Annali italiani di chirurgia最新文献

Aim: To evaluate the feasibility and preliminary effects of ultrasound-guided erector spinae plane block (ESPB) in patients undergoing percutaneous transforaminal endoscopic discectomy (PTED).

Methods: This exploratory randomized controlled trial enrolled 60 patients with lumbar disc herniation who underwent PTED between May and December 2021 at our institution. Participants were randomly assigned to either a local anesthesia (LA) group or an ESPB group (n = 30). Heart rate (HR), mean arterial pressure (MAP), and visual analogue scale (VAS) scores were recorded at four time points: before anesthesia (T0), during foraminoplasty (T1), during annulus fibrosus manipulation (T2), and at the end of surgery (T3). Additional outcomes included operative time, intraoperative blood loss, length of hospital stay, willingness to undergo reoperation, and outcomes based on the modified Macnab criteria. The Oswestry Disability Index (ODI) and VAS scores were also assessed preoperatively and at 3 and 6 months postoperatively.

Results: All patients successfully completed the procedure. Compared with the LA group, the ESPB group exhibited more stable intraoperative HR and MAP, along with significantly lower VAS scores from T1 to T3 (p < 0.05), indicating potential benefits in intraoperative analgesia and hemodynamic control. No significant differences were observed in operative time, blood loss, or length of hospital stay between groups (p > 0.05). Both groups showed significant improvements in VAS and ODI scores over time (p < 0.05), although intergroup differences at follow-up were not statistically significant (p > 0.05).

Conclusions: Ultrasound-guided ESPB may enhance intraoperative comfort and analgesia compared to local anesthesia in PTED. These findings suggest that ESPB is a feasible and potentially beneficial approach in this setting. However, larger-scale confirmatory studies are required to establish definitive clinical efficacy and long-term benefits.

Clinical trial registration: ISRCTN (ISRCTN69505916).

Aim: This study aimed to retrospectively analyze the effects of comprehensive nursing care on postoperative complications and clinical outcomes in elderly patients undergoing prone lumbar spine surgery.

Methods: A retrospective study was conducted between July 2020 and July 2025, including 130 elderly patients undergoing prone lumbar spine surgery at Taihe County People's Hospital. Based on the nursing model, the patients included were classified into a control group (conventional care, n = 71) and an observation group (comprehensive care, n = 59). Evaluation criteria included preoperative anxiety and depression, clinical outcomes (time to first in-bed activity, time to first out-of-bed activity, and average length of hospital stay), perioperative hypothermia classification (mild/moderate/severe), incidence of perioperative shivering, postoperative infection rate, postoperative postural nerve damage, and incidence of pressure injuries 12 hours, 24 hours, and 48 hours after surgery.

Results: There were no statistically significant differences in the distribution of depression and anxiety scores and severity between the observation group and the control group before the intervention. After the intervention, the depression and anxiety levels in the observation group were significantly lower than those in the control group (p < 0.05), and the severity distribution was significantly better in the observation group than in the control group (p < 0.05). Time to first in-bed activity, time to first out-of-bed activity, and average length of hospital stay were significantly shorter in the observation group than in the control group (p < 0.001). The incidence rates of mild, moderate, and severe hypothermia were significantly lower in the observation group than in the control group (13.56%, 5.08%, and 1.69% vs 23.94%, 14.08%, and 11.27%, p < 0.05). The incidence of perioperative shivering was significantly lower in the observation group than in the control group (15.25% vs 33.81%, p < 0.05). There was no significant difference in the incidence of postoperative postural nerve damage between the two groups. The postoperative infection rate in the observation group was 5.08%, which was significantly lower than the 16.90% in the control group. Furthermore, the incidence rates of pressure injuries in the observation group 12 hours, 24 hours, and 48 hours after surgery were significantly lower than those in the control group (0%, 3.39%, and 10.17% vs 2.82%, 18.31%, and 29.58%, p < 0.05).

Conclusions: In this retrospective cohort, the implementation of comprehensive nursing significantly improved psychological status, reduced the incidence of perioperative hypothermia and other complications, and accelerated postoperative recovery in elderly patients undergoing prone lumbar spine surgery.

Aim: Chronic lymphocytic thyroiditis (CLT) is recognized as the most prevalent inflammatory disorder of the thyroid, while the B-Raf proto-oncogene, serine/threonine kinase (BRAF) V600E mutation is the most frequently identified genetic alteration in papillary thyroid carcinoma (PTC). This study aims to explore the relationship between CLT and BRAF V600E mutation and to assess their combined impact on tumor behavior across different tumor sizes.

Methods: We conducted a retrospective analysis of clinical and pathological data from 1474 patients who underwent surgical treatment for PTC. Univariate and multivariate logistic regression analyses were applied to identify independent factors influencing tumor characteristics.

Results: CLT was detected in 27.5% (405/1474) of the PTC cases. Multivariate analysis revealed that CLT was significantly associated with female sex; simultaneously, CLT was significantly negatively associated with BRAF V600E mutation, extrathyroidal extension (ETE), central lymph node metastasis (CLNM), and advanced disease stage (all p < 0.05). The BRAF V600E mutation was observed in 80.7% (1189/1474) of patients. Stratified analysis by tumor size showed that BRAF V600E mutation independently predicted CLT and advanced tumor-node-metastasis (TNM) stage in papillary thyroid microcarcinoma (PTMC); CLT, ETE, and CLNM in tumors 1-2 cm; CLT, ETE, CLNM, and lateral lymph node metastasis (LLNM) in tumors 2-4 cm; and CLT, ETE, vascular invasion, CLNM, and LLNM in tumors >4 cm (all p < 0.05). Notably, PTC patients without CLT but harboring BRAF V600E mutation showed a combined association with advanced TNM stage and aggressive features.

Conclusions: The presence of CLT appears to exert a protective effect in PTC. However, the prognostic significance of BRAF V600E mutation varies with tumor size. While CLT-related inflammatory microenvironment may counteract tumor progression in small cancers, it seems insufficient to mitigate the aggressive behavior driven by BRAF V600E mutation in larger tumors.

Aim: This study aimed to compare perioperative outcomes, lymphadenectomy quality, postoperative recovery, pulmonary function, and short-term oncologic results between robotic-assisted thoracoscopic surgery (RATS) and uniportal video-assisted thoracoscopic surgery (U-VATS) for early-stage non-small cell lung cancer (NSCLC).

Methods: This retrospective cohort study included 231 consecutive patients with stage I-IIA NSCLC who underwent curative-intent anatomic lobectomy at our institution between January and December 2023. Based on the surgical approach, patients were assigned to either the RATS group (n = 105) or the U-VATS group (n = 126). All procedures were performed by the same experienced surgical team using standardized perioperative protocols. Clinical characteristics, intraoperative and postoperative parameters, pulmonary function, and 12-month oncologic outcomes were collected for comparative evaluation.

Results: RATS resulted in shorter operative time, reduced blood loss, and increased lymph node and mediastinal station retrieval compared with U-VATS. Postoperative pain, drainage volume, length of hospital stay, and complication rates were comparable between groups. Patients undergoing RATS demonstrated significantly higher global health and functional scores, along with lower symptom scores, during the first 6 months after surgery (p < 0.05). Pulmonary function recovery, 1-year disease-free survival (DFS), and overall survival (OS) did not differ significantly between the two approaches. However, hospitalization costs were higher for the RATS group (p < 0.001).

Conclusions: Both RATS and U-VATS are safe and effective minimally invasive approaches for anatomic lobectomy in early-stage NSCLC. RATS offers advantages in operative precision, lymph node dissection, and short-term quality of life without compromising safety or early oncologic outcomes, although it is associated with increased cost.

Aim: Melanoma of unknown primary origin (MUP) is a rare clinical entity, accounting for approximately 3-4% of all cases of melanoma. It is defined as histologically confirmed metastases of melanoma occurring in the absence of any identifiable primary lesion. Due to its rarity, diagnostic and therapeutic guidelines remain poorly defined. The aim of this literature review of published case reports is to investigate the most commonly affected anatomical sites, the most frequent presenting symptoms, the diagnostic approaches, and the available therapeutic strategies.

Case presentation: 81-year-old woman was admitted with a right inguinal mass of unknown origin. Biopsy revealed metastatic melanoma involving the inguinal lymph nodes, with no clinically or radiologically detectable primary lesion. The patient underwent right inguinal-iliac-obturator lymphadenectomy. The postoperative course was uneventful, with no significant medical or surgical complications. Considering the patient's advanced age and overall condition, no adjuvant therapy was administered, and a strategy of active surveillance was adopted. At present, no evidence of disease recurrence has been observed.

Results: A total of 94 case reports were included in our review. MUP appears to be more frequent in males than in females. The axillary lymph nodes were the most commonly involved site, followed by the cervical and inguinal lymph nodes. Among extranodal sites, the gastrointestinal tract, particularly the stomach and small bowel, was most frequently affected. Patients with MUP should be managed similarly to those with melanoma of known primary origin (MKP), based on corresponding stage and anatomical involvement.

Conclusions: MUP is an uncommon and challenging presentation of metastatic melanoma. Its pathogenesis remains unclear, although several theories, including immune-mediated regression of the primary lesion, have been proposed. MUP should be staged as stage IV disease and treated with the same systemic therapies used for stage IV MKP, including immune checkpoint inhibitors and targeted agents. Prompt recognition and standardized management are crucial to optimizing outcomes in this subset of patients.

The application of the minimally invasive concept in the extraction of impacted mandibular third molars has significantly improved surgical outcomes and patient prognosis. This review systematically examines the up-to-date research advances in various methods used for the extraction of impacted mandibular third molars within the context of the minimally invasive concept. Modified incision and flap designs have effectively reduced tissue damage. Ultrasonic bone knife technology has proven to reduce intraoperative bleeding and the risk of thermal injury, and its combined use with a dental electric motor further enhances procedural precision and efficiency. Dynamic navigation technology holds significant potential in improving surgical accuracy, facilitating precise debridement and distraction techniques, and reducing the risk of nerve injury and postoperative complications. Future integration of dynamic navigation with preoperative artificial intelligence assessment will further advance the minimally invasive approach, making it more widespread and cost-effective. Minimally invasive techniques are not only the starting point but also the means to achieve functional objectives, propelling the development of minimally invasive alveolar surgery to new heights.

Aim: This study aims to develop and externally validate machine-learning models that effectively predict the risk and severity of postoperative symptoms one week following mandibular third molar extractions.

Methods: This retrospective cohort study included 321 patients (18-35 years old) who underwent lower third-molar surgery. Demographics, Pell-Gregory vertical (PGV) and Pell-Gregory level (PGL) classifications, surgical variables, and day-7 pain visual analogue scale (VAS) were recorded for all participants. The data were randomly divided into training (70%) and validation (30%) datasets. Five machine-learning algorithms-Gradient Boosting Machine (GBM), Extreme Gradient Boosting (XGBoost), Random Forest (RF), Decision Tree (DT), and Neural Network (NNET)-were developed using nested cross-validation. Model performance was assessed through area under the receiver operating characteristic (AUROC) values, Brier scores, and calibration slopes, with a nomogram constructed from the best-performing model.

Results: GBM achieved the highest discrimination on the validation dataset with an AUROC of 0.687 (95% CI, 0.624-0.744), followed by the Neural Network (AUROC = 0.677). The GBM model yielded a calibration slope of 0.98 and a Brier score of 0.225, indicating excellent predictive accuracy. However, the top six predictors were found to be operative time, mouth opening, PGV, PGL, smoking, and preoperative symptoms. The GBM model, which underlies the nomogram, achieved an area under the curve (AUC) value of 0.666, indicating its discrimination capability. Additionally, the calibration curve confirmed the model's accuracy, and the decision curve analysis (DCA) suggested that the nomogram provides clinically promising potential for effective risk stratification.

Conclusions: A GBM-based nomogram provides moderate yet clinically useful discrimination for healthy adults aged 18-35 years at risk for severe early symptoms after third-molar extraction. However, this approach requires external validation in older or medically complex patients before it is recommended for clinical predictions.