Annals of surgery最新文献

The American College of Surgeons, the American Board of Surgery, and the American Surgical Association have created a Blue Ribbon Committee II to evaluate the current status of surgical education in the United States. As part of this endeavor, a subcommittee was formed to address issues pertinent to the development of surgical faculty as teachers. This entailed multiple discussions among a group of experienced surgical educators, a review of the literature, and a Delphi analysis of possible suggested improvements for faculty educational support, resulting in a final set of recommendations for improvement for future surgical faculty development. These recommendations include a task force to establish a validated system of compensation for faculty teaching, a task force to determine an accurate assessment of the value of surgical trainees to health systems, a review by the Surgical Residency Review Committee and the Association of Program Directors in Surgery of minimal faculty resources for program accreditation in the area of teaching learners, collaborative efforts across surgical specialties for the definition of a national curriculum for faculty, and development of a tool for evaluation of faculty teaching performance.

Objective: To compare living wages and salaries at US residency programs.

Background: It is unknown how resident salary compares to living wages across the United States.

Methods: Cross-sectional analysis of publicly available resident salary affordability from training centers with postgraduate year (PGY)-1 through PGY-7 resident compensation for 2022-2023 was compared with the Massachusetts Institute of Technology Living-Wage Calculator. Resident salary-to-living wage ratios were calculated using PGY-4 salary for each family composition. Univariate and multivariable analysis of PGY-4 salary affordability was performed, accounting for the proportion of expected living wages to taxes, transportation, housing, health care, childcare, and food, as well as unionization and state income tax.

Results: One hundred eighteen residency programs, representing over 60% of US trainees, were included, 20 (17%) of which were unionized. Single-parent families were unable to earn a living wage until PGY-7. Residents with 1 child in 2-adult (single-income) and 2-adult (dual-income) families earn below living wages until PGY-5 and PGY-3, respectively. Residents with more than 1 child never earn a living wage. Multivariable regression analysis using PGY-4 salary: living wage ratios in single-child, 2-parent homes showed food expense and unionization status were consistent predictors of affordability. Unionization was associated with lower affordability prestipend, almost equivalent affordability poststipend, and lower affordability poststipend and union dues.

Conclusions: Resident salaries often preclude residents with children from earning a living wage. Unionization is not associated with increased resident affordability in this cross-sectional analysis. All annual reimbursement data should be centrally compiled, and additional stipends should be considered for residents with children.

Objective: To give surgeons a review of the current and future use of neoadjuvant immunotherapy in patients with localized colorectal cancer (CRC).

Background: Immunotherapy has revolutionized the standard of care in oncology and improved survival outcomes in several cancers. However, the applicability of immunotherapy is still an ongoing challenge. Some cancer types are less responsive to immunotherapy, and the heterogeneity in responses within cancer types is poorly understood. Clinical characteristics of the patient, the timing of immunotherapy in relation to surgery, diversities in the immune responses, clonal heterogeneity, different features of the tumor microenvironment, and genetic alterations are some factors among many that may influence the efficacy of immunotherapy.

Results: In this narrative review, we describe the major types of immunotherapy used to treat localized CRC. Furthermore, we discuss the prediction of response to immunotherapy in relation to biomarkers and radiologic assessment. Finally, we consider the future perspectives of clinical implications and response patterns, as well as the potential and challenges of neoadjuvant immunotherapy in localized CRC.

Conclusions: Establishing mismatch repair (MMR) status at the time of diagnosis is central to the potential use of neoadjuvant immunotherapy, in particular immune checkpoint inhibitors, in localized CRC. To date, efficacy is primarily seen in patients with deficient MMR status and polymerase epsilon mutations, although a small group of patients with proficient MMR does respond. In conclusion, neoadjuvant immunotherapy shows promising complete response rates, which may open a future avenue of an organ-sparing watch-and-wait approach for a group of patients.

Objective: Describe the latest technological in surgical education and assessment.Background:Surgical education is challenged by continuously increasing clinical content, greater subspecialization, and public scrutiny of access to high-quality surgical care. Since the last Blue Ribbon Committee on surgical education, novel technologies have been developed, including artificial intelligence and telecommunication.

Methods: The goals of this Blue Ribbon Sub-Committee were to construct a framework for applying these technologies to improve the effectiveness and efficiency of surgical education and assessment.An additional goal was to identify implementation frameworks and strategies for centers with different resources and access. All subcommittee recommendations were included in a Delphi consensus process with the entire Blue Ribbon Committee (N = 67).

Results: Our subcommittee found several new technologies and opportunities that are well-poised to improve the effectiveness and efficiency of surgical education and assessment (Tables 1-3). Our top recommendation was that a Multidisciplinary Surgical Educational Council be established to serve as an oversight body to develop consensus, facilitate implementation, and establish best practices for technology implementation and assessment. This recommendation achieved 93% consensus during the first round of the Delphi process.

Conclusions: Advances in technology-based assessment, data analytics, and behavioral analysis now allow us to create personalized educational programs based on individual preferences and learning styles. If implemented properly, education technology has the promise of improving the quality and efficiency of surgical education and decreasing the demands on clinical faculty.

Objective: To compare the effect of balanced multielectrolyte solutions (BMESs) versus normal saline (NS) for intravenous fluid on chloride levels and clinical outcomes in patients with predicted severe acute pancreatitis (pSAP).

Background: Isotonic crystalloids are recommended for initial fluid therapy in acute pancreatitis, but whether the use of BMES in preference to NS confers clinical benefits is unknown.

Methods: In this multicenter, stepped-wedge, cluster-randomized trial, we enrolled patients with pSAP (acute physiology and chronic health evaluation II score ≥8 and C-reactive protein >150 mg/L) admitted within 72 hours of the advent of symptoms. The study sites were randomly assigned to staggered start dates for a one-way crossover from the NS phase (NS for intravenous fluid) to the BMES phase (sterofudin for intravenous fluid). The primary endpoint was the serum chloride concentration on trial day 3. Secondary endpoints included a composite of clinical and laboratory measures.

Results: Overall, 259 patients were enrolled from 11 sites to receive NS (n = 147) or BMES (n = 112). On trial day 3, the mean chloride level was significantly lower in patients who received BMES [101.8 mmol/L (SD: 4.8) vs 105.8 mmol/L (SD: 5.9), difference -4.3 mmol/L (95% CI: -5.6 to -3.0 mmol/L) ; P < 0.001]. For secondary endpoints, patients who received BMES had less systemic inflammatory response syndrome (19/112, 17.0% vs 43/147, 29.3%, P = 0.024) and increased organ failure-free days [3.9 days (SD: 2.7) vs 3.5 days (SD: 2.7), P < 0.001] by trial day 7. They also spent more time alive and out of the intensive care unit [26.4 days (SD: 5.2) vs 25.0 days (SD: 6.4), P = 0.009] and hospital [19.8 days (SD: 6.1) vs 16.3 days (SD: 7.2), P < 0.001] by trial day 30.

Conclusions: Among patients with pSAP, using BMES in preference to NS resulted in a significantly more physiological serum chloride level, which was associated with multiple clinical benefits (Trial registration number: ChiCTR2100044432).

Objective: To compare differences in pain, depression, function, and informal caregiving pre-and-post major elective surgery among older adults with and without serious illness; and determine if serious illness was independently associated with increasing pain, depression, assistance in activities of daily living (ADLs) and informal caregiving post-surgery.

Background: The American College of Surgeons has endorsed the integration of palliative care (PC) into surgical care in adults with serious illness but targets for PC during surgical episodes such as pain, depression, function, and informal caregiving are understudied.

Methods: We used Health and Retirement Study-linked Medicare data (2008-2018) to identify older (≥66 y) adults with and without serious illness who had major elective surgery. We performed difference-in-difference analysis to measure changes in pain, depression, function and informal caregiving pre-and-post-surgery between groups. We tested associations between serious illness and changes in pain, depression, function and informal caregiving using multivariable regression.

Results: Among 1896 adults who had major surgery, 1139 (60%) were seriously ill. Compared to adults without serious illness, those with serious illness had greater baseline pain (43 vs. 38%), depression (22 vs.13%), assistance with ADLs(12 vs.0%) and informal caregiving (18 vs.4%); and, greater increases in assistance with ADLs pre-and-post-surgery(DID 6%, 95%CI 3.7-8.3). Serious illness was independently associated with increasing pain (OR 1.6, 95%CI 1.1-2.2), depression (OR 1.5, 95%CI 1.1-2.2), assistance with ADLs (OR 2.1, 95%CI 1.3-3.4) and informal caregiving (OR 2.1, 95%CI 1.4-3.1) post-surgery.

Conclusions: Most older adults having elective surgery are seriously ill. Pain, depression, function, and caregiving are targets for PC to improve post-surgical outcomes.

Objective: To assess the burden of ergonomic strain and to examine factors influencing intention to use wearable technology that may improve ergonomics during surgery.

Background: Surgical ergonomic strain leads to high rates of work-related musculoskeletal disorders (MSDs) and pain, contributing to early surgeon retirement and an epidemic of burnout.

Methods: A cross-sectional survey of surgeons at a single institution was conducted using two validated instruments, the Nordic Musculoskeletal Questionnaire and Unified Theory of Acceptance and Use of Technology (UTAUT2), assessing musculoskeletal strain and facilitators of wearable sensor use, respectively. Additional survey items examined preferred ergonomic device features. Partial least squares structural equation modeling tested model validity.

Results: 161 participants completed the entire survey. Most respondents were male (63.4%) and were more likely to be from General Surgery (26.1%) than from other subspecialties. The majority of surgeons had never received prior ergonomic training (n=107, 72.3%). Twenty surgeons (14.1%) required hospitalization and 31 (21.8%) surgeons changed operating responsibilities due to musculoskeletal injury with 77 (59.1%) reporting an impact of ergonomic pain on their ability to work as a surgeon. Perceived efficacy (β=0.190, P=0.005), social influence (β=0.135, P=0.039), hedonic motivation (β=0.274, P<0.001), and innovativeness (β=0.243, P<0.001) were significantly associated with behavioral intention to use a wearable ergonomic device. The waist (n=36, 24.3%), followed by the neck/upper back (n=29, 19.6%), were the most preferred sensor locations.

Conclusions: Surgeons report a high burden of MSDs impacting their ability to work. Wearable sensors that provide feedback on ergonomic strain represent an opportunity to reduce MSDs among surgeons.