Surgery最新文献

Background: Ischemia is a complication that can lead to failure of skin flap reconstruction. Thioredoxin-1, a redox protein, enhances recovery in ischemic models of myocardial infarction, peripheral vascular disease, and full-thickness wounds. This study examined the survival effect of thioredoxin-1 overexpression on an ischemic skin flap.

Methods: A 3-sided 1.25 × 2.25 cm dorsal ischemic skin flap was made in B6 wild-type mice and transgenic mice overexpressing thioredoxin-1 (Trx-1^Tg/+). A silicone sheet was placed under the flap to promote healing from the proximal end of the skin flap, creating an ischemic gradient. Images were taken on postoperative days 4, 8, and 12 to assess tissue viability and perfusion. Mice were killed on postoperative day 12, and skin flaps were collected and processed for histopathologic and immunohistochemical analysis. Immunofluorescence analysis was performed to determine the mechanism of wound healing mediated by thioredoxin-1.

Results: Skin flap survivability was significantly improved in Trx-1^Tg/+ mice compared with wild-type mice on postoperative days 4, 8, and 12. Doppler analysis showed enhanced perfusion of the distal skin flaps of Trx-1^Tg/+ mice compared with wild-type mice. PHD1 and TXNIP expression by immunofluorescence analysis was decreased, whereas thioredoxin-1, vascular endothelial growth factor, Bcl-2, HO-1, and HIF1α expression was increased in the Trx-1^Tg/+ mice compared with wild-type mice. Increased vessel density was observed in the skin flap by CD31 staining in Trx-1^Tg/+ mice compared with wild-type mice.

Conclusion: Overexpression of thioredoxin-1 improves skin flap survivability by promoting angiogenesis, reducing oxidative stress, and preventing apoptosis by inhibiting prolyl hydroxylase 1. In the future, thioredoxin-1 treatment may be used in reconstructive procedures such as local tissue rearrangement and split- or full-thickness skin grafts.

Putting together a successful research grant application can be an arduous, confusing, and lengthy process, particularly with recent changes in the federal funding landscape. Being selected to receive the funding is cause for celebration and a major academic milestone. At the same time, the hard work of executing the proposed project and research financial management begins. Here, we outline considerations for successful project execution and pitfalls to avoid.

Background: Metabolic and bariatric surgery yields substantial weight loss while maintaining a favorable safety profile. The effects of previous abdominal surgery on metabolic and bariatric surgery outcomes remain underexplored.

Methods: This single-center retrospective cohort study examined patients who underwent metabolic and bariatric surgery between January 2008 and December 2023 at a specialized tertiary center. Patients were stratified into 3 groups: (1) no previous abdominal surgery, (2) major previous abdominal surgery, or (3) minor previous abdominal surgery. Specific surgical variables including number and location of previous abdominal surgery were examined on subgroup analysis. Data collected over 5 years included baseline and intraoperative characteristics and postoperative outcomes. Statistical tests included χ², Kruskal-Wallis, analysis of variance, post hoc analyses, and multivariate regression.

Results: Of 3,202 patients, 1,141 (35.6%) had no previous abdominal surgery, 1,629 (50.9%) had minor surgery, and 432 (13.5%) had major surgery. Patients with major previous abdominal surgeries had a higher rate of lysis of adhesions (P < .001) and conversion to open (P = .04). Sleeve gastrectomy was also significantly prolonged in patients with major previous abdominal surgeries (P < .001). Postoperatively, patients with previous abdominal surgeries had higher rates of early strictures (P = .04), urinary complications (P = .002), small-bowel obstructions (P < .001), and marginal ulcers (P = .01). Patients with previous abdominal surgeries also underwent more reoperations (P < .001), most commonly for small-bowel obstructions. Anastomotic metabolic and bariatric surgery and number of previous abdominal surgeries were independent predictors of multiple outcomes. Weight loss outcomes were comparable across the cohort.

Conclusion: A detailed surgical history is essential in candidates for metabolic and bariatric surgery. Recognizing intraoperative complexity and anticipating complications can guide tailored approaches to improve outcomes in patients with previous abdominal surgeries, through informing procedure selection and guiding preoperative patient counseling regarding expected postoperative outcomes and the intraoperative potential for conversion to open, if significant intraoperative difficulty is encountered.

Background: Roux-en-Y gastric bypass has emerged as an effective treatment for obesity. The biliopancreatic limb is a critical determinant of surgical efficacy. Existing research predominantly focuses on extreme lengths, whereas the impact of a medium-length biliopancreatic limb (75-125 cm) remains unclear. This study explored the effect of a medium-length biliopancreatic limb on weight loss efficacy at 1-year post-Roux-en-Y gastric bypass.

Methods: We collected 587 patients undergoing Roux-en-Y gastric bypass at our center between September 2015 and September 2023. Patients were stratified into a medium-length biliopancreatic limb group (biliopancreatic limb between ≥75 cm and ≤125 cm) and a short-length biliopancreatic limb group (biliopancreatic limb ≤50 cm). Propensity score matching was performed at a 1:1 ratio. The primary end points were percentage of total weight loss and percentage of excess weight loss at 1 year postoperatively. Multivariable logistic regression analysis identified independent predictors of weight loss efficacy.

Results: In the propensity score matching cohort, the medium-length biliopancreatic limb group exhibited significantly superior weight loss outcomes compared with the short-length biliopancreatic limb group at 1 year: percentage of total weight loss (31.76% vs 27.71%, P < .001) and percentage of excess weight loss (76.28% vs 67.61%, P = .006). Multivariable analysis identified higher preoperative body mass index (odds ratio = 1.10, 95% confidence interval 1.02-1.19, P = .017), longer biliopancreatic limb (odds ratio = 2.27, 95% confidence interval 1.42-3.66, P < .001), and absence of hyperlipidemia (odds ratio = 0.20, 95% confidence interval 0.09-0.39, P < .001) as independent predictors of effective postoperative weight loss.

Conclusion: Use of a medium-length biliopancreatic limb in Roux-en-Y gastric bypass is associated with significantly enhanced weight loss at 1 year postoperatively. Biliopancreatic limb length, preoperative body mass index, and hyperlipidemia status are significant predictors for Roux-en-Y gastric bypass surgical efficacy.

Background: Device usage in operating rooms consumes significant electricity, resulting in high hospital expenditure and emissions. Prior studies have evaluated institutional policy approaches toward this problem, but there is limited analysis of individual devices' energy consumption in US operating rooms. This study's objective was to quantify the energy expenditure of equipment commonly used in the operating room, serving as a foundation for future sustainability efforts.

Methods: The 29 most commonly identified operating room devices at a tertiary academic medical center were categorized as structural (built into operating rooms) or procedural (brought in for procedures). Each device's electrical use was quantified in kilowatt-hours using standard technical ratings and estimated use times. Cost calculations using 2024 electrical prices were scaled to estimate those in average (7 operating rooms, as per literature) and large (69 operating rooms, as per literature) size hospitals.

Results: An average size hospital spends $19,207 annually on operating room equipment electricity; larger institutions spend around $189,327 annually. Stand-alone suction devices, x-ray generators of C-arm x-ray machines, and heated air devices were the highest energy consumers. Procedural devices accounted for 64% of total annual electrical costs.

Conclusions: Annual electricity costs for operating room equipment at a large hospital equal that of 5 school buildings; an average size hospital equates to a warehouse. Stand-alone suction devices at a large hospital draws the equivalent as 5,120 electrical cars; even turning them off for 1 hour per day can save $4,650.56 per year. Incremental reforms in operating room equipment utilization can substantially reduce hospital expenses and carbon footprint.

Background: Given the significant relationship between the number of metastatic lymph nodes and primary tumor location, which is overlooked in the current pathologic node staging system, this study seeks to optimize pathologic node staging by incorporating this critical factor.

Methods: This study analyzed patients with primary gastric cancer who underwent radical gastrectomy, comprising 4,926 from a local cohort, 623 from a domestic cohort, and 4,243 from a public database. Patients were stratified by tumor location: upper, middle, or lower gastric subgroups. Restricted cubic spline plots evaluated nonlinear relationships between the number of metastatic lymph nodes and mortality across locations. The Cox proportional hazards model was used to assess the effects of clinical factors on patient prognosis. Univariate analyses assessed metastatic lymph nodes and tumor location effects on overall survival.

Results: Survival disparities persist by tumor location within identical pathologic node stages. Patients with upper-third gastric cancer show significantly worse survival than middle- or lower-third groups across pathologic node stages (P < .001 for pathologic node 0-3; P < .05 for pathologic node 4), whereas survival for patients with middle versus lower gastric cancer is similar (P > .05). Mortality risk progressively increases with more metastatic lymph nodes regardless of location. Critically, patients in the upper gastric cancer group exhibit a markedly accelerated mortality risk escalation than middle and lower groups (P for overall < .001, P for nonlinear < .001), a trend consistent across pathologic tumor stages.

Conclusion: This study demonstrated that patients in the upper gastric cancer group have significantly worse survival than those in the middle and lower groups with identical metastatic lymph nodes. Leveraging tumor location and metastatic lymph nodes, we established a novel pathologic node staging system that outperformed the conventional pathologic tumor-node-metastasis staging in prognostic discrimination.

Background: Nonoperative management with antibiotics is an alternative to appendectomy for patients with uncomplicated appendicitis. Nonoperative management may reduce initial costs and recovery time, but concerns about recurrence and delayed surgery raise questions about its long-term value. We compared clinical outcomes and determined the cost-effectiveness of appendectomy and nonoperative management using a national data set.

Methods: We selected patients with uncomplicated appendicitis from the Nationwide Readmissions Database (2016-2021). Patients were stratified by appendectomy or nonoperative management at index admission. Outcomes included 6-month readmissions, in-hospital mortality, discharge disposition, and length of stay. Costs included index admission, readmissions, and total expenditures. Cost-effectiveness was assessed as the incremental cost-effectiveness ratio, defined as incremental cost per readmission avoided. Probabilistic sensitivity analysis and cost-effectiveness acceptability curves tested robustness.

Results: Among 83,533 patients, 68,908 (82.5%) had appendectomy and 14,625 (17.5%) nonoperative management. Readmissions were higher in nonoperative management (6.3% vs 0.1%). Nonoperative management patients had longer index stays (median 4 vs 2 days), less routine discharge (85.2% vs 95.0%), and greater need for postdischarge care. In-hospital mortality was rare but higher with nonoperative management (0.2% vs 0.1%). Total 6-month costs were modestly lower with nonoperative management ($11,558 vs $12,648), but appendectomy nearly eliminated readmissions. The incremental cost-effectiveness ratio was $17,615 per readmission avoided, with robust sensitivity analyses.

Conclusions: Appendectomy provided definitive cure with near-zero readmissions and an acceptable incremental cost. Nonoperative management offered initial savings, but higher recurrence limited its value. Appendectomy was clinically superior and cost-effective within 6 months, whereas nonoperative management may be reasonable only in select patients or settings.