April 2025

Synopsis: This retrospective cohort study examined the management of gallbladder perforation and its effect on clinical outcomes. The authors found that early laparoscopic cholecystectomy within 2 days of presentation was associated with a shorter total hospital length of stay compared to delayed cholecystectomy. However, there were no significant differences in 30-day postoperative complications, postoperative length of stay, readmission, or reoperation rates.

Summary:
Gallbladder perforation, though rare, is associated with substantial morbidity and mortality. However, the optimal timing of surgical management—whether early or delayed cholecystectomy—remains unclear. This study aimed to compare early versus delayed cholecystectomy following gallbladder perforation. Using the NSQIP database, the authors identified 771 patients with a diagnosis of gallbladder perforation, of whom 268 (34.76%) underwent urgent or emergent “early” surgery (defined as <48 hours after admission) and 111 (41.73%) underwent “delayed” surgery (≥48 hours after admission). The primary endpoint was total hospital length of stay, with secondary endpoints including 30-day postoperative complications, reoperation, and readmission.

There were no statistically significant differences between the two groups in terms of age, gender, or race; however, the delayed group had significantly higher estimated probabilities of morbidity and mortality compared to the early group (p<0.05). Early laparoscopic cholecystectomy was associated with a shorter total hospital length of stay: a median of 4 days in the early group versus 7 days in the delayed group (p<0.05). No statistically significant differences were observed in postoperative length of stay, operative time, or 30-day postoperative complications. To account for baseline differences, multivariable regression analyses were conducted and again demonstrated a 2.94-day reduction in hospital stay in the early surgery group, but only among patients without sepsis on presentation (p<0.05); this difference was not observed in patients presenting with sepsis.

This study has several limitations that warrant consideration. First, significant differences in baseline morbidity and mortality estimates may introduce selection bias. Additionally, due to variation in clinical practice and limitations of the NSQIP dataset, the study could not evaluate nonoperative management strategies, conversion to open surgery, or alternative operative techniques such as subtotal cholecystectomy. Missing data—including BMI, antibiotic use, imaging findings, and reasons for surgical delay—may also skew results. Lastly, as only 34.76% of patients with a diagnosis of gallbladder perforation in NSQIP were included, the findings may have limited external validity.

Bottom Line:
Early laparoscopic cholecystectomy within 2 days of presentation may be associated with a shorter total hospital length of stay following gallbladder perforation compared to delayed surgery. However, this benefit was only demonstrated in non-septic patients and should be considered in the broader context of patient selection and surgical risk.

Synopsis: This multicenter, randomized controlled trial evaluated whether heart transplants from donors after circulatory death (DCD), using portable extracorporeal perfusion, are noninferior to traditional heart transplants from donors after brain death (DBD), preserved with cold storage. In the as-treated population, 6-month risk-adjusted survival in DCD recipients was noninferior to that of DBD recipients. Rates of serious graft-related adverse events were similar, though DCD recipients had a higher incidence of primary graft dysfunction.

Summary:
Historically, heart transplants (HT) have relied almost exclusively on organs donated after brain death (DBD). This approach allows for continuous perfusion until retrieval, enabling real-time assessment of cardiac function and optimal preservation. However, the ongoing shortage of donor hearts has prompted exploration of alternative sources. One such strategy is donation after circulatory death (DCD), in which organs are recovered after cessation of cardiac activity. Unlike DBD, DCD requires the use of ex-situ perfusion systems to restore and assess heart function prior to transplantation. While early single-center data have been promising, robust comparative evidence has been limited. To address this, the Donors after Circulatory Death Heart Trial was conducted to compare clinical outcomes of DCD heart transplantation using portable extracorporeal perfusion with traditional DBD transplantation using cold storage.

This unblinded, multicenter, prospective randomized controlled trial enrolled adult patients listed for HT. Participants were randomized in a 3:1 ratio to be eligible for either DCD or DBD HT. Patients in the DCD-eligible group could receive either a DCD or DBD heart—whichever became available first according to UNOS priority—to avoid transplant delay. DCD hearts were reanimated, preserved, and evaluated using the TransMedics Organ Care System (OCS) Heart; DBD hearts were preserved using traditional cold static storage.

The primary efficacy endpoint was noninferiority of 6-month survival, adjusted for prespecified donor and recipient risk factors (noninferiority margin: 20%). The secondary efficacy endpoint was the utilization rate of DCD hearts placed on the perfusion system. The primary safety endpoint was serious adverse events associated with the graft within 30 days post-transplant, including moderate or severe left or right ventricular primary graft dysfunction (PGD) or graft failure requiring retransplantation. Safety events were adjudicated by a clinical events committee and analyzed descriptively.

Between December 2019 and November 2020, 297 adults across 15 centers were randomized to the DCD-eligible (n=226) or DBD-only (n=71) groups. Ultimately, 180 patients underwent HT; the as-treated population included 80 DCD recipients and 86 DBD recipients. Risk-adjusted 6-month survival was 94% (95% CI: 88–99) in the DCD group versus 90% (95% CI: 84–97) in the DBD group (p<0.001 for noninferiority). Of the 101 DCD hearts placed on OCS, 90 (89%) were successfully transplanted. The mean number of serious adverse events per patient within 30 days was 0.2 in the DCD group and 0.1 in the DBD group. PGD occurred more frequently in the DCD group (22%) compared to the DBD group (10%).

There were several limitations to this study. It was unblinded and allowed crossover to maximize transplant opportunities, which may introduce selection bias. Additionally, recipients in the DCD group were younger and had lower urgency status, potentially confounding comparisons despite risk adjustment. Finally, the study only reported outcomes through one year, leaving long-term durability unknown.

Bottom line:
Heart transplantation using circulatory-death donors with ex-situ perfusion is a viable and safe alternative to traditional brain-death donation, with comparable 6-month survival. These results support expanding the donor pool through broader adoption of DCD transplant protocols.

Synopsis: In this study, the authors examine the association between surgeon physiologic stress, reflected by sympathovagal balance measured via heart rate variability, and surgical outcomes. They found that increased surgeon sympathovagal balance at the start of a procedure is associated with a reduced risk of major surgical complications after controlling for patient, surgeon, and operative factors.

Summary:
While surgeon stress has been studied in relation to performance, its link to clinical outcomes—particularly early intraoperative stress—remains underexplored. Heart rate variability, specifically the low frequency to high frequency (LF:HF) ratio, is a quantitative metric of sympathovagal balance and has been shown to correlate with observed and self-reported stress levels. Previous studies have examined surgeon stress throughout task performance; however, stress at the start of the operation may be more readily modifiable than stress impacted by intraoperative events. Therefore, the authors used the surgeon’s LF:HF ratio during the first 5 minutes after incision to examine the association between physiologic stress and clinical outcomes.

This study was a post hoc analysis of the preintervention phase of a prospective cohort study including attending surgeons across 14 surgical departments and 7 surgical specialties at four university hospitals in Lyon, France. Surgeon heart rate variability (HRV) was measured using commercially available chest monitors. HRV data from the first 5 minutes after incision were used to calculate the LF:HF ratio, with larger LF:HF ratios representing greater sympathetic tone and physiologic stress. The LF:HF ratio for each case was normalized to a surgeon’s median LF:HF ratio across all cases. The primary outcome was a composite metric of major surgical complications, which included any major adverse event during surgery or within 30 days postoperatively. Secondary outcomes included extended ICU stay and 30-day mortality. Simple logistic regression and mixed-effects multivariable logistic regression, adjusting for patient, surgeon, and operative factors, were used to determine associations between normalized LF:HF ratio and each outcome. Sensitivity analyses were performed, limiting to higher-volume surgeons (>10 procedures) and stratifying by surgical specialty risk level (low, medium, high).

A total of 798 patients underwent operations by 38 surgeons (21% female) during the study period. Substantial intra- and inter-surgeon variability in LF:HF ratios was observed, with a median surgeon LF:HF ratio of 7.16 (IQR, 4.52–10.72) before and 1.00 (IQR, 0.71–1.32) after normalization. Increased surgeon sympathovagal balance during the first 5 minutes of an operation was associated with significantly reduced major surgical complications (adjusted odds ratio [AOR] 0.63, 95% CI 0.41–0.98, P = 0.04). This association persisted when limited to surgeons performing >10 procedures, but not when restricted to high-risk surgical specialties. After adjustment, normalized LF:HF ratio was not significantly associated with extended ICU stay (AOR 0.34, 95% CI 0.11–1.01, P = 0.05) or 30-day mortality (AOR 0.18, 95% CI 0.03–1.03, P = 0.05). Among high-risk specialties, increased LF:HF ratio was significantly associated with a reduced risk of extended ICU stay (AOR 0.17, 95% CI 0.03–0.87, P = 0.03).

This study was limited by its nonrandomized nature and residual confounding due to challenges in case-mix adjustment and the potential influence of surgeon substance or medication use on HRV. Furthermore, the LF:HF ratio as a metric of physiologic stress is limited by the nonlinear interactions between sympathetic and parasympathetic nervous systems, the influence of respiratory variability, and the inability to distinguish between causes of stress. Finally, this study included a high proportion of male surgeons in a restricted geographic area at academic hospitals, thus limiting generalizability.

Bottom Line:
Increased surgeon physiologic stress at the beginning of an operation, as measured by sympathovagal balance, is associated with improved surgical outcomes. This somewhat unexpected finding highlights the complex relationship between physiologic stress and surgeon performance. Future efforts to understand and optimize surgeon sympathovagal balance may provide opportunities to improve performance and clinical outcomes, though these must be weighed against the potential deleterious effects of increased physiologic stress on surgeons’ physical and mental well-being.