World Journal of Gastrointestinal Surgery最新文献

Background: Acute nonvariceal upper gastrointestinal bleeding (NVUGIB) is a life-threatening emergency. Endoscopic hemostasis and vascular interventional therapy are two major minimally invasive treatment strategies. Although these modalities are widely used, their comparative efficacy and safety across different patient populations and anatomical sites remain controversial.

Aim: To evaluate the clinical outcomes and safety of endoscopic hemostasis combined with vascular interventional therapy for NVUGIB.

Methods: A systematic search was done on PubMed, EMBASE, Cochrane Library, and Web of Science (from database establishment to April 2025). Randomized controlled trial (RCT) quality was assessed via Cochrane RoB 2.0, and observational studies via the Critical Appraisal Skills Program. RevMan 5.4 was used for quantitative analysis; fixed/random-effects models were chosen through I²-assessed heterogeneity. Publication bias was checked using funnel plots and sensitivity analysis via model switching.

Results: Twenty-one studies (3 RCTs, 12 single-group studies, and 6 retrospective cohort studies) with good quality were included. For single-group data, combined therapy had risk differences of 0.70 (clinical success), 0.24 (mortality), and 0.22 (rebleeding; all P < 0.00001, I² = 0). Moreover, the ≥ 60-year rebleeding risk difference was 0.43. Reintervention was found to differ by approach (Z = 3.03, P = 0.002, inter-subgroup I² = 99%). In the RCT and cohort studies, combined vs standard therapy had similar initial hemostasis (Z = 0.04, P = 0.97) and mortality (Z = 1.56, P = 0.12) but lower rebleeding (Z = 3.26/P = 0.001; Z = 2.95/P = 0.03). Symmetrical funnel plots and robust sensitivity analysis showed no publication bias.

Conclusion: Combined endoscopic hemostasis and vascular interventional therapy for acute NVUGIB can significantly reduce rebleeding, without differences in mortality. Age and vascular interventional methods may influence the therapeutic efficacy.

Background: Chronic esophagitis can progress to esophageal cancer via "inflammation-dysplasia-cancer" transformation, with nitric oxide (NO) serving as a critical mediator in this process. Traditional diagnostic methods (e.g., endoscopic biopsy) for esophageal cancer transformation have low sensitivity and require long detection time, while existing fluorescent probes lack specificity and stability for real-time NO monitoring. High-performance fluorescent probes like DAF-FM, with NO-targeting ability, show potential for visual screening and efficacy evaluation but need systematic validation in esophageal cancer models.

Aim: To validate the applicability of the fluorescent probe DAF-FM for visual screening of esophageal cancer transformation, explore the underlying mechanism of NO-regulated transformation, and evaluate the probe's efficacy in monitoring therapeutic responses.

Methods: Laser confocal imaging and flow cytometry were used to analyze DAF-FM's NO concentration/time-dependent fluorescence response, lysosomal targeting (via Pearson coefficient), and cytotoxicity (with cholecystokinin-8 assay) in esophageal cells. Sprague-Dawley rat esophageal cancer models (normal, esophagitis, esophageal cancer, and drug/radiotherapy intervention) were established to monitor NO dynamics and tumor volume correlation. Clinical diagnostic comparison (50 suspected patients) with endoscopic biopsy/histopathology was conducted using Kolmogorov-Smirnov test and Student's t-test (P < 0.05). Western blot and quantitative real-time polymerase chain reaction were used to explore NO's role in the nuclear factor-kappa B (NF-κB) pathway.

Results: DAF-FM exhibited concentration/time-dependent fluorescence with NO (300 μM NO: 60-minute fluorescence intensity 458 ± 15 arbitrary units, P < 0.05) and specific lysosomal targeting (Pearson's coefficient = 0.82 ± 0.03). It had low cytotoxicity (82.3% ± 4.1% cell viability at 50 μM). In rat models, DAF-FM showed that NO was correlated with tumor volume (R² = 0.87). Clinically, its sensitivity (92.5%) outperformed endoscopic biopsy (78.3%), with shorter detection time (30 minutes vs 48 hours, P < 0.05). Mechanistically, NO regulated transformation via the NF-κB pathway (Pearson's coefficient = 0.78 ± 0.05 between DAF-FM and NF-κB).

Conclusion: DAF-FM is a feasible tool for visual screening of esophageal cancer transformation, enabling real-time NO monitoring, high-sensitivity diagnosis, and therapeutic efficacy evaluation. It provides a new approach for esophageal cancer diagnosis and mechanism research.

Background: Neoadjuvant therapy prior to surgery plays a critical role in improving the prognosis of patients with unresectable or locally advanced gastric cancer (GC). Postoperative complications, particularly those classified as Clavien-Dindo grade ≥ II, remain a major concern for surgeons. In recent years machine learning (ML) has emerged as a prominent approach for disease diagnosis and prediction. However, studies on both postoperative complications and ML in patients with GC receiving neoadjuvant therapy remain limited.

Aim: To develop an ML model to predict Clavien-Dindo grade ≥ II complications in patients with GC after neoadjuvant therapy and laparoscopic gastrectomy.

Methods: Clinical data were collected from 455 patients with GC who underwent neoadjuvant therapy followed by laparoscopic gastrectomy at Peking Union Medical College Hospital (2014-2024). Potential predictors were identified through univariate analysis and least absolute shrinkage and selection operator regression. Six ML algorithms including XGBoost, random forest, neural network ensemble (NNE), logistic regression, GLMnet, and decision tree were trained and optimized using nested cross-validation. Model performance was evaluated using the area under the receiver operating characteristic curve, decision curve analysis, and calibration curves.

Results: A total of 455 patients were included of whom 69 (15.16%) developed Clavien-Dindo grade ≥ II complications. The predictive model was constructed using seven variables, including smoking status, Nutritional Risk Screening-2002 score, American Society of Anesthesiologists classification, neoadjuvant therapy, surgical approach, operating time, and intraoperative blood loss. Among the six models the NNE model outperformed the others, achieving the highest area under the receiver operating characteristic curve (0.789, 0.739-0.840) and demonstrating superior discrimination, clinical utility, and calibration.

Conclusion: The NNE-based prediction model effectively identified patients with GC at high risk of Clavien-Dindo grade ≥ II complications after neoadjuvant therapy and laparoscopic gastrectomy.

In this editorial, we comment on the article published by Qiu et al. Pyogenic liver abscess is a serious clinical condition requiring timely and effective intervention. Ultrasound (US)-guided techniques - whether needle aspiration (NA) or catheter drainage - are key minimally invasive treatments, especially in patients with multiple or deep-seated abscesses where conventional surgery is often impractical. The timing and choice of evacuation method significantly influence clinical outcomes. Although catheter drainage may be necessary for larger or refractory collections, NA represents a less invasive alternative that is often sufficient for smaller abscesses - particularly multiloculated ones - and can avoid multiple catheter placements. This consideration is especially important in the early phase of the disease, when the abscess collection is poorly demarcated from surrounding tissue and more prone to bleeding during or after intervention. Traditional practice delays intervention until liquefaction occurs; however, emerging evidence supports early US-guided evacuation - even in partially liquefied or non-liquefied abscesses - as both safe and effective. Early intervention, particularly via NA when feasible, is associated with faster symptom resolution, shorter hospitalization, and fewer complications. This editorial explores the role of US-guided interventions in pyogenic liver abscess manaement, emphasizing the importance of individualized, timely approaches that optimize disease outcomes while minimizing procedural risk.

Background: No optimal treatment has been established for metabolic dysfunction-associated fatty liver disease with phlegm-turbidity and blood-stasis syndrome (MAFLD-PTBS), highlighting the need for more effective therapeutic approaches.

Aim: To elucidate the clinical effectiveness of acupoint catgut embedding therapy (ACET) for MAFLD-PTBS and preliminarily examine its association with biomarkers, particularly platelet-derived growth factor (PDGF).

Methods: We retrospectively enrolled 80 patients with MAFLD-PTBS, divided into an ACET group (n = 40) receiving ACET therapy and a control group (n = 40) treated with conventional hepatoprotective and enzyme-lowering oral medications. Therapeutic outcomes were compared between the groups. Changes in body mass index (BMI), abdominal circumference (AC), body weight (BW), total cholesterol (TC), triglycerides (TG), alanine aminotransferase (ALT), aspartate aminotransferase (AST), liver stiffness measurement (LSM), a four-item liver fibrosis panel, and serum concentration of PDGF, transforming growth factor-β1 (TGF-β1), and cytokeratin 18 (CK-18) were assessed before and after treatment.

Results: Significant differences were observed both within group (pre- vs post-treatment) and between group post-intervention for all measured indicators, including BMI, AC, BW, TC, TG, ALT, AST, LSM, liver fibrosis indices, PDGF, TGF-β1, and CK-18 (all P < 0.05).

Conclusion: ACET exhibits promising clinical effectiveness for managing MAFLD-PTBS, with effects closely associated with serum concentrations of PDGF, TGF-β1, and CK-18.

The retrospective study by Gan et al evaluated the three-year survival rate and prognostic factors in 100 patients with primary gastric cancer who underwent laparoscopic surgery at a Chinese hospital between 2019 and 2021. The observed three-year survival rate was 73%. Multivariate analysis identified age, tumor-nodes-metastasis stage, tumor size, depth of invasion, lymph node metastasis, extent of lymph node dissection, postoperative adjuvant chemo-radiotherapy, postoperative carcinoembryonic antigen levels, surgical duration, extent of gastric resection, and postoperative complications as independent predictors of survival. Older age, advanced disease stage, larger tumors, deeper invasion, lymph node involvement, and elevated carcinoembryonic antigen were associated with poorer outcomes, while thorough lymph node dissection and adjuvant therapy improved survival. The study highlights the complex interplay of clinical and pathological factors affecting prognosis after laparoscopic surgery. Strengths include detailed perioperative data and robust analysis, though limitations are noted in its retrospective design and patient selection. The findings emphasize the need for multidisciplinary, individualized treatment planning, considering both disease and patient-related factors, to optimize outcomes in localized gastric cancer. Prospective studies are warranted to validate these results and refine treatment strategies.

Post-esophagectomy anastomotic leak (AL) is a severe complication following esophagectomy, contributing to increased morbidity, prolonged hospitalization, and a significant risk of mortality. Endoscopic vacuum-assisted closure (EndoVac) has emerged as a promising first-line treatment, offering a highly effective approach for managing post-esophagectomy AL. EndoVac therapy utilizes continuous negative pressure within the esophageal lumen or mediastinal cavity, promoting granulation tissue formation, accelerating wound healing, and enhancing AL closure rates. Compared to stenting, EndoVac provides distinct advantages, including superior adaptability to varying leak sizes and locations, enhanced secretion drainage, and lower rates of reintervention. Clinical studies have demonstrated higher success rates, decreased post-intervention complications, and shorter hospital stays. Despite its advantages, challenges persist in patient selection, procedural expertise, and accessibility. EndoVac application requires experienced endoscopic teams and multidisciplinary expertise, which is best achieved in high-volume centers with specialized care. Variability in EndoVac protocols necessitate further refinement and standardization to optimize treatment outcomes. The integration of EndoVac into standardized treatment guidelines holds promise for improving patient outcomes and redefining the management approach for this challenging postoperative complication.

The landscape of hepatobiliary surgical education has undergone a significant transformation with the integration of advanced technologies such as three-dimensional modeling, virtual reality, augmented reality, and artificial intelligence. This review synthesizes recent advancements in surgical education, examining the role of these technologies in improving anatomical understanding, surgical skill acquisition, and overall trainee engagement. Evidence from randomized controlled trials, systematic reviews, and cohort studies shows that immersive training tools, including virtual reality, augmented reality, and haptic feedback, outperform traditional apprenticeship methods in fostering cognitive and psychomotor skills. Artificial intelligence applications provide real-time feedback, further enhancing learning efficiency. However, these technologies should complement, rather than replace, traditional hands-on training. Some challenges remain to be addressed, such as high costs, infrastructure requirements, and limited long-term validation of these technologies. The review concludes that while these innovations offer promising educational benefits, further research is needed to standardize their application and evaluate their long-term impact on surgical outcomes.

Background: Bouveret syndrome is a rare cause of gastric outlet obstruction resulting from the passage of a gallstone into the duodenum or stomach through a biliary-enteric fistula. It is a complication of chronic cholelithiasis and accounts for only 1%-3% of all gallstone-related intestinal obstructions.

Case summary: A 49-year-old male presented with nausea, vomiting, and upper abdominal pain. Imaging revealed a large gastric stone and a cholecystoduodenal fistula, confirming Bouveret syndrome. An initial endoscopic attempt to remove the stone was unsuccessful, necessitating surgical intervention. The patient subsequently underwent successful stone extraction and fistula repair, followed by an uneventful postoperative recovery. While Bouveret syndrome typically affects elderly individuals (average age: 74 years), this case in a younger patient provides valuable insights into its management in this demographic.

Conclusion: Bouveret syndrome is a serious but uncommon condition often presenting with nonspecific symptoms, leading to potential diagnostic delays. Timely diagnosis, usually confirmed by imaging, is critical for optimal outcomes. Although endoscopy is often the first-line therapy, surgery remains essential for cases with failed endoscopic intervention or complex anatomical involvement. This case highlights the importance of recognizing the syndrome's clinical features in younger patients and enhancing the understanding of its diagnosis and management strategies.