Updates in Surgery最新文献

Background and aim: Statistical cure occurs when the mortality of a specific population returns to mortality values of the general population. Whether antiviral therapy is associated with achievement of statistical cure of patients with hepatocellular carcinoma (HCC) undergoing liver resection (LR) remains unknown. We aimed to clarify this issue.

Methods: We enrolled 1004 patients with HCC who underwent LR. We evaluated overall survival (OS) as the primary survival measure for estimating cure fractions through a mixture model.

Results: The probability of resection enabling patients with HCC to achieve the same life expectancy as that of the general population was 48.6%. The multivariable cure model revealed that age ≤ 65 years, 7th edition pathological American Joint Committee on Cancer (AJCC) stage 1, no cirrhosis, receipt of antiviral therapy, and a Model for End-Stage Liver Disease (MELD) score of ≤ 9 were predictors of cure after LR.

Conclusions: About five in 10 patients could be considered cured after LR for HCC. In addition to tumor- and liver-related variables, receipt of antiviral therapy was associated with achievement of statistical cure. We highlight the importance of antiviral therapy for maximizing outcomes of resection for HCC.

University-hospital conventions within the Italian Servizio Sanitario Nazionale, regulated by D.Lgs. 517/1999, allow academic clinicians to serve as clinical directors in public hospitals. While the educational and scientific benefits are well described, systematic economic evaluation of these arrangements is lacking. A 12-month Budget Impact Analysis was conducted comparing two staffing models: (i) a hospital-employed clinical director fully remunerated by the regional health service, and (ii) a university-affiliated professor whose base salary is funded by the university under national conventions. Direct personnel costs were calculated using CCNL Dirigenza Medica salary tables, statutory allowances, employer contributions, and institutional payroll data. Analyses were performed from both the hospital perspective and the system-wide public-sector perspective, with deterministic sensitivity analyses assessing robustness. Academic integration reduced hospital personnel expenditures by 66.6%, with average annual savings of €145,100 (95% CI: €141,900-€148,600) per department. Savings remained above 50% across all sensitivity analyses. When university-funded salary components were included, total public-sector expenditure for the academic-integrated model approximated that of the conventional model, indicating cost redistribution rather than system-wide savings. University-affiliated clinical directors provide substantial and reliable hospital-level cost savings for Italian public hospitals through redistribution of salary obligations across the public sector. However, this economic advantage does not imply demonstrated improvements in clinical productivity, research output, or educational value, which were not evaluated in this study and require dedicated empirical investigation. Clear distinction between economic and non-economic dimensions is essential when interpreting the role of university-hospital conventions.

To identify parathyroid carcinoma patients who may be eligible for conservative surgery in the form of primary tumor resection while maintaining oncological safety. Clinical and pathological data were extracted from parathyroid carcinoma cases in the Surveillance, Epidemiology, and End Results database (2000-2021) and Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (2013-2024). The primary outcome of this study was disease-specific survival (DSS). Univariate and multivariate Cox proportional hazards models were constructed to identify factors independently associated with DSS; these factors were then used to define risk-based stratification criteria for surgical comparison. DSS was compared between patients undergoing primary tumor resection and those undergoing en-bloc resection using Kaplan-Meier analysis after propensity score matching. A total of 451 patients were included, with a median follow-up duration of 90.0 months. Multivariate analysis revealed that tumor size > 30 mm and the presence of distant metastasis were independent predictors of worse DSS. In the matched cohort of patients with tumor size ≤ 30 mm and no regional lymph node metastasis, no significant survival difference was observed between the primary tumor resection and en-bloc resection groups (DSS: p = 0.513). In patients with parathyroid carcinoma, the presence of tumors > 30 mm in size or distant metastasis suggests poor prognosis. Cases with a tumor size ≤ 30 mm and no regional lymph node metastasis may be optimal candidates for the primary tumor resection approach.

Background: Minimally invasive distal pancreatectomy (MIDP) has become more common in recent years, offering shorter recovery times and fewer perioperative complications compared to open surgery. However, postoperative pancreatic fistula (POPF) remains a major concern, driving the search for effective stump management strategies to minimize complications and healthcare costs.

Methods: Between February and March 2025, a 25-item Google Forms questionnaire was emailed to the lead surgeons of all 44 IGOMIPS centers. One response per center was requested. The questionnaire covered a wide range of topics, including the preferred surgical platform (laparoscopic vs robotic), types of transection devices (motorized or non-motorized staplers, energy-based tools), use of staple-line reinforcement, pre-firing compression durations, and postoperative drain-management practices. Descriptive analyses were performed and correlated with existing literature.

Results: A total of 36 invited centers, each utilizing minimally invasive surgical techniques for distal pancreatectomy, completed the survey (response rate: 81.8%, 36/44). The adopted surgical platform was robotic in 14 centers (38.9%), laparoscopic in 11 (30.6%) and mixed in 11 (30.6%). Parenchymal transection relied on motorised staplers in 24 centers (66.7%), conventional staplers in 8 (22.2%) and energy-based devices in 2 (5.6%); two centers (5.5%) tailored the device to gland thickness. Pre-firing compression lasted < 1 min in 6 centers (16.7%), 1-3 min in 16 (44.4%) and > 3 min in 6 (16.7%), while 7 centers (19.4%) had no fixed interval. Staple-line reinforcement was never used in 14 centers (38.9%), always used in 6 (16.7%) and applied selectively in the remainder. Routine prophylactic drainage was practised by 32 centers (88.9%); drains were removed < POD 5 in 14 (38.9%).

Conclusion: The marked heterogeneity in stump-management techniques in MIDP highlights the absence of robust, standardized guidelines, reflecting persistent controversies in the literature. Respondents expressed strong interest in future multicenter trials to establish evidence-based protocols, emphasizing that collaborative, large-scale research is crucial for improving patient outcomes and reducing the risk of POPF.

Indocyanine Green (ICG) fluorescence imaging is increasingly used in emergency bowel surgery to assess intestinal perfusion. While literature reports high technical efficacy, intraoperative interpretation remains variable. This systematic review explores how cognitive and systemic human factors influence ICG's perceived effectiveness, compared to reported quantitative outcomes. A systematic search of PubMed and Embase identified 31 original studies from 266 screened articles. Qualitative synthesis was guided by ENTREQ principles. Bias identification followed a thematic approach using cognitive bias categories based on established clinical decision-making frameworks. ICG was reported to influence surgical decision-making in 302 of 308 cases. However, discrepancies between fluorescence findings and clinical actions occurred in 38.3% of cases. Common cognitive patterns included confirmation and anchoring bias, overconfidence in fluorescence interpretation, and reliance on ICG to support pre-established surgical decisions. Systemic limitations included lack of interdisciplinary input, case-report bias, and absence of standardized interpretation protocols. These were analyzed across a full article-by-article bias matrix and summarized by domain and sentiment. ICG is not solely a diagnostic tool, but a cognitive interface shaped by time pressure, decision momentum, and human interpretation. Rather than providing objective certainty, ICG often reinforces existing clinical judgments. Addressing bias-awareness and integrating interdisciplinary frameworks may enhance interpretive consistency and improve patient outcomes. These findings call for greater cognitive standardization in the intraoperative use of ICG during emergency surgery.

Introduction: It is not clear if the acquisition of robotic simulation skills can be affected by external factors during the simulation.

Methods: A cohort of medical students performed five times a basic simulation exercise. Performance indexes were collected to build up individual "learning curves". The participants were randomly divided into five groups and Groups 2 to 5 were "disturbed" by classic music, heavy metal, radio podcast, irregular noises, respectively, whereas participants of Group 1 were not distracted.

Results: In the whole series, there was a progressive improvement of all the simulation parameters and the variability among the participants reduced with time. Group 5 do not reach the higher standards of the other four groups.

Conclusions: Our study demonstrated that simulation could standardize the skills of the trainees at the top level despite different starting points. Irregular noises during the training can delay the acquisition of robotic skills.

Postoperative pancreatic fistula (POPF) complicates 9.9-28.5% of pancreatic surgeries. This protocol describes a preclinical study in a large animal model comparing endoluminal radiofrequency ablation (ERFA) and glue occlusion of the main pancreatic duct (MPD), both performed four weeks prior to surgery to induce pancreatic atrophy and potentially reduce the risk of POPF. In this randomized study, healthy pigs were allocated to either the ERFA or the glue occlusion groups. The protocol comprises three sequential procedures: (1) MPD occlusion via a hybrid laparoscopic or robotic approach, (2) minimally invasive pancreatic transection at four weeks, and (3) necropsy 15 days post-transection. This study addresses the technical challenges of manipulating pancreatic ducts in large animals and provides a standardized approach for evaluating MPD occlusion techniques. The methodology enables a robust comparison between ERFA and glue occlusion while accounting for anatomical variations between porcine and human models to support future clinical applications.