Annals of Surgery (original) (raw)
December 11, 2024: 284(2):e51-e61
Objective:
To assess the efficacy of this approach and establish the criteria that identify patients with locally advanced pancreatic cancer (LAPC) who may achieve survival benefits from radical resection combined with intestinal autotransplantation (RRCIA).
Background:
Surgical resection for LAPC remains challenging and is associated with high morbidity and mortality, especially for surgery with major arterial reconstruction. We previously showed the feasibility and safety of RRCIA after systemic treatment.
Methods:
A retrospectively observational and prospectively validated study with 3 cohorts was conducted using multiple treatments. Overall survival (OS) and progression-free survival (PFS) were compared for both analyses. Propensity-score matching (PSM) and stabilized inverse probability of treatment weighting (IPTW) were performed to adjust for potential confounders.
Results:
Among 208 patients with LAPC, we identified 48 who underwent systemic treatment followed by RRCIA. Using PSM and stabilized IPTW analyses, we observed that patients who underwent RRCIA had better overall and PFS compared with patients who did not have surgery (PSM cohort: median OS: 25.8 vs 14.2 months, P = 0.0031, and IPTW cohort: median OS: 23.2 vs 15.4 months, P = 0.0069) and PFS (PSM cohort: median PFS: 13.3 vs 7.0 months, P = 0.0246, and IPTW cohort: median OS: 13.3 vs 8.8 months, P = 0.002). Further prospective analysis showed that patients who received systemic treatment, followed by RRCIA, were associated with improved OS and PFS compared with patients who were eligible but did not receive RRCIA (median OS: 22.6 vs 18.2 months, P = 0.035; median PFS: 13.2 vs 10.3 months, P = 0.0412). Moreover, the stratified and multivariable analysis demonstrated that preoperative carbohydrate antigen 19-9 normalization and duration of initial treatment over 8 cycles were predictors for the precise selection of patients who would benefit from RRCIA. Meanwhile, adjuvant therapy after RRCIA was a significant factor in improving survival.
Conclusions:
This study suggests that RRCIA appears to be effective and associated with improved outcomes for patients with LAPC with favorable responses to systemic treatment. Patients with LAPC Should have at least 8 cycles of systemic treatment and carbohydrate antigen 19-9 normalization to be considered for RRCIA.
November 7, 2024: 284(2):e41-e50
Objective:
To investigate patency and clinical outcomes of alloplastic and other venous interposition graft materials in pancreatic surgery.
Background:
Vascular pancreatic surgery is increasingly performed for locally advanced pancreatic neoplasms. Different than other centers, we prefer to use alloplastic vascular graft materials for superior mesenteric vein and portal vein interposition in pancreatic surgery. Advantages are off-the-shelf availability at any customizable length, different diameters, and ring-enforcement but proposed concerns are their thrombogenicity and fatal complications.
Methods:
Patients who underwent elective pancreatic resections with mesoportal venous interposition grafts (ISGPS type 4) between 2003 and 2022 were identified from the institutional pancreatectomy registry. Alloplastic vascular grafts imply synthetic materials, either based on polytetrafluorethylene (PTFE) or polyethylene terephthalate (PET). Surgical, clinicopathological, and follow-up data were analyzed. The patients were followed for graft patency by cross-sectional imaging.
Results:
In this study, 201 patients with venous interposition grafts were included (23% simultaneous arterial resections). Total pancreatectomy (41%) and pancreatoduodenectomy (35%) were the most frequent procedures. Vascular graft materials were alloplastic in 180 patients (83% PTFE and 17% PET) with a median diameter of 10 mm and a median length of 33 mm (measurement by computed tomography scan). Patency rates among all graft materials at 7, 30, and 90 days were 99%, 93%, and 87%, respectively. Alloplastic grafts demonstrated superior patency over other materials (hazard ratio: 2.7, P = 0.009), and PTFE reached a 1-year patency of 78%. The all-cause 90-day mortality rate was 10%. No graft infection occurred.
Conclusions:
Alloplastic venous vascular grafts are safe and readily available tools in pancreatic surgery, especially for long-segmental mesoportal venous reconstructions.
November 5, 2024: 284(2):e31-e40
Objective:
To evaluate machine learning (ML) models’ performance in predicting acute pancreatitis (AP) severity using early-stage variables while excluding laboratory and imaging tests.
Background:
Severe acute pancreatitis (SAP) affects ∼20% of patients with AP and is associated with high mortality rates. Accurate early prediction of SAP and in-hospital mortality is crucial for effective management. Traditional scores such as Acute Physiology and Chronic Health Disease Classification System II and Bedside Index of Severity in Acute Pancreatitis are complex and require laboratory tests, while early predictive models are lacking. ML has shown promising results in predictive modeling, potentially outperforming traditional methods.
Methods:
We analyzed data from a prospective database of patients with AP admitted to Vall d’Hebron Hospital from November 2015 to January 2022. Inclusion criteria were adults diagnosed with AP according to the 2012 Atlanta classification. Data included basal characteristics, current medication, and vital signs. We developed ML models to predict SAP, in-hospital mortality, and intensive care unit (ICU) admission. The modeling process included 2 stages: (1) stage 0, which used basal characteristics and medication, and (2) stage 1, which included data from stage 0 and vital signs.
Results:
Out of 634 cases, 594 were analysed. The stage 0 model showed an area under the curve values of 0.698 for mortality, 0.721 for ICU admission, and 0.707 for persistent organ failure. The stage 1 model improved performance with area under the curve values of 0.849 for mortality, 0.786 for ICU admission, and 0.783 for persistent organ failure. The models demonstrated comparable or superior performance to Acute Physiology and Chronic Health Disease Classification System II and Bedside Index of Severity in Acute Pancreatitis scores.
Conclusions:
The ML models showed good predictive capacity for SAP, ICU admission, and mortality using early-stage data without laboratory or imaging tests. This approach could revolutionize initial triage and management of patients with AP, providing a personalized prediction method based on early clinical data.
March 19, 2025: 284(2):436-444
Objective:
To evaluate the impact of primary targeted muscle reinnervation (TMR) performed at the time of major limb amputation on long-term opioid use, opioid dependence, and neuropathic pain medication use compared with standard amputation.
Background:
Postoperative pain following major limb amputation is common, often leading to prolonged opioid use, dependence, and neuropathic pain. TMR, a surgical technique that redirects amputated nerves into motor targets, has been proposed as a method to reduce pain-related complications, but prior studies are limited by small sample sizes, single-center experiences, and insufficient follow-up data. This study utilizes a multicenter database to assess long-term outcomes of TMR compared with standard amputation.
Methods:
A multicenter query was conducted using the TriNetX Research Network to identify patients undergoing major limb amputation with or without TMR over 20 years. Propensity score matching was used to create comparable cohorts for analysis. Primary outcomes included opioid use, opioid dependence, neuropathic pain medication use, and stump-related complications, evaluated from 90 days to 3 years postoperatively.
Results:
Among 43,890 patients, those undergoing primary TMR (n = 644) had significantly lower risks of opioid use [risk ratio (RR) = 0.72; 95% CI: 0.60, 0.86; P < 0.001] and opioid dependence (RR = 0.50; 95% CI: 0.27, 0.92; P = 0.023) compared with matched controls undergoing standard amputation (n = 644). In the ischemia subgroup, TMR patients had a 41% lower risk of opioid use (RR = 0.59; 95% CI: 0.42, 0.83; P = 0.002). No differences in neuropathic pain medication use or stump-related complications were observed between cohorts. Time-course analysis demonstrated persistent reductions in opioid use among TMR patients at all intervals from 3 months to 3 years.
Conclusions:
Primary TMR at the time of major limb amputation significantly reduces long-term opioid use and dependence, particularly in patients with limb-threatening ischemia, without increasing the risk of stump-related complications. These findings support the broader adoption of TMR to improve postoperative outcomes in amputees.
March 26, 2025: 284(2):429-435
Objective:
To determine the relationship between the intraoperative lowest measured temperature (LMT) during cardiac surgery using cardiopulmonary bypass (CPB) and the risk for postoperative stroke. Secondarily, to determine the association between LMT and the risk for 30-day mortality and other adverse outcomes.
Background:
The effectiveness of deliberate hypothermia during CPB for the prevention of cardiac surgery-associated stroke and adverse outcomes remains uncertain.
Methods:
This cohort study from the Society of Thoracic Surgeons Adult Cardiac Surgery Database included 1,847,808 patients who underwent coronary artery bypass graft surgery, valve surgery, and combined coronary artery bypass graft-valve procedures between July 1, 2011 and March 1, 2022. Using propensity score-weighted regression analysis, we analyzed the effect of LMT on the incidence of postoperative stroke and other adverse outcomes. Since the relationship between LMT and the examined outcomes was nonlinear, LMT was treated as a continuous variable.
Results:
In risk-adjusted analyses, no association was observed between the LMT and the primary outcome of postoperative stroke (_P_=0.316). For the secondary outcomes, encephalopathy or coma (_P_=0.649) or 30-day mortality (_P_=0.691) were also not associated with lower LMT. Acute kidney injury (P<0.001) was less common with lower and more common with higher LMTs. Pneumonia (_P_=0.002) was less common, yet reoperation for bleeding (P<0.001) was more common with higher LMTs.
Conclusions:
Hypothermia during CPB did not alter the risk of postoperative stroke. Secondary outcomes varied in their directionality of association with temperature, indicating that certain cardiac surgery patients may benefit, but others could be harmed by routine therapeutic hypothermia during CPB.
Annals of Surgery. July 3, 2026
Objective:
To evaluate the real-world reliability, safety, and effectiveness of a novel platform for robotic microsurgery when used to assist with microsurgical anastomoses.
Summary Background Data:
The physical demands associated with advanced supermicrosurgical techniques strain human limitations. The Symani Surgical System® is a robotic platform designed to support these challenging procedures with extreme motion scaling, tremor reduction, and miniaturized, wristed instruments.
Methods:
This was a non-randomized, multicenter, post-market clinical follow-up study (NCT04843436) evaluating use of Symani for microsurgical anastomosis in adults (age 18+) requiring free-flap (FF), nerve-repair, or lymphovenous anastomosis (LVA) procedures. Cases were enrolled both prospectively and retrospectively. The primary endpoints were robotic-procedure technical success and incidence of procedure-associated complications. Key secondary endpoints were subjective usability, intraoperative patency, and FF viability at discharge.
Results:
Between May 2021 and February 2025, 412 patients at 10 sites underwent at least one microsurgical robotic anastomosis. The procedure technical success rate was 94.1% (507/539 robotic anastomoses; 95% CI: 91.7%–95.9%). Freedom from device-related events was 99.8%. Intraoperative patency at first attempt was 91.7% for FF (331/361, 95% CI: 88.3%–94.3%) and 96.2% (225/234, 95% CI: 92.8%–98.2%) for LVA. Intraoperative revision rates were 8.4% for FF (31/367, 95% CI: 5.8%–11.8%), 3.4% for LVA (8/234, 95% CI: 1.5%–6.6%), and 0% for nerve repair (95% CI: 0.0%–26.5%). FF survival at discharge was 97.8% (268/274, 95% CI: 95.3%–99.2%).
Conclusions:
The study results support the safety, reliability, and efficacy of Symani when used for robotic-assisted, microsurgical reconstructions.
Annals of Surgery. July 3, 2026
Objective:
To evaluate national trends and clinical outcomes of donation after circulatory death (DCD) simultaneous liver–kidney transplantation (SLKT) in the US, particularly in the modern era following adoption of machine perfusion (MP) and normothermic regional perfusion (NRP).
Background:
Utilization of DCD donors for liver transplantation has increased substantially in the US, and MP and NRP were reported to reduce complications, including reperfusion syndrome and early allograft dysfunction. However, national trends and outcomes of DCD-SLKT in the contemporary era of organ perfusion have not been characterized.
Methods:
Using UNOS STAR files, we analyzed 10.687 adult primary SLKT performed between 2000 and 2025. Outcomes of DCD and donation after brain death (DBD) SLKT during 2020–2025 were compared using propensity score matching (PSM) to adjust for donor and recipient characteristics. Kaplan–Meier methods were used to assess graft/patient survival.
Results:
The utilization of DCD-SLKT increased markedly after 2018, accounting for 29.3% of all SLKT cases in 2024. In 2024, liver MP, kidney MP, and NRP were used in 58.1%, 82.9%, and 40.1% of DCD-SLKT cases. Before matching, recipients in the DBD-SLKT group more frequently required dialysis at transplantation (69.1% vs 54.2%) and were hospitalized preoperatively (51.0% vs 17.2%), and had higher MELD scores (30 vs 23) during 2020–2025. Median follow-up was shorter in DCD-SLKT (706 vs 364 days), reflecting the more recent adoption of DCD transplantation. Liver graft/patient survival were comparable between DCD- and DBD-SLKT regardless of PSM.
Conclusions:
Utilization of DCD donors for SLKT has increased substantially in parallel with the expanding use of MP and NRP, with graft/patient outcomes comparable to those of DBD-SLKT regardless of PSM. However, DBD-SLKT recipients had higher baseline preoperative risk. These support broader adoption of DCD donors for SLKT in appropriately selected recipients.
Annals of Surgery. July 1, 2026
Background:
International medical graduates (IMGs) play a critical role in the United States physician workforce and are essential to sustaining access to surgical care, particularly in underserved communities. Despite their contributions, IMGs pursuing surgical training continue to face significant systemic, financial, cultural, and institutional barriers.
Objective:
To examine the historical role, workforce contributions, challenges, and future implications of IMGs within the U.S. surgical workforce and identify opportunities to better support their integration into surgical training and practice.
Summary of Background Data:
IMGs comprise a substantial portion of the U.S. physician workforce but remain underrepresented in many surgical specialties. Persistent barriers include licensing requirements, financial burden, limited access to clinical and research opportunities, visa restrictions, bias within training environments, and reduced match success rates compared with U.S. medical graduates.
Methods:
This article synthesizes presentations from the American Surgical Association Inclusive Excellence Forum and incorporates current literature regarding IMG participation in U.S. surgical education, workforce trends, residency training, and professional advancement.
Results:
IMGs contribute significantly to clinical care, academic medicine, healthcare leadership, and culturally competent patient care. However, structural barriers within recruitment, credentialing, residency training pathways, and immigration processes continue to limit equitable access to surgical careers. Preliminary surgical positions, visa-related constraints, and cultural bias remain major challenges affecting IMG trainees and practicing surgeons.
Conclusions:
IMGs are indispensable to the future of the U.S. surgical workforce. Institutional support, mentorship, equitable recruitment practices, expanded residency opportunities, and immigration policy reform are necessary to strengthen IMG integration and ensure continued access to high-quality surgical care.