Updates in Surgery最新文献

Thymoma, a tumor originating from thymic epithelial cells, can have its prognosis significantly improved through early risk assessment. We proposed a fuzzy comprehensive evaluation fusion model (FCE-FM) to assess tumor risk. In this retrospective study, we enrolled 286 thymoma patients from two centers between 2018 and 2024 and partitioned the study cohorts into a training set (n = 196), an internal test set (n = 50), and an external test set (n = 40). We developed a fuzzy comprehensive evaluation-based fusion model to predict tumor risk using demographics, radiomic and multi-planar deep features. The FCE-FM integrates five base classification models(Logistic Regression, Support Vector Machine, XGBoost, LightGBM, and GBDT) via fuzzy comprehensive evaluation(FCE), analytic hierarchy process (AHP), and triangular membership function techniques. Feature selection was performed sequentially using Spearman rank correlation followed by LASSO regression. A total of 26 deep learning features (5 transverse, 13 sagittal, and 8 coronal planar features) and 4 radiomic features, along with gender, were identified to construct the models. Model performance was evaluated using the area under the curve (AUC) and accuracy metrics.The SHapley Additive exPlanations (SHAP) methodology was utilized to rank feature importance. The FCE-FM model exhibited superior predictive performance, achieving AUC values of 0.982 (95% CI 0.964-0.996), 0.927 (95% CI 0.847-0.990), and 0.895 (95% CI 0.771-0.992) on the training, internal test, and external test sets, respectively. Corresponding accuracies were 0.949, 0.860, and 0.800 across these datasets. Notably, the model consistently outperformed five baseline classifiers in terms of AUC performance on both internal and external validation sets. The FCE-FM model exhibited high stability and accuracy in multi-center validation, demonstrating its robustness. This interpretable framework offers clinicians a reliable early warning tool for tumor risk assessment, enabling timely intervention to significantly improve patient prognosis.

Introduction: Complication rates after thyroidectomy vary widely among centres. Various factors can affect the "complexity" of a case. However, an internationally agreed upon definition of what constitutes a "complex" case in thyroid surgery is currently lacking. We aimed to establish a framework supporting the development of a standardized definition of "complexity" in thyroid surgery by collecting endocrine surgeons' opinions through a survey.

Materials and methods: A 28-item survey was distributed through the mailing lists of the Italian and European Societies of Endocrine Surgeons and via social media. Questions explored respondents' opinions on determinants and endpoint measures of "complexity". Responses were compared by unit and individual thyroidectomy volume (> 50 vs. < 50 cases/year), and by routine use of pre-operative ultrasound and intra-operative nerve monitoring.

Results: Among 192 respondents, 97.3% acknowledged the potential usefulness of a shared definition of "complexity" in thyroid surgery for patients' workflow optimization. Permanent vocal-cord palsy (78.6%), operative duration (77.1%) and permanent hypoparathyroidism (77.1%) were most frequently chosen as appropriate endpoint measures of "complexity". Among determinants, previous neck surgery, adhesions/infiltration, mediastinal extension and large thyroid volume were considered impactful by the majority of respondents. High volume surgeons more frequently selected permanent palsy, tracheal injury and R1 margins as endpoints, and BMI as determinants of "complexity" (all Ps ≤ 0.05).

Conclusion: Endocrine surgeons recognize the need for a standardized definition of "complexity" in thyroid surgery to enhance risk stratification and care. Perceived complexity varies with proficiency. Collected data support a reproducible framework, to be validated in future studies.

Extralevator abdominoperineal excision (ELAPE) improves surgical margins in distal rectal cancer compared to conventional amputation; however, it is associated with higher rates of perineal morbidity. This study aimed to evaluate the incidence of perineal infections and identify associated risk factors in patients with rectal adenocarcinoma undergoing ELAPE with perineal reconstruction using an absorbable synthetic prosthesis. This prospective observational study including consecutive patients treated between 2009 and 2024. All patients underwent standardized perineal reconstruction with an absorbable synthetic prosthesis. Clinical, tumor, surgical, and postoperative complication variables were recorded. Univariate and multivariate analyses were performed to identify factors associated with perineal infection. A total of 61 patients were analyzed. Perineal infection occurred in 23%, with most infections developing within the first 30 postoperative days. Multivariate analysis identified obesity (Odds Ratio [OR] 74.3), active smoking (OR 33.7), and circumferential margin involvement observed on basal magnetic resonance imaging (OR 28) as independent risk factors. Patients with perineal infection had longer hospital stays, more readmissions, more postoperative visits, and higher complications severity. Infection was not associated with an increased rate of perineal hernia, which was low in our cohort (3%). In conclusion, perineal reconstruction with an absorbable synthetic prosthesis following ELAPE is safe and effective. Identification of patients at high risk for perineal infection enables targeted preventive strategies and informs future comparative studies of perineal reconstruction techniques.

Kidney transplantation (KT) is the preferred treatment for end-stage renal disease (ESRD), but socio-economic disparities significantly influence access to transplantation, waiting list (WL) outcomes, and post-transplant results. This study evaluates the impact of the socio-economic deprivation index (SEDI) on WL and KT outcomes in an Italian center. This monocentric, retrospective cohort study analyzed 1560 adult patients enlisted for KT at Sapienza University of Rome (2000-2024). Socio-economic and clinical data were collected, and patients were stratified into low-SEDI and high-SEDI groups. The primary outcome was a composite of death and WL drop-out due to clinical worsening. Secondary outcomes included post-transplant graft loss. Kaplan-Meier survival analysis and Cox regression models were used to evaluate risk factors. Patients in high-SEDI areas had longer times from dialysis initiation to WL inscription (27 vs. 20 months, P < 0.001) and from WL inscription to transplantation (22 vs. 17 months, P < 0.001). The composite outcome of death or WL drop-out occurred in 8.7% of patients, with no significant differences between SEDI groups. However, high-SEDI patients faced significantly higher risks of post-transplant graft loss due to socio-economic factors, including vulnerable housing conditions and demographic disparities. Multivariable Cox analysis identified dialysis-to-WL duration and socio-economic factors as significant predictors of WL and post-transplant outcomes. Socio-economic factors, as measured by SEDI, significantly influence WL and KT outcomes, underscoring the need for targeted interventions to minimize delays and improve access in high-SEDI regions. Strategies such as early referral, live donor promotion, and equitable healthcare access are crucial for optimizing KT outcomes.

Premedication with Lugol's solution (LS) has traditionally been used to reduce the vascularization and friability of the thyroid gland before total thyroidectomy in patients with Graves' disease (GD) and toxic multinodular goiter (TMNG) with thyrotoxicosis and/or with undetectable serum TSH. However, the effectiveness and applicability of this treatment remain subjects of debate. This study aims to evaluate the surgical and postoperative outcomes in patients premedicated with LS compared to those who were not premedicated. Data from 100 patients who underwent total thyroidectomy for GD and TMNG at our center from 2014 to 2024 were analyzed. Patients were divided into two groups: Lugol+, premedicated with LS (n = 57), and Lugol-, not premedicated (n = 43). Variables analyzed included thyroid diameter, thyroid weight, operative time, postoperative hemorrhage, hypocalcemia, recurrent laryngeal nerve palsy, length of hospital stay, rate of reintervention for hemorrhage, intraoperative thyroid consistency. No statistically significant differences were found between the groups regarding postoperative hemorrhage (1.7% in Group Lugol+ vs. 2.3% in Group Lugol-), operative time (median: 95 vs. 85 min), immediate postoperative complications such as transient hypoparathyroidism (15.8% vs. 9.3%) and transient recurrent laryngeal nerve (RLN) palsy (3.5% vs. 2.3%), nor the other variables analyzed. Our data suggest that routine preoperative preparation with LS may not be mandatory. This study supports the thesis that patients with GD and TMNG who cannot be premedicated due to inability to obtain LS, insufficient time for preoperative preparation, or lesser compliance by patient, may still be eligible for surgery.

Background: Acute calculous cholecystitis (ACC) is a common gastrointestinal emergency, with early laparoscopic cholecystectomy (ELC) as the standard of care. However, the risk of postoperative complications remains significant. This study developed and validated two machine learning models-CholeSurgRisk I (preoperative) and CholeSurgRisk II (comprehensive)-to predict major postoperative complications in ACC.

Methods: A prospectively collected, multicenter database of 1,253 patients was retrospectively analyzed. Lasso regression identified key predictive variables among demographic, clinical, and perioperative factors. Three machine learning algorithms (Random Forest, XGBoost, Decision Tree) were trained and tested, comparing their performance via AUC-ROC.

Results: CholeSurgRisk I achieved an AUC-ROC of 0.8456, while incorporating intraoperative variables (CholeSurgRisk II) improved performance to 0.8903. To facilitate clinical use, a web-based tool - "CholeSurgRisk I" - was developed based on the preoperative model, providing real-time, patient-specific risk estimations.

Conclusion: Machine learning enhances perioperative risk stratification in ACC. CholeSurgRisk I facilitates early preoperative assessment, whereas CholeSurgRisk II refines predictions by integrating intraoperative factors. The user-friendly application "CholeSurgRisk I" offers individualized complication risk forecasts, potentially aiding clinical decision-making and optimizing outcomes.

Objective: To evaluate the effectiveness of integrating 3D digital holographic reconstruction and intraoperative navigation with case-based learning (CBL) in enhancing the educational outcomes of laparoscopic partial nephrectomy training for urology residents.

Methods: A prospective randomized controlled trial was conducted at the Second People's Hospital of Hefei from August 2021 to May 2024. A total of 120 urology residents were randomly assigned to either a combined teaching group (3D holography + CBL, n = 60) or a conventional CBL-only group (n = 60). The experimental group utilized reconstructed CT/MRI DICOM data rendered into interactive holographic models via Microsoft HoloLens 2 for real-time anatomical visualization and intraoperative guidance. Key outcome measures included post-training performance (theoretical and practical scores), self-directed learning ability, teaching satisfaction, critical thinking disposition, and knowledge retention at 1-, 3-, and 6-month follow-ups.

Results: The combined teaching group demonstrated significantly superior outcomes across all measured domains (P < 0.05). Post-training scores were higher in theoretical knowledge (44.58 ± 2.09 vs. 40.28 ± 2.96), practical skills (44.63 ± 2.69 vs. 40.00 ± 2.64), and total score (89.21 ± 4.33 vs. 80.28 ± 5.55). Additionally, the group showed enhanced self-directed learning (4.38 ± 0.74 vs. 3.07 ± 0.73), higher teaching satisfaction (4.30 ± 0.74 vs. 3.15 ± 0.58), and improved critical thinking, notably in analyticity and cognitive maturity. Longitudinal assessments revealed better knowledge retention at all time points, with 6-month total scores of 76.92 ± 2.25 vs. 60.77 ± 5.97.

Conclusions: Integrating 3D holographic reconstruction and intraoperative navigation into CBL teaching significantly improves urology residents' comprehension, critical thinking, surgical preparedness, and long-term knowledge retention during laparoscopic partial nephrectomy training. This multimodal teaching model may serve as a valuable adjunct to traditional residency training frameworks.

To analyze independent risk factors for distant metastasis of Hurthle cell carcinoma (HCC)of the thyroid and to construct and validate a nomogram, thereby assisting clinicians in making more individualized clinical decisions. Patient data were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Chi-square tests and Logistic regression analysis were used to determine independent risk factors for distant metastasis of HCC. Logistic regression models based on significant independent risk factors were established using the rms package of R software (version 4.3.3) and visualized as a nomogram. The performance of the nomogram was evaluated using subject operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). A total of 1312 HCC patients were included, among whom 48 patients developed distant metastasis, accounting for 3.66% of the entire cohort. Results of chi-square test and univariate logistic regression analysis indicated that age, gender, marital status, tumor size, and lymph node metastasis were significantly associated with distant metastasis of HCC. Multifactorial logistic regression analysis revealed that age, gender, marital status and lymph node metastasis were independent risk factors for distant metastasis of HCC, which were used to construct the nomogram. Results of ROC curve analysis, calibration curves, and DCA demonstrated that the nomogram had good predictive performance. We successfully constructed and validated a nomogram for predicting distant metastasis of HCC. This nomogram is important for clinicians to promptly identify patients at high risk of distant metastasis and formulate more individualized clinical decisions.

To evaluate the impact of early (< 8 weeks) versus late (≥ 8 weeks) stoma closure on postoperative recovery and complications in preterm infants following surgery for necrotizing enterocolitis (NEC). In this multicenter retrospective cohort study, we analyzed data from preterm infants who underwent stoma closure between 2011 and 2022. Propensity score matching (PSM) was applied in a 1:2 ratio to balance baseline characteristics between early and late closure groups. Outcomes assessed included stoma-related complications, operative characteristics, gastrointestinal recovery, and postoperative complications. Of 367 eligible infants, 80 in the early closure group and 186 in the late closure group were included after matching. Baseline characteristics were well-balanced. The early closure group had significantly lower median weight at closure (2674 g vs. 3374 g, p = 0.038) and shorter stoma duration (48 vs. 69 days, p = 0.0064). Time to first flatus/defecation was shorter in the early group (2.7 ± 1.8 days vs. 3.2 ± 1.9 days, p = 0.012). There were no significant differences in overall complication rates, reoperation, readmission, mortality, duration of parenteral nutrition, or hospital stay. A non-significant trend toward higher median weight at 6 months corrected age was observed in the early group (6548 g vs. 6287 g, p = 0.12). Early stoma closure (< 8 weeks) is associated with faster recovery of gastrointestinal function and does not increase the risk of postoperative complications. These findings support the feasibility and safety of early closure in selected NEC infants, though timing should be individualized based on clinical assessment.

We investigated changes in platelet count after surgery for strangulated bowel obstruction (SBO), evaluated associations between postoperative thrombocytopenia and short-term outcomes, and identified risk factors for postoperative thrombocytopenia. This study included 109 patients who underwent emergency surgery for SBO between January 2014 and December 2023. Postoperative short-term outcomes were compared among three groups according to the lowest postoperative platelet count. Logistic regression analysis was used to identify risk factors associated with severe thrombocytopenia. All patients had platelet counts below the preoperative level within 72 h post-surgery. The severe thrombocytopenia (postoperative platelet count < 10 × 10⁴/µL) group exhibited significantly increased postoperative complications, 28-day mortality, and length of hospital stay. Preoperative thrombocytopenia, Sequential Organ Failure Assessment score, and bowel resection were independent risk factors for severe thrombocytopenia. Postoperative platelet counts fell below preoperative levels in all patients with SBO. Severe thrombocytopenia was associated with poor postoperative outcomes.