Updates in Surgery最新文献

Liver transplantation (LT) is the primary treatment for selected patients with hepatocellular carcinoma (HCC). However, HCC-related mortality post-LT remains a significant concern, with up to 10% of cases reported in international series. Identifying risk factors for adverse clinical outcomes is essential. We hypothesized that post-LT HCC-related mortality rates are higher in patients with a high (≥ 42) Comprehensive Complication Index (CCI) calculated at discharge. This study aims to compare post-LT HCC-related mortality rates between two groups of patients with high versus low CCI following LT for HCC. This study included data from seven collaborative European centers. A cohort of 1121 HCC patients transplanted between 2005 and 2019, surviving more than six months post-LT, was analyzed retrospectively. Patients were divided into two groups based on the CCI at discharge: Low-CCI Group (n = 942, 84.0%) and High-CCI Group (n = 179, 16.0%). An inverse probability of treatment weighting (IPTW) approach was applied for analysis. In the post-IPTW cohort, four multivariable logistic regression models with mixed effects identified independent risk factors for HCC-related death, overall death, recurrence, and early recurrence. A CCI score of ≥ 42 emerged as an independent risk factor across all models. Specifically, CCI ≥ 42 was associated with increased odds of HCC-related death (OR = 3.35; P < 0.0001), overall death (OR = 2.63; P < 0.0001), overall recurrence (OR = 2.09; P = 0.001), and early recurrence (OR = 1.88; P = 0.02). A CCI score at discharge should be considered a critical factor for recurrence and HCC-related mortality risk. Incorporating CCI into standard post-LT predictive models may enhance prognostic accuracy for adverse HCC outcomes.

The study was designed to compare the effectiveness of two-step percutaneous transhepatic choledochoscopic lithotripsy (T-PTCSL) with laparoscopic anatomical hepatectomy combined with choledocholithotomy (LAHC) for patients with hepatolithiasis. From January 2020 to September 2023, 98 patients who underwent LAHC (n = 40) or T-PTCSL (n = 58) for hepatolithiasis in our hospital were included in this study. Their perioperative and long-term outcomes were analyzed. There was no statistical difference between the two groups in stone clearance rates (90.0% vs. 84.5%, P = 0.429) and postoperative complication rates (35.0% vs. 22.4%, P = 0.170). The T-PTCSL group had significantly shorter operative time, postoperative hospitalization, and intake time (all P < 0.001). Postoperative biochemical indices showed lower ALB, ALT, AST, and WBC in the T-PTCSL group compared to the LAHC group (all P < 0.05). Multivariate logistic regression indicated age as an independent risk factor for stone clearance (OR = 0.94, 95% CI = 0.89-0.99, P = 0.049). Subgroup analysis showed no significant impact of gender and type of stone distribution on stone clearance (all P > 0.05). The KM curve analysis revealed no significant difference in stone recurrence between the groups (log-rank P = 0.925). Hemoglobin concentration was significantly associated with time-to-stone recurrence (TR = 1.02, 95% CI = 1.01-1.04, P < 0.05) in the multivariate Accelerated Failure Time Model. T-PTCSL may be an alternative option to LAHC. Compared with LAHC, T-PTCSL offers favorable postoperative recovery and less surgical injury for patients with hepatolithiasis, as well as equivalent effectiveness of stone clearance and recurrence.

We analyzed the electrical characteristics of the da Vinci system's low-power monopolar coagulation mode with an electrocautery analyzer to determine its suitability as an alternative to monopolar soft coagulation mode. The voltage at the plateau of the power limit between 15 and 16 W and between 23 and 24 W of the forced coagulation mode of the da Vince system was close to that of the effect 8 and 10 of the soft coagulation mode, respectively. Experiments using chicken meat and an infrared thermographic camera confirmed the safety and effectiveness of low-power monopolar coagulation mode showing no carbonization at temperatures below 90 °C. In 73 robotic-assisted lung resection using low-power coagulation mode, no electric spark or carbonization was observed and all cauterizations were similar to soft coagulation mode. In conclusion, Forced coagulation mode of the da Vinci system can be used as an alternative to monopolar soft coagulation mode with appropriate effect and power limit settings.

Appendectomy, whether open or minimally invasive (MIS) is one of the most frequent procedures performed by young residents. We designed and tested a new methodology and a new inexpensive silicone model for Laparoscopic Appendectomy (LA) simulation. This study aimed to assess their fidelity, usefulness and educational value in an introduction to laparoscopy course. The course was open to first-year general surgery residents. The group was divided in two and one of the groups watched a video of the procedure before the simulation. Individual performances were assessed directly on the models, using a specific assessment scale. Participants answered a questionnaire at the end of the course for evaluation. Thirty-five residents participated in this study. Execution, quality, and global performance were higher in the group that had more experience with the model. Thirty-two trainees (91%) answered the questionnaire. There was a strong agreement that the model was adequate for this type of course and face and content validity was considered high/very high. Participants strongly agreed that this model gives more confidence to perform a real LA and almost 97% (n = 31) considered they have learned solid foundations about LA. This study shows face, content and construct validation and also educational value for this new low-cost, laparoscopic appendectomy model. The integration of this model in an introduction to laparoscopy course showed good results in regard to an increase of confidence among first-year surgery residents. It can be a valuable tool for learning and training laparoscopic appendectomy.

Esophagectomy for cancer is a highly invasive procedure with significant post-operative morbidity and mortality. The literature suggests a clear volume outcome correlation. Since 2019, esophageal surgery has been centralized in Belgium. In 2019, enhanced recovery after surgery (ERAS) guidelines were published for esophagectomy. The purpose of this study was to evaluate the level of implementation of these ERAS guidelines in Belgium. Surgeons from centralized esophageal surgery centers in Belgium were questioned. A Delphi questionnaire regarding peri-operative ERAS care and center-specific outcome data were sent to all participating surgeons. An ERAS scoring system was created to estimate and compare the level of ERAS implementation. Length of stay, post-operative pneumonia, anastomotic leakage and 30-day and 90-day mortality were evaluated. A high response rate of 94.1% was achieved. All surgeons used a peri-operative protocol in their center. The mean ERAS score for Belgian surgeons was 15.5 out of 20. The highest ERAS score per center is 18.6. Anastomotic leakage rate is 14.6% and post-operative pneumonia rate is 20.8% in Belgium. The mean length of stay is 12 days. Mortality after 30 days and 90 days are, respectively, 3.2% and 6.6%. This study gives an overview of the Belgian situation regarding the implementation of ERAS protocols in esophageal surgery centers. The overall implementation of ERAS guidelines in Belgium is good, but there is room for improvement in terms of uniformity nationally.

To define the risk factors of post-operative voiding dysfunction according to the type of surgical procedure performed. A systematic review through PubMed, the Cochrane Library, and Web of Science databases was performed. The Medical Subject Headings terms aimed for English articles about colorectal endometriosis surgery and voiding dysfunction published until December 26, 2022 were used. The primary outcome was the occurrence of post-operative voiding dysfunction. Secondary outcome was the presence of a persistent voiding dysfunction at 1 month. MeSH terms included ''deep endometriosis'', ''surgery'', or ''voiding dysfunction''. Two reviewers (AM, PE) assessed the quality of each article independently. A Study Quality Assessment Tool was used to provide rating of the quality of the included studies. 22 studies were included in the final analysis. Rectal shaving was associated with less voiding dysfunction than segmental resection (OR 0.33; 95%CI [0.20: 0.54]; I² = 0%; p < 10^-3). No difference was found between rectal shaving and discoid excision (OR 0.44; 95%CI [0.07: 2.84]; I² = 55%; p = 0.39), nor between discoid excision and segmental resection (OR 0.44; 95%CI [0.18: 1.09]; I² = 49%; p = 0.08). Conservative surgery (i.e., shaving and discoid) was associated with less voiding dysfunction than radical surgery (i.e., segmental resection) (OR 0.37; 95%CI [0.25: 0.55]; I² = 0%; p < 10^-3). Regarding persistent voiding dysfunction, rectal shaving and discoid excision were less associated with voiding dysfunction than segmental resection (respectively, OR 0.30; 95%CI [0.14: 0.66]; I² = 0%; p = 0.003 and OR 0.13; 95%CI [0.03: 0.57]; I² = 0%; p = 0.007). Conservative bowel procedures are associated with lower rates of persistent post-operative voiding dysfunction and should be considered first when possible.Trial registration: Our meta-analysis was registered under the PROSPERO number: CRD42023395356.

The aim of our study is to evaluate the impact of metastasectomy on survival in patients with oligometastatic stage 4 lung cancer. Fifty-nine oligometastatic lung cancer cases operated on in our clinic between January 2015 and January 2024 were retrospectively examined. Demographic characteristics, metastasis type, metastasis locations, treatments applied, location of the primary tumor, histological type of the tumor, and metastasectomy status of the patients included in the study were evaluated. All patients underwent surgery for primary lung cancer. Generally, the mass in the lung was excised first. The metastasis was then removed. When brain surgery became a priority in some brain metastases, the metastasis was first removed and then the lesion in the lung was completely removed. In patients with oligometastasis, the tumor was either completely removed surgically or a complete cure was achieved with radiotherapy. All patients were stage 4a patients with metastases. The median age of the patients was 61 (36-76) years. 31 (52.6%) of the patients were aged 60 and over. 96.6% (n:57) of the patients were male and 3.4% (n:2) were female. Histopathological diagnosis was 35.6% squamous cell carcinoma (SCC) and 42.4% adeno cancer. 61.0% of the patients had brain metastases and 23.7% had adrenal metastases. The hospital stay of the patients was 14.0 ± 9.9 days. Disease-free survival time was 18.3 ± 24.4 months and overall survival time was 13.6 ± 11.5 months. While 32.2% (n:19) of the patients were alive, 67.8% (n:40) died. The survival rate was statistically significantly higher in patients who underwent metastasectomy compared to those who did not undergo metastasectomy (p = 0.027). The risk factors were found to be significantly associated with survival in the logistic regression analysis included metastasectomy (OR: 3.942, p = 0.030), diagnosis (SCC) (OR: 9,000, p = 0.042), recurrence (OR: 5.248, p = 0.012), adjuvant RT (OR: 0.298, p = 0.045), and neoadjuvant therapy (OR: 4.154, p = 0.040). In stage 4a lung cancer patients with oligometastasis, curative treatment of metastasis (metastasectomy) has a positive effect on survival. The low rate of radiotherapy and chemotherapy treatments given after metastasectomy will protect patients from the side effects of these treatments.

Introduction: Neurogenic thoracic outlet syndrome (nTOS) is commonly treated with first-rib resection, a procedure linked to postoperative complications, but its necessity remains debated among experts, highlighting the need for further research. This randomized controlled trial aims to compare conventional first-rib resection with the avulsion method to identify the most effective surgical approach.

Methods: This single-center, randomized, group-sequential trial compared two surgical approaches for treating nTOS. Participants were randomly assigned to undergo first-rib resection (Group A) or first-rib avulsion (Group B), with both groups blinded to treatment allocation. The University of Sulaimani granted ethical approval and obtained written informed consent. Inclusion criteria included nTOS patients requiring surgery, excluding those with other TOS types, cervical ribs, clavicular fractures, or other complications. Outcome measures included pain scores, numbness, and patient satisfaction at multiple time points. Statistical analysis was performed using SPSS and Microsoft Excel.

Results: A total of 48 female patients were enrolled (23 in Group A, 25 in Group B). The mean age was 32.58 ± 7.23 years, and the average operation duration was 48.27 ± 13.95 min. Group B had significantly longer ribs (P < 0.001). Both groups showed significant pain and numbness reduction, with no significant differences in outcomes (P = 0.647, P = 0.839). At 6 months, 92.0% of Group B and 87.0% of Group A patients recommended the surgery.

Conclusion: Although statistically not significant, first rib avulsion may offer a viable alternative to resection for nTOS, providing comparable pain relief and functional recovery with reduced invasiveness.

Three-port (trocar) laparoscopic appendectomy is the standard treatment for acute appendicitis and previous studies have compared to single-incision approach, however, they often include both pediatric and adult patients and fail to account for surgeons' experience, leading to variability in outcomes. This systematic review and meta-analysis aims to address these literature gaps by focusing on adult patients and controlling for surgeon expertise. We conducted a comprehensive search of randomized controlled trials comparing single-incision laparoscopic appendectomy (SILA) and conventional laparoscopic appendectomy (CLA) up to November 2024. We assessed the length of hospitalization, operative duration, postoperative complications, and surgical wound infections. Data were synthesized using random-effects models to account for variability among studies. The meta-analysis included four studies with a total of 408 patients, comprising 202 in the single-incision laparoscopic appendectomy (SILA) group and 206 in the conventional laparoscopic appendectomy (CLA) group. For the length of hospitalization, no statistically significant difference was observed, with a weighted mean difference (WMD) of 0.07 days (95% CI  - 0.32 to 0.47, I² = 0%, p = 0.72). Similarly, the operative duration showed no significant difference, with a WMD of 4.49 min (95% CI  - 7.02 to 16.00, I² = 89%, p = 0.44). The analysis of postoperative complications also revealed no significant difference between the groups, with an odds ratio (OR) of 1.32 (95% CI 0.69 to 2.51, I² = 0%, p = 0.40). Surgical wound infections were found to be comparable, with an OR of 1.14 (95% CI 0.46 to 2.83, I² = 0%, p = 0.78). Sensitivity analysis indicated that the results were statistically significant regarding operative duration when Kim et al. was excluded from the analysis. SILA and CLA yield comparable outcomes in terms of hospitalization length, operative duration, and complications, suggesting that both techniques are viable options for the management of acute appendicitis in adults. Further studies investigating overall cosmesis, patient satisfaction, and postoperative pain are warranted to optimize surgical approaches.PROSPERO registration: CRD42024612596.