Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database.

Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.

The roles of yeast formins and their regulators Bud6 and Bil2 in the pheromone response.

In response to pheromone Saccharomyces cerevisiae extend a mating projection. This process depends on the formation of polarized actin cables which direct secretion to the mating tip and translocate the nucleus for karyogamy. Here, we demonstrate that proper mating projection formation requires the formin Bni1, as well as the actin nucleation promoting activities of Bud6, but not the formin Bnr1. Further, Bni1 is required for pheromone gradient tracking. Our work also reveals unexpected new functions for Bil2 in the pheromone response. Previously we identified Bil2 as a direct inhibitor of Bnr1 during vegetative cell growth. Here, we show that Bil2 has Bnr1-independent functions in spatially focusing Bni1-GFP at mating projection tips, and in vitro Bil2 and its binding partner Bud6 organize Bni1 into clusters that nucleate actin assembly. bil2∆ cells also display entangled Bni1-generated actin cable arrays and defects in secretory vesicle transport and nuclear positioning. At low pheromone concentrations, bil2∆ cells are delayed in establishing a polarity axis, and at high concentrations they prematurely form a second and a third mating projection. Together, these results suggest that Bil2 promotes the proper formation and timing of mating projections by organizing Bni1 and maintaining a persistent axis of polarized growth.

Analysis of Conflicts of Interest in Studies Related to Robotics in Gastrointestinal and Abdominal Wall Surgery.

BACKGROUND: Industry payments to physicians represent a potential conflict of interest (COI) and can influence the study conclusions. This study aimed to evaluate the accuracy of the COIs reported in major surgical journals. STUDY DESIGN: Studies with at least one American author published between 2016 and 2021 that discussed observational and intervention studies assessing robotic surgery were included in the analysis. The Centers for Medicare & Medicaid Services' Open Payments database was used to collect the industry payments. A COI is defined as receiving funding from a robotics company while publishing research directly related to the company's products. A COI statement was defined as disclosed (or accurate) if the disclosure statement for the study in question acknowledged funding from the robotics companies. A COI was defined as undisclosed (or inaccurate) if the disclosure statement for the study in question did not acknowledge funding from the robotics companies. RESULTS: A total of 314 studies and 1978 authors were analyzed. Only 13.6% of the studies had accurate COI statements, whereas the majority (86.4%) had inaccurate COI disclosures. Additionally, 48.9% of the authors who received funding of $10,000 to $100,000 failed to report this amount in their disclosures, and 18% of the authors who received funding of $100,000 or more did not report it in their disclosures. CONCLUSIONS: There was a significant discordance between the self-reported COI in gastrointestinal and abdominal wall surgeries. This study calls for continued efforts to improve the definitions of what constitutes a relevant COI and encourages a standardized reporting process. It is imperative for investigators to make accurate disclosure statements.

Effect of conditions being present at time of surgery (PATOS) on outcomes in liver surgery.

INTRODUCTION: Information about condition(s) being present at time of surgery (PATOS) in the American College of Surgeons (ASC) National Surgical Quality Improvement Program (NSQIP) database can influence the postoperative complication rates after liver surgeries. Here, we compare the postoperative complication rates with and without taking condition(s) being PATOS into account. METHODS: We retrospectively reviewed the ACS NSQIP Participant User Files (PUFs) from 2015 through 2019. We analyzed rates of eight different postoperative complications: superficial surgical site infection (SSI), deep SSI, organ space SSI, pneumonia, urinary tract infection, ventilator, sepsis, and septic shock. In addition, we calculated the percent change in event rates after taking into account whether a condition is PATOS. RESULTS: Of the 22,463 patients in the ACS NSQIP PUFs for liver surgery, 334 (1.49%) had one or more conditions PATOS. The percentages of patients with PATOS events ranged from 2.03% for superficial SSI to 14.74% for sepsis. For all complications, event rates declined when taking condition(s) PATOS into account. From 2015 through 2019, the observed-to-expected ratios for most complications remained unchanged. CONCLUSION: Whether a condition is PATOS is important in reporting postoperative complication rates for patients undergoing liver surgery. When taking whether a condition is PATOS into account, we demonstrated an overall decrease in event rates across all eight postoperative complications.

Financial Relationships in General Surgery Education: Recent Trends in Industry Payments to General Surgery Residency Leadership.

INTRODUCTION: Residency programs and their directors frequently receive funding from industry payers. Both general surgery residency program directors (PDs) and assistant program directors (APDs) receive industry funding for various reasons, including educational advancement. This study investigates recent trends in industry payments to both PDs and APDs to better understand the financial relationships among leaders in residency education. METHODS: We compared industry payments to general surgery residency PDs and APDs from 2019 to 2021 utilizing the U.S. Centers for Medicare & Medicaid Services (CMS) open payments database. In addition, secondary analyses were performed among PDs to assess differences based on gender, practicing surgical specialty, and geographical region. RESULTS: During the study period (2019-2021), PDs received payments amounting to 2,882,821 USD. PDs were found to receive more funding than APDs, with each receiving average funding of 10,045 vs. 323 USD (p < 0.01), respectively, over the study period. There was a significant decrease in total payments from 2019 to 2020 (1,512,190 vs. 868,811 USD; p < 0.01). Total payments made in 2021 were similar compared to 2020 (905,836 vs. 868,811 USD; p = 0.1). We found that male PDs received significantly more in-industry payments when compared to female PDs (11,702 USD per PD vs. 3971 USD per PD, p < 0.01). CONCLUSION: This study presents initial data that residency program leadership has robust biomedical industry relationships, and further research is warranted to investigate the impacts of these payments on program resources, educational opportunities for residents, and program outcomes. Male PDs received significantly more industry payments when compared to female PDs. Leaders in the surgical training community must cautiously ensure that these industry relationships are appropriately navigated.

Effect of Present at Time of Surgery (PATOS) on Outcomes in Pancreatic Surgery.

INTRODUCTION: While there is some data available on the importance of accounting for the effect of present at time of surgery (PATOS) when estimating unadjusted postoperative complication rates, little is known about the impact of PATOS on outcomes in patients undergoing pancreatic surgery specifically. By taking PATOS into account, we hypothesized that unadjusted, observed postoperative complication rates might be reduced, with these reductions being different across outcomes; however, we expected fewer differences in risk-adjusted results, i.e., observed to expected ratios (O/E ratios). METHODS: We retrospectively analyzed the ACS NSQIP Participant Use Files (PUFs) from 2015 to 2019. PATOS data were analyzed for the 8 postoperative complications of superficial, deep, and organ space surgical site infection; pneumonia; urinary tract infection; ventilator dependence; sepsis; and septic shock. Postoperative complication rates were compared by ignoring PATOS vs. taking PATOS into account. RESULTS: Of the 31,919 patients in the ACS NSQIP PUFs who underwent pancreatic surgery, 1120 (3.51%) patients had one or more PATOS conditions. The event rates after taking PATOS into account declined for all outcomes-superficial surgical site infection (SSI) rates reduced by 2.56%, deep SSI rates reduced by 4.28%, organ space SSI rates reduced by 9.31%, pneumonia rates reduced by 2.91%, urinary tract infection rates declined by 4.69%, and septic shock rates declined by 9.27%. CONCLUSION: Our paper highlights that accounting for PATOS is important for estimating unadjusted postoperative complication rates in patients undergoing pancreatic surgery. Risk adjustment is essential to any attempt at quality assessment and benchmarking. Failure to account for PATOS may penalize surgeons who care for the sickest and most complicated patients and subsequently encourage cherry-picking of less risky patients and procedures.

The undisclosed disclosures: Conflicts of interest in studies related to robotics in hepatobiliary and pancreatic surgery.

BACKGROUND: The use of robotics in hepatobiliary and pancreatic surgery has increased. With this increased collaboration, there has also been a push toward improving the transparency of conflicts of interest in terms of funding provided by robotics companies. METHODS: Studies with ≥1 American author published between 2016 and 2020 discussing robotic hepatobiliary and pancreatic surgery were included in the analysis. The Centers for Medicare and Medicaid Services Open Payments Program was used to evaluate the accuracy of industry payment disclosures. Conflict of interest was defined as a lack of disclosure of ≥$100 funding from any robotics company in the United States. The primary outcome of this study was to determine the efficacy of the current standard conflict of interest reporting in surgery. RESULTS: A total of 355 studies (2,413 authors) were included. Of the studies that received robotics funding (n = 133), 20.3% did not disclose their conflicts of interest, whereas 79.7% had a conflict of interest disclosure. However, most of the disclosures (76.5%) were inaccurate. CONCLUSION: The findings of this study require an update in journal policies to ensure the accurate disclosure of conflicts of interest in robotic hepatobiliary and pancreatic surgery studies. Similarly, the investigators should ensure that their disclosures are accurate. Finally, surgeons must be more on top of their relationships with these companies and consider their vulnerability to bias.