Annals of surgery最新文献

{"title":"Development and Validation of Models for Preoperative Prediction of Risk and Postoperative Detection of Non-Infectious Complications Using Interpretable Machine Learning and Electronic Health Record Data.","authors":"Adam Dyas, Christina M Stuart, Yizhou Fei, Robert A Meguid, Yaxu Zhuang, William G Henderson, Michael R Bronsert, Kathryn L Colborn","doi":"10.1097/SLA.0000000000006709","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006709","url":null,"abstract":"<p><strong>Objective: </strong>To apply interpretable machine learning methodology to electronic health record (EHR) data to develop models for preoperative risk estimation and postoperative detection of non-infectious postoperative complications.</p><p><strong>Summary background data: </strong>We previously developed preoperative risk and postoperative detection models for surveillance of postoperative infections. The purpose of the present study was to develop and validate similar models for the non-infectious complications of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).</p><p><strong>Methods: </strong>Preoperative and postoperative EHR data from five hospitals across one healthcare system (University of Colorado Health), 2013-2019, including diagnoses, procedures, operative variables, patient characteristics, and medications were obtained. Lasso and the knockoff filter were used to perform controlled variable selection to develop preoperative risk models and postoperative detection models of 30-day non-infectious outcomes of mortality, overall morbidity, bleeding, cardiac, pulmonary, renal, and venous thromboembolism morbidity, non-home discharge, and unplanned readmission.</p><p><strong>Results: </strong>Among 30,639 patients included, postoperative complication rates for each outcome ranged from 0.1% (stroke) to 10.4% (overall morbidity). Area under the receiver operating characteristic curve for preoperative risk models ranged from 0.68-0.91 and from 0.92-0.97 for postoperative detection models. Between 6-22 predictor variables were included in each model.</p><p><strong>Conclusions: </strong>We developed parsimonious models for estimating risk of and detection of postoperative non-infectious complications. Our models showed good to excellent performance suggesting that these models could be used to augment manual surveillance.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143707916","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":"Language Serving Hospitals and their Impact on Readmission for Surgical Patients with a Non-English Primary Language: A Retrospective Cohort Study.","authors":"Brittany M Dacier, Alyssa N Jones, Benjamin G Allar, Jesus Mejia, Bryan S Torres, Rachel E Murphy, Nayeli Magana, Regan W Bergmark, Andrea L Pusic, Alicia Fernandez, David W Bates, Gregory L Peck, Gezzer Ortega","doi":"10.1097/SLA.0000000000006707","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006707","url":null,"abstract":"<p><strong>Objective: </strong>To assess postoperative readmission for patients with non-English primary language (NEPL) at Language Serving Hospitals (LSH) versus non-LSH.</p><p><strong>Summary background data: </strong>Patients with NEPL have worse surgical outcomes compared to patients with an English primary language. Hospital-level language access resources vary, potentially leading to disparate health outcomes.</p><p><strong>Methods: </strong>We performed a retrospective cohort study from 2010-2022 using the New Jersey AHRQ-HCUP State Inpatient Database. Patients with a primary language variable seen at a hospital that met LSH or non-LSH criteria were identified. Patients with NEPL and who underwent appendectomy, breast surgery, cholecystectomy, colectomy, or lower extremity arterial revascularization and were discharged to home were included. LSH are hospitals where the proportion of patients with NEPL served meets or exceeds the proportion of NJ's population with LEP (12.3%). The primary outcome was 7-day readmission. Multivariable logistic regression was performed, adjusting for patient-level confounders.</p><p><strong>Results: </strong>We included 28,157 patients with NEPL and identified 17 LSH and 43 non-LSH. The proportion of patients readmitted (2.6% vs. 5.7%, P<0.001) was lower at LSH compared to non-LSH. Patients discharged from LSH had a 56% lower likelihood of readmission compared to those at non-LSH (aOR 0.44, 95% CI 0.39-0.50).</p><p><strong>Conclusions: </strong>Surgical patients with NEPL at LSH were less likely to be readmitted than those at non-LSH. Given that LSH care for more patients with NEPL, they may be better equipped to serve a linguistically diverse population. Elucidating the reasons for readmission rate differences between LSH and non-LSH could inform surgical care for patients with NEPL at all hospitals.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143707868","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":"Personalized Surveillance Intervals for Intraductal Papillary Mucinous Neoplasm (IPMN): Multicenter Study Using Parametric Models.","authors":"Claudio Ricci, Stefano Crippa, Johnathan Hee, Hyesol Jung, Gabriele Capurso, Marco Ferronato, José Lariño Noia, Myrte Gorris, Paula Ghaneh, Ihsan Ekin Demir, Nuzhat Ahmad, Max Heckler, Giulio Belfiori, Francesca Aleotti, Youngmin Han, Wooil Kwon, Gaetano Lauri, Matteo Tacelli, Olivier Busch, Kulbir Mann, Marina Migliori, Paolo Giorgio Arcidiacono, Helmut Friess, Charles M Vollmer, Thilo Hackert, Marc Besselink, Riccardo Casadei, Jin-Young Jang, Brian Kim-Poh Goh, Massimo Falconi, Giovanni Marchegiani","doi":"10.1097/SLA.0000000000006702","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006702","url":null,"abstract":"<p><strong>Objective: </strong>The aim was to build a calculator for personalized surveillance of BD-IPMNs.</p><p><strong>Summary background data: </strong>The interval time for surveillance of low-risk branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) has not been established yet.</p><p><strong>Methods: </strong>The study included an international cohort of BD-IPMNs without worrisome features (WFs) or high-risk stigmata (HRS). IPMN evolution was defined as the occurrence of HRS or WFs. The derivation cohort comprised 60% of patients. The validation group comprised the remaining patients. A parametric survival model was developed in the derivation cohort using Akaike (AIC) and Bayesian (BIC) information criteria and c-index. A \"k-fold\" validation was used to measure the covariate effect on the accelerated failure time. Two models (\"standard\" and \"conservative\") were built and validated using the second cohort.</p><p><strong>Results: </strong>The derivation and validation cohorts included 1,992 and 1,119 BD-IPMNs. The lognormal distribution best fitted the derivation cohort (AIC=2673; BIC=2718). The pooled c-index was 0.689 (0.668 to 0.718, 95%CI). The factors reducing the time needed for IPMN evolution were age [- 2% (-1% to -3%) for each year] and cyst size [-2% (0% to -3%); for each mm]. The \"conservative\" model, called PANORAMA, was the only one that correctly classified the validation cohort (c-index 0.712 vs. 0.696; P=0.072).</p><p><strong>Conclusion and relevance: </strong>The development of WF and HRS is influenced by the patient's age and cyst size. After a prudential first control at six months, repeating a semestral/annual follow-up in this time frame could be too tight.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143668859","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":"Contemporary Outcomes of Pancreatic Head Resection for Chronic Pancreatitis.","authors":"Kyle A Lewellen, Thomas K Maatman, Andrew J Thyen, Meghan E Lark, James R Butler, Eugene P Ceppa, Michael G House, Attila Nakeeb, Alexandra M Roch, C Max Schmidt, Nicholas J Zyromski","doi":"10.1097/SLA.0000000000006700","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006700","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate perioperative morbidity and mortality outcomes in a large, contemporary series of patients undergoing pancreas head resection for chronic pancreatitis.</p><p><strong>Summary background data: </strong>Select chronic pancreatitis (CP) patients benefit from pancreatic head resection, but contemporary data are sparse. Anatomy dictates selection of duodenum-preserving pancreatic head resection (DPPHR) or pancreatoduodenectomy (PD). We hypothesized that both DPPHR and PD are safe in select patients.</p><p><strong>Methods: </strong>CP patients undergoing pancreas head resection from 2007-2023 at a high-volume institution were analyzed. Patient comorbidities, operative data, and postoperative 30-day outcomes were defined according to National Surgical Quality Improvement Program (NSQIP) and International Study Group on Pancreatic Surgery (ISGPS). Preoperative and intraoperative variables between groups were compared. Continuous data are presented as median [interquartile range].</p><p><strong>Results: </strong>Among 338 patients (50% female), 252 underwent PD and 86 DPPHR (69 Frey, 11 Beger, 4 Izbicki, 2 Bern). Median age was 52[17] years (PD 53.1[17], DPPHR 50.1[20], P=0.036). Preoperative tobacco use (57%) and diabetes (27%) were common. The PD group had longer operative times (282[131] vs. 207.5[91] minutes, P<0.001) and higher intraoperative blood loss (307.5[400] vs. 100[200] milliliters, P<0.001). Median length of stay was 8[6] days (PD 8[6.3], DPPHR 7[4]). Major morbidity occurred in 22% of patients (PD 23%, DPPHR 21%). At 30 days, the readmission rate was 17% (PD 17%, DPPHR 17%) and mortality occurred in 1.2% (PD 1.6%, DPPHR 0%).</p><p><strong>Conclusions: </strong>This large, contemporary analysis demonstrated safety of pancreatic head resection in select CP patients.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143668856","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":"Rural Surgery Needs a Strategy, Not Just Another Training Track or Rotation.","authors":"Cody Lendon Mullens, Tyler G Hughes","doi":"10.1097/SLA.0000000000006701","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006701","url":null,"abstract":"","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143668863","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 Gold Standard? Impact of Broad-spectrum Penicillin-based Antibiotic Prophylaxis on Outcome After Pancreatoduodenectomy - Results of a Systematic Review and Meta-analysis (PROSPERO CRD42024559197).","authors":"Julian C Harnoss, Darius Halm, Sophie Weber, Benedict Kinny-Köster, Max Heckler, Rosa Klotz, Eva Kalkum, Jonathan M Harnoss, Julian Musa, Pascal Probst, Christoph W Michalski, Martin Loos, Thomas Hank","doi":"10.1097/SLA.0000000000006703","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006703","url":null,"abstract":"<p><strong>Objective: </strong>This review evaluated whether broad-spectrum penicillin-based antibiotic prophylaxis (BS-AB) such as piperacillin-tazobactam might lead to better outcomes in pancreatoduodenectomy compared to standard care antibiotics, mainly cephalosporins (CE-AB).</p><p><strong>Background: </strong>Pancreatoduodenectomy is commonly associated with high postoperative infectious complications contributing to increased morbidity, mortality and healthcare costs.</p><p><strong>Methods: </strong>A systemic literature search (PubMed, EMBASE, Cochrane Library and Web of Science) was conducted to identify suitable RCTs and non-RCTs. After inclusion, the data were analyzed using a random-effects model with the Mantel-Haenszel model or inverse variance to calculate, odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI).</p><p><strong>Results: </strong>One RCT and 11 non-RCTs were included with 12,469 patients (35,3% BS-AB, 64,7% CE-AB). Surgical site infections (SSI) were significantly lower after BS-AB when compared to CE-AB, (OR 0.53; CI [0.32-0.86]; P =0.01; I 2 =79%) as well as the occurrence of postoperative pancreatic fistula (POPF) (OR 0.62; CI [0.47-0.81]; P <0.01; I 2 =0%), days of hospitalization (MD-2.02; CI [-4.08-0.03]; P =0.05; I 2 =98%) and mortality (OR 0.56; CI [0.34-0.95]; P =0.03; I 2 =0%). Subgroup analyses of patients with preoperative biliary drainage demonstrated an even higher effect of BS-AB in reducing SSI (OR 0.45, CI [0.45-0.67]; P =0.01; I 2 =78%), POPF (OR 0.52; CI [0.36-0.75]; P <0.01; I 2 =0%) and mortality (OR 0.34; CI [0.15-0.76]; P <0.01; I 2 =0%).</p><p><strong>Conclusion: </strong>BS-AB significantly reduces the risk of infectious complications and surgical outcomes in pancreatoduodenectomy compared to CE-AB, particularly in patients with preoperative biliary drainage. These findings support the use of BS-AB as a new gold standard for patients undergoing pancreatoduodenectomy.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143668787","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":"Circulating Tumor DNA Assessment to Predict Risk of Recurrence after Surgery in Patients with Locally Advanced Esophageal Squamous Cell Carcinoma: A Prospective Observational Study.","authors":"Shogo Takei, Daisuke Kotani, George Laliotis, Kazuma Sato, Naoto Fujiwara, Akihito Kawazoe, Tadayoshi Hashimoto, Saori Mishima, Izuma Nakayama, Yoshiaki Nakamura, Hideaki Bando, Yasutoshi Kuboki, Shingo Sakashita, Erik Spickard, Giby V George, Punashi Dutta, Shruti Sharma, Meenakshi Malhotra, Himanshu Sethi, Adham Jurdi, Minetta C Liu, Takayuki Yoshino, Kohei Shitara, Takashi Kojima, Takeo Fujita","doi":"10.1097/SLA.0000000000006699","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006699","url":null,"abstract":"<p><strong>Objective: </strong>To investigate the association between perioperative ctDNA status and prognosis in patients with esophageal squamous cell carcinoma (ESCC).</p><p><strong>Background: </strong>Circulating tumor DNA (ctDNA) has emerged as a promising biomarker for assessing molecular residual disease (MRD) in various malignancies. However, there are limited studies evaluating the utility of ctDNA for predicting recurrence risk in patients with ESCC.</p><p><strong>Methods: </strong>We prospectively enrolled patients with locally advanced ESCC who were scheduled to receive neoadjuvant chemotherapy (NAC) followed by surgery. This report retrospectively analyzed ctDNA with a personalized, tumor-informed 16-plex mPCR-NGS assay at multiple time points: pre-NAC, post-NAC but before surgery, postoperatively, and longitudinally during follow-up.</p><p><strong>Results: </strong>A total of 28 patients who underwent curative surgery, and had successful whole-exome sequencing analysis of tumor tissue samples were included in this report. At the pre-NAC time point, ctDNA was detected in 50% of patients with stage I and 100% of those with stages II, III, and IV. Post-NAC but before surgery, ctDNA was detected in 33.3% of patients. The recurrence rate was 77.8% in ctDNA-positive patients compared to 27.8% in ctDNA-negative patients, with significantly worse recurrence-free survival (RFS) for ctDNA-positive patients vs. ctDNA-negative patients (HR: 4.56, P =0.01). In patients analyzed during the MRD window (2-16 weeks post-surgery), the recurrence rate was 100% in ctDNA-positive patients compared to 30.4% in ctDNA-negative patients, with significantly worse RFS (HR: 30.99, P <0.0001). Similarly, during surveillance (>16 weeks post-surgery), detectable ctDNA was significantly associated with poor RFS (HR: 27.34, P =0.003).</p><p><strong>Conclusion: </strong>This study suggests that ctDNA-based MRD assessment may be valuable for evaluating patients with ESCC, particularly in post-NAC and postsurgical settings.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143668789","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":"BA-ECM Score: Automated Quantification of Liver Fibrosis Architecture in Biliary Atresia with Potential for Prognostic Value - A Pilot Study.","authors":"Norah E Liang, Jason L Guo, Michelle F Griffin, Khristian Erich Bauer-Rowe, Amrita Narang, Michael Januszyk, Gillian L Fell, James C Y Dunn, Stephanie D Chao, Serena Y Tan, Michael T Longaker, Jeong S Hyun","doi":"10.1097/SLA.0000000000006698","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006698","url":null,"abstract":"<p><strong>Objective: </strong>To quantify liver fibrosis in infants with biliary atresia (BA) through automated analysis of collagen extracellular matrix (ECM) ultrastructure in index liver biopsies and use a composite fibrosis architecture score to predict native liver survival.</p><p><strong>Summary background data: </strong>Despite early management with Kasai portoenterostomy , BA remains the leading indication for pediatric liver transplantation. There is no established method for quantitatively assessing liver fibrosis in patients with BA, and no factors to accurately predict which patients will ultimately require transplantation early versus late.</p><p><strong>Methods: </strong>Index liver biopsies from 12 BA patients were retrieved from our pathology archives Masson's Trichrome-stained biopsies were scanned, tiled, binarized, and quantified for 147 ECM features. These features were reduced by Uniform Manifold Approximation and Projection. Pseudotime analysis was applied to summarize global variations in architecture and assign BA-ECM scores to all biopsy images. Retrospective chart review was performed to correlate clinical characteristics with BA-ECM score.</p><p><strong>Results: </strong>BA-ECM score, a multi-dimensional fibrosis architecture score, was significantly higher for biopsies from listed patients compared to non-listed patients (35.9 vs. 22.9, *P<0.0001). High BA-ECM score was characterized by thick, patchy, irregular ECM, while low BA-ECM score was associated with large-volume thin, porous collagen fibers. Survival analysis stratified by the third quartile BA-ECM score of all data points demonstrated a significant difference in native liver survival (*P=0.02).</p><p><strong>Conclusions: </strong>We present the application of an automated ECM ultrastructure analysis tool designed to capture and quantify 147 aspects of fibrotic tissue heterogeneity. These manifold features are summarized using a multi-dimensional BA-ECM score that could be used to prognosticate disease course for BA patients.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143662131","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":"Targeted Muscle Reinnervation at the Time of Major Limb Amputation Reduces Long-Term Use and Dependence for Opioid Analgesic Therapy: A Multicenter Propensity-Matched Study.","authors":"Jackson M Cathey, Kevin M Klifto, Justin L Anderson, Sean Y Li, Eliana B Saltzman, Neill Y Li","doi":"10.1097/SLA.0000000000006697","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006697","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the impact of primary targeted muscle reinnervation (TMR) performed at the time of major limb amputation on long-term opioid use, opioid dependence, and neuropathic pain medication use compared to standard amputation.</p><p><strong>Summary background data: </strong>Postoperative pain following major limb amputation is common, often leading to prolonged opioid use, dependence, and neuropathic pain. TMR, a surgical technique that redirects amputated nerves into motor targets, has been proposed as a method to reduce pain-related complications, but prior studies are limited by small sample sizes, single-center experiences, and insufficient follow-up data. This study utilizes a multicenter database to assess long-term outcomes of TMR compared to standard amputation.</p><p><strong>Methods: </strong>A multicenter query was conducted using the TriNetX Research Network to identify patients undergoing major limb amputation with or without TMR over 20 years. Propensity score matching was used to create comparable cohorts for analysis. Primary outcomes included opioid use, opioid dependence, neuropathic pain medication use, and stump-related complications, evaluated from 90 days to 3 years postoperatively.</p><p><strong>Results: </strong>Among 43,890 patients, those undergoing primary TMR (n=644) had significantly lower risks of opioid use (RR=0.72; 95%CI [0.60, 0.86], P<0.001) and opioid dependence (RR=0.50; 95%CI [0.27, 0.92], P=0.023) compared to matched controls undergoing standard amputation (n=644). In the ischemia subgroup, TMR patients had a 41% lower risk of opioid use (RR=0.59; 95%CI [0.42, 0.83], P=0.002). No differences in neuropathic pain medication use or stump-related complications were observed between cohorts. Time-course analysis demonstrated persistent reductions in opioid use among TMR patients at all intervals from 3 months to 3 years.</p><p><strong>Conclusions: </strong>Primary TMR at the time of major limb amputation significantly reduces long-term opioid use and dependence, particularly in patients with limb-threatening ischemia, without increasing the risk of stump-related complications. These findings support the broader adoption of TMR to improve postoperative outcomes in amputees.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143655905","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":"Impact of Rural Exposure during General Surgery Residency on Practice in a Rural Community.","authors":"Nina M Clark, Paul McClure, Aaron Erickson, C Holly A Andrilla, Gordon Riha, Ashley Dennis, Barclay T Stewart, Dana C Lynge, Davis G Patterson","doi":"10.1097/SLA.0000000000006696","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006696","url":null,"abstract":"<p><strong>Objective: </strong>We sought to evaluate associations between rural training exposure during surgical residency and eventual practice in a rural community, and whether specific types of exposure were more likely to yield rural surgeons.</p><p><strong>Background: </strong>Growing deficits in the rural surgery workforce have prompted increased attention toward rural training. However, the association between exposure to rural surgery during residency and practice in rural communities remains limited.</p><p><strong>Methods: </strong>We performed a retrospective cohort study of US general surgery residency graduates from 2011-2020. Program information was abstracted from residency websites, the American College of Surgeons (ACS), and the American Medical Association. A survey distributed to programs and direct review of residency websites were used to characterize the type of rural surgery exposure offered to trainees. We evaluated associations between exposure to rural surgery in training and ultimate practice in a rural location.</p><p><strong>Results: </strong>Of 11,407 surgeons, 6.2% reported working in rural communities. Graduates of programs with rural training according to residency websites or the ACS were more likely to work in rural areas (OR 1.81 [95%CI 1.32-2.49] and 2.09 [1.28-3.40]). Rurally located programs, rural rotations, and programs with a rural mission were associated with greater odds of graduates working in rural areas (P<0.05 for all). Rural tracks were not associated with more rural graduates.</p><p><strong>Conclusions: </strong>Among graduates of general surgery residency programs, rural exposures during training were associated with eventual practice in rural communities. Programs with rural missions, in rural locations, or offering rural rotations produced graduates who were more likely to work in rural areas, while rural track programs did not, highlighting the need for further study of individual rural exposure to establish effective training paradigms. Specific policies facilitating rural exposure and surgical programs in rural communities may be effective methods for addressing workforce deficits.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143655804","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}