Surgery最新文献

Background: Standard of care for locally advanced esophageal cancer is neoadjuvant therapy followed by surgical resection. The objective of this study is to explore perioperative factors associated with recurrence and survival among patients with locally advanced esophageal cancer.

Methods: A retrospective analysis of prospectively collected data on all consecutive minimally invasive Ivor Lewis esophagectomy cases for esophageal cancer performed from September 2013 to September 2023 was performed. Univariable and multivariable Cox proportional hazard regression models were used explore the risk and protective factors associated with recurrence-free and overall survival.

Results: In total, 222 consecutive patients who underwent neoadjuvant chemoradiation followed by minimally invasive Ivor Lewis esophagectomy were included. On univariable analysis, hypertension, Eastern Cooperative Oncologic Group, N stage, number of positive lymph nodes, lymphovascular invasion, cellular differentiation, and positive margins were associated with recurrence. Age, N stage, number of positive lymph nodes, lymphovascular invasion, and cellular differentiation were associated with a worse overall survival. On multivariable analysis, N stage (1.911 [1.295-2.819], P = .009) and worsening cellular differentiation (2.042 [1.036-4.025], P = .039) remained risk factors for recurrence, whereas older age (1.056 [1.013-1.102], P = .011) and cellular differentiation (1.949 [1.004-3.782], P = .049) remained significantly associated with a greater risk of death.

Conclusion: Our data suggest that older age and cellular differentiation are strong independent risk factors associated with overall survival. N stage and age are strong independent risk factors associated with both recurrence and survival. These findings may help guide treatment options and shared decision-making among patients with locally advanced esophageal cancer on the basis of their risk and protective factors to maximize recurrence-free and overall survival.

Background: Risk factors for in-hospital mortality related to gastrointestinal complications requiring operative intervention after cardiovascular surgery have not been previously described.

Methods: Adult patients who underwent cardiovascular surgery followed by gastrointestinal surgery during the same admission between January 2010 and June 2023 were included. Multivariable logistic regression was used to identify predictors of in-hospital mortality. Kaplan-Meier survival analysis was performed to assess overall survival based on identified risk factors.

Results: Gastrointestinal complications requiring operative intervention after cardiac surgery occurred in 151 patients, with an overall in-hospital mortality of 35.76% (n = 54). The most common diagnosis was bowel ischemia (50.33%). On multivariable logistic regression, the history of cirrhosis (odds ratio: 37.96, 95% confidence interval: 3.57-543.90) and the clinical condition at the time of emergency general surgery consultation, described by elevated lactate (odds ratio: 5.76, 95% confidence interval: 1.71-22.82), platelets <50 × 10⁹/L (odds ratio: 11.34, 95% confidence interval: 1.60-162.37), ≥3 vasoactive medications (odds ratio: 4.93, 95% CI: 1.29-20.14), and the need for renal replacement therapy (odds ratio: 5.18, 95% confidence interval: 1.46-20.79) were predictive of in-hospital mortality. In-hospital mortality was low when none of the risk factors identified on multivariable analysis were present (2.38%, n = 1 of 42), but in-hospital mortality was universal among patients with 4-5 risk factors (100%, n = 8 of 8).

Conclusions: Gastrointestinal complications after cardiac surgery are disastrous when patient illness becomes severe. Clinicians should maintain a high index of suspicion for gastrointestinal complications to promote early involvement of general surgery. Knowledge of these risk factors could help guide discussions among the multidisciplinary care team, patients, and their families.

Objectives: Semaglutide is a glucagon-like peptide 1 (GLP-1) analog that binds to GLP-1 receptors (GLP-1R) on beta-cells and neuronal cells and is used for treating type 2 diabetes and obesity. Insulin-secreting pancreatic neuroendocrine neoplasms have been reported to express high levels of GLP-1R protein, raising the possibility that GLP-1 receptor agonists could promote tumor growth. Our goal was to quantify GLP-1R expression levels in 6 neuroendocrine neoplasm cellular models and determine their proliferative response to semaglutide treatment.

Methods: Gene expression of GLP-1R in neuroendocrine neoplasm cells (BON, GOT1, NT-3, NEC913, NEC1452, and NEC1583) was measured by quantitative polymerase chain reaction. Protein expression was determined by immunofluorescent staining and Western blotting. Neuroendocrine neoplasm cells were incubated with semaglutide, and cell growth was measured using a cell viability assay. Mice harboring GOT1 xenografts were treated with semaglutide, and tumor volumes were measured.

Results: BON, NEC1452, and NEC1583 cells expressed significantly lower levels of GLP-1R transcript and protein than GOT1, NT-3, and NEC913 cells. GOT1 and NT-3 showed the highest response to semaglutide treatment, with a 19% and 22% increase in growth. Semaglutide promotes tumor growth in mice with GOT1 xenografts by 72%.

Conclusion: The impact of the GLP-1 receptor agonist semaglutide on neuroendocrine cancer growth is understudied. Our data revealed that 50% of neuroendocrine neoplasm cell lines tested expressed GLP-1R, and semaglutide treatment promoted their growth. These results indicate a potential risk in the use of semaglutide in patients with neuroendocrine neoplasms expressing GLP-1R. Investigations into a larger set of neuroendocrine neoplasms would be important because they are highly heterogeneous.

Background: Endoscopic submucosal dissection is increasingly used to treat early-stage colorectal cancer. This study evaluated the feasibility of endoscopic submucosal dissection in this setting and the determinants of lymph node metastasis.

Methods: We reviewed patients who underwent colorectal endoscopic submucosal dissection for early-stage colorectal cancer at a tertiary center between 2011 and 2023. The primary outcome was the identification of high-risk pathologic features predictive of lymph node metastasis in patients undergoing oncologic colon resection following endoscopic submucosal dissection.

Results: We reviewed 1,398 patients who underwent endoscopic submucosal dissection, and 83 (6%) had colorectal cancer. Twenty-four patients (29%) were closely monitored after endoscopic submucosal dissection, and 59 (71%) underwent oncologic colon resection because of high-risk pathologies of the endoscopic submucosal dissection specimen. In the oncologic colon resection group, the mean age was 62.7 years (±10.2), with 56% male predominance, and 14% showed positive lymph nodes in the final pathology. Analysis comparing patients with and without lymph node metastasis showed significant differences in sex, lesion size, submucosal invasion depth, and budding scores. Multivariate analysis showed that lesions with a submucosal invasion depth ≥2.00 mm of the endoscopic submucosal dissection resection specimen had higher odds of lymph node metastasis (odds ratio 18.7, P = .028), whereas lesions with a diameter >20 mm were associated with a lower likelihood of lymph node metastasis (odds ratio 0.07, P = .036).

Conclusion: The study highlights the oncologic safety of early-stage endoscopic submucosal dissection as a viable treatment option for carefully selected patients with colorectal cancer. After tissue resection with endoscopic submucosal dissection, if the lesion size is less than 20 mm, depth of invasion up to 2 mm may be considered safe in the absence of other high-risk pathologic factors.

Background: Inguinal hernia repair is one of the most common surgical procedures in the world. Each repair technique, open, laparoscopic, and robotic, has its advantages and advocates. Prior studies have compared 2 techniques, but there are little data comparing all 3 approaches with long-term follow-up.

Methods: Prospectively collected data for unilateral inguinal hernia repair between 2007 and 2022 were reviewed. Using more than 3,300 inguinal hernia repairs, a 1:1:1 propensity score match was performed for open inguinal hernia repair, laparoscopic inguinal hernia repair, and robotic inguinal hernia repair based on patient age, sex, body mass index, and laterality. Standard descriptive and comparative statistics were performed. Data below is reported consistently as open inguinal hernia repair versus laparoscopic inguinal hernia repair versus robotic inguinal hernia repair.

Results: A total of 420 patients were matched, with 140 in each group. There was no difference in age, body mass index, or smoking status between groups. Open inguinal hernia repair had significantly more comorbidities (2.8 vs 2.6 vs 2.3; P = .035), including higher rates of chronic obstructive pulmonary disease (5.0% vs 0.0% vs 1.4%; P = .013), cirrhosis (4.3% vs 0.0% vs 1.4%; P = .032), and congestive heart failure (5.0% vs 0.7% vs 0.7%; P = .023). American Society of Anesthesiologists scores differed significantly between groups (stage III and IV: 35.0% vs 20.0% vs 28.6%; P = .004). Open inguinal hernia repair were more often recurrent (48.6% vs 27.9% vs 17.1%; P < .001). The mean operative time was significantly different between groups (88.0 vs 86.1 vs 101.4 minutes; P < .001). There was no difference in wound infection (0.7% vs 0.0% vs 0.0%; P > .99), hematoma (1.4% vs 0.7% vs 1.4%; P > .99), seroma requiring intervention (2.9% vs 0.7% vs 0.7%; P = .377), or readmission (0.0% vs 2.1% vs 1.4%; P = .378). The rate of prolonged discomfort, requiring more than 2 pain medication refills, was similar between groups (2.9% vs 2.1% vs 2.1%; P = .903). Robotic inguinal hernia repair was significantly more expensive than laparoscopic inguinal hernia repair and open inguinal hernia repair ($10,005 ± $7,050 vs $17,155 ± $6,702 vs $31,173 ± $8,474; P < .001). With follow-up of at least 2.4 years in each group (3.6 vs 4.8 vs 2.4 years; P < .001), the recurrence rate was comparable (3.6% vs 0.7% vs 0.7%; P = .226).

Conclusions: All techniques are safe and effective in qualified hands. Open inguinal hernia repair was more commonly used in comorbid patients and recurrent hernias, but the techniques had comparable rates of wound complications, postoperative prolonged discomfort, and recurrence.

Background: Large language models have successfully navigated simulated medical board examination questions. However, whether and how language models can be used in surgical education is less understood. Our study evaluates the efficacy of domain-specific large language models in curating study materials for surgical board style questions.

Methods: We developed EAST-GPT and ACS-GPT, custom large language models with domain-specific knowledge from published guidelines from the Eastern Association of the Surgery of Trauma and the American College of Surgeons Trauma Quality Programs. EAST-GPT, ACS-GPT, and an untrained GPT-4 performance were assessed trauma-related questions from Surgical Education and Self-Assessment Program (18th edition). Large language models were asked to choose answers and provide answer rationales. Rationales were assessed against an educational framework with 5 domains: accuracy, relevance, comprehensiveness, evidence-base, and clarity.

Results: Ninety guidelines trained EAST-GPT and 10 trained ACS-GPT. All large language models were tested on 62 trauma questions. EAST-GPT correctly answered 76%, whereas ACS-GPT answered 68% correctly. Both models outperformed ChatGPT-4 (P < .05), which answered 45% correctly. For reasoning, EAST-GPT achieved the gratest mean scores across all 5 educational framework metrics. ACS-GPT scored lower than ChatGPT-4 in comprehensiveness and evidence-base; however, these differences were not statistically significant.

Conclusion: Our study presents a novel methodology in identifying test-preparation resources by training a large language model to answer board-style multiple choice questions. Both trained models outperformed ChatGPT-4, demonstrating its answers were accurate, relevant, and evidence-based. Potential implications of such AI integration into surgical education must be explored.

Objective: Subtotal cholecystectomy provides a safe, bail-out alternative for difficult gallbladders. However, long-term outcomes comparing fenestrating and reconstituting subtotal cholecystectomy subtypes remain underexplored.

Methods: This retrospective cohort included patients who underwent subtotal cholecystectomy between 2010 and 2020 within a single hospital system. Subtotal cholecystectomy was identified by parsing operative notes for keywords. Demographic and clinical variables were collected by manual review. Patient-reported outcomes were collected via phone using an abbreviated Gastrointestinal Quality-of-Life Index.

Results: We identified 218 subtotal cholecystectomies, with 113 (51.8%) fenestrating subtotal cholecystectomy and 105 (48.2%) reconstituting subtotal cholecystectomy and a median follow-up of 63 months (interquartile range 27-106). Rates of bile duct injury (0.9% vs 1.0%; P > .99), bile leak (10.6% vs 9.5%; P > .99), and 30-day readmission (7.6% vs 8.0%; P > .99) did not differ between fenestrating and reconstituting subtotal cholecystectomy. For fenestrating subtotal cholecystectomy, the postoperative bile leak rate decreased fourfold when cystic duct closure was achieved (6.0% vs 24.1%; P = .012). Subtotal cholecystectomies completed laparoscopically had fewer postoperative bile leaks (2.9% vs 16.8%; P = .001), fewer wound complications (4.8% vs 13.3%; P = .035), and decreased length of stay (7.00 ± 9.07 vs 10.15 ± 13.50 days; P < .001) compared with open operations. The survey response rate was 38.9% (n = 51/131); 47 patients (92.2%) did not report recurrent biliary pain or postprandial nausea or vomiting, but 19 patients (37.2%) reported dietary restriction. Long-term completion cholecystectomy rate was 0.9%.

Conclusion: Given no notable difference in postoperative or quality of life outcomes between subtotal cholecystectomy subtypes, consideration of technique depends on intraoperative conditions. Cystic duct closure during fenestrating subtotal cholecystectomy and laparoscopic completion of subtotal cholecystectomy are associated with improved postoperative outcomes.

Background: Lorazepam recently has been reported to alter the tumor microenvironment of pancreatic adenocarcinoma in a murine model. We sought to evaluate whether the use of lorazepam was associated with worse outcomes among patients with pancreatic adenocarcinoma.

Methods: Medicare beneficiaries diagnosed with stage I-IV pancreatic adenocarcinoma between 2013 and 2019 were identified from the Surveillance, Epidemiology and End Results-Medicare database. The association of lorazepam prescription relative to overall survival and recurrence-free survival was examined.

Results: Among 2,810 patients with stage I-III and 10,181 patients with stage IV pancreatic adenocarcinoma, a total of 133 (4.7%) and 444 individuals (4.4%) had a lorazepam prescription before disease diagnosis, respectively. Although the overall lorazepam group had comparable 5-year overall survival (15.0% vs 14.2%, P = .20) and recurrence-free survival (12.7% vs 10.9%, P = .42) with the no-lorazepam group after pancreatic adenocarcinoma resection, individuals with long-term lorazepam prescription (>30 days) had worse 5-year overall survival (9.0% vs 21.0%, P = .02) and recurrence-free survival (6.4% vs 17.1%, P = .009) compared with short-term lorazepam users (≤30 days). Similarly, among patients with metastatic pancreatic adenocarcinoma, individuals with a long-term lorazepam prescription had worse 1-year overall survival (9.7% vs 15.9%, P = .02) compared with patients who had short-term lorazepam prescriptions. On multivariable analysis, long-term lorazepam prescription was independently associated with overall survival among patients with resectable (hazard ratio, 1.82; 95% confidence interval, 1.22-2.74) and metastatic pancreatic adenocarcinoma (hazard ratio, 1.24; 95% confidence interval, 1.02-1.51).

Conclusion: Long-term lorazepam prescription was associated with worse long-term outcomes among patients who underwent resection for pancreatic adenocarcinoma and patients with metastatic pancreatic adenocarcinoma. These data support the need for further large scale studies to confirm a potential harmful effect of lorazepam among patients with pancreatic adenocarcinoma.