The latest medical research on General Surgery

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Management of Clinical T2N0 Esophageal and Gastroesophageal Junction Adenocarcinoma: What Is the Optimal Treatment?

Gastrointestinal Surgery

The current standard of care for locally advanced esophageal and gastroesophageal junction (GEJ) adenocarcinoma includes neoadjuvant chemoradiation and surgery. The optimal treatment for clinical T2N0M0 (cT2N0) disease is debated. This study aims to determine the optimal treatment in these patients.

The National Cancer Database was used to identify patients who underwent surgery for cT2N0 esophageal and GEJ adenocarcinoma from 2004 to 2017. Patients were grouped into surgery-alone, neoadjuvant therapy (NAT), and adjuvant therapy (AT) groups. Subgroups of high-risk patients (tumor ≥ 3 cm, poor differentiation, or lymphovascular invasion) and patients upstaged after upfront surgery were identified. Kaplan-Meier method and Cox proportional hazard ratios were used to compare overall survival.

Of 2160 patients included, 957 (44.3%) underwent surgery-alone, 821 (38.0%) underwent NAT and surgery, and 382 (17.7%) underwent surgery and AT. One thousand six hundred nineteen (75.0%) patients had high-risk features. Six hundred fourteen (45.9%) patients were upstaged after upfront surgery. In the overall cohort, AT was associated with improved survival compared to NAT (HR 0.618, p < 0.001) and surgery-alone (HR 0.699, p < 0.001). There was no difference in survival between NAT and surgery-alone (HR 1.132, p = 0.112). Similar results were observed in high-risk patients. Patients upstaged after upfront surgery who received AT had improved survival compared to those initially treated with NAT (HR 0.613, p < 0.001).

This analysis suggests that cT2N0 esophageal and GEJ adenocarcinomas may not benefit from the intensive multimodality therapy utilized in locally advanced disease. Selective use of AT for patients who are upstaged pathologically, or have high-risk features, is associated with improved outcomes.

Interobserver agreement for the Chest Wall Injury Society taxonomy of rib fractures using CT images.

J Trauma Acute Care

In 2020, a universal nomenclature for rib fractures was proposed by the international Chest Wall Injury Society taxonomy collaboration. The purpose of this study is to validate this taxonomy. We hypothesized that there would be at least moderate agreement, regardless of the observers' background.

level IV, diagnostic test.

A total of 90 observers participated, with 76 (84%) complete responses. Strong agreement was found for the classification of fracture location (κ 0.83; 95% CI 0.69-0.97 and AC1 0.84; 95% CI 0.81-0.88), moderate for fracture type (κ 0.46; 95% CI 0.32-0.59 and AC1 0.50; 95% CI 0.45-0.55), and fair for rib fracture displacement (κ 0.38; 95% CI 0.21-0.54 and AC1 0.38; 95% CI 0.34-0.42).

Agreement on rib fracture location was strong and moderate for fracture type. Agreement on displacement was lower than expected.. Evaluating strategies such as comprehensive education, additional imaging techniques, or further specification of the definitions will be needed to increase agreement on the classification of rib fracture type and displacement as defined by the CWIS taxonomy.

Use of Whole Blood Deployment Programs for Mass Casualty Incidents: South Texas Experience in Regional Response and Preparedness.

J Trauma Acute Care

Firearm-related deaths have become the leading cause of death in adolescents and children. Since the Sutherland Springs, TX mass casualty incident (MCI), the Southwest Texas Regional Advisory Council (STRAC) for trauma instituted a prehospital whole blood (WB) program and blood deployment program for MCI's.

Level VII.

On May 24, 2022, 19 children and 2 adults were killed at an MCI in Uvalde, TX. The MCI WB deployment protocol was initiated, and South Texas Blood and Tissue Center (STBTC) prepared 15 units of low titer O positive whole blood (LTO + WB) and 10 units of Leukoreduced O- packed cells (LPC). The deployed blood arrived at Uvalde Memorial Hospital within 67 minutes. One of the pediatric patients sustained multiple gunshots to the chest and extremities. The child was hypotensive and received 2 units of LPC, one at the initial hospital, and another during transport. On arrival, the patient required two units of LTO + WB and underwent a successful hemorrhage control operation. The remaining blood was returned to STBTC for distribution.

Multiple studies have shown the association of early blood product resuscitation and improved mortality, with WB being the ideal resuscitative product for a many. The ongoing efforts in South Texas serve as a model for development of similar programs throughout the country to reduce preventable deaths. This event represents the first ever successful deployment of WB to the site of a mass casualty incident related to a school shooting in the modern era.

The Effect of Center Esophagectomy Volume on Outcomes in Clinical Stage I-III Esophageal Cancer.

Annals of Surgery

To determine the threshold annualized esophagectomy volume that is associated with improved survival, oncologic resection, and post-operative outcomes.

Esophagectomy at high-volume centers is associated with improved outcomes; however, the definition of high-volume remains debated.

The 2004-2016 National Cancer Database (NCDB) was queried for patients with clinical stage I-III esophageal cancer undergoing esophagectomy. Center esophagectomy volume was modeled as a continuous variable using restricted cubic splines. Maximally selected ranks were used to identify an inflection point of center volume and survival. Survival was compared using multivariable Cox Proportional Hazards methods. Multivariable logistic regression was used to examine secondary outcomes.

Overall, 13,493 patients met study criteria. Median center esophagectomy volume was 8.2 (IQR 3.2-17.2) cases/year. On restricted cubic splines, inflection points were identified at 9 and 30 cases/year. A multivariable Cox model was constructed modeling annualized center surgical volume as a continuous variable using three linear splines and inflection points at 9 and 30 cases/year. On multivariable analysis, increasing center volume up to 9 cases/year was associated with a substantial survival benefit (HR 0.97, 95% CI 0.95-0.98; P=<0.001). On multivariable logistic regression, factors associated with undergoing surgery at a high-volume center (greater than 9 cases/year) included private insurance, care at an academic center, completion of high school education, and greater travel distance.

This NCDB study utilizing multivariable analysis and restricted cubic splines suggests the threshold definition of a high-volume esophagectomy center as one that performs at least 10 operations a year.

Laparoscopic Proximal Gastrectomy with Novel Valvuloplastic Esophagogastrostomy vs. Laparoscopic Total Gastrectomy for Stage I Gastric Cancer: a Propensity Score Matching Analysis.

Gastrointestinal Surgery

Laparoscopic total gastrectomy for early proximal gastric cancer is widely performed. Recently, the number of laparoscopic proximal gastrectomies performed, a surgery limited to early proximal gastric cancer, has gradually increased. However, evidence for the long-term outcomes of laparoscopic total gastrectomy and laparoscopic proximal gastrectomy is insufficient. Therefore, this study aimed to clarify and compare the long-term outcomes of laparoscopic total gastrectomy and laparoscopic proximal gastrectomy with novel valvuloplastic esophagogastrostomy for treatment of clinical stage I proximal gastric cancer.

This study included 111 patients who underwent laparoscopic total gastrectomy or laparoscopic proximal gastrectomy for the treatment of upper third clinical stage I gastric cancer between April 2004 and December 2017. After adjusting for propensity score matching analysis, we compared the postoperative complications, nutritional status, and long-term outcomes between the two groups.

After matching the inclusion criteria, 56 patients (28 in each group) were enrolled. No significant differences were noted in the postoperative complications between the two groups. While laparoscopic proximal gastrectomy was associated with lower albumin levels, lower body weight loss was seen by 1 year after surgery and higher hemoglobin levels by 1, 2, and 3 years after surgery. No significant differences were observed in the 3-year overall survival and 3-year recurrence-free survival between the laparoscopic total gastrectomy and laparoscopic proximal gastrectomy groups (P = 0.74 and 0.72, respectively).

Laparoscopic proximal gastrectomy and laparoscopic total gastrectomy for patients with upper third clinical stage I gastric cancer are feasible as regards its safety and outcomes.

The uniportal VATS in the treatment of stage II pleural empyema: a safe and effective approach for adults and elderly patients-a single-center experience and literature review.

World J Emerg Surg

Pleural empyema (PE) is a frequent disease, associated with a high morbidity and mortality. Surgical approach is the standard of care for most patients with II-III stage PE. In the last years, the minimally invasive surgical revolution involved also thoracic surgery allowing the same outcomes in terms of safety and effectiveness combined to better pain management and early discharge. The aim of this study is to demonstrate through our experience on uniportal-video-assisted thoracoscopy (u-VATS) the effectiveness and safety of its approach in treatment of stage II PE. As secondary endpoint, we will evaluate the different pattern of indication of u-VATS in adult and elderly patients with literature review.

We retrospectively reviewed our prospectively collected database of u-VATS procedures from November 2018 to February 2022, in our regional referral center for Thoracic Surgery of Regione Molise General Surgery Unit of "A. Cardarelli" Hospital, in Campobasso, Molise, Italy.

A total of 29 patients underwent u-VATS for II stage PE. Fifteen (51.72%) patients were younger than 70 years old, identified as "adults," 14 (48.28%) patients were older than 70 years old, identified as "elderly." No mortality was found. Mean operative time was 104.68 ± 39.01 min in the total population. The elderly group showed a longer operative time (115 ± 53.15 min) (p = 0.369). Chest tube was removed earlier in adults than in elderly group (5.56 ± 2.06 vs. 10.14 ± 5.58 p = 0.038). The Length of Stay (LOS) was shorter in the adults group (6.44 ± 2.35 vs. 12.29 ± 6.96 p = 0.033). Patients evaluated through Instrumental Activities of Daily Living (IADL) scale returned to normal activities of daily living after surgery.

In addition, the u-VATS approach seems to be safe and effective ensuring a risk reduction of progression to stage III PE with a lower recurrence risk and septic complications also in elderly patients. Further comparative multicenter analysis are advocated to set the role of u-VATS approach in the treatment of PE in adults and elderly patients.

Comparing 5-Year Survival Rates Before and After Re-stratification of Stage I-III Right-Sided Colon Cancer Patients by Establishing the Presence/Absence of Occult Tumor Cells and Lymph Node Metastases in the Different Levels of Surgical Dissection.

Gastrointestinal Surgery

"Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-Detector Computed Tomography (MDCT) Angiography" registered at

Consecutive patients were drawn from a multicenter prospective trial. After surgery, the surgical specimen was divided into the D1/D2 and D3 volumes before being further analyzed separately. All lymph nodes were examined with cytokeratin CAM 5.2 immunohistochemically. Lymph nodes containing metastases and OTC (micrometastases; isolated tumor cells) were identified. Re-stratification was as follows: RS1, stages I/II, no OTC in D1/D2 and D3 volumes; RS2, stages I/II, OTC in D1/D2 and/or D3; RS3, stage III, lymph node metastases in D1/D2, with/without OTC in D3; RS4, stage III, lymph node metastases in D3, with/without OTC in D3.

Eighty-seven patients (39 men, 68.4 + 9.9 years) were included. The standard stratified (SS) group contained the following: stages I/II (SS1) 57 patients; stage III (SS2) 30 patients. Re-stratified (RS) contained RS1 (38), RS2 (19), RS3 (24), and RS4 (6) patients. Lymph node ratio (OTC) RS2: 0.157 D1/D2; 0.035 D3 and 0.092 complete specimens. Lymph node ratio RS3: 0.113 D1/D2; complete specimen 0.056. Overall survival and disease-free survival were p = 0.875 and p = 0.049 for SS and p = 0.144 and p = 0.001 for RS groups, respectively.

This re-stratification identifies a patient group with poor prognosis (RS4). Removing this group from SS2 eliminates all the differences in survival between RS2 and RS3 groups. The level of dissection of the affected nodes may have an impact on survival.

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass Up to 5 Years After Surgery in Patients with Medicaid.

Annals of Surgery

Compare adverse outcomes up to 5 years after sleeve gastrectomy and gastric bypass in patients with Medicaid.

Sleeve gastrectomy is the most common bariatric operation among patients with Medicaid, however its long-term safety in this population is unknown.

Using Medicaid claims, we performed a retrospective cohort study of adult patients who underwent sleeve gastrectomy or gastric bypass from January 1, 2012 to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence and heterogeneity of outcomes up to 5 years after surgery.

Among 132,788 patients with Medicaid, 84,717 (63.8%) underwent sleeve gastrectomy and 48,071 (36.2%) underwent gastric bypass. 69,225 (52.1%) patients were White, 33,833 (25.5%) were Black, and 29,730 (22.4%) were Hispanic. Compared to gastric bypass, sleeve gastrectomy was associated with a lower 5-year cumulative incidence of mortality (1.29% vs. 2.15%), complications (11.5% vs. 16.2%), hospitalization (43.7% vs. 53.7%), ED use (61.6% vs. 68.2%), and reoperation (18.5% vs. 22.8%), but a higher cumulative incidence of revision (3.3% vs. 2.0%). Compared to White patients, the magnitude of the difference between sleeve and bypass was smaller among Black patients for ED use (5-year aHR 1.01 [95% CI 0.94-1.08] vs. 0.94 [95% CI 0.88-1.00], P<0.001) and Hispanic patients for reoperation (5-year aHR 0.95 [95% CI 0.86-1.05] vs. 0.76 [95% CI 0.69-0.83], P<0.001).

Among patients with Medicaid undergoing bariatric surgery, sleeve gastrectomy was associated with a lower risk of mortality, complications, hospitalization, ED use, and reoperations, but a higher risk of revision compared to gastric bypass. Although the difference between sleeve and bypass was generally similar among White, Black, and Hispanic patients, the magnitude of this difference was smaller among Black patients for ED use and Hispanic patients for reoperation.

Prediction of R Status in Resections for Pancreatic Cancer Using Simplified Radiological Criteria.

Annals of Surgery

Predicting R status before surgery for pancreatic cancer (PDAC) patients with upfront surgery and neoadjuvant therapy.

Negative surgical margins (R0) are a key predictor of long-term outcomes in PDAC.

Patients undergoing pancreatic resection with curative intent for PDAC were identified. Using the CT scans from the time of diagnosis, the 2019 NCCN borderline resectability criteria were compared to novel criteria: presence of any alteration of the superior mesenteric-portal vein (SMPV) and perivascular stranding of the superior mesenteric artery (SMA). Accuracy of predicting R status was evaluated for both criteria. Patient baseline characteristics, surgical, histopathological parameters, and long-term overall survival (OS) after resection were evaluated.

A total of 593 patients undergoing pancreatic resections for PDAC between 2010 and 2018 were identified. Three hundred and twenty-five (54.8%) patients underwent upfront surgery, whereas 268 (45.2%) received neoadjuvant therapy. In upfront resected patients, positive SMA stranding was associated with 56% margin positive resection rates, whereas positive SMA stranding and SMPV alterations together showed a margin positive resection rate of 75%. In contrast to these criteria, the 2019 NCCN borderline criteria failed to predict margin status. In patients undergoing neoadjuvant therapy, only perivascular SMA stranding remained a predictor of margin positive resection, leading to a rate of 33% R+ resections. Perivascular SMA stranding was related to higher clinical T stage (P = 0.003) and clinical N stage (P = 0.043) as well as perineural invasion (P = 0.022). SMA stranding was associated with worse survival in both patients undergoing upfront surgery (36 vs 22 months, P = 0.002) and neoadjuvant therapy (47 vs 34 months, P = 0.050).

The novel criteria were accurate predictors of R status in PDAC patients undergoing upfront resection. After neoadjuvant treatment, likelihood of positive resection margins is approximately halved, and only perivascular SMA stranding remained a predictive factor.

Safety of Intraoperative Blood Salvage During Liver Transplantation in Patients With Hepatocellular Carcinoma: A Systematic Review and Meta-analysis.

Annals of Surgery

The effects of intraoperative blood salvage (IBS) on time to tumor recurrence, disease-free survival and overall survival in hepatocellular carcinoma (HCC) patients undergoing liver transplantation were assessed to evaluate the safety of IBS.

IBS is highly effective to reduce the use of allogeneic blood transfusion. However, the safety of IBS during liver transplantation for patients with HCC is questioned due to fear of disseminating malignant cells.

Comprehensive searches through June 2021 were performed in 8 databases. The methodological quality of included studies was assessed using the Robins-I tool. Meta-analysis with the generic inverse variance method was performed to calculate pooled hazard ratios (HRs) for disease-free survival, HCC recurrence and overall survival.

Nine studies were included (n=1997, IBS n=1200, no-IBS n=797). Use of IBS during liver transplantation was not associated with impaired disease-free survival [HR=0.90, 95% confidence interval (CI)=0.66-1.24, P=0.53, IBS n=394, no-IBS n=329], not associated with increased HCC recurrence (HR=0.83, 95% CI=0.57-1.23, P=0.36, IBS n=537, no-IBS n=382) and not associated with impaired overall survival (HR=1.04, 95% CI=0.79-1.37, P=0.76, IBS n=495, no-IBS n=356).

Based on available observational data, use of IBS during liver transplantation in patients with HCC does not result in impaired disease-free survival, increased HCC recurrence or impaired overall survival. Therefore, use of IBS during liver transplantation for HCC patients is a safe procedure.

Association Between American Board of Surgery Initial Certification and Medical Malpractice Payments.

Annals of Surgery

To measure associations between surgeons' examination performance and obtaining American Board of Surgery certification with the likelihood of having medical malpractice payments.

Further research is needed to establish a broader understanding of the association of board certification and patient and practice outcomes.

Retrospective analysis using propensity score-matched surgeons who attempted to obtain American Board of Surgery certification. Surgeons who completed residency between 2000 and 2019 (n=910) and attempted to become certified were categorized as certified or failing to obtain certification. In addition, groups were categorized as either passing or failing their first attempt on the qualifying and certifying examinations. Malpractice payment reports were dichotomized for surgeons who either had a payment report or not.

The hazard rate (HR) of malpractice payment reports was significantly greater for surgeons who attempted and failed to obtain certification [HR=1.87; 95% confidence interval (CI), 1.28-2.74] than for surgeons who were certified. Moreover, surgeons who failed either the qualifying (HR=1.64; 95% CI, 1.14-2.37) or certifying examination (HR=1.72; 95% CI, 1.14-2.60) had significantly higher malpractice payment HRs than those who passed the examinations on their first attempt.

Failing to obtain board certification was associated with a higher rate of medical malpractice payments. In addition, failing examinations in the certification examination process on the first attempt was also associated with higher rates of medical malpractice payments. This study provides further evidence that board certification is linked to potential indicators for patient outcomes and practice quality.