Langenbeck's Archives of Surgery最新文献

Background: Due to the complex anatomical structure surrounding the basilar artery trunk, basilar trunk aneurysms (BTAs) can result in severe complications and poor prognosis for patients. The treatments for BTAs still remain challenging and uncertain.

Methods: We conducted a comprehensive search of Embase, MEDLINE, Cochrane Library databases using medical subject headings and free-text terms, with the last search completed on July 1st, 2024. Both single-arm and two-arm meta-analysis were performed to compare the safety and effectiveness of different treatments for BTAs. Both fixed-effects models and random-effects models were calculated. When the heterogeneity was over 50%, we chose the random-effects model.

Results: We identified 21 studies enrolling 593 participants and 599 aneurysms. The summary favorable outcome proportion was 0.46 (95% CI: 0.303 to 0.625) for open surgery and 0.75 (95% CI: 0.671 to 0.819) for endovascular treatments in the random-effects model, as the I² for heterogeneity was 66% (P < 0.01) for open surgery and 53% for endovascular treatments (P < 0.01). Significant differences were observed between the two subgroups in the single-arm meta-analysis (P < 0.01). In the direct comparisons of good outcomes between open surgery and endovascular treatments in BTAs, no statistically significant difference was observed. The relative risk (RR) was 0.82 (95% CI: 0.549 to 1.224) and the P value was 0.5226. The comparison revealed no statistically significant changes in mortality, complications and complete occlusion (P > 0.05).

Conclusion: No statistically significant difference was observed between the open surgery and endovascular treatments. The mortality and complication outcomes revealed no distinctions between the two subgroups, regardless of whether direct or indirect comparisons was conducted. The influence of institutional expertise emerged as a critical factor in treatment outcomes. Furthermore, more effective controls and larger sample size are required to achieve more credible and conclusive results.

Background: Intraoperative hypotension is associated with a postoperative decline in renal function, and the effect of personalized blood pressure control on renal function remains unknown. The aim of this study was to investigate the effects of individualized intraoperative blood pressure management on renal function and serum microRNA-21-5p levels in older patients with hypertension after major gastrointestinal surgery.

Methods: A total of 220 patients scheduled for elective major gastrointestinal surgery were randomly divided into two groups: conventional blood pressure management (Group C) and individualized blood pressure management (Group S), with 110 patients in each group. In Group S, blood pressure was controlled within ± 10% of baseline systolic blood pressure or ± 20% of baseline mean arterial pressure. Moderately open fluid management strategies were adopted in both groups. Blood samples were collected from all patients before and after surgery to measure creatinine and microRNA-21-5p levels.

Results: The creatinine level was significantly lower in Group S than in Group C 7 days after surgery (P < 0.05), and the reduction in creatinine levels in the week following surgery was also significantly greater in Group S than in Group C (P < 0.05).

Conclusion: Intraoperative individualized blood pressure management could reduce the release of microRNA-21-5p related to renal injury and attenuate the increase in postoperative creatinine levels in older patients with hypertension.

Background: This study aimed to determine the optimal screw length in Le Fort I osteotomy and to evaluate its specific relationship with postoperative nasal mucosal thickening.

Materials and methods: This retrospective study analyzed 37 patients who underwent Le Fort I osteotomy, either in isolation or in combination with mandibular surgery. Postoperative CT scans were utilized to measure screw lengths and bone widths. Postoperative complications, including maxillary mobility, mucosal thickening, and epiphora due to iatrogenic injury to the nasolacrimal duct, were recorded and analyzed.

Results: The study population consisted of 25 female and 12 male patients, with a mean age of 26.49 ± 6.75 years. Among the 592 screws analyzed, 530 (89.5%) exceeded the optimal length, while only 62 (10.5%) met the recommended criteria. Statistical analysis revealed a significant difference in bone thickness between the piriform and zygomatic buttress regions (p < 0.001). No statistically significant difference in bone thickness was found between males and females. However, there was a significant association between excessive screw length and the occurrence of postoperative mucosal thickening (p = 0.033).

Conclusion: Accurate screw length selection is crucial for reducing postoperative mucosal thickening. A 5 mm screw length may provide stable fixation while reducing the risk of sinus mucosal thickening, potentially contributing to improved surgical outcomes and patient satisfaction.

Purpose: Patients undergoing major emergency abdominal surgery are often elderly with multiple comorbidities and previous abdominal operations, contributing to procedural complexity. Factors such as adhesions increase technical challenges, potentially influencing postoperative recovery. This study examined how objectively defined intraoperative complexity markers are associated with postoperative morbidity and mortality in this high-risk cohort.

Methods: In a prospective cohort of 754 consecutive patients undergoing major emergency abdominal procedures, we investigated three indicators of intraoperative complexity: iatrogenic injury, blood loss ≥ 750 mL, and operative duration ≥ 2.5 h. A composite variable incorporating all three was also created to reflect overall complexity. We analyzed associations with postoperative outcomes, including complication severity, length of stay (LOS), reoperations, and mortality.

Results: At least one complexity marker was observed in 32% of patients. Bleeding ≥ 750 mL and prolonged operative time each independently increased the likelihood of extended hospitalization by 23.0 and 22.1% points, respectively. Iatrogenic injuries were identified in 14% and correlated with longer LOS and increased reoperations. Although complexity markers were consistently linked to higher morbidity, including elevated Comprehensive Complication Index scores, reoperations, and prolonged LOS. No significant association with mortality was observed.

Conclusion: Intraoperative complexity is frequent in major emergency abdominal surgery and is closely associated with postoperative morbidity and healthcare utilization. Bleeding exceeding 750 mL and operative time over 2.5 were the strongest associations with postoperative morbidity. These findings provide a pragmatic framework for quantifying surgical complexity and may inform future work on preoperative risk stratification and resource planning. The observed dissociation between morbidity and mortality may reflect improved perioperative care and patient selection, but should be interpreted cautiously given the limited number of deaths.

Purpose: Hepatic arterial anomalies are commonly encountered during pancreaticoduodenectomy. However, their impact on perioperative outcomes in robotic pancreaticoduodenectomy (RPD) remains unclear.

Methods: We retrospectively analyzed 79 consecutive patients who underwent RPD. Hepatic arterial anatomy was classified according to the systems of Michels and Hiatt. Perioperative outcomes were compared between patients with hepatic arterial variants and those with normal anatomy.

Results: Hepatic arterial anomalies were identified in 22 patients (27.8%). According to Hiatt's classification, 57 patients (72.2%) had normal type I anatomy, while type II and III variants were observed in 4 (5.1%) and 9 (11.4%) patients, respectively. Two patients exhibited type IV variants with both replaced right and left hepatic arteries. Data are presented in the order of absence and presence of arterial anomalies. Median age was similar (72 vs. 73 years, P = 0.86), with no difference in sex distribution (P = 0.25). Operative time (549 vs. 586 min, P = 0.92), blood loss (73 vs. 50 mL, P = 0.49), rates of clinically relevant postoperative pancreatic fistula (5.3% vs. 4.5%, P = 0.69), postoperative bleeding(0% vs. 4.5%, P = 0.27), pseudoaneurysm hemorrhage (5.3% vs. 0%, P = 0.55), and major complications (Clavien-Dindo grade ≥ 3a) (8.8% vs. 9.0%, P = 0.63) did not differ significantly.

Conclusion: The presence of hepatic arterial anomalies did not adversely affect perioperative outcomes in patients undergoing RPD. These findings suggest that, with appropriate preoperative planning and meticulous surgical technique, RPD can be performed safely in selected patients with hepatic arterial variants at experienced centers.

Background: One of the most common and significant complication of acute diverticulitis is visceral perforation. Current clinical guidelines suggest conservative medical therapy can be adopted for selected patients with perforation, especially those with pericolic air, while its role remains less clear in cases of distant air. The aim of our study is to evaluate the role of non-operative management (NOM) in case of pericolic and distant air.

Materials and methods: The authors conducted a comprehensive literature review; this search yielded 23 studies (17 retrospective, 5 prospective and 1 randomized control trial), including 2689 patients.

Results: Conservative management of patients with air in perforated diverticulitis was safe and feasible, with a overall pooled success rate of 90.2% (95% CI: 86.4-93). Specifically, among patients with pericolic extraluminal air, the success rate of NOM was 89.9%. In contrast, the role of NOM in cases with distant free air remains uncertain, with a lower success rate of only 27.8%.

Conclusion: Non-operative management (NOM) appears safe and effective for patients with perforated diverticulitis and pericolic extraluminal air, provided there are no clinical signs of generalized peritonitis. In contrast, its role in cases with distant free air is highly uncertain: the pooled success rate is lower, even among hemodynamically stable patients. Based on these findings, early surgical management should be strongly considered for patients with distant free air, while NOM should only be attempted in highly selected cases under strict clinical and radiological monitoring. Conversely, NOM can be confidently recommended for patients with pericolic air who are stable and without diffuse peritonitis.

Purpose: To evaluate the impact of extended versus nonextended perioperative antibiotic prophylaxis (PAP) on reducing postoperative complications and hospital stays in patients undergoing radical cystectomy and urinary diversion.

Methods: We conducted this systematic review and meta-analysis in accordance with the PRISMA guidelines. A comprehensive literature search was conducted across PubMed, Scopus, Web of Science, and the Cochrane Library for studies comparing short-term (≤ 24 h) and extended (≥ 24 h) PAP in patients undergoing radical cystectomy and urinary diversion. The primary outcomes were surgical site infections (SSIs), urinary tract infections (UTIs), and length of hospital stay. The statistical analysis was performed via RevMan version 5.3. The results are presented as risk ratios (RRs) and mean differences (MDs). Results are presented as risk ratios (RRs) and mean differences (MDs). The quality of evidence was assessed using the GRADE methodology.

Results: A total of 214 studies were screened. Four studies involving 680 patients were included. No significant differences were detected between short-term and extended PAP in terms of SSIs (RR = 0.71 [95% CI 0.43-1.17]; P = 0.18]), febrile UTIs (RR = 1.19 [95% CI 0.91-1.56]; P = 0.20]), or length of hospital stay (MD = 0.76 days [95% CI [-2.72, 4.25]; P = 0.67]).

Conclusion: No significant difference was observed between 24-h and extended PAP for reducing postoperative complications after radical cystectomy and urinary diversion. Short-term PAP is a reliable and effective strategy and is recommended as the standard practice for reducing antimicrobial resistance and improving postoperative outcomes.