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.