Annals of surgery最新文献

Objective: To test the hypothesis that peripheral nerve block (PNB) use might be associated with improved perioperative outcomes following major surgery.

Summary background data: PNB has been used to improve postoperative analgesia.

Methods: This was a retrospective cohort study with propensity score matching. We included patients aged ≥65 years who underwent major (≥2 h) non-cardiac thoracic and abdominal surgery under general anesthesia. Data were analyzed according to whether patients received PNB or not during anesthesia. Our primary outcome was the length of hospital stay; secondary outcomes included occurrence of major complications in hospital after surgery.

Results: A total of 1,915 patients were included in the full cohort, of whom 1,316 received PNB and 599 did not; 1,174 patients remained in the cohort after matching, with 587 in each group. Length of hospital stay after surgery was shorter in patients who received PNB than in those who did not (7 days [5 to 9] with PNB vs. 7 days [5 to 11] without PNB: HR 1.15, 95% CI 1.02 to 1.29, P=0.012). When compared with patients who did not receive PNB, those who received PNB developed fewer major complications during hospital stay (RR 0.41, 95% CI 0.30 to 0.58, P<0.001). Patients with PNB required less supplemental analgesia within 72 h (RR 0.70, 95% CI 0.59 to 0.84, P<0.001).

Conclusions: Use of PNB was associated with shortened length of hospital stay and reduced major complications in older patients after major non-cardiac thoracic and abdominal surgery, possibly due to improved analgesia.

Objective: Evaluate the long-term outcomes of pleurectomy decortication, systemic chemotherapy and prophylactic radiotherapy in pleural mesothelioma (PM).

Summary background data: There is no known cure for PM and cytoreductive surgery remains controversial.

Methods: Retrospective analysis of a cohort of patients treated consecutively between October 2004 and October 2019. Patients with PM were referred to our clinic and those with favorable prognostic factors and with completely resectable disease were selected for trimodality therapy. Our treatment protocol involved total pleurectomy decortication (P/D) and hyperthermic intrapleural povidone-iodine, prophylactic chest wall radiotherapy and systemic chemotherapy. 18FDG-PET-CT was used routinely to diagnose disease recurrence. Further systemic therapies were administered when appropriate. Survival and prognostic factors were analyzed using the Kaplan-Meier method and univariate and multivariate Cox regressions.

Results: 152 consecutive patients had P/D performed with curative intent. Median age was 64 years and the male/female ratio was 123/29. Thirty-one patients (20.4%) had received chemotherapy preoperatively. Thirty-five patients (23%) underwent extended resections. Sixty-four patients (42%) suffered a postoperative complication, but 90-day mortality was nil. Histological types were epithelioid in 107 patients (70.4%) and non-epithelioid in 45 (29.6%). Pathological stages were: I:88, II: 0, III: 63, and IV:1 (8th TNM classification). Six patients (4%) did not receive systemic chemotherapy and three (2%) no radiotherapy, postoperatively. Seventy-four patients (48.7%) received further systemic therapies for relapse. Median overall survival was 31.7 months, 35.0 months for epithelioid and 18.3 months for non-epithelioid histology. Histological type was the only predictor of overall survival, independent of resection status, pathological stage, or lymph node status, on multivariate analysis.

Conclusions: P/D is a safe and well-tolerated procedure resulting in no mortality and acceptable morbidity. Most patients can receive radiotherapy and systemic chemotherapy in due time and receive further therapies on relapse, resulting in prolonged survival mainly in those with early-stage epithelioid mesothelioma.

Objective: Intraabdominal drainage following left pancreatectomy (LP) has been a longstanding practice to mitigate postoperative complications, particularly postoperative pancreatic fistulas (POPF).

Summary background data: Recent studies challenge the necessity of routine drainage, suggesting potential benefits in omitting drains.

Methods: The PANDRA II trial was a randomized controlled non-inferiority study conducted at the University Hospital Heidelberg between 2017 and 2023. It compared outcomes between patients undergoing open or minimally-invasive LP with and without abdominal drainage. The primary endpoint was overall postoperative morbidity assessed by the Comprehensive Complication Index (CCI).

Results: A total of 246 patients were included in the intention-to-treat analysis (125 with drainage, 121 without drainage). The no-drain group demonstrated non-inferiority to the drain group in terms of CCI (13.90 ± 16.51 vs. 19.43 ± 16.92, P<0.001 for non-inferiority). Moreover, the no-drain group had lower overall complication rates (50.41% vs. 78.40%, P<0.001). Specific complications such as POPF (14.88% vs. 20.8%, P=0.226) and postpancreatectomy hemorrhage (PPH) (4.96% vs. 4.80%, P>0.999) did not differ significantly between groups.

Conclusion: The results of the PANDRA II trial demonstrate that omitting routine abdominal drainage after LP is non-inferior to placing a routine abdominal drainage regarding morbidity measured by the CCI. Omitting a routine abdominal drainage even led to a significant reduction of the overall complication rate.

Objective: To develop and validate two predictive models, the Diabetes Remission Index (DRI) and the Weight Loss-Adjusted Diabetes Remission Index (W-DRI), for assessing type 2 diabetes (T2D) remission following metabolic and bariatric surgery (MBS).

Summary background data: Metabolic and bariatric surgery, including Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), is highly effective in achieving T2D remission, but outcomes vary across populations. Predicting remission remains critical for individualized patient care and optimizing surgical outcomes. Existing tools focus on general outcomes, and a specific model incorporating weight loss data has been lacking.

Methods: This multicenter, retrospective cohort study included patients with T2D and overweight/obesity (BMI ≥27 kg/m²) who underwent RYGB or SG between 2008 and 2018. Institution 1 (I-1) data (n=503) was used to develop and internally validate the models, while Institution 2 (I-2) data (n=409) was used for external validation. The DRI model incorporated preoperative variables, and the W-DRI model additionally included post-surgical weight loss. Predictive accuracy was assessed using AUC, calibration plots, and stratified analyses.

Results: In I-1, 44.7% of patients achieved T2D remission, with a DRI model AUC of 0.80. In I-2, 52.6% achieved remission, with a model AUC of 0.78. Incorporating weight loss improved W-DRI predictive accuracy (AUC: 0.82 in I-1, 0.79 in I-2). Calibration plots demonstrated strong agreement between predicted and observed remission rates. An online DRI and W-DRI calculator is available via the Mayo Clinic webpage: https://newsnetwork.mayoclinic.org/dri-calculator/ .

Conclusions: The DRI and W-DRI models accurately predict T2D remission post-MBS, enabling personalized patient care and informed decision-making. Further validation across diverse populations is warranted.

Objective: Although pancreatic ductal adenocarcinoma (PDAC) is still a devastating disease, the survival rate for surgically removed PDACs has significantly improved in recent years. Early detection is essential in managing PDAC.

Summary background data: The presence of KRAS mutations in PDAC leads to the initial genetic abnormality and offers a significant timeframe for identifying resectable PDACs. A minimally invasive and highly specific PDAC screening test is necessary to prevent the need for invasive follow-up tests.

Methods: Between July 2021 and March 2023, 169 cases were enrolled in 7 institutions. By administering secretin before esophagogastroduodenoscopy (EGD), the excretion of pancreatic juice into the papillary fluid can be stimulated, creating a resource for testing. Washing fluid was collected using a specialized catheter from control individuals (n=75) and patients with resectable PDAC (n=89) at the initial diagnosis. A highly sensitive technique was employed to study KRAS gene mutations.

Results: This study obtained an AUC of 0.934 [95%CI: 0.904, 0.964] when using KRAS mutations in duodenal lavage fluid to differentiate between patients with resectable PDAC and healthy controls. The estimated sensitivities were calculated with specificity set at 100%, resulting in a sensitivity of 83.1% [95%CI: 71.7%, 91.2%]. The McNemer test showed a significantly higher sensitivity for KRAS mutations than serum CEA and CA19-9 (P<0.0001).

Conclusions: We created a method to identify resectable PDACs by analyzing KRAS mutation levels in duodenal fluid collected during EGD with secretin stimulation of pancreatic juice secretion.

Objective: To examine the impact of hospital volume on mortality and healthcare utilization in patients admitted with necrotizing pancreatitis (NP).

Background: Over 20% of patients with acute pancreatitis develop NP, which has been associated with higher rates of procedural intervention, morbidity, and mortality.

Methods: Adult patients admitted with NP were identified in the 2016-2019 Nationwide Readmissions Database 2016-2019. Hospital volume cutoffs were defined by tertiles of total NP admissions per year (low-volume [<9 admissions/year]; medium-volume [9-25 admissions/year]; high-volume [≥26 admissions/year]). Subgroup analyses were performed for NP patients undergoing procedural intervention. The primary outcome was in-hospital mortality. Multivariable logistic regression models determined the association between clinical outcomes and hospital volume.

Results: A total of 25,483 patients were identified, 14.3% of whom underwent procedural intervention, with the highest rate of intervention occurring in high-volume hospitals. The most common interventions offered at low- and medium-volume hospitals were open necrosectomy and percutaneous drainage. In contrast, high-volume hospitals had increased rates of minimally invasive surgery and endoscopic management. High-volume centers had the highest mortality rate among all patients (7.3% vs. 6.6% vs. 5.5%, P<0.001) but the lowest among the intervention-only cohort (7.5% vs. 10.4% vs. 12.0%, P<0.001). After adjusting for confounders, high-volume centers had lower odds of mortality in all patients (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.65-0.93) and in the intervention-only cohort (OR 0.64, 95% CI 0.42-0.96). High-volume hospitals were also associated with a shorter hospital stay and lower healthcare costs.

Conclusion: Management of NP at high-volume hospitals was associated with improved survival and decreased healthcare utilization. As interventional techniques advance, following evidence-based guidelines and implementing clear referral pathways will optimize outcomes for both patients and hospital systems.

Objective: To understand how breast cancer patients experience the surgical decision process and identify strategies surgeons can employ to empower patients to engage in decision-making.

Background: Patient engagement in decision-making is associated with improved patient outcomes. Although, some patients prefer that their healthcare provider drive the decision, the benefits of engaging in decision-making hold true even for patients who prefer to defer to their provider.

Methods: We performed semi-structured interviews with patients that experienced low engagement in clinical trial A231701CD (n=30). We used qualitative content analysis to analyze data and organize it into overarching themes that represent experiences with decision-making.

Results: Patients could be grouped based on their experiences with the decision process into those that wanted to defer, share, or drive the decision. Three domains differentiated patients between groups: (1) overall disposition toward the surgeon, (2) tendency to exchange information and ask questions, and (3) attitudes toward how their preferences should shape the treatment decision. We identified surgeon behaviors that could optimize patient engagement. These opportunities were observed across all patients, regardless of their experience with the decision process.

Conclusion: Surgeons can empower patients to engage in decision-making by getting to know patients as individuals, ensuring all treatment options are presented, and integrating patient preferences into the decision process. Through these actions, surgeons can help patients with varied preferences for decision-making engage in making high quality decisions that reflect patients' priorities. These suggestions may have the greatest impact on socially disadvantaged patients and help to reduce disparities in care.

Aim: To validate the prognostic value of the PAncreatic NeoAdjuvant MAssachusetts (PANAMA)-score and to determine its predictive ability for survival benefit derived from adjuvant treatment in patients after resection of pancreatic ductal adenocarcinoma (PDAC) following neoadjuvant FOLFIRINOX.

Background: The PANAMA-score was developed to guide prognostication in patients after neoadjuvant therapy and resection for PDAC. As this score focuses on the risk for residual disease after resection, it might also be able to select patients who benefit from adjuvant after neoadjuvant therapy.

Methods: This retrospective international multicenter study is endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA). Patients with PDAC who underwent resection after neoadjuvant FOLFIRINOX were included. Mantel-Cox regression with interaction analysis was performed to assess the impact of adjuvant chemotherapy.

Results: Overall, 383 patients after resection of PDAC following neoadjuvant FOLFIRINOX were included of whom 187 (49%), 137 (36%), and 59 (15%) had a low-risk, intermediate-risk, and high-risk PANAMA-score, respectively. A discrimination in median OS was observed stratified by risk groups (48.5, 27.6, and 22.3 months, Log-Rank-Plow-intermediate=0.004, Log-Rank-Pintermediate-high=0.027). Adjuvant therapy was not associated with an OS difference in the low-risk group (HR 1.50, 95%CI:0.92-2.50), whereas improved OS was observed in the intermediate (HR 0.58, 95%CI:0.34-0.97) and high-risk groups (HR 0.47, 95%CI:0.24-0.94) (p-interaction=0.008).

Conclusions: The PANAMA 3-tier risk groups (low-risk, intermediate-risk, and high-risk, available via pancreascalculator.com) correspond with differential survival in patients with resected PDAC following neoadjuvant FOLFIRINOX. The risk groups also differentiate between survival benefit associated with adjuvant treatment, with only the intermediate- and high-risk groups associated with improved OS.

Objective: To assess the research productivity, career advancement, grant funding, and scholarly impact of international medical graduates (IMGs) in academic cardiothoracic surgery.

Summary background data: Physician shortages undermine patient care and risk exacerbating inequities, especially in cardiothoracic surgery, which may lose a quarter of its workforce by 2050-the most substantial reduction in surgery. IMGs could help alleviate these shortages, but there is limited data about their academic experiences.

Methods: All cardiothoracic surgeons (n=1065) at accredited United States cardiothoracic surgery training centers in 2020 were included. IMGs were defined as surgeons who completed medical school outside the US and Canada, per the Association of American Medical Colleges. Educational and professional backgrounds were recorded from publicly available sources.

Results: 24.0% of academic cardiothoracic surgeons were IMGs. These surgeons started as attendings in later years (2012 vs. 2005, P<0.001) than non-IMGs. In unadjusted analyses, IMGs had lower publication counts and H-index, as well as reduced likelihood of R01 funding and full professor attainment. To match for attending start year, propensity score analysis created two groups of 254 surgeons: both IMGs and non-IMGs had similar publication counts (45.0 vs. 45.0, P=0.98), H-index (10.5 vs. 11.0, P=0.61), R01 funding rates (4.3% vs. 5.1%, P=0.83), and full professor attainment (24.8% vs. 20.5%, P=0.45).

Conclusions: IMGs represent a more junior cohort of surgeons but contribute significantly to the cardiothoracic surgery workforce, with comparable academic success. Policy efforts to streamline IMGs' path toward US practice could help alleviate surgical shortages, while enhancing diversity and strengthening academia.