Surgery最新文献

Background: Laparoscopic subtotal cholecystectomy is an acceptable method of preventing bile duct injuries in "difficult" gallbladders. However, it is associated with postoperative bile leaks and retained gallstones that may necessitate resection of the gallbladder remnant. This study evaluates the outcomes of patients who underwent completion cholecystectomy for ongoing symptoms or complication after subtotal cholecystectomy.

Methods: We performed a retrospective review of adults who underwent laparoscopic completion cholecystectomy after previous subtotal cholecystectomy at a single institution from 2009 to 2023. Indications for reoperation were collected and intraoperative findings, operative outcomes, and rates of postoperative morbidity were evaluated.

Results: Over 14 years, 46 patients underwent completion cholecystectomy, with 40 (80%) in the last 5 years. Remnant cholecystitis was the most common reason for reoperation in 37 patients (80.4%). Choledocholithiasis was seen in 4 cases (8.7%). Bile leak, gallstone pancreatitis, and abdominal abscess were observed in 8 (17.4%), 4 (8.7%), and 5 (10.8%) patients, respectively. Four patients (8.7%) had intestinal fistulas intraoperatively. Laparoscopic completion cholecystectomy was attempted in all, with 2 (4.4%) converted to open laparotomy. The median operative time was 111 minutes (interquartile range, 83-140 minutes), and the median hospital stay was 1 day (interquartile range, 0-2 days). Minor complications occurred in 5 patients (10.9%), which were managed conservatively. Four patients had major complications requiring endoscopic retrograde cholangiopancreatography or percutaneous intervention. There were no bile duct injuries or reoperations, and 44 (95.6%) patients had complete symptom resolution at follow-up.

Conclusion: Laparoscopic completion cholecystectomy is feasible and safe but technically challenging. With the increased use of subtotal cholecystectomy, patients presenting with persistent postoperative pain require timely work-up and management of their symptoms.

Background: Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with limited treatment options. Although there have been recent advancements revealing genomic drivers of these tumors, it remains unclear which genomic signatures are associated with recurrence, particularly following R0 resection.

Methods: Adrenocortical carcinoma patients treated with adrenalectomy in the Cancer Genome Atlas with recurrence data were identified using cBioPortal. Clinicopathologic variables, genomics, treatment patterns, and outcomes were retrospectively analyzed.

Results: Among 92 adrenocortical carcinoma patients, 84 had recurrence data, with 52% experiencing tumor recurrence. Age and sex were not significantly different between recurrent and nonrecurrent groups. Nonrecurrent patients had a significantly longer overall survival (54 months vs 35 months, P = .0036). Adjuvant radiation was administered similarly in both groups (25.0% vs 16.2%, P = .4164). There were no differences in capsular or venous invasion or median tumor size. Sixty-two patients had R0 resection and 40.3% (n = 25/62) recurred. Multivariate logistic regression in this cohort, when controlling for vascular invasion, venous invasion, and capsular invasion, revealed that the WNT (odds ratio 4.43 [1.09-18.0], P = .034), PI3K (odds ratio 7.80 [1.33-45.65], P = .023), and cell cycle (odds ratio 6.81 [1.43-32.30], P = .016) pathways were significantly associated with recurrence. Median time to recurrence was 7.9 months; early recurrence (<7.9 months) was associated with MYC pathway alterations (40.9% vs 9.1%, P = .0339).

Conclusion: This study identified genomic signatures in the PI3K, WNT, and cell cycle pathways associated with adrenocortical carcinoma recurrence, including in those who underwent R0 resection. Investigations regarding the utility of these signatures as a prognostic tool to dictate adjuvant therapies or targeted treatment are warranted.

Background: Although many parathyroid and thyroid operations are performed by nonfellowship-trained general surgeons in the United States, there is growing uncertainty of whether graduating residents can perform these procedures competently. This study investigates trends in competency and autonomy among general surgery residents performing parathyroid and thyroid operations using a national survey-based dataset.

Methods: A retrospective analysis of the Society for Improving Medical Professional Learning database was performed. Case data from categorical general surgery residents performing parathyroidectomy or thyroidectomy between 2015 and 2023 were included. Competent performance and meaningful autonomy were dichotomized on the basis of faculty surgeon responses. Agreement between resident and faculty evaluations were assessed. Logistic regression was used to examine resident performance and autonomy using postgraduate year level and case complexity as covariates.

Results: The study included 907 parathyroidectomies and 1,555 thyroidectomies from 724 residents at 77 residency programs. Competent performance was observed in 34.0% of parathyroidectomies and 38.6% of thyroidectomies. Meaningful autonomy was observed in 31.6% of parathyroidectomies and 32.3% of thyroidectomies. Residents and faculty agreed on performance (50.3%) and autonomy (59.1%) in most cases, however when discordant residents often underestimated their performance (44.7%) or autonomy (25.3%). The likelihood of postgraduate year 5 residents demonstrating competent performance or meaningful autonomy was 65.9% and 51.6%, respectively for parathyroidectomy and 77.2% and 58.4%, respectively for thyroidectomy.

Conclusion: Many graduating residents do not demonstrate competent performance or meaningful autonomy in parathyroidectomy and thyroidectomy. Further initiatives are needed to improve graduating general surgeons' competence for these operations, given access disparities to high-volume endocrine surgeons.

Introduction: Parathyroidectomy is the definitive treatment for tertiary hyperparathyroidism post-kidney transplantation. However, cinacalcet-based medical management is increasingly used as an alternative. The financial consequences of each treatment remain unclear. We aimed to identify the most cost-effective strategy for managing hyperparathyroidism from the kidney transplantation recipient's perspective.

Methods: We constructed a patient-level discrete event simulation model to compare parathyroidectomy and cinacalcet-based medical management. The effects of hyperparathyroidism on allograft survival and all-cause mortality were considered in the discrete event simulation model with a time horizon of 15 years. Our base case was a 55-year-old kidney transplantation recipient with persistent hyperparathyroidism and hypercalcemia. The primary outcome was the cost-effectiveness measured by cost per quality-adjusted life years.

Results: The monthly out-of-pocket cost of cinacalcet ranged from $12 to $288, depending on insurance coverage, with a base case cost of $150. Our base case analysis showed that parathyroidectomy was the dominant treatment with lesser cost ($1,315 vs $7,147) and greater effectiveness (3.17 quality-adjusted life years and 2.92 quality-adjusted life years) than cinacalcet. One-way sensitivity analysis on the cinacalcet treatment duration showed that parathyroidectomy became more cost-effective at 9 months. Two-way sensitivity analysis on the cost of cinacalcet and the duration of treatment with cinacalcet showed that as the monthly cost of cinacalcet increases, the expense of cinacalcet-based medical management quickly exceeds the cost of parathyroidectomy.

Conclusion: Parathyroidectomy becomes more cost-effective for kidney transplantation recipients with tertiary hyperparathyroidism when they require cinacalcet-based medical management for more than 9 months. As part of shared decision-making, it is important to discuss the financial costs involved in treating tertiary hyperparathyroidism.

Background: Control of hemodynamic features during adrenalectomy for pheochromocytoma is recommended to minimize perioperative cardiovascular complications. However, episodes of intraoperative hemodynamic instability have been observed during adrenalectomies with other indications than pheochromocytoma. The objective of this study was to compare the hemodynamic instability score assessed during unilateral adrenalectomy for pheochromocytoma without preoperative medical preparation to hemodynamic instability score in nonsecreting tumor.

Methods: This was an observational study with prospective intraoperative hemodynamic data collection (every 20 seconds) and retrospective analysis.

Results: During the study period, 60 consecutive patients (30 pheochromocytomas vs 30 nonsecreting tumors) were included with a median number of data collections during total procedure time of 318 (interquartile range, 257-388). Mean cumulative intraoperative time outside the target blood pressure range expressed as a percentage of total procedure time was 13.3% vs 6.8% for systolic blood pressure >160 mm Hg (P = .01) and 2.4% vs 2.8% for mean arterial pressure <60 mm Hg (P = ns), respectively. The median hemodynamic instability score during total procedure time was 33 (interquartile range, 27-43) and 20 (interquartile range, 11-26) in the pheochromocytoma and nonsecreting tumor group, respectively (P < .01). Hemodynamic instability score were similar in patients with compared with without long-term antihypertensive treatment in each patient group (P = ns). The mean length of hospital stay was 2.0 ± 1.5 days, and 30-day morbidity rate was 6.6% (4/60) with no significant difference observed between both groups.

Conclusion: Although intraoperative hemodynamic instability remains greater in the pheochromocytoma group without preoperative medical preparation, both groups have similar hypotensive episodes. These data highlight the need to better understand the role of preoperative medical preparation in pheochromocytoma patients.

Background: Patient electronic messaging has increased clinician workload contributing to burnout. Large language models can respond to these patient queries, but no studies exist on large language model responses in thyroid disease.

Methods: This cross-sectional study randomly selected 33 of 52 patient questions found on Reddit/askdocs. Questions were found through a "thyroid + cancer" or "thyroid + disease" search and had verified-physician responses. Additional responses were generated using ChatGPT-3.5 and GPT-4. Questions and responses were anonymized and graded for accuracy, quality, and empathy using a 4-point Likert scale by blinded providers, including 4 surgeons, 1 endocrinologist, and 2 physician assistants (n = 7). Results were analyzed using a single-factor analysis of variance.

Results: For accuracy, the results averaged 2.71/4 (standard deviation 1.04), 3.49/4 (0.391), and 3.66/4 (0.286) for physicians, GPT-3.5, and GPT-4, respectively (P < .01), where 4 = completely true information, 3 = greater than 50% true information, and 2 = less than 50% true information. For quality, the results were 2.37/4 (standard deviation 0.661), 2.98/4 (0.352), and 3.81/4 (0.36) for physicians, GPT-3.5, and GPT-4, respectively (P < .01), where 4 = provided information beyond what was asked, 3 = completely answers the question, and 2 = partially answers the question. For empathy, the mean scores were 2.37/4 (standard deviation 0.661), 2.80/4 (0.582), and 3.14/4 (0.578) for physicians, GPT-3.5, and GPT-4, respectively (P < .01), where 4 = anticipates and infers patient feelings from the expressed question, 3 = mirrors the patient's feelings, and 2 = contains no dismissive comments. Responses by GPT were ranked first 95% of the time.

Conclusions: Large language model responses to patient queries about thyroid disease have the potential to be more accurate, complete, empathetic, and consistent than physician responses.