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Number of lymph nodes retrieved in patients with locally advanced rectal cancer after total neoadjuvant therapy: post-hoc analysis from the STELLAR trial. 新辅助治疗后局部晚期直肠癌患者取回的淋巴结数量:STELLAR 试验的事后分析。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae118
Yueyang Zhang, Yuan Tang, Huiying Ma, Hao Su, Zheng Xu, Changyuan Gao, Haitao Zhou, Jing Jin

Background: The current gold standard for extraperitoneal locally advanced rectal cancer is total neoadjuvant therapy (TNT) followed by total mesorectal excision. This research explored the number of lymph nodes in patients with locally advanced rectal cancer after TNT and its correlation with survival.

Materials and methods: This is a post-hoc analysis based on the STELLAR trial, including patients with locally advanced rectal cancer from 16 tertiary centres who were randomized for short-term radiotherapy followed by chemotherapy (TNT group) or long-term concurrent chemotherapy group followed by total mesorectal excision between 2015 and 2018. This lymph node-related analysis is based on the TNT group. Subgroups were differentiated based on the lymph node harvest (below the median number: limited lymphadenectomy group, and greater than/equal to the median number: extended lymphadenectomy group). The primary outcomes were overall survival and disease-free survival (DFS). Correlations with clinical/pathological variables, lymphadenectomy categories and use of adjuvant chemotherapy were explored.

Results: Among the 451 patients enrolled in the STELLAR trial, 227 patients (50.3%) were assigned to the TNT group, including 29.5% females. The median number of lymph nodes retrieved in the TNT group was 11.0. Patients in the limited lymphadenectomy subgroup exhibited worse overall survival than those with extended lymphadenectomy (HR 2.95 (95% c.i. 1.47 to 5.92), P = 0.001). The overall survival was similar in the ypN0-limited and ypN1-extended subgroups (HR 0.38 (95% c.i. 0.11 to 1.30), P = 0.109). Adjuvant chemotherapy was associated with better overall survival and DFS than no adjuvant chemotherapy overall (P < 0.001) and in the limited lymphadenectomy subgroup (P < 0.001). However, there was no significant difference in overall survival or DFS with or without adjuvant chemotherapy in the extended lymphadenectomy subgroup (P = 0.887 and P = 0.192, respectively).

Conclusion: In the STELLAR trial, the median number of lymph nodes harvested was 11. In patients with limited lymphadenectomy, the use of adjuvant therapy after TNT was beneficial and correlated with better prognosis compared with patients who did not receive adjuvant chemotherapy.

背景:目前治疗腹膜外局部晚期直肠癌的金标准是新辅助治疗(TNT)后进行全直肠系膜切除术。本研究探讨了TNT治疗后局部晚期直肠癌患者的淋巴结数量及其与生存期的相关性:这是一项基于STELLAR试验的事后分析,包括来自16个三级中心的局部晚期直肠癌患者,他们在2015年至2018年间被随机分配为短期放疗后化疗组(TNT组)或长期同期化疗组后全直肠系膜切除术。本淋巴结相关分析基于 TNT 组。亚组根据淋巴结切除情况进行区分(低于中位数:有限淋巴结切除组,大于/等于中位数:扩大淋巴结切除组)。主要结果为总生存期和无病生存期(DFS)。研究还探讨了与临床/病理变量、淋巴腺切除类别和辅助化疗使用的相关性:在参加STELLAR试验的451名患者中,有227名患者(50.3%)被分配到TNT组,其中女性占29.5%。TNT组淋巴结取材的中位数为11.0个。有限淋巴结切除术亚组患者的总生存率低于扩大淋巴结切除术亚组患者(HR 2.95 (95% c.i. 1.47 to 5.92),P = 0.001)。ypN0局限亚组和ypN1扩展亚组的总生存率相似(HR 0.38(95% c.i.0.11至1.30),P = 0.109)。与不进行辅助化疗相比,辅助化疗可提高总生存率和DFS(P<0.001),在淋巴结切除术受限的亚组中也是如此(P<0.001)。然而,在扩大淋巴腺切除术亚组中,采用或不采用辅助化疗在总生存期或DFS方面没有明显差异(分别为P = 0.887和P = 0.192):结论:在STELLAR试验中,切除淋巴结的中位数为11个。结论:在STELLAR试验中,淋巴结切除的中位数为11个。在淋巴腺切除术受限的患者中,TNT术后使用辅助治疗是有益的,与未接受辅助化疗的患者相比,辅助治疗与更好的预后相关。
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引用次数: 0
Surgical outcomes of neoadjuvant endocrine treatment in early breast cancer: meta-analysis. 早期乳腺癌新辅助内分泌治疗的手术效果:荟萃分析。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae100
Beatrice Brett, Constantinos Savva, Bahar Mirshekar-Syahkal, Martyn Hill, Michael Douek, Ellen Copson, Ramsey Cutress

Background: Neoadjuvant endocrine therapy presents an important downstaging option with lower toxicity than neoadjuvant chemotherapy in oestrogen receptor (ER)-positive early breast cancer. Meta-analysis of the effects of neoadjuvant endocrine therapy on surgical outcomes across randomized clinical trials (RCTs) and cohort studies has not previously been performed.

Methods: A systematic review and meta-analysis was performed to evaluate the effect of neoadjuvant endocrine therapy on surgical outcomes (PROSPERO (international prospective register of systematic reviews, 2020)) compared with surgery followed by adjuvant endocrine therapy. PubMed and EMBASE were searched to identify RCT and cohort studies between 1946 and 27 March 2024. Two independent reviewers manually screened the identified records and extracted the data. Risk of bias was assessed using the Cochrane Collaboration tools and random-effects meta-analysis was done with ReviewManager.

Results: The search identified 2390 articles eligible for screening. The review included 20 studies (12 cohort and 8 RCTs); 19 were included in the meta-analysis with a total of 6382 patients. Overall, neoadjuvant endocrine therapy was associated with a lower mastectomy rate compared with surgery first (risk ratio (RR) 0.53, 95% c.i. 0.44 to 0.64). Subgroup analysis showed similar improvement in the mastectomy rate in the neoadjuvant endocrine therapy group versus control group irrespective of study type (RCT: RR 0.58, 95% c.i. 0.50 to 0.66; cohorts: RR 0.48, 95% c.i. 0.33 to 0.70). There was no difference in the mastectomy rate by duration of neoadjuvant endocrine therapy (more than 4 months: RR 0.57, 95% c.i. 0.42 to 0.78; 4 months or less than 4 months: RR 0.52, 95% c.i. 0.43 to 0.64). Most of the studies were characterized by moderate-quality evidence with significant heterogeneity.

Conclusion: Neoadjuvant endocrine therapy is associated with a reduction in mastectomy rate. Given the moderate methodological quality of previous studies, further RCTs are required.

Registration id: CRD42020209257.

背景:对于雌激素受体(ER)阳性的早期乳腺癌,新辅助内分泌治疗是一种重要的降期选择,其毒性低于新辅助化疗。此前尚未对随机临床试验(RCT)和队列研究中新辅助内分泌治疗对手术效果的影响进行荟萃分析:方法:我们进行了一项系统综述和荟萃分析,评估新辅助内分泌治疗与手术后辅助内分泌治疗相比对手术效果的影响(PROSPERO(国际前瞻性系统综述注册,2020年))。检索了 PubMed 和 EMBASE,以确定 1946 年至 2024 年 3 月 27 日期间的 RCT 和队列研究。两位独立审稿人手动筛选了已确定的记录并提取了数据。使用 Cochrane 协作工具评估了偏倚风险,并使用 ReviewManager 进行了随机效应荟萃分析:搜索共发现 2390 篇符合筛选条件的文章。综述包括 20 项研究(12 项队列研究和 8 项 RCT);19 项纳入荟萃分析,共有 6382 名患者。总体而言,与先手术相比,新辅助内分泌治疗与较低的乳房切除率相关(风险比 (RR) 0.53,95% c.i. 0.44 至 0.64)。亚组分析显示,无论研究类型如何,新辅助内分泌治疗组与对照组相比,乳房切除率都有类似的改善(RCT:RR 0.58,95% c.i.0.50-0.66;队列:RR 0.48,95% c.i.0.50-0.66):RR:0.48,95% 置信区间:0.33 至 0.70)。新辅助内分泌治疗持续时间对乳房切除率没有影响(4 个月以上:RR 0.57,95% c. i. 0.50 至 0.66;队列:RR 0.48,95% c. i. 0.33 至 0.70):RR为0.57,95% c.i.为0.42至0.78;4个月或少于4个月:RR 0.52,95% 置信区间为 0.43 至 0.64)。大多数研究的证据质量中等,异质性明显:结论:新辅助内分泌治疗与乳房切除率的降低有关。结论:新辅助内分泌治疗与降低乳腺切除率有关。鉴于以往研究的方法学质量一般,需要进一步开展 RCT 研究:CRD42020209257。
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引用次数: 0
Noise in the operating room coincides with surgical difficulty. 手术室的噪音与手术难度相吻合。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae098
Sarah Peisl, Daniel Sánchez-Taltavull, Hugo Guillen-Ramirez, Franziska Tschan, Norbert K Semmer, Martin Hübner, Nicolas Demartines, Simon G Wrann, Stefan Gutknecht, Markus Weber, Daniel Candinas, Guido Beldi, Sandra Keller

Background: Noise in the operating room has been shown to distract the surgical team and to be associated with postoperative complications. It is, however, unclear whether complications after noisy operations are the result of objective or subjective surgical difficulty or the consequence of distraction of the operating room team by noise.

Methods: Noise level measurements were prospectively performed during operations in four Swiss hospitals. Objective difficulty for each operation was calculated based on surgical magnitude as suggested by the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), duration of operation and surgical approach. Subjective difficulty and distraction were evaluated by a questionnaire filled out by the operating room team members. Complications were assessed 30 days after surgery. Using regression analyses, the relationship between objective and subjective difficulty, distraction, intraoperative noise and postoperative complications was tested.

Results: Postoperative complications occurred after 121 (38%) of the 294 procedures included. Noise levels were significantly higher in operations that were objectively and subjectively more difficult (59.89 versus 58.35 dB(A), P < 0.001) and operations that resulted in postoperative complications (59.05 versus 58.77 dB(A), P = 0.004). Multivariable regression analyses revealed that subjective difficulty as reported by all members of the surgical team, but not distraction, was highly associated with noise and complications. Only objective surgical difficulty independently predicted noise and postoperative complications.

Conclusion: Noise in the operating room is a surrogate of surgical difficulty and thereby predicts postoperative complications.

背景:研究表明,手术室中的噪音会分散手术团队的注意力,并与术后并发症有关。然而,目前还不清楚噪音手术后的并发症是客观或主观手术困难的结果,还是噪音分散手术室团队注意力的结果:方法:在瑞士四家医院对手术过程中的噪音水平进行了前瞻性测量。每项手术的客观难度是根据降低死亡率和发病率的生理和手术严重程度评分(POSSUM)、手术持续时间和手术方法计算得出的。主观难度和注意力分散情况由手术室团队成员填写的问卷进行评估。术后 30 天对并发症进行评估。通过回归分析,检验了客观和主观难度、牵拉、术中噪音与术后并发症之间的关系:结果:在 294 例手术中,有 121 例(38%)发生了术后并发症。客观和主观难度较高的手术(59.89 对 58.35 dB(A),P < 0.001)以及导致术后并发症的手术(59.05 对 58.77 dB(A),P = 0.004)的噪音水平明显较高。多变量回归分析表明,手术团队所有成员报告的主观难度与噪音和并发症高度相关,而分心则不然。只有客观手术难度能独立预测噪音和术后并发症:结论:手术室噪音是手术难度的代用指标,因此可预测术后并发症。
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引用次数: 0
Influence of a surgeon's exposure to operating room turnover delays on patient outcomes. 外科医生受手术室周转延迟影响对患者预后的影响。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae117
Arnaud Pasquer, Quentin Cordier, Jean-Christophe Lifante, Gilles Poncet, Stéphanie Polazzi, Antoine Duclos

Background: A surgeon's daily performance may be affected by operating room organizational factors, potentially impacting patient outcomes. The aim of this study was to investigate the link between a surgeon's exposure to delays in starting scheduled operations and patient outcomes.

Methods: A prospective observational study was conducted from 1 November 2020 to 31 December 2021, across 14 surgical departments in four university hospitals, covering various surgical disciplines. All elective surgeries by 45 attending surgeons were analysed, assessing delays in starting operations and inter-procedural wait times exceeding 1 or 2 h. The primary outcome was major adverse events within 30 days post-surgery. Mixed-effect logistic regression accounted for operation clustering within surgeons, estimating adjusted relative risks and outcome rate differences using marginal standardization.

Results: Among 8844 elective operations, 4.0% started more than 1 h late, associated with an increased rate of adverse events (21.6% versus 14.4%, P = 0.039). Waiting time surpassing 1 h between procedures occurred in 71.4% of operations and was also associated with a higher frequency of adverse events (13.9% versus 5.3%, P < 0.001). After adjustment, delayed operations were associated with an elevated risk of major adverse events (adjusted relative risk 1.37 (95% c.i. 1.06 to 1.85)). The standardized rate of major adverse events was 12.1%, compared with 8.9% (absolute difference of 3.3% (95% c.i. 0.6% to 5.6%)), when a surgeon experienced a delay in operating room scheduling or waiting time between two procedures exceeding 1 h, as opposed to not experiencing such delays.

Conclusion: A surgeon's exposure to delay before starting elective procedures was associated with an increased occurrence of major adverse events. Optimizing operating room turnover to prevent delayed operations and waiting time is critical for patient safety.

背景:外科医生的日常表现可能会受到手术室组织因素的影响,从而对患者预后产生潜在影响。本研究的目的是调查外科医生在开始预定手术时受到的延误与患者预后之间的联系:从 2020 年 11 月 1 日至 2021 年 12 月 31 日,在四家大学医院的 14 个外科部门开展了一项前瞻性观察研究,涵盖了不同的外科学科。对45名主治医生的所有择期手术进行了分析,评估了手术开始时间的延迟以及手术间等待时间超过1或2小时的情况。混合效应逻辑回归考虑了外科医生内部的手术分组情况,利用边际标准化估算了调整后的相对风险和结果率差异:在 8844 例择期手术中,4.0% 的手术开始时间晚于 1 小时,这与不良事件发生率增加有关(21.6% 对 14.4%,P = 0.039)。在71.4%的手术中,两次手术之间的等待时间超过了1小时,这也与不良事件发生率较高有关(13.9%对5.3%,P<0.001)。经调整后,延迟手术与重大不良事件风险升高有关(调整后相对风险为1.37(95% c.i.为1.06至1.85))。当外科医生在手术室排期或两台手术之间的等待时间超过1小时时,重大不良事件的标准化发生率为12.1%,而未经历此类延迟的发生率为8.9%(绝对差异为3.3%(95% c.i.0.6%至5.6%)):结论:外科医生在开始择期手术前遭遇延迟与重大不良事件的发生率增加有关。优化手术室周转以防止手术延迟和等待时间对患者安全至关重要。
{"title":"Influence of a surgeon's exposure to operating room turnover delays on patient outcomes.","authors":"Arnaud Pasquer, Quentin Cordier, Jean-Christophe Lifante, Gilles Poncet, Stéphanie Polazzi, Antoine Duclos","doi":"10.1093/bjsopen/zrae117","DOIUrl":"https://doi.org/10.1093/bjsopen/zrae117","url":null,"abstract":"<p><strong>Background: </strong>A surgeon's daily performance may be affected by operating room organizational factors, potentially impacting patient outcomes. The aim of this study was to investigate the link between a surgeon's exposure to delays in starting scheduled operations and patient outcomes.</p><p><strong>Methods: </strong>A prospective observational study was conducted from 1 November 2020 to 31 December 2021, across 14 surgical departments in four university hospitals, covering various surgical disciplines. All elective surgeries by 45 attending surgeons were analysed, assessing delays in starting operations and inter-procedural wait times exceeding 1 or 2 h. The primary outcome was major adverse events within 30 days post-surgery. Mixed-effect logistic regression accounted for operation clustering within surgeons, estimating adjusted relative risks and outcome rate differences using marginal standardization.</p><p><strong>Results: </strong>Among 8844 elective operations, 4.0% started more than 1 h late, associated with an increased rate of adverse events (21.6% versus 14.4%, P = 0.039). Waiting time surpassing 1 h between procedures occurred in 71.4% of operations and was also associated with a higher frequency of adverse events (13.9% versus 5.3%, P < 0.001). After adjustment, delayed operations were associated with an elevated risk of major adverse events (adjusted relative risk 1.37 (95% c.i. 1.06 to 1.85)). The standardized rate of major adverse events was 12.1%, compared with 8.9% (absolute difference of 3.3% (95% c.i. 0.6% to 5.6%)), when a surgeon experienced a delay in operating room scheduling or waiting time between two procedures exceeding 1 h, as opposed to not experiencing such delays.</p><p><strong>Conclusion: </strong>A surgeon's exposure to delay before starting elective procedures was associated with an increased occurrence of major adverse events. Optimizing operating room turnover to prevent delayed operations and waiting time is critical for patient safety.</p>","PeriodicalId":9028,"journal":{"name":"BJS Open","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11477981/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142457414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Post-pancreatectomy acute pancreatitis and pancreatic fistula after pancreatoduodenectomy: two distinct but potentially correlated clinical entities. 胰十二指肠切除术后急性胰腺炎和胰瘘:两种不同但可能相关的临床实体。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae107
Giuseppe Quero, Claudio Fiorillo, Chiara Lucinato, Flavia Taglioni, Vito Laterza, Edoardo Panza, Giuseppe Massimiani, Teresa Mezza, Roberta Menghi, Ludovica Di Cesare, Beatrice Biffoni, Davide De Sio, Fausto Rosa, Vincenzo Tondolo, Sergio Alfieri
{"title":"Post-pancreatectomy acute pancreatitis and pancreatic fistula after pancreatoduodenectomy: two distinct but potentially correlated clinical entities.","authors":"Giuseppe Quero, Claudio Fiorillo, Chiara Lucinato, Flavia Taglioni, Vito Laterza, Edoardo Panza, Giuseppe Massimiani, Teresa Mezza, Roberta Menghi, Ludovica Di Cesare, Beatrice Biffoni, Davide De Sio, Fausto Rosa, Vincenzo Tondolo, Sergio Alfieri","doi":"10.1093/bjsopen/zrae107","DOIUrl":"https://doi.org/10.1093/bjsopen/zrae107","url":null,"abstract":"","PeriodicalId":9028,"journal":{"name":"BJS Open","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11426162/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142336291","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Short-term outcomes after primary total mesorectal excision (TME) versus local excision followed by completion TME for early rectal cancer: population-based propensity-matched study. 早期直肠癌初次全直肠系膜切除术 (TME) 与局部切除术后再行全直肠系膜切除术的短期疗效对比:基于人群的倾向匹配研究。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae103
Annabel S van Lieshout, Lisanne J H Smits, Julie M L Sijmons, Susan van Dieren, Stefan E van Oostendorp, Pieter J Tanis, Jurriaan B Tuynman

Background: Colorectal cancer screening programmes have led to a shift towards early-stage colorectal cancer, which, in selected cases, can be treated using local excision. However, local excision followed by completion total mesorectal excision (two-stage approach) may be associated with less favourable outcomes than primary total mesorectal excision (one-stage approach). The aim of this population study was to determine the distribution of treatment strategies for early rectal cancer in the Netherlands and to compare the short-term outcomes of primary total mesorectal excision with those of local excision followed by completion total mesorectal excision.

Methods: Short-term data for patients with cT1-2 N0xM0 rectal cancer who underwent local excision only, primary total mesorectal excision, or local excision followed by completion total mesorectal excision between 2012 and 2020 in the Netherlands were collected from the Dutch Colorectal Audit. Patients were categorized according to treatment groups and logistic regressions were performed after multiple imputation and propensity score matching. The primary outcome was the end-ostomy rate.

Results: From 2015 to 2020, the proportion for the two-stage approach increased from 22.3% to 43.9%. After matching, 1062 patients were included. The end-ostomy rate was 16.8% for the primary total mesorectal excision group versus 29.6% for the local excision followed by completion total mesorectal excision group (P < 0.001). The primary total mesorectal excision group had a higher re-intervention rate than the local excision followed by completion total mesorectal excision group (16.7% versus 11.8%; P = 0.048). No differences were observed with regard to complications, conversion, diverting ostomies, radical resections, readmissions, and death.

Conclusion: This study shows that, over time, cT1-2 rectal cancer has increasingly been treated using the two-stage approach. However, local excision followed by completion total mesorectal excision seems to be associated with an elevated end-ostomy rate. It is important that clinicians and patients are aware of this risk during shared decision-making.

背景:结直肠癌筛查计划促使人们转向早期结直肠癌,在某些情况下,可采用局部切除术治疗早期结直肠癌。然而,局部切除术后再进行完整的全直肠系膜切除术(两阶段法)的疗效可能不如初次全直肠系膜切除术(一阶段法)。这项人群研究的目的是确定荷兰早期直肠癌治疗策略的分布情况,并比较初次全直肠系膜切除术与局部切除术后再行完整全直肠系膜切除术的短期疗效:方法:从荷兰结直肠审计(Dutch Colorectal Audit)中收集了2012年至2020年间荷兰cT1-2 N0xM0直肠癌患者仅接受局部切除术、初次全直肠系膜切除术或局部切除术后再行完整全直肠系膜切除术的短期数据。根据治疗组别对患者进行分类,并在多重归因和倾向得分匹配后进行逻辑回归。主要结果是末端造口术率:结果:从2015年到2020年,两阶段方法的比例从22.3%上升到43.9%。匹配后,共纳入 1062 名患者。初次全直肠系膜切除术组的终末切除率为16.8%,而局部切除术后再行完整全直肠系膜切除术组的终末切除率为29.6%(P < 0.001)。初次全直肠系膜切除术组的再介入率高于局部切除术后再行完整全直肠系膜切除术组(16.7% 对 11.8%;P = 0.048)。在并发症、转归、分流造口、根治性切除、再入院和死亡方面没有观察到差异:本研究表明,随着时间的推移,cT1-2 直肠癌越来越多地采用两阶段方法进行治疗。然而,局部切除后再进行完整的全直肠系膜切除术似乎与较高的终末切除率有关。临床医生和患者在共同决策时必须意识到这一风险。
{"title":"Short-term outcomes after primary total mesorectal excision (TME) versus local excision followed by completion TME for early rectal cancer: population-based propensity-matched study.","authors":"Annabel S van Lieshout, Lisanne J H Smits, Julie M L Sijmons, Susan van Dieren, Stefan E van Oostendorp, Pieter J Tanis, Jurriaan B Tuynman","doi":"10.1093/bjsopen/zrae103","DOIUrl":"10.1093/bjsopen/zrae103","url":null,"abstract":"<p><strong>Background: </strong>Colorectal cancer screening programmes have led to a shift towards early-stage colorectal cancer, which, in selected cases, can be treated using local excision. However, local excision followed by completion total mesorectal excision (two-stage approach) may be associated with less favourable outcomes than primary total mesorectal excision (one-stage approach). The aim of this population study was to determine the distribution of treatment strategies for early rectal cancer in the Netherlands and to compare the short-term outcomes of primary total mesorectal excision with those of local excision followed by completion total mesorectal excision.</p><p><strong>Methods: </strong>Short-term data for patients with cT1-2 N0xM0 rectal cancer who underwent local excision only, primary total mesorectal excision, or local excision followed by completion total mesorectal excision between 2012 and 2020 in the Netherlands were collected from the Dutch Colorectal Audit. Patients were categorized according to treatment groups and logistic regressions were performed after multiple imputation and propensity score matching. The primary outcome was the end-ostomy rate.</p><p><strong>Results: </strong>From 2015 to 2020, the proportion for the two-stage approach increased from 22.3% to 43.9%. After matching, 1062 patients were included. The end-ostomy rate was 16.8% for the primary total mesorectal excision group versus 29.6% for the local excision followed by completion total mesorectal excision group (P < 0.001). The primary total mesorectal excision group had a higher re-intervention rate than the local excision followed by completion total mesorectal excision group (16.7% versus 11.8%; P = 0.048). No differences were observed with regard to complications, conversion, diverting ostomies, radical resections, readmissions, and death.</p><p><strong>Conclusion: </strong>This study shows that, over time, cT1-2 rectal cancer has increasingly been treated using the two-stage approach. However, local excision followed by completion total mesorectal excision seems to be associated with an elevated end-ostomy rate. It is important that clinicians and patients are aware of this risk during shared decision-making.</p>","PeriodicalId":9028,"journal":{"name":"BJS Open","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11375580/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142131735","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Outcome of the novel description of arterial position changes after major liver resections: retrospective study. 肝脏大部切除术后动脉位置变化新描述的结果:回顾性研究。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae110
Sepehr Abbasi Dezfouli, Arash Dooghaie Moghadam, Philipp Mayer, Miriam Klauss, Hans-Ulrich Kauczor, De-Hua Chang, Mohammad Golriz, Arianeb Mehrabi, Katharina Hellbach

Background: After major liver resections, anatomical shifts due to liver parenchymal hypertrophy and organ displacement can happen. The aim of this study was to evaluate the impact of these anatomical changes on the main abdominal arteries (coeliac trunk and superior mesenteric artery) and on patient outcomes.

Methods: All patients who underwent major liver resections (between January 2010 and July 2021) and who underwent preoperative and postoperative arterial-phase contrast-enhanced abdominal CT imaging were studied. Observed arterial position changes were classified into three groups: no position changes; class I position changes (vessel displacement with or without kinking with a vessel angle greater than 105°); and class II position changes (kinking less than or equal to 105°). The Mann-Whitney test and the Kruskal-Wallis test were used to compare continuous variables and the chi-squared test and Fisher's exact test were used to compare categorical variables. Univariable and multivariable logistic regression analyses were used to identify the risk factors for morbidity and mortality.

Results: A total of 265 patients (149 men and median age of 59 years) were enrolled. Arterial position changes were detected in a total of 145 patients (54.7%) (99 patients (37%) with class I position changes and 46 patients (18%) with class II position changes) and were observed more often after extended resection and right-sided resection (P < 0.001). Major complications were seen in 94 patients (35%) and the rate of mortality was 15% (40 patients died). Post-hepatectomy liver failure (P = 0.030), major complications (P < 0.001), and mortality (P = 0.004) occurred more frequently in patients with class II position changes. In multivariable analysis, arterial position change was an independent risk factor for post-hepatectomy liver failure (OR 2.86 (95% c.i. 1.06 to 7.72); P = 0.038), major complications (OR 2.10 (95% c.i. 1.12 to 3.93); P = 0.020), and mortality (OR 2.39 (95% c.i. 1.03 to 5.56); P = 0.042).

Conclusion: Arterial position changes post-hepatectomy are observed in the majority of patients and are significantly related to postoperative morbidities and mortality.

背景:肝脏大部切除术后,肝实质肥大和器官移位会导致解剖结构的改变。本研究旨在评估这些解剖变化对腹部主要动脉(腹腔干和肠系膜上动脉)的影响以及对患者预后的影响:研究对象为所有接受肝脏大部切除术的患者(2010年1月至2021年7月期间),这些患者均接受了术前和术后动脉相对比增强腹部CT成像检查。观察到的动脉位置变化分为三组:无位置变化;I类位置变化(血管移位伴或不伴扭结,血管角度大于105°);II类位置变化(扭结小于或等于105°)。连续变量的比较采用 Mann-Whitney 检验和 Kruskal-Wallis 检验,分类变量的比较采用卡方检验和费雪精确检验。采用单变量和多变量逻辑回归分析来确定发病率和死亡率的风险因素:共纳入 265 名患者(149 名男性,中位年龄为 59 岁)。共有 145 名患者(54.7%)发现动脉位置改变(99 名患者(37%)为 I 级位置改变,46 名患者(18%)为 II 级位置改变),扩大切除术和右侧切除术后更常观察到动脉位置改变(P < 0.001)。94名患者(35%)出现主要并发症,死亡率为15%(40名患者死亡)。肝切除术后肝功能衰竭(P = 0.030)、主要并发症(P < 0.001)和死亡率(P = 0.004)更多地发生在 II 级体位改变的患者中。在多变量分析中,动脉位置改变是肝切除术后肝衰竭(OR 2.86(95% 置信区间 1.06 至 7.72);P = 0.038)、主要并发症(OR 2.10(95% 置信区间 1.12 至 3.93);P = 0.020)和死亡率(OR 2.39(95% 置信区间 1.03 至 5.56);P = 0.042)的独立风险因素:结论:大多数患者在肝切除术后会出现动脉位置变化,这与术后发病率和死亡率有显著关系。
{"title":"Outcome of the novel description of arterial position changes after major liver resections: retrospective study.","authors":"Sepehr Abbasi Dezfouli, Arash Dooghaie Moghadam, Philipp Mayer, Miriam Klauss, Hans-Ulrich Kauczor, De-Hua Chang, Mohammad Golriz, Arianeb Mehrabi, Katharina Hellbach","doi":"10.1093/bjsopen/zrae110","DOIUrl":"https://doi.org/10.1093/bjsopen/zrae110","url":null,"abstract":"<p><strong>Background: </strong>After major liver resections, anatomical shifts due to liver parenchymal hypertrophy and organ displacement can happen. The aim of this study was to evaluate the impact of these anatomical changes on the main abdominal arteries (coeliac trunk and superior mesenteric artery) and on patient outcomes.</p><p><strong>Methods: </strong>All patients who underwent major liver resections (between January 2010 and July 2021) and who underwent preoperative and postoperative arterial-phase contrast-enhanced abdominal CT imaging were studied. Observed arterial position changes were classified into three groups: no position changes; class I position changes (vessel displacement with or without kinking with a vessel angle greater than 105°); and class II position changes (kinking less than or equal to 105°). The Mann-Whitney test and the Kruskal-Wallis test were used to compare continuous variables and the chi-squared test and Fisher's exact test were used to compare categorical variables. Univariable and multivariable logistic regression analyses were used to identify the risk factors for morbidity and mortality.</p><p><strong>Results: </strong>A total of 265 patients (149 men and median age of 59 years) were enrolled. Arterial position changes were detected in a total of 145 patients (54.7%) (99 patients (37%) with class I position changes and 46 patients (18%) with class II position changes) and were observed more often after extended resection and right-sided resection (P < 0.001). Major complications were seen in 94 patients (35%) and the rate of mortality was 15% (40 patients died). Post-hepatectomy liver failure (P = 0.030), major complications (P < 0.001), and mortality (P = 0.004) occurred more frequently in patients with class II position changes. In multivariable analysis, arterial position change was an independent risk factor for post-hepatectomy liver failure (OR 2.86 (95% c.i. 1.06 to 7.72); P = 0.038), major complications (OR 2.10 (95% c.i. 1.12 to 3.93); P = 0.020), and mortality (OR 2.39 (95% c.i. 1.03 to 5.56); P = 0.042).</p><p><strong>Conclusion: </strong>Arterial position changes post-hepatectomy are observed in the majority of patients and are significantly related to postoperative morbidities and mortality.</p>","PeriodicalId":9028,"journal":{"name":"BJS Open","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11421472/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142341093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Author response to: Comment on: Surgeon age in relation to patients' long-term survival after gastrectomy for gastric adenocarcinoma: nationwide population-based cohort study. 作者回复:评论:外科医生年龄与胃腺癌胃切除术后患者长期生存的关系:全国性人群队列研究。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae101
Wilhelm Leijonmarck, Jesper Lagergren
{"title":"Author response to: Comment on: Surgeon age in relation to patients' long-term survival after gastrectomy for gastric adenocarcinoma: nationwide population-based cohort study.","authors":"Wilhelm Leijonmarck, Jesper Lagergren","doi":"10.1093/bjsopen/zrae101","DOIUrl":"10.1093/bjsopen/zrae101","url":null,"abstract":"","PeriodicalId":9028,"journal":{"name":"BJS Open","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11387996/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142280170","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Neoadjuvant therapy versus upfront surgery in resectable pancreatic cancer: reconstructed patient-level meta-analysis of randomized clinical trials. 可切除胰腺癌的新辅助治疗与前期手术:随机临床试验的患者层面重构荟萃分析》(Neoadjuvant therapy versus upfront surgery in resectable pancreatic cancer: reconstructed patient-level metaalysis of randomized clinical trials)。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae087
Daniel Aliseda, Pablo Martí-Cruchaga, Gabriel Zozaya, Nuria Blanco, Mariano Ponz, Ana Chopitea, Javier Rodríguez, Eduardo Castañón, Fernando Pardo, Fernando Rotellar

Background: Neoadjuvant treatment has shown promising results in patients with borderline resectable pancreatic ductal adenocarcinoma. The potential benefits of neoadjuvant treatment on long-term overall survival in patients with resectable pancreatic ductal adenocarcinoma have not yet been established. The aim of this study was to compare long-term overall survival of patients with resectable pancreatic ductal adenocarcinoma based on whether they received neoadjuvant treatment or underwent upfront surgery.

Methods: A systematic review including randomized clinical trials on the overall survival outcomes between neoadjuvant treatment and upfront surgery in patients with resectable pancreatic ductal adenocarcinoma was conducted up to 1 August 2023 from PubMed, MEDLINE and Web of Science databases. Patient-level survival data was extracted and reconstructed from available Kaplan-Meier curves. A frequentist one-stage meta-analysis was employed, using Cox-based models and a non-parametric method (restricted mean survival time), to assess the difference in overall survival between groups. A Bayesian meta-analysis was also conducted.

Results: Five randomized clinical trials comprising 625 patients were included. Among patients with resectable pancreatic ductal adenocarcinoma, neoadjuvant treatment was not significantly associated with a reduction in the hazard of death compared with upfront surgery (shared frailty HR 0.88, 95% c.i. 0.72 to 1.08, P = 0.223); this result was consistent in the non-parametric restricted mean survival time model (+2.41 months, 95% c.i. -1.22 to 6.04, P < 0.194), in the sensitivity analysis that excluded randomized clinical trials with a high risk of bias (shared frailty HR 0.91 (95% c.i. 0.72 to 1.15; P = 0.424)) and in the Bayesian analysis with a posterior shared frailty HR of 0.86 (95% c.i. 0.70 to 1.05).

Conclusion: Neoadjuvant treatment does not demonstrate a survival advantage over upfront surgery for patients with resectable pancreatic ductal adenocarcinoma.

背景:新辅助治疗在边缘可切除胰腺导管腺癌患者中显示出良好的效果。新辅助治疗对可切除胰腺导管腺癌患者长期总生存期的潜在益处尚未确定。本研究旨在根据可切除胰腺导管腺癌患者是接受新辅助治疗还是接受前期手术,比较他们的长期总生存率:截至2023年8月1日,从PubMed、MEDLINE和Web of Science数据库中对可切除胰腺导管腺癌患者的新辅助治疗和前期手术的总体生存结果进行了系统性回顾,包括随机临床试验。研究人员从现有的 Kaplan-Meier 曲线中提取并重建了患者生存数据。采用基于 Cox 模型和非参数方法(受限平均生存时间)的频数主义单阶段荟萃分析来评估组间总生存率的差异。此外还进行了贝叶斯荟萃分析:结果:共纳入了五项随机临床试验,包括 625 名患者。在可切除的胰腺导管腺癌患者中,与前期手术相比,新辅助治疗与死亡风险的降低无显著相关性(共享虚弱 HR 0.88,95% c.i.0.72~1.08,P = 0.223);这一结果在非参数限制性平均生存时间模型中也是一致的(+2.41个月,95% c.i.-1.22至6.04,P <0.194)、排除了高偏倚风险随机临床试验的敏感性分析(共享虚弱HR为0.91(95% c.i.0.72至1.15;P = 0.424))以及贝叶斯分析中的后验共享虚弱HR为0.86(95% c.i.0.70至1.05):结论:对于可切除的胰腺导管腺癌患者,新辅助治疗与前期手术相比并不具有生存优势。
{"title":"Neoadjuvant therapy versus upfront surgery in resectable pancreatic cancer: reconstructed patient-level meta-analysis of randomized clinical trials.","authors":"Daniel Aliseda, Pablo Martí-Cruchaga, Gabriel Zozaya, Nuria Blanco, Mariano Ponz, Ana Chopitea, Javier Rodríguez, Eduardo Castañón, Fernando Pardo, Fernando Rotellar","doi":"10.1093/bjsopen/zrae087","DOIUrl":"10.1093/bjsopen/zrae087","url":null,"abstract":"<p><strong>Background: </strong>Neoadjuvant treatment has shown promising results in patients with borderline resectable pancreatic ductal adenocarcinoma. The potential benefits of neoadjuvant treatment on long-term overall survival in patients with resectable pancreatic ductal adenocarcinoma have not yet been established. The aim of this study was to compare long-term overall survival of patients with resectable pancreatic ductal adenocarcinoma based on whether they received neoadjuvant treatment or underwent upfront surgery.</p><p><strong>Methods: </strong>A systematic review including randomized clinical trials on the overall survival outcomes between neoadjuvant treatment and upfront surgery in patients with resectable pancreatic ductal adenocarcinoma was conducted up to 1 August 2023 from PubMed, MEDLINE and Web of Science databases. Patient-level survival data was extracted and reconstructed from available Kaplan-Meier curves. A frequentist one-stage meta-analysis was employed, using Cox-based models and a non-parametric method (restricted mean survival time), to assess the difference in overall survival between groups. A Bayesian meta-analysis was also conducted.</p><p><strong>Results: </strong>Five randomized clinical trials comprising 625 patients were included. Among patients with resectable pancreatic ductal adenocarcinoma, neoadjuvant treatment was not significantly associated with a reduction in the hazard of death compared with upfront surgery (shared frailty HR 0.88, 95% c.i. 0.72 to 1.08, P = 0.223); this result was consistent in the non-parametric restricted mean survival time model (+2.41 months, 95% c.i. -1.22 to 6.04, P < 0.194), in the sensitivity analysis that excluded randomized clinical trials with a high risk of bias (shared frailty HR 0.91 (95% c.i. 0.72 to 1.15; P = 0.424)) and in the Bayesian analysis with a posterior shared frailty HR of 0.86 (95% c.i. 0.70 to 1.05).</p><p><strong>Conclusion: </strong>Neoadjuvant treatment does not demonstrate a survival advantage over upfront surgery for patients with resectable pancreatic ductal adenocarcinoma.</p>","PeriodicalId":9028,"journal":{"name":"BJS Open","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11428068/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142341080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Economic impact of limb-salvage strategies in chronic limb-threatening ischaemia: modelling and budget impact study based on national registry data. 肢体挽救策略对慢性肢体缺血威胁的经济影响:基于国家登记数据的建模和预算影响研究。
IF 3.5 3区 医学 Q1 SURGERY Pub Date : 2024-09-03 DOI: 10.1093/bjsopen/zrae099
Athanasios Saratzis, Hany Zayed, Anna Buylova, William Rawlinson, Giota Veliu, Markus Siebert

Background: Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented.

Methods: A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure.

Results: In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259.

Conclusion: A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.

背景:以前曾有文献指出,在治疗慢性肢体缺血时,减少主要下肢截肢和增加肢体抢救程序的机会已经错过。然而,在抢救受慢性肢体缺血威胁的肢体时,医疗服务提供者可能节省的经济成本却没有得到很好的记录:方法:利用英格兰和威尔士 160 万人的国民健康服务医疗保健使用和成本数据以及 2019-2021 年慢性肢体危重缺血初级外科手术的平均数量创建了一个模型,以进行预算影响分析。测试了两种方案:国家血管登记处的全国主要下肢截肢(踝关节以上)、血管成形术、开放式搭桥手术或动脉内膜切除术的平均比率(当前方案);根据国家血管登记处在研究时报告的最低截肢率调整的血管再通率(假设方案)。主要结果是指数手术后12个月内对国民健康服务成本的净影响:结果:在当前情况下,不同指数手术的比例分别为:下肢大截肢术 10%、血管成形术 55%、开放式搭桥手术 25%、动脉内膜切除术 10%。在假设情况下,下肢大截肢率为 3%,血管成形术为 59%,开放式搭桥手术为 27%,动脉内膜切除术为 11%。对于 16 025 例慢性危及肢体缺血指数手术,当前情景下的总护理成本为 243 924 927 欧元。在假设方案中,指数手术(-10 013 814 欧元)、社区护理(-633 943 欧元)和重大心血管事件(-383 407 欧元)的费用将减少,而初级护理(59 827 欧元)、门诊预约(120 050 欧元)和随后的慢性肢体缺血相关手术(1 179 107 欧元)的费用将增加。国民医疗服务的净节省额为 9 645 259 欧元:结论:从主要的下肢截肢手术转向血管再通手术,可为国家卫生服务部门节省大量费用,而不会导致后期护理成本大幅增加,这表明医院做出的护理决定具有更广泛的益处。
{"title":"Economic impact of limb-salvage strategies in chronic limb-threatening ischaemia: modelling and budget impact study based on national registry data.","authors":"Athanasios Saratzis, Hany Zayed, Anna Buylova, William Rawlinson, Giota Veliu, Markus Siebert","doi":"10.1093/bjsopen/zrae099","DOIUrl":"https://doi.org/10.1093/bjsopen/zrae099","url":null,"abstract":"<p><strong>Background: </strong>Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented.</p><p><strong>Methods: </strong>A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure.</p><p><strong>Results: </strong>In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259.</p><p><strong>Conclusion: </strong>A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.</p>","PeriodicalId":9028,"journal":{"name":"BJS Open","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11408877/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142280172","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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