Annals of surgery最新文献

Objective: To investigate whether revision of pancreatic neck margin based on intraoperative frozen section analysis has oncologic value in postneoadjuvant pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma.

Background: The role of intraoperative neck margin revision has been controversial, with little information specific to postneoadjuvant PD.

Methods: Patients who underwent postneoadjuvant PD (2013-2019) for conventional pancreatic ductal adenocarcinoma with frozen section analysis of neck margin at 3 academic institutions were included. Overall survival (OS) and recurrence-free survival were compared across 3 groups: complete resection achieved en bloc (CR-EB), complete resection achieved non-en bloc (CR-NEB), and incomplete resection (IR).

Results: Among the 671 patients included, 524 (78.1%) underwent CR-EB, 119 (17.7%) CR-NEB and 28 (4.2%) IR. Patients undergoing CR-NEB and IR exhibited larger tumors and lower rates of "Response Evaluation Criteria in Solid Tumors" response, requiring vascular resections more often. Likewise, CR-NEB and IR were associated with a worse pathologic profile than CR-EB. The incidence of postoperative complications and access to adjuvant treatment were comparable among groups. A CR-EB was associated with the longest OS duration (34.3 months). In patients with positive neck margin, obtaining a CR-NEB through reexcision was associated with a comparable OS relative to patients with an IR (26.9 vs 27.1 months, P = 0.901). Similar results were observed for recurrence-free survival. At multivariable analysis, neck margin status was not independently associated with survival and recurrence.

Conclusions: Conversion of an initially positive pancreatic neck margin by additional resection is not associated with oncologic benefits in postneoadjuvant PD and cannot be routinely recommended.

Objective: To determine the epidemiology of postoperative complications among general surgery patients, inform their relationships with 30-day mortality, and determine the attributable fraction of death of each postoperative complication.

Background: The contemporary causes of postoperative mortality among general surgery patients are not well characterized.

Methods: VISION is a prospective cohort study of adult non-cardiac surgery patients across 28 centers in 14 countries who were followed for 30 days after surgery. For the subset of general surgery patients, a Cox proportional hazards model was used to determine associations between various surgical complications and postoperative mortality. The analyses were adjusted for preoperative and surgical variables. Results were reported in adjusted hazard ratios (HR) with 95% confidence intervals (CI).

Results: Among 7950 patients included in the study, 240 (3.0%) patients died within 30 days of surgery. Five postoperative complications [myocardial injury after non-cardiac surgery (MINS), major bleeding, sepsis, stroke, and acute kidney injury resulting in dialysis] were independently associated with death. Complications associated with the largest attributable fraction (AF) of postoperative mortality (ie, percentage of deaths in the cohort that can be attributed to each complication, if causality were established) were major bleeding (n=1454, 18.3%, HR 2.49 95% CI: 1.87-3.33, P <0.001, AF 21.2%), sepsis (n=783, 9.8%, HR 6.52, 95% CI: 4.72-9.01, P <0.001, AF 15.6%), and MINS (n=980, 12.3%, HR 2.00, 95% CI: 1.50-2.67, P <0.001, AF 14.4%).

Conclusions: The complications most associated with 30-day mortality following general surgery are major bleeding, sepsis, and MINS. These findings may guide the development of mitigating strategies, including prophylaxis for perioperative bleeding.

Objective: To evaluate changes in opioid prescribing and patient-reported outcomes after surgery following the implementation of Michigan's prescription drug monitoring program (PDMP) use mandate in June 2018.

Background: Most states mandate clinicians to query PDMP databases before prescribing controlled substances. Whether these PDMP use mandates affect opioid prescribing and patient-reported outcomes after surgery is unclear, especially among patients with elevated "Narx" scores, a risk score for overdose death used in most PDMPs.

Methods: We conducted an interrupted time series analysis of a statewide surgical registry linked to Michigan's PDMP database. Analyses included adults undergoing general surgical procedures from January 2017 to October 2019. Outcomes included monthly mean days supplied in dispensed opioid prescriptions (those filled within 3 days of discharge) and monthly mean scores for 3 patient-reported outcomes (pain in the week after surgery, care satisfaction, and regret undergoing surgery). Segmented regression models were used to assess for level and slope changes in outcomes in June 2018. Analyses were repeated among patients with Narx scores ≥200, a threshold that defines the top quartile.

Results: The analyses included 21,897 patients. The mandate was associated with a -0.5 (95% CI: -0.8, -0.2) level decrease in mean days supplied in dispensed opioid prescriptions, but not with worsened patient-reported outcomes. Findings were similar among patients with Narx scores ≥200.

Conclusions: Following the implementation of Michigan's PDMP use mandate, the duration of opioid prescriptions decreased, but patient-reported outcomes did not worsen. The findings suggest that PDMP use mandates may not be associated with worsened experience among general surgical patients.

Objective: The objective of this study was to identify clinical and anatomic characteristics of Popliteal artery aneurysms (PAAs) associated with acutely limb-threatening events.

Background: Popliteal artery aneurysms (PAAs) are associated with high morbidity and mortality. Current guidelines recommend operative repair for PAAs with a diameter greater than 20 mm based on very limited evidence.

Methods: This retrospective cross-sectional cohort was derived from a multi-institutional database queried for all patients with a PAA from 2008 to 2022. Duplex ultrasound characteristics of PAAs were abstracted by registered physicians in vascular interpretation. Symptom status at the time of duplex ultrasound was divided into 3 categories: asymptomatic PAA, symptomatic PAA with claudication or chronic limb ischemia, and acutely limb-threatening PAAs with a thromboembolic event, acute limb ischemia, or rupture.

Results: There were 470 PAAs identified in 331 patients. The mean age was 74 years at diagnosis; 94% of patients were white, and 97% of patients were male. In a univariate analysis, patient comorbidities and medications were not associated with symptom status. In a multivariate analysis including age, a higher percent thrombus was significantly associated with symptomatic PAAs (RRR 15.2; CI: 2.69-72.3; P<0.01) and PAAs with an acutely limb-threatening event (RRR 17.9; CI: 3.76-85.0; P<0.01). All other anatomic characteristics were not associated with symptom status.

Conclusions: Percent thrombus was significantly associated with symptomatic PAAs and acutely limb-threatening events, whereas diameter was not significantly associated with any symptom group. This analysis supports the use of percent thrombus in identifying high-risk PAAs that warrant repair.

Objective: To evaluate the oncological superiority of laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (OPD) in left-sided pancreatic cancer.

Background: The oncological efficacy of LDP in left-sided pancreatic cancer remains controversial.

Methods: We performed a multicenter, open-label, randomized controlled trial of LDP versus OPD in left-sided pancreatic cancer patients. Candidates were recruited from 6 centers in China, and randomly assigned to receive either LDP or ODP. The primary outcome was recurrence-free survival, and the secondary outcomes were overall survival, R0 resection rate, and retrieved lymph node numbers.

Results: Of the 481 eligible pancreatic cancer patients between January 9, 2019 and December 8, 2021, 306 candidates were initially enrolled and randomly assigned at 1:1 to receive either LDP or ODP. The last follow-up was performed on December 15, 2023, and 130 patients in the LDP group and 129 patients in the ODP group were included for per-protocol analysis. Median recurrence-free survival was 15.5 (12.5-18.5) months in the LDP group compared with 15 (9.5-20.5) months in the ODP group ( P = 0.471). The R0 resection rate in 2 groups was 88.5% versus 89.1%, respectively. Median retrieved lymph node numbers in 2 groups were similar [13.5 (10-20) vs 12 (7-17), P = 0.165]. Complications with a Clavien-Dindo score ≥ 3 occurred in 10 of 130 patients in the LDP group, and 11 of 129 patients in the ODP group.

Conclusions: Although LDP did not provide significant oncological benefits for left-sided pancreatic cancer, it was safe, applicable, and appropriate.

Objective: To establish globally applicable benchmark outcomes for pelvic exenteration (PE) in patients with locally advanced primary rectal cancer (LARC) and locally recurrent rectal cancer (LRRC), using outcomes achieved at highly specialised centres.

Background: PE is established as the standard of care for selected patients with LARC and LRRC. There are currently no available benchmarks against which surgical performance in PE can be compared for audit and quality improvement.

Methods: This international multicentre retrospective cohort study included patients undergoing PE for LARC or LRRC at 16 highly experienced centres between 2018 and 2023. Ten outcome benchmarks were established in a lower-risk subgroup. Benchmarks were defined by the 75th percentile of the results achieved at the individual centres.

Results: Seven hundred sixty-three patients underwent PE, of which 464 patients (61%) had LARCs and 299 (39%) had LRRCs. Five hundred forty-four patients (71%) who met predefined lower-risk criteria formed the benchmark cohort. For patients with LARC, the calculated benchmark threshold for major complication rate was ≤44%; Comprehensive Complication Index: ≤30.2; 30-day mortality rate: 0%; 90-day mortality rate: ≤4.3%; R0 resection rate: ≥79%. For patients with LRRC, the calculated benchmark threshold for major complication rate was ≤53%; Comprehensive Complication Index: ≤34.1; 30-day mortality rate: 0%; 90-day mortality rate: ≤6%; R0 resection rate: ≥77%.

Conclusions: The reported benchmarks for PE in patients with LARC and LRRC represent the best available care for this patient group globally and can be used for rigorous assessment of surgical quality and to facilitate quality improvement initiatives at international exenteration centres.

Objective: To assess the performance of an algorithm for automated grading of surgery-related adverse events (AEs) according to Clavien-Dindo (C-D) classification.

Background: Surgery-related AEs are common, lead to increased patient morbidity, and raise health care costs. Resource-intensive manual chart review is still standard, and, to our knowledge, algorithms using electronic health record (EHR) data to grade AEs according to C-D classification have not been explored.

Methods: The algorithm was developed in a research database containing all EHR data of Karolinska University Hospital Stockholm and returns a C-D grade for each AE within 30 days. This raw score was used to grade the postoperative recovery of 1379 elective colorectal procedures according to C-D classification and Comprehensive Complication Index. Agreement with manual annotation of colorectal surgeon (gold standard) and research nurse (current practice) was assessed in a random sample of 399 procedures.

Results: For the C-D classification, kappa was 0.77 (95% CI: 0.71 to 0.84) for algorithm versus surgeon and 0.74 (95% CI: 0.67 to 0.82) for algorithm versus nurse. The kappa value increased to 0.89 (95% CI: 0.84 to 0.95) after the correction of misclassified annotations by the surgeon. The intraclass correlation for Comprehensive Complication Index between algorithm and surgeon was 0.89 (95% CI: 0.87 to 0.91) after correction and 0.76 (95% CI: 0.71 to 0.80) for algorithm versus nurse.

Conclusions: The performance of the algorithm motivates in our opinion implementation to real-time data under continuous scientific evaluation of the impact on AEs in different types of surgery. In the future, local EHR data could be used to enhance risk prediction with machine learning techniques.

Objective: This study aimed to investigate the clinical significance and risk factors of postoperative pancreatic fistula (POPF) after post-pancreatectomy acute pancreatitis (PPAP) in patients who underwent pancreaticoduodenectomy (PD).

Background: PPAP has been recognized as a critical factor in the pathophysiology of POPF after PD.

Methods: A total of 817 consecutive patients who underwent elective PD between January 2020 and June 2022 were included. PPAP and POPF were defined in accordance with the International Study Group for Pancreatic Surgery (ISGPS) definitions. Multivariate logistic analyses were performed to investigate the risk factors for POPF. Comparisons between PPAP-associated POPF and non-PPAP-associated POPF were made to further characterize this intriguing complication.

Results: Overall, 159 (19.5%) patients developed POPF after PD, of which 73 (45.9%) occurred following PPAP, and the remaining 86 (54.1%) had non-PPAP-associated POPF. Patients with PPAP-associated POPF experienced significantly higher morbidity than patients without POPF. Multivariate analyses revealed distinct risk factors for each POPF type. For PPAP-associated POPF, independent risk factors included estimated blood loss >200 mL (OR: 1.93), main pancreatic duct ≤3 cm (OR: 2.88), and soft pancreatic texture (OR: 2.01), largely overlapping with fistula risk score elements. On the other hand, non-PPAP-associated POPF was associated with age >65 years (OR: 1.95), male (OR: 2.10), and main pancreatic duct ≤3 cm (OR: 2.57). Notably, among patients with PPAP, the incidence of POPF consistently hovered around 50% regardless of the fistula risk score stratification.

Conclusions: PPAP-associated POPF presents as a distinct pathophysiology in the development of POPF after PD, potentially opening doors for future prevention strategies targeting the early postoperative period.

Objective: We sought to compare the identification of unhealthy substance use before surgery using Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS), a standardized 4-item instrument, versus routine clinical documentation in the electronic medical record (EHR).

Background: Over 20% of individuals exhibit unhealthy substance use before elective surgery. Routine EHR documentation is often based on nonstandard questions that may not fully capture the extent of substance use and are subject to bias. In contrast, brief standardized screening could provide a more efficient and systematic approach.

Methods: We conducted a cross-sectional study among adults (≥18 y) at a preoperative clinic from August to September 2021. Positive screens for unhealthy substances by TAPS were compared with data from the EHR. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were reported. Receiver operating characteristic curves were used to assess diagnostic ability. Multivariable logistic regression was used to estimate the predictors of positive screens by TAPS.

Results: The cohort included 240 surgical patients. TAPS screening identified significantly more positive screens than EHR documentation (43.3% vs. 14.2%). Patients with unhealthy substance use were younger (50.8 vs. 56.7 y; P =0.003), and TAPS revealed alcohol misuse in 30.8% of cases, contrasting with 0% in clinician documentation ( P <0.001). Of the 104 TAPS-positive patients, 69.2% were missed by EHR documentation. Sensitivity (31%) and accuracy (AUC=0.65) of clinician documentation for any unhealthy substance use were lower compared with TAPS.

Conclusions: Standardized TAPS screening detected preoperative unhealthy substance use more frequently than routine clinician documentation, emphasizing the need for integrating standardized measures into surgical practice to ensure safer perioperative care and outcomes.