Society Of Surgeons Research Articles

Beating-Heart Coronary Artery Bypass grafting (BH-CABG) in patients with End-Stage Renal Disease (ESRD): comparison of the Society of Thoracic Surgeons (STS) predicted risk with actual outcomes

BackgroundEnd-Stage Renal Disease (ESRD) is an independent risk factor in outcomes for traditional coronary artery bypass grafting (TRAD-CAB) utilizing aortic cross-clamping and cardioplegic arrest. In order to determine if Beating-Heart CABG (BH-CABG) techniques offer benefit in patients with ESRD, an analysis of the Society of Thoracic Surgeons (STS) predicted risk versus the actual outcomes was performed.MethodsBetween March 2017 - October 2023, all ESRD patients underwent BH-CABG by a single surgeon at a single institution. Patients were kept normothermic, ventilation was maintained, and intra-coronary shunts with flow-probe graft assessment were utilized during the procedure. The STS predicted risk calculator was used to compare outcomes with actual results.ResultsThere were 55 patients– 37 men and 18 women with a mean age of 61.5 years (41–77 years). Co-medical conditions consisted of the following: HTN (100%), DM (85%), Pulmonary HTN (49%), PVD (45%), CVD with CVA (18%), and COPD (9%). Fifty-one patients underwent Pump-Assisted Direct Coronary Artery Bypass Grafting (PADCAB) and four underwent Off-Pump CABG (OP-CAB). There were 16 Elective, 35 Urgent, and 4 Emergent cases. Case presentation included: 24 NSTEMI, 4 STEMI, 6 Unstable Angina, 7 CHF, 1 Cardiac Arrest, and 13 with a positive exercise stress test (EST) for renal transplant screening. The mean EF was 47% (range: 15–75%). The mean number of grafts was 2.4 (1–4) and CPB time was 78 min (34–128 min) for the PAD-CAB group. Nine of the thirteen patients (69%) listed for kidney transplant underwent the transplant, one of whom was a combined liver-kidney. There was 1 hospital mortality (1.8%) compared to a predicted 6.2%. There was 1 stroke (1.8%) compared to a predicted 3.3%. There was 1 prolonged ventilation (1.8%) compared to a predicted 20.2%. There were no return to OR and no sternal wound infections. Prolonged Lengths of Stay occurred in 3 patients (5.5%) compared to a predicted 16.9%. One-year mortality occurred in 8 patients (14.5%). The observed-to-expected outcomes was < 1 in all categories.ConclusionsThe BH-CABG appears to demonstrate superior outcomes compared to the STS predicted risk for CABG. The Beating-Heart technique may offer advantages by avoidance of aortic cross-clamping and cardioplegia, maintenance of normothermia and ventilation, as well as preservation of coronary blood flow during construction of bypass grafting.

Redo Aortic Valve Replacement After Prior Transcatheter versus Surgical Aortic Valve Replacement: Insights from Western Experience

Introduction: The demand for reoperation on the aortic valve in Albania is rising, mirroring the increasing average age of the population and the subsequent rise in patients requiring aortic valve surgery. This trend underscores the need for this informative article, which aims to provide insights into the risks and outcomes of aortic valve reoperations, particularly in light of efforts by interventional cardiologists to expand the indications for TAVR to younger and lower-risk patients. Data from the Society of Thoracic Surgeons (STS) National Database reveal results that warrant attention, with concerns over reoperations after TAVR growing, mainly due to the uncertain feasibility of repeat TAVR. This article presents a novel perspective on the risks associated with surgical aortic valve replacement (SAVR) after prior TAVR or SAVR. It underscores the urgent need to develop an optimal strategy for managing these patients and offers fresh insight. Material and Methods: Our research, based on a comprehensive analysis of data from the Society of Thoracic Surgeons in the USA's 10-year database, included individuals who underwent bioprosthetic SAVR following prior TAVR and/or SAVR. Our analyses, which included total and isolated SAVR groups, focused on the primary outcome of operative mortality, ensuring the reliability and thoroughness of our study. Results: The study included 31,106 patients who underwent SAVR. Among them, 1,126 had prior TAVR (TAVR-SAVR), 674 had undergone SAVR followed by TAVR and SAVR (SAVR-TAVR-SAVR), and 29,306 had undergone prior SAVR (SAVR-SAVR). Matched analysis for isolated SAVR cases showed a 1.74-fold higher operative mortality for TAVR-SAVR than SAVR-SAVR (P = 0.020). In our center, 5 cases have been performed in the last two years with excellent results, no losses, and operating times close to the first-time interventions. Conclusions: This study's findings significantly contribute to the field. They could influence clinical practice, particularly for patients with longer life expectancies and anatomy unsuitable for TAVR. They suggest an initial SAVR approach may provide better results even in necessary surgical re-interventions on the aortic valve.

Cost‐effectiveness analysis of postoperative surveillance for stage IV colorectal cancer in Japan: An economic modeling study

AbstractBackgroundThe optimal postoperative surveillance strategy after curative resection in patients with stage IV colorectal cancer remains unclear. The present study aimed to assess the cost‐effectiveness of postoperative surveillance strategies recommended by the various academic societies for stage IV colorectal cancer after curative resection.MethodsThis economic evaluation used a Markov state‐transition model to compare the cost‐effectiveness of postoperative surveillance programs proposed in guidelines published by the American Society of Clinical Oncology, American Society of Colon and Rectal Surgeons, European Society for Medical Oncology, National Comprehensive Cancer Network, and Japanese Society for Cancer of the Colon and Rectum. Model parameters were extracted from our retrospective data for patients with colorectal cancer who had synchronous liver and/or lung metastases and underwent curative resection. Cost‐effectiveness was assessed using an incremental cost‐effectiveness ratio for quality‐adjusted life years, with a maximum acceptable value of 5 000 000–6 000 000 JPY/33333–40 000 USD. Uncertainty in the model was assessed by probabilistic sensitivity analyses.ResultsFor patients with stage IV colorectal cancer after curative resection, the JSCCR‐strategy was the most cost‐effective, with an incremental cost‐effectiveness ratio of 2 888 628 JPY/19256 USD compared with the next most cost‐effective program. Probabilistic sensitivity analysis showed that the JSCCR‐strategy was most likely to be selected as the most cost‐effective (76.1%–77.9%).ConclusionsThis modeling analysis found that the JSCCR‐strategy was the most cost‐effective strategy for stage IV colorectal cancer. Our findings suggest that intensive postoperative surveillance is acceptable for stage IV colorectal cancer.

The Society of Thoracic Surgeons (STS) Clinical Practice Guideline on Surgical Management of Oligometastatic Non-small Cell Lung Cancer.

The use of local consolidative therapy (LCT) in patients with oligometastatic non-small cell lung cancer (NSCLC) is rapidly evolving, with a preponderance of data supporting the benefits of such therapeutic approaches incorporating pulmonary resection for appropriately selected candidates. However, practices vary widely institutionally and regionally, and evidence-based guidelines are lacking. The Society of Thoracic Surgeons assembled a panel of thoracic surgical oncologists to evaluate and synthesize the available evidence regarding the role of pulmonary resection as LCT. Clinical and research questions of interest were identified, and a complete literature review was conducted. Best practice guidelines were developed accordingly. The panel identified 7 areas of controversy, and data were assimilated to support the best recommended practices related to these clinical issues. Ultimately, a number of issues in this realm were found to have a high level of evidence to support the role for surgical therapy in patients with stage IV lung cancer. However, the nuances of how these operations are conducted remain in equipoise, without ample evidence to support the extent of resection or nodal dissection. Clear data exist to support the use of surgical resection of the primary lung tumor as LCT in stage IV lung cancer. Evidence-based recommendations have been provided to guide multidisciplinary teams on the implementation of treatment plans as well as to guide researchers on areas of ongoing need for further investigation.

Predicting mortality after transcatheter aortic valve replacement using AI-based fully automated left atrioventricular coupling index.

This study aimed to determine whether artificial intelligence (AI)-based automated assessment of left atrioventricular coupling index (LACI) can provide incremental value above other traditional risk factors for predicting mortality among patients with severe aortic stenosis (AS) undergoing coronary CT angiography (CCTA) before transcatheter aortic valve replacement (TAVR). This retrospective study evaluated patients with severe AS who underwent CCTA examination before TAVR between September 2014 and December 2020. An AI-prototype software fully automatically calculated left atrial and left ventricular end-diastolic volumes and LACI was defined by the ratio between them. Uni- and multivariate Cox proportional hazard methods were used to identify the predictors of mortality in models adjusting for relevant significant parameters and Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score. A total of 656 patients (77 years [IQR, 71-84 years]; 387 [59.0​%] male) were included in the final cohort. The all-cause mortality rate was 21.6​% over a median follow-up time of 24 (10-40) months. When adjusting for clinical confounders, LACI ≥43.7​% independently predicted mortality (adjusted HR, 1.52, [95​% CI: 1.03, 2.22]; p​=​0.032). After adjusting for the STS-PROM score in a separate model, LACI ≥43.7​% remained an independent prognostic parameter (adjusted HR, 1.47, [95​% CI: 1.03-2.08]; p​=​0.031). In a sub-analysis of patients with preserved left ventricular ejection fraction, LACI remained a significant predictor (adjusted HR, 1.72 [95​% CI: 1.02, 2.89]; p​=​0.042). AI-based fully automated assessment of LACI can be used independently to predict mortality in patients undergoing TAVR, including those with preserved LVEF.

How Accurate Are Surgeons at Assessing the Quality of Their Critical View of Safety During Laparoscopic Cholecystectomy?

IntroductionObtaining the critical view of safety (CVS) is considered an important step to reduce bile duct injuries during laparoscopic cholecystectomy (LC). However, existing literature suggests that few surgeons obtain adequate CVS when LC videos are directly evaluated by experts. This discrepancy calls for effective, standardized CVS teaching methods. While self-assessment (SA) remains the principal tool utilized by practicing surgeons for performance improvement, its effectiveness is controversial. The aim of this study was to compare surgeon SAs of repeated LC performance and attainment of the CVS with that of expert raters. MethodsMulti-institutional study of surgeon members from the Society of American Gastrointestinal and Endoscopic Surgeons who volunteered to participate. All surgeons were asked to submit an LC video and complete a SA of the CVS quality using the Strasberg scale (0-6 score with ≥5 score indicating appropriate CVS). The same videos were reviewed by two blinded expert raters, members of the Society of American Gastrointestinal and Endoscopic Surgeons safe cholecystectomy task force, who had received prior rater training. Surgeon self-ratings and expert ratings were compared with a Wilcoxon signed-rank test. ResultsTwenty-five surgeon-participants were recruited, 13 of whom submitted an LC video. Surgeons did not achieve adequate CVS in their first submitted video based on expert ratings. Surgeons in the SA group overestimated their performance across all four scales: Operative Performance Rating System (z = −0.36, P = 0.715), Global Operative Assessment of Laparoscopic Skills (z = −0.37, P = 0.712), Strasberg (z = −1.84, P = 0.066), and Competency Assessment Tool (z = −0.73, P = 0.465). Surgeons in the coaching group overestimated their performance on each scale as well: Operative Performance Rating System (z = −0.67, P = 0.500), Global Operative Assessment of Laparoscopic Skills (z = −1.48, P = 0.138), Strasberg (z = −1.07, P = 0.285), and Competency Assessment Tool (z = −1.21, P = 0.225). ConclusionsOur study confirms that an adequate CVS is infrequently obtained during LC in a small but national sample of general surgeons. It further adds to the existing body of literature that suggests that SA alone may be inadequate for performance improvement. Effective teaching methods such as expert or artificial intelligence coaching are needed to improve the use of appropriate CVS by surgeons that may help decrease bile duct injury risk.

Hemodynamic Valve Deterioration After Transcatheter Aortic Valve Replacement: Incidence, Predictors, and Clinical Outcomes.

Reports on the durability of transcatheter aortic valve replacement (TAVR) prostheses are scarce and confounded by varying definitions and competing risks of death. The authors sought to determine the incidence, predictors, and clinical outcomes of hemodynamic valve deterioration (HVD) according to the Valve Academic Research Consortium 3 definition after TAVR. We analyzed consecutive patients undergoing TAVR in the prospective Bern TAVI (Transcatheter Aortic Valve Implantation) registry between August 2007 and June 2022 for the incidence and predictors of HVD and performed case control-matching to compare outcomes according to HVD. A total of 2,403 eligible patients (mean age 81.8 ± 6.2 years, median Society of Thoracic Surgeons Predicted Risk of Mortality score 3.8% [Q1-Q3: 2.4%-6.0%]) were included and had a median duration of follow-up of 376days (Q1-Q3: 365-1,825days). The cumulative incidence of moderate or severe HVD was 2.2% (95%CI: 1.6%-3.1%), 10.8% (95%CI: 9.2%-12.7%), and 25.6% (95%CI: 17.5%-36.5%) at 1, 5, and 10 years, respectively. Aortic valve complex calcium volume (HR: 1.81; 95%CI: 1.11-2.97; P=0.018), residual aortic regurgitation at discharge (HR: 1.87; 95%CI: 1.34-2.60; P<0.001), and treatment with oral anticoagulants (HR: 1.78; 95%CI: 1.00-3.15; P=0.048) were independent predictors of HVD. In the case control-matched cohort (HVD, n=155, no-HVD, n=600), patients with HVD had similar yearly rates of all-cause and cardiovascular mortality, and infective endocarditis, but higher rates of repeat aortic valve intervention (rate ratio [RR]: 4.81 [95%CI: 1.74-13.26]; P=0.001). HVD occurred in up to 1 in 4 patients throughout 10-year post-TAVR and was associated with a 5-fold increase in the risk of aortic valve reintervention.

Surgical Bailout in Patients UndergoingTransfemoral TranscatheterAortic Valve Replacement: Incidence, Trends, and Clinical Outcomes.

Transcatheter aortic valve replacement (TAVR) harbors the risk of periprocedural complications that require emergent cardiac surgery, or "surgical bailout." Surgical bailout intends to be lifesaving but is associated with high mortality. This has given rise to discussion on the necessity of surgical backup during TAVR. Therefore, recent studies in contemporary TAVR patients are warranted. This study aimed to assess the incidence, trends, and clinical outcomes of surgical bailout in patients undergoing transfemoral TAVR. The CENTER2 (Cerebrovascular Events in Patients Undergoing Transcatheter Aortic Valve Implantation With Balloon-Expandable Valves Versus Self-Expandable Valves 2) study contains patient-level data from 10 clinical studies with patients undergoing TAVR between 2007 and2022. A total of 24,010 patients undergoing transfemoral TAVR were included. The mean age was 81.5 ± 6.7 years, and 56% were female. The median Society of Thoracic Surgeons Predicted Risk of Mortality declined over time (2007-2014: 7.1% [Q1-Q3: 4.3%-14.8%] vs 2015-2022: 3.9% [Q1-Q3: 2.6%-6.0%]; P< 0.001). Surgical bailout was reported in 125 (0.52%) patients, and its incidence decreased over time, from 0.84% in 2007 to 2010 to 0.25% in 2019 to 2022 (Ptrend< 0.001). Surgical bailout was more frequently observed in women compared with men (0.61% vs 0.41%; P=0.03). Ventricular perforation was the most prevalent reason for surgical bailout (28.0%). Patients who underwent surgical bailout reported higher mortality rates during the 1-year follow-up compared with patients without surgical bailout (68.3% vs 15.3%; HR: 8.60; 95%CI: 6.74-10.97; P< 0.001). Interestingly, patients surviving the first 90days reported a similar mortality risk (HR: 2.19; 95%CI: 0.91-5.27; P=0.08). The incidence of surgical bailout is very low in the contemporary TAVR population. Mortality rates remain high among patients requiring surgical bailout during transfemoral TAVR, but this risk diminishes in patients surviving the postprocedural period. (Cerebrovascular Events in Patients Undergoing Transcatheter Aortic Valve Implantation With Balloon-Expandable Valves Versus Self-Expandable Valves 2 [CENTER2]; NCT03588247).

Theoretical Impact of Optilume Drug-Coated Balloon on Urethroplasty Education Among Society of Genitourinary Reconstructive Surgeons Fellows and United States Urology Residents.

Theoretical Impact of Optilume Drug-Coated Balloon on Urethroplasty Education Among Society of Genitourinary Reconstructive Surgeons Fellows and United States Urology Residents.

Advancing laparoscopic skills training in Namibia: Implementation of the Global Laparoscopic Advancement Program (GLAP)of the Society of American Gastrointestinal and EndoscopicSurgeons (SAGES).

In low- and middle-income countries (LMICs), laparoscopic surgery is challenging to implement due to limited resources and lack of expert surgeons as teachers. The Global Laparoscopic Advancement Program (GLAP) was developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to deliver sustainable and effective methods for teaching safe laparoscopic surgery. GLAP aims to train surgical leaders and trainees with the goal of eventual in-country replication of GLAP programming. After successful implementation in Mexico and Costa Rica, this study evaluates the feasibility of a pilot training course in Namibia, Southern Africa. In December 2022 and September 2023, GLAP partnered with the Namibian Surgical Society and the College of Surgeons of East,Central,and Southern Africa (COSECSA) to administer 2 GLAP courses, with hands-on simulation practice and lectures on surgical education, training, and curriculum development. Participants completed surveys assessing their surgical background and experiences, their experience with simulation, and interest in curriculum development at their home institutions. Participants were also evaluated on their time to completion for the five FLS tasks during the initial and final days of the program. Over two GLAP courses, there were a total of 31 practicing general, gynecologic, and urologic surgeons from Namibia, Ethiopia, Malawi, Somali, and Zambia, taught by 5-7 GLAP faculty members. Overall, 35.5% had formal laparoscopic training during residency or fellowship, 16.13% had no experience with laparoscopy, and 77.42% learned laparoscopy through observation. Fifty-three percent of respondents had never practiced laparoscopy on a simulator before and 45% of respondents noted they did not have mentors to help them learn laparoscopic skills. Eighty percent of participants noted lack of equipment as the most important factor limiting the use of laparoscopy, followed by 76% noting lack of trained surgeons and 73% noting lack of formal training. The majority of respondents noted a very strong desire for formal training (61%), including additional short-term courses in laparoscopy (58%) and FLS skills testing opportunities (63%) in the future. For skills acquisition, there was a statistically significant reduction in the time to complete the circle cut task at the end of the course (359.2s vs 206s, p-value 0.016) across both years. There is limited adoption of laparoscopy in Namibia, hindered by lack of training, expert trainers, and equipment. Implementation of GLAP is feasible and offers an additional training opportunity to the region.

Expert consensus on endovascular reconstruction of visceral branch arteries in the treatment of aortic expansion diseases (2024 edition)

Aortic expansion diseases, especially those involving visceral branch arteries, pose significant challenges for clinicians in terms of treatment strategy selection and implementation. With the advancement of endovascular repair techniques, the mode of treatment is shifting gradually from open surgery to minimally invasive surgery, significantly reducing perioperative mortality and complication rates. However, the application of techniques for reconstructing visceral artery branches is not yet widespread, and there is considerable controversy in the management of complex cases. In response, the Vascular Surgery Group of Surgery Society of Chinese Medical Association, the Vascular Surgery Group of Cross-straits Medicine Exchange Association and the Thoracic Aorta Group of Vascular Surgeons Society of Chinese Medical Doctor Association convened relevant experts in China with extensive experience in the endovascular reconstruction of visceral branches for aortic expansion diseases, based on systematic reviews of clinical practice and domestic and international literature, and after in-depth discussions, have developed the Expert consensus on endovascular reconstruction of visceral branch arteries in the treatment of aortic expansion diseases (2024 edition). The consensus focuses on endovascular techniques involving the reconstruction of visceral artery branches, aiming to provide principled guidance for clinicians and to promote the improvement of diagnostic and treatment levels in this field within China.

Hepato-Pancreato-Biliary Surgery: Analysis of Outcomes Among Graduates of Different Fellowship Pathways.

To characterize the association between type of fellowship training and patient outcomes following hepatopancreatic (HP) surgery across different surgeon career stages using a national representative cohort of Medicare beneficiaries. The current state of training in HPB surgery in North America is defined through three main pathways: the Complex General Surgical Oncology (CGSO), the Americas HPB Association fellowship, and the American Society of Transplant surgeons fellowship. Each pathway offers a unique perspective on HPB surgery with different number of training years, yet outcomes of graduates performing HP surgery relative to type of fellowship training have not been defined. Medicare claims were used to identify patients who underwent HP surgery for cancer between 2016-2021. The association of textbook outcomes (TO), defined as no postoperative complications, no prolonged LOS, no 90-day mortality and no 90-day readmission, relative to different fellowship pathways was examined. Overall, 15,411 cancer operations (pancreatectomy: 11,003, 71.4%; hepatectomy: 4,408, 28.6%) were performed by 1,030 HPB surgeons. A total of 9,390 patients (60.9%) were operated on by a CGSO/SONC graduate, 2,315 patients (15.0%) by an HPB fellowship graduate and 3,706 (24.1%) by a transplant fellowship graduate. Patients who were operated on by an HPB fellowship graduate more frequently had a higher Charlson score (>5: 44.8% vs. 38.1%) and more frequently were operated on an urgent basis (7.7% vs. 6.1%) compared with individuals treated by CGSO/SONC graduates. After adjusting for patient, procedural, hospital, and surgeon related factors, the likelihood of TO following an HP operation by an HPB fellowship graduate was 47.7% versus 45.2% among CGSO (% difference 2.7%) and 42.8% among transplant fellowship graduates (% difference 4.9%, P=0.01). While the probability of TO was higher among surgeons having completed a dedicated HPB fellowship during early (1-7th year of independent practice, P=0.032) and middle (8-14th year, P<0.001) career stages, the probability of TO did not differ based on fellowship type among late career surgeons (>15th year, P=0.257). Achievement of TO following an HP procedure was higher among surgeons who had completed a dedicated HPB fellowship, especially during early and middle career stages. Further efforts should be made to enhance HP surgery exposure and training for CGSO fellows interested in a career in HPB surgery.

Renal Failure in Type A-Aortic Dissection Repair: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis.

We sought to identify predictors of acute renal failure (ARF) following acute type A aortic dissection (ATAAD) and its implications on postoperative outcomes. ATAAD cases were identified from The Society of Thoracic Surgeons - Adult Cardiac Surgery Database (2017-2022). Cases with chronic dissection, prior aortic repair, primary endovascular repair, preoperative extracorporeal membrane oxygenation, preoperative renal failure, and operative room deaths were excluded. ARF was defined as either a threefold increase in creatinine or creatinine >4 mg/dL with an increment ≥0.5 mg/dL from baseline, or new dialysis requirement postoperatively. Predictors of ARF were identified using multivariable logistic regression with corresponding adjusted odds ratios [AOR (95% Confidence Intervals)]. Among 22,313 patients (age: 60.2±13.7 years; 66.2% male) undergoing ATAAD repair at 868 hospitals, 3,696 (16.6%) developed ARF and, of these, 2,918 (79.0%) required dialysis. ATAAD volume increased from 3,693 in 2017 to 4,334 in 2022 (p<0.001), while the proportion of ARF decreased slightly yet significantly from 17.2% in 2017 to 16.3% in 2022 (p<0.001). A well calibrated and discriminating (C-Statistic: 0.77 (0.75, 0.78)) multivariable model identified 27 independent predictors of ARF. Bilateral renal malperfusion (AOR=4.88 (3.50-6.81)), preoperative creatinine per 0.1 mg/dL (AOR=1.12 (1.11-1.14)), intraoperative transfusion (AOR=1.63 (1.21-2.18)), and cardiogenic shock (AOR=1.46 (1.24-1.72)) were strongly associated with increased ARF. Conversely, female gender (AOR=0.72 (0.61-0.86)) was protective. Failure-to-rescue after ARF following ATAAD repair was 42%. This study identified patient factors that significantly increase the risk of ARF following ATAAD repair, which may alert the clinical team to implement potential protective interventions.

Four-dimensional Cardiac Modelling of Multiphase Computed Tomography for Predicting Outcomes After Transcatheter Aortic Valve Replacement.

Multiphase computed tomography angiography (mpCTA) is routinely performed prior to transcatheter aortic valve replacement (TAVR) to determine eligibility and enable preprocedural planning. Incremental prognostic value may be realized from full-cycle, multiphase reconstructions to assess the contractile health of the cardiac chambers. In this study we assessed the feasibility of 4-dimensional chamber modelling of the left ventricle (LV) to support 3-dimensional minimum principal strain (3DminPS)-based predictions of clinical outcomes after TAVR. Two hundred five patients undergoing pre-TAVR mpCTA were studied. UNet-based 3D chamber segmentation was followed by mesh modelling and 3D feature tracking-based deformation to determine global 3DminPS for endocardial, epicardial, and transmural layers. Independent associations of 3DminPS with the primary outcome of heart failure hospitalization or death are described. Of the 205 patients studied, 196 (96%) had analyzable mpCTAs (median age, 85 years; 55% male; Society of Thoracic Surgeons Predicted Risk of Mortality score= 3.10; 60.0% echocardiographic LV ejection fraction). At a median of 25 months after TAVR, 55 patients (28%) experienced the primary outcome. After adjustment for baseline variables, patients with an endocardial 3DminPS amplitude worse than-23.7% experienced a 2.7-fold higher risk of the outcome (adjusted hazard ratio, 2.7; 95% confidence interval, 1.4-5.1; P= 0.001), with this high-risk cohort having 1- and 3-year event rates of 32% and 49%, respectively. Four-dimensional chamber modelling of mpCTA using UNet-based segmentation and standardized mesh deformation is feasible and enables delivery of 3D deformation markers with strong prognostic value for the prediction of outcomes after TAVR. Prospective validation in a multicentre setting is currently being undertaken.

The Society of Thoracic Surgeons Expert Consensus Statements on a Framework for a Standardized National Robotic Curriculum for Thoracic Surgery Trainees.

With robotic technology's rapid growth and integration, an urgent need to bridge the educational gap in thoracic surgical training has emerged. This document, a result of consensus among a group of experts in the practice and training of robotic surgery from the Society of Thoracic Surgeons (STS), aims to provide a framework for a standardized national robotic curriculum for thoracic surgery trainees. The STS Task Force on Robotic Thoracic Surgery and Workforce on E-learning and Educational Innovation assembled an expert group with the input of the Thoracic Surgery Director's Association (TSDA). A focused literature review was performed, and expert consensus statements were developed using a modified Delphi process to address three major themes: (1) Program expectations, (2) Components of training, and (3) Assessment and feedback. A consensus was reached on 12 recommendations. These consensus statements reflect updated insights on developing a standardized robotics curriculum based on the latest literature and current educational experience, focusing on program expectations and educational guidelines to develop an optimal training curriculum. The expert panel provides several key recommendations to provide a framework for developing a standardized national robotic thoracic curriculum, which would improve resident education and abridge any educational disparity that may exist among programs.

Japanese clinical practice guidelines for oral cancer, 2023.

The Japanese Society of Oral Oncology and Japanese Society of Oral and Maxillofacial Surgeons have jointly developed clinical practice guidelines for oral cancer (oral squamous cell carcinoma) to improve and standardize the quality of oral cancer treatment in Japan. The first, second, and third editions were published in 2009, 2013, and 2019, respectively, and the 2023 edition was recently developed. In the development of the 2023 edition, 60 clinical questions (CQs) were listed. Systematic reviews following the GRADE approach were performed for 11 of these CQs. This article outlines the 2023 edition and describes the most relevant guidelines and CQs for the diagnosis, treatment, follow-up, and supportive care of oral cancer patients in Japan.

Abdominal wall closure: how do we do it in Spain? Survey of specialist general surgeons members of the AEC (Spanish Society of Surgeons).

To evaluate the knowledge of abdominal wall closure in a cohort of specialist general surgeons who are members of the AEC and to see its adequacy with current recommendations. Sub-analysis in terms of years of specialization. Individual questionnaire of 21 questions on abdominal wall closure in elective and urgent context. A total of 371 responses were received from specialist surgeons who are members of the AEC. Closure of the median laparotomy is performed with continuous suture in 99.7% and with slowly absorbable materials in 95.4%. 88.4% of surgeons report using the ratio equal to or greater than 4:1 between suture length and incision length (SL:IL) and short stitches. These results are equivalent in transverse and urgent elective laparotomy. 85.2% of the respondents systematically close trocars of 10 millimeters or more and 30.7% use prophylactic mesh in high-risk patients. Surgeons with less than 10 years of experience use the ratio ≥ 4:1 SL:IL and short stitches (93.4% vs 84.9%; p = 0.013). Abdominal wall closure among general surgeons who are members of the ACS is adequate and adjusted to the recommendations with a tendency to improve among surgeons with less experience. There is an opportunity for improvement in the use of prophylactic mesh in high-risk patients.

Expert consensus on the application of supra-arch branch reconstruction technique in endovascular aortic repair(2024 edition)

Endovascular aortic repair has become a pivotal treatment option for aortic pathologies. For lesions involving the aortic arch, multiple approaches have been developed to reconstruct supra-arch branches, including hybrid surgery, parallel graft, in-situ fenestration, physician-modified stent-graft, and commercial branched or fenestrated stent-graft. Despites, the implementation of these techniques and the application of new devices are still faced with great challenges such as ambiguous indications, non-standardized operational procedures, difficulties in mastering technical tactics, and uncertainties about long-term outcomes. Consequently, the Vascular Surgery Group of Surgery Society of Chinese Medical Association, Vascular Surgery Group of Cross-straits Medicine Exchange Association and Thoracic Aorta Group of Vascular Surgeons Society of Chinese Medical Doctor Association convened relevant experts to engage in comprehensive discussions leading to this "Expert consensus on the application of supra-arch branch reconstruction technique in endovascular aortic repair（2024 edition）" based on contemporary evidence-based medicine and clinical practices both domestically and internationally, delineating the methods, challenges, key points, scope of application, and precautions related to supra-arch branch reconstruction during thoracic endovascular aortic repair. This consensus aims to provide principled guidance for the application of these techniques in treating lesions involving the aortic arch.

TAVI with the ACURATE neo2 in severe bicuspid aortic valve stenosis: the Neo2 BAV Registry.

The ACURATE neo2 is a contemporary transcatheter aortic valve implantation (TAVI) system approved for the treatment of severe aortic stenosis in Europe. The ACURATE neo2 has not been evaluated in bicuspid aortic valve (BAV) stenosis. We sought to evaluate the safety and efficacy of ACURATE neo2 in patients with BAV stenosis. We retrospectively analysed consecutive severe BAV stenosis patients undergoing TAVI with ACURATE neo2 at 10 European centres. Imaging data from preprocedural multislice computed tomography, pre- and postprocedural echocardiography, and procedural cinefluoroscopy were evaluated by a core laboratory. Valve Academic Research Consortium 3 (VARC-3)-defined 30-day procedure safety and efficacy were the primary endpoints. Adverse events were site-reported according to VARC-3 criteria. Among 181 patients with BAV stenosis treated with the ACURATE neo2, the mean age was 77.5±7.2 years, 58.0% were female, and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score was 2.3% (1.6-3.7%). Most procedures were transfemoral, and predilatation was performed in all cases. A second valve was required in 4 cases (2.2%). VARC-3-defined technical success was 95.6%. The primary endpoints of device success and early safety occurred in 90.6% and 82.3%, respectively. At 30 days, cardiovascular death occurred in 2.2% (N=4) and stroke in 1.6% (N=3). Core laboratory-adjudicated echocardiography reported an effective orifice area of 2.0 (1.7-2.5) cm2 and a mean transvalvular gradient of 6.5 (4.6-9.0) mmHg. Half of all cases (51.2%) had no paravalvular leak, while moderate leak occurred in 4.3%. A new permanent pacemaker was required in 11 patients (6.5%). The ACURATE neo2 demonstrated favourable clinical outcomes and bioprosthetic valve performance at 30 days in selected patients with severe BAV stenosis.

Pilonidal Disease Management in Young Adults: A Retrospective Analysis of Practices in a single tertiary centre in Bahrain

Abstract Background Pilonidal disease is a prevalent skin condition that predominantly affects young males. This study, conducted at Salmaniya Medical Complex in Bahrain, aimed to analyze the demographics, treatment methodologies, and complications associated with pilonidal disease. Materials and Methods We analyzed the medical records of 56 patients, comparing our practices to the American Society of Colon and Rectal Surgeons (ASCRS) guidelines. Variables collected included patient demographics (age and gender), details on preoperative and postoperative antibiotics, the type of surgical intervention performed, the closure technique used, and follow-up results at 2 months post-discharge, Results Our findings confirmed the high prevalence of the disease in young males (75%), with a median age at presentation being 20.5 years. Our practices showed minimal compliance (≤69%) to key recommendations. We found no documented practices for hair removal, phenol application, fibrin glue, or minimally invasive approaches. The most common surgical approach was primary closure (60%), followed by flap reconstruction (16%) and leaving wounds open (7%). The commonest complications were wound dehiscence and surgical site infection (27% each). Post-operative complications were significant, with 67.6% in patients who received pre- operative antibiotics and 63.6% in those who received post-operative antibiotics. However, no statistical link to closure type was found, likely due to our small sample size. Conclusion We recommend reassessing our management protocols to align with ASCRS guidelines and considering non-operative treatments to reduce morbidity. This study underscores the need for guideline adherence and the potential benefits of non-operative treatments in managing pilonidal disease.