Annals of surgery最新文献

Objective: To understand psychosocial functioning before and after gender-affirming facial feminization surgery (FFS) as well as identify predictors of postoperative psychosocial functioning.

Background: Few investigations have rigorously explored the impact of gender-affirming FFS on psychosocial functioning in transgender and gender non-binary (TGNB) individuals. This knowledge gap hinders the identification of methods to optimize mental health quality-of-life outcomes after FFS and carries repercussions for access to care.

Methods: Adult TGNB participants awaiting gender-affirming FFS were prospectively enrolled and administered Patient-Reported Outcomes Measurement Information System (PROMIS) instruments assessing anxiety, anger, depression, global mental and physical health, positive affect, emotional support, social isolation, companionship, and meaning and purpose before and 3-6 months after FFS. Paired t tests compared preoperative and postoperative scores. Multivariable linear models identified predictors of postoperative psychosocial outcomes.

Results: Among the domains, psychosocial scores improved for anxiety, depression, global mental health, social isolation, and positive affect after FFS. When accounting for potential variables contributing to postoperative psychosocial scores, including other gender-affirming surgeries, hormone therapy duration, and private versus public insurance type, we found that preoperative depression scores independently predicted the variance in all other postoperative scores with global mental health (β=-0.52, 95% CI: -0.58 to -0.31 P <0.001), anxiety (β=0.40, 95% CI: 0.21-0.51, P <0.001), and meaning and purpose (β=-0.52, 95% CI: -0.78 to -0.42 P <0.001) as the strongest models.

Conclusions: This study suggests that gender-affirming FFS improves psychosocial functioning; however, such improvements are highly influenced by the baseline psychological functioning of each individual. These findings indicate that preoperative psychological functioning may be a potential avenue for improving outcomes after FFS via perioperative psychological interventions.

Objective: We sought to compare postdischarge outcomes and health care utilization between English-speaking non-Hispanic White (NHW), English-speaking Hispanic/Latinx (ESHL), and Spanish-speaking Hispanic/Latinx (SSHL) survivors of traumatic injury.

Background: While there is evidence of racial and ethnic disparities in health care utilization and postdischarge outcomes after injury, the role of English-language proficiency in these disparities remains unclear.

Methods: Moderate to severely injured adults from 3 level-1 trauma centers completed an interview in English or Spanish between 6 and 12 months postinjury to assess physical health-related quality-of-life (SF-12-PCS), return to work, and postdischarge health care utilization. The language used in the interview was used as a proxy for English-language proficiency, and participants were categorized as either NHW (reference), ESHL, or SSHL. Multivariable regression models estimated independent associations between language and race/ethnicity with SF-12-PCS, return to work, and postdischarge health care utilization outcomes.

Results: A total of 3304 injury survivors were followed: 2977 (90%) NHW, 203 (6%) ESHL, and 124 (4%) SSHL. In adjusted analyses, no significant differences were observed between ESHL and NHW injury survivors for any outcomes at 6 to 12 months postinjury. However, SSHL injury survivors exhibited a lower mean SF-12-PCS (41.6 vs. 38.5), -3.07 (95% CI=-5.47, -0.66; P =0.012), decreased odds of returning to work [odds ratio (OR)=0.47; CI=0.27-0.81; P =0.007], and were less likely to engage in non-injury-related outpatient visits, such as primary care visits (OR=0.45; 95% CI=0.28-0.73; P =0.001), compared with NHW patients.

Conclusion: Hispanic/Latinx injury survivors have worse postdischarge outcomes and lower non-injury-related health care utilization than NHW if they have limited English-language proficiency. Addressing LEP-related barriers to care could help mitigate outcome and health care utilization disparities among Hispanic/Latinx injury survivors.

Objective: To investigate the potential of acute canagliflozin administration to mitigate acute kidney injury (AKI) and attenuate deleterious pro-inflammatory cytokine release in a clinically relevant swine model of severe renal ischemia reperfusion injury (IRI) induced by hemorrhage and aortic occlusion.

Background: Long-term canagliflozin use attenuates renal function decline and reduces AKI in diabetes mellitus and heart failure patients. While several reports indicate prophylactic SGLT2 inhibition prevents AKI in IRI, the efficacy of acute administration on IRI and inflammation is not known.

Methods: Female swine (n = 16) underwent controlled hemorrhage of 25% blood volume, followed by 90 min of aortic occlusion at the level of the renal ostia (through resuscitative endovascular balloon occlusion of the aorta). A single 300 mg dose of oral canagliflozin or vehicle (saline) was delivered 5 mins into aortic occlusion. Hemodynamic monitoring, markers of renal function (serum creatinine, blood urea nitrogen, proteinuria, and urinary neutrophil gelatinase-associated lipocalin), and serum cytokine concentrations [including interleukins (ILs): IL-1RA, IL-6, IL-8, IL-10, IL-18, and tumor necrosis factor-alpha] were analyzed after IRI, and during a 6-hour critical care phase.

Results: Compared with controls, animals receiving canagliflozin had less severe AKI, improved creatinine clearance, reduced proteinuria, and significantly lower tubular damage as evidenced by histopathology and urinary neutrophil gelatinase-associated lipocalin (NGAL). Furthermore, the pro-inflammatory cytokine IL-6 was markedly attenuated without reduction in anti-inflammatory cytokines (IL-1RA and IL-10).

Conclusions: A single dose of canagliflozin administered shortly into ischemic insult mitigates AKI and attenuates harmful pro-inflammatory cytokine release after controlled hemorrhage in a swine model. These findings suggest a potential novel therapeutic role for canagliflozin in mitigating the effects of renal IRI worthy of further investigation.

Objective: To define the association of privilege on rates of unplanned surgery and perioperative outcomes for access-sensitive surgical conditions.

Background: Social determinants of health (SDOH) are critical in influencing timely access to health care. Privilege represents a right, benefit, advantage, or opportunity that positively influences all SDOH.

Methods: The California Department of Health Care Access and Information database identified patients who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2017 and 2020 and was merged using ZIP codes with the Index of Concentration of Extremes, a validated measure of racial and economic privilege obtained from the American Community Survey. Clustered multivariable regression was performed to assess the association between privilege and outcomes.

Results: Among 185,316 patients who underwent a surgical procedure for one of 3 access-sensitive surgical conditions, roughly 1 in 5 individuals resided in areas with the highest (Q5; n = 37,308; 20.1%) or lowest (Q1; n = 36,352, 19.6%) privilege. Nearly one-half of the surgeries were unplanned (n = 88,814, 46.9%), and colectomy for colon cancer was the most performed emergent procedure. Patients residing in the lowest privileged areas had higher rates of unplanned surgery compared with those residing in the highest privilege [Q1; 55.4% vs 39.4%; referent: Q5; adjusted odds ratio (OR), 1.23, 95% CI: 1.16-1.31; P < 0.001]. For each access-sensitive surgical condition, patients in the least privileged areas were more likely to experience higher rates of inpatient mortality (Q1; 3.1% vs 2.1%; referent: Q5; adjusted OR: 1.41, 95% CI: 1.24-1.60; P < 0.001), perioperative complications (Q1; 30.4% vs Q5; 23.8%; referent: Q5; adjusted OR: 1.24, 95% CI: 1.18-1.31; P < 0.001) and extended hospital stays (Q1; 26.3% vs 20.1%; referent: Q5; adjusted OR: 1.16, 95% CI: 1.09-1.22; P < 0.001).

Conclusions: Privilege was associated with unplanned surgery and adverse clinical outcomes. These data highlight the role of privilege as a key SDOH that influences patient access to and quality of surgical care.

Objective: This review evaluated whether broad-spectrum penicillin-based antibiotic prophylaxis (BS-AB) such as piperacillin-tazobactam might lead to better outcomes in pancreatoduodenectomy compared with standard care antibiotics, mainly cephalosporins (CE-AB).

Background: Pancreatoduodenectomy is commonly associated with high postoperative infectious complications, contributing to increased morbidity, mortality, and health care costs.

Methods: A systemic literature search (PubMed, EMBASE, Cochrane Library, and Web of Science) was conducted to identify suitable RCTs and non-RCTs. After inclusion, the data were analyzed using a random-effects model with the Mantel-Haenszel model or inverse variance to calculate odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI).

Results: One RCT and 11 non-RCTs were included with 12,469 patients (35.3% BS-AB, 64.7% CE-AB). Surgical site infections (SSI) were significantly lower after BS-AB when compared with CE-AB, [OR 0.53; CI (0.32 to 0.86); P =0.01; I2 =79%] as well as the occurrence of postoperative pancreatic fistula (POPF) [OR 0.62; CI (0.47 to 0.81); P <0.01; I2 =0%], days of hospitalization [MD -2.02; CI (-4.08 to 0.03); P =0.05; I2 =98%] and mortality [OR 0.56; CI (0.34 to 0.95); P =0.03; I2 =0%]. Subgroup analyses of patients with preoperative biliary drainage demonstrated an even higher effect of BS-AB in reducing SSI [OR 0.45, CI (0.45 to 0.67); P =0.01; I2 =78%], POPF [OR 0.52; CI (0.36 to 0.75); P <0.01; I2 =0%] and mortality [OR 0.34; CI (0.15 to 0.76); P <0.01; I2 =0%].

Conclusion: BS-AB significantly reduces the risk of infectious complications and surgical outcomes in pancreatoduodenectomy compared with CE-AB, particularly in patients with preoperative biliary drainage. These findings support the use of BS-AB as a new gold standard for patients undergoing pancreatoduodenectomy.

Objective: To compare robotic-assisted proctectomy with ileal pouch-anal anastomosis (R-IPAA) outcomes and laparoscopic proctectomy with IPAA within a specialized robotic surgery center, using matching techniques to minimize potential confounding factors.

Background: Minimally invasive approaches, particularly laparoscopy, have improved outcomes for patients with inflammatory bowel disease and familial adenomatous polyposis undergoing IPAA. Robotic-assisted surgery offers potential technical advantages, but its definitive superiority over laparoscopy in this context remains under debate.

Methods: This retrospective, "Strengthening the Reporting of Observational Studies in Epidemiology"-compliant study analyzed 234 consecutive patients undergoing IPAA (117 robotic and 117 laparoscopic). Data encompassed patient demographics, intraoperative details, and postoperative outcomes. We employed various matching techniques to address potential bias. Primary endpoints focused on 30-day complications, readmissions, and reoperations, with secondary endpoints including hospital stay, blood loss, and stoma closure rates.

Results: R-IPAA demonstrated a lower conversion rate to open surgery ( P = 0.02), a shorter hospital stay ( P = 0.04), and reduced blood loss ( P = 0.0003) compared with laparoscopic proctectomy with IPAA. While overall 30-day morbidity rates were similar ( P = 0.4), matched analyses suggested a trend towards fewer reoperations and 3-month IPAA-associated complications after diverting loop ileostomy closure in the robotic group. However, these differences did not reach statistical significance.

Conclusions: In a high-volume robotic surgery center, R-IPAA reduced the risk of conversion to open surgery while reducing intraoperative blood loss and providing shorter lengths of stay with equivalent perioperative outcomes. Promising trends to reduce 30-day reoperations and surgical complications after diverting loop ileostomy closure were observed after a matching analysis.

Objective: To prospectively validate the recently established International Study Group for Pancreatic Surgery (ISGPS) pancreas classification as a parenchymal risk classification system for pancreatic fistula after pancreatoduodenectomy.

Background: Postoperative pancreatic fistula (POPF) is the major driver for complications after partial pancreatoduodenectomy (PD). Recently, the ISGPS published a pancreas classification containing the parameters of main pancreatic duct diameter and pancreatic texture to help assess the risk of POPF development after PD.

Methods: From January 2020 to July 2021, 271 patients receiving elective PD were included after informed consent. The postoperative course was documented prospectively up to postoperative day 30. Among the pancreas characteristics, the main pancreatic duct and pancreatic texture were assessed intraoperatively at the pancreatic resection margin, and the pancreatic glands were assigned to one of the 4 pancreas classes according to the ISGPS (A-D). The primary endpoint was POPF according to the updated ISGPS definition. Secondary endpoints comprised other post-PD morbidity and mortality.

Results: Of 271 patients, 264 had available data according to the ISGPS pancreas classification. Of those, 78 were assigned to class A (30%), 53 to class B (20%), 50 to class C (19%) and 83 to class D (31%). POPF occurred in 54 of 271 patients (19.9%). The 30-day mortality was 7/271 (2.6%), with 6/7 having developed POPF (86%). POPF rates within the classes A, B, C, and D were 9.0%, 11.3%, 20.0%, and 37.4%, respectively ( P < 0.001). In the univariable regression analysis, only patients in pancreas class D demonstrated a significantly higher risk for POPF when compared with class A (odds ratio: 6.05; 95% CI: 2.6-15.9; P < 0.001). In the multivariable regression model, patients in class D had a significantly higher risk for POPF compared with class A (odds ratio: 3.45; 95% CI: 1.15-11.3; P = 0.032). The model comprised body mass index, surgery duration, microscopic fibrosis, and the ISGPS pancreas classification, demonstrating an area under the curve (AUC) value of ∼0.82 when tested on the PARIS data set.

Conclusions: This prospective trial shows that the ISGPS pancreas classification is valid. Patients in risk class D are prone to POPF independently of other factors. Therefore, all future publications on pancreatic surgery should report the risk class according to the ISGPS pancreas classification to allow for a better comparison of reported cohorts.

Objective: To determine whether lymph node yield (LNY) is associated with improved overall survival (OS) and time to recurrence (TTR) in patients with node-negative pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant therapy (NAT).

Background: LNY has been associated with survival in solid gastrointestinal cancers, including PDAC.

Methods: Patients with pathologic T stage I to III, node-negative (N0), PDAC treated with NAT followed by pancreatoduodenectomy were identified in the Massachusetts General Hospital pancreatectomy database and the National Cancer Database (NCDB). A cutoff point of 22 nodes was identified in the NCDB using the point with the optimal (log-rank test) split. OS and TTR were evaluated using univariate and multivariable analyses.

Results: In the Massachusetts General Hospital cohort, 233 node-negative patients following NAT were included. A LNY ≥ 22 was associated with prolonged median OS (59 vs 25 mo, P <0.001) and prolonged TTR (32 vs 14 mo, P =0.019). On multivariable analysis, LNY was an independent predictor of survival (HR 0.97, 95% CI: 0.95-0.99, P =0.034) per sampled node. In the NCDB, 2029 node-negative patients following NAT were included. A LNY ≥ 22 was associated with prolonged median OS (49 vs 33 mo, P <0.001). On multivariable analysis, LNY was an independent predictor of survival (HR 0.99, 95% CI: 0.98-0.99, P <0.001) per sampled node.

Conclusions: LNY was associated with improved oncologic outcomes in patients treated with NAT followed by pancreatoduodenectomy in two independent data sets. Responsible mechanisms by which LNY impacts the outcomes of node-negative patients following NAT warrant further exploration.

Objective: To analyze the reasons for stopping pressurized intraperitoneal aerosolized chemotherapy (PIPAC) delivered for unresectable peritoneal surface malignancies (PSMs) and to determine survival in a large patient cohort of an experienced PIPAC center.

Background: PIPAC alone or combined with systemic chemotherapy was developed to palliatively treat unresectable PSM. Safety, tolerance, and promising survival results were already reported, but the reasons for stopping treatment remain unclear, and the influence of the number of PIPAC procedures on prognosis has not been evaluated.

Methods: A retrospective analysis of PIPAC procedures from a prospectively maintained single-institution PSM database was conducted from January 2016 to January 2023.

Results: A total of 346 patients underwent 1200 PIPAC treatments in the defined time period. Two-thirds of the patients completed 3 or more PIPAC procedures, and 2 patients had more than 15 treatment procedures. Reasons for PIPAC cessation were disease progression or complication (56%), reorientation to a potential curative procedure (19%), surgical complications of the procedure (13%), death between procedures (8%), and patient request (3%). PSM origin and receiving 3 or more PIPAC treatments were independently correlated with better survival in the overall population, in the group of ultimately unresectable PSM, and after propensity score weighting.

Conclusions: The main reason for stopping PIPAC treatment in the palliative management of PSM is disease progression. When 3 or more PIPAC procedures can be delivered in combination with systemic chemotherapy, survival is significantly improved. Its use should be validated by prospective studies.

Objective: To compare the rates of unplanned procedures for access-sensitive surgical conditions among beneficiaries living in census tracts of varying social capital levels.

Background: Access-sensitive surgical conditions are conditions ideally screened for and treated in an elective setting. However, when left untreated, these conditions may result in unplanned (ie, urgent or emergent) surgery. It is possible that social capital-the resources available to individuals through their membership in a social network-may impact the likelihood of a planned procedure occurring.

Methods: Medicare beneficiaries who underwent 1 of 3 access-sensitive procedures (abdominal aortic aneurysm repair, colectomy for cancer, and ventral hernia repair) between 2016 and 2020 were stratified by their census tract level of social capital, the exposure variable. Outcomes included rate of unplanned surgery, readmission, 30-day mortality, and complications which were risk-adjusted with a logistic regression model that accounted for patient age, sex, race, comorbidities, and area deprivation.

Results: A total of 975,048 beneficiaries were included [mean (SD) patient age, 76 (7.6) years; 443,190 were male (45.45%)]. Compared with patients from census tracts in the highest overall social capital decile, those from census tracts with the least social capital were, on average, more likely to undergo unplanned surgery [40.67% vs 35.28%, odds ratio (OR)=1.26 P <0.001]. In addition, beneficiaries in these communities were also more likely to experience postoperative complications (24.99% vs 22.90%, OR=1.12 P <0.001), but there was no significant difference in rates of readmission or mortality. When evaluating only elective procedures, the differences between the lowest and highest social capital decile groups reduced significantly for complications (12.77% vs 12.11%, OR=1.06 P =0.04), the differences in mortality rates collapsed, and differences in readmission rates remained insignificant.

Conclusions: These data suggest that Medicare beneficiaries who live in communities with lower social capital are more likely to undergo unplanned surgery for access-sensitive conditions. Efforts to improve social capital in these communities may be one strategy for reducing the rate of unplanned operations.