Surgery最新文献

Background: For patients with human epidermal growth factor receptor 2-positive breast cancer, an upfront surgery or neoadjuvant systemic therapy approach can influence the need for axillary lymph node dissection depending on pathologic nodal status. This study aimed to evaluate the impact of an upfront surgery versus neoadjuvant systemic therapy approach in women with cT1-2 human epidermal growth factor receptor 2-positive breast cancer on pathologic nodal status and odds of axillary lymph node dissection.

Methods: This retrospective study used the National Cancer Database and included female patients aged ≥18 years, diagnosed between 2016 and 2021, with cT1-2 N0 M0 human epidermal growth factor receptor 2-positive breast cancer. Demographic, clinicopathologic, and treatment data were collected. Analyses included analysis of variance, Kruskal-Wallis, χ², Fisher exact tests, and multivariable logistic regression analysis.

Results: A total of 62,927 women met inclusion criteria: 66.6% (n = 39,024) underwent upfront surgery, and 33.4% (n = 19,562) received neoadjuvant systemic therapy. The neoadjuvant systemic therapy cohort was younger (mean age: 53.8 vs 59.9 years, P < .001), had fewer comorbidities (86.9% vs 82.7% with a Charlson-Deyo score of 0, P < .001), and more frequently had cT2 tumors (71.7% vs 21.7%, P < .001). On multivariable analysis, patients with upfront surgery were more likely to be pN+ (1-3 nodes: 14.7% vs 6.8%, odds ratio: 3.19, 95% confidence interval: 2.96-3.45 and ≥4 nodes: 2.0% vs 0.7%, odds ratio: 5.48, 95% confidence interval: 4.43-6.80); however, there was no difference in the odds of axillary lymph node dissection (odds ratio: 0.96, 95% confidence interval: 0.86-1.08).

Conclusion: Patients who underwent upfront surgery had a greater likelihood of being pN+; however, there was no difference in the likelihood of axillary lymph node dissection. Therefore, neoadjuvant systemic therapy use should be based on current systemic therapy guidelines and patient-centered shared multidisciplinary decision-making.

Background: At our institution, an extended venous thromboembolism prophylaxis protocol was initiated in which all patients undergoing bariatric surgery received a minimum of 2 weeks of enoxaparin prophylaxis postoperatively. The objective of this study was to evaluate the safety of this extended venous thromboembolism prophylaxis protocol.

Methods: Patients who underwent primary bariatric surgery between 2020 and 2024 were identified using our institution's bariatric surgery database. Venous thromboembolism rates, bleeding complications, and emergency department visits within 30 days of surgery before and after protocol implementation were compared. For outcomes that had statistically significant differences before and after protocol implementation, multivariable logistic regression analysis was used to identify associated factors.

Results: We included 327 patients before and 573 patients after protocol implementation. There were no differences in rates of venous thromboembolism (0.9% vs 0.2%, P = .14), bleeding complications (1.8% vs 1.9%, P = .93), and emergency department visits (5.2% vs 7.5%, P = .18) before and after protocol implementation. When stratified by surgery type, there were no differences in rates of venous thromboembolism or bleeding complications. Patients who underwent gastric bypass had higher rates of emergency department visits after protocol implementation (11.5% vs 4.3%, P = .02). On multivariable analysis, implementation of venous thromboembolism prophylaxis protocol was not associated with increased odds of having an emergency department visit.

Conclusions: Use of extended venous thromboembolism prophylaxis for all patients undergoing bariatric surgery is safe, with no differences in bleeding complications or emergency department visits. Future studies will aim to assess the impact that extended prophylaxis has on venous thromboembolism rates.

Background: Patients who undergo thyroid lobectomy are routinely observed for 4 hours in the postanesthesia care unit and are discharged if there is no evidence of neck hematoma. The aim of this study was to determine the outcome of routine discharge after a 4-hour observation following thyroid lobectomy.

Methods: A retrospective review of consecutive patients who underwent thyroid lobectomy from 2008 to 2023 was completed. Patients were evaluated for neck hematoma requiring urgent evacuation, emergency department visits, and hospital readmission. Univariate analysis and multivariate regression analysis were used to analyze potential factors associated with an unsuccessful discharge after 4 hours of observation.

Results: A total of 494 patients underwent thyroid lobectomy; 330 (67%) were discharged after a 4-hour postanesthesia care unit stay (group I), and 164 (33%) were observed overnight (group II). Neck hematoma occurred in 2 (0.4%) patients before they were both discharged. Thirty-seven (7%) patients presented to the emergency department, 23 (7%) from group I and 14 (9%) from group II (P = .53). Six (1%) patients were readmitted, 3 (1%) from groups I and 3 (2%) from group II (P = .38). Factors independently associated with an overnight stay and their odds ratio and confidence interval were dependent status (10.76, 2.18-53.07), American Society of Anesthesiologists class ≥3 (5.32, 2.04-13.86), increased blood loss (4.00, 1.04-2.45), age >50 years (2.68, 1.38-5.20 years), and substernal extension (1.60, 1.04-2.45).

Conclusion: Discharge to home after 4 hours of observation is safe after thyroid lobectomy. However, patients who are older, dependent, have an American Society of Anesthesiologists score ≥3, or undergo a more difficult operation should be prepared for overnight observation.

Background: Endoscopic peroral pyloromyotomy for medically refractory gastroparesis requires advanced endoscopic skill. This study describes a learning framework using combined in-person and video-based proctoring.

Methods: Retrospective data were collected for consecutive patients who underwent peroral pyloromyotomy by a single surgeon trained through a structured program: 4 case observations, 4 animal models, 9 in-person proctoring, and 8 video-based proctoring. Patient demographics, Gastroparesis Cardinal Symptom Index score, gastric emptying scintigraphy, and procedural details were collected. Data were analyzed using a 2-tailed, unpaired t test with unequal variance to compare the safety and effectiveness of video-based to the traditional, in-person proctoring. Short-term clinical outcomes, Gastroparesis Cardinal Symptom Index, and gastric emptying scintigraphy were measured.

Results: Peroral pyloromyotomy was performed on 17 patients (12 female; mean age, 53.8 years). Etiologies included diabetic (n = 6, 35.3%), idiopathic (n = 9, 52.9%), and postsurgical (n = 2, 11.8%). The median procedure time was 42.7 minutes (mean, 45.3 minutes; range, 29-65 minutes). Throughout both proctoring methods, the surgeon demonstrated safe, effective performance without complications or reintervention. There were no significant differences between in-person proctoring and video-based proctoring in total operative duration (P > .227). Patients exhibited expected clinical improvements with a Gastroparesis Cardinal Symptom Index score reduction of 2.38 units (70.6% reduction, P < .001).

Conclusion: Through the integration of a novel learning framework, this study showed minimal time and outcome differences between in-person and video-based proctoring. Steps requiring cognitive training unique to endoscopic surgery (mucosotomy and tunneling) and standard myotomy had no statistical difference. This study supports an integrated in-person and video-proctoring framework as a safe and effective method to introduce advanced endoscopic surgery.