Langenbeck's Archives of Surgery最新文献

Purpose: Diverting Loop Ileostomy (DLI) with intraoperative colonic lavage has emerged as a potential alternative to Total Abdominal Colectomy (TAC) for treating Fulminant Clostridium Difficile Colitis (FCDC). This study aims to provide an updated review comparing DLI with TAC in managing FCDC.

Methods: A systematic literature search was conducted using PubMed, Scopus, and Embase to identify retrospective and prospective studies comparing DLI with TAC for fulminant CDC treatment. A meta-analysis was performed to evaluate postoperative mortality rates and complications using R Studio version 4.4.1, calculating odds ratios (ORs) with 95% confidence intervals via the Mantel-Haenszel method. Heterogeneity was assessed using the Cochrane Q test and I² statistics.

Results: Our search yielded 228 relevant citations, of which 7 studies with a total of 7,048 patients were included. Of these, 1,728 underwent DLI. The mean age was 63.33 years in the DLI group and 65.74 years in the TAC group. Compared to TAC, DLI had significantly lower postoperative mortality (OR 0.75; 95% CI 0.62-0.90; P = 0.002; I² = 34%). Trial sequential analysis for postoperative mortality rates showed the benefit of DLI with a sufficiently powered sample. The DLI group also had a significantly higher rate of ostomy reversal (OR 5.68; 95% CI 2.35-13.72; P < 0.001; I² = 36%). Postoperative complications, such as thromboembolic events, surgical site infections, urinary tract infections, renal failure, and pneumonia, were not significantly different.

Conclusion: DLI shows a lower postoperative mortality rate and higher ostomy reversal rate than TAC, suggesting it as a potential organ-preserving, minimally invasive alternative. Further high-quality studies and trials are needed to confirm these findings.

Purpose: Locally advanced pancreatic ductal adenocarcinoma (PDAC) with an unreconstructible superior mesenteric vein (SMV) invasion is one of the criteria of unresectability in the National Comprehensive Cancer Network guidelines. Advances in chemotherapy have improved downstaging and conversion surgery outcomes, thereby broadening surgical options for locally advanced PDAC. However, operations for PDAC with an unreconstructible SMV is less well-documented. If the collateral route is well-developed and can be preserved or reconstructed, SMV resection can be performed without reconstruction. In this paper, we detail our surgical technique and the outcomes for patients undergoing pancreatoduodenectomy with SMV resection and non-reconstruction (PD-SMVR-NR).

Methods: All consecutive patients with pancreatic head cancer who underwent PD at Juntendo University Hospital, Japan, between January 2019 and December 2022 were evaluated from a prospectively maintained preoperative database. Demographic data, clinical history, operative record, morbidity, mortality, and pathologic data were reviewed.

Results: Over four years at our Institute, 161 patients with pancreatic head cancer underwent PD, and 86 of these patients underwent PD with portal vein (PV) or SMV resection. There were three patients who underwent PD-SMVR-NR. Each patient had well-developed collateral vessels bypassing the obstructed segment of the SMV. All three patients had no hospital mortality with acceptable complications (Clavien-Dindo grade 2). Two patients achieved R0 resection.

Conclusion: By understanding the hemodynamics of venous flow and preserving collateral vessels, especially the superior right colic vein arcade and porto-mesenterico-splenic confluence, pancreatoduodenectomy with superior mesenteric vein resection and non-reconstruction can be performed safely.

Background: Drains are used to reduce abdominal collections after procedures where such risk exists. Using abdominal drains after cholecystectomy has been controversial since the open surgery era. Universally accepted indications and agreement exist that routine drainage is unnecessary but the role of selective drainage remains undetermined. This study evaluates the indications and benefits of sub-hepatic drainage in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (BDE) in a specialist unit with a large biliary emergency workload.

Methods: Prospectively collected data from 6,140 LCs with a 46.6% emergency workload over 30 years was reviewed. Demographic factors, pre-operative presentations, imaging and operative details in patients with and without drains were compared. Sub-hepatic drains were inserted after all transductal explorations, subtotal cholecystectomies, almost all open conversions and 94% of LC for empyemas. Adverse or beneficial postoperative drain-related outcomes were analysed.

Results: Abdominal drains were utilised in 3225/6140 (52.5%). Patients were significantly older with more males. 59.4% were emergency admissions. Preoperative imaging showed thick-walled gallbladders in 25.2% and bile duct stones or dilatation in 36.2%. At operation they had cystic duct stones in 19.8%, acute cholecystitis, empyema or mucocele in 28.4% and operative difficulty grades III or higher in 59%. 38% underwent BDE, 5.4% had fundus-first dissection and the operating times were longer ( 80 vs.45 min). Drain related complications were rare; 3 abdominal pains after anaesthetic recovery settling when drains were removed, 2 drain site infections and one re-laparoscopy to retrieve a retracted drain. 55.8% of 43 bile leaks and 35% of 20 other collections in patients with drains resolved spontaneously.

Conclusions: The utilisation of drains in this study was relatively high due to the high emergency workload and interest in BDE. While drains allowed early detection of bile leakage, avoiding some complications and monitoring conservative management to allow early reinterventions, the study has identified operative criteria that could potentially limit drain insertion through a selective policy.

Purpose: Choosing the best stump closure method for laparoscopic appendectomy has been a debated issue, especially for patients with acute appendicitis. The lack of consensus in the literature and the diverse techniques available have prompted the need for a comprehensive evaluation to guide surgeons in selecting the most optimal appendiceal stump closure method.

Methods: A comprehensive search was conducted on multiple databases from inception until December 2023 to find relevant studies according to eligibility criteria. The primary outcome was the incidence of total complications.

Results: 25 studies with a total of 3308 patients were included in this study, overall complications did not reveal a significant advantage for any intervention (RR = 0.72, 95% CI: 0.53; 1.01), Superficial and deep infection risks were similar across all methods, Operative time was significantly longer with endoloop and Intracorporeal sutures (MD = 7.07, 95% CI: 3.28; 10.85) (MD = 26.1, 95% CI: 20.9; 31.29).

Conclusions: There are no significant differences in overall complications among closure methods. However, Intracorporeal sutures and endoloop techniques were associated with extended operative durations.

Purpose: Augmented reality navigation in liver surgery still faces technical challenges like insufficient registration accuracy. This study compared registration accuracy between local and external virtual 3D liver models (vir3DLivers) generated with different rendering techniques and the use of the left vs right main portal vein branch (LPV vs RPV) for landmark setting. The study should further examine how registration accuracy behaves with increasing distance from the ROI.

Methods: Retrospective registration accuracy analysis of an optical intraoperative 3D navigation system, used in 13 liver tumor patients undergoing liver resection/thermal ablation.

Results: 109 measurements in 13 patients were performed. Registration accuracy with local and external vir3DLivers was comparable (8.76 ± 0.9 mm vs 7.85 ± 0.9 mm; 95% CI = -0.73 to 2.55 mm; p = 0.272). Registrations via the LPV demonstrated significantly higher accuracy than via the RPV (6.2 ± 0.85 mm vs 10.41 ± 0.99 mm, 95% CI = 2.39 to 6.03 mm, p < 0.001). There was a statistically significant positive but weak correlation between the accuracy (d_Feature) and the distance from the ROI (d_ROI) (r = 0.298; p = 0.002).

Conclusion: Despite basing on different rendering techniques both local and external vir3DLivers have comparable registration accuracy, while LPV-based registrations significantly outperform RPV-based ones in accuracy. Higher accuracy can be assumed within distances of up to a few centimeters around the ROI.

Purpose: Robotic-assisted rectal surgery (RARS) and Laparoscopic-assisted rectal surgery are the two techniques that are increasingly used for rectal cancer, and both have their advantages and disadvantages. This meta-analysis will analyze the outcomes of both techniques to determine their relative performance and suitability.

Methods: An extensive search was carried out on PubMed, Cochrane, Scopus, Embase, and Google Scholar, followed by a meta-analysis of all randomized controlled trials (RCTs) to assess both approaches for rectal cancer.

Results: This meta-analysis is comprised of fifteen RCTs. The conversion to open surgery (RR = 0.53, 95% CI: 0.38-0.74, P = 0.0002) was significantly lower in the RARS group. The outcomes like anastomotic leak, postoperative ileus, postoperative urinary retention (POUR), surgical site infection (SSI), and intra-abdominal abscess showed no significant difference between the two groups. The reoperation rate (RR = 0.56, 95% CI: 0.34-0.95, P = 0.03) was lower in the robotic group. High heterogeneity was obtained when pooling data on operative time, length of hospital stay, and blood loss. Oncological outcomes, including local recurrence, the number of harvested lymph nodes (LN) and distal resection margin showed no significant distinction among both groups, while the positive circumferential resection margin (CRM) (RR = 0.67, 95% CI: 0.49-0.91, P = 0.01) was lower in the RARS group. RARS demonstrated a significantly higher rate of total mesorectal excision (TME) (RR = 1.07, 95% CI: 1.01-1.14, P = 0.03).

Conclusion: RARS is safe and feasible for rectal cancer patients and may be superior or equivalent to Laparoscopic-assisted rectal surgery, but high-standard, large-scale trials are required to determine the best approach.

Background: With the rapid implementation of enhanced recovery after surgery, most gynecological patients are discharged without full recovery. Discharge planning is necessary for patients and their families to transition from hospital to home. Discharge teaching and discharge readiness are two core indicators used to evaluate the quality of discharge planning, which impacts the post-discharge outcomes. To improve post-discharge outcomes, the interaction mechanism of the three variables needs to be determined, but few studies have focused on it.

Objectives: Explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes of gynecological inpatients.

Methods: Discharge teaching and discharge readiness were measured by the Quality of Discharge Teaching Scale (QDTS) and Readiness for Hospital Discharge Scale (RHDS). Post-discharge outcomes on postoperative Day 7 (POF-D7) and postoperative Day 28 (POF-D28) were measured by a self-designed tool. Spearman correlations, Kruskal‒Wallis tests and Mann‒Whitney U tests were conducted to explore the correlation between post-discharge outcomes and other variables. Mediation analysis was used to explore the mediating effect of discharge readiness between discharge teaching and post-discharge outcomes.

Results: QDTS and RHDS showed strong positive correlations with post-discharge outcomes. The mediation analyses verified that RHDS was a full mediator between QDTS and POF-D7, and the indirect effect accounted for 95.6% of the total direct effect. RHDS was a partial mediator between QDTS and POF-D28, and the indirect effect accounted for 50.0% of the total direct effect. RHDS was a full mediator between QDTS and total scores of post-discharge outcomes, and the indirect effect accounted for 88.9% of the total direct effect.

Conclusions: Discharge teaching can improve the post-discharge outcomes of gynecological inpatients through the intermediary role of discharge readiness. Doctors and nurses should value the quality of discharge teaching and the discharge readiness improving of gynecological inpatients. Future studies should note the interaction mechanism of the three variables to explore more efficient ways of improving post-discharge outcomes of gynecological inpatients.

Purpose: Despite mobilization is highly recommended in the ERAS^® colorectal guideline, studies suggest that more than half of patients don't reach the daily goal of 360 min out of bed. However, data used to quantify mobilization are predominantly based on self-assessments, for which the accuracy is uncertain. This study aims to accurately measure postoperative mobilization in ERAS^®-patients by validated motion data from body sensors.

Methods: ERAS^®-patients with elective bowel resections were eligible. Self-assessments and motion sensors (movisens: ECG-Move 4 and Move 4; Garmin: Vivosmart4) were used to record mobilization parameter from surgery to postoperative day 3 (POD3): Time out of bed, time on feet and step count.

Results: 97 patients were screened and 60 included for study participation. Self-assessment showed a median out of bed duration of 215 min/day (POD1: 135 min, POD2: 225 min, POD3: 225 min). The goal of 360 min was achieved by 16.67% at POD1, 21.28% at POD2 and 20.45% at POD3. Median time on feet objectively measured by Move 4 was 109 min/day. During self-assessment, patients significantly underestimated their "time on feet"-duration with 85 min/day (p = 0.008). Median number of steps was 933/day (Move 4).

Conclusion: This study confirmed with objectively supported data, that most patients don't reach the daily mobilization goal of 360 min despite being treated by an ERAS^®-pathway with ERAS^®-nurse. Even considering an empirically approximated underestimation, the ERAS^®-target isn't achieved by more than 75% of patients. Therefore, we propose an adjustment of the general ERAS^®-goals into more patient-centered, individualized and achievable goals.

Registration: This study is part of the MINT-ERAS-project and was registered prospectively in the German Clinical Trials Register on 25.02.2022. Trial registration number is "DRKS00027863".

Purpose: The purpose of this randomized controlled trial was to evaluate whether early urinary catheter removal is feasible during epidural anesthesia during gastrointestinal surgery in male patients at high risk for urinary retention.

Methods: Male patients who underwent radical surgery for gastric or colon cancer were enrolled in this randomized controlled trial. Patients were randomized 1:1 into 2 groups: the early group, in which the urinary catheter was removed before removal of the epidural catheter on the second or third postoperative day, and the late group, in which the urinary catheter was removed after removal of the epidural catheter. The randomization adjustment factors were age (≥ 65 or < 65 years) and operative site (gastric or colon). The primary endpoint was urinary retention. The secondary endpoints were the incidence of urinary tract infection and length of postoperative hospital stay.

Results: Seventy-three patients were enrolled between March 2020 and February 2024 and assigned to the Early (n = 37) and Late (n = 36) groups. Four patients withdrew their consent after randomization. The intention-to-treat analysis showed that urinary retention occurred in 4 patients (11.1%) in the early group and 1 patient (3.0%) in the late group (P = 0.20). Urinary tract infection occurred in 1 patient (3.0%) in the late group. The median postoperative hospital stay was 9 days in both groups.

Conclusion: Early urinary catheter removal in male patients undergoing gastrointestinal surgery with epidural anesthesia could increase urinary retention within the expected acceptable range.

Trial registration number: UMIN000040468, Date of registration: May 21, 2020.

Purpose: TULAA combines the laparoscopic and open technique and is considered to be a safe, fast and cost-effective procedure. On the other hand, preparation is limited due to the single instrument, especially in complicated appendicitis. In this study we analyze the outcome of our TULAA patients, focusing on conversion and complication rates.

Methods: We performed a retrospective study including all patients treated with TULAA in our department between 2006 and 2016. We analyzed patient data, operative data, costs, complications, and conversion rate to standard laparoscopic or open appendectomy.

Results: 1275 children and adolescents were enrolled. Mean age was 10.2 years. TULAA was completed in 88% of cases. The overall mean operative time was 33 min. The overall complication rate was 5.7%. The most common complications were wound infection (2.7%), seroma (1.7%) and wound abscess (1.4%). Both the conversion rate and the complication rate were significantly higher in complicated appendicitis. Furthermore, the conversion rate is higher in overweight or obese patients.

Conclusion: TULAA is a safe, quick and cost-effective treatment option for acute appendicitis in children and adolescents. The complication rate and conversion rate are significantly correlated with the degree of appendiceal inflammation and comparable other surgical procedures.