Updates in Surgery最新文献

Ageism is an underrecognized form of discrimination that compromises equity, autonomy, and health outcomes for older adults. Inappropriate age-based assumptions can result in the underutilization of beneficial procedures, delayed interventions, and inequitable resource allocation. To conceptualize ageism in surgery by exploring its cognitive, systemic, and ethical underpinnings, and to propose actionable strategies to mitigate its impact on surgical decision-making and patient care. Through a conceptual framework, data from epidemiological studies, clinical trials, systematic reviews, and health policy reports were synthesized, providing proof for physicians' attitudes, systemic practices and ethical frameworks in perpetuating surgical ageism. Proof that cognitive biases can fuel ageism in surgery was demonstrated across multiple studies involving over 149,000 participants and more than 30 individual studies, each highlighting distinct biases that skew surgical decision-making, especially for older adults. Proof that systemic inequities contribute to surgical ageism was evidenced by studies on transplant referral, clinical trial exclusion, and ethical resource allocation frameworks, involving over 24,000 participants and multiple large-scale reviews. Finally, evidence supporting that educational strategies can mitigate ageism and the need for anti-ageism measures, was drawn from a range of studies involving over 20,000 participants across at least 80 studies. Surgical ageism stems from a confluence of cognitive, structural, and cultural factors. By addressing the drivers of ageism and implementing inclusive policies, the surgical community can promote person-centred care and uphold the dignity and rights of older adults in line with global health equity goals.

Laparoscopic cholecystectomy (LC) has become the standard management for gallstones. However, it is associated with postoperative elevations in liver enzymes. This scoping review of 52 studies involving over 28,000 patients was undertaken to evaluate the frequency, causes, and clinical significance of these conditions. Levels of ALT and AST increased in 75% to 82% of patients 24 to 48 h after surgery and returned to baseline by day 7. ALP, GGT, and bilirubin levels exhibited mild elevation in 10% to 30% of patients. Adverse events resulting from elevated pneumoperitoneum pressure (> 14 mmHg) and protracted surgical duration were markedly associated with enzyme-level imbalances. The transient alterations did not result in adverse clinical outcomes, suggesting that routine monitoring of liver enzymes may not be necessary for low-risk patients. The present review advocates for individualized perioperative assessment of high-risk patients and indicates the need for further research to optimize patient management strategies.

The post anesthesia care unit (PACU) was introduced to optimize intensive care unit (ICU) bed availability for patients requiring specialized perioperative care, providing comprehensive monitoring during the recovery phase in high-risk surgical patients. However, though several advantages of PACUs have been clearly demonstrated, no previous studies have investigated the overall costs. This retrospective study aimed at comparing the costs of postoperative monitoring in PACU and ICU after elective hepato-pancreatic-biliary (HPB) surgery at our hospital. A retrospective cohort study was conducted between January 2022 and December 2024. The investigations periods were divided according to the institution of PACU at our institution: before (January 1, 2022-May 31, 2023) and after (June 1, 2023-December 31, 2024). Three groups were identified: ICU 1 and 2, including all pt admitted to ICU before and after the institution of PACU, respectively, and PACU, including all pt admitted to PACU. The primary outcome was the cost of monitoring/pt. Secondary outcome was the overall hospital length of stay (LOS). 171 consecutive pt undergoing HPB surgery were included and divided into 49 pt belonging to ICU 1 group, 60 to ICU 2 and 62 to PACU. Multivariable analysis of monitoring cost revealed the following independent predictors: postoperative surveillance in PACU (P < 0.0001), duration of monitoring (P < 0.0001), male gender (P = 0.028) and severity of complications (P = 0.001), the latter resulting the only significant risk factor for prolonged LOS (P < 0.0001). PACU has emerged as a safe and efficient alternative to ICU in the postoperative surveillance of HPB surgical patients, with associated significant cost savings. Further research is required to identify specific criteria addressing the individual needs for postoperative admission to ICU or PACU.

This systematic review and meta-analysis investigated the efficacy and safety of support rods and bridges in loop stoma formation, a practice frequently employed in colorectal surgery despite the associated complications and controversial efficacy. The aim of this study is to provide evidence-based guidance on their routine use. Adhering to the Cochrane Collaboration's recommendations, we conducted this systematic review and meta-analysis systematically searching PubMed, Scopus and Web of Science for randomized controlled trials (RCTs) evaluating the efficacy of rods/ bridges in loop ileostomies. Key outcomes assessed included stoma retraction, stoma/skin necrosis, peristomal dermatitis, infection, and mucocutaneous separation. This review included six studies encompassing 1,239 patients (195 ileostomy, 1,044 colostomy). Analysis revealed no statistically significant difference in stoma retraction (RR = 0.70, 95% CI [0.37 to 1.33], P = 0.28). Conversely, for stoma/skin necrosis, four studies were analyzed and showed a statistically significant difference favoring the non-rod/bridge group (RR = 5.04, 95% CI [1.72 to 14.73], P = 0.003). For peristomal dermatitis, three studies revealed a statistically significant difference favoring the non-rod/bridge group (RR = 2.01, 95% CI [1.55 to 2.60], P < 0.00001), with ostomy rod use identified as a significant risk factor (OR 3.42, p < 0.01). Outcomes for infection and mucocutaneous separation showed no significant difference. Based on the our results, routine rod/bridge use does not appear to reduce stoma retraction and may be associated with an increased risk of necrosis and dermatitis. That is why the routine use of rod/bridge does not appear to be justified, but the small number of the included studies limit the generalizability of these results. Trial sequential analysis indicated that future high-quality RCTs with diverse and larger populations and are recommended to obtain more rigorous evidence.

For locally advanced rectal cancer (LARC), adding immunotherapy after patients receive standard neoadjuvant chemoradiotherapy (nCRT) or short-course radiotherapy (SCRT) is a new method. This study aims to evaluate the efficacy and safety of the combination of nCRT/SCRT and immunotherapy on LARC patients based on the current published studies. A comprehensive electronic search of literature up to December 1, 2024 was carried out in Pubmed, the Cochrane Library, Web of Science, Google Scholar databases and Embase. Studies comparing the nCRT/SCRT with preoperative immunotherapy (nCRT/SCRT + IMT group) and nCRT/SCRT alone (nCRT/SCRT group) were included. The primary outcome was the pathological complete response (pCR) rate. Three randomized control trials and one retrospective study, involving 692 LARC patients, were included. The pooled pCR rate was 40.6% (134/330) in the nCRT/SCRT + IMT group and 22.5% (66/293) in the nCRT/SCRT group (RR = 1.68, 95% CI 1.11-2.55, p = 0.01). The pTRG 0-1 rate was 69.0% (180/261) in the nCRT/SCRT + IMT group and 47.1% (106/225) in the nCRT/SCRT group (RR = 1.43, 95% CI 1.22-1.68, p < 0.001). The major adverse events rate (grade 3-4) were comparable between the nCRT/SCRT + IMT group and the nCRT/SCRT group (61/194, 31.4% vs 51/197, 25.9%, RR = 1.22, 95% CI 0.90-1.65; P = 0.20). Preoperative immunotherapy in combination with standard nCRT/SCRT may improve the tumor regression and increase the pCR rate in selected LARC patients without additional major treatment adverse events.

Sarcopenia predicts negative outcomes in colorectal surgery, including anastomotic leakage (AL). Folic acid (FA) is essential for cellular processes such as DNA synthesis and tissue repair, which may indicate that it could impact anastomotic healing. The objective of this study was to evaluate the association between preoperative blood levels of FA, sarcopenia defined radiologically by psoas density, and postoperative outcomes in patients undergoing resection for colorectal cancer. A prospective study was conducted on patients undergoing oncological colorectal resection with anastomosis between June 2022 and November 2024. FA levels and the average psoas density at the L3 level on computed tomography (CT) were analyzed. Postoperative complications were recorded. Of the 250 patients that were analyzed, 12% had low FA levels (< 2.7 ng/ml) and 16% were diagnosed with sarcopenia. Furthermore, low FA levels were associated with a higher risk of sarcopenia diagnosis [RR 4.63 (95% CI 2.26-9.49)], and radiological sarcopenia was associated with an increased risk of AL [RR 1.98 (95% CI 1.3-2.83)]. Low FA levels are associated with an increased risk of sarcopenia, therefore FA deficiency could be considered a modifiable risk factor for sarcopenia and, consequently, its supplementation preoperatively could reduce the risk of anastomotic dehiscence in colorectal cancer patients.

This study aimed to evaluate and compare the predictive performance of negative lymph nodes (NLN), lymph node ratio (LNR), and N stage in pancreatic ductal adenocarcinoma (PDAC) among patients with ≤ 12 retrieved lymph nodes and those with > 12 retrieved lymph nodes. Moreover, the association between the three nodal staging systems and survival was also explored. Clinical data on patients diagnosed with PDAC between 2004 and 2020 were downloaded from the Surveillance, Epidemiology, and End Results (SEER) database. Cox regression was performed to identify independent predictors of cancer specific survival (CSS) and overall survival (OS). Survival probability was calculated and compared by the Kaplan-Meier method and log rank test. Akaike information criterion (AIC) and Harrell's C-index were used to evaluate the prognostic ability of each nodal staging system. All three lymph node staging systems were independent predictors of CSS and OS. A higher NLN, a lower N stage, and a lower LNR were associated with improved survival. Compared with N stage, LNR staging performed better with a lower AIC and higher C-index for predicting the prognosis regardless of the sufficiency of retrieved lymph nodes, while NLN staging performed poorly in both the training and validation set. Subgroup analyses showed that the NLN successfully predicted survival outcomes in both lymph node-positive and node-negative patients. LNR demonstrated better predictive performance in PDAC patients regardless of the sufficiency of retrieved lymph nodes. Notably, for stage N0 disease, NLN was a more important prognostic predictor. The combination of LNR and NLN may offer more precise information on lymph node staging than the current staging system.

Laparoscopic anatomical hepatectomy (LAH) of segments 5 and 8 (LAHSg5/Sg8) for hepatocellular carcinoma (HCC) remains one of the most challenging procedures due to the difficulty in exposing the main vascular structure. The aim of our study was to investigate the anatomical characteristics of inter-SVs based on the three-dimensional (3D) visualization technology exploring its safety and feasibility during LAHSg5/Sg8. A total of 110 patients who underwent LAHSg5/Sg8 in our center between January 2019 and August 2022 were enrolled and analyzed retrospectively. During the operation, the inter-SVs of the first 10 patients were observed. Subsequently, 100 patients were included based on the previous intraoperative understanding. The anatomical parameters of inter-SVs and the perioperative outcomes were recorded and evaluated. The safety and short-term efficacy of LAHSg5/Sg8 were assessed. All the patients underwent preoperative 3D processing software analysis. Of the included patients, 74.6% had inter-SVs in Sg5/Sg8, which could be classified into three types: trunk type, double branch type and multi branch type, accounting for 35.4%, 22.2% and 17.0%, respectively. The concordance between pre-operation and intra-operation in terms of portal vein territory of Sg5/Sg8 was 82 ± 31%. The inlet point diameter was 3.3 ± 1.0 mm. The distance between the inter-SVs in Sg5/Sg8 and P8, point "B" were 17.7 ± 6.2 mm, 6.1 ± 17 mm, respectively. The confluence of inter-SVs in Sg5/Sg8 at "point B" and below accounted for 10.2%. Preoperative 3D reconstruction and personalized surgical planning based on individual anatomical variations are crucial for successful LAHSg5/Sg8. Inter-SVs between Sg5/Sg8 as a landmark along the ISP during LAHS for HCC may be safe and feasible.

Single-stage tracheal resection and anastomosis represents the gold standard for benign subglottic stenosis' management. Nevertheless, also considering the complexity of the surgical procedure, some patients are considered unfit for tracheal surgery (stenosis involving vocal cords, comorbidities, and relapse after surgery). Until now, the only alternative was tracheostomy which represents the only real alternative to secure the patency of the airway. Thanks to the creation of "transcordal stents", patients considered unfit for surgery have a valid alternative to tracheostomy and the conformation of the stent reduces the risk of stent migration, preserving airway patency, swallowing, and phonation. This study aims to evaluate the use of a new custom-made transcordal stent, comparing its safeness with traditional transcordal stent. Between 2017 and 2021, 28 consecutive patients underwent transcordal stenting for benign tracheal stenosis in 3 centers. Patients were divided into 2 groups: 16 treated with the new custom-made stent (Group 1) and 12 treated with conventional stents (Group 2). Intra-, post-operative complications, swallowing capacity, quality of voice, granulation tissue, stent migration, and quality of life (QoL) were compared between the two groups. Group 2 showed reduced swallowing capacity (p = 0.0001), higher rate of stent migration (p = 0.0003), higher rate of granulation tissue (p = 0.0044), and higher rate of stent replacement (p = 0.0001). Voice reduction was not significantly different between the two groups. QoL was better in Group 1. Despite this represent the largest study analyzing transcordal stenting as definitive treatment of subglottic stenosis in patients unfit for surgery, results could not draw definitive conclusions because of the small number of patients, the lack of randomization, and the small follow-up. Nevertheless, the use of the new custom-made transcordal stent could be considered safe and effective, guaranteeing stable results with low rate of long-term complications and better QoL compared to the traditional stents.