Annals of surgery最新文献

Objectives: Determine whether the timing of transplantation affects patient mortality.

Background: Neoadjuvant therapy and liver transplantation have emerged as an excellent treatment option for select patients with perihilar cholangiocarcinoma (pCCA). However, the optimal timing of transplantation is not known.

Methods: We reviewed all patients registered for a standardized pCCA protocol between 1996 and 2020 at our center. After adjusting for confounders, we examined the association of waiting time with patient mortality in an intention-to-treat cohort (n=392) and those who received a liver transplant (n=256).

Results: The median (interquartile range) time from registration to transplant or dropout was 5.74 (3.25-7.06) months. Compared with a short wait time (0-3 mo), longer waiting times did not affect all-cause mortality: (3-6 mo) hazard ratio (HR) 0.98; 95% CI: 0.52-1.84; (6-9 mo) HR: 0.80; 95% CI: 0.39-1.65; (9-12 mo) HR: 0.56; 95% CI: 0.26-1.22. Subgroups with a shorter waiting time had similar survival to those with long waiting times: living donor available HR: 0.97; 95% CI: 0.67-1.42; AB or B blood group HR: 0.93; 95% CI: 0.62-1.39. Longer waiting times were associated with decreased all-cause mortality after transplantation (HR: 0.92; 95% CI: 0.87-0.97). This benefit began after a 6-month waiting time minimum (HR: 0.53; 95% CI: 0.26-1.10) and increased further after 9 months (HR: 0.43 95% CI: 0.20-0.93). Waiting time was not associated with residual adenocarcinoma in the explant (odds ratio 0.99; 95% CI: 0.98-1.00).

Conclusions: A waiting time of at least 6 months will optimize results with transplantation without affecting overall (intention-to-treat) patient survival.

Objective: To evaluate the effectiveness of an intraoperative exoskeleton that supports surgeons' heads, necks, and backs to reduce neck discomfort.

Background: Surgeons are at a considerable risk of developing neck pain and related injuries. Passive exoskeletons are a potential intervention to support surgeons' body parts and alleviate strain and discomfort.

Methods: The NekSpine (a passive neck exoskeleton) was trialed on 12 surgeons (7 males and 5 females) across 6 specialties. Each surgeon performed 4 surgical procedures, 2 with the NekSpine (exoskeleton) and 2 without (baseline). Exoskeleton and baseline surgeries were paired primarily by surgical procedure and secondarily by duration. Surgeons completed surveys that included the NASA-TLX and usability questions before and after surgical procedures to evaluate body part discomfort, overall fatigue, workload, and potential disruptions to the surgical workflow. Surgeons also wore inertial measurement units to objectively record their upper arms, neck, and torso postures.

Results: Use of the exoskeleton yielded significant decreases in discomfort in the neck, left shoulder, right shoulder, and left arm. Reductions in percent surgical duration in risk 4 (extreme risk postures) coupled with increases spent in risk 2 (moderate risk postures) for the neck and torso were noted. Surgeons reported overall favorable usability results with the exoskeleton not interfering with the surgical workflow, and most stated that they would use the exoskeleton again.

Conclusions: The NekSpine is a promising intervention to alleviate surgeons' neck discomfort and improve their neck and torso postures.

Objective: To examine the role of Multidisciplinary Surgical Pause Committees (MDSPCs) in perioperative planning to reduce adverse postoperative events and mortality rates.

Background: Frail patients could benefit from preoperative MDSPCs when utilizing risk-benefit ratios for the proposed surgical plan. We examined whether MDSPCs improved clinical outcomes by developing individualized care plans and stratifying patients based on their level of frailty and ability to overcome external stressors.

Methods: We retrospectively collected patient information after MDSPC evaluation, at our medical center for 12 years since 2011. Patient's frailty Risk Analysis Index (RAI) scores were calculated, and survival status was updated. MDSPCs plans were put into the following categories: proceed with the planned surgery (G1), proceed after medical optimization (G2), reduce the invasiveness of surgery or anesthesia plan (G3), or adopt a nonsurgical approach (G4). χ 2 and independent t tests were used for categorical and numerical data, respectively. Survival analysis for 30-day (primary endpoint), 1-year, and overall mortality rates used Kaplan-Meier. The alpha was set at 0.05.

Results: Clinical information was accessed from 12 women and 382 men. The average age was 71 ± 11 years. Of planned surgical operations, 87.3% were stratified as American Society of Anesthesiologists class III and IV. RAI scores were 36.4 ± 9.6 (G1), similar to 37.4 ± 10.8 (G2) but lower than 41.4 ± 9.3 (G3) and 44.2 ± 9.7 (G4; P < 0.001). Average survival duration was 35 months (G1), 35 months (G2), both significantly longer than 20 months (G3) and 18 months (G4; P < 0.001).

Conclusions: Medical optimization improved overall survival and reduced death within 30 days and 1 year to be comparable to G1. In addition, reducing the surgical invasiveness only improved survival advantage for 6 months, after which it was comparable to those in G4 with the worst outcome. RAI scoring is an excellent tool to predict the outcome of surgery, and it was used successfully in critically ill patients.

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.