Annals of surgery最新文献

Objective: To determine whether the timing of parathyroid surgery impacts the risk of renal stone retreatment and cardiovascular interventions.

Background: Long-term, untreated primary hyperparathyroidism (pHPT) is associated with significant morbidity, including nephrolithiasis and cardiovascular disease.

Methods: We conducted a population-based cohort study of New York and California state-wide data from 2000 to 2020. Adult patients who underwent renal stone treatment and were subsequently diagnosed with pHPT and underwent parathyroidectomy (PTX) were included. Patients were excluded if PTX was before the index stone procedure, they underwent second stone treatment within 6 months, with stage V chronic kidney disease, with secondary or tertiary hyperparathyroidism, with prior kidney transplant or hemodialysis, or with prior cancer diagnosis. The rate of renal stone retreatment and cardiovascular interventions after PTX in patients with pHPT with nephrolithiasis who underwent parathyroid surgery at ≤2 years and >2 years after the index stone procedure was measured.

Results: We identified 2093 patients who underwent first-time stone treatment and subsequent PTX. The median time to PTX was 560 days (interquartile range: 187-1477), and follow-up was 7.4 years (interquartile range: 4.5-13.1). Delaying PTX for more than 2 years increased the risk of renal stone retreatment by 59% (HR=1.59; P <0.001), increased the risk of experiencing coronary disease or associated interventions by 118% (HR=2.18; P =0.01), and increased the risk of experiencing an overall cardiovascular event by 52% (HR=1.52; P <0.01).

Conclusions: In symptomatic pHPT, delaying PTX significantly increases the risk of requiring future stone retreatment and cardiac/vascular surgical interventions. This highlights the importance of early surgical referral and multidisciplinary approaches to optimize outcomes and resource utilization in pHPT.

Objective: To determine the optimal estimated glomerular filtration rate (eGFR) cutoff for use in risk stratification and prediction models.

Background: Chronic kidney disease increases morbidity and mortality in most vascular procedures. However, a binary classification of eGFR <60 mL/min/1.73 m 2 , which is often used in both modeling and clinical trials, may not be optimal for predicting clinical outcomes.

Methods: Vascular quality initiative data for nonemergent, first-time open aortic repair, endovascular aortic aneurysm repair, thoracic endovascular aortic repair, carotid endarterectomy, carotid artery stenting, peripheral vascular intervention, supra-inguinal bypass, and infra-inguinal bypass were analyzed from 2013 to 2023 and divided into cohorts based on eGFR (≥60, 45-59, 30-44, <30, and preoperative dialysis). χ 2 and logistic regression were used to evaluate perioperative outcomes.

Results: Compared with patients with eGFR ≥60, those with eGFR 45 to 59 had similar odds of mortality following all procedures, except thoracic endovascular aortic repair. Driven by this group, the combined cohort showed a slight increase in the odds of mortality for eGFR 45 to 59 (0.6% vs 0.7%, adjusted odds ratio(aOR): 1.16, P = 0.002). Those in the 30 to 44 group demonstrated increased odds of mortality both overall and in the individual procedure groups (0.6% vs 1.2%, aOR: 1.78, P < 0.001). The odds of mortality continued to increase with worsening eGFR. The overall rate of new permanent dialysis was low for all eGFR cohorts, with a 0.02% difference between those with eGFR ≥60 and those in the 45 to 59 cohort (0.04% vs 0.06%; aOR: 1.65, P < 0.001). The odds of permanent dialysis likewise continued to increase with decreasing eGFR.

Conclusions: Rather than a binary eGFR cutoff of ≥60 and <60 to stratify patient risk, better risk stratification may be achieved by using 5 groups of ≥60, 45 to 59, 30 to 44, <30, and preoperative dialysis.

Objective: We sought to determine how kidney transplant center volume impacts waitlisted candidate access to transplant.

Background: Over 90,000 candidates await a kidney transplant, of which we hypothesized that waitlist access is subject to significant program-level variation, potentially resulting in pseudo-access: a state where the waitlisted candidate does not achieve expected transplantation.

Methods: Center-level data on all US adult kidney transplant programs was collected using the Scientific Registry of Transplant Recipients program-specific reports, updated through December 31, 23. Programs (N=196) were stratified into quartiles by yearly deceased donor kidney transplant volume (Q1 lowest, Q4 highest); program acceptance practices and outcomes were compared.

Results: Compared with lower volume programs, Q4 programs transplanted a higher proportion of their waitlist (30.5% vs 13.1% for Q1; P <0.001) with a higher transplant rate ratio (1.41 vs 0.74 for Q1; P <0.001), and an accelerated time to transplant (median time to transplant ratio: 0.79 vs 1.2 for Q1; P =0.008). Offer acceptance ratios were significantly higher at Q4 programs, particularly for marginal allografts (KDRI >1.75: 1.51 vs 0.46 for Q1; P <0.001) and hard-to-place kidneys (>100 offers: 1.18 vs 0.25 for Q1; P <0.001). Despite increased utilization of more marginal grafts, Q4 programs demonstrated shorter post-transplant hospital lengths of stay [median 4 days (4-5) vs 6 (5-7) for Q1; P <0.001].

Conclusions: High-volume (HV) programs excel through aggressive organ utilization, while low-volume (LV) programs often provide pseudo-access to transplantation, characterized by low transplant rate ratios, conservative offer acceptance practices, and prolonged wait times. To increase kidney allograft utilization, LV programs unable to improve acceptance practices should consider consolidation or the development of access programs to facilitate candidate migration to HV centers.

Objective: To identify characteristics associated with high-quality and low-quality multi-hospital systems for major cancer surgery.

Background: Although multi-hospital health systems provide most inpatient health care in the United States, our understanding of how these systems can optimize surgical quality among their hospitals remains limited. Identifying the structural characteristics (eg, number of hospitals, procedural volume, geographic dispersion) that distinguish high-quality and low-quality systems may inform actionable strategies to improve surgical quality.

Methods: We conducted a retrospective cross-sectional observational study of 270,491 Medicare beneficiaries (2016-2020) undergoing major cancer surgery at a multi-hospital health system. Systems were classified into quartiles of quality based on risk-adjusted and reliability-adjusted rates of 30-day mortality using a hierarchical multivariable logistical regression model to adjust for patient, procedural, and hospital factors.

Results: The adjusted 30-day operative mortality rate in the highest-quality versus lowest-quality quartile of systems was 1.7% versus 3.1% ( P <0.001). High-quality systems had fewer hospitals per system [median (IQR), number of system hospitals, 5 (3-11) vs 12 (8-30); P <0.001], with each performing more procedures per hospital [median (IQR) annual procedure volume, 104 (52-218) vs 45 (22-90); P <0.001]. High-quality systems were also more geographically concentrated [median (IQR) maximum distance between hospitals, 62 (19-194) vs 321 (91-1125) miles; P <0.001]. Furthermore, high-quality systems demonstrated less variation in quality between hospitals [mean (SD) within-system absolute variation in mortality, 0.8% (0.3%) vs 2.6% (1.0%); P <0.001].

Conclusions: The highest-quality multi-hospital systems had fewer, more geographically concentrated hospitals, with each performing more procedures per hospital. Among the highest-quality systems, diverse system phenotypes were represented, suggesting the potential to overcome structural limitations and achieve high quality.

Objective: We aimed to better understand patients' treatment preferences and quantify the level of cancer risk at which treatment preferences change (risk threshold) to inform better counseling of patients with intraductal papillary mucinous neoplasms (IPMNs).

Background: The complexity of IPMN management provides an opportunity to align treatment with individual preferences.

Methods: We surveyed a sample of healthy volunteers simulating a common scenario: undergoing an imaging study that incidentally identifies an IPMN. In the scenario, the estimated risk of cancer in the IPMN was 5%. Patients were asked about their treatment preference (surgery or surveillance) to quantify the level of cancer risk in the IPMN at which their treatment preference would change (ie, risk threshold) and their level of cancer anxiety as measured on a 5-point Likert scale. We examined associations between participant characteristics, treatment preferences, and risk threshold using multivariable linear regression.

Results: The median risk threshold among the 520 participants was 25% (IQR 2.3%-50%). The risk threshold had a bimodal distribution: 40% of participants had a risk threshold between 0% and 10%, and 47% had a risk threshold above 30%. When informed that the risk of cancer was 5%, 62% of participants (n=323) preferred surveillance, and the remaining 38% (n=197) preferred surgery. After adjusting for potential confounders, participants who expressed "worry" or "extreme worry" about the malignancy risk of IPMN had significantly lower risk thresholds than participants who were "not at all worried" (Coefficient -12, 95% CI: -21 to -2, P =0.015 and Coefficient -18, 95% CI -29 to -8, P <0.001, respectively).

Conclusions: Participants varied in treatment preference and risk threshold of incidentally identified IPMNs. Given the uncertainty in estimating the true malignant potential of IPMNs, a better understanding of a patient's risk threshold, as influenced by patient concern about malignancy, will help inform the shared decision-making process.

Objective: To establish whether the Accreditation Council for Graduate Medical Education Milestones predict the future performance of general surgery trainees.

Background: Milestones provide bi-annual assessments of trainee progress across 6 competencies. It is unknown whether the Milestones predict surgeon performance after the transition to independent practice.

Methods: We performed a retrospective cohort study of surgeons with complete Milestone assessments in the fourth and fifth clinical years who treated patients in acute care hospitals within Florida, New York, and Pennsylvania, 2015-2018. To account for the multiple ways in which the Milestone assessments might predict postgraduation outcomes, we included 120 Milestones features in our elastic net machine learning models. The primary outcome was risk-adjusted patient death or serious morbidity.

Results: A total of 278 general surgeons were included in the study. Milestone assessments 6 months into the fourth clinical year displayed a normal score distribution while multicollinearity and low score discrimination at the final assessment period were detected. Individual Milestones features from the Patient Care, Professionalism, and Systems-based Practice domains were most predictive of patient-related outcomes. For example, surgeons with worse patient outcomes had significantly lower scores in Patient Care 3 when compared with surgeons with better patient outcomes (high DSM, yes: 2.86 vs no: 3.04, P =0.011).

Conclusions: The Milestones features that were most predictive of better patient outcomes related to intraoperative skills, ethical principles, and patient navigation and safety measured 12 to 18 months before graduation. The development of a parsimonious set of evidence-based Milestones that better correlate with surgeon experience could enhance surgical education.