World Journal of Gastrointestinal Surgery最新文献

Liver transplantation (LT) remains the definitive treatment for end-stage liver disease, yet early detection of graft dysfunction and rejection is still challenging. Conventional blood-based markers provide systemic information but lack hepatic specificity. Bile, directly secreted by hepatocytes and cholangiocytes, represents an organ-specific biofluid with diagnostic potential for assessing graft viability and early complications. This minireview examined the biochemical, immunological, and molecular features of bile as biomarkers in LT, focusing on pH, bicarbonate, glucose, lactate, bile acids, and proteomic/lipidomic profiles in relation to ischemia-reperfusion injury, early allograft dysfunction, and ischemic-type biliary lesions. The integration of bile-based parameters into ex situ perfusion and post-transplant monitoring, supported by omics technologies and predictive modeling, was also discussed. Building on these insights, we designed a single-center prospective study (ClinicalTrials.gov: NCT03882164) evaluating biliary tacrolimus (TACbile) as a predictor of acute rejection after LT. Paired daily TACbile and plasma tacrolimus levels are measured in recipients with Kehr T-tubes to define a blood-bile ratio of tacrolimus. The primary endpoint was the predictive accuracy of blood-bile ratio of tacrolimus for biopsy-proven rejection; secondary outcomes include associations with early allograft dysfunction. Bile-based biomarkers, particularly TACbile, may revolutionize graft monitoring and personalize immunological surveillance after LT.

Background: Early risk stratification in severe acute pancreatitis (SAP) remains challenging with traditional scoring systems overlooking etiological heterogeneity, particularly in hypertriglyceridemic acute pancreatitis (HTG-AP).

Aim: To develop and evaluate a machine learning (ML) model combining intra-abdominal pressure (IAP) and procalcitonin (PCT) for SAP prognosis and evaluate its clinical impact across different etiologies.

Methods: We retrospectively analyzed 245 patients with pancreatitis (98 patients with SAP). An ML model using 24-h peak IAP and PCT levels was used to predict 28-day mortality. Propensity score matching was used to compare IAP-PCT-guided management with conventional management.

Results: The ML-IAP-PCT model outperformed the Acute Physiology and Chronic Health Evaluation II score (area under the curve: 0.853 vs 0.801, P = 0.044) and Bedside Index of Severity in Acute Pancreatitis score. IAP-PCT-guided management was associated with lower mortality (15.8% vs 25.0%, P = 0.043) and multiple organ dysfunction syndrome (48.7% vs 61.8%, P = 0.027) rates. Patients with HTG-AP showed the greatest benefit (multiple organ dysfunction syndrome: 39.3% vs 60.7%, P = 0.018).

Conclusion: ML-optimized IAP-PCT monitoring provides superior prognostic accuracy and guides management associated with improved outcomes, especially in patients with HTG-AP. Prospective validation is needed to establish causality for this etiology-stratified approach.

Background: Esophageal cancer surgery is associated with a high risk of postoperative pulmonary complications, particularly pneumonia. Although conventional respiratory rehabilitation strategies - such as preoperative inspiratory muscle training - have demonstrated limited efficacy, the low-intensity traditional Chinese Qigong practice "Liuzijue" (Six-Character Formula) shows promise. However, robust clinical evidence supporting its use in patients undergoing esophagectomy remains lacking.

Aim: To evaluate the effects of early postoperative "Liuzijue" training on pulmonary function and pneumonia incidence following radical esophagectomy.

Methods: This retrospective study included 306 patients who underwent esophagectomy. The control group (n = 163) received standard care, consisting of abdominal breathing, incentive spirometry, and early ambulation. The intervention group (n = 143) received the same standard care plus twice-daily "Liuzijue" training for 14 days. Primary outcomes were the incidence of pneumonia (defined by Centers for Disease Control and Prevention criteria) and changes (Δ) in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), and maximum voluntary ventilation (MVV) from baseline to postoperative day 14.

Results: The "Liuzijue" intervention was associated with a significantly lower incidence of pneumonia (11.9% vs 24.5%, P = 0.005; relative risk = 0.48). Significant improvements were observed in ΔFVC (+502.1 mL vs +326.5 mL, P < 0.001), ΔFEV₁ (+701.7 mL vs +434.4 mL, P < 0.001), and ΔMVV (+19.4 L/minute vs +14.4 L/minute, P < 0.001). Absolute FEV₁ values on postoperative day 14 were higher in the intervention group (2270.8 mL vs 2066.1 mL, P = 0.021), along with significantly lower Borg dyspnea/fatigue scores (P = 0.045). No significant differences were observed in changes in diffusing capacity of the lung for carbon monoxide, total lung capacity, or 6-minute walk distance.

Conclusion: Early initiation of "Liuzijue" training after esophagectomy is associated with reduced pneumonia incidence and accelerated recovery of key pulmonary function parameters. These findings support the integration of "Liuzijue" into enhanced recovery after surgery protocols for esophageal cancer patients.

Background: Delayed post-pancreatectomy hemorrhage (PPH) is life-threatening, and endovascular interventions show promise. This retrospective study aimed to evaluate endovascular treatment outcomes for delayed PPH and identify mortality risk factors.

Aim: To conduct a single-center retrospective study of 88 patients with delayed PPH to systematically evaluate the clinical efficacy of endovascular treatment, identify independent risk factors for six-month mortality, and propose and validate a predictive model for individualized management of high-risk patients.

Methods: This retrospective analysis included 88 patients with delayed PPH treated by endovascular intervention. Patients were stratified into survival (n = 64) and mortality (n = 24) groups. Clinical and procedural variables were assessed using univariate and multivariate logistic regression. Significant predictors were incorporated into a prognostic nomogram. Model performance was assessed through discrimination (area under the receiver operating characteristic curve), calibration, and decision curve analysis.

Results: Technical and clinical success rates were 92.0% and 60.2%, respectively. The overall six-month mortality rate was 27.3% (24/88). Independent predictors of mortality included advanced age, prolonged operative time, shorter hospital stay, intra-abdominal infection, coagulation dysfunction, common hepatic artery bleeding, and failure to achieve clinical success. The nomogram demonstrated excellent discrimination (area under the receiver operating characteristic curve = 0.943), with good calibration and favorable net benefit on decision curve analysis.

Conclusion: We proposed and validated a predictive nomogram for six-month mortality following endovascular treatment for delayed PPH. The model facilitates individualized risk stratification and may guide clinical decision-making. Early identification of high-risk patients - particularly older individuals or those with infection or coagulopathy - and prompt, personalized intervention may improve outcomes in this high-risk population.

Background: Patients with tumors often develop multiple autoantibodies against tumor-associated antigens. Among these, antinuclear antibodies (ANAs) constitute a clinically important group distributed across the nucleus, cytoplasm, and cytoskeleton. Emerging evidence suggests that ANAs are closely associated with the development and progression of various malignancies, including colorectal cancer (CRC).

Aim: To detect ANA fluorescence patterns in CRC using indirect immunofluorescence (IIF) and investigate their correlation with the disease.

Methods: We collected serum samples from patients and healthy controls visiting The Affiliated Panyu Central Hospital of Guangzhou Medical University between May 2023 and March 2024 for analysis. The study included 38 patients with newly diagnosed CRC, 43 patients with colorectal polyps (CRP), and 29 healthy controls. Serum ANA expression was assessed by IIF, and fluorescence patterns were recorded for each group. Differences in ANA titers were compared among each group to analyze the differences in serum ANA-positive expression, which were further analyzed to explore the correlation between ANA expression and CRC screening.

Results: ANA positivity rates were 50.00% in the CRC group, 46.51% in the colorectal polyp group, and 6.90% in the healthy control group, with significantly higher rates in the two patient groups compared to the control group (P < 0.05). In the CRC group, the most common fluorescence patterns were nuclear speckled (15.79%) and cytoplasmic speckled (15.79%), with titers predominantly low (1:100, 28.95%). In the colorectal polyp group, nuclear speckled (18.60%) and nuclear homogeneous (11.63%) were the most frequent, with titers also predominantly low (1:100, 37.21%). The distribution of intermediate titers differed significantly among groups (P < 0.05).

Conclusion: ANAs are associated with both CRP and CRC and may be useful in early CRC screening. Medium-to-high ANA titers, in particular, should prompt further evaluation for possible CRC correlation. Multiple ANA fluorescence patterns can be detected across all groups, with patients with CRP and CRC showing greater pattern diversity than healthy controls.

Esophageal manometry has undergone significant advancements, transitioning from conventional line tracings to high-resolution manometry with topographic analysis. This evolution has improved the classification and diagnosis of esophageal motility disorders, as defined by the Chicago Classification. However, challenges remain in interpreting borderline cases, assessing esophagogastric junction outflow obstruction, and correlating manometric findings with clinical symptoms. Artificial intelligence (AI) has emerged as a promising tool for enhancing esophageal manometry by enabling automated data analysis, pattern recognition, and predictive modeling. Future perspectives include the integration of AI for automated analysis, refinement of pressure topography metrics, and incorporation of adjunctive testing such as functional luminal imaging probe technology. Additionally, novel catheter designs and ambulatory manometry may enhance diagnostic accuracy and patient comfort. Integrating manometry findings with biomechanical models and machine learning techniques may support the development of more personalized management strategies. This review explores current and emerging technologies and their potential impact on the future of esophageal manometry, aiming to improve diagnostic precision and therapeutic outcomes in esophageal motility disorders.

There is a lack of consensus on the optimal surgical approach for splenic flexure malignancies. Surgeons face the challenge of balancing successful oncological outcomes with the morbidity and functional effects of extended colonic resection, considering the variable 'watershed' vasculature and lymphatic anatomy of the splenic flexure. While there is an increasing body of evidence supporting the oncological safety of a more conservative segmental resection, most of the data stems from retrospective single center studies. This article reviews the management strategies and examines the evidence supporting various surgical approaches to splenic flexure malignancies.

Background: Distribution of the colonic diverticula differs in different populations, and right-sided colon diverticulitis (RCD) and left-sided colon diverticulitis (LCD) manifest distinct clinical features. Complicated diverticulitis (CD) mostly requires hospitalization and can be treated within a spectrum from observation to surgery. Treatment choice is formed depending on the patient's general condition, the presence of diffuse peritonitis, the localization of diverticulitis, Hinchey stage, and responsiveness to the prior treatment. Clinical disparities regarding right and LCD also led to the differences in the incidences of both emergency surgery and future elective surgery.

Aim: To evaluate the clinical features of CD, display the differences according to colonic localizations, and present treatment approaches.

Methods: This was a retrospective study from a single centre analysing data from a prospective database. The 253 patients with history of hospitalization for CD were included and divided into two groups: RCD and LCD. To compare the differences between the two groups, the Student's t-test was used when the parametric test prerequisites were fulfilled, and the Mann-Whitney U test was used when such requirements were not fulfilled.

Results: The 208 (82.2%) patients were found to have LCD, and 45 (17.8%) had RCD. The majority of the patients had Hinchey 1A diverticulitis (49.8%). Male gender was significantly more common in patients who underwent surgery for LCD. While persistent abdominal pain was the main prior finding in the conservative treatment of both localizations, surgery was most performed due to abscess in RCD and perforation in LCD. The presence of an accompanying malignancy during colonoscopy was significantly more common in LCD cases who underwent surgery. Hartmann's procedure was the most performed technique in emergency settings (56.3%), while laparoscopic colectomy with anastomosis was in elective settings (53.9%). In addition, surgery was found to prolong the mean length of hospital stay in LCD patients.

Conclusion: Although diverticulitis is a benign condition, the need for an individualized and evidence-based approach makes management challenging. Localization of the disease has an important role in determining the appropriate treatment.

Background: Acute pancreatitis (AP) is a severe inflammatory condition of the pancreas that leads to significant morbidity and metabolic disturbances. Hypercalcemia, or elevated serum calcium levels, is a concerning complication that may contribute to kidney stone formation and exacerbate renal issues. Calcium homeostasis is regulated by hormones, such as parathyroid hormone (PTH), calcitonin, and vitamin D, which can be altered in AP. Understanding the interplay among hypercalcemia, kidney stones, and hormonal changes is crucial for improving management strategies and clinical outcomes in patients with AP.

Aim: To investigate the relationship between hypercalcemia and kidney stone formation in patients with AP, along with changes in calcium-regulating hormone levels.

Methods: This study was conducted in 200 patients diagnosed with AP at Ningbo Urology and Nephrology Hospital. The participants underwent regular monitoring of serum calcium levels and kidney stone formation using imaging. Additionally, blood samples were analyzed to measure the levels of calcium-regulating hormones, including PTH, calcitonin, and vitamin D, at baseline and during the course of the disease.

Results: Of the 185 patients who completed the study, 31 (16.8%) developed kidney stones during the 7-day follow-up period. Hypercalcemia occurred in 53 patients (28.6%), with a peak incidence on day 3. Among hypercalcemic patients, 41.5% developed kidney stones compared to 6.8% in normocalcemic patients (odds ratio = 9.67, 95% confidence interval: 4.12-22.68, P < 0.001). A significant positive correlation was found between hypercalcemia and kidney stone formation (P < 0.001). Elevated PTH levels were noted in 60% of the patients with hypercalcemia, indicating a strong association between increased PTH levels, hypercalcemia, and kidney stone formation.

Conclusion: This study highlights the complex interplay between AP, calcium metabolism, and renal complications, providing insights that may guide future therapeutic strategies.

Background: Hepatocellular carcinoma (HCC) in segments VII and VIII poses technical challenges for both liver resection and radiofrequency ablation (RFA). Robotic-assisted techniques may enhance safety and precision, but comparative evidence remains limited.

Aim: To compare the clinical outcomes of robotic liver resection (R-LR) and robotic intraoperative RFA (RIO-RFA) for HCC located in liver segments VII and VIII.

Methods: We retrospectively analyzed 93 HCC patients in segments VII/VIII with de novo (n = 57) or first recurrent (n = 36). HCC who underwent R-LR or RIO-RFA between 2015 and 2024. Propensity score matching was performed to reduce selection bias. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Kaplan-Meier curves, log-rank tests, and Cox regression were used to identify prognostic factors for OS and RFS.

Results: In the de novo group, OS and RFS did not differ significantly between R-LR and RIO-RFA before or after propensity score matching. In contrast, the recurrent group showed significantly improved OS and RFS with R-LR (P = 0.005 and P = 0.012, respectively). Subgroup analyses revealed that low-risk de novo patients with smaller tumors achieved superior OS after R-LR, whereas carefully selected low-risk recurrent patients undergoing RIO-RFA (smaller tumors, absence of complications) achieved outcomes comparable to R-LR. Platelet count, tumor size, and postoperative complications constituted key prognostic factors.

Conclusion: For HCC in challenging liver segments VII and VIII, R-LR and RIO-RFA achieve comparable outcomes in de novo cases, whereas R-LR confers superior survival in recurrent disease. R-LR should be prioritized for small de novo HCCs and for recurrent disease overall; RIO-RFA may serve as an effective alternative in carefully selected low-risk recurrent patients. Tumor size, platelet count, and postoperative complications are key prognostic indicators to guide individualized treatment.