Annals of surgery最新文献

Objective: We analyzed the use of a self-expandable absorbable biliary stent (SEABS) to reduce biliary complications in liver transplant (LT).

Background: Complications related to biliary anastomosis are still a challenge in LT, with a high impact on patient outcomes and hospital costs.

Methods: This nonrandomized prospective study was conducted between July 2019 and September 2023 in adult LT patients with duct-to-duct biliary anastomoses. The primary endpoint was to assess early biliary complications at 90 days in LT patients with intraoperative SEABS versus no SEABS. We also compared overall biliary complications, costs, and SEABS adverse effects related.

Results: A total of 158 patients were included, 78 with SEABS and 80 no-SEABS (22 T-tube and 58 no-stent). There were no adverse effects related to SEABS. Early biliary complications (23.8 vs 2.6%, P <0.001) and hospital stay (19 vs 15 days, P = 0.001) were higher in no-SEABS. No-SEABS group required 63 endoscopic retrograde cholangiopancreatography and 13 surgeries (including 2 LT) versus 35 endoscopic retrograde cholangiopancreatography and 2 surgeries in SEABS group. After PSM between SEABS (n=58) versus no-SEABS (n=58), early biliary complications (22.4% vs 0%, P <0.001) were higher in no-SEABS group. T-tube had more early biliary complications (22.7% vs 5%, P =0.23) compared with SEABS high-risk biliary anastomosis. SEABS excess cost per patient was lower compared with T-Tube and no-stent (6.988€ vs 17.992€ vs 36.364€, P =0.036 and 0.002, respectively).

Conclusions: SEABS during biliary anastomosis in LT is feasible with no adverse effects and avoids the T-tube in high-risk biliary anastomoses. Its use has been associated with less early biliary complications, hospital costs, and reoperations or interventional treatments for biliary complications resolution.

Objective: To determine whether state-level social, emotional, and academic development (SEAD) policies are associated with pediatric firearm homicides and suicides.

Background: Firearm deaths continue to rise among US children. School-based efforts to promote SEAD may be a means to reduce such deaths, but state-level policies vary, and the effect on firearm deaths is unknown.

Methods: We used Education Trust data regarding state-level SEAD policies, averaging 6 domains to create a cumulative score and investigating each domain individually. The primary outcomes were pediatric firearm homicides and suicides, using covariates from the American Community Survey and State Firearm Laws database. We mapped SEAD policies and pediatric death rates. Poisson regression was used to investigate associations between SEAD policies and pediatric firearm deaths.

Results: Annual statewide pediatric firearm deaths ranged from 0.85 to 7.81 per 100,000; homicides from 0.64 to 5.69, and suicides from 0.21 to 4.75. Univariate analyses demonstrated associations between SEAD scores and both homicides ( P =0.003) and suicides ( P =0.032), but these were nonsignificant after adjustment. Professional Development and Engagement policies were associated with lower rates of pediatric firearm homicides after adjustment (IRR=0.33, P =0.004 and IRR=0.46, P =0.014, respectively). There was no significant association between any domain and pediatric firearm suicide.

Conclusions: Professional Development and Student, Family, and Community Engagement policies are associated with lower rates of pediatric firearm homicides; however, there was no significant association between pediatric firearm deaths and summary SEAD measures after adjustment. Certain SEAD policies may be helpful in decreasing pediatric firearm deaths.

Objective: To explore the impact of delayed or deferred ventral hernia repair for surgical optimization, including consequences on physical, social, and emotional well-being.

Summary background data: While previous studies have shown that surgical optimization can reduce complications of ventral hernia repair surgery, many patients face various barriers that preclude them from meeting these requirements, resulting in delayed or deferred surgery. Though these optimization requirements are well intentioned, the unintended consequences on patient well-being of needing to live with untreated hernia repairs remains unknown.

Methods: Semistructured qualitative interviews from January to June 2022 were conducted in a preoperative optimization clinic of 20 participants with ventral wall hernias were analyzed using an inductive thematic approach. The discussions aimed to explore challenges that patients living with untreated hernias faced, and what their expectations were during clinic visits. The transcripts were coded and analyzed using the MAXQDA software.

Results: Our study demonstrated 3 predominant themes in unintended consequences of delaying ventral hernia repair surgery for surgical optimization, including decreased feelings of emotional and social well-being, feelings of fear and uncertainty about the future, and frustration with lack of patient autonomy and preferences.

Conclusion: Untreated hernias have many unintended psychosocial consequences that need to be accounted for when determining surgical candidacy, using a shared decision-making approach.

Objective: The aim of this study was to compare the outcomes of robotic minor liver resection (RMLR) versus laparoscopic minor liver resection (LMLR) of the anterolateral segments.

Background: Robotic liver surgery has been gaining prominence over the years with increasing usage for a myriad of hepatic resections. Robotic liver resection (RLR) has demonstrated noninferiority to laparoscopic resection (LR), while illustrating advantages over conventional laparoscopy especially for technically difficult and major LR. However, the advantage of RMLR for the anterolateral (AL) (segments II, III, IVb, V, and VI) segments, has not been clearly demonstrated.

Methods: Between 2008 to 2022, 15,356 of 29,861 patients from 68 international centres underwent robotic minor liver resection (RMLR) or laparoscopic minor liver resection (LMLR) for the AL segments propensity score-matching (PSM) analysis was performed for matched analysis.

Results: A total of 10,517 patients met the study criteria of which 1481 underwent RMLR and 9036 underwent LMLR. A PSM cohort of 1401 patients in each group were identified for analysis. Compared with the LMLR cohort, the RMLR cohort demonstrated significantly lower median blood loss (75 vs 100 mL, P <0.001), decreased blood transfusion (3.1% vs 5.4%, P =0.003), lower incidence of major morbidity (2.5% vs 4.6%, P =0.004), lower proportion of open conversion (1.2% vs 4.5%, P <0.001), shorter postoperative stay (4 vs 5 days, P <0.001), but higher rate of 30-day readmission (3.5% vs 2.1%, P =0.042). These results were then validated by a 1:2 PSM analysis. In the subset analysis for 3614 patients with cirrhosis, RMLR showed lower median blood loss, decreased blood transfusion, lower open conversion, and shorter postoperative stay than LMLR.

Conclusion: RMLR demonstrated statistically significant advantages over LMLR even for resections in the AL segments although most of the observed clinical differences were minimal.

Objective: The purpose of this study was to determine the association between bariatric surgery and maternal, fetal, and infant outcomes.

Background: Obesity during pregnancy is a risk factor for adverse pregnancy outcomes. Bariatric surgery is the most effective weight loss treatment but the impact of bariatric surgery on pregnancy outcomes remains poorly characterized.

Methods: This was a population-based, matched cohort study of prospective databases in Ontario, Canada. Patients with obesity who received bariatric surgery from 2010 to 2016 and subsequently became pregnant matched on multiple factors to nonsurgical pregnant patients with obesity. The primary outcomes of interest were the incidence included of gestational diabetes, preeclampsia/hemolysis, elevated liver enzymes, and low platelets syndrome, small for gestational age, large for gestational age, and a composite of severe fetal/infant morbidity/mortality. Multivariable regression evaluated outcomes.

Results: Six hundred eighty patients who underwent bariatric surgery and later became pregnant were matched to 2002 pregnant patients with obesity. Gestational diabetes occurred in 8.7% of the surgery group and 18.8% of the nonsurgical group [adjusted OR (aOR) 0.29, 95% CI: 0.21-0.40, P<0.001]. A lower incidence of preeclampsia/hemolysis, elevated liver enzymes and low platelets was observed postsurgery (aOR 0.20, 95% CI: 0.13-0.31, P<0.001). Bariatric surgery impacted small for gestational age (aOR 2.74, 95% CI: 2.04-3.70, P<0.001) and large for gestational age (aOR 0.25, 95% CI: 0.18-0.36, P<0.001). There were no observed associations between bariatric surgery and any adverse fetal or infant outcomes. A lower composite severe fetal/infant morbidity/mortality was observed postsurgery (aOR 0.73, 95% CI: 0.54-0.97, P<0.05).

Conclusions: Pregnancy after bariatric surgery appears safe and was associated with a reduced risk of several obesity related adverse pregnancy outcomes.

Objective: This study aimed to understand the effectiveness of regular care in reducing the incidence of severe peristomal skin disorders, as well as to identify their risk factors.

Background: Peristomal skin disorders occur frequently in outpatient settings and require appropriate intervention. It remains, however, to be demonstrated when the need to follow up these patients decreases and whether assessing severity of peristomal skin disorders is useful.

Methods: This prospective, multicenter, observational cohort study was conducted in 6 regional high-volume Japanese hospitals. The primary endpoint of the study was the effectiveness of regular follow-up in reducing the incidence of severe peristomal skin disorders via a scoring system at a defined regular outpatient visit. Propensity score matching was performed to compare a control group and patients with severe peristomal skin disorders.

Results: In total, 217 patients between December 2019 and December 2021 were enrolled, and 191 patients were analyzed. Multivariate analysis showed that loop stoma (odds ratio, 5.017; 95% CI: 1.350-18.639; P =0.016) and stoma height of <10 mm (odds ratio, 7.831; 95% CI: 1.760-34.838; P =0.007) were independent risk factors for all peristomal skin disorders. After propensity score matching, the incidence of the disorders was not significantly different between the specified evaluation timing and historical control groups (75.7% vs 77.2%, P =0.775), and the incidence of the severe disorders based on the ABCD and DET scores (5.9% vs 19.1%, P <0.001 and 1.5% vs 29.4%, P <0.001, respectively) was significantly lower in the specified evaluation timing group than in the historical control group.

Conclusions: Regular peristomal skin disease follow-up and scoring, as well as appropriate stoma care at the stoma outpatient visit, did not change the frequency of peristomal skin disease, but severe peristomal skin disorders were prevented. In addition, risk factors for peristomal skin disorders were found to be height <10 mm and loop stoma.

Objective: To externally validate the International Study Group of Pancreatic Surgery (ISGPS) classification and test its performance for predicting clinically relevant pancreatic fistula (CRPF) for periampullary (P-amp) tumors.

Background: The ISGPS is a simple 2-factor, 4-tier classification of pancreas-related risk for CRPF after a pancreatoduodenectomy. External validation and performance of the classification specific to P-amps are lacking. P-amps have different disease biology, lesser need for neoadjuvant therapy, softer pancreas, and a higher rate of CRPF, underscoring the importance of site-specific prediction.

Methods: Validation was performed in a cohort of 1422 patients, with CRPF as the primary outcome. Model performance was tested by plotting the receiver operating curve and calibration plots. After analyzing the factors predicting CRPF, the model was optimized for P-amps.

Results: CRPF rate was 22.2% (315/1422), for P-amps being 25.8%. The ISGPS model performed moderately [area under the curve (AUC) = 0.632, 95% CI: 0.598-0.666, P < 0.001], with worse performance for P-amps (AUC = 0.605, 95% CI: 0.566-0.645, P < 0.001). On multivariate analysis, soft pancreas [odds ratio (OR): 1.689, 95% CI: 1.136-2.512, P = 0.010], body mass index ≥ 23 kg/m 2 (OR: 2.112, 95% CI: 1.464-3.046, P < 0.001) and pancreatic duct ≤ 3 mm (OR: 2.113, 95% CI: 1.457-3.064, P < 0.001) emerged as independent predictors, and the model was optimized. The adjusted ISGPS for P-amps showed improved discrimination (AUC = 0.672, P < 0.001, 95% CI: 0.637-0.707), with adequate performance on internal validation.

Conclusions: The adjusted ISPGS performs better than the original ISGPS in predicting CRPF for P-amps. Large-scale multicenter data are needed to generate and validate site-specific predictive models.

Objectives: To assess the feasibility of acute type A dissections treatment with a dedicated aortic root endograft concept and introduce a new aortic classification.

Background: Acute type A aortic dissection remains a catastrophic aortic condition with perioperative mortality ranging from 12% and 20%. Total Aortic root endovascular repair, the "Endo-Bentall concept," has been explored as an alternative but only documented in the case report.

Methods: An imaging study of all consecutive patients treated in 3 French centers was achieved. The study introduces an adapted aortic classification to report entry tear locations. Measurements included aortic annulus mensuration, coronary height, and several aortic lengths. Two treatment concepts were described "fenestrated Endo-Bentall" (FEB) and "branched Endo-Bentall (BEB)." Patients were eligible for the "FEB" design if their aortic root dimensions fitted the Edwards Sapien and Corevalve Medtronic instructions for use. Eligibility for the "BEB" required meeting the criteria for a "FEB" and having a left coronary main stem length exceeding 5 mm. "BEB" was mandatory when the entry was located in the aortic root.

Results: A total of 250 computed tomography scans for acute type A aortic dissection were reviewed, and 116 were finally included for analysis. The primary entry tear was found in the aortic root in 9% of patients, and in 31% of cases, it was located within the first centimeter distal to the sinotubular junction. Of the patients, 63.7% were eligible for an Endo-Bentall procedure, even 73.3% when considering extended criteria. FEB accounted for 2/3 of cases.

Conclusions: In our study, 63.7% of patients with aortic type A dissections are deemed eligible for an "Endo-Bentall repair," increasing to 73.3% when considering extended anatomic criteria.

Objective: To determine the influence of operating room familiarity on surgeon stress.

Background: Regulating surgeon stress may improve patient safety. This study evaluated how assisting surgeons and operating room familiarity influence intraoperative heart rate variability among surgeons.

Methods: Attending surgeons from 7 specialties within 4 university hospitals in France were enrolled from November 1, 2020 to December 31, 2021. Vagal tone, an indicator of stress derived from heart rate variability, was assessed during the first 5 minutes after incision using the root mean square of successive differences (RMSSD). Higher RMSSD values indicate greater vagal tone. Team familiarity was quantified as the cumulative time the attending and assisting surgeons had operated together in the past, while operating rooms in which the surgeon conducted >10% of their operations were termed familiar. The effect of each on the RMSSD was assessed via a linear mixed-effect model adjusting for the random effect of the surgeon and possible confounders.

Results: Overall, 643 surgeries performed by 37 surgeons were included. The median surgeon age was 49 years; 299 (78.4%) were male, and 22 (59.5%) were professors. Surgeons spent an average of 21.2 hours with the assisting surgeon before surgery and conducted 585 (91.0%) of their operations in a familiar operating room. For every 10 additional hours spent operating together, ln(RMSSD) significantly increased by 0.018 (95% CI: 0.003 to 0.033, P =0.016). Familiar operating rooms also tended to increase surgeon ln(RMSSD) [0.098 (95%CI: -0.007 to 0.203, P =0.068)].

Conclusion: Familiar with assisting surgeons and potentially operating rooms, increased surgeon vagal tone. Maintaining a stable operating room environment may improve surgeon stress and patient care.