World Journal of Surgery最新文献

Background: For small papillary thyroid cancers (PTCs) with no lateral nodal involvement, American Thyroid Association guidelines recommend performing prophylactic central lymph node dissection (pCLND) if it influences further management. Our cohort study explored to what extent performing pCLND for small PTCs can de-escalate subsequent therapy including completion thyroidectomy and adjuvant radioactive iodine (RAI) ablation.

Methods: Adults with T1, T2, and cN0 PTCs were identified from 42 centers across the prospectively maintained Australian and New Zealand Thyroid Cancer Registry (ANZTCR) between 2017 and 2023. Patients were excluded if they had clinical nodal involvement or distant metastases. Subsequent therapy and complication rates were compared between patients with and without pCLND.

Results: Out of 1290 patients with T1, T2, and cN0 PTCs (78% female and median age 53 years), 660 (51%) received a total thyroidectomy and 630 (49%) received a hemithyroidectomy. Prophylactic CLND was performed for 477 patients (37%) and 36% uncovered occult lymph node metastases. After adjusting for differences in age, sex, and tumor characteristics, absence of lymph node metastasis after pCLND was independently associated with fewer completion thyroidectomies (adjusted relative risk [aRR] = 0.65 and p = 0.008) and reduced RAI ablation (aRR 0.55 and p < 0.001). Additionally, pCLND was not associated with higher risks of recurrent laryngeal nerve injury (p = 0.33), temporary hypocalcemia (p = 0.21), or permanent hypoparathyroidism (p = 0.48).

Conclusions: In specialized settings across Australia and New Zealand, identifying negative lymph nodes from pCLND is associated with reduced completion thyroidectomies and RAI ablation amongst low risk cN0 PTCs. There were no additional complications rates when performed by experienced thyroid surgeons.

Background: Costal cartilage injuries are unappreciated, and there is a paucity of reports on fixation methods. This study aims to evaluate the safety of titanium plate internal fixation for costal cartilage injuries.

Methods: A retrospective analysis was conducted on 30 patients with costal cartilage injuries who underwent titanium plate internal fixation between April 2016 and November 2022 at our hospital. The internal fixation devices consisted of titanium plates and locking screws, securing 60 costal cartilage injury sites. Injuries were classified based on the fixation location: costal cartilage-costal cartilage (22 sites), bone (sternum, rib)- costal cartilage (24 sites), and bone (sternum)- costal cartilage-bone (rib) (14 sites). Follow-ups at 1, 3, 6, and 12 months postoperatively included CT assessments to evaluate injury healing and the presence of displacement or screw loosening.

Results: The average lengths of the titanium plates used for the three different fixation positions were 6, 7, and 10 holes, respectively, with at least two locking screws securing each end. The maximum follow-up period was 90 months, with 6 cases lost to follow-up (3 at 1 month postoperatively, affecting 4 fixation sites, and 3 at 3 months postoperatively, affecting 6 fixation sites). Excluding these cases, all fixed costal cartilage injuries healed without nonunion or displacement, with two instances of screw loosening observed at 1 month postoperatively.

Conclusion: Titanium plate fixation with locking screws is a safe and effective method for treating costal cartilage injuries, with all patients showing good injury healing.

Background: Despite widespread use of standardized classification systems, risk stratification of thyroid nodules is nuanced and often requires diagnostic surgery. Genomic sequencing is available for this dilemma however, costs and access restricts global applicability. Artificial intelligence (AI) has the potential to overcome this issue nevertheless, the need for black-box interpretability is pertinent. We aimed to create an ultrasonographic segmentation and classification model that offers explainability and risk accountability.

Methodology: Four hundred and fourteen ultrasonography images were collected from 105 patients undergoing thyroidectomy, divided into training and testing groups. Classification ground truth used is exclusively surgical histopathology. Relevant nodules were manually annotated by a dedicated study radiologist and surgeon. Three AI architectures with and without block attention modules were trained to identify the relevant nodule and the best performing was selected for the subsequent task in classifying identified nodules into benign or malignant. Gradient-Weighted Class Activation Map is used to provide saliency mapping for visual interpretability.

Findings: Superior performance was recorded by the block attention model which stratified thyroid nodules into benign versus malignant with an accuracy of 93% versus 90%, F-score 90% versus 89%, sensitivity 93% versus 91% and specificity 92% versus 91% on a training dataset versus a testing dataset respectively.

Gradcam: Visual interpretability maps demonstrate salient areas for a benign nodule diagnosis overlaps spongiform areas and malignant diagnosis salient areas overlap solid components of a partially cystic-solid nodule and microcalcifications within nodules. These findings are consistent with established diagnostic criteria for benign and malignant nodules.

Conclusion: We developed an image segmentation and classification model for the risk stratification of thyroid nodules benchmarking surgical histopathology as ground truth and providing visual interpretability.

Background: Postoperative survival of esophageal cancer patients has improved with advances in technology and treatment modalities. However, squamous cell carcinoma (SCC) often affects the esophagus together with the head and neck regions, with second primary head and neck cancer (SPHNC) adversely influencing the patients' quality of life. Therefore, patients with esophageal squamous cell carcinoma (ESCC) should be carefully followed up postoperatively. This study evaluated the risk of developing SPHNCs after an esophagectomy for ESCC.

Methods: Patients with ESCC who underwent curative esophagectomy from January 2008 to December 2017 from two tertiary medical centers, Taipei Veteran General Hospital and Kaohsiung Veteran General Hospital, were retrospectively reviewed. SPHNC development was documented according to the anatomic region and the cumulative incidence rate and risk factors were analyzed.

Results: The median follow-up period of the 435 patients included in our study was 48.5 months [interquartile range (IQR) 16.7-92.4 months]. Among the ESCC patients after curative esophagectomy, younger age <50 [hazard ratio 4.13, 95% CI: 2.53-6.75, p < 0.001) was the only independent factor for developing SPHNCs in the multivariable analysis. The cumulative incidence rate of SPHNCs of patients aged <50 years old was 14.3%, 22.1%, and 34.2% after 3, 5, and 10 years, respectively.

Conclusions: There was a high risk of secondary cancer after ESCC in the upper aerodigestive tract, especially the head and neck regions; therefore, active surveillance is strongly recommended, especially in younger patients.

Background: Trauma and pregnancy are both risk factors for venous thromboembolism (VTE). We hypothesized that pregnant blunt trauma patients would have a higher incidence of VTE complications compared with matched nonpregnant females.

Methods: We conducted a retrospective cohort study using National Trauma Data Bank data from 2017 to 2022. Female patients with blunt mechanism, age between 15 and 50 years old, were eligible for inclusion. Patients who presented as transfers, hospitalized for less than 72 h, discharged against medical advice, injury severity score <9, or abbreviated injury scale = 6 of any region were excluded. Pregnant patients were matched 1:2 with nonpregnant female patients by age, injury characteristics, comorbidities, and type and timing of chemical VTE prophylaxis. The primary outcomes were the incidences of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE). Secondary outcomes included other complications and length of stay.

Results: We included 735 pregnant and 1470 matched nonpregnant controls. The median time to initiate chemical VTE prophylaxis was 33 h in pregnant and 34 h in nonpregnant patients (p = 0.42). The incidence of VTE in pregnant blunt trauma patients was 27 (3.7%) versus 45 (3.1%) in matched controls (p = 0.446). There were no significant differences in DVT, PE, or any other complication or mortality or in ICU or hospital length of stay. Unplanned admissions to the ICU were significantly more frequent in pregnant patients (3.8% vs. 2.2% and p = 0.026).

Conclusion: The incidence of VTE complications was similar in pregnant and matched nonpregnant female blunt trauma patients in this retrospective cohort study, supporting the safety of current VTE prophylaxis practices in pregnant patients.

Background: We elucidated the influence of sarcopenic obesity on postoperative outcomes in patients with oesophago-gastric cancer.

Methods: We conducted a systematic search on MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov to identify observational studies published from their inception to September 26, 2024. Studies involving patients who underwent radical resection for oesophago-gastric cancer and were evaluated for visceral fat mass and skeletal muscle mass through body composition were included in our analysis. The primary outcomes assessed were overall survival (OS) and postoperative complications. This protocol was registered in PROSPERO (CRD42023418403).

Results: Ultimately, 13 studies (involving 4912 patients) were included in our qualitative and quantitative analyses. Among these studies, three were prospective cohort studies, while the remaining 10 were retrospective cohort studies. Twelve studies specifically investigated gastric cancer, while one focused on esophageal cancer. The prevalence of sarcopenic obesity ranged from 5.7% to 28.7%. Compared to the absence of sarcopenic obesity, its presence worsens OS (hazard ratio: 1.52, 95% confidence interval: 1.08-2.15, heterogeneity (I²) = 66%, certainty of the evidence: low) and increases the risk of postoperative complications (relative risk ratio: 1.88, 95% CI: 1.29-2.73, I² = 77%, certainty of the evidence: moderate). The risk of bias in each study was deemed moderate to high.

Conclusions: Sarcopenic obesity worsens OS and increases the risk of postoperative complications in patients with oesophago-gastric cancer undergoing radical resection.

Objective: To identify and address areas for improvement within the current surgical training model in Australia and New Zealand relating to family planning and inflexible training as top barriers to gender equity in surgery.

Methods: A cross-sectional study of accredited surgical trainees and early career surgeons in Australia and New Zealand was conducted between September and October 2023. Participants were recruited by the RACS Fax Mentis, the Urological Society of Australia and New Zealand (USANZ) e-newsletter, and medical social media networks. Qualitative and quantitative data were collated by the electronic survey and thematically analyzed.

Results: There was a total of 146 participants. Approximately two-thirds of respondents identified as mothers and one-third as fathers, with representation from all surgical specialties. We identified four key themes including the disruptive impact of poor work-life balance on family planning, an absence of workplace systemic supports, a need for structured support program upon return-to-work from parental leave, and challenges in balancing professional and parental identities and responsibilities.

Conclusion: To promote a culture of equity, inclusivity, and acceptance, restructuring of surgical training programs are necessary to support trainees as they navigate family planning and parenthood. Promotion of flexible training options and recruitment of additional clinical supports around parental leave period may reduce negative biases toward trainees simultaneously balancing family and work. Systemic change is required to lower barriers to entry and achieve gender equality in surgery.

Aim: The tubercle of Zuckerkandl (TZ) is considered to be the fusion point of the ultimabranchial body and the median thyroid body. We aimed to evaluate the frequency of TZ and its relationship with other anatomical variations and recurrent laryngeal nerve (RLN) paralysis.

Material and methods: Data regarding the thyroid lobe and RLN of patients with thyroidectomy between June 2016 and December 2019 were retrospectively evaluated. TZ is classified according to its dimensions as follows: category 0; invisible, category 1; thickening only the lateral to thyroid lobe, category 2; ≤1 cm, and category 3; >1 cm. Categories 2 and 3 were accepted as TZ.

Results: In 627 patients, 1011 necks and thyroid lobes were evaluated. TZ was found as 58.9% in categories 0 and 1, 18.7% in category 2%, and 22.4% in category 3. In the presence of TZ, the RLN was located posteromedially in 95.2% and laterally in 4.8%. RLN entrapment in the Berry ligament region was significantly higher in categories 2 and 3 compared to category 1 (25.4% vs. 28% vs. 17.3% and p < 0.0001). There was no significant difference in RLN paralysis based on the presence and size of TZ or the relationship between RLN and TZ.

Conclusion: TZ is not rare and can be observed in 41.1% of thyroid lobes. It should be noted that the likelihood of RLN entrapment in the Berry region is higher in categories 2 and 3. Therefore, performing TZ dissection without applying traction to the thyroid lobe and mapping RLN could contribute to better RLN preservation.

Background: Although laparoscopic hemihepatectomy has gained prominence, one of the critical challenges in this procedure is the approach to the middle hepatic vein (MHV). The MHV, which runs in the midplane of the liver, is situated above the hilar plate and serves as an anatomical landmark in hemihepatectomy. We have introduced dorsal approach to the MHV from the hilar plate in laparoscopic hemihepatectomy under the laparoscopic caudo-dorsal view.

Methods: The liver parenchyma was divided along the midplane, which was identified as a surface ischemic line caused by selective inflow control of the right or left hemiliver. The MHV is dissected from the main root from the hilar plate toward the peripheral branches. The liver parenchyma was divided from the dorsal toward the ventral side, and the transection plane was tailored according to the particular type of hemihepatectomy.

Results: This approach was utilized in 28 patients with 9 undergoing right hepatectomy and 19 undergoing left hepatectomy. The median duration of the surgery was 260 min (range, 140-360 min), whereas median estimated blood loss was 80 mL (range, 40-400 mL). One patient (3.6%) has experienced postoperative major complications. The median length of postoperative hospitalization was 7 days (range, 5-20 days).

Conclusion: In conclusion, the dorsal approach to the MHV from the hilar plate in laparoscopic hemihepatectomy represents a significant advancement in the surgical technique. This approach offers enhanced visualization and precise dissection, which are critical for minimizing complications and improving surgical outcomes.