Surgery最新文献

Background: Gene expression profiling of cutaneous melanoma has become pervasive in clinical practice, with minimal independent, nonindustry-sponsored, data to guide implementation and influence practice patterns. We developed a scoring system on the basis of anatomic staging and molecular profiling to risk stratify patients into 4 categories for prospective surveillance.

Methods: Patients with cutaneous melanoma were recruited from 2019 to 2023 for enrollment into the study. Inclusion criteria included pathologic stage IA-IIC and use of a commercialized 31-gene expression profile system. Patients were stratified into 1 or 4 surveillance groups: A1 (stage IA-IIA/gene expression profiling class 1), A2 (stage IA-IIA/gene expression profiling class 2), B1 (stage IIB-IIC/gene expression profiling class 1), and B2 (stage IIB-IIC/gene expression profiling class 2). The primary outcome measure is rate of asymptomatic imaging-detected recurrence. Interim analysis has been performed at median follow-up of 24 months.

Results: A total of 200 patients were enrolled. Mean age was 61.0 years (standard deviation, 14.6 years) and 55.5% of the population was male. Primary lesions were distributed between the head and neck (n = 40, 20%), trunk (n = 76, 38%), and extremity (n = 84, 42%). Median depth was 1.1 mm (range, 0.3-8.8 mm) and 14% had ulceration present. Stage distribution was as follows: IA (n = 82, 41.0%), IB (n = 71, 35.5%), IIA (n = 27, 13.5%), IIB (n = 16, 8.0%), and IIC (n = 4, 2.0%). Gene expression profiling classification was class 1 (n = 145, 72.5%) and class 2 (n = 55, 27.5%). This provided a distribution of 71.0% in A1, 19.5% in A2, 2.0% in B1, and 7.5% in B2. Recurrences have been detected in 16 patients (8.0%) including 12 local/regional (6.0%) and 4 distant (2.0%) recurrences. Recurrence rates by surveillance group are: A1 = 4.9%, A2 = 10.3%, B1 = 0%, and B2 = 33.3%. Recurrences were detected by surveillance imaging in 3 (1.5%), history and physical examination in 10 (5.0%), and symptoms in 3 patient (1.5%), respectively.

Conclusion: Pragmatic implementation of a risk-stratified surveillance strategy has resulted in few instances of asymptomatic, imaging-detected recurrences among early-stage cutaneous melanoma patients at short-term follow-up benchmarks. Further follow-up is necessary to determine the validity of this approach.

Introduction: Application of minimally invasive approaches has met some resistance in pancreaticoduodenectomy because of the technical complexity of the operation and the specific skills required. Use of the robotic approach is increasing, but corroborated results still lack in differentiating outcomes after laparoscopic pancreaticoduodenectomy from outcomes after robotic pancreaticoduodenectomy.

Materials and methods: Data of patients undergoing minimally invasive pancreaticoduodenectomy between 2017 and 2024 were considered. The primary end point was severe complications. To reduce biases, a 1:1 propensity score matching was applied.

Results: The laparoscopic pancreaticoduodenectomy group included 119 patients, and the robotic pancreaticoduodenectomy group included 101 patients. After propensity score matching, each group comprised 85 patients. Severe complications were comparable between the 2 groups (laparoscopic pancreaticoduodenectomy 25.9% vs robotic pancreaticoduodenectomy 29.4%, P = .607). No differences were found in pancreas-specific complications and mortality, whereas length of stay was shorter in robotic pancreaticoduodenectomy (16 days vs 11 days, P = .046). Robotic pancreaticoduodenectomy also had lower operative time (545 minutes vs 505 minutes, P < .001) and blood loss (300 mL vs 200 mL, P = .010). Patients treated for malignant disease did not show differences in R0 rate and lymph nodes harvested.

Conclusion: Robotic pancreaticoduodenectomy was comparable to laparoscopic pancreaticoduodenectomy in terms of complications and had reduced operative time, blood loss, and length of stay.

Background: In humanitarian settings, resuming daily activities after injury is a pivotal aspect of recovery, though under-reported. This study aimed to describe recovery of functioning and identify factors associated with independence in activities up to 6 months after injury in 4 humanitarian settings.

Methods: This prospective cohort study included patients older than 5 years, admitted for acute injury to 4 health facilities managed or supported by Médecins Sans Frontières, located in Cameroon, Central African Republic, Burundi, and Haiti. Aspects of functioning, including independence in activities, using the Activity Independence Measure-Trauma, were assessed at hospital admission and discharge, and at 3 and 6 months after injury. Multivariable logistic regression models were run at discharge, and 3 and 6 months after injury to identify factors associated with independence in activities.

Results: Between June 2020 and January 2022, 554 patients were included, with follow-up data available for 477 and 486 patients at 3 and 6 months, respectively. At 6 months, 257 patients were independent from human and material assistance. Factors associated with independence at several of the time points included being a child, having visceral injury, not having any fracture, having a higher independence at the previous time point, and/or having received early physiotherapy, when adjusted for covariates (P < .05).

Conclusion: Nearly half of patients continued to experience difficulties in functioning at 6 months, emphasizing the necessity for trauma care beyond lifesaving procedures. Early physiotherapy was significantly associated with recovery of independence, indicating its potential to enhance recovery after injury in humanitarian settings.

Background: There is still debate about whether ligation or reconstruction is optimal for the management of the left renal vein during resection of tumors involving the infrarenal inferior vena cava. We assessed factors associated with thrombosis of left renal vein reconstruction.

Methods: We retrospectively reviewed consecutive resections of the infrarenal inferior vena cava between 2010 and 2024.

Results: Of 20 included patients, simultaneous right nephrectomy was performed in 19 patients. Segmental inferior vena cava resection was performed for 19 patients (1 lateral resection). In all cases, a ringed polytetrafluoroethylene prothesis was used for inferior vena cava reconstruction. The left renal vein was reconstructed in 14 cases. Reconstruction included interposition of a polytetrafluoroethylene prosthesis between the left renal vein and the inferior vena cava prothesis (n = 6), direct reimplantation of the left renal vein on the inferior vena cava prosthesis (n = 5), and transposition of the left renal vein on the native inferior vena cava below the natural confluence (n = 3). During the first 90 days postoperatively, thrombosis of the reconstructed left renal vein occurred in 7 patients (50%) (4 after direct reimplantation and 3 after interposition of a polytetrafluoroethylene prothesis). The rate of left renal vein reconstruction thrombosis was significantly higher in cases of preoperative stenosis of the confluence of the left renal vein into the inferior vena cava (5/7; P = .02) and cases of collateral left genital or lumbar veins with diameter ≥10 mm (7/7; P < .0001). The rate of acute renal failure did not differ between reconstructed and ligated left renal vein (2 vs 1; P = .467). Left renal vein reconstruction thrombosis was not associated with chronic renal failure in long-term follow-up.

Conclusion: During resection of the infrarenal inferior vena cava with simultaneous right nephrectomy, large lumbar or genital veins (≥10 mm) seen in preoperative imaging may obviate the need for left renal vein reconstruction. Because of the small size of this study, this finding needs to be confirmed prospectively in larger series.

Background: Colorectal cancer is increasing in low- and middle-income countries, necessitating improved worldwide access to acute oncologic care. This study aimed to evaluate global outcomes of emergency surgery in acute colorectal cancer.

Methods: The Acute Presentation of Colorectal Cancer-an International Snapshot study was a prospective international cohort study of adults acutely admitted with colorectal cancer (January-June 2023). Key outcomes included rates of urgent/immediate surgery, resection margin positivity (R1/R2), and surgeon specialization compared across high-income, upper- middle-income, and low- and middle-income countries. Risk-adjusted models analyzed 90-day complications and mortality.

Results: The study included 1,861 patients (high-income: 1,410 patients, 18 countries; upper- and middle-income: 277 patients, 11 countries; low- and middle-income: 174 patients, 10 countries). Urgent- or immediate-surgery rates were highest in low- and middle-income countries (high-income: 43.2%; upper- and middle-income: 47.7%; low- and middle-income: 56.3%; P = .001, adjusted odds ratio 2.18, 95% confidence interval 1.48-3.21). Low- and middle-income countries had higher R1/R2 resection rates (high-income: 23.5%; upper- and middle-income: 41.3%; low- and middle-income: 52.2%; P < .001) independent of cancer stage, and 38% of surgeries were performed by nonspecialist surgeons (high-income: 18%; P < .001). Adjusted 90-day complication rates were similar, but mortality was higher in low- and middle-income countries (27.6% vs 16.1% in high-income; P = .005, adjusted odds ratio 2.84, 95% confidence interval 1.17-6.92).

Conclusion: Patients presenting with acute colorectal cancer in low- and middle-income countries are more likely to undergo urgent surgery, but have decreased access to specialized surgical care and hospital capacity to rescue. Urgent efforts are needed to empower the global health care workforce and facilitate equitable access to safe unplanned surgery.

Background: Mild autonomous cortisol secretion is identified in up to 50% of patients with adrenal nodules after a low-dose dexamethasone-suppression test. Although steroids are routinely started in patients with Cushing syndrome after adrenalectomy, there is confusion about postoperative steroid replacement in patients with mild autonomous cortisol secretion. The aim of this study was to investigate the frequency and clinical predictors of postoperative steroid replacement in patients with mild autonomous cortisol secretion undergoing unilateral adrenalectomy.

Methods: This was an institutional review board approved retrospective study. Mild autonomous cortisol secretion was defined as preoperative serum cortisol level of >1.8 μg/dL after low-dose dexamethasone suppression without signs and symptoms of overt Cushing syndrome. In patients who underwent unilateral adrenalectomy between 2000 and 2024 for mild autonomous cortisol secretion, a decision for postoperative steroid replacement was made based on a combination of parameters, including postoperative day 1 cortisol levels, adrenocorticotropic hormone stimulation test results and clinical evidence of adrenal insufficiency. Univariate and multivariate logistic regression models were used to identify predictors of steroid replacement. Continuous data are expressed as medians (interquartile ranges).

Results: There was a total of 139 patients with mild autonomous cortisol secretion who underwent minimally invasive adrenalectomy. All patients had am cortisol levels, and 85 patients had adrenocorticotropic hormone stimulation tests done on postoperative day 1. Postoperative steroid replacement was done on 32 patients on the basis of postoperative day 1 cortisol level <5 μg/dL (n = 15), postoperative day 1 cortisol level <10 μg/dL and failed adrenocorticotropic hormone stimulation test (n = 15), and or symptoms of adrenal insufficiency (n = 2). Independent predictors of postoperative steroid replacement therapy included preoperative plasma adrenocorticotropic hormone <7.0 pg/mL (P = .02) and cortisol >4.2 μg/dL on low-dose dexamethasone test (P = .008). Patients were followed up for a median of 15 months (interquartile range, 5-38 months) with no evidence of adrenal insufficiency with this management. Steroids were weaned off within a median of 78 days (interquartile range, 35-251 days).

Conclusion: To the best of our knowledge, this is the largest study to date on postoperative steroid management of patients with mild autonomous cortisol secretion. A safe algorithm was described to select patients for steroid replacement. In contrast to previous reports in the literature, a minority (23%) of the patients with mild autonomous cortisol secretion needed postoperative steroid replacement in this cohort with the algorithm used.

Objective: To develop explainable machine learning models for predicting the risk of early postoperative recurrence and distant metastasis in patients with early-onset colorectal cancer.

Methods: Patients with early-onset colorectal cancer who underwent radical resection at the 900th Hospital of PLA Joint Logistic Support Force (2014-2020) were included. Clinical data were retrieved from electronic medical records with 3-year postoperative follow-up. Patients were stratified into recurrence/metastasis and no recurrence/metastasis groups based on clinical outcomes. Feature selection was performed using univariate analysis and least absolute shrinkage and selection operator regression. Subsequently, 5 machine learning algorithms-k-nearest neighbors, logistic regression, random forest, support vector machine, and extreme gradient boosting-were employed to develop predictive models. Model performance and clinical utility were validated through receiver operating characteristic curves and their corresponding area under the curve values, calibration curves, and decision curve analysis. Model explainability was assessed using Shapley additive explanations.

Results: Among 256 enrolled patients with early-onset colorectal cancer, 121 (47.3%) experienced recurrence/metastasis. Ten predictive features were identified: T stage, N stage, histologic subtype, vascular/neural invasion, carcinoembryonic antigen, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, hemoglobin-to-red blood cell distribution width ratio, triglyceride-glucose index, and Prognostic Nutritional Index. The random forest model demonstrated optimal performance in the test set (area under the curve 0.827, sensitivity 0.760, specificity 0.852, accuracy 0.808, precision 0.826, F1 score 0.792). Shapley additive explanations analysis revealed T stage as the most influential predictor.

Conclusion: Among the 5 machine learning models developed, the random forest algorithm demonstrated superior predictive performance for early postoperative recurrence and distant metastasis in patients with early-onset colorectal cancer. Explainable random forest models can provide personalized clinical decision making for the diagnosis and treatment of these patients.

Background: As rectal cancer management evolves, the multidisciplinary committee becomes increasingly important in integrating expertise to optimize patient outcomes. Current artificial intelligence large language models have demonstrated preliminary capacity to apply medical guidelines to specific patient scenarios. This study assesses the ability of these publicly available artificial intelligence large language models (Gemini, Grok, ChatGPT) to predict multidisciplinary committee recommendations for rectal cancer.

Methods: Adult patients who presented to the multidisciplinary committee at a Canadian tertiary hospital with a new diagnosis of rectal adenocarcinoma before March 2025 were sequentially and retrospectively included in the study. Baseline demographic characteristics were recorded. Redacted patient vignettes were presented to each artificial intelligence large language models, and concordance between artificial intelligence large language models and multidisciplinary committee management recommendations was graded on a 5-point Likert scale by 3 independent reviewers. The Cohen κ coefficient was used to assess inter-rater agreement, and descriptive statistics, odds ratios, and multivariable regression used to assess each artificial intelligence large language model's performance.

Results: One hundred patients were included, with a median age of 60 years (range, 38-90 years). Most patients were male (70%), with a mean Charlson comorbidity index of 4.37 (range, 2-10). All 4 stages of rectal cancer were represented. Gemini had the greatest average concordance with multidisciplinary committee recommendations (3.89/5), with ChatGPT (3.33/5) and Grok (3.01/5) showing promise. Grok and Gemini concordance with multidisciplinary committee recommendations increased with positive nodal status when patients have limited options for management.

Conclusion: Artificial intelligence large language models have substantial ability to replicate multidisciplinary committee recommendations but struggle with nuance. With improvement, artificial intelligence large language models can have a future role in health care decision support and guideline integration.