Journal of Surgical Research最新文献

Introduction: We studied the relationship between heart transplant centers with and without liver transplant programs regarding volume, waitlist duration, waitlist survival, and 1-y posttransplant survival.

Methods: Scientific Registry of Transplant Recipients data were acquired in July 2023 and represented transplant centers with adult organ transplant volumes in the United States over the past year. This system involved a five-tier ranking system from one to five, where tier one programs had the lowest rating and tier five programs had the highest rating.

Results: Among heart transplant centers, there were 37 (29.6%) heart-only centers and 88 (70.4%) heart-liver centers. Median heart transplant volume was greater in heart-liver centers (28 [interquartile range: 18-47]) relative to heart-only centers (10 [2-20]; P < 0.001). Median heart waitlist duration rating was higher among heart-liver centers (3 [2-4] versus 2 [2-3]; P = 0.05). A higher waitlist duration rating was associated with greater annual transplant volume (P < 0.001). Waitlist survival rating distributions were similar across heart-only and heart-liver centers (3 [2-4] versus 4 [2-4]; P = 0.33). No significant association was observed between heart transplant volume and waitlist survival rating (P = 0.52). Median posttransplant survival rating between the two transplant center types was also comparable (3 [2-4] versus 3 [2-4]; P = 0.43). A higher posttransplant survival rating was associated with higher transplant volume (P < 0.05).

Conclusions: Heart transplant centers with concomitant liver transplant programs have a superior waitlist duration rating as well as higher overall transplant volumes when compared with heart-only transplant centers.

Introduction: Frailty is a risk factor for adverse outcomes after injury. Herein, we compared three frailty scales: the Canadian Study of Health and Aging clinical frailty scale, the rib fracture frailty index (RFFI) and the modified frailty index-5, to assess which scale is most applicable in predicting risk for negative outcomes in older patients with rib fractures.

Methods: Patients ≥65 admitted for rib fractures were retrospectively scored for frailty using the RFFI, Canadian Study of Health and Aging clinical frailty scale, and modified frailty index-5. Outcomes examined were in-hospital mortality, pneumonia, in-hospital intubation, hospital length of stay, and discharge to skilled nursing facilities. Areas under the curve, sensitivity, specificity, negative predictive value, and positive predictive value were determined for each frailty scale with each outcome. Agreement was determined using Fleiss' Kappa. P <0.05 was considered significant.

Results: Three hundred forty-one patients were included. All three scales demonstrated similar predictive abilities for the measured outcomes. RFFI predicted mortality and pneumonia 70% of the time. All three scales predicted discharge to skilled nursing facilities 60% of the time. The concordance for all three frailty scales was 241/341 (70.7%). Fleiss Kappa was 0.40 [0.34-0.46] (P < 0.001), indicating a fair to moderate agreement. The predictive ability of all three scales was higher in patients 65-74 y old than in patients ≥75.

Conclusions: Overall, no scale appeared to significantly outperform the others by areas under the curve estimation. Interrater reliability was higher in the 65 to 74-y-old population compared to the 75 and older population.

Introduction: Patients with end-stage renal disease (ESRD) are at increased risk for bleeding complications following surgery. However, the approach to the preoperative risk assessment and risk reduction, if feasible, in ESRD patients undergoing nonelective abdominal surgery has not been comprehensively studied. We aim to determine the prevalence and risk factors for perioperative bleeding in patients on dialysis undergoing nonelective abdominal surgery.

Methods: Using the American College of Surgeons National Surgical Quality Improvement Program 2005-2017 database, we identified patients on dialysis who underwent a variety of nonelective abdominal surgeries by Current Procedural Terminology code. Rates of major perioperative bleeding, defined as bleeding requiring red blood cell transfusion within 72 h after surgery, were calculated and stratified by procedure type. Multivariate logistic regression was used to identify risk factors for major perioperative bleeding. Thirty-day mortality rates were compared between those who had a major perioperative bleed and those who did not.

Results: Of 9102 patients on dialysis undergoing nonelective abdominal surgery, 2793 (30.7%) experienced major perioperative bleeding requiring transfusion and 2002 (22.0%) died within 30 d of surgery. By multivariable logistic regression, patients who were female, independent or partially dependent in activities of daily living, ventilator dependent, had disseminated cancer, or had chronic steroid use at baseline were found to be at elevated risk for major perioperative bleeding. Elevated partial thromboplastin time, blood urea nitrogen, anemia, and hypoalbuminemia were also associated with higher odds of major bleeding. Compared to patients undergoing herniorrhaphy (lowest risk), the odds of major perioperative bleeding were highest for patients undergoing hepatic surgery (odds ratio [OR] = 18.09), splenic surgery (OR = 10.86), and pancreatic surgery (OR = 9.59). Major perioperative bleeding was associated with increased 30-d mortality (34.0% versus 16.7%, P < 0.001).

Conclusions: Patients with ESRD experience high rates of bleeding requiring transfusion following emergent abdominal surgery. Derangements in preoperative laboratories and baseline patient characteristics may be useful in assessing bleeding risk in this patient population.

Introduction: Abdominal and perineal repairs for rectal prolapse are offered to patients based on surgeon assessment of risk. Interpretations of risk can vary. We sought to understand how the preoperative Risk Analysis Index (RAI) score, a validated measure of frailty, aligned with our existing decision-making process for rectal prolapse repair.

Methods: Rectal prolapse repair cases were recorded in an Institutional Review Board approved registry from 2017 to 2022. Abdominal and perineal operations were determined based on an experienced surgeon's recommendation. The preoperative RAI was collected; a score≥30 indicates significant frailty. Preoperative and postoperative characteristics were compared using t-tests and Fisher's exact tests.

Results: About 130 patients underwent abdominal repairs and 51 underwent perineal repairs. Perineal patients were more often frail (abdominal: 9 [7%] versus perineal: 21 [41%], P < 0.001) and had a higher rate of cardiac comorbidities (abdominal: 42 [32%] versus perineal: 35 [69%], P < 0.001). A similar share of patients were undergoing repair for recurrent prolapse (abdominal: n = 29 [22%] versus perineal: n = 11 [22%], P > 0.99). Perineal repair patients were more likely to need assistance with mobility (n = 24 [47%]) and live in a facility (n = 15 [29%]). Patients in both groups recovered well (complication rate abdominal: 28 [22%] versus 11 [22%], P > 0.99) and were satisfied with postoperative outcomes (Patient Global Impression of Change score abdominal: 6 [interquartile range: 6, 7] versus perineal: 6 [5, 7], P = 0.12). Recurrence rates were higher after perineal repair (abdominal: 12 [9%] versus perineal: 20 [39%], P < 0.001).

Conclusions: Most abdominal repair patients were not frail, but many nonfrail patients underwent perineal operations based on surgeon perception of comorbidities. Using the RAI tool may provide an opportunity to guide decision-making around operative approach for rectal prolapse and overcome potential surgeon bias.

Introduction: Automobile-pedestrian (AP) crashes can cause severe injuries and are increasing in frequency. We sought to determine factors contributing to severe injuries.

Methods: Patients ≥15 y with AP injuries admitted from January 1, 2020, through December 31, 2022, comprised the study population. Demographic data, injury severity score (ISS), and abbreviated injury scale (AIS) were obtained from the trauma registry. An electronic medical record review collected location, time and description of the incident, and substance use. Locations were grouped into multilane, high speed (>40 mph) streets, residential streets, and off-road. Pedestrian safety features were assessed using Google Street View. Each location census tract Area Deprivation Index was determined. Logistic regression was used to determine if safety features predicted increasing ISS or AIS.

Results: There were 426 patients. The mean ISS was 13.3. AP patients struck with a sidewalk present had a higher ISS (P = 0.03) and higher AIS head or neck (P = 0.01). Those struck on a street with <6 lanes had a lower ISS (P = 0.035). AP victims under the influence of a substance had higher ISS (P = 0.035) and AIS external (P = 0.049). More AP accidents occurred between 18:00-23:59 (43.8%). Most AP fatalities occurred between 18:00-5:59 (76%). Most AP injuries, 94.06% (P = 0.0), occurred in areas with an Area Deprivation Index of 9 or 10.

Conclusions: More severe AP injuries occurred along multilane roads with high-speed traffic and with a sidewalk. Injuries and fatalities more commonly occurred at night. Pedestrians using substances suffered more severe injuries. Most AP injuries occurred in socioeconomically disadvantaged areas.

Introduction: This study aims to retrospectively analyze the perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in asymptomatic patients, stratifying the results by sex.

Methods: Data on CEAs performed from January 2009 to December 2020 at our institution were collected. A neurologic evaluation was conducted 30 d after surgery to assess the occurrence of neurological events. Instrumental evaluations using Doppler ultrasound were performed within the first 3 mo, at 12 mo, and annually thereafter. The primary endpoints were perioperative mortality, major neurological events, and major complications. Secondary endpoints included long-term overall survival, stroke-free survival, absence of neurological symptoms, and absence of significant (>70%) restenosis.

Results: Two thousand one hundred ninety-four CEAs were performed in asymptomatic patients, with 758 females and 1436 males. There were no differences in perioperative outcomes between the two groups. In the multivariate analysis, female sex was found to be a protective factor for the risk of 30-d stroke (hazard ratio: 0.2; 95% confidence interval: 0.04-0.9; P = 0.05). At a median follow-up of 24 mo, the estimated 10-y overall and stroke-free survival rates were 77.6% in males versus 62.7% in females, P = 0.2 and 70% in males versus 61% in females, P = 0.1, respectively. Also the rates of significant restenosis did not differ between males and females (82.2% versus 87.7%, P = 0.5).

Conclusions: This study suggests that female sex, by itself, does not represent a risk factor for adverse outcomes after carotid surgery and it appears to be protective in the first 30 d following surgery.

Introduction: Neointimal hyperplasia is one of the persistent complications after vascular interventions, and is the major cause of treatment failure. Interleukin-33 (IL-33) emerges as a crucial factor in many biological processes and plays an important role in vascular diseases. Adventitial injection is catching attention for its effectiveness and fewer side effects. We hypothesize that targeting IL-33 by adventitial injection can be a therapeutic method to inhibit neointimal hyperplasia.

Method: IL-33 expression was examined in human vein graft. The hydrogel was fabricated by the interaction of hyaluronic acid, sodium alginate, and CaCO₃; and phosphate buffered saline (PBS) or IL-33 antibody or recombinant IL-33 was mixed within the hydrogel uniformly. A rat aortic wire injury-induced neointimal hyperplasia model was developed; rats were divided into three groups and received an adventitial injection of a hydrogel loaded with PBS or IL-33 antibody or recombinant IL-33 after wire injury. Tissues were harvested at day 21 and analyzed by histology and immunohistochemical staining. Hydrogel loaded with PBS, IL-33 antibody, or IL-33 was also used in a mouse carotid artery ligation neointimal hyperplasia model.

Result: There was a high expression of IL-33 in human vein graft neointima. Hydrogel can be successfully injected into the aortic wall and is encapsulated by the adventitia. The hydrogel could be seen beneath the adventitia after adventitial injection and was partly degraded at day 21. There was a significantly thinner neointimal thickness and less proliferation and inflammation in the IL-33 antibody group compared to the control group. On the contrary, the IL-33 group has a thicker neointima, increased proliferation, and inflammation. The mouse carotid artery ligation model showed similar results.

Conclusions: IL-33 plays a role in arterial neointimal hyperplasia in both human and rodent models; adventitial injection of hydrogel loaded with IL-33 antibody can effectively decrease neointimal thickness. Neutralizing IL-33 by IL-33 antibody may be a potential therapeutic method to inhibit intimal hyperplasia after vascular interventions.

Introduction: Regional anesthetic approach and surgical volume have been shown to outcomes in patients undergoing Nuss procedure for pectus excavatum. However, their independent relationship is not described. We investigated how regional anesthesia and surgical volume are associated with length of stay (LOS), postoperative opioid use, operating room utilization, and complications.

Methods: This is a 9-center retrospective review of patients ≤21 ys after Nuss procedure for pectus excavatum (2016-2020). High-volume centers and surgeons defined as the upper-quartile for annual procedures. Outcomes were compared with mixed effects linear/logistic regression models with random intercepts by institution as appropriate. A single-center unadjusted analysis was performed of erector spinae catheter (ESC) utilization (due to nonuniform use; high-volume only at 1-center).

Results: 780 patients were included. Significant variation existed in anesthetic approach and volume. Cryoablation was independently associated with shorter LOS (-2.1 d; 95% confidence interval [CI]: -2.6,-1.7) and lower postoperative opioid utilization (-120 morphine milligram equivalents, 95% CI: -181, -58.1) but increased surgical time (+45 min; 95% CI: 30.3, 59.8). Individual surgeon volume was associated with decreased LOS (-0.3 d; 95% CI: -0.5, -0.01), though high-volume centers had increased complications (odds ratio 2.2; 95% CI: 1.1, 4.2). There was no association between anesthetic approach and surgical complications. Within the single center utilizing ESCs (n = 138), a shorter LOS (2 versus 3 d, P < 0.01) was observed compared to those not receiving an ESC (n = 19).

Conclusions: Analgesic approaches varied significantly across institutions and limited our ability to directly compare cryoablation and ESCs. On multivariate analysis, cryoablation was associated with decreased LOS and postoperative opioid use, irrespective of center and surgeon volume. ESCs were similarly associated with improved outcomes. Rigorous prospective comparison of ESCs and cryoablation is warranted.

Introduction: The use of robotic surgery for pancreatic cancer resections is increasing over time. There are multiple studies comparing this approach to open surgery, specifically for Whipple and distal pancreatectomies. But there are limited data on its feasibility and oncologic efficacy in patients requiring total pancreatectomy.

Methods: This is a retrospective study from the 2010 to 2019 National Cancer Database comparing the postoperative, pathological, and long-term oncologic outcomes between robotic total pancreatectomy (RTP) and open total pancreatectomy (OTP) for pancreatic adenocarcinoma.

Results: One hundred eighty-eight (5%) RTP and 3447 (95%) OTP patients were identified. The number of RTP increased from four in 2010 to 32 in 2019. There were no major differences in patient demographics and treatment characteristics, except that RTP patients were more likely to be performed at nonacademic centers and less likely to get radiation. After adjustment, there was similar yield of examined lymph nodes, rate of positive margin, 90-d mortality and receipt of adjuvant therapy between both groups. RTP was associated with a statistically significant shorter length of stay than OTP (9 versus 11 d respectively, P value <0.001). There was no difference in median overall survival between RTP and OTP (22.3 mo versus 23.3 mo, P value 0.688). The 1-, 3-, and 5-y overall survival rates for RTP were 78%, 31%, and 34% and those for OTP were 75%, 38%, and 30%, respectively. After adjustment, the use of robotic surgery was associated with similar overall survival to the open approach (hazard ratio 0.939, 95% confidence interval 0.760-1.161).

Conclusions: RTP is associated with similar short- and long-term mortality without sacrificing oncologic outcomes including adequate lymphadenectomy and adjuvant chemotherapy receipt with the advantage of shorter length of stay.

Introduction: The opioid crisis is a major public health issue, and postoperative opioids play a unique role. Many institutions have implemented standardized protocols to decrease excess opioids available. The objective of this study was to establish a standardized pain protocol for common surgical procedures and assess postoperative pain control.

Methods: This is a prospective observational study based on the Michigan Opioid Prescribing Engagement Network network guidelines which provides prescription recommendations for surgical procedures. We evaluated all laparoscopic/robotic cholecystectomy, appendectomy, and all herniorrhaphies. Patients were prescribed a predetermined number of narcotics by procedure as part of a multimodal pain regimen. A survey was conducted within 14 d postoperatively to assess pain control and narcotic utilization.

Results: A total of 442 patients were included from July 1, 2022 to October 28, 2022. Survey response was 40% (178/442) with 56% (249/442) prescribed per protocol. Fewer patients prescribed per protocol required refills, 9.6% (24/249) compared to 18.1% (35/193) (P = 0.007) without protocol. Patients reported taking significantly fewer narcotics with the protocol versus without (median = 5.0 versus 10.0, P < 0.001). The median number of narcotics taken were 5.5 for appendectomy, 7.0 for cholecystectomy, and 9.0 for herniorrhaphy. There was no difference in pain control when comparing patients with and without protocol (91.1% versus 90.5%, P = 1.0).

Conclusions: This study demonstrated that postoperative opioid prescriptions can be decreased by implementing a standardized protocol incorporating a multimodal regimen while adequately controlling pain following surgery.