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Trends in Timely Access to High-Quality and Affordable Surgical Care in the United States. 美国及时获得高质量和负担得起的外科护理的趋势。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-06 DOI: 10.1097/SLA.0000000000006586
Cody Lendon Mullens, Andrew M Ibrahim, Nina M Clark, Nicholas Kunnath, Joseph L Dieleman, Justin B Dimick, John W Scott

Objective: To quantify recent trends in access to timely, high-quality, affordable surgical care in the US.

Background: Insufficient access to surgical care remains an ongoing concern in the US. Previous attempts to understand and quantify barriers in access to surgical care in the US lack a comprehensive, policy-relevant lens.

Methods: This observational cross-sectional study evaluates multiple domains of access to surgical care across the US from 2011-2015 and 2016-2020. Our stepwise model included timeliness (<60-minute drive time), quality (surgically capable hospital with ≥3 CMS stars), and affordability (neither uninsured nor underinsured) of access to surgical care using a novel combination of data from the American Hospital Association, Medicare claims, CMS's Five-Star Quality Rating System, the American Community Survey, and the Medical Expenditure Panel Survey.

Results: The number of Americans lacking access to timely, high-quality, affordable surgical care increased from 97.7 million in 2010-2015 to 98.7 million in 2016-2020. Comparing these two periods, we found improvements in the number of Americans lacking access due to being uninsured (decrease from 38.5 to 26.5 million). However, these improvements were offset by increasing numbers of Americans for whom timeliness (increase from 9.5 to 14.1 million), quality (increase from 3.4 to 4.9 million), and underinsured status (increase from 46.3 to 53.1 million) increased as barriers to access. Multiple sensitivity analyses using alternative thresholds for each access domain demonstrated similar trends. Those with insufficient access to care tended to be more rural (6.7% vs. 2.0%, P<0.001), lower income (40.7% vs. 30.0%, P<0.001), and of Hispanic ethnicity (35.9% vs. 15.8%, P<0.001).

Conclusions: Nearly one-in-three Americans lack access to surgical care that is timely, high-quality, and affordable. This study identifies the multiple actionable drivers of access to surgical care that notably can each be addressed with specific policy interventions.

摘要量化美国及时获得高质量、可负担得起的外科医疗服务的最新趋势:背景:在美国,无法充分获得外科医疗服务仍是一个持续存在的问题。以前曾试图了解和量化美国在获得外科医疗服务方面存在的障碍,但缺乏一个全面的、与政策相关的视角:本观察性横断面研究评估了 2011-2015 年和 2016-2020 年美国外科医疗服务获取的多个领域。我们的逐步分析模型包括及时性(结果:美国缺乏及时获得外科医疗服务的人口数量为 1.5 亿人,而缺乏及时获得外科医疗服务的人口数量为 2.5 亿人:无法获得及时、优质、负担得起的外科医疗服务的美国人数从 2010-2015 年的 9770 万增加到 2016-2020 年的 9870 万。比较这两个时期,我们发现因没有保险而无法获得医疗服务的美国人数有所改善(从 3850 万减少到 2650 万)。然而,这些改善被越来越多的美国人所抵消,这些人的及时性(从 950 万增加到 1410 万)、质量(从 340 万增加到 490 万)和保险不足的状况(从 4630 万增加到 5310 万)增加了他们获得医疗服务的障碍。使用每个就医领域的替代阈值进行的多重敏感性分析表明了类似的趋势。无法充分获得医疗服务的人往往更多地在农村地区(6.7% 对 2.0%,PConclusions.Net):将近三分之一的美国人无法获得及时、优质和负担得起的外科医疗服务。本研究确定了获得外科医疗服务的多种可操作驱动因素,这些因素都可以通过具体的政策干预措施加以解决。
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引用次数: 0
Your Weight and Your Wallet: Comparing Out-of-Pocket Costs of Bariatric Surgery and GLP1 Agonists. 您的体重和钱包:比较减肥手术和 GLP1 激动剂的自付费用。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-06 DOI: 10.1097/SLA.0000000000006583
Avery Brown, Karan R Chhabra
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引用次数: 0
Interdisciplinary Operating Room Ergonomics Needs and Priorities: A Survey of Operating Room Staff. 跨学科手术室人体工学需求和优先事项:手术室工作人员调查。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-06 DOI: 10.1097/SLA.0000000000006582
Alexis Mah, Fahad Alam, Jeremie Larouche, Marie-Antonette Dandal, Tara Cohen, Susan Hallbeck, Hamid Norasi, Csilla Kallocsai, Sapna Sriram, James D Helman, Julie Hallet

Objective: To examine perceived OR ergonomics facilitators and barriers, with a focus on the interdisciplinary team.

Summary background data: Poor ergonomics causes musculoskeletal injuries affecting all operating room (OR) staff with repercussions on patient care, outcomes, and sustainability. Lack of ergonomic awareness and education are risk factors.

Methods: We conducted a self-administered web-based survey of OR nurses, surgeons, and anesthesiologists at a single centre (n=238). We developed a questionnaire through items generation and reduction, followed by reliability and validity testing.

Results: Response rate was 53.8%. Respondents perceived that on average 80% of nurses, 70% of surgeons, and 40% anesthesiologists experienced MSK injuries, with no difference in professional groups' perceptions. Guideline ergonomics interventions were rarely used (<25%) except for specialized clothing (33%), equipment repositioning (59%), and seating (37%), though perceived beneficial by 80-90%. Reported barriers to optimal ergonomics were organizational/structural (lack of time, space, equipment, funding), whereas solutions were individual. Fear of unfavourable perception from others was a concern for 62%. Teams discussing, prioritizing, monitoring, or helping with ergonomics was indicated by <50%. Individual ergonomic adaptations were perceived as convenience by other staff.

Conclusions: While structural/organizational issues are reported as barriers to ergonomics, solutions appeared as individual responsibilities. Team dynamics did not prioritize nor support ergonomics. Education tools leveraging the interdisciplinary team are warranted. This work will be supplemented by interviews and live observations to build tailored educational tools for OR teams.

目标:研究手术室工效促进因素和障碍,重点关注跨学科团队:不良的人体工程学设计会造成肌肉骨骼损伤,影响手术室(OR)的所有工作人员,并对患者护理、治疗效果和可持续性产生影响。缺乏人体工程学意识和教育是风险因素:方法:我们对一个中心的手术室护士、外科医生和麻醉师(人数为 238 人)进行了一次自填式网络调查。我们通过项目生成和缩减开发了调查问卷,随后进行了信度和效度测试:结果:回复率为 53.8%。受访者认为,平均 80% 的护士、70% 的外科医生和 40% 的麻醉师都经历过 MSK 损伤,各专业群体的看法没有差异。很少使用人体工程学指南干预措施(结论:虽然报告称结构/组织问题是人体工程学的障碍,但解决方案似乎是个人的责任。团队动力既不优先考虑也不支持人体工程学。需要利用跨学科团队的教育工具。这项工作将通过访谈和现场观察加以补充,为手术室团队量身打造教育工具。
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引用次数: 0
Prediction of Severe Acute Pancreatitis at a Very Early Stage of the Disease Using Artificial Intelligence Techniques, Without Laboratory Data or Imaging Tests: The PANCREATIA Study. 利用人工智能技术,在没有实验室数据或成像测试的情况下,预测疾病早期阶段的严重急性胰腺炎:PANCREATIA 研究》。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-05 DOI: 10.1097/SLA.0000000000006579
Sara Villasante, Nair Fernandes, Marc Perez, Miguel Angel Cordobés, Gemma Piella, María Martinez, Concepción Gomez-Gavara, Laia Blanco, Piero Alberti, Ramón Charco, Elizabeth Pando

Objective: To evaluate machine learning models' performance in predicting acute pancreatitis severity using early-stage variables while excluding laboratory and imaging tests.

Summary background data: Severe acute pancreatitis (SAP) affects approximately 20% of acute pancreatitis (AP) patients and is associated with high mortality rates. Accurate early prediction of SAP and in-hospital mortality is crucial for effective management. Traditional scores such as APACHE-II and BISAP are complex and require laboratory tests, while early predictive models are lacking. Machine learning (ML) has shown promising results in predictive modelling, potentially outperforming traditional methods.

Methods: We analysed data from a prospective database of AP patients admitted to Vall d'Hebron Hospital from November 2015 to January 2022. Inclusion criteria were adults diagnosed with AP according to the 2012 Atlanta classification. Data included basal characteristics, current medication, and vital signs. We developed machine learning models to predict SAP, in-hospital mortality, and intensive care unit (ICU) admission. The modelling process included two stages: Stage 0, which used basal characteristics and medication, and Stage 1, which included data from Stage 0 and vital signs.

Results: Out of 634 cases, 594 were analysed. The Stage 0 model showed AUC values of 0.698 for mortality, 0.721 for ICU admission, and 0.707 for persistent organ failure. The Stage 1 model improved performance with AUC values of 0.849 for mortality, 0.786 for ICU admission, and 0.783 for persistent organ failure. The models demonstrated comparable or superior performance to APACHE-II and BISAP scores.

Conclusions: The ML models showed good predictive capacity for SAP, ICU admission, and mortality using early-stage data without laboratory or imaging tests. This approach could revolutionise AP patients' initial triage and management, providing a personalised prediction method based on early clinical data.

目的评估机器学习模型利用早期变量预测急性胰腺炎严重程度的性能,同时排除实验室和影像学检查:重症急性胰腺炎(SAP)约影响 20% 的急性胰腺炎(AP)患者,并与高死亡率相关。早期准确预测 SAP 和院内死亡率对有效治疗至关重要。传统的评分方法(如 APACHE-II 和 BISAP)非常复杂,需要进行实验室检测,同时缺乏早期预测模型。机器学习(ML)在预测建模方面取得了可喜的成果,有可能超越传统方法:我们分析了 2015 年 11 月至 2022 年 1 月期间入住 Vall d'Hebron 医院的 AP 患者的前瞻性数据库数据。纳入标准为根据 2012 年亚特兰大分类法确诊为 AP 的成人。数据包括基础特征、当前用药和生命体征。我们开发了机器学习模型来预测 SAP、院内死亡率和重症监护室(ICU)入院率。建模过程包括两个阶段:第一阶段包括第一阶段的数据和生命体征:结果:在 634 个病例中,分析了 594 个。第 0 阶段模型显示死亡率的 AUC 值为 0.698,入住重症监护室的 AUC 值为 0.721,持续器官衰竭的 AUC 值为 0.707。第 1 阶段模型的性能有所提高,死亡率的 AUC 值为 0.849,入住重症监护室的 AUC 值为 0.786,器官持续衰竭的 AUC 值为 0.783。这些模型的性能与 APACHE-II 和 BISAP 评分相当或更优:ML模型利用没有实验室或影像学检查的早期数据,对SAP、入住ICU和死亡率显示出良好的预测能力。这种方法可以彻底改变 AP 患者的初始分诊和管理,提供一种基于早期临床数据的个性化预测方法。
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引用次数: 0
Revolutionizing Liver Transplantation: Transitioning to an Elective Procedure Through Ex Situ Normothermic Machine Perfusion - A Benefit Analysis. 肝脏移植的革命性变革:通过原位常温机器灌注过渡到选择性手术 - 效益分析。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 Epub Date: 2024-07-30 DOI: 10.1097/SLA.0000000000006462
Zhihao Li, Matthias Pfister, Florian Huwyler, Waldemar Hoffmann, Mark W Tibbitt, Philipp Dutkowski, Pierre-Alain Clavien

Objective: To assess the impact of normothermic machine perfusion (NMP) on patients, medical teams, and costs by gathering global insights and exploring current limitations.

Background: NMP for ex situ liver graft perfusion is gaining increasing attention for its capability to extend graft preservation. It has the potential to transform liver transplantation (LT) from an urgent to a purely elective procedure, which could revolutionize LT logistics, reduce burden on patients and health care providers, and decrease costs.

Methods: A 31-item survey was sent to international transplant directors to gather their NMP experiences and vision. In addition, we performed a systematic review on cost-analysis in LT and assessed studies on cost-benefit in converting urgent-to-elective procedures. We compared the costs of available NMPs and conducted a sensitivity analysis of NMP's cost benefits.

Results: Of 120 transplant programs contacted, 64 (53%) responded, spanning North America (31%), Europe (42%), Asia (22%), and South America (5%). Of the total, 60% had adopted NMP, with larger centers (>100 transplants/year) in North America and Europe more likely to use it. The main NMP systems were OrganOx-metra (39%), XVIVO (36%), and TransMedics-OCS (15%). Despite NMP adoption, 41% of centers still perform >50% of LTs at nights/weekends. Centers recognized NMP's benefits, including improved work satisfaction and patient outcomes, but faced challenges like high costs and machine complexity. 16% would invest $100,000 to 500'000, 33% would invest $50,000 to 100'000, 38% would invest $10,000 to 50'000, and 14% would invest <$10,000 in NMP. These results were strengthened by a cost analysis for NMP in emergency-to-elective LT transition. Accordingly, while liver perfusions with disposables up to $10,000 resulted in overall positive net balances, this effect was lost when disposables' cost amounted to >$40,000/organ.

Conclusions: The adoption of NMP is hindered by high costs and operational complexity. Making LT elective through NMP could reduce costs and improve outcomes, but overcoming barriers requires national reimbursements and simplified, automated NMP systems for multiday preservation.

摘要通过收集全球见解和探讨当前的局限性,评估常温机器灌注(NMP)对患者、医疗团队和成本的影响:背景:用于原位肝移植灌注的常温机器灌注因其能够延长移植物保存时间而日益受到关注。它有可能将肝移植(LT)从紧急手术转变为纯粹的选择性手术,这将彻底改变LT的后勤工作,减轻患者和医护人员的负担,并降低成本:方法: 我们向国际移植主任发送了一份包含 31 个项目的调查问卷,以收集他们的 NMP 经验和愿景。此外,我们还对LT的成本分析进行了系统回顾,并评估了将紧急手术转为选择性手术的成本效益研究。我们比较了现有 NMP 的成本,并对 NMP 的成本效益进行了敏感性分析:我们联系了 120 个移植项目,其中 64 个(53%)做出了回应,这些项目分布在北美(31%)、欧洲(42%)、亚洲(22%)和南美(5%)。60%的项目采用了 NMP,北美和欧洲的大型中心(>100 例移植/年)更有可能使用 NMP。主要的 NMP 系统是 OrganOx-metra(39%)、XVIVO(36%)和 TransMedics-OCS(15%)。尽管采用了 NMP,但仍有 41% 的中心在夜间/周末进行超过 50% 的 LT。各中心认识到了 NMP 的好处,包括提高工作满意度和患者疗效,但也面临着高成本和机器复杂性等挑战。16%的中心将投资 100'000-500'000 美元,33%投资 50'000-100'000 美元,38%投资 10'000-50'000 美元,14%投资 40'000 美元/器官:结论:高成本和操作复杂性阻碍了 NMP 的采用。通过 NMP 使 LT 成为选择性手术可降低成本并改善疗效,但要克服障碍,需要国家补偿和用于多天保存的简化、自动化 NMP 系统。
{"title":"Revolutionizing Liver Transplantation: Transitioning to an Elective Procedure Through Ex Situ Normothermic Machine Perfusion - A Benefit Analysis.","authors":"Zhihao Li, Matthias Pfister, Florian Huwyler, Waldemar Hoffmann, Mark W Tibbitt, Philipp Dutkowski, Pierre-Alain Clavien","doi":"10.1097/SLA.0000000000006462","DOIUrl":"10.1097/SLA.0000000000006462","url":null,"abstract":"<p><strong>Objective: </strong>To assess the impact of normothermic machine perfusion (NMP) on patients, medical teams, and costs by gathering global insights and exploring current limitations.</p><p><strong>Background: </strong>NMP for ex situ liver graft perfusion is gaining increasing attention for its capability to extend graft preservation. It has the potential to transform liver transplantation (LT) from an urgent to a purely elective procedure, which could revolutionize LT logistics, reduce burden on patients and health care providers, and decrease costs.</p><p><strong>Methods: </strong>A 31-item survey was sent to international transplant directors to gather their NMP experiences and vision. In addition, we performed a systematic review on cost-analysis in LT and assessed studies on cost-benefit in converting urgent-to-elective procedures. We compared the costs of available NMPs and conducted a sensitivity analysis of NMP's cost benefits.</p><p><strong>Results: </strong>Of 120 transplant programs contacted, 64 (53%) responded, spanning North America (31%), Europe (42%), Asia (22%), and South America (5%). Of the total, 60% had adopted NMP, with larger centers (>100 transplants/year) in North America and Europe more likely to use it. The main NMP systems were OrganOx-metra (39%), XVIVO (36%), and TransMedics-OCS (15%). Despite NMP adoption, 41% of centers still perform >50% of LTs at nights/weekends. Centers recognized NMP's benefits, including improved work satisfaction and patient outcomes, but faced challenges like high costs and machine complexity. 16% would invest $100,000 to 500'000, 33% would invest $50,000 to 100'000, 38% would invest $10,000 to 50'000, and 14% would invest <$10,000 in NMP. These results were strengthened by a cost analysis for NMP in emergency-to-elective LT transition. Accordingly, while liver perfusions with disposables up to $10,000 resulted in overall positive net balances, this effect was lost when disposables' cost amounted to >$40,000/organ.</p><p><strong>Conclusions: </strong>The adoption of NMP is hindered by high costs and operational complexity. Making LT elective through NMP could reduce costs and improve outcomes, but overcoming barriers requires national reimbursements and simplified, automated NMP systems for multiday preservation.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":"887-895"},"PeriodicalIF":7.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141791752","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Omitting the Escalating Dosage of Alpha-adrenergic Blockade Before Pheochromocytoma Resection: Implementation of a Treatment Strategy in Discordance With Current Guidelines. 在嗜铬细胞瘤切除术前省略α-肾上腺素能阻滞剂的递增剂量:实施与现行指南不一致的治疗策略。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 Epub Date: 2024-08-06 DOI: 10.1097/SLA.0000000000006493
Isabelle Holscher, Anton F Engelsman, Koen M A Dreijerink, Markus W Hollmann, Tijs J van den Berg, Els J M Nieveen van Dijkum

Objective: This study describes the effects of introducing a protocol omitting preoperative α-blockade dose-escalation (de-escalation) in a prospective patient group.

Background: The decline of mortality and morbidity associated with pheochromocytoma resection is frequently attributed to the introduction of preoperative α-blockade. Current protocols require preoperative α-blockade dose-escalation and multiple-day hospital admissions. However, correlating evidence is lacking. Moreover, recent data suggest equal perioperative safety regardless of preoperative α-blockade escalation.

Methods: Single-institution evaluation of protocol implementation, including patients who underwent adrenalectomy for pheochromocytoma between 2015 and 2023. Intraoperative hemodynamic control was regulated by active adjustment of blood pressure using vasoactive agents. The primary outcome was intraoperative hypertension, defined as the time-weighted average of systolic blood pressure (TWA-SBP) above 200 mm Hg. Secondary outcomes included perioperative hypotension, postoperative blood pressure support requirement, hospital stay duration, and complications.

Results: Of 102 pheochromocytoma patients, 82 were included; 44 in the de-escalated preoperative α-adrenergic protocol and 38 following the previous dose-escalation protocol. Median [IQR] TWA-SBP above 200 mm Hg was 0.01 [0.0-0.4] mm Hg in the de-escalated group versus 0.0 [0.0-0.1] mm Hg in the dose-escalated group ( P =0.073). The median duration of postoperative continuous norepinephrine administration was 0.3 hours [0.0-5.5] versus 5.1 hours [0.0-14.3], respectively ( P =0.003). Postoperative symptomatic hypotension occurred in 34.2% versus 9.1% of patients ( P =0.005). Median hospital stay was 2.5 days [1.9-3.6] versus 7.1 days [6.0-11.9] ( P <0.001). No significant differences in complication rates were observed.

Conclusion: Our data suggest that adrenalectomy for pheochromocytoma employing a de-escalated preoperative α-blockade protocol is safe and results in a shorter hospital stay.

目的:本研究描述了在前瞻性患者群体中采用省略术前α-受体阻滞剂量递增(去递增)方案的效果:本研究描述了在前瞻性患者群体中采用省略术前α-受体阻滞剂剂量递增(去递增)方案的效果:嗜铬细胞瘤切除术相关死亡率和发病率的下降常常归功于术前α-受体阻滞剂的引入。目前的治疗方案要求术前α-受体阻滞剂剂量递增和多天住院。然而,目前还缺乏相关证据。此外,最近的数据表明,无论术前α-受体阻滞剂的剂量是否增加,围手术期的安全性都是相同的:方法:对协议执行情况进行单机构评估,包括2015年至2023年间因嗜铬细胞瘤接受肾上腺切除术的患者。术中血流动力学控制通过使用血管活性药物主动调整血压来调节。主要结果是术中高血压,定义为时间加权平均收缩压(TWA-SBP)超过 200 mm Hg。次要结果包括围手术期低血压、术后血压支持需求、住院时间和并发症:在 102 名嗜铬细胞瘤患者中,有 82 人被纳入其中;44 人采用了术前α肾上腺素能降级方案,38 人采用了之前的剂量升级方案。中位数[IQR]TWA-SBP超过200毫米汞柱时,去升级组为0.01[0.0-0.4]毫米汞柱,而剂量升级组为0.0[0.0-0.1]毫米汞柱(P=0.073)。术后持续注射去甲肾上腺素的中位时间分别为 0.3 小时 [0.0-5.5] 和 5.1 小时 [0.0-14.3](P=0.003)。术后出现症状性低血压的患者比例为34.2%对9.1%(P=0.005)。中位住院时间为2.5天[1.9-3.6]对7.1天[6.0-11.9](PC结论:我们的数据表明,采用降级的术前α-受体阻滞方案进行嗜铬细胞瘤肾上腺切除术是安全的,并能缩短住院时间。
{"title":"Omitting the Escalating Dosage of Alpha-adrenergic Blockade Before Pheochromocytoma Resection: Implementation of a Treatment Strategy in Discordance With Current Guidelines.","authors":"Isabelle Holscher, Anton F Engelsman, Koen M A Dreijerink, Markus W Hollmann, Tijs J van den Berg, Els J M Nieveen van Dijkum","doi":"10.1097/SLA.0000000000006493","DOIUrl":"10.1097/SLA.0000000000006493","url":null,"abstract":"<p><strong>Objective: </strong>This study describes the effects of introducing a protocol omitting preoperative α-blockade dose-escalation (de-escalation) in a prospective patient group.</p><p><strong>Background: </strong>The decline of mortality and morbidity associated with pheochromocytoma resection is frequently attributed to the introduction of preoperative α-blockade. Current protocols require preoperative α-blockade dose-escalation and multiple-day hospital admissions. However, correlating evidence is lacking. Moreover, recent data suggest equal perioperative safety regardless of preoperative α-blockade escalation.</p><p><strong>Methods: </strong>Single-institution evaluation of protocol implementation, including patients who underwent adrenalectomy for pheochromocytoma between 2015 and 2023. Intraoperative hemodynamic control was regulated by active adjustment of blood pressure using vasoactive agents. The primary outcome was intraoperative hypertension, defined as the time-weighted average of systolic blood pressure (TWA-SBP) above 200 mm Hg. Secondary outcomes included perioperative hypotension, postoperative blood pressure support requirement, hospital stay duration, and complications.</p><p><strong>Results: </strong>Of 102 pheochromocytoma patients, 82 were included; 44 in the de-escalated preoperative α-adrenergic protocol and 38 following the previous dose-escalation protocol. Median [IQR] TWA-SBP above 200 mm Hg was 0.01 [0.0-0.4] mm Hg in the de-escalated group versus 0.0 [0.0-0.1] mm Hg in the dose-escalated group ( P =0.073). The median duration of postoperative continuous norepinephrine administration was 0.3 hours [0.0-5.5] versus 5.1 hours [0.0-14.3], respectively ( P =0.003). Postoperative symptomatic hypotension occurred in 34.2% versus 9.1% of patients ( P =0.005). Median hospital stay was 2.5 days [1.9-3.6] versus 7.1 days [6.0-11.9] ( P <0.001). No significant differences in complication rates were observed.</p><p><strong>Conclusion: </strong>Our data suggest that adrenalectomy for pheochromocytoma employing a de-escalated preoperative α-blockade protocol is safe and results in a shorter hospital stay.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":"817-824"},"PeriodicalIF":7.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141892688","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Impact of Preoperative Time Intervals for Neoadjuvant Chemoradiotherapy on Short-term Postoperative Outcomes of Esophageal Cancer Surgery: A Population-based Study Using the Dutch Upper Gastrointestinal Cancer Audit (DUCA) Data. 新辅助化放疗的术前时间间隔对食管癌手术术后短期疗效的影响:利用荷兰上消化道癌症审计 (DUCA) 数据进行的人群研究。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 Epub Date: 2024-08-08 DOI: 10.1097/SLA.0000000000006476
Jingpu Wang, Cas de Jongh, Zhouqiao Wu, Eline M de Groot, Alexandre Challine, Sheraz R Markar, Hylke J F Brenkman, Jelle P Ruurda, Richard van Hillegersberg

Objective: To clarify the impact of the preoperative time intervals on short-term postoperative and pathologic outcomes in patients with esophageal cancer who underwent neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy.

Background: The impact of preoperative intervals on patients with esophageal cancer who received multimodality treatment remains unknown.

Methods: Patients (cT1-4aN0-3M0) treated with nCRT plus esophagectomy were included using the Dutch national DUCA database. Multivariate logistic regression was used to determine the effect of different time intervals upon short-term postoperative and pathologic outcomes: diagnosis-to-nCRT intervals (≤5, 5-8, and 8-12 weeks), nCRT-to-surgery intervals (5-11, 11-17, and >17 weeks) and total preoperative intervals (≤16, 16-25, and >25 weeks).

Results: Between 2010 and 2021, a total of 5052 patients were included. Compared with diagnosis-to-nCRT interval ≤5 weeks, the interval of 8 to 12 weeks was associated with a higher risk of overall complications ( P =0.049). Compared with nCRT-to-surgery interval of 5 to 11 weeks, the longer intervals (11-17 and >17 weeks) were associated with a higher risk of overall complications ( P =0.016; P <0.001) and anastomotic leakage ( P =0.004; P =0.030), but the interval >17 weeks was associated with lower risk of ypN+ ( P =0.021). The longer total preoperative intervals were not associated with the risk of 30-day mortality and complications compared with the interval ≤16 weeks, but the longer total preoperative interval (>25 weeks) was associated with higher ypT stage ( P =0.010) and lower pathologic complete response rate ( P =0.013).

Conclusions: In patients with esophageal cancer undergoing nCRT and esophagectomy, prolonged preoperative time intervals may lead to higher morbidity and disease progression, and the causal relationship requires further confirmation.

目的旨在明确术前时间间隔对接受新辅助化放疗(nCRT)后食管切除术的食管癌患者术后短期疗效和病理结果的影响:术前间隔期对接受多模式治疗的食管癌患者的影响尚不清楚:方法:利用荷兰国家 DUCA 数据库纳入了接受 nCRT+ 食管切除术治疗的患者(cT1-4aN0-3M0)。采用多变量逻辑回归确定不同时间间隔对短期术后和病理结果的影响:诊断到nCRT的时间间隔(≤5、5-8和8-12周)、nCRT到手术的时间间隔(5-11、11-17和>17周)以及术前总时间间隔(≤16、16-25和>25周):结果:2010-2021年间,共纳入5052例患者。与诊断到 nCRT 间隔≤5 周相比,8-12 周的间隔与较高的总体并发症风险相关(P=0.049)。与 nCRT 到手术间隔 5-11 周相比,间隔时间越长(11-17 周和 >17 周),总体并发症的风险越高(P-value=0.016;P-value17 周与 ypN+ 的低风险相关(P-value=0.021)。与间隔时间≤16周相比,较长的术前总间隔时间与30天死亡率和并发症风险无关,但较长的术前总间隔时间(>25周)与较高的ypT分期(P-value=0.010)和较低的pCR率(P-value=0.013)有关:结论:对于接受nCRT和食管切除术的食管癌患者,延长术前时间间隔可能会导致更高的发病率和疾病进展,其因果关系有待进一步证实。
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引用次数: 0
Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy and Liver Resection is a Treatment Option for Patients With Peritoneal and Liver Metastases From Colorectal Cancer. 腹腔内热化疗和肝脏切除的细胞剥脱手术是结直肠癌腹膜和肝脏转移患者的一种治疗选择。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 Epub Date: 2024-08-26 DOI: 10.1097/SLA.0000000000006492
Vegar Johansen Dagenborg, Kristoffer Watten Brudvik, Christin Lund-Andersen, Annette Torgunrud, Marius Lund-Iversen, Kjersti Flatmark, Stein Gunnar Larsen, Sheraz Yaqub

Objective: To study outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) in patients also treated for colorectal liver metastases (CLM).

Background: Colorectal cancer (CRC) frequently metastasizes to the liver and peritoneum and is associated with a poor prognosis. In selected patients, a benefit in overall survival (OS) was shown for both peritoneal metastases (PM-CRC) offered CRS-HIPEC, and CLM treated with surgical resection. However, the presence of CLM was considered a relative contraindication to CRS-HIPEC, causing a paucity of outcome data in this patient group.

Methods: Patients with PM-CRC having CRS-HIPEC at a single national center between 2007 and 2023, with additional intervention for CLM, were included (previous curative treatment for extraperitoneal and extrahepatic metastases was allowed). Three groups were defined: CLM before CRS-HIPEC (pre-CRS-HIPEC), CLM resected simultaneously with CRS-HIPEC (sim-CRS-HIPEC), and CLM after CRS-HIPEC (post-CRS-HIPEC), aiming to retrospectively analyze outcomes.

Results: Fifty-seven patients were included and classified as: pre-CRS-HIPEC (n = 11), sim-CRS-HIPEC (n = 29), and post-CRS-HIPEC (n = 17). Median Peritoneal Cancer Index (PCI) was 8; 13 patients had severe complications (Clavien-Dindo ≥3), and no 90-day mortality. Median OS was 48 months after CRS-HIPEC. PCI was a predictor of OS (hazard ratio: 1.11, P < 0.001). We observed no difference in short or long-term outcomes between intervention groups.

Discussion: This study demonstrated that patients with CLM having CRS-HIPEC had comparable OS to reports on CRS-HIPEC only, likely explained by a low PCI. Simultaneous CLM resection did not increase the risk of severe complications.

Conclusions: In this national cohort, CRS-HIPEC and CLM intervention offers long-term survival, suggesting that this treatment may be offered to selected patients with PM-CRC and CLM.

背景:结直肠癌经常转移至肝脏和腹膜,预后较差。在选定的患者中,腹膜转移(PM-CRC)患者接受细胞切除手术和腹腔内热化疗(CRS-HIPEC),以及结直肠肝转移(CLM)患者接受手术切除治疗后,总生存期(OS)均有获益。然而,CLM的存在被认为是CRS-HIPEC的相对禁忌症,导致该患者群体的结果数据很少:研究设计:纳入 2007 年至 2023 年期间在一个国家中心接受 CRS-HIPEC 治疗的 PM-CRC 患者,并对 CLM 进行额外干预(允许之前对腹膜外和肝外转移瘤进行过治愈性治疗)。共分为三组CRS-HIPEC前的CLM(preCRS-HIPEC);与CRS-HIPEC同时切除的CLM(simCRS-HIPEC);CRS-HIPEC后的CLM(postCRS-HIPEC),旨在对结果进行回顾性分析:结果:共纳入57例患者,分为:CRS-HIPEC前(11例)、simCRS-HIPEC(29例)和CRS-HIPEC后(17例)。腹膜癌指数(PCI)中位数为 8,13 名患者出现严重并发症(Clavien-Dindo ≥3),无 90 天死亡病例。CRS-HIPEC术后的中位OS为48个月。PCI是预测OS的指标(HR 1.11,PD讨论:这项研究表明,接受CRS-HIPEC治疗的CLM患者的OS与仅接受CRS-HIPEC治疗的患者相当,这可能是因为PCI较低。同时进行CLM切除术不会增加严重并发症的风险:在这个全国性队列中,CRS-HIPEC和CLM干预可提供长期生存,这表明这种治疗方法可提供给选定的PM-CRC和CLM患者。
{"title":"Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy and Liver Resection is a Treatment Option for Patients With Peritoneal and Liver Metastases From Colorectal Cancer.","authors":"Vegar Johansen Dagenborg, Kristoffer Watten Brudvik, Christin Lund-Andersen, Annette Torgunrud, Marius Lund-Iversen, Kjersti Flatmark, Stein Gunnar Larsen, Sheraz Yaqub","doi":"10.1097/SLA.0000000000006492","DOIUrl":"10.1097/SLA.0000000000006492","url":null,"abstract":"<p><strong>Objective: </strong>To study outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) in patients also treated for colorectal liver metastases (CLM).</p><p><strong>Background: </strong>Colorectal cancer (CRC) frequently metastasizes to the liver and peritoneum and is associated with a poor prognosis. In selected patients, a benefit in overall survival (OS) was shown for both peritoneal metastases (PM-CRC) offered CRS-HIPEC, and CLM treated with surgical resection. However, the presence of CLM was considered a relative contraindication to CRS-HIPEC, causing a paucity of outcome data in this patient group.</p><p><strong>Methods: </strong>Patients with PM-CRC having CRS-HIPEC at a single national center between 2007 and 2023, with additional intervention for CLM, were included (previous curative treatment for extraperitoneal and extrahepatic metastases was allowed). Three groups were defined: CLM before CRS-HIPEC (pre-CRS-HIPEC), CLM resected simultaneously with CRS-HIPEC (sim-CRS-HIPEC), and CLM after CRS-HIPEC (post-CRS-HIPEC), aiming to retrospectively analyze outcomes.</p><p><strong>Results: </strong>Fifty-seven patients were included and classified as: pre-CRS-HIPEC (n = 11), sim-CRS-HIPEC (n = 29), and post-CRS-HIPEC (n = 17). Median Peritoneal Cancer Index (PCI) was 8; 13 patients had severe complications (Clavien-Dindo ≥3), and no 90-day mortality. Median OS was 48 months after CRS-HIPEC. PCI was a predictor of OS (hazard ratio: 1.11, P < 0.001). We observed no difference in short or long-term outcomes between intervention groups.</p><p><strong>Discussion: </strong>This study demonstrated that patients with CLM having CRS-HIPEC had comparable OS to reports on CRS-HIPEC only, likely explained by a low PCI. Simultaneous CLM resection did not increase the risk of severe complications.</p><p><strong>Conclusions: </strong>In this national cohort, CRS-HIPEC and CLM intervention offers long-term survival, suggesting that this treatment may be offered to selected patients with PM-CRC and CLM.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":"745-752"},"PeriodicalIF":7.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11446514/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142054731","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
New Biomarkers to Define a Biological Borderline Situation for Pancreatic Adenocarcinoma: Results of an Ancillary Study of the PANACHE01-PRODIGE48 Trial. 定义胰腺腺癌生物学边界情况的新生物标记物--PANACHE01-PRODIGE48 试验的辅助研究结果
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 Epub Date: 2024-08-05 DOI: 10.1097/SLA.0000000000006468
Jean Pinson, Julie Henriques, Ludivine Beaussire, Nasrin Sarafan-Vasseur, Antonio Sa Cunha, Jean-Baptiste Bachet, Dewi Vernerey, Frederic Di Fiore, Lilian Schwarz
<p><strong>Objective: </strong>To investigate in patients treated for a resectable pancreatic ductal adenocarcinoma [pancreatic adenocarcinoma (PA)], the prognostic value of baseline carbohydrate antigen 19.9 (CA19-9) and circulating tumor DNA (ctDNA) for overall survival (OS), to improve death risk stratification, based on a planned ancillary study from PANACHE01-PRODIGE 48 trial.</p><p><strong>Background: </strong>Biological borderline situation that was first used by the MD Anderson, became a standard practice following the international consensus conference in 2016 to manage PA. Regarding the risk of systemic disease, especially in the setting of "markedly elevated" CA19-9, neoadjuvant therapy is advised to avoid unnecessary surgery, with a risk of early recurrence. To best define biological borderline situations, new biomarkers are needed.</p><p><strong>Methods: </strong>Characteristics at diagnosis and OS were compared between patients with or without ctDNA status available. OS was estimated with the Kaplan-Meier method and compared with a log-rank test. The restricted cubic spline approach was used to identify the optimal threshold for biological parameters for death risk stratification. Univariate and multivariate Cox proportional hazard models were estimated to assess the association of ctDNA status and other parameters with OS.</p><p><strong>Results: </strong>Among the 132 patients from the primary population for analysis in the PANACHE01 -PRODIGE 48 trial, 92(71%) were available for ctDNA status at diagnosis. No selection bias was identified between patients with or without ctDNA status. Fourteen patients (15%) were ctDNA+ and exhibited a higher risk for death [ P = 0.0188; hazard ratio (95% CI): 2.28 (1.12-4.63)]. In the 92 patients with ctDNA status available among the other parameters analyzed, only CA19-9 was statically associated with OS in univariate analysis. Patients with a log of CA19-9 equal or superior to 4.4 that corresponds to a CA19-9 of 80 UI/mL were identified at higher risk for death [ P = 0.0143; hazard ratio (95% CI): 2.2 (1.15-4.19)]. In multivariate analysis, CA19-19 remained independently associated with OS ( P = 0.0323). When combining the 2 biomarkers, the median OS was 19.4 [IC 95%: 3.8-not reached (NR)] months, 30.2 (IC 95%: 17.1-NR) months and NR (IC 95%: 39.3-NR) for "CA19-9 high and ctDNA+ group," "CA19-9 high or ctDNA+ group," and "CA19-9 low and ctDNA- group," respectively (log-rank P = 0.0069).</p><p><strong>Conclusions: </strong>Progress in the management of potentially operable PA remains limited, relying solely on strategies to optimize the sequence of complete treatment, based on modern multidrug chemotherapy (FOLFIRINOX, GemNabPaclitaxel) and surgical resection. The identification of risk criteria, such as the existence of systemic disease, is an important issue, currently referred to as "biological borderline disease." Few data, particularly from prospective studies, allow us to identify biomarkers
目的基于PANACHE01-PRODIGE 48试验的一项计划辅助研究,研究基线CA19-9和循环肿瘤DNA(ctDNA)对可切除胰腺导管腺癌(PA)患者总生存期(OS)的预后价值,以改善死亡风险分层:在 2016 年国际共识会议之后,MD Anderson 首次使用的生物边界情况成为管理 PA 的标准做法。考虑到全身性疾病的风险,尤其是在 CA19-9 "明显升高 "的情况下,建议进行新辅助治疗,以避免不必要的手术和早期复发的风险。为了更好地界定生物学边界情况,需要新的生物标志物:方法:比较有或没有ctDNA状态的患者的诊断特征和OS。OS 采用 Kaplan Meier 法估算,并用对数秩检验进行比较。采用限制立方样条法确定用于死亡风险分层的生物参数的最佳阈值。估算了单变量和多变量考克斯比例危险模型,以评估ctDNA状态和其他参数与OS的关系:在PANACHE01 -PRODIGE 48试验的主要分析人群132名患者中,有92人(71%)在诊断时可获得ctDNA状态。有无ctDNA状态的患者之间未发现选择偏差。14名患者(15%)为ctDNA+,死亡风险较高(P=0,0188;HR95% CI:2.28(1.12-4.63))。在 92 例可获得 ctDNA 状态的患者中,在分析的其他参数中,只有 CA19-9 在单变量分析中与 OS 有统计学相关性。CA19-9对数等于或大于4.4(相当于CA19-9为80 UI/mL)的患者死亡风险较高(P=0,0143;HR95% CI:2.2(1.15-4.19))。在多变量分析中,CA19-19 仍与 OS 独立相关(P 值=0.0323)。如果将两种生物标志物结合起来,"CA19-9高和ctDNA+组"、"CA19-9高或ctDNA+组 "和 "CA19-9低和ctDNA-组 "的中位OS分别为19.4个月(IC 95% 3.8-未达到)、30.2个月(IC 95% 17.1-NR)和未达到(IC 95% 39.3-NR)(logrank P=0,0069):讨论:潜在可手术 PA 的治疗进展仍然有限,仅依赖于基于现代多药化疗(FOLFIRINOX、GemNabPaclitaxel)和手术切除的完全治疗顺序优化策略。确定风险标准(如存在全身性疾病)是一个重要问题,目前被称为 "生物学边界疾病"。很少有数据,尤其是来自前瞻性研究的数据,能让我们确定 CA19-9 以外的生物标志物:结论:将ctDNA与CA19-9结合起来可能有助于更好地界定PA的生物学边界情况。
{"title":"New Biomarkers to Define a Biological Borderline Situation for Pancreatic Adenocarcinoma: Results of an Ancillary Study of the PANACHE01-PRODIGE48 Trial.","authors":"Jean Pinson, Julie Henriques, Ludivine Beaussire, Nasrin Sarafan-Vasseur, Antonio Sa Cunha, Jean-Baptiste Bachet, Dewi Vernerey, Frederic Di Fiore, Lilian Schwarz","doi":"10.1097/SLA.0000000000006468","DOIUrl":"10.1097/SLA.0000000000006468","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To investigate in patients treated for a resectable pancreatic ductal adenocarcinoma [pancreatic adenocarcinoma (PA)], the prognostic value of baseline carbohydrate antigen 19.9 (CA19-9) and circulating tumor DNA (ctDNA) for overall survival (OS), to improve death risk stratification, based on a planned ancillary study from PANACHE01-PRODIGE 48 trial.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Biological borderline situation that was first used by the MD Anderson, became a standard practice following the international consensus conference in 2016 to manage PA. Regarding the risk of systemic disease, especially in the setting of \"markedly elevated\" CA19-9, neoadjuvant therapy is advised to avoid unnecessary surgery, with a risk of early recurrence. To best define biological borderline situations, new biomarkers are needed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;Characteristics at diagnosis and OS were compared between patients with or without ctDNA status available. OS was estimated with the Kaplan-Meier method and compared with a log-rank test. The restricted cubic spline approach was used to identify the optimal threshold for biological parameters for death risk stratification. Univariate and multivariate Cox proportional hazard models were estimated to assess the association of ctDNA status and other parameters with OS.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Among the 132 patients from the primary population for analysis in the PANACHE01 -PRODIGE 48 trial, 92(71%) were available for ctDNA status at diagnosis. No selection bias was identified between patients with or without ctDNA status. Fourteen patients (15%) were ctDNA+ and exhibited a higher risk for death [ P = 0.0188; hazard ratio (95% CI): 2.28 (1.12-4.63)]. In the 92 patients with ctDNA status available among the other parameters analyzed, only CA19-9 was statically associated with OS in univariate analysis. Patients with a log of CA19-9 equal or superior to 4.4 that corresponds to a CA19-9 of 80 UI/mL were identified at higher risk for death [ P = 0.0143; hazard ratio (95% CI): 2.2 (1.15-4.19)]. In multivariate analysis, CA19-19 remained independently associated with OS ( P = 0.0323). When combining the 2 biomarkers, the median OS was 19.4 [IC 95%: 3.8-not reached (NR)] months, 30.2 (IC 95%: 17.1-NR) months and NR (IC 95%: 39.3-NR) for \"CA19-9 high and ctDNA+ group,\" \"CA19-9 high or ctDNA+ group,\" and \"CA19-9 low and ctDNA- group,\" respectively (log-rank P = 0.0069).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Progress in the management of potentially operable PA remains limited, relying solely on strategies to optimize the sequence of complete treatment, based on modern multidrug chemotherapy (FOLFIRINOX, GemNabPaclitaxel) and surgical resection. The identification of risk criteria, such as the existence of systemic disease, is an important issue, currently referred to as \"biological borderline disease.\" Few data, particularly from prospective studies, allow us to identify biomarkers","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":"734-744"},"PeriodicalIF":7.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141888299","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Interobserver Variability in the International Study Group for Pancreatic Surgery (ISGPS)-Defined Complications After Pancreatoduodenectomy: An International Cross-Sectional Multicenter Study. 国际胰腺外科研究小组(ISGPS)定义的胰十二指肠切除术后并发症的观察者间差异:一项国际多中心横断面研究。
IF 7.5 1区 医学 Q1 SURGERY Pub Date : 2024-11-01 Epub Date: 2024-08-01 DOI: 10.1097/SLA.0000000000006473
Tessa E Hendriks, Alberto Balduzzi, Susan van Dieren, J Annelie Suurmeijer, Roberto Salvia, Thomas F Stoop, Marco Del Chiaro, Sven D Mieog, Mark Nielen, Sabino Zani, Daniel Nussbaum, Thilo Hackert, Jakob R Izbicki, Ammar A Javed, D Brock Hewitt, Bas Groot Koerkamp, Roeland F de Wilde, Yi Miao, Kuirong Jiang, Kohei Nakata, Masafumi Nakamura, Jin-Young Jang, Mirang Lee, Cristina R Ferrone, Shailesh V Shrikhande, Vikram A Chaudhari, Olivier R Busch, Ajith K Siriwardena, Oliver Strobel, Jens Werner, Bert A Bonsing, Giovanni Marchegiani, Marc G Besselink

Objective: To determine the interobserver variability for complications of pancreatoduodenectomy as defined by the International Study Group for Pancreatic Surgery (ISGPS) and others.

Background: Good interobserver variability for the definitions of surgical complications is of major importance in comparing surgical outcomes between and within centers. However, data on interobserver variability for pancreatoduodenectomy-specific complications are lacking.

Methods: International cross-sectional multicenter study including 52 raters from 13 high-volume pancreatic centers in 8 countries on 3 continents. Per center, 4 experienced raters scored 30 randomly selected patients after pancreatoduodenectomy. In addition, all raters scored 6 standardized case vignettes. This variability and the "within centers" variability were calculated for 2-fold scoring (no complication/grade A vs grade B/C) and 3-fold scoring (no complication/grade A vs grade B vs grade C) of postoperative pancreatic fistula, postpancreatoduodenectomy hemorrhage, chyle leak, bile leak, and delayed gastric emptying. Interobserver variability is presented with Gwet AC-1 measure for agreement.

Results: Overall, 390 patients after pancreatoduodenectomy were included. The overall agreement rate for the standardized cases vignettes for 2-fold scoring was 68% (95% CI: 55%-81%, AC1 score: moderate agreement), and for 3-fold scoring 55% (49%-62%, AC1 score: fair agreement). The mean "within centers" agreement for 2-fold scoring was 84% (80%-87%, AC1 score; substantial agreement).

Conclusions: The interobserver variability for the ISGPS-defined complications of pancreatoduodenectomy was too high even though the "within centers" agreement was acceptable. Since these findings will decrease the quality and validity of clinical studies, ISGPS has started efforts aimed at reducing the interobserver variability.

目的确定国际胰腺外科研究小组(ISGPS)和其他机构定义的胰十二指肠切除术并发症的观察者间差异性:手术并发症定义的良好观察者间变异性对于比较中心之间和中心内部的手术结果至关重要。然而,关于胰十二指肠切除术特异性并发症的观察者间变异性的数据还很缺乏:国际横断面多中心研究,包括来自 3 大洲 8 个国家 13 个高容量胰腺中心的 52 名评分员。每个中心由 4 名经验丰富的评分员对随机抽取的 30 名胰十二指肠切除术后患者进行评分。此外,所有评分员还对 6 个标准化病例进行评分。对术后胰瘘 (POPF)、胰十二指肠切除术后出血 (PPH)、糜烂性渗漏 (CL)、胆汁渗漏 (BL) 和胃排空延迟 (DGE) 的两倍评分(无并发症/A 级 vs B/C 级)和三倍评分(无并发症/A 级 vs B 级 vs C 级)计算了这种变异性和 "中心内 "变异性。用 Gwet's AC-1 测量法显示观察者之间的一致性:结果:共纳入了 390 名胰十二指肠切除术后患者。标准化病例小节两倍评分的总体一致率为 68%(95%-CI:55%-81%,AC1 评分:中等一致),三倍评分的总体一致率为 55%(49%-62%,AC1 评分:一般一致)。两倍评分的平均 "中心内 "一致性为 84%(80%-87%,AC1 评分;基本一致):结论:尽管 "中心内 "的一致性可以接受,但ISGPS定义的胰十二指肠切除术并发症的观察者间变异性过高。由于这些发现会降低临床研究的质量和有效性,ISGPS 已开始努力降低观察者之间的变异性。
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引用次数: 0
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Annals of surgery
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