Updates in Surgery最新文献

Background Rectal cancer, accounting for a significant proportion of colorectal malignancies, presents unique challenges in treatment. Surgery remains the primary curative approach, but recurrence rates post-surgery poses challenges. While neoadjuvant chemoradiation has improved outcomes, the role of adjuvant chemotherapy is still debated. Herein, we aimed to clarify the efficacy of adjuvant chemotherapy in patients with confirmed pathological stage II rectal cancer. Methods In this retrospective single-center study, we investigated the role of adjuvant chemotherapy in 173 patients with biopsy-proven stage II rectal adenocarcinoma. Participants received neoadjuvant chemoradiation followed by open TME surgery, with or without adjuvant chemotherapy. The study was conducted at Sina Hospital between January 2014 and 2019, and analyzed overall survival (OS) and disease-free survival (DFS) outcomes. Propensity score matching (PSM) was used to adjust for potential confounders. Survival outcomes were assessed using Cox proportional hazards models, and sensitivity analysis was conducted using doubly robust estimation. Results Before matching, 173 patients showed significantly improved overall survival (HR:0.33, 95%C:0.22-0.50, p < 0.001) and disease-free survival (HR:0.41, 95%CI:0.28-0.61, p < 0.001) with adjuvant chemotherapy. Age ≥ 70 years was associated with poorer overall survival (HR:1.76, 95%CI:1.08-2.88, p = 0.02). After matching, in 100 patients (50 with chemotherapy, 50 without), adjuvant chemotherapy remained significantly beneficial for both overall and disease-free survival (p < 0.001), while age ≥ 70 years continued to negatively impact overall survival. Conclusion Our findings suggest that adjuvant chemotherapy provides benefits in terms of OS and DFS in stage II rectal cancer following neoadjuvant chemoradiation and TME surgery. Further prospective studies are warranted to confirm these results and optimize treatment strategies.

Celiac artery stenosis presents significant risks in pancreatoduodenectomy (PD), including elevated incidences of postoperative hepatic ischemia and clinically relevant pancreatic fistulae. Addressing this stenosis preoperatively is crucial to avoid complication. While stenosis predominantly arises from vasculopathy, managed with stenting, median arcuate ligament syndrome (MALS) is an atypical cause characterized by the median arcuate ligament's extrinsic compression of the celiac artery. Pre-PD surgical release of this ligament has demonstrated nearly 90% success rate in resolving ischemic complications. The celiac axis can be decompressed through open or minimally invasive techniques. Robotic-assisted celiac artery decompression is an attractive approach due to superior visualization and enhanced dexterity, which facilitate the complex dissection required at the diaphragmatic hiatus. The patient is a 49-year-old male diagnosed with pancreatic adenocarcinoma, who also exhibited severe celiac axis stenosis on preoperative imaging. Median arcuate ligament release prior to PD was pivotal in preventing hepatic ischemia consequent to the ligation of the gastroduodenal artery during PD and in re-establishing normal arterial flow to the upper gastrointestinal tract, thereby circumventing otherwise preventable complications. The patient underwent an uneventful robotic PD following the median arcuate ligament release. Robotic-assisted median arcuate ligament release prior to pancreatoduodenectomy is a safe and effective technique for decompression of celiac axis stenosis. This procedure facilitates meticulous dissection while minimizing postoperative complications and helps to circumvent otherwise preventable outcomes.

Adrenal masses are being found more and more often over the years. Given the association of these masses with advancing age, the decision to perform surgery in older, sometimes asymptomatic patients presents a clinical dilemma. These patients are potentially more vulnerable to adverse postoperative outcomes due to increased frailty. Therefore, this study aimed to compare the postoperative course after adrenalectomy in patients aged 70 years and older to that of a younger cohort. This single center retrospective study included patients aged ≥ 70 years who underwent adrenalectomy between 2000-2020, and propensity-score matched younger patients (< 70 years). Patients were matched based on hormonal overproduction, malignant diagnosis, surgical approach and year of surgery. The study included 77 elderly patients (median age 74 years) and 77 younger patients (median age 52 years; p < 0.001). Serious complications (Clavien-Dindo ≥ 3) occurred in 9.1% of elderly patients and 6.5% of the matched younger cohort (p = 0.773). The overall complication rate was 44.2% in elderly and 40.3% in younger patients (p = 0.771), with similar duration of hospital admission and mortality in both groups. Elderly patients experienced mostly infectious (33.8%) or cardiovascular complications (27.0%), and cardiovascular complications were more frequent in elderly than in younger patients (6.7%, p = 0.039). In conclusion, patients aged 70 years and older who undergo adrenalectomy have a similar postoperative course and complication rate as younger patients, with most postoperative complications being minor, and mortality being minimal. Therefore, older age itself should not be a reason to refrain from adrenalectomy.

Introduction: Obesity is a multifactorial and chronic disease, constantly growing in prevalence. Metabolic and Bariatric Surgery (MBS) is among the most effective therapies for obesity, determining consistent long-term weight loss and maintenance. Increasing evidence suggests a relevant mental health contribution to obesity pathogenesis. European and International Guidelines for MBS emphasize the importance of a pre-surgical psychological/psychiatric assessment and a post-surgical follow-up to improve MBS outcomes. Yet, no standard psychological/psychiatric procedures currently exist.

Methods: This paper overviews the psychological/psychiatric procedures which Italian mental health providers currently perform on MBS candidates to provide psychological support through every step of the MBS, from the assessment to the postsurgical follow-up, to evaluate eligibility, prevent mental health flare-ups and weight regain, as endorsed by the Board of the Italian Society of Surgery for Obesity and Metabolic Diseases (SICOB).

Results: The psychological/psychiatric procedures should encompass two phases: pre-surgical assessment and post-surgical follow-up. Pre-surgical assessment should investigate every condition that might reduce the MBS effectiveness or contraindicate the surgical process. It must include a mental state evaluation, weight history, eating behavior, body image, psychosocial conditions, and motivation. The post-surgical follow-up should offer psychological support to patients in achieving weight loss and maintenance. It should also prevent the onset or recurrence of psychiatric disorders that may affect clinical outcomes.

Discussion: This paper is the first to introduce a standardized protocol for psychological/psychiatric procedures for each phase of the surgical process, to allow MBS candidates to receive similar care despite geographical differences. It also serves as a potential clinical model for assessing mental eligibility or contraindications prior to MBS, and subsequently support the individual behavioral and lifestyle changes to achieve and maintain weight loss.

This study was to explore the degree of flat thoracic cage (FTC), cardiopulmonary function, and bone metabolism of pectus excavatum (PE) children of different ages after NUSS surgery. A retrospective analysis was conducted on 90 children with PE who underwent minimally invasive pectus excavatum correction surgery (NUSS), divided into three age groups: group I (1-3 years), group II (3-6 years), and group III (6-12 years), with 30 patients in each group. The study compared differences in thoracic flattening index, surgical-related metrics, pulmonary function, peripheral blood levels of alkaline phosphatase (ALP), calcium, magnesium, zinc, and phosphorus, and complication rates among the groups. Preoperative ALP level increased with aging of the children (P < 0.05). After surgery, the FTC index and ALP level of all the three groups greatly decreased, but increased with aging (P < 0.05). The operating time, intraoperative blood loss, and postoperative duration of analgesia also showed a trend of group III > group II > group I (P < 0.05). Postoperative levels of pulmonary function, including vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), peak expiratory flow (PEF), maximum expiratory flow at 75% of vital capacity (MEF75), maximum expiratory flow at 50% of vital capacity (MEF50), maximum expiratory flow at 25% of vital capacity (MEF25), and maximal mid-expiratory flow (MMEF), were significantly higher than preoperative levels in group I (P < 0.05); but without significant changes in groups II and III (P > 0.05). Neglectable differences were found in peripheral blood Ca, Mg, Zn, and P levels before and after surgery and postoperative complications in three groups (P > 0.05). The degree of FTC worsened with aging; the younger the children receiving NUSS surgery are, the more obvious the improvement of postoperative PF.

Sportsman's hernia is very frequent in some sports, particularly in football. This painful syndrome is reported by high-level athletes as well as amateurs. There is no consensus about the management of sportsman's hernia, because of the heterogeneity in anatomoclinic forms. In case of surgical indication, the Nesovic procedure, also named "fasciomyoplasty", is one of the recommended procedures for the abdomino-parietal forms. Our objective was to report our experience with this procedure in terms of short- and mid-term results. All the patients who underwent Nesovic procedure between January 2009 and December 2022 in our center were retrospectively reviewed. 43 patients (98% men; mean age: 29.5 ± 9.2 years) were included. 37% of patients were professional athletes. The median time from symptoms' onset to diagnosis was 3 months (range = 1-72 months). The median time from diagnosis to surgery was 7 months (range = 1-58 months). Postoperative overall morbidity occurred in six patients (14%), including scrotum swelling (n = 2), hematoma (n = 1), serous collection (n = 1) and acute urinary retention (n = 2). No major complication occurred. At the end of follow-up (median: 1 year; range = 1 month-11 years), 84% of patients recovered their previous sports activity, after a mean delay of 2 months. Nesovic procedure is efficient in more than 80% of sports patients without any major morbidity.

Anastomotic leaks are a significant complication in colorectal surgery. Indocyanine green fluorescence angiography (ICG-FA) has been suggested as a method to reduce the risk. This meta-analysis aims to evaluate the effect of ICG-FA on reducing anastomotic leaks in colorectal surgery. This study follows PRISMA guidelines and is registered on PROSPERO (CRD42022370748). We conducted a comprehensive search of multiple databases and registers for randomized controlled trials (RCTs) comparing ICG-FA with standard methods in colorectal surgery. Data extraction and quality assessment were performed by two independent reviewers, with a third resolving disputes. Odds ratios (OR) and mean differences (MD) were calculated using comprehensive meta-analysis software, version 3. Heterogeneity and publication bias were assessed, and a sensitivity analysis was performed. The analysis included five RCTs with a total of 1369 patients from four countries. The ICG-FA was associated with a 45% reduction in the risk of overall anastomotic leaks (OR: 0.550, p = 0.012). Subgroup analysis showed a 47% reduction in leaks for low anastomoses (OR: 0.53, p = 0.143) and a 69% reduction in grade A leaks (OR: 0.31, p = 0.008). No significant effects were observed for grade B and C leaks, blood loss, surgery duration, hospital stay, mortality, postoperative ileus, reoperation, or surgical site infections. ICG-FA significantly reduces the overall risk of anastomotic leaks, especially grade A leaks, and shows a trend towards fewer leaks in low anastomosis. No significant impact was found on secondary outcomes. Further RCTs are needed to confirm these findings.

Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) was proposed as a simplification of the biliopancreatic diversion (BPD) procedure with duodenal switch (DS) in order to reduce operative time and postoperative complications rate, however, keeping effectiveness in weight loss and in comorbidities' resolution. We performed a systematic review of the literature with the aim of summarizing the current evidence of SADI-S clinical outcomes in order to assess its effectiveness and safety, and a total of 17 studies were included. Short- and mid-term follow-up results were reported, with a mean TWL loss ≥ 25% at 12 months and > 44% after 24 months, comparable to BPD-DS, also in reoperative surgery. Comorbidity remission rates for T2D, hypertension, dyslipidemia and OSAS were of 75.8%, 61.2%, 60.4%, 71.9%, respectively. Some nutritional deficiencies were reported (total proteins, albumin, folate, Vitamin B12 and Vitamin D), but the hypoabsorption rate decreased with the lengthening of the common limb to 250/300 cm. SADI-S can be defined as an efficient bariatric operation both as primary and reoperative procedure for recurrent weight gain, with good results in comorbidity resolution.

The Rives-Stoppa (RS) procedure is a gold standard treatment of midline abdominal wall hernias. Comparability of pain control and outcomes to the enhanced-view totally extraperitoneal prosthetic (eTEP) repair remain unclear. A single-centre retrospective surgical cohort was selected including 30 RS repairs (January 2019-November 2021) and 30 consecutive eTEP procedures (September 2021-August 2022) for midline abdominal wall hernia(s) with rectus abdominis diastasis. Postoperative pain and outcomes were compared up to 1 month. Presence and median duration of patient-controlled analgesia were, respectively, 90% and 3 nights with RS, versus 30% and 0 nights with eTEP. Median switch to only oral analgesics occurred at postoperative day (POD) 3 after RS and at POD 2 after eTEP. Postoperative analgesics and opioid prescription at discharge were comparable. Median length of hospital stay was six nights after RS versus 3 nights after eTEP. Median duration of surgery was 110.5 and 164.5 min for RS and eTEP, respectively. After RS, 30 patients had postoperative drain(s) compared to 3 patients after eTEP. Conversion was needed in 3 eTEP procedures. Postoperative complications were comparable. No early recurrences were observed. Minimal residual diastasis was seen at postoperative consultation in 11 patients after eTEP. Compared to RS, eTEP is a minimally invasive alternative treatment of midline abdominal wall hernias with rectus abdominis diastasis and is associated with a shorter length of hospital stay, less postoperative pain and a comparable risk of short-term complications. At 1 month after eTEP, minimal residual diastasis can be present. ClinicalTrials.gov: NCT05446675. Secondary identifying number: EC/EH/220608-SK. Date of Registration: June 24, 2022.

Functional pancreatic neuroendocrine tumors (pNET) necessitate surgical resection. Enucleation is the preferred surgical method for well-differentiated pNETs that measure less than 2 cm in diameter, as it offers a greater likelihood of enhancing post-operative recovery and decreasing morbidity and mortality. Insulinomas are particularly suitable for enucleation when such a procedure is viable. However, enucleating tumors within the uncinate process of the pancreas, especially on its posterior aspect, can present substantial challenges. The accompanying video illustrates a robotic-assisted enucleation of an insulinoma in the uncinate process, performed on a 41-year-old male with recurrent hypoglycemia. This intervention led to the resolution of symptoms and incurred minimal post-operative morbidity.