Surgery最新文献

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.

Introduction: Reported outcomes for synthetic mesh versus biologic mesh in open abdominal wall reconstruction vary widely and are influenced by mesh type, location, fascial closure, wound complications, and patient characteristics. Little comparative data controlling for these variables or long-term results exists. This study compared outcomes between synthetic mesh and biologic mesh with >5 years of follow-up.

Methods: A prospectively maintained database was queried for open abdominal wall reconstruction with >5 years of follow-up. A 1:1 propensity score match was performed based on age, body mass index, tobacco status, diabetes, American Society of Anesthesiologists classification, and defect. Standard descriptive and comparative statistics were calculated.

Results: The 76 pairs generated were well balanced for age, body mass index, comorbidities, American Society of Anesthesiologists score, and rate of recurrent hernia. Wound class varied significantly (Centers for Disease Control and Prevention class 2-4: 15.8% vs 81.6%; P < .001). Defect size (244.6± 267.0 cm² vs 254.1 ± 141.4 cm²; P = .0866) and mesh placement (preperitoneal 97.6% vs 100.0%; P = .497) were similar; mesh size differed (943.8 ± 415.0 cm² vs 581.5 ± 297.4 cm²; P < .001). There were no differences in component separation or fascial closure. Biologic mesh had increased operative time (189.9 ± 73.2 minutes vs 229.3.5 ± 95.7 minutes; P = .010), operating room charges ($12,682 ± $7,352 vs $22,293 ± $14,373; P < .001), and total charges ($58,265 ± $27,712 vs $119,740 ± $69,670; P < .001). Delayed primary closure was more frequent with biologic mesh secondary to wound contamination (1.3% vs 30.3%; P < .001). Postoperatively, there were no differences in wound dehiscence (11.8% vs 11.8%), infection (0.5% vs 14.5%), seroma (17.1% vs 14.5%), mesh infection (3.9% vs 2.6%), or hernia recurrence (11.8% vs 9.2%) (all P > .05). Follow-up averaged >7 years (3.2 ± 25.2 months vs 86.1 ± 24.5 months).

Conclusion: In propensity-matched patients with complex, large abdominal wall reconstructions with at least 5 years of follow-up, biologic mesh and synthetic mesh yielded equivalent hernia recurrence and wound complication outcomes. Biologic mesh is as effective as synthetic mesh in abdominal wall reconstruction despite being more frequently used in a contaminated setting.

Background: Undocumented immigrants face significant barriers to health care access, including organ transplantation. However, their post-liver transplant outcomes remain poorly understood. This study evaluates graft survival and overall survival among undocumented immigrants undergoing liver transplant compared with US citizens.

Methods: A retrospective cohort study was conducted using the Scientific Registry of Transplant Recipients database, including adult liver transplant recipients from 1987 to 2022. The primary outcomes were 1-year graft survival and 5-year overall survival, analyzed using Fine-Gray competing risks and Cox proportional hazards models. A total of 88,603 adult liver transplant recipients were included, with 1,331 (1.5%) identified as undocumented immigrants.

Results: Compared with US citizens, undocumented immigrants had a lower body mass index (27.4 vs 28.1 kg/m²), lower diabetes prevalence (0.2% vs 4.4%), and higher rates of alcohol-associated liver disease (53.9% vs 43.9%) (all P < .05). Median Model for End-Stage Liver Disease with Sodium Adjustment scores (undocumented immigrant: 21 vs US citizen: 18) and wait times (undocumented immigrant: 105 vs US citizen: 95 days) were statistically different (P < .001) but clinically similar. In unadjusted analyses, undocumented immigrants had higher 1-year graft survival (hazard ratio: 0.27, 95% confidence interval: 0.19-0.39) and 5-year overall survival (hazard ratio: 0.49, 95% confidence interval: 0.42-0.58) than US citizens (P < .05). Adjusted analyses found no significant differences in 1-year graft survival (hazard ratio: 0.79, 95% confidence interval: 0.20-3.15) or 5-year overall survival (hazard ratio: 0.68, 95% confidence interval: 0.35-1.32) (both P > .05).

Conclusion: Post-liver transplant survival among undocumented immigrants was comparable to US citizens after adjustment. These findings support policies that enhance equitable liver transplant access while maintaining comparable outcomes.

Background: Risk stratification in aortic arch surgery remains a significant challenge because of the heterogeneity of clinical presentations and surgical approaches. Existing models such as Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation II often lack precision in this subset. The ARCH score was developed to predict morbidity and mortality in patients undergoing aortic arch surgery with hypothermic circulatory arrest, regardless of urgency or procedural complexity. However, its external validation has been limited.

Methods: This study represents the first multicenter external validation of the ARCH score in a mixed European and North American population. A total of 851 consecutive patients who underwent aortic arch surgery of any urgency with hypothermic circulatory arrest in 2 centers between 2013 and 2024 were retrospectively analyzed. Discriminatory ability and calibration were assessed using receiver operating characteristic curve, bootstrap validation, and Brier scores. Comparative analysis of the populations was also conducted against the original ARCH score cohort and a previous single-center validation.

Results: The ARCH score demonstrated excellent discrimination (c-statistic 0.798) and good calibration (Brier score 0.09) for mortality. Society of Thoracic Surgeons morbidity and mortality predictions showed fair discrimination (c-statistic 0.724, Brier score 0.12). Comparative analysis showed consistency with the original study and suggested that lower-than-expected mortality may contribute to the reduced discriminatory power observed in the previous validation cohort, despite high predictive accuracy.

Conclusion: The ARCH score is a reliable and broadly applicable risk prediction tool in aortic arch surgery, including high-risk and emergent settings. Its simplicity and strong performance support wider adoption, particularly with the future development of an accessible online calculator.

Background: The oncologic benefit of neoadjuvant therapy in resectable pancreatic ductal adenocarcinoma remains uncertain. We conducted an updated systematic review and meta-analysis to evaluate the efficacy of neoadjuvant therapy versus upfront surgery in patients with resectable pancreatic cancer.

Methods: Searches of various databases identified 9 randomized controlled trials comprising 604 neoadjuvant therapy and 527 upfront surgery patients. Hazard ratios for overall survival and event-free survival were extracted or reconstructed from Kaplan-Meier curves. Dichotomous outcomes were pooled as risk ratios under a random effects model.

Results: Neoadjuvant therapy produced a significant improvement in event-free survival (hazard ratio 0.77, 95% confidence interval 0.65-0.90) but only a nonsignificant trend toward better overall survival (hazard ratio 0.85, 95% CI 0.68-1.05). One-stage individual patient data reconstruction showed median overall survival rising from 23.7 to 29.6 months (+5.9 months) and median event-free survival from 11.4 to 13.6 months (+2.2 months). Although R0 resection rates appeared higher with neoadjuvant therapy (58.8% vs 52.6%), this difference was not statistically significant (risk ratio 1.13, 95% confidence interval 1.00-1.27). Neoadjuvant therapy reduced noncurative surgeries (surgical exploration rate: risk ratio 0.90, 95% confidence interval 0.87-0.94) and doubled the likelihood of node-negative histology (pN0; 1.73, 95% CI 1.31-2.28). Other outcomes were comparable between the 2 groups. Trial sequential analysis (α = .05, 80% power) confirmed that the event-free survival benefit is definitive, but indicated that both overall survival and R0 resection findings remain inconclusive because of insufficient accumulated data.

Conclusion: Neoadjuvant therapy significantly prolongs event-free survival, lowers unnecessary surgical exploration and increases pN0 resections in resectable pancreatic cancer. Further adequately powered trials are still needed to confirm the impact of neoadjuvant therapy on overall survival and R0 resection rates.