Surgery Today最新文献

Anorectal fistulas remain one of the most challenging conditions in colorectal surgery and require precise anatomical knowledge for successful management. This comprehensive review synthesizes the current evidence on the anatomical foundations of fistula development and treatment, particularly focusing on the cryptoglandular hypothesis and its clinical implications. A systematic analysis of the recent literature has examined the relationship between anatomical structures and fistula formation, classification systems, diagnostic modalities, and therapeutic approaches. The review revealed that anatomical considerations fundamentally influence treatment outcomes, with modern imaging techniques achieving up to 98% accuracy in delineating fistula anatomy. Key findings demonstrate that surgical success rates vary significantly based on anatomical complexity: 92-97% for simple fistulas versus 40-95% for complex cases using sphincter-sparing techniques. Emerging minimally invasive approaches and regenerative therapies, including mesenchymal stem cells, show promising results with 50-60% healing rates in complex cases. Special considerations are needed for complex cases such as Crohn's disease-related and rectovaginal fistulas. This review provides surgeons with an evidence-based framework for selecting optimal treatment strategies based on anatomical considerations, emphasizing the importance of preserving the anal sphincter function while achieving complete fistula eradication. Integrating advanced imaging, surgical techniques, and emerging therapies offers new possibilities for improving patient outcomes. This review aimed to bridge the gap between anatomical knowledge and practical surgical application, enhance clinical decision-making, and improve patient outcomes in anorectal fistula management.

Purpose: To investigate the effect of preoperative prealbumin levels on long-term survival outcomes after gastrectomy in patients with gastric cancer (GC) dichotomized based on age.

Methods: This retrospective cohort study included consecutive patients who underwent radical gastrectomy for primary stage I-III GC between May 2006 and March 2017. Patients were allocated to groups based on age (≥ 70 or < 70 years) and subgroups based on prealbumin levels (high, ≥ 22 mg/dL; moderate, 15-22 mg/dL; or low, < 15 mg/dL), and multivariate Cox regression was used for survival analyses.

Results: Of 4732 patients, 3172 (67.0%) were aged < 70 years and 1560 (33.0%) were ≥ 70 years of age. The median follow-up period was 66 months. A low prealbumin level was an independent prognostic factor for poor overall survival in older patients only [hazard ratio, 2.057; 95% confidence interval, 1.528-2.770; P < 0.001]. A low prealbumin level was an independent prognostic factor for poor other-cause survival in the older (hazard ratio: 2.719, 95% confidence interval: 1.887-3.918, P < 0.001) and younger (HR: 4.611, 95% CI 2.424-8.772, P < 0.001) groups.

Conclusion: Low preoperative prealbumin levels were associated with poor overall survival in older patients with GC after gastrectomy and with earlier non-GC death in older and younger patients.

Purpose: Inflammatory, nutritional, and immune biomarkers are associated with the prognosis of patients with various tumors. Recently, a comprehensive predictive biomarker, the hemoglobin, albumin, lymphocyte, and platelet (HALP) score, was introduced to predict clinical outcomes. We investigated the prognostic impact of preoperative HALP scores in patients who underwent hepatectomy for colorectal liver metastasis (CRLM).

Method: The subjects of this study were 209 patients who underwent hepatectomy for CRLM between February, 2005 and September, 2023. The HALP score was defined as (albumin [mg/dL] × hemoglobin [g/L] × lymphocyte [count/L]) / platelet [count/L]. The cutoff value was calculated according to the receiver operating characteristic curve based on 3-year survival.

Results: The cutoff value of the HALP score was 35, and a low HALP score was confirmed in 107 patients (51%). Multivariate analysis of disease-free survival identified lymph node metastasis (HR 1.53, p = 0.03), extrahepatic lesions (HR 2.48, p < 0.01), and a low HALP score (HR 2.0, p < 0.01) as independently poor prognostic factors. Multivariate analysis of overall survival identified extrahepatic lesions (HR 2.98, p < 0.01), a high CEA (HR 1.78, p = 0.02), and a low HALP score (HR 1.92, p = 0.02) as independently poor prognostic factors.

Conclusions: The HALP score is a useful prognostic factor for patients undergoing hepatectomy for CRLM.

Purpose: To clarify the status of multigene panel testing for suspected hereditary breast cancer in our institute, and disclose the characteristics of the variants detected.

Methods: This was a retrospective study of individuals who underwent next-generation sequencing-based multigene panel testing at our institute to investigate hereditary genetic variants for suspected hereditary breast cancer.

Results: We identified 36 women who underwent multigene panel testing: 8 (22.2%) had a pathogenic variant, with or without other variants of uncertain significance (VUSs); 15 (41.7%) had VUSs only; and 13 (36.1%) had negative genetic test results. Of the eight pathogenic variants, five were BRCA2 variants and one each were BRCA1, MLH1, and RINT1 variants. The VUSs included BRCA1 and BRCA2, as well as other breast cancer-associated genes, such as ATM, CDH1, CHEK2, and PALB2. Referring to the latest ClinVar database, one of the variants identified as a VUS at diagnosis was re-determined as likely pathogenic, and three of the variants identified as VUSs at diagnosis were re-determined as benign.

Conclusion: VUSs are frequently identified during testing and it is important to monitor these individuals because VUS evaluations can change over time.

Purpose: To validate the clinical impacts of the prognostic nutritional index (PNI), an immune-nutritional blood marker, in patients with resectable non-small cell lung cancer (NSCLC) using multicenter cohort data.

Methods: The subjects of this retrospective multicenter study, involving 11 hospitals, were patients who underwent curative lung resection for pathological stage IA-IIIA NSCLC. We analyzed the relationship between the preoperative PNI and postoperative outcomes. Patients were divided into a high PNI group and a low PNI group (cutoff: 45). We also performed exact matching and three propensity score-based methods to validate the results.

Results: Among the total 2,770 patients, 2,272 (82.0%) had a high PNI (>45) and 498 (18.0%) had a low PNI (≤45). A low preoperative PNI was a predictor of increased overall postoperative complications (relative risk 1.49; 95% confidence interval (CI) 1.31-1.69) and an independent adverse prognostic factor for overall survival (hazard ratio 1.77; 95% CI 1.45-2.17) and recurrence-free survival (1.34; 95% CI 1.14-1.59). All the methods we used (whole cohort, exact matching, and three propensity score methods) showed consistent results.

Conclusions: The findings of this multicenter study suggest that immune-nutritional assessment using the PNI will provide useful prognostic information for patients with resectable NSCLC.

Purpose: In recent years, major advancements have been made in rectal cancer surgery with the introduction of new techniques such as robotic surgery and indocyanine green fluorescence imaging (ICG-FI). This study aimed to evaluate the comprehensive risk factors for anastomotic leakage (AL) following rectal cancer surgery, incorporating recently introduced techniques and other existing factors, to reflect current practices.

Methods: A retrospective analysis was conducted of 304 patients who underwent either robotic or laparoscopic anterior resection between January 2019 and December 2023. The study analyzed patient, tumor, and surgical factors, with AL defined by clinical or radiological findings requiring intervention within 30 days after surgery.

Results: A univariate analysis indicated that moderate or severe anemia and the non-use of ICG-FI were strongly associated with AL. A multivariate analysis identified moderate or more severe anemia (hemoglobin ≤10.9 g/dL for males and ≤9.9 g/dL for females) (odds ratio [OR]: 9.94, p = 0.002) and non-use of ICG-FI (OR: 10.40, p < 0.001) as independent risk factors for AL.

Conclusion: Moderate or severe anemia and absence of ICG-FI were found to significantly increase the risk of AL. Preoperative anemia correction and the routine use of ICG-FI may help mitigate this risk, thus suggesting the need for further research in these areas.

Purpose: The double-flap technique (DFT) is an anti-reflux reconstruction procedure performed after proximal gastrectomy (PG), but its complexity and high incidence of anastomotic stenosis are problematic. We conducted this study to demonstrate the efficacy of robot-assisted DFT, with refinements, to address these issues.

Methods: Surgical outcomes were compared between the following procedures modified over time at our institution: conventional open DFT (group O, n = 16); early robotic DFT (group RE, n = 19), which follows the conventional open PG approach; and late robotic DFT (group RL, n = 21), which incorporates refinements to the early robotic DFT technique by exploiting more of the robotic capabilities available. These robotic capabilities include pre-anchoring the stomach to the diaphragmatic crus and connecting it to the esophagus, placing interrupted sutures for anastomosis, and maximally embedding the esophagus through the entire flap.

Results: Anastomotic stenosis requiring balloon dilatation developed in two (11.8%) patients from group O and three (14.3%) from group RE, but not in any patients from group RL. Reflux esophagitis, classified as Los Angeles Classification grade ≥ B, decreased from 25.0% in group O to 10.5% in group RE and was completely controlled in group RL (group RL vs group O, odds ratio 0.065, 95% confidence interval < 0.001-0.684, P = 0.007).

Conclusion: Robotic surgery helps minimize anastomotic stenosis, while enhancing the benefits of anti-reflux reconstruction with DFT.

Purpose: This study aimed to evaluate the relationship between the quantity and quality of subcutaneous fat and prognosis following colorectal cancer resection.

Method: We conducted a retrospective analysis of the clinical data of 399 patients who underwent curative resection for stage 2 or 3 colorectal cancer between January 2013 and March 2019. This study examined the correlation between sarcopenia and various fat parameters, including fat area and density, and assessed their impact on the prognosis.

Results: Sarcopenia was associated with a lower subcutaneous and visceral fat area, higher Hounsfield unit value in subcutaneous fat, and reduced modified intramuscular adipose tissue content in the multifidus, erector spinae, and psoas muscles. A low modified intramuscular adipose tissue content in the multifidus and erector spinae muscles was an independent prognostic factor for overall survival (hazard ratio, 2.28; p = 0.0329) and recurrence-free survival (hazard ratio: 2.32, p = 0.0233). Additionally, subcutaneous fat with a high Hounsfield unit was an independent predictor of a recurrence-free survival (hazard ratio, 2.68; p = 0.0142).

Conclusion: Subcutaneous fat quality is correlated with sarcopenia and it thus serves as a prognostic factor for recurrence after stage 2 or 3 colorectal cancer resection.

We conducted this study to evaluate the efficacy of robot-assisted minimally invasive esophagectomy (RAMIE) on cadavers in the prone position, utilizing telesurgical support through the double-surgeon cockpit (double SC) of the novel Japanese-made surgical robot system, hinotori^™ (Medicaroid, Kobe, Japan). The Cadaveric Anatomy and Surgical Training Laboratory (CAST Lab) at Hokkaido University and Kushiro City General Hospital (KCGH) are interconnected by a dedicated 1 Gbps internet line, spanning 300 km. An operation unit and double SC were installed at CAST Lab, whereas the double SC proctor was installed at KCGH. RAMIE was performed with telesurgical support on two adult cadavers. The onsite and proctor operation times were recorded as 88/79 min and 64/75 min, respectively. Throughout the surgical procedures, communication remained stable, with an average communication delay of 13.1 ms (range: 11.0-15.0 ms). This study demonstrated the feasibility of performing RAMIE with the patient in the prone position, supported by telesurgical support using a double SC on the hinotori^™ platform.

Purposes: We analyzed the acute-phase response in unilateral thyroidectomy by comparing the transoral endoscopic thyroidectomy vestibular approach (TOEVA) with the minimally invasive video-assisted thyroidectomy (MIVAT).

Methods: Patients were randomly assigned to undergo either TOEVA or MIVAT, after we obtained their written informed consent to participate in this study. Blood count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-1β (IL-1β), IL-6 and tumor necrosis factor (TNF-) were measured before surgery and then 4, 24, and 48 h after surgery. The VAS pain score, analgesic utilization, and time to resume normal activities were recorded.

Results: There were 29 patients who underwent TOETVA and 30 who underwent MIVAT. The groups were well balanced in terms of age, gender, American Society of Anesthesiologists (ASA) score, and preoperative values. There were no postoperative complications in this series. The operation time was longer in the TOETVA group (p < 0.001). Patients recommenced routine activities earlier after MIVAT (p < 0.05). The TOETVA group showed a greater drop in lymphocyte count 4 h (p < 0.01) and 24 h (p = 0.04) postoperatively, a higher ESR value 48 h postoperatively (p = 0.02), a longer increase in IL-6 (p = 0.05), 24 (p = 0.003) and 48 h postoperatively (p < 0.001), and a higher CRP 24 (p = 0.05) and 48 h postoperatively (p = 0.01) than the MIVAT group. There was no difference in postoperative IL-1β, TNF, total white blood cell count, polymorphonuclear cell count, and VAS or analgesic requirement between the groups, except on the day of surgery.

Conclusions: An increased inflammatory response in the acute phase was observed after TOETVA compared with MIVAT, suggesting that TOETVA is associated with increased tissue trauma. This may account for the earlier recovery after the MIVAT procedure.