Journal of Gastrointestinal Surgery最新文献

Background: There is ongoing debate on surgical training and its evolution to meet the demands of a complex and changing healthcare environment.

Methods: A GI Surgery Summit held in January 2024 included prominent leaders and rising talents from the Society for Surgery of the Alimentary Tract (SSAT), Society of Surgical Oncology (SSO), Association for Academic Surgery (AAS), and Society of University Surgeons (SUS). This meeting was convened to address the multifaceted current and future challenges of surgery.

Results: This paper addresses the topic of recruitment and training of the next generation of surgeons in the US and abroad, and reflects a collective focus on surgical education to ensure delivery of high-quality care in an increasingly sophisticated medical and surgical landscape CONCLUSION: The discussions and recommendations from the 2024 GI Surgery Summit underscore the critical need to support diversity, embrace innovative educational frameworks, build a robust global surgical workforce, and foster a culture of wellness and support. By focusing on these key areas, we can ensure that the future leaders of surgery are not only skilled and knowledgeable, but also resilient and compassionate, ready to meet the evolving challenges of the healthcare landscape.

Background: Microsatellite instability (MSI-H) represents a small subgroup of gastric cancer (GC) with a favorable prognostic and predictive significance. This study aimed to investigate locoregional nodes involvement, overall survival (OS) and disease-free survival (DFS), and the interplay between molecular subtypes and histological profiles in relation to survival outcomes in MSI versus MSS GC.

Methods: This study included 72 GC patients treated with surgery with or without chemotherapy from 2017 to 2023. Clinicopathological characteristics, OS and DFS were compared between LN-positive and negative patients, stratified by microsatellite status, treatments, molecular profiles, tumor cell types.

Results: MSI GC was more common in older patients (79.0 versus 70.2 years, p<0.001), predominantly females (73.68% vs. 43.32%, p=0.023), and associated with intestinaltype histology (94.5% vs. 49%, p=0.002). Positive LN and lymphovascular invasion were lower in the MSI group (2.73 vs. 4.15 p=0.366; 36.8% vs. 64.5% p=0.039). MSI showed slightly better OS and DFS (84.2% vs. 66% p=0.108; 84.62% vs. 63.89% p=0.120). MSI GC also had improved OS and DFS in both LNs positive (OS 72.7% vs. 61.3% p=0.255; DFS 75% vs. 50% p=0.148) and LNs negative groups (OS 100% vs. 85.7% p=0.149; DFS 100% vs. 85.7% p=0.376). In patients not receiving chemotherapy, MSI/intestinal-type had the highest OS and DFS (77% and 87.5%), whereas MSS/mixed-type group had the poorest (25% and 100%)(p=0.024 and p=0.290). With chemotherapy, MSI/intestinal-type had the highest OS and DFS (100% and 100%), whereas MSS/mixed-type group had the poorest (66.7% and 50%)(p=0.741 and p=0.397, respectively).

Conclusions: MSI GCs have a significantly lower risk of locoregional lymph node involvement and better OS and DFS compared to MSS tumors. Secondly, treatment responses diverge based on MSI status: patients with MSI tumors benefit more from upfront surgical interventions, while those with MSS, particularly mixed histotypes, demonstrate improved outcomes with preoperative chemotherapy. These results advocate for a tailored therapeutic approach that considers microsatellite status, Lauren classification as well as clinical conditions of patients.

Background: Acute and chronic pancreatitis (AP and CP) has a high incidence and poor prognosis. The early screening of at-risk populations still awaits further study. The limitation was mainly based on observational studies, with limited sample size and the presence of confounding factors. We used a two sample MR analysis based on publicly available data from Genome-Wide Association Studies (GWAS) to reveal the causal impact of gut microbiota and metabolites on pancreatitis.

Methods: This study collected summary statistics regarding gut microbiota, metabolites, AP, and CP. Two-sample Mendelian randomization analysis was performed using MR-Egger, inverse variance weighted (IVW), MR-PRESSO, maximum likelihood, and weighted median.

Results: Two sample Mendelian randomization showed that only Eubacterium coprostanoligenes was an independent protective factor for AP among all gut microbiota, and the other microbiota were not significant for pancreatitis. Unsaturated fatty acids in metabolites are protective factors for both AP (OR=0.730, 95% Cl: 0.593-0.899, P = 0.003) and CP (OR=0.660, 95% Cl: 0.457-0.916, P = 0.013). Furthermore, carnitine was a protective factor but glucose was an independent risk factor for CP.

Conclusions: This study provides for the first-time potential evidence which is the causal role of gut microbiota and metabolites on pancreatitis, which may be conducive to design microbiome and metabolite interventions on AP or CP in profound study in the future.

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) is the major complication of pancreatoduodenectomy, and the pancreatic texture is one of the potential affecting factors. Multi-frequency Magnetic Resonance Elastography (MRE) is a novel technique for measuring stiffness of tissue, while its value in predicting CR-POPF preoperatively has not been well-documented.

Method: Seventy patients who underwent multi-frequency MRE before pancreatoduodenectomy between July 2021 and April 2024 were retrospectively recruited into the study. The parameter of MRE, shear wave speed (c) and phase angle (φ), and clinical data were collected. Logistic regression and the receiver operating characteristic curve (ROC) analyses were used to assess the performance of multi-frequency MRE in predicting CR-POPF.

Results: CR-POPF was developed in 14 out of 70 patients (20%), all categorized as Grade B. CR-POPF group had significantly lower c (1.339±0.210m/s) and longer hospital stays (21±22days) than no CR-POPF group. The MRE parameters, c and φ were moderately correlated with pancreas stiffness (eta² for φ =0.189, eta² for c =0.106). Dilated major pancreatic duct (MPD) (≥3mm) and higher c were independently associated with lower risk of CR-POPF in univariant and multivariant analysis (odds ratio for c = 0.041, 95%CI: 0.002~0.879, odds ratio for dilated MPD: 0.129, 95%CI: 0.022~0.768). The AUC of the predictive model based on c and MPD diameter was 0.786, which was better than Fistula Risk Score (FRS) (AUC=0.587) and alternative Fistula Risk Score (a-FRS) (AUC=0.556) in our center, with DeLong's test p= 0.028 and p=0.002 respectively.

Conclusion: The MRE parameters were associated with pancreatic stiffness, and c was an independent predictor for CR-POPF after pancreatoduodenectomy.

Background: Approximately 15-20% of patients with duodenal or periampullary malignancies develop GOO. While small, randomized trials have reported more rapid recovery and shorter hospital stay with ES, limited studies have evaluated outcomes on a national level. The present study characterized short-term clinical and financial outcomes associated with gastrojejunostomy (GJ) versus endoscopic stenting (ES) in malignant gastric outlet obstruction (GOO).

Methods: Adults with malignant GOO treated with ES or GJ were identified in the 2016-2020 Nationwide Readmissions Database. Entropy balancing was used to balance covariates between groups, and multivariable regression was used to evaluate the association between GJ or ES and in-hospital mortality, total parenteral nutrition (TPN) use, complications, length of stay (LOS), costs, and 90-day readmission.

Results: Of 8,186 GOO patients, 68.4% underwent ES and 31.6% GJ. The cohorts were similar in age, sex, and comorbidities, while GJ patients were more commonly frail. After risk adjustment, mortality, composite complications, and 90-day readmission were comparable between GJ and ES. GJ was associated with greater odds of blood transfusion (AOR 1.74 [95% CI [1.37-2.21]) and postoperative TPN use (AOR 3.76 [95% CI 2.64-5.35]). Furthermore, GJ patients experienced a significant increment of +$15,800 in costs and +6.9-day in LOS. On subgroup analysis of patients with metastatic disease, mortality, complications, and readmission remained comparable between palliation strategies.

Conclusions: ES appears to yield comparable short-term morbidity and mortality relative to GJ with significant cost reduction. Increasing access to endoscopic technology and regionalizing care to high-volume centers may help improve outcomes for patients with malignant GOO.

Background: Prophylactic total gastrectomy (PTG) is performed in carriers of CDH1 pathogenic and likely pathogenic (P/LP) variants and is becoming more frequent with broader use of germline genetic testing. There is an unmet need to standardize care and enhance outcomes among patients undergoing surgery for the prevention of gastric cancer.

Methods: This was a retrospective analysis of 150 individuals with germline CDH1 P/LP variants who underwent PTG as part of a prospective natural history study from October 2017 to May 2023. All individuals received multidisciplinary, protocolized care before and after total gastrectomy.

Results: A total of 150 asymptomatic patients with germline CDH1 P/LP variants underwent PTG with the aid of a multidisciplinary enhanced recovery after surgery (ERAS) pathway. This study demonstrated that acute major morbidity (Clavien-Dindo grade of ≥3) was low (17/150 [11.3%]) and that the most common complication was anastomotic leak (11/150 [7.3%]) in the setting of a comprehensive preoperative and postoperative care pathway. Nearly all gastrectomy specimens (132/150 [88.0%]) harbored occult signet ring cell lesions on final pathology. There were no gastric cancer recurrences or gastric cancer-related deaths during the study period, with a median overall follow-up of 36 months (IQR, 24-48) from gastrectomy.

Conclusion: PTG can be performed with low surgical morbidity in a high-volume center. The delivery of patient-centered care by a multidisciplinary team and the application of an ERAS pathway may improve short-term outcomes. However, interventions that can reduce chronic morbidity associated with total gastrectomy warrant further study.