Digestive Surgery最新文献

Background: Acute mesenteric ischaemia (AMI) is a life-threatening condition with mortality exceeding 50%. This scoping review evaluates current diagnostic and management strategies, comparing endovascular and open surgical approaches.

Summary: Following Arksey and O'Malley's framework, a systematic search was conducted in OVID MEDLINE, Embase, and Web of Science (2005-2024). English-language studies on AMI were included. Data on diagnostic methods, mortality, hospital/ICU stay, and surgical outcomes were extracted. Thirty-nine studies (20,991 patients) were analysed. CT angiography was the primary diagnostic tool, with diagnostic delays ranging from 13.9 to 48 h. Endovascular interventions demonstrated lower 30-day mortality (0%-53.8%) versus open surgery (21%-81%). Hospital (5-15.35 vs. 5.7-27.26 days) and ICU stays (0-5.35 vs. 2-13 days) were shorter with endovascular management. Bowel resection and re-laparotomy rates were also reduced.

Key messages: Endovascular management is associated with improved outcomes, including reduced mortality and shorter hospital stays. Timely diagnosis and patient selection remain critical. A multidisciplinary approach is essential, though further prospective studies are needed to standardise protocols.

Introduction: Liquid biopsies enable noninvasive tumor material sampling in patients with pancreatic ductal adenocarcinoma (PDAC). Genetic information, especially alterations in circulating free DNA (cfDNA) levels, might help predict poorer tumor differentiation, disease progression, and might be used as treatment efficacy evaluator. However, the data on this topic are insufficient.

Methods: Newly diagnosed, PDAC patients without prior systemic treatment and chronic pancreatitis patients treated at the tertiary university hospital and healthy controls were included in this prospective study. Blood samples were collected pretreatment, and cfDNA was extracted and measured using necessary equipment according to manufacturer's protocols.

Results: Fifty-seven patients (47 PDAC and 10 chronic pancreatitis) and 8 healthy controls were included. cfDNA levels were significantly higher in cancer patients compared to chronic pancreatitis (p = 0.032) and healthy controls (p < 0.001). The determined cfDNA cut-off value for distinguishing PDAC from chronic pancreatitis was 23.65 ng/mL and for distinguishing PDAC from healthy controls - 22.9 ng/mL. However, no distinctions in cfDNA levels were noted concerning tumor characteristics or survival rates.

Conclusion: Liquid biopsies and alterations in cfDNA levels could aid in distinguishing PDAC from benign inflammatory diseases or healthy patients. Nonetheless, further studies are necessary for more comprehensive validation.

Introduction: Evidence regarding staging laparoscopy (SL) for clinical metastatic (cM+) gastric cancer (GC) patients is limited. Recently, an Italian Gastric Cancer Research Group (GIRCG) study showed SL changed peritoneal status in over 20% of cases. This study aimed to evaluate SL's role in cM+ patients and refine its indications.

Methods: Clinical data of cM+ GC patients who underwent SL between 2010 and 2022 at nine GIRCG centers were retrospectively analyzed. The primary outcome was SL's yield, defined as peritoneal status changed by SL over all SLs.

Results: Among 182 cM+ patients who received SL, 38 (20.9%) had SL-findings changing peritoneal status. Notably, 10.1% of cases with preoperative signs of carcinomatosis had no peritoneal disease, while 46.3% with extraperitoneal disease alone had peritoneal carcinomatosis (PC) at SL. Thirty-one patients (17.0%) underwent R0 resection: 17 (54.8%) with PC, 3 (9.7%) with liver metastases, 4 (12.9%) with PC and nodal metastases, 2 (6.4%) with lung, and 1 (3.2%) with bone metastases. Seventeen patients with suspected preoperative PC underwent curative treatment: 9 had peritoneal disease ruled out by SL, while the other 8 had limited PC, allowing R0 resection. Logistic regression revealed an inverse correlation between diffuse histotype and absence of PC at SL in patients with peritoneal involvement at imaging (p = 0.02).

Conclusion: SL aids in directing cM+ GC patients to appropriate treatment, with a 20.9% yield. For those with peritoneal involvement at imaging, SL helps identify candidates for curative treatment. In patients with extraperitoneal disease, SL should be considered to assess potential radical strategies.

Introduction: The incidence of adhesive small bowel obstruction (ASBO) after abdominal surgery is 2.4%. Delay in surgery increases morbidity and mortality. Plasma intestinal fatty acid binding protein (I-FABP) levels indicate intestinal damage and may guide treatment. The aim of this study was to investigate whether plasma I-FABP levels may optimize selection of patients requiring surgery presenting with ASBO.

Methods: Patients with suspected ASBO underwent a contrast swallow. If bowel transit was absent after 8 h, surgery was performed. I-FABP levels were assessed at several moments. Data were analyzed by comparing groups based on bowel transit, ischemia, and positive or negative laparotomies. Furthermore, a true operative group (patients with mechanical obstruction during surgery and patients needing operative treatment who deceased due to non-operative treatment) was compared to a true non-operative group (patients with negative laparotomies and patients successfully treated with non-operative treatment).

Results: Median I-FABP levels were higher in patients without bowel transit (1,207 pg/mL) than in patients with bowel transit (589 pg/mL, p = 0.01). Median I-FABP levels in the negative laparotomy group (301 pg/mL) showed a trend to significance compared to the positive laparotomy group (1,177 pg/mL, p = 0.05). There was no significant difference between the true operative group (1,150 pg/mL) and the true non-operative group (664 pg/mL) or between proven ischemia (975 pg/mL) and no ischemia (921 pg/mL).

Conclusion: I-FABP might help identify ASBO patients in whom surgery can be postponed.

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.

Background: Postoperative ileus (POI) is one of the most common postoperative complications after colorectal surgery and prolongs hospital stays. Minimally invasive surgery (MIS) has reduced POI, but it remains common. This review explores the current methods for preventing and managing POI after MIS.

Summary: Preoperative interventions, including optimising nutrition, preoperative medicationn, and mechanical bowel preparation with oral antibiotics, may have a role in preventing POI. Transversus abdominis plane blocks and lidocaine could replace epidural analgesia in MIS. Fluid overload should be avoided; in some cases, goal-directed fluid therapy may aid in achieving this. Pharmacological agents, such as prucalopride and dexmedetomidine, could target mechanisms underlying POI. New strategies to stimulate vagal nerve activity may promote postoperative gastrointestinal motility. Preoperative bowel stimulation could potentially reduce POI following loop ileostomy closure. However, the evidence base for several interventions remains weak and requires further corroboration with robust studies.

Key messages: Despite the increasing use of MIS, POI remains a major issue following colorectal surgery. Further strategies to prevent POI are rapidly emerging. Studies using standardised definitions and perioperative care will help validate these interventions and remove barriers to accurate meta-analysis. Future studies should focus on establishing the impact of these interventions on POI after MIS specifically.

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.

Introduction: Although effective, conventional excisional haemorrhoidectomy (CEH) is associated with significant postoperative pain. Novel techniques such as transanal haemorrhoidal dearterialization (THD) are suggested to reduce pain but may result in higher recurrence rates. We aimed to compare short- and long-term outcomes of CEH and THD in the present meta-analysis.

Methods: A PRISMA-compliant meta-analysis was performed, searching PubMed, Embase, and CENTRAL databases for randomised controlled trials (RCTs) from 1995 to December 2022. The primary objective was recurrence. Secondary objectives included complication rates, length of stay (LOS), operative time, and time to return to baseline. Random-effects models were used to calculate pooled effect size estimates. Subgroup analysis was also performed.

Results: A total of 6 RCTs encompassing 465 patients were captured. There were 142 (59%) males in the CEH group and 129 (54%) in the THD group. On random-effects analysis, THD had a higher recurrence rate (odds ratio = 2.76, 95% confidence interval [CI] = 1.03-7.38, p = 0.04) albeit a shorter return to baseline compared to CEH (mean difference = -14.05 days, 95% CI = -20.38 to -7.72, p < 0.0001). There were no differences in bleeding (p = 0.12), urinary retention (p = 0.97), incontinence (p = 0.41), anal stenosis (p = 0.19), thrombosed residual haemorrhoids (p = 0.16), operating time (p = 0.19), or LOS (p = 0.22). Results remained similar on subgroup analysis.

Conclusions: CEH is associated with lower recurrence but similar complication rates to THD, although patients take longer to return to baseline function postoperatively.