Annali italiani di chirurgia最新文献

Aim: Complex anal fistula poses a significant challenge for anorectal surgeons due to its high risks of recurrence and incontinence. A sphincter-preserving procedure named endorectal advancement flap (ERAF) is gradually being applied to clinical practice. Therefore, this meta-analysis aims to evaluate the efficacy and safety of ERAF in managing anal fistula.

Methods: We searched PubMed, Embase, Cochrane, and Web of Science databases for relevant manuscripts published from 29 August 2003 to 29 August 2023. Among these studies, outcomes included healing rate, recurrence rate, incontinence rate, and complications. Furthermore, the quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS) and the Cochrane risk-of-bias tool. The heterogeneity was determined using the chi-squared test and I2 statistic. A random effects model was applied if significant heterogeneity (p < 0.05 and I2 > 50%) was observed. Sensitivity analysis was conducted by excluding studies with a high risk of bias.

Results: Thirty-eight studies were included in the present analysis, involving 1559 participants. The pooled healing rate and recurrence rate of ERAF were 65.5% (95% confidence intervals (CI): 57.6%-73.4%) and 19.6% (95% CI: 14.8%-24.4%), respectively. The pooled incontinence rate was 10.6% (95% CI: 6.0%-15.1%). According to the subgroup analysis, the healing rate, recurrence rate, and incontinence rate of ERAF for fistula associated with inflammatory bowel disease (IBD) were 53.9% (95% CI: 38.1%-69.7%), 32.6% (95% CI: 21.3%-43.8%), and 2.8% (95% CI: 0%-10.6%), respectively. For patients without IBD, the healing rate, recurrence rate, and incontinence rate of ERAF were 70.6% (95% CI: 63.9%-77.4%), 15.7% (95% CI: 9.9%-21.5%), and 16.5% (95% CI: 8.1%-24.9%), respectively. We observed that bleeding, local infection or abscess, flap dehiscence, and haematomas were the common complications, with incidences of 2.2% (95% CI: 0%-4.5%), 9.5% (95% CI: 4.7%-14.4%), 10.4% (95% CI: 0.0%-21.6%), and 12.4% (95% CI: 0%-27.6%), respectively.

Conclusions: ERAF may be an optional treatment for anal fistula from the perspective of effectiveness and safety.

Systematic review registration: PROSPERO: CRD42023451451.

Aim: In terms of early-term mortality, there may be variability in terms of factors belonging to age groups. While some risk factors apply to all patients undergoing colorectal cancer surgery, some factors may come to the fore in terms of age. There have been very few studies on factors that increase the risk of early-term mortality, especially for geriatric patients. It was aimed to compare factors influencing prognosis and mortality within the first 30 postoperative days between geriatric patients and those <65 years of age, and to identify factors that increase the risk of anastomotic leakage and early-term mortality, particularly in geriatric patients.

Methods: Clinical, laboratory, and pathology findings from 341 patients (186 geriatric) who underwent surgery for colorectal cancer between January 2016 and December 2019 were collected and analyzed. In terms of categorical variables, comparisons between groups were made with Pearson's Chi Square test and Fisher's Exact Test. Risk coefficients of variables in terms of anastomotic leakage and early-term mortality were determined by logistic regression analysis. The results were evaluated within the 95% Confidence interval, and p < 0.05 values were considered significant.

Results: Anastomotic leakage was detected in 7% of patients, and 6.2% of the patients died within the first 30 postoperative days. The 30-day postoperative mortality rate was significantly higher in geriatric patients with hypertension (p = 0.003), those undergoing emergency surgery (p = 0.007), those with stage 4 tumors (p < 0.001), those with ostomy-related complications (p = 0.042), those who developed intraabdominal abscess or peritonitis (p < 0.001), those with respiratory failure (p = 0.009), and those with perforation (p = 0.001). In patients <65 years of age, groups stratified by these variables did not differ significantly in terms of early-term mortality rate (p > 0.05 for each).

Conclusions: These findings show that lack of bowel preparation and development of intraabdominal abscess/peritonitis significantly increase early-term mortality rates in both <65 and geriatric patients. Additionally, hypertension, emergency surgery, advanced tumor stage, development of ostomy-related complications, respiratory failure, and perforation significantly increase early-term mortality solely in geriatric patients.

Background: In the context of gastric cancer, surgical resection stands as the sole curative treatment. Central to influencing overall survival are the resection margins. This research aims to identify the factors influential in determining microscopically positive resection margins (R1) and to evaluate overall survival.

Methods: Our study encompassed 549 patients diagnosed with adenocarcinoma of the stomach who underwent curative-intent surgery between January 2011 and December 2021 in our Surgery Department. We investigated the incidence of positive margins (R1) and their impact on survival rates, as well as the determinants of R1. The standardization of R1 involved ensuring a margin distance of less than 1 mm from the tumor line to the margin.

Results: The incidence of R1 margins was 13.29% (73 patients). Among these, proximal R1 margins were observed in 29 patients (39.72%), while 49 cases (67.12%) presented circumferentially positive margins, with 20 cases (27.39%) exhibiting distally positive margins. Nineteen patients (26.02%) had two R1 margins, and 3 patients had all resection margins microscopically positive (4.10%). Factors such as tumor dimension, invasion of other organs, pT stage, pN stage, pL1 stage, pV1 stage, pPn stage, Lauren type, and tumoral grading demonstrated significance (p < 0.01) in the occurrence of positive R1 margins.

Conclusion: Tumor dimension, invasion of other organs, pT stage, pN stage, pL1 stage, pV1 stage, pPn stage, Lauren type, and tumoral grading could be regarded as factors for predicting microscopically positive margins. Moreover, positive resection margins have a detrimental impact on overall survival.

Aim: The aim of this study was to investigate whether multimodal analgesia can decrease postoperative opioid usage in patients undergoing shoulder arthroscopy.

Methods: Patients diagnosed with subacromial impingement syndrome who underwent acromioplasty at our institution between October 2022 and November 2023 were retrospectively analyzed. Patients were divided into an observation group and a control group based on postoperative pain management methods. The control group received intravenous self-controlled electronic analgesia (sufentanil injection 1 μg/kg + butorphanol injection 4 mg + 0.9% NaCl injection to 100 mL), while the observation group received multimodal analgesia (ropivacaine subacromial pump 3 mL/h, combined with oral celecoxib and acetaminophen). Visual Analog Scale (VAS) scores were recorded preoperatively and at various postoperative time points, and opioid usage, length of hospital stay, and analgesia-related complications within 1 week postoperatively were compared between groups. The 36-item Short Form Health Survey (SF-36) scores and the Constant-Murley score (CMS), were also assessed 1 day and 1 week after treatment.

Results: One hundred thirty-two patients were included in the study, 66 in the observation group and 66 in the control group. In the control group, there were 46 males and 20 females, with a mean age of 55.47 ± 11.42 years and in the observation group 44 males and 22 females, with a mean age of 56.13 ± 12.19 years The observation group consistently reported significantly lower pain intensity compared to the control group at 8 h (T1), 24 (T2), and 48 h (T3) after surgery (p < 0.05). Additionally, the observation group exhibited significantly lower opioid usage and complication rates compared to the control group (p < 0.05). SF-36 scores and CMS scores were significantly higher in the observation group 1 week after treatment compared to the control group (p < 0.05).

Conclusions: Following shoulder arthroscopy, multimodal analgesia effectively reduces opioid consumption, lowers complication rates, and provides effective short-term pain relief. This approach carries significant implications for improving patient outcomes.

Aim: Chronic dacryocystitis often leads to a poor prognosis due to factors like chronic inflammation resulting in lacrimal duct obstruction and recurrent infections. Therefore, this study aims to investigate the risk factors of poor prognosis in patients with chronic dacryocystitis treated by endoscopic nasal dacryocystostomy and to establish a risk prediction model.

Methods: We retrospectively analyzed the clinical data of chronic dacryocystitis patients (n = 101) treated between January 2022 and February 2024. They were divided into a training set (n = 71) and a validation set (n = 30). Patients were followed up for three months post-operation, and recurrence rates were assessed. Logistic regression analysis was used to identify risk factors for poor prognosis, and a nomogram model was developed utilizing these risk factors. Model validation involved the bootstrap method, calibration curves, receiver operator characteristic (ROC) curves, and the Hosmer-Lemeshow test.

Results: Out of the 101 patients, 27 (26.73%) experienced recurrence. The older age, longer operation time, and greater intraoperative bleeding were all associated with poor prognosis (all p < 0.05). Multivariate regression indicated that age (odds ratio (OR) = 2.18, 95% CI: 1.30-3.68), operation time (OR = 1.89, 95% confidence interval (CI): 1.13-3.17), and intraoperative bleeding (OR = 1.69, 95% CI: 1.06-2.69) were significant risk factors. The nomogram model incorporating these factors showed an area under the curve (AUC) of 0.666 for the training set and 0.585 for the validation set. Furthermore, for the training set, sensitivity and specificity were 0.654 and 0.621, and for the validation set, they were 0.598 and 0.548, respectively, with calibration curves indicating good agreement.

Conclusions: Age, operation time, and intraoperative bleeding are significant factors affecting the prognosis of patients with chronic dacryocystitis.

Aim: This study aims to evaluate the efficacy and long-term prognosis of all-inside and outside-in suturing methods for meniscus repair under knee arthroscopy.

Methods: A retrospective analysis was conducted on 120 patients with meniscus injuries who underwent surgical treatment at Yuhuan People's Hospital, Department of Joint Surgery, from January 2019 to March 2021. Based on the suturing method, patients were assigned into two groups: Group A (64 cases, all-inside suturing) and Group B (56 cases, outside-in suturing). Surgical indicators and adverse events were recorded for both cohorts. The variances in proprioception before and after surgery, International Knee Documentation Committee (IKDC) scores, Lysholm scores, knee range of motion (ROM), and Visual Analogue Scale (VAS) pain scores were compared between the two groups.

Results: Group A had significantly shorter operative time, postoperative immobilization, and hospital stay compared to Group B (p < 0.05). The overall incidence of adverse events was 12.50% in Group A and 16.07% in Group B, with no significant difference between the groups (p > 0.05). There were no substantial differences in preoperative knee proprioception difference values, IKDC scores, Lysholm scores, VAS scores, and knee ROM between the two groups (p > 0.05). At three months postoperatively, Group A exhibited lower proprioception difference values at 15°C, 45°C, and 75°C angles compared to Group B (p < 0.05). Additionally, at three months and three years postoperatively, Group A showed higher IKDC scores, Lysholm scores, and ROM and lower VAS scores compared to Group B (p < 0.05).

Conclusions: Compared to the outside-in suturing approach, the all-inside suturing method for treating meniscus damage is more effective. It attenuates operative time, postoperative immobilization time, and hospital stay, ameliorates knee proprioception, promotes knee function recovery, alleviates pain, and is safe and reliable.

Aim: This study aimed to evaluate the impact of different ultrasound-guided nerve blocks on the postoperative inflammatory and stress response in elderly patients undergoing total hip arthroplasty (THA), providing a theoretical foundation for clinical application.

Methods: Elderly patients with THA who received ultrasound-guided nerve block combined with general anesthesia from June 2021 to June 2022 in the hospital were selected as a retrospective cohort study. Patients were divided into two groups based on the type of nerve block used. The observation group (n = 60) received ultrasound-guided pericapsular nerve group (PENG) block combined with femoral nerve block (FNB), while the control group (n = 60) received ultrasound-guided PENG block. The cortisol (Cor), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), visual analogue scale (VAS) scores, and pain medication consumption in both groups were compared.

Results: The observation group demonstrated significantly lower serum levels of Cor, TNF-α, and IL-6 at postoperative 1 day, 3 days and 7 days, as well as lower soluble protein-100β (S100β) levels at postoperative 1 day compared to the control group (p < 0.001). The VAS score in the observation group was significantly lower than that in the control group at postoperative 1 day, 3 days and 7 days (p < 0.001), with no significant difference in preoperative VAS score between the two groups (p > 0.05). Additionally, opioid consumption in the observation group was significantly lower than that in the control group at postoperative 48 h (p < 0.001).

Conclusions: The combination of ultrasound-guided PENG block and FNB effectively reduces postoperative pain and the inflammatory response in elderly patients undergoing THA, facilitating early recovery.

Aim: This study aimed to explore potential risk factors associated with chronic pain after total knee arthroplasty (TKA) and to establish the risk prediction model of chronic postoperative pain (CPSP).

Methods: This study retrospectively analyzed the clinical data of 160 patients who underwent TKA in our hospital between January 2021 and January 2024. Relevant data such as the baseline characteristics, past medical history, CPSP condition, and pain numerical rating scale (NRS) were retrieved from the medical information system. Logistic regression analysis was performed on the risk factors affecting the postoperative CPSP of the patients. The identified risk factors were incorporated to develop a risk-prediction model.

Results: Among the 160 patients, 67 (41.88%) had CPSP at or around the operation incision. The NRS pain score was significantly higher in the CPSP group than in the non-CPSP group during exercise preoperative and 3 months post-operation. Furthermore, the CPSP group had a higher NRS score than the non-CPSP group at rest 3 months after the procedure (p < 0.05). We observed that the preoperative NRS score, preoperative hospital for special surgery (HSS) score, postoperative functional training, and postoperative adverse events were the independent factors influencing the occurrence of CPSP after TKA (p < 0.05). Additionally, there was a significant positive correlation between preoperative NRS score, postoperative adverse events, and CPSP pain severity, and a significant negative correlation between preoperative HSS score, postoperative functional training, and CPSP pain severity (p < 0.05). The receiver operating characteristic (ROC) curve had excellent calibration and prediction capabilities for the predictive model of CPSP after TKA, with the area under the curve (AUC) of 0.868 (95% CI: 0.811-0.925).

Conclusions: In this study, the predictive model of CPSP risk for patients after TKA surgery was initially constructed, which can help medical staff predict the risk of CPSP in patients after surgery individually, thereby preventing the occurrence of CPSP.

Aim: Due to the diversity and complexity of tissues involved in secondary nasal deformities following unilateral cleft lip, secondary nasal deformity correction surgeries are challenging and often yield unsatisfactory results, posing a difficult problem for plastic surgeons. Autologous cartilage, with its low sculpting difficulty, minimal absorption, and stable tissue compatibility, is considered the optimal material for reconstructing the columella, nasal tip, and alar. This study analyzed the clinical outcomes of using autologous cartilage to create a Y-shaped columella to correct secondary nasal deformities after cleft lip surgery.

Methods: In this retrospective study, 75 patients with secondary nasal deformity after unilateral cleft lip surgery were treated from January 2018 to December 2023. Appropriate costal cartilage, auricular cartilage, and iliac crest cartilage were fashioned into Y-shaped stents and implanted into the nasal columella of the patients to strengthen the tip cartilage. The free alar cartilage was sutured and fixed with a Y-shaped bracket. The wound healing rate, subjective satisfaction evaluation, and complications were analyzed. The nasal appearance, nasal deformity classification, and objective indices of healthy and affected nasal sides, function, and quality of life were compared before and after the operation.

Results: All patients healed well during the first stage without related complications, and the average incision healing time was 5.16 ± 1.37 days. The scores of nasal tip position, nasal tip shape, nostril shape, nasal dorsum shape, and nasal floor shape at 6 months post-operation were significantly lower compared to pre-operation (p < 0.001). The grade of nasal deformity at 6 months post-operation was lower than the pre-operation (p < 0.001). Pre-operation, the nasal base and nasal width of the affected side were higher than those of the healthy side, while the nasal columellar and nostril height were lower (p < 0.001). At 6 months post-operation, the nasal base and nasal width decreased, and the nasal columellar and nostril height increased (p < 0.001), with no significant difference between the two sides (p > 0.05). The nasal obstruction symptom evaluation (NOSE) and Functional Rhinoplasty Outcome Inventory-17 (FROI-17) scores at 6 months post-operation were significantly lower than pre-operation, while the rhinoplasty outcome evaluation (ROE) score was higher (p < 0.001). The total patient satisfaction was 97.33% (73/75).

Conclusions: Y-shaped nasal columella made of autologous cartilage can effectively correct secondary nasal deformity after cleft lip surgery, improve nasal alar collapse, lengthen nasal columella, elevate nasal end, enhance the quality of life, nasal appearance, and nasal ventilation function of patients, with high satisfaction and few complications.

Aim: Surgical intervention is crucial in radical resection of renal cell carcinoma (RCC). Different surgical procedures have different oncologic outcomes and safety in patients with RCC. Therefore, we aimed to investigate the oncologic outcomes and safety of retroperitoneal laparoscopic partial nephrectomy (RLPN) versus open partial nephrectomy (OPN) in treating patients with localized RCC.

Methods: This retrospective cohort study included 160 patients with localized RCC who underwent either OPN or RLPN from January 2016 to June 2020. Out of these patients, 75 patients were treated with OPN and 85 patients were treated with RLPN. After propensity score matching, 130 patients (65 cases in each group) were finally included in the analysis. Additionally, surgical outcomes, three-year survival rates, and renal function parameters were assessed between the two groups, and the data were statistically analyzed using SPSS.

Results: Compared to the OPN group, RLPN demonstrated significantly shorter surgical time, lower estimated blood loss (p < 0.05), and lower incidence of complications (p = 0.024). In contrast, the RLPN group had significantly longer warm ischemia time (p = 0.011) than the OPN group. Furthermore, there were no significant differences in three-year overall survival, disease-free survival, cancer specific survival rates, positive surgical margins, hospitalization time between the RLPN and OPN groups (p > 0.05). The incidence of complications in the RLPN group was significantly lower than that in the OPN group (p = 0.024). Postoperatively, creatinine level was significantly lower following RLPN at one year compared to OPN (p = 0.029).

Conclusions: RLPN offers advantages in surgical time, estimated blood loss, and postoperative complications, and it positively affects postoperative renal function, while OPN shows a shorter warm ischemia time. These two approaches result in comparable three-year survival rates. This study provides valuable insights into the oncologic outcomes and safety of RLPN compared to OPN in treating localized RCC.