Annals of Surgical Treatment and Research最新文献

Purpose: Hilar cholangiocarcinoma is known for its poor prognosis due to late diagnosis. To achieve long-term survival, curative resection often is necessary. However, after surgical resection, the 5-year survival rates vary from 14% to 48%. The aim of this study is to evaluate the prognostic factors for long-term survival in hilar cholangiocarcinoma.

Methods: Patients who underwent curative resection for hilar cholangiocarcinoma at Samsung Medical Center from January 2000 to December 2020 were included. Demographics, surgical and oncological outcomes, short-term complications, recurrence, pathologic results, and survival were analyzed. Prognostic factors were analyzed with Cox proportional hazards models.

Results: A total of 449 patients diagnosed with hilar cholangiocarcinoma who underwent intent-to-treat resection at Samsung Medical Center from 2000 to 2020 were included in this study. The median disease-free survival was 19 months, and the median survival was 40 months. One-, 3-, and 5-year survival rates were 82.8%, 53.7%, and 35.8%, respectively.

Conclusion: The 5-year survival rate of patients with hilar cholangiocarcinoma was 35.8% at Samsung Medical Center. Median survival was 40 months. N2 stage and tumor biology were factors affecting 5-year survival.

Purpose: The selection of primary tumor resection (PTR) vs. self-expanding metallic stents (SEMS) in obstructive unresectable stage IV colorectal cancer (CRC) is critical, profoundly impacting patient outcome. This study evaluates the influence of PTR and SEMS on overall survival (OS) in conjunction with chemotherapy.

Methods: The analysis included 137 patients with obstructive, unresectable stage IV CRC who underwent PTR or attempted SEMS placement. The primary objective was to assess the OS of patients, specifically examining how PTR and SEMS interventions influence these survival outcomes.

Results: In a cohort of 137 patients with obstructive, unresectable stage IV CRC, 30 initially opted for PTR, while stent placement was attempted in 107 cases. Following 14 stent failures, which resulted in 8 diversions and 6 additional PTR interventions, exclusions due to elective surgeries led to a final analysis of 36 PTR and 72 SEMS cases. Cox regression analysis identified no significant survival advantage between PTR and SEMS interventions (hazard ratio [HR], 0.848; 95% confidence interval [CI], 0.555-1.298; P = 0.449). Critical findings highlighted that the absence of chemotherapy markedly reduced survival prospects (HR, 1.963; 95% CI, 1.200-3.211; P = 0.007). These insights were substantiated through propensity score matching.

Conclusion: The comparative analysis reveals that neither PTR nor SEMS offers a definitive survival advantage in managing obstructive, unresectable stage IV CRC. However, the necessity for subsequent invasive interventions is notably lower in the PTR group.

Purpose: This study investigates risk factors for recurrence in patients who underwent laparoscopic primary closure (PC) for pyloroduodenal ulcer perforation (PUP).

Methods: We retrospectively analyzed data from patients who underwent laparoscopic PC with or without highly selective vagotomy (HSV) for PUP at a tertiary hospital from 2010 to 2019. Demographics, surgical outcomes, proton pump inhibitor (PPI) use, Helicobacter pylori status, and endoscopic findings were reviewed. Long-term (5 years) endoscopic and clinical outcomes regarding ulcer and perforation recurrence, were collected.

Results: A total of 139 patients were included in the analysis. Of these, 109 (78.4%) were male, and 76 (54.7%) were current smokers. Ninety-five patients (68.3%) underwent PC only, while 44 (31.7%) received PC + HSV. During the follow-up period, ulcer recurrence was observed in 19 patients (13.7%) and perforation recurrence in 9 (6.5%). In Cox proportional analysis for ulcer recurrence, smoking (hazard ratio [HR], 6.476; 95% confidence interval [CI], 1.834-22.873; P = 0.004) and older age (HR, 1.049; 95% CI, 1.012-1.088; P = 0.009) were identified as significant factors. For peptic ulcer perforation recurrence, smoking (HR, 19.129; 95% CI, 2.048-178.702; P = 0.010) and older age (HR, 1.062; 95% CI, 1.009-1.118; P = 0.021) were significant. No significant associations were found between sex, duration of PPI therapy, H. pylori eradication success, or surgery type and the risk of either ulcer or perforation recurrence.

Conclusion: Smoking and age are important factors for recurrence following laparoscopic PC for PUP. These findings emphasize the need for smoking cessation and close postoperative monitoring.

Purpose: This study introduced adenomas per polypectomy (APP) as a novel metric for evaluating the progression of lesion discrimination skills among colonoscopy trainees.

Methods: This retrospective study was conducted at the National Cancer Center, Korea between March 2020 and February 2023. Nine colorectal surgeons who completed a structured 1-year colonoscopy training program were included, and their performance was compared with that of 5 expert endoscopists. APP was defined as the number of histologically confirmed adenomas among the total number of polypectomies performed. The APPs were calculated serially to assess changes from the beginning to the end of the training.

Results: A total of 8,072 colonoscopies were performed by 9 trainees and 11,687 by 5 experts. The average APP of the 9 trainees was 67.0%, which was significantly different from the 73.9% APP of the experts (P < 0.001). The APP progression of trainees exhibited 3 phases: phase 1 (<200 cases) showed increasing polyp detection and APP; phase 2 (200-500 cases) displayed a sharp rise in the number of polypectomies but a decline in APP; and phase 3 (>500 cases) demonstrated a decrease in the number of polypectomies with a moderate rise in APP. However, even in phase 3, the trainees' APP remained significantly lower than that of the experts (69.9% vs. 73.9%, P = 0.027).

Conclusion: APP, a measure of visual adenoma discrimination ability, undergoes 3 stages of progression during colonoscopy training. This progression suggests that the APP may serve as an additional metric for assessing the effectiveness of colonoscopy training.

Purpose: Given the widening of the donor pool to include patients with steatosis, small-for-size grafts, and older patients, this study examined the effect of age on liver volumetric regeneration after a donor right hepatectomy.

Methods: We enrolled 33 older (≥55 years) and 277 younger (<30 years) donors who underwent donor right hepatectomy between March 2012 and December 2022. After propensity score-matched analysis, the perioperative surgical outcomes and growth rates of the remnant liver in 63 younger and 32 older donors were compared. Liver regeneration was assessed using CT volumetry for up to 6 months after surgery. Poor liver regeneration was defined as restoration of less than 80% of the original liver volume. The risk factors for poor liver regeneration were analyzed using a binary logistic regression model.

Results: The mean age of older and younger donors was 58.0 and 24.3 years, respectively. Despite comparable preoperative factors, older donors showed significantly lower regeneration rates at all observed time points (1 month: 75.5% vs. 82.3%, P = 0.001; 3 months: 80.4% vs. 90.5%, P < 0.001; and 6 months: 87.9% vs. 95.8, P = 0.006, compared to total liver volume). A large total liver volume and older age were identified as risk factors for poor liver regeneration.

Conclusion: Older donors showed a reduced capacity for liver regeneration. This finding suggests the need for the development of more conservative criteria for residual liver volume in older donors than for younger donors to ensure donor safety.

Purpose: The oncologic benefits of adjuvant chemotherapy for resected ampulla of Vater cancer (AoVCa) remain contentious. This study aimed to evaluate the long-term oncologic effects of postoperative adjuvant chemotherapy (PACT) in patients who underwent radical surgery for AoVCa.

Methods: From 2005 to 2019, clinical and pathological data of 306 AoVCa patients who underwent pancreatoduodenectomy were retrospectively reviewed. Patients were divided into the PACT (+) and PACT (-) groups. Propensity score matching (PSM) was conducted to adjust for clinical factors.

Results: The PACT (+) group (n = 124) and PACT (-) group (n = 182) showed significant differences in cancer stage, lymph node metastasis, perineural invasion, lymphovascular invasion, and cancer differentiation. Lower overall survival (OS) (P < 0.001) and disease-free survival (DFS) (P < 0.001) were observed in the PACT (+) group. After PSM, no significant differences in OS or DFS were found between the groups. Multivariate analysis identified lymph node metastasis and perineural invasion as significant prognostic factors, while PACT did not significantly impact long-term survival. Paradoxically, PACT was associated with worse outcomes in patients with favorable prognostic factors.

Conclusion: This study suggests that PACT does not provide a clear oncologic benefit for resected AoVCa patients and may even be detrimental for those with favorable prognostic factors. There is an urgent need to develop effective anticancer treatments and consider tailored therapeutic approaches based on individual patient profiles. Future research should focus on long-term follow-up and the integration of precision medicine to improve outcomes for AoVCa patients.

Purpose: Accurate anatomical knowledge and precise visualization are critical during liver surgery. We developed augmented reality (AR) software that overlays digital 3-dimensional (3D) models onto laparoscopic or robotic views, providing real-time visual aids for surgical navigation during 3D laparoscopic and robotic liver surgeries. This study assesses the accuracy of manual registration and the subjective perception of this AR software by the operator.

Methods: Ten consecutive patients undergoing 3D laparoscopic or robotic liver surgery from December 2023 to February 2024 were selected for application of the AR software during surgery. Manual registration accuracy was quantified post-registration using the Dice similarity coefficient (DSC) to compare the stereoscopic and virtual liver images. A 6-question operator survey, using a 5-point Likert scale, was administered after each surgery to evaluate the software's helpfulness in clinical settings.

Results: Seven males and 3 females (mean age, 62.4 ± 6.4 years) underwent liver surgery (3D laparoscopic, 5; robotic, 5). Surgical procedures included 4 right hemihepatectomies, 1 extended left hemihepatectomy, 1 left lateral sectionectomy, and 4 segmentectomies. The mean tumor size was 4.4 ± 2.2 cm (range, 1.0-7.5 cm). The mean DSC was 0.912 ± 0.052 (range, 0.879-0.954). The operator rated registration alignment favorably before (mean score, 3.9 ± 1.1) and after mobilization (mean score, 4.1 ± 1.2). The software was reported as very helpful overall (mean score, 4.2 ± 0.8), and in locating blood vessels (4.2 ± 0.6) and tumors (4.3 ± 0.7).

Conclusion: Clinical application of the AR software during 3D laparoscopic and robotic liver surgery is feasible, with favorable registration accuracy and high operator perception of helpfulness.

Purpose: Diffuse sclerosing variant papillary thyroid carcinoma (DSV-PTC) is a rare and aggressive subtype of PTC. Preoperative diagnosis is challenging owing to the overlapping of imaging characteristics with those of other thyroid conditions. This study aimed to evaluate the accuracy of preoperative ultrasound (US) in predicting DSV-PTC and to identify significant diagnostic factors.

Methods: This retrospective study analyzed 34 patients who were preoperatively suspected of having DSV-PTC based on US findings and later underwent thyroidectomy. Patients were divided into 2 groups based on the final histopathological diagnosis: DSV-PTC and non-DSV-PTC. Demographic, radiological, and pathological characteristics were also compared.

Results: Only 32.4% of patients initially suspected of having DSV-PTC were confirmed postoperatively. Among the US features, the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) score 5 was significantly associated with DSV-PTC (P = 0.038), whereas other radiological factors, including echogenicity and microcalcifications, were not. The histopathological features, such as tumor size, BRAF and TERT mutations, vascular invasion, and lymph node metastasis, showed no significant differences between the groups.

Conclusion: Preoperative US has limited accuracy (32.4%) in diagnosing DSV-PTC. Because of the aggressive treatment recommendations based on preoperative suspicion, clinicians should carefully consider the limitations of imaging. Further studies incorporating fine-needle aspiration or core needle biopsy are required to improve diagnostic accuracy.

Purpose: Traditionally, 6-8 hours of fasting has been recommended before surgery to prevent respiratory complications. However, recent evidence suggests that intake of clear fluids up to 2 hours before general anesthesia may be safe. This study aimed to evaluate the safety and efficacy of reduced fasting time with clear liquid intake in surgical patients under general anesthesia.

Methods: In this randomized controlled trial, 60 adult patients undergoing elective endoscopic total extraperitoneal plasty under general anesthesia were divided into two groups (n = 30 each). The control group fasted overnight (nothing per oral), while the liquid group was allowed clear fluids until 2 hours before surgery. Gastric content volume and pH were measured after intubation. Thirst and hunger levels were assessed pre- and postoperatively using a visual analogue scale. Postoperative hoarseness, nausea, vomiting, and oxygen saturation were monitored in the recovery room.

Results: The liquid group consumed an average of 520 mL of fluid. No serious respiratory complications were observed in either group. Pre- and postoperative thirst and hunger scores were significantly lower in the liquid group (P < 0.001). Gastric content volume and acidity showed no significant differences between groups, with most patients having negligible volumes (<1 mL).

Conclusion: Permitting clear liquid intake up to 2 hours before general anesthesia is safe and does not increase the risk of respiratory complications. It effectively reduces thirst and hunger, improving patient comfort without compromising safety.

Purpose: This study evaluated the effectiveness of the extraperitoneal tunneling (EPT) method for drain fixation compared to conventional drain insertion following (low) anterior resection (AR).

Methods: A retrospective review was conducted on 334 patients who underwent AR with an anastomotic height ≤15 cm from the anal verge at a single center between January 2020 and May 2024. In patients with permanent stoma formation, no drain insertions were excluded.

Results: Of the 334 patients, 192 (57.5%) underwent drain insertion via the conventional method, while 142 (42.5%) underwent the EPT method. No drain-related complications were reported in either group. Drain displacement occurred in 81 patients (24.3%), with a significantly lower rate in the EPT group compared to the conventional group (2.8% vs. 40.1%, P < 0.001). Multivariate analysis identified EPT fixation as a significant factor in reducing drain displacement (odds ratio [OR], 0.043; 95% confidence interval [CI], 0.015-0.123; P < 0.001) whereas postoperative ileus was identified as a significant risk factor for increasing drain displacement (OR, 2.952; 95% CI, 1.594-5.465; P = 0.001). Anastomotic leakage (AL) occurred in 25 patients (7.4%). Among 18 patients with AL but no drain displacement, 16 (88.9%) were successfully treated with drain maintenance and antibiotics alone. Conversely, 4 of 7 patients (57.1%) with AL and drain displacement required surgery or interventional procedures.

Conclusion: This retrospective study suggests that the EPT method may be effective in securing drain tubes, potentially enhancing their clinical utility. Maintaining the drain in its original position could help reduce the need for additional surgical or interventional procedures in AL management.