World Journal of Surgery最新文献

Objective: To compare the outcomes of open appendectomy (OA) and laparoscopic appendectomy (LA) for acute appendicitis during pregnancy by trimester.

Methods: We conducted a nationwide retrospective cohort study using the Diagnosis Procedure Combination database in Japan. We identified pregnant women diagnosed with appendicitis who underwent OA or LA from 2010 to 2022. Pathological confirmation of appendicitis was not required for inclusion. The patients were categorized by the trimester of pregnancy. Outcomes were compared using multivariate analysis with generalized estimating equations.

Results: A total of 1624 patients were included. In the first trimester, 64.2% patients underwent OA, whereas 35.8% patients underwent LA; in the second trimester, 59.1% patients had OA and 40.9% patients had LA; and in the third trimester, 72.8% patients had OA and 27.2% patients had LA. LA was associated with a higher rate of preterm labor, preterm delivery, or abortion in the second (odds ratio, 3.37; 95% confidence interval, 1.76-6.47; and p < 0.001) and third trimesters (odds ratio, 2.57; 95% confidence interval, 1.15-5.70; and p = 0.021) but not in the first trimester. The duration of surgery was longer across all trimesters in patients who underwent LA. Additionally, the postoperative hospital stay was shorter in patients who had LA than in those who had OA in the second trimester.

Conclusions: In-hospital outcomes vary by trimester, and our results suggest that LA does not consistently lead to better outcomes than OA. Based on our findings, treatment options for appendicitis during pregnancy must be carefully selected.

Background: Management of clinically unifocal node-negative papillary thyroid carcinoma ≤1 cm (PTMC) is controversial with nonsurgical treatment as a potential alternative to thyroid lobectomy (TL). However, conservative strategies, such as active surveillance or thermal ablation, do not allow the evaluation of biological aggressive features or occult lymph node metastases (LNMs), which play a primary role as prognostic factors.

Methods: Among 4216 thyroidectomies for malignancy (between September 2014 and September 2023), TL plus ipsilateral central neck dissection was performed in 203 (4.8%) unifocal N0 PTMCs. Completion thyroidectomy was accomplished in case of positive frozen section examination of removed nodes or within 6 months from index operation in presence of biological aggressive features.

Results: Seventy-six out of 203 (37.4%) patients were staged pN1a and extranodal extension was detected in 5 (6.6%) patients. At final histology, biological aggressive features, including multifocality, lymphovascular invasion (LVI), extracapsular invasion, tumor aggressive subtypes, and BRAF-V600E mutation, were detected in 69 (34%), 93 (45.8%), 3 (1.5%), 30 (14.8%), and 7 (3.5%) patients, respectively. A comparative analysis between pN0 and pN1a patients showed younger age (p < 0.001), LVI (p = 0.037), and multifocality (p < 0.001) as risk factors for occult central LNMs. After logistic regression analysis, age (p < 0.001) and multifocality (p < 0.001) were confirmed as independent risk factors for nodal involvement.

Conclusions: Although most PTMC has been widely defined as indolent disease, a non-negligible rate of patients may present one or more biologically aggressive features including nodal involvement. Nonsurgical management should be considered with caution to avoid undertreatment especially in the younger population.

Background: Idiopathic granulomatous mastitis (IGM) is a rare, chronic inflammatory, and benign breast disease. Its unclear etiology may involve autoimmune reactions, secretion-related factors, and microorganisms.

Aim: To analyze data from our IGM patient series and compare potential etiological factors.

Methods: We prospectively collected data using follow-up forms for patients diagnosed with IGM at our breast clinic from September 2014 to December 2020 and analyzed it retrospectively.

Results: The study cohort included 220 patients, with a median age of 34 years (range: 20-58). A majority, 217 patients (98.6%), reported a history of breastfeeding, with a median duration of 36 months (range: 0-156). The median interval between the last breastfeeding session and disease onset was 25 (25th-75th percentiles: 15-44) months. Additionally, 116 patients (53.5%) reported breastfeeding-related problems. In 41 surgical patients, dense milky-brown debris in the breast ducts was noted. Although no independent seasonal fluctuations in disease onset were detected, a reduction in IGM cases during the summer months was found to correlate with a general decrease in all breast clinic visits.

Conclusion: Most patients reported recent breastfeeding and half experienced related problems, supporting the secretion theory's relevance in IGM's etiology. The absence of seasonal fluctuations suggests that secretion-related factors may be more central to IGM development than autoimmunity or infections. These findings offer crucial insights for future research into IGM's complex causes.

Background: Follicular thyroid carcinoma (FTC) in adolescents and young adults (AYAs) is rare and data on long-term oncological outcomes are scarce. This study aimed to describe the long-term recurrence and survival rates of AYAs with FTC, and identify risk factors for recurrence.

Methods: This is a retrospective cohort study combining two national databases, including all patients aged 15-39 years, diagnosed with FTC in The Netherlands between 2000 and 2016. Age, sex, tumor size, focality, positive margins, angioinvasion, pT-stage, and pN-stage were included in a Cox proportional hazard model to identify risk factors for recurrence.

Results: We included 192 patients. Median age was 31.0 years (IQR 24.7-36.3) and the male to female ratio was 1:4.1. Most patients presented with a minimally invasive FTC (MI-FTC) (95%). Five patients presented with synchronous metastases (2.6%), including two with locoregional metastases (1%) and three with distant metastases (1.6%). During a median follow-up of 12.0 years, three patients developed a recurrence (1.6%), of which one patient developed a local recurrence (33%), and two patients a distant recurrence (67%). Five patients died during follow-up (2.6%). Cause of death was not captured. A Cox proportional hazard model could not be performed due to the low number of recurrences.

Conclusions: FTC in AYAs is generally characterized as a low-risk tumor, as it exhibits a very low recurrence rate, a high overall survival, and it typically presents as MI-FTC without synchronous metastases. These findings underscore the favorable long-term oncological prognosis of FTC in AYAs.

Background: To evaluate recent minimally invasive pancreatectomy (MIP) trends for neoplastic disease and compare perioperative outcomes.

Methods: Patients who underwent open (OS) or MIP (laparoscopic-LS or robotic-RS) pancreaticoduodenectomy (PD) or non-pancreati-coduodenectomy resections (non-PD) were identified from PINC AI Healthcare Database. Outcomes were compared using multivariable regressions.

Results: OS was the predominant approach for PD (87.8%); MIP was more common in non-PD (48.5%) than PD with a substantial RS uptake (11.7%-29.9%). In PDs, outcomes were similar except OS had a longer length of stay (LOS) and lower costs. In non-PDs, MIP patients were less likely to have prolonged LOS, intensive care unit admission, and overall complications than OS. Conversion to OS was lower in the RS approach than LS in PD and non-PD.

Conclusions: MIP for non-PD has become the most common operative approach with improved outcomes; MIP-PD has flat adoption and similar outcomes to OS. Robotics facilitates MIP (PD and non-PD) completion through fewer conversions to open surgery (OS).

Background: The relative outcomes following the resection of screen-detected right-sided colon cancer compared to symptomatic cases are unknown. In this study, short and long-term outcomes after right-sided colectomy in screen-detected colon cancer are compared with symptomatic cases, both emergency and elective.

Methods: A prospective observational cohort study of patients, including both screen-detected and symptomatic patients (elective and emergency resections), undergoing right-sided colectomy for colon cancer (2010-2020) in a tertiary care unit was conducted. Each patient was followed up for long-term recurrence and survival.

Results: A total of 909 patients (median age, 70; IQR, 58-82; male, 52%) were included (151 patients (16.6%) screen-detected; 598 (65.8%) elective and 160 (17.6%) emergency). Screen-detected patients were more likely to have T1 or T2 lesions compared to elective and emergency groups (T1: 14.6% vs. 3.8% vs. 0.6% p < 0.001; T2: 16.6% vs. 8.9% vs. 3.1% p < 0.001), but were less likely to have T3 or T4 lesions (p < 0.001), respectively. Rates of N0 were higher in the screen-detected group (68.9% vs. 63.5% vs. 41.9%, respectively; p < 0.001). 98% of the screen-detected group achieved R0 resection compared to 93.3% of elective and 79.4% of emergency patients (p < 0.001). At 5-years following resection, overall survival for the screen-detected, elective, and emergency groups were 85.4%, 75.4%, and 53.1%, respectively (p < 0.001). Recurrence at 5-year post-resection were 8%, 15.1%, and 22.5% for the screen-detected, elective, and emergency groups, respectively (p < 0.001).

Discussion: When considering right-sided colon cancer alone, screen-detected cancers have a lower long-term recurrence rate, lower rates of postoperative complication, and superior survival compared to symptomatic groups following resection.

Background: Lymph node yield (LNY) is a validated quality control parameter in colorectal cancer surgery, with >12 nodes reflecting an adequate oncological resection. No formal guidelines exist in the context of central and lateral compartment lymph node dissection for papillary thyroid cancer (PTC). This study aimed to investigate the association between LNY and regional recurrence in PTC patients, and to define a threshold LNY that indicates adequate compartmental lymphadenectomy.

Methods: A retrospective analysis of patient data (1992-2022) was conducted using "The University of Sydney Endocrine Surgery Unit" database. Patients undergoing either prophylactic or therapeutic dissection of the central compartment or therapeutic dissection of the lateral compartment for PTC were included. Multivariate logistic regression analysis was performed to examine the relationship between nodal yield and local recurrence.

Results: On multivariate analysis, a central LNY ≤3 was an independent adverse prognostic factor for central recurrence (odds ratios [OR] 2.19, 95% confidence intervals [CI] 1.15-4.17, and p = 0.018) and a lateral LNY ≤20 was independently predictive of lateral recurrence (OR 2.45, 95% CI 1.24-5.31, and p = 0.007).

Conclusions: This study highlights the association between LNY and local recurrence in PTC. Our findings suggest that minimum LNY thresholds (>3 for central and >20 for lateral) may serve as indicators of adequate dissection. Further research should validate these findings across healthcare centers.

Background: Up to 45% of patients may have persistently elevated parathyroid hormone (PTH) levels after curative parathyroidectomy for primary hyperparathyroidism (PHPT), although the clinical significance is unclear. We aimed to assess the long-term clinical significance of persistently elevated PTH early after parathyroidectomy.

Methods: A prospectively collected institutional database was queried for patients who underwent parathyroidectomy for sporadic PHPT between 12/99 and 6/22 and had normal serum calcium levels at 6 months postoperatively. Demographic and clinical data were collected, including diagnoses associated with secondary HPT (gastrointestinal malabsorptive diseases, kidney disease, and vitamin D deficiency). Patients were divided into two groups: normal PTH or elevated PTH at 6 months postoperatively. The rate of persistently elevated PTH, average time to PTH normalization, and time to recurrence were determined.

Results: The final cohort included 1146 patients; 849 (91%) had normal PTH levels and 194 (17%) had early postoperative normocalcemia with elevated PTH at 6 months postoperatively. Among 194 patients (mean follow-up: 50 ± 53 months), 14 (7.2%) developed recurrent pHPT and 86 (44.3%) had normalization of PTH levels (median time to normalization: 12 months) (IQR: 9 and 15). There was no difference in the presence of diagnoses associated with secondary HPT between patients who had recurrent PHPT, normalization of PTH levels, or remained normocalcemic with persistently elevated PTH levels. The median time to recurrence was 22 months (IQR: 11 and 48) for the 7.2% of patients who developed recurrent PHPT compared to 2.4% in the 849 patients with normal calcium and PTH levels at 6 months (p < 0.001).

Conclusions: Following curative parathyroidectomy, persistent elevation of PTH levels is not uncommon. Although most patients have a durable cure, it may be an early sign of persistent/recurrent PHPT. Long-term surveillance for recurrence is necessary.