BJS Open最新文献

Background: Achalasia is rare disease in children and young people (CYP) that causes significant symptoms and often requires invasive interventions. There is currently no consensus on the optimal management strategy. This study investigated the current management and outcomes of CYP with achalasia in the UK.

Methods: A retrospective study was conducted of CYP (aged ≤ 16 years) diagnosed with achalasia between 2011 and 2021 in the UK. The study was co-designed with the patient group Achalasia Action. Data were collected from patient records. The primary outcome was treatment success.

Results: In all, 126 patients were included from 13 UK centres; 64 of the patients (50.8%) were male and the median age at diagnosis was 12 (interquartile range (i.q.r.) 9-14) years. The most frequent presenting features were dysphagia (73.8%), vomiting (53.2%), and weight loss (38.9%). The median time from symptom onset to diagnosis was 11 (i.q.r. 6-24) months. Treatment success was achieved in 55 of 120 patients (45.8%) after first-line intervention. Heller's cardiomyotomy (HCM) as the first-line intervention had a higher success rate than endoscopic balloon dilatation (EBD; (52 of 72 (72%) versus 3 of 48 (6%), respectively; P < 0.001). However, overall HCM had a higher frequency of complications than EBD (17 of 98 (17%) versus 3 of 57 (5%), respectively; P = 0.045). In the entire cohort, 53% of patients reported symptoms at the 1-year follow-up.

Conclusions: Variation exists in the management of CYP with achalasia in the UK. The highest rates of treatment success were associated with HCM. Many CYP remain symptomatic after treatment and require multiple interventions. The present data can be used to inform management decisions in CYP with achalasia.

Background: Postoperative mortality is a key indicator of surgical quality and central to volume-outcome research, which has shaped minimum case volume standards. In Switzerland, evidence for gastric cancer surgery outcomes remains limited, and regulation is still debated. This study analysed nationwide perioperative volume-outcome associations.

Methods: The study comprised an analysis of the inpatient database from the Swiss Federal Statistical Office. Patients undergoing surgical or endoscopic resection for gastric cancer between 1998 and 2021 were included. Data were stratified by surgical caseload (quartiles), hospital inpatient volume, and hospital type. Outcomes included in-hospital mortality, failure to rescue, and perioperative morbidity.

Results: Some 8708 patients from over 30 million hospital admissions were included. The annual resection volume increased from 290 in 2000 to 432 in 2020. The overall in-hospital mortality rate was 3.9%, with an inverse association with surgical caseload (2.2% in centres performing > 20 resections annually versus 2.8, 4.2, and 4.6% in lower-volume quartiles; P = 0.001). Similar correlations were observed for hospitals with > 35 000 inpatient admissions annually (2.3 versus 3.6 and 4.7%; P < 0.001) and for university hospitals (2.0 versus 4.2 and 4.3%; P < 0.001). Although the reported proportion of severe complications was higher, the rate of failure to rescue was lower in hospitals with high inpatient volumes (P < 0.001) and in university hospitals (P = 0.002).

Conclusion: The findings of lower rates of in-hospital mortality and failure to rescue in hospitals with higher surgical and inpatient volumes support the potential value of centralization in gastric cancer surgery, and may guide future discussions on regulation.

Background: Robot-assisted surgery (RAS) is increasingly being used, yet its cost-effectiveness remains debated. Cost analyses of RAS are therefore essential but remain challenging. This systematic review evaluated the quality of cost analyses in randomized clinical trials (RCTs) comparing RAS with alternative surgical approaches.

Methods: A systematic review was performed in PubMed, EMBASE, Cochrane Library, and Web of Science from inception up to August 2025. RCTs were included if they compared RAS with other approaches and conducted a cost analysis. Risk of bias was assessed using the revised Cochrane Risk-of-Bias tool. The methodological quality and comprehensiveness of cost analyses were evaluated with the Economic Evaluation Bias Assessment Tool (ECOBIAS) and Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, respectively. Studies were evaluated for key structural and component-specific costs of RAS.

Results: Overall, 38 RCTs involving 5832 patients were included. Most studies focused on general surgical procedures (20 RCTs, 53%), followed by urology (7), gynaecology (7), and cardiothoracic surgery (4). RAS was compared with laparoscopic surgery in 23 RCTs, open surgery in 14 RCTs, and another robotic modality in one RCT. Regarding bias, 10 RCTs (26%) were considered high risk, and 24 (63%) had some concerns. On average, RCTs met 5 of 11 ECOBIAS criteria and 14 of 28 CHEERS items. Only 15 of 38 RCTs (39%) included key structural costs of RAS, such as robot acquisition and maintenance, whereas 12 of 38 RCTs (32%) provided a component-specific cost overview. RAS was more expensive in 33 of 36 RCTs (92%).

Conclusion: Randomized trials comparing RAS with other surgical approaches rarely perform adequate cost assessments and cost-effectiveness analyses. The substantial risk of bias, methodological heterogeneity, and partial cost reporting observed underline the need for uniform economic evaluation in RCTs on RAS. Registration number: CRD42024520677 (https://www.crd.york.ac.uk/prospero/).

Background: Multimodal prehabilitation has the potential to reduce complications, shorten hospital stays, and decrease healthcare resource utilization. However, its impact on patient-centred outcomes, such as patient reported-outcomes, has been less extensively studied. This study assessed the effect of multimodal prehabilitation on patient-perceived quality of recovery following elective surgery.

Methods: This was a prospective cohort study of patients undergoing elective gastrointestinal surgery between 1 February 2024 and 28 February 2025 who met institutional criteria for prehabilitation. Outcomes, including comparing postoperative complications, length of hospital stay, and perceived recovery, were compared between patients who completed the prehabilitation program and those who did not (control cohort). The primary outcome measure was the Quality of Recovery-15 (QoR-15) questionnaire score.

Results: In all, 188 patients were included in the study. The 94 patients who completed the prehabilitation program over a mean(standard deviation) of 4.5(1.6) weeks had fewer postoperative complications per patient than did patients in the control group (mean(standard deviation) 1.0(1.4) versus 1.4(1.4); P = 0.008). In addition, mean(standard deviation) QoR-15 scores were significantly higher in the prehabilitation than control group at baseline (129.5(15.0) versus 122.9(17.0); P = 0.003), discharge (117.2(14.0) versus 106.8(15.0); P < 0.001), and 30 days after discharge (128.2(16.0) versus 118.5(14.0); P < 0.001). At 30 days after discharge, 66% of patients in the prehabilitation group had recovered all three pre-identified essential activities, compared with 35% in the control group (P = 0.001).

Conclusions: The findings suggest that prehabilitation not only reduces postoperative morbidity and facilitates physical recovery but also enhances patients' subjective experience of recovery throughout the surgical journey, supporting its integration into routine perioperative care for digestive surgery.

Background: Intraoperative neuromonitoring-that is, recording of electromyographic signals-is used routinely during (para)thyroid surgery. Surgeons label selected signals to document nerve identity, body side, and time point of stimulation (before or after resection), with a mislabelling rate of 20%. For the purpose of an automated error alert of mislabelled electromyographic signals, the authors developed a multitask one-dimensional convolutional neural network.

Methods: Raw intraoperative neuromonitoring data were corrected using MIONQA software. Labelled electromyographic signals were extracted and metadata (duration of surgery, timing, median electromyographic peak values of actual surgery) were added to each electromyographic wave. Between 150 and 280 extracted features were used to train, validate, and test various convolutional neural networks.

Results: Available raw data from a single centre including 1541 operations with continuous intraoperative nerve monitoring and 508 with intermittent intraoperative nerve monitoring between 2014 and 2024 were used. By repeated adjustments of the model architecture and the number of extracted features, an optimized one-dimensional convolutional neural network was designed. After multiple runs with randomized training (11 414 electromyograms) and test (4891) data, the final optimized convolutional neural network achieved a mean(standard deviation) accuracy of 95.72(0.76)% for correct identification of recurrent laryngeal, vagal, and superior laryngeal nerves; 97.68(0.72)% for correct prediction of the resected body side; and 97.61(0.89)% for correct identification of the stimulation time point (before versus after resection). The receiver operating characteristic curve for classification of the electromyographic peak signals had an excellent area under the curve of 0.993.

Conclusion: The newly developed convolutional neural network enables accurate automated classification of electromyographic peak signals, facilitating the identification and correction of mislabelled intraoperative nerve monitoring data. Such optimized data quality is essential for artificial intelligence training, enabling neuromonitoring machines to alert the surgeon in the operating theatre of mislabelling. Future studies will aim to include a wider range of clinical scenarios and external data sets, in order to further optimize the existing labelling tool and allow clinical applications.

Background: The incidence of colorectal cancer is increasing, and the liver remains the predominant site for metastases. Whereas liver resection is the standard treatment for colorectal liver metastases (CRLMs), liver transplantation (LT) has re-emerged as a viable option for selected patients. The aim of this study was to investigate whether tumour volume and changes in tumour volume during chemotherapy before transplantation predict overall survival.

Methods: Patients who underwent LT for CRLMs between November 2006 and August 2020 were included. Tumour volumes were measured via manual segmentation on computerized tomography scans at baseline, at maximum tumour volume, and immediately before LT. Response to chemotherapy was assessed using Response Evaluation Criteria in Solid Tumours (RECIST) criteria, and the heterogeneous response was noted to investigate whether this subgroup performs differently. Receiver operating characteristic analysis was conducted to determine a tumour volume cut-off value for predicting overall survival. Overall survival between groups was compared using Kaplan-Meier curves and log rank test.

Results: Fifty-nine patients who underwent LT for CRLMs were analysed retrospectively. Receiver operating characteristic analysis revealed that final tumour volume at time of LT was a strong predictor of 5-year overall survival (area under the curve= 0.789), with a 35 mL cut-off providing optimal clinical discrimination. Patients achieving a final tumour volume below 35 mL, either consistently or via downstaging, demonstrated significantly improved survival compared with those with persistently high tumour volumes (4.54 years versus 2.17 years; P < 0.001). Heterogeneous responses to chemotherapy were associated with poorer prognosis with no patients surviving beyond 2.16 years (P < 0.001).

Conclusion: Dynamic tumour assessment, particularly measuring tumour volume to below 35 mL, is an important prognostic marker in LT for CRLMs.