Langenbeck's Archives of Surgery最新文献

Purpose: Laparoscopic gastrectomy (LG) is a promising approach for older patients who require less invasive surgery because of their reduced functional reserve and increased comorbidities, with the expansion of its indication to locally advanced gastric cancer. However, the specific benefits of LG in older patients remain unclear. We evaluated whether LG positively influences the postoperative maintenance of skeletal muscle (SM) and bodyweight (BW).

Methods: We retrospectively analyzed the data of consecutive patients aged ≥ 75 years who underwent open gastrectomy (OG) and LG for cStage II or III gastric cancer between 2016 and 2021. After adjustment using propensity score matching, surgical and postoperative outcomes were compared between the groups including the postoperative changes of SM index (%SMI) and BW (%BW).

Results: A total of 167 patients who underwent OG (n = 93) and LG (n = 74) were included in the study. After matching, 48 patients in each group were eligible. No significant difference in postoperative complications was observed. Both %SMI and %BW after LG were significantly maintained compared with those after OG during the postoperative first year. LG had consistently positive effects on the maintenance of %SMI and %BW across the prespecified subgroups. Notably, patients with body mass index < 25, performance status 0-1, non-total gastrectomy, and absence of adjuvant chemotherapy benefited from LG in the maintenance of %SMI and %BW.

Conclusion: LG offers greater advantages over OG in maintaining postoperative SM mass as well as BW in patients aged ≥ 75 with locally advanced gastric cancer.

Background: The gold standard for treating acute cholecystitis is an early laparoscopic cholecystectomy. However, whether this still applies for a > 7-day existing cholecystitis remains heavily debated. Therefore, this systematic review investigates the safety of early laparoscopic cholecystectomy for a > 7-day existing cholecystitis.

Methods: PubMed and Embase were systematically searched for all studies comparing early laparoscopic cholecystectomy in patients with 0-7 versus > 7-day existing cholecystitis at time of surgery. Meta-analyses were performed on dichotomous and continuous outcomes with risk difference (RD) and mean difference (MD) as measures of effect.

Results: A total of 3007 studies were screened, resulting in the inclusion of 13 non-randomised studies comprising 5481 patients. Of these, 4690 received cholecystectomy within 7 days, and 791 after 7 days. Operating times (MD -11.8 min; 95% CI [-18.4; -5.2]) and total hospital stay (MD -2.7 days; 95% CI [-4.0; -1.4]) were longer in the > 7-day group. However, no significant risk difference was found for combined major complications: bile duct injury/leakage and bowel injury (RD -1.0%; 95% CI [-2.3; 0.3]), for complications graded Clavien-Dindo ≥ 3 (RD -0.3%; 95% CI [-2.5; 1.9]), or for conversions (RD -1.5%; 95% CI [-3.9; 0.9]).

Conclusion: Early laparoscopic cholecystectomy for cholecystitis after the 7-day barrier might be harder, as reflected by longer operating times. However, a significant increase in complications or conversions was not found. Due to the risk of bias and lack of well-powered studies directly comparing early cholecystectomy after 7 days with alternative strategies, strong recommendations cannot be made. Meanwhile, it is advised to carefully weigh the treatment options in case of a > 7-day existing cholecystitis, based on patient's characteristics and surgeon's experience.

Purpose: The PowerGlide Pro™ Midline Catheter is a peripheral venous access device with a length of 8-10 cm, allowing the tip to reach far into the venous system. The aim of this study was to evaluate the dwell time of the catheter. Secondary endpoints included suitability for specific medications (e.g. prostaglandins) and assessment of complications.

Methods: Between January 2019 and November 2021, 50 patients were included in the study. Data on patient demographics, placement characteristics, complications and reasons for removal, were collected.

Results: Placement was technically successful in 92% (n = 46) of cases. In all cases, veins of the upper extremity were punctured (34 basilic veins, 7 brachial veins, 6 cephalic veins, and 3 median cubital veins). The average dwell time was 6.1 days (1-17 days). A significant difference between duration and medication administered could not be demonstrated.

Conclusions: The longer maximum dwell time compared to a standard peripheral venous catheter makes it particularly suitable for intravenous therapy for more than 7 days or patients who have poor peripheral vein status.

Objective: To investigate the mechanism by which Montelukast inhibits abdominal aortic aneurysm (AAA) formation through the AMPK/mTOR signaling pathway in mice.

Methods: Mice were randomly assigned to the Normal group, Model group, Montelukast group, and Montelukast + compound C (C.C) group. The Model, Montelukast, and Montelukast + C.C groups were induced with AAA by continuous infusion of 1000 ng/kg/min of Ang II. The Montelukast group received daily oral administration of 10 mg/kg Montelukast, while the Montelukast + C.C group received 10 mg/kg Montelukast and 10 mg/kg C.C orally for 28 days. Abdominal aortas were isolated, and their diameters and AAA occurrence were measured using a micrometer. Histological analysis was performed using Hematoxylin-Eosin (HE) staining to assess the morphological changes. TUNEL staining was conducted to measure cell apoptosis levels in the abdominal aortas. Western Blot was employed to evaluate protein expressions of Bax, Bcl-2, MMP-2, MMP-9, α1-AT, p-AMPK, AMPK, p-mTOR, mTOR in the abdominal aortic tissues. qRT-PCR was used to assess the expression of IL-6, TNF-α, IFN-γ in the mouse abdominal aortas.

Results: Compared to the Normal group, the Model group showed significantly increased abdominal aortic diameter, AAA occurrence, TUNEL positivity, Bax/Bcl-2 ratio, IL-6, TNF-α, IFN-γ, MMP-2, MMP-9, p-mTOR/mTOR, and decreased α1-AT, p-AMPK/AMPK (P < 0.05). The Montelukast group exhibited significant decreases in abdominal aortic diameter, AAA occurrence, TUNEL positivity, Bax/Bcl-2 ratio, IL-6, TNF-α, IFN-γ, MMP-2, MMP-9, p-mTOR/mTOR, and increases in α1-AT, p-AMPK/AMPK compared to the Model group (P < 0.05). The Montelukast + C.C group showed opposite trends compared to the Montelukast group (P < 0.05). The Normal group exhibited intact abdominal aortic wall structure with orderly arranged cells. The Model group showed thickened aortic walls, plaque formation, and inflammatory cell infiltration. The Montelukast group demonstrated reduced aortic wall thickening, approaching a morphology closer to the Normal group. The Montelukast + C.C group exhibited a morphology between the Model and Montelukast groups.

Conclusion: Montelukast can inhibit AAA formation in mice, possibly through the downregulation of cell apoptosis, inflammatory response, and matrix metalloproteinase levels via the AMPK/mTOR signaling pathway.

Background: The cure for patients with primary hyperaldosteronism (PHA) secondary to solitary adrenal adenoma is adrenalectomy. We investigated the impact of size of Conns' tumour on hypertension resolution in a multi-ethnic South East Asian Cohort.

Methods: Retrospective cohort study of patients who underwent surgery for PHA between January 2010 to December 2022 was performed. Clinicopathological parameters that included tumour size, blood pressure parameters, class and dosage of drugs, biochemical indices and details of surgery were collected. Cure of hypertension was defined as normal blood pressure post-adrenalectomy. Statistical significance was defined as a P value of < 0.05.

Results: 94 patients (40 female:54 male; 102 women; age 49.3 ± 11.8 years) with PHA were operated on laparoscopically (79 trans-abdominal and 15 retroperitoneal approach). Tumour size ranged from 0.4 to 4.6 cm (mean 1.5 ± 0.6 cm). Hypertension Grades were Grade 1 in 38 (40%), Grade 2 in 45 (48%) and Grade 3 in 11 (12%) patients. Patients were on a mean of 3 classes of drugs prior to surgery and this decreased to mean of 1 class of drug post adrenalectomy. All patients were rendered normokalaemic and overall cure of the patients from hypertension was 82.0%. Large adenoma (defined as greater than 1.5 cm) resulting in a greater decrease in blood pressure (mean decrease of 32mmHg systolic, 15mmHg diastolic and MAP 20mmHg) in comparison to smaller adenomas (p = 0.003), but with lower cure rates of hypertension (p = 0.038).

Conclusions: Large Conn's adenomas result in a greater reduction in blood pressure post-adrenalectomy but with decreased cure rates of hypertension compared to the small adenomas.

Introduction: Resection margin status is the important prognostic factor in resected perihilar cholangiocarcinoma (pCCA). Although the impact of ductal margin (DM) was reported in many studies, the influence of radial margin (RM) is unclear. This study aims to investigate the effect of positive RM on survival.

Methods: Patients with pCCA underwent curative resection between 2013 and 2018 were retrospectively reviewed. Resection margin status was divided into negative resection margin (R0) and positive resection margin (R1); positive RM alone (RM+) and positive DM with or without positive RM (DM+).

Results: Of the 167 pCCA patients, 62 (37.1%) had R1 margin. Among 62 R1 patients; 17 (27.4%) had positive DM alone, 20 (32.3%) had positive RM alone and 25 (40.3%) had both positive DM and RM. The R1 patients had a significantly greater number of lymph node metastasis (LNM) and advanced tumor staging than R0 patients, however there was no difference between the RM + and DM + patients. The median survival time of patients with RM + was significantly poorer than R0 patients (13.8 vs. 24.5 months; p < 0.001, respectively) and similar to the DM + patients (9.1 months, p = 0.556). However, in patients with LNM, those who underwent R0 resection had no statistically significant difference in survival outcomes compared to those with R1 resection.

Conclusion: Positive resection margin remains the important prognostic factor, and positive RM is common in these patients. Positive RM also had a comparable effect on survival as positive DM. As a result, in pCCA, surgical resection should target both RM and DM.

Background: Inverted kidney transplant (KT) has been applied in many transplant centers, but the experiences and outcomes of this technique was limited.

Aim: To describe the technical characteristics, indications and evaluate the outcomes of inverted kidney transplantation.

Methods: Retrospective study from January 2016 to December 2023, included 74 patients who underwent inverted kidney transplantation with 72 cases of right kidney transplant into the right iliac fossa and 2 cases of left kidney transplant into the left iliac fossa performed in Viet Duc University Hospital.

Results: 63 cases in stage 1 (ipsilateral kidney transplant), all kidney graft were transplanted on the same side and 11 cases in stage 2 in which the kidney transplant was performed in some special cases such as recipients with severe atherosclerotic iliac arteries or incompatibility between the arteries and venous. The operation time was significantly higher (192.8 vs. 173.7 min, p = 0.037). However, the kidney function showed no difference when being discharged and remained stable until the latest follow-up. 3-year graft survival was 98.3%. There was 1 case of graft loss due to chronic graft rejection- immunosuppression incompliance requiring retransplantation after 2 years. Main complications included acute pancreatitis (2.7%), and ureteral stenosis at the ureter-bladder junction (6.8%), not significantly different compared to conventional KT.

Conclusion: Inverted kidney transplantation is a simple, safe and effective technique and could be a feasible solution for some specific circumstances.

Background: This study aimed to report the long-term outcomes after surgical resection for invasive (I) intraductal papillary mucinous neoplasm (IPMN) and to define prognostic factors for survival.

Methods: We retrospectively evaluated all consecutive pancreatic resections performed IPMN between January 1, 2007, and December 31, 2022. Multivariate Cox analysis identified risk factors for survival.

Results: Surgery for IPMN was performed in 125 patients including 78 I-IPMN (62%). Ninety-day mortality rates was 1.6% (n = 2) with an overall morbidity rate of 44.4%. I-IPMN showed higher serum CA 19 - 9 serum values (p < 0.0001), more frequently jaundice (p = 0.008), more high-risk stigmata (p = 0.002) and diffuse IPMN form (p = 0.005) compared with non-invasive IPMN. The median overall survival for I-IPMN was 178.36 months (95% confidence interval [CI]: 87.01-NR) with overall survival rates at one, three, five, and 10 years of 91%, 75%, 72%, and 62%, respectively. Jaundice (hazard ratio [HR]: 4.23; 95% CI: 1.48-12.07; p = 0.006), T3 lesions (HR: 3.24; 95% CI: 1.65-6.39; p = 0.006), absence of lymph node involvement (HR: 0.15; 95% CI: 0.04-0.60; p = 0.0007), R1 margin status (HR: 2.96;95%CI:1.08-8:15;p = 0.03) and need for venous resection (HR: 4.30; 95% CI: 1.26-14.6; p = 0.006) were identified as independent risk factors for survival.

Conclusions: Long-term survival and cure can be observed after surgical resection of pancreatic adenocarcinomas originating from I-IPMN when resected at early stage (Tis, T1, T2). I-IPMN spreading beyond pancreatic ducts (jaundice, T3 lesions, lymph nodes, Veins) have limited long-term survival.

Purpose: Our perioperative management center provides preoperative intervention and functional and nutritional assessments for colorectal cancer patients aged over 75 years. This study evaluated the associations of preoperative nutritional status with postoperative outcomes and prognosis in colorectal cancer patients aged 75 years or older.

Methods: This was a prospective, observational study of 71 colorectal cancer patients aged 75 years or older who underwent surgery between July 2020 and September 2022. The Subjective Global Assessment (SGA) was evaluated as a nutritional index. The patients were classified into three groups: SGA-A (well nourished), B (moderately malnourished), and C (severely malnourished), and the correlations with postoperative outcomes and prognosis were examined.

Results: The median age of the 71 patients (34 males, 37 females) was 78 (75-92) years, and their median body mass index (BMI) was 22.3 (13.4-31.9) kg/m². Forty-eight patients had colon cancer, and 23 had rectal cancer. On the SGA, 28 patients were SGA-A, 25 SGA-B, and 18 SGA-C. The SGA-B/C group had significantly higher BMI (p < 0.01) and more ICU admissions (p = 0.02). The G8 score was significantly lower (p = 0.03) in the SGA-B/C group, suggesting coexisting functional decline. In terms of postoperative outcomes, the SGA-B/C group had a significantly longer postoperative hospital stay (p = 0.04). The 3-year OS rates for all stages were 100% in the SGA-A group and 49.7% in the SGA-B/C group (p = 0.03), while the 3-year OS rates for patients excluding Stage IV were 100% in the SGA-A group and 68.5% in the SGA-B/C group, not significantly different (p = 0.14). The 3-year RFS rate was 95.5% in the SGA-A group and 65.3% in the SGA-B/C group (p = 0.15).

Conclusion: The SGA is a promising nutritional index associated with short-term outcomes in older patients undergoing colorectal cancer surgery. The SGA can be assessed in a few minutes during an outpatient visit, making it useful for routine clinical use.

Purpose: After resection during a laparoscopic right colectomy (LRC), reconstruction can be conducted with an intracorporeal (IA) or extracorporeal anastomosis. Although IA benefits are well documented, its implementation has been slow due to a steep learning curve (LC) mainly associated with intracorporeal suturing. The aim of this study is to assess the LC of IA in LRC.

Methods: Consecutive patients undergoing a LRC with IA between January 2016 and June 2023 were included. Clinical, perioperative, and histopathological variables were collected. Correlation and cumulative sum (CUSUM) analyses between the operating time and case number were performed. 'Surgical success' as a composite outcome was also analysed by performing a CUSUM plot. Completion LC case number was determined based on these analyses. Pre-LC and post-LC perioperative outcomes were compared.

Results: Two-hundred-and-ninety patients underwent a LRC during the study period. Sixty-seven met inclusion criteria. Correlation analysis identified a significant operating time reduction with increasing case numbers (p = 0.034). Total complications during implementation period were 25,3%, with 6% of severe complications. Operative time CUSUM analysis identified a consistent downwards trend after case 36 and surgical success CUSUM analysis after case 37. Two phases were established: pre-LC (case 0-37th) and post-LC (38th-67). Pre-LC and post-LC revealed a significant decrease in operative time (187vs177.8 min;p = 0.016), and length of stay (4vs3 days;p < 0.001). No difference between overall complications, severe complication, or reoperation rates were detected.

Conclusion: The LC of laparoscopic IA can be achieved after 37 cases in centres with experience in advanced laparoscopic surgery. Further studies will be required to confirm these results.