Updates in Surgery最新文献

Midline laparotomy incision is mostly used in emergent surgery, especially in hemodynamic instability patients. We aim to compare the Modified Smead-Jones (MSJ) and Smead-Jones (SJ) sutures against conventional continuous suture in midline laparotomy closure. PubMed, Scopus, Web of Science, and Ovoid were searched. We utilized Revman 5.4.1 for statistical analysis. Five studies involving 403 patients were included. Compared to continuous sutures, MSJ showed a significant reduction in wound dehiscence, wound infection, and hospital stay (RR = 0.29, 95% CI [0.14-0.59], p = 0.0006), (RR = 0.41, 95% CI [0.26-0.65], p = 0.0002), and (MD = - 4.50, 95% CI [- 5.43 to - 3.57], p = 0.00001). Conversely, the SJ subgroup showed no statistically significant difference in wound dehiscence, wound infection, and hospital stay. Also, both techniques, MSJ and SJ, showed no significant difference in incisional hernia risk (RR = 0.17, 95% CI [0.02-1.33], p = 0.09) and (RR = 5.16, 95% CI [0. 26-103.27], p = 0.28), respectively. MSJ follows the same far-near-near-far pattern as SJ but is applied continuously rather than interrupted. The MSJ suture technique might be promising in reducing wound dehiscence, infection, and hospital stay compared to conventional continuous closure. However, future large-scale RCTs with standardized methodologies and extended follow-up are essential to determine whether MSJ should be established as the preferred technique for midline laparotomy closure.

Anastomotic leakage remains a serious complication following colorectal surgery. Various reinforcement techniques have been explored in literature, with multiple systematic reviews and meta-analyses addressing their effectiveness. However, no umbrella review has yet comprehensively synthesized this evidence. We aimed to summarize and critically appraise the available systematic reviews and meta-analyses investigating the effectiveness of anastomotic reinforcement techniques in colorectal surgery. A comprehensive literature search was conducted in PubMed, Embase, Scopus, and Cochrane Library up to June 2025. Eligible studies were systematic reviews or meta-analyses evaluating any reinforcement technique (biological, mechanical, or chemical) in colorectal anastomoses. Data extraction included review characteristics, reinforcement strategies, primary outcomes (anastomotic leak), and methodological quality assessed using AMSTAR 2. Twenty-one systematic reviews and meta-analyses were included. The reinforcement strategies evaluated comprised transanal tube (TAT) placement, suture reinforcement, and omentoplasty. Most reviews showed a reduction in anastomotic leak rates, particularly with TAT (43-70%) and sutures (59-75%), with the most pronounced effect observed in patients without a diverting stoma. TAT was also associated with a reduction in reintervention rates (62-84%). Findings on hospital stay were inconsistent, while no significant effects were reported for anastomotic bleeding, infections, stenosis, or mortality. The overall methodological quality of the included studies was rated as critically low. TAT and reinforcement sutures show potential in reducing anastomotic leakage in colorectal surgery. However, significant heterogeneity and variable methodological quality across reviews limit definitive conclusions. High-quality, targeted studies and standardized outcome definitions are warranted.

When treating rectal prolapse, traditionally perineal procedures are recommended for elderly patients, while abdominal approaches are usually preferred in healthier and younger ones. We hypothesize that octogenarian patients can be safely treated with abdominal approaches. Our study aimed to evaluate the safety of abdominal procedures in the treatment of rectal prolapsed and to evaluate the recurrence rate. We conducted a retrospective IRB approved review of all patients ≥ 80 years old who underwent rectal prolapse surgery from 2010 to 2023 in our tertiary referral center. Patients were grouped according to the approach used to treat the prolapse (perineal or abdominal). Of the 164 patients included, abdominal approaches were performed in 58 (35.4%) and perineal in 106 (64.6%). Comparing the two approaches, no differences were observed in the female sex (96.6% vs 93.4%. p = 0.5), mean BMI (22.7 vs 23.8 kg/m², p = 0.14), mean ASA class (2.9 vs 2.72, p = 0.4), comorbidities and history of prior rectal prolapse surgery. No differences were found in the use of general anesthesia (100% vs 93.4% p = 0.052) hospitalization course, 30-day morbidity, and mortality rates. Rectal prolapse recurrence was significantly more common following perineal procedures (8.6% vs 18.9%, p = 0.001), with a mean follow-up period of 6.8 months. When treating rectal prolapse in octogenarians, abdominal approaches are safe and have a lower recurrence rate. We recommend for abdominal approaches whenever possible and limiting perineal approaches exclusively to patients with non-permissible risk for general anesthesia or abdominal surgery.

Since its development, Enhanced Recovery After Surgery (ERAS) protocol has generally improved patient outcomes and enhanced peri-operational organization. The protocol includes less intraoperative invasiveness and enhances perioperative mobility and nutrition. Robotic technology has demonstrated similar benefits, particularly in complex hepatobiliary resections. This study describes comparative outcomes of robotic hepatectomy before and after ERAS protocol implementation in our program. With Institutional Review Board (IRB) approval, 609 patients who underwent robotic liver resection between 2013 and 2024 were retrospectively analyzed. A total of the first 65 patients were excluded to eliminate the impact of a learning curve. The remaining 544 patients were divided into 2 groups based on ERAS protocol use. Propensity score matching 1:2 was applied according to age, BMI, tumor size, tumor type, and extent of liver resection. Perioperative outcomes of pre-ERAS and post-ERAS groups were compared. Patients in the post-ERAS group more frequently had coronary artery disease (5.7% vs. 10.6%) and hypertension (5.7% vs 57%), whereas patients in the pre-ERAS group more frequently had heart disease (46.2% vs 11.1%). Estimated blood loss (EBL) decreased (214.7(150.0) ± 250.9 vs. 141.7(100.0) ± 151.5) in the post-ERAS group. A decrease in 90-day readmission rate was also observed in the post-ERAS group (22.6% vs. 13.4%). A propensity score-matched comparison of robotic hepatectomy outcomes before and after ERAS protocol showed improvement in perioperative outcomes, with lower estimated blood loss and fewer 90-day readmissions.

In locally advanced colorectal cancer (LACRC), neoadjuvant therapy (NT) followed by total mesorectal or complete mesocolic excision is standard. Although a pathological complete response at the primary site (ypT0) predicts excellent survival, this benefit is offset when residual nodal metastasis (ypT0N⁺) is present. Reliable predictors of ypT0N⁺ are lacking. We retrospectively reviewed LACRC patients (2009-2024) who received NT and achieved ypT0 after curative surgery. Clinicopathologic variables were analyzed by uni- and multivariable logistic regression. A lymph node (LN) showing fibrosis, necrosis, acellular mucin, or foamy-cell reaction without viable carcinoma was classified as a regressed LN (RLN). An external ypT1-4 cohort treated during 2022-2024 served for validation. Among 503 ypT0 patients, 29 (5.8%) were ypT0N⁺. RLN-positivity occurred in 38% of ypT0N⁺ versus 10% of ypT0N0 cases (p < 0.001). On multivariable analysis, RLN-positivity was the sole independent risk factor for ypT0N⁺ (OR 4.11, 95% CI 1.71-9.52, p = 0.001). In the validation cohort (n = 615), RLNs remained enriched in ypN⁺ patients (21% vs 13%, p = 0.001), corroborating the association. RLN-positivity is a robust histologic marker of occult nodal metastasis in ypT0 LACRC. ypT0N0 should be diagnosed cautiously when RLNs are present, and such patients may require intensified adjuvant therapy and surveillance.

Anastomotic leakage (AL) is a serious complication in colorectal surgery, particularly after laparoscopic intersphincteric resection (LsISR) for ultra-low rectal cancer. This study evaluates the effectiveness of ICG fluorescence laparoscopic (FL) resection in reducing AL and improving recovery, especially in high-BMI patients. A retrospective cohort study was conducted on patients undergoing LsISR for ultra-low rectal adenocarcinoma from January 2012 to July 2023, comparing FL (n = 133) and non-FL groups (n = 266). The primary endpoint was the incidence of anastomotic leakage, including symptomatic AL. Secondary endpoints included intraoperative blood loss, lymph node yield, and short-term recovery parameters such as bowel function recovery, soft diet initiation, and hospital stay.Propensity score matching (PSM) was used to reduce baseline differences. In the PSM cohort, the FL group had a significantly lower AL rate (3.0%) compared to the non-FL group (9.4%) (P = 0.035). Severe symptomatic anastomotic leaks (SSAL) were also reduced in the FL group (0.8% vs. 5.6%, P = 0.045). Subgroup analysis showed that FL significantly reduced AL in normal BMI patients (2.4% vs. 8.5%, P = 0.041). In high-BMI patients, FL reduced AL (3.9% vs. 10.8%, P = 0.063), but the difference was not statistically significant. FL also reduced blood loss, improved lymph node yield, and accelerated recovery, including earlier return of bowel function, quicker soft diet initiation, and shorter hospital stays. ICG FL reduces AL and enhances recovery, particularly in normal BMI patients, with a potential benefit for high-BMI patients. Further studies are needed to confirm its effect in this group.

Background: Regional lymph-node metastasis plays a pivotal role in predicting recurrence in patients with differentiated thyroid cancer (DTC). Recent studies have highlighted the prognostic potential of the lymph-node ratio (LNR). This research aims to discern and compare LNR values in patients who underwent neck dissection specifically for micropapillary DTC and those with nonmicropapillary DTC.

Methods: Patients who underwent central lymph-node dissection (CND) due to DTC at three different tertiary centers in Istanbul between 2013 and 2023 were retrospectively reviewed. Patient and tumor characteristics (age, sex, type of neck dissection, multifocality, subtype of DTC, and LNR) were recorded and analyzed. The total harvested lymph-node (LN) number, metastatic LN number, and LNR were recorded and compared between the micropapillary and nonmicropapillary groups.

Results: The mean age of the patients was 44 ± 13.1 years, and the F/M ratio was 290/75. The mean dominant nodule size measured 15.53 ± 0.63 mm. Neck dissection procedures were unilateral CND in 62% (n = 226) and bilateral CND in 38% (n = 139). According to the histopathological examination results, nonmicropapillary thyroid carcinoma (non-PTMC) was detected in 220 patients (60%), whereas papillary thyroid microcarcinoma (PTMC) was detected in 145 patients (40%). The mean LNR was 0.14 ± 0.2 in patients with PTMC and 0.17 ± 0.2 in patients with non-PTMC (p = 0.286).

Conclusion: This study demonstrated that when regional lymph-node metastases (LNMs) develop in patients with PTMC, the LNR can be as high as that in patients with PTC. These findings emphasize that, in clinical assessments of PTC, the LNR is independent of the main tumor size.

Identifying the parathyroids is compulsory for success of parathyroidectomy for parathyroid adenoma. The aim of the present study is to evaluate and compare the efficacy of PTeye™ and FLUOBEAM® LX in identifying parathyroid adenomas. Patients undergoing parathyroidectomy due to a parathyroid adenoma were enrolled prospectively in this study and were randomly included to Group A (PTeye™) or Group B (FLUOBEAM® LX). After intraoperative identification of parathyroid adenomas and before tissue dissection (minute 0), we evaluated the efficacy of both devices in confirming the adenomas. We re-evaluated devices' efficacy in minutes 1, 3 and 5 during tissue dissection and before adenoma excision. All PAs were confirmed and identified with PTeye™, while FLUOBEAM® LX could not identify 3/20 adenomas (15%). PTeye™ confirmed parathyroid tissue in less than 1 min in 13 cases (65%), in < 3 min in 7 (35%), whereas FLUOBEAM® LX identified 4 adenomas in < 3 min (20%), in < 5 min 9 adenomas (60%) and > 5 min in 4 (20%). PTeye™ and FLUOBEAM® LX are both useful tools in confirming parathyroid tissue intraoperatively. PTeye™ confirmed the suspected adenoma earlier before tissue dissection, while FLUOBEAM® LX demands tissue dissection as it identifies the normal parathyroid tissue.