World Journal of Surgery最新文献

Introduction: We sought to assess the variations in practice metrics and billing practices among US Medical Graduates (USMGs) and International Medical Graduates (IMGs) in surgical oncology who serve a fee-for-service population.

Methods: Medicaid Services Medicare fee-for-service provider utilization and payment files were used to obtain publicly available data between January 1, 2021, and December 31, 2021. Comparisons were conducted using the t-test for parametric variables and Wilcoxon rank-sum for nonparametric variables.

Results: A total of 952 surgical oncologists (IMGs: n = 102 [10.7%]) were included in the analytic cohort. The average risk score among beneficiaries treated by IMGs was higher than USMGs (1.70 [0.04] vs. 1.46 [0.02], p < 0.001) and IMGs also had a higher total number of unique codes (47.0 [IQR: 36.0-69.0] vs. 38.0 [IQR: 24.0-60.0], p < 0.05). IMG surgical oncologists had higher payment-per-service amounts ($236.56 [10.34] vs. $196.20 [$2.65]; p < 0.05), charge-per-service amounts ($1242.48 [$83.14] vs. $1014.89 [$26.13]; p < 0.05), and higher total submitted charges ($400,373.26 [$342,978.45] vs. $360,020.29 [$523,675.91]; p < 0.05). IMGs provided a higher percentage of procedural services (34.1% vs. 27.9%; p < 0.001) and treatment services (2.1% vs. 1.9%; p < 0.001) versus USMGs. Female surgical oncologists, particularly female IMGS, billed lower annual mean Medicare charges (female IMGS: $295,383 vs. male IMGs: $424,407 vs. female USMGs: $294,168 vs. male USMGs: $414,543; p < 0.001).

Conclusions: IMGs provided more procedural services, cared for patients with a higher average risk score, and performed a greater variety of procedures compared with USMGs. Consequently, IMGs had higher mean annual charges, payment-per-service, and charge-per-service amounts.

We aim to enhance the reporting of complications in surgical operations by establishing a classification for patient complexity. Current comorbidity assessment tools are insufficient due to their reliance on physiological parameters. The proposed patient surgical class category (PSCC) aims to address these limitations and enhance results by incorporating relevant aspects of a patient's surgical history. The new classification system for patient surgical classes was developed via a modified Delphi method across two iterations with urological scenarios. The consensus on the importance of individual classes within PSCC ranged from 72.83% for Class 0 to 87.95% for Class 4A. The survey results show that our proposed grading system is easy, broadly applicable, and useful for categorizing the surgical history of patients.

Background: Although laparoscopic hemihepatectomy has gained prominence, one of the critical challenges in this procedure is the approach to the middle hepatic vein (MHV). The MHV, which runs in the midplane of the liver, is situated above the hilar plate and serves as an anatomical landmark in hemihepatectomy. We have introduced dorsal approach to the MHV from the hilar plate in laparoscopic hemihepatectomy under the laparoscopic caudo-dorsal view.

Methods: The liver parenchyma was divided along the midplane, which was identified as a surface ischemic line caused by selective inflow control of the right or left hemiliver. The MHV is dissected from the main root from the hilar plate toward the peripheral branches. The liver parenchyma was divided from the dorsal toward the ventral side, and the transection plane was tailored according to the particular type of hemihepatectomy.

Results: This approach was utilized in 28 patients with 9 undergoing right hepatectomy and 19 undergoing left hepatectomy. The median duration of the surgery was 260 min (range, 140-360 min), whereas median estimated blood loss was 80 mL (range, 40-400 mL). One patient (3.6%) has experienced postoperative major complications. The median length of postoperative hospitalization was 7 days (range, 5-20 days).

Conclusion: In conclusion, the dorsal approach to the MHV from the hilar plate in laparoscopic hemihepatectomy represents a significant advancement in the surgical technique. This approach offers enhanced visualization and precise dissection, which are critical for minimizing complications and improving surgical outcomes.

Background: The Naples prognostic score (NPS) is a remarkable marker of short- and long-term outcomes in various types of cancer. However, its impact on the postoperative outcomes of hepatocellular carcinoma remains controversial. This study aimed to clarify the impact of the NPS on the prognosis and incidence of postoperative complications in hepatocellular carcinoma.

Methods: Patients with hepatocellular carcinoma (n = 374) were categorized into high- and low-Naples prognostic score groups; their postoperative outcomes were compared. Prognostic and risk factors for severe postoperative complications were identified using multivariate analyses.

Results: The low-Naples prognostic score group had significantly longer overall and recurrence-free survivals than the high-Naples prognostic score group (p = 0.03 and 0.04, respectively). Subgroup analysis revealed a superior predictive value of the NPS in the group with a single tumor (p = 0.03), tumor diameter ≤5 cm (p = 0.04), and tumor stage I or II (p = 0.04). A high NPS was an independent prognostic factor for overall survival (hazard ratio, 1.45; 95% confidence interval (CI), 1.01-2.05; and p = 0.04). The NPS 2-4 group had a higher incidence of the Clavien-Dindo grade ≥ IIIa postoperative complications than the 0-1 group (p = 0.03) and a score of 2-4 was identified as an independent risk factor for the Clavien-Dindo grade ≥ IIIa postoperative complications (odds ratio, 2.06; 95% CI, 1.01-4.20; and p = 0.05).

Conclusions: The NPS effectively predicts postoperative outcomes in patients with hepatocellular carcinoma.

Background: Esophagectomy with lymphadenectomy is the primary treatment for esophageal squamous cell carcinoma (ESCC). However, intensive dissection of lymph nodes (LNs) along the recurrent laryngeal nerve (RLN) is associated with RLN palsy and pulmonary complications leading to poor survival. Therefore, this study aimed identify the risk factors for LNs metastasis along the RLN in patients with ESCC.

Methods: The present study included 168 patients with lower thoracic esophageal and esophagogastric junction (EGJ) squamous cell carcinoma who underwent esophagectomy with total mediastinal lymphadenectomy at Kobe University Hospital. Left/Right cervical paraesophageal (101 L/R), left/right recurrent nerve (106 recL/R), and left tracheobronchial LNs (106 tbL) were defined as LNs along the RLN. We evaluated the pathological distance between the proximal tumor boundary and the EGJ using images of the fixed specimen (PB-EGJ length).

Results: LN metastasis along the RLN was observed in 19 (11%) patients. The percentage of patients with a longer PB-EGJ length and cLNs metastasis was higher in the LNs metastasis along the RLN positive-group than in the RLN-negative group (p = 0.0075 and p = 0.013, respectively). The incidence of LNs metastasis along the RLN was 0% (95% confidence interval [CI] = 0-7.7%) when the PB-EGJ length was <4 cm. Univariate analysis showed that patients with cLNs metastasis negative had a low risk for LNs metastasis along the RLN (odds ratio = 0.26 and 95% CI = 0.083-0.82).

Conclusions: Patients with a PB-EGJ length <4 cm and negative for cLNs metastasis may be candidates for the omission of lymphadenectomy along the RLN.

Background: Glycocalyx degradation is implicated in endothelial damage and microcirculatory dysfunction in sepsis, whereas the effectiveness of plasma syndecan-1 levels and sublingual microcirculatory parameters in evaluating sepsis's prognosis has not yet been determined. This study aims to track their dynamic changes and investigate the prognostic utility of these indexes in sepsis.

Methods: In this prospective study conducted at the First Affiliated Hospital of Sun Yat-sen University, blood samples were collected from adult surgical septic patients within 2 days after intensive care unit admission measuring plasma syndecan-1 concentrations. Relevant sublingual microcirculatory parameters were also obtained simultaneously. Additionally, capillary refill time and serum lactate levels were recorded. The primary outcome was 30-day mortality.

Results: Of the 74 patients enrolled, the 30-day mortality rate was 35.1%. Significantly, higher syndecan-1 levels were observed in nonsurvivors at baseline, day 1, and day 2 (62.43 [37.37 and 103.16] vs. 97.24 [52.95 and 186.40] ng/mL and p = 0.035; 62.22 [41.50 and 87.52] vs. 96.71 [60.82 and 176.00] ng/mL and p = 0.009; and 56.03 [39.16 and 94.48] vs. 87.69 [72.52 and 159.70] ng/mL and p = 0.005, respectively). High syndecan-1 levels (≥121 ng/mL) were associated with lower survival rates (p = 0.001) and an increase exceeding 8 ng/mL within 2 days indicated a higher mortality risk (p = 0.0075). Syndecan-1 levels displayed satisfactory prognostic capability (AUC: 0.7056), whereas combining syndecan-1 and blood lactate demonstrated the highest predictive ability for 30-day survival (AUC: 0.7726).

Conclusions: Plasma syndecan-1 levels effectively predict sepsis prognosis, with higher baseline levels or increasing trends indicating worse outcomes. Combining syndecan-1 with blood lactate enhances predictive accuracy for 30-day mortality in sepsis.

Trial registration: This study registered in China on December 31, 2021 at Chinese Clinical Trial Registry (ChiCTR2100055066).