Surgery最新文献

The Supreme Court's ruling against the use of race as a consideration for higher education admissions programs has had a profound impact on diversity, equity, and inclusion efforts at many of our academic institutions. Many of us who understand the value of diversity in business and health care and who value equity are now confronted with a changing political landscape. Given these challenges and changes with respect to diversity, equity, and inclusion policies, it will be important for the surgical community to better codify the aspects of diversity that are beneficial and not specific to race, such as ability to overcome adversity, or the richness of the lived experience. It will become increasingly important to engage legislative bodies and implement institutional strategies to ensure the best outcomes for our patients and support an increasingly diverse surgical workforce.

Background: Patients diagnosed with pathologic T1N0 esophageal squamous cell carcinoma and treated with surgery alone have a good prognosis and are generally followed up without adjuvant therapy. However, recurrence has been observed in this patient group. Therefore, this study aimed to identify recurrence and prognostic factors in patients with pathologic T1N0 esophageal squamous cell carcinoma who were treated with surgery alone.

Methods: Of the 532 patients who underwent esophagectomy with R0 resection at Hiroshima University Hospital between August 2003 and November 2018, 124 who underwent only esophagectomy and had pathological T1N0 esophageal squamous cell carcinoma were included in the study. Recurrence and prognostic factors were analyzed and details of recurrence were evaluated.

Results: The 5-year recurrence-free survival and 5-year overall survival rates were 84.7% and 87.2%, respectively. Recurrence was observed in 12 (9.7%) patients. Univariate and multivariate analyses showed that the histologic type (poorly differentiated compared with others) and lymphatic and/or vascular invasion (positive compared with negative) were statistically significant for recurrence-free survival. Kaplan-Meier curves for recurrence-free survival and overall survival showed that prognosis was significantly stratified according to these factors. All patients with poorly differentiated and positive lymphatic and/or vascular invasion experienced recurrence and recurrence pattern is all distant metastases.

Conclusions: Poorly differentiated and lymphatic and/or vascular invasion are important recurrence and prognostic predictors in pathologic T1N0 esophageal squamous cell carcinoma treated with surgery alone. Patients with these prognostic factors experienced increased recurrence rates, often with distant metastasis. Therefore, adjuvant therapy may be beneficial for such patients and follow-ups should be performed at closer intervals.

Background: Insecure surgical knots can cause surgical complications ranging from wound dehiscence to massive exsanguination and death. Most surgeons tie half-hitch knots, of which some configurations are prone to slippage. We aim to characterize the securities of different half-hitch knot configurations.

Methods: A literature search was conducted using PubMed and Embase for studies in which comparisons of knot security were made between different half-hitch knot configurations. Two reviewers screened and selected articles.

Results: From 2,204 abstracts identified, 14 were selected for inclusion. In all 8 of the studies in which there was a direct comparison between knots tied with opposite throws on the same post, which are tied when greater tension is applied to the same strand end, and knots tied with any throws on alternating posts which are tied when the strand on which greater tension is applied switches between the strand ends, there was at least one comparison of configurations in which any throws on alternating posts knots were more secure than opposite throws on the same post knots. There was also less variability in the securities of any throws on alternating posts knots than opposite throws on the same post knots. Knots tied with identical throws on the same post were less secure than opposite throws on the same post and any throws on alternating posts.

Conclusions: The securities of half-hitch knots exist on a spectrum. any throws on alternating posts knots were consistently the most secure independent of whether throws were opposite or identical, and identical throws on the same post knots were less secure than opposite throws on the same post and any throws on alternating posts. Surgeons should consider any throws on alternating posts knots as opposed to the more commonly utilized opposite throws on the same post knots.

Background: Few studies compared laparoscopic and open pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy.

Methods: Retrospective cohort of patients who underwent laparoscopic or open pancreatoduodenectomy for resectable or borderline resectable pancreatic ductal adenocarcinoma after chemoradiotherapy between 2012 and 2023 was analyzed. Open pancreatoduodenectomy patients could theoretically benefit from the laparoscopic approach. We used a 1:2 (laparoscopic-to-open pancreatoduodenectomy) propensity score matching analysis stratified on age, gender, and body mass index.

Results: We included 128 patients (33 laparoscopic and 95 open pancreatoduodenectomy), and after propensity score matching, 33 laparoscopic pancreatoduodenectomy and 66 open pancreatoduodenectomy were compared. There was no difference in demographic data except for lower tobacco use in laparoscopic pancreatoduodenectomy group (9% vs 30%, P = .023) with similar clinical presentation. Laparoscopic pancreatoduodenectomy compared to open pancreatoduodenectomy showed a longer median operative duration (380 vs 255 minutes, P < .001), shorter median length of resected vein (15 vs 23 mm, P = .01), longer median venous clamping time (29 vs 15 minutes, P = .005), similar median blood loss (300 vs 300 mL, P = .223), similar rate of hard pancreas (97% vs 85%, P = .094), and a larger median size of Wirsung duct (5 vs 4 mm, P = .02). Postoperative outcomes showed similar 90-day mortality rates (3% vs 3%, P > .99), Clavien-Dindo III-IV complications (6% vs 14%, P = .158), median lengths of hospital stay (12 vs 13 days, P = .409), and readmission rates (9% vs 18%, P = .366). Pathologic data showed similar R0 resection rates (88% vs 82%, P = .568). With a similar rate of adjuvant chemotherapy (P = .324) and shorter median follow-up with laparoscopic pancreatoduodenectomy (18 vs 34 months, P = .004), 3-year overall (P = .768) and disease-free (P = .839) survival rates were similar.

Conclusion: In selected patients, laparoscopic pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy appears to be safe and feasible when performed in experienced centers.

Background: Observational studies reported that nontrauma/low-level trauma centers less frequently transferred insured injured patients to high-level centers. The dependent coverage provision of the Affordable Care Act was a natural experiment expanding insurance eligibility in 2010 by allowing young adults to remain on their parents' insurance until age 26 years old. The objective was to determine whether expanded insurance eligibility reduced interhospital transfers.

Methods: This observational, retrospective cohort study of the 2007-2013 National Trauma Data Bank used a difference-in-differences design to compare the change in interhospital transfer rates before and after dependent coverage provision implementation between dependent coverage provision-eligible (aged 19-25 years) and dependent coverage provision-ineligible (aged 27-34 years) injured patients. The exposure of interest was the dependent coverage provision. The main outcome was yearly rate of interhospital transfer. Least-squares linear regression modeled interhospital transfer rates and quantified association with the age-based dependent coverage provision eligibility binary interaction term in the pre-dependent coverage provision versus post-dependent coverage provision time periods.

Results: A total of 535,036 dependent coverage provision-eligible and 431,462 dependent coverage provision-ineligible patients were identified. The median Injury Severity Score was 6.0 (interquartile range = 4.0-13.0) for both cohorts. Private insurance rates increased from 28.1% to 38.7% among the dependent coverage provision-eligible cohort and from 27.0% to 30.5% among the older cohort between the pre-dependent coverage provision to post-dependent coverage provision time period. The average yearly interhospital transfer rate was not significantly different between the cohorts in the pre-dependent coverage provision (2.3% lower among dependent coverage provision-eligible) and the post-dependent coverage provision time periods (2.9% lower among dependent coverage provision-eligible). Difference-in-differences analysis revealed nonsignificant 14.6 fewer transfers/10,000 patients (95% confidence interval = 33.7 fewer to 4.4 more transfers/10,000 patients).

Conclusion: Policies expanding insurance eligibility do not reduce interhospital transfers in a mature trauma system.

Background: Expedited discharge after surgery with construction of an ostomy may leave patients less prepared for home self-care, leading to increased hospital readmissions. We evaluated whether readmission rates were greater for patients with an expedited discharge (1-2 days) compared with nonexpedited discharge (3-5 days) after ostomy construction.

Methods: A retrospective analysis of a prospective database of patients undergoing ostomy construction was performed using the American College of Surgeons National Safety and Quality Improvement Project data between years 2019 and 2020. Inclusion criteria included age >18 years, discharge to home, and postoperative length of stay 1-5 days. Patients were grouped into either expedited or nonexpedited discharge by postoperative length of stay. The primary outcome was 30-day postoperative readmission. Analysis included multivariable logistic regression models and partial effects analysis.

Results: Of 13,628 patients included, 14.5% (n = 1,980) had an expedited discharge. Rates of 30-day readmission were 13.6% in the expedited group and 14.2% in the nonexpedited group (P = .51). Adjusting for patient and procedure factors, there was no significant difference in readmission rates between expedited and nonexpedited discharge groups (odds ratio, 1.08; 95% confidence interval, 0.94-1.25). In stratified analysis, there was no difference in readmission by discharge timing for any procedure type. The top 3 contributors to having an expedited discharge, as assessed by partial effects analysis, were procedure type, elective surgery, and pre-operative sepsis.

Conclusions: Early discharge within 1-2 days of ostomy construction was not associated with increased 30-day hospital readmissions. These findings support expedited discharges after ostomy construction in carefully selected, eligible patients.

Background: Recently, a competency assessment tool has been developed within the RIGHT project, a national quality improvement program for minimally invasive right hemicolectomy in patients with colon cancer. This study aimed to evaluate whether trained medical students can reliably evaluate minimally invasive right hemicolectomy videos using a competency assessment tool.

Methods: Nine expert colorectal surgeons, 13 trained medical students, and 17 untrained medical students assessed the surgical quality of 6 full-length minimally invasive right hemicolectomy videos with the competency assessment tool. The expert surgeons were trained using the competency assessment tool by the RIGHT project leaders, who were also involved in the development and validation of the competency assessment tool. Training for medical students included anatomy, step-by-step procedure explanation, and competency assessment tool review with 2 supervised video assessments. The untrained students were taught only anatomy and minimally invasive right hemicolectomy steps. The intraclass correlation coefficient was calculated to determine inter-rater reliability, and analysis of variance with the Bonferroni correction for multiple testing was used to assess potential differences between the groups per video.

Results: The trained students demonstrated an overall excellent inter-rater reliability (intraclass correlation coefficient score of 0.885). When their scores were combined with those of the expert surgeons, a high inter-rater reliability was also demonstrated (intraclass correlation coefficient score of 0.945). Trained students consistently aligned with surgeons' mean total scores, also accurately identifying lower quality surgeries. Untrained students assigned statistically significantly higher scores to the 3 lower quality surgeries as compared with expert surgeons and trained students.

Conclusion: Among trained students, excellent inter-rater reliability and concordance with expert colorectal surgeons was found. The study highlights the potential to engage trained medical students for objective minimally invasive right hemicolectomy video assessment.

Background: Several risk-stratified studies have compared the outcomes of external and internal pancreatic stents in pancreatoduodenectomy (PD), but no resolute standard for a fistula-mitigation strategy exists. The study investigated the efficacy of these stents in a preoperative risk-stratified setting.

Methods: Data from 285 patients who underwent PD with pancreaticojejunostomy using an external or internal stent from 2015 to 2023 were analyzed. The preoperative pancreatic fistula score (preFRS) was used to classify patients into low-risk (preFRS: 0-5) and high-risk (preFRS: 6-8) groups.

Results: PreFRS accurately predicted the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) as 0% and >40% in patients with preFRS ≤1 and ≥7, respectively. Although no significant difference was observed in postoperative outcomes in low-risk patients, the external stent significantly reduced CR-POPF (21% vs 44%, P = .024) and postpancreatectomy hemorrhage (PPH, 0% vs 19%, P = .02) in high-risk patients, leading to the superiority of the external stent in the entire cohort in terms of CR-POPF (12% vs 24%, P = .033) and PPH (1% vs 11%, P = .013). There were no significant differences in stent-related complications or pancreatic dysfunction. External stent malfunction occurred in 14% and significantly affected CR-POPF development in both low- (20% vs 0%, P < .01) and high-risk groups (60% vs 14%, P = .021).

Conclusion: The external pancreatic stent showed a more beneficial effect on CR-POPF and PPH, especially in high-risk patients, without increasing other complications. Risk-stratified strategy and improving stent management might enhance postoperative outcomes.

Background: Although cancer prognosis is most commonly estimated by tumor stage, survival is multifactorial. Our objective was to develop an American College of Surgeons "Biliary Tract Cancer Survival Calculator" prototype using machine learning to generate personalized survival estimates based on patient, tumor, and treatment factors.

Methods: The National Cancer Database was used to identify all patients with biliary tract malignancies between 2010 and 2017 including intrahepatic bile duct, extrahepatic bile duct, and gallbladder cancers. Included variables were determined based on random forest algorithms and review by subject matter experts. Data were split into 80% training and 20% test data sets. Extreme gradient boosting with survival embeddings, a machine learning class, generated 3-year survival curves. Internal 5-fold cross validation was evaluated through concordance statistics (c-index), Brier scores, distant calibration, and time-dependent area under the curve.

Results: Overall, 62,877 patients were included. Metastatic disease, age at diagnosis, and lack of surgical treatment were identified as most influential on worse survival outcomes via random forest. The final model included patient (age, sex, race and ethnicity, comorbidities), tumor (clinical TNM stage, disease site, grade), and treatment (surgery, chemotherapy, radiation) factors. Accurate model discrimination, calibration, and performance was demonstrated on internal validation (c-index: 0.74, Brier score: 0.14, distant calibration: P < .001, area under the curve: 0.83). These metrics were notably improved compared to a model based solely on stage (c-index: 0.64, Brier score: 0.18, distant calibration: P < .001, time-dependent area under the curve: 0.68).

Conclusion: This "Biliary Tract Cancer Survival Calculator" represents a highly accurate and comprehensive prognostic tool to estimate individualized survival estimates in real time.