Annals of surgery最新文献

Objective: To review the evidence on mindfulness-based interventions (MBIs) for surgeons.

Background: Health care professionals have alarmingly high rates of burnout, yet little is known about psychological factors that support resilience. MBIs, which involve codified training in specific skills such as self-awareness, emotional regulation, and perspective-taking, have shown benefit to professionals in high-stress environments but have had limited implementation in the health care workplace and in surgery. To our knowledge, there has not been a scoping review of MBIs in surgery to date.

Methods: We conducted a scoping review of the evidence for the feasibility and effectiveness of MBIs for surgeons, including evidence on interventions that explicitly train mindfulness, which spans multiple cohorts and settings, utilizing different methodologies and outcome measures.

Results: This scoping review yielded 24 studies, including 2 mixed method/qualitative studies, 9 randomized control trials, 3 nonrandomized interventional studies, and 8 single-arm interventional studies.

Conclusions: We find that MBIs in surgery (1) are feasible in surgical contexts, with implementation science providing insights on sustainability; (2) increase mindfulness, (3) improve well-being in terms of burnout and both psychological and neurophysiological measures of stress, and (4) enhance performance as measured in executive function, surgical skills, and communication skills. These conclusions are supported by psychometric measures, observations of technical skills, and neurophysiological evidence. Future directions include studying MBIs in larger and more diverse populations and iteratively tailoring mindfulness-based interventions to other health care contexts.

Objective: Improvement of surgical care is dependent upon evidence-based practices (EBPs), policies, procedures, and innovations. The objective of this study was to understand and synthesize the use of implementation science (IS) in surgical care.

Background: This article summarizes the existing literature to identify the frequency and types of EBPs selected for surgical care, IS frameworks that guided the published research, and prominent facilitators and barriers.

Methods: A modified version of the Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews Checklist were used to provide the guidance and standards to conduct this scoping review. We queried Ovid MEDLINE, American Psychological Association PsycINFO, Embase, Cumulated Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar for manuscripts published January 2001-June 2023.

Results: The initial search found 3674 citations, of which 129 met the inclusion criteria. The heterogeneity and volume of innovations within the surgical IS field were vast. The most frequent innovations were in perioperative care, safety in surgery, and Enhanced Recovery After Surgery. Six constructs were identified as both major facilitators and barriers: support from leadership, surgeon and staff knowledge regarding EBPs, relationship/team building, environmental context, data, and resources.

Conclusion: Identifying these implementation factors used in the surgical field enables us to determine variables that support and inhibit the adoption and implementation of new practices, support practice change, enhance quality and equity of surgical care, and identify research gaps for future IS in surgical care.

Objectives: To define how dynamic changes in pre versus postoperative serum aspartate aminotransferase (AST) and alanine transaminase (ALT) levels may impact postoperative morbidity after curative-intent resection of hepatocellular carcinoma (HCC).

Background: Hepatic ischemia/reperfusion can occur at the time of liver resection and may be associated with adverse outcomes after liver resection.

Methods: Patients who underwent curative resection for HCC between 2010 and 2020 were identified from an international multi-institutional database. Changes in AST and ALT (CAA) on postoperative day 3 versus preoperative values ( ) were calculated using the formula: based on a fusion index through the Euclidean norm, which was examined relative to the Comprehensive Complication Index (CCI). The impact of CAA on CCI was assessed by the restricted cubic spline regression and Random Forest analyses.

Results: A total of 759 patients were included in the analytic cohort. Median CAA was 1.7 (range: 0.9-3.25); 431 (56.8%) patients had a CAA <2 215 (28.3%) patients with CAA 2 to 5, and 113 (14.9%) patients had CAA ≥5. The incidence of postoperative complications was 65.0% (n = 493) with a median CCI of 20.9 (interquartile range: 20.9-33.5). Spline regression analysis demonstrated a nonlinear incremental association between CAA and CCI. The optimal cutoff value of CAA was 5, identified by the recursive partitioning technique. After adjusting for other competing risk factors, CAA ≥5 remained strongly associated with the risk of postoperative complications (reference CAA <5, odds ratio: 1.63, 95% CI: 1.05-2.55, P = 0.03). In fact, the use of CAA to predict postoperative complications was very good in both the derivative (area under the curve: 0.88) and external (area under curve: 0.86) cohorts (n = 1137).

Conclusions: CAA was an independent predictor of CCI after liver resection for HCC. The use of routine laboratories, such as AST and ALT, can help identify patients at the highest risk of postoperative complications after HCC resection.

Objective: To analyze the impact of Body Mass Index (BMI) on clinical and patient-reported outcomes following gender-affirming mastectomy (GM).

Background: BMI is a barrier for obese patients seeking GM despite increasing evidence that it is safe in this population. Currently, little is known about the impact of BMI on chest-specific body image and satisfaction after GM.

Methods: This single-center, cross-sectional study included individuals 18 years and older who underwent GM between 1990 and 2020 and were at least 2 years postoperative. Patient-reported chest-specific body image was measured using the BODY-Q and Gender Congruence and Life Satisfaction chest subscales. Satisfaction was measured using the Holmes-Rovner Satisfaction with Decision scale. Clinical and demographic variables were identified from the chart review. Bivariate analysis was performed to determine whether BMI was associated with chest-specific body image, satisfaction, and complications within 30 days or revisions in GM.

Results: Two hundred twenty-seven individuals meeting eligibility criteria were contacted to participate and 137 responded (60.4% response rate). The mean age was 29.1 (SD=9.0), and mean BMI was 30.9 (SD=8.0), with 26.4% (N=60) of the cohort having a BMI>35. Chest-specific body image and satisfaction with the decision did not vary by BMI or breast resection weight. Complications and revisions were not associated with BMI.

Conclusions: Individuals undergoing GM reported high rates of satisfaction after GM regardless of BMI. Complication and revision rates did not vary significantly by BMI or breast resection weight. Surgeons should re-evaluate the role BMI plays in patient selection and counseling for GM.

Objective: Biliary atresia is a rare disease and reported outcomes of surgical management, typically a Kasai portoenterostomy (KPE), vary considerably across the world. Centralization has been proposed to improve this.

Background: A national centralization program was started in January 1999, involving 3 English units with colocated liver transplant facilities. As the program has now reached the 20-year point, the main aim was to update outcome statistics and identify trends.

Methods: Prospective registry and database. The main measures of outcome were (1) time to KPE, (2) clearance of jaundice (CoJ), defined as reaching a bilirubin value of <20 µmol/L (≈1.5 mg/dL), and (3) actuarial native liver survival and overall survival (OS). Data are quoted as median (interquartile range) and nonparametric statistical comparison used with P <0.05 regarded as statistically significant.

Results: A total of 867 infants were born with biliary atresia and managed between January 1999 and December 2019. Death occurred without intervention (n = 10, 1.1%) or were subject to primary transplant (n = 26, 3.0%); leaving 831 (95.9%) infants who underwent KPE at a median age of 51 (interquartile range: 39-64) days. Age at KPE reduced over the period ( P = 0.0001) becoming 48 (35-57) days in the last 5-year era. CoJ was achieved in 505/831 (60.6%), also increasing over the period ( P = 0.002). Forty-two (5.0%) died post-KPE and 384 were transplanted, leaving 405 alive with their native livers at the last follow-up. Of the 412 children transplanted, there were 23 (5.6%) deaths, leaving 387 alive. Five-year and 10-year native liver survivals were 51.3% (95% CI: 54.8-47.8) and 46.5% (95% CI: 50.1-42.9) and OSs were 91.5% (95% CI 93.2-89.4) and 90.5% (95% CI 92.3-88.2%), respectively.

Conclusions: There have been continued improvements in efficiency over the period of centralization with a significant reduction in time to KPE and improved CoJ after KPE. OS in this disease remains >90%.

Objective: To examine trends in end-of-life care services and satisfaction among veterans undergoing any inpatient surgery.

Background: The Veterans Health Administration has undergone system-wide transformations to improve end-of-life care yet the impacts on end-of-life care services use and family satisfaction are unknown.

Methods: We performed a retrospective, cross-sectional analysis of veterans who died within 90 days of undergoing inpatient surgery between January 2010 and December 2019. Using the Veterans Affairs (VA) Bereaved Family Survey (BFS), we calculated the rates of palliative care and hospice use and examined satisfaction with end-of-life care. After risk and reliability adjustment for each VA hospital, we then performed a multivariable linear regression model to identify factors associated with the greatest change.

Results: Our cohort consisted of 155,250 patients with a mean age of 73.6 years (SD: 11.6). Over the study period, rates of palliative care consultation and hospice use increased more than two-fold (28.1%-61.1% and 18.9%-46.9%, respectively) while the rate of BFS excellent overall care score increased from 56.1% to 64.7%. There was wide variation between hospitals in the absolute change in rates of palliative care consultation, hospice use, and BFS excellent overall care scores. Rural location and Accreditation Council for Graduate Medical Education accreditation were hospital-level factors associated with the greatest changes.

Conclusions: Among veterans undergoing inpatient surgery, improvements in satisfaction with end-of-life care paralleled increases in end-of-life care service use. Future work is needed to identify actionable hospital-level characteristics that may reduce heterogeneity between VA hospitals and facilitate targeted interventions to improve end-of-life care.