Operative Volume Research Articles

Estimation of the Economic and Environmental Impact of Single-Use Instruments in Routine Cataract Surgery.

To estimate the economic and environmental impact of single-use instruments (SUIs) to perform standard cataract surgery in six ophthalmology centers located in Europe and in the United States. Online survey and interview. Comparative cost analysis based on an online survey with follow-up questionnaire and interview. The carbon footprint calculation was made by ClimatePartner. Annual costs of reusable instruments (RUIs) were calculated based on data provided by the centers. Annual costs of SUIs were estimated based on the average-selling price of a single-use cataract set of 5 instruments and the reported annual volume of cataract surgery. The calculation carbon footprint of a cataract instrument covered the whole life cycle from production to end-of-life. Annual costs for SUIs were found inferior or similar to the annual costs for RUIs for 4 out of the 6 centers included in this study. The centers where SUIs were demonstrated to be the most cost-effective were also associated with the highest costs of sterilization per instrument. The carbon footprint of 5-years usage of a cataract instrument was found to be 5478.2 kg CO2 eq for SUIs without recycling, 4639.9 kg CO2 eq for SUIs with recycling and 20.6 kg CO2 eq for RUIs. The study demonstrated that SUIs can be an alternative solution to using RUIs in multispecialty hospitals associated with high sterilization costs.

Feasibility of twenty-four-hour discharge of patients with anterior mediastinal tumors after subxiphoid video-assisted thoracoscopic surgery (VATS) procedure.

A wide variety of surgical procedures are administrated in day-surgery unit and are able to be discharged within 24 hours with high efficiency, safety and economy. This study sought to evaluate the safety and feasibility of 24-hour discharge of patients with anterior mediastinal tumors after subxiphoid video-assisted thoracoscopic surgery (VATS) and describe our surgery procedure experiences. A total of 70 selected patients with anterior mediastinal tumors undergoing subxiphoid VATS were included in this prospective study. The patients' clinical features, intraoperative and postoperative complications were assessed, and postoperative pain scale and satisfaction scores were also evaluated. The subxiphoid VATS was completed with no conversion to open surgery in all included patients and were all discharged within 24 hours after surgery. The mean operative time ± standard deviation (SD) was 70.50±18.98 min, and the mean operative blood loss volume ± SD was 45.50±15.25 mL. In addition, 80% of the patients reported a postoperative pain scale score less than 3 by the day before discharge, and all patients expressed satisfaction with receiving VATS in the day-surgery unit at 2 weeks after discharge. The use of subxiphoid VATS is a safe, efficient and feasible surgical approach for patients with anterior mediastinal tumors discharged within 24 hours.

Association of Surgeon Self-Reported Gender and Surgical Outcomes in Current US Practice.

This study aimed to evaluate the association of surgeon self-reported gender on clinical outcomes in contemporary US surgical practice. Previous research has suggested that there are potentially improved surgical outcomes for female surgeons, yet the underlying causal path for this association remains unclear. Using the Vizient Clinical Database(2016-2021), 39 operations categorized by the CDC's National Healthcare Safety Network were analyzed. The surgeon self-reported gender as the primary exposure. The primary outcome was a composite of in-hospital death, complications, and/or 30-day readmission. Multivariable logistic regression and propensity score matching were used for risk adjustment. The analysis included 4,882,784 patients operated on by 11,955 female surgeons (33% of surgeons performing 21% of procedures) and 23,799 male surgeons (67% of surgeons performing 79% of procedures). Female surgeons were younger (45±9 vs males-53±11y; P <0.0001) and had lower operative volumes. Unadjusted incidence of the primary outcome was 13.6%(10.7%-female surgeons, 14.3%-male surgeons; P <0.0001). After propensity matching, the primary outcome occurred in 13.0% of patients [12.9%-female, 13.0%-male; OR (M vs. F)=1.02, 95% CI: 1.01-1.03; P =0.001), with female surgeons having small statistical associations with lower mortality and complication rates but not readmissions. Procedure-specific analyses revealed inconsistent or no surgeon-gender associations. In the largest analysis to date, surgeon self-reported gender had a small statistical, clinically marginal correlation with postoperative outcomes. The variation across surgical specialties and procedures suggests that the association with surgeon gender is unlikely causal for the observed differences in outcomes. Patients should be reassured that surgeon gender alone does not have a clinically meaningful impact on their outcome.

550. INTRAOPERATIVE VOLUME STATUS DOES NOT AFFECT ERAS OUTCOMES OR COMPLICATION RATES IN HYBRID ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Intraoperative volume management in patients undergoing esophagectomy is nuanced. Data is conflicting in regards to the benefits of volume restrictive versus liberal approaches. Within a hybrid robotic assisted minimally invasive esophagectomy (hRAMIE) population undergoing oncologic resection there is a paucity of data regarding intraoperative volume status as it affects postoperative outcomes and no data regarding the impact on enhanced recovery after surgery (ERAS) outcomes. Methods Demographics, anthropometrics, cancer characteristics, and perioperative outcome data were gathered between January 2020 and December 2023 at a single, tertiary referral center in patients undergoing oncologic hRAMIE. Intraoperative volume status was defined, as in other reports, by identifying the median operative volume rate per hour and normalizing via the Du Bois body surface area; above or below 225 mL/hour/m2. ERAS outcomes were reported. Complications were stratified in accordance with the Esophagectomy Complications Consensus Group guidelines. Continuous variables were compared via Mann-Whitney U-Test; categorical via Fisher's Exact. Alpha set to 0.05. Results 96 patients (46 volume restrictive, 45 volume liberal) were identified. There were no differences in age, sex, body mass index, ASA class, Charlson Comorbidity Index, cancer histology, location, rate of neoadjuvant chemotherapy, or chemoradiotherapy. ERAS outcomes analysis reveals no statistical difference in ICU length of stay, mobilization times, return of bowel function, or length of stay (Table 1). Complications were reported in 45.8% of patients and did not differ between groups (p=0.8934). Pulmonary complications were most frequent (total 21.9%; restrictive 17.4%, liberal 28.9%, p=0.1422) followed by anastomotic leak (total 12.5%; restrictive 17.4%, liberal 8.9%, p=0.3681). Conclusion The current study demonstrates no impact of volume restriction on perioperative outcomes, ERAS benchmarks, or length of stay in patients undergoing hRAMIE for esophageal cancer. Data suggests that minimally invasive approaches may be associated with less total body and pleural inflammatory mediator generation, perhaps limiting susceptibility to variation in volume status. Highly powered, multicenter retrospective minimally invasive esophagectomy and volume status investigation is warranted prior to proceeding with controlled trial.

532. OPERATIVE TRENDS AND CLINICAL OUTCOMES OF OPEN, LAPAROSCOPIC AND ROBOTIC APPROACHES TO HIATAL AND PARAOESOPHAGEAL HERNIAS-A STUDY OF 1834 PATIENTS

Abstract Background Indications for repair of hiatal and paraesophageal hernia (HH/PEH) repair evolved significantly over the past two decades, impacted by the increasing application of minimally invasive surgical (MIS) approaches. This transition underscores the importance of evaluating the operative trends and clinical outcomes associated with open (open), laparoscopic (lap), and robotic surgeries especially in cases of giant hernias (over 50% intrathoracic stomach). Understanding these dynamics is crucial, especially as MIS becomes increasingly prevalent in managing complex cases, including giant hernias. The aim of this study is to assess critical outcomes achieved during the evolution from open to lap to robotic HH/PEH repair in a high volume center. Methods This is a retrospective review of 1834 patients undergoing open (958), lap (390), and robot (486), consecutive HH/PEH repairs prospectively entered into an IRB approved database from 2000 to 2023 at a high-volume center. Patient demographics, operative techniques, and top three most common presenting symptoms were studied overtime. Impact of operative technique, hernia type and size, operative outcomes including length of stay (LOS), radiographic recurrence (esophagram at 3 and 12 months), revisional surgery, on post-operative symptom resolution was evaluated. Results Annual volume increased overtime, with 418 repairs (78% robotic) in the last two years. Average hernia size decreased over the study period. The majority of patients (99.1%) presented with symptoms (Fig 1) and robotic repair had significantly better symptomatic resolution than open surgery (p&amp;lt;0.05). This advantage persists with symptoms in giant hernias (p&amp;lt;.001) LOS decreased over the study period (Fig 1). Overall radiographic recurrence (8.6%) and reoperative rate (2.4%) did not differ among operative techniques, however robotic repair had higher radiographic recurrence rate in case of giant hernia (18%, p&amp;lt;.001). Conclusion The operative volume of HH/PEH repair has increased overtime associated with the increased application along with advancements in MIS and robotic operative techniques. Surgical interventions markedly ameliorate HH/PEH symptoms, with greater improvement observed in large hernia cases. Significant improvement in LOS and at least equivalent clinical results favors MIS, particularly robotic surgery. Although the incidence of anatomic recurrent hernia and reoperation is relatively low continued assessment of especially robotic operations to decrease this incidence further is warranted.

Anatomic endoscopic enucleation of the prostate using a novel hybrid thulium:yttrium-aluminium-garnet laser generator: surgical technique and clinical outcomes.

We aim to report here the first clinical series of patients treated with AEEP using a novel hybrid thulium:yttrium-aluminium-garnet (Tm:YAG) laser generator (RevoLix HTL, LISA Laser Products, Germany), i.e. capable of emitting both in pulsated and continuous-wave. We included 39 consecutive patients who underwent hybrid Tm:YAG AEEP (hybrid ThuLEP) at a single center starting from July 2022 and were followed-up until 3months after surgery. Complete baseline, intraoperative, and follow-up demographic and clinical data were collected. The International Prostatic Symptoms Score (IPSS) questionnaire was used to quantify urinary symptoms at baseline and during follow-up. Post-operative follow-up further included a PSA test, uroflowmetry with post-void residual volume (PVR) measurement. Clavien-Dindo classification was used to classify complications. Median (IQR) age at surgery and prostate volume were 68 (IQR 63-74) years and 85 (60-105) cc. Both en-bloc or two-lobes technique enucleation were performed according to the intraoperative and endoscopic anatomy, with a median operative time of 85 (63-108) minutes. Bladder catheter was removed in all cases on postoperative day two. Intraoperative bleeding requiring conversion to bipolar enucleation was observed in two patients. After discharge, one patient developed arm phlebitis which was treated with anticoagulants leading to new onset haematuria requiring short term catheterisation (Clavien-Dindo grade II) and two more patients had a single episode of acute urinary retention (Clavien-Dindo grade I). Median pre- vs postoperative Qmax and IPSS were 8.0 (7.0-9.4) vs. 25.0 (22.5-32.5) ml/s and 22 (20-28) vs. 1 (0-2), whereas PVR decreased from 70 (50-115) to 0 (0-26) ml. Hybrid ThuLEP is a feasible and effective surgical procedure for the management of benign prostatic obstruction.

Методичні аспекти формування облікової політики товарів у системі управління підприємством

The article studies methodological aspects of accounting and controlling goods in enterprises to form an informational foundation for managerial decision-making. The study’s relevance is associated with the widespread nature of trade operations in enterprises across various sectors of economic activity. The statistical data analysis has proven that the volume of trade operations is increasing, and such operations are conducted across different economic sectors. The development of trade activities enhances the importance of goods in enterprise operations, thus underscoring the need to develop theoretical and methodological provisions for accounting and controlling goods. The purpose of the article is to systematize the theoretical and methodological foundations of goods accounting and control and to determine the role of these processes in an enterprise’s operations and overall management system. The role of accounting and control of goods in the management system of an enterprise’s activities is substantiated. It is determined that the quality development of such a system will facilitate the collection of timely and accurate information on inventory and serve as a tool for ensuring the enterprise’s financial stability. The existing methodological foundations of this process have been systematized to enable the development of a goods accounting system for enterprises. Regulatory acts governing the accounting and control of goods operations are summarized in two directions: external and internal. The main aspects of goods accounting regulated by the examined documents are characterized. The main elements of goods accounting policy, which serve as the foundation for forming information support for managerial decisions, are highlighted; thus, enterprise management must develop and coordinate them. The system of accounts for recording transactions involving enterprise goods is specified, along with the correspondence of accounts for reflecting such operations, including the documentary support for their representation. The necessity of goods control is substantiated, and the primary methods for its implementation are specified. The research results can be applied in the practical activities of enterprises to organize a system of accounting and control of goods. Keywords: information support, control, accounting, regulation, goods, managerial decisions.

An Audit of Outcomes in Cosmetic Rhinoplasty with the Mandatory Psychiatric Evaluation Protocol.

With the high demand of rhinoplasty surgery, careful selection and management of aspirants, as well as proper assessment of outcomes after surgery, are imperative for achieving successful outcomes and learning from it. The aim of this study was to answer two important questions: (1) What is the success rate in cosmetic rhinoplasty? (2) How can we best identify candidates who would achieve good outcomes in cosmetic rhinoplasty? In this study cohort, we excluded patients with any functional concerns and confounding factors that could in any way influence patient satisfaction with a cosmetic surgery. This study is a part of the trilogy of articles on "psychology of rhinoplasty" submitted to this volume of Facial Plastic Surgery, using mandatory psychiatric evaluation (MPE) to optimize candidacy. In total, 184 patients (144 females and 40 males) aged 16 to 63 years (M = 31.09) met the inclusion criteria and were included in this study (follow-up: 3-122 months; M = 70.18 months), and outcome satisfaction was assessed using the visual analog scale (VAS) score and a 5-point Likert scale. The mean improvement between preoperative (M = 4.26) and postoperative VAS scores (M = 8.47) was 4.23. Most patients were happy or very happy (95.1%) about the surgical outcome. Patients who were very happy generally scored between 8 and 10 on the VAS (77.2%) and those who were happy generally scored between 6 and 7.9 (21.2%). Some patients, however, were neutral (3.3%) or unhappy (1.6%) about their surgical outcome, and generally scored around ≤7 on the VAS. Although the successful outcome in 95.1% patients reflects a carefully designed protocol for rhinoplasty candidacy, 4.9% patients reported poor satisfaction despite these efforts. An ever-present proportion of unhappy outcomes is a reality of this popular surgery.

Comparative analysis of volumetric changes between resection volume of oral tongue cancer and post operative volume of radial forearm flaps

ObjectivesThis study investigates the relationship between the total volume of oral tongue cancer pre-operatively and the RFFF volume post-operatively.Materials and methodsA total of 52 DICOM imaging datasets (CT or MRI) of 26 patients were included in this study. The volume of the desired structure was quantified using semi-automatic segmentation using the software ITK-SNAP. All extracted measurements were validated by two further clinicians at separate instances.ResultsThe variation of MeanVolTu can be predicted by MeanVolFlap moderately reliable with 59.1% confidence (R-Qua: 0.591). ANOVA Testing to represent how well the regression line fits the data, resulted in the overall regression model being statistically significant in predicting the MeanVolTu (p < 0.001). The flap volume may be predicted using the following algorithm: MeanVolFlap0 = 3241,633 + 1, 322 * MeanVolTu.ConclusionThe results of this study show positive correlation between tumor volume and flap volume, highlighting the significance of efficient flap planning with increasing tumor volume. A larger extraction volume of the radial forearm free flap from the donor site compromises the forearm more, thus increasing the probability of post-operative complications.Clinical relevanceRadial forearm free flap design in accordance with its corresponding 3D tumor volume.

Surgical Skill Decay as a Result of the COVID-19 Pandemic.

This study aimed to objectively evaluate the impact of the gap in surgical practice caused by COVID-19 on surgical skill decay. This retrospective cohort study enrolled 148 cases of adult patients who were qualified for elective or urgent laparoscopic cholecystectomy. This study compared the period of nine months before the pandemic outbreak and nine months after the end of the pandemic. We analyzed the duration of surgery, the number of intraoperative adverse events (IAEs), postoperative complications (PCs), and differences between the surgeries performed by residents and those performed by specialists. The number of IAEs did not differ significantly between groups (after COVID-19 (AC) and before COVID-19 (BC)). A difficult gallbladder (DGB) was associated with an increased risk of IAEs during surgery in both groups (BC:OR = 2.94, p = 0.049; AC:OR = 2.81, p = 0.35). The multivariate analyses showed no significant differences in IAEs or PCs when the residents performed surgeries compared to specialists. The average duration of surgery was significantly longer in the post-pandemic group (BC-102.4 min vs. AC-119.9 min, p = 0.024). Measurable determinants of surgical skills are the duration of surgery and the number of intraoperative adverse events. By defining this indicators, our study objectively shows that the reduction in the volume of surgeries during COVID-19 resulted in a phenomenon known as surgical skill decay.

Development of preoperative nomograms to predict the risk of overall and multifocal positive surgical margin after radical prostatectomy

ObjectiveTo develop preoperative nomograms using risk factors based on clinicopathological and MRI for predicting the risk of positive surgical margin (PSM) after radical prostatectomy (RP).Patients and methodsThis study retrospectively enrolled patients who underwent prostate MRI before RP at our center between January 2015 and November 2022. Preoperative clinicopathological factors and MRI-based features were recorded for analysis. The presence of PSM (overall PSM [oPSM]) at pathology and the multifocality of PSM (mPSM) were evaluated. LASSO regression was employed for variable selection. For the final model construction, logistic regression was applied combined with the bootstrap method for internal verification. The risk probability of individual patients was visualized using a nomogram.ResultsIn all, 259 patients were included in this study, and 76 (29.3%) patients had PSM, including 40 patients with mPSM. Final multivariate logistic regression revealed that the independent risk factors for oPSM were tumor diameter, frank extraprostatic extension, and annual surgery volume (all p < 0.05), and the nomogram for oPSM reached an area under the curve (AUC) of 0.717 in development and 0.716 in internal verification. The independent risk factors for mPSM included the percentage of positive cores, tumor diameter, apex depth, and annual surgery volume (all p < 0.05), and the AUC of the nomogram for mPSM was 0.790 in both development and internal verification. The calibration curve analysis showed that these nomograms were well-calibrated for both oPSM and mPSM.ConclusionsThe proposed nomograms showed good performance and were feasible in predicting oPSM and mPSM, which might facilitate more individualized management of prostate cancer patients who are candidates for surgery.

Effects of increasing tidal volume and end-expiratory lung volume on induced bronchoconstriction in healthy humans

BackgroundIncreasing functional residual capacity (FRC) or tidal volume (VT) reduces airway resistance and attenuates the response to bronchoconstrictor stimuli in animals and humans. What is unknown is which one of the above mechanisms is more effective in modulating airway caliber and whether their combination yields additive or synergistic effects. To address this question, we investigated the effects of increased FRC and increased VT in attenuating the bronchoconstriction induced by inhaled methacholine (MCh) in healthy humans.MethodsNineteen healthy volunteers were challenged with a single-dose of MCh and forced oscillation was used to measure inspiratory resistance at 5 and 19 Hz (R5 and R19), their difference (R5-19), and reactance at 5 Hz (X5) during spontaneous breathing and during imposed breathing patterns with increased FRC, or VT, or both. Importantly, in our experimental design we held the product of VT and breathing frequency (BF), i.e, minute ventilation (VE) fixed so as to better isolate the effects of changes in VT alone.ResultsTripling VT from baseline FRC significantly attenuated the effects of MCh on R5, R19, R5-19 and X5. Doubling VT while halving BF had insignificant effects. Increasing FRC by either one or two VT significantly attenuated the effects of MCh on R5, R19, R5-19 and X5. Increasing both VT and FRC had additive effects on R5, R19, R5-19 and X5, but the effect of increasing FRC was more consistent than increasing VT thus suggesting larger bronchodilation. When compared at iso-volume, there were no differences among breathing patterns with the exception of when VT was three times larger than during spontaneous breathing.ConclusionsThese data show that increasing FRC and VT can attenuate induced bronchoconstriction in healthy humans by additive effects that are mainly related to an increase of mean operational lung volume. We suggest that static stretching as with increasing FRC is more effective than tidal stretching at constant VE, possibly through a combination of effects on airway geometry and airway smooth muscle dynamics.

The current diagnosis and treatment strategy of breast cancer based on multicentre retrospective data in Shaanxi province

BackgroundBreast cancer is a common malignancy, and early detection coupled with standardized treatment is crucial for patient survival and recovery. This study aims to scrutinize the current state of breast cancer diagnosis and treatment in Shaanxi province, providing valuable insights into the local practices and outcomes.MethodsWe selected 25 hospitals that typically represent the current diagnosis and treatment strategy of breast cancer in Shaanxi (a province in northwest China). The questionnaire comprised sections on fundamental information, outpatient consultations, breast-conserving surgery, neoadjuvant and adjuvant therapy, sentinel lymph node biopsy, breast reconstruction surgery.ResultsA total of 6665 breast cancer operations were performed in these 25 hospitals in 2021. The overall proportion of breast-conserving surgery (BCS) is 23.6%. There was a statistically significant positive correlation between the annual volume of breast cancer surgery and the implementation rate of BCS (P = 0.004). A total of 2882 cases of neoadjuvant treatment accounted for 43.24% of breast cancer patients treated with surgery in 2017. Hospitals in Xi’an performed more neoadjuvant therapy for patients with breast cancer compared to other districts (P = 0.008). There was a significantly positive correlation between outpatient visits and the implementation rate of sentinel lymph node biopsy (SLNB) (P = 0.005). 14 hospitals in Shaanxi performed reconstructive surgery.ConclusionsBreast conserving surgery, adjuvant and neoadjuvant therapy and sentinel lymph node biopsy in Shaanxi province have reached the China’s average level. Moreover, hospitals in Xi ’an have surpassed this average. However, a disparity is observed in the development of breast reconstruction surgery when compared to top-tier hospitals.

Case Finding and Management of Childhood Cataracts: The Role of a Child Eye Health Programme in Kaduna State, Nigeria

Abstract Objective: To evaluate the output of a child eye health programme in terms of identification, referral, and volume of paediatric cataract surgeries in Kaduna State, Nigeria. Materials and Methods: This was a retrospective review of the North-West Nigeria Child Eye Health Initiative programme referral registers at primary, secondary and tertiary hospitals in Kaduna State. Theatre registers of children 0–16 years who had cataract surgery at National Eye Centre Kaduna between 2016 and 2019 were also reviewed. Information on numbers of children, age, sex, laterality of cataract and programme status were summarised as frequencies, percentages and mean ± standard deviation. The initial 2 years of the programme (2018–2019) were compared with the 2 years (2016–2017) preceding them. Results: Between January 2018 and December 2019; primary health workers screened 41,552 children and referred 2,316 (5.6%). Of those referred 1772 (76.5%) presented at one of three zonal secondary hospitals where nurses identified 492 (27.8%) with leukocoria using torchlights and referred them to the tertiary hospital. At the tertiary hospital, 364 (74.0% of 492) attended and 262 (72.0% of 364) were confirmed to have operable cataracts after dilated slit lamp examination by ophthalmologists. Between 2016 and 2017 (pre-programme years), 201 children had cataract surgery compared to 352 in 2018 and 2019 (programme years) of whom 239 (67.9% of 352) were beneficiaries of the programme. The proportion of girls who had cataract surgery declined from 39.8% to 35.0%, while mean age increased from 5.7 ± 4.2 years to 7.5 ± 4.1 over 4 years. More children with unilateral cataracts (214 [60.8%]) presented during the programme years (Fishers exact test, P = 0.004), whereas unilateral cataract (207 [60.2%]) was significantly more common in males than females (Fisher’s exact P = 0.017). Conclusion: The programme has resulted in improved case detection of childhood leukocoria at primary eye care level. additionally, the eye health referral system in Kaduna State has been strengthened with increasing numbers of children accessing services: majority boys, older children, and unilateral cataracts.

Simultaneous thoracoscopic surgery in patients with atrial fibrillation and early-stage lung cancer

ObjectivesAtrial fibrillation (AF) and early-stage lung cancer can both be treated under thoracoscopy. This study aims to evaluate the feasibility and safety of simultaneous thoracoscopic surgery for atrial fibrillation and early-stage lung cancer. MethodsThis was a single-center, retrospective study of 865 patients with paroxysmal or non-paroxysmal AF who underwent surgical ablation between October 2014 and December 2021. Patients were divided into two groups according to whether they have undergone simultaneous thoracoscopic early-stage lung cancer surgery and resulting in 24 pairs of patients. ResultsIn total, 48 patients (24 matched pairs) were analyzed. The age was 63.71 ± 8.43 years. Procedure time and postoperative mechanical ventilation time were significantly lower in the group AF than group AFLC (Atrial fibrillation and lung cancer) (140.38 ± 27.53 vs. 230.79 ± 59.06 min, P<0.001; 5 vs 6.5 h, P = 0.002). There was no significant difference between the groups in terms of operative bleeding volume (90.00 ± 29.78 vs 85.83 ± 53.56 ml, P = 0.741), total postoperative drainage volume (1020.83 ± 516.5 vs 1406.25 ± 840.33 ml, P = 0.067), ICU (intensive care unit) length of stay (LOS) (43.5 vs 44 h, P = 0.33), hospitalization LOS (9.29 ± 1.92 vs 8.58 ± 1.98 days, P = 0.214) and incidence of freedom from AF or complications. ConclusionsSimultaneous thoracoscopic surgical AF ablation and early-stage lung cancer is safe and feasible. It can be used as an alternative method for coexisting atrial fibrillation and lung cancer with acceptable operative risks.

Changes in the recent three decades and survey on the current status of surgical treatment for esophageal cancer in China.

To review the changes and survey on status quo of the surgical treatment for esophageal cancer in China. The differences in diagnosis and treatment for esophageal cancer among hospitals in different regions across China were also investigated. We sent questionnaires to 46 hospitals across China, investigating the volume of esophageal cancer surgeries, surgical procedures, and perioperative management under the guidance of esophageal surgery chiefs. A total of 46 questionnaires were sent out and collected. The survey results showed that in the past 5 years, the volume of surgeries for esophageal cancer remained stable by 23.9% of those hospitals, increased by 30.4%, and decreased by 45.7%. Of those patients treated by surgery, 19.1% were in the early stages, and 80.9% were in locally advanced stages. In terms of surgical procedures, 73.4% of the patients were treated by minimally invasive surgery and 85.7% of esophageal substitutes were a gastric conduit, 93.1% of the substitutes were pulled to the neck through the esophageal bed. For the lymph node dissection, 78.5% of the patients had a complete two-field lymph node dissection including the para-recurrent laryngeal nerve lymph nodes. Of the patients with neoadjuvant therapy, 53.5% received chemotherapy or chemotherapy plus immunotherapy (47.0%), and 43.5% had chemoradiation. Currently, in China, minimally invasive surgery-oriented multimodality treatment, including complete two-field lymph node dissection, has become the standard approach for esophageal cancer management. Over the past decade, this standardized approach has significantly improved prognosis compared to previous decades.

Reoperation Rates After Initial Thyroid Lobectomy for Patients with Thyroid Cancer: A National Cohort Study.

Introduction: The 2015 American Thyroid Association (ATA) guidelines recommended thyroid lobectomy (TL) as an alternative to total thyroidectomy (TT) for the surgical treatment of low-risk differentiated thyroid cancer. Increasing use of TL has since been reported despite concerns for an increased risk of disease recurrence and need for reoperation. This study sought to compare reoperation rates among patients who underwent initial TL or TT for malignancy, characterize trends at centers based on operative volume, and examine factors associated with reoperation. Methods: We queried the Vizient Clinical Data Base for TL and TT performed preguideline change (pre-GC = 2013-2015) and postguideline change (post-GC = 2016-2021). Reoperations included reoperative thyroid surgery (RTS) and neck dissection (ND); timing was defined as early (≤180 days), thought to indicate inadequacy of initial operative choice, or late (>180 days), suggesting potential disease recurrence. Results: Of 65,627 patients, 31.8% underwent initial TL and 68.2% underwent initial TT; TL increased from 21.4% of total cases pre-GC to 37.0% post-GC (p < 0.001). Among TL patients, early RTS declined from 33.9% to 14.2% and ND declined from 0.8% to 0.4% (p < 0.001). Among TT patients, early RTS remained 0.2%, while ND increased from 0.4% to 0.7% (p < 0.001). TL-associated late RTS declined from 2.0% to 1.7%, while ND increased from 0.6% to 0.8% (p = 0.17). In TT patients, both late RTS and ND increased, from 0.2% to 0.3% (p = 0.04) and 1.7% to 2.1% (p < 0.01), respectively. There was no difference in the late reoperation rate for TL compared with TT post-GC (+0.2%, p = 0.18). TL volume grew annually by 12.5% [8.9-16.2%] at high-volume centers (HVCs) and 8.3% [5.6-11.1%] at low-volume centers (LVCs). TL-associated reoperations at HVCs declined annually by 12.6% [5.6-19.0%] and 10.8% [2.7-18.1%] at LVCs. Uninsured status and more recent initial operation were associated with an increased risk of late reoperation (HR = 1.84 [1.06-3.20] and HR = 1.30 [1.24-1.36], respectively). The type of index operation performed, however, was not predictive of late reoperation. Conclusions: The rate of early reoperations declined for TL after the 2015 ATA guideline release, but late reoperations remained unchanged despite a significant shift in practice patterns towards initial lobectomy. Patients appear to be receiving less aggressive, guideline-concordant care without a significant increase in the late reoperation rate for TL compared with TT.

Defining the Cross-Volume Effect of Extracorporeal Life Support on Outcomes of Cardiogenic Shock

BackgroundCardiogenic shock (CS) remains a leading cause of mortality despite advancements in mechanical circulatory support and other management strategies. In particular, venoarterial extracorporeal membrane oxygenation (ECMO) requires expertise in cardiac surgery, cardiology, and critical care. The benefits of such expertise may extend beyond patients undergoing ECMO. MethodsHospitalizations in adults (aged ≥18 years) with a primary diagnosis of CS who were not undergoing ECMO, cardiac operations, durable left ventricular assist device therapy, or heart transplantation were abstracted from the 2016-2020 Nationwide Readmissions Database. Multivariable regression models were developed to assess the association of cardiac surgical and ECMO institutional caseload with clinical and financial outcomes. ResultsOf an estimated 70,339 patients with CS identified for study, 33,643 (47.8%) were treated at a high-volume hospital for ECMO (HVH-ECMO). HVH-ECMO was associated with decreased odds of in-hospital mortality (adjusted odds ratio [aOR], 0.85; 95% CI, 0.75-0.95), respiratory complications (aOR, 0.86; 95% CI, 0.79-0.94), and nonhome discharge (aOR, 0.86; 95% CI, 0.79-0.94). However, HVH-ECMO was associated with a longer length of stay by 1.7 days (95% CI, 1.3-2.1) and higher inpatient costs by $9170 (95% CI, $6,490-$12,060). Although ECMO volume was inversely associated with the predicted risk of in-hospital mortality, institutional volume of cardiac operations was not significantly associated with mortality. ConclusionsOur findings suggest improved outcomes for patients with CS who were treated at an HVH-ECMO. Multidisciplinary care pathways, including those among surgery, cardiology, and critical care, may influence CS management. Further studies are needed to characterize long-term outcomes of regionalization and ensure equitable access for all populations.

Does Severity of Chronic Urinary Retention as Estimated by Preoperative Residual Urine Estimation Negatively Impact the Outcome of Holmium Laser Enucleation of the Prostate?

ObjectivesTo evaluate the influence of preoperative post-void residual (PVR) volume on the outcomes of Holmium Laser Enucleation of the Prostate (HoLEP). Long term bladder obstruction can impair bladder contractility, which has been linked to failure to improve lower urinary tract symptoms (LUTS) after bladder outlet procedures. Elevated PVR constitutes a proxy for chronic retention and detrusor underactivity that can be non-invasively determined in office. MethodsWe evaluated men undergoing “en-bloc” HoLEP from July 2017 to August 2022 from our prospectively maintained database. PVR, prostate-specific antigen, International Prostate Symptom Score (IPSS) and uroflowmetry were assessed before surgery, at 3 months, 6 months and 1 year post- operatively. Patients’ clinical characteristics and outcomes were compared according to preoperative PVR measurement by Group 1 (< 100 ml), Group 2 (101-300 ml), Group 3 (301-600 ml), and Group 4 (>600 ml). ResultsWe included 318 men and found no significant differences between groups regarding clinical or perioperative characteristics including operative time, resected volume, catheter time and complications. Post-operative improvement in voiding parameters was found to be similar in all four groups up to one year of follow up. ConclusionsSeverity of chronic urinary retention did not impact the outcomes of HoLEP, which provided great improvement in voiding parameters to men with LUTS secondary to benign prostatic hyperplasia, with no significant differences in outcomes between patient with preoperative PVR < 100 ml or > 600 ml. These findings should assist in reassuring patients with large bladder capacity that HoLEP can provide them with excellent functional voiding outcomes.

Predicting the future caretakers of traumatic vascular injury management via operative exposure among surgical trainees

BackgroundThe management of vascular trauma requires specialized training and expertise. Although traumatic vascular injury is treated currently by both vascular and trauma surgeons in modern practice, it remains unclear who will inherit the role of managing vascular trauma in the coming decades. In this study, we examined disparities in operative experience in vascular trauma among surgical trainees across different surgical specialties. MethodsAccreditation Council for Graduate Medical Education national operative log reports were collected for graduating vascular surgery residents (VSRs), vascular surgery fellows (VSFs), and general surgery residents (GSRs) from 2012 to 2022. Total operative volume for traumatic vascular injury was examined, as were the five major contributing operative domains (neck, thoracic, abdominal, peripheral, and fasciotomy). ResultsA total of 22,052 GSRs, 334 VSRs, and 1672 VSFs graduated over the 10-year study period. VSR had the highest vascular trauma case volume (24.9 ± 3.9 cases/5 years), followed by VSF (22.1 ± 1.5 cases/2 years) then GSR (2.4 ± 0.3 cases/5 years; P < .001). Thoracic vessel exploration/repair (0.7 cases vs 0.6 cases vs 0.0 cases), abdominal vessel exploration/repair (1.0 cases vs 0.9 cases vs 0.0 cases), neck vessel exploration/repair (4.0 cases vs 3.4 cases vs 0.2 cases), peripheral vessel exploration/repair (12.1 cases vs 9.5 cases vs 1.1 cases), and lower extremity fasciotomy for trauma (7.2 cases vs 7.6 cases vs 1.1 cases) were most frequent among the VSR and VSF groups (P < .001 each). On linear regression analysis, both VSF (+0.5 cases/y; R2 = 0.81; P < .001) and GSR (+0.1 cases/y; R2 = 0.75; P = .001) groups experienced a growth in vascular trauma volume. Contrariwise, vascular trauma volume did not change among graduating VSRs (R2 = 0.13; P = .31). ConclusionsDedicated vascular surgical training provides the highest operative exposure to civilian vascular trauma in the United States.