Updates in Surgery最新文献

Anal Melanoma (AM) is a rare and aggressive disease lacking standardized treatment protocols. Despite advancements in medical oncology, the 5-year overall survival (OS) remains at 20%. Local surgery (LS) has gained popularity over radical surgery (RS) due to its comparable OS when negative margins are achieved. Neoadjuvant chemotherapy and radiotherapy do not improve margins status, while neoadjuvant immunotherapy (Neo-IT) has not been studied on AM margins status. Patients diagnosed with AM in the National Cancer Database (2011-2021) who received Neo-IT were retrospectively identified and divided into two cohorts based on the surgical approach (LS or RS). In each cohort, patients were matched in a 1:1 ratio to those who did not receive Neo-IT based on age and tumor size. Univariate analyses were performed to compare Neo-IT influence on surgical margins in both cohorts. Thirty patients were included in the LS cohort, with 56.7% of positive margins. Univariate analysis revealed that Neo-IT did not improve surgical margins in LS in AM (p value = 0.713). However, the 22 RS (31.8% positive margins) patient cohort's univariate analysis revealed that Neo-IT significantly improved surgical margins in AM (p value = 0.022). Achieving negative margins is crucial to increase OS in anal melanoma. Neo-IT appears to improve negative surgical margin status in RS for anal melanoma. However, Neo-IT did not improve margins in LS. This opportunity to improve margin suggests a potential to increase the 5-year OS of 20%. Future work is needed to determine the impact to OS and confirm the IT role in LS.

Patients with esophageal cancer and concomitant liver cirrhosis (LC) pose a surgical challenge because of the increased risk of postoperative complications and mortality. Purpose of this study was to review the existing literature and estimate perioperative short-term outcomes of esophagectomy in this patient population. Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. The search was last updated on July 30th, 2024. Primary outcomes were anastomotic leak (AL) and 90 day mortality. Ten observational studies were included for a total of 387 patients with LC. The age of the included patients ranged from 35 to 85 years, 91.2% were males. The main causes of liver cirrhosis were alcoholic (75%) and viral hepatitis (20.4%). Esophageal squamous cell carcinoma was diagnosed in 58.7% of patients. Ivor-Lewis esophagectomy with intrathoracic anastomosis was reported in 69.9% of patients, while McKeown esophagectomy with cervical anastomosis was reported in 30.1% of patients. The estimated pooled prevalence of AL and 90-day mortality were 13% (95% CI = 6-24%; I² = 72%) and 17% (95% CI = 10-27%; I² = 72%), respectively. The estimated pooled prevalence of postoperative pulmonary complication, sepsis, and liver failure were 52% (95% CI = 39-65%), 30% (95% CI = 14-52%), and 9% (95% CI = 4-17%), respectively. Esophagectomy can be performed in properly selected patients with LC and concomitant esophageal cancer. Foregut surgeons should be aware of the not negligible postoperative complications rates and mortality. Risk stratification and attentive perioperative care are essential to minimize serious adverse events.

Ventral hernias are abnormalities in anterior abdominal wall occurring due to an incision or are congenital. This comprehensive review and meta-analysis aim to objectively compare laparoscopic to retro-muscular or any other mesh repair approach to manage ventral incisional hernia. To identify studies that managed ventral incisional hernia using laparoscopic, open, or retro-muscular mesh repair techniques, a comprehensive literature search was performed. Random effects model was used, and data were presented as log odds ratio (logOR) or as Hedge's g with corresponding 95% confidence intervals (CI). Cochran's Q test was implemented to measure heterogeneity among articles, and funnel plots were utilized to examine publication bias visually. Quality of all selected studies was assessed using Critical Appraisal Checklists for Studies developed by the Joanna Briggs Institute. 20 studies (16,247 patients) were included published from 2003 to 2023. Significantly reduced incisional hernias developed in laparoscopic group. The recurrence of hernia lowered with laparoscopic repair vs. open repair. In retro-muscular vs. laparoscopic, recurrence was lower, however, not statistically significant (p = 0.97). Open repair type resulted in a longer hospital stay than laparoscopic (p = 0.03). In laparoscopic repair, the postoperative complications reduced compared to the open repair (p = 0.02). Laparoscopic incisional and ventral hernia repair is a practical and successful alternative to open method. It is associated with shorter hospital stay and lower risk of postoperative complications. In few instances, retro-muscular mesh repair may be opted for.

To evaluate the feasibility, safety, and efficacy of the lateral single-incision laparoscopic totally extraperitoneal (L-SILTEP) approach in patients with inguinal hernia who had contraindications to the midline approach. This study included 58 patients who underwent L-SILTEP. Data on their baseline characteristics and perioperative details were collected. Quality of life and cosmetic satisfaction assessments were performed. Of the evaluated patients, 25.9% had a history of middle and lower abdominal surgery and 10.3% had skin diseases around the umbilicus. The mean surgical duration, blood loss volume, and incision length were 53.5 (± 22.3) min, 7.2 (± 9.7) mL, and 2.0 (± 0.13) cm, respectively. Additionally, 29.3% of patients experienced intraoperative peritoneal rupture, and one patient had epigastric vessel bleeding. The 6-, 24-, and 48-h postoperative pain scores were 3.0 (± 0.6), 1.6 (± 0.6), and 1.1 (± 0.4), respectively. Postoperative complications included seroma (n = 3), hematoma (n = 1), and scrotal edema (n = 1). The surgical incision in the L-SILTEP approach was more aesthetically pleasing than that in previous surgeries. Approximately 17.2%, 8.6%, and 10.3% of patients reported pain, mesh sensation, and movement limitation, respectively. Severe or disabling symptoms were not reported, and there were no cases of 30-day readmissions. Hernia recurrence or incisional hernia was not observed over a mean follow-up duration of 14.6 (± 6.1) months. L-SILTEP can be used for patients with contraindications to the midline approach. Furthermore, it is a safe and effective procedure.

The role of inflammation in the bile duct injury has been suggested. Regarding, this study aims to determine the relationship between preoperative White Blood Cell count (WBC), C-reactive protein (CRP), and neutrophil-lymphocyte ratio (pNLR) with post-operative short- and long-term outcomes in patients undergoing a hepaticojejunostomy (HJ) for a bile duct injury (BDI) repair. This prospective longitudinal study (R-2022-3001-127) enrolled fifty patients. pNLR, WBC, and CRP were determined from preoperative laboratory analysis. Morbidity/Mortality, Accordion and National Surgical Quality Improvement Program (NSQIP), primary HJ patency and actual primary patency rate were registered. Perioperative morbidity and mortality were 34% and 2%. Primary patency was 92%. Median CRP and pNLR were statistically significantly higher in patients with Accordion > 3, NSQIP any complication, and biliary complications. CRP cut-off was consistent (6.3-6.6 mg/dl) with area under curve (AUC) 0.8, in all post-operative complications. pNLR had a good AUC (0.7; 2.7-3.1 cut-off value) in any complication and biliary complications. Preoperative inflammatory biomarkers of patients who underwent a HJ for BDI repairs were associated with post-operative complications.

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching, potentially leading to the "small-for-size syndrome" (SFSS). SFSS is a rare dysfunction that may affect a partial liver graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. A key role in the physiopathology of SFSS is played by portal hypertension (PHT) to which a small allograft is submitted after reperfusion, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. Thus, SFSS prevention relies not only on increasing graft volume (implementing the use of larger grafts or auxiliary/dual liver transplantation), but also on the control of the increased portal vein pressure (PVP) and portal vein flow (PVF). To this aim, surgical graft inflow modulation techniques (GIM) such as splenic artery ligation (SAL), splenectomy and hemiportocaval shunts, can be considered when an imbalance between the PVP and the hepatic arterial flow (HAF) is acknowledged. However, such strategies have their pros and cons, and a deep knowledge of the indications and complications is needed. Furthermore, pharmacological modulation has also been proposed. This review is aimed to update available literature on the current knowledge and strategies for modulating portal vein flow in LDLT.

Ultrasound-guided Transversus Abdominis Plane Block (UG-TAPB) reduces post-operative pain better than i.v. painkillers in patients operated with laparoscopic surgery. This study aims to compare the postoperative course of patients undergoing bariatric surgery treated with UG-TABP to that of patients treated with standard analgesic therapy. We retrospectively analyzed patients who have undergone bariatric surgery from November 2021 to April 2023, comparing patients treated with UG-TAPB (Group A) with patients treated with standard i.v. analgesic therapy (Group B). Post-operative numeric-pain rating scale (NRS), nausea and vomiting (PONV), opioid and antiemetic consumption were compared between the two groups until postoperative day (POD) 2. 41 patients underwent bariatric surgery in the aforementioned period. 11 patients were included in group A, whereas 30 patients were included in group B. The two groups were homogeneous for age, BMI, surgery type and comorbidities. Females were more common in Group B (64% vs. 80%; p = 0.019). NRS was significantly lower in Group A than Group B from POD0 to POD2 (3.8 ± 1.2 vs. 6.1 ± 2; p = 0.001 and 1.1 ± 0.3 vs. 3.1 ± 1.3; p < 0.001 after surgery and on POD2 8 pm, respectively). On POD 0, opioid consumption (9% vs. 57%; p = 0.011 and 9% vs. 47%; p = 0.033 after surgery and at 8 pm, respectively), PONV (27% vs. 90%; p < 0.001 and 9% vs. 57%; p = 0.011) and antiemetic consumption (36% vs. 90%; p = 0.001 and 9% vs. 53%; p = 0.014) were higher in Group B. Patients in Group A can be discharged earlier than patients in Group B (1.45 ± 0.82 vs. 2.67 ± 1.39 days; p = 0.005). UG-TAPB is associated with a better and faster recovery after bariatric surgery and should be considered in ERABS.

To compare the efficacy and safety of cryorecanalisation and cryoablation using flexible bronchoscopy for the treatment of tumor-like endobronchial tuberculosis (EBTB). Patients with tumor-like EBTB (104) were randomly divided into a cryorecanalisation (54 patients) or cryoablation (50 patients) group to assess the differences in efficacy and complications between the treatments. The cryorecanalisation and cryoablation treatments' therapeutic efficacies were 81.5% and 48.0%, respectively (p = 0.000); in patients with less than moderate obstruction (≤ 50%), the therapeutic efficacies were 92.9% and 88.9%, respectively (p = 1.000). In patients with more than moderate obstruction (> 50%), cryorecanalisation and cryoablation's therapeutic efficacies were 77.5% and 25.0%, respectively (p = 0.000). The number of treatments in the cryorecanalisation and cryoablation groups were 2.46 ± 1.06 and 3.26 ± 0.75, respectively (p = 0.000). The main complication of the treatment protocol in both groups was bleeding, and the overall bleeding rate was 96.2% and 16.0% in the cryorecanalisation and cryoablation groups, respectively (p = 0.000). Cryorecanalisation via flexible bronchoscopy improved the outcome of patients with tumor-like EBTB and reduced the number of treatments required compared with cryoablation; however, it had a higher bleeding rate and the potential risk of severe bleeding.