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Background: A real-time deep learning system was developed to identify the extrahepatic bile ducts during indocyanine green fluorescence-guided laparoscopic cholecystectomy.

Methods: Two expert surgeons annotated surgical videos from 113 patients and six class structures. YOLOv7, a real-time object detection model that enhances speed and accuracy in identifying and localizing objects within images, was trained for structures identification. To evaluate the model's performance, single-frame and short video clip validations were used. The primary outcomes were average precision and mean average precision in single-frame validation. Secondary outcomes were accuracy and other metrics in short video clip validations. An intraoperative prototype was developed for the verification experiments.

Results: A total of 3993 images were extracted to train the YOLOv7 model. In single-frame validation, all classes' mean average precision was 0.846, and average precision for the common bile duct and cystic duct was 0.864 and 0.698 respectively. The model was trained to detect six different classes of objects and exhibited the best overall performance, with an accuracy of 94.39% for the common bile duct and 84.97% for the cystic duct in video clip validation.

Conclusion: This model could potentially assist surgeons in identifying the critical landmarks during laparoscopic cholecystectomy, thereby minimizing the risk of bile duct injuries.

Background: Anastomotic leakage is a feared complication after colorectal resection. Recent advancements in surgical techniques, particularly the use of circular staplers, have aimed to improve postoperative outcomes. However, the optimal choice of circular stapler remains uncertain, with debate surrounding its impact on anastomotic leakage rates. The aim of this meta-analysis was to evaluate the impact of different circular stapler characteristics on anastomotic leakage occurrence after left colorectal resection.

Methods: A systematic review and meta-analysis using PubMed, Scopus, and Web of Science databases to identify studies on the correlation between circular staplers and anastomotic leakage occurrence were performed up to November 2023 (PROSPERO registration: CRD42024519036). The literature search was conducted according to the PRISMA guidelines and performed using the following search terms: 'colorectal surgery', 'staplers', 'complications'. Only retrospective, cohort, prospective and randomized clinical trials on anastomotic leakage rate after left colorectal resection, including adult patients (over 18 years of age) and published in English were included. Exclusion criteria were articles with different designs, and studies including extra-colonic or right/transverse colon diseases. The quality assessment of the study was performed using the Newcastle-Ottawa classification. The outcome of interest was the analysis of each staplers' characteristics including: diameter, number of rows, technology (manual versus powered) and anastomotic technique (single- versus double-stapling technique) on anastomotic leakage occurrence.

Results: Twenty-one retrospective studies were selected including 24 511 patients. A higher anastomotic leakage rate was documented for 31/33 mm stapler diameters compared with the 28/29 mm (OR -0.92, 95% c.i. -1.74 to -0.10; P = 0.02), while no significant difference was found between the 25 mm and 28/29 mm diameters (OR -0.46, 95% c.i. -1.39 to 0.46; P = 0.2). Similar anastomotic leakage rates were found for the two- and three-row circular stapler groups (OR -0.01, 95% c.i. -0.16 to 0.13; P = 0.85). Conversely, the powered technology related to a significantly lower rate of anastomotic leakage compared with the manual technology (OR -0.83, 95% c.i. -1.13 to -0.35; P < 0.001). Similarly, the single-stapling technique related to a lower rate of anastomotic leakage compared with the double-stapling technique (OR 0.79, 95% c.i. 0.33 to 1.25; P < 0.001).

Conclusion: This study shows a higher anastomotic leakage rate for larger circular staplers and manual technology. Similarly, the single-stapling technique has advantages over the double-stapling technique, while the tri-staple technology does not appear to confer advantages on anastomotic leakage occurrence.

Background: Evidence-based medicine relies on randomized clinical trials, which should represent the patients encountered in clinical practice. Characteristics of patients recruited to randomized clinical trials involving vascular index operations (carotid endarterectomy, abdominal aortic aneurysm repair, infrainguinal bypass and major lower limb amputations) were compared with those recorded in the National Vascular Registry across England and Wales.

Methods: MEDLINE, Embase, Web of Science, CENTRAL, clinicaltrials.gov and World Health Organization International Trials Registry Platform (CRD42021247905) were searched for randomized clinical trials involving the index operations. Demographic (age, sex, ethnicity) and clinical (co-morbidities, medications, body mass index, smoking, alcohol, cognition) data were extracted, by operation. Characteristics of operated on patients were extracted from publicly available National Vascular Registry reports (2014-2020). All findings are reported according to PRISMA guidelines. Rayyan.AI, Excel and GraphPad Prism were used for screening and analysis.

Results: A total of 307 randomized clinical trials (66 449 patients) were included and compared with National Vascular Registry data for 119 019 patients. Randomized clinical trial patients were younger across all operations; for carotid endarterectomy, bypass and major lower limb amputation randomized clinical trials, there were differences in female patient representation. Further comparisons were limited by the insufficient baseline data reporting across randomized clinical trials, though reporting improved over decades. National Vascular Registry reports lacked information on patient factors such as patient ethnicity or body mass index.

Conclusions: There are significant differences in demographic and clinical factors between patients recruited to vascular surgery randomized clinical trials and the real-world National Vascular Registry vascular surgery patient population. Minimum reporting standards for baseline data should be defined to allow future randomized clinical trials to represent real-world patient populations and ensure the external validity of their results.

Background: Resection outcomes for perihilar cholangiocarcinoma differ between Western and Eastern centres, but reasons behind these disparities remain unclear. This study aimed to compare current outcomes between a Western and an Eastern expert centre to identify prognostic factors.

Methods: Patients who underwent hepatobiliary resection for perihilar cholangiocarcinoma between 2010 and 2022 at Karolinska University Hospital (Stockholm, Sweden) and Cancer Institute Hospital (Tokyo, Japan) were retrospectively included. Primary outcome was overall survival. Secondary outcomes were disease-free survival, postoperative complications and 90-day mortality rate.

Results: Two hundred and forty-nine patients were included (Cancer Institute Hospital n = 159, Karolinska n = 90). Median overall survival was 20.4 months at Karolinska and 52.0 months at Cancer Institute Hospital (P < 0.001). Median disease-free survival was 11.9 months at Karolinska and 32.4 months at Cancer Institute Hospital (P < 0.001). Advanced tumours, ASA class ≥III, poor differentiation and radial margin positivity were more common in the Western cohort. Treatment centre, T-status, N1-status, resection side, R1-status, age and carbohydrate antigen 19-9 were prognostic for overall survival. The Eastern cohort had a lower rate of postoperative complications (24.5%) and a lower mortality rate (2.5%) compared with the Western cohort (51.1% and 10.0%).

Conclusion: Advanced tumour stage and radial margin positivity contributed to poor long-term survival in the Western cohort. A higher burden of co-morbidity and a higher rate of extended resections with smaller remnant liver volume influenced the Western postoperative mortality rate.

Background: Acute Stanford type A aortic dissection is a severe emergency condition that, if left untreated, is associated with a high mortality rate. The extent of surgical repair may impact the outcomes of these patients.

Method: Patients operated for acute type A aortic dissection from a multicentre European registry were included. Patients were categorized based on the following types of surgical intervention: isolated ascending aortic replacement, ascending aortic replacement with concomitant aortic valve replacement, aortic root replacement, partial or total arch replacement, and partial or total arch replacement with concomitant aortic root replacement. The primary outcome was mortality rate, both in-hospital and at 10 years. Secondary outcomes were acute kidney injury requiring dialysis, neurological complications, a composite endpoint including in-hospital death, neurological complications and/or dialysis, and proximal endovascular or surgical aortic re-operations at 10 years.

Results: 3702 patients were included. The adjusted risk of in-hospital mortality was higher in all subsets of patients compared to those who underwent isolated ascending aortic replacement. The adjusted rates of in-hospital mortality ranged from 16.4% (95% c.i. 15.3 to 17.4) among patients who underwent isolated ascending aortic replacement to 27.7% (95% c.i. 23.3 to 31.2) among those who underwent aortic arch and concomitant aortic root replacement. The adjusted risks of neurological complications, renal replacement therapy and of the composite endpoint were significantly higher in patients who underwent partial/total aortic arch replacement. The adjusted risk estimates of 10-year mortality rate were markedly higher in patients who underwent partial/total aortic arch replacement with or without concomitant aortic root replacement. Extensive aortic repair did not significantly reduce the risk of distal or proximal aortic reoperations.

Conclusion: These findings suggest that, when feasible, limiting the extent of aortic replacement for acute type A aortic dissection may be beneficial in reducing mortality rate and major complications both in the short and long term.

Trial registration: ClinicalTrials.gov identifier: NCT04831073.