Updates in Surgery最新文献

The standard treatment for locally advanced rectal cancer (LARC) involves neoadjuvant chemoradiotherapy (nCRT) followed by surgery. While nCRT improves tumor downstaging and R0 resection rates, heterogeneous responses among patients necessitate predictive tools to identify poor responders. This study aimed to develop a predictive model for tumor regression after nCRT using baseline clinical indicators. We retrospectively analyzed LARC patients treated with nCRT and total mesorectal excision (TME) at the Second Affiliated Hospital of Nanchang University (2016-2020). Baseline clinical data, including laboratory tests, tumor markers, and MRI findings, were collected. Tumor regression was evaluated post-nCRT using the RECIST criteria. Multivariate logistic regression identified predictors, and a predictive model was constructed. Model performance was assessed via ROC curves, decision curve analysis (DCA), calibration curves, and tenfold cross-validation. Finally, perform external validation on the model. Among 158 patients, 98 achieved objective response (CR/PR; 62%), while 60 showed poor regression (SD/PD). Independent predictors of tumor regression included pretreatment tumor diameter (P < 0.001), interval to surgery post-nCRT (P = 0.006), D-dimer (P = 0.010), prognostic nutrition index (PNI, P = 0.035), carcinoembryonic antigen (CEA, P = 0.004), and extramural vascular invasion (EMVI, P = 0.026). The predictive model demonstrated an AUC of 0.84 (95% CI 0.780-0.899), sensitivity of 85.0%, and specificity of 72.4%. Calibration curves indicated high accuracy, and DCA confirmed clinical utility. External validation demonstrated the model's reasonably good predictive value (AUC = 0.864, 95% CI 0.787-0.879). Pretreatment tumor diameter, interval to surgery, D-dimer, PNI, CEA, and EMVI are independent predictors of tumor regression after nCRT. The proposed model effectively stratifies LARC patients, guiding personalized treatment decisions to optimize outcomes.

The robotic approach to liver and pancreatic surgery is expanding worldwide. However, limited data are available on vascular management in these complex procedures. The unique characteristics of the robotic platform may enhance the feasibility of minimally invasive vascular resection and reconstruction. This retrospective, single-arm, single-center study includes patients who underwent liver, biliary, and pancreatic resections with superior mesenteric and portal vein resection performed robotically between April 2021 and June 2024. The study evaluates short-term outcomes and provides technical insights. Eight patients underwent superior mesenteric or portal vein resection during the study period. Among them, six cases occurred during pancreatic resections, while two were performed during liver resections. In four cases, the chosen strategy involved tangential clamping and direct suturing (Type 1). In two cases, the vessel was repaired using a patch (Type 2). The remaining two cases required end-to-end anastomosis-one performed directly (Type 3) and one with the interposition of a prosthetic graft (Type 4). Postoperatively, only two patients developed complications classified as > 3a according to the Clavien classification, with Comprehensive Complication Index (CCI) scores of 47.6 and 37.1, respectively. Vascular reconstructive skills are essential for surgeons performing hepatopancreatobiliary (HPB) surgery to achieve R0 resections in locally advanced cases. The robotic approach to vascular resection and reconstruction requires a stepwise implementation to ensure favorable oncologic and postoperative outcomes.

The optimal management of synchronous colorectal liver metastases (CLM) remains debated, particularly regarding the role of centralized care. This study aimed to assess the impact of comprehensive management at a high-volume center on perioperative and long-term outcomes in patients undergoing curative-intent hepatectomy for synchronous CLM. We retrospectively analyzed 613 patients treated from 2010 to 2021 at a tertiary referral center. Patients were categorized as exclusively internally managed (n = 273) or partially externally managed (n = 340). Propensity score matching (PSM) was performed to minimize bias. Exclusively internally managed patients were characterized by a greater rate of rectal cancer and a higher liver tumor burden. Overall, major morbidity was 11.0% and 90-day mortality was 0.6%, with no significant difference between groups. Median overall survival (OS) was 68 months. Independent predictors of worse OS included rectal cancer, advanced T-stage, nodal positivity, > 6 chemotherapy cycles, major hepatectomy, and R1 margins. After PSM (n = 428), exclusively internally managed patients showed improved 5-year OS (54.5% vs. 44.6%, p = 0.054). Comprehensive multidisciplinary management at a high-volume center may improve long-term outcomes in patients with synchronous CLM, particularly those with more advanced disease. Timely referral and consistent multidisciplinary tumor board evaluation are essential to optimize outcomes and guide personalized treatment strategies.

We aimed to determine the usefulness of the new setup, the "Narrow setting," by examining our initial experience with the Hugo^™ RAS system. 78 hysterectomies using the Hugo^™ RAS system performed in "Narrow setting" at our institution from November 2023 to December 2024 were included in this study. We retrospectively examined the patient's clinical information and surgical outcomes from the medical record. We also investigated the learning curve of docking time in this setting by cumulative summation analysis. The median age, body mass index, and uterine weight of the patients were 48 (31-76) years, 22.9 kg/m² (16.1-42.4), and 178 g (40-2000 g), respectively. More than half of the surgical indications were uterine myomas (52.6%, 41/78). The median operative, console, and docking times were 68 min (48-198 min), 46 min (29-151 min), and 9 min (6-31 min), respectively. The median estimated blood loss was 5 mL (5-220 mL). A total of eight perioperative complications were observed, but only one was classified as Clavien-Dindo grade III or higher. No conversion to open or laparoscopic surgery was required. The learning curve for docking time showed that docking in the "Narrow setting" can be proficient in 19 cases. We reported on our initial experience with hysterectomy using the Hugo^™ RAS system and found the "Narrow setting" to be safe and efficient.

The present study aims to evaluate the impact of stoma closure timing on anal function following low anterior resection (LAR) in rectal cancer patients and to investigate the factors associated with the development of low anterior resection syndrome (LARS). There is currently a lack of clarity regarding this issue, necessitating a comprehensive comparison. Between January 2017 and December 2021, a major public medical center consecutively performed LAR with temporary stoma construction for patients with rectal cancer. The primary objective of this study was to investigate the optimal timing of stoma closure following LAR, with a particular focus on its impact on anal function. To achieve this goal, we compared baseline characteristics, short-term postoperative complications, long-term oncological outcomes, as well as 5-year overall survival (OS) rate and disease-free survival (DFS) rate between two groups of patients: the early stoma closure group (stoma closure time < 6 months) and the late stoma closure group (stoma closure time ≥ 6 months). The secondary objective was to explore factors associated with the development of LARS. A total of 323 patients diagnosed with rectal cancer who underwent LAR were included in this cohort study. Based on the ROC cutoff point, patients were divided into two groups: the early stoma closure group (< 6 months, N = 110) and the late stoma closure group (≥ 6 months, N = 199). No significant differences were observed in baseline patient characteristics between the two groups (p > 0.05). In the comparison of short-term postoperative complications, patients with stoma closure time ≥ 6 months had a higher incidence of anastomotic leakage following LAR (0.9% vs. 6.3%, p = 0.029) and a higher rate of neural invasion (5.5% vs. 13.5%, p = 0.03). Regarding long-term oncological functional outcomes, a significantly higher proportion of patients with stoma closure time ≥ 6 months experienced LARS (35.9% vs. 47.7%, p = 0.045). In terms of long-term oncological outcomes, no differences were observed in OS rate and DFS rate between the two groups (p > 0.05). Logistic regression analysis was performed to identify factors associated with LARS, and the results indicated that stoma closure time (OR = 1.27, 95% CI 0.89-1.43, p = 0.042), gender (OR = 0.50, 95% CI 0.31-0.84, p = 0.008), and tumor distance from the anal verge (OR = 0.86, 95% CI 0.75-0.98, p = 0.029) were independent risk factors of LARS occurrence. We have ascertained that the timepoint for optimal stoma closure following LAR is at 5.5 months postoperatively, at which juncture patients attain the most favorable anal function. Therefore, we advocate performing stoma closure surgery within 6 months after LAR. Moreover, this study results demonstrate that the timing of stoma closure, patient gender, and tumor distance from the anal verge are independent risk factors associated with the development of LARS.

Enhanced Recovery Protocols (ERPs) have improved outcomes in colorectal surgery. Same-day discharge (SDD) after colonic resection is promising but often limited to highly selected patients. This study evaluates the safety and efficacy of a universal same-day discharge (USDD) program compared to traditional ERPs. The objective was to assess if USDD in a broader patient population is non-inferior to traditional ERP in terms of 30-day complications, readmissions, and reoperations. This was a retrospective matched cohort study at a single U.S. institution that launched a USDD program in May 2022. Thirty-six patients in the USDD program were compared to a matched control group receiving traditional ERP. USDD eligibility criteria included outpatient agreement, minimally invasive approach, no new stoma, and caregiver availability. Main outcome measures were 30-day post-operative complications, ED visits, readmissions, and reoperations. The USDD group had shorter operative times, increased TAP block use, and lower intraoperative fluid administration. No significant differences were found in 30-day complications or reoperations between groups. However, ED visits and readmission rates were higher in the USDD group. USDD appears to be safe and non-inferior to traditional ERP for selected patients. SDD can potentially be safely expanded to a wider patient population, but further prospective studies are needed.