International journal of surgery最新文献

Background: Preoperative differentiation of precursor glandular lesions (PGL), minimally invasive (MIA), and invasive adenocarcinoma (IAC) in stage IA lung adenocarcinoma (LUAD) is critical for surgical planning but remains challenging due to overlapping CT features and interobserver variability. While existing artificial intelligence (AI) models focus predominantly on binary classification with limited multicenter validation, this study developed and validated a ternary classification framework using pretrained TabPFN and traditional machine learning (ML) algorithms based on AI-derived histogram features, benchmarking against intraoperative frozen section analysis.

Materials and methods: This multicenter retrospective study utilized preoperative CT scans from three institutions between September 2014 and October 2023. Data were divided into training, internal validation, and external test sets. Histogram features (n = 26) were automatically extracted using a commercial AI system (InferRead CT Lung). TabPFN and five ML algorithms were trained with selected clinical and histogram features. Performance was evaluated by accuracy, macro-AUC, sensitivity, specificity, and Cohen's Kappa. Statistical comparisons included DeLong tests for AUC and chi-square for categorical variables.

Results: The cohort comprised 584 stage IA LUAD patients (mean age 57.9 ± 11.0 years; 386 female), divided into training/validation sets (n = 412, center 1) and external test sets (n = 114, center 2; n = 58, center 3). TabPFN achieved macro-AUC of 0.781-0.911 and accuracy of 67.2-78.9% across external test sets, outperforming other ML algorithms. Of note, TabPFN achieved an overall better prediction accuracy compared to frozen section analysis on all test sets (internal: 92.3% vs 84.6%, P = 0.503; external 1: 87.5% vs 75%, P = 1.000; external 2: 67.2% vs 43.1%, P < 0.001). Subgroup analysis revealed superior performance for mGGN lesions (85%) on both external test sets.

Conclusions: TabPFN enables robust, generalizable ternary classification of LUAD subtypes, surpassing conventional ML and frozen section analysis. Its integration with automated histogram analysis offers a scalable solution for preoperative stratification of early-stage lung cancer.

Background: The obesity paradox - where overweight and mild obesity appear associated with improved survival in some cardiometabolic conditions - challenges clinical risk stratification. The inability of body mass index (BMI) to discriminate lean mass from fat, or visceral from subcutaneous adipose tissue, may underlie this paradox.

Methods: To evaluate whether direct measures of abdominal fat distribution and metabolic health status more strongly associate with cardiometabolic morbidity and mortality than BMI alone, and whether they clarify the observed obesity paradox. This cross-sectional analysis with prospective mortality follow-up included 15 925 adults from the 2011-2018 U.S. National Health and Nutrition Examination Survey (NHANES), a nationally representative cohort. Data analysis was performed from July 2025 to October 2025.

Results: Among 15 925 participants, higher VFI and VFI/SFI ratio were consistently associated with increased mortality, whereas higher SFI was protective. After full adjustment, the highest quartile of VFI was associated with significantly increased risk of all-cause [hazard ratio (HR), 1.67; 95% CI, 1.19-2.33] and cardiometabolic mortality (HR, 2.92; 95% CI, 1.44-5.93). The VFI/SFI ratio showed similarly strong associations (all-cause mortality HR, 1.75; 95% CI, 1.19-2.58; cardiometabolic mortality HR, 2.90; 95% CI, 1.42-5.90). In contrast, overweight and obesity class I showed a lower risk of all-cause mortality compared to normal weight (overweight HR, 0.74; 95% CI, 0.56-0.99). Fat distribution indices demonstrated a strong association with CMD incidence in older adult (≥45 years). Metabolically unhealthy status was also a significant mortality risk factor, particularly in females.

Conclusions: In this cross-sectional study of U.S. adults, visceral fat accumulation and an unfavorable fat distribution ratio were more strongly associated with mortality and CMD risk than BMI alone. The apparent survival advantage of elevated BMI was attenuated after accounting for fat distribution and metabolic health. These findings suggest that clinical assessment of obesity-related risk should incorporate measures of fat distribution and metabolic phenotype beyond BMI.

Background: Ureteral strictures constitute an important clinical problem due to the increasing number of cases. Endoscopy has an established but limited role in the treatment of ureteral strictures. Endoscopic treatment of other than single, short strictures results in a high recurrence rate and treatment failure. Promising tools are metallic stents available now on the urological market; however, there are no standardized indications for the treatment of ureteral strictures with the use of metallic stents. Study aim was to determine the features influencing the results of the self-expanding ureteral stents (SUS)-assisted endoscopic treatment. The secondary endpoint was to relate the etiology of the stricture to the effectiveness of the SUS-related endoscopic treatment.

Methods: In a retrospective, single-center study, we present our experience in implantation of 65 SUS in the treatment of ureteral strictures of different etiology. The assessment of the efficacy and safety of the treatment was performed by the author's quality of life questionnaire, number of serious complications (Clavien-Dindo > 3a), patency of the SUS during stenting and the possibility of full recovery of the ureteral stricture with endoscopic methods assisted by the SUS. Uni- and multivariate regression models have been applied to define treatment failure predictors.

Results: Effective treatment of ureteral strictures with the SUS can be achieved in patients with a short ureteral stricture which usually occur after point injury of the ureter, without significant thermal damage. In long ureteral strictures typical of inflammatory diseases, complications after radiotherapy, and extensive thermal damage, the treatment failure rate with the use of the SUS is high.

Conclusions: Univariate analysis identified strictures longer than 2 cm, a dilatation diameter below 14 F and impaired stent patency during stenting as significant predictors of treatment failure, of which the possibility of an appropriately wide dilation and the patency of the SUS resulted from the length of the stricture.

Background: This study aimed to investigate the relationship between the timing of anticoagulation initiation and clinical outcomes in critically ill patients with sepsis-induced coagulopathy (SIC).

Methods: We conducted a retrospective cohort study using the MIMIC-IV database. Adult patients diagnosed with SIC (ISTH-SIC score ≥ 4) and receiving anticoagulation therapy during their ICU stay were included. Anticoagulation therapy was defined as administration of unfractionated heparin, low-molecular-weight heparin, vitamin K antagonists, or direct oral anticoagulants, as captured in medication records; additionally, a heparin-only analysis was performed given its predominant use in this population. Patients were stratified into early (≤ 48 hours post-ICU admission) or delayed (> 48 hours) anticoagulation groups. Baseline characteristics were balanced using propensity score matching (PSM). Primary outcomes included 28-day, 60-day, and 90-day mortality. Cox proportional hazard models were applied to assess survival differences across subgroups.

Results: Among 12 738 eligible patients, 10 689 received early anticoagulation and 2049 received delayed treatment. After PSM (n = 3986), delayed anticoagulation was associated with significantly lower 28-day mortality (15% vs 19%, P < 0.001), and similar reductions were observed at 60 and 90 days. Kaplan-Meier survival curves showed significantly better survival in the delayed group (P < 0.001). Subgroup analyses revealed that the survival benefit was more pronounced in patients aged >65 years, those without acute kidney injury (AKI), platelet count ≥ 100 × 109/L, Sequential Organ Failure Assessment score ≥ 6, and those treated with unfractionated heparin.

Conclusions: Among critically ill patients with SIC, delayed initiation of anticoagulation was independently associated with improved short- and medium-term survival. These findings support a phenotype-guided, time-stratified approach to anticoagulation in sepsis and highlight the need for prospective trials to validate optimal timing strategies.

Background and aims: Recently, increasing studies have reported that Parkinson's disease (PD) may experience an increased incidence of venous thromboembolic events and complications for patients who undergo surgery. We aimed to explore the actual prevalence and risk factors of venous thromboembolism (VTE) for patients with PD as well as its influence on the operative outcomes.

Methods: We searched PubMed, Embase, and Cochrane library up to 1 May 2025 for observational studies exploring the risk factors of venous thromboembolic events or comparing the frequency of venous thromboembolic events and complications in PD and non-PD patients. The primary outcomes were the risk factors for and incidence of venous thromboembolic events in patients with PD. The secondary outcome was comparing the complications or adverse events between PD and non-PD patients. Two reviewers screened the titles and abstracts of searched records for qualified reports according to the including and excluding criteria and extracted the data independently.

Results: Finally, we totally identified 17 observational studies involving 760 380 patients for the present analysis. Our pooled results indicated that when compared to patients without PD, patients with PD had significantly higher incidence of venous thromboembolic events, including VTE (OR 1.35, 95% CI 1.11-1.65), deep vein thrombosis (DVT; OR 1.56, 95% CI 1.24-1.96) and pulmonary embolism (PE; OR 1.54, 95% CI 1.20-1.96), respectively. In addition, when comparing DVT (+) and DVT (-) in patients with PD, female patients with PD had a higher frequency of DVT (OR 2.45, 95% CI 1.47-4.06), patients with lower Barthel index [mean difference (MD) -11.5, 95% CI -20.85-2.15] and those with smaller abdominal circumference (MD -7.13 cm, 95% CI -9.99 to -4.26), respectively. When compared to PD patients without DVT, PD patients with DVT had significantly higher average real variability of systolic blood pressure (MD 3.2 mmHg, 95% CI 0.75-5.65), lower heart rate at admission (MD -3.32 bpm, 95% CI -6.58 to -0.06), higher D-dimer (MD 2.14 µg/mL, 95% CI 1.20-3.08), and longer duration of illness (MD 22.68 months, 95% CI 6.77-38.58), respectively. Our pooled analysis also indicated that PD increased complications and adverse events of patients receiving operation.

Conclusions: Patients with PD were more prone to venous thromboembolic events and had an increased incidence of intra- and post-operative complications. Though several risk factors of DVT were identified for Parkinson's patients, they need further demonstration with specific researches in the future. Greater vigilance should be exercised to make an informed decision regarding patient care and preferred healthcare setup for patients with PD.

Background: Acute kidney injury (AKI) is a frequent yet severe complication following major surgery. Although malnutrition is an established risk factor for postoperative AKI, the comparative predictive value of different objective nutritional assessment tools remains poorly defined.

Materials and methods: This retrospective cohort study consecutively included adult patients undergoing major surgery from two independent sources: a single academic hospital (derivation: 2018-2020; internal validation: 2021) and the MIMIC-IV database (external validation). Preoperative nutritional status was assessed using four objective tools, including the prognostic nutritional index (PNI), the geriatric nutritional risk index (GNRI), the controlling nutritional status (CONUT), and serum albumin. The primary outcome was postoperative AKI, defined as AKI occurring within 7 days after major surgery.

Results: The derivation, internal validation and external validation cohorts comprised 16 761 (1.9% AKI), 6243 (1.5% AKI), and 422 (36.3%AKI) patients, respectively. Malnutrition prevalence varied substantially by tool: PNI (2.0-19.9%), GNRI (18.5-28.1%), CONUT (49.3-69.4%), and serum albumin (4.9-28.4%). In the derivation cohort, all four nutritional assessment tools as continuous variables were independently associated with postoperative AKI after fully adjustment; when analyzed as categorial variables, only serum albumin showed independent associations for both mild and moderate-to-severe malnutrition. Serum albumin also demonstrated superior predictive performance (AUC: 0.697) and the highest incremental value for postoperative AKI, with this superiority maintained across both internal and external validation cohorts. Notably, serum albumin showed more pronounced inverse association with postoperative AKI in diabetics (aOR: 0.888, 95% CI: 0.832-0.948) than non-diabetics (aOR: 0.962, 95% CI: 0.923-1.003; P for interaction = 0.026).

Conclusion: Malnutrition prevalence in surgical patients varies across nutritional assessment tools. Serum albumin demonstrated superior and consistent predictive value for postoperative AKI compared to nutritional indices (PNI, GNRI, and CONUT), with particularly enhanced performance in diabetic patients.

Digital twin-assisted surgery referred to the use of a dynamic, patient specific virtual model that mirrored physical patient in real time to enhance surgical planning, guidance, and outcomes. This emerging approach integrated data from robotic manipulators, intelligent implants, biosensors, and imaging systems to create a continuously updated digital representation that responded to physiological and procedural changes. This review provided a comprehensive analysis of the conceptual foundations and technological architecture that enabled digital twin functionality in surgical environments along with associated implementation challenges. It further explored real-world integration of digital twins across preoperative, intraoperative, and postoperative phases, highlighting their role in predictive modeling, real-time decision support, and personalized surgical recovery. Moreover, this review critically evaluated key implementation challenges, including technical hurdles (data interoperability, sensor accuracy, real-time processing), practical barriers (economic costs, infrastructure, and training), and broader concerns (regulatory standards, ethics, and global equity). To address these challenges, the review proposes targeted future directions including leveraging AI and edge computing to overcome technical hurdles like real-time processing, developing secure, standardized data frameworks to ensure interoperability and meet regulatory standards and, moreover, fostering public-private partnerships to solve economic, infrastructural, and training barriers while promoting global equity. As the field evolved, digital twin-assisted surgery is poised to become a cornerstone of precision surgical care.

Renal cell carcinoma (RCC) is a prevalent malignancy of the urinary system. Despite significant advances achieved through targeted therapies and immunotherapies, therapeutic resistance remains a major obstacle to sustained clinical efficacy. This review comprehensively examines the molecular mechanisms driving resistance to both targeted therapy and immunotherapy in RCC from a multi-omics perspective. By integrating findings across diverse omics layers, we underscore the pivotal role of multi-level regulatory networks in mediating drug resistance and immune evasion. Our objective is to provide an in-depth understanding of these resistance mechanisms and to establish a theoretical framework for developing innovative therapeutic strategies aimed at overcoming resistance, thereby facilitating the advancement of precision oncology in RCC.

Background: Molecular subtyping of bladder cancer (BCa) using bulk transcriptomic data is hindered by tumor microenvironment (TME) contamination and intra-tumoral heterogeneity. These factors also contribute to variable responses to immune checkpoint inhibitor (ICI) therapy. Single-cell RNA sequencing offers a high-resolution approach to overcome these limitations by enabling tumor-specific analysis and improving therapeutic target identification.

Materials and methods: We constructed a large multicenter single-cell atlas of BCa by integrating nine cohorts comprising 123 samples and 842 127 cells. Tumor epithelial cells (n = 265 962) were identified via copy number variation (CNV) analysis using inferCNV. Pseudobulk RNA profiles were generated to simulate conventional bulk samples (Pseudobulkall) and purified tumor profiles (Pseudobulktumor), enabling systematic evaluation of bulk-based classifiers. Inter-tumoral and intra-tumoral heterogeneity programs were defined based on transcriptional profiles and validated through in vitro and in vivo experiments. Additionally, we cross-analyzed five immunotherapy datasets encompassing 13 immune response phenotypes to identify molecular features associated with therapeutic resistance and sensitivity.

Results: Unsupervised clustering identified 11 major cell types and 55 non-epithelial subtypes, with TME heterogeneity driven by tissue origin and malignancy status. Existing molecular classifiers UNC (University of North Carolina at Chapel Hill) showed compromised concordance between Pseudobulkall and Pseudobulktumor, particularly in stroma-rich samples. We defined three inter-tumoral (GEinter2-4) subtypes with distinct CNV and transcription factor signatures that remained stable even at low tumor purity. Seven intra-tumoral (GEintra) programs captured key biological states, including an EMT/Stem-like module associated with immunosuppression and ICI resistance. Mechanistically, TGF-β1 induced expression of EMT/Stem-like genes (e.g., PTHLH), while Pthlh knockdown synergized with anti-PD-L1 therapy in murine models by enhancing T cell cytotoxicity without altering T cell infiltration.

Conclusions: This study provides a robust single-cell framework for resolving inter- and intra-tumoral heterogeneity in BCa, overcoming limitations of bulk-based subtyping. The TGF-β1-PTHLH axis contributes to ICI resistance, positioning PTHLH as a promising therapeutic target. These findings offer new insights for improving immunotherapeutic strategies in BCa.