Annals of surgery最新文献

Objective: To develop and evaluate machine learning algorithms for predicting patient-reported outcomes following breast reconstruction.

Summary of background data: Machine learning may inform PROs in breast reconstruction, possibly enhancing shared decision-making and tailoring patient care.

Methods: Data on patient characteristics, reconstructive technique, and BREAST-Q scores from women undergoing breast reconstruction at Memorial Sloan Kettering Cancer Center (MSKCC) between January 2010 and March 2024 was retrospectively collected. Five machine learning algorithms were developed and validated on this data to predict improved versus not improved BREAST-Q scores after reconstruction. Models were externally validated models using multicenter data from the Mastectomy Reconstruction Outcomes Consortium (MROC). Models were evaluated using the area under the receiver operator curve, sensitivity, specificity, and Brier score.

Results: A total of 4,776 patients (2,687 from MSKCC, 2,089 from MROC) were included in model development and validation. Machine learning algorithms demonstrated AUCs of 0.97 for physical wellbeing of the abdomen, 0.86 for satisfaction with breast, 0.79 for sexual wellbeing, 0.78 for physical wellbeing of the chest, and 0.74 for psychosocial wellbeing. Variables that contributed the most to model predictions across all domains were preoperative BREAST-Q scores, timing of radiation, BMI, age, and reconstructive technique.

Conclusions: Machine learning algorithms can accurately predict PROs before breast reconstruction. Ultimately, this data-driven approach may streamline shared decision-making and enhance patient-centered care.

Objective: To investigate accuracy of ICD-9/10 billing codes in a multicenter cohort.

Summary of background data: Health services research on appendicitis often relies on administrative databases. However, billing codes may misclassify disease severity, as we demonstrated previously in a single institution study.

Methods: We performed a multicenter study of adult patients with appendicitis who presented to one of six US medical centers during 2012-2015 (ICD-9 era) and 2018-2021 (ICD-10 era). Patients were identified based on ICD codes. Diagnosis was confirmed via chart review. Each patient was characterized as complicated or uncomplicated based on AAST criteria; this was considered the gold standard. Billing codes were compared to gold standard to calculate test parameters (i.e., sensitivity).

Results: 1832 patients met inclusion criteria. 54.1% were male, 25% non-white, and 44% publicly insured or uninsured. In total, 21.1% of patients had complicated appendicitis based on gold standard: 18.8% (312/1661) of surgical patients and 43.9% (75/171) of non-operative patients (P<0.001). Among all patients, 17.3% had a billing code for complicated appendicitis (12.5% true positives and 4.8% false positives). 40.8% (158 of 387) of patients with complicated appendicitis were misclassified as having uncomplicated appendicitis via ICD codes. Sensitivity and PPV for complicated appendicitis were 0.59 (95% CI: 0.54-0.64) and 0.72 (95% CI: 0.67-0.77), respectively.

Conclusions: Billing codes have poor sensitivity and PPV for distinguishing complicated from uncomplicated appendicitis. These results have significant implications for how we should interpret data from administrative database studies and construct future analyses. Inaccuracies in billing codes negatively impact hospital reimbursement, with tendency toward underpayment.

Summary of background data: Intraductal papillary mucinous neoplasm (IPMN)-derived pancreatic cancer is typically managed like pancreatic intraepithelial neoplasia (PanIN)-derived pancreatic cancer. However, in IPMN-derived pancreatic cancer, the role of chemotherapy remains controversial, particularly in the neoadjuvant setting (NAT).

Objective: To evaluate the role of neoadjuvant chemotherapy in IPMN-derived pancreatic cancer.

Methods: Patients with IPMN-derived pancreatic cancer treated with either upfront surgery (US) or NAT were identified from eight international centers (2000-2023). Clinicopathologic data were compared. Date of first treatment was used for Kaplan-Meier and log-rank tests to compare overall (OS) and recurrence free survival (RFS). Multivariable Cox-regression was performed in patients that underwent NAT.

Results: In 1,019 patients, 76 (7%) underwent NAT. Patients who received NAT had higher baseline CA19-9 levels (P<0.001). Of these 76 patients, 27 (36%), 20 (26%), and 29 (38%) had resectable, borderline resectable, or locally advanced pancreatic cancer at diagnosis, respectively. Advanced resectability stage was significantly more common in the NAT patients as compared to those who underwent US (P<0.001). OS for US patients was 38.0 months (95%CI: 33.7.1-44.3), which was not statistically different than those that received NAT [27.5 mo (95%CI: 23.1-46.7), P=0.121]. This was also valid for patients with resectable disease [US: 38.1 mo vs. NAT: 35.6 mo, P=0.920)]. Complete or marked pathological treatment response (P=0.046) and serological CA19-9 normalization after NAT (P=0.017) were associated with improved survival. On Cox-regression for OS, N2 disease [HR: 4.15 (95%CI: 1.71-10.10)], elevated CA19-9 [HR: 2.02 (95%CI:1.06-3.85)] and R1 margin [HR: 2.36 (95%CI:1.20-4.61)] was independently associated with OS after NAT, while resectability status was not.

Conclusion: After NAT and resection, advanced resectability stage was not associated with worse OS indicating the value of this approach for borderline resectable and locally advanced IPMN-derived pancreatic cancer. The benefit of NAT in resectable disease is unclear and may require an individualized approach. Biological treatment effect can be assessed with CA19-9 and confirmed by pathologic response.

Objective: To assess factors affecting the cumulative lifespan of a transplanted liver.

Background: Liver aging is different from other solid organs. It is unknown how old a liver can actually get after liver transplantation.

Methods: Deceased donor liver transplants from 1988 to 2021 were queried from the United States UNOS registry. Cumulative liver age was calculated as donor age + recipient graft survival.

Results: In total, 184,515 livers were included. Most were donation after brain death donors (n = 175,343). The percentage of livers achieving >70, 80, 90, and 100 years cumulative age was 7.8% (n = 14,392), 1.9% (n = 3576), 0.3% (n = 528), and 0.01% (n = 21), respectively. The youngest donor age contributing to a cumulative liver age >90 years was 59 years, with posttransplant survival of 34 years. In pediatric recipients, 736 (4.4%) and 282 livers (1.7%) survived >50 and 60 years overall, respectively. Transplanted livers achieved cumulative age >90 years in 2.86 per 1000 and >100 years in 0.1 per 1000. The U.S. population at large has a cumulative "liver age" >90 years in 5.35 per 1000 persons, and >100 years in 0.2 per 1000. Livers aged >60 years at transplant experienced both improved cumulative survival ( P < 0.0001) and interestingly improved survival after transplantation ( P < 0.0001). Recipient warm ischemia time of >30 minutes was most predictive of reduced cumulative liver survival overall (n = 184,515, hazard ratio = 1.126, P < 0.001) and excluding patients with mortality in the first 6 months (n = 151,884, hazard ratio = 0.973, P < 0.001).

Conclusions: In summary, transplanted livers frequently get as old as those in the average population despite ischemic-reperfusion-injury and immunosuppression. The presented results justify using older donor livers regardless of donation type, even in sicker recipients with limited options.

Objective: The aim of this study was to quantify lymph node metastasis (LNM) risk and outcomes following treatment of early esophago-gastric (EG) adenocarcinoma.

Background: The standard of care for early T1N0 EG cancer is endoscopic resection (ER). Radical surgical resection is recommended for patients perceived to be at risk of LNM. Current models to select organ-preserving versus surgical treatment are inconsistent.

Methods: CONGRESS is a UK-based multicenter retrospective cohort study. Patients diagnosed with clinical or pathological T1N0 EG adenocarcinoma from 2015 to 2022 were included. Outcomes and rates of LNM were assessed. Cox regression was performed to assess the impact of prognostic and treatment factors on overall survival.

Results: A total of 1601 patients from 26 centers were included, with median follow-up 32 months (IQR 14-53). 1285/1612 (80.3%) underwent ER, 497/1601 (31.0%) underwent surgery. Overall rate of LNM was 13.5%. On ER staging, tumour depth (T1bsm2-3 17.6% vs T1a 7.1%), lymphovascular invasion (17.2% vs 12.6%), or signet cells (28.6% vs 13.0%) were associated with LNM. In multivariable regression analysis, these were not significantly associated with LNM rates or survival. Adjusting for demographic and tumour variables, surgery after ER was associated with significant survival benefit, HR 0.33 (0.15-0.77), P =0.010.

Conclusions: This large multicenter data set suggests that early EG adenocarcinoma is associated with significant risk of LNM. These data are representative of current real clinical practice with ER-based staging, and suggests previously held beliefs regarding reliability of predictive factors for LNM may need to be reconsidered. Further research to identify patients who may benefit from organ-preserving versus surgical treatment is urgently required.

Objective: To delineate how identity-based bias exposure evolves with rank and/or context among health care workers, and assess their attitudes toward existing diversity, equity, and inclusion (DEI) education.

Background: Although DEI training is widely mandated for health care workers, few studies examine how clinicians' needs evolve across a career, how context impacts recipients' ability to respond, or how well existing programs adapt to individual contexts.

Methods: A 54-question electronic survey was distributed during Morbidity and Mortality conferences beginning in December 2020. Descriptive statistics were performed regarding respondents' bias exposure across rank, perceptions regarding existing training's fidelity to recipients' lived experience, and ability to confer useful response strategies.

Results: This study included 648 individuals (65.6% White; 50.2% women) practicing in mostly academic medical centers (70.6%). Respondents affirmed that discrimination was common, with half (320, 49.4%) reporting that they experienced bias at least monthly. Among people of color, the proportion reporting monthly exposure decreased with rank. Women of color experienced the biggest drop (74% as residents/fellows down to 11% in late career). Broadly, participants reported the greatest discomfort in addressing subtle bias from patients or high-ranked individuals, and this did not uniformly improve with seniority. Finally, although 478 (73.8%) individuals reported receiving DEI training, 51.3% of respondents reported online DEI modules had little utility. Shortcomings included that training focused on individual rather than structural solutions and that it did not confer response strategies users could reliably employ.

Conclusions: Identity and context strongly influence both clinicians' exposure and ability to respond to bias in the hospital environment, independent of seniority. Existing DEI training fails to account for this nuance, ultimately diminishing its utility to clinicians.

Objective: To assess the incidence of posthepatectomy liver failure (PHLF) and the role of the future liver remnant (FLR) in children undergoing major hepatectomy.

Background: Incidence and risk factors of PHLF in children are unclear, with no validated definition for this age group. Consequently, the role of the FLR in pediatric hepatectomy and evidence-based preoperative guidelines remains undefined.

Methods: All pediatric patients undergoing major hepatectomy at a tertiary care center over a 10-year study period were analyzed. Preoperative imaging was used for volumetry. The incidence of PHLF was assessed by applying predefined definitions, and the prognostic impact of the FLR on PHLF and complications was evaluated.

Results: A total of 125 children underwent major hepatectomy, including 35 trisectionectomies. There was a strong correlation between imaging-based measured total liver volume (TLV) and calculated standard liver volume ( r = 0.728, P < 0.001). The median TLV-to-body weight (BW) ratio was 3.4%, and the median FLR/BW ratio was 1.5%. The median FLR-to-TLV ratio was 44% (range: 18%-97%). No clinically relevant PHLF occurred. FLR/TLV and FLR/BW ratios had low predictive value for postoperative liver dysfunction and morbidity.

Conclusions: This is the largest reported single-center series of pediatric major hepatectomies. PHLF is exceedingly rare in children. The liver volume-to-BW ratio is higher in children compared with adults, and the FLR is sufficient even in extreme resections with <20% of the liver remnant. These findings strongly question the use of asociating liver partition and portal vein ligation for staged hepatectomy, portal vein embolization, or transplantation based on suspected insufficient liver remnants in children.