Surgery Today最新文献

Purpose: One of the challenges in performing surgery on obese patients with rectal cancer is the prolonged operation time. This study investigates whether or not this issue can be overcome through the surgeon's learning curve as they become proficient in robotic surgery.

Methods: A retrospective review of 396 consecutive robotic procedures. The cases were divided into a learning phase (LP) group (first 20 cases) and a stabilized phase (SP) group (from case 21 onward). Patients were divided into obese (BMI ≥ 25 kg/m²) and non-obese groups using 1:1 propensity score matching. This resulted in 130 and 72 patients in the LP and SP groups, respectively. The primary endpoint of this study was operation time.

Results: In the LP group, obese patients had significantly longer operative times (329 min vs. 289 min) and greater blood loss (10 g [0-50] vs. 10 g [0-12]) than non-obese patients. In the SP group, the perioperative outcomes, including operation time, were similar between the two patient groups.

Conclusion: This study suggests that during the early phase of the learning curve, operation time may be prolonged in obese patients. However, once the learning curve stabilizes, the issue of prolonged operative time can be overcome.

Purpose: Machine learning (ML) is a method of creating models by learning latent patterns and features from collected data to predict and classify new unknown data. We constructed an ML model to predict postoperative complications using various pre- and intraoperative factors from electronic medical records and examined its prediction accuracy.

Methods: Data of 617 patients who underwent major organ resection were included in this study. Patient information was collected from the medical records. Consequently, we created Dataset 1, which included all of the data, and Dataset 2, which was adjusted for the factors. The ML models were applied to the two datasets, and the performances of the ML models were compared.

Results: In Dataset 1, the Logistic Regression model showed the best performance, with correct predictions of serious postoperative complications (accuracy), area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve (AUPRC) values of 0.798, 0.671, and 0.374, respectively. The random forest (RF) model performed best in Dataset 2, with accuracy, AUROC, and AUPRC values of 0.855, 0.725, and 0.412, respectively.

Conclusions: The RF model performed well in predicting serious postoperative complications of gastrointestinal surgery. Further studies are required to improve the accuracy of this ML model for clinical applications.

Purpose: When using the stomach for esophageal reconstruction is not viable, the jejunum or colon is used, but the optimal choice of organ remains unclear.

Methods: We conducted this multicenter retrospective cohort study to compare the short-term outcomes of patients who underwent jejunal or colonic reconstruction across four centers between January 2011 and March 2023. We also conducted a meta-analysis of studies published before November 2024 using the Mantel-Haenszel random-effects model to compare cervical anastomosis outcomes between jejunal and colonic reconstruction after esophageal cancer surgery.

Results: Vascular anastomosis was more frequent in the jejunal group (n = 16; p = 0.001), whereas simultaneous gastrectomy was more common in the colonic group (n = 13; p = 0.029). No significant differences were observed in anastomotic leakage (31.3 vs. 46.2%, p = 0.466), graft necrosis (6.3 vs. 0.0%, p = 1), or hospital mortality (6.3 vs. 7.7%, p = 1) between the groups. The meta-analysis showed a trend toward reduced leakage for jejunal reconstruction with vascular anastomosis (OR = 0.42, 95% CI = 0.16-1.01, p = 0.05). Other outcomes were similar.

Conclusions: The short-term outcomes of jejunal and colonic reconstructions were comparable. Jejunal reconstruction with vascular anastomosis may reduce leakage, but its prognostic benefits remain unclear.

Trial registration: no. M-2023-102.

Purpose: To assess the predictive value of the endotoxin (ET) assay for the detection of anastomotic leakage (AL) after colorectal surgery (CRS).

Methods: ET levels in the drainage fluid were measured using endotoxin scattering photometry (ET-ESP) and turbidimetric (ET-TUB) assays on postoperative day (POD) zero, POD1 and POD3, comparing tumor necrosis factor (TNF)-α.

Results: AL was observed in 8 (4.9%) of the 162 patients. ET-ESP, ET-TUB, and TNF-α levels on POD0 and serum C-reactive protein (CRP) on POD1 were significantly elevated in the AL group. The area under the receiver operating characteristic curve (AUROC) for ET-ESP level (0.903) on POD0 showed early and better predictive performance for AL compared to that for ET-TUB (0.869, p = 0.230) and TNF-α (0.758, p = 0.034) levels on POD0; the AUROC for CRP level (0.711) on POD1 was inferior to other parameters. In subgroup analysis, five (3.7%) of 136 patients with colorectal cancer (CRC) developed AL. Additionally, the ET-ESP level on POD0 showed relatively good predictive performance for AL after CRC (AUROC: ET-ESP [0.871], ET-TUB [0.840], and TNF-α [0.737] on POD0).

Conclusion: ET levels in drainage fluid, especially those measured using ESP, on POD0 may have an early predictive ability to detect AL post-CRS.

Purpose: To compare the outcomes of chimney endovascular aneurysm repair (Ch-EVAR) and open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in consideration of the lack of comparative evidence.

Methods: The subjects of this retrospective study were patients who underwent elective Ch-EVAR or OSR for short-neck AAAs between 2013 and 2020 at five vascular centers. The primary endpoint was 30-day mortality and the secondary endpoints were postoperative complications and midterm clinical outcomes, including renal function changes, reintervention, overall survival, and aneurysm-related mortality.

Results: We analyzed 38 Ch-EVARs and 42 OSRs. The 30-day mortality rates were 2.6 and 2.4% in the Ch-EVAR and OSR groups, respectively (P = 1.00). The acute kidney injury incidence was higher in the OSR group than in the Ch-EVAR group (P < 0.01). The freedom from reintervention rate at 5 years was lower in the Ch-EVAR group than in the OSR group (81.0% vs. 100%, P = 0.04). Other midterm clinical outcomes did not differ between the groups.

Conclusions: Ch-EVAR may be a feasible treatment option for short-neck AAA; however, it should be limited to patients at high operative risk for OSR, considering the concern about its long-term durability.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies. Although surgical resection is the only potentially curative option, recurrence from microscopic residual disease develops in more than half of these patients, underscoring the importance of adjuvant chemotherapy. Over the past two decades, multiple randomized controlled trials have demonstrated that adjuvant chemotherapy can improve the disease-free and overall survival of patients with resected PDAC significantly. Although S-1 monotherapy became the standard of care in Japan following the JASPAC-01 trial, gemcitabine-based regimens are still used widely in Western countries. This review provides an overview of key clinical trials supporting adjuvant chemotherapy, including an introduction of the 2022 Clinical Practice Guidelines for Pancreatic Cancer in Japan and the current NCCN Guidelines for Pancreatic Adenocarcinoma. We also discuss some of the problems that remain unresolved, such as for how long and when adjuvant therapy should be given. Moreover, there is still insufficient evidence for certain subgroups of patients, such as those with borderline resectable or initially unresectable PDAC. Thus, new treatments, such as immune checkpoint inhibitors, may be useful in future. More clinical studies are needed to establish the most appropriate regimens, as adjuvant chemotherapy should be selected based on patient age, tumor stage, and prior treatment.

Purpose: To investigate the clinical characteristics of residual lung complications following segmentectomy.

Methods: Among 901 patients who underwent segmentectomy for lung cancer between 2009 and 2022, 256 patients who underwent postoperative computed tomography (CT) for abnormal shadows on chest radiography were retrospectively evaluated and categorized into three groups: Type 1 (consolidation only adjacent to the intersegmental line), Type 2 (partial infiltration extended to the residual segment [< 50%]), and Type 3 (infiltration extended to the large area of the residual segment [≥ 50%]). The association between the CT findings and complications was also assessed.

Results: There were no significant differences in the background factors among the three types. However, Type 3 patients experienced more severe pulmonary-related complications than Types 1 and 2 (45.8% vs. 25.0%, P = 0.002). Most patients (n = 894, 99.2%) were discharged without surgical intervention, but seven (0.78%) required reoperation for complications. Of these, six had Type 3 CT findings, and five underwent left upper division segmentectomy.

Conclusions: Extensive postoperative infiltrative shadows in the residual segment are associated with severe complications after segmentectomy. In cases in which the shadow occupies more than half of the remaining segment, special attention to postoperative management is necessary to prevent lethal complications.

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.