Journal of the American College of Surgeons最新文献

Background: Large hernia repairs, particularly those involving abdominal wall reconstruction (AWR), can elevate intra-abdominal pressure due to the reintegration of herniated contents into the abdominal cavity, potentially contributing to renal injury. Despite the theoretical risk, the long-term impact of AWR-induced intra-abdominal pressure elevation on renal function remains insufficiently studied. This study aims to evaluate the incidence of acute kidney injury (AKI) and chronic kidney disease (CKD) after AWR and to identify key factors associated with postoperative renal impairment.

Study design: Adult patients undergoing elective open AWR with transversus abdominis release between January 2014 and March 2022 were included. Patients were stratified by baseline renal function to evaluate the incidence of postoperative AKI, long-term CKD, and CKD progression. Multivariable logistic regression identified predictors of renal impairment.

Results: AKI occurred in 14.2% of patients, with a significantly higher incidence among those with preexisting CKD compared with patients with normal baseline renal function (26.6% vs 11.8%; p < 0.001). At 1-year follow-up, 6.9% of patients with normal baseline renal function developed new-onset CKD, whereas 19.6% of patients with preexisting CKD experienced disease progression (p < 0.001). Dialysis was required in 1.03% of the total cohort, almost exclusively among patients with advanced preoperative CKD (p < 0.001). Postoperative AKI emerged as an independent predictor of CKD progression, with an adjusted odds ratio of 7.51 (95% CI 3.83 to 14.72; p < 0.001).

Conclusions: Patients with preexisting CKD undergoing AWR for large hernias are at elevated risk for postoperative AKI and long-term renal deterioration. Given these findings, perioperative risk stratification and vigilant postoperative renal monitoring are essential. Prevention and early management of AKI should be prioritized to mitigate long-term renal complications in this high-risk population.

Background: Acute mesenteric ischemia (AMI) is a vascular emergency where delays in diagnosis or treatment can lead to irreversible bowel injury and death. Many patients initially present to hospitals without surgical or vascular capabilities and require interhospital transfer. The clinical impact of such transfers on treatment and outcomes in AMI remains poorly defined.

Study design: We performed a retrospective cohort study using the National Inpatient Sample (2019 to 2021) to evaluate the association between interhospital transfer and outcomes in patients with AMI. Adult patients with a primary diagnosis of AMI were identified using ICD-10 codes. Patients were categorized by transfer status. Multivariable logistic regression was used to evaluate associations with in-hospital mortality and procedural interventions, adjusting for age and comorbidity burden.

Results: Of 39,690 hospitalizations for AMI, 14.6% involved interhospital transfer. Transferred patients had a higher comorbidity burden and were more often treated at rural or micropolitan hospitals. They were significantly more likely to undergo major surgical and vascular procedures, including bowel resection (odds ratio [OR] 3.48), mesenteric bypass (OR 3.32), and angioplasty (OR 2.66; all p < 0.0001). Markers of critical illness, such as intubation (OR 2.15) and dialysis (OR 1.30), were also more frequent in this group. In-hospital mortality was significantly higher among transferred patients (OR 2.05), and transfer remained independently associated with increased mortality after adjusting for age and comorbidity burden (adjusted OR 1.67, 95% CI 1.32 to 2.10).

Conclusions: Interhospital transfer in AMI is strongly associated with increased clinical severity and in-hospital mortality. These findings emphasize the urgency of early diagnosis, rapid triage, and timely access to definitive care, supporting the need for structured regional systems and transfer protocols for AMI.

Background: Single-phase efforts to reduce opioid prescriptions after surgery have been somewhat effective. This is the first report of a low-cost, scalable, and self-sustaining opioid stewardship program spanning all perioperative phases.

Study design: We implemented a comprehensive opioid stewardship program comprised of multimedia patient- and staff-directed educational materials, prescribing badges, 4 electronic medical record modifications, and a dashboard that tracked and analyzed opioid prescribing. A retrospective analysis of baseline discharge prescribing habits (2019) was compared with prospective postimplementation data (2021 to 2022). Opioid naive adults undergoing 1 of 15 elective procedures in the short-term care, colorectal, thoracic, transplant, and surgical oncology divisions at our institution were included. Primary outcomes included discharge prescription size (normalized to oxycodone 5 mg pills), percent reduction of opioids, and percentage of patients requiring postdischarge opioid prescription.

Results: A total of 6,619 adults (median age 59 years [interquartile range 36 to 82 years]; 69.7% woman) were enrolled, 2,334 before and 4,285 after implementation. Overall, median (interquartile range) prescription size decreased (5 [0 to 15] to 0 [0 to 5; p < 0.0001]) and average (SD) decreased from 8.7 ± 12.9 to 2.9 ± 7.1 for a 67.1% reduction and a savings of 24,212 pills. A reduction in median discharge opioid prescription was achieved in 14 of 15 procedures (all p < 0.05, range 37.1% to 89.6%), and the median postintervention prescription quantity was 0 for 10 of 15 procedures. After risk adjustment, postintervention patients discharged with opioid prescriptions received 8 fewer oxycodone 5 mg pills (p < 0.0001). The postintervention period was associated with increased odds of discharge on-target (odds ratio [OR] 8.9 [7.74 to 10.18] and opioid-free discharge (OR 3.4 [3.06 to 3.87]) and reduced odds of receiving a prescription refill (OR 0.72 [0.59 to 0.88]). Compared with patients who were discharged without opioids, those who were discharged with an opioid prescription had increased odds of receiving another postdischarge prescription (OR 3.90 [3.12 to 4.86]).

Conclusions: This low-cost, self-sustaining departmental opioid stewardship program was remarkably effective at reducing opioid overprescription at discharge after common operations.

Background: A career in surgery demands intensive training, long and irregular work hours that often challenge a surgeon's social well-being. We sought to investigate the impact of the surgical profession on marital status and divorce rates.

Study design: The American Community Survey database, which comprised nationally representative surveys between 2018 and 2023, was queried to investigate trends and prevalence of divorce among surgeons and nonsurgeon physicians. Multivariable logistic regression analyses were conducted to identify factors independently associated with divorce.

Results: A total of 4,167 surgeons and 64,647 nonsurgeon physicians were identified. The median age was 49 years (interquartile range 38 to 63) and most of physicians were male (42,943, 62.4%) and White (47,434, 68.9%). The prevalence of divorce was higher among surgeons (20.9% [95%CI 19.6 to 21.1]) than nonsurgeon physicians (17.6% [95% CI 17.3 to 17.9]) and was comparable to the general population (20.8% [95% CI 20.7 to 20.8]; p < 0.001). On multivariable analysis, after adjusting for baseline characteristics, surgeons had a 16% higher risk of divorce (odds ratio [OR] 1.16 [95%CI: 1.05 to 1.28]). The risk of divorce was higher among male (OR 1.30 [95% CI 1.11 to 1.42]) and White (OR 1.28 [95% CI 1.10 to 1.40]) surgeons.

Conclusions: Surgeons experience a higher risk of divorce compared with their nonsurgeon physician counterparts. There is a need for support systems to improve work-life balance and well-being among surgeons.

Background: Frontline quality improvement (QI) projects are important, but they are not always done well. One reason lies in the weaknesses in the early planning stages, known as the "front-end" of projects. We aimed to develop a framework to guide the very early planning of small-scale, frontline surgical QI efforts.

Study design: We used a participatory, iterative design over 5 phases. We first identified content items relevant to QI from existing frameworks. Next, based on this content, sorting exercise was applied to generate thematic categories. A 4-round modified Delphi process involving clinicians and improvement experts was used to prioritize the features of these categories. A 9-step framework diagram and accompanying guidance table were then created. We tested the prototype with frontline clinicians (both attending or consultant surgeons and resident surgeons) using a clinical vignette, comparing the plans prepared by participants with 3 levels of framework exposure: without the framework, with the framework diagram only, and with the framework diagram plus guidance table.

Results: A framework to guide early planning of small-scale surgical QI projects was developed and tested. It comprised a 9-step diagram and an accompanying table of guidance. Seven planning steps include assembling an improvement team, problem detailing, defining aims, intervention identification, planning implementation and monitoring, and planning end-of-project decisions. Two further steps focus on proceeding and transitioning to launch. Testing with a clinical vignette indicated that using the full framework (framework diagram plus guidance table) may improve project planning by attending or consultant surgeons and resident surgeons.

Conclusions: The Early Planning of Small-Scale Surgical Improvement framework for surgeons and teams may be valuable in supporting QI. It requires further evaluation to assess its role in improving improvement efforts.

Background: Concurrent ventral hernia repair with mesh (mVHR) at the time of gastrointestinal (GI) cancer resection remains controversial due to concerns of increased skin and soft tissue infections (SSTIs) and mesh-related complications, which may delay receipt of systemic cancer therapies and affect both surgical and oncologic outcomes. Given the health and quality-of-life burden imposed by hernias, we sought to analyze the safety of concurrent mVHR and GI cancer resection.

Study design: The American College of Surgeons NSQIP database was queried for patients who underwent resection of GI malignancy and concurrent open VHR (with and without mesh) from 2016 to 2022. Perioperative outcomes of mVHR vs primary VHR (pVHR) were assessed before and after 1:2 propensity score matching. The primary outcome was 30-day postoperative SSTI rate.

Results: Of 3,449 patients undergoing concurrent VHR with GI cancer resection, 224 (6.5%) underwent mVHR. After matching (n = 174 mVHR; n = 305 pVHR), mVHR was found to be associated with longer operative time (242.5 vs 170 minutes, p < 0.001) and length of stay (7 vs 5 days, p = 0.002). The overall complication rate was higher in the mVHR cohort (43.1% vs 28.2%, p = 0.001), but there was no significant difference in SSTI rate (7.5% vs 5.6%, p = 0.410). mVHR was associated with higher rates of readmission (20.7% vs 11.5%, p = 0.006), blood transfusion (20.7% vs 10.5%, p = 0.006), and reoperation (8.6% vs 3.6%, p = 0.020).

Conclusions: Of patients undergoing hernia repair concurrently with GI cancer resection, only 6.5% of patients underwent mVHR. mVHR was not associated with increased 30-day postoperative SSTIs vs pVHR but was associated with increased length of stay and other postoperative complications. Patient selection for concurrent mVHR must weigh the benefits of durable mesh-based repair with increased perioperative morbidity.

Background: Crime Victim Compensation (CVC) exists in the US to help individuals and their families following violent injury. In Illinois, the CVC program can reimburse up to $45,000 per claim to assist with mental health, relocation, and burial expenses. CVC provides an opportunity to address recovery after violent injury across the continuum of care as part of the mission of trauma centers. We aimed to study CVC claim outcomes in Illinois, assessing delays in reimbursements and differences between crimes.

Study design: We filed a Freedom of Information Act claim with the Office of the Illinois Secretary of State from 2012 to 2024, requesting data on individual CVC claims. We analyzed CVC claim requests, focusing specifically on reimbursements and delays.

Results: On average, 3,677 claims were filed annually. The most common crimes for which compensation was requested were assault (47.1%) and homicide (20.8%). Overall, only 36.7% of claims were awarded. Claims following homicide were more likely to be awarded (65.2%) compared with all other claims (23.4% to 33.8%, p < 0.01). The median award following assault was $1,670 (interquartile range $658 to $4,576), whereas the median award following homicide was $7,500 (interquartile range $5,380 to $7,500). The overall time to payment was a median of 281 days, with only 17.9% of claimants awarded within 6 months of claim. Since 2022, wait times have decreased (p < 0.01).

Conclusions: CVC was created to support injured people; however, most claims in Illinois are rejected after a long delay. To be an effective program, CVC applications must be efficiently administered to address the needs of victims of violence.