General Surgery

Latest Advances in General Surgery

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      Check out this Topic for the latest and most popular articles and advances in General Surgery

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        Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

        imageObjective:

        To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon.

        Background:

        Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons.

        Methods:

        We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days.

        Results:

        We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01).

        Conclusion:

        Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

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        August 10, 2021, 12:48 am

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          Gentrification in America – The Potential Deadly Consequences

          No abstract available

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          August 10, 2021, 12:48 am

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            Firearm Violence, Access to Care, and Gentrification: A Moving Target for American Trauma Systems

            imageObjective:

            We aimed to determine whether gentrification predicts the movement of shooting victims over time and if this process has decreased access to care.

            Background:

            Trauma centers remain fixed in space, but the populations they serve do not. Nationally, gentrification has displaced disadvantaged communities most at risk for violent injury, potentially decreasing access to care. This process has not been studied, but an increase of only 1 mile from a trauma center increases shooting mortality up to 22%.

            Methods:

            We performed a cross-sectional study utilizing Philadelphia Police Department (PPD) and Pennsylvania trauma systems outcome (PTOS) data 2006–2018. Shootings were mapped and grouped into census tracts. They were then cross-mapped with gentrification data and hospital location. PPD and PTOS shooting data were compared to ensure patients requiring trauma care were captured. Census tracts with ≥500 residents with income and median home values in the bottom 40th percentile of the metropolitan area were eligible to gentrify. Tracts were gentrified if residents ≥25 with a bachelor’s degree increased and home price increased to the top third in the metropolitan area. Change in distribution of shootings and its relation to gentrification was our primary outcome while proximity of shootings to a trauma center was our secondary outcome.

            Results:

            Thirty-two percent (123/379) of eligible tracts gentrified and 31,165 shootings were captured in the PPD database. 9090 (29.2%) patients meeting trauma criteria were captured in PTOS with an increasing proportion over time. The proportion of shootings within gentrifying tracts significantly dropped 2006–2018 (40%–35%, P

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            August 10, 2021, 12:48 am

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              Implementation of Enhanced Recovery Pathways in the Real World: Change is Hard

              No abstract available

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              August 10, 2021, 12:48 am

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                Clinical and Economic Outcomes of Enhanced Recovery Dissemination in Michigan Hospitals

                imageObjective:

                To evaluate real-world effects of enhanced recovery protocol (ERP) dissemination on clinical and economic outcomes after colectomy.

                Summary Background Data:

                Hospitals aiming to accelerate discharge and reduce spending after surgery are increasingly adopting perioperative ERPs. Despite their efficacy in specialty institutions, most studies have lacked adequate control groups and diverse hospital settings and have considered only in-hospital costs. There remain concerns that accelerated discharge might incur unintended consequences.

                Methods:

                Retrospective, population-based cohort including patients in 72 hospitals in the Michigan Surgical Quality Collaborative clinical registry (N = 13,611) and/or Michigan Value Collaborative claims registry (N = 14,800) who underwent elective colectomy, 2012 to 2018. Marginal effects of ERP on clinical outcomes and risk-adjusted, price-standardized 90-day episode payments were evaluated using mixed-effects models to account for secular trends and hospital performance unrelated to ERP.

                Results:

                In 24 ERP hospitals, patients Post-ERP had significantly shorter length of stay than those Pre-ERP (5.1 vs 6.5 days, P

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                August 10, 2021, 12:48 am

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                  Outcomes After Tracheostomy in COVID-19 Patients

                  imageObjective:

                  To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures.

                  Background:

                  Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure.

                  Methods:

                  A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19.

                  Results:

                  Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ± 6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ± 6.9 days (range 2–32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure.

                  Conclusions:

                  Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

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                  September 1, 2021, 1:01 am

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                    Comparison of Intestinal Lengthening Procedures for Patients With Short Bowel Syndrome

                    imageObjective:

                    Review the clinical results of 24 years of intestinal lengthening procedures at one institution.

                    Methods:

                    Retrospective review of a single center experience comparing the outcome of 2 intestinal lengthening procedures (Bianchi and serial transverse enteroplasty [STEP]) in terms of survival, total parenteral nutrition (TPN) weaning, and complications.

                    Results:

                    Sixty-four patients, including 14 adults, underwent 43 Bianchi and 34 STEP procedures between 1982 and 2007. Three patients had prior isolated liver transplants. The median (range) remnant bowel length before first lengthening was 45 (11-150) cm overall; (Bianchi = 44 cm, STEP = 45 cm) and 68 (20-250) cm after lengthening; (Bianchi = 68 cm, STEP = 65 cm). Actual survival is 91% overall (Bianchi 88%, STEP 95%) with median follow-up of 3.8 years (Bianchi = 5.9 years, STEP = 1.7 years). Average enteral caloric intake in pediatric patients was 15 kcal/kg before lengthening and 85 kcal/kg at 1 year after lengthening. Sixty-nine percent of patients are off TPN at most recent follow-up, including 8 who were weaned from TPN after intestinal transplantation. Liver disease (when present) was reversed in 80%. Surgical complications occurred in 10%, more commonly requiring reoperation after Bianchi than STEP. Intestinal transplantation salvage was required in 14% at a median of 2.9 years (range = 8 months to 20.7 years) after lengthening.

                    Conclusions:

                    Surgical lengthening with both Bianchi and STEP procedures results in improvement in enteral nutrition, reverses complications of TPN and avoids intestinal transplantation in the majority with few surgical complications. Intestinal transplantation can salvage most patients who later develop life-threatening complications or fail to wean TPN.

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                    September 1, 2021, 1:01 am

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                      Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial

                      Objective:

                      The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP).

                      Summary Background Data:

                      The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown.

                      Methods:

                      We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches.

                      Results:

                      Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87–1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64–1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference

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                      September 1, 2021, 1:01 am

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                        Textbook Outcome in Laparoscopic and Open Liver Surgery

                        This cohort study assesses the achievement rate of textbook outcome in patients receiving laparoscopic liver resection and open liver resection procedures in a large international multicenter database using a propensity-score matched analysis.

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                        September 1, 2021, 1:01 am

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                          Factors Associated With Functional Impairment After Pediatric Injury

                          This cohort study assesses whether certain categories of injury among youths are associated with higher prevalence of functional impairment after hospital discharge and estimated the number of children and adolescents with injuries in these categories who received treatment at pediatric trauma centers.

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                          September 1, 2021, 1:01 am

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                            Evaluation Tools for Outcomes Assessment in Hepato-Pancreato-Biliary Surgery

                            Assessment of quality of care is an essential part of surgical practice and is particularly important in a quickly evolving field such as hepato-pancreato-biliary (HPB) surgery. Evaluation tools are necessary to examine the performance of individual surgeons and programs but are even more important in the valuation of new tools and practice paradigms. In this issue of JAMA Surgery, Görgec and colleagues provide a validated tool for HPB surgery, derived from a study involving 8188 patients undergoing surgical procedures by 116 surgeons in 14 centers and 10 countries.

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                            September 1, 2021, 1:01 am

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