Journal of Gastrointestinal Surgery最新文献

Surgical resection of a colorectal adenocarcinoma remains a cornerstone in its treatment. Yet, despite proper patient selection and neoadjuvant and/or adjuvant chemotherapy/radiation, up to 30% of patients thought to be cured will develop a postoperative recurrence. Unfortunately, the outcomes in patients who develop a postoperative recurrence are poor and are associated with high morbidity and mortality. The gut microbiome has emerged to play a role in virtually all aspects of human health. In this manuscript, we critically examine the current literature implicating the gut microbiome's role in the pathogenesis of postoperative recurrence following attempted curative resection. We discuss how microbes can drive a more advanced stage and explore how surgery itself can precipitate a gut microenvironment with tumorigenic bacteria and bacterial derived metabolites that can drive postoperative tumor formation. Finally, we review evidence as to how the gut microbiome can be manipulated to improve oncological outcomes.

Background: Circulating tumor DNA (ctDNA) has been used to diagnose and monitor response to therapy in the setting of advanced pancreatic ductal adenocarcinoma (PDAC), but its utility in the adjuvant setting to monitor for relapse following curative resection is less understood.

Materials and methods: In this single-institution, retrospective study, we evaluated use of ctDNA during the post-operative window (within 90 days from surgical resection and 30 days from start of adjuvant therapy) and subsequent adjuvant/surveillance window (after post-operative window) as prognostic biomarkers for relapse. We compared demographic and clinical characteristics among patients with radiographic disease relapse based on ctDNA positivity.

Results: We identified 51 patients with PDAC who underwent curative-intent surgical resection between 2013-2024 and completed post-operative ctDNA testing. Median follow-up was 635 days and n=28 (54.9%) patients experienced disease relapse. ctDNA during the post-operative window had a sensitivity of 35.7% and specificity of 88.9% for prognosticating disease relapse following resection, with a positive predictive value (PPV) of 79.6% and negative predictive value (NPV) of 53.2%. ctDNA during the adjuvant/surveillance window had a sensitivity of 62.5%, specificity of 95.5%, PPV of 94.4%, and NPV of 67.7%. Patients with disease relapse as liver metastases had the highest rate of ctDNA positivity (n=10/12, 83.3%) followed by resection bed recurrence (n=4/7, 57.1%) and non-liver distant metastatic recurrence (n=4/9, 44.4%).

Conclusion: Positive ctDNA is a strong prognostic factor for relapse following resection for PDAC, however ctDNA testing lacks sensitivity to replace conventional surveillance testing in patients with resected PDAC.

Background: Stereotactic body radiation therapy (SBRT) is increasingly used in neoadjuvant chemoradiotherapy (NCRT) for borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PC), but head-to-head data versus conventionally fractionated radiation therapy (CFRT) remain limited. We compared clinical and pathological outcomes of SBRT vs. CFRT in BR/LA PC.

Methods: We retrospectively analyzed 312 patients with BR/LA PC who received NCRT followed by R0/R1 surgery at three high-volume academic centers (2011 - 2021). To reduce selection bias, 1:1 propensity score matching (PSM) was applied based on baseline clinical variables. Primary outcome was overall survival (OS), and secondary outcome was clinical and pathological response to NCRT.

Results: Of 312 patients, 177 (56.7%) received SBRT and 135 (43.3%) received CFRT. Before PSM, significant differences were observed in patient age, neoadjuvant chemotherapy (NAC) regimen, and duration of the preoperative interval. After PSM, 180 patients were matched, with no significant differences in pretreatment variables between groups. Clinical and pathological outcomes were similar between the matched cohorts, including complete/near-complete pathological response rates (36.7% vs. 45.6%, P=.56), node-positive disease (32.2% vs. 36.7%, P=.53), and R0 resection rates (80.0% vs. 82.2%, P=.70). Median OS was not significantly different (27.2 vs. 40.6 months, P=.70). Patients in the SBRT cohort were more likely to receive adjuvant therapy compared with those in the CFRT cohort (60.0% vs. 38.9%, P=.007). In subgroup analyses restricted to patients treated with neoadjuvant FOLFIRINOX, SBRT was associated with a significantly longer OS among those presenting with markedly elevated pretreatment CA19-9 levels (≥1500U/mL) (29.8 vs. 12.1 months, P=.02).

Conclusions: Neoadjuvant SBRT achieves oncologic outcomes comparable to CFRT in BR/LA PC and is associated with greater adjuvant therapy use. A potential survival signal for SBRT in patients receiving FOLFIRINOX with CA19-9 > 1500U/mL is hypothesis-generating and warrants validation and formal interaction testing.

Introduction: The "difficult gallbladder" in acute cholecystitis can preclude safe achievement of the critical view of safety, prompting subtotal cholecystectomy (STC) as a guideline-supported bailout. We performed a contemporary synthesis to clarify STC's safety effectiveness trade-offs versus total cholecystectomy (TC) and to delineate technique-specific outcomes and patient factors that may influence risk.

Methods: We conducted a systematic review and meta-analysis of studies from 2010-June 2025. Three comparisons were evaluated: (1) single-arm outcomes after STC, (2) STC versus TC, and (3) fenestrating (f-STC) versus reconstituting (r-STC) STC. Random-effects models were applied, with prespecified subgroup analyses, leave-one-out sensitivity analyses, and exploratory meta-regression.

Results: In single-arm analysis, bile duct injury occurred in 0.3%, bile leak in 13.5%, retained stones in 6.1%, and overall complications in 24.7% of patients. Readmission and reoperation occurred in 17.8% and 6.3%, while mortality was 0.8%. Post-procedure ERCP occurred in 16.2%, and percutaneous drainage in 5.7%. Compared with TC, STC had significantly higher bile leak, retained stones, overall complications, readmission, reoperation, and ERCP, with no significant difference in mortality, ICU admission, or LOS. Meta-regression linked diabetes with higher leak, complications, and ERCP, and male sex with higher SSI. f-STC had significantly higher bile leak and longer LOS than r-STC, with ERCP trending higher.

Conclusions: STC carries a very low bile duct injury rate, but higher postoperative morbidity and secondary interventions compared with TC. r-STC demonstrated superior outcomes to f-STC. Diabetes and male sex were important risk modifiers. STC remains a rational bailout when the critical view cannot be achieved.

Introduction: Management of pregnancy-associated cancers (PACs)-malignancies diagnosed during pregnancy or within one year postpartum-poses unique clinical challenges. Treatment decisions must balance maternal cancer control with fetal safety, yet little is known about how cancer treatment timing varies between pregnant and nonpregnant individuals or how PACs impact obstetric and neonatal outcomes. Understanding these associations is critical to improving care strategies for this vulnerable population.

Methods: We conducted a retrospective cohort study using Epic Cosmos, a large multicenter U.S. electronic health record database. The primary "cancer" cohort included individuals aged 18 to 49 years diagnosed with cancer between January 2018 and December 2022. These individuals were categorized by pregnancy status at diagnosis: gestational PAC, postpartum PAC, or nonpregnant. A secondary "maternal" cohort comprised individuals with viable deliveries during the same period; gestational PAC pregnancies were matched 1:4 with cancer-unexposed pregnancies. Primary outcomes were time from cancer diagnosis to initiation of surgery, radiotherapy, and chemotherapy. Secondary outcomes included 30-day surgical complications, mortality, readmissions, and obstetric and neonatal outcomes such as cesarean delivery, preterm birth, low birth weight, and 5-minute Apgar scores.

Results: Among 38,345 individuals in the cancer cohort (median age, 43 years [IQR, 38-47]), most were White (n=26,594; 71.3%) and married (n=19,230; 51.5%). Gestational PAC was associated with 15% longer time to surgery (aRR, 1.15; 95% CI, 1.13-1.17), 28% longer time to radiotherapy (aRR, 1.28; 95% CI, 1.27-1.29), and 29% shorter time to chemotherapy initiation (aRR, 0.71; 95% CI, 0.70-0.72) compared with nonpregnant controls. Postpartum PAC was associated with 13% shorter time to surgery (aRR, 0.87; 95% CI, 0.86-0.88) and 30% shorter time to chemotherapy (aRR, 0.70; 95% CI, 0.70-0.71). In the maternal cohort, gestational PAC was associated with higher odds of cesarean delivery (aOR, 1.21; 95% CI, 1.04-1.41), preterm birth (aOR, 3.79; 95% CI, 3.15-4.56), low birth weight (aOR, 3.08; 95% CI, 2.50-3.77), and low 5-minute Apgar scores (aOR, 1.86; 95% CI, 1.20-2.82).

Conclusion: Pregnancy-associated cancer was associated with delays in loco-regional treatment and increased maternal and neonatal morbidity, underscoring the need for coordinated multidisciplinary care to optimize outcomes for women with PACs.

Background: Recent literature suggests that volume outcome associations for pancreatectomy have attenuated over time, leading some to question the continued relevance of volume thresholds. However, this perceived attenuation may reflect methodological limitations of single, binary cutoffs rather than a true weakening of the underlying relationship. Stratum specific likelihood ratios (SSLR) generate multiple empirically derived volume strata that may detect persistent gradients that are obscured by binary stratification. The objectives of this study were to (1) define volume strata for pancreatectomy using SSLR (2) assess the robustness of these strata across multiple outcomes and (3) examine whether the association persists in modern cohorts.

Methods: Patients undergoing pancreatectomy from 2004-2021 were identified using the National Cancer Database. Volume strata were defined by SSLR based on 90-day postoperative mortality. Temporal threshold stability was assessed by stratified outcome analysis (chi-squared).

Results: Overall, 61,920 patients underwent pancreatectomy at 982 facilities with a 90-day mortality rate of 5.4%. SSLR analysis yielded six volume strata: ≤3, 4-9, 10-20, 21-47, 48-120, and ≥121 procedures/year with decreasing 90-day mortality (≤3: 11%, 4-9: 7.3%, 10-20: 6.1%, 21-47: 4.2%, 48-120: 3.3%, and ≥121: 2.3%; p<0.001). The optimized threshold of 21 procedures/year was identified based on SSLR. Temporal stratification into five-year periods (2006-2010, 2011-2015, 2016-2020) demonstrated persistent volume outcome associations across volume strata (p<0.001).

Conclusions: SSLR reveals persistent volume outcome associations for pancreatectomy across multiple empirically derived strata, even in contemporary data. These findings suggest that reports of an attenuated volume outcome relationship may reflect limitations of single, static cutoffs rather than true weakening of this association.