Digestive Surgery最新文献

Introduction: Early detection and timely treatment of anastomotic leakage (AL) following rectal surgery are crucial for improving outcomes. However, no standardized early detection pathway exists. This study evaluates a multicenter clinical care pathway integrating bedside endoscopy to reduce time to diagnose AL.

Methods: This international, multicenter, prospective observational study evaluates early endoscopic inspection for AL detection. Endoscopic assessments are performed at the bedside using a point-of-care digital rectoscope. Eligible patients include those undergoing colorectal resection for cancer with a colorectal or coloanal anastomosis within 15 cm of the anorectal junction. The clinical pathway includes bedside endoscopic inspection 3-6 days post-surgery, C-reactive protein-guided CT scans with rectal contrast, and follow-up endoscopy at 2-3 weeks. The primary outcome is time to AL diagnosis. Secondary outcomes include diagnostic accuracy, patient-reported comfort (Modified Gloucester Scale), stoma rate, anastomosis healing at 1 year, and cost-effectiveness. A propensity score-matched historical cohort will be used for comparison. Based on previous reports, we hypothesize this pathway will reduce the median diagnosis time from 15 to 5 days. With 95% confidence and 80% power, 130 patients are needed, with 153 total to account for a 15% maximum dropout rate.

Conclusion: The REAL study is designed to evaluate whether a clinical pathway incorporating routine endoscopic assessment of colorectal anastomoses reduces time to diagnosis of AL and initiation of treatment.

Background: Posthepatectomy liver failure (PHLF) remains a leading cause of morbidity and mortality following major liver resection. Despite advances in surgical techniques and perioperative care, treatment options for PHLF are limited. Pharmacological interventions targeting ischemia-reperfusion injury and portal flow modulation have gained interest as potential therapeutic strategies.

Summary: This review provides a clinically applicable overview of the current evidence on pharmacological management of PHLF. Perioperative glucocorticoids may reduce inflammatory complications and lower PHLF incidence, though patient selection is crucial. N-acetylcysteine demonstrates antioxidant effects in experimental models and omega-3 fatty acids reduce inflammation, but both lack clinical efficacy. Somatostatin and terlipressin, which modulate portal hemodynamics, have shown promise in preclinical and early-phase clinical studies; however, randomized trials have yet to confirm their benefit in reducing PHLF. Nonselective β-blockers impair liver regeneration in preclinical models and are not recommended posthepatectomy. Early postoperative heparin administration and hyperinsulinemic-normoglycemic strategies have been associated with reduced PHLF but require further validation.

Key messages: While perioperative glucocorticoids may reduce PHLF risk in selected patients, other pharmacological agents show theoretical or preliminary promise, but cannot be routinely recommended based on current evidence. Prospective clinical trials are needed to establish effective pharmacological strategies for the prevention and treatment of PHLF.

Introduction: Laparoscopic fundoplication is the current standard for HH repair. HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS), or mesh placement. We analyzed the influence of patient factors on the surgical technique for laparoscopic repair in a teaching hospital.

Methods: Between 2012 and 2019, all patients who underwent repair of HH were assessed in this retrospective cohort study. HH was measured on CT scans and baseline patient characteristics and surgical details were collected.

Results: In total, 307 patients were included. A total of 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients, and mesh in 17 patients. The use of anterior sutures was significantly associated with female gender, higher type of HH, and higher age. The use of VMS during surgery was significantly associated with higher type of HH, higher age, and larger transverse diameter of the HH. The use of mesh during surgery was significantly associated with higher type of HH and larger transverse diameter of the HH.

Conclusion: In this retrospective study, the reinforcement techniques used during surgery were significantly associated with patient factors such as gender, body length and weight, type of HH, and transverse diameter. An unexpected patient-associated factor was age.

Introduction: The development of anastomotic leakage (AL) after esophagectomy is a severe complication, often leading to mediastinitis and systemic infections. Effective empiric antimicrobial therapy is crucial, but there is no consensus on the optimal regimen. This study aimed to document antimicrobial regimens used in the Netherlands and to evaluate culture results from AL after esophagectomy at our center.

Methods: An online questionnaire about the preferred antimicrobial treatment of AL after esophagectomy was sent to all upper gastrointestinal surgeons in the Netherlands. In addition, drain culture results from patients with AL after esophagectomy in our center were retrospectively analyzed.

Results: From 76 responses, 28 were included, representing 13 of the 15 esophagectomy-performing centers in the Netherlands. For treating AL after esophagectomy, respondents typically choose broad-spectrum regimens covering Gram-negative, Gram-positive, and anaerobic bacteria. The cultures of 57 patients were analyzed. Overall, 61% had positive cultures for yeast, 61% of patients for Enterobacterales, and 16% for Pseudomonas and other non-fermenters.

Conclusion: Based on the studied cultures, empiric antibiotics should cover Gram-positive, Gram-negative, anaerobe bacteria and Pseudomonas. We recommend the use of empiric amoxicillin/clavulanic acid with tobramycin for patients with AL after esophagectomy, which is now protocol in our center. The addition of antifungals remains debatable. Given the high incidence of yeast-positive cultures in the studied cohort, we recommend the addition of an echinocandin in clinically unstable patients.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis and lacks local treatment options. This study aimed to assess the feasibility and safety of the first-in-human intraoperative ultrasound-guided intratumoral injection of radioactive holmium-166 microsphere in patients with PDAC.

Methods: Patients with proven PDAC eligible for open surgical resection were included. If resection was abandoned during exploration, study intervention was performed. Feasibility was defined by injection success and on-/off-target radiation. Safety was based on adverse event (AE) monitoring for 12 weeks categorized by severity grade and study attribution.

Results: Three of the thirteen included patients received study intervention. Injection was successful in all 3 patients. Mean tumor doses of 5.0, 17.0, and 39.0 Gy and maximum tumor doses of 25.0, 41.0 and 256.0 Gy were achieved. Off-target radiation was found once in the lungs and once in the colon with a mean dose <1.0 Gy. There were no AEs with high study attribution, 16, 14, and 19 AEs with low study attribution, including 3, 2, and 4 AEs with grade ≥3. Holmium-166 microspheres appeared hyperdense on CT.

Conclusion: Intratumoral injection of holmium-166 microspheres in patients with unresectable PDAC seems feasible and safe. Research into minimally invasive image-guided application is advised.

Introduction: This study investigated the relationship between textbook outcomes of liver surgery (TOLS) and overall survival (OS) in patients who underwent curative-intent resection of GBC.

Methods: Patients with GBC who underwent curative-intent resection between 2014 and 2021 were selected from 16 hospitals. Patients were divided into either the TOLS group or the non-TOLS group, according to whether TOLS were observed. Patients who died within 90 days of surgery were excluded prior to the survival analysis. Log-rank test was used to compare the difference in the OS rate between TOLS and non-TOLS groups. Univariate and multivariate analyses were performed using Cox regression analysis to identify factors independently associated with OS.

Results: A total of 913 patients were selected, 565 (61.9%) exhibited TOLS. The 5-year OS rate in the TOLS group was significantly higher than that in the non-TOLS group (45.4% vs. 21.9%; p < 0.001). Multivariate Cox regression analysis confirmed TOLS, total bilirubin level >54 µmol/mL, carcinoembryonic antigen level >5 µg/mL, CA 19-9 level >37 U/L, poor differentiation, stages T2 and T3/4 according to the 8th edition AJCC T staging manual, N1 and N2 according to the 8th edition AJCC N staging manual, and adjuvant chemotherapy as independent risk factors that affect OS after curative-intent resection of GBC.

Conclusion: Among patients who undergo curative-intent resection of GBC, approximately 61.9% experience TOLS. TOLS are not only the optimal short-term outcome but also associated with long-term survival.

Introduction: In gastric cancer surgery, an adequate D2 lymphadenectomy is associated with improved cancer-specific survival. The aim of this study was to test the reliability of a new score (PhotoNodes Score [PNS]) conceived to rate the quality of lymphadenectomy in minimally invasive gastrectomy. The primary outcome of the study was to assess the inter-observer agreement among the reviewers assigning the score. The secondary outcome was the association between PNS and survival.

Methods: This is a multicentric observational prospective study enrolling patients undergoing minimally invasive gastrectomy for gastric cancer with D2 lymphadenectomy. A set of laparoscopic/robotic images will be collected from each patient. Based on each set of images, the quality of lymphadenectomy performed will be rated with the new PNS by three surgeons. Fleiss' Kappa measure of agreement will be used to study the rating agreement among examining surgeons. The PNS score will correlate with disease-free and overall survival.

Conclusion: The spread of minimally invasive approaches in oncologic gastric surgery made the collection of intraoperative images easier; for this reason, we believe that PNS could represent a new and efficient tool to assess the quality of D2 lymphadenectomy in clinical practice. The PhotoNodes study was registered at ClinicalTrials.gov #NCT06466902.

Introduction: Multifocal intrahepatic cholangiocarcinoma (m-iCCA) is a complex and aggressive form of primary liver cancer, often associated with poor outcomes. Although surgical resection is considered the only curative treatment for intrahepatic cholangiocarcinoma (iCCA), multifocality is frequently regarded as a contraindication due to the high risk of recurrence and limited survival benefits. Advances in surgical techniques and evolving treatment strategies have reopened discussions about the feasibility of resection in these cases.

Methods: We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A study protocol for the review was registered in the International Prospective Register of Systematic Reviews database. We systematically searched PubMed, Web of Science, MEDLINE, and ScienceDirect databases up to July 30, 2024, for studies analyzing surgical treatment outcomes for m-iCCA. We assessed the quality of the included studies according to the Newcastle-Ottawa Scale (NOS).

Results: After our initial search, 2,482 articles were found related to this topic and 381 articles were left for screening. We checked each article against the eligibility criteria and selected for the full-text analysis. Ten articles with 2,392 patients who had m-iCCA were included in our review. The reviewed studies reported extensive surgical procedures, such as extended hemihepatectomy and associating liver partition and portal vein ligation for staged hepatectomy, with median survival ranging from 18.9 to 27 months. Recurrence rates were higher in m-iCCA patients (67.8-74.3%) compared to solitary iCCA cases (52.4-60.5%), with recurrence-free survival as short as 4.5 months. Adjuvant chemotherapy was frequently used, although its effectiveness in terms of survival was inconsistent. One study reported a 5-year survival rate of 12.9% for surgical patients compared to 0% for non-operated patients. Survival outcomes were influenced by adverse prognostic indicators such as lymph node metastases and perineural invasion.

Conclusion: Surgical resection for m-iCCA, while associated with high recurrence rates (67.8-74.3%), provides a survival advantage over nonsurgical management (median overall survival: 18.9-27 months vs. 8 months; 5-year survival: 12.9% vs. 0%) for carefully selected patients. More studies are needed to improve patient selection and refine treatment approaches to enhance long-term outcomes.

Background: Esophagectomy, the cornerstone in the multimodal treatment of esophageal cancer, has evolved from open surgery to minimally invasive esophagectomy (MIE) in recent decades. MIE reduces complications, facilitates faster recovery, and provides comparable or superior oncologic outcomes and survival rates compared to open surgery.

Summary: Since the early 2000s, robot-assisted minimally invasive esophagectomy (RAMIE) has emerged, offering enhanced precision over MIE through features such as three-dimensional visualization, improved instrument dexterity, tremor filtration, and motion scaling. These innovations help overcome the challenges of MIE, particularly in the thoracic phase, where limited access and reduced instrument dexterity hamper the procedure. RAMIE is associated with lower complication rates, particularly pulmonary complications, improved recovery, and comparable oncological outcomes. Despite higher initial costs, its potential to reduce complications makes it financially comparable to other approaches. Moreover, mastering RAMIE requires navigating a significant learning curve, making collaboration and training vital. The integration of artificial intelligence and advancements in robotic platforms, including single-port systems, will broaden patient eligibility and improve outcomes.

Key messages: RAMIE has established itself as an integral part of modern surgical practice and will continue to evolve, driving further innovation. Collaboration and training are essential for refining techniques and ensuring safe and effective implementation.

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.

Methods: This study included all consecutive adult patients undergoing PH between January 01, 2010, and December 12, 2019. DRGF was defined as the need for postoperative nasogastric tube (NGT) insertion. Patients leaving the operation room with a NGT were excluded. Independent DRGF predictors were identified with multivariable logistic binary regression.

Results: A total of 501 patients were included. DRGF occurred in 82 patients (16%). Among DRGF patients, 17% (n = 14) needed a second NGT placement. DRGF incidences were similar before and after Enhanced Recovery after Surgery implementation in 2013 (16/78 = 20% vs. 66/423 = 16%, p = 0.305). A hundred-and-twelve patients (22%) underwent a minimally invasive approach and DRGF incidence was significantly lower in this group (5/112 = 4.5% vs. 77/389 = 19.8%, p < 0.001). DRGF was more frequent after major PH (55/238 = 23% vs. 27/263 = 10%, p < 0.001). DRGF occurred more often in patients with preoperative embolization (26/88 = 30% vs. 55/407 = 14%, p < 0.001), biliary anastomosis (20/48 = 42% vs. 61/450 = 14%, p < 0.001), and extrahepatic resection (37/108 = 34% vs. 45/393 = 11%, p < 0.001). Patients with DRGF had longer median operation duration (374 vs. 263 min, p < 0.001), more biliary leaks/bilomas (27/82 = 33% vs. 33/419 = 7.9%, p < 0.001), and higher median blood loss (1,088 vs. 701 mL, p < 0.001). DRGF patients developed more pneumonia (14/22 = 64% vs. 8/22 = 36%, p < 0.001) and had longer median length of stay (19 vs. 8 days, p < 0.001). On multivariable analysis, operation duration (OR 1.005, 95% CI: 1.002-1.008, p < 0.001), major hepatectomy (OR 3.606, 95% CI: 1.931-6.732), and postoperative biloma/biliary leak (OR 6.419, 95% CI: 3.019-13.648, p < 0.001) were independently associated with DRGF occurrence.

Conclusion: Postoperative DRGF occurred in 16% of the patients and was associated with a longer length of stay. Surgery duration, major PH and postoperative biloma/biliary leak were found as independent predictors of DRGF.

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.

Methods: This study included all consecutive adult patients undergoing PH between January 01, 2010, and December 12, 2019. DRGF was defined as the need for postoperative nasogastric tube (NGT) insertion. Patients leaving the operation room with a NGT were excluded. Independent DRGF predictors were identified with multivariable logistic binary regression.

Results: A