Updates in Surgery最新文献

The postoperative overall survival of patients with pancreatic ductal adenocarcinoma is not optimal. The aim of this study was to explore the perioperative risk factors for overall survival after laparoscopic pancreaticoduodenectomy (LPD) in patients with pancreatic ductal adenocarcinoma (PDAC). From January 2015 to January 2022, consecutive patients who underwent LPD with a pathological diagnosis of PDAC at our center were included in the study. LASSO regression and multivariate Cox regression were used to explore perioperative risk factors associated with overall survival. A total of 159 patients were included in the study. The median overall survival was 21 months. In the multivariate analysis, the level of direct bilirubin in serum (HR: 1.01, 95% CI 1.00-1.02, P = 0.043), postoperative pancreatic fistula (HR: 0.36, 95% CI 0.18-0.86, P = 0.010), and adjuvant therapy after surgery within 12 weeks (HR: 0.53, 95% CI 0.34-0.83, P = 0.001) were identified as independent risk factors associated with overall survival. A high level of direct bilirubin in the serum, happened with postoperative pancreatic fistula and delayed postoperative adjuvant therapy are prognostic risk factors affecting the overall survival of patients with PDAC after LPD.

This study aimed to explore the safety, feasibility, and efficacy of using KangDuo-Surgical Robot-01 (KD-SR-01) for distal gastrectomy in patients with gastric cancer. We prospectively enrolled patients undergoing KD-SR-01 assisted distal gastrectomy at our center from September 2023 to December 2023. Data on baseline characteristics, perioperative details, and short-term follow-up were collected prospectively. Descriptive statistical analysis was performed. This study included 15 patients with a median age of 60 years (range: 44-74) and a median body mass index of 24.7 [interquartile range (IQR): 19.8-27.0]. None of the patients required conversion to laparotomy or open surgery during lymphadenectomy. Ten patients underwent D2+ lymphadenectomy, four had D2, and one had D1+. Eleven patients had robotic-assisted BII anastomosis, one had robotic-assisted BI anastomosis, and three had laparoscopic BII anastomosis. All patients had negative surgical margins. The median operative time was 210.0 min (IQR: 200.0-225.0), with a median anastomosis time of 32.0 min (IQR: 21.5-54.5) for robotic-assisted BII anastomosis and 20 min for BI anastomosis. The median estimated blood loss was 30 ml (range: 30-50), and the median postoperative hospital stay was 7.0 days (IQR: 7.0-8.0). Four patients (26.7%) experienced Clavien-Dindo grade II postoperative complications, including two cases of hypoalbuminemia, one case of pneumonia, and one case of moderate anemia, with no device-related complications. Short-term follow-up indicated normal postoperative recovery with no radiographic evidence of recurrence. The KD-SR-01 is safe, feasible, and effective for distal gastrectomy and robotic-assisted gastrointestinal reconstruction.

Since long-term results after laparoscopic sleeve gastrectomy (LSG) are rather scarce, this study aims to add LSG results with a minimum of 5 years of follow-up. Prospectively collected data from primary LSG in a tertiary bariatric center from 08/2007 to 12/2018 with follow-up ≥ 5 years were analyzed retrospectively. Primary endpoints included total body weight loss (%TBWL) and excess weight loss (%EWL), insufficient weight loss (IWL), weight regain (WR), remission of associated diseases, development of new-onset gastroesophageal reflux disease (GERD), and nutritional deficiencies. Furthermore, the study focused on incidence, time point, and causes of conversion and revision operations. A total of 207 LSG (132 female, mean age 43 (± 10.7) years) entered this study. 33.3% (52 of 156 without conversion) were lost to follow-up for ≥ 5-year data. Perioperative mortality was 0.5% (n = 1). %TBWL was 27.1% (± 12.4) and %EWL 52.5% (± 24.3). IWL or WR was found in 48.8%, new-onset GERD occurred in 27.5% of cases, leading to conversion in 26.6% and revisions in 2%. Nutritional deficiencies were observed in 23.7%, while resolution of associated diseases was sufficient. This patient group with a mean BMI > 50 kg/m² at baseline showed fair results regarding weight loss issues and remission of associated diseases at ≥ 5 years postoperatively. Yet, a rate of 48.8% of either IWL and/or WR and 27.5% of new-onset GERD required conversion and revision operations in 28.6%. To better learn about long-term results of LSG, further studies preferably with larger multicenter samples and comparisons with alternative primary procedures, preferably in a prospectively randomized approach, possibly with focus on high BMI patients, are required.

Background: Metabolic/bariatric surgery (MBS) remains the most effective and long-lasting treatment for obesity and its complications. Apart from any surgical complications, the often less obvious but possibly severe side-effects of nutritional deficiencies have become of interest in recent years. OAGB is known to come with the need for thorough supplementation.

Setting: Retrospective study; university-hospital based.

Aim: Assessing nutritional issues and their management in a real-life cohort of patients undergoing OAGB.

Methods: Patients that underwent OABG between 01/2018 and 08/2019 were retrospectively assessed. Laboratory values (gained from electronic patients charts) were analyzed for nutritional issues (parathyroid hormone, vitamin A, E, D, B12, folic acid, albumin, ferritin, iron, and transferrin saturation) as well as postoperative complications and reoperations. Furthermore, weight development, improvement/remission of obesity-related complications, and regular intake of multivitamin supplementation (MVS) were assessed.

Results: 120 patients underwent OAGB; 89 were female. A follow-up was available for 101 patients. Mean length of follow-up was 27.8 ± 20.9 months. OAGB led to a %TWL of 36.7 ± 9.5% and %EWL of 86.8 ± 25.5%. Preoperative deficiencies were vitamin D (53.3%), followed by folic acid (16.7%) and vitamin A (6.7%). During follow-up, every patient developed at least one deficiency, hypovitaminosis D and A were predominant (74.3% and 41.0%), and 31 suffered from folic acid deficiency (30.7%). Hypovitaminosis B12 and calcium deficiency was observed in three patients (2.9%). Although advised to, only 45.5% opted for the intake of specialized MVS, whereas 10% did not take any MVS at all. More than half of all patients (53.5%) took additional supplements. Nineteen patients underwent reoperations associated with the initial OAGB.

Conclusion: Two conclusions can be drawn: First, there is a general need for bypass patients to get assessed for a broad array of deficiencies over time. Second, MVS is essential for patients that had bypass surgery. Additionally, compliance needs to be promoted by educating patients as well as other treating physicians.

Surgical coaching has been proven to effectively enhance clinical performance. However, diverse implementation strategies present challenges when initiating new programs. Our scoping review aimed to synthesize the existing literature on surgical coaching, thereby informing the direction of future coaching initiatives. We reviewed published articles in PubMed/Medline and suppletory manuscripts from reference lists. The protocol of our review was registered (osf.io, Z3S8H). Inclusion criteria were studies that provided a detailed description of structured surgical coaching programs aimed at improving clinical performance. Excluded were studies focused on mentoring, teaching, or other forms of coaching that did not align with our specific definition of surgical coaching. We extracted and charted variables such as authors, publication year, geographic region, and others for subsequent analysis. A total of 117 studies were screened, and 11 met our inclusion criteria. Among these, five articles (45%) employed objective metrics to evaluate clinician performance. One study reported on the overall complication rates within 30 days as a measured outcome. Surgeons were the primary coachees in ten of the studies (91%), and the training of coaches was deemed necessary in seven studies (64%). The analyses revealed a preference for expert coaching models (6/11, 55%), video-based coaching (9/11, 82%), and postoperative timelines (7/11, 64%). Various coaching models were identified, including PRACTICE, GROW, and WISCONSIN. As an effective education method, surgical coaching has been conducted in many regions with varied designs. The implementation of structured surgical coaching programs offers substantial benefits for trainers, enhancing efficiency. Future research should focus on generating higher-level evidence, utilizing objective measurement tools, and integrating innovative technologies to further enhance the efficacy of surgical coaching programs.

Rectal cancer is universally considered a different disease entity as compared to colon cancer, except when dealing with colorectal peritoneal carcinomatosis (PC), in which the two cancers are deemed as the same one. The present study aims to investigate the influence of primary tumor location (colon vs. rectum) on oncologic outcomes in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal peritoneal metastases. Data from three referral centers undergoing CRS plus HIPEC for PC of colorectal origin were prospectively collected. The primary outcomes were overall survival (OS) and disease-free survival (DFS) according to primary tumor location (colic vs. rectal). Univariate and multivariate analyses were performed using the Cox proportional hazard model first on the total number of patients. Then, a propensity score matching using the nearest-neighbour method with a 1:1 ratio was performed. The study included 167 patients: 126 colic and 41 rectal PC. After propensity score matching, rectal primary tumor location was independently predictive of a lower DFS (HR 1.91; 95%CI 1.06-3.45; p = 0.031) but not of a lower OS (HR 1.12; 95%CI 0.57-2.21; p = 0.73). Post-matching 3-year DFS rates were 49.2% (95%CI 34,3-70,5%) and 19.4% (95%CI 9,4-40,2%) for colic and rectal PC, respectively. The present study shows a significantly worse DFS for rectal cancer PC undergoing CRS and HIPEC compared to colon cancer PC, suggesting a possible need for dedicated pathways for rectal PC patients and posing a question for rectal PC to be considered as a unique disease entity.

The surgical risk is higher for obese patients undergoing laparoscopic left hemicolectomy. To enhance the surgical safety and efficacy for obese patients, we have innovatively integrated the advantages of various surgical approaches to modify a pancreas-guided C-shaped surgical procedure. The safety and quality were assessed through a retrospective analysis. Colon cancer patients who underwent laparoscopic left hemicolectomy were categorized into two groups, C-shaped group and Medial-to-lateral group. Baseline data, operative safety indices, operative quality indices and learning curve were subjected to statistical analysis. The complete mesocolic excision rate and R0 resection rate were 100% in both groups. In terms of surgical safety, C-shaped group experienced significantly less blood loss (50(20) mL vs. 50(50) mL, p = 0.002), shorter total operative time (252.65 ± 50.43 min vs. 280.12 ± 70.45 min, p = 0.004) and no organ damage occurred. All patients were classified into four BMI grades (I: BMI < 18.5 kg/m²; II: 18.5 ≤ BMI < 24 kg/m²; III: 24 ≤ BMI < 28 kg/m²; IV: BMI ≥ 28 kg/m²). The total operative time and estimated blood loss were significantly lower in obese patients (BMI grade III and IV) of C-shaped group. In addition, intra-group analysis further confirmed that this modified surgical technique could effectively enhance safety and efficiency for obese patients. Learning curve analysis revealed a significant reduction in total operative time after the completion of 20 surgeries. Utilization of the pancreas-guided C-shaped surgical procedure in obese patients ensures reliable surgical outcomes and significantly increases safety and efficiency. In addition, it is easier to learn and master.

This study aimed to compare mucinous carcinoma and adenocarcinoma of the appendix in terms of survival and investigate the risk factors influencing survival. The data for this study were retrieved from the SEER database (SEER Research Plus 17 registries). Patients diagnosed with appendix cancer between 2004 and 2019 were included. Demographic data, such as age, gender, marital status, and year of diagnosis, along with oncological variables like stage, surgery, chemotherapy, radiotherapy, and survival time, were extracted from the SEER database. Pathological subtypes were classified as adenocarcinoma (AC) and mucinous adenocarcinoma (MAC) based on the College of American Pathologists guidelines. Patients with other pathological subtypes or missing data were excluded from the study. This study included 4524 patients, with 2118 (46.8%) classified as AC and 2406 (53.2%) as MAC. There was no significant difference in mean age between AC and MAC groups (63.22 ± 14.30 vs. 59.46 ± 14.07, p = 0.483). AC was more common in males, while MAC was more prevalent in females (46.8% vs. 53.2%; 55.6% vs. 44.4%, p < 0.001, respectively). Married status was high in both groups (p = 0.001). While no difference was found in white race distribution, the black race was more prevalent in the AC group (57.1% vs. 42.9%, p < 0.001). Grade 1 tumors were more frequent in the AC group, whereas Grades 2 and 3 were more common in the MAC group (p < 0.001). Stages 1, 2, and 3 were more prevalent in the AC group, while the majority of MAC cases were at Stage 4. Surgery rates were higher in the AC group (98.6% vs. 96.4%, p < 0.001). Chemotherapy was used more frequently in the MAC group (50.9% vs. 40.6%, p < 0.001), while radiotherapy rates were similar in both groups (p = 0.498). The mean follow-up period was 55.70 ± 47.2 months. Five- and ten-year survival rates for the MAC group were 64.4% and 50.2%, respectively, higher than the AC group's rates of 54.2% and 39.7% (p < 0.001). The overall risk of mortality was 1.4 times higher in the AC group compared to the MAC group (p < 0.001, HR: 1.377 [CI 95% 1.259-1.507]). While adenocarcinomas and mucinous adenocarcinomas have similar incidences, non-metastatic adenocarcinomas were more frequently observed. In contrast, mucinous adenocarcinomas often exhibited distant metastases. Nevertheless, the survival rate was higher in mucinous adenocarcinomas.

The applicability of risk assessment tools (RATs) for preoperative risk assessment (PRA) in Emergency General Surgery (EGS) is unclear. Limited knowledge of surgeons' approach to risk assessment is available. We investigated how Canadian surgeons approach PRA for EGS and their awareness of available RATs. Canadian Association of General Surgeons members were invited to complete an online cross-sectional survey. Descriptive statistics were reported. Of 278 respondents, 70% were attending surgeons (44% had 5-10 years in practice, 43% > 10 years), 5% fellows, and 25% residents. Most worked in medium-/large-volume centers (89%) and teaching hospitals (77%). During preoperative risk assessment, 2/3 of respondents reported applying clinical experience/instinct and referring to literature, while 55% used RATs. The best-known and used tools were the ACS-NSQIP calculator (68% and 59%) and the Emergency Surgery Acuity Score (ESAS, 66% and 47%, respectively). Surgeons were divided regarding the accuracy of RAT estimates, with 47% considering them generally accurate and 49% inaccurate. Trainees reported greater interest in major morbidity risk (86% vs. 65%) and probability of supported discharge (45% vs. 29%) than surgeons. Among participants not using RATs, 41% indicated they are scarcely accessible in the EGS context, while 33% found them cumbersome and time-consuming. RATs are underused in favor of personal judgment. The use of RATs may facilitate decision-making in elderly/complex patients and help reduce variability in practice, particularly for trainees and less-experienced surgeons. A greater effort in education is needed to spread the culture of RATs for PRA.