Annals of surgery最新文献

Objective: To investigate the impact of racial disparities and socioeconomic status on pelvic floor disorder (PFD) care.

Background: Racial disparities in colorectal PFD remain uninvestigated, despite prior research in urogynecology.

Methods: This retrospective study was conducted at Guy's and St. Thomas' Hospital of London in 2023. Patients with colorectal PFD from 2013 to 2018 were evaluated. Patients were classified according to the Index of Multiple Deprivation (IMD) scores and divided into quintiles. The lowest quintile represents the most deprived, whereas the higher quintile represents the least deprived. Assessed variables are: patient complaints, symptoms, consultant and biofeedback referrals, investigations, multidisciplinary meeting (MDM) discussions, treatment, and follow-up appointments.

Results: A total of 2001 patients were considered. A total of 1126 patients were initially analyzed, and 875 patients were excluded owing to incomplete data. Eight ethnic groups were identified in this study. Constipation was the most common complaint across ethnic groups ( P = 0.03). Diagnostics, MDM discussions, and conservative treatment did not vary among ethnicities. White British and Asian patients were significantly more likely to be seen by a consultant ( P = 0.001) and undergo surgery ( P = 0.002). In the second part of the study, the IMD was calculated for 1992 patients who were categorized into quintiles. Diagnostic tests, discussion in MDM, consultant review, and surgical treatments were significantly lower in the 2 lowest quintiles ( P < 0.001, P < 0.001, P = 0.02, and P = 0.02, respectively). Conservative treatment did not vary between the IMD groups.

Conclusions: Disparities in the diagnosis and treatment of colorectal PFD exist among ethnic minorities and patients of low socioeconomic status. This study allows for the replication of service provision frameworks in other affected areas to minimize inequalities.

Objective: To define the role of adjuvant therapy in duodenal adenocarcinoma (DAC) and intestinal subtype ampullary carcinoma (iAC).

Background: DAC and iAC share a similar histologic differentiation but the benefit of adjuvant therapy remains unclear.

Methods: Patients undergoing curative intent surgical resection for DAC and iAC between 2010 and 2021 at 5 high-volume centers were included. Patient baseline, perioperative, and long-term oncological outcomes were evaluated. Statistical testing was performed with SPSS 25 (IBM).

Results: A total of 136 patients with DAC and 171 with iAC were identified. Patients with DAC had more advanced tumors than those with iAC. Median overall survival (OS) in patients with DAC was 101 months versus 155 months for patients with iAC ( P = 0.098). DAC had a higher rate of local (14.1% vs 1.2%, P < 0.001) and systemic recurrence (30.4% vs 3.5%, P < 0.001). Adjuvant therapy failed to improve OS in all patients with DAC and iAC. For DAC, patients with perineural invasion, but not other negative prognostic factors, had improved OS rates with adjuvant therapy (72 vs 44 m, P = 0.044). Patients with iAC with N+ (190 vs 57 m, P = 0.003), T3-T4 (177 vs 59 m, P = 0.050), and perineural invasion (150 vs 59 m, P = 0.019) had improved OS rates with adjuvant therapy.

Conclusions: While adjuvant therapy fails to improve OS in all patients with DAC and iAC in the current study, it improved OS in patients with DAC with perineural invasion and in patients with iAC with T3-T4 tumors, positive lymph nodes, and perineural invasion.

Objective: To understand professional norms regarding the value of surgery.

Background: Agreed-upon professional norms may improve surgical decision-making by contextualizing the nature of surgical treatment for patients. However, the extent to which these norms exist among surgeons practicing in the United States is not known.

Methods: We administered a survey with 30 exemplar cases asking surgeons to use their best judgment to place each case on a scale ranging from "definitely would do this surgery" to "definitely would not do this surgery." We then asked surgeons to repeat their assessments after providing responses from the first survey. We interviewed respondents to characterize their rationale.

Results: We received 580 responses, a response rate of 28.5%. For 19 of 30 cases, there was consensus (≥60% agreement) about the value of surgery (range: 63% to 99%). There was little within-case variation when the mode was for surgery and more variation when the mode was against surgery or equipoise. Exposure to peer response increased the number of cases with consensus. Women were more likely to endorse a nonoperative approach when treatment had high mortality. Specialists were less likely to operate for salvage procedures. Surgeons noted their clinical practice was to withhold judgment and let patients decide despite their assessment.

Conclusions: Professional judgment about the value of surgery exists along a continuum. While there is less variation in judgment for cases that are highly beneficial, consensus can be improved by exposure to the assessments of peers.

Objective: To characterize the quality of statistical methods for studies of racial and ethnic disparities in the surgical-relevant literature during 2021-2022.

Background: Hundreds of scientific papers are published each year describing racial and ethnic disparities in surgical access, quality, and outcomes. The content and design quality of this literature have never been systematically reviewed.

Methods: We searched for 2021 to 2022 studies focused on describing racial and/or ethnic disparities in surgical or perioperative access, process quality, or outcomes. Identified studies were characterized in terms of 3 methodological criteria: (1) adjustment for variables related to both race/ethnicity and outcomes, including social determinants of health (SDOH), (2) accounting for clustering of patients within hospitals or other subunits ("providers"), and (3) distinguishing within-provider and between-provider effects.

Results: We identified 224 papers describing racial and/or ethnic differences. Of the 38 single-institution studies, 24 (63.2%) adjusted for at least one SDOH variable. Of the 186 multisite studies, 113 (60.8%) adjusted for at least one SDOH variable, and 43 (23.1%) accounted for the clustering of patients within providers using appropriate statistical methods. Only 10 (5.4%) of multi-institution studies made efforts to examine how much of the overall disparities were driven by within versus between-provider effects.

Conclusions: Most recently published papers on racial and ethnic disparities in the surgical literature do not meet these important statistical design criteria and, therefore, may risk inaccuracy in the estimation of group differences in surgical access, quality, and outcomes. The most potent leverage points for these improvements are changes to journal publication guidelines and policies.

Objective: To compare expenditures between surgical and matched nonsurgical patients in a retrospective cohort study.

Background: Bariatric surgery leads to substantial improvements in weight and weight-related conditions, but prior literature on postsurgical health expenditures is equivocal.

Methods: In a retrospective study, total outpatient, inpatient, and medication expenditures 3 years before and 5.5 years after surgery were compared between 22,698 bariatric surgery [n = 7127 Roux-en-Y gastric bypass (RYGB), 15,571 sleeve gastrectomy (SG)] patients from 2012 to 2019 and 66,769 matched nonsurgical patients, using generalized estimating equations. We also compared expenditures between patients receiving the 2 leading surgical procedures in weighted analyses.

Results: Surgical and nonsurgical cohorts were well matched, 80% to 81% females, with mean body mass index of 44 and mean age of 47 (RYGB) and 44 (SG) years. Estimated total expenditures were similar between surgical and nonsurgical groups 3 years before surgery ($27 difference, 95% CI: -42, 102), increased 6 months before surgery for surgical patients, and decreased below preperiod levels for both groups after 3 to 5.5 years to become similar (difference at 5.5 years = -$61, 95% CI: -166, 52). Long-term outpatient expenditures were similar between groups. Surgical patients' lower long-term medication expenditures ($314 lower at 5.5 years, 95% CI: -419, -208) were offset by a higher risk of hospitalization. Total expenditures were similar between patients undergoing RYGB and SG 3.5 to 5.5 years after surgery.

Conclusions: Bariatric surgery translated into lower medication expenditures than matched controls, but not lower overall long-term expenditures. Expenditure trends appear similar for the two leading bariatric operations.

Objective: To assess the probability of being cured of pancreatic ductal adenocarcinoma (PDAC) by pancreatic surgery.

Background: Statistical cure implies that a patient treated for a specific disease will have the same life expectancy as if he/she never had that disease.

Methods: Patients who underwent pancreatic resection for PDAC between 2010 and 2021 were retrospectively identified using a multi-institutional database. A nonmixture statistical cure model was applied to compare disease-free survival to the survival expected for a matched general population.

Results: Among 2554 patients, either in the setting of upfront (n=1691) or neoadjuvant strategy (n=863), the cure model showed that the probability that surgery would offer the same life expectancy (and tumor-free) as the matched general population was 20.4% (95% CI: 18.3, 22.5). Cure likelihood reached the 95% of certainty (time to cure) after 5.3 years (95% CI: 4.7, 6.0). A preoperative model was developed based on tumor stage at diagnosis ( P =0.001), radiologic size ( P =0.001), response to chemotherapy ( P =0.007), American Society of Anesthesiology class ( P =0.001), and preoperative Ca19-9 ( P =0.001). A postoperative model with the addition of surgery type ( P =0.015), pathologic size ( P =0.001), tumor grading ( P =0.001), resection margin ( P =0.001), positive lymph node ratio ( P =0.001), and the receipt of adjuvant therapy ( P =0.001) was also developed.

Conclusions: Patients operated for PDAC can achieve a life expectancy similar to that of the general population, and the likelihood of cure increases with the passage of recurrence-free time. An online calculator was developed and available at https://aicep.website/?cff-form=15 .

Objective: To compare clinical outcomes of patients treated by female surgeons versus those treated by male surgeons.

Background: It remains unclear as to whether surgical performance and outcomes differ between female and male surgeons.

Methods: We conducted a meta-analysis to compare patients' clinical outcomes-including patients' postoperative mortality, readmission, and complication rates-between female versus male surgeons. MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov were searched from inception to September 8, 2022. The update search was conducted on July 19, 2023. We used random-effects models to synthesize data and GRADE to evaluate the certainty.

Results: A total of 15 retrospective cohort studies provided data on 5,448,121 participants. We found that patients treated by female surgeons experienced a lower postoperative mortality compared with patients treated by male surgeons [8 studies; adjusted odds ratio (aOR), 0.93; 95% CI, 0.88-0.97; I2 =27%; moderate certainty of the evidence]. We found a similar pattern for both elective and nonelective (emergent or urgent) surgeries, although the difference was larger for elective surgeries (test for subgroup difference P =0.003). We found no evidence that female and male surgeons differed for patient readmission (3 studies; aOR, 1.20; 95% CI, 0.83-1.74; I2 =92%; very low certainty of the evidence) or complication rates (8 studies; aOR, 0.94; 95% CI, 0.88-1.01; I2 =38%; very low certainty of the evidence).

Conclusion: This systematic review and meta-analysis suggests that patients treated by female surgeons have a lower mortality compared with those treated by male surgeons.

Objective: To assess the performance of a lower predicted postoperative (ppo) forced expiratory volume in 1 second (FEV 1 ) or diffusion capacity of the lung for carbon monoxide (DLCO) (ppoFEV 1 /ppoDLCO) threshold to predict cardiopulmonary complications after minimally invasive surgery (MIS) lobectomy.

Background: Although MIS is associated with better postoperative outcomes than open surgery, MIS uses risk-assessment algorithms developed for open surgery. Moreover, several different definitions of cardiopulmonary complications are used for assessment.

Methods: All patients who underwent MIS lobectomy for clinical stage I to II lung cancer from 2018 to 2022 at our institution were considered. The performance of a ppoFEV 1 /ppoDLCO threshold of <45% was compared against that of the current guideline threshold of <60%. Three different definitions of cardiopulmonary complications were compared: Society of Thoracic Surgeons (STS), European Society of Thoracic Surgeons (ESTS), and Berry and colleagues' study.

Results: In 946 patients, the ppoFEV 1 /ppoDLCO threshold of <45% was associated with a higher proportion correctly classified [79% (95% CI, 76%-81%) vs 65% (95% CI, 62%-68%); P <0.001]. The complication with the biggest difference in incidence between ppoFEV 1 /ppoDLCO of 45% to 60% and >60% was prolonged air leak [33 (13%) vs 34 (6%); P <0.001]. The predicted probability curves for cardiopulmonary complications were higher for the STS definition than for the ESTS or Berry definitions across ppoFEV 1 and ppoDLCO values.

Conclusions: The ppoFEV 1 /ppoDLCO threshold of <45% more accurately classified patients for cardiopulmonary complications after MIS lobectomy, emphasizing the need for updated risk-assessment guidelines for MIS lobectomy to optimize additional cardiopulmonary function evaluation.