Digestive Surgery最新文献

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.

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 to 0.65). Anastomotic leakage was also reduced in the EOF group (OR 0.40; 95% CI 0.19 to 0.83); however, an increased incidence of vomiting (OR 1.58; 95% CI 1.11 to 2.26) as well as a tendency of higher rate of nasogastric tube reinsertion (OR 1.49; 95% CI 0.96 to 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 to 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.

Introduction Partial hepatectomy (PH) remains associated with complication rates around 30-50%. Delayed return of gastrointestinal function (DRGF) has been reported in 10-20%. This study aimed to assess DRGF predictors after PH. Aim This retrospective study aimed to assess DRGF predictors after PH. Methods All patients who underwent PH between 01/2010 and 12/2019 were included. DRGF was defined as need of postoperative nasogastric tube (NGT). Independent DRGF predictors were identified with multivariable logistic binary regression. Results Overall, 501 patients were included. DRGF occurred in 82 patients (16%). A hundred-and-twelve patients (22%) underwent a minimally invasive approach and DRGF incidence was significantly lower in this group (p <0.001). DRGF was more frequent after major PH (p<0.001). DRGF occurred more often in patients with preoperative embolization (p<0.001), biliary anastomosis (p<0.001) and extrahepatic resection (p<0.001). Patients with DRGF had longer median operation duration (p<0.001), more biliary leaks/bilomas (p<0.001) and higher median blood loss (p<0.001). DRGF patients developed more pneumonias (p<0.001) and had longer median length of stay (p<0.001). On multivariable analysis, operation duration (p<0.001), major hepatectomy (p<0.001) and postoperative biloma/biliary leak (p<0.001) were independently associated with DRGF occurrence. Conclusion Postoperative DRGF occurred in 16% of the patients and was associated with longer length of stay. Surgery duration, major PH and postoperative biloma/biliary leak were found as independent predictors of DRGF.

Introduction Telementoring could increase the quality, reduce the time, and increase cost efficiency of the proctoring program for robot-assisted minimally invasive esophagectomy (RAMIE). However, feasibility is unclear as no studies assessed telementoring for RAMIE. Methods The feasibility of telementoring was assessed during the thoracic part of RAMIE procedures in three high-volume centers. RAMIEs were performed by trained surgeons, proctored by two experts. The primary outcome was impact of the technology on conveying and understanding instructions. Results Between December 2021 and December 2022, nine RAMIE procedures were proctored using the telementoring. Overall quality of the telementoring technique was scored good to excellent (median score: good). The vast majority of the 24 proctor instructions were conveyed and understood fluently (n=21, 96%). Most proctor instructions were aimed at improving surgical exposure (n=9, 38%). The major point of criticism was the use of the audio as the communication through the headset of the performing surgeon was not accessible by the complete team. Conclusion Telementoring is deemed feasible for proctoring trained RAMIE surgeons after onsite proctoring. Technical improvements with regard to audio technology are warranted for broad implementation, especially in earlier training settings. The role of telementoring in the training pathway of learning surgeons needs clinical validation. Study registration number: 21/322 Date of registration: 14-5-2021.

Introduction: One of the most common causes of bleeding during pancreaticoduodenectomy (PD) is dissection of the pancreatic head from the superior mesenteric vein (SMV) and superior mesenteric artery (SMA). Knowledge of the anatomical variants of the veins draining the proximal jejunum may allow a better control of bleeding during detachment of the uncinate process and pancreatic head from the mesenteric pedicle and division of the mesopancreas. The aim of this systematic review and meta-analysis is to evaluate the anatomical variations of the first jejunal vein (FJV) and jejunal trunk (FJT).

Methods: Fourteen studies (1,888 patients) were included. We performed a systematic review of the available Literature according to the PRISMA guidelines.

Results: The analysis has shown that the posterior course of the FJT and FJV represents the most frequent topographical location (PPE 79.6%) with the anterior jejunal trunk (JT) having a lower rate (PPE 20.4%). Few articles reported the variations with separate trunks for the first and second jejunal vein.

Conclusions: A thorough preoperative radiological assessment of the anatomical variation of FJT and FJV may confer some advantage to establish the best therapeutic strategy and the best surgical approach in case of pancreatic head carcinoma, as it can allow a better estimate of the extent of the neoplasm and improve the accuracy of surgical dissection with potential for reduced bleeding.

Introduction: Laparoscopic distal pancreatectomy (LDP) is a safe and effective procedure; however, its impact on perioperative inflammatory reactions compared with open distal pancreatectomy (ODP) remains unclear. This study aimed to assess short-term outcomes following LDP and ODP regarding inflammatory reactions.

Methods: This retrospective study of 77 consecutive patients who underwent distal pancreatectomy for low-grade malignancies between 2005 and 2022 compared white blood cell (WBC) count, C-reactive protein (CRP) level, serum albumin level, and CRP/albumin ratio (CAR) between LDP and ODP. Complications, especially postoperative pancreatic fistula (POPF), recovery program, and hospital stay period, were also compared.

Results: POPF (17.1% vs. 38.7%, p = 0.039) and surgical morbidity (≥Clavien-Dindo grade III, 12.2% vs. 32.3%, p = 0.038) were significantly lower in LDP than in ODP, as for the difference in postoperative inflammatory response, including CRP and CAR, was just temporary. By multivariate analysis, CAR ≥6.94 on POD 3 was significant predictor of POPF (42.1% vs. 13.2%, odds ratio 4.828, p = 0.030).

Conclusion: LDP has lower POPF and earlier postoperative recovery. CAR could be a predictor of POPF.

Introduction: Laparoscopic right hemicolectomy has become the standard surgical procedure for the treatment of right colon disease; however, the choice of anastomosis remains controversial. This study aimed to compare the safety and efficacy of intracorporeal anastomosis and extracorporeal anastomosis in laparoscopic right hemicolectomy.

Methods: A systematic literature search was performed in PubMed, Embase, Web of Science, and Cochrane Library. Randomized controlled trials that compared intracorporeal anastomosis with extracorporeal anastomosis in patients with laparoscopic right hemicolectomy until June 4, 2023, are selected. The primary outcomes measured were incidence of anastomotic leakage within 30 days post-operation. Statistical analyses were performed using Review Manager (version 5.4.1).

Results: Seven RCTs, including 720 patients, were eligible for the meta-analysis. The incidence of anastomotic leakage showed no significant difference between the intracorporeal anastomosis group and the extracorporeal anastomosis group (RR 0.93, 95% CI: 0.49, 1.76, p = 0.83, and I2 = 0%). However, the intracorporeal anastomosis group had significantly lower rates of postoperative ileus (RR 0.67, 95% CI: 0.45-0.99, p = 0.04, I2 = 46%) and surgical site infections (RR 0.34, 95% CI: 0.16-0.74, p = 0.007, I2 = 0%) compared to the extracorporeal anastomosis group. Additionally, patients in the intracorporeal anastomosis group experienced earlier postoperative passage of gas and stool (WMD -0.39, 95% CI: -0.60, -0.19, p = 0.0002, and I2 = 67%; WMD -0.53, 95% CI: -0.85, -0.21, p = 0.001, and I2 = 75%), as well as shorter hospital stays (WMD -0.46, 95% CI: -0.74, -0.18, p = 0.001, and I2 = 34%).

Conclusion: In laparoscopic right hemicolectomy, intracorporeal anastomosis does not increase the incidence of anastomotic leakage within 30 days post-operation compared to extracorporeal anastomosis. In addition, intracorporeal anastomosis resulted in faster recovery of bowel function. This suggests that intracorporeal anastomosis is safe and effective.

Background: Prognosis of perihilar cholangiocarcinoma (PHCC) is poor, and curative-intent resection is the most effective treatment associated with long-term survival. Surgery is technically demanding since it involves a major hepatectomy with en bloc resection of the caudate lobe and extrahepatic bile duct. Furthermore, to achieve negative margins, it may be necessary to perform concomitant vascular resection or pancreatoduodenectomy. Despite this aggressive approach, recurrence is often observed, considering 5-year recurrence-free survival below 15% and 5-year overall survival that barely exceeds 40%.

Summary: The literature reports that survival rates are better in patients with negative margins, and surprisingly, R0 resections range between 19% and 95%. This variability is probably due to different surgical strategies and the pathologist's expertise with specimens. In fact, a proper pathological examination of residual disease should take into consideration both the ductal and the radial margin (RM) status. Currently, detailed pathological reports are lacking, and there is a likelihood of misinterpreting residual disease status due to the missing of RM description and the utilization of various definitions for surgical margins.

Key messages: The aim of PHCC surgery is to achieve negative margins including RM. More clarity in reporting on RM is needed to define true radical resection and consistent design of oncological studies for adjuvant treatments.

Introduction: Cholangiocarcinoma is the second most common primary liver tumour worldwide with an increasing incidence in recent decades. While the effects of fibrosis on hepatocellular carcinoma have been widely demonstrated, the impact on cholangiocarcinoma remains unclear. The aim of this study was to evaluate the impact of liver fibrosis on overall survival (OS) and disease-free survival (DFS) in patients who have undergone liver resection for cholangiocarcinoma.

Methods: Eighty patients with cholangiocarcinoma who underwent curatively intended liver surgery between January 2007 and December 2020 were included in this retrospective single-centre study. Clinical and histopathological features were analysed. The primary endpoint was cause-specific survival. Secondary endpoints were DFS and identification of prognostic factors.

Results: The present study shows that the median OS is significantly reduced in patients with fibrosis (p < 0.001). The median OS in patients with fibrosis was three times shorter than in the group without fibrosis. In addition, a significantly shorter DFS was observed in patients with fibrosis (p < 0.002). Multivariate analysis showed that fibrosis is the strongest independent factor with a negative impact on OS and DFS.

Conclusion: Liver fibrosis has a significant impact on OS and DFS in patients with cholangiocarcinoma. Patients with known liver fibrosis require thorough perioperative care and postoperative follow-up.

Introduction: This study aimed to evaluate associations between frailty and outcomes in patients with intrahepatic cholangiocarcinoma (ICC) undergoing hepatic lobectomy using a large, nationally representative sample.

Methods: This population-based, retrospective observational study extracted the data of adults ≥20 years old with ICC undergoing hepatic lobectomy from the US Nationwide Inpatient Sample database between 2005 and 2018. Frailty was assessed by the validated Hospital Frailty Risk Score (HFRS). Associations between frailty and surgical outcomes were analyzed using logistic regression analyses.

Results: After exclusions, 777 patients were enrolled, including 427 frail and 350 non-frail. Patients' mean age was 64.5 (±0.4) years and the majority were males (51.1%) and whites (76.5%). Frailty was significantly associated with increased odds of in-hospital mortality (aOR: 18.51, 95% CI: 6.70, 51.18), non-home discharge (aOR: 3.58, 95% CI: 2.26, 5.66), prolonged LOS (aOR: 5.56, 95% CI: 3.87, 7.99), perioperative cardiac arrest/stroke (aOR: 5.44, 95% CI: 1.62, 18.24), acute respiratory distress syndrome (ARDS)/respiratory failure (aOR: 3.88, 95% CI: 2.40, 6.28), tracheostomy/ventilation (aOR: 3.83, 95% CI: 2.23, 6.58), bleeding/transfusion (aOR: 1.67, 95% CI: 1.24, 2.26), acute kidney injury (AKI) (aOR: 14.37, 95% CI: 7.13, 28.99), postoperative shock (aOR: 4.44, 95% CI: 2.54, 7.74), and sepsis (aOR: 11.94, 95% CI: 6.90, 20.67).

Discussion/conclusion: Among patients with ICC undergoing hepatic lobectomy, HFRS-defined frailty is a strong predictor of worse in-patient outcomes, including in-hospital death, prolonged LOS, unfavorable discharge, and complications (perioperative cardiac arrest/stroke, ARDS/respiratory failure, tracheostomy/ventilation, bleeding/transfusion, AKI, postoperative shock, and sepsis). Study results may help stratify risk in frail patients undergoing hepatic resection for ICC.

Introduction: Gastroesophageal cancer patients' information needs remain understudied, despite their complex treatment trajectories.

Methods: This study examined the (i) information needs of patients with or without postoperative complications, (ii) information needs of male and female patients, and (iii) the association between information needs and health-related quality of life (HR-QoL) following gastroesophageal cancer surgery. Patients completed the EORTC-QLQ-INFO25, QLQ-C30, and QLQ-OG25 questionnaires before and after curative surgery. Five information needs domains were investigated: information about the disease, about treatments, about medical tests, about things patients can do to help themselves, and overall helpfulness. Additionally, HR-QoL domains global health status, eating restrictions, and anxiety were explored.

Results: A total of 132 patients completed the questionnaires at baseline, 216 patients at 6-12 months, 184 patients at 18-24 months, and 163 patients at 3-5 years post-operation. There were no significant differences in information needs between patients with or without complications or between male and female patients. Patients with a higher global health status found the information more helpful at 6-12 months (p < 0.001), 18-24 months (p < 0.001), and 3-5 years (p < 0.001) postoperatively, as did patients who experienced more anxiety at 18-24 months (p = 0.009) and 3-5 years (p < 0.001).

Conclusion: Gastroesophageal cancer patients, regardless of sex or postoperative complications, have consistent information needs, yet those with higher global health status and elevated anxiety levels find the information particularly helpful, emphasizing the importance of tailored communication strategies.