International journal of surgery最新文献

Background: Early recurrence in patients with locally advanced gastric cancer (LAGC) portends aggressive biological characteristics and a dismal prognosis. Predicting early recurrence may help determine treatment strategies for LAGC. The goal is to develop a deep learning model for early recurrence prediction (DLER) based on preoperative multiphase computed tomography (CT) images and to further explore the underlying biological basis of the proposed model.

Materials and methods: In this retrospective study, 620 LAGC patients from January 2015 to March 2023 were included in three medical centers and The Cancer Image Archive (TCIA). The DLER model was developed using DenseNet169 and multiphase 2.5D CT images, and then crucial clinical factors of early recurrence were integrated into the multilayer perceptron (MLP) classifier model (DLER MLP ). The area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity were applied to measure the performance of different models. The log-rank test was used to analyze survival outcomes. The genetic analysis was performed using RNA-sequencing data from TCIA.

Results: Using the MLP classifier combined with clinical factors, DLER MLP showed higher performance than DLER and clinical models in predicting early recurrence in the internal validation set (AUC: 0.891 vs. 0.797, 0.752) and two external test sets: test set 1 (0.814 vs. 0.666, 0.808) and test set 2 (0.834 vs. 0.756, 0.766). Early recurrence-free survival, disease-free survival, and overall survival can be stratified using the DLER MLP (all P < 0.001). High DLER MLP score is associated with upregulated tumor proliferation pathways (WNT, MYC, and KRAS signaling) and immune cell infiltration in the tumor microenvironment.

Conclusion: The DLER MLP based on CT images was able to predict early recurrence of patients with LAGC and served as a useful tool for optimizing treatment strategies and monitoring.

Background: The utilization of robot-assisted surgery (RAS) has been increasing among cancer patients. However, evidence supporting the use of RAS remains uncertain. The availability of randomized controlled trials (RCTs) for each surgical procedure is limited. This study aimed to assess the safety and efficacy of RAS in cancer patients.

Materials and methods: A comprehensive search was performed in Embase, PubMed, the Cochrane Library, and ClinicalTrials.gov from the inception of the databases until 1 April 2023. We included RCTs of RAS in cancer patients compared with laparoscopic, thoracoscopic, or open surgery, and random-effects meta-analyses were performed.

Results: A total of 32 trials (6092 patients) met the eligibility criteria. Among these, 22 trials had a low risk of bias, seven trials had some concerns, and three trials were at high risk. Most trials were conducted for bladder cancer ( n = 8), rectal cancer ( n = 5), prostate cancer ( n = 4), and endometrial cancer (n = 4). In all cancers, RAS likely resulted in a slight reduction in the length of hospital stay (31 comparisons; mean difference [MD], - 0.91 days; 95% CI, - 1.33 to - 0.49), but resulted in little to no difference in overall survival (11 comparisons; hazard ratio [HR], 0.96; 95% CI, 0.78 to 1.17). Compared with open surgery, RAS was found to reduce estimated blood loss (MD, - 239.1 mL; 95% CI, - 172.0 to - 306.2) and overall complication (relative risk [RR] 0.88; 95% CI, 0.81 to 0.96), but increase total operative time (MD, 55.4 minutes; 95% CI, 30.9 to 80.0). Additionally, RAS seemed to be not associated with positive surgical margin, any recurrence, disease-free survival, and quality of life.

Conclusion: RAS has demonstrated small favorable effects on short-term outcomes, particularly when compared to open surgery. However, these effects may vary across different cancers. Additionally, RAS may not impact long-term survival, oncological outcomes, or quality of life in cancer patients.

Purpose: To evaluate the effectiveness and safety of an upgraded integrated vacuum suction catheter in semi-rigid ureteroscopic laser lithotripsy (VC-URSL) compared to traditional methods for treating impacted upper ureteral stones.

Patients and methods: This prospective, randomized controlled trial was conducted from September 2022 to March 2024 at a single center, enrolling 95 patients aged 18-70 years with a single radiopaque impacted upper ureteral stone. Participants were randomized into two groups: the VC-URSL group used an integrated vacuum suction catheter featuring a stainless steel stabilizing tube and a narrowed distal end to prevent obstruction, while the T-URSL group underwent standard ureteroscopic lithotripsy without vacuum assistance. Both groups utilized a holmium-YAG laser under general anesthesia. Primary outcomes included operative time, stone-free rates on the first postoperative day and after one month, and complication rates, specifically fever and stone retropulsion.

Results: The VC-URSL group achieved significantly shorter operative times (37.60 ± 3.87 min vs. 46.21 ± 7.54 min, P < 0.001) and higher initial stone-free rates (91.7% vs. 74.5%, P = 0.025) compared to T-URSL. Additionally, the VC-URSL group had fewer complications, with lower rates of fever (2.1% vs. 17.0%, P = 0.015) and stone retropulsion (6.3% vs. 21.3%, P = 0.033).

Conclusions: VC-URSL offers a more effective, safer, and efficient alternative to T-URSL, enhancing outcomes while reducing complications. Further multicenter trials with larger populations are recommended for broader validation.

Background: RPN1, also known as ribophorin I (RPN1), is a type I transmembrane protein that plays an important role in glycosylation. However, the effects of RPN1 on cancer progression and immune evasion in breast cancer (BC) have not been identified.

Materials and methods: The expression of RPN1 was evaluated using RT-qPCR and immunohistochemistry (IHC). The effects of RPN1 on tumor cells were assessed using RT-qPCR, western blotting, flow cytometry, Cell Counting Kit 8 (CCK-8), colony formation assays, and in vivo experiments. The mechanism by which RPN1 modifies programmed death ligand-1 (PD-L1) and the tumor microenvironment was examined by RT-qPCR, western blotting, co-immunoprecipitation (Co-IP), and flow cytometry. The influence of the transcription factor YY1 on RPN1 expression was revealed using bioinformatics analysis, RT-qPCR, and dual-luciferase reporter and chromatin immunoprecipitation (ChIP) assays.

Results: RPN1 is aberrantly expressed in triple-negative breast cancer (TNBC) cells, correlating with increased proliferation and poor prognosis. RPN1 mediates the post-translational modification of PD-L1, enhancing its glycosylation and stability, thus facilitating PD-L1-mediated immune escape and tumor growth. The deletion of RPN1 improves the TNBC microenvironment and enhances the efficacy of anti-PD-1 therapy. Additionally, we uncovered a novel regulatory axis involving YY1/RPN1/YBX1 in PD-L1 regulation, affecting TNBC growth and metastasis.

Conclusions: Our preliminary study reveals that targeting RPN1 promotes immune suppression, providing a new potential immunotherapy strategy for TNBC. However, further research is necessary to fully elucidate and understand the specific mechanisms of RPN1 in TNBC and its potential for clinical application.

Hilar cholangiocarcinoma (h-CCA) originates from the epithelial cells, which characters as longitudinal growth along the bile ducts and invasion of peripheral vascular nerves. Due to the tumors insidious progression and usually become advanced stage disease at presentation, patients' mortality could parallel incidence rates. For patients who are not amenable to resection, systemic therapy and palliative treatment become the way to go. Dawn of the immunotherapy era offers new opportunity for patients with advanced tumors. Numbers of successful clinical trials have been conducted these years, giving us the chance to optimize multiple treatment modalities. Although liver transplantation is worth to be considered, there is no high-level evidence to support it better outcomes over surgical resection. Given the poor prognosis of h-CCA, radical resection (R0) undoubtfully becomes the only irreplaceable treatment to prolonged survival. Thus, tumors free boundary assessment along the bile duct hit the crucial point. Over the years, numerous imaging techniques leveraging computed tomography, MRI, intraoperation ultrasound and endoscopy with the aim of guiding operation to eliminating cancers. Novel fiberscopes utilizing the second near-infrared region light (NIR-II) offer the potential to assist surgeon visualize tumors precisely. In this review, we summarize the clinical palliative care for advanced h-CCA patients and new opportunities for medications, discussing liver transplantation and other available treatment that not widely disseminated. In addition, we mainly focus on the novel technique of real-time intraoperation imaging navigation to achieve R0 resection and potential molecule prognosis development in the intractable disease.

Introduction: Laennec's capsule serves as a critical anatomical landmark in liver resection. Despite its potential, a lack of large-scale prospective studies limits the widespread use of the Laennec approach for minimally invasive hepatectomy. This multicenter cohort study aimed to compare the outcomes of the traditional and Laennec approaches in minimally invasive anatomical hepatectomy across multiple centers in China.

Methods: A total of 445 patients from 11 centers were included, with 339 undergoing the Laennec approach and 106 receiving the traditional approach. Intraoperative parameters such as the duration of hepatic pedicle isolation, hepatic vein exposure, parenchymal transection, and liver mobilization were analyzed. Postoperative outcomes, including recurrence-free survival and R0 resection rates, were also assessed. Additionally, a series of subgroup analyses were conducted to evaluate the efficacy of the Laennec approach.

Results: The Laennec approach demonstrated notable intraoperative advantages, including reduced durations for hepatic pedicle isolation, liver mobilization, hepatic vein exposure, and parenchymal transection. Robotic-assisted procedures, in particular, showed superior outcomes when compared with laparoscopic platform. The Laennec approach proved highly effective across various liver diseases, particularly hepatocellular carcinoma, hemangioma, and hepatolithiasis. The Laennec gap, a distinct gap between the liver parenchyma and surrounding vasculature, played a key role in identifying candidates for the Laennec approach. Subgroup analysis revealed that although the Laennec approach provides significant intraoperative benefits, these advantages do not seem not to translate into substantial postoperative improvements.

Conclusions: The Laennec approach offers clear intraoperative advantages over the traditional approach when utilizing laparoscopic or robotic systems. These findings support the Laennec approach as a standardized technique for anatomical liver resection.

Background: The outcome of major surgery is determined not only by the success of the procedure itself but also by its neurocognitive effects. We previously reported improved cognition following spine surgery (Müller et al. 2023 Spine ), but the mechanisms underlying these changes remain unknown.

Materials and methods: We analyzed resting-state functional magnetic resonance images of 79 patients (mean/SD age: 71/7 years) acquired at baseline in this previously published trial. For 26 patients, data was additionally available at 3-months follow-up visits. To delineate large-scale connectivity, we calculated functional connectivity (FC) within and between three core neural networks, the central executive network (CEN), the salience network (SAL), and the default mode network (DMN).

Results: FC between CEN and SAL predicted cognitive improvement (beta = 0.36, 95%-CI 0.28 to 0.45, P = 0.033). Average FC between all nodes of the CEN showed changes toward an increase after surgery (beta = 0.057, 95%-CI -0.01 to 0.123, P = 0.086). Further seed-based FC analyses revealed that this increase was most pronounced in the functional coupling between left dorsolateral prefrontal and right posterior parietal cortex (beta = 0.10, T(24) = 2.73, Punc  = 0.012, PFDR  = 0.035). The increase of CEN-FC correlated with individual enhancements of executive scores (beta = 0.34, 95%-CI 0.32 to 0.36, P = 0.034).

Conclusion: Integration of activity between the CEN and SAL networks predicted postoperative cognitive improvements, suggesting that less segregated large-scale functional networks may facilitate beneficial cognitive changes following surgery. Postoperative increases in functional coupling may serve as a biomarker for individual improvements in executive functions. These results indicate that surgery should not be routinely deferred in elderly patients due to concerns about postoperative neurocognitive complications. Moreover, our findings highlight potential targets for non-invasive brain stimulation interventions aimed at preventing neurocognitive complications.

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.