International journal of surgery最新文献

Intrauterine adhesions (IUAs) may lead to abnormal menstruation, infertility, and pregnancy-related complications. Hysteroscopic separation is the gold standard treatment for IUA and can be performed using a variety of instruments and methods, including cold scissors and electrotomy. However, it is unclear which method is more effective for relieving IUA, restoring uterine anatomy, and improving the pregnancy rate in women of childbearing age. This multicenter prospective randomized clinical trial included 218 women aged 20-40 years who were treated for IUA between 1 March 2021 and 30 June 2022 and followed for 1.5 years. The women were randomly assigned to a cold scissors group ( n  = 109) or electrosurgical excision group ( n  = 109). Second-look hysteroscopy was performed in all patients within 3-10 days after the end of the first postoperative menstrual period. The primary outcome was the change in American Fertility Society score. Secondary outcomes included postoperative menstrual blood loss, the recurrence rate, and the reproductive outcome. There was no significant difference in the curative effect of hysteroscopic adhesiolysis between the cold scissors group and the electrosurgical excision group (5 [interquartile range, 4-6] vs. 5 [interquartile range, 4-6], P  = 0.729) or in the postoperative recurrence rate (27.5% vs. 30.6%, relative risk 0.901, 95% confidence interval 0.594-1.366, P  = 0.623) or pregnancy outcomes between the two groups. Postoperative menstrual blood loss was significantly greater in the cold scissors group than in the electrosurgical excision group (65.1% vs. 48.1%, P  = 0.029). The treatment cost was significantly lower in the cold scissors group ( P  < 0.001). In conclusion, hysteroscopic adhesiolysis using cold scissors does not differ significantly from electrosurgery in terms of treatment efficacy, recurrence rate, pregnancy rate, or pregnancy-related complications in patients with IUA who have normal ovarian reserve and an endometrial thickness of ≥6 mm before ovulation. The cold scissors ploughing technique can increase menstrual blood loss and is a cost-effective procedure.

Aim: We aim to investigate the optimal timing for surgical interventions to maximize patient benefit.

Background: The guidelines recommending a minimum deferral of 6 months for non-cardiac surgeries following drug-eluting stent percutaneous coronary intervention (DES-PCI) do not adequately address the requirements for individuals undergoing gastrointestinal cancer surgery (GCS).

Methods: The study encompassed 2501 patients treated from January 2017 to December 2021, all of whom underwent GCS within 1 year after DES-PCI. We conducted an analysis by comparing the occurrence of major adverse cardiovascular events (MACEs) within 30 days post-surgery at different time points.

Results: This study enrolled a total of 2501 participants with meticulously recorded data who underwent DES-PCI and subsequently underwent GCS within 1 year post-implantation. The incidence rate of MACEs is 14.2%, including MI (5.1%), HF (5.8%), IS (3.2%), and cardiac death (0.2%), across all patients in this study. The threshold probability was determined using the Youden Index, resulting in a value of 0.320, corresponding to a "time-to-surgery value" of 87. Significant statistical differences were observed in the occurrence rates of MACEs for adjacent time intervals at 30 days ( P < 0.001), 90 days ( P < 0.009), and 180 days ( P < 0.001).

Conclusions: The timing of surgical intervention following DES-PCI significantly influences the occurrence of MACEs at 1, 3, and 6 months. GCS may be appropriately advanced within the 6-month timeframe, but with the exception of emergency, efforts should be made to defer them beyond the initial month.

Background: Dural arteriovenous fistulas (DAVFs) pose a significant health threat owing to their high misdiagnosis rate. Case reports suggest that DAVFs or related acute events may follow medication use; however, drug-related risk factors remain unclear. In clinical practice, the concomitant use of multiple drugs for therapy is known as "polypharmacy situations," further increasing the risk of drug-induced DAVF. Real-world studies linking medications and DAVF can alert clinicians to their possibilities and contribute to clinical decision-making and patient education.

Method: This study investigated adverse events spanning a decade from the FAERS database, employing pharmacovigilance analysis to systematically assess the risk of drug-induced DAVF. Furthermore, the clinical characteristics of these drug-related DAVFs, such as demographic information, complications, and outcomes, were characterized.

Result: This study generated a broad spectrum of drugs associated with DAVFs. A total of 355 DAVF events, involving 161 drugs across 73 categories, were compiled from millions of records. We identified eight classes of drugs for thorough investigation. Pharmacovigilance analysis revealed that tamoxifen, methylprednisolone, betamethasone, prednisone, rebif, ustekinumab, natalizumab, baclofen, dabigatran etexilate, and bupivacaine have the potential to induce DAVFs. Cerebrovascular thrombotic and embolic events emerge as the most prominent co-adverse events of drug-induced DAVFs. Analyses based on drug-disease targets suggested that the regulation of angiogenesis could be a potential mechanism in tamoxifen-induced DAVFs. Apart from medications with gender-specific prescription patterns, most medications exhibit a high risk of DAVF in adult male cohorts. Five patients with drug-related DAVFs experienced severe (fatal) outcomes, with four reports attributed to tamoxifen.

Conclusion: These findings highlight the diverse range of drugs implicated in the occurrence or progression of DAVF. Drugs such as tamoxifen, corticosteroids, multiple sclerosis medications, and oral anticoagulants require particular attention. Future research should focus on elucidating the underlying mechanisms and risk factors, such as thrombosis, contributing to drug-induced DAVF to inform preventive strategies and optimize patient care.

Background: The inclusion of clinical frailty in the assessment of patients planned for major surgery has proven to be an independent predictor of outcome. Since approximately half of all patients in the UK diagnosed with oesophagogastric (OG) cancer are over 75 years of age, assessment of frailty may be important in selection for surgery.

Materials and methods: This retrospective cohort study applied the Hospital Frailty Risk Score to data obtained from the NHS Secondary Uses Service electronic database for patients aged 75 years or older undergoing oesophagectomy and gastrectomy between April 2017 and March 2020. Descriptive statistics were performed to assess the effect of patient frailty on length of stay, 30-day readmission, and 30-day mortality rates. These outcomes were compared with those published by the National Oesophago-Gastric Cancer Audit.

Results: Over 90% of the 1775 patients identified according to the age and resection criteria exhibited some degree of frailty. The median length of stay and 30-day readmission rate increased as patient frailty increased following both oesophagectomy and gastrectomy, as did the 30-day mortality rate following gastrectomy.

Conclusion: Frailty is a dynamic state and increasing age alone should not be a barrier to receiving the most appropriate treatment. Introducing standardized assessment of clinical frailty for patients with OG cancer to identify this cohort of patients earlier might enable targeted screening for frailty syndromes. This could facilitate the enhanced delivery of more holistic, frailty-attuned, approaches to person-centred care, and evidence-based treatment pathways for improved patient outcomes.

Background: Robotic pancreaticoduodenectomy (RPD) is used more commonly, but high-level evidence is still scarce. This meta-analysis aimed to compare the short-term outcomes between RPD and laparoscopic pancreaticoduodenectomy (LPD) using data collected from propensity score-matched (PSM) studies.

Materials and methods: We searched PubMed, Cochrane Library, Embase, and Web of Science databases for PSM studies comparing RPD and LPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated.

Results: Ten PSM studies were included, encompassing 8106 patients (RPD group: 3695 patients; LPD group: 4411 patients). Compared with LPD, RPD was associated with a lower conversion rate (RR, 0.56) and blood transfusion rate (RR, 0.49), as well as a higher number of harvested lymph nodes (MD, 2.15). There were no significant differences observed in 30-day readmission (RR, 1.02), 90-day mortality (RR, 1.01), overall morbidity (RR, 0.94), major complications (RR, 1.06), operative time (MD, -8.00 min), blood loss (MD, -19.37 mL), reoperation (RR, 0.95), bile leak (RR, 0.93), chylous leak (RR, 1.40), postoperative pancreatic fistula (RR, 1.06), delayed gastric emptying (RR, 0.92), wound infection (RR, 1.12), length of stay (MD, -0.32 days), and R0 resection (RR, 0.98) between the groups.

Conclusions: Although LPD and RPD had similar surgical outcomes, RPD had the perioperative advantage over LPD in decreasing conversion rates and blood transfusion rates and increasing the number of lymph nodes harvested. Further randomized controlled trials evaluating the potential advantages of RPD over LPD are warranted.

Background: Major adverse cardiovascular events (MACEs) within 30 days following noncardiac surgery are prognostically relevant. Accurate prediction of risk and modifiable risk factors for postoperative MACEs is critical for surgical planning and patient outcomes. We aimed to develop and validate an accurate and easy-to-use machine learning model for predicting postoperative MACEs in geriatric patients undergoing noncardiac surgery.

Materials and methods: The cohort study was conducted at an academic medical center between June 2019 and February 2023. The outcome was postoperative MACEs within 30 days after surgery. Significant predictors were selected using permutation-shuffling. Ten machine learning models were established and compared with the Revised Cardiac Risk Index (RCRI). The SHapley Additive exPlanations algorithm was used to interpret the models.

Results: Of the 18,395 patients included, 354 (1.92%) experienced postoperative MACEs. Eighteen predictors were included in model development. The AutoGluon model outperformed other models and the RCRI with an AUROC of 0.884 (95% CI: 0.878-0.890), an accuracy of 0.976 (95% CI: 0.973-0.978), and a Brier score of 0.023 (95% CI: 0.020-0.026). In interpretability analyses, the hemoglobin level was the most important predictor. We identified the relationships between predictors and postoperative MACEs and interaction effects between some predictors. The AutoGluon model has been deployed as a web-based tool for further external validation ( https://huggingface.co/spaces/MDC2J/Predicting_postoperative_MACEs ).

Conclusion: In this prospective study, the AutoGluon model could accurately predict MACEs after noncardiac surgery in geriatric patients, outperforming existing models and the RCRI. Subsequent interpretability analysis can provide insight into how our model works and help personalize surgical strategies.

Background: Intra-leaflet hemorrhage (IH) plays a well-recognized detrimental role in calcified aortic valve disease (CAVD). However, IH-induced fibro-osteogenic responses in valvular interstitial cells (VICs) appear to be triggered under specific pathological conditions. Iron deficiency (ID), a common co-morbidity in CAVD, may influence these responses. This study investigated the relationship between ID and pathological changes associated with CAVD, and its effects on IH-mediated fibro-osteogenic differentiation of VICs.

Methods and results: Two independent studies were conducted, including 2495 patients in the discovery study and 34 in the validation study. Our data demonstrated that ID was associated with CAVD severity and progression, particularly in an age-dependent manner. Based on these clinical findings, immunofluorescence and Western blot analyses revealed that TFR1, a key iron import transporter, was significantly upregulated in human calcified aortic valves. Concurrently, iron accumulation was detected by Perl's staining in both calcific and non-calcific valve sections. In vitro , VICs cultured with human serum from ID patients showed red blood cell lysis-induced iron overload and fibro-calcific differentiation.

Conclusions: ID triggers TFR1-mediated intracellular iron overload, leading to fibrosis and calcification in human VICs, thereby contributing to IH-mediated valve remodeling and calcification. These findings supported the potential role of monitoring and correcting ID to slow or prevent the progression of valvular calcification.

Background: Pulmonary ischemia-reperfusion injury (PIRI) is a major cause of fatality post-lung transplantation. Though some long non-coding RNAs (lncRNAs) have been studied in acute lung injury (ALI), their effects on PIRI remain undefined. The present study aims to explore the underlying mechanism of small nucleolar RNA host gene 16 (SNHG16) in PIRI.

Methods: PIR mouse and oxygen-glucose deprivation/reoxygenation (OGD/R) cell models were established. Exosomes were extracted from human pulmonary microvascular endothelial cells (HPMECs). Functional and rescue experiments were conducted in OGD/R-exposed HPMECs, OGD/R-exposed pulmonary alveolar epithelial type II cells (AECs), and I/R model mice. The relationships among SNHG16, miR-372-3p/miR-373-3p, and MTCH2 were also verified using dual luciferase reporter assay, RNA pull-down and RIP assay.

Results: SNHG16 was downregulated in OGD/R-exposed HPMECs, and SNHG16 overexpression accelerated proliferation, angiogenesis, and ameliorated mitochondrial respiration in OGD/R-exposed HPMECs. HPMEC-derived exosomal SNHG16 suppressed OGD/R-induced type II AEC injury. SNHG16 ameliorated lung injury in PIR mice. Mechanistically, SNHG16 targeted and negatively regulated miR-372-3p and miR-373-3p expression, and MTCH2, a target gene of miR-372-3p/miR-373-3p. SNHG16 was found to upregulate MTCH2 expression not only in a miR-372-3p and miR-373-3p-dependent manner but also suppress ubiquitination induced MTCH2 degradation.

Conclusions: Our findings revealed that SNHG16 overexpression suppressed OGD/R-induced HPMEC apoptosis by promoting Warburg effect, and HPMEC-derived exosomal SNHG16 alleviated PIRI through the miR-372-3p/miR-373-3p/MTCH2 axis, suggesting that SNHG16 as a therapeutic target for PIRI.