Langenbeck's Archives of Surgery最新文献

Background: Malignant biliary obstruction is usually attributed to the enlargement of tumors within or adjacent to the biliary tract, leading to blockage or compression of the bile ducts. Common causes include pancreatic head cancer, bile duct cancer, gallbladder cancer, liver cancer, and metastatic diseases. Most cases have an insidious onset, lack effective early screening methods, and 70% of patients cannot undergo surgical resection, with a 5-year survival rate of about 30%. Therefore, relieving biliary tree obstruction is crucial. Biliary stents often mitigate the obstruction but can be hindered by tumor progression, endothelial hyperplasia, and bile sludge. As a result, new treatment approaches are constantly being explored to improve outcomes for patients with malignant biliary obstruction.

Current situation: One promising technique that has emerged in recent years is radiofrequency ablation (RFA). This innovative method utilizes high-frequency radio waves to generate heat and selectively target tumor cells through localized heating while preserving surrounding healthy tissue. RFA aims to slow tumor growth and enhance biliary stent durability. Studies on endoscopic RFA for malignant biliary obstruction are encouraging. Integrating it with palliative care may better manage symptoms and extend patient quality of life.

Conclusion: In conclusion, while malignant biliary obstruction remains a complex medical challenge with limited treatment options available for some patients, ongoing research into innovative techniques like radiofrequency ablation offers hope for better outcomes in the future. It is crucial for healthcare professionals to stay informed about these advancements and continue exploring new ways to enhance patient care in this difficult clinical scenario.

Background: There is an ongoing debate about the most appropriate method for reconstructing the pancreas after a pancreaticoduodenectomy (PD). This study assessed the impact of pancreaticogastrostomy (PG) with an external pancreatic stent on postoperative outcomes following PD in high-risk patients.

Patients and methods: This study involves a propensity score-matched analysis of high-risk patients who underwent PD with PG reconstruction. The primary outcome measure was the occurrence of Postoperative Pancreatic Fistula (POPF). Secondary outcomes included operative time, intraoperative blood loss, length of hospital stay, re-exploration rate, as well as postoperative morbidity and mortality rates.

Results: The study included 78 patients; 26 patients underwent PD with Pancreatogastrostomy (PG) and an external pancreatic stent, while 52 underwent PG without a pancreatic stent. Blood loss and operative time did not significantly differ between the two groups. The overall postoperative morbidity was higher in the group without a stent than in the stented group (34.6% vs. 15.4%, P = 0.06). No patient in the pancreatic stent group developed a clinically relevant POPF; however, in the non-stented group of PG, 17.3% developed POPF. There were no cases of hospital mortality in the stented group. However, in the non-stented group, two hospital mortality happened (one case was due to the systemic inflammatory response syndrome (SIRS) secondary to POPF grade C, and the other was due to pulmonary embolism.

Conclusion: PG with an external pancreatic stent results in fewer clinically relevant pancreatic fistulas, a decrease in postoperative morbidities, and a non-existent mortality rate in high-risk patients.

Purpose: Postoperative hypoparathyroidism (HypoPT) is one of the most feared complications after thyroid surgery. In most cases, HypoPT is transient, requiring temporary substitution with calcium and active vitamin D. The analysis was conducted to investigate how calcium and vitamin D substitution was managed in routine postoperative clinical practice after discharge from hospital.

Methods: From March 2015 to December 2023, patients with HypoPT after thyroidectomy at the university medical center (UMC) Mainz, were included in a retrospective study. The rate of continued prescription of calcium and vitamin D by external practitioners in relation to the PTH and calcium levels at the first postoperative outpatient visit at the outpatient clinic of the UMC Mainz was analyzed and critically discussed.

Results: Ninety-four of 332 patients (28.3%) were continuously prescribed with calcium/vitamin D supplements: 14 had PTH deficiency and hypocalcemia and 14 had normal/elevated PTH levels with hypocalcemia, 59 had PTH values below the normal range and normo- or hypercalcemia and 7 had normal or elevated PTH levels with normocalcemia.

Conclusions: There are inconsistent procedures regarding the adjustment of the calcium and vitamin D substitution by the practices providing external follow-up treatment. To avoid iatrogenic suppression of PTH levels, high calcium load and potential affection of the kidney function, a reduction scheme should be actively recommended by thyroid surgeons.

Purpose: Low cardiorespiratory fitness (CRF) increases the risk of postoperative morbidity and mortality following major surgery. Assessing CRF preoperatively, by measuring peak oxygen uptake (VO_2peak) during cardiopulmonary exercise testing (CPET), is valuable yet not widely available. This study aimed to assess whether questionnaires could be used preoperatively to identify high-risk surgical patients.

Methods: Healthy participants and patients who underwent CPET completed the FitMáx, Duke Activity Status Index (DASI), the modified 4-questions DASI (M-DASI-4Q), Veterans-Specific Activity Questionnaire (VSAQ), and Metabolic Equivalents of Task (MET) questionnaire. Questionnaire-VO_2peak was compared with CPET-VO_2peak. Overall performance of the questionnaires was assessed by the area under the curve (AUC) of receiver operating characteristic (ROC) curves. Furthermore, corresponding to the Youden index or pre-specified levels, sensitivity, specificity, and predictive values were determined.

Results: In total, 361 participants were included. All questionnaires showed high AUC values to identify high-risk patients, defined on the basis of CPET-VO_2peak thresholds. FitMáx and VSAQ demonstrated superior results compared to the other questionnaires. Based on the Youden index, the optimal questionnaire-VO_2peak cut-off values were 20.6, 21.3, and 26.1 ml·kg^-1·min^-1 for the FitMáx and 16.3, 18.2, and 20.4 ml·kg^-1·min^-1 for the VSAQ corresponding to the VO_2peak thresholds 16.0, 18.2 and 24.5 ml·kg^-1·min^-1 respectively.

Conclusion: The ability to identify high-risk surgical patients preoperatively (defined by the CPET-VO_2peak thresholds) by the FitMáx and the VSAQ indicates that they could be used to identify high-risk surgical patients. Patients with a poor predicted VO_2peak ≤ 21.3 and ≤ 18.2 ml·kg^-1·min^-1, respectively for FitMáx and VSAQ, should be referred to formal preoperative (cardiopulmonary) exercise testing.

Trial registration: The study was registered as NL-OMON23304 in the Overview of Medical Research in the Netherlands, retrospectively at 28-04-2020.

Purpose: There is no established surgical method for metastatic lesion to the pancreas. In the case of relatively small lesion, we often hesitate to select which surgical method, that is, wedge/partial resection or Whipple/distal pancreatectomy. Moreover, it is debatable whether lymph node dissection is necessary or not. We investigated clinicopathological characteristics in order to resolve the above problems.

Methods: Forty-three patients underwent pancreatic resection for metastatic tumors in Cancer Institute of the Japanese Foundation for Cancer Research, whose specimens were investigated clinicopathologically.

Results: Primary tumors included renal cell carcinoma(RCC), colorectal carcinoma (CRC), and miscellaneous malignancy (MM) in 23, 9, and 11 cases, respectively. Plural metastases in a resected specimen or mpd, i.e., tumor extension into the main pancreatic duct (MPD) was observed in eleven (26%, 11/43) or 9 (21%, 9/43) patients, respectively. Five of 9 mpd cases had more over 2 cm intraductal tumor extention from the main metastatic lesion. Lymph node metastasis surrounding the main metastasis was observed in 11 patients (5 CRCs, 5 MMs, and 1 RCC), with a metastatic rate to lymph node of 56% (5/9), 45% (5/11), and 4% (1/23) for CRCs, MMs, and RCCs, respectively.

Conclusions: 1) Wedge or partial resection of the pancreas for metastatic tumor should not be easily chosen, because of positive resection margin due to mpd and/or leaving another metastatic lesion. 2) Lymph node dissection is not strictly necessary for the surgical removal of pancreatic metastasis from RCC, whereas this is highly recommended for patients with metastasis from CRC or MM.

Background: Hartmann's procedure (sigmoid resection with end colostomy) is a commonly performed emergency procedure for diseases of the sigmoid colon.

Aim: To determine the proportion of patients undergoing Hartmann's reversal (restoration of GI continuity) following Hartmann's procedure, the clinical and demographic factors associated with reversal, and the reasons for non-reversal.

Method: This is a single center, retrospective audit of patients undergoing Hartmann's procedure between June 2011 and May 2020. Age, sex, American Society of Anesthesiologists classification (ASA), indication for Hartmann's, surgical approach, specialty of responsible surgeon (General or Colorectal), 30-day reoperation, requirement for radiologically-guided drain, and reason for non-reversal were recorded. The association between these factors and reversal was determined with Fischer's exact test and logistic regression. Cumulative reversal proportions were calculated with the Kaplan-Meier method.

Results: Data was obtained for 114/117 patients, of whom 31% (35/114) underwent Hartmann's reversal. The median (IQR) time to reversal was 372 (188-500) days. Patients with restoration of GI continuity were younger (median 67 versus 73 years, P < 0.001) with fewer co-morbidities, (ASA ≤ 2 34% versus 9% P = 0.002). The estimated cumulative 24-month reversal incidence was 37%. Patients who had a Hartmann's procedure performed for diverticulitis had an increased odds of being reversed (OR 4.1 (95% CI 1.6, 10.5) P = 0.001); Hartmann's for malignancy was associated with decreased odds of reversal (OR 0.37 (95% CI 0.12, 1) P = 0.035).

Conclusion: Of patients who underwent Hartmann's procedure, the majority retained a permanent stoma. Older patients, those with high ASA, and those who underwent index procedures for malignancy had lower rates of reversal.

Objective: To evaluate the safety and efficacy of mobile CT combined with procedural sedation and analgesia for the preoperative localization of multiple nodules.

Methods: The clinical data of 200 patients who underwent CT-guided localization before single-port thoracoscopic pulmonary lobe surgery at our hospital from July 2023 to September 2023 were retrospectively analyzed. The patients were divided into two groups according to the localization method: Group A consisted of 100 patients who were localized under local anesthesia, and Group B consisted of 100 patients who were localized under procedural sedation and analgesia combined with local anesthesia. The general clinical data and localization data of the two groups were compared and analyzed.

Results: The incidence of localization complications in Group B was significantly lower than that in Group A (4% vs. 13%, P = 0.04). The localization success rate in Group B was significantly greater than that in Group A (98% vs. 92%, P = 0.04). The localization time in Group B was significantly shorter than that in Group A (15.23 ± 5.96 min vs. 19.90 ± 8.66 min, P<0.01), and the pain score in Group B was significantly lower than that in Group A (2.01 ± 2.09 min vs. 3.29 ± 2.54 min, P<0.01).

Conclusion: Mobile CT combined with procedural sedation and analgesia for preoperative puncture localization of multiple pulmonary nodules is safe and effective, with significant clinical application value.

Introduction: Advancements in robotic technology have revolutionized general surgery, with new platforms and continuous improvements enhancing surgical procedures. Our unit adopted the Da Vinci Si model in 2012 and later the X model for various abdominal surgeries. In early 2023, we integrated the Hugo RAS system by Medtronic into our practice following comprehensive training. This study examines the transition of experienced robotic surgeons from the Da Vinci platform to the Hugo RAS system, focusing on robotic right hemicolectomy.

Methods: We conducted a retrospective analysis of consecutive adult patients who underwent robotic right hemicolectomy using the Da Vinci X and Hugo RAS systems. Outcomes from the latest seven cases with the Da Vinci X system were compared to the initial seven cases with the Hugo RAS system.

Results: The baseline characteristics of the two groups were comparable, with no significant differences in age, sex, comorbidities, ASA score, or BMI. Operative times showed a trend towards being shorter with the Da Vinci X (127 ± 30 min) compared to the Hugo RAS (163 ± 43 min), but this was not statistically significant (p = 0.2). Other measures, including blood loss, anastomotic configuration, and length of hospital stay, were similar. Two non-surgical postoperative complications occurred in the Hugo RAS group, with no complications in the Da Vinci X group. There were no 30-day readmissions or reoperations in either group.

Conclusion: Experienced robotic surgeons can seamlessly transition to the Hugo RAS system for right hemicolectomy, achieving comparable outcomes to the Da Vinci system.

Purpose: The treatment of pelvic tumors has been widely recognized as challenging. Patient-specific osteotomy templates were designed and generated for precise surgery, based on tumor fusion images and 3D printing technology. This study aimed to investigate the accuracy of patient-specific osteotomy templates for the resection of pelvic tumors.

Methods: From April 2014 to August 2023, 27 patients with pelvic tumors at our hospital were enrolled in this study. All patients underwent CT and enhanced MRI before surgery to develop a 3D preoperative imaging plan model for pelvic tumors based on tumor fusion images. For patients in the intraoperative use of osteotomy templates group, we designed and generated patient-specific osteotomy templates for intraoperative assisted tumor resection. For patients in the no use of osteotomy templates group, surgeons performed tumor resection according to conventional techniques. All patients were followed up to obtain postoperative CT images of the pelvis. Preoperative planning osteotomy surface and intraoperative actual osteotomy surface were obtained by means of the image registration technique. Then, the distance deviation and angle deviation between the two surfaces were compared to assess the accuracy of surgery.

Results: Surgery was successfully completed in 27 patients, and all specimens were obtained for tumor-free resection margins. The median of intraoperative bleeding was 2350(1425 ∼ 3000) ml in the intraoperative use of osteotomy templates group and 4500(3150 ∼ 5200)ml in the no use of osteotomy templates group. p-value was 0.016. The median angular deviation of the actual osteotomy surfaces from the planned osteotomy surfaces was 5.02 (2.84 ∼ 7.37)° in the intraoperative use of osteotomy templates group, and 7.17 (4.49 ∼ 11.96)° in the no use of osteotomy templates group. p-value was 0.044. The absolute mean distance deviation between the two surfaces was 4.90 ± 3.01 mm in the intraoperative use of osteotomy templates group, and 7.21 ± 3.89 mm in the no use of osteotomy templates group. p-value was 0.038.

Conclusions: 3D-printed patient-specific osteotomy templates can be accurately customized based on preoperative tumor fusion image, which can help improve the precision of pelvic tumor surgery.

Background: The appropriate extent of resection for esophagogastric junction cancer and the method of surgical approach remain controversial. This study aimed to assess the safety and outcomes of the parachute technique, which is an open transhiatal reconstruction method that facilitates stable reconstruction.

Materials and methods: The surgical outcomes of 20 consecutive patients who underwent open lower- esophagogastrectomy for EGJ cancer at Kitasato University Hospital from June 2019 to July 2023 were retrospectively reviewed.

Surgical procedure (parachute technique): The esophagus was transected, and a purse-string suture was placed at the stump. Then, a fixing string was placed. Hence, the mucosa, muscular layer, and adventitia, including the string of the purse-string suture, were not displaced. By placing approximately 10 stay sutures around the whole esophageal stump, the esophageal stump can be opened to the maximum diameter. Then, insert the anvil head into the esophagus lumen while laying it sideways, and it can be put on smoothly without stress.

Results: In total, there were 17 and 3, male and female patients, respectively. The median esophageal invasion length was 12.5 (0-30) mm. One patient presented with cStage I EGJ cancer, four with cStage II, 14 with cStage III, and one with cStage IV. In terms of postoperative complications, three (15%) patients developed grade II intra-abdominal fluid correction according to the Clavien-Dindo classification. However, none of the patients presented with anastomotic leakage.

Conclusions: The parachute technique can be a safe and effective reconstruction technique as it does not cause anastomotic leakage.