Updates in Surgery最新文献

Loss of signal (LOS) at intraoperative nerve monitoring (IONM) is defined as an >100 mV amplitude decrease  and a >10% latency reduction and represents a predictor of postoperative impaired vocal cord motility (VCM). We aimed to evaluate if an intraoperative signal recovery (ISR) after LOS may predict a positive outcome of VCM. Among 5884 consecutive intermittent IONM-guided thyroidectomies (April 2021- March 2025) all the patients in whom a LOS was observed were evaluated. Topic and intravenous corticosteroids were administered to all of them. Eventual recovery was evaluated after 20 minutes. Patients with  an ISR less than  50% compared to the baseline were included. The rate of vagal signal (VS) ISR was defined as a percent from the minimum value: VS-recovery-VS-minimal/VS-predissection-VS-minumum. ISR was correlated to VCM (ROC curve analysis). Among 169 patients with LOS, 65 (38.5%) showed ISR, with 48 (73.8%) of them exhibiting normal VCM on postoperative day 1 (POD-1). The remaining 17 patients with impaired VCM on POD-1 recovered normal VCM on POD-15 (7-10.8%) or POD-30 (10-15.4%). The AUC for impaired VCM at POD-1 was 0.938 (95% CI: 0.849-0.983, p <0.0001) and the ISR cut-off was 13%, with a 94.1% sensitivity and a 89.6% specificity. All patients with ISR >31% showed normal VCM. All patients with ISR <13% exhibited impaired motility at POD-15 but recovered at POD-30. ISR can predict full recovery of VCM. ISR >31% is associated with normal postoperative VCM and staged thyroidectomy could be avoided in this subgroup of patients with LOS.

This study evaluated the feasibility and safety of Synchroseal (SS), a new articulating bipolar energy-based device, in da Vinci robotic gastrectomy for gastric cancer. A prospective study of 25 patients using SS was compared with retrospective data from 218 patients treated with conventional ultrasonic shears (US). Propensity score matching (PSM) ensured comparability. Metrics analyzed included C-reactive protein (CRP) levels, operative time, lymph nodes (LNs) retrieved, intraoperative blood loss, laboratory tests, hospital stay duration, and complication rates. PSM yielded a balanced comparison between the two groups (standardized differences < 0.1). SS (n = 25) significantly reduced CRP levels on postoperative days 2, 4, and 6 compared to US (n = 123) [7.67 ± 4.73 vs. 10.18 ± 5.66, (p = 0.040), 5.11 ± 3.33 vs. 6.65 ± 4.23, (p = 0.090), 2.74 ± 2.10 vs. 4.26 ± 3.78, (p = 0.001)]. Additionally, SS showed lower serum amylase levels and shorter operation times than US [67.60 ± 48.31 vs. 168.66 ± 316.92, (p = 0.027) and 234.52 ± 65.03 vs. 274.75 ± 54.90, (p = 0.002)]. Although SS retrieved fewer total LNs (31.80 ± 9.5 vs. 36.88 ± 14.96, p = 0.034), both groups achieved adequate LN dissection (> 30 LNs). No significant differences were observed in other parameters. SS led to lower postoperative CRP and serum amylase levels, shorter operation time, and adequate LN dissection, suggesting reduced postoperative inflammation and faster sealing function as potential benefits.

Background: Anastomotic leakage still represents the most feared complication in colorectal surgery. However, there is limited data focusing on management and how this affects outcome in case of leakage following open versus laparoscopic right colectomy. We, therefore, performed an observational multicenter study addressing this issue.

Methods: Data of patients undergoing elective right colectomy for benign and malignant disease using an open or laparoscopic approach were collected in seven colorectal units among Austria between January 2010 and December 2019. Patients undergoing emergency surgery or suffering from Crohn's disease with chronic anastomotic fistula were excluded. Demographic, peri- and postoperative data were analyzed retrospectively.

Results: During the study, a total of 3446 patients were operated on using an open (n = 2282, 66.2%) or laparoscopic (n = 1164, 33.8%) approach. Anastomotic leak rates accounted for 2.8% (65/2281) and 3.2% (37/1165), respectively (p = .588). Age at operation (p < .001), initial surgical approach (open versus laparoscopic; p = .034) and the Mannheim Peritonitis Index (MPI; p < .001) at revision represented independent risk factors for mortality. We divided the surgical strategy during revision into three subgroups: suturing of leak (SD), formation of new anastomosis (NA) or fecal diversion with or without formation of new anastomosis (FD). SD, NA or FD had no influence on clinical outcome and mortality (p = .599). The initial approach had no influence on which strategy was used later, but time to revision was significantly shorter following initial laparoscopic resection (6.2 versus 8.8 days, p = .008). Leak-associated mortality was lower in the minimally invasive group (8.1% vs 23.1%; p = .057).

Conclusions: Timing of revision and not the surgical strategy (± fecal diversion) has an impact on the clinical outcome of patients with a leak following right colectomy. An initial laparoscopic approach may lead to an earlier revision resulting in a lower mortality rate.

Enhanced recovery pathways (ERPs) are evidence-based, multimodal strategies designed to promote early recovery and to optimize surgical outcomes. While extensively implemented in elective surgery, their adaptation to emergency general surgery (EGS) raises challenges due to patient instability and limited preoperative time. The study aimed to evaluate the adherence to each ERPs item and the impact on short-term outcomes in patients undergoing emergency general surgery. This is a multicenter observational prospective study carried out in 13 Italian centers. Inclusion criteria targeted adults undergoing surgery for intestinal occlusion or perforation. Patients re-operated after elective surgery were excluded. The primary endpoints were the adherence to intraoperative ERP items and the compliance to the postoperative recovery pathway. Secondary endpoints were postoperative mortality, morbidity, and length of hospital stay. Between March 2023 and March 2024, 760 patients were analyzed. The highest adherence was observed for active warming (97%), PONV prevention (92%), and long-acting opioid avoidance (87%). The lowest adherence was found for invasive arterial pressure monitoring (35%), depth of anesthesia monitoring (34%), locoregional analgesia (31%), and minimally invasive surgery (26%). By postoperative day 3, 66% of patients tolerated solid diets and 58% had discontinued intravenous fluids. Postoperative mortality, morbidity, and major complications occurred in 3%, 33%, and 9% of patients, respectively. Median hospital stay was 7 days. This study underscores the adherence to ERP in EGS, highlighting the potential of ERP to improve perioperative outcomes in a high-risk population. Future research should prioritize strategies to enhance adherence, particularly to underutilized components as goal-directed fluid therapy and minimally invasive surgery and further optimize ERP protocols for emergency settings.

Up to this date, there have been no reports on immersive virtual reality (IVR) training in thyroid surgery. The purpose of this blinded, randomized controlled trial was to determine the validity and impact of VR training in residents' education. Nineteen general surgery residents participated in the trial comparing IVR with traditional learning, utilizing a technical textbook as a control. A stratified randomization was used to secure balance in the distribution of residents according to their experience. The examined task pertained to the surgical steps from neck incision up to the placement of the continuous intraoperative neuromonitoring electrode and was evaluated by a blinded Fellow of the European Board of Surgery (FEBS) certified endocrine surgeon. Training superiority was assessed by the outcome measures of Objective Structured Assessment of Technical Skills (OSATS) score, need for the main surgeon to intervene, verbal answers, and time to task completion. Participants completed questionnaires regarding face validity and perceived benefits of the educational process. Immersive VR group completed the task significantly faster (p = 0.012), at a mean time of 27.25 ± 3.8 vs 35.25 ± 6.5 min in the control group, and was superior in OSATS Overall score (p = 0.035), knowledge of instruments (p = 0.015) and flow of operation (p = 0.021) scores. In the dedicated questionnaire, the participants of the IVR group stated greater overall satisfaction of the educational process (p = 0.002), ease of use (p = 0.015), enjoyment (p < 0.001), repetitivity (0.001), and perceived improvement in surgical technique (0.021). The IVR group dedicated more time in training 39 ± 8.9 vs 27.5 ± 7.2 min (p = 0.014), and performed more repetitions of the educative module, 3.5 (2-5) vs 2 (1-3) (p = 0.003) than the control group. IVR training demonstrated improved outcomes in several translational technical skills acquisition over traditional learning, while yielding improved satisfaction and repetitivity for participants. Clinical trials registration number No: NCT06917755.

The climate emergency requires effective measures to reduce the environmental impact of the healthcare system. Approximately 20% of medical waste originates from operating rooms. Proper waste segregation, along with adherence to a correct definition of biohazardous waste, are good practice procedures in the operating unit that ensure waste reduction. This study aims to assess the effectiveness of waste segregation in a multispecialty Surgical Unit. During a 3-week observational period, compared with a subsequent 3-week experimental period, counts of paper and plastic bags and the number and weight of biohazardous waste were recorded. The experimental period incorporated heightened waste sorting attention and introduced new criteria for surgical uniform disposal. While no significant differences in paper and plastic bag production were observed between the two periods, there was a non-statistically significant reduction in numbers and weight of biohazardous waste (p = 0.22; p = 0.16 respectively). Multiple regression analysis revealed a statistically significant 20 kg reduction in biohazardous waste over 3 weeks, with the same number of surgical procedures performed (p<0.05), resulting in 3.7 kg of biohazardous waste per surgical procedure. This reduction increased to 24 kg in the second period under the same number and type of interventions (p<0.05). Notably, General Surgery, Urology, Otolaryngology, and Orthopedics were identified as the surgical branches with the highest biohazardous waste production. In particular, orthopedic procedures generated 9.35 kg of hazardous medical waste per intervention, with statistical significance (p = 0.006). A careful separate collection of waste in the operating room, focusing on limiting biohazardous waste production, could be an important tool for reducing environmental impact and fostering economic savings. A good practice involves finding tailored solutions through teamwork as demonstrated by the present study.

Conditional survival (CS) is a measure of prognosis of patients who have already survived several years since diagnosis. However, few studies have investigated the CS of patients who underwent liver resection (LR) for early-stage hepatocellular carcinoma (HCC). We enrolled 942 consecutive patients who underwent LR for HCC with pathology-defined American Joint Committee on Cancer (AJCC) 7th edition stage 1 or 2 disease. The three-year CS was calculated as CS = S(x + 3)/S(x) and represented the probability of surviving an additional three years, given that the patient had already survived x years. The one-, three-, and five-year survival rates were 97.1%, 86.7%, and 76.1%, respectively, and were lower in cases with AJCC stage 2 disease, alpha-fetoprotein level of ≥ 20 ng/ml, presence of cirrhosis, anti-hepatitis C virus positivity, age > 65 years, and Model for End-Stage Liver Disease score of > 9. However, the three-year CS indicated that these variables were associated with shortened survival only in the first two years. From the third year after LR, the probability of survival of patients was similar between subgroups. CS is useful for providing a dynamic evaluation of survival during postoperative follow-up.

Background: Liver resection is still the most effective and curative treatment for recurrent liver cancer, laparoscopic repeat liver resection (LRLR) offers an option for recurrent liver cancer due to invasive advantages. However, multicenter, large-sample population-based LRLR has rarely been reported. We aimed to assess the advantages and drawbacks of LRLR compared with laparoscopic and open surgery for recurrent liver cancer by meta-analysis.

Methods: Relevant literature was searched using the PubMed, Embase, Cochrane, Ovid Medline, Web of Science databases up to January 16th, 2022. Quality assessment was performed based on a modified version of the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. The data were calculated by odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI) for fixed-effects and random-effects models.

Results: 12 retrospective observational studies were suitable for this analysis, involving 1315 patients with 602 undergoing LRLR and 713 undergoing open repeat liver resection (ORLR). Compared with ORLR, LRLR had less intraoperative blood loss (SMD - 0.7, 95% CI - 1.01 to - 0.39; P < 0.0001), shorter hospital stay (SMD - 0.57, 95% CI - 0.88 to - 0.27; P = 0.0002), less overall postoperative complications (OR 0.37; 95% CI 0.2-0.68; P = 0.001), and higher R0 resection rate (OR = 2.51, 95% CI 1.5-4.17, P = 0.0004); However, there were no statistically significant differences between LRLR and ORLR regarding operative time (P = 0.68), transfusion rate (P = 0.08), mortality (P = 0.8), and 3-year overall survival (P = 0.72).

Conclusions: LRLR has an advantage in the hospital stay, blood loss, complications rate and R0 resection. LRLR is a very useful, safe technology and feasible choice in patients with the recurrent liver cancer.

In candidates for hepatectomy, different techniques to induce liver hypertrophy and modulate the future liver remnant are available. However, their use in specific clinical scenarios is highly heterogeneous and there is no consensus about minimal safety standards needed to incorporate these strategies into routine clinical practice. The aim of this position paper was to summarize newly available evidence in the field and compare medical practice among different hepatobiliary surgical units to evaluate the transformative potential of liver hypertrophy techniques in surgical oncology. This paper sets the stage for a future structured consensus on the application of liver hypertrophy techniques before hepatectomy.