Surgery最新文献

Introduction: The evolution of abdominal wall reconstruction has produced multiple effective techniques for hernia repair. Transversus abdominis release and preperitoneal repair allow for the placement of large mesh constructs. The outcomes of these techniques have not been compared, and this was the aim of this study.

Methods: Prospective data from 3,783 open abdominal wall reconstructions underwent a 1:1 propensity-score match for elective transversus abdominis release and preperitoneal repair using comorbidities, wound class, and defects. Standard descriptive and comparative statistics were applied.

Results: Propensity-score matching produced 347 pairs. There was no difference in age, body mass index, tobacco use, diabetes, American Society of Anesthesiologists score, wound class, or number of comorbidities. Patients who underwent transversus abdominis release had more recurrent hernias (69.2% vs 53.9%; P < .001). Preoperative Botox injections used for chemical component separation were similar (8.1% vs 9.8%; P = .425). These hernias were large and complex, with more than 22.3% being contaminated. Transversus abdominis release involved larger defects (247.8 ± 137.2 vs 223.4 ± 152.3 cm²; P = .003) and mesh sizes (994.5 ± 417.5 vs 845.7 ± 412.4 cm²; P < .001) with greater use of synthetic versus biologic mesh (70.6% vs 62.0%; P = .019). Fascial closure was not significantly different (98.6% vs 96.3%; P = .056). Transversus abdominis release had longer operative time (209.6 ± 69.6 vs 184.9 ± 75.6 minutes; P < .001), but operating room charges were similar ($18,565 ± 11,792 vs $18,209 ± 11,847; P = .390). There were no differences in infection (6.6% vs 6.9%), seroma intervention (12.7% vs 8.4%), or mesh infection (1.7% vs 0.6%) (all P > .05). Patients who underwent transversus abdominis release experienced greater wound breakdown (7.8% vs 4.0%; P = .036) and overall wound complications (25.6% vs 18.4%; P = .022). With an average follow-up of 21.8 ± 31.9 and 29.1 ± 36.1 months, there was no difference in hernia recurrence (2.9% vs 2.9%; P > .999).

Conclusion: Compared with transversus abdominis release, preperitoneal abdominal wall reconstruction demonstrated equivalent hernia recurrence rates with fewer wound complications. Preperitoneal repair represents an effective approach to complex hernia repair for large defects, facilitating wide mesh placement while mitigating wound morbidity.

Background: The purpose of this article is to evaluate the short-term and long-term efficacy of laparoscopic D2 lymphadenectomy plus complete mesogastrium excision in treating locally advanced upper gastric cancer.

Methods: We conducted a retrospective analysis of clinical data from 242 patients with locally advanced upper gastric cancer who underwent laparoscopic radical gastrectomy at the First Hospital of Putian in Fujian Province between January 2014 and August 2019. Short- and long-term outcomes were compared between the 2 groups.

Results: The D2 lymphadenectomy plus complete mesogastrium excision group demonstrated significantly less intraoperative blood loss (89.43 ± 74.66 mL vs 145.70 ± 63.20 mL, P < .001), a higher lymph node yield (42.91 ± 17.29 vs 37.10 ± 14.98, P = .008), and shorter postoperative recovery times (first flatus: 3 [2-3] vs 3 [3-3] days, P < .001; first liquid diet: 8 [7-8] vs 8 [7-9] days, P = .021; hospital stay: 14 [12-16] vs 15 [14-15] days, P = .035). Subgroup analysis showed significant overall survival and disease-free survival benefits for patients with stage T4a in the D2 lymphadenectomy plus complete mesogastrium excision group (P = .014 for both).

Conclusion: Compared with D2 lymphadenectomy, laparoscopic D2 lymphadenectomy plus complete mesogastrium excision for locally advanced upper gastric cancer demonstrates significant advantages, including more extensive lymph node dissection, reduced blood loss, and faster postoperative recovery. Although no significant difference in overall survival was observed (P = .067), the D2 lymphadenectomy plus complete mesogastrium excision approach achieved lower local recurrence rates and superior 5-year disease-free survival. Notably, patients with stage T4a derived particular benefits from D2 lymphadenectomy plus complete mesogastrium excision, showing significantly improved long-term survival outcomes.

Background: Neighborhood-level indices serve as proxies for social risk in clinical research, although self-reported social determinants of health may better identify vulnerable patients, especially in the context of traumatic injury. We hypothesized that self-reported social determinants of health have stronger predictive value for short-term trauma outcomes than neighborhood aggregates.

Methods: Adult inpatients with trauma tic injury (2020-2024) who completed hospital-administered social determinants of health screeners were assigned Social Vulnerability Index, Area Deprivation Index, and Environmental Justice Index scores based on census tract and categorized as high risk/low risk using median splits. Patients were also categorized as at risk/no risk across the 8 self-reported social determinants of health domains, measured by the screener. Primary outcomes were 30-day readmissions and hospital length of stay. Regression models measured the association of social determinants of health measures with outcomes, adjusting for injury and patient factors.

Results: A total of 3,115 patients completed social determinants of health screeners with 917 screened pre-trauma (median 152 days) and 2,198 screened post-trauma (median 17 days). Social Vulnerability Index and Environmental Justice Index predicted readmission risk (odds ratio 1.41 [95% confidence interval 1.07-1.86], P = .014, and 1.37 [1.00-1.87], P = .047). Social isolation was associated with significantly greater odds of readmission (odds ratio 2.17 [95% confidence interval 1.12-4.76], P = .032). No other social determinants of health domains predicted readmissions. Social isolation and stress were associated with longer length of stay (β = 1.44 days [95% confidence interval 0.36-2.52], P = .009, and β = 1.31 days [95% confidence interval 0.37-2.24], P = .006). No neighborhood measures predicted length of stay.

Conclusions: Social isolation demonstrated a stronger association with 30-day readmissions than neighborhood measures for trauma inpatients. Both social isolation and stress predicted hospital length of stay. Interventions to mitigate isolation and to increase outpatient support after discharge may be effective in reducing readmission in high-risk trauma patients.

Background: Approximately 20% of women diagnosed with ductal carcinoma in situ on core biopsy will be upstaged to invasive disease on final pathology. Sentinel lymph node biopsy at the time of mastectomy for ductal carcinoma in situ is the current standard of care. However, the underlying invasive cancer is frequently of low grade with favorable biology, bringing into question the necessity of sentinel lymph node biopsy to help guide clinical treatment recommendations. The primary study objective was to determine how often sentinel lymph node biopsy at the time of mastectomy for ductal carcinoma in situ alters adjuvant therapy recommendations.

Methods: A single-institution cancer registry retrospectively identified women treated with mastectomy for a preoperative diagnosis of ductal carcinoma in situ between November 2017 and November 2023, excluding those with a previous history of ipsilateral breast cancer. The impact of pathologic nodal status on adjuvant treatment was evaluated.

Results: The study population included 175 patients with a total of 38 invasive cancers identified. Of those with pT1 malignancies, 3 had a positive sentinel node. One patient was recommended for additional adjuvant treatment, in the form of radiation therapy, as a result of axillary staging. No patients were recommended for chemotherapy based solely on sentinel lymph node biopsy results.

Conclusion: Despite current recommendations to perform sentinel lymph node biopsy in ductal carcinoma in situ treated with mastectomy in the event invasive cancer is identified on final pathology, our outcomes suggest nodal status has limited impact on adjuvant therapy offerings. These findings indicate that sentinel lymph node biopsy may not be requisite for every patient undergoing mastectomy for ductal carcinoma in situ.