Annals of surgery最新文献

Objective: To investigate the efficacy of psychological prehabilitation in improving surgical outcomes.

Summary background data: Prehabilitation aims to improve surgical outcomes through prevention. While most prehabilitation protocols have focused on improving patient knowledge and physical function, mental health has started to receive greater attention due to its effects on postoperative recovery, including persistent opioid use. However, the efficacy of psychological prehabilitation remains unclear due to the heterogeneity of psychological modalities, intervention characteristics, and surgical contexts.

Methods: A systematic review, meta-analysis, and meta-regression of randomized controlled trials (RCTs) from 2004-2024 were conducted per PRISMA guidelines to assess the effect of psychotherapy on four postoperative outcomes: length of stay (LOS), pain, anxiety, and depression. RCTs were retrieved from MEDLINE, EMBASE, CENTRAL, and Google Scholar databases (March 2024). Studies with >50 adult surgical patients were included. Random-effects meta-analyses estimated pooled effect sizes, with meta-regression analyzing intervention and surgery types.

Results: Twenty articles comprising 2,376 patients were included. Psychological prehabilitation interventions included cognitive behavioral therapy (70%), supportive psychotherapy (25%), and acceptance and commitment therapy (5%). Pooled analysis revealed greater reductions in LOS (Mean Difference (MD)=-1.62 days, 95%CI: -2.899,-0.349, P=0.012), pain (MD=-3.52, 95%CI: -2.642,-4.401, P<0.001), anxiety (standard mean difference (SMD)=-1.51, 95%CI: -0.634,-2.385, P<0.001) and depression (SMD=-1.48, 95%CI: -0.578,-2.382, P=0.001). Psychotherapy modality and surgery type showed no significant effects, except for anxiety.

Conclusion: Psychological prehabilitation reduces LOS, pain, anxiety, and depression after surgery. Further studies are necessary to compare different types, duration, and delivery methods of psychotherapy for specific postoperative outcomes of interest.

Objective: To assess patient radiation exposure as reflected by cumulative air kerma (CAK) and dose area product (DAP) during fenestrated-branched endovascular aortic repair (FB-EVAR).

Summary background data: Patient radiation exposure during FB-EVAR has been reported inconsistently.

Methods: Data from 2,111 patients enrolled in 10 physician-sponsored investigational device exemption studies (2012-2022) were analyzed from the United States Aortic Research Consortium database. Procedures were performed using seven fixed imaging systems (A to G). Patients were classified into three groups by imaging era: 2012-2015 (Group 1), 2016-2018 (Group 2), and 2019-2022 (Group 3). Primary endpoints were CAK and DAP risk factors, assessed using linear mixed-effect models. Secondary endpoints were diagnostic reference levels (DRL) for FB-EVAR.

Results: Of the 2,111 patients (71% males; mean 74±9 years years-old) treated by FB-EVAR; 263 (12%) were in Group 1, 541 (26%) in Group 2, and 1,307 (62%) in Group 3. Use of ≥4 vessel stent-graft designs increased from 69% (Group 1) to 79% (Group 3) (P<0.001). Median CAK decreased from 3,644 mGy (Group 1) to 1,753 mGy (Group 3), and DAP from 441 Gy.cm² to 208 Gy.cm² (P<0.001). Higher BMI, iliac branch device (IBD) use, and longer fluoroscopy time (FT) were associated with increased CAK and DAP, while experienced operators and systems D, F, and G were protective (P<0.05). DRLs for Group 3 were 2,800 mGy (CAK) and 340 Gy.cm² (DAP).

Conclusions: Radiation exposure during FB-EVAR significantly decreased over time. Higher BMI, IBD use, and FT were linked to increased exposure, while experienced operator and System D, F or G were protective. Trial registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02043691 NCT00583817 NCT00483249 NCT01937949 NCT02050113 NCT02323581 NCT01874197 NCT01654133 NCT02266719.

Background: A rise in the proportion of day surgery has seen a concomitant increase in the proportion of patients recovering at home. Blended eHealth is well situated to provide this group with medical support and supervision. However, a data-driven description of the heterogeneity is missing.

Objective: To identify clinically meaningful patterns of functional recovery following abdominal surgery and describe how the emergent patient characteristics differ between them.

Methods: This was a secondary data analysis of two datasets collected through two previously conducted RCTs. We used k-medoids clustering and Growth Mixture Modelling on the longitudinal patient reported outcome measurement information system (PROMIS) physical function (PF) t-scores of 649 patients. Differences in patient characteristics between the resultant clusters were identified through statistical tests.

Results: Three clusters - fast, intermediate and uneven recovery - were identified regardless of the dataset or statistical technique. A fourth cluster - relapse - was identified by both statistical techniques but only in the presence of heavy surgery. The fifth and sixth clusters - low gain and high gain - were identified for both light and heavy surgery, but only through k-medoids clustering.

Conclusions: Trajectories of physical function following abdominal surgery are heterogenous but distinct clinically meaningful patterns can be extracted. This classification may facilitate shared-decision making during pre-operative care and future research may utilize them as targets for prediction.

Objective: To evaluate the prognostic impact of invasive nodules (IN) detected by contrast-enhanced endoscopic ultrasound (CE-EUS) in intraductal papillary mucinous neoplasms (IPMNs) with high-risk stigmata (HRS) and their role in guiding surgery.

Summary of background data: IPMNs with HRS are surgical candidates, but their long-term outcomes and the need for surgery in all patients remain unclear.

Methods: This single-center retrospective study included 257 patients with IPMN and HRS, comparing CE-EUS and CT for detecting IN. It evaluated overall survival (OS) and disease-specific survival (DSS) between surgical and observation groups and identified factors influencing OS through multivariate analysis.

Results: Median follow-up was 53.4 months. Of 257 patients, 226 (87.9%) underwent surgery and 31 (12.1%) were observed. Non-IN patients showed significantly better 5-year OS and DSS than IN patients in both groups (surgery, OS 87.9% vs. 53.2% and DSS 96.9% vs. 64.3%; observation, OS 84.7% vs. 23.3% and DSS 100% vs. 32.8%). Non-IN group that underwent surgery had better 10-year DSS than those in the observed group (96.9% vs. 66.7%). However, with an age-adjusted Charlson comorbidity index (ACCI) ≥5, there was no significant difference in 5-year OS between the groups (77.1% vs. 79.3%, P=0.7036). CE-EUS showed higher sensitivity than CT detecting IN (P=0.042). Independent predictors of poor OS included ACCI ≥5, nonsurgery, mural nodule ≥10 mm, and IN.

Conclusions: CE-EUS effectively detected IN, significantly impacting the prognosis of IPMN with HRS. Its superior sensitivity to CT and ability to predict OS/DSS highlight its importance in guiding clinical management.

Objective: To determine if video grading using Objective Structured Assessment of Technical Skills (OSATS) could estimate the risk of postoperative bile leak (BL) after robotic pancreatoduodenectomy (RPD) and to identify a learning curve effect.

Summary background data: The hepaticojejunostomy (HJ) bile leak rate after RPD is rather high with 10% and may be improved by structured training and skills. Robotic HJ therefore requires confirmation of adequate performance. Grading of surgical performance during HJ could be used in competency-based surgical training.

Methods: Post-hoc analysis of patients included the Dutch LAELAPS-3 RPD training program in 6 centers. Technical performance during robotic HJ was graded by two blinded graders using OSATS (attainable scores 6-30). Primary outcome was grade B/C bile leak according to the ISGLS. Logistic regression determined the performance cut-off and CUSUM analysis identified the learning curve.

Results: Videos from robotic HJ in 259 patients were included with a 6.9% rate of grade B/C bile leak (n=18/259). The median OSATS for the HJ was 25.0 [22-27], with an OSATS score>21 associated with a reduced risk of BL. The rate of BL was 5.1% in patients for OSATS>21 and 12.5% for OSATS ≤21, amounting to a relative reduction of 59.2% and an absolute reduction of 7.4% (8/64 vs. 10/195, OR 0.378, P =0.013). These findings remained similar when only including grade C BL: OR 0.076, P =0.004. On multivariable analysis for grade B/C BL, the only significant predictive factor was OSATS>21: OR 0.273, P =0.025. Stabilization of the CUSUM learning curve for grade B/C BL was reached at 19 RPD procedures, and after 44 procedures the learning curve showed a continuous downward trend. The rate of grade B/C BL was significantly lower beyond 19 RPD: 5.6% versus 8.6% (8/143 vs. 10/116, OR 0.710, P =0.040).

Conclusions: The risk of postoperative BL after RPD is strongly associated with surgical performance during robotic HJ as objectified using OSATS. This approach can be used for rapid assessment of the learning curve and competency-based surgical training, aiming for a safe implementation RPD.

Objective: To propose a shared T classification system for biliary cancers located around the cystic duct junction.

Summary background data: These cancers include perihilar cholangiocarcinoma (PCC), distal cholangiocarcinoma (DCC), and cystic duct carcinoma (CDC), which are staged according to discrete tumor classification.

Methods: From 2011 to 2019, patients with biliary cancers that clinically invaded the junction (junctional cholangiocarcinoma [JCC] ) were classified as having PCC, DCC, CDC, or unclassifiable tumor (UT) based on topologic predominance. The prognostic stratifying ability of the specific American Joint Committee on Cancer T system and depth-based classification were compared between patients with JCC and UT.

Results: Among 191 patients with JCC, 63, 20, and 20 had PCC, DCC, and CDC, respectively; the remaining 88 (46%) had UT. The DCC group showed a better survival rate of 70% at 5 years than the other groups (48% for UT, 36% for PCC, and 29% for CDC). Specific tumor classifications of PCC, DCC, and CDC significantly stratified survival in 88 patients with UT, with c-indices of 0.611, 0.613, and 0.563, respectively. Stratified by depth-based classification (T1, ≤1 mm; T2, >1-5; T3, 6-10; and T4, >10 mm), the 5-year survival rates were 83%, 67%, 44%, and 0% in the UT cohort (P<0.001, C-index, 0.654) and 88%, 60%, 41%, and 24% in the entire JCC cohort (P<0.001, C-index, 0.632), respectively.

Conclusions: The depth-based T classification significantly stratified survival in the clinical category of JCC and histologically defined UT. Cholangiocarcinoma and CDC in this region can be grouped under the banner of the JCC.

Objective: To evaluate demographics and quality metrics across racial and ethnic groups amongst patients undergoing lung resection for non-small cell lung cancer (NSCLC) within the Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD).

Summary background: Studies evaluating disparities amongst patients undergoing lung resection for NSCLC are limited.

Methods: A retrospective cohort analysis of the STS GTSD was performed between 2015-2022. Multivariable logistic regression was performed for operation (wedge versus anatomic resection), operative approach (open versus minimally invasive), 30-day major morbidity, and combined 30-day morbidity/mortality. Non-Hispanic White patients were the reference group.

Results: 103,407 patients underwent resection between 2015-2022. Patients identified as White (88,153; 85.6%), Black (8,924; 8.6%), Asian/PI (4,028; 3.90%), American Indian (274; 0.26%), and Other race (2,028; 1.96%). Black and Hispanic patients were less likely to receive a minimally invasive surgery (MIS) (aOR 0.92 [0.86-0.98], 0.72 [0.70-0.75], respectively). Patients with Medicare (aOR 1.21, 95% CI: 1.08-1.36) or dual Medicare-Medicaid coverage (aOR 1.29, 95% CI: 1.14-1.44) had higher odds of postoperative morbidity, as well as combined morbidity/mortality (Medicare: aOR 1.21, 95% CI: 1.08-1.35; dual coverage: aOR 1.27, 95% CI: 1.13-1.42), compared to those with commercial insurance. These payor types were most prevalent among Black and Hispanic patients.

Conclusions: Surgical volumes for racial and ethnic minorities with operable NSCLC remain disproportionately low. Black and Hispanic patients experience disparities in key quality metrics, including lower likelihood of receiving MIS. Payor status was strongly associated with postoperative complications. These findings underscore the need for targeted interventions.

Objective: To investigate whether the cumulative operative time spent by a surgeon operating on patients on the same day prior to starting a new procedure was associated with surgical outcomes.

Background: The impact of daily operating room workload on a surgeon's performance and patient outcomes is uncertain.

Methods: All elective patients, operated by attending surgeons across seven specialties in four French hospitals between 11/01/2020-12/31/2021, were included. Surgeons' operative workload the same day before each operation was measured in minutes by cumulating incision-to-closure times for all their patients as the primary operator. Composite of adverse events within 30 days post-surgery, encompassed major surgical complications, unplanned reoperation, extended ICU stay, and patient death. Generalized linear mixed models estimated the association between each outcome and operative workload, considering the clustering of operations by surgeons, and adjusting for patient comorbidities, procedure complexity, and surgeon characteristics.

Results: The cohort included 7,979 elective surgeries performed by 44 surgeons. Composite adverse events rates were higher in the 0-minute group compared to those with a higher duration (20.7% vs. 12.5%, P <0.001), as were rates of major complications (19.3% vs. 11.7%, P <0.001), reoperations (6.5% vs. 3.4%, P =0.005), and ICU stay (3.7% vs. 1.2%, P =0.016). When the surgeon had already spent time operating on patients prior to the procedure, adjusted relative risks were lower for composite adverse events (aRR 0.85 [95%CI 0.76-0.95]), major complications (0.86 [0.76-0.97]), reoperation (0.78 [0.63-0.97]), and ICU stay (0.69 [0.49-0.98]).

Conclusions: First patient of the day may experience worse outcomes, prompting surgeons to warm up before starting surgery. Further research is needed to replicate these findings, as many surgeons may prioritize starting with the most complex and challenging cases, which inherently carry greater risks.

Objective: To evaluate the efficacy of non-fixation versus fixation of meshes in laparoendoscopic repair of M3 inguinal hernias in terms of recurrence, postoperative pain, and surgical complications.

Summary background data: International guidelines recommend mesh fixation for large M3 inguinal hernias during laparoendoscopic repairs due to high recurrence rates. However, emerging experimental and registry data suggest that anatomically shaped, rigid and three-dimensional meshes may maintain stability without fixation. This study aimed to address this knowledge gap through a multicenter randomized controlled trial.

Methods: The MEFISTO Trial is a prospective, multicenter, double-blind, randomized controlled trial conducted in 12 surgical centers. A total of 204 patients with M3 inguinal hernias were randomized into two groups: a non-fixation group using three-dimensional, rigid, anatomical meshes. Fixation group using flat lightweight meshes fixed with tissue adhesive. The primary outcome was the recurrence rate at 12 months. The secondary outcomes included postoperative pain (Visual Analog Scale) and surgical site occurrence. Data were analyzed using appropriate statistical methods for non-inferiority studies.

Results: The recurrence rate at 12 months was 3.1% and 2.1% in the non-fixation and fixation groups respectively (P = 0.6847). No differences were observed in pain at discharge, 7-10 days post-surgery, or 12 months post-surgery. No significant differences were found in surgical complications or operative times between groups.

Conclusions: Non-fixation of three-dimensional meshes is non-inferior to fixation of flat lightweight meshes for M3 inguinal hernia repair. These findings support the potential revision of international hernia management guidelines to incorporate non-fixation approaches with appropriate mesh types.