Annals of surgery最新文献

Objective: To evaluate the impact of prophylactic antibiotics on early infectious complications after central venous access device (VAD) placement in children with cancer.

Background: Despite the frequency of VAD procedures in children, the effectiveness of prophylactic antibiotics for reducing infectious complications is unknown.

Methods: This was a retrospective cohort study of children with cancer undergoing central VAD placement identified in the Pediatric Health Information System database between 2017 and 2021. The primary outcome was the rate of early infectious complications (composite surgical site infections, central line-associated bloodstream infections, and bacteremia). Multivariable logistic regression was used to evaluate factors associated with early infection, and heterogeneity of treatment effect of prophylactic antibiotics was compared across subgroups.

Results: A total of 9216 patients were included (6058 ports and 3158 tunneled lines). Prophylactic antibiotics were associated with lower early infectious complications overall [1.3% vs 2.4%; odds ratio (OR): 0.55 (95% CI: 0.39-0.79), P < 0.001], an effect demonstrated for tunneled lines (OR: 0.59, 95% CI: 0.41-0.84) but not ports (OR: 3.01, 95% CI: 0.66-13.78). On multivariate analysis, prophylactic antibiotics (OR: 0.67, 95% CI: 0.45-0.97) and solid tumors (OR: 0.38, 95% CI: 0.22-0.64) were associated with reduced odds of early infections, whereas tunneled lines (OR: 20.78, 95% CI: 9.83-43.93) and acute myelogenous leukemia (OR: 2.37, 95% CI: 1.58-3.57) had increased odds.

Conclusions: Prophylactic antibiotics are associated with reduced early infectious complications after central VAD placement overall. Despite recommendations from multiple national organizations against prophylactic antibiotics, these findings suggest a benefit in children with malignancy undergoing tunneled line placement.

Objective: To evaluate the interaction between whole blood (WB) and blood component resuscitation in relation to mortality after trauma.

Background: WB is increasingly available in civilian trauma resuscitation, and it is typically transfused concomitantly with blood components. The interaction between WB and blood component transfusions is unclear.

Methods: Adult patients with trauma with a shock index >1 who received ≥4 combined units of red blood cells and/or WB within 4 hours across 501 U.S. trauma centers were included using the American College of Surgeons Trauma Quality Improvement Program database. The associations between (1) WB resuscitation and mortality, (2) WB to total transfusion volume ratio (WB:TTV) and mortality, and (3) balanced blood component transfusion in the setting of combined WB and component resuscitation and mortality were evaluated with multivariable analysis.

Results: A total of 12,275 patients were included (WB: 2884 vs component-only: 9391). WB resuscitation was associated with lower odds of 4-hour [adjusted odds ratio: 0.81 (0.68-0.97)], 24-hour, and 30-day mortality compared with component-only. Higher WB:TTV ratios were significantly associated with lower 4-hour, 24-hour, and 30-day mortality, with a 13% decrease in odds of 4-hour mortality for each 10% increase in the WB:TTV ratio [0.87 (95% CI: 0.80-0.94)]. Balanced blood component transfusion was associated with significantly lower odds of 4-hour [adjusted odds ratio: 0.45 (95% CI: 0.29-0.68)], 24-hour, and 30-day mortality in the setting of combined WB and blood component resuscitation.

Conclusions: WB resuscitation, higher WB:TTV ratios, and balanced blood component transfusion in conjunction with WB were associated with lower mortality in patients with trauma presenting in shock requiring at least 4 units of red blood cells and/or WB transfusion within 4 hours of arrival.

Objective: To understand views of staff in relation to attitudes, enablers, and barriers to implementation of environmentally sustainable surgery in operating theatres. This will ultimately help in the goal of successfully implementing more sustainable theatres.

Background: Global health care sectors are responsible for 4.4% of greenhouse gas emissions. Surgical operating theatres are resource intensive areas and improvements will be important to meet Net-Zero carbon emissions within health care.

Methods: Three databases were searched (Web of Science, Ovid, and PubMed), last checked January 2024. We included original manuscripts evaluating staff views regarding sustainable operating theatres. The Mixed Methods Appraisal Tool was used for quality appraisal and data analysed using thematic synthesis.

Results: A total of 2933 articles were screened and 14 fulfilled inclusion criteria, using qualitative (1), quantitative (2), and mixed methods (11). Studies were undertaken in a variety of clinical (Department of Anaesthesia, Surgery, Otolaryngology, Obstetrics and Gynaecology and Ophthalmology) and geographical settings (Australia, Canada, France, Germany, New Zealand, United States, United Kingdom, and Ireland). Across studies there was a lack of evidence exploring enablers to implementation, but barriers mainly related to the following themes: education and awareness, leadership, resistance to change, facilities and equipment, time, and incentive.

Conclusions: This systematic review identified attitudes and barriers perceived by clinicians towards improving environmental sustainability within operating theatres, which may inform future strategy towards sustainable surgery. Most studies used a survey-design, whereas use of interviews may provide deeper insights. Future work should be extended to wider stakeholders influencing operating theatres. In addition, implementation studies should be carried out to examine whether barriers do change in practice.

Objective: To use updated 2021 weighted Pediatric Readiness Score (wPRS) data to identify a threshold level of trauma center emergency department (ED) pediatric readiness.

Background: Most children in the United States receive initial trauma care at nonpediatric centers. The aim of the National Pediatric Readiness Project (NPRP) was to ensure that all EDs are prepared to provide quality care for children. Trauma centers reporting the highest quartile of wPRS on the 2013 national assessment have been shown to have lower mortality. Significant efforts have been invested to improve pediatric readiness in the past decade.

Study design: A retrospective cohort of trauma centers that completed the NPRP 2021 national assessment and contributed to the National Trauma Data Bank (NTDB) from 2019 to 2021 was analyzed. Center-specific observed-to-expected mortality estimates for children (0-15 y) were calculated using Pediatric Trauma Quality Improvement Program models. Deterministic linkage was used for transferred patients to account for wPRS at the initial receiving center. Center-specific mortality odds ratios were then compared across quartiles of wPRS.

Results: A total of 66,588 children from 630 centers with a median (interquartile range) wPRS of 79 (66-93) were analyzed. The average observed-to-expected odds of mortality [1.02 (0.97-1.06)] for centers in the highest quartile (wPRS≥93) was lower than any of the lowest 3 wPRS quartiles [1.19 (1.14-1.23) (Q1), 1.29 (1.24-1.33) (Q2), and 1.28 (1.19-1.36) (Q3), all P <0.05). The presence of a pediatric-specific quality improvement plan was the domain with the strongest independent association with mortality [standardized beta -0.095 (-0.146 to -0.044)].

Conclusion: Trauma centers should address gaps in pediatric readiness to include a pediatric-specific quality improvement plan and aim to achieve wPRS ≥93.

Objective: To describe the incidence of and risk factors for pregnancy complications in female cardiothoracic surgeons compared with women of similar sociodemographic profiles.

Background: Female cardiothoracic surgeons often postpone childbearing, but little is known about their pregnancy outcomes.

Methods: In 2023, a self-administered survey was distributed to US cardiothoracic surgeons/trainees. Surgeons with ≥1 live birth were queried on maternal work hours during pregnancy and major antenatal pregnancy complications. Male surgeons answered on behalf of non-surgeon childbearing partners (female non-surgeons).

Results: The study included 255 surgeons (63.53% male; 36.47% female). Compared with female surgeons, male surgeons more often had partners who were not employed outside the home (25.64% vs 13.33%, P <0.001). Female surgeons were older than female non-surgeons at first live birth (34.49±4.41 vs 31.45±4.16, P <0.001), more often worked >60 h/wk during pregnancy (70.33% vs 14.08%, P <0.001), and more often had pregnancy complications (45.16% vs 27.16%, P =0.003; operating room (OR): 1.78, 95% CI: 1.01-3.13). Among female surgeons, 18.28% reduced work hours during pregnancy. During their third trimester, 54.84% worked >6 overnight calls/mo, and 72.04% operated >12 h/wk. Age ≥35 years (OR: 3.28, 95% CI: 1.27-8.45) and operating >12 h/wk during the third trimester (OR: 3.72, 95% CI: 1.04-13.30) were associated with pregnancy complications.

Conclusions: Female cardiothoracic surgeons are more likely to experience major pregnancy complications than non-surgeon partners of their male peers. Long operative hours during pregnancy and older maternal age are significant risk factors for pregnancy complications. To advance gender equity, policies to protect maternal-fetal health and facilitate childbearing during training and early career are needed.

Objective: To examine the characteristics of patients with pancreatic cancer with long-term survival.

Background: Although pancreatic cancer is a highly lethal malignancy, a minority of patients experience long-term survival. The characteristics of these patients remain largely unidentified.

Methods: An indolent subgroup was established using carbohydrate antigen 19-9 (CA19-9), which is the best-validated biomarker for pancreatic cancer. Of 1558 patients, 13.9% were included in the CA19-9-normal (≤37 U/mL) subgroup.

Results: A normal CA19-9 level was an independent variable for overall survival (median survival, 18.1 vs 9.7 months, hazard ratio = 0.53, P < 0.001). The 5-year survival of patients with stage IV CA19-9-normal cancer was higher than that of patients with stage I-IV CA19-9-high cancer (22.4% vs 6.8%, P = 0.034). The CA19-9-normal subgroup exhibited reduced levels of circulating glucose ( P < 0.001) and increased expression of insulin ( P < 0.001) compared with the CA19-9-high subgroup. Glucose was a substrate for CA19-9 biosynthesis through the hexosamine biosynthesis pathway. In addition, in pancreatic cancer animal models of diabetes, glucose control decreased CA19-9 levels and improved overall survival. In a clinical trial (NCT05306028) of patients before undergoing major anticancer treatments, glucose control decreased CA19-9 levels in 90.9% of the patients.

Conclusions: CA19-9-normal pancreatic cancer is a strikingly indolent subgroup with low glucose and high insulin. Glucose control is a promising therapeutic strategy for pancreatic cancer.

Objective: To identify well-being threats for surgeons and anesthesiologists and develop interventions using the quality of life improvement (QOLI) approach.

Background: Developing feasible perioperative well-being interventions requires identifying shared and specialty-specific well-being needs. The QOLI framework integrates human-centered design, implementation science, and quality improvement to address well-being needs.

Methods: Anesthesia and surgery faculty in 8 perioperative departments at an academic medical center completed cross-sectional surveys containing validated measures of well-being and workplace satisfaction, and open-ended questions about professional motivations, pain points, strategies for improvement, and well-being priorities. Using template analysis, we analyzed open-ended survey data and presented resulting themes at a joint-specialty town hall for live voting to identify well-being priorities.

Results: One hundred four perioperative faculty completed the survey. Across specialties, higher Mental Health Continuum-Short Form scores (representative of individual global well-being) were associated with higher satisfaction with workplace control, values, decision latitude, and social support. Anesthesiologists reported lower satisfaction and control than surgeons across multiple domains. Template analysis yielded 5 areas for intervention: (1) work culture, (2) work environment/resources, (3) sources of fulfillment, (4) work/life harmony, and (5) financial compensation. Surgeons and anesthesiologists both prioritized high-quality patient care but differed in their other top priorities. The most frequently cited well-being threats for surgeons were operating room inefficiencies/delays and excessive workload, whereas anesthesiologists cited understaffing and unpredictable work hours.

Conclusions: Surgeons and anesthesiologists share many needs and priorities, with pain points that are often negatively synergistic. Applying the QOLI approach across specialties allows for well-being interventions that honor complexity and promote the development of feasible solutions.