American journal of surgery最新文献

Introduction: Early diagnosis of acute appendicitis is crucial to prevent complications. Numerous scores exist, but a comprehensive review comparing them is lacking. This systematic review aimed to compare all published clinical scoring systems for diagnosing acute appendicitis in adults.

Methods: A systematic review and meta-analysis included studies assessing the diagnostic accuracy of clinical scores compared to histopathological findings for appendicitis. Sensitivities, specificities, diagnostic odds ratios (DOR), and summary receiver operating characteristics (SROC) were calculated.

Results: A total of 40 studies were included. The RIPASA score showed superior sensitivity (0.93 [95 ​% CI 0.78-0.98]; I² ​= ​96 ​%), specificity (0.81 [95 ​% CI 0.62-0.91]; I² ​= ​86 ​%), and DOR (45.3 [95 ​% CI 10.9-187.2]; I² ​= ​89 ​%). The AUC for the SROC curve of the RIPASA score was 0.913. A significant difference was found between the RIPASA score and both the Alvarado score (p ​< ​0.002) and the Modified Alvarado score (p ​< ​0.004) in SROC curves.

Conclusions: Our findings indicate that RIPASA is the most effective scoring system. Although the Alvarado score is the most studied, many other scores possess higher diagnostic accuracy.

Background: Although laparoscopy is widely used in oncologic digestive surgery, many centers are still reluctant to replace open surgery for gastric cancer treatment, especially in advanced disease. The aim of this study was to assess long-term survival and recurrence in patients after laparoscopic (LG) versus open (OG) oncological gastrectomy, in a tertiary reference center.

Methods: All consecutive patients with gastric adenocarcinoma undergoing curative gastrectomy between December 2007 and December 2021 were retrospectively analyzed. Clinico-pathological characteristics, survival and recurrence were compared among LG, OG or converted (CoG) patients. The ×2 test was used for categorical variables and the Mann-Whitney U test for continuous ones. Survival was assessed with the Kaplan-Meier method and log-rank test, as well as a multivariable Cox regression analysis.

Results: Among 156 included patients, 49 (31.4 ​%) were in the LG group, 93 (59.6 ​%) in the OG group, and 14 (9 ​%) in the CoG group. Baseline demographics were similar among the groups. R0 resection rates were 75.5 ​% in LG, 80.6 ​% in OG, and 64.3 ​% in CoG (p ​= ​0.489). Open surgery was associated with a higher mean lymph node yield (28.4 ​± ​11.6) compared to LG (22.8 ​± ​9.7) and CoG (26.5 ​± ​12.3, p ​= ​0.036). Severe postoperative complications were higher in the CoG group (64.3 ​% CoG versus 29 ​% OG, 32.7 ​% LG, p ​= ​0.035). The CoG group had a significantly inferior disease-free survival (p ​= ​0.012 vs OG, p ​= ​0.003 vs LG; 53.3 ​% OG, 62.7 ​% LG and 28.1 ​% CoG) although overall survival was similar (57.1 ​% OG, 62.7 ​% LG and 32.7 ​% CoG, all p ​> ​0.005).

Conclusions: Laparoscopic gastrectomy, while associated with a lower lymph node yield, provides similar overall survival rates compared to open surgery. Conversion to open surgery was associated with higher major postoperative morbidity and inferior disease-free survival.

Background: Treatments for invasive T₄ non-small cell lung cancer (NSCLC) tumors have been traditionally individualized and often require multidisciplinary team (MDT) evaluation. Advances in precision medicine may open up new opportunities for these patients.

Methods: This retrospective cohort study, using the Surveillance, Epidemiology, and End Results (SEER) database, identified T₄N_0-3M₀ NSCLC patients with central structure invasion from 2010 to 2020. Precision medicine has progressed in three periods: 2010-2014 (targeted therapy), 2015-2017 (initial immunotherapy), and 2018-2020 (latest immunotherapy). We utilized Propensity Score Matching (PSM) to control confounding factors and competing risk regression models to evaluate cancer-specific survival (CSS).

Results: A total of 9,106 cases were matched after PSM. For all populations, the median overall survival (OS) significantly increased with the advancement of precision medicine: 23.0 months in Period I (95 ​% CI: 22.0-25.0), 28.0 months in Period II (95 ​% CI: 26.0-31.0), and not reached (NR) in Period III (95 ​% CI: 30.0 - NR). Multivariate analysis also revealed a sequential survival improvement from Period I to III (p ​< ​0.001). Surgery-based treatment yielded the longest median OS at 46.0 months (95 ​% CI: 43.0-49.0, p ​< ​0.001), compared with chemoradiotherapy, chemotherapy alone and radiation alone. Surgery-based treatment has also yielded the best survival in three precision medicine eras, in both N_0-1 and N_2-3 categories. After analyzing CSS, the results above remained consistent. The survival following chemoradiotherapy and chemotherapy alone has seen significant and progressive enhancements across the three eras of precision medicine. There were no significant survival differences between Periods I and II among surgery-based patients, but a slight improvement trend was noted in Period III.

Conclusion: This retrospective study indicated that as precision medicine for NSCLC evolved, personalized treatment strategies supported by effective MDT led to survival improvement. Notably, for invasive stage III patients, surgery-based strategies have consistently shown substantial benefits across all the periods, irrespective of the N stage. The integration of perioperative therapies to enhance surgical feasibility, especially the latest immunotherapy, holds particular promise for further survival benefits.

Background: Intraoperative adverse events (iAEs) during general surgery can lead to significant morbidity and healthcare burden, yet their impact remains underexplored. We aimed to estimate the nationwide incidence of iAEs in general surgery and explore their associations with mortality, complications, length of stay, and costs.

Methods: We conducted a retrospective cohort study using the Nationwide Readmissions Database 2019 and included adult patients (aged 18 years and older) who underwent general surgical procedures. Eligible patients were grouped based on the presence of an iAE, defined as an unrecognized abdominopelvic accidental puncture or laceration. The primary outcome was in-hospital mortality, while secondary outcomes included 30-day post-operative complications, length of stay, and total inpatient costs. Multivariable logistic and linear regression models were used to examine the association between the presence of an iAE and post-operative outcomes and costs.

Results: A total of 701,866 patients were included. The mean age was 55.1 years, and 60.0 ​% were female. 6350 (0.9 ​%) experienced an iAE. The procedure with the highest incidence of iAE was small bowel resection (2.3 ​%). On univariate analysis, patients who experienced an iAE had higher mortality (3.8 ​% vs. 1.5 ​%, P ​< ​0.001), 30-day complications, length of stay, and inpatient costs. After multivariable regression, iAEs were independently associated with an increase in in-hospital mortality, length of stay, unplanned readmission, wound complications, acute kidney injury, sepsis, surgical site infection, ileus, and inpatient costs.

Conclusions: Despite their low incidence, iAEs are associated with heightened rates of complications and healthcare utilization. Incorporating iAEs into surgical quality initiatives and developing iAE reporting standards is warranted.

Background: Cutaneous malignant melanoma has traditionally been a surgically managed disease. Recent clinical trials highlight major shifts in surgical management of this disease, emphasizing a multidisciplinary approach.

Methods: Clinical trials evaluating the role of completion lymph node dissection (CLND) in the management of sentinel lymph node positive patients and more recent trials evaluating the impact of neoadjuvant immunotherapy on patients presenting with clinically advanced but surgically resectable melanoma are reviewed, as well as ongoing trial evaluating surgical margins.

Results: Both DeCOG and MSLT-II trials confirmed that CLND is no longer standard management of the sentinel node positive patient. CLND offers no melanoma-specific survival benefit. Associated surgical morbidity justifies a surveillance and observation approach, combined with adjuvant therapy. Patients presenting with clinically advanced surgically resectable disease are best served by neoadjuvant therapy. This approach demonstrates significantly improved melanoma-specific survival compared to upfront surgery, underscoring the need for rapid adoption by surgeons.

Conclusions: Changes in surgical management of melanoma have been dramatic and offer patients improved outcomes though both reduction in the magnitude of surgery, as well as improved disease specific survival for patients with advanced surgically resectable disease.

Background: The study aims to describe current use of participant-reported outcome measures (PROM) to assess stress in surgeons that may impact patient and surgeon wellbeing.

Methods: Medline, Embase, Cochrane library, and clinical trial registries were searched. Articles reporting PROM of stress in live or simulated surgery were included.

Results: Of 10,160 articles screened, 67 were included in the review. PROM tools identified include task load index (TLX), State-Trait Anxiety Inventory (STAI), Dundee Stress State Questionnaire (DSSQ), and single question scales. PROM scores increased from baseline to procedure in single question scales and DSSQ. STAI increased by ​≥ ​1 point in 37-75 ​%. TLX scores were greater at laparoscopy vs robot, single incision laparoscopy and open surgery vs conventional laparoscopy. Residents showed higher mental demand than attendings. Music lowered TLX scores.

Conclusions: Anxiety, stress, and workload have been measured in surgeons although the most appropriate to monitor surgeon wellbeing is not clear.

Introduction: Pancreatic neuroendocrine tumors (pNETs) are slow growing, malignant tumors that show different survival outcomes by race. Current size-based guidelines were largely developed in White patients. Our aim was to investigate tumor size and incidence of lymph node metastasis (LNM) between White and Asian pNET patients to evaluate generalizability of established guidelines.

Methods: Using the National Cancer Database (NCDB), we conducted a multi-institutional analysis of patients with low grade, resected, nonfunctional, sporadic, non-metastatic pNETs. Chi-squared tests were implemented to determine correlation between PTS and LMN incidence as well as race and LMN incidence. A logistic regression model was utilized to determine correlation between LMN, tumor size, and race. Overall survival was assessed using the Kaplan-Meier method.

Results: A total of 4977 pNET patients (205 Asian and 4772 White) were included in our analysis. Asian patients presented with smaller tumors (3.0 ​cm vs 3.9 ​cm, p ​= ​0.029) but when grouped by size, there was no difference in the distribution (p ​= ​0.77). White patients demonstrated a higher incidence of lymph node metastasis at presentation compared to Asian patients (27 ​% vs 19 ​%, p ​= ​0.013), a higher likelihood of an R0 resection (95.3 ​% vs. 89.3 ​%, p ​< ​0.0001). Within both populations, tumor size (<2 ​cm, 2-3 ​cm, and ≥3 ​cm) positively correlated with incidence of LNM (11.5 ​%, 24.6 ​%, and 39.1 ​%). No difference of LNM was seen between racial cohorts at PTS <3 ​cm, however, Asian patients were less likely to exhibit LNM at PTS ≥3 ​cm (28.2 ​% and 39.5 ​%, p ​= ​0.04). Overall survival was not significantly different between racial groups (p ​= ​0.92).

Conclusion: Size based surgical resection guidelines for pancreatic neuroendocrine tumors based on a predominantly White patient population may not be generalizable to the Asian population. Within this population, we found the risk of lymph node metastasis did not increase at similar rates with increasing primary tumor size.

Introduction: Early urinary catheter removal has been incorporated into Enhanced Recovery After Surgery (ERAS) pathways to aid faster recovery and minimize urinary tract infection. However, early catheter removal can result in urinary retention, which may lead to catheter reinsertion and a prolonged hospital stay. Tamsulosin, an alpha-blocking medication, effectively treats urinary retention in both men and women. Our study aims to compare urinary retention rates and short-term outcomes between patients treated with tamsulosin and those who were not.

Methods: This retrospective cohort study included patients who underwent elective abdominopelvic colorectal procedures using the ERAS protocol between September 2020 and October 2023. After April 2022, postoperative 0.4 ​mg tamsulosin treatment was added to the ERAS protocol. Univariate analysis was used to compare demographics and perioperative treatment history. The control and tamsulosin groups were matched in a 2:1 ratio, using propensity scores. The primary outcomes were urinary retention and the length of hospital stay.

Results: The study included 2072 patients (1215 female, 58.6 ​%), with a mean age of 53.1 (±17.1) years. The initial univariate analysis was followed by propensity score matching, resulting in 344 patients in the tamsulosin group and 688 in the control group. The urinary retention rate was notably lower in patients who received tamsulosin during hospitalization (9.2 ​% vs. 4.7 ​%, p ​= ​0.01). Furthermore, the length of hospital stay was shorter in patients treated with tamsulosin (5 vs. 4.2 p ​< ​0.01).

Conclusion: Postoperative prophylactic tamsulosin use decreases urinary retention rates and length of stay after colorectal surgery and should be considered complementary to ERAS protocols for improved recovery.