JAMA surgery最新文献

{"title":"Anterior Gastropexy for Paraesophageal Hernia Repair: A Randomized Clinical Trial.","authors":"Clayton C Petro, Ryan C Ellis, Sara M Maskal, Sam J Zolin, Chao Tu, Adele Costanzo, Lucas R A Beffa, David M Krpata, Diya Alaedeen, Ajita S Prabhu, Benjamin T Miller, Kevin F Baier, Alisan Fathalizadeh, John Rodriguez, Michael J Rosen","doi":"10.1001/jamasurg.2024.5788","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5788","url":null,"abstract":"<p><strong>Importance: </strong>Paraesophageal hernias can cause severe limitations in quality of life and life-threatening complications. Even though minimally invasive paraesophageal hernia repair (MIS-PEHR) is safe and effective, anatomic recurrence rates remain notoriously high. Retrospective data suggest that suturing the stomach to the anterior abdominal wall after repair-an anterior gastropexy-may reduce recurrence, but this adjunct is currently not the standard of care.</p><p><strong>Objective: </strong>To determine whether anterior gastropexy reduces 1-year recurrence after MIS-PEHR.</p><p><strong>Design, setting, and participants: </strong>This registry-based randomized clinical trial was conducted by 10 surgeons at 3 academic hospitals within the Cleveland Clinic Enterprise. Between June 26, 2019, and July 24, 2023, 348 patients were assessed for eligibility, and 240 patients were enrolled and randomized. Statistical analysis was performed from January to March 2024.</p><p><strong>Intervention: </strong>Enrolled patients were randomized to and received either an anterior gastropexy (n = 119) or no anterior gastropexy (n = 121).</p><p><strong>Main outcome: </strong>The primary outcome was recurrence as determined by reherniation of the stomach greater than 2 cm above the diaphragm on routine imaging at 1 year or reoperation. Secondary outcomes included quality of life as measured by the Gastroesophageal Reflux Health-Related Quality of Life survey, additional foregut symptom questionnaire, and patient satisfaction at 30 days and 1 year.</p><p><strong>Results: </strong>A total of 240 patients were randomized to either anterior gastropexy (n = 119; 104 [97%] women; median [IQR] age, 70 [64-75] years) or no anterior gastropexy (n = 121; 97 [80%] women; median [IQR] age, 68 [62-73] years) at the end of their MIS-PEHR. At 1 year, 188 patients (78%) had completed follow-up. By intention-to-treat analysis, 1-year recurrence was significantly lower in patients who received an anterior gastropexy (15% vs 36%; risk difference, 0.21 [95% CI, 0.09-0.33]), which remained significant after risk-adjusted regression analysis (hazard ratio, 0.38 [95% CI, 0.23-0.60]). Of 13 reoperations (5.4%) for recurrence in the first year, 3 (2.5%) were in the anterior gastropexy group and 10 (8.2%) were in the no-gastropexy group (P = .052). Two patients (1.7%) had their anterior gastropexy sutures removed for pain. There were no significant differences in quality-of-life outcomes at 30 days and 1 year between treatment groups.</p><p><strong>Conclusions and relevance: </strong>This randomized clinical trial found that the addition of an anterior gastropexy to MIS-PEHR is superior to no gastropexy in regard to reducing 1-year paraesophageal hernia recurrence. These results suggest that an anterior gastropexy should be routinely used in the context of minimally invasive paraesophageal hernia repair.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identif","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877043","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Frailty and Long-Term Health Care Utilization After Elective General and Vascular Surgery.","authors":"Shernaz S Dossabhoy, Laura A Graham, Aditi Kashikar, Elizabeth L George, Carolyn D Seib, Manjula Kurella Tamura, Todd H Wagner, Mary T Hawn, Shipra Arya","doi":"10.1001/jamasurg.2024.5711","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5711","url":null,"abstract":"<p><strong>Importance: </strong>Surgical quality improvement efforts have largely focused on 30-day outcomes, such as readmissions and complications. Surgery may have a sustained impact on the health and quality of life of patients considered frail, yet data are lacking on the long-term health care utilization of patients with frailty following surgery.</p><p><strong>Objective: </strong>To examine the independent association of preoperative frailty on long-term health care utilization (up to 24 months) following surgery.</p><p><strong>Design, setting, and participants: </strong>This retrospective, observational cohort study included patients undergoing elective general and vascular surgery performed in the Veterans Affairs (VA) Surgical Quality Improvement Program with study entry from October 1, 2013, to September 30, 2018. Patients were followed up for 24 months. Patients with nursing home visits prior to surgery, emergent cases, and in-hospital deaths were excluded. Data analysis was conducted from September 2022 to May 2024.</p><p><strong>Exposures: </strong>Preoperative frailty as assessed by the Risk Analysis Index (RAI-A) score: robust, less than 20; normal, 20 to 29; frail, 30 to 39; and very frail, 40 or more.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was health care utilization through 24 months, defined as inpatient admissions, outpatient visits, emergency department (ED) visits, and nursing home or rehabilitation services collected via Corporate Data Warehouse and Centers for Medicare & Medicaid Services data. χ2 Tests and analysis of variance were used to assess preoperative frailty status, and a Cox proportional hazards model was used to calculate the adjusted association of preoperative frailty on each postdischarge health care utilization outcome.</p><p><strong>Results: </strong>This study identified 183 343 elective general (80.5%) and vascular (19.5%) procedures (mean [SD] age, 62 [12.7] years; 12 915 females [7.0%]; 28 671 Black patients [16.0]; 138 323 White patients [77.3%]; 94 451 Medicare enrollees [51.5%]) with mean (SD) RAI-A score of 22.2 (7.0). After adjustment for baseline characteristics and preoperative use of health care services, frailty was associated with higher inpatient admissions (frail: hazard ratio [HR], 1.75; 95% CI, 1.70-1.79; very frail: HR, 2.33; 95% CI, 2.25-2.42), ED visits (frail: HR, 1.39; 95% CI, 1.36-1.41; very frail: HR, 1.70; 95% CI, 1.65-1.75), and nursing home or rehabilitation encounters (frail: HR, 4.97; 95% CI, 4.36-5.67; very frail: HR, 7.44; 95% CI, 6.34-8.73). For patients considered frail and very frail, health care utilization was higher after surgery and remained significant through 24 months for all outcomes (using piecewise Cox proportional hazards modeling).</p><p><strong>Conclusions and relevance: </strong>In this study, frailty was a significant risk factor for high long-term health care utilization after surgery. This may have quality of life implicat","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877056","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Not Time to Abandon Cholecystectomy for Symptomatic Cholelithiasis-Reply.","authors":"Daan J Comes, Philip R de Reuver","doi":"10.1001/jamasurg.2024.5708","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5708","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877021","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Investigational Device Exemption Effect-More Than Just Volume.","authors":"Juliet Blakeslee Carter, Adam W Beck","doi":"10.1001/jamasurg.2024.5664","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5664","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Not Time to Abandon Cholecystectomy for Symptomatic Cholelithiasis.","authors":"Chase J Wehrle, Abby Gross, R Matthew Walsh","doi":"10.1001/jamasurg.2024.5705","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5705","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877016","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Surgical Frailty and Health Care Utilization-The Chicken or the Egg.","authors":"Jason M Johanning","doi":"10.1001/jamasurg.2024.5698","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5698","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877076","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of Paraesophageal Hernia-Still a Controversial Topic.","authors":"Francisco Schlottmann, Fernando A M Herbella, Marco G Patti","doi":"10.1001/jamasurg.2024.5765","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5765","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877062","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Fenestrated and Branched Endovascular Aortic Repair and Mortality at Hospitals Without Investigational Device Trials.","authors":"Sara L Zettervall, Chen Dun, Jesse A Columbo, Bernardo C Mendes, Phillip P Goodney, Andres Schanzer, Marc L Schermerhorn, Martin A Makary, James H Black, Caitlin W Hicks","doi":"10.1001/jamasurg.2024.5654","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5654","url":null,"abstract":"<p><strong>Importance: </strong>Fenestrated and branched endovascular aortic repairs (F/BEVAR) have been adopted by many centers. However, national trends of F/BEVAR use remain unclear, particularly at sites who perform them without an US Food and Drug Adminstration (FDA)-approved investigational device exemption (IDE).</p><p><strong>Objective: </strong>To quantify the use of F/BEVAR in the US and to determine if mortality was different at IDE vs non-IDE sites.</p><p><strong>Design, setting, and participants: </strong>This retrospective cohort study examined 100% fee-for-service Medicare claims data from 2016 to 2023. Participants were patients who underwent endovascular treatment of the visceral aorta incorporating 2 or more visceral artery endoprostheses. Hospitals with vs without an IDE were identified using hospitals' Employer Identification Number as a time varying exposure.</p><p><strong>Exposure: </strong>F/BEVAR.</p><p><strong>Main outcomes and measures: </strong>Trends in the center-level F/BEVAR case volume stratified by IDE status were assessed using cumulative incidence curves. Mortality outcomes at 30 days and 3 years were compared using Kaplan-Meier methods and Cox proportional hazards models with adjustment for baseline patient characteristics.</p><p><strong>Results: </strong>From 2016 to 2023, 8017 patients were treated with F/BEVAR at 549 hospitals. The median (IQR) age was 75.8 (71.3-80.8) years; 5795 patients (72.3%) were male and 2222 (27.7%) female. A total of 2226 F/BEVAR (27.8%) were performed at 22 hospitals with an IDE. The number of patients treated with F/BEVAR increased from 771 in 2016 to 1251 in 2023. The median (IQR) annual case volume per hospital was significantly higher at IDE sites (22.3 [11.0-30.4] vs 1.2 [1.0-2.0] cases/y; P < .001); 18 IDE sites (90.0%) and 20 non-IDE sites (3.7%) completed 9 or more cases per year. The 30-day mortality (3.0% vs 4.9%) but not 3-year mortality (26.0% vs 27.1%) was lower for patients treated at hospitals with vs without an IDE. After risk adjustment, both 30-day (odds ratio, 0.47; 95% CI, 0.32-0.69) and midterm mortality (hazard ratio, 0.81; 95% CI, 0.69-0.95) were lower for patients treated at IDE sites.</p><p><strong>Conclusions and relevance: </strong>The use of F/BEVAR is increasing across the United States, with the majority of cases being performed outside of IDE studies and at low-volume centers. F/BEVAR performed at non-IDE centers are associated with higher adjusted 30-day and midterm mortality. Transparent outcome reporting and identification of process measures from IDE sites may help achieve more equity in patient outcomes.</p>","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142877049","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Leveraging Lean Methodology to Improve Compliance With Work-Hour Restrictions","authors":"J. Jeffery Reeves, Nicole Goldhaber, Hannah Hollandsworth, Kristin Cox, Ana Maria Dumitru, Beiqun Zhao, Christopher A. Longhurst, Jennifer Berumen, Allison E. Berndtson, Garth Jacobsen, Bryan Clary","doi":"10.1001/jamasurg.2024.5518","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5518","url":null,"abstract":"ImportanceSince work-hour restrictions were instituted in 2003, sustainably complying with duty-hour regulations remains a challenge for general surgery residency programs across the nation.ObjectiveTo determine whether industry-based process improvement techniques could be leveraged to increase compliance with work-hour restrictions within a general surgery residency.Design, Setting, and ParticipantsThis quality improvement project using Lean methodology was conducted from October to November of the 2021 to 2022 academic year. The setting was a university-based general surgery residency program in southern California with rotations across 5 regional hospitals. The program trains 7 categorical general surgery residents per postgraduate year (PGY) and offers an optional 1 to 3 years for research and career development.InterventionsProgrammatic structures were examined, current and target states were analyzed, opportunities for improvement were identified, root-cause analyses were conducted, and targeted interventions were developed.Main Outcomes and MeasuresResident time logs and annual Accreditation Council for Graduate Medical Education resident and faculty surveys were reviewed from academic years 2019/2020 to 2022/2023. Attending faculty were surveyed on resident preparedness using a 5-point Likert scale. Differences between means and proportions were calculated with corresponding 95% CIs.ResultsThe web-based survey responses of 29 residents (residents per PGY, 7 [PGY1], 14 [PGY2/3], 8 [PGY4/5]; 17 female [54.7%]) were included in this study. Root causes included maxed baseline schedules, late in shift work, culture, service variability, clinical volume, and inefficient workflows. Fifteen multifactorial interventions impacting call and weekend scheduling, work practices and efficiencies, intern and service orientations, and faculty and cultural expectations were implemented. The mean number of residents per block who logged more than 80 hours per week decreased by 3.6 violations per block (95% CI, 2.98-4.22), from 4.4 (12.4%) to 0.8 (2.2%) for a difference of 10.2% (95% CI, 8.4%-16.2%). On the annual resident survey, perceived compliance with 80 hours was 72%, 83%, 83%, and 88%, respectively, over the following study periods: 2019 to 2020, 2020 to 2021, 2021 to 2022, and 2022 to 2023. Faculty perception of resident preparedness for the case increased from a mean (SD) of 2.6 (0.8) to 3.0 (0.5), with a difference of 0.47 (95% CI, −0.52 to 0.68). There were no statistically significant differences in technical skill, clinical judgment, sense of responsibility, efficiency, or sense of well-being.Conclusions and RelevanceResults of this quality improvement study suggest that through Lean methodology, surgical residency programs can improve working environments. This novel approach can increase compliance with resident work hours by engaging front line trainees in the process.","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":"98 1","pages":""},"PeriodicalIF":16.9,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142841773","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A New Look at a Tenacious Problem-Resident Work-Hour Violations.","authors":"Luise I Pernar","doi":"10.1001/jamasurg.2024.5697","DOIUrl":"https://doi.org/10.1001/jamasurg.2024.5697","url":null,"abstract":"","PeriodicalId":14690,"journal":{"name":"JAMA surgery","volume":" ","pages":""},"PeriodicalIF":15.7,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142846602","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}