Digestive Surgery最新文献

The article "Are There Any Differences in Clinical Outcome after the Surgical Management of Patients with Stomach versus Duodenal Perforation?" [Dig Surg 2025;42:220-228; https://doi.org/10.1159/000547869] by Lahes et al. was published with the wrong open access license. The correct license of the article is CC-BY.The original article has been updated.

Introduction: Non-occlusive mesenteric ischemia (NOMI) is a rare but lethal complication after gastric cancer (GC) surgery, marked by intestinal hypoperfusion without arterial occlusion. Nonspecific symptoms and rapid deterioration hinder timely diagnosis. This study evaluated outcomes, diagnostic pathways, and management.

Methods: We retrospectively reviewed eight GC patients who developed NOMI (February 2022-January 2024). Collected variables included demographics, surgical details, feeding practices, presentation, imaging, treatment, and outcomes. The primary endpoint was 30-day mortality.

Results: NOMI presented a median of 3 days postoperatively (range 2-5). Median age was 63.5 years; 75% were male; all had advanced GC and 62.5% had gastric outlet obstruction. Common signs were abdominal distension (75%), hypotension (50%), and peritonitis (25%). CT consistently showed small-bowel dilatation, pneumatosis intestinalis, and portal venous gas, mainly in distal jejunum/ileum. Seven patients underwent re-exploration: five required resection. After implementing a modified feeding protocol, cases reduced from seven to one. Thirty-day mortality was 50%, largely from sepsis and multiorgan dysfunction syndrome (MODS).

Conclusion: In GC patients with feeding jejunostomy, NOMI remains a serious complication. A cautious feeding strategy-deferring feeds during vasopressor support, initiating low-strength kitchen feeds, slow escalation, and early oral intake-was associated with fewer cases. High clinical suspicion, rapid CT, and timely surgery are critical to improve outcomes.

Introduction: Acute appendicitis is a common surgical emergency. Laparoscopic appendicectomy is preferred for faster recovery and less pain, but conversion to open surgery remains necessary in some cases. Most evidence on conversion comes from high-income countries, while data from low- and middle-income settings (LMIC), where resource limitations may influence surgical decisions, are scarce. This study aimed to identify factors associated with conversion in a public, resource-limited Peruvian hospital.

Methods: We conducted a retrospective cross-sectional study of patients undergoing laparoscopic appendicectomy at a public hospital in Lima, Peru, between 2022 and 2023. Variables were compared between patients requiring conversion and those completing the procedure laparoscopically. Multivariate analyses were performed to identify risk factors.

Results: A total of 523 patients were included. Conversion to open appendicectomy occurred in 4 patients (0.76%), primarily due to difficult dissection from severe adhesions, intraoperative hemorrhage associated with equipment malfunction. Multivariate analysis identified adhesions (OR=8.91, 95%CI 1.48-53.42, p=0.017), appendicolith (OR=11.49, 95%CI:1.74-75.69, p=0.001), and intraoperative complications (OR=45.74, 95%CI:6.71-311.55, p < 0.001) as significant factors of conversion.

Conclusions: Laparoscopic appendicectomy is safe and effective in public hospitals, even in low-resource settings. Conversion was rare and mainly driven by adhesions, appendicoliths, or intraoperative complications. These findings reinforce that laparoscopic appendicectomy can be reliably performed in LMIC.

Background The incidence of esophageal adenocarcinoma (EAC) has risen significantly in recent decades, with Barrett's esophagus (BE) as the most important precursor. When a visible lesion is identified within BE, endoscopic resection (ER) is the preferred treatment, providing both histologic staging and curative therapy for dysplasia and low-risk EAC. Summary Two ER techniques are commonly used: cap-based endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is an extensively studied technique considered safe, effective, and easy to learn. However, due to the cap-based approach, lesions larger than 15-20 mm need to be removed by multiple adjacent resections, so called piecemeal resection. This may result in remnant tissue in the resection field and may compromise histopathological assessment. In contrast, ESD enables en-bloc removal regardless of lesion size. While ESD has also demonstrated safety and efficacy, it is technically more demanding and associated with longer procedure times. For some lesions, there is general agreement on treatment, with ESD preferred for lesions with suspected submucosal invasion, bulky morphology, or fibrosis. Conversely, EMR remains the standard for smaller, superficial lesions without these features. Key Message A significant grey zone persists, clinical scenarios for which comparative evidence is lacking and consensus on the optimal treatment approach remains unclear.

Introduction: The indications for resection of intraductal papillary mucinous neoplasms (IPMNs) have been optimized according to the high-risk stigmata (HRS) and worrisome features (WFs). However, the proportion of resected IPMNs diagnosed as low grade is not insignificant. This study aimed to investigate whether fibrinogen-to-albumin ratio (FAR) improves the diagnostic ability of high-grade dysplasia (HGD) or invasive carcinoma (IC) in IPMN.

Methods: This study included 47 patients who underwent surgery between April 2008 and July 2024. Clinical factors were examined to determine HGD or IC. We also compared the accuracy of predicting HGD or IC between HRS alone and HRS plus FAR.

Results: A total of 23 were diagnosed with HGD or IC based on pathological diagnosis. On multivariable analysis, contrasted walled nodules ≥5 mm and FAR ≥0.0833 were significant predictors of HGD or IC. Moreover, the HRS and high FAR (≥0.0833) group had better the positive predictive value and diagnostic accuracy rate.

Conclusions: FAR may be a significant predictor of HGD or IC in IPMN. In addition, when combined with HRS, its diagnostic ability as a predictor of HGD or IC may be further improved.

Introduction: Anatomical resection of tumor in liver segment S7 is the most technically challenging procedure in laparoscopic liver hepatectomy due to its deep location and complex vascular structures, which results in a steep learning curve for beginners. We explored a simple and feasible approach: a dorsal approach combined with a dorsoventral method for liver segment S7 resection.

Methods: The key innovations we propose through the dorsal approach combined with a dorsoventral method include the following: (1) systematic dissection of the S7 hepatic pedicle through Rouviere's sulcus; (2) parenchymal transection guided by the dorsal ischemic demarcation line of segment S7; (3) advance along the right hepatic vein toward the ventral aspect of segment S7. By decomposing complex maneuvers into three standardized steps (steps 1-3), this protocol significantly reduces technical barriers. The procedural details are meticulously demonstrated in this report to enhance reproducibility.

Results: In the preliminary phase of this study, 20 patients were included. All patients underwent surgery smoothly, with no conversion to open surgery and no deaths, and all patients achieved R0 resection. The operation time was 190.0 (178.0-210.0) min, and intraoperative blood loss was 200.0 (150.0-280.0) mL.

Conclusions: This method standardizes the laparoscopic S7 segment resection, which, while ensuring precise removal, is expected to reduce the learning curve for surgeons.

Introduction: Systematic reviews (SRs) provide crucial evidence for gastric cancer interventions, but their reliability can be compromised by methodological flaws. We aimed to evaluate the methodological quality of SRs on gastric cancer interventions and identify factors affecting their quality.

Methods: We searched MEDLINE, APA PsycInfo, Embase, and Cochrane Database of SRs for eligible SRs published between January 2014 and October 2023. The methodological quality was assessed using AMSTAR 2. Multivariable regression analyses were conducted to identify factors influencing quality.

Results: Among 119 identified SRs (including 1,305 randomized controlled trials with 233,197 participants), only 2.5% were rated as high quality, while 89.1% were critically low quality. Higher journal impact factor was associated with better performance in addressing heterogeneity (adjusted odds ratio [AOR]: 1.37, 95% confidence interval [CI]: 1.02-1.84), investigating publication bias (AOR: 1.41, 95% CI: 1.03-1.94), reporting conflicts of interest (AOR: 2.85, 95% CI: 1.59-5.11), and establishing protocols (AOR: 3.33, 95% CI: 1.89-5.87). More review authors predicted better statistical methods (AOR: 1.20, 95% CI: 1.03-1.40) and protocol establishment (AOR: 1.31, 95% CI: 1.06-1.63). Recent publications showed improved conflict of interest reporting (AOR: 1.54, 95% CI: 1.09-2.10) and risk of bias assessment (AOR: 1.34, 95% CI: 1.03-1.75). Non-pharmacological SRs better discussed heterogeneity compared to pharmacological (AOR: 0.27, 95% CI: 0.09-0.85) or mixed interventions (AOR: 0.12, 95% CI: 0.03-0.53).

Conclusion: The methodological quality of gastric cancer intervention SRs is unsatisfactory. Future SRs should focus on establishing protocols, explaining study design selection, using comprehensive search strategies, documenting excluded studies with reasons, and describing primary studies in detail.

Background: The management of locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) now relies on an integrated, multidimensional assessment that goes beyond just the relationship of the tumour to vascular anatomy. Summary: By combining dynamic imaging, biomarker monitoring, genetic profiling, and thorough physiological evaluation, clinicians can more accurately select patients who are most likely to benefit from aggressive surgical intervention. These patients can then be offered NAT, singly or in combination, and preferably within the context of a clinical trial. The re-staging of patients post-NAT remains a challenge, but in patients who have shown no evidence of tumour growth or metastases and preferably with evidence of biochemical, metabolic, or radiological response and are fit enough, a trial dissection may be indicated. This evolving strategy transforms a disease once considered palliative into one with curative potential in selected patients. In this setting, surgical techniques have also evolved to include artery-first approaches to the SMA and CA, arterial divestment as an alternative to arterial resection, and the triangle operation. Patients with LA-PDAC should be managed in a high-volume centre with experience in treating this type of patient. There is no established role for minimally invasive techniques, including laparoscopic or robotic surgery, with LA-PDAC. Key Messages: Determining the role of surgery for locally advanced pancreatic cancer requires more than just an assessment of the tumour-vasculature relationship. The multidisciplinary selection integrates dynamic imaging, biomarker monitoring, genetic profiling, and physiological evaluation. For some patients, a previous palliative strategy is transformed to a potentially curative one. In this setting, new surgical techniques include an artery-first approach to avoid futile resection, periadventitial dissection instead of arterial resection, and the triangle operation for complete nodal clearance.

Introduction: Preoperative anaemia is common in gastric cancer patients. Although restrictive blood product transfusion strategies have been introduced, their use in standard practice is not well known. This national register study investigated the perioperative haemoglobin and platelet levels and the use of blood product transfusions in gastric cancer surgery.

Methods: In order to improve and unify blood transfusion policies, the Finnish Red Cross Blood Service carried out a project concerning the optimal use of blood products (VOK project). These register data were used to form the patient population containing 70% of blood product transfusions in Finland. Patients undergoing open surgery for gastric cancers were included.

Results: A total of 500 patients were included. Perioperative anaemia was observed in 75% of males and 52% of females. Fifty-one percent of patients received blood transfusions, with a median transfusion trigger point of 91 g/L [IQR 84-98 g/L] and a median 3 units transfused [IQR 2-4 units]. Seven percent received platelet transfusion (median trigger 77, IQR 15-146; median 4 units, IQR 2-8), and 6.5% received either fresh frozen plasma or pooled human plasma products. At discharge, the median haemoglobin level was 109 g/L in non-transfused patients and 114 g/L in transfused patients. If restrictive strategies had been applied, only 1.7% (n = 9) had required blood and 0.5% (n = 3) had a platelet transfusion.

Conclusion: Anaemia is common among patients undergoing gastric cancer surgery. We encourage clinicians to follow restrictive transfusion policies in gastric cancer patients as Hb levels seem to recover after gastric surgery without blood transfusions.