Journal of Gastrointestinal Surgery最新文献

Introduction: Histotripsy is a novel, non-invasive, non-ionizing, non-thermal approach using focused ultrasound waves to treat liver tumors. The technology received FDA De Novo grant in late 2023. We aim to provide the first reporting of post-trial, real-world clinical safety data.

Methods: Safety outcomes within 30 days of histotripsy were collected since FDA clearance (12/22/2023 - 7/25/2024). All centers who have performed histotripsy were invited to participate. Complications requiring treatment were graded using Clavien-Dindo and Comprehensive Complications Index (CCI).

Results: In total, 295 patients received histotripsy to 510 tumors at 18 centers. Treated liver tumor types included colorectal metastases (n=140), neuroendocrine (n=46), hepatocellular carcinoma (n=31), pancreas (n=30), and breast metastases (n=26). The most common number of tumors treated per procedure were 1 (n=170), 2 (n=69), and 3 (n=37). Tumors were treated in all 8 liver segments. Safety data was available for 230 patients from 9 centers. A total of 12 out of 230 patients experienced complications of any grade (5.2%). Most (n=9, 75%) were minor (< Clavien-Dindo Grade II). Median and mean CCI were 0 (IQR 0-0) and 0 points (95%CI 0-0.75). All three major complications (>Clavien-Dindo grade II, 1.3%) were death from disease progression. All three of these patients had undergone histotripsy with palliative intent for known advanced intra- and extrahepatic disease.

Conclusions: This is the first report on the real-world therapeutic use of histotripsy for liver tumors. Histotripsy was well tolerated with few overall complications and rare serious complications indicating a safety profile which compares favorably with other liver-directed and surgical therapies for the treatment of liver tumors. Long-term follow-up data including oncologic outcomes are being collected.

Background: Gallbladder cancer (GBC) is associated with dismal prognosis. Recurrence patterns and their impact on survival remain ill-defined. We sought to analyze recurrence patterns and develop a machine-learning (ML) model to predict survival after recurrence (SAR) of GBC.

Methods: In this cohort study, patients who underwent curative-intent resection of GBC between 1999 and 2022 were identified using an international database. A XGBoost (Extreme Gradient-Boosting) ML-model to predict SAR was developed and validated.

Results: Among 348 patients, 110 (31.6%) developed disease recurrence during follow-up. The most common recurrence site was local (29.1%), followed by multiple-site (26.4%), liver (21.8%), peritoneal (18.2%), and lung (0.05%). Median SAR was longest among patients with lung recurrence (36.0 months) followed by individuals with local recurrence (15.7 months); in contrast, patients with peritoneal (8.9 months), liver (8.5 months), and multiple-site (6.4 months) recurrence had markedly shorter SAR. Notably, patients with multiple-site recurrence had a significantly worse SAR (6.43 vs. 11.10 months, respectively; p=0.014). The model demonstrated good performance in the evaluation and bootstrapping cohorts (AUC:71.4, 71.0, respectively). The most influential variables were ASA (American Society of Anesthesiologists) class, local recurrence, receipt of adjuvant chemotherapy, AJCC (American Joint Committee on Cancer) T and N categories, and developing early disease recurrence (<12 months). To enable clinical applicability, an easy-to-use calculator was made available (https://catalano-giovanni.shinyapps.io/SARGB).

Conclusions: Except for lung recurrence, SAR for GBC was poor. A subset of patients with less aggressive disease biology may have favorable SAR. ML-based SAR prediction may help individuating candidates for curative re-resection when feasible.

Background: The study aims to establish which surgical technique used for the repair of perforated peptic ulcers is associated with more favorable outcomes.

Methods: A retrospective chart review of the patients who underwent surgery for perforated peptic ulcers at the Mayo Clinic Rochester campus between 2004 and 2021 was performed.

Results: The final analysis included 277 patients: 182 suture closure of the perforation, 55 patch-only repairs, 15 gastrectomies with reconstruction, 14 wedge resections, and other techniques in 11 patients. There were no leaks in patients who had stapled wedge resection. Among patients with repair of the perforation (n=237), three variables associated with the leak on univariate analysis were included in a logistic regression model. All three were independently associated with a leak: lack of suture closure of the perforation (OR 7, 95% CI 2.5-19.1), immunosuppression (OR 5.5, 95% CI 1.7-17.6), and lactate levels (OR 1.4, 95% CI 1.1-1.7).

Conclusion: When both sutured and patch-only closure techniques are feasible for a perforated peptic ulcer, sutured closure is associated with a lower risk of leakage. However, given our study's retrospective, single-institution nature, the findings should be interpreted cautiously.

Background or purpose: Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic landscape for esophageal achalasia, offering efficacy comparable to surgery with the convenience of an endoscopic approach. With the growing popularity of POEM, insufflation-related adverse events present unique challenges that have been widely discussed in the literature. This study aimed to investigate the safety profiles and risk factors linked to insufflation-related events in patients undergoing POEM in endoscopy suites.

Methods: This retrospective analysis included 100 consecutive patients with achalasia treated by POEM at our institute between March 2016 and October 2022. All procedures were conducted in an endoscopy suite and employed CO₂ insufflation and general anesthesia with endotracheal intubation and positive pressure ventilation. We documented variations in cardiopulmonary dynamics, intra-procedural adverse events, and postoperative recovery.

Results: All procedures were successfully performed with an average POEM duration of 92.3minutes and an average anesthesia duration of 108.4minutes. One major adverse event involving an esophageal leak and requiring endoscopic stenting was observed, along with a 27% incidence of minor adverse events. Insufflation-related events, manifesting as capnoperitoneum, subcutaneous emphysema, or capnomediastinum, were identified in 48% of cases, but none required additional interventions or extended hospitalization. A peak airway pressure increase of 20% or more was identified as the only predictor for insufflation-related events.

Conclusions: Performing POEM in an endoscopy suite can generally be considered safe from major adverse events related to insufflation. Monitoring peak airway pressure for a 20% increase may be an early indicator for other potential insufflation-related events.