Annals of surgery最新文献

Objective: To identify factors related to research success for academic surgeons.

Background: Many recognize mounting barriers to scientific success for academic surgeons, but little is known about factors that predict success for individual surgeons.

Methods: A phase 1 survey was emailed to department chairpersons at highly funded U.S. departments of surgery. Participating chairpersons distributed a phase 2 survey to their faculty surgeons. Training and faculty-stage exposures and demographic data were collected and compared with participant-reported measures of research productivity. Five primary measures of productivity were assessed, including the number of grants applied for, grants funded, papers published, first/senior author papers published, and satisfaction with research.

Results: Twenty chairpersons and 464 faculty surgeons completed the survey, and 444 faculty responses were included in the final analysis. Having a research-focused degree was significantly associated with more grants applied for [Doctor of Philosophy, incidence rate ratio (IRR) = 6.93; Masters, IRR = 4.34] and funded (Doctor of Philosophy, IRR = 4.74; Masters, IRR = 4.01) compared with surgeons with only clinical degrees (all P < 0.01). Having a formal research mentor was significantly associated with more grants applied for (IRR = 1.57, P = 0.03) and higher satisfaction in research (IRR = 2.22, P < 0.01). Contractually protected research time was significantly associated with more grants applied for (IRR = 3.73), grants funded (IRR = 2.14), papers published (IRR = 2.12), first/senior authors published (IRR = 1.72), and research satisfaction (odds ratio = 2.15; all P < 0.01). The primary surgeon-identified barrier to research productivity was lack of protection from clinical burden.

Conclusions: Surgeons pursuing research-focused careers should consider the benefits of attaining a research-focused degree, negotiating for contractually protected research time, and obtaining formal research mentorship.

Objective: To evaluate whether a machine-learning algorithm (ie, the "NightSignal" algorithm) can be used for the detection of postoperative complications before symptom onset after cardiothoracic surgery.

Background: Methods that enable the early detection of postoperative complications after cardiothoracic surgery are needed.

Methods: This was a prospective observational cohort study conducted from July 2021 to February 2023 at a single academic tertiary care hospital. Patients aged 18 years or older scheduled to undergo cardiothoracic surgery were recruited. Study participants wore a Fitbit watch continuously for at least 1 week preoperatively and up to 90 days postoperatively. The ability of the NightSignal algorithm-which was previously developed for the early detection of Covid-19-to detect postoperative complications was evaluated. The primary outcomes were algorithm sensitivity and specificity for postoperative event detection.

Results: A total of 56 patients undergoing cardiothoracic surgery met the inclusion criteria, of which 24 (42.9%) underwent thoracic operations and 32 (57.1%) underwent cardiac operations. The median age was 62 (Interquartile range: 51-68) years and 30 (53.6%) patients were female. The NightSignal algorithm detected 17 of the 21 postoperative events at a median of 2 (Interquartile range: 1-3) days before symptom onset, representing a sensitivity of 81%. The specificity, negative predictive value, and positive predictive value of the algorithm for the detection of postoperative events were 75%, 97%, and 28%, respectively.

Conclusions: Machine-learning analysis of biometric data collected from wearable devices has the potential to detect postoperative complications-before symptom onset-after cardiothoracic surgery.

Objective: To examine the association between surgeon gender and early postoperative complications, including 30-day death and readmission, in elective surgery.

Background: Variations between male and female surgeon practice patterns may be a source of bias and gender inequality in the surgical field, perhaps impacting the quality of care. However, there are limited and conflicting studies regarding the association between surgeon gender and postoperative outcomes.

Methods: MEDLINE and Embase were searched in October 2023 for observational studies, including patients who underwent elective surgery requiring general or regional anesthesia across multiple surgical specialties. Multiple independent blinded reviewers oversaw the data selection, extraction, and quality assessment according to the PRISMA, MOOSE, and Newcastle Ottawa Scale guidelines. Data were pooled as odds ratios, using a generic inverse-variance random-effects model.

Results: Of 944 abstracts screened, 11 studies were included in this systematic review and meta-analysis. A total of 4,440,740 postoperative patients were assessed for a composite primary outcome of mortality, readmission, and other complications within 30 days of elective surgery, with a total of 325,712 (7.3%) surgeries performed by 7072 (10.9%) female surgeons. There was no association between surgeon gender and the composite of mortality, readmission, and/or complications (odds ratio=0.97, 95% CI 0.95-1.00; I2 =64.9%; P =0.001).

Conclusions: These results support that surgeon gender is not associated with early postoperative outcomes, including mortality, readmission, or other complications in elective surgery. These findings encourage patients, health care providers, and stakeholders not to consider surgeon gender as a risk factor for postoperative complications.

Objective: To define recent trends in opioid prescribing after surgery and new persistent opioid use in the United States.

Background: New persistent opioid use after surgery among opioid-naive individuals has emerged as an important postoperative complication. In response, initiatives to promote more appropriate postoperative opioid prescribing have been adopted in recent years. However, current estimates of opioid prescribing and new persistent opioid use following surgery remain unknown.

Methods: A retrospective cohort study of opioid-naive privately insured adult patients undergoing 17 common surgical procedures between 2013 and 2021 was conducted utilizing multi-payer claims data from the Health Care Cost Institute (HCCI). Initial opioid prescription size in oral morphine equivalents (OMEs) and new persistent opioid use were the outcomes of interest. Trends in opioid prescribing and rates of new persistent opioid use were evaluated across the study period. Mixed effects logistic regression was performed to evaluate independent predictors of new persistent opioid use while adjusting for patient-level factors and year.

Results: Among 989,354 opioid-naive individuals, the adjusted initial opioid prescription size decreased from 282 mg OME to 164 mg OME, a reduction of 118 mg OME (95% CI: 116-120). The adjusted incidence of new persistent opioid use decreased from 2.7% in 2013 (95% CI: 2.6%-2.8%) to 1.1% in 2021 (95% CI: 1.0%-1.2%). For every 30 OME increase in initial opioid prescription size, new persistent opioid use increased by 3.1%. Other predictors of new persistent opioid use included preoperative nonopioid controlled substances fills [31-365 days: adjusted odds ratio (aOR)=1.78, 95% CI: 1.70-1.86; 0-30 days: aOR=2.71, 95% CI: 2.59-2.84] and undergoing orthopedic procedures [total knee arthroplasty (aOR=3.43, 95% CI: 3.15-3.72); shoulder arthroscopy (aOR=2.39, 95% CI: 2.24-2.56)].

Conclusions: Both opioid prescription size after surgery and new persistent opioid use decreased over the last decade, suggesting that opioid stewardship practices had favorable effects on the risk of long-term opioid use.

Objective: To evaluate and compare magnetic sphincter augmentation (MSA) device sizing protocols on postoperative outcomes and dysphagia.

Background: Among predictors of dysphagia after MSA, device size is the only factor that may be modified. Many centers have adopted protocols to increase device size. However, there are limited data on the impact of MSA device upsizing protocols on surgical outcomes.

Methods: Patients who underwent MSA were implanted with 2 or 3 beads above the sizing device's pop-off point (POP). Clinical and objective outcomes >1 year after surgery were compared between patients implanted with POP+2-versus-POP+3 sizing protocols. Multiple subgroups were analyzed for the benefit of upsizing. Preoperative and postoperative characteristics were compared between the size patients received, regardless of protocol.

Results: A total of 388 patients were implanted under POP+2 and 216 under POP+3. At a mean of 14.2 (7.9) months, pH normalization was 73.6% and 34.1% required dilation, 15.9% developed persistent dysphagia, and 4.0% required removal. The sizing protocol had no impact on persistent dysphagia ( P =0.908), pH normalization ( P =0.822), or need for dilation ( P =0.210) or removal ( P =0.191). Subgroup analysis found that upsizing reduced dysphagia in patients with <80% peristalsis (10.3% vs 31%, P =0.048) or distal contractile integral >5000 (0% vs 30.4%, P =0.034). Regardless of sizing protocol, as device size increased there was a stepwise increase in the percent male sex ( P <0.0001), body mass index >30 ( P <0.0001), and preoperative hiatal hernia >3 cm ( P <0.0001), Los Angeles grade C/D esophagitis ( P <0.0001), and DeMeester score ( P <0.0001). Increased size was associated with decreased pH normalization ( P <0.0001) and need for dilation ( P =0.043) or removal ( P =0.014).

Conclusions: Upsizing from POP+2 to POP+3 does not reduce dysphagia or affect other MSA outcomes; however, patients with poor peristalsis or hypercontractile esophagus do benefit. Regardless of sizing protocol, preoperative clinical characteristics varied among device sizes, suggesting size is not a modifiable factor, but a surrogate for esophageal circumference.

Objective: To compare nutritional and postoperative outcomes between early oral feeding and late oral feeding with jejunostomy feeding support after esophagectomy.

Background: Esophagectomy is associated with substantial body weight loss and malnutrition, impacting the prognosis of esophageal cancer patients. Despite many studies on postesophagectomy nutritional support, optimal strategies remain elusive. This study investigates the impact of jejunostomy feeding with late oral feeding compared to conventional oral feeding on nutritional and postoperative outcomes.

Methods: We performed a single-center prospective open-labelled randomized controlled trial between 2020 and 2022. Patients aged 18 to 75 years with resectable esophageal cancer were randomly assigned to undergo either early oral feeding (early group) or late oral feeding with jejunostomy feeding support (late group) after esophagectomy. The primary endpoint was body weight loss from preoperative body weight at postoperative 4 to 5 weeks and 4 months. Other perioperative and nutritional outcomes were also evaluated.

Results: We randomly assigned 29 patients to the early group and 29 patients to the late group. The late group exhibited significantly less body weight loss at both postoperative 4 to 5 weeks (8.3% vs. 5.6%; P =0.002) and 4 months (15.0% vs. 10.5%; P =0.003). The total calorie intake and protein intake were higher in the late group for both postoperative 4 to 5 weeks (1800 kcal/day vs. 1100 kcal/day; P <0.001) and 4 months (1565 kcal/day vs. 1200 kcal/day; P =0.010). Sixty percentage of the early group changed to malnutrition state, while 40% of the late group changed to malnutrition. The complication rate and length of hospital stays were similar.

Conclusions: The late group demonstrated prevention of significant body weight loss, enhanced nutritional intake, and reduced malnutrition without compromising short-term surgical outcomes.

Objectives: To evaluate the impact of persistent opioid use (POU) following surgery or trauma on health outcomes using linked data.

Background: Surgery and trauma can lead to POU, characterized by continuous opioid consumption following hospital discharge. Outside the United States, there is a lack of population-based studies on POU outcomes in opioid-naive patients following these events.

Methods: We included opioid-naïve patients who have dispensed opioids after being discharged following admission for surgery or trauma to any New Zealand (NZ) hospital from 2007 to 2019. Differences in outcomes between individuals with and without POU were assessed between 180 and 360 days after discharge. The primary outcome was all-cause mortality, the secondary outcomes were all-cause and opioid-related hospitalization, and Days Alive and Out of Hospital (DAOH). Cox and quantile multivariable regression models were used to examine the association between POU and outcomes.

Results: Overall, 298,928 surgical and 206,663 trauma patients were included in the final analyses, and 17,779 (5.9%) surgical and 17,867 (8.6%) trauma patients developed POU. POU was significantly associated with increased risk of all-cause mortality (surgical, aHR=6.59; 95% CI: 5.82-7.46; trauma, aHR=2.77; 95% CI: 2.47-3.11), all-cause hospitalization (surgical, aHR=2.02; 95% CI: 1.95-2.08; trauma, aHR=1.57; 95% CI: 1.52-1.62), opioid-related hospitalization (surgical, aHR=2.49; 95% CI: 2.24-2.76; trauma, aHR=1.89; 95% CI: 1.73-2.05) and reduced DAOH.

Conclusions: Among opioid-naive patients who received opioids after surgery or trauma, POU was associated with worse outcomes, including increased mortality. Further investigation is warranted to understand the reasons for continued opioid use beyond 90 days and mechanisms associated with harm.