World Journal of Surgery最新文献

An aberrant right hepatic artery (rHA) arising from the superior mesenteric artery (SMA) is present in about 10%-23% of the patients. There has been extensive debate about oncologic significance related to the presence of rHA, during pancreatoduodenectomy (PD) for pancreatic adenocarcinomas, and some authors suggested that rHA should be sacrified to avoid opening of peritumoral planes. Once rHA had been resected, three different surgical strategies have been described: resection without reconstruction, preoperative embolization followed by resection without reconstruction, and resection with arterial reconstruction. In this technical report, we describe our institutional experience with transposition of rHA on the gastroduodenal artery (GDA) after resection of aberrant rHA at our specialized pancreatic vascular surgery unit. This technique, used in 22 consecutive patients, entails direct reimplantation of the rHA into the GDA stump using 8/0 sutures after having trimmed anastomotic ends by spatulation. Technical advantages and drawbacks are presented and discussed. Transposition of an rHA on the GDA represents a valid surgical alternative for arterial reconstruction during PD in specialized vascular pancreatic surgery center.

Background: Bile leakage is a severe complication after cholecystectomy and is associated with an increased risk of morbidity and mortality. The aim of this study was to evaluate the incidence of bile leakage post-cholecystectomy and to identify potential risk factors and their association with changes in the incidence of bile leakage over time.

Methods: Demographic and perioperative data of all patients who underwent cholecystectomy in Sweden between 2006 and 2019 were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). Data on the occurrence of bile leakage within 30 days were recorded and risk factors were identified using uni- and multivariable logistic regression analyses.

Results: Bile leakage occurred in 1738 of the 152,413 patients who underwent cholecystectomy, resulting in an overall incidence of 1.14%. The incidence was relatively consistent over the study period. ASA-score II and III, emergent surgery, open cholecystectomy, conversion from laparoscopic to open technique, bleeding requiring intervention, not performing, or incomplete intraoperative cholangiography (IOC) were identified as risk factors for bile leakage. The proportion of ASA II and ASA III patients undergoing cholecystectomy increased over time (p < 0.001). There was also a significant increase in the proportions of emergent cholecystectomies from 27.9% to 43.6% (p < 0.001) and surgery for complicated gallstone disease from 35.4% to 52.5% (p < 0.001) during the study period.

Conclusion: The incidence of bile leakage was relatively consistent over the study period despite an observed increase in the prevalence of identified risk factors of bile leakage.

Background: Indocyanine green (ICG) fluorescence imaging has gained popularity for preventing anastomotic leakage (AL), which was previously evaluated using the Doppler method. However, no study has directly compared the use of Doppler and ICG fluorescence imaging simultaneously. When introducing ICG fluorescence imaging in our department, we also used the conventional Doppler method to confirm the validity of its results. We hypothesized that the length of the available gastric tube might differ depending on the evaluation method potentially affecting the risk of AL and the choice of surgical technique. This study evaluated the usefulness of ICG fluorescence imaging and tested this hypothesis.

Methods: We retrospectively analyzed the data of 248 patients with esophageal cancer who underwent subtotal esophagectomy with gastric tube reconstruction and cervical anastomosis. After excluding 17 cases, 231 patients were included (Doppler-only group, n = 175; Doppler + ICG group, n = 56). In the Doppler + ICG group, changes in the available gastric tube length were evaluated by directly comparing Doppler-based and ICG-based perfusion assessments. To assess the clinical significance of these changes, surgical outcomes, including anastomotic technique and postoperative complications, were compared with those in the Doppler-only group.

Results: In the Doppler + ICG group, the available gastric tube length was extended in 37 cases, unchanged in 15 cases, and shortened in 4, showing that extension was significantly more frequent than other changes (p < 0.001). The anastomosis rate with a circular stapler was significantly higher in the Doppler + ICG group (89%) than in the Doppler-only group (61%; p < 0.001). The incidence of Clavien-Dindo grade IIIa AL was significantly lower in the Doppler + ICG group (3.6%) than in the Doppler-only group (15%; p = 0.03).

Conclusion: By extending the available gastric tube length, ICG fluorescence imaging was associated with a lower incidence of AL compared with the Doppler method, suggesting it has the potential to improve surgical outcomes and patient safety.

Background: Bilobar colorectal liver metastases (CRLMs) are often addressed through a two-stage hepatectomy (TSH) strategy. The outcomes of TSH according to the presence of criteria used for Liver Transplantation (LT) for unresectable CRLMs has yet to be investigated.

Methods: We conducted a retrospective review of 100 consecutive patients treated with a TSH. Patients were categorized based on the presence of ideal LT criteria, and compared. The selection criteria included: (1) absence of extrahepatic disease, (2) no metastatic lymph nodes in the hepatic pedicle, (3) tumor diameter less than 55 mm, (4) no disease progression before or between the two surgical stages, and (5) preoperative serum carcinoembryonic antigen (CEA) levels below 80 μg/L.

Results: Based on the selection criteria, 30 patients filled LT criteria, while 70 patients fell outside these criteria. The median overall survival and the survival rates at 1, 3, and 5 years were significantly higher for patients within the LT criteria, with median overall survival of 57 months, and survival rates of 93%, 71%, and 49%, respectively, compared to 27.2 months, 79%, 41%, and 19% for those outside the criteria (p < 0.001). Characteristics of patients in the two groups were largely similar, except that the transplant-criteria group was younger and had a lower Fong's score.

Conclusions: Patients undergoing TSH for bilobar CRLMs, ideally selected based on strict LT criteria, experienced very favorable long-term survival outcomes. The potential role of LT for bilobar CRLMs addressed through a TSH strategy warrant further investigation in a randomized study.

Background: Endovascular surgery is a high-risk specialty where safety protocols are vital to prevent adverse events. Although WHO Surgical Safety Checklist (SSC) implementation showed significantly reduced overall surgical morbidity and mortality, more recent studies have shown mixed results. This study aims to observe real-world adherence to the time-out phase of the WHO SSC in a hybrid Operating Room (OR) and to evaluate the Checklist Performance Observation for ImprovemeNT (CheckPOINT) tool.

Methods: This single-center retrospective observational study of prospectively collected data included endovascular procedures performed in a hybrid OR between May 2021 and December 2022. In October 2021, paper SSCs were replaced with electronic SSCs. Procedures were recorded using the OR Black Box (Surgical Safety Technologies Inc., Toronto, Canada). Time-out evaluation of recorded procedures was performed using the CheckPOINT tool.

Results: Time-out was initiated in 87.7% (n = 186/212) of all procedures. Average overall reported completion was 95.5% with a median of 15 completed items. Average overall observed completion was 46.8% with a median of seven items completed. Observed adherence was significantly lower than reported adherence for all but one item, "Patient Name". Experienced surgeons were significantly less likely to initiate (p = 0.033) and thoroughly complete (p < 0.001) the checklist. CheckPOINT engagement scored significantly lower than adherence, communication effectiveness, and attitude.

Conclusions: Video-based observation reveals significant discrepancies between observed and reported SSC adherence. These results highlight the need for improved SSC assessment and implementation, and suggest that combining reliable tools with video recording can enable data-driven quality improvement initiatives.

Background: Bone mineral density (BMD) measurement at the lumbar spine, femoral neck, total hip, and distal 1/3 radius is recommended for patients with primary hyperparathyroidism (PHPT). Osteoporosis at any site justifies surgery. The distal 1/3 radius is often neglected. This study evaluated the prevalence of distal 1/3 radius measurement, the proportion of osteoporosis at this site alone, and BMD changes 1 year post-parathyroidectomy in patients with PHPT.

Methods: A total of 548 patients who underwent parathyroidectomy for PHPT between 2016 and 2024 in University Hospital Center of Nantes (France) were reviewed. Patients without pre-surgery BMD measurements at the lumbar spine or the femoral neck were excluded. BMD was assessed via dual x-ray absorptiometry before and 12-months after surgery.

Results: Four hundred patients (mean age 63.3 ± 12.3 years, 80.5% female, and 86.2% menopausal) were included. Mean baseline serum calcium was 2.76 ± 0.19 mmol/L; median PTH was 99.2 pg/mL [76.1; 138.7]. Osteoporosis was present in 47.0% of patients. Distal 1/3 radius BMD was measured in 46.2%, identifying 11.4% with forearm-only osteoporosis. They were younger (60.6 ± 13.9 vs. 67.1 ± 10.2 years, p = 0.048), less frequently menopausal (66.7% vs. 95.9%, p = 0.001) and had higher calcium levels (2.88 ± 0.18 vs. 2.73 ± 0.20 mmol/L, p = 0.002) than the other osteoporotic patients. After surgery, BMD increased significantly at the lumbar spine (+0.06 g/cm²) and the total hip (+0.03 g/cm²), in a similar way to other osteoporotic patients.

Conclusion: After measuring distal 1/3 radius BMD, performed in < 50% of PHPT patients, it was identified that 11.4% patients had forearm-only osteoporosis, who could have a bone benefit from surgery. These findings emphasize the importance of systematic measurement during PHPT evaluation.

Trial registration: NCT05469087.

Aim: Postoperative C-reactive protein (CRP) levels are good predictors of anastomotic leak (AL) following colorectal surgery, with postoperative day-3 CRP thresholds ranging between 162 and 195 mg/L in open and laparoscopic resections. This study aims to determine a cut-off CRP value that predicts ALs following robotic colorectal surgery and identifies patients suitable for safe early discharge.

Methods: A single-center retrospective analysis of patients who underwent an elective robotic colorectal resection, with primary anastomosis, between February 2017 and December 2024, was conducted. Primary outcome measure was clinically and radiologically confirmed AL (graded). Data were analyzed using IBM SPSS v30.0.0.

Results: Seven hundred eighty-four elective robotic colorectal resections with anastomosis were performed. Median age was 69 years (IQR 60-77), 448 male, 336 female, and BMI 27.5 (IQR 24.4-31.1), indication for surgery was cancer in 681 (86.9%) patients. 51 (6.5%) patients had an AL, of which 12/51 (23.5%) had a grade ≥ 3 leak. A POD-3 CRP level of 136.0 mg/L (73% sensitivity, 79% specificity, and AUC 0.788) and POD-4 CRP level of 94.4 mg/L (84% sensitivity, 62% specificity, and AUC 0.806) were predictive of AL. At POD-5, a cut-off CRP of 243 mg/L (88% sensitivity, 73% specificity, and AUC 0.818) was predictive of ALs requiring re-operation and/or escalation to level 2-3 care. Male sex, colo-rectal anastomoses, and resections performed before 2020 were associated with higher AL rates.

Conclusion: Postoperative CRP levels have high predictive value in early detection and exclusion of AL, facilitating early patient discharge under the enhanced recovery after surgery (ERAS) pathways. CRP thresholds in robotic colorectal resections are lower than previously reported thresholds in open and laparoscopic surgery.

Introduction: Postoperative nutrition after pancreatoduodenectomy (PD) remains controversial. Although many centers routinely place a feeding jejunostomy tube (FJT) after PD, it is associated with morbidity. We conducted this study to compare the perioperative outcomes with and without FJT placement post-PD.

Methods: This was an open-label randomized controlled trial, in which the FJT was placed in one arm and the nasojejunal tube (NJT) in the other. All patients with periampullary neoplasm who underwent pylorus resecting PD were included in this study. The primary outcome assessed was clinically relevant delayed gastric emptying (CR-DGE), and the secondary outcomes were clinically relevant postoperative pancreatic fistula (CR-POPF), postoperative complications, and hospital stay.

Results: Forty patients were allocated to the FJT and NJT groups, and the two groups were comparable in baseline demographics, disease characteristics, and perioperative outcomes, including CR-POPF rates. The FJT group had a significantly higher CR-DGE rate (55% vs. 25%, p = 0.006), required increased use of prokinetic drugs (77.5% vs. 45%, p = 0.003), and had a longer median postoperative hospital stay (11 vs. 9 days, p = 0.007). Both groups had similar tube-related complications. In the NJT group, 22.5% of the patients with CR-DGE required parenteral nutrition. On multivariate analysis, the presence of FJT [adjusted odds ratio (aOR), 6.030 (1.431-25.402), p = 0.014] and intra-abdominal collection [aOR, 7.108 (1.026-49.224), p = 0.047] were independent risk factors for CR-DGE.

Conclusion: Post-PD placement of FJT was an independent risk factor for CR-DGE. Hence, the routine use of the FJT can be omitted after PD without compromising postoperative morbidity and nutrition.

Trial registration: The trial was registered with the Clinical Trial Register with CTRI number: CTRI/2021/02/030942 (https://ctri.nic.in/Clinicaltrials/advancesearchmain.php).

Aim: To compare the sentinel lymph node (SLN) identification proportions using Indocyanine green with the standard radio colloid-blue dye method.

Background: Radioisotope and blue dye are standard agents for performing sentinel lymph node (SLN) biopsy in breast cancer. Limited centers offering nuclear medicine services along with the short half-life of technetium and the hazards associated with radioactive materials contribute to the low acceptability of SLNB.

Methods: This randomized controlled trial conducted between September 2022 and May 2024 compared SLN identification proportions of radioisotope-blue dye [Group A] with Indocyanine Green (ICG) [Group B]. Sample size of 70 (35 in each arm) was calculated. Upfront operable node negative early breast cancer patients were included in the study. Clinico-demographic data, number and type of SLN, and time taken were recorded. Chi-squared/Fisher exact tests were used to compare proportions between two groups. p value of less than 0.05 was considered to represent statistical significance.

Results: Seventy patients were randomized to either group (35 in Group A and 35 in group B). The clinico-demographics and the tumor characteristics were similar between both the groups. SLN identification rate (IR) was 100% in group A and 97.14% in group B. Median of 3 lymph nodes were identified in Group A and Group B. Median operative time for SLNB was 12 min in both the groups.

Conclusions: Indocyanine green (ICG) fluorescence offers comparable sentinel node identification rate when compared to current standard of radioisotope and blue dye.

Trial registration: This study is registered under Clinical Trials Registry-India (CTRI) vide registration no. CTRI/2022/09/045719.