World Journal of Surgery最新文献

Background: Lichtenstein hernia repair is a common surgical procedure. Previously, combined rectus sheath (RS) and transversus abdominis plane (TAP) blocks have been shown to be beneficial in laparoscopic inguinal hernia surgery. Our hypothesis is that combining the two blocks will also be beneficial in open Lichtenstein hernioplasty day-case procedures.

Methods: This retrospective study analyzed data from 186 patients undergoing inguinal hernia surgery chosen using the propensity score matching. Primary endpoint was intraoperative and postoperative opioid consumption. Secondary endpoints were conversion of the anesthetic method, postoperative nausea and vomiting (PONV), unscheduled hospitalization or emergency room visits, perioperative duration, analysis of the patient flow, and surgical complications.

Results: Ninety-three patients treated with the blocks (study group) and 93 controls were analyzed. The study group had significantly lower opioid use in the operating room (2.5-7.5 mg vs. 5.0-7.5 mg and p < 0.01) and in the recovery room (0.0-2.0 mg vs. 1.0-10.6 mg and p < 0.0001). There was no difference in postoperative recovery room times nor in the patient flow. Postoperative hospitalization due to pain was 9.1% in the control group, whereas no patients in the study group were hospitalized (p < 0.01).

Conclusions: RS and TAP blocks reduce postoperative pain in inguinal hernia surgery, resulting in significantly lower postoperative opioid use and hospitalization rates. The blocks are technically easy and quick to perform and should be considered for pain management in inguinal hernia day-case surgery.

Background: Aims conventional bowel preparation restricts dietary intake up to 72 h prior to colonoscopy. Bowel preparation process is often perceived as unpleasant leading to poor compliance and subsequent poor bowel preparation. The aim of this trial is to compare the efficacy of low-residue semi-elemental enteral formula (LREF) incorporated diet versus the standard diet in polyethylene glycol (PEG)-based bowel preparation in the aim of creating a more tolerable bowel preparation regimen without compromising bowel cleanliness.

Methods: This was a multicenter, prospective, single-blinded, randomized controlled noninferiority trial. The noninferiority margin was set at 15%. One hundred sixty-seven patients were recruited and randomized to either the LREF group or the standard diet (SD) group using a 3L PEG preparation regimen.

Results: The LREF group results in comparable satisfactory preparation rating to the standard diet group with a mean BPPS score of 6.87 (SD 1.59) versus 7.14 (SD 1.54) (95% CI[-0.86; 0.32] and p = 0.367). The mean difference (MD) of the BBPS total score between the two groups was -0.27 (95% CI [-0.764 and 0.224]). Equivalence were demonstrated using the two one-sided test (alpha = 5%) with the lower t-value of 2.682 (p = 0.0042) and the upper t-value of -4.493 (p < 0.01). There was also no significant difference in PEG compliance, willingness to repeat the procedure and tolerance to the bowel preparation between the two groups.

Conclusion: The LREF incorporated diet is equivalent to regimen in achieving satisfactory bowel cleanliness in patients undergoing PEG-based bowel preparation. We suggest that a LREF incorporated regimen for bowel preparation can be considered in patients who are unable to sustain prolonged fasting to improve the procedural experience.

Background: Hyperparathyroidism (HPT) is common in end-stage kidney disease and resolves in less than half of kidney transplant (KT) recipients. The ideal timing of parathyroidectomy (PTX), before or after KT, remains unclear. We sought to understand differences in morbidity and mortality after PTX pre-KT and post-KT.

Methods: We identified adult patients who underwent PTX pre-KT or post-KT between 2012 and 2021 utilizing the National Surgical Quality Improvement Program database. Demographics, clinical characteristics, morbidity, and mortality were compared. Adjusted logistic regression with propensity score weighting assessed odds of 30-day composite morbidity, major adverse cardiovascular events (MACE), readmission, and mortality.

Results: We identified 1972 patients who underwent PTX pre-KT and 541 patients who underwent PTX post-KT. Post-KT HPT patients were older (mean age 53.9 v 48.2 and p < 0.01) and more commonly White (45.3% v 32.3% and p < 0.01) and diabetic (30.0% v 18.5% and p < 0.01). In comparison, pre-KT HPT patients were more commonly Black (53.2% v 30.1%), had American Society of Anesthesiologists (ASA) class 3-4 (98.0% v 89.6% and p < 0.01), chronic obstructive pulmonary disease (4.2% v 1.5% and p < 0.01), and congestive heart failure (4.4% v 1.1% and p < 0.01). After adjusting for confounders, patients pre-KT had 1.72-fold increased odds of morbidity (95% confidence interval [CI]: 1.13-2.61), 8.39-fold increased odds of MACE (95% CI: 1.13-62.18), and 2.07-fold increased odds of readmission (95% CI: 1.38-3.10). There was no difference in mortality or risk of infections.

Conclusions: Patients who underwent PTX prior to KT were at significantly increased risk for 30-day morbidity and MACE, but no different odds of mortality compared to PTX after KT. This can help inform decision-making regarding timing of PTX in patients with HPT.

Purpose: The use of neoadjuvant chemotherapy in treating breast cancer has expanded in recent years. There was increased interest in using positron emission tomography (PET) for the evaluation of treatment response. We aimed to study the accuracy of metabolic complete response (mCR) on PET scan in predicting pathological complete response (pCR) after neoadjuvant treatment.

Methods and results: Between January 1, 2014 and June 30, 2019, 356 consecutive patients who completed neoadjuvant treatment underwent PET scan before surgery. 207 patients (58.1%) achieved mCR and 128 patients (36.0%) achieved pathologic CR. Among mCR patients, 101 (48.8%) had pCR. Among pCR patients, 27 (21%) did not achieve mCR on PET. The overall sensitivity of predicting pCR with mCR was 78.9% and specificity of 53.5%. The overall accuracy was 0.691 by area under the receiver operating characteristic curve (AUC). Analysis using mCR to predict breast/axilla pCR had a sensitivity of 76.2%/67.9%, specificity of 54%/62.1%, and AUC of 0.682/0.675, respectively. Sensitivity and specificity were highest among HR-/HER2+ (87.1% and 57.1%), followed by HR+/HER2- (85% and 59.6%) and triple negative (82.1% and 54.1%) and the lowest were HR+/HER2+ (triple positive) (69.4% and 40.3%). There was little difference in sensitivity and specificity among the high and low Ki67 proliferation index (78.3% vs. 75% and 52.1% vs. 62.5%).

Conclusion: PET was useful in evaluation of tumor response to neoadjuvant chemotherapy especially in the HR-HER2+ subtype. However, its accuracy was not high enough to replace surgery.

Background: A recent prospective phase II study (ECOG-ACRIN E2211) demonstrated that MGMT deficiency was associated with a significant response to capecitabine and temozolomide (CAPTEM) in pancreatic neuroendocrine neoplasms (NENs); however, routine MGMT analysis in NENs was not recommended. Our study sought to demonstrate whether loss of MGMT protein expression is associated with improved overall survival (OS) in patients receiving CAPTEM for NENs from various tumor sites.

Materials and methods: Paraffin-embedded tumor samples were evaluated by immunohistochemistry (IHC) using an MGMT monoclonal antibody. Intact MGMT protein expression (i.e., IHC positivity) was defined as any staining intensity (> 1+) in ≥ 36% of neoplastic cells according to an internal validation study. IHC and pyrosequencing for MGMT promotor methylation was performed in an independent cohort of 58 NENs. Real-world OS was extrapolated from insurance claims data with Kaplan-Meier estimates from the date of first CAPTEM administration to the last date of contact.

Results: The study cohort included 80 patients (42 men and 38 women) with a median age of 57 years (range: 19-89). They had various NENs (33 pancreatic, 17 intestinal, 7 pulmonary, 8 other, and 15 of unknown origin) treated with CAPTEM. The median OS for the 48 patients with MGMT negative tumors was 31 months compared to 17.5 months for the 32 patients whose tumors were MGMT positive by IHC (HR: 1.75 [95% CI: 1.066-2.87] and p = 0.025). IHC results from the independent cohort of 58 NENs showed only 57% concordance with pyrosequencing results.

Conclusions: MGMT promotor status by IHC may be a clinically useful indicator that predicts improved OS for NENs treated with CAPTEM, but IHC does not reliably correlate with the findings of MGMT promoter methylation by pyrosequencing.

Background: Risk models to predict perioperative mortality rates (POMR) are critical to surgical quality improvement yet are not widely adapted for use in humanitarian and low-resource settings (LRS). We developed a POMR and corresponding nomogram and calculator for use in humanitarian surgical care.

Methods: Electronic health record data from a high-income academic medical center from 2015 to 2019 were retrospectively extracted, selecting variables and operations specific to LRS. This development dataset was used to create a logistic regression POMR model, which was then prospectively validated using data from 2022 to 2023 from the same institution.

Results: EHR from a total of 49,277 patients were used. The model fitted eight variables feasibly obtainable in LRS: age > 65 years (OR = 4.05 and 95% CI: 3.71-4.43), male sex (OR = 1.32 and 95% CI: 1.25-1.40), GCS < 13 (OR = 5.20 and 95% CI: 4.73-5.73), glucose > 200 mg/dL (OR = 2.19 and 95% CI: 2.01-2.38), Hgb ≤ 11 g/dL (OR = 2.65 and 95% CI: 2.43-2.89), HR > 120 bpm (OR = 2.49 and 95% CI: 2.35-2.64), T > 38 degrees Celsius (OR = 1.32 and 95% CI: 1.19-1.45), and SBP > 180 mmHg (OR = 1.18 and 95% CI: 1.02-1.37). The model demonstrated a high area under the curve (0.847, 0.867, and 0.925), sensitivity (0.739, 0.886, and 0.844), specificity (0.807, 0.780, and 0.864), and negative predictive value (0.750, 0.997, and 0.999) on training, holdout, and prospective validation sets.

Conclusion: We validated a POMR model for use in LRS using eight variables that are readily available in the target environment. This model's predictors and accompanying clinical tools of an Excel calculator and nomogram make it simultaneously comprehensive and accessible in LRS.

Background: The role of robot-assisted approach in hernia surgery remains controversial due to high procedural costs and the proposed equal outcomes compared with open surgery. In this study, we report the 30-day results of the introduction of robot-assisted approach in a specialized regional ventral hernia repair center.

Methods: This was a retrospective single-center cohort study including patients undergoing either robot-assisted or open ventral hernia repair from 2017 to 2022. Patients undergoing either approach were matched by propensity scores in a 1:2 ratio on the variables age, type of hernia (primary/incisional), and horizontal fascial defect size to reduce bias risk. Multivariable logistic regression on outcomes length of stay, reoperation, and readmission was performed.

Results: A total of 109 patients undergoing robot-assisted repair were compared to 229 undergoing open repair. Overall, 61.2% were patients had incisional hernia. Mean hernia defect size was 4.9 × 6.5 cm (horizontal × vertical). The mean length of stay was shorter after robot-assisted repair (0.1 vs. 1.9 days, p < 0.001) as was the incidence of readmission (3.7% vs. 17.0%, p < 0.001). The incidence of reoperation was tangentially significantly lower after robot-assisted repair (0.9% vs. 6.6%, p = 0.045); however, the estimate was significant after adjusting for confounders (OR 0.11, CI 0.01-0.89, p = 0.038).

Conclusions: Length of stay and readmission rates were significantly decreased after the introduction of a robot-assisted approach for ventral hernia repair.

Background: Pathological regression grade after chemotherapy evaluated by surgically resected specimens is closely related with prognosis. Since usefulness of measuring the area of the residual tumor (ART) has been reported, this study aimed to evaluate the utility of ART in predicting the prognosis of patients with gastric cancer (GC) who received preoperative chemotherapy.

Methods: This single-center retrospective study examined the relationship between ART and survival outcomes. We included 92 patients who underwent preoperative chemotherapy followed by radical surgery for GC. Digital images were used to measure the ART in the largest pathological slice of each patient's surgical tumor specimen. We simply subclassified the patients as either ART-0 (< 0.1 mm² or carcinoma in situ) or non-ART-0 to compare the prognoses.

Results: Significant differences were noted in overall survival and recurrence-free survival (RFS) between ART-0 (n = 19) and non-ART-0 (n = 73). The survival curves were similar to those of major pathological response (MPR) (n = 24) or non-MPR (n = 68), which are commonly used as surrogate endpoint presently. Multivariate analysis revealed ART and ypN independent prognostic factors for RFS. Survival curves stratified using ART and ypN to indicate risk grades (low-, moderate-, or high-) were not significantly different from those stratified using the other three existing pathological regression grade systems and ypN.

Conclusion: ART-based pathological assessment is a simple and useful method for predicting the prognosis in patients with GC who underwent radical surgery after chemotherapy.