Annals of surgery最新文献

Objective: To compare the rate of conversion to open surgery (OC) between robotic-assisted surgery (RAS) and laparoscopy (LAP) across 15 abdominal procedures.

Background: OC worsens outcomes and costs; a cross-disciplinary estimate of OC risk in RAS versus LAP across general surgery and subspecialties has been lacking.

Methods: PRISMA-guided systematic review (PubMed, Web of Science, Scopus; 2000-2023). Primary endpoint: pooled random-effects odds ratio (OR) for OC (RAS vs LAP) with 95% CIs; heterogeneity quantified by I² and τ². Meta-regression tested age, BMI, and sex.

Results: 360 studies (14 RCTs, 36 prospective, 310 retrospective; 211,078 RAS and 1,358,201 LAP) from 30 countries met inclusion. RAS had lower pooled odds of OC than LAP across procedures and study types. Meta-regression showed no significant effect of age, BMI, or sex on OC. Heterogeneity was moderate-to-high overall and varied by procedure (full metrics and forest plots in SDC, http://links.lww.com/SLA/F670).

Conclusions: Across diverse abdominal procedures, RAS is associated with lower OC risk. Findings support multi-specialty decision-making, while acknowledging heterogeneity, learning-curve effects, and procedure-specific evidence gaps.

Summary background data: We examined the Best Endovascular versus Best Surgical Therapy in patients with chronic limb threatening ischemia (BEST-CLI) Trial to determine if ethnoracial disparities persist in the setting of a contemporary randomized controlled trial.

Methods: Designed as a comparative effectiveness trial evaluating surgical bypass against endovascular therapy in adults with between 2014-2019, this secondary analysis examines Hispanic, Black, and White participants. Exposure variable is ethnoracial identity and primary outcome is major adverse limb events (MALE) or all-cause death (referred to as MALE-free survival). Secondary endpoints include index limb major amputation, major reintervention, mortality, MALE, major adverse cardiac events (MACE).

Results: Among 1677 patients (median follow-up 2.4 years [IQR 1.0-3.5]), 350(20.9%) identified as Black and 225(13.4%) as Hispanic. Compared to White patients, Black and Hispanic patients were younger, more likely to be female, have diabetes and/or dialysis dependence (ESKD), and present with advanced disease severity. There were no differences in preoperative guideline directed medical therapy. On univariable analysis, compared to White patients, Black and Hispanic patients had increased likelihood of major amputation. There were no differences noted for MALE-free survival, major reintervention, mortality, MALE, or MACE. After controlling for age, sex, diabetes, ESKD, smoking history, prior revascularization, presenting WIfI stage, anatomic segment of disease treated, revascularization method, there was no association between ethnoracial identity and MALE-free survival, amputation, major reintervention, mortality, MALE, or MACE.

Conclusions: Disparities are mitigated when evidence-based care (e.g., appropriate surgical conduits, early access to care) is provided to Black and Hispanic patients in the BEST-CLI trial.

Objective: An endoscopically placed duodenal-jejunal bypass liner (DJBL) may provide a safe adjunctive therapy for those with poorly controlled type 2 diabetes mellitus (T2DM) and obesity.

Summary background data: While some endoscopic therapies have been shown to improve glycemic indices secondary to weight loss, small bowel interventions may have direct metabolic effects. A meta-analysis of observational studies demonstrated reduction in HbA1c by 1.3% at one year following DJBL in patients with T2DM and obesity.

Methods: This was a multicenter, double-blind, randomized, sham-controlled trial comparing DJBL to sham procedure with medical management and lifestyle modification. Primary endpoints included mean difference in changes in HbA1c at 12 months between arms, and device-related serious adverse events (SAEs). Secondary endpoints included percent total weight loss (%TWL) and subjects achieving HbA1c≤7% and TWL≥5% at 12 months.

Results: 320 subjects were randomized to DJBL (n=212) and sham (n=108). Baseline HbA1c and BMI were 8.79±0.92% and 38.45±5.75 kg/m2. On modified intent-to-treat analysis, change in HbA1c at 12 months was -1.10±1.45% and -0.28±1.54% for DJBL and sham groups, respectively (P=0.0004). Rate of device-related SAEs was 9.4% including intolerance (3.7%), hemorrhage (2.8%) and hepatic abscess (2.3% stopping study early). At 12 months, DJBL group experienced greater weight loss compared to sham (7.7±9.6% TWL and 2.1±5.4% TWL, respectively; P<0.0001), with significantly more patients achieving HbA1c ≤ 7% (28.3% vs. 9.4%; P<0.0003) and TWL ≥ 5% (60.4% vs. 21.3%; P<0.0001).

Conclusions: DJBL met primary glycemic control efficacy and primary safety endpoints, while providing clinically significant weight loss, and comorbidity improvement.