Surgery Today最新文献

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: 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 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.

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.