https://journals.lww.com/annalsofsurgery/pages/currenttoc.aspx Surgery! en-us Fri, 08 Aug 2025 04:17:14 -0500 Wolters Kluwer Health RSS Generator https://images.journals.lww.com/annalsofsurgery/XLargeThumb.00000658-202508000-00000.CV.jpeg https://journals.lww.com/annalsofsurgery/pages/currenttoc.aspx https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/thank_you,_dr_keith_lillemoe,_for_your_service_to.1.aspx No abstract available]]> Tue, 06 May 2025 00:00:00 GMT-05:00 00000658-202508000-00001 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/change_is_hardest_right_before_the_glass_ceiling.2.aspx Objectives: This study aims to provide a comprehensive update on the representation of women in academic surgery by specialty, measuring progress and opportunity with regard to women “breaking” the glass ceiling at the trainee, faculty, and department chair levels. Background: Over the past 2 decades, initiatives have contributed to educational awareness, culture shifts, and a focus on inclusive excellence in surgery, leading to an increase in the number of women surgeons. Despite progress, a persistent gender gap in surgical faculty positions remains, and projections suggest that it will take more than a century to reach parity at the highest levels of academic surgery. Methods: Data from the Association of American Medical Colleges' FACTS and Faculty Rosters and the American Medical Colleges' Graduate Medical Education reports from 2006 to 2023 were analyzed to assess gender representation in surgery. Linear regression analyses were used to describe trends in the proportions of women who were promoted along the professional development pathway (resident to faculty to department chair) from 2006 to 2023. Results: Over our 17-year study period, all included surgical subspecialties increased in the proportion of women trainees, with the largest average annual increases observed in pediatric, plastic, and vascular surgery training programs. Although all surgical faculty levels experienced growth in the proportion of women faculty, the average annual change in the proportion of women decreased as seniority increased. At the observed trend, it is projected that surgical department chairs will not achieve equal proportions of men and women until the year 2102. Conclusions: Across the board, the proportion of women in surgery has increased. However, there remains opportunity for improvement, particularly at the senior faculty and department chair levels.]]> Mon, 07 Apr 2025 00:00:00 GMT-05:00 00000658-202508000-00002 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/can_women_surgeons_have_it_all__if_not_now,_when_.3.aspx No abstract available]]> Wed, 28 May 2025 00:00:00 GMT-05:00 00000658-202508000-00003 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/impact_of_rural_exposure_during_general_surgery.4.aspx Objective: 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. Background: 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. Methods: We performed a retrospective cohort study of U.S. general surgery residency graduates from 2011 to 2020. Program information was abstracted from residency websites, the American College of Surgeons, 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. Results: Of 11,407 surgeons, 6.2% reported working in rural communities. Graduates of programs with rural training, according to residency websites or the American College of Surgeons, were more likely to work in rural areas [odds ratio: 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. Conclusions: 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.]]> Wed, 19 Mar 2025 00:00:00 GMT-05:00 00000658-202508000-00004 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/rural_surgery_needs_a_strategy,_not_just_another.5.aspx No abstract available]]> Fri, 21 Mar 2025 00:00:00 GMT-05:00 00000658-202508000-00005 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/beyond_the_scalpel__tackling_challenges_faced_by.6.aspx No abstract available]]> Wed, 02 Apr 2025 00:00:00 GMT-05:00 00000658-202508000-00006 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/an_alternative_to__checkmark_credentialing__for.7.aspx No abstract available]]> Wed, 09 Apr 2025 00:00:00 GMT-05:00 00000658-202508000-00007 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/introducing_a_new_annals_of_surgery_section_.8.aspx No abstract available]]> Thu, 08 May 2025 00:00:00 GMT-05:00 00000658-202508000-00008 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/reconsidering_abdominal_drainage_after_left.9.aspx Objective: To evaluate intra-abdominal drainage after left pancreatectomy (LP), as it has been a longstanding practice to mitigate postoperative complications, particularly postoperative pancreatic fistulas. Background: Recent studies challenge the necessity of routine drainage, suggesting potential benefits in omitting drains. Methods: The PANDRA II trial was a randomized controlled noninferiority study conducted at the University Hospital Heidelberg between 2017 and 2023. It compared outcomes between patients undergoing open or minimally invasive LP with and without abdominal drainage. The primary endpoint was overall postoperative morbidity assessed by the Comprehensive Complication Index (CCI). Results: A total of 246 patients were included in the intention-to-treat analysis (125 with drainage, 121 without drainage). The no-drain group demonstrated noninferiority to the drain group in terms of CCI (13.90 ± 16.51 vs 19.43 ± 16.92, P < 0.001 for noninferiority). Moreover, the no-drain group had lower overall complication rates (50.41% vs 78.40%, P < 0.001). Specific complications such as postoperative pancreatic fistula (14.88% vs 20.8%, P = 0.226) and postpancreatectomy hemorrhage (4.96% vs 4.80%, P > 0.999) did not differ significantly between groups. Conclusions: The results of the PANDRA II trial demonstrate that omitting routine abdominal drainage after LP is noninferior to placing routine abdominal drainage regarding morbidity measured by the CCI. Omitting a routine abdominal drainage even led to a significant reduction in the overall complication rate.]]> Wed, 05 Feb 2025 00:00:00 GMT-06:00 00000658-202508000-00009 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/reduction_of_central_venous_pressure_in_elective.10.aspx Objective: To compare perioperative outcomes in patients undergoing minimally invasive liver surgery (MILR) with or without central venous pressure (CVP) reduction (≤5 mm Hg). Background: Reduction of CVP during parenchymal transection is widely accepted in open hepatectomy to reduce intraoperative blood loss, as a major predictor of postoperative outcomes. However, the effect of CVP reduction on blood loss in MILR remains unclear. Methods: This study is a randomized controlled, double-blinded trial. Patients undergoing elective MILR between August 2020 and April 2023 were equally randomized to either no CVP reduction (No CVP reduction group) or CVP reduction by anesthesiological interventions (CVP reduction group). The remaining perioperative care was kept identical between groups. The primary endpoint was total intraoperative blood loss. Results: In total, 120 patients were randomized and 112 were analyzed. Baseline characteristics did not differ between groups. Total intraoperative blood loss in MILR was equivalent between groups [No CVP reduction: 280 mL (120–560) vs CVP reduction: 360 mL (150–640); P = 0.30], despite higher CVP values during resection in the No CVP reduction group (9.3 mm Hg ± 4.2 vs 3.2 mm Hg ± 2.2; P < 0.001). Similarly, there was no difference in blood loss during parenchymal transection between the No CVP reduction (220 mL; 80–400) and the CVP reduction group (240 mL; 110–560; P = 0.39). Postoperative 90-day mortality (No CVP reduction: n=3, 5% versus CVP reduction: n=2, 4%; P = 0.68) and total morbidity rates (No CVP reduction: n = 10, 18% vs CVP reduction: n = 11, 20%; P = 0.77) were comparable. Intraoperative hemodynamic instability was less frequent in the No CVP reduction group (n = 7, 12% vs CVP reduction group: n = 16, 30%; P = 0.03). Conclusions: MILR without CVP reduction during liver transection is safe and is not associated with increased intraoperative blood loss. Moreover, a no CVP reduction strategy might prevent potential adverse effects of fluid restriction in MILR, such as hemodynamic instability.]]> Tue, 08 Apr 2025 00:00:00 GMT-05:00 00000658-202508000-00010 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/telesurgery__a_systematic_literature_review_and.11.aspx Objective: To undertake a systematic review of the medical literature on telesurgery, with a key focus on identifying the key technical and nontechnical themes searched in medical articles and to analyze gaps in the current knowledge base on telesurgery. Background: It has now been over 2 decades since the first successful case of telesurgery and since this time, there have been significant technological and telecommunications advancements. Methods: A systematic review of the literature was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Details of the protocol for this systematic review were registered on PROSPERO (CRD42024511530). Results: In total, 102 unique references were allocated into 5 categories: technical, cybersecurity, ethical, financial, and regulatory considerations to discuss key themes. The vast majority of references were related to technical considerations, which have demonstrated the feasibility of telesurgery. The nontechnical considerations have a paucity of literature and a lack of guidance on telesurgery which appears to still be the major barriers to telesurgery. Conclusions: Telesurgery presents many interdisciplinary challenges, encompassing both important technical and nontechnical (such as cybersecurity, ethical, financial, and regulatory) considerations. Further research, collaboration between stakeholders, a collaborative community of experts, and the development of comprehensive consensus frameworks are essential steps toward the widespread adoption of telesurgery.]]> Tue, 22 Oct 2024 00:00:00 GMT-05:00 00000658-202508000-00011 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/association_of_opioid_prescribing_and_consumption.12.aspx Objective: To investigate the relationships among opioid prescribing, consumption, and patient-reported outcomes (PROs) in patients undergoing emergency surgery. Background: Overprescribing of opioids for pain management after surgery has become a public health concern and a major contributor to opioid misuse and dependency. Current guidelines do not address opioid prescribing after emergency surgical procedures, highlighting the importance of understanding the relationship between opioid prescribing and consumption in this setting. Methods: Retrospective analysis of the quantity of opioids prescribed and PROs in a population-based setting. The sample included adults ≥18 years undergoing emergency surgery across 69 hospitals in Michigan. Patients were included if they received a discharge opioid prescription and had valid data for opioid consumption and PROs. Surgical procedures took place between January 1, 2018 and December 31, 2020. Results: During the study period, a total of 3742 patients underwent an emergency operation. The mean number of opioid pills prescribed was 9.6 and the mean number of opioid pills consumed was 4.6. In a 2-model with logit in the first part and a linear regression in the second, prescription size was significantly associated with both the probability of consumption (adjusted odds ratio: 1.02; 95% CI: 1.01–1.04) and the amount of consumption conditional on any consumption (coefficient: 0.70; 95% CI: 0.54–0.86). Conclusions: Patients only consumed half of the opioids they were prescribed after undergoing emergency surgery. In addition, patients who were given larger prescriptions consumed more opioids, but did not experience less pain, higher satisfaction, better quality of life, or less regret to undergo surgery. Overall, this suggests that opioids may be excessively prescribed to patients undergoing emergency surgical procedures and that larger prescriptions do not improve the patient experience after surgery.]]> Thu, 14 Mar 2024 00:00:00 GMT-05:00 00000658-202508000-00012 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/the_association_of_preoperative_opioid_use_with.13.aspx Objective: To examine the association of prescription opioid fills over the year before surgery with postoperative outcomes. Background: Nearly one-third of patients report opioid use in the year preceding surgery, yet an understanding of how opioid exposure influences patient-reported outcomes after surgery remains incomplete. Therefore, this study was designed to test the hypothesis that preoperative opioid exposure may impede recovery in the postoperative period. Methods: This retrospective cohort study used a statewide clinical registry from 70 hospitals linked to opioid fulfillment data from the state’s prescription drug monitoring program to categorize patients’ preoperative opioid exposure as none (naïve), minimal, intermittent, or chronic. Outcomes were patient-reported pain intensity (primary), as well as 30-day clinical and patient-reported outcomes (secondary). Results: Compared with opioid-naïve patients, opioid exposure was associated with higher reported pain scores at 30 days after surgery. Predicted probabilities were higher among the opioid exposed versus naive group for reporting moderate pain [43.5% (95% CI: 42.6%–44.4%) vs 39.3% (95% CI: 38.5%–40.1%)] and severe pain [13.% (95% CI: 12.5%–14.0%) vs 10.0% (95% CI: 9.5%–10.5%)], and increasing probability was associated increased opioid exposure for both outcomes. Clinical outcomes (incidence of emergency department visits, readmissions, and reoperation within 30 days) and patient-reported outcomes (reported satisfaction, regret, and quality of life) were also worse with increasing preoperative opioid exposure for most outcomes. Conclusions: This study is the first to examine the effect of presurgical opioid exposure on both clinical and nonclinical outcomes in a broad cohort of patients and shows that exposure is associated with worse postsurgical outcomes. A key question to be addressed is whether and to what extent opioid tapering before surgery mitigates these risks after surgery.]]> Thu, 14 Mar 2024 00:00:00 GMT-05:00 00000658-202508000-00013 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/_there_s_so_much_that_they_re_enduring__.14.aspx Objective: This qualitative study aimed to explore the psychosocial experience of older adults undergoing major elective surgery from the perspective of both the patient and family caregiver. Summary Background Data: Older adults face unique psychological and social vulnerabilities that can increase susceptibility to poor health outcomes. How these vulnerabilities influence surgical treatment and recovery is understudied in the geriatric surgical population. Methods: Adults aged 65 and older undergoing a high-risk major elective surgery at the University of California, San Francisco and their caregivers were recruited. Semi-structured interviews were conducted at three time points: 1 to 2 weeks before surgery, and at 1- and 3-months following surgery. An inductive qualitative approach was used to identify underlying themes. Results: Twenty-five older adult patients (age range 65–82 years, 60% male) and 11 caregivers (age range 53–78 years, 82% female) participated. Three themes were identified. First, older surgical patients experienced significant challenges to emotional well-being both before and after surgery, which had a negative impact on recovery. Second, older adults relied on a combination of personal and social resources to navigate these challenges. Lastly, both patients and caregivers desired more resources from the healthcare system to address “the emotional piece” of surgical treatment and recovery. Conclusions: Older adults and their caregivers described multiple overlapping challenges to emotional well-being that spanned the course of the perioperative period. Our findings highlight a critical component of perioperative care with significant implications for the recovery of older surgical patients.]]> Tue, 09 Apr 2024 00:00:00 GMT-05:00 00000658-202508000-00014 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/accuracy_of_conflicts_in_interest_in_general.15.aspx Objective: To evaluate the accuracy of self-reported conflicts of interest (COIs) for articles published in prominent minimally invasive and general surgical journals. Background: Accurate reporting of industry relationships and COIs is crucial for unbiased assessment of a particular study. Despite the enactment of COI laws, such as the Physician Payments Sunshine Act in 2010, prior work suggests that 40% to 70% of self-reported COIs have discrepancies. Methods: We utilized 3 public databases—Open Payments (USA), Disclosure UK, and Disclosure Australia—to assess the accuracy of COI disclosures among authors of 918 published articles from these respective countries. Seven journals were utilized to review the COIs for authors of manuscripts published in 2022—JAMA Surgery, Annals of Surgery, British Journal of Surgery (BJS), Journal of American College of Surgeons (JACS), Surgical Endoscopy, Obesity Surgery, and Surgery for Obesity and Related Diseases (SOARD). Results: Among the analyzed 6206 authors, 5675 belonged to countries of interest: United States (4282), UK (718), and Australia (213). Of these, 774 authors (12.5%) self-reported a conflict of interest in their papers. Overall, only 4055 researchers (69.1%) reported COIs accurately. Authors from the United States had the lowest accuracy of reporting COI at 69% as opposed to the UK (93%) and Australia (96%). Inaccurate COI reporting was most common in corresponding/senior authors (39%) and least common among first authors (18%). Most payments in excess of $50,000 made to authors by an industry sponsor were not disclosed appropriately. Conclusions: Our study shows that inaccuracy of self-reported COIs in general surgery journals remains high at 31%. While our findings should encourage authors to overreport any possible COI, journals should consider verifying the authors’ COI to facilitate more accurate reporting.]]> Fri, 19 Apr 2024 00:00:00 GMT-05:00 00000658-202508000-00015 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/overlapping_surgery_verbiage_in_informed_consent.16.aspx Objective: To assess informed consent documents from U.S. institutions for verbiage regarding overlapping surgery. Background: Overlapping surgery remains a controversial practice. Recent guidance from the Senate Finance Committee and American College of Surgeons emphasizes transparency with patients regarding this practice through the informed consent process, but it remains unclear how many institutions adopted their recommendations. Methods: Informed consent documents were collected from a national sample of 104 institutions and assessed for verbiage regarding overlapping surgery and/or attending absence during a surgical case. The verbiage of these forms was further analyzed for inclusion of key terms (e.g., “overlapping surgery,” “critical portions”), as well as transparency regarding surgeon absence. Results: Thirty (29%) forms included verbiage regarding overlapping surgery and/or surgeon absence during a case. Most of these 30 utilized the terms “overlapping surgery” or “critical portions” (18 [60%] and 25 [83%], respectively), although only 3 (10%) explicitly stated that portions of the procedure that may be performed in the absence of the attending surgeon. Six forms (20%) specifically stated who may perform the procedure without the attending present, and 3 forms (10%) had patients acknowledge this section of the consent form with an additional signature or initial. Only 2 of the forms (7%) fulfilled all of the criteria set forth by the Senate Finance Committee. Conclusions: Detailed information regarding overlapping surgery is infrequently included in hospitals’ procedure informed consent documents. Forms that include this information rarely provide explicit statements of attending presence and trainee participation, raising concerns regarding surgeon-patient transparency.]]> Mon, 06 May 2024 00:00:00 GMT-05:00 00000658-202508000-00016 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/outcomes_from_871,441_consecutive_surgical.17.aspx Objective: To isolate the impact of subsumed surgery (a shorter procedure completed entirely during overlapping noncritical portions of a longer antecedent procedure) on patient outcomes. Summary Background Data: The American College of Surgeons recently recommended the elimination of “concurrent surgery” with overlap during a procedure’s critical portions. Guidelines for nonconcurrent overlap have been established, but the safety of subsumed surgery remains to be examined. Methods: All consecutive procedures from 2013 to 2021 within a multihospital academic medical center were included (n=871,441). Simple logistic regression was performed to compare postoperative events between patients undergoing non-overlaping surgery (n=533,032) and completely subsumed surgery (n=11,319). Thereafter, coarsened exact matching was used to match patients with non-overlaping and subsumed surgery 1:1 on CPT code, 18 demographic features, baseline health characteristics, and procedural variables (n=7,146). Exact-matched cases were subsequently limited to pairs performed by the same surgeon (n=5,028). Primary outcomes included 30-day readmission, ED visits, and reoperations. Results: Univariate analysis suggested that subsumed surgery had a higher 30-day risk of readmission (OR 1.55, P<0.0001), ED evaluation (OR 1.19, P<0.0001), and reoperation (OR 1.98, P<0.0001). When comparison was limited to the exact same procedure and patients were matched on demographics and health characteristics, there were no outcome differences between patients with subsumed surgery and non-overlapping surgery, even when limiting analyses to the same surgeon. Conclusions: Similar surgeries for similar patients result in similar outcomes whether they are performed completely subsumed or without overlap. Individual surgeons performing a specific procedure have no outcome differences with subsumed and non-overlapping cases.]]> Fri, 10 May 2024 00:00:00 GMT-05:00 00000658-202508000-00017 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/predicting_mortality_before_interhospital_hospital.18.aspx Objective: Develop and validate a mortality risk calculator that could be utilized at the time of transfer, leveraging routinely collected variables that could be obtained by trained nonclinical transfer personnel. Background: There are no objective tools to predict mortality at the time of interhospital transfer for Emergency General Surgery patients that are “unseen” by the accepting system. Methods: Patients transferred to general or colorectal surgery services from January 2016 to August 2022 were retrospectively identified and randomly divided into training and validation cohorts (3:1 ratio). The primary outcome was admission-related mortality, defined as death during the index admission or within 30 days postdischarge. Multiple predictive models were developed and validated. Results: Among 4664 transferred patients, 280 (6.0%) experienced mortality. Predictive models were generated utilizing 19 routinely collected variables; the penalized regression model was selected over other models due to excellent performance using only 12 variables. The model performance on the validating set resulted in an area under the receiver operating characteristic curve, sensitivity, specificity, and balanced accuracy of 0.851, 0.90, 0.67, and 0.79, respectively. After bias correction, the Brier score was 0.04, indicating a strong association between the assigned risk and the observed frequency of mortality. Conclusions: A risk calculator using 12 variables has excellent predictive ability for mortality at the time of interhospital transfer among “unseen” Emergency General Surgery patients. Quantifying a patient’s mortality risk at the time of transfer could improve patient triage, bed and resource allocation, and standardize care.]]> Fri, 10 May 2024 00:00:00 GMT-05:00 00000658-202508000-00018 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/making_choices__a_multi_institutional,.19.aspx Objective: To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). Background: Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT, resulting in outcomes that do not align with their preferences. Methods: Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from November 2019 to June 2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points among 10 outcomes. t tests and Hotelling T2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs lobectomy). Results: Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less (P<0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice and more points to energy levels (P<0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT (P<0.05). Conclusions: The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.]]> Mon, 20 May 2024 00:00:00 GMT-05:00 00000658-202508000-00019 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/intraductal_papillary_mucinous_neoplasm.20.aspx Objective: To examine whether long-term surveillance of intraductal papillary mucinous neoplasms (IPMNs) leads to early diagnosis and better clinical outcomes of pancreatic ductal adenocarcinomas (PDACs) developing concomitantly with IPMNs. Background: Long-term image-based surveillance is recommended for patients with low-risk IPMNs. However, it is unknown whether the surveillance can improve surgical and survival outcomes of patients with concomitant PDACs. Methods: Using a prospective single-institutional cohort of 4620 patients with pancreatic cysts, including 3638 IPMN patients, we identified 63 patients who developed concomitant PDAC during long-term surveillance. We compared the overall survival of 46 cases with concomitant PDAC to that of 460 matched cases diagnosed with non-IPMN-associated PDAC at the same institution. Multivariable hazard ratios and 95% CIs for overall mortality were computed using the Cox regression model with adjustment for potential confounders. Results: Concomitant PDACs were identified at an earlier cancer stage compared to non-IPMN–associated PDACs, with 67% and 38% cases identified at stage 2 or earlier, respectively (P<0.001) and 57% and 21% cases with R0 resection, respectively (P<0.001). Compared with non-IPMN-associated PDACs, concomitant PDACs were associated with longer overall survival (P=0.034) with a multivariable hazard ratio of 0.61 (95% CI: 0.39–0.96). The 5-year survival rate of patients with concomitant PDAC was higher compared with patients with non-IPMN-associated PDAC (34% vs 18%, respectively; P=0.018). Conclusions: The surveillance for patients with IPMNs was associated with early identification of concomitant PDACs and longer survival of patients diagnosed with this malignancy.]]> Wed, 20 Mar 2024 00:00:00 GMT-05:00 00000658-202508000-00020 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/postoperative_hyperamylasemia__poh__is_an_early.21.aspx Objectives: The aim of this international multicentric study is to characterize postoperative hyperamylasemia (POH) after distal pancreatectomy (DP), with particular focus on its relationship with postoperative pancreatic fistula (POPF) occurrence and severity. Background: The clinical relevance of POH after DP and its relationship with the occurrence and severity of POPF have not been explored yet. Methods: All patients undergoing DP for any indication between 2015 and 2021 at 3 European referral centers for pancreatic surgery were retrospectively analyzed. Drain fluid amylase, C-reactive protein, and serum amylase were examined from postoperative day (POD) 1 to 3. Biochemical leak, POPF, POH, and postpancreatectomy hemorrhage were defined and graded according to ISGPS definitions. Results: In total, 1192 patients were included. Overall rates of POH and POPF were 18% (n= 210) and 29% (n= 344), respectively. The presence of drain fluid amylase ≥2000 U/L on POD 1 (OR=2.11, 95% CI: 1.68–2.86), C-reactive protein ≥200 mg/L on POD 3 (OR=2.19, 95% CI: 1.68–2.86), and POH (OR=1.58, 95% CI: 1.14–2.19) were all independent early predictors of POPF (all P<0.01). The presence of POH almost doubled the rate of POPF (43% vs 26%, P<0.001), and higher POPF severity presented also higher POH rates (no POPF=12%; biochemical leak=19%; B POPF=24%; C POPF=52%). Among patients developing POPF, patients with POH had higher rates of postpancreatectomy hemorrhage (22% vs 9%, P=0.001), sepsis (24% vs 13%; P=0.011), reoperation (21% vs 8%; P< 0.01), and mortality (3% vs 0.3%; P=0.025). Conclusions: The occurrence of POH is an early predictor of POPF and its severity after DP. The diagnosis of POH might define patients at higher risk for a complicated course, targeting them for prevention/mitigation strategies against pancreas-specific complications.]]> Fri, 02 Feb 2024 00:00:00 GMT-06:00 00000658-202508000-00021 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/preoperative_covid_19_vaccination_is_associated.22.aspx Objective: The objective of this study was to examine the effect of COVID-19 vaccination on perioperative outcomes after major vascular surgery. Background: COVID-19 vaccination is associated with decreased mortality in patients undergoing various surgical procedures. However, the effect of vaccination on perioperative mortality after major vascular surgery is unknown. Methods: This is a multicenter retrospective study of patients who underwent major vascular surgery between December 2021 and August 2023. The primary outcome was all-cause mortality within 30 days of index operation or before hospital discharge. Multivariable models were used to examine the association between vaccination status and the primary outcomes. Results: Of the total 85,424 patients included, 19,161 (22.4%) were unvaccinated. Unvaccinated patients were younger compared with vaccinated patients (mean age 68.44 +/− 10.37 y vs 72.11 +/− 9.20 y, P<0.001) and less likely to have comorbid conditions, including hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dialysis. After risk factor adjustment, vaccination was associated with decreased mortality (OR 0.7, 95% CI: 0.62–0.81, P<0.0001). Stratification by procedure type demonstrated that vaccinated patients had decreased odds of mortality after open abdominal aortic aneurysm (OR 0.6, 95% CI: 0.42–0.97, P=0.03), endovascular aneurysm repair (OR 0.6, 95% CI: 0.43–0.83, P=0.002), carotid artery stenting (OR 0.7, 95% CI: 0.51–0.88, P=0.004) and infrainguinal lower extremity bypass (OR 0.7, 95% CI: 0.48–0.96, P=0.03). Conclusions: COVID-19 vaccination is associated with reduced perioperative mortality in patients undergoing vascular surgery. This association is most pronounced in patients undergoing aortic aneurysm repair, carotid stenting, and infrainguinal bypass.]]> Fri, 10 May 2024 00:00:00 GMT-05:00 00000658-202508000-00022 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/a_method_for_continuous_surgeon_improvement_in.23.aspx Objective: To develop and analyze a risk-adjusted cumulative sum (RA-CUSUM) chart as a potential method to monitor individual surgeon performance in robotic total mesorectal excision (TME) for rectal cancer. Background: Currently, surgeons lack real-time tools to monitor and enhance their performance beyond residency completion. While national quality programs exist, granular, individual-level data are crucial for continuous improvement. Previous studies suggest cumulative sum charts hold promise in identifying performance trends and outliers. Methods: This retrospective study analyzed data from 640 robotic TME cases performed by 12 surgeons at 2 institutions. RA-CUSUM charts were generated for 3 outcomes: (1) complications, (2) operative time, and (3) length of stay. Results: The overall RA-CUSUM curves for operative time and complications showed an initial learning phase, followed by a plateau or downward slope, indicating proficiency or improvement. However, individual surgeon curves revealed significant heterogeneity. Three surgeons consistently excelled in operative time, while 5 minimized complications most effectively. Potential quality improvement could be implemented to drive performance toward positive outliers. No differences were found in unadjusted outcomes, including conversion, number of lymph nodes harvested, and positive circumferential margins. Conclusions: The RA-CUSUM chart is a promising method for identifying individual surgeon performance in robotic TME. It could help surgeons, teams, and leaders identify improvement areas and benchmark themselves against positive outliers. Further studies are needed to explore the potential of RA-CUSUM for implementing interventions to improve surgical quality.]]> Mon, 06 May 2024 00:00:00 GMT-05:00 00000658-202508000-00023 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/association_of_lateral_pelvic_lymph_nodes_with.24.aspx Objective: To assess the significance of enlarged lateral lymph nodes (LLN) for disease recurrence, metastasis, and organ preservation in patients with rectal cancer. Background: Optimal treatment of rectal adenocarcinoma involving LLN is subject to debate. Methods: A post hoc analysis of the Organ Preservation in Rectal Adenocarcinoma trial, a multicenter study of patients with rectal cancer treated with total neoadjuvant therapy (TNT) followed by total mesorectal excision or watch-and-wait management. We analyzed the association of visible LLN (LLN+), LLN ≥7 mm (short axis) on baseline magnetic resonance imaging (MRI), and LLN ≥4 mm on restaging MRI with recurrence, metastasis, and rectum preservation. Results: At baseline, 57 out of 324 (18%) patients had LLN+. In 30 (53%) of 57 patients with LLN+ on baseline MRI, the LLN disappeared after TNT. Disease recurrence in LLN was rare (3.5% of patients with LLN+ and 0.4% of patients with LLN−). All patients with recurrence in LLN also had distant metastasis. The rate of organ preservation was significantly lower in patients with LLN ≥4 mm on restaging MRI (P = 0.013). We found no significant differences in rates of local recurrence or metastasis between patients with LLN+ versus LLN− and in patients with LLN ≥7 versus <7 mm on baseline MRI. LLN dissection was performed in 3 patients; 2 of them died of distant metastasis. Conclusions: LLN involvement is not associated with disease recurrence or metastasis, but persistence of LLN ≥4 mm after TNT is negatively associated with rectum preservation in patients with locally advanced rectal cancer treated with TNT. Dissection of lateral nodes likely benefits few patients.]]> Mon, 22 Apr 2024 00:00:00 GMT-05:00 00000658-202508000-00024 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/appendectomy_and_long_term_colorectal_cancer.25.aspx Objective: To test hypotheses that appendectomy history might lower long-term colorectal cancer risk and that the risk reduction might be strong for tumors enriched with Fusobacterium nucleatum, bacterial species implicated in colorectal carcinogenesis. Background: The absence of the appendix, an immune system organ and a possible reservoir of certain pathogenic microbes, may affect the intestinal microbiome, thereby altering long-term colorectal cancer risk. Methods: Utilizing databases of prospective cohort studies, namely the Nurses’ Health Study and the Health Professionals Follow-up Study, we examined the association of appendectomy history with colorectal cancer incidence overall and subclassified by the amount of tumor tissue Fusobacterium nucleatum​​ (Fusobacterium animalis). We used an inverse probability weighted multivariable-adjusted duplication-method Cox proportional hazards regression model. Results: During the follow-up of 139,406 participants (2,894,060 person-years), we documented 2811 incident colorectal cancer cases, of which 1065 cases provided tissue Fusobacterium nucleatum analysis data. The multivariable-adjusted hazard ratio of appendectomy for overall colorectal cancer incidence was 0.92 (95% CI, 0.84−1.01). Appendectomy was associated with lower Fusobacterium nucleatum-positive cancer incidence (multivariable-adjusted hazard ratio, 0.53; 95% CI, 0.33−0.85; P=0.0079), but not Fusobacterium nucleatum-negative cancer incidence (multivariable-adjusted hazard ratio, 0.98; 95% CI, 0.83−1.14), suggesting a differential association by Fusobacterium nucleatum status (Pheterogeneity=0.015). This differential association appeared to persist in various participant/patient strata including tumor location and microsatellite instability status. Conclusions: Appendectomy likely lowers the future long-term incidence of Fusobacterium nucleatum-positive (but not Fusobacterium nucleatum-negative) colorectal cancer. Our findings do not support the existing hypothesis that appendectomy may increase colorectal cancer risk.]]> Mon, 06 May 2024 00:00:00 GMT-05:00 00000658-202508000-00025 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/international_collaborative_study_comparing.26.aspx Objective: With an increasing life expectancy, more octogenarian patients are referred with complex aortic aneurysms (cAAA). The aim of this study was to evaluate short and mid-term outcomes following fenestrated aortic repair (FEVAR) in octogenarians. Background: Few studies looking at octogenarian-specific outcomes with diverging results. Methods: Retrospective, multicentre cohort study including consecutive patients undergoing elective FEVAR for cAAAs or type IV thoracoabdominal aortic aneurysms between 2007 and 2022 in 8 high-volume centres. Octogenarians versus nonoctogenarians were compared. The primary outcome was 30-day mortality. Secondary outcomes included 1-, 2-, and 5-year survival and reintervention rates. Results: A total of 729 patients [median age of 74.8 years (IQR: 69.2–79.14 years)] were included, 169 (23%) of which were octogenarians, with 316 (43.3%) patients undergoing juxtarenal/pararenal aneurysm repair. Although octogenarians presented less complex but larger (61 vs 58 mm) aneurysms, the number of fenestrations was similar across groups. No differences in in-hospital mortality (4.1% vs 3.0%), MAE (16.6% vs 12.2%) or reintervention rates (11.2% vs 10%) were found. Multivariable logistic regression of in-hospital mortality identified BMI (OR=0.66, 95% CI: 0.51–0.95, P=0.003), chronic heart failure (OR=7.70, 95% CI: 1.36–36.15, P=0.003), and GFR<45 mL/min/1.73 m2 (OR=5.25, 95% CI: 1.20–22.86, P=0.027) as independent predictors. Median follow-up was 41 months. The 1-, 2-, and 5-year survival rates were 91.3%, 81.8%, and 49.5% in octogenarians versus 90.6%, 86.5%, and 68.8% in nonoctogenarian patients (log-rank=0.001). Freedom from aortic-related death and freedom from reintervention at 5 years were similar across groups (log-rank=0.94 and 0.76, respectively). Age above 80 years was not an independent predictor of 30-day or long-term mortality on multivariable and Cox regression analysis. Conclusions: Elective FEVAR in octogenarians appears to be safe, with similar outcomes as in younger patients. Future studies looking at improved patient selection methods to ensure long-term survival benefits in both octogenarians and younger patients are warranted.]]> Mon, 22 Apr 2024 00:00:00 GMT-05:00 00000658-202508000-00026 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/ambulatory_cardiology_or_general_internal_medicine.27.aspx Objective: To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment before surgery and outcomes after scheduled major vascular surgery. Background: Cardiovascular risk assessment and management before high-risk surgery remains an evolving area of care. Methods: This is a population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, from April 1, 2004 to March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months before surgery were compared with those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke, 30-day cardiovascular death, 1-year mortality, composite of 1-year mortality, myocardial infarction or stroke, and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting was used to mitigate confounding by indication. Results: Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment before surgery: 11,074 (54.1%) with cardiology, 8071 (39.4%) with GIM, and 1339 (6.5%) with both. Compared with patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index [N with Index over 2 = 4989 (24.4%) vs 4587 (15.4%), P < 0.001] and more frequent preoperative cardiac testing [N = 7772 (37.9%) vs 6113 (20.6%), P < 0.001], but lower 30-day mortality [N = 551 (2.7%) vs 970 (3.3%), P < 0.001]. After the application of inverse probability of treatment weighting, cardiology or GIM assessment before surgery remained associated with a lower 30-day mortality [weighted hazard ratio (95% CI) = 0.73 (0.65–0.82)] and a lower rate of all secondary outcomes. Conclusions: Major vascular surgery patients assessed by a cardiology or GIM physician before surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.]]> Mon, 06 May 2024 00:00:00 GMT-05:00 00000658-202508000-00027 https://journals.lww.com/annalsofsurgery/fulltext/2025/08000/prophylactic_regenerative_peripheral_nerve.28.aspx Objective: To evaluate the prophylactic effect of regenerative peripheral nerve interface (RPNI) surgery on pediatric postamputation pain. Background: Chronic postamputation pain is a debilitating and refractory sequela of limb amputation affecting up to 83% of pediatric patients with limb loss, resulting in disability and decreased quality of life. We postulate that prophylactic RPNI surgery performed during amputation may decrease the incidence of symptomatic neuroma and development of phantom limb pain, as well as limit analgesic use among pediatric patients with limb loss. Methods: Retrospective chart review was performed on pediatric patients between the ages of 8 and 21 years who underwent major lower limb amputation with and without RPNI surgery. Documented neuroma and phantom limb pain scores, as well as analgesic use, were recorded. Narcotic use was converted to milligrams morphine equivalents per day, whereas overall analgesic use was converted to Medication Quantification Scale version III scores. Analysis was performed using Stata. Results: Forty-four pediatric patients were identified; 25 RPNI patients and 19 controls. Of control patients, 79% developed chronic postamputation pain versus 21% of RPNI patients (P < 0.001). Among the patients who developed postamputation pain, 20% of controls developed clinical neuroma pain, compared with 0% of RPNI patients (P < 0.001). In addition, RPNI patients demonstrated a significant decrease in pain score (P = 0.007) and narcotic usage (P < 0.01) compared with controls. Overall analgesic use did not vary significantly between groups. Conclusions: Prophylactic RPNI surgery shows promise for pediatric patients undergoing major lower limb amputation by preventing both symptomatic neuromas and possibly the development of phantom limb pain.]]> Wed, 08 May 2024 00:00:00 GMT-05:00 00000658-202508000-00028