Surgery最新文献

Background: With a growing proportion of patients undergoing surgery for colorectal cancer being older adults, it is unknown whether traditional quality metrics are achieved as often compared with younger adults. This work was done with a view to understand tailoring needs of quality metrics for older adults with colorectal cancer.

Methods: This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program registry to identify adults (≥18 years) between 2016 and 2021 who underwent elective colorectal cancer surgery for nonmetastatic cancer. older adults was defined as adults ≥65 years. The association between older adults and attainment of consensus quality metrics were evaluated using multivariable logistic regression adjusting for patient, cancer, and treatment factors.

Results: Of 46,159 patients undergoing elective colon cancer resection, 18,592 (40.3%) were older adults. Being an older adult was independently associated with a 14% reduction in odds of harvest of ≥12 nodes and 4.3 times increase in odds of 30-day mortality. Of 9,106 patients undergoing elective rectal cancer resection 5,143 (56.5%) were older adults. Being an older adult was independently associated with a 19% reduction in odds of harvest of ≥12 nodes, 2.3 times increase in odds of 30-day mortality and a 44% reduction in odds of receiving neoadjuvant radiation. Findings were robust to sensitivity analyses of alternate methods of handling missing data and alternate analytic approaches.

Conclusion: Given unique needs of the older adult population, interpretation of disparities in quality metrics is challenging because of an inability to differentiate between patient factors, tailored care, or bias. Monitoring and reporting of quality metrics for older adults need to be re-evaluated with consideration to stratification, unique benchmarks, and older adult-specific quality metrics.

Background: Transanal excision of rectal cancer can be considered the definitive surgical treatment if the depth spread is T1 or lower, and the lesion is completely included within the resection margin. This study aims to analyze the immune microenvironment in healthy rectal mucosa as a possible predictor of tumor infiltration depth, lateral tumor spread, and recurrence of rectal cancer after transanal local excision.

Methods: This study is a subanalysis of data from the IMMUNOREACT 1 and 2 trials (NCT04915326 and NCT04917263, respectively) including all the patients who underwent transanal excision of rectal cancer. This multicentric study collected healthy mucosa surrounding the neoplasms of patients with rectal cancer. A panel of immune markers was investigated at immunohistochemistry: CD3, CD4, CD8, CD8β, Tbet, FoxP3, PD-L1, MSH6, and PMS2 and CD80. Flow cytometry determined the proportion of epithelial cells expressing CD80, CD86, CD40, HLA ABC or HLA DR and the proportion of activated CD8+ T cells, CD4+ Th1 cells, and Treg.

Results: Receiver operating characteristic curve analysis for predicting deep tumor spread showed an area under the curve of 0.70 (95% confidence interval: 0.60-0.80) for CD25+FoxP3+ cell rate and 0.74 (95% confidence interval: 0.53-0.92) for CK+CD86+ cell rate. Receiver operating characteristic curve analysis for predicting lateral tumor spread showed an area under the curve of 0.82 (95% confidence interval: 0.61-0.99) for CD8+CD38+ MFI, 0.96 (95% confidence interval: 0.85-0.99) for CD8β infiltration, and 0.97 (95% confidence interval: 0.87-0.99) for CK+HLAabc+ cell rate. Receiver operating characteristic curve analysis for predicting recurrence showed an area under the curve of 0.93 (95% confidence interval: 0.76-0.99) for CD8+CD38+ MFI and 0.94 (95% confidence interval: 0.78-0.99) for CD8+CD28+ MFI. Low CD8+CD38+ MFI and low CD8+CD28+ MFI were associated with shorter disease-free survival (P = .025 and P = .021, respectively).

Conclusion: Our study showed that the association between the high proportion of epithelial cells acting as presenting cells and deep or lateral tumor spread may be explained by the presence of a greater tumor load at the site. Moreover, it showed that weak activation of CD8+ T cells within the rectal mucosa is associated with lateral tumor spread and eventually a higher recurrence rate. The mucosal level of CD8β infiltration detected at immunohistochemistry might be tested as a marker of lateral tumor spread and potentially translated into clinical practice.

Background: Our acute care surgery team sustainably launched a pain management quality improvement project to reduce opioid prescriptions without affecting pain control in our elective surgery patients that was adopted on the inpatient acute care surgery service. Consequently, we implemented patient education on opioids and pain management aiming at decreasing opioid use without compromising pain management for acutely injured patients on the trauma service.

Methods: Trauma patients admitted from August 1, 2021, to July 31, 2022, and discharged to home were included. Pain management education started on February 2022. Demographics, injury severity scores (ISSs), preadmission opioid and adjunct use, and type/dose of opioids and nonopioid adjuncts prescribed 24 hours predischarge and at discharge were collected. Opioids were converted to oral morphine milligram equivalents (MME). Phone calls for pain and opioid prescription refills were collected. The pre- and posteducation groups were compared using univariate analysis. Multivariate analyses were conducted to identify factors associated with phone calls for pain and opioid refills.

Results: Three hundred sixty-eight patients were included, 200 pre- and 168 posteducation. MME prescribed at discharge was positively associated with 24-hour predischarge MME (B = 0.010 [0.007-0.012], P < .001) and negatively associated with preinjury opioid use (B = -0.405 [-0.80 to -0.008], P = .045). Patient education led to an increased number of adjuncts prescribed (P < .008), decreased phone calls for pain (OR = 0.356 [0.165-0.770], P = .009), and decreased opioid refills (OR = 0.297 [0.131-0.675], P = .004), but no change in opioid prescriptions.

Conclusion: Patient education on opioids and pain management led to decreased phone calls for inadequate pain management and decreased number of opioid refills.

Background: Long-term implications of postoperative complications, particularly non-cancer-related mortality in patients with gastric cancer following gastrectomy, remain unclear. We aimed to evaluate the impact of these complications on non-cancer-related deaths.

Methods: A cohort of 236 patients who underwent curative gastrectomy for gastric cancer in a Japanese hospital was divided based on complications classified as Clavien-Dindo grade II or higher. The Kaplan-Meier method, log-rank tests, and Cox hazard ratio analysis were used to evaluate recurrence-free survival and overall survival and to identify complications and survival predictors.

Results: Delirium was the most common complication (21 of 52 patients). A significant difference was observed in the overall survival (with complications, 3-year: 58.1% and 5-year: 51.6%; without complications, 3-year: 82.3% and 5-year: 73.6%; P < .001) but not in recurrence-free survival (with complications, 3-year: 77.8% and 5-year: 77.8%; without complications, 3-year: 87.5% and 5-year: 85.2%). Non-cancer-related deaths, predominantly resulting from pneumonia, were more prevalent in the complications group than in the noncomplications group. Factors, including high American Society of Anesthesiologists Physical Status scores, blood transfusion, open surgery, male sex, total gastrectomy, and a history of neurologic/psychiatric disease, were independently associated with decreased overall survival.

Conclusion: Postoperative complications affect long-term prognosis, resulting in decreased overall survival and increased noncancer mortality. Proactive strategies, including optimizing preoperative management, preventing complications, and postdischarge interventions, are essential, with a focus on pulmonary disease prevention to improve prognosis after gastrectomy.

Background: Improvements in surgical techniques and perioperative care as well as increased patient life expectancies have led cardiothoracic surgeons to perform more complex operations, including reoperative open-heart surgeries. However, there is debate as to which patients are appropriate operative candidates for reoperative procedures.

Methods: This is a retrospective, single-center study of patients who underwent reoperative open-heart surgery via median sternotomy or thoracotomy over a 10-year period. Patients with previous ventricular assist device or heart transplant were excluded. Patients were stratified by age <65 years compared with age ≥65 years for analysis. Survival was assessed using Kaplan-Meier curves and log-rank tests. Multivariate analysis was performed with Cox proportional hazards regression.

Results: A total of 250 patients underwent reoperative open-heart surgery at our center from 2012 to 2022. In total, 176 patients underwent valve surgery, 53 underwent coronary artery bypass grafting, 31 underwent aortic surgery, and 29 underwent other operations. The overall mortality rate was 13.6% at 30 days and 21.2% at 1-year postoperatively. Patients ≥65 years old had a greater average survival compared with patients <65 years old (5.0 vs 4.1 years, P = .046). However, there were no differences in survival by age when patients were stratified by procedure, either coronary artery bypass grafting (P = .29) or valve surgery (P = .16). On multivariate analysis, reoperative valve surgery, intraoperative use of extracorporeal membrane oxygenation, and a greater number of reoperative surgeries were associated with lower survival.

Conclusion: Patients undergoing reoperative open-heart surgery are clinically complex and had lower survival with each subsequent reoperation.