Annals of surgery最新文献

Objective: Compare radioactive seed localization (RSL) and wire-guided localization (WL) for nonpalpable malignant breast disease.

Background: While WL has been the most common approach for localization of nonpalpable breast tumors, other techniques such as RSL, intraoperative ultrasound, radioactive intraoperative occult lesion localization, hematoma localization, radar localization, and magnetic seed localization have been suggested as safe and efficacious alternatives. However, very few randomized controlled trials have compared these localization techniques.

Methods: Between July 2015 and January 2021, 400 women with nonpalpable malignant breast disease were randomized 1:1 to RSL or WL, stratified by the surgeon and invasive disease status. The primary outcome was initial resection negative margin rates. Secondary outcomes included time efficiencies, cost, and satisfaction.

Results: There was no significant difference in negative margin rates between RSL and WL [RSL 0.80 (95% CI: 0.75-0.86) vs WL 0.85 (95% CI: 0.80-0.89); P=0.29]. RSL received better patient scores for anxiety [OR=2.62 (95% CI: 1.79-3.84); P<0.01], pain [OR=2.50 (95% CI: 1.69-3.71); P<0.01], and overall satisfaction [OR=3.24 (95% CI: 1.70-6.22); P<0.01] compared with WL. Radiologists and surgeons associated RSL with better convenience [OR=3.32 (95% CI: 1.65-6.69); P<0.01] and satisfaction of surgical procedure conduct [OR=1.67 (95% CI: 1.09-2.58); P=0.02]. Time in radiology did not differ [RSL mean (SD) 12.8±9.5 min vs. WL 11.4±6.0 min; P=0.18]. RSL incurred a $600 higher cost than WL.

Conclusions: The results of the largest randomized controlled trial in the United States support RSL as an acceptable alternative to WL in the treatment of nonpalpable malignant breast disease. While RSL was not superior to WL in achievement of negative margins, patients and providers reported improved satisfaction scores.

Objective: To describe the management of T1 colon cancer in a retrospective study of a national cancer registry.

Background: There is increasing interest in the potential of local excision (LE) as an organ-preserving treatment for early colon cancer. However, accurate identification of patients who may have lymph node metastases (LNM) and require further surgery is a major challenge.

Methods: Patients diagnosed with T1 colon cancer in Denmark from 2016 to 2020 were included and divided according to treatment: polypectomy (referred to as LE), upfront colectomy, and completion colectomy. The primary outcome was the proportion of patients diagnosed with LE. Secondary outcomes included the rate of LNM, the association of histopathological risk factors with LNM, and overall survival.

Results: A total of 1749 patients were included, and 1022 patients (58.4%) underwent initial LE. The rate of R1 margins after the initial LE was 31.0%. Colectomy was performed in 1160 patients (upfront in 727, completion in 433), of whom 58.3% had pT1 cancer. The rate of LNM was 11.5%. Rates of LNM were similar in patients undergoing upfront or completion colectomy (10.2% vs 12.4%, P = 0.392) and in patients with any single histopathological risk factor compared with those with none (8.9% vs 10.6%, P = 0.565). Although overall survival was significantly shorter in patients undergoing LE alone, no association between survival and treatment strategy was found in multivariable analysis.

Conclusions: LE is the most common mode of diagnosis in patients with T1 colon cancer and does not negatively impact survival and postoperative outcomes. Current strategies to stratify patients to complete surgery appear insufficient, and more robust predictors are needed.

Objective: To optimize the management strategies of delayed postpancreaticoduodenectomy hemorrhage (PPH) by evaluating data from a high-volume pancreatic center.

Background: Delayed PPH is a potentially lethal complication. The management of delayed PPH remains controversial.

Methods: Patients who underwent pancreaticoduodenectomy between July 2018 and June 2023 were identified from an institutional database. The clinical scenarios, management, and outcomes of patients with delayed PPH (>5 days postoperatively) were analyzed.

Results: Of the 2013 patients who underwent elective pancreaticoduodenectomy, 130 (6.5%) with delayed PPH were identified. The overall mortality was 15.4%. The success rates of endoscopy, angiographic intervention, and relaparotomy in treating delayed PPH were 54.5%, 56.5%, and 68.8%, respectively. For PPH from the hepatic arteries or their branches, complete blockade of the common or proper hepatic artery (C/PHA) was performed in 17 patients, either by coil embolization (n=7) or surgical ligation (n=10). Coil embolization of the C/PHA resulted in significant infarction of the left liver in 2 patients. No postoperative liver infarction occurred in patients who underwent ligation of the C/PHA during relaparotomy. Ten patients underwent suture repair of the C/PHA 13 times during relaparotomy. Arterial ligation achieved a significantly higher success rate of hemostasis than suture repair of the C/PHA during relaparotomy (100% vs 30.8%, P <0.001).

Conclusions: Angiography should be attempted first in managing hemodynamically stable delayed PPH. Arterial ligation was preferred for bleeding from the hepatic arteries during relaparotomy with minor consequences for the liver.

Objective: To identify cognitive biases and heuristics experienced by surgeons in operative settings and the impact these biases and heuristics have on patient care.

Background: Cognitive biases and heuristics are systematic errors in thinking that can affect clinical decisions. Both are noted in surgical settings and are a risk to patient safety.

Methods: This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and PROSPERO registered (CRD42023432099). Five major databases were searched from inception to August 28, 2022, with an updated search on January 27, 2024. Original primary research studies in English were included, with relevant risk of bias tools employed for each study.

Results: Twenty-one papers were included. Thirty-eight biases were identified across 6 experiments, 5 analyses, and 10 survey studies. Confirmation bias, anchoring, risk aversion, and overconfidence bias were the most represented. Risk of bias was moderate across most studies. Cognitive biases and heuristics were found to influence surgical outcomes and 6 studies cited a negative impact on patient care, with one associating biases with fatal outcomes.

Conclusions: Biases and heuristics contribute to surgical errors and never events, and will continue to do so until they are recognised and addressed. Implementing debiasing strategies, such as mindfulness training and deliberate reflection, was found to reduce surgical errors in 2 studies. This review highlights the need for experimental studies, which are essential for understanding how and why biases lead to negative outcomes and for evaluating further debiasing interventions. We propose directions for future research and system changes.