Annals of surgery最新文献

Objective: To explore how surgical faculty experience belonging and professional identity within the context of institutional efforts to foster an inclusive culture.

Summary background data: Belonging has been recognized as a key contributor to well-being, engagement, and retention across multiple professions, including business, healthcare, and education. However, while belonging has been studied among surgical trainees, little is known about how attending surgeons experience belonging within academic surgical departments, where professional structures and expectations differ substantially.

Methods: We conducted a qualitative descriptive study at a single academic medical center where institutional efforts to strengthen workplace culture, equity, and well-being were already visible and ongoing. Thirty-nine actively practicing surgical faculty were purposively sampled and recruited via departmental listserv. Semi-structured interviews were conducted in person or virtually by a trained non-clinician qualitative analyst. Interview transcripts were analyzed iteratively using a codebook-based thematic analysis, with themes developed through team consensus and memoing.

Results: Three key themes shaped faculty experiences of belonging: (1) Values congruence and engagement: alignment between personal and institutional goals fostered connection, and engagement; (2) Recognition, trust, and professional voice: recognition of contributions and professional autonomy reinforced identity and inclusion; (3) Community and connection: supportive relationships promoted belonging, while social isolation eroded it.

Conclusions: Belonging among surgical faculty is shaped by institutional values, recognition, professional autonomy, and relational dynamics, which impacts engagement, retention, and culture. Departments can foster belonging through visible and equitable recognition of contributions, intentional relational supports, and ensuring alignment between institutional and professional values.

Objective: To assess the proportion of unresectable colorectal liver metastasis (CRLM) patients meeting liver transplant (LT) criteria and define their outcomes following hepatic artery infusion pump (HAIP) chemotherapy.

Summary background data: The TransMet RCT demonstrates improved survival with combined LT and systemic versus systemic therapy alone; however, systemic therapy might not be the best control. This study assesses outcomes in similarly selected patients treated with HAIP.

Methods: We identified unresectable CRLM patients treated with HAIP between 2006-2016. Modified TransMet/SECA-II selection criteria were applied, including pre-treatment with at least 1st line chemotherapy before HAIP placement. Overall survival (OS) and progression-free survival (PFS) were estimated using Kaplan-Meier methods from HAIP placement.

Results: Of 483 patients identified, 23 (4.8%) were LT-eligible. Median age was 52 years (range:37,73). Primary tumors were right-sided in 6 (23%) and rectal in 12 (52%). Eight (38%) patients were KRASmut. Median CRLM size and number were 28 mm (range:9,92) and 11 (range:4,38). Median pre-HAIP chemotherapy cycles were 8 (range:3,20), and most patients were on 1st (15,65%) or 2nd (7,30%) line therapy. Conversion to resection occurred in 18 (78%) patients after a median of 5 (range:1,20) HAIP chemotherapy cycles. With a median follow-up time of 98 (95%CI:96,NR) months, median OS was 61 (95%CI:36,92) months, and 5-year OS was 53% (95%CI:36,79). Median PFS was 13 (95%CI:10,22) months.

Conclusions: In this cohort, less than 5% of unresectable CRLM patients were LT-eligible. After treatment with HAIP chemotherapy, overall 5-year survival was 53%, similar to a recent LT randomized trial (5-year OS 57%).

Objective: To investigate whether underrepresentation of racial and ethnic minorities exists in metastatic colorectal carcinoma (CRC) clinical trials.

Background: Representation of vulnerable subpopulations is essential for the generalizability of clinical trials. Limited studies to date have investigated the racial and ethnic representation of patients enrolled in clinical trials for metastatic CRC.

Methods: ClinicalTrials.gov was queried for metastatic CRC clinical trials in the United States from 2000 to 2020. Incidence data were extracted from the SEER Database. Enrollment fraction was defined as the number of trial participants divided by U.S. incidence of metastatic CRC in each race, ethnicity, and sex. Representation quotient (RQ) was defined as the proportion of trial participants divided by the proportion of U.S. metastatic CRC incidence for each subgroup.

Results: A total of 8084 patients from 135 clinical trials were analyzed. Of clinical trials, 49.6% reported race data and 34.8% reported ethnicity data. Compared with 2000 to 2009, 2010 to 2019 had increased representation data reporting for race (61.2% vs 38.8%) and ethnicity (64.6% vs 35.4%). Of trials with race data, White patients represented 77.0%, Black patients 6.6%, Asian/Pacific Islander patients 16.1%, American Indian/Alaska Native patients 0.2%, and Hispanic patients 6.8%. Black patients (median RQ: 0.54), Asian/Pacific Islander patients (median RQ: 0.19), American Indian/Alaska Native patients (median RQ: 0.00), and Hispanic patients (median RQ: 0.26) were underrepresented. Black patients had a higher degree of underrepresentation in clinical trials with serum creatinine inclusion criteria (RQ: 0.40 vs 0.86, P = 0.034).

Conclusions: Strategies are needed to increase minority enrollment in clinical trials for metastatic CRC. Identification of systemic barriers is integral in public policy advocacy to increase representation.

Objective: To identify whether depression, resilience, and perceived control of health are related to 2.5-year mortality and instrumental activities of daily living (IADL) decline among older adults after surgery.

Background: The relationships of psychosocial factors with postoperative mortality and IADL decline among older adults are understudied.

Methods: We identified 3778 community-dwelling older adults in the health and retirement study with Medicare claims for surgery [mean (SD) age: 75.4 (7.8) years, 53.9% women, and 86.0% non-Hispanic White]. We assessed associations of depression, resilience, and perceived control of health with 2.5-year postoperative mortality and IADL decline using Cox and modified Poisson regression analyses, adjusting for sociodemographic and health variables.

Results: The incidence of 2.5-year postoperative mortality was 18.5%, and IADL decline was 9.4%. Depression was associated with a higher incidence and adjusted hazard (95% CI) of mortality [26% vs 16%, adjusted hazard ratio: 1.2 (0.9, 1.5)], but high resilience was associated with a lower incidence and adjusted hazard of mortality [9% vs 21%, adjusted hazard ratio: 0.6 (0.5, 0.8)]. Those with depression had higher incidence and adjusted relative risk (95% CI) of IADL decline [17% vs 7%, aRR: 1.6 (1.2, 2.2)], but the lower incidence and adjusted relative risk of IADL decline were identified for those with high resilience [4% vs 11%, aRR: 0.6 (0.4, 1.0)] and high perceived control of health [7% vs 10%, aRR: 0.6 (0.4, 1.0)].

Conclusions: While depression confers a greater risk of mortality and IADL decline, higher resilience and perceived control of health may be protective. Addressing psychosocial factors in the perioperative period may improve outcomes among older adults.

Objective: To investigate whether prolonged time to surgery negatively affects survival, pathologic outcome, or postoperative complications in patients with histologically proven residual disease after neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal cancer.

Background: Historically, the standard time to surgery (TTS) has been 6 to 8 weeks after completion of nCRT. The effect of prolonged TTS is gaining interest, with contradicting results on survival and surgical morbidity. It can be hypothesized that, in patients with residual disease 6 weeks after completion of nCRT, prolonged TTS might be associated with worse survival and higher morbidity.

Methods: Patients with locally advanced esophageal cancer who had biopsy-proven residual disease 6 weeks after nCRT and underwent surgery, were categorized according to interval to surgery (TTS>12w vs TTS≤12w). The primary outcome of this study was overall survival. Secondary outcomes were disease-free survival, surgical outcomes, pathologic outcomes, and postoperative complications. Multivariable Cox regression was used for comparing survival and logistic regression for other outcomes, adjusted for the confounders age, cT, cN, Charlson comorbidity index, weight loss during nCRT, and WHO performance score after completion of nCRT.

Results: Forty patients were included for TTS>12w and 127 for TTS≤12w. TTS>12w was associated with better overall survival [adjusted hazard ratio (aHR) 0.46, 95% CI: 0.24-0.90], and disease-free survival (aHR 0.48, 95% CI: 0.24-0.94), but also with more postoperative respiratory complications (aOR 3.66, 95% CI: 1.52-9.59). Other outcomes were comparable between both groups.

Conclusions: Prolonged TTS in patients with histologically proven residual disease after completion of nCRT for esophageal cancer did not have a negative effect on overall and disease-free survival, but patients did have a higher risk for postoperative respiratory complications.

Objective: The aim of this study was to assess the impact of having a living donor on waitlist outcomes and overall survival through an intention-to-treat analysis.

Background: Living-donor liver transplantation (LDLT) offers an alternative to deceased donation in the face of organ shortage. An as-treated analysis revealed that undergoing LDLT, compared with staying on the waiting list, is associated with improved survival, even at Model for End-stage Liver Disease-sodium (MELD-Na) score of 11.

Methods: Liver transplant candidates listed at the Ajmera Transplant Centre (2000-2021) were categorized as pLDLT (having a potential living donor) or pDDLT (without a living donor). Employing Cox proportional-hazard regression with time-dependent covariates, we evaluated pLDLT's impact on waitlist dropout and overall survival through a risk-adjusted analysis.

Results: Of 4124 candidates, 984 (24%) had potential living donors. The pLDLT group experienced significantly lower overall waitlist dropouts (5.2% vs 34.4%, P <0.001) and mortality (3.8% vs 24.4%, P <0.001) compared with the pDDLT group. Possessing a living donor correlated with a 26% decline in the risk of waitlist dropout (adjusted hazard ratio=0.74, 95% CI: 0.55-0.99, P =0.042). The pLDLT group also demonstrated superior survival outcomes at 1 year (84.9% vs 80.1%), 5 years (77.6% vs 61.7%), and 10 years (65.6% vs 52.9%) from listing (log-rank P <0.001) with a 35% reduced risk of death (adjusted hazard ratio=0.65, 95% CI: 0.56-0.76, P <0.001). Moreover, the predicted hazard ratios consistently remained <1 across the MELD-Na range of 11 to 26.

Conclusions: Having a potential living donor significantly improves survival in end-stage liver disease patients, even with MELD-Na scores as low as 11. This emphasizes the need to promote awareness and adoption of LDLT in liver transplant programs worldwide.

Objective: Our investigation on in-hospital mortality after 4474 pancreatoduodenectomies aimed to identify time-dependent risks as well as windows of opportunity to rescue patients from complications.

Background: Pancreatoduodenectomy is generally considered a safe procedure with a 1% to 10% perioperative mortality based on complexity and surgical volume. Yet, patients are susceptible to life-threatening complications particularly with extended resections. Recognition of distinct vulnerabilities over time while patients recover is required to permit focused monitoring, sophisticated resource allocation, and the greatest surgical safety.

Methods: Patients who deceased in-hospital after pancreatoduodenectomy between 2003 and 2021 were retrieved from the institutional pancreatectomy registry and analyzed in detail with respect to their postoperative course.

Results: Among 4474 pancreatoduodenectomies, 156 patients deceased in-hospital (3.5%). When assessing root causes of mortality, we observed 3 different clusters of complications, which were postpancreatectomy-specific (51.9%), visceral vasculature-associated (25.6%), or cardiopulmonary in origin (17.9%). The median times of root cause onset in the 3 categories were postoperative day (POD) 9, POD 4.5 ( P =0.008), and POD 3 ( P <0.001), respectively. Medians of in-hospital mortality were POD 31, POD 18 ( P =0.009), and POD 8 ( P <0.001). Intervals between root cause onset and mortality varied with medians of 23 days, 11 days ( P =0.017), and 1 day ( P <0.001). The 3 categories were similarly distributed between different types of surgical complexity.

Conclusions: Postpancreatectomy-specific complications prompt almost half of the in-hospital mortalities after pancreatoduodenectomy, with rather long intervals for interventions to prevent failure to rescue. In contrast, visceral vasculature-related events and cardiopulmonary complications dominate early in-hospital mortalities with short intervals until mortality, demanding rigorous management of such events or preoperative conditioning. These data externally validate a previous high-volume initiative and highlight distinct windows of opportunity to optimize perioperative safety.

Objectives: Determine whether the timing of transplantation affects patient mortality.

Background: Neoadjuvant therapy and liver transplantation have emerged as an excellent treatment option for select patients with perihilar cholangiocarcinoma (pCCA). However, the optimal timing of transplantation is not known.

Methods: We reviewed all patients registered for a standardized pCCA protocol between 1996 and 2020 at our center. After adjusting for confounders, we examined the association of waiting time with patient mortality in an intention-to-treat cohort (n=392) and those who received a liver transplant (n=256).

Results: The median (interquartile range) time from registration to transplant or dropout was 5.74 (3.25-7.06) months. Compared with a short wait time (0-3 mo), longer waiting times did not affect all-cause mortality: (3-6 mo) hazard ratio (HR) 0.98; 95% CI: 0.52-1.84; (6-9 mo) HR: 0.80; 95% CI: 0.39-1.65; (9-12 mo) HR: 0.56; 95% CI: 0.26-1.22. Subgroups with a shorter waiting time had similar survival to those with long waiting times: living donor available HR: 0.97; 95% CI: 0.67-1.42; AB or B blood group HR: 0.93; 95% CI: 0.62-1.39. Longer waiting times were associated with decreased all-cause mortality after transplantation (HR: 0.92; 95% CI: 0.87-0.97). This benefit began after a 6-month waiting time minimum (HR: 0.53; 95% CI: 0.26-1.10) and increased further after 9 months (HR: 0.43 95% CI: 0.20-0.93). Waiting time was not associated with residual adenocarcinoma in the explant (odds ratio 0.99; 95% CI: 0.98-1.00).

Conclusions: A waiting time of at least 6 months will optimize results with transplantation without affecting overall (intention-to-treat) patient survival.