Annals of Gastroenterological Surgery最新文献

Background

This study aimed to investigate survival outcomes, the efficacy of lymph node (LN) dissection, and recurrence patterns in patients who underwent salvage surgery (SALV) for esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy (dCRT).

Methods

We retrospectively reviewed 69 patients with clinical stage I–IV thoracic ESCC who underwent SALV. Recurrence patterns and the distribution of LN metastases were analyzed according to the primary tumor location.

Results

The 90-day mortality rate was 2.9%, and the 3-year overall survival (OS) rate of the 69 patients was 47.1%. OS curves were significantly stratified by the presence of abdominal LN metastases (p = 0.007). Among six patients whose clinically positive LNs were not dissected because their swelling disappeared after dCRT (cN+/CRT-cN0 cases), two (33.3%) developed locoregional recurrence. In contrast, among 25 patients whose clinically positive LNs were dissected regardless of CRT-cN status, the incidence of locoregional recurrence alone was 4.0%. Patients with lower thoracic (Lt) tumors had a higher incidence of distant metastases than those with middle (Mt) or upper thoracic (Ut) tumors (61.5% vs. 36.8%/33.3%). Mediastinal LN metastases were rare (7.7%) in Lt tumors, whereas LN metastases were widely distributed within the regional zones in Mt/Ut tumors. Patients with Lt tumors and pathological LN metastases had extremely poor OS (3-year OS: 0%).

Conclusions

Abdominal LN metastases had a negative impact on survival in ESCC patients who underwent SALV. Clinically positive LNs should be dissected, provided it is technically feasible. The tumor location might influence the distribution and prognostic impact of pathological LN metastases.

Aim

The prevalence of kyphosis is increasing with increasing life expectancy. One of the most notable gastrointestinal complications is gastroesophageal reflux disease (GERD) in patients with kyphosis. In this study, we investigated the association between kyphosis and the incidence of postoperative GERD in patients who underwent proximal gastrectomy (PG), a procedure with a particularly high risk of GERD.

Methods

In total, 54 consecutive patients who underwent PG between 2009 and 2023 met the inclusion criteria. The thoracic/lumbar angle ratio (T/L ratio) derived from sagittal computed tomography was performed to preoperatively assess kyphosis, defined as a T/L ratio ≥ 1.25.

Results

Fifteen patients (27.8%) had kyphosis. Overall, postoperative GERD occurred in seven patients (13.0%). Preoperative albumin levels were significantly lower in the Kyphosis group than in the Normal group (p = 0.03), whereas other clinical characteristics showed no significant differences between the two groups. The incidence of postoperative GERD was significantly higher in the Kyphosis group than in the Normal group (33.3% vs. 5.1%, p = 0.01). Postoperative reflux symptoms also were more frequently observed in the Kyphosis group than in the Normal group (60.0% vs. 16.0%, p = 0.13). Kyphosis was one of the independent predictive factors for postoperative GERD (Odds ratio, 18.7; 95% confidence interval, 1.46–240; p = 0.02) in the multivariate analysis.

Conclusion

Kyphosis was significantly associated with the occurrence of postoperative GERD in patients who underwent PG. Alternative preventive measures may be considered when patients with kyphosis undergo PG.

Aim

This study evaluated the short-term outcomes of low anterior resection for rectal cancer in Japan before and after the COVID-19 pandemic, with a particular focus on the timing of its reclassification within Japan in May 2023.

Methods

Using data from the Japanese National Clinical Database, we analyzed 109 754 low anterior resection cases between January 2018 and December 2023, categorized into pre-pandemic (February 2020 and earlier), pandemic (March 2020–April 2023), and post-pandemic (May 2023 onward) periods. Trends in the number of low anterior resection cases, postoperative intensive care unit utilization, and complications, including anastomotic leakage and pneumonia, were examined. Standardized morbidity ratios were used to adjust for risk and assess trends over time.

Results

The number of low anterior resection cases declined during the pandemic but returned to pre-pandemic levels thereafter. The postoperative intensive care unit admission rates remained stable, with a slight increase post-pandemic. The incidence of major complications gradually declined from pre-pandemic to post-pandemic, with anastomotic leakage rates decreasing from 9.8% to 7.1% and the standardized morbidity ratio for anastomotic leakage decreasing from 1.0 to 0.8, reflecting improved outcomes. The number of robot-assisted surgeries significantly increased from 246 cases in March 2020 to 535 in May 2023, and their proportion among total surgeries also rose from 16.8% to 41.2%.

Conclusion

Despite initial challenges, the healthcare system of Japan effectively managed rectal cancer surgeries during and after the pandemic. Robotic surgery became more widely adopted, and complication rates improved, demonstrating resilience and adaptability in surgical care.

Aims

To determine the optimal extent of lymph node dissection for non-metastatic colon cancer by tumor location based on the therapeutic value index (TVI) for each lymph node station.

Methods

Consecutive patients with surgical stage I–III colon or rectosigmoid cancer in the Japanese Society for Cancer of the Colon and Rectum database who underwent curative resection between January 2003 and December 2014 were analyzed. The TVI was defined as the incidence of lymph node metastasis multiplied by 5-year overall survival and calculated for each nodal station stratified by tumor location.

Results

A total of 33 231 patients were eligible for analysis. In cecal cancer, the TVI was 2.086 for nodal station #203, but only 0.000 for #213. In ascending colon cancer, the TVI was 1.080 for #203 and 0.644 for #213, but only 0.178 for #223. In transverse colon cancer, the TVI was 1.942 for #223, but only 0.066 for #213 and 0.159 for #203. In descending colon cancer, the TVI was 0.215 for #253. The TVI was 1.172 for #253 in sigmoid colon cancer and 1.155 for #253 in rectosigmoid cancer.

Conclusion

Considering that a previous systematic review reported TVIs in the range of 0.295–0.576 for the para-aortic lymph nodes in patients with colorectal cancer, dissection of the main lymph nodes along the feeding artery has a therapeutic value in non-metastatic colon cancers. Meanwhile, the significance of #253 dissection for descending colon cancer requires further discussion.

Backgrounds

Incidence of malignant disease in older patients has been increasing. These geriatric patients have more comorbidities and frailty than younger patients, necessitating different approaches in evaluation and treatment. Geriatric surgery studies in Japan have followed those conducted in the US. The aims of this study were to compare trends in geriatric variables for patients who underwent gastroenterological surgeries between two countries, and to elucidate the characteristics of them.

Study Design

Geriatric variables and outcomes were analyzed via nationwide databases in both countries. Subjects were defined as patients with age ≥ 65 who underwent seven major gastroenterological surgeries for malignant disease. Basic statistical values were compared between them.

Results

A total of 2703 patients in the National Clinical Database (NCD) and 1342 patients in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) were included. Among preoperative comorbidities, dyspnea, hypertension, bleeding disorder, and emergency cases increased with age in both databases, while the rates of obesity and emergency cases were more frequent in NSQIP. Most postoperative complications were not significantly associated with age in either database. Geriatric-associated preoperative variables and outcomes varied with age in both countries. Cognitive variables (history of dementia, surrogate-signed consent, and delirium) were similar between the two databases. However, mobility elements (use of mobility aid, fall history, high fall risk, and new use of mobility aid) and postoperative functional dependency were more frequent in NSQIP than NCD.

Conclusion

Geriatric-associated variables and outcomes changed similarly with age in both countries, while mobility and function were different between the two.

Aim

We successfully established the stapler repair technique (SRT), a straightforward laparoscopic Rives-Stoppa approach utilizing a linear stapler. This study retrospectively evaluated its short-term outcomes to determine its safety and efficacy.

Methods

The surgical outcomes of 87 patients who underwent laparoscopic median incisional hernia repair at our hospital were reviewed between August 2017 and May 2024. Patients were treated with intraperitoneal onlay mesh (IPOM), laparoscopic trans-abdominal retromuscular (TARM), or SRT.

Results

Among these patients, 37 were treated with IPOM, 16 with TARM, and 34 with SRT, with no significant differences in patient characteristics. The median surgical time (range) was 96 min (50–211) for IPOM, 256 min (196–300) for TARM, and 112 min (60–289) for SRT, respectively. The median mesh areas (ranges) were 210 cm² (80–500) for IPOM, 500 cm² (270–780) for TARM, and 379 cm² (176–864) for SRT, respectively. The SRT group had significantly shorter operative times (p < 0.001) and smaller mesh areas (p = 0.005) than the TARM group. Compared to the IPOM group, there was no significant difference in operative time in the SRT group (p = 0.444), but the mesh area was significantly larger (p < 0.001). The SRT group had no significant intraoperative complications or conversions to open surgery.

Conclusion

SRT offers a comparable operative time to IPOM and a significantly shorter time than TARM. Additionally, SRT can be performed extraperitoneally with no significant intraoperative complications or conversion to open surgery. These findings suggest that SRT is a safe and effective minimally invasive approach in median laparoscopic incisional hernia repair.

Background

Our previous study suggested that low bone mineral density (BMD), known as osteopenia, was a poor prognostic factor in patients who underwent esophagectomy for esophageal cancer (EC).

Meanwhile, the association between BMD reduction during neoadjuvant chemotherapy (NAC) and the worse prognosis remains unknown, although esophagectomy after NAC is the first option for the treatment of advanced esophageal squamous cell carcinoma (ESCC). Therefore, this study intended to investigate the prognostic impact of BMD reduction during NAC.

Method

A total of 101 ESCC patients who underwent curative Mckeown esophagectomy after NAC between January 2008 and December 2019 were analyzed. BMD reduction (+) was defined as ≥ 6.8% of the BMD reduction rate during NAC. The patients were classified into the BMD reduction (+) group (n = 32) and the BMD reduction (−) group (n = 69) by measuring the BMD reduction during NAC.

Results

Overall survival (OS) and relapse-free survival (RFS) in the BMD reduction (+) group were significantly worse than those in the BMD reduction (−) group (p < 0.01). In multivariate analysis, BMD reduction was associated with worse OS (Hazard ratio [HR], 2.95; 95% confidence interval [CI], 1.44–6.05) and RFS (HR, 2.29; 95% CI, 1.30–4.03). Moreover, low skeletal muscle index before NAC was an independent risk factor for BMD massive reduction (Odds ratio, 6.21; 95% CI, 2.10–18.30).

Conclusions

BMD reduction during NAC was considered to be an adverse prognostic factor for OS and RFS in patients underwent NAC followed by esophagectomy for ESCC.

Background

Robot-assisted surgery has short-term benefits in rectal cancer surgery; however, its long-term advantages remain unclear. This study compared short- and long-term outcomes of open, laparoscopic, and robot-assisted rectal cancer surgeries using large-scale, database-driven evidence.

Methods

Patients (28 711) diagnosed with clinical stages I–III rectal cancer who underwent rectal resection and were registered in the Japanese Medical Data Vision Co. Ltd. database were included. Open rectal resection (ORR), laparoscopic rectal resection (LRR), and robot-assisted rectal resection (RARR) were identified. The primary outcomes were 5-year overall survival (OS) and relapse-free survival (RFS). Secondary outcomes included perioperative outcomes.

Results

After applying overlap weight, the RARR, LRR, and ORR groups had 3635 (15.3%), 17 142 (72.3%), and 2935 (12.4%) patients, respectively. Among the cohort (mean age: 69.5 years), 64.9% were male, and 24.7%, 31.5%, and 43.8% had clinical stages I, II, and III, respectively. The RARR group demonstrated the lowest postoperative complication rate, 30- and 90-day mortality rates, and shortest hospital stay. The RARR group had the highest 5-year OS (95%) and RFS (93%) compared to LRR (OS: 89%, RFS: 86%) and ORR (OS: 81%, RFS: 77%; p < 0.001). Multivariable analysis revealed that RARR was significantly associated with improved OS, whereas higher risks were observed for LRR (hazard ratio [HR]: 2.18, 95% confidence interval [CI]: 1.69–2.81) and ORR (HR: 3.96, 95% CI: 3.03–5.19).

Conclusions

The RARR group demonstrated superior short- and long-term outcomes than the LRR and ORR groups, indicating robot-assisted surgery as a potential new standard treatment for rectal cancer.