Digestive Surgery最新文献

Introduction: Laparoscopic fundoplication is the current standard for HH repair. HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS) or mesh placement. We analyzed the influence of patient factors on the surgical technique for laparoscopic repair in a teaching hospital.

Methods: Between 2012-2019, all patients who underwent repair of HH were assessed in this retrospective cohort study. HH was measured on CT scans and baseline patient characteristics and surgical details were collected.

Results: In total, 307 patients were included. 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients and mesh in 17 patients. The use of anterior sutures was significantly associated with female gender, higher type of HH and higher age. The use of VMS during surgery was significantly associated with higher type of HH, higher age and larger transverse diameter of the HH. The use of mesh during surgery was significantly associated with higher type of HH and larger transverse diameter of the HH.

Conclusion: In this retrospective study, the reinforcement techniques used during surgery were significantly associated with patient factors such as gender, body length and weight, type of HH and transverse diameter. An unexpected patient associated factor was age.

Introduction The proposed centralisation of colonic cancer surgery (CCS) to dedicated cancer centres may overburden such units while removing the opportunity for patients to receive treatment locally. This study presents outcomes of patients undergoing CCS in a regional hospital by a fellowship-trained colorectal surgeon. Methods Demographic, perioperative, postoperative and oncological outcomes for fifty successive patients who underwent CCS in a regional hospital were collected. Outcomes were compared to colorectal cancer key performance indicators and textbook outcomes. Results Fifty patients (56% male) were identified, of whom 41 (82%) underwent elective surgery. Median follow-up was 49 months. Operations performed included 31 (62%) right hemicolectomies, 18 (36%) high anterior resections, one (2%) subtotal colectomy, one (2%) low anterior resection. The majority (64%, n=32) were completed laparoscopically. Anastomotic leak rate was 4.3% (n=2). Major morbidity rate (Clavien-Dindo ≥III) was 14% (n=7). Readmission, reoperation and mortality at 30 days were 0%, 8%, 0% respectively. R0 resection rate was 98% with median lymph node yield of 20. Textbook outcome was achieved in 27 patients (54%). Overall survival at one, three and five years was 96%, 77% and 77% respectively. Disease-free survival at one, three and five years was 86%, 77% and 75%. Conclusion CCS can be delivered safely and effectively in regional hospitals under the care of appropriately supported subspecialists. Both patient and healthcare system benefit from delivering of high-quality oncological surgery locally, reducing the burden on tertiary centres. The projected doubling of colorectal cancer cases by 2040, requires appropriate utilization of available resources.

Introduction: Post-sleeve gastrectomy (SG) proximal staple line leak is a rare yet serious complication. Endoscopic negative pressure therapy (ENPT) has emerged as a safe technique, showing promising results in treating leakages of the upper and lower gastrointestinal tract, often in conjunction with surgical interventions. A standardized treatment algorithm has not been established. This study aims to assess the safety and efficacy of ENPT in the multi-disciplinary management of proximal staple line leaks after SG.

Methods: This is an observational study of 40 post-SG proximal staple line leak cases treated with an ENPT-based approach. Revisional surgery was performed in addition to ENPT in critically ill patients or nondiagnostic imaging results. Success was defined as the healing of the defect and paraluminal cavity with no further need for surgical or endoscopic intervention following ENPT.

Results: Thirty-three patients were successfully treated with ENPT (82.5% success rate). Additional surgical interventions were performed in 37 patients, with re-laparoscopy, lavage, and drain of the abdominal cavity being the most frequently performed procedures. The mean duration of treatment was 25.6 days with an average of 6.4 endoscopic interventions per patient.

Conclusions: ENPT is a safe and effective technique for treating proximal staple line leaks following SG. Its application should be considered alongside other endoscopic and surgical approaches.

Background: Acute cholecystitis (AC) is one of the most common abdominal emergencies worldwide. Biliary infections can easily induce bacteremia, leading to severe general conditions including systemic inflammation and blood coagulation abnormalities. However, bacteremia in AC has not been investigated so far. Herein, we analyzed the blood cultures and clinical data of patients with AC.

Methods: Of 319 consecutive patients with AC at our hospital, we retrospectively investigated 176 patients who were evaluated by blood culture at diagnosis to assess risk factors and develop an identification model for bacteremia in AC.

Results: Based on blood culture results, 37 (21.0%) of 176 patients were diagnosed with bacteremia. The bacteremia-positive group had a significantly worse systemic status at diagnosis than the negative group, including age, severity grading, comorbidities, performance status, systemic inflammatory status, and blood coagulation abnormalities. Multivariate analysis revealed previous endoscopic papillary procedures, total bilirubin, and systemic inflammatory response syndrome ≥ 3 as significant risk factors for bacteremia. On dividing early and late cohorts according to the onset time of AC, an identification signature derived from the three risk factors robustly distinguished bacteremia in both cohorts (AUC, early cohort = 0.93; late cohort = 0.91).

Conclusions: In this study, we identified risk factors and identification signatures that accurately detect bacteremia in patients with AC. This study enriches our medical knowledge of AC, helping us step towards designing individualized treatment strategies for this disease.

Introduction: Evidence regarding staging laparoscopy (SL) for clinical metastatic (cM+) gastric cancer (GC) patients is limited. Recently, an Italian Gastric Cancer Research Group (GIRCG) study showed SL changed peritoneal status in over 20% of cases. This study aimed to evaluate SL's role in cM+ patients and refine its indications.

Methods: Clinical data of cM+ GC patients who underwent SL between 2010 and 2022 at nine GIRCG centers were retrospectively analyzed. The primary outcome was SL's yield, defined as peritoneal status changed by SL over all SLs.

Results: Among 182 cM+ patients who received SL, 38 (20.9%) had SL-findings changing peritoneal status. Notably, 10.1% of cases with preoperative signs of carcinomatosis had no peritoneal disease, while 46.3% with extraperitoneal disease alone had peritoneal carcinomatosis (PC) at SL. Thirty-one patients (17.0%) underwent R0 resection: 17 (54.8%) with PC, 3 (9.7%) with liver metastases, 4 (12.9%) with PC and nodal metastases, 2 (6.4%) with lung, and 1 (3.2%) with bone metastases. Seventeen patients with suspected preoperative PC underwent curative treatment: 9 had peritoneal disease ruled out by SL, while the other 8 had limited PC, allowing R0 resection. Logistic regression revealed an inverse correlation between diffuse histotype and absence of PC at SL in patients with peritoneal involvement at imaging (p = 0.02).

Conclusion: SL aids in directing cM+ GC patients to appropriate treatment, with a 20.9% yield. For those with peritoneal involvement at imaging, SL helps identify candidates for curative treatment. In patients with extraperitoneal disease, SL should be considered to assess potential radical strategies.

Introduction: The development of anastomotic leakage (AL) after esophagectomy is a severe complication, often leading to mediastinitis and systemic infections. Effective empiric antimicrobial therapy is crucial, but there is no consensus on the optimal regimen. This study aimed to document antimicrobial regimens used in the Netherlands and to evaluate culture results from AL after esophagectomy at our center.

Methods: An online questionnaire about the preferred antimicrobial treatment of AL after esophagectomy was sent to all upper gastrointestinal surgeons in the Netherlands. In addition, drain culture results from patients with AL after esophagectomy in our center were retrospectively analyzed.

Results: From 76 responses, 28 were included, representing 13 of the 15 esophagectomy-performing centers in the Netherlands. For treating AL after esophagectomy, respondents typically choose broad-spectrum regimens covering Gram-negative, Gram-positive, and anaerobic bacteria. The cultures of 57 patients were analyzed. Overall, 61% had positive cultures for yeast, 61% of patients for Enterobacterales, and 16% for Pseudomonas and other non-fermenters.

Conclusion: Based on the studied cultures, empiric antibiotics should cover Gram-positive, Gram-negative, anaerobe bacteria and Pseudomonas. We recommend the use of empiric amoxicillin/clavulanic acid with tobramycin for patients with AL after esophagectomy, which is now protocol in our center. The addition of antifungals remains debatable. Given the high incidence of yeast-positive cultures in the studied cohort, we recommend the addition of an echinocandin in clinically unstable patients.

Introduction: The safety and feasibility of robotic pancreatoduodenectomy (RPD) in high-risk patients for postoperative pancreatic fistula (POPF) have rarely been investigated, although the rate of POPF is lower than in open pancreatoduodenectomy (OPD). This study aimed to examine the impact of robotic surgery on POPF in high-risk patients after pancreatoduodenectomy (PD).

Methods: We performed a retrospective study of 204 patients who underwent RPD and OPD between January 2018 and June 2023. Of the 204 patients, 126 with high-risk pancreaticojejunostomies for developing POPF were included. The outcomes of RPD and OPD were compared. Multivariate analyses were conducted to identify risk factors associated with the development of clinically relevant POPF (CR-POPF) after surgery.

Results: Of the 126 patients, 50 underwent RPD and 76 underwent OPD. The incidence of CR-POPF was significantly lower in the RPD group than in the OPD group (6.0% vs. 38.2%, p < 0.001). Multivariate analyses identified OPD as an independent risk factor associated with CR-POPF (odds ratio [OR]: 7.87, 95% confidence interval [CI]: 2.11-29.4, p = 0.002).

Conclusion: This study demonstrated the impact of robotic surgery on POPF in high-risk patients after PD. These results suggest that RPD may be significantly associated with a decreased incidence of CR-POPF in high-risk anastomoses.

Introduction: Maximum oxygen uptake (VO2max) is a predictor for postoperative complications after esophagectomy. Cardiopulmonary exercise test (CPET) is the golden standard for measuring VO2max. The alternative steep ramp test (SRT) is less strenuous with several benefits, providing an estimation of VO2max. This study aimed to determine whether SRT is a reliable alternative for CPET to evaluate preoperative fitness.

Methods: A total of 113 patients were included in this study. The agreement between SRT and CPET was analyzed using a t test, Intraclass correlation coefficient (ICC), and the Bland-Altman analysis. The threshold for adequate preoperative fitness was set at 17.0 mL/kg/min.

Results: The mean difference between CPET and SRT was 2.77 mL/kg/min (95% confidence interval [CI]: 2.14-3.41). The ICC was 0.79 (95% CI: 0.70-0.85). The upper limit of agreement of the Bland-Altman was 9.44. The addition of 9.44 to the CPET threshold gives an SRT threshold of 26.44 mL/kg/min. Thirty-one (27.4%) patients scored higher than the SRT threshold.

Conclusion: The SRT VO2max differs from VO2max as measured by CPET. However, the difference was found to be clinically irrelevant for a substantial portion of patients. Hence, SRT is a promising alternative to CPET for determining physical fitness and might render CPET obsolete for fit individuals.

Introduction: This study aimed to evaluate the influence of early oral feeding (EOF), a key component of enhanced recovery after surgery protocols, on postoperative outcomes in patients undergoing elective colorectal surgery.

Methods: We searched the MEDLINE, Embase, Cochrane Library, and KoreaMed databases to include randomized clinical trials comparing EOF that started on postoperative day 1 and conventional oral feeding that commenced after first flatus. Two authors independently screened the retrieved records and extracted data. The primary outcome was total complications. Data were pooled, and the overall effect size was calculated using a fixed-effect model.

Results: We screened 13 studies, and 1,556 patients were included in the analysis. The EOF group exhibited fewer total complications (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.38-0.65). Anastomotic leakage was also reduced in the EOF group (OR: 0.40; 95% CI: 0.19-0.83); however, an increased incidence of vomiting (OR: 1.58; 95% CI: 1.11-2.26) as well as a tendency of higher rate of nasogastric tube reinsertion (OR: 1.49; 95% CI: 0.96-2.31) were observed. The EOF group demonstrated a decreased time to flatus (mean difference [MD] -0.87; 95% CI: -1.00 to -0.74) and shortened hospital stay (MD: -0.76; 95% CI: -0.89 to -0.6). No significant difference in mortality was observed between the two groups (OR: 0.54; 95% CI: 0.15-2.01).

Conclusion: EOF proved to be a safe and effective practice for patients undergoing elective colorectal surgery. However, the increased incidence of vomiting necessitates careful consideration.