Annals of surgery最新文献

Objective: We aimed to better understand patients' treatment preferences and quantify the level of cancer risk at which treatment preferences change (risk threshold) to inform better counseling of patients with intraductal papillary mucinous neoplasms (IPMNs).

Background: The complexity of IPMN management provides an opportunity to align treatment with individual preferences.

Methods: We surveyed a sample of healthy volunteers simulating a common scenario: undergoing an imaging study that incidentally identifies an IPMN. In the scenario, the estimated risk of cancer in the IPMN was 5%. Patients were asked about their treatment preference (surgery or surveillance) to quantify the level of cancer risk in the IPMN at which their treatment preference would change (ie, risk threshold) and their level of cancer anxiety as measured on a 5-point Likert scale. We examined associations between participant characteristics, treatment preferences, and risk threshold using multivariable linear regression.

Results: The median risk threshold among the 520 participants was 25% (IQR 2.3%-50%). The risk threshold had a bimodal distribution: 40% of participants had a risk threshold between 0% and 10%, and 47% had a risk threshold above 30%. When informed that the risk of cancer was 5%, 62% of participants (n=323) preferred surveillance, and the remaining 38% (n=197) preferred surgery. After adjusting for potential confounders, participants who expressed "worry" or "extreme worry" about the malignancy risk of IPMN had significantly lower risk thresholds than participants who were "not at all worried" (Coefficient -12, 95% CI: -21 to -2, P =0.015 and Coefficient -18, 95% CI -29 to -8, P <0.001, respectively).

Conclusions: Participants varied in treatment preference and risk threshold of incidentally identified IPMNs. Given the uncertainty in estimating the true malignant potential of IPMNs, a better understanding of a patient's risk threshold, as influenced by patient concern about malignancy, will help inform the shared decision-making process.

Objective: To establish whether the Accreditation Council for Graduate Medical Education Milestones predict the future performance of general surgery trainees.

Background: Milestones provide bi-annual assessments of trainee progress across 6 competencies. It is unknown whether the Milestones predict surgeon performance after the transition to independent practice.

Methods: We performed a retrospective cohort study of surgeons with complete Milestone assessments in the fourth and fifth clinical years who treated patients in acute care hospitals within Florida, New York, and Pennsylvania, 2015-2018. To account for the multiple ways in which the Milestone assessments might predict postgraduation outcomes, we included 120 Milestones features in our elastic net machine learning models. The primary outcome was risk-adjusted patient death or serious morbidity.

Results: A total of 278 general surgeons were included in the study. Milestone assessments 6 months into the fourth clinical year displayed a normal score distribution while multicollinearity and low score discrimination at the final assessment period were detected. Individual Milestones features from the Patient Care, Professionalism, and Systems-based Practice domains were most predictive of patient-related outcomes. For example, surgeons with worse patient outcomes had significantly lower scores in Patient Care 3 when compared with surgeons with better patient outcomes (high DSM, yes: 2.86 vs no: 3.04, P =0.011).

Conclusions: The Milestones features that were most predictive of better patient outcomes related to intraoperative skills, ethical principles, and patient navigation and safety measured 12 to 18 months before graduation. The development of a parsimonious set of evidence-based Milestones that better correlate with surgeon experience could enhance surgical education.

Objective: This study aimed to identify parameters that allow the estimation of tumor-infiltrated lymph nodes (LN) after pretreatment for unilateral Wilms tumor (WT).

Background: Complete tumor resection with removal of regional LN is always necessary. Positive LNs require local irradiation influencing benefits in the case of NSS in long-term follow-up. Clinical and tumor-related data available at the time of surgery, in combination with intraoperative abdominal findings (IAF), were used to estimate the LN status during surgery.

Methods: Altogether, 2115 patients with unilateral WT were prospectively enrolled in SIOP-93-01 / GPOH and SIOP-2001 / GPOH over a period of 30 years (1993-2023). LN infiltration by tumor was calculated for age, sex, metastases at diagnosis, tumor volume (TV), TV shrinkage, and IAF using logistic regression models.

Results: Age ≥48 months ( P <0.001, OR: 2.17, CI: 1.57-3.00), TV at diagnosis ≥300 ( P <0.001, OR: 3.72, CI: 2.37-5.85), metastasis at diagnosis ( P <0.001, OR: 6.21, CI: 4.47-8.62) and IAF (>1: P <0.001, OR: 3.54, CI: 2.13-5.88) correlated with positive LNs. TV shrinkage was not predictive of positive LN. Three flow charts were developed based on age, TV at diagnosis, metastasis, and IAF. These flowcharts defined risks between 0% and 41.5% for LN infiltration by tumor.

Conclusions: The combination of age, TV at diagnosis, and metastasis with IAF allows the estimation of the frequency of positive LNs, which may help surgeons decide about NSS.

Objective: To analyze the effectiveness of prophylactic mesh augmentation (PMA) of the abdominal wall following open aortic aneurysm repair as compared to primary sutured (PS) closure in preventing incisional hernia (IH) formation by performing an individual patient-data meta-analysis (IPDMA).

Background: IH is a prevalent complication after abdominal surgery, especially in high-risk groups. PMA of the abdominal wall has been studied as a preventive measure for IH formation, but strong recommendations are lacking.

Methods: A systematic literature search was conducted till September 23, 2024, to identify randomized controlled trials (RCTs) that compared PMA with PS after open AAA surgery. Lead authors of eligible studies were asked to share individual patient-data. A one-stage analysis was performed, and Cox regression analyses were used to assess time-to-event outcomes.

Results: Five randomized trials with a total of 493 patients were included. Intention to treat analysis revealed that PMA was associated with a significantly lower risk of IH [hazard ratio of 0.25 (95% CI: 0.12-0.50)] as compared with PS closure. Three-year incisional hernia rates were 13.2% and 39.6%, respectively, with a number needed to treat of 3.7. The effect was similar for onlay and retro-rectus PMA. PMA resulted in longer operative time (mean 27 min) and more seroma formation (especially onlay PMA) but did not increase the risk of surgical site infection.

Conclusions: PMA after elective open abdominal aortic aneurysm surgery is proven to be an effective measure to reduce IH formation and should be considered in future guidelines as a standard of care.

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.