Journal of Surgical Research最新文献

Introduction: Damage Control Surgery (DCS) is a surgical technique used to manage critically ill and injured patients. This study examines the most recent 10-y outcomes related to DCS, with the secondary goal of scrutinizing the outcomes after DCS across surgical theaters.

Methods: Studies published between 2012 and 2021 that described adult patients undergoing Abdominal DCS after traumatic injury were included. Outcomes were reported as medians-of-means and interquartile range.

Results: Fifty-two studies met inclusion criteria (9932 patients), all 52 were included in the Military versus Civilian comparison which includes 46 Civilian (9244 patients) and 6 Military (688 patients) studies. Forty-three studies were included in the United States (US) and non-US comparison, with 10 non-US (2092 patients), and 33 US (6572 patients) studies. Overall, study quality was low, the majority having a high or unclear risk of bias. Across all studies, the median 24-h mortality was 14% (5.1-21.2) and 30-d mortality was 17.9% (9.4-28.3). Between subgroups, the Military cohort had a 30-d mortality 9-fold lower than the Civilian cohort (2.1% versus 18.9%), and the non-US cohort had more than 3 times the 24-h mortality (23.8% versus 7.5%) and double the 30-d mortality (37.2% versus 14.6%) of the US cohort.

Conclusions: Striking disparities are seen within current literature as it relates to outcomes after DCS between Military and Civilian and US and non-US populations. Trauma surgeons both within the US and internationally may benefit from looking to their Military counterparts for guidance to better care patients requiring DCS.

Introduction: Evidence demonstrating overall survival benefit of neoadjuvant chemotherapy (NAC) followed by surgical resection over upfront surgical resection for resectable pancreatic ductal adenocarcinoma (PDAC) has been mixed. The time to first therapy (TTFT) variable has not been studied as a contributing factor.

Methods: A nationwide retrospective analysis using the National Cancer Database to evaluate patients with clinical stage T1 and T2 PDACs from 2010 to 2020. Cox proportional hazards model was used to evaluate the impact of NAC followed by definitive surgery compared to upfront surgery on overall survival with and without TTFT.

Results: Total of 43,174 patients were included-9874 patients with clinical stage T1 and 33,300 patients with T2 PDACs. There were increasing trends in the NAC approach from 2.9% in 2010 to more than 25% by 2020 and decreasing trends in the upfront surgery approach from 69.34% in 2010 to 31.87% by 2020. There were significant differences in TTFT according to the treatment choice with upfront surgery group having a significantly shorter TTFT-proportion of those receiving first treatment within the first week was 24.32% in the upfront surgery compared to 4.22% in the NAC group. In the adjusted cox regression without the TTFT variable, there was a 25% higher rate of death in the upfront surgery compared to the NAC group (hazard ratio 1.25, 95% confidence interval 1.19-1.30). When the adjusted regression was performed with addition of a TTFT interaction term, there was survival disadvantage of upfront surgery approach in patients whose TTFT occurred after 1 wk, but not in those with TTFT occurring in less than 1 wk (hazard ratio 1.01, 95% confidence interval 0.86-1.17).

Conclusions: Our study emphasizes the importance of incorporating TTFT variable when comparing NAC versus upfront surgery approach in PDAC. Future studies comparing NAC to upfront surgery in resectable PDAC should consider incorporating the TTFT variable.

Introduction: Pediatric-onset Crohn's disease (CD) has a more severe phenotype than adult-onset, and nearly one-third of pediatric CD patients will require surgical therapy. There is limited data on patient/disease characteristics that are associated with earlier surgical management.

Methods: All pediatric CD patients (<22 yrs) who underwent ileocolectomy from 2005 to 2021 were included. Unadjusted analyses were performed with Pearson chi-squared tests for categorical dependent variables, and t-tests, or analysis of variance, for numerical dependent variables.

Results: One hundred thirty-five pediatric CD patients underwent ileocolectomy. The median time to surgery was 3.75 yrs. Patients treated with early surgery (<3.75 yrs from diagnosis) were older at diagnosis (16.5 versus 11.6 yrs, P < 0.001) yet had surgery at a younger age (16.8 versus 18.9 yrs, P < 0.001). They also were prescribed fewer CD medications (2.0 versus 4.0, P < 0.001), were less likely to have trialed multiple biologics (25.6% versus 54.2%, P = 0.001), had a shorter time from diagnosis to biologic (0.3 versus 3.5 yrs, P < 0.001), and had a shorter interval from biologic to surgery (0.4 versus 2.5 yrs, P < 0.001). Abscess formation was a more common indication for early surgery (39.4% versus 14.7%, P = 0.002), whereas failure to thrive/refractory pain was more common for later surgery (27.3% versus 55.9%, P = 0.001).

Conclusions: Surgical therapy remains an important component of the overall management of pediatric CD. In our cohort, earlier surgical management was associated with earlier use of biologics, a shorter duration between biologic and surgery, and decreased number of overall medications and biologic agents prior to surgery, suggesting a severe disease phenotype refractory to medical management.

Introduction: Hypocalcemia occurs in 20%-40% of total thyroidectomy cases, traditionally requires 1-2 ds of hospitalization for management. This study examines the extent of hypocalcemia following a postanesthesia care unit (PACU) parathyroid hormone (PTH)-based protocol after outpatient thyroidectomy.

Methods: Patients who underwent total or completion thyroidectomy for non-Graves' disease at a single institution between December 2015 and September 2023 were included. Postoperative calcium and calcitriol supplementation followed a standardized protocol based on PACU PTH levels (<2, 2-9, 10-19, or >20 pg/mL), with higher doses given to patients with lower PACU PTH levels. Clinical outcomes including hypocalcemia were assessed.

Results: Of the 250 patients included, the majority were female (77%) and White (69%), with a mean age of 47 ± 19 ys. The percentages of patients in the <2, 2-9, 10-19, and >20 PACU PTH groups were 4.4%, 20.0%, 20.8%, and 54.8%, respectively. A total of 61 (24.4%) patients experienced symptomatic hypocalcemia, with the highest incidence (81.8%) in the <2 group and the lowest (5.1%) in the >20 group. By 2 wks postsurgery, 6% had low serum calcium (<8.4 mg/dL), and 3.6% had persistent hypocalcemia symptoms. All patients resolved their symptoms at the last follow-up. There were 17 (6.8%) phone consultations and 3 (1.2%) emergency department visits due to hypocalcemia concerns. The readmission rate was 3.6%, with hypocalcemia causing only one case (0.4%).

Conclusions: Using our PACU PTH protocol for outpatient total thyroidectomy is associated with a relatively low incidence of hypocalcemia requiring emergency department visits or readmission.

Introduction: Child Opportunity Index (COI) is associated with complicated appendicitis (CA) in children. Value-based care through an accountable care organization (ACO) may modify this association. We aimed to determine if enrollment in our state's ACO, Partners For Kids (PFK), modified the association between COI and CA.

Methods: Using a single-institution, retrospective review of children with public insurance undergoing appendectomy for acute appendicitis, COI and clinical confounders were compared by simple versus CA. Multivariable logistic regression models using COI, insurance, and age were fit with and without interaction terms to determine if PFK enrollment modified the association between COI and CA.

Results: Among 1337 children, 31.0% had CA. Most (78.6%) were enrolled in PFK; this was not different between simple and CA. CA was associated with younger median age (7.0 y versus 8.0 y, P < 0.001). As overall COI quintile decreased (lower opportunity), the percentage of children with CA increased (P = 0.01). On multivariable regression controlling for age, PFK, and COI, only Very Low COI and age remained significantly associated with CA. The association between COI and CA was not modified by PFK enrollment. COI and PFK enrollment were not associated with postoperative complications, except children with PFK had fewer 30-d readmissions (4.2% versus 14.6%, P < 0.001) compared to those with other public insurance.

Conclusions: Low COI was associated with higher CA, and this association was not modified by enrollment in an ACO, suggesting that ACO enrollment alone may not be sufficient in addressing social determinants of health among children with CA.

Introduction: Undertriage of children contributes to poorer clinical outcomes. The objective of this study was to determine factors associated with undertriage of pediatric major trauma victims.

Methods: We performed a retrospective cross-sectional study of children (aged < 16 ys) using the 2021 American College of Surgeons National Trauma Data Bank. We identified children who met the definition of major trauma defined by the Standard Triage Assessment Tool. We performed multivariable logistic regression to determine factors associated with undertriage, defined as encounters which met criteria, but did not receive highest-level activation.

Results: Of 97,812 included children, 5.3% met major trauma criteria. Undertriage occurred in 34.4% of encounters with major trauma. Factors associated with undertriage included fall and striking mechanisms, missing blood pressure, private vehicle arrival, and incoming interfacility transfers. Hypotension, decreased level of consciousness, prehospital and in-hospital intubation, tachycardia, hypothermia, penetrating mechanism, presentation to a pediatric level 2 or adult level 1 trauma center relative to pediatric level 1 center, and arrival by flight were associated with lower odds of undertriage.

Conclusions: Many children with major trauma were undertriaged, particularly those presenting with lower-risk histories, such as private vehicle arrivals and fall mechanisms. Future work should seek to develop risk-stratification systems that can better identify children with major trauma, with an emphasis on those with blunt traumatic mechanisms.

Introduction: There is a noticeable lack of information on iatrogenic error (IE)-related deaths in the United States. To address this, we conducted a retrospective analysis examining temporal, regional, urbanization, and age-related trends in IE-related mortality from 1999 to 2020.

Methods: Utilizing the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research database, we identified crude and age-adjusted mortality rates (AAMR) per 100,000 persons. We calculated annual percentage changes (APCs) via the Joinpoint regression program.

Results: From 1999 to 2020, a total of 531,792 IE-related deaths were reported, with an overall decline in mortality rates. From 2015 to 2020, an increase in AAMR by an APC of 17.19% was noted. Similar trends were seen in the 65-85+ age group from 2015 to 2020 (18.39%). The largest percentage increase in death rates occurred in Noncore metropolitan areas. Significant disparities were observed among states, with mortality rates ranging from 4.45 of 100,000 in Massachusetts and 10.43 of 100,000 in Mississippi. Other states with high AAMR values include New Mexico and Wyoming. In addition, the West census region demonstrated the greatest increase in APC in mortality rates (APC: 25.36%) from 2015 to 2020 followed by the South, Midwest, and lastly Northeast regions.

Conclusions: The data indicate a notable fluctuation in mortality rates over the years, underscoring the importance of targeted interventions to address the regional and age-specific disparities. Investigating the causes of mortality variations offers crucial opportunities to reduce IEs.

Introduction: This systematic review aims to evaluate the optimal management of acute respiratory distress syndrome (ARDS) in critically ill surgical patients, specifically focusing on positioning, extracorporeal membrane oxygenation (ECMO) use, ventilation, fluid resuscitation, and pharmacological treatments.

Methods: A systematic review was conducted utilizing four databases including PubMed, Google Scholar, EMBASE, and ProQuest. This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with The International Prospective Register of Systematic Reviews. Studies published until May 20, 2024, that assessed the management of ARDS in critically ill surgical adult populations were included in our review. The primary outcome of interest was mortality, with secondary outcomes like intensive care unit (ICU) length of stay (LOS), ventilator days, and oxygenation also being considered.

Results: A total of fifteen studies met inclusion criteria; four studies assessed positional interventions, four assessed treatments with ECMO, three assessed mechanical ventilation settings, and four assessed fluid resuscitation and medications. Prone position was found to decrease mortality, ICU LOS, ventilator days, and increased oxygenation (P < 0.001). ECMO utilization decreased the overall mortality rate when compared to patients without ECMO (36.4% versus 43.9%, P < 0.001). Maintaining a tidal volume ≤8 mL/kg body weight and plateau pressure ≤35 cm H₂O on mechanical ventilation also decreased patient mortality (P < 0.001). Finally, conservative fluid management decreased ICU LOS, whereas methylprednisolone use demonstrated decreased mortality.

Conclusions: Prone positioning, ECMO utilization, lung protective ventilation settings, and methylprednisolone reduced mortality among surgical patients with ARDS. In addition, prone positioning and conservative fluid management were associated with decreased ICU LOS, ventilator days, and improved oxygenation status.

Introduction: Anal acoustic reflectometry (AAR), a novel test of anal sphincter function, was shown to predict a successful trial phase of sacral neuromodulation (SNM) for fecal incontinence. This follow-up study aims to explore if AAR can also predict short- and long-term SNM outcomes at less than and more than 5 y, respectively.

Methods: Outcome data were reviewed from a prospectively managed database. Successful treatment was defined as >50% improvement in patient reported fecal incontinence or urgency episodes, or in a symptom severity score.

Results: Twenty-six female patients (median: 53 y [range 31-80]) who received a permanent SNM implant were analyzed. In the short-term, no differences were observed in baseline AAR and symptom severity parameters between patients reporting success or failure. At long-term follow-up (median: 122 mo [113-138]) data was available from 17 (17/26, 65%) patients with 7 (7/17, 41%) reporting continued treatment success. Baseline fecal urgency episodes (P = 0.003), and the AAR parameters of opening elastance (P = 0.043) and squeeze opening elastance (P = 0.025) were significantly different between patients reporting success and those reporting failure. Squeeze opening elastance demonstrated the greatest ability to discriminate between success and failure (area under the curve: 0.82 (95% confidence interval 0.60-1.01, P = 0.003)).

Conclusions: AAR may have a role in identifying patients suitable for SNM treatment with clinically relevant metrics associated with successful response to treatment. Future work should explore this further to improve SNM patient selection.

Introduction: Despite the widespread use of branched (bEVAR) and fenestrated endovascular aortic repair (fEVAR) for complex aortic pathologies, there are no reliable recommendations regarding postsurgery antiplatelet therapy. We therefore evaluated the outcome of single (SAPT) and dual antiplatelet therapy (DAPT) following fEVAR and bEVAR.

Methods: A total of 63 patients from two German centers treated for complex aortic pathologies were included in this retrospective study. Patient data and computed tomography angiograms were analyzed. Kaplan-Meier analyses for overall survival and freedom from target vessel (TV)-related complications were performed. The outcomes were compared between SAPT versus DAPT and bEVAR versus fEVAR. Univariate logistic regression was applied to analyze the correlation between TV patency and various anatomical aortic parameters.

Results: In total, 30 patients were treated with fEVAR and 33 with bEVAR. Of these, 19 patients received SAPT and 44 received DAPT postsurgery. Anatomical aortic characteristics and comorbidities were comparable among groups. Overall survival was 95% (±5.1) for SAPT and 88% (±8.8) for DAPT after 36 mo of follow-up. Patency was evaluated individually for each TV SAPT versus DAPT (celiac trunk 100% ± 0 versus 87% ± 9.6; superior mesenteric artery 86% ± 13.2 versus 100% ± 0; left renal artery 92% ± 8.0 versus 95% ± 3.6; right renal artery 72% ± 15.2 versus 81% ± 9.9). Freedom from endoleak was 35% (±13.7) for SAPT versus 30% (±13.8) for DAPT. There was no statistically significant difference for SAPT versus DAPT or for bEVAR versus fEVAR. Further, none of the anatomical aortic characteristics and bridging stent graft-related parameters analyzed predicted TV occlusion in logistic regression analysis.

Conclusions: We did not observe differences in overall survival, endoleak, and TV patency rates between SAPT and DAPT treated patients following bEVAR and/or fEVAR. Patient-specific factors therefore appear to be more relevant for the long-term outcomes rather than the antiplatelet regime applied postsurgery.