Annals of surgery最新文献

Objective: To compare perioperative outcomes in patients undergoing minimally invasive liver surgery (MILR) with or without central venous pressure (CVP) reduction (≤5 mmHg).

Background: Reduction CVP during parenchymal transection is widely accepted in open hepatectomy to reduce intraoperative blood loss, as a major predictor of postoperative outcomes. However, the effect of CVP reduction on blood loss in MILR remains unclear.

Methods: Randomized controlled, double-blinded trial. Patients undergoing elective MILR between August 2020 and April 2023 were equally randomized to either no CVP reduction (No CVP reduction group) or CVP reduction by anesthesiological interventions (CVP reduction group). The remaining perioperative care was kept identical between groups. The primary endpoint was total intraoperative blood loss.

Results: In total 120 patients were randomized and 112 were analyzed. Baseline characteristics did not differ between groups. Total intraoperative blood loss in MILR was equivalent between groups (No CVP reduction: 280 mL (120-560) versus CVP reduction: 360 mL (150-640); P=0.30), despite higher CVP values during resection in the No CVP reduction group (9.3 mmHg±4.2 versus 3.2 mmHg±2.2; P<0.001). Similarly, there was no difference in blood loss during parenchymal transection between the No CVP reduction (220 mL; 80-400) and the CVP reduction group (240 mL;110-560) (P=0.39). Postoperative 90-day mortality (No CVP reduction: n=3, 5% versus CVP reduction: n=2, 4%; P=0.68) and total morbidity rates (No CVP reduction: n=10, 18% versus CVP reduction: n=11, 20%; P=0.77) were comparable. Intraoperative hemodynamic instability was less frequent in the No CVP reduction group (n=7, 12% versus CVP reduction group: n=16, 30%; P=0.03).

Conclusions: MILR without CVP reduction during liver transection is safe and is not associated with increased intraoperative blood loss. Moreover, a no-CVP-reduction strategy might prevent potential adverse effects of fluid restriction in MILR, such as hemodynamic instability.

Objective: To assess the prevalence of chronic pain and sexual dysfunction after groin hernia repair in adolescents.

Summary background data: Adolescents present unique challenges in groin hernia management due to their evolving anatomy, yet data on patient-reported outcomes remain limited.

Methods: A nationwide survey was conducted in Denmark, linking patient-reported outcomes to the Danish National Patient Register and Civil Registration System. Patients who underwent primary unilateral groin hernia repair during adolescence (10-19 years) between 1992 and 2022 were identified. The primary outcome was chronic pain assessed with the short-form Inguinal Pain Questionnaire. Secondary outcomes included chronic pain assessed with the Activities Assessment Scale and sexual dysfunction assessed with the Sexual Inguinal Hernia Questionnaire.

Results: Among 2,486 participants (response rate: 60.8%) completing the survey (80% male; median age at repair 16 [IQR, 12-19] years), 7.3% (95% CI, 6.3-8.4) reported chronic pain across all follow-up periods. In participants with less than 15 years of follow-up, 9% to 15% reported chronic pain depending on age at the time of repair and repair method. Chronic pain during sexual activity was reported by 8.6% (95% CI, 7.5-10) of participants. No significant differences in chronic pain or sexual dysfunction were observed between repair methods. Femoral hernia repairs were rare.

Conclusions: Chronic pain and sexual dysfunction were common long-term complications of groin hernia repair in adolescents, regardless of repair methods. Optimizing outcomes could include a tailored, patient-centered approach by hernia experts, ensuring optimal care for this unique, young, low-volume population within hernia surgery.

Objectives: This study aims to provide a comprehensive update on the representation of women in academic surgery by specialty, measuring progress and opportunity with regard to women "breaking" the glass ceiling at the trainee, faculty, and department chair levels.

Background: Over the past two decades, initiatives have contributed to educational awareness, culture shifts, and a focus on inclusive excellence in surgery, leading to an increase in the number of women surgeons. Despite progress, a persistent gender gap in surgical faculty positions remains, and projections suggest that it will take more than a century to reach parity at the highest levels of academic surgery.

Methods: Data from the Association of American Medical Colleges FACTS and Faculty Rosters and the American Medical Colleges and Graduate Medical Education reports from 2006 to 2023 were analyzed to assess gender representation in surgery. Linear regression analyses were used to describe trends in the proportions of women who are promoted along the professional development pathway (resident to faculty to department chair) from 2006 to 2023.

Results: Over our 17-year study period, all included surgical subspecialties increased in the proportion of women trainees, with the largest average annual increase in the proportion of women trainees observed in pediatric, plastic, and vascular surgery training programs. Although all surgical faculty levels experienced growth in the proportion of women, the average annual change in the proportion of women decreased as seniority increased. At the observed trend, it is projected that surgical department chairs will not achieve equal proportions of men and women until the year 2102.

Conclusion: Across the board, the proportion of women in surgery has increased. However, there remains opportunity for improvement, particularly at the senior faculty and department chair levels. There continues to be significant opportunity around retention and promotion of women.

Objective: To evaluate the outcomes of a multidisciplinary effort involving surgical and gastroenterological departments in managing bowel dysfunction, specifically low anterior resection syndrome (LARS), following rectal cancer treatment.

Summary background data: An increasing number of rectal cancer survivors experience LARS, heightening the need for specialized treatment.

Methods: Patients referred to our late sequelae clinics with LARS following sphincter-preserving treatment were eligible for inclusion. Patients were treated in the surgical or gastroenterological units or both based on symptoms. Patients completed patient-reported outcome measures at the first visit, upon discharge, and 12 months after discharge. Treatment outcomes were evaluated by the LARS score and its five single items, six single items covering additional LARS symptoms, the EuroQoL 5-dimension 5-level (EQ-5D-5L) VAS and utility scores, self-rated bowel function, and bowel function impact on quality of life (QoL).

Results: We included 201 patients. Three-quarters were treated in the surgical units, whereas the rest required gastroenterological treatment. After treatment, the mean LARS score decreased by 4.7 points (P<0.001), whereas the mean EQ-VAS and utility score increased by 7.1 (P<0.001) and 0.06 points (P<0.001), respectively. All individual symptoms significantly improved. Improvement in self-rated bowel function and bowel function impact on QoL were 55.8% (P<0.001) and 45.7% (P<0.001), respectively. Similar results were recorded at the 12-month follow-up.

Conclusion: These results encourage establishing late sequelae clinics with a joint gastroenterological and surgical approach to treat LARS following rectal cancer treatment.

Objective: To evaluate the long-term outcomes of laparoscopic pylorus-preserving gastrectomy (LPPG) with laparoscopic distal gastrectomy (LDG) for early gastric cancer.

Background: Pylorus-preserving gastrectomy is considered a function-preserving surgery for early gastric cancer. However, there has been no multicenter randomized controlled trial comparing pylorus-preserving gastrectomy with distal gastrectomy until now.

Methods: A multicenter randomized controlled trial (KLASS-04) with 256 patients with cT1N0M0 gastric cancer located in the mid portion of the stomach was conducted. The primary endpoint was the incidence of dumping syndrome at postoperative 1 year. Secondary endpoints included survival and recurrence, gallstone formation, nutritional parameters, gastroscopic findings, and quality of life for 3 years.

Results: In the intention-to-treat analyses, there was no difference in the incidence of dumping syndrome at 1 year postoperatively (13.2% in LPPG vs 15.8% in LDG, P = 0.622). Gallstone formation after surgery was significantly lower in LPPG than in LDG (2.33% vs 8.66%, P = 0.026). Hemoglobin (+0.01 vs -0.76 gm/dL, P < 0.001) and serum protein (-0.15 vs -0.35 gm/dL, P = 0.002) were significantly preserved after LPPG. However, reflux esophagitis (17.8% vs 6.3%, P = 0.005) and grade IV delayed gastric emptying (16.3% vs 3.9%, P = 0.001) were more common in LPPG. Changes in body weight and postoperative quality of life were not significantly different between groups. Three-year overall survival and disease-free survival were not different (1 case of recurrence in each group, P = 0.98).

Conclusions: LPPG can be used as an alternative surgical option for cT1N0M0 gastric cancer in the mid portion of the stomach.

Objective: The primary objective was to compare the rates of early allograft dysfunction (EAD) in patients undergoing elective adult live donor liver transplantation (ALDLT) with and without graft portal inflow modulation (GIM) for portal hyperperfusion. The secondary objectives were to compare time to normalization of bilirubin and International Normalized Ratio, day 14 ascitic output more than 1 L, small-for-size syndrome, intensive care unit/high dependency unit and total hospital stay, and 90-day morbidity and mortality.

Background: GIM can prevent EAD in ALDLT patients with portal hyperperfusion.

Methods: A single-center randomized trial with and without GIM for portal hyperperfusion by splenic artery ligation (SAL) in ALDLT was performed. After reperfusion, patients with portal venous pressure (PVP)>15 mm Hg with a gradient (PVP-central venous pressure) of ≥7 mm Hg and/or portal venous flow (PVF) >250 mL/min/100 g of liver were randomized into 2 groups: GIM and No GIM.

Results: 75 of 209 patients satisfied the inclusion criteria, and 38 underwent GIM. Baseline PVF and PVP were comparable between the GIM and no GIM groups. SAL significantly reduced the PVF and PVP ( P <0.001). There were no significant differences in the primary and secondary outcomes between the 2 groups. In the subgroup analysis, with a Graft to Recipient Weight Ratio ≤0.8, there were no significant differences in the primary and secondary outcomes.

Conclusions: SAL significantly decreased PVP and PVF but did not decrease rates of EAD in adult LDLT.

Objective: To investigate the impact of carotid interventions on the mental well-being of patients with carotid stenosis.

Background: Ongoing research highlights the effect of carotid interventions on neurocognitive function in patients with advanced carotid atherosclerosis. However, data regarding the impact of carotid revascularization on mood are scarce.

Methods: A total of 157 patients undergoing carotid revascularization were prospectively recruited. The primary outcome was depressive mood, evaluated preoperatively and at 1-, 6-, and 12-month postintervention using the long form of the geriatric depression scale (GDS-30) questionnaire. Other tests were also used to assess cognition at the respective timepoints. Statistical analyses were performed to assess the postoperative outcomes compared with baseline.

Results: Baseline depression (GDS>9) was observed in 49 (31%) subjects, whereas 108 (69%) patients were not depressed (GDS≤9). The average preoperative GDS score was 15.42 ± 4.40 (14.2-16.7) and 4.28 ±2.9 (3.7-4.8) in the depressed and nondepressed groups, respectively. We observed a significant improvement in GDS scores within the depressed group at 1 month ( P =0.002), 6 months ( P =0.027), and 1 year ( P <0.001) postintervention compared with pre-op, whereas the nondepressed group had similar post-op GDS scores at all timepoints compared with baseline. Significant improvement in measures of executive function was seen in nondepressed patients at all 3 timepoints, whereas depressed patients showed an improvement at 1-year follow-up.

Conclusions: Our study highlights improvement in mood among patients with advanced carotid disease who screened positive for depression at baseline. Further studies with larger sample sizes are warranted to investigate the association between depression, carotid disease, and carotid intervention.