Annals of surgery最新文献

Objective: The DoubleCheck study aimed to introduce preoperative and perioperative interventions minimizing exposure to modifiable risk factors and determine their effect on colorectal anastomotic leakage (CAL).

Background: CAL is a severe complication. To predict and prevent its occurrence, the LekCheck study identified intraoperative modifiable risk factors for CAL: anemia, hyperglycemia, hypothermia, incorrect timing of antibiotic prophylaxis, administration of vasopressors, and epidural analgesia.

Methods: This international open-labeled interventional study was performed between September 2021 and December 2023. An enhanced care bundle consisting of anemia correction, glucose measurement, attaining normothermia, antibiotics administration within 60 to 15 minutes preoperatively, refraining from vasopressors and epidural analgesia was introduced. The primary outcome was the occurrence of intraoperative risk factors just before the anastomosis creation. Secondary outcomes were CAL and mortality. Univariate and multivariate regression analyses were performed to establish the relationship between the enhanced care bundle, exposure to the 6 factors and CAL.

Results: The historical LekCheck group consisted of 1572 patients versus 902 in the DoubleCheck. The LekCheck group had a mean of 1.84 risk factors versus 1.63 in DoubleCheck ( P <0.001). In the DoubleCheck, significantly less patients had ≥3 risk factors ( P <0.001). CAL was significantly lower in the DoubleCheck group (8.6% vs 6.2%, P =0.039). The reduction of CAL was associated with the enhanced care bundle in multivariate regression analysis (odds ratio 1.521, 95% CI: 1.01-2.29, P =0.045). The mortality rate did not differ significantly (1.3%, vs 0.8%, P =0.237).

Conclusions: The DoubleCheck study showed that optimization of modifiable risk factors reduced CAL in colorectal surgery.

Objective: To assess whether administration of surgical antimicrobial prophylaxis (SAP) versus absence of SAP is associated with a decreased risk of surgical site infections (SSIs) after low-risk cholecystectomies (LR-CCEs).

Background: Current guidelines do not recommend routine SAP administration before LR-CCE.

Methods: This cohort study included adult patients who underwent LR-CCE and were documented by the Swissnoso SSI surveillance system between January 2009 and December 2020 at 66 Swiss hospitals. LR-CCE was specified as elective endoscopic surgery, age <70, no active cholecystitis, ASA score <3, operating time <120 minutes without implantation of foreign material. Exposure was defined as the administration of cefuroxime or cefazoline ± metronidazole within 120 minutes before incision versus no SAP administration. Our main outcome was the occurrence of SSI until day 30. Logistic regression models were used to adjust for institutional, patient, and perioperative variables.

Results: Of 44,682 surveilled adult patients undergoing cholecystectomy, 12,521 [8726 women (69.7%); median (interquartile range) age, 49.0 (38.1-58.2) years] fulfilled the inclusion criteria. SSI was identified in 143 patients (1.1%). SAP was administered in 9269 patients (74.0%) and was associated with a lower SSI rate (adjusted odds ratio, 0.50; 95% CI, 0.35-0.70; P  < 0.001). The number needed to treat to prevent 1 SSI episode is 100.

Conclusions: The overall LR-CCE SSI rate was 1.1%. SAP was associated with a 50% lower overall SSI rate. Patients undergoing LR-CCE may benefit from routine SAP.

Objective: To assess the association between the Global Budget Revenue (GBR) payment model and shifts to the outpatient setting for surgical procedures among Medicare fee-for-service beneficiaries in Maryland versus control states.

Background: The GBR model provides fixed global payments to hospitals to reduce spending growth and incentivize hospitals to reduce the costs of care while improving care quality. Since surgical care is a major contributor to hospital spending, the GBR model might accelerate the ongoing shift from the inpatient to the outpatient setting to generate additional savings.

Methods: A difference-in-differences (DiD) design was used to compare changes in surgical care settings over time from pre-GBR (2011-2013) to post-GBR (2014-2018) for Maryland versus control states for common surgeries that could be performed in the outpatient setting. A cross-sectional approach was used to compare the difference in care settings in 2018 for total knee arthroplasty which was on Medicare's Inpatient-Only List before then.

Results: We studied 47,542 surgical procedures from 44,410 beneficiaries in Maryland and control states. GBR's 2014 implementation was associated with an acceleration in the shift from inpatient to outpatient settings for surgical procedures in Maryland (DiD: 3.9 percentage points, 95% CI: 2.3, 5.4). Among patients undergoing total knee arthroplasty in 2018, the proportion of outpatient surgeries in Maryland was substantially higher than that in control states (difference: 27.6 percentage points, 95% CI: 25.6, 29.6).

Conclusions: Implementing Maryland's GBR payment model was associated with an acceleration in the shift from inpatient to outpatient hospital settings for surgical procedures.

Objective: To estimate the association between surgeon sex with surgical postponements or cancelations.

Background: Female surgeons receive lower hourly, per-patient, and total compensation than their male colleagues. Bias in the decision to postpone or cancel surgical cases may contribute to compensation inequality, since this results in unpaid surgeon time.

Methods: This retrospective cohort study used administrative health data to identify surgeries performed at 4 hospitals in Calgary, Alberta, Canada, that were canceled or postponed due to surgeon/operating room overbooking or to accommodate an emergency case between April 1, 2015 and March 31, 2020. Surgeries performed in dedicated operating or procedure rooms (eg, bronchoscopy, cardiac surgery, etc) were excluded. The exposure of interest was surgeon sex, identified by matching their name to the provincial regulatory body record of self-identified sex, which allowed for selection between female and male only during the time of this study.

Results: There were 214,832 eligible surgical cases, of which 1481 and 2473 were postponed or canceled due to overbooking and to accommodate an emergency, respectively. After adjusting for surgical specialty, whether the procedure was a day case, and for patient sex, female surgeons were more likely to be canceled or postponed to accommodate an emergency case compared with male surgeons (odds ratio: 1.21, 95% CI: 1.05-1.38).

Conclusions: There may be sex bias in the decision about which surgical cases to postpone or cancel to accommodate emergency surgeries in our setting. This bias may contribute to compensation inequality in a fee-for-service setting.

Objective: The purpose of this study was to determine quality improvement outcomes following the pilot implementation of an in-situ simulation designed to enhance surgical safety checklist performance.

Background: OR Black Box (ORBB) technology allows near real-time assessment for surgical safety checklist performance. Before our study, timeout quality was 73.3%, compliance was 99.9%, and engagement was 89.7% (n=1993 cases); Debrief Quality was 76.0%, compliance was 66.9%, and engagement was 66.7% (n=1842 cases).

Methods: This IRB-approved study used prospective convergent multi-methods. During 2 months, a 15-minute in-situ simulation, incorporating rapid cycle deliberate practice, was implemented for OR teams. ORBB analytics generated Timeout and Debrief scores for actual operations performed by surgeons who participated in simulation (Sim-group) versus those who did not (No-sim group) over 6 months, including 2 months pre-intervention, during-intervention, and post-intervention. Inductive content analysis was performed based on simulation discussions to determine team member perspectives.

Results: Thirty simulations with 163 interprofessional participants were conducted. ORBB data from 1570 cases were analyzed. Scores were significantly better for the Sim-group compared with the No-sim group for debrief quality (84% vs. 79% P <0.001, during-intervention), compliance (73% vs. 66%, P <0.001, post-intervention), and engagement (80% vs. 73%, P =0.012, during-intervention). There were no between-group differences for Timeout scores. Thematic analysis identified 2 primary categories: "culture of safety" and "policy."

Conclusions: This simulation-based QI intervention created a psychologically safe training environment for OR teams. The novel use of ORBB technology facilitated outcome analysis and showed significantly better Debrief scores for simulation-trained surgeons compared with nontrained surgeons.

Objective: To compare short-term outcomes and survival in patients undergoing pancreatic head resection after preoperative endoscopic stenting (ES) versus preoperative surgical drainage (SD) through T-tube insertion.

Background: Patients with pancreatic cancer and obstructive jaundice routinely undergo ES placement. It is well known that ES causes bacterial contamination and infectious complications after pancreatic resection.

Methods: Patients with obstructive jaundice who underwent SD or ES from 2016 to 2022 were identified from a prospective database. Outcome analyses included microbiological bile contamination, overall morbidity, and assessment of the overall complication burden using the Comprehensive Complication Index. Overall survival was investigated by Kaplan-Meier analysis.

Results: A total of 55 patients who underwent SD were identified and matched with 110 patients who underwent ES. After the primary intervention, patients who underwent ES experienced more complications (ES: 17.3% vs SD: 3.6%; P = 0.013). The overall complication burden after pancreatic resection was higher in patients who underwent ES than in patients who underwent SD (Comprehensive Complication Index: 27.2 vs 19.9; P = 0.022). In addition, bacterial contamination of the bile was more frequent in patients who underwent ES compared with individuals who underwent SD (94.3% vs 7.1%; P < 0.001) with similar bacteria in 83.3% of postoperative abdominal infections in patients who underwent ES. While overall survival did not differ between the two groups, patients with postinterventional complications after ES had impaired survival compared with those without complications (11.3 vs 20.4 mo; P = 0.03).

Conclusions: SD for obstructive jaundice in resectable pancreatic cancer is associated with a lower overall complication burden. In addition, patients with complications after ES experience worse overall survival. These findings indicate a rethink of our standards of treatment of obstructive jaundice in patients with pancreatic cancer.

Objective: To evaluate the utility of cfMeDIP-seq for detecting hepatocellular carcinoma (HCC) and monitoring recurrence following curative-intent liver surgery.

Summary background data: HCC remains a leading cause of cancer mortality, with high recurrence rates after surgery. Current surveillance depends on imaging and tumor-informed genomics, both limited by sensitivity and tissue access. A tumor-agnostic, noninvasive cfDNA-based method could significantly improve clinical management.

Methods: 236 cfDNA samples were collected at surgery (b-HCC, n=89) and follow-up (f-HCC, n=112) from 89 HCC patients undergoing liver transplantation (n=57) or resection (n=32), plus 35 healthy controls (CTL). cfMeDIP-seq was performed followed by machine learning to: (i) develop an HCC-specific classifier in a discovery cohort (52 b-HCC vs. 35 CTL); (ii) test the classifier in a validation cohort of 37 patients; and (iii) assign an HCC methylation score (HMS) reflecting the probability of a sample containing HCC-derived cfDNA. Relationships between HMS and clinical variables were assessed.

Results: The classifier identified HCC with 97% sensitivity and 99% specificity in the discovery cohort and 97% accuracy in the validation cohort. Baseline HMS >0.9 was associated with higher recurrence risk (HR 3.43, 95% CI 1.30-9.06, P=0.013). HMS decreased by 3-44% (median 17%) within 13 weeks post-surgery. HMS trajectories diverged for recurrent and non-recurrent patients, with HMS rise indicating clinical recurrence. HMS was independent of other clinicopathologic variables.

Conclusion: Tumor-agnostic cfDNA methylomes accurately detect HCC and predict recurrence after liver resection or transplantation. This approach may have important implications for HCC diagnosis, treatment, and monitoring.