Digestive Surgery最新文献

Background: Neoadjuvant chemoradiotherapy (nCRT) or perioperative chemotherapy followed by surgical resection is the standard of care for oesophageal and gastroesophageal junction cancer. Up to a third of patients will have a pathological complete response to neoadjuvant treatment. Given the significant morbidity associated with surgery, active surveillance is considered as a potential alternative for patients with clinical complete response post-nCRT. Summary: The preSANO and preSINO trials have validated a multimodal diagnostic strategy combining oesophagogastroduodenoscopy with bite-on-bite biopsies, endoscopic ultrasonography with fine-needle aspiration of suspicious lymph nodes, and PET-CT to detect residual disease. The SANO trial is assessing whether active surveillance leads to non-inferior overall survival compared to planned surgery. Early results of randomized studies support previous retrospective reports of comparable oncological outcomes, with improved quality of life in the surveillance group. Despite concerns of increased morbidity of postponed surgery upon recurrence, recent data indicate comparable surgical outcomes of delayed oesophagectomy. Ongoing trials, including SANO-2, CELEAC, and NEEDS, aim to rationalize surveillance protocols, while SANO-3 is investigating the role of adding immunotherapy in improving response durability. Key Messages: Active surveillance represents a promising alternative to surgery for oesophageal cancer patients achieving complete clinical response after neoadjuvant therapy. While it can spare patients the morbidity of oesophagectomy and significantly improve quality of life, it requires accurate response assessment and structured follow-up. Future developments, including immunotherapy and non-invasive diagnostics, may further refine this approach and expand its safe applicability.

Introduction: The present study aimed to determine the clinical value of serum procalcitonin (PCT) level in predicting postoperative infections after hepatectomy.

Methods: Medical records of 301 consecutive patients who underwent hepatectomy were retrospectively reviewed. We divided the patients into infection-positive and infection-negative groups. We investigated the changes in perioperative inflammatory markers such as C-reactive protein level (CRP) and PCT level. Associations between infectious complications and perioperative inflammatory markers were evaluated to identify predictive factors of infectious complications after hepatectomy.

Results: Postoperative infectious complications occurred in 67 (22.3%) patients. The areas under the curve (AUCs) using PCT levels on postoperative days (PODs) 1 and 3 were 0.794 and 0.845, respectively, whereas those using CRP were 0.493 and 0.641, respectively. PCT level had a better AUC than CRP for predicting postoperative infectious complications on PODs 1 and 3. Multivariate analysis indicated PCT levels on PODs 1 and 3 were an independent predictor of infectious complications after hepatectomy.

Conclusion: PCT is the only predictive marker for infectious complications after hepatectomy and is valuable for detecting infectious complications from POD 1.

Introduction: The present study aimed to determine the clinical value of serum procalcitonin (PCT) level in predicting postoperative infections after hepatectomy.

Methods: Medical records of 301 consecutive patients who underwent hepatectomy were retrospectively reviewed. We divided the patients into infection-positive and infection-negative groups. We investigated the changes in perioperative inflammatory markers such as C-reactive protein level (CRP) and PCT level. Associations between infectious complications and perioperative inflammatory markers were evaluated to identify predictive factors of infectious complications after hepatectomy.

Results: Postoperative infectious complications occurred in 67 (22.3%) patients. The areas under the curve (AUCs) using PCT levels on postoperative days (PODs) 1 and 3 were 0.794 and 0.845, respectively, whereas those using CRP were 0.493 and 0.641, respectively. PCT level had a better AUC than CRP for predicting postoperative infectious complications on PODs 1 and 3. Multivariate analysis indicated PCT levels on PODs 1 and 3 were an independent predictor of infectious complications after hepatectomy.

Conclusion: PCT is the only predictive marker for infectious complications after hepatectomy and is valuable for detecting infectious complications from POD 1.

Introduction: Free perforation of the stomach or the duodenum usually requires emergency surgery. In fact, perforation is associated with short-term mortality and morbidity in up to 30 and 50% of patients, respectively, due to secondary peritonitis and sepsis. We hypothesized that postoperative clinical outcomes with duodenal perforation (DP) are worse than those with stomach perforation (SP). This retrospective study aimed to compare the early postoperative clinical outcomes of patients with SP and DP, focusing on morbidity and mortality, to identify differences that could indicate potential changes in surgical management.

Methods: A total of 110 patients underwent emergency surgery between 2012 and 2022 for free SP or DP. We compared the demographic, intra-, and postoperative data, including morbidity and mortality during primary hospitalization in the two groups of patients. One group consisted of patients with SP and the second group consisted of patients with DP.

Results: The incidence of any postoperative complication, the rate of planned reoperation, median operation time, as well as the median hospital stay after surgery were significantly increased in patients with DP compared to those with SP. In addition, surgical and nonsurgical complications, as well as mortality were common in the total patient population, and higher in DP than in SP patients; however, these differences were not statistically significant.

Conclusion: Common postoperative problems occurring after surgery for DP or SP are similar and often life-threatening in both situations. However, patients with DP experienced these problems significantly more often, indicating a more complex injury that required considerably more medical intervention and extended treatment.

Introduction: As the nonoperative management of acute appendicitis becomes more widespread, identifying patients at high risk of appendiceal tumors is increasingly important. This study aimed to clarify the predictive factors of appendiceal tumors before appendectomy.

Methods: We retrospectively analyzed 434 patients diagnosed with acute appendicitis who underwent emergency or interval appendectomy.

Results: Appendiceal neoplasms were found in 3.9% of patients. Patients with tumors were significantly older (64.4 vs. 49.6 years, p < 0.001). The tumor group exhibited a lower appendicolith incidence (48% vs. 12%, p = 0.011) and larger appendiceal diameters (18.0 vs. 12.3 mm, p < 0.001). Multivariate analysis demonstrated that age ≥60 years, absence of appendicolith, and an appendiceal diameter ≥12 mm were independent risk factors of appendiceal tumors. Among patients who underwent interval appendectomy, only the non-tumor group exhibited significant improvement in appendiceal diameter after nonoperative management (tumor, +1.6 mm vs. no tumor, -3.5 mm, p < 0.001).

Conclusions: Advanced age, absence of appendicolith, and an enlarged appendiceal diameter may be significant predictive factors of appendiceal tumors. These factors will aid in the selection of appropriate appendicitis treatment strategies.

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 anastomotic leakages in the upper and lower gastrointestinal tract, often in conjunction with surgical interventions. A standardized treatment algorithm has not been established. This study aimed to assess the safety and efficacy of ENPT in the multidisciplinary 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.

Introduction: Irreversible electroporation (IRE) is a form of non-thermal ablation that delivers pulses of high-voltage electric current between electrodes. Although IRE has been demonstrated to achieve tumor necrosis, its role in the treatment of colorectal hepatic metastases is unestablished. This study is an international questionnaire survey on the use of IRE for patients with colorectal hepatic metastases.

Methods: A questionnaire addressing views on the use of IRE for colorectal liver metastases was circulated to clinicians with an interest and/or expertise in this technique. The questionnaire addressed indications for the use of IRE in a range of scenarios: methods of use, assessment of treatment response, and outcome.

Results: 64 clinicians from 17 different countries replied to the questionnaire. The preferred mode of delivery of IRE was percutaneous treatment under computed tomographic guidance. Thirty-three (70% of 47 respondents) used IRE exclusively for lesions in proximity to inflow or outflow structures. Twenty (43% respondents) used IRE as their sole ablative treatment, while 19 (40% of 47 respondents) used IRE in combination with thermal ablation. The maximum number of lesions that could be treated by IRE was two and the preferred size of lesion was <3 cm.

Conclusion: Respondents to this international questionnaire survey indicate that IRE is an acceptable ablative option for small colorectal liver metastases (<3 m in diameter) close to inflow/outflow structures.

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: 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 to identify the risk factors and develop a statistical identification model for bacteremia.

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 (area under the curve, early cohort = 0.93; late cohort = 0.91).

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

Introduction: Total pancreatectomy (TP) is a technically demanding procedure for patients with multifocal pancreatic diseases. Although the benefits of the superior mesenteric artery (SMA)-first approach for pancreatic cancer (PC) have been reported in pancreatic surgery, few studies have demonstrated surgical techniques of SMA-first approach in TP.

Methods: This report presents our novel SMA-first approach for PC in TP, including six steps. First, the resectability was confirmed (step 1). Next, SMA approach was applied (step 2). In this step, the anterior and left sides of the SMA were dissected, and the left renal vein was confirmed. Following retroperitoneal dissection (step 3), the pancreatic body and tail were completely mobilized (step 4). Subsequently, Whipple procedure was performed with lymphadenectomy around the right side of the SMA (step 5). Finally, hepaticojejunostomy and gastrojejunostomy were performed (step 6). Using SMA-first approach, en bloc resection with adequate lymphadenectomy around the SMA and retroperitoneal dissection was performed.

Conclusion: The present study presents surgical techniques of TP using the SMA-first approach for PC. This unique approach may be useful to perform TP for PC to obtain negative resection margins.