Digestive Surgery最新文献

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.

Technique: The key innovations we propose through the dorsal approach combined with a dorsoventral method include: 1) systematic dissection of the S7 hepatic pedicle through Rouviere 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 (Step 1-3), this protocol significantly reduces technical barriers. The procedural details are meticulously demonstrated in this report to enhance reproducibility.

Result: 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.

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. 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 tumor 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.

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. This register data was used to form the patient population containing 70% of blood product transfusions in Finland. Only those undergoing 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. 51% of patients received blood transfusions, with a median transfusion trigger point of 91 g/L and a median of 3 units transfused. 7% received platelet transfusion, 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 would have been applied, only 1.7% would have required blood and 0.5% platelet transfusion.

Conclusions: 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 without blood transfusions.

Background: The appropriate regimen for induction therapy with the intent of conversion therapy for advanced hepatocellular carcinoma (HCC) is unknown. This study aimed to evaluate whether the overall response rate (ORR) of chemotherapy correlates with the conversion rate.

Summary: The studies of phase 2/3 trials of systemic or hepatic arterial infusion chemotherapy (HAIC) for patients with advanced HCC were searched. A total of 42 patient groups from 32 trials were included in the analysis. The ORR and conversion rates in a total of 3516 patients were 24.7% and 8.3%, respectively. The analysis of only the patient groups treated with 1st-line immune checkpoint inhibitors, tyrosine-kinase inhibitors or HAIC revealed strong correlation between the ORR and the conversion rate (ρ=0.647, p=0.0003). In addition, strong correlations between the ORR and median PFS/OS were observed (ρ=0.772, p<0.0001 and ρ=0.754, p<0.0001, respectively). Messages: Because of the strong correlations of the ORR with the conversion rate and PFS/OS, regimens with high ORRs may be used for patients with advanced HCC who are potential candidates for conversion therapy.

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 RCTs 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 (AOR: 1.37, 95% 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.

Introduction: In this first preclinical evaluation study of the hinotori™ system in gastric resection procedure, its capabilities to perform distal and total gastrectomy while using human cadaver models were evaluated.

Methods: Three robotic distal gastrectomies (RADGs) and one total gastrectomy were performed in human cadavers using the same setup. A delta-shaped anastomosis in the RADG procedures were performed with a manual stapler.

Results: The mean operative time for three distal gastrectomies was 118 min, while the total gastrectomy procedure focused on the resection only. The dissection could be made up to pulmonary veins, while the entire setup was kept. The procedures were done safely according to the surgical standards with smooth instrument and overall performance without any complications seen. An ergonomic surgeon cockpit and head rest supported the outcome.

Conclusion: Docking-free design and human arm-like movement with a high degree of operation arm mobility showed a wide range of motion of the wristed robotic instruments. This could be beneficial for multiquadrant procedures resulting in potential shorter procedures times with smother performance, which should be evaluated in further studies.

Background: Long-limb Roux-en-Y (LLRY) reconstruction has recently been implemented as an oncometabolic surgery to improve glycemic control following surgery for gastric cancer (GC); however, data on its feasibility are insufficient. We investigated the 1-year outcomes of LLRY reconstruction for glycemic control in patients with type 2 diabetes (T2D).

Methods: We reviewed the records of 15 patients with GC and T2D who underwent LLRY reconstruction after gastrectomy, with biliopancreatic and Roux limb lengths of 130-250 cm, to improve postoperative glycemic control. The primary outcome was the T2D remission (glycated hemoglobin <6.5% without antidiabetic medication) rate at 12 months postoperatively. The diabetes prediction (DP) score and Korean nationwide average T2D remission rates following GC surgery were compared.

Results: The mean patient age was 66.5 years (standard deviation [SD] 9.6), mean body mass index was 26.4 kg/m2 (SD 4.4), and mean glycated hemoglobin level was 7.7% (SD 1.5). The overall T2D remission rate was 46.7%. The postoperative T2D remission rate was 12.9% higher than the DP score estimate (33.8%) and 25.7% higher than the Korean national average rate (21%) of T2D remission following GC surgery.

Conclusion: Our results show that LLRY reconstruction after gastrectomy is an effective oncometabolic surgery for treating T2D and GC.

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.