International journal of surgery最新文献

Evidence suggests a potential link between metabolic dysfunction and head and neck cancer (HNC). This study investigates the potential causal relationships between metabolic dysfunction and HNC using genetic data. While no significant causal associations were identified between metabolic indicators and HNC risk, the research revealed that inhibition of certain genes could reduce cancer risk. Specifically, inhibiting SLC5A2 was associated with a decreased risk of HNC and oropharyngeal cancer (OPC), while KCNJ11 inhibition was linked to a reduced risk of oral cavity cancer (OCC). Additionally, inhibiting SLC5A1 and CACNB2 showed a connection to lower OPC risk. These findings suggest that targeting these genes could offer promising therapeutic strategies for preventing and treating HNC, as well as improving both preoperative and postoperative management in affected patients.

Introduction: Since its beginning in 1963, Liver Transplantation (LT) has significantly advanced, now including transplant oncology. As indications broaden, donor supply reduces. The two-stage RAPID procedure (initially abbreviated as "Resection And Partial Liver Segment 2/3 Transplantation With Delayed Total Hepatectomy") has emerged to address the use of small-for-size (SFS) grafts. However, a comprehensive evaluation of RAPID is essential given its novelty, scarcity, and diverse outcomes reported.

Methods: The RAPID Consensus International Society of Liver Surgeons (ISLS) 2023 Zurich initiative established evidence around the RAPID procedure using the Danish Model of Consensus. Engaging an international community of specialists, the initiative ensured multidisciplinary involvement and used the GRADE framework to evaluate the quality of evidence and grade the recommendations.

Results: Comprehensive discussions and debates led to internationally recognized recommendations addressing perioperative measures for RAPID. Key recommendations highlighted the significance of standardized nomenclature, specific indications, graft criteria, surgical techniques, optimal interstage timings, and measures to manage potential complications.

Conclusion: The consensus provides recommendations for the RAPID procedure, emphasizing transparency and outcome reporting. Establishing dedicated registries can improve care standards which may ensure the benefits of RAPID by maximizing patient safety and improving outcomes.

Background: In the current "sickest first" allocation policy for limited deceased liver grafts, identifying patients "too sick to transplant" before transplantation is crucial to optimize outcomes. This study aimed to predict futile outcomes following deceased donor liver transplantation (DDLT) in patients with Model for End-Stage Liver Disease-Sodium (MELD-Na) scores ≥30.

Methods: This international multicenter study was conducted as part of the International Society of Liver Surgeons. We collected data from patients with a MELD-Na score ≥30 who underwent DDLT. A total of 994 patients were enrolled between 2010-2021, including 654 from the Republic of Korea, 224 from the US, and 116 from other regions. Futility was defined as death within three months or during the hospital stay following a DDLT. After exclusion, 160 (16.6%) patients were classified into a futile group and 803 (83.4%) into a non-futile group.

Results: The MELD-Na scores collected at three time points (listing, matching, and transplantation) were comparable between the groups (P = 0.442, P = 0.180, and P = 0.554, respectively). Regarding concomitant organ failure factors, the futile group showed a higher incidence of organ dysfunction across all measured parameters, including the use of mechanical ventilators, continuous renal replacement therapy (CRRT), pneumonia, bacteremia, and vasopressor use (all P<0.01). Independent risk factors for futile outcome were recipient age (≥65 years), body mass index (<18.5 kg/m2), mechanical ventilator use, CRRT (≥1 week), and prolonged ICU stay before transplantation (≥2 weeks). The futility rate was 53.3% in patients with ≥3 risk factors (P<0.001). We developed a nomogram to predict futility after DDLT based on multivariate regression analysis, which showed a better predictive power than previous models.

Conclusions: The risk factors and new nomogram, which adequately reflect concomitant organ failure before liver transplantation, could effectively predict the risk of futile outcomes after DDLT and contribute to decision-making regarding transplantation eligibility in clinical practice.

Background: The dilemma of achieving 'onco-functional balance' in gliomas affecting the motor cortex highlights the importance of functionally-guided resection strategies. While accurate mapping of eloquent areas often requires frequent electrical stimulation, this practice can lead to side effects like seizures and postoperative deficits. To enhance safety in functional mapping, we studied how gliomas impact hand movement areas and assessed the effectiveness of cortical electrical activity for functional mapping in this setting.

Materials and methods: We recruited patients with gliomas affecting the motor cortex and individuals with an unaffected motor cortex for awake craniotomy. During the procedures, electrocorticography (ECoG) grids were employed to record signals under three conditions: resting state, finger movements, and wrist movements. We then quantified the distances from the positively stimulated sites to the specific anatomical landmarks. Additionally, we analyzed the relationship between the ECoG power features and the stimulation responses.

Results: The cortical layout for finger activity in the MCG group was more dispersed and overlapped, typically clustering near the central sulcus and Sylvian fissure. The predictive performance of ECoG mapping exhibited significant variability across different frequency bands and clinical scenarios. Specifically, the area under the curve (AUC) for the Non-MCG group during the resting state reached its peak, with a value of 0.802 for Gamma3 (95% CI = 0.729-0.875) and 0.865 for broadband (95% CI = 0.804-0.926). In contrast, the MCG group achieved the highest AUC during wrist movements, with Gamma3 at 0.785 (95% CI = 0.719-0.849) and broadband at 0.824 (95% CI = 0.753-0.890).

Conclusion: Gliomas in the motor cortex disrupt the distribution of hand activity, complicating intraoperative functional mapping. As a novel and reliable approach, ECoG technique can complement and guide direct cortical stimulation for precise mapping, potentially reducing its frequency, minimizing the risk of functional deficits, and achieving a balance between maximal tumor resection and neurological preservation.

Background: Previous studies have demonstrated similar short-term efficacy between subserosal (SSA) and submucosal (SMA) approaches for ICG injection in gastric cancer (GC). This study aims to compare the long-term oncological outcomes of these two injection methods for lymph node (LN) tracing in ICG-guided laparoscopic gastrectomy.

Materials and methods: This study was a phase 3, open-label, randomized clinical trial (FUGES-019). A total of 266 patients with resectable gastric adenocarcinoma (cT1-4a, N0/ +, M0) were enrolled. We report predefined long-term secondary outcomes, including three-year actual overall survival (OS), three-year actual disease-free survival (DFS), and recurrence patterns.

Results: Of the 266 participants, 259 patients were included in the per-protocol analysis; 129 in the SSA group and 130 in the SMA group. The actual OS in the SSA group (87.6%) was comparable to that in the SMA group (90.8%, P = 0.41), as were the 3-year actual DFS rates (SSA: 82.9% vs. SMA: 88.5%, Log-rank P = 0.19). Per-protocol analysis confirmed the equivalence of the SSA compared with the SMA. The most common type of recurrence was multiple site metastasis (11 of 259[4.24%]), with no differences in recurrence types across cancer stages. Further stratified analysis based on pT, pN staging, tumor size, and BMI showed no significant differences between the two groups.

Conclusion: The 3-year outcomes of the FUGES-019 trial confirm the equivalence of SSA and SMA in ICG-guided laparoscopic lymphadenectomy for GC, supporting the previous short-term findings. The subserosal approach can be recommended for ICG administration based on clinical considerations.

Objectives: Effective training methods and learning curve (LC) assessment are crucial for more difficult endoscopic procedures. The present study sought to assess the LC of ureteral flexible scopes for thulium fiber laser (TFL) lithotripsy and determine the effectiveness of using a porcine kidney model in training modality, to inform future training.

Methods: Postgraduate medical students without experience in ureteroscopy were recruited, and surgical data were collected from 10 consecutive flexible ureteroscopic (fURS) lithotripsy procedures performed on our homemade porcine kidney training model. Cumulative sum (CUSUM) analysis and pooled mean CUSUM curves were applied to determine the LC turning points (TPs), and pre-LC and post-LC data were compared with that of an experienced attending physician.

Results: Data from 110 surgeries were included in the analysis. The mean number of surgical units to overcome the LC for the duration of fURS TFL lithotripsy was 4. The operation time, number of tissue damage, and number of central visual shifts were significantly lower in students after the TP than before. No statistically significant difference in operation time was found between the students after the LC (817.50 [703.75-964.75]) and the surgeon group (732.50 [51.00-822.25]).

Conclusion: Overcoming the LC of fURS TFL lithotripsy requires four surgeries, and the developed ex vivo porcine kidney is a conveniently accessible and effective clinical training model.

Background: Postoperative delirium (POD) is a severe complication following cardiac surgery and is associated with increased morbidity and mortality. The impact of intra- and early postoperative factors on the occurrence of POD following cardiac surgery remains controversial. To close this gap, we investigated intra- and early postoperative factors and their predictive values for POD.

Methods: We performed a prospective observational study that aimed to FIND DElirium RIsk factors (FINDERI) for patients undergoing elective cardiac surgery. POD was assessed using the Confusion Assessment Method (CAM) algorithm. Intra- and early postoperative factors were extracted from electronic medical records and reviewed by cardiac surgeons. To identify potential predictors of POD, we used univariate and multivariate logistic regression along with machine learning (ML) with tenfold cross-validation.

Results: In our study cohort of 490 patients, 106 screened positive for POD (21.6%). In the multivariate analysis, we found a positive association between POD occurrence and age (p<0.001), duration of surgery (p = 0.027), combined (versus isolated) surgical procedures (p = 0.024), opening of the cardiac chambers (p = 0.046), and ventilation time (p<0.001). The ML-based decision tree identified a two level-algorithm including ventilation time and aortic cross-clamping time, with an AUC of 0.7116 (p = 0.0002) in the validation set. In the ML-based LASSO regression analysis, we identified ventilation time, administration of erythrocyte concentrates (EC), and usage of cardiopulmonary bypass (CPB) as predictors of POD, with an AUC of 0.7407 (p<0.0001) in the validation set.

Conclusion: The results of this analysis highlight the associations between ventilation time, aortic cross-clamping time, administration of EC, and usage of CPB and POD. Additionally, they suggest that the optimization of surgical protocols has the potential to reduce POD risk in individuals undergoing cardiac surgery.

This study aimed to predict positive surgical margins in breast-conserving surgery (BCS) using multiparametric MRI (mpMRI) and radiomics. A retrospective analysis was conducted on data from 444 BCS patients from three Chinese hospitals between 2019 and 2024, divided into four cohorts and five datasets. Radiomics features from preoperative mpMRI, along with clinicopathological data, were extracted and selected using statistical methods and LASSO logistic regression. Eight machine learning classifiers, integrated with a transfer learning (TL) method, were applied to enhance model generalization. The model achieved an AUC of 0.889 in the internal test set and 0.771 in the validation set. Notably, TL significantly improved performance in two external validation sets, increasing the AUC from 0.533 to 0.902 in XAH and from 0.359 to 0.855 in YNCH. These findings highlight the potential of combining mpMRI and TL to provide accurate predictions for positive surgical margins in BCS, with promising implications for broader clinical application across multiple hospitals.

Objectives: This study aimed to develop an artificial intelligence-assisted model for the preoperative prediction of lateral cervical lymph node metastasis (LCLNM) in papillary thyroid carcinoma (PTC) using computed tomography (CT) radiomics, providing a new noninvasive and accurate diagnostic tool for PTC patients with LCLNM.

Methods: This retrospective study included 389 confirmed PTC patients, randomly divided into a training set (n = 272) and an internal validation set (n = 117), with an additional 40 patients from another hospital as an external validation set. Patient demographics were evaluated to establish a clinical model. Radiomic features were extracted from preoperative contrast-enhanced CT images (venous phase) for each patient. Feature selection was performed using analysis of variance and the least absolute shrinkage and selection operator algorithm. We employed support vector machine, random forest (RF), logistic regression, and XGBoost algorithms to build CT radiomic models for predicting LCLNM. A radiomics score (Rad-score) was calculated using a radiomic signature-based formula. A combined clinical-radiomic model was then developed. The performance of the combined model was evaluated using the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results: A total of 1724 radiomic features were extracted from each patient's CT images, with 13 features selected based on nonzero coefficients related to LCLNM. Four clinically relevant factors (age, tumor location, thyroid capsule invasion, and central cervical lymph node metastasis) were significantly associated with LCLNM. Among the algorithms tested, the RF algorithm outperformed the others with five-fold cross-validation on the training set. After integrating the best algorithm with clinical factors, the areas under the ROC curves for the training, internal validation, and external validation sets were 0.910 (95% confidence interval [CI]: 0.729-0.851), 0.876 (95% CI: 0.747-0.911), and 0.821 (95% CI: 0.555-0.802), respectively, with DCA demonstrating the clinical utility of the combined radiomic model.

Conclusions: This study successfully established a clinical-CT radiomic combined model for predicting LCLNM, which may significantly enhance surgical decision-making for lateral cervical lymph node dissection in patients with PTC.