Langenbeck's Archives of Surgery最新文献

Objective: This study aimed to investigate the impact of abdominal infection control duration on the spontaneous closure (SC) of small intestinal fistula (SIF) following emergency abdominal procedure.

Methods: A retrospective cohort study was conducted on 153 patients from November 2022 to November 2024. The primary outcome was SC. The duration required to achieve infection control was evaluated as a potential factor associated with SC.

Results: Among 153 included patients (median age 48 years, 57.5% male), 60 (39.2%) achieved spontaneous closure (SC) during pre-definitive surgery treatment. The median time to infection control was 28 days overall and 25 days for those achieving SC. Segmented analysis identified 33 days as the optimal cutoff for early versus delayed source control. Early source control (≤33 days) was associated SC (adjusted OR=3.41, 95% CI: 1.36-8.56, P=0.009). Of patients achieving SC, 44 (73.3%) did so within 30 days post-source control. Restricted cubic spline analysis suggested 26 days as a threshold for infection control duration influencing SC within 30 days. Source control duration <26 days was associated with increased likelihood of SC within 30 days (adjusted OR=2.58, 95% CI: 1.23-5.39, P=0.012).

Conclusion: The duration required to achieve infection control was associated with SC of SIF following emergency abdominal procedure.

Background: Data on multinational 90-day mortality and morbidity rates after surgery for gastric cancer is limited in the literature. This study aimed to understand the 90-day mortality and morbidity outcomes among patients undergoing elective gastric cancer surgery, as in the GASTRODATA Registry, and to identify associated risk factors.

Methods: We conducted an international prospective study on patients aged ≥ 18 years undergoing elective surgery for gastric cancer with curative intent from January 4 to September 30, 2022. Known metastatic disease, concurrent secondary cancers, gastrointestinal stromal tumour (GIST) and Siewert type I/II oesophagogastric junction malignancies were excluded. Univariate and multivariate logistic regression were used to identify variables associated with the 90-day outcome.

Results: 380 collaborators from 47 countries submitted data on 1538 patients. Median age was 65 years (IQR: 19-94), and 58.5% were males. 90-day morbidity and mortality rates were 38.2% (n = 587) and 2.9% (n = 45), respectively. Pre-operative higher Charlson Comorbidity Index, higher ASA score, pre-operative weight loss > 10%, positive specimen margin, and post-operative pathological IV staging (p value < 0.05) were significantly associated with clinically relevant complications and mortality.

Conclusion: Elective gastric cancer surgery has a 90-day morbidity of 38.2% and a 90-day mortality of 2.9% globally. This study provided the most comprehensive international 90-day prospective data to date regarding gastric cancer surgery. Several factors associated with higher morbidity were identified, highlighting the importance of a unified language on surgical morbidity, prehabilitation, and ongoing audits to enhance patient outcomes.

Background: Current guidelines recommend surgical interventions for stage I rectal cancer (S1RC). Impaired functions and permanent colostomy remain undesirable outcomes, particularly in low-located stage I rectal cancer. Selective use of total neoadjuvant treatment (TNT) in S1RC may be a potential treatment option.

Study design: Patients with S1RC who declined total mesorectal excision (TME) and opted for TNT between 2015 and 2023 were retrospectively reviewed. The study included two groups: (1) patients with S1RC who demonstrated a partial response following chemoradiation and chose consolidation chemotherapy, and (2) patients who underwent local excision of rectal lesions that were subsequently confirmed as S1RC but declined the recommended TME. Primary outcomes were complete response and organ preservation rates.

Results: The study included sixteen S1RC patient (69% male) who underwent TNT. Eleven patients received TNT following partial response, while the remaining underwent TNT after transanal full-thickness local excision. In the first group (n = 11), nine patients achieved a complete clinical response. One patient with a near-complete response underwent endoscopic submucosal dissection, which revealed a tubulovillous adenoma. Another patient demonstrated a partial clinical response and subsequently underwent low anterior resection, with the final pathology showing a complete response. In patients who received TNT after local excisions, no local recurrence or distant metastasis was observed, with a median follow-up of 20 months (IQR 12). The overall complete response rate following TNT is 93.7%, and organ preservation rate of the study was 87.5%.

Conclusion: Selective utilization of TNT in S1RC holds the potential to foster organ preservation, particularly for low rectal cancer. Larger prospective studies with longer follow-up and standardized treatment protocols are needed to validate these preliminary findings.

Background/aim: Gallbladder polyps (GBPs) are increasingly detected during imaging and often identified incidentally in cholecystectomy specimens. However, management strategies vary, particularly for small, asymptomatic polyps. This study aimed to determine the prevalence, types, and malignant potential of GBPs through pathological examination of cholecystectomy specimens.

Methods: We retrospectively reviewed 11,108 cholecystectomies performed from January 2014 to January 2024. Histopathologically confirmed GBPs were identified in 148 patients. Data on demographics, comorbidities, imaging, surgical approach, and polyp features were analyzed.

Results: Of 148 patients with GBPs, 77% were female and the median age was 48 years. Hypertension (31.8%) and diabetes (16.9%) were common comorbidities. Preoperative ultrasonography detected polyps in only 33.8% of cases. Most polyps (81.8%) were pedunculated and ≤ 10 mm. Cholesterol polyps accounted for 64.2%, and precancerous/malignant lesions for 19.6%. Multivariable analysis showed sessile morphology (OR: 4.2, p = 0.001) and size ≥ 10 mm (OR: 3.8, p = 0.004) were significantly associated with malignancy.

Conclusion: While most GBPs are benign, a significant proportion carry malignant potential, particularly sessile polyps ≥ 10 mm. Improved risk stratification based on morphology and size is essential to guide management. Development of standardized follow-up protocols and refinement of imaging criteria are warranted.

Background: Postoperative pancreatic fistula (POPF) is the major complication following pancreatic surgery, significantly impacting patient outcomes. Intraoperative blood loss (IBL) represents a modifiable risk factor for POPF, but its actual clinical relevance is not clearly defined. This study explores the available literature to reappraise the association of IBL and the development of POPF.

Methods: A systematic review and meta-analysis of original studies published between January 2006 and August 2025, reporting IBL in patients undergoing pancreatic resections and its association with POPF were performed. Studies that used the International Study Group on Pancreatic Surgery (ISGPS) or the International Study Group on Pancreatic Fistula Definition (ISGPF) definitions for POPF were included. Qualitative synthesis included all eligible studies; quantitative meta-analysis was conducted for studies reporting IBL in both POPF and no-POPF groups.

Results: A total of 26 studies were included in the qualitative review and 12 in the meta-analysis. Among 13,108 patients who underwent pancreatic resections, the overall POPF rate was 20%. IBL was identified as an independent risk-factor of POPF in 17 studies. The meta-analysis, which included 10,008 patients, showed that IBL was significantly higher in the POPF group compared to the no-POPF group [Mean difference (MD): 112.46 ml (30.39, 194.53), p = 0.01].

Conclusions: IBL is an independent predictor of POPF. Intraoperative measures to minimize its occurrence and magnitude are key to ameliorate the outcomes of pancreas surgery.

Purpose: Peritoneal dialysis has been demonstrated to be a cost-effective modality of dialysis treatment, providing a greater quality of life in comparison to hemodialysis. However, complications associated with the peritoneal dialysis catheter (PD catheter) can lead to increased patient morbidity and thus the necessity of PD catheter removal. While prior studies have identified patient-related risk factors, the impact of various surgical risk factors on technical survival is yet to be elucidated.

Methods: A retrospective, monocentric cohort study was conducted including all patients who underwent PD catheter implantation through an open surgical technique utilizing a small surgical incision above the rectus abdominis muscle from January 2010 to March 2022. The technical survival of PD catheters was observed retrospectively over a period of three years and the reasons for PD catheter removal were summarized. Furthermore, Cox regression analysis was conducted to evaluate potential risk factors for a reduced technical survival.

Results: A total of 340 patients were included, and a median PD catheter functionality of 980 days was presented in this study. The main reasons for PD catheter removal included infectious complications and mechanical malfunctions. Postoperative revision was identified as a significant risk factor for a reduced technical survival.

Conclusion: PD catheter implantation through a small surgical incision showed a high long-term functionality regardless of prior abdominal surgery, prior PD catheter implantation, or the necessity of adhesiolysis. Only postoperative revision was identified as a significant risk factor for PD catheter removal.

Trial registration: The study was registered in the German clinical trial database (Application number DRKS00036575, registration date 19.05.2025).

Background: Perioperative nutrition is a cornerstone of enhanced recovery in gastrointestinal cancer surgery, with international guidelines recommending early oral intake and standardized screening. This study aimed to assess current perioperative nutrition practices in German surgical departments and evaluate their alignment with guideline-based recommendations.

Methods: A nationwide cross-sectional survey was conducted between September 18, 2024, and January 2, 2025, involving surgical departments that perform major gastrointestinal cancer resections. The 93-item anonymous questionnaire addressed pre- and postoperative nutrition strategies related to esophagectomy, gastrectomy, pancreatoduodenectomy and colorectal resections. Descriptive statistics were used to analyse the responses.

Results: A total of 263 hospitals participated in the survey. More than one-third of hospitals (35.1%) reported no routine preoperative malnutrition screening and only 6.7% performed a structured nutritional assessment. There was no consistent agreement on postoperative feeding strategies including the timing of oral intake especially in upper gastrointestinal surgery. Nasogastric tubes were routinely placed postoperatively in 66 .1% of gastrectomies, 63.5% of esophagectomies, and 64.6% of pancreatoduodenectomies, but timing of postoperative removal varied widely. Hospitals with higher levels of care (e.g. university or maximum care hospitals) were significantly more likely to perform routine malnutrition screening (p = 0.002) and to allow early drinking after colorectal surgery (p < 0.001). The presence of structured nutrition support teams was associated with higher rates of guideline-compliant preoperative screening (76.3% vs. 47.4%; p < 0.001).

Conclusion: Perioperative nutrition practices in German gastrointestinal cancer surgery vary considerably and often deviate from established guidelines.These findings underline the need for greater standardization and broader adoption of evidence-based perioperative nutrition strategies to ensure optimal patient outcomes.

Background: Totally implantable venous access devices (TIVADs) are essential for the long-term management of oncology patients. Although access via the right internal jugular vein is usually preferred due to its favorable anatomy, left-sided access becomes necessary in certain cases (anatomical variations, previous surgeries, or thromboses) by employing the supraclavicular Yoffa technique.

Methods: We describe a standardized and optimized approach using the Yoffa technique for left-sided TIVAD placement. Our protocol details patient positioning, venous puncture, guidewire insertion, subcutaneous tunneling, and port chamber implantation. This retrospective study included 719 patients, of which 216 underwent the left-sided approach.

Results: The left-sided technique was successfully performed with low rates of early complications (pneumothorax 0.42%, hematoma 1.25%, arterial puncture 0.42%) and late complications (catheter-associated thrombosis 0.42%, port pocket infection 1.39%, catheter migration 0.14%) comparable to those obtained with the right-sided approach (503 patients, 69.95%). The main indications for the left-sided approach included right-sided obstruction, previous surgical or radiation history, and failed right-sided access (Rupp SM and Apfelbaum JL Anesth Analg 85(4):741-746) (1997); McGee DC and Gould MK. N Engl J Med 348(12):1123-1133 (2003); Souadka et al PLoS ONE 15(11):e0242727 (2020).

Conclusion: The left-sided Yoffa technique offers a safe and effective alternative for TIVAD placement when right-sided access is contraindicated or difficult. Its supraclavicular approach minimizes the risk of complications (pneumothorax, arterial puncture) and ensures an optimal catheter trajectory toward the superior vena cava.

Background: Neuroinflammation is a common consequence of intracerebral hemorrhage (ICH), leading to neurological impairments. Research indicates that the gut microbiome can influence neuroinflammatory responses. Erianin, is a potential therapeutic agent in the treatment of inflammation. Yet, the specific impact of erianin on ICH-induced inflammation and its interaction with the gut microbiome remain areas of ongoing investigation.

Methods: ICH mouse model was established and treated with erianin. Neurobehavioral tests, brain water content, immunofluorescence, western blotting, and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining were performed to measure the neurological defects and neuroinflammation and neuron apoptosis. Immunofluorescent staining and western blotting assay were performed to assess the activation states of microglia and inflammation. The quantitative real-time polymerase chain reaction (qRT-PCR), enzyme-linked immunosorbent assay (ELISA), and FITC-dextran assays were utilized to measure the intestinal barrier integrity. The composition of the gut microbiota was analyzed by sequencing the 16 S rRNA extracted from fecal samples.

Results: Administration of Erianin notably decreased inflammation in the brain and improved neurological function in ICH mice by inhibiting the proinflammatory activation of microglia. Additionally, Erianin bolstered intestinal barrier integrity, evidenced by decreased levels of lipopolysaccharide-binding protein. Furthermore, treatment with Erianin led to observable shifts in the gut microbiota. Notably, the activation of the ERK signaling pathway was found to counteract the neuroprotective effects of Erianin following ICH.

Conclusions: Erianin is a therapeutic candidate for addressing neuroinflammation triggered by ICH, with its mechanisms of action likely involving the modulation of ERK signaling and the gut microbiome.

Background: Liver transplantation (LT) remains the definitive treatment for end-stage liver disease, with intraoperative estimated blood loss (EBL) receiving limited attention despite its potential impact on outcomes. This study investigated the impact of EBL on graft survival (GS) in LT recipients and aimed to identify a clinically optimal EBL cutoff to guide surgical management.

Methods: This observational cohort study analyzed 914 adult patients who underwent primary orthotopic LT at Ohio State University Wexner Medical Center between January 2016 and December 2023. Intraoperative EBL was calculated by subtracting the volume of salvaged blood from the total volume lost during surgery, then normalized by dividing by the patient's body weight, resulting in adjusted EBL (aEBL). The primary outcome was GS, defined as the time from transplantation to graft failure, re-LT, or death. Kaplan-Meier analysis and Cox regression were used to evaluate GS, and a restricted cubic spline with five knots was applied to determine the optimal aEBL cutoff.

Results: Multivariate analysis confirmed aEBL as an independent risk factor for 1-year GS (HR:1.01, 95%CI:1.00-1.01, p < 0.001) and 3-year GS (HR:1.01, 95%CI:1.00-1.01, p < 0.001). The optimal aEBL cutoff was established at 25.0 mL/kg. Patients with aEBL < 25.0 mL/kg demonstrated superior GS rates at 90 days (p = 0.03), 1 year (p = 0.007), and 3 years (p = 0.003) compared to those with aEBL ≥ 25.0 mL/kg. Higher MELD-Na scores (OR:1.07, 95%CI:1.05-1.09, p < 0.001) and DCD donor status (OR:1.61, 95%CI:1.13-2.29, p = 0.01) were significant predictors of exceeding this threshold.

Conclusions: This study establishes aEBL as an independent risk factor for GS in LT recipients and identifies 25.0 mL/kg as a significant cutoff impacting both short-term and long-term outcomes. These findings underscore the importance of tailoring blood loss management to individual patient characteristics, particularly body weight, and suggest a practical approach to enhance outcomes for LT recipients.