BMC Surgery最新文献

Background: Hepatocellular carcinoma (HCC) is prevalent in Taiwan, primarily due to the high incidence of hepatitis B and C infections, with high recurrence rates of 50-70% within five years after initial treatment. Treatment options for recurrent HCC include salvage liver transplantation, trans-arterial chemoembolization, re-hepatectomy, and radiofrequency ablation. Repeat hepatectomy exhibits superior oncological outcomes compared with alternative approaches. Although laparoscopic liver resection has demonstrated safety and feasibility for primary HCC resection, the persistence of intrahepatic recurrence necessitates effective intervention. However, repeat liver resection poses several challenges including adhesions from previous surgeries, limited access to recurrent tumors, altered liver structure post-regeneration, difficulties in obtaining hilar control, and compromised liver reserves. Suggesting a laparoscopic approach for recurrent HCC is typically based on the surgeons' experience and confidence. In this study, we reconfirmed the safety, feasibility and oncological outcome of laparoscopic repeat liver resection and investigated the optimal timing for initiation of this procedure by a pioneering team in minimally invasive liver resection.

Methods: We retrospectively reviewed our collective experience of 57 patients with recurrent HCC between January 2009 and December 2021.The patients were followed until June 30, 2024. Among them, 37 underwent laparoscopic approaches and 20 opted for open procedures.

Results: Both groups exhibited similar operative times and perioperative outcomes, with significantly reduced hospital stays in the laparoscopic cohort (median: 5 vs. 7, p < 0.001). The median follow-up duration was 41.5 months (range, 2.8 to 112.6 months). Mortality occurred in 22 patients (38.6%) and recurrence occurred in 26 patients (45.6%) The overall survival and disease-free survival after the operation were similar in both groups and comparative to the literatures.

Conclusion: Using a stepwise approach, laparoscopic repeat liver resection can be performed safely and effectively with a low incidence of conversion by an experienced surgical team with similar oncological outcomes. The introduction of laparoscopic techniques has also sparked a strategic shift in the surgical approach for recurrent HCC. This treatment option should be offered to patients by an experienced surgical team for minimally invasive liver resections.

Background: The feasibility and safety of laparoscopic pancreaticoduodenectomy (LPD) in overweight patients is still controversial. This study was designed to analyze the impact of overweight on surgical outcomes in patients undergoing LPD.

Methods: Data from patients who underwent LPD between January 2018 and July 2022 were analyzed retrospectively. A 1:1 propensity score-matching (PSM) analysis was performed to minimize bias between groups.

Results: A total of 432 patients were enrolled, with a normal weight group (n = 241) and an overweight group (n = 191). After matching, 144 patients were enrolled in each group. The results showed that the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) and delayed gastric emptying (DGE) was significantly higher in the overweight group compared to the normal weight group (P = 0.036). However, there were no significant differences in perioperative mortality (1.4% vs. 2.1%, P = 0.652) and long-term survival outcomes between malignancy patients with different body mass index (BMI) before and after PSM (all P > 0.05).

Conclusions: It is safe and feasible for overweight patients to undergo LPD with mortality and long-term survival outcomes comparable to the normal weight group. High-quality prospective randomized controlled trials are still needed.

Background: Posttraumatic spinal cord tethering and syringomyelia are considered disabling diseases in patients with spinal cord injury. In symptomatic patients, surgical management can achieve promising clinical outcomes. As the raising economic pressure might jeopardize optimal and thus personalized patient care, we aimed to exemplify expenses of surgical treatment in contrast to reimbursement by the Swiss diagnosis related group (DRG) system.

Methods: This retrospective investigation includes 60 patients who underwent surgery for spinal cord tethering and syringomyelia. The duration of surgeries was used to estimate the costs of care in the operating room (OR) considering established bench marks. Coverage of costs was calculated by comparing Swiss DRG reimbursements with the expenses from the investigated cases.

Results: The mean duration of surgeries was 251.0 ± 93.5 min while 2.8 ± 1.4 vertebral segments were treated by spinal cord untethering. The mean OR costs (in USD) were $9,401.2±$3,500.2 (range $4,119.5 to $20,223.0). The mean reimbursement and the ratio of OR costs to reimbursement (in USD) were $24,122.5±$7,409.3 (range $17,249.8 to $31,977.1) and 0.41 ± 0.15 (range 0.14 to 0.74) for standard, and $39,106.0±$4,028.6 (range $35,369.1 to $43,376.8) and 0.24 ± 0.08 (range 0.10 to 0.47) for complex cases, respectively. The estimated costs of surgeries were different from reimbursements (p = 0.005).

Conclusions: Although the cost of surgical management of patients with posttraumatic spinal cord tethering and syringomyelia are principally covered, it remains questionable if total hospital expenses are sufficiently outweighed by the current reimbursement system. This could potentially limit the availability of best medical care and might endanger personalized patient management.

Background: Pelvic fractures are often associated with life-threatening damage and mechanical instability. Surgical therapy is a prior choice. To minimize surgical invasion and risk, bilateral screws combined with curved rod were applied to stabilize posterior pelvic ring. This study was aim to explore the clinical effect of this procedure.

Methods: From January 2018 to January 2022, 27 patients with posterior pelvic fracture were included retrospectively. There were 12 males and 15 females with an average age of 56.3 ± 14.2 years. The prognosis of pelvis was evaluated by Matta and Majeed scores. Relevant clinical evaluation indications include the time of fracture healing, limb function and complications.

Results: The average follow-up time was 14.2 ± 5.4 month. Matta scoring standard: excellent in 18 cases, good in 7 cases, the good rate was 92.6%. The average healing time was 8.4 months. The standard of Majeed score in 6 months after operation: excellent in 14 cases, good in 10 cases, the good rate was 88.8%. At the last follow-up, the functional recovery of the affected limb was satisfactory. No deep infection occurred after operation. The neurological symptoms of patients with caudal sacral nerve injury were recovered 6 months after operation.

Conclusion: The results indicated that screw-rod system is a safe technique. Minimally invasive technology reduced frequency of fluoroscopy. It provides a simple and safety method for posterior pelvic fracture.

Background: Robot-assisted thoracoscopic surgery (RATS) thymectomy has been increasingly performed for treating thymic epithelial tumors in recent years. However, there are very limited reports on the long-term oncologic outcomes after RATS thymectomy, particularly in comparison to Video-assisted thoracoscopic surgery (VATS). This study aimed to compare the perioperative and long-term oncological outcomes between RATS and VATS.

Methods: The study was conducted on 180 consecutive patients undergoing RATS or VATS between July 2016 and December 2019, 85 of whom underwent RATS, and 95 of whom underwent VATS. A 1:1 matched propensity score-matched analysis was performed and the perioperative and long-term oncologic outcomes of the two groups compared.

Result: RATS group experienced a shorter operation time (median: 100 min vs. 120 min; P = 0.039) and less blood loss (40.00 ml vs. 50.00 ml, P = 0.011). RATS demonstrated a significantly lower conversion rate to open surgery compared to VATS, with only two patients requiring conversion in the RATS group as opposed to ten patients in the VATS group (3.03% vs. 15.15%, P = 0.030). In the RATS group, the 5-year progression-free survival rate was 87.70%, and the 5-year tumor-related survival rate was 92.31%, demonstrating no statistically significant difference compared to those in the VATS group.

Conclusion: Compared with VATS, robotic thymectomy demonstrated excellent perioperative outcomes, and RATS achieved long-term oncologic outcomes comparable to those of VATS. RATS thymectomy could be considered as an effective alternative approach for treating thymic epithelial tumors.

Background: Open pancreaticoduodenectomy (OPD) is an essential surgical procedure for expert hepato-biliary-pancreatic (HBP) surgeons. However, there is no standard for how many surgeries must be performed by a surgeon in training before they are considered to have enough experience to ensure surgical safety.

Methods: Cumulative Sum (CUSUM) analysis was performed using the surgical data of OPDs performed during the training period of board-certified expert surgeons of the Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Results: Fourteen HBP surgeons participated in this study and performed 334 OPDs during their training period. The median (interquartile range) values for operative time, blood loss, and length of hospital stay were 455 (397-519) minutes, 450 (234--716) ml, and 28 (21-38) days, respectively. CUSUM analysis showed inflection points at 20 surgeries performed for operative time. After 20 procedures, operative time was significantly shorter (461 min vs. 425 min, p = 0.021) and blood loss was significantly lower (470 ml vs. 340 ml, p = 0.038). No significant differences between within 20 and after 21 procedures were found in the complication rate (53% vs. 48%, p = 0.424) and rate of in-hospital deaths (1.5% vs.1.4%. p = 0.945). Up to 20 surgeries, PDAC and another malignant tumor had longer operative time than benign/low malignant diseases (486 min vs. 472 min vs. 429 min, p < 0.001), and higher blood loss (500 ml vs. 502 ml vs. 355 ml, p < 0.001). Mortality rate was higher at PDAC cases (5% vs. 0% vs. 0%, p = 0.01). After the 21 procedures, these outcomes were improved and no differences in by primary disease were observed. Multivariable analysis showed that within 20 surgeries were independent risk factors of longer operative time (HR2.6, p = 0.013) and higher blood loss (HR2.0, p = 0.049).

Conclusions: To stabilize the surgical outcome of OPD for malignant disease, at least 20 surgeries should be performed at a certified institution during surgeon training.

Trial registration: Clinical trial number: Not applicable.

Objective: This study aims to explore the appropriate surgical treatment method for acute intestinal obstruction caused by gastrointestinal foreign bodies in children through a comparison of clinical characteristics in patients treated via laparoscopically assisted approach and open surgery.

Methods: This study retrospectively analyzed 12 children with acute intestinal obstruction caused by gastrointestinal foreign bodies treated at Shanghai Children's Hospital and Huzhou Maternity and Child Care Hospital from June 2019 to June 2024. Basic information, treatment methods, and prognoses of the patients were collected. General data, operation time, postoperative fasting time, postoperative hospital stay, and intraoperative and postoperative complications were compared between the two groups. Categorical data were compared using Fisher's exact test. Normally distributed continuous data were expressed as mean ± standard deviation and analyzed using an independent samples t-test; non-normally distributed data were expressed as M (P25, P75) and analyzed using the non-parametric Mann-Whitney U test.

Results: Six cases underwent laparoscopic transumbilical extended incision, successfully extracting the intestines and removing the foreign bodies without converting to open surgery. Compared to Six cases undergoing traditional open surgery during the same period, the postoperative fasting time and postoperative hospital stay in the laparoscopic group were 4 (5 ± 3.65) days and 5.5 (5 ± 7.5) days, respectively, while in the traditional open surgery group, they were 5 (4.25 ± 6) days and 6 (5 ± 8.6) days, respectively; the differences were statistically significant (P < 0.05). The laparoscopic group had significantly shorter operation time and faster postoperative recovery. The acceptance of the laparoscopically assisted approach by the families was significantly higher than that of the open surgery treatment.

Conclusion: The method of extracting obstructed intestines and removing foreign bodies via laparoscopic-assisted transumbilical extended incision has advantages over open surgery for treating acute intestinal obstruction caused by gastrointestinal foreign bodies, such as shortening hospital stay and operation time. However, for children with secondary gastrointestinal perforation caused by magnetic foreign bodies, open surgery, due to its broader exploration scope, is more advantageous for detecting occult perforations.

Background: Elderly hip fracture was a common orthopedic emergency with high perioperative complication risks. Combined with preoperative acute heart failure, the risk increases further, with pneumonia being a common complication. The aim of this study was to construct and evaluate risk factor prediction models for perioperative pneumonia in these patients and to explore prognostic factors.

Methods: A retrospective study design was used to collect data on elderly patients with hip fracture combined with preoperative acute heart failure at the Third Hospital of Hebei Medical University from January 2020 to December 2022. The feature variables were screened by logistic regression and nomogram was constructed. The receiver operating characteristics curve (ROC), decision curve analysis (DCA), and calibration curve were employed to assess the predictive power of the model. Correlation heatmaps and shapley additive explanation (SHAP) were employed to assess key variables and their impact. Employing the Kaplan-Meier curve and Cox regression, the patients' prognosis was ultimately evaluated.

Results: 535 elderly patients with hip fracture combined with preoperative acute heart failure were included in this study. Logistic regression analysis was used to identify combined respiratory disease, hemoglobin, albumin, neutrophils, and blood glucose as independent danger factors for perioperative pneumonia (p < 0.05). The nomogram was designed to display the outcomes instinctively, with an AUC of 0.819. The model was internally validated by initiating self-sampling 1000 times. The calibration curve indicated that the model had excellent treaty. The DCA curve showed that the model had good validity and clinical practicability. Correlation heatmaps and SHAP were visualized and analyzed. The K-M curves indicated that the prognosis of the non-pneumonia group was better than that of the pneumonia group (p = 0.014). COX regression analysis found that the major risk factors for all-cause mortality in patients with acute heart failure(AHF) were age, brain natriuretic peptide, platelet count, and combined respiratory failure (p < 0.05).

Conclusion: The prediction model, established in this study, was highly accurate and proved a potent instrument for clinical evaluation of the perioperative pneumonia risk of elderly hip fracture patients with preoperative acute heart failure. We hope that this study can reduce the occurrence of perioperative pneumonia in patients and improve the prognosis of patients.

Aim: To evaluate the safety and outcomes of modified Kasai operation combined with autologous bone marrow mononuclear cell (BMMNC) infusion for biliary atresia (BA).

Methods: A matched control study was conducted between January 2015 and December 2021. Ten consecutive children with biliary atresia (BA) who underwent the modified Kasai operation combined with autologous BMMNC infusion (cell therapy group) and ten children who had only the modified Kasai operation (control group) were included in the study. The Kasai operation was performed with two modifications: partial exteriorization of the liver, and encirclement with lateral retraction of two hepatic pedicles to facilitate the removal of fibrotic tissue. Bone marrow was harvested through anterior iliac crest under general anesthesia then a modified Kasai operation was performed. After processing, bone marrow mononuclear cells were infused through the umbilical vein at the end of the operation. Serum bilirubin, albumin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, and prothrombin time were monitored at baseline, six months, twelve months, and the last follow-up (4.5 years) after the operation. In addition, esophagoscopy and liver biopsies were performed on patients whose parents agreed. Mixed-effects analysis was used to evaluate the changes in Pediatric End-Stage Liver Disease (PELD) scores.

Results: There were no intraoperative or postoperative complications related to the operation or cell infusion. The average infused BMMNC and CD34 + cell counts per kg bodyweight were 85.5 ± 56.0 × 10⁶/kg and 10.0 ± 3.6 × 10⁶ for the injection, respectively. Following the intervention, all ten patients in the cell therapy group survived, with a mean follow-up duration of 4.5 ± 0.9 years. Meanwhile, three patients in the control group died due to end-stage liver failure, with a mean follow-up time of 4.3 ± 0.9 years. Liver function of the cell therapy group was maintained or improved after the operation and cell infusion, as assessed by biochemical tests. The disease severity reduced markedly in the CT group compared to the control group, with a significant reduction in PELD scores (p < 0.05).

Conclusion: Autologous BMMNC administration combined with Kasai operation for BA is safe and may maintain or improve liver function in the studied patients.

Trial registration: ClinicalTrials.gov Identifier: NCT05517317 on August 26th, 2022.

Obesity has been recognized as a chronic disorder by the World Health Organisation (WHO) and was first reported in the Paleolithic age. In the recent years there has not been an international collaborative that facilitates professional cooperation on a worldwide level to increase the output of high-level evidence in the fields of obesity treatment and metabolic and bariatric surgery (MBS). In other surgical and medical fields, international collaborative research networks have shown to increase the quality and amount of treatment-changing evidence. In general, Global Collaborative Research in MBS (GCRMBS) should have the following goals: (1) clinical specialty-based research in obesity and MBS, (2) designing research protocols and studies to generate long-term data in obesity and MBS, (3) understanding the uncommon/rare complications and events associated with obesity and MBS, (4) increasing the number of participants in research and (5) investigating ethical and racial disparities in bariatric research. This review gives an overview of the current status and the future of international collaborative research in MBS.