JAMA surgery
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Randomized Controlled Trial
Perioperative mortality following repair of abdominal aortic aneurysms: application of a randomized clinical trial to real-world practice using a validated nationwide data set.
Because of the restrictions applied to the conduct of randomized clinical trials, the risks reported in their comparison of open and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) may not be applicable to real-world vascular surgical practice. The magnitude of this deviation is indeterminate. ⋯ Perioperative mortality reported by the OVER trial is significantly lower than outcomes from practices outside the restriction of randomized clinical trials. We attribute this difference to the fact that the OVER trial excluded high-risk patients deemed unfit for open repair. This finding supports the need for individualized assessment of risk and treatment selection for patients with infrarenal AAA. There has been no change in perioperative mortality after EVAR in recent years despite improvements in techniques, devices, and proficiency.
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Multicenter Study
Lobectomy, sublobar resection, and stereotactic ablative radiotherapy for early-stage non-small cell lung cancers in the elderly.
The incidence of early-stage non-small cell lung cancer (NSCLC) among the elderly is expected to rise dramatically owing to demographic trends and increased computed tomographic screening. However, to our knowledge, no modern trials have compared the most common treatments for NSCLC. ⋯ Lobectomy was associated with better outcomes than sublobar resection in elderly patients with early-stage NSCLC. Propensity score matching suggests that SABR may be a good option among patients with very advanced age and multiple comorbidities.
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Multicenter Study Comparative Study
Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass.
Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (AGB) are 2 of the most commonly performed bariatric procedures worldwide. However, few large, multisite studies have directly compared the benefits and harms of these procedures. ⋯ In this large bariatric cohort from 10 health care systems, we found that RYGB resulted in much greater weight loss than AGB but had a higher risk of short-term complications and long-term subsequent hospitalizations. On the other hand, RYGB patients had a lower risk of long-term subsequent intervention procedures than AGB patients. Bariatric surgery candidates should be well informed of these benefits and risks when they make their decisions about treatment.
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Randomized Controlled Trial Multicenter Study
Cost-effectiveness of cervical total disc replacement vs fusion for the treatment of 2-level symptomatic degenerative disc disease.
Cervical total disc replacement (CTDR) was developed to treat cervical spondylosis, while preserving motion. While anterior cervical discectomy and fusion (ACDF) has been the standard of care for 2-level disease, a randomized clinical trial (RCT) suggested similar outcomes. Cost-effectiveness of this intervention has never been elucidated. ⋯ The incremental cost-effectiveness ratio of CTDR compared with traditional ACDF is lower than the commonly accepted threshold of $50,000 per QALY. This remains true with varying input parameters in a robust sensitivity analysis, reaffirming the stability of the model and the sustainability of this intervention.
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Randomized Controlled Trial Comparative Study Observational Study
Surgeon's 30-day outcomes supporting the carotid revascularization endarterectomy versus stenting trial.
While the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) has been widely accepted as a landmark trial establishing an equivalent risk of major adverse events following carotid endarterectomy (CEA) or carotid artery stenting (CAS), the applicability of these findings to single centers has been questioned owing to the rigid selection criteria for investigators in the study. Although refuted by the findings of a subsequent study, a substudy of CREST established a higher periprocedural stroke rate for CAS when the surgeon was a vascular surgeon. ⋯ Similar to CREST, the 30-day risk of composite major adverse events was equivalent for the 2 treatment modalities. We attribute our comparable incidence of perioperative stroke with CAS and CEA to improved patient selection. We excluded most patients older than 80 years and those with complex anatomy from consideration for CAS. Our results confirm those of CREST and demonstrate that both CEA and CAS can be performed safely by a vascular surgeon in properly selected patients.