Langenbeck's Archives of Surgery最新文献

Aim: Two main theories have been proposed for the development of sacrococcygeal pilonidal sinus disease (SPSD), but the exact etiology remains unclear. Better understanding of etiologic factors could improve insight into the disease and help prevent both primary and recurrent pilonidal sinus disease. This study aimed to identify etiologic factors in the development of pilonidal sinus disease.

Method: For this case control study, potential etiologic factors such as family history of SPSD, BMI, working in a sitting position, and smoking were evaluated in 83 patients with primary SPSD and 83 controls. Additionally, anatomical factors, including the depth, width, and hair density of the natal cleft were compared. Lastly, microscopic hair analysis assessed hair characteristics such as thickness, pigmentation, breakage, hair cuticle irregularities and hair thickness irregularities.

Results: Patients with SPSD were significantly more often smokers and had a family history of SPSD. They also had a significantly shallower and wider natal cleft, a greater number of hairs in the natal cleft, and these hairs were significantly thicker with more cuticle and thickness irregularities compared to the controls. However, after multivariable analysis, only working in a sitting position, a shallower natal cleft and more hairs at the natal cleft were independently associated with SPSD.

Conclusion: A shallower natal cleft, more hair at the natal cleft and working in a sitting position were independent etiologic factors of SPSD. Therefore, keeping the natal cleft free of hair and avoiding prolonged sitting position should be recommended as preventive measures when counselling patients with SPSD.

Background: In-office fluoroscopy can be a useful tool for foregut and bariatric surgeons. It can be used to evaluate patients before and after surgery. Fluoroscopy provides a platform to teach patients about their anatomy and even be used to modify behavior. Based on our clinical experience, IOF appears to provide valuable insights in selected patient populations where conventional diagnostics are inconclusive Xu (BJR|case Rep 3:1-20160076, 2017). Our experience with fluoroscopy began with the popularity of adjustable gastric bands. Our practice does not advocate for the blind access of band ports. Because there are multiple types of bands made by multiple companies we find that the blind accessing of ports and thus the blind guessing of the amount of fluid to put in or take out of a band is unacceptable. For years, we utilized fluoroscopy for our band patients to accurately and safely adjust their bands to create the desired amount of restriction [2]. As the band fill frequency and popularity has waned, we fortuitously found that fluoroscopy was helpful in other scenarios.

Methods: Between January 2019 and December 2024, patients presenting to our bariatric and foregut surgery clinic underwent IOF based on clinical indications, including postoperative symptoms, evaluation of prior surgical anatomy, or preoperative assessment for GERD. All procedures were performed using a GE Healthcare OEC One C-arm and interpreted by the attending surgeon. We present 11 representive cases to illustrate the clinical utility of IOF. Patient consent for use of de-identified imaging and clinical data was obtained.

Purpose: Lateral lymph node dissection for rectal cancer is challenging because of the presence of blood vessels and nerves essential for postoperative genitourinary function and leg movements. Identifying these structures during surgery is crucial. We developed a deep learning-based semantic segmentation model to recognize and visualize critical anatomical structures during laparoscopic lateral lymph node dissection automatically.

Methods: Intraoperative video data from laparoscopic lateral lymph node dissections performed on 22 patients between 2018 and 2021 were used. Specific scenes from the beginning to end of the procedures were extracted and divided into still images, which were annotated to delineate the external iliac artery, external iliac vein, and obturator nerve. The model was trained with pixel-level annotation labels, and its performance was evaluated using precision, recall, and the Dice coefficient through five-fold cross-validation.

Results: Overall, 992 images were extracted from 22 lateral lymph node dissection videos. The Dice coefficient values were 0.789 (± 0.009), 0.736 (± 0.033), and 0.574 (± 0.082) for the obturator nerve, external iliac artery, and external iliac vein, respectively. The model's inference speed was 12.7 fps, corresponding to processing one still image in 0.08 s, enabling near real-time intraoperative analysis.

Conclusion: The deep learning-based semantic segmentation model automatically recognized the obturator nerve, external iliac artery, and external iliac vein during laparoscopic lateral lymph node dissection, achieving reasonable segmentation accuracy as measured by the Dice coefficient. This technology will be used as a foundation for developing surgical navigation systems to improve the safety and efficiency of lateral lymph node dissection procedures.

Objective: Esophageal squamous cell carcinoma (ESCC) remains a significant health concern, particularly among older patients. While both minimally invasive esophagectomy (MIE) and open esophagectomy (OE) are established surgical types, there is ongoing debate about their comparative long-term outcomes in older patients.

Methods: This retrospective cohort study analyzed data from 469 patients with ESCC aged over 70 years who underwent esophagectomy between May 2016 and August 2021. Patients were divided into MIE and OE groups. Overall survival (OS), disease-free survival (DFS), and postoperative complications were evaluated. Propensity score matching was performed to minimize selection bias. Complications were assessed using the Clavien-Dindo classification system.

Results: Among 469 patients, 358 (76.33%) underwent MIE, while 111 (23.67%) underwent OE. After a median follow-up of 47.5 months, the MIE group had significantly better OS (median OS: 60.17 vs. 29.18 months, HR = 1.566, P = 0.002) and DFS (median DFS: 37.70 vs. 25.20 months, HR = 1.411, P = 0.010) compared to the OE group. After PSM, MIE remained associated with significantly improved OS (HR = 1.450, P = 0.039), while the difference in DFS was no longer significant (HR = 1.240, P = 0.201). The incidence of Clavien-Dindo grade III-IV complications was similar between groups.

Conclusion: MIE is associated with better long-term survival outcomes compared to OE in older patients with ESCC, without increasing major postoperative complications. These findings support the consideration of MIE as a preferred surgical approach for older patients with ESCC to enhance survival and optimize postoperative recovery.

Background: Multiple renal arteries (MRA) in a donor kidney can increase surgical complexity in living donor kidney transplantation. However, the impact of MRA on early transplant outcomes, including delayed graft function (DGF) and early graft failure, remains unclear.

Methods: We performed a single-center retrospective cohort study of 1,200 living donor kidney transplants conducted between 2019 and 2024. Donor kidneys were classified as having a single renal artery or multiple renal arteries (two or more). Recipient and donor characteristics, intraoperative details (ischemia times, vascular anastomosis technique), and postoperative outcomes (delayed graft function [DGF], primary nonfunction, and graft survival) were compared between the two groups. Logistic regression analyses were used to examine associations between MRA and the risk of DGF or graft failure within the first 90 days, both before and after adjusting for prespecified covariates.

Results: Of the 1,200 transplanted kidneys, 882 (73.5%) had a single artery and 318 (26.5%) had multiple arteries. Although the median cold-ischemia time was longer for multi-artery grafts (35.2 min vs. 29.4 min, p = 0.004), there were no significant differences in donor or recipient baseline characteristics. Multivariable logistic regression revealed no significant association between MRA and either DGF or early graft loss. Kaplan-Meier curves, censored for death, demonstrated similar graft survival in both groups (log-rank p = 0.25).

Conclusions: In this single-center cohort of living donor kidney transplants, grafts with multiple renal arteries did not exhibit an elevated risk of DGF or early graft loss. While additional surgical complexity is often required for MRA grafts, our findings suggest that these kidneys remain a safe and effective option for transplantation, supporting their broader use to expand the donor pool.

Background: Gastric cancer remains a major clinical challenge with poor prognosis. This study investigated survival outcomes based on treatment strategy, tumor stage, and histology in Danish gastric cancer patients.

Methods: From January 2013 to December 2021, 2,156 gastric cancers were registered in the Danish Esophagogastric Cancer Group database, covering 99% of national cases. Data were analyzed for patients with intestinal and diffuse-type cancers. Survival was assessed using Kaplan-Meier curves and Cox regression, adjusting for tumor stage, treatment, and demographics.

Results: Median survival was significantly higher with surgery ± perioperative chemotherapy (SCT) than with palliative treatment. For the intestinal-type cancers, SCT resulted in a median survival of 45.2 months (95% CI [35.4-55.1]) versus 5.1 months (95% CI [4.6-5.7]) with palliative treatment. Patients with diffuse type, treated with SCT had a median survival exceeding 128 months, compared with 6.3 months (95% CI [5.2-7.5]) with palliative treatment. Patients receiving epirubicin based CT had a lower risk of death (HR 0.74, p = 0.04) compared with upfront surgery, while FLOT (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel) similarly reduced the risk of death (HR 0.69, p = 0.04). No significant difference was observed between the two CT regimens. Palliative CT and radiotherapy improved survival over best supportive care (p < 0.001). Advanced tumor stage was associated with worse survival, while the histological subtype had no impact on overall survival outcomes.

Conclusion: This study emphasizes the survival benefit of multimodal treatment strategies, especially surgery combined with perioperative CT. Palliative interventions also improved outcomes in advanced disease.

Purpose: Considering that the treatment of patients with complex vascular disease requires multidisciplinary collaboration in teams and personality traits can impact team dynamics, we investigated the personality structures of vascular surgeons, cardiothoracic surgeons, and interventional radiologists using the validated big five model.

Methods: A cross-sectional study utilizing the validated Big Five Inventory-2 (BFI-2) questionnaire. Corrected one-way analyses of variance were performed to compare personality domain scores between the specialist groups. Questionnaires were distributed among all Dutch general surgery departments and through the Dutch Societies for Interventional Radiology (NVIR) and Cardiothoracic Surgery (NVT). A total of 224 specialists participated: 78 interventional radiologists (mean age 48.2y, 20.5% female), 41 cardiothoracic surgeons (mean age 49.2y, 26.8% female), and 105 vascular surgeons (mean age 49.9y, 17.1% female).

Results: For the personality domains agreeableness and negative emotionality, differences were observed between the three specialist groups, while the scores for open-mindedness, conscientiousness, and extraversion were similar. In particular, cardiothoracic surgeons scored higher on agreeableness (4.13 vs. 4.00; p = .046) relative to interventional radiologists. Vascular surgeons had lower scores on negative emotionality relative to interventional radiologists (2.00 vs. 2.20, p = .007). Differences at the facet-level were present in four of the five personality domains between interventional and surgical specialists, including sub-traits such as compassion, creative imagination, and assertiveness.

Conclusion: While vascular surgeons, cardiothoracic surgeons, and interventional radiologists are involved in shared cardiovascular care pathways, they display nuanced differences across domains and more granular facets of personality. These findings lay the foundation for studies on self-awareness and interprofessional collaboration in shared clinical pathways through joint understanding of personality in multidisciplinary teams.

Purpose: Body composition has a significant role to predict survival in patients with malignant disease. This study evaluates the importance of body composition for predicting short- and long-term survival after liver transplantation. Additionally, the sex specific differences will be evaluated.

Methods: Body composition, of all patients who underwent liver transplantation between January 2011 and December 2023 with computed tomography prior liver transplantation, was assessed fully automated with AI based technique. Pre-, intra- and postoperative data were retrospectively reported. Uni- and multivariate regression analyses was performed to identify independent prognostic factors for survival. The statistical analyses was performed separately for male and female with comparison of the both groups.

Results: There were 346 patients (60.1%male, 39.9%female) with median age of 52.2 years (SD 10.8) included to the study. The univariate and multivariate cox regression analyses have identified the ratio of the subcutaneous fat volume to muscle volume as well as the ratio of the visceral fat volume to muscle volume as significant prognostic parameter for the overall survival. The separate analyses of the two groups show that these factors predict survival in male and female. However, visceral fat and also the ratio of FVM is significantly higher in male.

Conclusion: Based on the results of our study we can conclude that the ratio of visceral fat volume to muscle volume (FVM-ratio) has an essential impact on overall survival after liver transplantation in male and female patients. The fully automated AI based assessment is fast, accurate and investigator independent.

Purpose: Historically, laparoscopic partial splenectomy has been associated with high rates of conversion to open surgery due to technical challenges. This emphasizes the need for surgical options that allow benign splenic lesion removal with splenic function preservation. Previous approaches primarily blocked the splenic artery, with inadequate intraoperative bleeding control. We aimed to evaluate postoperative clinical recovery and prognostic outcomes of patients who underwent modified three-block laparoscopic partial splenectomy.

Methods: This retrospective study assessed 18 patients with benign splenic lesions who underwent modified three-block laparoscopic partial splenectomy between April 2019 and February 2024. Patient eligibility was determined using predefined criteria; those with malignant lesions or severe comorbidities were excluded. The same laparoscopic hepatobiliary specialist performed all procedures using both splenic artery and pedicle occlusion techniques to minimize intraoperative blood loss.

Results: The cohort included 7 men and 11 women, with no conversions to open surgery. The mean operation time was 167.33 ± 59.08 min. The intraoperative blood loss was 50.00 [50.00, 100.00] mL, with no blood transfusion. All patients ambulated within 24 h post-surgery, with a mean hospital stay of 6.5 ± 1.76 days. Only one patient experienced transient pleural effusion classified as a Child-Pugh grade I complication. Follow-up evaluations demonstrated successful tissue preservation, with no overwhelming postsplenectomy infection.

Conclusions: Modified three-block laparoscopic partial splenectomy is a safe and effective approach for managing benign splenic lesions with preservation of splenic function. This technique not only reduces intraoperative bleeding but also facilitates rapid postoperative recovery, thereby mitigating the risks associated with total splenectomy.

Purpose: Postoperative pulmonary complications (PPCs) following liver surgery are associated with considerable morbidity and mortality. Nevertheless, data regarding the effectiveness of short-term, self-conducted preoperative respiratory training on pulmonary function and its influence on postoperative recovery are limited.

Methods: Patients scheduled for liver surgery at the University Hospital Dresden, were screened for eligibility and randomized 1:1 to the intervention or control group. The intervention consisted of self-conducted respiratory training with an incentive spirometer for 14 consecutive days before surgery. Pulmonary function was assessed using longitudinal bodyplethysmography. The feasibility of the study design and clinical outcomes were evaluated.

Results: Sixty-two patients were screened, 50 participants (81%) were randomized. Twenty control and 21 intervention participants (66.1%) completed all assessments and were included in the final analysis. Participants in the intervention group were highly compliant with the proposed inhalation training. Preoperative risk stratification for PPCs conducted according to the ARISCAT score revealed a high risk for PPCs in > 90% of all patients. Pneumonia occurred in 0 of intervention patients compared to 5 (25%) in the control group (p = 0.016). Pleural effusion was observed in 8 (38.1%) of intervention patients versus 16 (80%) in the control group (p = 0.007).

Conclusion: This pilot trial establishes the feasibility of a definitive randomized controlled trial to investigate the effect of short-term, self-conducted preoperative respiratory training on pulmonary function for the prevention of PPCs after hepatic resection.