Langenbeck's Archives of Surgery最新文献

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.

Introduction: Quality of life of medical school students is impaired by anxiety or depression. As they spend more than of their time as assistants in the hospitals, it is expected that the quality of life of supervisors directly impacts that of students. The objective of this survey was to assess the quality of life of senior surgeons and medical students in visceral surgery at a university hospital in France.

Methods: The survey was conducted from 1st to 31st December 2024 using the Google Form platform. Two scales of quality of life were utilized: the WHOQOL-BREF and the PROQOL. A correlation matrix was performed to study the association between aspects of quality of life. Multivariate linear regressions were performed for modelling QoL scores.

Results: Among the 106 subjects who responded to the questionnaire, 67 were senior surgeons (63.2%) and 39 were students (36.8%). The mean score on the Stress Traumatic Scale of the PROQOL was the only difference between groups and was found to be lower in the student group (19.9+/-6.9) in comparison to the senior surgeon group (22.9+/-8) (p=0.06). Interestingly, the mental health of the students was found to be improved with the highest score of mental health among the senior surgeons. Of particular interest is the observation that the burnout scale of the students was improved with the best score of the mental health of the senior surgeons.

Conclusion: This study advocates for a strong correlation between the QoL of senior surgeons and that of students.

Purpose: Inflammatory bowel disease (IBD) encompasses two main conditions - Crohn's disease (CD) and ulcerative colitis (UC). Its pathogenesis is vastly unknown but genetics, environmental factors and the gut microbiome are thought to play vital roles. While dysbiosis is thought to be a feature of IBD, its exact role in pathogenesis is unclear.

Methods: Relevant studies were identified through searching Medline and Embase from database inception to January 2025. Only gastrointestinal microbiome studies comparing IBD human patients with healthy controls (HC), performed on faecal, mucosal biopsy, saliva, or oral swab samples were examined. Studies were excluded if they included ≤ 10 IBD patients, did not compare IBD to HC, reported on IBD with other gastrointestinal infections, all were taking IBD medications, or included post-operative bowel resection patients.

Results: Of 83 identified observational studies, most reported reduced alpha and beta diversity in IBD, more prevalent in CD than UC. There was depletion of protective butyrate producing Firmicutes bacteria including Faecalibacterium (specifically F. prausnitzii), Eubacteria, Roseburia, Lachnospiraceae, Ruminococcaceae (mainly R. bromii). There was decreased Bacteroidetes phylum in IBD, with depletion of Bacteroides genus in CD but increased in UC. There was increased Proteobacteria and its family Enterobacteriaceae in IBD.

Conclusions: The gut microbiome in IBD demonstrated reduced biodiversity, more pronounced in CD, with increased pathogenic and reduced beneficial bacteria. While this study demonstrated important associations between the microbiome and IBD, the exact mechanism, whether it be from a multistep process, a causative agent, or interplay between mucosal immunology and dysbiosis, is yet be elucidated.

Background: Postpancreatectomy hemorrhage (PPH) is a severe complication in pancreatic surgery. This study focused on early PPH (E-PPH), aiming to identify its characteristics, evaluate the existing grading criteria by the International Study Group of Pancreatic Surgery (ISGPS), and explore effective treatment strategies.

Methods: Patients undergoing pancreatic surgery between March 2020 and January 2024 in two institutions were screened from prospectively maintained databases. Patients with E-PPH were divided into intervention group and the conservative group. The sites of hemorrhage were determined and categorized. Clinical presentation and outcomes were compared among different grades and interventions.

Results: Among 4062 patients who underwent pancreatic surgery, 113 cases of E-PPH were identified, with an incidence of 2.8%. E-PPH was more concentrated within 24 h (76.2%) and occurred more extraluminally (78.2%). The intervention group had a higher proportion of hemodynamic instability (40.9%) and ICU stays (54.5%). E-PPH in the mesenteric region was more common in pancreaticoduodenectomy (81.9%) and open surgery (90.9%). Branches of the common hepatic artery and superior mesenteric vessel were the majority responsible vessels. Appropriate E-PPH treatment was effective, with successful hemostasis in all intervention cases. The occurrence of ICU admission, the length of ICU and postoperative hospital stay and 90-day mortality were not significantly different between different grades with intervention.

Conclusion: Appropriate therapy for E-PPH could lead to a favorable prognosis. The current definitions and grades for PPH are inadequate and require further modification.

Purpose: The aim of the study was to examine whether there is an incidence difference on surgical site infections between surgeons using different surgical attire during intramedullary fixation for proximal femoral fractures.

Methods: 1,431 patients were included and divided into two groups; surgeons wearing balaclava- or skull caps (490 vs 941). The occurrence of surgical site infection was retrospectively assessed and divided into superficial- and deep wound infections.

Results: The occurrence of superficial wound infections did not differ significantly between the two groups, with three patients in the balaclava and six in the skull cap group (0.6% vs 0.6%, p = 1.00). Similarly, there was no significant difference in the occurrence of deep wound infections between the groups, with one case in the balaclava and eight in the skull cap group (0.2% vs 0.9%, p = 0.18).

Conclusion: This study found no statistically significant difference in the incidence of surgical site infections (including both superficial and deep wound infections) between balaclava caps and skull caps. These results suggest that the type of surgical attire does not have a significant impact on the occurrence of surgical site infections in intramedullary nailing for proximal femoral fractures. Therefore, factors such as cost, and sustainability should be considered when selecting surgical attire. In this context, the skull cap would be the preferred option.