British Journal of Surgery最新文献

Background: Previous retrospective studies have demonstrated the effectiveness of parenchymal pre-compression in reducing pancreatic fistula after left-sided pancreatic resection; however, no multicentre RCT has been conducted. The aim of this study was to investigate whether pre-compression reduces grade B/C pancreatic fistula after left-sided pancreatic resection.

Methods: Between 23 March 2021 and 26 January 2023, patients scheduled for left-sided pancreatic resection were enrolled in a multicentre RCT at 13 hospitals in Japan. These patients were randomly assigned (1 : 1) to the pre-compression group or the non-compression group. The primary endpoint was the incidence of grade B/C pancreatic fistula and the secondary endpoint was it in the subgroup.

Results: Overall, 180 patients were assigned to the pre-compression group and the non-compression group (92 patients and 88 patients respectively) and 171 patients were analysed (88 patients in the pre-compression group and 83 patients in the non-compression group). Grade B/C pancreatic fistula was observed in 22 patients (12.9%), including 11 of 88 patients (12.5%) in the pre-compression group and 11 of 83 patients (13.3%) in the non-compression group (OR 0.94 (95% c.i. 0.38 to 2.31); P = 0.883).

Conclusion: A statistically significant difference in the incidence of grade B/C pancreatic fistula was not observed between the pre-compression group and the non-compression group.

Registration number: UMIN000042700 (https://www.umin.ac.jp).

Background: Lengthy training and stressful work schedules can cause surgeons to renounce part-time work and delay pregnancy. The aim of this survey study was to evaluate constraints of part-time work, procreation, pregnancy, and early parenthood among young surgeons in Switzerland.

Methods: An anonymous survey on different aspects of private life and surgical training was distributed to young board-certified general surgeons in Switzerland.

Results: Out of the 680 surveys sent, a total of 375 were completed (response rate of 55.1%), with 308 included for further analysis (157 from female participants and 151 from male participants). There was no difference between male and female participants in the time required for board and sub-specialty certification. Female participants had a higher rate (59 of 157 (37.6%) versus 28 of 151 (18.5%), P < 0.001) and longer duration (mean(s.d.) of 5.5(4.0) versus 1.8(1.1) years, P < 0.001) of part-time employment. Female participants less frequently had children (70 of 157 (44.6%) versus 106 of 151 (70.2%), P < 0.001). They were older (median age of 35 (interquartile range 33-37.5) years) than male participants (median age of 33.5 (interquartile range 31.75-35) years) (P < 0.001) and female partners of male participants (median age of 32 (interquartile range 30-33) years) (P < 0.001) at first childbirth. Female participants more frequently delayed pregnancy due to training (94 of 127 (74.0%) versus 28 of 138 (20.3%), P < 0.001) and had higher rates of infertility (16 of 70 (23%) versus 11 of 106 (10.4%), P = 0.032) and use of assisted reproductive technology (18 of 127 (14.2%) versus 6 of 138 (4.3%), P = 0.009). Female participants more frequently perceived their gender as a negative career influence (105 of 157 (66.9%) versus 9 of 151 (6.0%), P < 0.001).

Conclusion: Combining procreation, pregnancy, and early parenthood with surgical training is challenging for young surgeons in Switzerland. Providing equal opportunities for all genders and promoting changes in working conditions will be necessary to ensure optimal surgical training for future generations.

Background: Postoperative pancreatic fistula is the main driver of morbidity and mortality after pancreatoduodenectomy. In high-risk patients, the rate of postoperative pancreatic fistula approaches 50%, whereas it is below 5% in patients with pancreatic cancer who receive neoadjuvant chemoradiotherapy. The aim of this study was to evaluate the safety, feasibility, and efficacy of preoperative stereotactic body radiotherapy on the pancreatic neck transection margin in high-risk patients undergoing pancreatoduodenectomy to prevent postoperative pancreatic fistula.

Methods: In this prospective multicentre open-label single-arm trial (progressing from a safety run-in phase to a phase II design), patients undergoing pancreatoduodenectomy for neoplasms other than pancreatic ductal adenocarcinoma received a single preoperative stereotactic body radiotherapy dose of 12 Gy. Primary endpoints included safety (less than or equal to 15% grade 3-5 toxicity), feasibility (a significant change in pancreatic texture measured using a durometer), and efficacy (a 15% reduction in the grade B/C postoperative pancreatic fistula rate compared with patients from the Dutch Pancreatic Cancer Audit who were eligible but not included in this study). Secondary endpoints assessed tissue fibrosis (collagen density).

Results: Overall, 38 patients were included, of whom 33 (87%) completed the study protocol and were included in the per-protocol analysis. The safety cut-off was met, with 3% grade 3-5 toxicity. Pancreatic tissue treated with stereotactic body radiotherapy showed increased firmness using a durometer (median of 47 (interquartile range 36-57) versus 37 (interquartile range 30-41) Shore OO units; P < 0.001) and a higher collagen density (median of 6.1% (interquartile range 4.4%-9.5%) versus 4.6% (interquartile range 2.5%-7.4%); P = 0.003). The grade B/C postoperative pancreatic fistula rate with stereotactic body radiotherapy was 57.6% (95% c.i. 41% to 74%), compared with 34% (95% c.i. 27% to 42%) in audit controls (P = 0.011).

Conclusion: Preoperative stereotactic body radiotherapy is safe in high-risk patients undergoing pancreatoduodenectomy and increases parenchymal firmness and fibrosis, but fails to show evidence of efficacy.

Background: Malnutrition is a risk factor for postoperative morbidity but the optimal tool for the assessment of malnutrition is unclear.

Methods: This is a prospective multicentre cohort study. Consecutive patients undergoing elective or emergency major abdominal surgery for benign or malignant disease in 12 Greek hospitals between January 2022 and December 2023 were included. Patients unable to provide nutrition history and/or informed consent were excluded. Subjective global assessment (SGA) was used as a reference standard for malnutrition diagnosis. GLIM (global leadership initiative on malnutrition), MNA-SF (mini nutrition assessment short form), MST (malnutrition screening tool), MUST (malnutrition universal screening tool), NRI (nutritional risk index), NRS-2002 (nutrition risk scale 2002), PONS (perioperative nutrition screen) and SNAQ (short nutrition assessment questionnaire) tools were applied for malnutrition risk assessments. Indicators of diagnostic accuracy (sensitivity, specificity, diagnostic odds ratio, areas under the receiver operating characteristic curve-AUC), construct validity (convergent associations with relevant variables) and prognostic validity (logistic regression) were appraised.

Results: 1649 patients were included (58% colorectal, 21% upper gastrointestinal, 14% hepatobiliary operations). SGA defined 562 (34.1%) patients as malnourished with excellent construct and prognostic validity. Malnutrition risk assessments varied from 24.0% using NRS-2002 to 58.6% with the MNA-SF. On their ordinal scales, MNA-SF (AUC = 0.83, 95% c.i. 0.81 to 0.85) and MUST (AUC = 0.79, 95% c.i. 0.77 to 0.82) had the best discriminatory abilities with minimal between-centre heterogeneity. As binary classifiers, MNA-SF (OR = 30.2; 95% c.i. 20.2 to 45.1) and MUST (OR = 16.1; 95% c.i. 12.4 to 21.1) had the highest diagnostic ORs but only MUST had sensitivity and specificity close to 80%. MUST performed well in construct and prognostic validity appraisals.

Conclusion: This study supports the use of the MUST as it is the most valid nutritional screening tool in patients after major abdominal surgery.

Background: Which patients with locally advanced pancreatic cancer may benefit from surgical exploration after induction treatment remains debated. The aim of this retrospective cohort study was to identify independent factors for overall survival after surgical exploration for locally advanced pancreatic cancer, which are available at restaging after induction therapy.

Methods: Consecutive patients with locally advanced pancreatic cancer from the Trans-Atlantic Pancreatic Surgery cohort who underwent surgical exploration after FOLFIRINOX as induction chemotherapy were included. Multivariable Cox proportional hazards analyses with contour plots were used for the predicted 3-year overall survival in patients who underwent surgical exploration.

Results: Overall, 958 patients with locally advanced pancreatic cancer were treated with FOLFIRINOX as induction therapy. At restaging, 221 patients (23.1%) had metastatic disease (M1) and 724 patients (75.6%) did not have metastatic disease (M0)-234 patients (24.4%) with M0 disease underwent surgical exploration and 490 patients (51.1%) with M0 disease did not undergo surgical exploration; restaging information was not available for 13 patients (1%). The surgical exploration cohort included 213 patients with locally advanced pancreatic cancer, after excluding 21 carbohydrate antigen 19-9 non-producers. The independent prognostic factors for overall survival after surgical exploration were post-induction carbohydrate antigen 19-9 level (HR 1.14 (95% c.i. 1.01 to 1.29)), carbohydrate antigen 19-9 decrease (HR 0.89 (95% c.i. 0.79 to 0.99)), and a WHO performance status of greater than or equal to one (HR 1.71 (95% c.i. 1.21 to 2.42)). Baseline carbohydrate antigen 19-9 was not prognostic for overall survival after surgical exploration (HR 0.98 (95% c.i. 0.90 to 1.07)). The best predicted 3-year overall survival was achieved with a greater than 80% decrease in carbohydrate antigen 19-9 and a post-induction carbohydrate antigen 19-9 less than 50 U/ml.

Conclusion: Carbohydrate antigen 19-9 after induction therapy, carbohydrate antigen 19-9 decrease, and performance status are independent prognostic factors for overall survival after surgical exploration for locally advanced pancreatic cancer. Three-year overall survival is best in patients with a performance status of zero, a greater than 80% decrease in carbohydrate antigen 19-9, and a post-induction carbohydrate antigen 19-9 level less than 50 U/ml.