Langenbeck's Archives of Surgery最新文献

Purpose: Low intraabdominal pressure (IAP) during laparoscopy is associated with improved post-operative outcomes across a variety of surgical specialties. A prospective cohort study was undertaken to assess post-operative outcomes in patients undergoing laparoscopic colorectal surgery (LCRS) with low (8mmHg) versus conventional (15mmHg) IAP.

Methods: A prospective real-world observational study of patients undergoing LCRS in a single-centre, between June 2020 and June 2023 was performed. Operative procedures for diverse colonic pathology such as diverticular disease, inflammatory bowel disease (IBD), and colorectal cancers (CRC) were included. The evaluated primary outcomes were post-operative pain, return of gastrointestinal motility, and length of hospital stay. Secondary outcomes were the overall safety profile including intra- and post-operative complications and morbidity. Outcomes of interest were investigated using multivariate analysis.

Results: A total of 120 patients were included of which 69 (57.5%) were male. Median age and BMI of the cohort was 67 years (51-75 years) and 27 kg/m² (24-32 kg/m²), respectively. 61 (50.8%) patients were categorised as an ASA grade 3. Two (1.7%) patients had diverticular disease; 31 (25.9%) had IBD, and 87 (72.4%) were operated on for colonic malignancy. Low IAP (8mmHg) was used in 53 (44.2%) cases, whilst the remainder (55.8%) had IAP set at 15mmHg (conventional). Low-pressure surgery was associated with improved intraoperative lung compliance (p < 0.001) and peak inspiratory pressures up to 6 h (p < 0.001); reduced analgesic requirement (p ≤ 0.028), and decreased postoperative pain both at rest (p = 0.001) and on exertion (p < 0.001). Moreover, low IAP was associated with an earlier time to pass flatus postoperatively (p = 0.047) with no significant difference in length of hospital stay (p = 0.574). Additionally, no significant difference was observed between the groups for outcomes including median operating time (p = 0.089), conversion to open surgery (p = 0.056), overall complication rate (p = 0.102), and 90-day mortality (p = 0.381).

Conclusion: Low IAP use during LCRS is feasible with a comparable safety profile to conventional laparoscopy. Intra-operative respiratory physiology is improved with reduced postoperative pain and analgesic requirement, and earlier time to pass flatus. Future rationally designed; well-powered, randomised trials are needed to understand the benefits of low intra-peritoneal pressure during laparoscopic colorectal resections.

Objective: This study aims to evaluate the therapeutic effectiveness of totally endoscopic thyroidectomy via the completely submental tri-hole approach and transoral endoscopic thyroidectomy without insufflation.

Methods: A total of 60 patients with thyroid tumors who were admitted to Panyu College Affiliated Hospital from August 2022 to August 2023 were collected in this study. The patients were divided into two groups, the transoral endoscopic thyroidectomy group (20 cases) and the totally endoscopic thyroidectomy via the completely submental tri-hole approach group (40 cases). Then, we evaluated the difference of surgical data, operative details, postoperative complications, duration of postoperative swelling, cosmetic satisfaction, discomfort during eating, and pain scores between two groups.

Results: There were no significant differences between two groups in terms of operation time, intraoperative blood loss, postoperative drainage, extubation time, length of hospital stay, autotransplantation of parathyroid glands, or postoperative swelling. And neither group experienced voice hoarseness, postoperative bleeding, or lymphatic leakage. The incidence of hypocalcemia did not differ significantly between two groups, although the transoral endoscopic thyroidectomy group had a significantly higher incidence of chin numbness (p<0.01). Futhermore, there was no obvious differences in neck pain scores or cosmetic satisfaction scores at 3 days, 7 days, 2 weeks, and 1 month postoperatively. However, the discomfort during eating score was markedly lower in the totally endoscopic thyroidectomy group compared to the transoral endoscopic thyroidectomy group (P < 0.05).

Conclusion: Totally endoscopic thyroidectomy via the completely submental tri-hole approach offers advantages in reducing postoperative discomfort during eating compared to transoral endoscopic thyroidectomy, indicating promising prospects for clinical application.

Background: Laparoscopic total gastrectomy (LTG) is still limited because intracorporeal oesophagojejunostomy is technically demanding and difficult in laparoscopic gastrectomy. Circular-stapled anastomosis is considered the "gold standard" method for oesophagojejunostomy in open total gastrectomy. A purse-string suture instrument is used to create a purse-string suture along the distal oesophagus as a standard technique for classic circular-stapled oesophagojejunostomy in the open total gastrectomy. However, a simple and optimal laparoscopic purse-string suture device or instrument with an appropriate and optimal tube in the abdomen remains to be developed as a standard procedure for simple intracorporeal oesophagojejunostomy.

Study design: Between May 2023 and October 2023, a new laparoscopic purse-string suture clamp (Lap-PSC) and multi-functional seal cap (MSC) were applied to obtain a simple intracorporeal circular-stapled oesophagojejunostomy after laparoscopic total gastrectomy in 21 patients with gastric cancer in our hospital. The surgical details and postoperative outcomes were analyzed to evaluate this method.

Results: The mean operation time was 203.8 ± 39.1 min. The mean time for the purse-string suture was 6.6 ± 2.8 min. An average of 13 min was required for purse-string creation and anvil placement. Tumor-free margins were obtained in 21 patients, with a median proximal margin length of 2 cm (range, 1.5-5 cm). Four postoperative complications occurred in this study. There was no mortality. During the median follow-up periods of 11 months, no anastomosis-related complications were observed.

Conclusions: The standardized single-stapling end-to-side oesophagojejunostomy in open surgery can be easily and safely performed during LTG using both Lap-PSC and MSC. The procedure using Lap-PSC with MSC may be considered as a better procedure to option in LTG.

Background/objectives: The oncological importance of lymphatic, microvascular, and perineural invasions and their association with outcomes in patients with non-functioning pancreatic neuroendocrine neoplasm (NF-PanNEN) remains unclear. We aimed to investigate the role of these factors in the prognosis of patients with NF-PanNEN.

Methods: We retrospectively analyzed 115 patients who underwent curative resection and were pathologically and clinically diagnosed with NF-PanNEN. We evaluated the relationship between clinicopathological factors and recurrence.

Results: Thirty (26%), 38 (33%), and 11 (10%) patients had lymphatic, microvascular, and nerve invasions, respectively. Twenty-one patients (18%) experienced recurrence, with a median time to recurrence of 2.6 years (range: 0.3-8.2). The 3-, 5-, and 10-year recurrence-free survival (RFS) rates were 88.3%, 84.4%, and 79.1%, respectively. In multivariate analyses, World Health Organization Grade G2-3 (vs. G1, hazard ratio (HR): 16.2), T factor T3-4 (vs. T1-2, HR: 5.2), and the presence of microvascular invasion (vs. absence, HR: 5.6) were significant risk factors for RFS. When these risk factors were assigned as risk score of three, one, and one points depending on the HR, the 5-year recurrence rates in patients with risk score groups 0-1 and 2-5 were 98.6% and 53.3%, (P < 0.001). Moreover, only the presence of microvascular invasion significantly increased the likelihood of recurrence within 3 years.

Conclusions: The presence of microvascular invasion is an independent risk factor for recurrence in patients with NF-PanNEN. Our risk scoring system, which includes "the presence of microvascular invasion," may be useful for predicting recurrence.

Purpose: Oligometastatic gastroesophageal cancer is a clinical entity with no standard treatment recommendation. Treatment with curative intent has recently emerged as an option for selected patients in contrast to the traditional palliative treatment strategy. This prospective study aimed to assess the safety and efficacy of combined systemic and local treatment with curative intent for patients with oligometastatic gastroesophageal cancer.

Methods: In a multicenter study, consecutive patients with gastroesophageal cancer and metastases in the liver and/or extra-regional lymph nodes were screened for inclusion. Eligible patients were offered curatively intended perioperative chemotherapy followed by surgical resection or liver ablation. Primary endpoints were treatment safety and feasibility. Secondary outcomes included postoperative mortality, treatment response, progression-free survival, and overall survival. Subgroup analyses were stratified based on oligometastatic location.

Results: A total of 29 (82.9%) patients completed treatment with surgical resection (93.1%), liver ablation (3.4%), or definitive chemoradiotherapy (3.4%). Postoperative complications were found in 19 (73.1%) patients, whereas postoperative mortality was 0%. The most common complications included infection (34.6%) and respiratory complications (34.6%). Median overall survival was 20.9 months (interquartile range 11.2-42.6) from diagnosis and 17.0 months (interquartile range 6.4-35.9) from surgery in patients who were treated with neoadjuvant chemotherapy followed by surgery. Median progression-free survival was 5.8 months (interquartile range 3.1-11.3).

Conclusion: This study found curative treatment to be a relatively safe option, with an overall survival of 20.8 months and no postoperative mortality.

Purpose: Recently, several investigators have focused on the clinical significance of osteosarcopenia in malignancies; however, its prognostic impact on patients with gastric cancer after conversion surgery (CS) remains unclear. Therefore, we aimed to investigate sarcopenia, osteopenia, and osteosarcopenia in this patient population.

Methods: We retrospectively analyzed 24 patients with gastric cancer who underwent CS. Before CS, the skeletal muscle index at the L3 vertebra and bone mineral density at the Th11 vertebra were measured to investigate sarcopenia and osteopenia, respectively. Osteosarcopenia was defined as the coexistence of sarcopenia and osteopenia. The relationship between perioperative osteosarcopenia and patient prognosis, including clinicopathological factors, was assessed.

Results: Among the 24 patients, 10 (42%) had osteosarcopenia. Osteosarcopenia was significantly correlated with body mass index, depth of tumor invasion, and tumor stage (all p < 0.05). The median overall survival and disease-free survival after CS in patients with osteosarcopenia were significantly shorter than those in patients without osteosarcopenia (all p < 0.05). In the multivariate analysis, osteosarcopenia was identified as an independent factor related to overall survival alone (p = 0.04).

Conclusion: Assessment of osteosarcopenia has clinical utility in predicting the prognosis after CS in patients with stage IV gastric cancer after chemotherapy.

Purpose: The dynamics of postoperative carcinoembryonic antigen (CEA) in pancreatic ductal adenocarcinoma (PDAC) patients have not been well assessed. This study investigated the correlation between postoperative CEA elevations and tumor recurrence.

Methods: Medical records were retrospectively analyzed for 84 patients who received curative resection for PDAC from January 2019 to December 2020. Postoperative CEA levels were monitored for a minimum of 12 months. False-positive CEA elevation was defined as a CEA level exceeding 5 ng/mL without evidence of recurrence in imaging studies.

Results: Of the examined patients, 59 (70%) exhibited CEA > 5 ng/mL within the observation period. The sensitivity and specificity of elevated CEA levels for detecting recurrence were 84% and 41%, respectively. CEA elevations without tumor recurrence were observed in 27 patients, indicating a false-positive rate of 59%. More than half of these patients demonstrated peak CEA levels between 5 and 10 ng/mL, while only true-positive patients exhibited CEA levels exceeding 40.0 ng/mL.

Conclusion: CEA may rise in more than half of postoperative PDAC patients without recurrence. CEA alone is not a robust postoperative marker.

Importance: There is conflicting evidence regarding weekday dependent outcome in complex abdominal surgery, including pancreatic resections.

Objective: To clarify weekday-dependency of outcome after pancreatic resections in a comprehensive nationwide context.

Design: Retrospective cross-sectional study of anonymized nationwide hospital billing data (DRG data).

Setting: Germany between 2010 and 2020. PARTICIPANTS AND EXPOSURE: all patient records with a procedural code for a pancreatic resection.

Main outcome and measures: Primary endpoint was complication occurrence and failure to rescue, i.e. mortality in case of complications, by weekday of index surgery.

Results: 94,661 patient records with a pancreatic resection were analyzed, of whom 45.2% were female. Mean age was 65.3 years. In 46.3% of all patient records, the main diagnosis was pancreatic carcinoma. The most common index surgery was pancreaticoduodenectomy (61.2%). Occurrence of at least one of predefined complications was 67.6% (64,029 cases) and was highest following a Monday index surgery. In-hospital mortality in case of at least one complication, i.e. failure to rescue (FtR), accounted for 8,040 deaths (97.7% of 8,228 total deaths, 12.6% FtR, 8.7% in-hospital mortality). FtR was highest (13.1%) following a Monday index surgery and lowest (11.8%) after a Thursday index surgery. Overall in-hospital mortality followed the same trend as FtR. In a multivariable logistic regression, in the overall cohort, in addition to increased age, frailty, male sex, benign entities, and total pancreatectomy performance, Wednesday (adjusted Odd's Ratio, OR, 0.92, 95% Confidence Interval, CI, 0.85-0.99) and Thursday (adjusted OR, 0.89, CI, 0.82-0.96) index surgeries were associated with lower FtR in reference to Monday. Stratified by patient volume, complication occurrence and FtR was only dependent of the weekday of index surgery in low volume hospitals.

Conclusions and relevance: Pancreatic resections are complex procedures with high complication rates and FtR, resulting in high in-hospital mortality. Complication occurrence and FtR is dependent on the weekday of index surgery and mediates the same distribution pattern for overall in-hospital mortality. Stratified by patient volume, this weekday dependency of the index surgery on complication occurrence and FtR was only observed in low volume hospitals.

Introduction: To explore whether neoadjuvant Sintilimab is suitable for patients with gastroesophageal junction (GEJ) adenocarcinoma, we designed this study to evaluate the short-term efficacy and safety of neoadjuvant Sintilimab in combination with chemotherapy for resectable GEJ adenocarcinoma.

Methods: We retrospectively collected data on patients with GEJ adenocarcinoma who underwent surgery after receiving neoadjuvant immunotherapy combined with chemotherapy at Jining First People's Hospital between October 2020 and October 2023. The primary endpoint was complete pathological response (pCR) rate; secondary endpoints: major pathological response (MPR) rate, neoadjuvant therapy-related adverse events (AES), the safety of surgery, Postoperative Complications, and overall survival (OS).

Results: 24 eligible patients were enrolled in the study and achieved a pCR rate of 16.7%. The treatment-related AES was manageable. The median time interval between the end of neoadjuvant therapy and surgery was 35 days (28-81 days), R0 resection rate was 100%. The most common postoperative complications in the study were pneumonia (n = 11, 45.8%). Median follow-up was 13.5(interquartile range: 8.00, 25.50) months, Kaplan-Meier survival analysis showed median OS was not reached.

Conclusions: It was safe and effective for resectable GEJ adenocarcinoma to undergo neoadjuvant Sintilimab combined with chemotherapy followed by surgery, and long-term efficacy needs to be confirmed by further follow-up.

Purpose: The clinical significance of lymph node dissection (LND) in patients with peripheral type intrahepatic cholangiocarcinoma (ICC) remains unclear. Although LND is usually performed for perihilar type ICC, there is no consensus on whether routine LND should be performed for peripheral type ICC. This study aimed to investigate the prognostic significance of LND in patients who underwent hepatectomy for peripheral type ICC.

Methods: This study included consecutive patients who underwent macroscopically curative initial hepatectomy for ICC at our hospital from 2000 to 2018. Among them, peripheral type ICCs with the macroscopic appearance of mass-forming (MF) or MF + periductal infiltrating (PI) types were analyzed. Propensity score analyses (1:1 matching and inverse probability treatment weighting) were adopted to adjust confounding variables. Overall survival (OS) and disease-free survival (DFS) were compared between the LND and no LND (NLND) groups.

Results: During the study period, 201 patients underwent hepatectomy for ICC. The number of peripheral ICC patients with MF type or MF + PI type was 142. The LND group comprised 94 patients and the NLND group comprised 48 patients. The N1 group showed significantly poorer OS and DFS than the N0 and NLND groups (P < 0.001). After propensity score adjustment, there were no significant differences in OS and DFS between the LND and NLND groups.

Conclusions: The prognostic impact of lymph node metastasis was significant; however, the therapeutic effect of LND was not demonstrated in peripheral type ICC. The indication of LND should be carefully considered on an individual patient basis.