Langenbeck's Archives of Surgery最新文献

Background and objectives: Esophagojejunal (EJ) leakage is a serious complication following total gastrectomy for gastric cancer. While several nutritional and treatment-related risk factors have been described, the role of Candida esophagitis (CE) in anastomotic failure has not been previously investigated.

Methods: This retrospective cohort study included 268 patients with gastric adenocarcinoma who underwent total gastrectomy with EJ anastomosis. The study was conducted between March 2021 and March 2025 at a tertiary referral center. CE was diagnosed by histopathologic examination of proximal esophageal margins submitted during surgery. Univariable and multivariable logistic regression analyses were performed to determine predictors of EJ leakage. Best subsets variable selection using Akaike's Information Criterion (AIC) and the Bayesian Information Criterion (BIC) guided final model development.

Results: Among the 268 patients, 48 (17.9%) developed EJ leakage. Multivariable analysis identified CE (OR: 2.19, p = 0.043), hypoalbuminemia (< 3.5 g/dL) (OR: 3.08, p = 0.007), BMI ≥ 25 kg/m² (OR: 3.68, p = 0.004), and administration of neoadjuvant therapy (OR: 2.34, p = 0.024) as independent predictors of EJ leakage. Additional analyses of diagnostic timing indicated that CE detected only on permanent histology (delayed treatment) was associated with higher odds of leak (adj OR 3.62; 95%CI: 1.42-9.23; p = 0.007), whereas CE detected on intraoperative frozen section was not.

Conclusion: CE was associated with increased odds of EJ leakage after adjustment, but causality cannot be inferred from this retrospective study. The finding that delayed CE diagnosis was linked to higher leak risk suggests diagnostic timing may matter. Prospective validation of targeted esophageal assessment and timed antifungal strategies is warranted. Elevated BMI, hypoalbuminemia, and neoadjuvant therapy also contributed to higher odds of EJ leakage.

Background: Peritoneal dialysis catheter (PDC) dysfunction significantly impacts patient survival. While individual risk factors are known, a practical tool that integrates multi-dimensional predictors-including surgical, anatomical, and postoperative parameters-for early risk stratification is lacking. This study evaluates open versus laparoscopic catheterization techniques and aims to develop such a predictive model.

Methods: A retrospective cohort study analyzed 462 end-stage renal disease patients undergoing first PDC implantation (2022-2024). Data included clinical characteristics, surgical method (open/laparoscopic), and dysfunction events. Multivariate COX regression identified independent risk factors, and a nomogram was developed. Model performance was assessed via ROC and calibration curves, with Bootstrap validation.

Results: Among 462 patients (324 modeling, 138 validation) with a median follow-up of 30.7 months, laparoscopic catheterization was associated with a significantly lower risk of dysfunction compared to the open approach (18% vs. 27%; hazard ratio [HR] 2.188, 95% CI 1.263-3.791, p = 0.005). Multivariate analysis identified five independent predictors of catheter dysfunction: history of abdominal surgery (HR 6.924, p < 0.001), open catheterization (HR 2.188, p = 0.005), diabetes (HR 2.373, p = 0.016), albumin < 30 g/L (HR 0.865, p < 0.001), and blood potassium < 4 mmol/L (HR 1.479, p = 0.015). The developed nomogram integrating these predictors showed outstanding discriminative performance, with C-indices of 0.953 (95% CI 0.940-0.967) in the modeling cohort and 0.951 (95% CI 0.929-0.972) in the validation cohort. Time-dependent ROC analysis further confirmed its predictive accuracy, with 1- and 2-year AUCs of 0.957/0.979 and 0.921/0.988 in the modeling and validation sets, respectively. Calibration curves showed close alignment between predicted and observed outcomes across both cohorts. The nomogram provides a clinically useful tool for individualized risk assessment and postoperative management.

Conclusions: Laparoscopic catheterization reduces dysfunction risk. The presented nomogram is unique in its integration of readily available surgical, comorbidity, and nutritional metrics into a single, visual tool. It facilitates early identification of high-risk patients, thereby aiding individualized surgical planning and targeted postoperative monitoring to improve PDC longevity.

Purpose: This study aims to identify UK general surgical trainees' perceptions, attitudes, and perceived barriers to EBM training and assessment so that interventions by general surgery educators to improve integration of EBM are informed by stakeholder data.

Method: A mixed-method survey was developed by adapting the validated McColl and BARRIERS questionnaires, informed by a scoping review and focus group discussions. Ethical approval was obtained (University of Sheffield - 056808). The survey was distributed through social media, surgical society newsletters, and deanery mailing lists, adhering to the CHERRIES checklist.

Results: The survey yielded 101 responses, 53 of which were complete (65% male, 35% female). A quarter of the 53 respondents did not hold higher academic degrees. Most participants (61%) worked in district general hospitals, with the highest response rates from Yorkshire and West Midlands. Attitudes towards EBM were predominantly positive from trainees (50.3%), with most of the respondents indicating their ability to understand and explain EBM terminology. However, they perceived their senior colleagues to be less enthusiastic about EBM (41.5%). Barriers to developing EBM competencies included lack of time, excessive evidence volume, limited access to resources, inadequate critical appraisal skills and limited opportunities for application during clinical practice. Existing postgraduate assessment strategies were deemed adequate for EBM by most of the trainees.

Conclusion: The surveyed UK General surgical trainees exhibit positive attitudes towards EBM but face barriers in its application within their training. One way of addressing this issue is through research informed targeted curricular interventions.

Background/aims: Single-port laparoscopic surgery (SPLS) is a promising alternative to multi-port laparoscopic surgery (MPLS) for emergency appendectomy, with potential advantages in cosmesis and recovery. However, its role remains uncertain, particularly in complex cases. This systematic review and meta-analysis evaluates SPLS's safety, effectiveness, and recent advancements to inform clinical decisions and practice.

Methods: A systematic search of PubMed, Embase, and Cochrane Library identified studies comparing SPLS with MPLS in emergency appendectomy. Outcomes included conversion to open surgery, operative time, postoperative complications, length of hospital stay, pain outcomes, and cosmetic satisfaction. Data synthesis followed PRISMA guidelines using a random-effects model.

Results: Eleven studies, including randomized controlled trials and cohort studies, were included. No significant differences were observed in conversion rates (OR 1.78, 95% CI: 0.63-5.03), complication rates (OR 0.96, 95% CI: 0.63-1.46), operative time (mean difference 2.93 min, 95% CI: - 3.17 to 9.02), length of stay (mean difference - 0.23 days, 95% CI: - 0.62 to 0.15), or postoperative pain (mean difference - 0.24, 95% CI: - 0.96 to 0.49). Substantial heterogeneity was present for operative time (I² = 91%), length of stay (I² = 92%), and pain (I² = 80%). Cosmetic satisfaction generally favoured SPLS, although assessment methods varied considerably.

Conclusion: While SPLS appears to be a safe and feasible alternative to MPLS for emergency appendectomy, current evidence does not support definitive equivalence across all outcomes due to significant heterogeneity, small study sizes, and inconsistent measurement tools. Future large-scale randomized trials are necessary to clarify SPLS's role, especially in complex cases and high-risk populations.

Background: Carpal Tunnel Syndrome (CTS) remains a pervasive condition, often resulting in functional impairment and pain. This study examines whether ultrasound guidance enhances the efficacy and safety of corticosteroid injections for CTS compared to traditional injections based on anatomical landmarks.

Methods: This meta-analysis was conducted in accordance with PRISMA guidelines. We performed a systematic search of PubMed, Embase, Web of Science, and the Cochrane Library up to September 19, 2023. Randomized controlled trials (RCTs) comparing ultrasound-guided(US) versus landmark-guided(LM) corticosteroid injections for CTS were included. Data were synthesized using a random-effects model.

Results: Eight RCTs were included in the analysis. US was associated with a significant reduction in BCTQ symptom severity scores (Standardized Mean Difference [SMD] = -0.32, 95% CI -0.44 to -0.20; I²=0%) and functional status scores (SMD = -0.21, 95% CI -0.31 to -0.10; I²=0%). Nerve injury events were rare; while the direction of effect favored US, the evidence was too sparse to permit a reliable pooled estimate.

Conclusions: US corticosteroid injections provide modest, consistent improvements in symptoms and function over landmark techniques. Safety signals directionally favor US, but adverse-event data are sparse and not definitive.

Purpose: This systematic review and meta-analysis aims to compare the recurrence and mortality rates of resection versus non-resection surgery for sigmoid volvulus (SV), a condition requiring a balance between recurrence prevention and mortality minimization.

Methods: A comprehensive search of PubMed, EMBASE, Web of Science, and Cochrane Library identified studies comparing resection and non-resection surgeries for SV. Primary outcomes included recurrence rates, and secondary outcomes included mortality rates. Randomed effects models were used to calculate pooled effect sizes.

Results: A total of 28 nonrandomized studies, comprising 837 resection and 660 non-resection patients, were included. Resection significantly reduced recurrence (RR: 0.12, 95% CI: 0.06-0.24, P < 0.001) with an NNT of 6 (95% CI: 5.7-7.0) but it was associated with increased mortality (RR: 1.69, 95% CI: 1.17-2.44, P = 0.005, NNH = 17 [95% CI: 11.1-33.3]). Subgroup analysis excluding gangrenous sigmoid patients showed resection effectively prevented recurrence (RR: 0.20, 95% CI: 0.08-0.50, P < 0.001, NNT = 9 [95% CI: 6.2-13.7]) with no significant mortality difference (RR: 1.12, 95% CI: 0.53-2.37, P = 0.760). Similar results were observed in sensitivity analyses excluding studies published before 1990, analyses limited to prospective studies, and when comparing resection with specific non-resection procedures.

Conclusions: Resection is effective in preventing SV recurrence, with no significant mortality increase in patients with virable colon, supporting its use in suitable patients. Future research should optimize patient selection and perioperative care.

Purpose: Acute arterial occlusive mesenteric ischemia (AAOMI) is a life-threatening emergency associated with high mortality rates. Revascularization is a key component of multimodal therapy; however, the optimal initial treatment strategy, open surgical (OR) versus endovascular revascularization (ER), remains a subject of ongoing debate. This study aimed to compare outcomes between open and endovascular revascularization in patients with AAOMI.

Methods: This retrospective single-center cohort study included all patients with AAOMI who underwent urgent revascularization between January 2004 and July 2024. Based on the initial revascularization method, patients were divided into two treatment groups: open surgical and endovascular. Outcomes included in-hospital mortality, bowel resection rate and extent, incidence of short bowel syndrome, and length of hospital and intensive care unit (ICU) stay.

Results: Of the 100 patients included, 79 were initially treated with open revascularization and 21 with endovascular revascularization. In-hospital mortality was 48.1% (38/79) of OR patients and 33.3% (7/21) of ER patients (p = 0.227). 42 patients (53.2%) with open surgical treatment required bowel resection, compared to 10 patients (47.6%) with endovascular-first revascularization (p = 0.651). The median extent of bowel resection was 69 cm in the OR group and 71 cm in the ER group (p = 0.350). No differences could be detected regarding short bowel syndrome. Median hospital stay was 15 days in the open surgical cohort vs. 11 days in the endovascular cohort (p = 0.484). Median ICU stay was 5 days in the OR group and 4 days in the ER group (p = 0.172).

Conclusion: Open surgical and endovascular revascularization resulted in comparable outcomes regarding in-hospital mortality, bowel resection, short bowel syndrome, and length of hospital and ICU stay in this retrospective cohort. Treatment decisions should be individualized based on occlusion type, patient condition, and institutional expertise. Prospective multicenter studies are warranted to further refine optimal management strategies for AAOMI.

Background: Postoperative evaluation in patients with acromegaly typically involves measuring insulin-like growth factor 1 (IGF-1) levels and assessing growth hormone (GH) suppression via an oral glucose tolerance test (OGTT). However, discrepancies between these results are not uncommon. Despite this, there are very few studies examining long-term clinical outcomes in patients with persistent discordance between GH nadir and IGF-1 levels. In this study, we focused on such patients and conducted a retrospective analysis to clarify their mid- to long-term outcomes, alongside a review of relevant literature.

Methods: We retrospectively reviewed patients with acromegaly who underwent transsphenoidal resection of pituitary tumors at a single institution and had serial endocrinological evaluations for more than one year between May 2005 and July 2020. Patients were divided into two groups: those with normal GH suppression during OGTT but elevated IGF-1 levels (Group I) and those with abnormal GH suppression but normal IGF-1 levels (Group II) at their 1-year postoperative evaluation. We investigated whether IGF-1 levels normalized or re-elevated over time, alongside monitoring clinical signs and comorbidity management.

Results: During the study period, 52 patients who were evaluated by serial IGF-1 and OGTT, 10 demonstrated discordance between GH nadir and IGF-1 levels-3 in Group I and 7 in Group II. In all Group I patients, delayed normalization of IGF-1 was observed, taking 3 to 5 years. No IGF-1 re-elevations occurred, and clinical signs and comorbidities were well controlled. In Group II, abnormal GH suppression during OGTT persisted in all patients; however, IGF-1 levels remained within the normal range without re-elevations. Clinical signs and comorbidities remained clinically stable without the need for additional therapy during the 11-year follow-up period.

Conclusion: Most patients achieved a mid- to long-term disease-controlled state without additional treatment. Given the potential risk of GH deficiency from further treatment, it may be reasonable to consider patients clinically controlled as long as IGF-1 levels remain normalized, with careful long-term monitoring recommended.