Annals of surgery最新文献

Objective: To explore the association of socioeconomic status (SES) and race/ethnicity with perioperative metrics within the Enhanced Recovery After Surgery (ERAS) framework to identify gaps for equity-informed improvements.

Summary background data: Although ERAS pathways improve perioperative outcomes through standardized care, disparities in protocol adherence and postoperative outcomes persist, particularly for vulnerable populations.

Methods: We conducted a retrospective cohort study using a single-institution database of elective colorectal surgeries (2018-2021). Patients were categorized and assessed by SES and race/ethnicity.

Results: Overall, 1,519 patients were analyzed: 180 had low SES (11.8%) and 1,339 - high SES (88.2%). Low SES patients had lower rates of bowel preparation completion, use of the electronic patient portal, and carbohydrate loading pre-surgery. Low SES was associated with a longer median length of stay (LOS) (4 vs. 3 days, P<0.001). Multivariate logistic regression analysis showed low SES was linked to higher odds of infectious (OR 2.46, 95%CI: 1.31-4.63) and all in-hospital complications (OR 1.50, 95%CI: 1.06-2.12). Among racial/ethnic cohorts, Black patients had lower rates of documented preoperative patient education, longer median LOS (5 vs. 3-4 days, P=0.002), and increased odds of respiratory complications (OR 4.11, 95%CI: 1.56-10.85).

Conclusions: Low SES was linked to lower compliance with important process measures, higher infectious and all in-hospital complication rates, and longer LOS. Despite high rates of protocol compliance, Black race/ethnicity showed an association with increased odds of respiratory complications and extended LOS. Adjustments to perioperative protocols could address such disparities, helping to improve postoperative outcomes of colorectal surgeries.

Objective: To explore the perspectives and experiences of patients and carers living with the long-term consequences of pelvic exenteration.

Summary background data: Pelvic exenteration is accepted as the standard of care for selected patients with locally advanced or recurrent rectal cancer. With contemporary 5-year survival reported at 40-60%, the number of long-term survivors is expected to increase. The long-term consequences of such radical surgery for patients and their survivorship needs are not well understood.

Methods: This was an exploratory, qualitative study conducted at a high-volume pelvic exenteration centre. Semi-structured interviews were conducted with survivors of pelvic exenteration surgery for locally advanced or recurrent rectal cancer and their carers. Purposive sampling was used to ensure a diverse cohort. Data were thematically analysed.

Results: Three major themes were identified: 1. The consequences of surgery are the price you pay for survival: the majority of participants accepted the sequelae of surgery as the cost of survival. 2. Our lives are changed forever: Adjusting to changes in body appearance and function was an ongoing challenge. Chronic pain, stomas, altered bowel function and mobility issues impacted work and social life. 3. The good days and bad days as a survivor: While several participants reported a more positive approach to life, many were living with a pervasive fear of recurrence and/or dying, and the ripple effect on family and friends was significant.

Conclusions: Although survivors of pelvic exenteration accept the long-term consequences of surgery as the price of survival, these are significant, and improved access to support services in the community may better equip survivors to manage these challenges.

Objective: Evaluate an electronic platform for remote symptom monitoring to enhance postdischarge care in thoracic surgery using patient reporting of symptoms.

Summary background data: Owing to the increased use of enhanced recovery after surgery protocols, patients are spending a larger portion of their postoperative course at home. For patients undergoing complex operations, this represents an opportunity for early identification of abnormal symptoms at home before deterioration.

Methods: An online symptom-tracking platform for thoracic surgery patients was created on the basis of opinions from stakeholders and a review of the literature. Starting in February 2021, patients were educated about the symptom tracker in preoperative clinics. After discharge, patients received a series of electronic surveys covering 23 symptom domains assessed using a Likert scale for severity. Moderate symptoms prompted a "yellow alert," and severe symptoms prompted a "red alert," both notifying the nursing team and prompting appropriate action. Patients were considered responders if they completed at least 1 survey.

Results: In total, 1997 patients were enrolled; 76% (n=1520) were responders. Responders were younger, more likely to be White, less likely to have medical comorbidities, and less likely to be readmitted (odds ratio, 0.53 [95% CI, 0.37-0.76]; P<0.001). Responders who were readmitted had a higher percentage of red alerts (47% vs. 24%; P<0.001) and yellow alerts (74% vs. 61%; P=0.016), compared with responders who were not readmitted.

Conclusions: Electronic reporting adds an additional mechanism of communication between the patient and the clinical team, with the potential to lower the odds of readmission.

Objective: To characterize the extent of private equity (PE) investment affecting surgical care.

Background: Over the last decade, investor-backed, for-profit PE groups have invested in health care at an unprecedented rate, but the breadth of these investments affecting surgical practice remains largely unknown.

Methods: Four nationally representative databases were used to identify all merger/acquisitions involving surgical practices between 2015 and 2019, determine PE investment in those transactions, and link the acquisitions with a physician data set.

Results: A total of 1542 unique transactions were identified, of which 539 were financed by PE. Fifty-eight transactions were then classified into their respective categories within surgical care: digestive disease, orthopedics, urology, vascular surgery, and plastic/cosmetic surgery. These transactions accounted for 199 practice sites and 1405 physicians, averaging 24.2 physicians per transaction. Acquisition activity peaked in 2017, with a total of 63 practices involved. Digestive disease, urology, and orthopedic surgery accounted for the most activity. General surgeons were involved in a small share of the digestive disease practice acquisitions. Three "surgery-adjacent" categories were also identified: anesthesiology, ambulatory surgery centers, and surgical staffing firms. Among these, anesthesia was the largest category in terms of practices (194) and physicians (2660) involved in transactions across the study period. Medical Service Organizations were a key mechanism through which PE firms invested in surgical care.

Conclusions: PE has engaged in substantial investment within surgical specialties, creating increased practice consolidation. These investments affect all levels of medical care and have notable implications for patients, practitioners, and policymakers.

Objective: Provide reports of the Blue Ribbon II Subcommittees.

Background: The Blue Ribbon Committee II (BRC II) was a panel of 67 experts selected on the basis of experience and leadership in surgical education and training.

Methods: It was organized into subcommittees, each of which was asked to prepare a manuscript on their findings and recommendations. The BRC II Subcommittees were: Blue Ribbon Committee 1 Review and Assessment, Surgical Workforce, Medical Student Education, Work Life Integration, Resident Education, Goals, Structure and Financing of Training, Education Support and Faculty Development, Research Training, and Educational Technology and Assessment. BRC II used the Delphi approach with consensus defined as equal to or greater than 80% and identified and recommended 31 priorities for surgical education in 2024.

Results: The initial findings were presented to a general surgery and related specialty resident and fellow focus group for comments and written feedback, and they were asked to prepare a manuscript as well.

Conclusions: The reports of the Subcommittees of the BRC II provide an assessment and key recommendations concerning surgical education and training in 2024.

Background: In September 2022, a summit was convened by the American Board of Surgery (ABS) to discuss competency-based reform in surgical education. A key output of that summit was the recommendation that the prior work of the Blue Ribbon I Committee convened 20 years earlier be revived. With leadership from the American College of Surgeons (ACS) and the American Surgical Association (ASA), the Blue Ribbon Committee (BRC) II was subsequently convened. This paper describes the output of the Residency Education Subcommittee of the BRC II Committee.

Methods: The Subcommittee organized its work around prioritized themes, including curriculum, assessment, and transition to practice. Top recommendations, time-based action steps, potential barriers, and required resources were detailed and vetted through group discussion, broader Committee review and critique, and subsequent refinement.

Results: Primary concluding emphases included transitioning to a competency-based training model, facilitating dynamically capable curricular reform emphasizing the digital transformation of surgical care, using predictive analytic assessment strategies to optimize training effectiveness and efficiency, and creating mentorship strategies to govern the transition from training to independent practice in an outcomes-accountable fashion.

Conclusions: To implement the recommendations outlined, it was recognized that coordinated efforts across existing organizational structures will be required, informed by data set integration strategies that meaningfully measure educational and related patient outcomes.

Objective: To update and add to the first report commissioned by the Blue Ribbon Committee (BRC) about 20 years prior.

Background: Following a summit in late 2022 commissioned by the American Board of Surgery regarding competency-based reforms in surgical education and through a partnership with the American College of Surgeons and other stakeholders, a BRC-II on surgical education was formed. The BRC-II would have 7 subcommittees. This paper details the work of the Medical Student Subcommittee within the BRC-II.

Methods: The subcommittee's work, supported by staff from the American College of Surgeons, entailed a thorough literature review, which involved collating and aggregating the findings, identifying key challenges and opportunities, and committing to draft recommendations. These recommendations were then presented and refined through discussions with the BRC at large in multiple virtual and in-person settings.

Results: The subcommittee's work is detailed below and further summarized in table format. The section below elucidates the medical student education continuum and discusses the pertinent topics of recruitment, surgical engagement in medical student training and the surgical image, training for the current surgical practice model, trainee selection for graduate medical education, and optimizing the transition from undergraduate medical education to graduate medical education.

Conclusions: The last 2 decades have shown significant changes and shifts in medical education and surgical practice. The findings of BRC-II in this manuscript help to structure the current and future necessary improvements, focusing on different aspects of medical student education.

Objective: To review the current state of research training during surgical residency and make recommendations commensurate with current surgical training and academic environment.

Background: Research training has been a mainstay of academic surgical programs, yet the scientific disciplines have evolved significantly from the traditional years of bench research. It is time to reconsider how research training should prepare surgeons for future academic practice and ensure the foundational knowledge of research evidence.

Methods: As part of the Blue Ribbon Committee II, a research subcommittee was tasked to make recommendations on research training during surgical residency. Our 8-member panel brought diverse perspectives on the roles and goals of research training. We also sought input from a convenience sample of current and recent surgical residents on the impact of research training during their residency.

Results: We identified a lack of a common framework and foundational research training for all surgical residents. Participation in dedicated years of scholarly activity helped trainees meet several professional and personal goals. The lack of an integrated, dedicated research track may dissuade some medical school graduates from pursuing surgery.

Conclusions: We recommend incorporating a minimum standard for all trainees and flexibility in dedicated scholarly training to meet the needs of future academic surgeons.