Annals of surgery最新文献

Objective: This study examines the success of surgeon-scientists compared with nonsurgeon physician-scientists in obtaining National Institutes of Health (NIH) funding after participation in a research training grant.

Background: Dedicated research time during postgraduate training for physician-scientists is advantageous for obtaining future independent funding from NIH.

Methods: NIH Reporter was used to identify F32 and T32 grants awarded to internal medicine and surgery departments from 2005 to 2015, and an internal NIH database was used to determine funding outcomes. Success rates were recorded for surgeon versus internist PIs who applied for either a mentored career grant or research project grant (RPG). The median time in years from the final year of the training grant and clinical graduation to the first awarded grant was investigated. χ 2 tests, Fisher exact tests, and Wilcoxon rank sum tests were used.

Results: A greater proportion of surgeons transitioned directly to an RPG, 27% (68 internist PIs) compared with 72% (63 surgeon PIs) ( P <0.001). Both T32 and F32 trained surgeons were able to obtain an RPG sooner than internists, taking a median of 5 years from the end of clinical training versus a median of 7 years for internists [ P =0.033 (F32), P =0.034 (T32)].

Conclusions: Although fewer F32 and T32-funded surgeons apply for subsequent NIH funding compared with nonsurgeons, more surgeons apply for an RPG instead of a K-grant. Remarkably, surgeons obtained independent funding sooner after clinical graduation compared with internists, despite the extensive gap in time between postgraduate training and first faculty appointment, an amazing accomplishment given their clinical training and surgical practice challenges.

Objective: The DELORES trial investigated whether laparoscopic resection rectopexy (LRR) is superior to Delorme's procedure (DP) in full-thickness rectal prolapse.

Background: Multiple perineal and transabdominal procedures are current practice for rectal prolapse surgery. Evidence from adequately designed randomized studies addressing the question of which of these procedures are superior in terms of recurrence and bowel function is lacking.

Methods: DELORES was a randomized, observer-blinded, expertise-based multicenter trial. Patients with full-thickness rectal prolapse were eligible. The primary outcome was time to recurrence of full-thickness rectal prolapse within 24 months after primary surgery. The main secondary endpoints were morbidity, hospital stay, quality of life, constipation, and fecal incontinence (DRKS00000482).

Results: A total of 358 patients were screened between September 2010 and January 2016. Based on screening, 70 patients were randomized and 65 were included in the analysis (33 LRR and 32 DP procedures). The median follow-up was 23.9 months. Analysis of the primary outcome showed that LRR was superior to DP ( P =0.0012). During the 24-month follow-up, 8.2% of patients in the LRR group had a full-thickness prolapse recurrence versus 42.8% in the DP group. The median time to recurrence was 17.8 months for LRR and 8.2 months for DP. The median duration of surgery was 212 min (LRR) versus 77 min (DP). Overall postoperative morbidity was low. The reoperation rate was higher for DP (0% LRR vs. 33.3% DP). Quality of life (FIQL) and incontinence scores (Wexner) were more favorable for LRR at 24-month follow-up.

Conclusions: LRR is superior to DP in terms of recurrence and has favorable functional results.

Objective: To recapitulate the use of radiation in preventing heterotopic ossification (HO) in an animal model to thereby mechanistically investigate radiation-induced changes at the single-cell level.

Background: HO is the formation of extra-skeletal bone in abnormal areas including muscle and soft tissue. Radiation therapy is a clinically proven, localized preventive measure for HO. Despite its efficacy, there is a lack of standardization of radiation prescription; however, the mechanism of the impact of radiation on HO prevention remains unknown.

Methods: C57BL6J male mice underwent burn/tenotomy with and without perioperative radiation treatment. Single-cell RNA sequencing was performed to analyze downstream signaling after HO-forming injury. Immunofluorescence microscopy was used to visualize protein expression changes in HO progenitor cells. In vivo range of motion analyses, histological staining, and micro-computerized tomography were performed to investigate mature HO's effect on joint function and to characterize total HO structure and volume.

Results: In one fraction, 7 Gy delivered to the injury site within 72 hours postoperatively significantly decreases HO formation and improves hindlimb range of motion. In-depth single-cell transcriptomic analyses with immunofluorescent staining demonstrate decreased cellular numbers, as well as aberrant endochondral differentiation and downregulation of associated upstream BMP and ALK4 signaling pathways in irradiated mesenchymal progenitor cells.

Conclusions: Our study is the first to explore the mechanism of radiotherapy prophylaxis in the prevention of traumatic HO. Not only does radiation decreases total HO progenitor cell numbers but also reduces aberrant osteochondral differentiation at the injury site, thereby decreasing overall HO and improving joint function.

Objective: To examine the association between intersectionality of race, ethnicity, and gender on retention of US general surgery residents.

Background: There are limited data on the role that intersectionality plays in the US general surgery resident experience.

Methods: Analysis was performed using Association of American Medical Colleges (AAMC) data for general surgery residents who started their training between 2005 and 2015 (followed through completion). Regression analyses were used to assess demographic associations with time to attrition or successful completion of residency training. Associations between faculty and resident demographics were assessed.

Results: In all, 25,029 residents were included. Over the decade-long study period, the number of underrepresented in medicine (UIM) residents as a percentage of all residents remained similar from 17% to 19% ( P =0.24). The percent of UIM males starting training in 2005 was 11% and 12% in 2015 ( P -value=0.38). UIM females comprised 5.5% of trainees in 2005 and increased to 6.9% ( P -value=0.003) in 2015, and female non-UIM residents increased from 23 to 28% ( P -value<0.001). The overall rate of resident attrition was 15%. UIM females had the highest yearly attrition rate at 21% compared with non-UIM males at 13% (HR 1.7, P <0.001). UIM females were more likely to leave residency compared with UIM males (HR: 1.5; P <0.001). The percent of UIM faculty was positively correlated with percent of UIM residents (r=0.64, P <0.001).

Conclusions: Increasing intersectionality is positively associated with attrition during surgery residency. The diversity of faculty appears to be associated with resident diversity.

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: 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 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: 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.