Surgery最新文献

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: Postoperative hypocalcemia is a common complication of thyroid and parathyroid surgery. Patients with prior gastric bypass face increased risk of postoperative hypocalcemia, but the impact of other malabsorptive conditions is not well understood. In this study, we evaluated the relationship between multiple medical and surgical malabsorptive states and hypocalcemia after thyroid and parathyroid surgery.

Methods: We performed a retrospective cohort study of patients who underwent total thyroidectomy and/or parathyroidectomy in Optum's deidentified Clinformatics Data Mart Database (2004-2022). Patients were categorized as having surgical (foregut/midgut: gastrectomy, intestinal bypass, enterectomy, enterostomy, pancreatectomy, or hindgut: colectomy/colostomy) or medical (Crohn or Celiac disease) malabsorptive conditions. The primary outcomes were early (<7 days) and late (7-365 days) postoperative hypocalcemia. Logistic regression was performed to determine the associations between malabsorptive conditions and outcomes.

Results: Of 25,400 patients (56.9% total thyroidectomy, 40.8% parathyroidectomy, and 2.4% both procedures), 4.0% had a pre-existing malabsorptive condition. Early postoperative hypocalcemia occurred in 8.8% of patients, and late hypocalcemia in 18.3%. Thyroidectomy was associated with a greater likelihood of hypocalcemia than parathyroidectomy (odds ratio: 1.22; P < .001). Pancreatectomy was associated with twice the adjusted odds of postoperative hypocalcemia (odds ratio: 2.27; P = .031) across both procedures. Patients with prior foregut/midgut surgery were at higher risk after total thyroidectomy (odds ratio: 1.65, P = .002). This association was significant in late (odds ratio: 1.82, P < .001) rather than early hypocalcemia (odds ratio: 1.33, P = .175). Hindgut surgery and medical malabsorption did not demonstrate such associations.

Conclusion: Prior foregut and midgut resections may predispose patients to postoperative hypocalcemia, particularly in patients undergoing total thyroidectomy.

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.

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: The tall cell variant of papillary thyroid cancer generally has a worse prognosis compared with the classical variant. Thyroid GuidePx is a genomic classifier capable of classifying papillary thyroid cancer into 3 molecular subtypes using fine-needle aspirate. Type 1 and 2 have low recurrence rates, particularly in early tumors (1-4 cm and N0). Type 3 is characterized by aggressive biology and high recurrence rates regardless of size and lymph node status. The study examines the interaction of tall cell variant histology with Thyroid GuidePx risk stratification.

Methods: Gene expression data from 736 patients (The Cancer Genome Atlas, Canada, and South Korea), were submitted to the Thyroid GuidePx classifier. Results across the 3 molecular subtypes were further dichotomized into "early" papillary thyroid cancer (tumor size 1-4 cm and N0) (n = 369; 51%) or "advanced" papillary thyroid cancer (n = 359; 49%). Structural recurrence was the primary outcome measure in our analysis. Transcriptomic and genomic analysis was conducted to explore what biological differences could account for clinical differences between tall cell variant and non- tall cell variants.

Results: Thyroid GuidePx identified 369 early papillary thyroid cancers: 129 (35%) type 1, 168 (45.5%) type 2, and 72 (19.5%) type 3. The recurrence rates for early type 1, type 2, and type 3 papillary thyroid cancers were 3.9%, 1.9%, and 19.4%, respectively. There were no type 1 tall cell variants. In type 2 papillary thyroid cancers, the incidence of tall cell variant was greater in advanced than early papillary thyroid cancers (10.2% vs 4.2%, P = .04). Notably, none of the 7 early type 2 tall cell variants recurred. In type 3 papillary thyroid cancers, the prevalence of tall cell variants was similar in early and advanced tumors (10% vs 9%, NS). When compared with non-tall cell variants, early type 3 tall cell variants trended toward greater recurrence (28.6% vs 18.5%, not significant) whereas advanced type 3 tall cell variants had a significantly greater recurrence rate (50% vs 28.6%, P = .01). Biologically, type 3 tall cell variants had had a pronounced enrichment in cell proliferation, epithelial-mesenchymal transition, invasion, and inflammation.

Conclusion: Thyroid GuidePx reliably identifies a low-risk subgroup (early type 1 and early type 2 papillary thyroid cancers) for which conservative procedures would be appropriate. Tall cell variants in this subgroup are uncommon (1.2%), and none of the tall cell variants in this subgroup recurred. Type 3 papillary thyroid cancers have greater recurrence rates in both early and advanced papillary thyroid cancers. Tall cell variant appears to further increase recurrence in this subgroup.

Background: Specific risk factors for suicide in patients with colorectal cancer have not been well established. Therefore, we aimed to assess factors associated with increased risk of suicide among patients with colorectal cancer.

Methods: This was a retrospective cohort analysis of consecutive patients with colorectal cancer. Patients who survived were compared with patients for whom suicide was registered as their cause of death. Data were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results Research Database 2000-2020. Primary outcome was risk factors for suicide.

Results: In total, 309,561 patients were included in the analysis; 160,095 (51.7%) were male. Suicide was the cause of death in 1,052 (0.34%). The suicide rate among patients with colorectal cancer decreased over time from 1% between 2000 and 2010 to 0.05% between 2011 and 2020 (P < .001). Male sex (odds ratio, 6.44; P < .001), non-Hispanic ethnicity (odds ratio, 2.84; P = .014), household income between $50,000 and $74,999 (odds ratio, 1.79; P = .008) or <$50,000 (odds ratio, 1.84; P = .030), and metastatic disease (odds ratio, 2.89; P = .001) were independent risk factors for suicide. Colorectal cancer diagnosis in the second half of the study (2011-2020) was associated with lower risk of suicide compared with the first half (odds ratio, 0.338; P < .001).

Conclusion: Among patients with colorectal cancer, male patients of non-Hispanic ethnicity and income <$75,000 USD who presented with metastatic disease were at increased risk of suicide. This trend decreased in the last decade, especially compared with the suicide rate among all patients with cancer. On the basis of these findings, we recommend targeted screening of this group of patients with colorectal cancer for suicidality as part of routine oncologic care.