over the study period, 118 patients with concomitant right diaphragm and liver injury were reviewed, of these 114 patients (96.6%) survived longer than 72 h. Four patients developed TBF (3.5%). Patients with TBF were younger (P = 0.01) and had trends toward less frequent liver repair (P = 0.061) or concomitant liver and diaphragm repair (P = 0.061). Video-assisted thoracoscopic surgery for retained hemothorax was associated with increased risk of TBF (P = 0.005). Patients with TBF were significantly more likely to develop infectious complications such as sepsis, pneumonia, or complicated parapneumonic effusion (P < 0.001). Treatment of TBF included endoscopic retrograde cholangiopancreatography, sphincterotomy, and stent placement.

Conclusions: Although TBF incidence is low, patients with concomitant right hemidiaphragm and liver trauma may be at higher risk for developing TBF without prompt and definitive operative intervention. This injury is characterized by infectious complications requiring further interventional treatment and monitoring.

Introduction: Primary hyperparathyroidism (PHPT) is more prevalent in populations with obesity. Obesity-related vitamin D deficiency may affect rates of multigland parathyroid disease, but this relationship is less clear. We aimed to assess the relationship between obesity and the rate of multigland disease in patients with PHPT.

Methods: Patients who underwent parathyroidectomy from 2015 to 2021 for sporadic PHPT at a tertiary center were retrospectively analyzed. The primary outcome was rates of single-gland versus four-gland parathyroid hyperplasia in relation to obesity. Secondary outcomes included analysis of serum biochemistries [parathyroid hormone (PTH), calcium, 25(OH) vitamin D (25OHD)] before and 6 mo postoperatively based on obesity classification: no obesity (body mass index [BMI] <30 kg/m²), Class 1 (BMI 30-34.9 kg/m²), Class 2 (BMI 35-39.9 kg/m²), Class 3 (BMI ≥40 kg/m²). Statistical analysis was performed using Chi-square, Mann-Whitney U, and Kruskal-Wallis tests where applicable.

Results: Of 2634 patients who underwent parathyroidectomy, a total of 1173 had obesity. Obesity did not confer any differences in the proportion of four-gland versus single-gland hyperplasia (25 versus 26%, P = 0.79). Compared to patients without obesity, preoperative PTH levels were higher in patients with Class 2 [86 (interquartile range [IQR] 66-118) versus 95 (IQR 70-137) pg/mL, P = 0.001] and Class 3 [86 (IQR 66-118) versus 104 (76-150) pg/mL, P < 0.001] obesity. Conversely, 25OHD before surgery was lower across obesity subclasses [no obesity: 36.0 (25.3-49.3), Class 1: 32.5 (24.0-46.0), Class 2: 32.9 (22.0-44.6), Class 3: 31.7 (20.4-45.0) ng/mL, P < 0.001]. Postoperative PTH and 25OHD improved in all cohorts. No calcium-related differences were found among patients based on obesity classification.

Conclusions: Obesity is not associated with an increased rate of four-gland hyperplasia in patients with PHPT, and therefore should not alter surgical management. The levels of 25OHD in patients with obesity should be monitored for vitamin deficiency preoperatively and postoperatively.

Introduction: Breast cancer is one of the most prevalent cancers worldwide, and following its treatment, many women turn to plastic surgery for reconstruction. A diagnosis of cancer is a heavy burden on patients. Yet, the effect of psychological/psychiatric comorbidities on patient satisfaction following their reconstruction remains unexplored. Thus, this paper aims to investigate how pre-existing psychological and psychiatric conditions impact patient-reported outcomes postreconstruction, compared to women without such conditions.

Methods: A systematic review of PubMed, Web of Science, and Cochrane was completed. A qualitative synthesis of all included studies was then performed, and a subgroup analysis was then performed using a random effect model.

Results: A total of 24 papers were included, encompassing a total population of 220,565 patients undergoing breast reconstruction between the ages of 18 and 84. The follow-up time ranged between 1.5 mo and 61 mo. In our study of breast reconstruction outcomes, the cohort with psychological/psychiatric comorbidities exhibited significant decreases in postoperative BREAST-Q scores compared to the control group: a 24-point [95% confidence interval (CI; -40, -8)] difference in satisfaction, a 20-point [95% CI (-57, -17)] difference in psychosocial well-being, an 18-point [95% CI (-28, 9)] difference in physical well-being, and a 33-point [95% CI (-51, -15)] difference in sexual well-being.

Conclusions: Ultimately, our analysis suggests that presurgical psychology status is a critical determinant of postsurgical patient-reported outcomes. These results encourage the development and inclusion of well-being screening and optimization prior to surgery as a mean to improve surgical outcomes.

Introduction: Obtaining the critical view of safety (CVS) is considered an important step to reduce bile duct injuries during laparoscopic cholecystectomy (LC). However, existing literature suggests that few surgeons obtain adequate CVS when LC videos are directly evaluated by experts. This discrepancy calls for effective, standardized CVS teaching methods. While self-assessment (SA) remains the principal tool utilized by practicing surgeons for performance improvement, its effectiveness is controversial. The aim of this study was to compare surgeon SAs of repeated LC performance and attainment of the CVS with that of expert raters.

Methods: Multi-institutional study of surgeon members from the Society of American Gastrointestinal and Endoscopic Surgeons who volunteered to participate. All surgeons were asked to submit an LC video and complete a SA of the CVS quality using the Strasberg scale (0-6 score with ≥5 score indicating appropriate CVS). The same videos were reviewed by two blinded expert raters, members of the Society of American Gastrointestinal and Endoscopic Surgeons safe cholecystectomy task force, who had received prior rater training. Surgeon self-ratings and expert ratings were compared with a Wilcoxon signed-rank test.

Results: Twenty-five surgeon-participants were recruited, 13 of whom submitted an LC video. Surgeons did not achieve adequate CVS in their first submitted video based on expert ratings. Surgeons in the SA group overestimated their performance across all four scales: Operative Performance Rating System (z = -0.36, P = 0.715), Global Operative Assessment of Laparoscopic Skills (z = -0.37, P = 0.712), Strasberg (z = -1.84, P = 0.066), and Competency Assessment Tool (z = -0.73, P = 0.465). Surgeons in the coaching group overestimated their performance on each scale as well: Operative Performance Rating System (z = -0.67, P = 0.500), Global Operative Assessment of Laparoscopic Skills (z = -1.48, P = 0.138), Strasberg (z = -1.07, P = 0.285), and Competency Assessment Tool (z = -1.21, P = 0.225).

Conclusions: Our study confirms that an adequate CVS is infrequently obtained during LC in a small but national sample of general surgeons. It further adds to the existing body of literature that suggests that SA alone may be inadequate for performance improvement. Effective teaching methods such as expert or artificial intelligence coaching are needed to improve the use of appropriate CVS by surgeons that may help decrease bile duct injury risk.

Introduction: Primary hyperparathyroidism (PHPT) increases the risk of osteoporosis and fractures. Despite American Association of Endocrine Surgeons guidelines that recommend bone mineral density (BMD) assessment via dual-energy x-ray absorptiometry (DEXA) for PHPT patients, adherence to these guidelines remains suboptimal.

Methods: We performed a retrospective review of preoperative and postoperative DEXA scan practices among PHPT patients at a single academic medical center between 2000 and 2018. Patient data, including demographics and history of bone pathology, was analyzed to identify factors influencing adherence to BMD assessment guidelines.

Results: Of the 3384 PHPT patients evaluated for surgery, only 45.4% (n = 1535) underwent preoperative DEXA scan. Women were significantly more likely to undergo preoperative DEXA than men (49.9% versus 29.0%, P < 0.001). Female sex, age ≥65 y, and a history of bone pain or fractures were significant positive predictors of preoperative DEXA scan. Of patients with 2-y follow-up who did not receive a preoperative DEXA (n = 145), only 13.8% (n = 20) received a postoperative DEXA.

Conclusions: This study highlights gaps in the adherence to national guidelines for DEXA screening among PHPT patients. This underscreening may contribute to increased morbidity due to unidentified osteoporosis. Efforts must be made to improve clinical practice and bring it into line with best practice as recommended by national guidelines.

Introduction: Recent studies investigating emergency department (ED) thoracotomies (EDTs) focus on patient outcomes to identify optimal candidates for this procedure. However, there is limited but concerning literature regarding healthcare workers occupational exposures resulting from EDT. In this study, we compare rates of blood-borne exposure to immediate procedural success (i.e., regaining pulses) as well as patient outcome.

Methods: A retrospective chart review of the trauma registry was performed from January 2019 to January 2023. We included all trauma patients who underwent EDT during the study period. 58 patients met the inclusion criteria and were reviewed, and no patients were excluded. The primary endpoint was the rate of occupational exposure as defined by mucous membrane or percutaneous exposure to the patient's blood during the procedure. Additional endpoints include rate of survival to operating room, intensive care unit (ICU), and discharge, type of exposure, Glasgow Coma Score score, and blood products transfused.

Results: Of the 58 patients, 10 EDTs (17%) had reported healthcare occupational exposure, 24 patients (41%) were resuscitated in the ED and moved to the OR or the ICU. 9 patients (16%) survived the OR, with 2 patients (3%) surviving to discharge from the hospital. Of the 10 patients with reported exposures, 4 (40%) regained spontaneous circulation in the ED, 2 patients (20%) survived the OR to the post anesthesia care unit and ICU, but neither survived to discharge (0%). Of the 48 patients without exposures reported, 20 (42%) regained spontaneous circulation in the ED, 7 (15%) survived to the ICU after the OR, and 2 (4%) survived to discharge. Of the 9 patients that survived the OR, 3 showed improvement in neurologic status shown by an improved Glasgow Coma Score.

Conclusions: The noted rate of healthcare worker exposures during these procedures is higher than expected. The rate of survival to the operating room and subsequently to the ICU was higher than current reported rates. Further research needs to be done to investigate ways to improve training and protocols to make this procedure safer for the patient and the team of providers.