Surgery Today最新文献

Postcholecystectomy syndrome (PCS) may result from either subtotal cholecystectomy or unintentional incomplete resection, leading to remnant gallbladder or residual cystic duct pathology. This scenario often presents years later, complicated by lithiasis that is not amenable to endoscopic treatment and prior surgery performed via laparotomy, typically due to difficult anatomy. Thus, reoperation becomes a technically demanding scenario, revisiting a surgical battlefield shaped by dense adhesions and distorted landmarks. We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review across five databases, including studies with five or more patients undergoing laparoscopic or robotic reoperation for remnant gallbladder or cystic ducts. Data on the surgical approach, complications, conversion, and symptom resolution were collected and analyzed descriptively. Nineteen studies (443 patients) were included (407 laparoscopies and 36 robotic surgeries). The overall morbidity rate was 9.0%; conversion to open surgery occurred in 3.6% of the patients in the laparoscopic group. The robotic subgroup showed no conversions and a slightly lower morbidity (5.6%) than the laparoscopic cohort. The symptom resolution rate was 98.4%. Reoperations are often indicated after failed endoscopic retrograde cholangiopancreatography. Minimally invasive reoperation is feasible and safe in select cases of PCS, even in hostile surgical fields. Robotics offers enhanced precision and visualization and is particularly valuable in reoperative biliary surgery. Prospective studies are needed to determine optimal indications.

Minimally invasive esophagectomy (MIE) has been adopted widely, but achieving an adequate surgical view during laparoscopic gastric mobilization is difficult, which can prolong the operation time and increase intraoperative blood loss. We describe a new laparoscopic approach using 5 trocars, starting with mobilization of the gastric fundus. First, we dissect around the hiatus and mobilize the gastric fundus; then we divide the left gastric artery and vein, and mobilize the greater curvature. In our experience of performing this procedure in 10 patients, the median operative time and blood loss were 410 min and 200 mL, respectively, and the median duration of the procedure was 90 min. There were no cases of anastomotic leakage (AL) and only one case of anastomotic stricture, which was managed with endoscopic dilatation. Our novel laparoscopic approach for gastric mobilization demonstrates potential for safety and feasibility as a minimally invasive form of McKeown esophagectomy.

Purpose: Seroma formation is a common complication of mastectomy. Recently, flap fixation using sutures was shown to significantly reduce the number of seroma aspirations. We attempted a new flap fixation technique to reduce seromas in patients undergoing mastectomy with a sentinel node biopsy (SLNB).

Methods: At Aichi Medical University, 469 patients with clinical stage 0-II breast cancer underwent mastectomy with an SLNB in 2018-2022. There were 47 patients who underwent flap fixation using sutures (study group) and 422 who underwent conventional wound closure (control group).

Results: In patients undergoing mastectomy with an SLNB, the drainage tube was removed within five days in the control group and three days in the study group. The median total in-hospital drainage volumes were 200 mL in the control group and 114 mL in the study group. After discharge, the study group had fewer seroma aspirations than did the control group. The total seroma volumes were 242 mL in the control group and 134 mL in the study group (p < 0.001). These results were the similar regardless of body mass index.

Conclusions: Our flap fixation technique resulted in approximately half of the usual total drainage volume. Many patients do not require outpatient visits for seroma aspiration, thus simplifying postoperative management.

Purpose: To clarify the characteristics of patients who received systemic therapy for recurrent hepatocellular carcinoma after liver resection and evaluate the associated prognostic factors.

Methods: We retrospectively analyzed data from 177 hepatocellular carcinoma patients with recurrence after liver resection; 79 received tyrosine kinase inhibitors or immune checkpoint inhibitors. Prognostic factors were analyzed in the patients who received systemic therapy.

Results: The median survival time after the initiation of systemic therapy was 23.3 months among the patients who received such therapy. These patients had more advanced disease at recurrence than those who did not receive systemic therapy. In the systemic therapy group, a deterioration of liver function relative to the preoperative status, expressed as the change in the albumin-bilirubin score (≥ 0.469 vs. <0.469), was independently associated with a poorer survival (9.5 vs. 25.2 months, respectively; P = 0.022). Receiving multiple regimens was associated with a longer survival than receiving a single regimen (36.6 vs. 17.7 months, respectively; P = 0.023). Four patients (5.1%) achieved complete remission, two with systemic therapy alone and two after conversion therapy; all achieved a long-term overall survival.

Conclusions: A preserved liver function and multiple systemic therapy regimens are favorable prognostic factors. Achieving complete remission results in an improved long-term survival.

Purpose: Lynch syndrome (LS), the most common hereditary colorectal cancer (CRC), is caused by germline mutations in mismatch repair (MMR) genes, resulting in microsatellite instability-high (MSI-H) tumors. Lynch-like syndrome (LL) exhibits MSI-H and MMR deficiency, but lacks identifiable germline MMR mutations. Although LS/LL CRCs share clinical and molecular features, they are distinct from sporadic MSI-H (SM) CRCs, emphasizing the need for refined molecular classification. This study investigated the somatic alterations that distinguish LS/LL CRC from SM CRC.

Methods: Whole-exome sequencing (WES) was performed on 49 LS/LL CRC and 96 SM CRC samples. Tumor-normal paired data were analyzed using GATK and MuTect2 to detect somatic variants. Mutation frequencies were compared using Fisher's exact test (p < 0.005). Logistic regression and receiver operating characteristic (ROC) curve analyses were used to evaluate the discriminatory performance.

Results: We identified 11 gene regions that were significantly enriched in LS/LL CRC, including KRAS, ITGB3BP, CLEC16A, ARHGEF28, PIK3CA, and RBM26. A variant panel based on these alterations showed an area under the curve (AUC) of 0.85 and an Akaike information criterion of 129.81.

Conclusions: These findings support the utility of LS/LL-specific somatic variants in stratifying MSI-H CRCs and identifying hereditary cases for personalized management.

Purpose: This study aimed to explore the value of neutrophil-to-platelet ratio (NPR) in predicting postoperative prognosis of distal cholangiocarcinoma(dCCA).

Methods: The optimal cutoff value of NPR was determined using a receiver operator characteristic curve (ROC) analysis. Patients were divided into low- and high-NPR groups, and perioperative data and long-term survival were compared. Independent risk factors for postoperative tumor recurrence and long-term survival were identified using univariate and multivariate analyses. An NPR-based prediction model was established and verified using ROC, calibration curve, and decision curve analyses.

Results: A total of 168 patients were included. The area under the ROC curve of preoperative NPR was 0.617, and the optimal cutoff value was 0.014. Postoperative disease-free survival and overall survival were significantly longer in the low-NPR group. Univariate and multivariate analyses indicated that NPR > 0.014 was an independent risk factor for postoperative recurrence (RR = 1.745, 95%CI: 1.027-2.965) and long-term survival (RR = 1.837, 95%CI: 1.127-2.993). The NPR-based prediction model could improve the predictive ability for the postoperative prognosis. Patients with a high preoperative NPR may have an advanced TNM stage and portal vein invasion.

Conclusion: Elevated NPR is an independent risk factor for postoperative tumor recurrence and a poor long-term prognosis in patients with dCCA.

Purpose: This study aimed to investigate the impact of an intraoperative external biliary drainage (EBD) tube on late benign biliary anastomotic strictures (BAS) after pancreaticoduodenectomy (PD).

Methods: Between 2011 and 2020, 209 patients who underwent PD, including 39 patients with an EBD tube placed in a hepaticojejunostomy (H-J) during surgery (EBD group) and 170 patients without EBD (no-EBD group), were enrolled. Clinical data and the incidence of BAS were compared between the groups.

Results: Thirty-four patients (16%) developed BAS, with a median interval of 5.6 months. Although the incidence of BAS was not significantly different, that of bile leakage (BL) was significantly lower in the EBD group (0% vs. 5%, p = 0.05). On multivariate analysis, a common hepatic duct (CHD) diameter < 7 mm and alkaline phosphatase (ALP) > 500 IU/L three months after surgery were independent risk factors for BAS. In patients with CHD diameter < 7 mm, the incidence of BL, BAS, and after PD was significantly lower in the EBD group, whereas there was no difference between the two groups in patients with CHD diameter ≥ 7 mm.

Conclusion: In patients with CHD diameter < 7 mm, an EBD tube should be placed in the H-J during PD.

Stem cell transplantation has emerged as a promising therapeutic modality for the treatment of anal fistulas, showing significant potential in addressing this challenging condition. This review aims to summarize the latest research advancements in the field of stem cell therapy for anal fistula, focusing on the underlying mechanisms that contribute to healing, the clinical applications that have been explored in various studies, and the assessment of therapeutic efficacy. Despite these encouraging results, several issues remain, including the optimal source of stem cells, methods of administration, and long-term outcomes. The review will also discuss future research directions, emphasizing the need for standardized protocols and larger-scale clinical trials to establish the safety and effectiveness of stem cell transplantation in routine clinical practice.

Purpose: Robotic total mesorectal excision (R-TME) is widely used to treat rectal cancer; however, data on robotic beyond TME (R-bTME) remain limited. The present study compared the short-term outcomes between robotic standard TME (R-sTME) and R-bTME in patients with primary rectal cancer.

Methods: This retrospective multicenter study included patients with mid-to-low rectal cancer who underwent robotic surgery between 2017 and 2024. The primary endpoint was postoperative morbidity, defined as Clavien-Dindo grade ≥ II.

Results: Of the 462 patients, 391 underwent R-sTME, and 71 underwent R-bTME. In the R-bTME group, the resected sites most commonly involved the lateral compartment (72%), particularly lateral lymph nodes (63%), followed by the anterior compartment (18%), where uterine resection was most frequent, and the posterior compartment (11%), predominantly involving the hypogastric nerve. Overall morbidity was higher in the R-bTME group than in the R-sTME group (26.8% vs. 16.4%), primarily due to increased urinary dysfunction. However, the rates of severe complications (Clavien-Dindo grade ≥ III), infectious complications, anastomotic leakage, and conversion were comparable between the groups. The rate of positive radial margin (RM) was higher in the R-bTME group than in the R-sTME group (8.5% vs. 1.0%), reflecting more advanced local disease.

Conclusions: R-bTME is feasible for advanced primary rectal cancer when performed in select patients at experienced centers.