Digestive Surgery最新文献

Introduction: Postoperative antibiotic treatment is indicated for 3-5 days following appendectomy for complex appendicitis. However, meeting discharge criteria may allow for safe discontinuation of antibiotics and discharge. This study assessed the association between time to reach discharge criteria and duration of postoperative antibiotic use and length of stay.

Methods: This is a multicenter retrospective cohort study including patients who underwent appendectomy for complex appendicitis and received postoperative antibiotics for >24 h. Main outcome measures were time to reach discharge criteria, duration of postoperative antibiotic use, length of hospital stay, and postoperative infectious complications. Discharge criteria were defined as absence of fever (temperature ≤38°C) for 24 h, ability to tolerate oral intake, and pain controlled by oral analgesics.

Results: Between May 2014 and January 2015, 124 patients were included. Time to reach discharge criteria was 2 days (interquartile range [IQR] 1-3). Patients received postoperative antibiotics and were in hospital for a median of 5 (IQR 3-5) and 5 (IQR 4-6) days, respectively. Infectious complications occurred in 12% and did not differ between patients reaching discharge criteria before or after 2 postoperative days.

Discussion: Discharge criteria were met by a median of 2 days after appendectomy for complex appendicitis. This suggests that postoperative antibiotics duration and thereby hospital stay can be reduced. In daily practice, prescribed antibiotics are not reduced in total days given. Prospective studies that evaluate limited postoperative antibiotic use, based on these criteria, are necessary.

Introduction: Failure to cure describes: (1) nonresectional ("open-close") surgery, (2) non-radical surgery (R1-R2), and/or (3) postoperative mortality. This study aimed to investigate whether hospitals offering surgery to a large proportion of patients have higher failure-to-cure rates than hospitals operating fewer patients.

Methods: From the Netherlands Cancer Registry, all cT1-cT4a/cTx-any cN-cM0 esophageal cancer patients diagnosed in 2015-2018 were included. For each center, the expected (E) proportion of patients undergoing surgery was established and divided by the observed (O) proportion. Hospitals were categorized into three groups: (1) hospitals treating relatively many patients with surgery, (2) average hospitals, and (3) hospitals treating relatively few patients with surgery. Multilevel multivariable regression investigated the association between these hospital groups and failure to cure.

Results: Some 3,437 (53.2%) of 6,457 patients underwent surgery, ranging from 45 to 64% among 16 hospitals. The failure-to-cure rate was 15.0% (hospital variation [4.6-23.7%]). After categorizing, 1,003 patients underwent surgery in hospitals with low surgery rates (O/E ratio <0.94/corrected percentage <50%), 1,297 patients in average hospitals, and 1,137 patients in hospitals treating many patients surgically (O/E ratio >1.01/corrected percentage >54%). Failure-to-cure rates were 16.8%, 12.2%, and 14.0%, respectively. This was nonsignificant in multilevel analyses (aOR: 0.63, 95% CI: 0.38-1.05; aOR: 0.76, 95% CI: 0.46-1.24).

Discussion/conclusion: Failure-to-cure rates were similar in hospitals with a high surgery rate and hospitals with a low rate. Increasing the proportion of patients undergoing a resection may offer more patients, a chance for cure.

We report a new surgical method in 10 patients who underwent hybrid laparo-endoscopic resection (HLER) of submucosal tumors with the combination of flexible articulated laparoscopic instruments (FALI). We have assessed technical reproducibility, safety, and morbidity. Resection was completed in all cases. Mean surgical time was 60 min (30-85). Median tumor size was 16 mm (12-30). The more frequent location was the gastroesophageal junction. No complications were observed during the procedure. Length of stay was 1 day in all cases. We have found HLER to be a safe procedure allowing margin resection and organ preservation. The addition of FALI added ease of performance in hard-to-reach tumor locations.

Donor hepatectomy is one of the most important procedures in LDLT because it affects the safety of donors and the outcome of the recipients. We standardized a method of securing the important vessels at the hepatic hilum while advancing the dissection toward the central direction. This research introduces our technique of handling hilar vasculature in living donor hepatectomy, using the extrahepatic Glissonean approach, and discusses its efficacy. At first, after the extrahepatic right Glissonean approach, the resected hepatic artery and portal vein are secured on the same line as with the secured Glisson. The resected hepatic artery and portal vein are followed in the central direction, and the surrounding area is dissected. The dissection is continued up to the main brunch of the hepatic artery and portal vein. The bile duct can be secured by subtracting the hepatic artery and portal vein from the tape that secured the Glissonean pedicle. The bile duct, hepatic artery, and the portal vein are dissected in this order, before dissecting the right hepatic vein, completing the surgery. This method of dissection approaching the extrahepatic Glisson carried out toward the central direction suggests to acquire minimal tissue removal and to shorten operative time. This could result in adequate perfusion to the remaining liver and donor safety, taken together effective results on the recipient.

Introduction: Sorafenib is the standard care for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT), though it offers limited survival. This study was designed to compare clinical outcomes between liver resection (surgery) and transarterial chemoembolization plus radiotherapy (TACE-RT) as the initial treatment modality for resectable treatment-naïve solitary HCC combined with subsegmental (Vp1), segmental (Vp2), and lobar (Vp3) PVTT.

Methods: From the institutional HCC registry, we identified 116 patients diagnosed with resectable treatment-naïve HCC with Vp1-Vp3 PVTT based on radiologic images who received surgery (n = 44) or TACE-RT (n = 72) as a primary treatment between 2010 and 2015. A propensity score matching (PSM) model was created.

Results: The TACE-RT group had a higher tumor burden (tumor size, extent, and markers) than the surgery group. Cumulative patient survival curve in the surgery group was significantly higher than that in the TACE-RT group before and after PSM. Liver function was relatively well preserved in the surgery group compared with the TACE-RT group. TACE-RT group, male, increased alkaline phosphatase, and increased platelet count were predisposing factors for patient death in resectable treatment-naïve solitary HCC with PVTT.

Discussion/conclusion: The present study suggests that surgery is considered as an initial treatment in selectively resectable treatment-naïve solitary HCC with Vp1-Vp3 PVTT.

Introduction: Controversy remains about the classification, differential diagnosis, and treatment strategy for gallbladder polypoid lesions (GPLs). This study sought to explore the individualized treatment strategy for GPLs.

Methods: We retrospectively studied 642 consecutive patients with GPLs from January 2015 to May 2020. Univariate and multivariable analyses were performed to explore the potential risk factors for neoplastic polyps. The outcome of laparoscopic gallbladder-preserving polypectomy (GPP) was evaluated and compared with that of laparoscopic cholecystectomy (LC).

Results: Of 642 enrolled patients, 572 underwent LC, and 70 underwent GPP. Pathologically, the majority of GPLs were cholesterol polyps (68.4%), followed by adenomyomatosis (19.9%), benign adenoma (7.3%), adenocarcinoma (3.6%), and rare pathological types (0.8%). Additionally, 66.3% (379/572) of the LC cases were classified as non-neoplastic, and 33.7% (193/572) neoplastic polyps. Multivariate analysis demonstrated that single polyps (OR 1.956, 95% CI: 1.121-3.412; p = 0.018), polyps located at the gallbladder fundus (OR 4.326, 95% CI: 2.179-8.591; p < 0.001), polyps not less than 14 mm (OR 2.833, 95% CI: 1.614-4.973; p < 0.001), and polyps with a broad base (OR 4.173, 95% CI: 1.743-9.990; p = 0.001) were independent risk factors for neoplastic polyps. The 5-year prospective results after GPP showed that the 1-year and 3-year polyp recurrence rates were 13.2% and 23.4%, respectively.

Conclusion: The majority of GPLs are cholesterol or other benign lesions without malignant potential. LC is the main treatment procedure for GPLs with a high neoplastic risk. GPP is potentially feasible and could be an alternative management strategy for a group of GPLs patients who meet the selection criteria.

Introduction: The safety of laparoscopic surgery (LS) and its effect on survival have not been sufficiently assessed in elderly colon cancer patients.

Methods: Clinicopathologic data of patients aged ≥75 years who underwent colectomy for primary colon cancer, between January 2018 and June 2021, were reviewed. Patients were divided into the LS and open surgery (OS) groups according to the intention-to-treat principle and were compared using propensity score matching. The primary outcomes were differences in surgical safety and 3-year survival.

Results: There were 98 patients with a median age of 82 years and 85 patients with a median age of 80 years assigned to the OS and LS groups, respectively. Propensity score matching revealed that LS did not prolong the operative time (190 vs. 180 min, p = 0.209) and was linked to less intraoperative blood loss (50 vs. 100 mL, p = 0.039) and shorter postoperative hospital stay (8 vs. 10 days, p = 0.005), compared to OS. In addition, LS was not accompanied by more stress response when the variations exhibited in laboratory tests and the Barthel index pre- and postsurgery were considered. There were no significant differences in the adjusted 3-year overall survival (86.0% vs. 81.2%, p = 0.795) and disease-free survival (86.6% vs. 87.9%, p = 0.356) between the groups.

Conclusion: LS enhanced postoperative recovery without increasing surgical risks, compared to OS, in colon cancer patients aged ≥75 years. Furthermore, no significant differences in the 3-year adjusted survival were observed between the groups.