European Surgical Research最新文献

Introduction: The role of simultaneous liver-kidney transplantation (SLKT) in end-stage liver disease patients with varying kidney dysfunction remains unclear. This study aims to compare clinical outcomes of SLKT recipients with those undergoing liver transplant alone (LTA) with comparable kidney dysfunction.

Methods: This retrospective cohort study included the SLKT cohort (n = 52) from the Dutch Organ Transplantation Registration and the LTA cohort (n = 829) from Erasmus Medical Center between 2000 and 2020. Patients were stratified by pretransplant renal function (chronic kidney disease [CKD] stages 3b-5) and pretransplant renal replacement therapy (RRT) status. Patient and graft survival, and renal function were compared across renal function strata.

Results: Across CKD stages 3b and 4, there was no statistically significant difference in overall survival rates (p = 0.59 and p = 0.23, respectively). For patients with CKD stage 5 or RRT, patient survival rates at 1, 3, and 5 years posttransplant were significantly lower in the LTA group (60.3%, 51.7%, and 51.7%, respectively) compared to the SLKT group (90.0%, 90.0%, and 80.8%, p = 0.048). Death-censored liver graft survival rates at 1, 3, and 5 years were also significantly lower in the LTA group (59.8%, 49.9%, and 49.9%) versus SLKT group (86.4%, 86.4%, and 77.0%, p = 0.048). Cox proportional hazards model confirmed the association between SLKT and improved patient survival (HR 0.31, 95% CI: 0.10-0.98, p = 0.046).

Conclusion: For patients with CKD stage 5 or those on pretransplant RRT, SLKT was associated with better survival outcomes compared to LTA. Primary etiology of liver disease and severity of kidney dysfunction should be considered when determining SLKT eligibility. Due to the limited group size, these findings should be interpreted with caution and further validated.

Introduction: This meta-analysis investigated differences in rebound pain and opioid consumption when using brachial plexus blockade (BPB) versus general anesthesia (GA) for upper limb surgery.

Methods: Four databases were searched. Odds ratios (OR), mean differences (MD), and standard mean differences (SMD) with 95% confidence intervals (CIs) were calculated. Outcomes included were pain, opioid consumption, adverse events, and discharge time. The risk of bias was assessed.

Results: Nine clinical trials involving 487 patients were included. BPB resulted in significantly lower pain scores within 2 h postoperatively (MD -4.57, 95% CI -5.76 to 3.38; participants = 263; studies = 5; I2 = 0%; p < 0.00001) but not from 6 to 24 h. Opioid consumption (mg) was lower in the BPB group in the first 24 h (SMD -0.85, 95% CI -1.41 to -0.29; participants = 188; studies = 3; I2 = 67%; p < 0.003). BPB was associated with fewer postoperative nausea/vomiting events (OR 0.19, 95% CI 0.10-0.33; participants = 326; studies = 6; I2 = 45%; p < 0.00001) and shorter hospital stay (SMD -1.20, 95% CI -1.73 to -0.66; participants = 213; studies = 4; I2 = 69%; p < 0.0001). There was no difference in the number of patients not requiring opioids from 24 to 48 h.

Conclusions: BPB provided superior pain control at 2 h postoperatively and was associated with reduced opioid use, fewer adverse events, and shorter discharge time. No significant differences in pain scores were observed at 6-24 h or beyond 24 h, likely due to block wear-off. Despite this limitation, BPB still offered perioperative advantages over GA.

Introduction: Wound healing is a complex biological process involving hemostasis, inflammation, proliferation, and tissue remodeling. Despite promising results with platelet-rich plasma (PRP) and synthetic scaffolds used separately, their combined in vivo effects remain insufficiently investigated. This experimental study presents the first results on a composite wound dressing integrating PRP, rich in growth factors, with electrospun polyvinyl alcohol (PVA) nanofibers, a biocompatible and stable polymer.

Methods: Full-thickness skin defects (1 × 1 cm2) were created in 21 adult female Sprague-Dawley rats and divided into three groups: control, PVA, and PRP/PVA. Wound healing was assessed histologically and biochemically on days 7 and 14, including fibroblast growth factor-2 (FGF-2) measurement.

Results: The PRP/PVA group showed enhanced epithelialization and angiogenesis compared to other groups (p < 0.05), along with higher FGF-2 levels.

Conclusion: The relatively small sample size, absence of a PRP-only group, and short observation period limit the generalizability of these findings. Within these constraints, the results indicate a potential synergistic role of PRP and PVA scaffolds in promoting wound repair, supporting further studies with larger cohorts and standardized PRP preparation before clinical translation.

Introduction: Artificial intelligence (AI), particularly deep learning-based computer vision technology, has been used in surgery as real-time intraoperative navigation; however, its clinical relevance remains unclear. To address this gap, well-designed randomized controlled trials (RCTs) are necessary to evaluate the effects of these systems by comparing surgical outcomes with and without their use. In this study, we will investigate a deep learning-based intraoperative image navigation system that operates in real time and uses semantic segmentation to help identify the ureter and autonomic nerves during laparoscopic colorectal surgery. We propose a multicenter RCT to compare the procedure of using this system against those that do not.

Methods: The ImNavi trial is a Japanese multicenter RCT involving 1:1 randomization between the use and nonuse of the deep learning-based intraoperative image navigation system. The participating institutions will include three high-volume centers with sufficient laparoscopic colorectal surgery caseloads (>100 cases/year), including one national cancer center and two university hospitals in Japan. All patients will provide written informed consent. Patients aged between 18 and 80 years scheduled to undergo laparoscopic left-sided colorectal resection will be included in the study. The primary outcome is the time required for each target organ, including the ureter and autonomic nerves, to be recognized by the surgeon after its initial appearance on the monitor. Secondary outcomes include intraoperative target organ injuries, intraoperative complications, operation time, blood loss, duration of postoperative hospital stay, postoperative complications within 30 days, postoperative male erectile and ejaculatory dysfunction 1 month post surgery, surgeon's confidence in recognizing each target organ, and the postoperative fatigue of the primary surgeon.

Conclusion: The impact of AI-based surgical applications on clinical outcomes beyond numerical expression will be explored from diverse viewpoints while evaluating quantitative items, including intraoperative complications and operation time, as secondary endpoints. The findings of this RCT can contribute to advancing research in the domain of AI in surgery.

Introduction: Robotic gastrectomy offers perioperative advantages such as reduced blood loss and faster recovery; however, infectious complications remain a significant concern. In this study, we aimed to identify the predictive factors for postoperative infectious complications following radical robotic gastrectomy in patients with gastric or esophagogastric junctional cancer.

Methods: This retrospective single-center study analyzed data from 155 patients with gastric or esophagogastric junction cancer who underwent curative robotic gastrectomy between December 2017 and April 2025 to identify predictive factors for postoperative infectious complications. Twenty-two variables, including nutritional indices and surgical factors, were evaluated.

Results: A total of 18 patients developed Clavien-Dindo grade II-IIIa infectious complications. Infectious complications included pneumonia (n = 5, 3.2%), intra-abdominal abscess (n = 5, 3.2%), anastomotic leakage (n = 3, 1.9%), cholecystitis (n = 2, 1.2%), nonocclusive mesenteric ischemia (n = 1, 0.6%), bile leakage (n = 1, 0.6%), and sepsis (n = 1, 0.6%). The number of patients with complications and American Society of Anesthesiologists Physical Status (ASA-PS) class ≥3 (p = 0.006) and preoperative smoking (p = 0.012) was higher than that among patients without complications. Although hemoglobin levels (p = 0.041) and lymphocyte-to-monocyte ratios (p = 0.017) were lower in patients with complications, the platelet-to-lymphocyte ratios (p = 0.034) were higher. Multivariate analysis revealed that current smoking (odds ratio, 3.21; 95% confidence interval, 1.24-18.21) and ASA-PS class of ≥3 (odds ratio, 3.8; 95% confidence interval, 1.18-7.52) were identified as predictors of infectious complications.

Conclusion: Robotic gastrectomy offers technical advantages, but optimizing patient-specific risk is essential for the best outcomes. Preoperative smoking and a high ASA-PS class were independent predictors of infectious complications following robotic gastrectomy. Enhanced perioperative management targeting these risk factors may reduce postoperative morbidity.

Introduction: Sentinel lymph node biopsy (SLNB) plays a critical role in the clinical management of malignant melanoma. The current standard of care involves the preoperative injection of a Technetium-labeled (99mTc) colloidal nanomaterial to facilitate lymphatic mapping. During surgery, patent blue (PB) is administered to enhance visualization of the lymphatic pathways. However, this dual-tracer approach presents notable drawbacks, including patient exposure to ionizing radiation and logistical challenges stemming from the short half-life of (99mTc). Superparamagnetic iron oxide nanoparticles (SPIO) have emerged as a nonradioactive alternative. Used in conjunction with a handheld magnetometer system (Magtrace® and Sentimag®, Endomagnetics Ltd.), SPIO enables SLN detection without the need for nuclear medicine infrastructure. In clinical studies involving breast cancer patients, SPIO has demonstrated non-inferiority to the conventional 99mTc and PB protocol. Given these findings, SPIO is hypothesized to offer equivalent performance in melanoma patients. This study is designed to evaluate the non-inferiority of preoperative magnetic resonance imaging (MRI) using SPIO compared to traditional lymphoscintigraphy and single-photon emission computed tomography/computed tomography with 99mTc for SLN identification in melanoma. Additionally, the study assesses the non-inferiority of intraoperative SLNB using SPIO and the Sentimag® device relative to the current gold standard based on 99mTc.

Methods: A prospective, single-arm, non-inferiority study will be conducted at the Department of Surgical Oncology, Zuyderland Medical Center, Sittard, the Netherlands. The study will enroll 140 adult patients diagnosed with stage I-II primary melanoma who are scheduled to undergo wide local excision and SLNB. All participants will undergo lymphatic mapping using both Magtrace® and 99mTc. The MRI protocol, previously evaluated in a pilot study, was demonstrated to be feasible. Implementation of the MRI protocol will proceed if non-inferiority is established within a predefined margin of 5%.

Conclusion: Elimination of radiation exposure is beneficial for both patients and healthcare personnel. Moreover, logistic challenges will be eliminated as SPIO can be injected several days before surgery, immediately followed by MRI scanning. Scheduled surgeries will not be jeopardized by preoperative logistics and procedures. It will increase hospital-oriented productivity, patient-friendliness and comfort as surgical delays are avoided.

Background: Cancer immunotherapy has transformed the therapeutic landscape of oncology by harnessing the body's immune system to recognise and eliminate malignant cells. In certain tumour types, such as melanoma and non-small cell lung cancer, immune-based therapies have led to durable clinical responses and significantly improved survival. These successes have fuelled the rapid integration of immunotherapeutic approaches into standard treatment regimens. However, their effectiveness in the majority of solid tumours remains limited. Several biological and physical barriers underlie this limited efficacy. A major challenge is the immunosuppressive nature of the tumour microenvironment (TME), which hampers effective immune cell infiltration and function. In many solid tumours, chronic inflammation, poor antigen presentation, a low mutational burden, and the presence of suppressive myeloid and stromal cells create an environment resistant to immune activation. In addition, high intra-tumoral pressure and abnormal vasculature further restrict drug delivery and immune cell trafficking, particularly in desmoplastic cancers such as pancreatic and prostate cancer.

Summary: Recent advances in immuno-oncology have focused on strategies to overcome these barriers and convert "cold" tumours, those lacking immune cell infiltration, into "hot," immune-inflamed tumours. Despite this progress, clinical translation has proven to be complex, with mixed results across various tumour types. While some patients derive long-term benefit from immunotherapy, others exhibit primary or acquired resistance, underscoring the need for better patient stratification and predictive biomarkers.

Key messages: This review provides a comprehensive overview of the evolving field of immunotherapy for solid tumours, discussing key mechanisms of immune resistance, the role of the TME, and the multifactorial nature of therapeutic failure. It highlights the importance of understanding tumour-immune interactions in their full biological context, and explores current thinking on how to reshape the immune landscape of solid tumours. By addressing both immunological and physical barriers, future approaches may broaden the benefit of immunotherapy beyond its current scope, ultimately improving outcomes for patients with traditionally treatment-resistant cancers.

Background: Allosensitization, defined as the presence of anti-HLA antibodies before transplantation, prolongs the waiting list time and increases the waiting list mortality in patients awaiting heart transplantation. Treatment protocols have been developed to reduce the load of preformed anti-HLA antibodies (pfDSAs), defined as desensitization, and allow safe transplantation across the anti-HLA antibody barrier. Aim of this review was to give an overview on the actual desensitization strategies in heart transplantation.

Summary: Desensitization can be performed before transplantation or at the time of transplantation when a donor offer becomes available. Treatment protocols should include drugs and interventions that clear pfDSA, target antibody production, and mitigate antibody-mediated graft damage. By now, several transplant centers have developed their own protocols, with optimal graft survival, freedom from antibody-mediated rejection and from coronary allograft vasculopathy, without any significant adverse events. The evolution of the immunoassays for pfDSA detection has allowed a better precision in pfDSA characterization, such as measurement of titer and complement-binding capacity. These refinements have permitted crossing acceptable pfDSA without any need of desensitization.

Key messages: Crossing the HLA barrier is feasible and safe in heart transplantation. The complexity and redundancy of the immune pathways requires the identification of the appropriate therapy for each patient. Desensitization protocols should include more than one drug and intervention.

The authors' accepted manuscript "Is Methylene Blue a Reliable Substitute in Sentinel Lymph Node Biopsy? A Systematic Review across Oncologic Sites" [Eur Surg Res. 2025; https://doi.org/10.1159/000549037] by Saurabh Raj, Rudrakshi Mahaldar, and Shahrukh Memon has been retracted by the Publisher and the Editor on the authors' behalf.After peer review, the accepted, unedited manuscript was published online as Early View. Before the final Version of Record was published, concerns were raised about the validity of references 4, 6, 7, 9, 10, 11, 13, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 40 and 41 of the manuscript.The corresponding author stated that errors arose due to their use of AI-assisted tools and requested that their manuscript be withdrawn from European Surgical Research. Consequently, the published author's accepted manuscript has been retracted.Saurabh Raj agrees to this retraction, Rudrakshi Mahaldar and Shahrukh Memon have not responded to our correspondence about this retraction.

Background: Sentinel lymph node biopsy (SLNB) is a pivotal technique for evaluating regional lymphatic spread in breast, melanoma, and gynecologic malignancies. It minimizes surgical morbidity by avoiding complete lymphadenectomy in early-stage disease. The standard dual-tracer approach-combining a radiocolloid such as technetium-99m with a blue dye like patent blue or isosulfan blue-has high sensitivity but is not universally accessible. Radiocolloids require nuclear medicine facilities' licensing and pose logistical burdens, while patent blue may provoke allergic reactions, including anaphylaxis. These limitations are particularly pronounced in low- and middle-income countries (LMICs), where access and affordability are ongoing challenges. Methylene blue (MB), a low-cost, widely available dye, has gained traction as an alternative tracer, offering a safer and more feasible option for SLNB in resource-limited settings.

Objective: This systematic review evaluates the diagnostic accuracy, detection reliability, and safety profile of methylene blue dye in SLNB across diverse oncologic sites, emphasizing comparing outcomes with traditional dual-tracer approaches.

Methods: A systematic review of PubMed, Embase, Scopus, and Cochrane Library was conducted for studies published from 2000 to 2025. Inclusion criteria comprised clinical studies utilizing MB for SLNB in breast, melanoma, gynaecological, or other solid tumours, reporting outcomes such as detection rate, false-negative rate, or tracer-related complications. Data were extracted and synthesized descriptively. Where possible, pooled performance metrics were calculated.

Results: Twenty-five studies encompassing 5,240 patients were included. The pooled sentinel node detection rate using MB alone was 84.5% (72.0-96.2%), with a false-negative rate of 8.6%. When MB was combined with radiocolloid, detection rates improved to 96.1%, and false-negative rates dropped below 5%. Adverse effects were rare, with skin necrosis in fewer than 2% of cases and no serious allergic events reported. Most studies focused on breast cancer (18/25), while data on melanoma and gynecologic cancers were comparatively limited.

Conclusion: Methylene blue is a viable alternative for SLNB, particularly in environments where dual-tracer methods are impractical. Though slightly less sensitive than dual-tracer techniques, MB offers substantial advantages in cost, safety, and accessibility. Further multicenter studies and long-term outcomes are needed to support its broader adoption in global oncology practice.