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Background: Complete surgical resection (R0 resection) is crucial for overall and disease-free survival in patients with pancreatic cancer undergoing curative surgery. The radical antegrade modular pancreatosplenectomy (RAMPS) procedure was developed to increase achievement of R0 resection margins for tumour resections of the pancreatic body and tail. By extending the posterior dissection plane, a more radical surgical resection can be achieved, as this is the most frequent site of positive margins in conventional left pancreatectomy. RAMPS includes a standardized lymph node dissection and early control of the splenic vessels. Feasibility and safety have already been demonstrated and retrospective studies have shown promising results regarding higher proportions of R0 resection and lymph node counts. To date, high-quality evidence from randomized clinical trials investigating the oncological benefit of RAMPS (that is, resection margin status, disease-free and overall survival) for this patient cohort is lacking.

Methods: The RAMPS trial is a multicentre, randomized clinical, patient and assessor-blinded, confirmatory, superiority trial. In all, 122 patients with an indication for left pancreatectomy due to malignancy of the pancreatic body or tail will be required in each study arm to achieve 80% power at a significance level of 0.025; patients will be randomized to either the RAMPS approach or conventional left pancreatectomy in a 1 : 1 ratio. Patients will be recruited over a 30-month enrolment period. The primary outcome will be the achievement of R0 resections. Secondary outcomes include survival and surgical, functional, and patient-reported outcomes with a 3-year follow-up.

Conclusion: The primary objective of the RAMPS trial is to demonstrate the superiority of the RAMPS approach over standard left pancreatectomy in improving the achievement of R0 resection and, consequently, long-term oncological patient outcomes. RAMPS could be established as the new surgical standard for tumour resection in patients with pancreatic cancer in the body or tail of the pancreas. Registration number: DRKS00033031 (https://www.bfarm.de/EN/BfArM/Tasks/German-Clinical-Trials-Register/_node.html).

Background: The optimal neoadjuvant strategy for high-risk locally advanced rectal cancer (LARC) remains a matter of debate. This study evaluated the efficacy and safety of neoadjuvant FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, irinotecan) plus bevacizumab without radiotherapy in patients with magnetic resonance imaging-defined high-risk LARC.

Methods: A prospective, multicentre, single arm phase II trial was conducted in four Japanese Institutions between 2018 and 2024, enrolling patients with rectal adenocarcinoma and at least one high-risk criterion: clinical T4, lateral pelvic lymph node metastasis, mesorectal fascia involvement, or positive extramural vascular invasion. Patients received four cycles of FOLFOXIRI plus bevacizumab, followed by two cycles of FOLFOXIRI alone, before total mesorectal excision. The primary endpoint was pathological complete response (pCR); secondary endpoints included the R0 resection rate, local recurrence (LR), recurrence-free survival (RFS), overall survival (OS), and safety.

Results: OF 50 eligible patients, 31 were enrolled before early trial closure due to a slow accrual (accrual rate 62%). All patients underwent surgery. The pCR rate was 10% (3 of 31) and R0 resection was achieved in 97% (30 of 31) of patients. The median follow-up was 36.7 months. The 3-year cumulative LR rate was 3%, with 3-year RFS and OS rates of 73 and 81%, respectively. Grade ≥ 3 neutropenia occurred in 29% of patients, with acceptable toxicity overall. No cases of gastrointestinal perforation were observed. Grade ≥ III postoperative complications occurred in seven patients (23%), with the most frequent events being anastomotic leakage in two patients (7%).

Conclusions: In this phase II trial, although recruitment was suboptimal, neoadjuvant FOLFOXIRI plus bevacizumab achieved good local control without radiotherapy in patients with high-risk LARC. Although the pCR rate was modest compared with radiotherapy-based regimens, this chemotherapy-only approach may represent a reasonable option for select patients who are not suitable candidates for pelvic radiotherapy. Registration number: UMIN000037367 (https://www.umin.ac.jp/english/).

Background: Enhanced recovery after surgery is associated with improved clinical outcomes and cost savings. Comparisons between studies and settings are challenging owing to variable data collection and definitions. The objective of this study was to explore variation in compliance with enhanced recovery after surgery and outcomes across surgery types and countries using a standardized database.

Methods: This international retrospective cohort study included adult patients who underwent surgical procedures (colorectal, gynaecological, pancreatic, hepatic, breast reconstruction, head and neck, urological, pulmonary), treated with enhanced recovery after surgery recorded in a standardized database between January 2017 and September 2021. The primary outcomes, length of hospital stay and complications, and the exposure variable, compliance with enhanced recovery after surgery, were captured from the standardized database. Patient demographic characteristics and surgical complexity were abstracted and considered as co-variates. Negative binomial and logistic regression analyses were used to model outcomes as a function of enhanced recovery after surgery compliance score.

Results: The cohort included 12 134 patients (from Canada, the Netherlands, and Switzerland) who had median age of 63 years and underwent colorectal (59%) or gynaecological (19%) surgery. The median compliance with enhanced recovery after surgery differed by country (Canada 78.6%, the Netherlands 67.7%, Switzerland 80.0%). Each 1-unit increase in enhanced recovery after surgery compliance score corresponded to reduced length of hospital stay across all operations, by 0.94 (95% confidence interval (c.i.) 0.85 to 1.04) days in Canada, 1.03 (0.85 to 1.20) days in the Netherlands, and 1.55 (1.12 to 1.97) days in Switzerland. Each 1-unit increase in enhanced recovery after surgery compliance score corresponded to a 29 (95% c.i. 25 to 33)% reduction in odds of experiencing a severe complication across all operations in Canada, a 22 (14 to 31)% reduction in the Netherlands, and a 5 (2 to 8)% reduction in Switzerland.

Conclusion: Using a standardized database, this study confirmed that enhanced recovery after surgery compliance is associated with reduced length of hospital stay and complications in an international multisurgical cohort.

Background: The Swedish National Board of Health and Welfare centralized the surgical care of patients with anorectal malformations from four to two centres in 2018. This retrospective review compares short-term complications after anorectal reconstruction before and after centralization.

Methods: Hospital records of all infants in Sweden who underwent reconstruction of an anorectal malformation between 1 July 2013 and 30 June 2023 were reviewed and divided in two 5-year periods: before and after centralization. The main outcomes were unplanned readmissions and surgical procedures requiring general anaesthesia up to 90 days after reconstruction, as well as early complications classified according to the Clavien-Madadi system up to 30 days after the procedure.

Results: Before centralization, 173 infants underwent anorectal reconstruction, compared with 176 infants after centralization. Patient groups were comparable with respect to associated malformations and type of anorectal malformation. Before centralization, 80 infants (46.2%) had a colostomy before the anorectal reconstruction, compared with 89 infants (50.6%) after centralization (P = 0.454). Anorectal reconstruction was performed at a median age of 61 and 47 days of age before and after centralization, respectively (P = 0.794). Unplanned readmissions up to 90 days after anorectal reconstruction were needed in 12 infants (6.9%) before centralization, compared with 22 infants (12.5%) after centralization (P = 0.104). Unplanned surgical procedures under general anaesthesia were required in 20 (11.6%) and 22 (12.5%) infants before and after centralization, respectively (P = 0.870). Complications (Clavien-Madadi grade III-V) within 30 days after anorectal reconstruction were seen in 16 (9.2%) and 12 (6.8%) infants before and after centralization, respectively (P = 0.436).

Conclusion: Centralization of the surgical care of patients with anorectal malformations in Sweden did not seem to have an impact on short-term complications.

Background: Recent Brescia guidelines suggest proficiency in robotic left-sided pancreatectomy (RLP) occurs after the first 21 cases (competency phase). This study reports textbook outcome (TO) rates in the competency and proficiency phases following RLP, and predictors of achieving TO.

Methods: A retrospective cohort study of all RLP procedures from six UK centres was undertaken from July 2014 to August 2024. TO was defined as a composite of hospital length of stay, major morbidity, in-hospital mortality, 90-day readmission, and clinically relevant postoperative pancreatic fistula (CR-POPF). Multivariable logistic regression analysis was used to model predictors of TO.

Results: In all, 281 patients underwent RLP. The median number of laparoscopic left-sided pancreatectomies undertaken before starting the RLP programme was 70 (interquartile range 40-175) per centre. In all, 109 patients underwent RLP in the competency phase and 172 underwent RLP in the proficiency phase; TO was achieved in 57 patients (52.3%) and 86 patients (50.0%), respectively (P = 0.801). Major morbidity occurred in 38 patients (13.5%), 68 patients were readmitted within 90 days (24.2%), and 57 patients had CR-POPF (20.3%). Patients in the proficiency phase had a longer operating time (315 versus 230 minutes; P < 0.0001), a lower rate of splenic preservation (23 versus 27; P = 0.023), and a lower rate of vascular infiltration (12 versus 22; P = 0.002) than patients in the competency phase. TO was less likely with a prolonged operation time (odds ratio 0.82 per hour; 95% c.i. 0.70 to 0.95; P = 0.010) with a non-linear trend noted.

Conclusion: TO after RLP was achieved in half the resected patients in this UK series. There was no difference in the TO rate between the competency and proficiency phases, and previous experience with laparoscopic left-sided pancreatectomy may have contributed to this.

Background: This study aimed to compare the accuracy of the Comprehensive Complication Index (CCI) with that of the Clavien-Dindo classification in patients undergoing pancreatoduodenectomy.

Methods: A two-centre, retrospective study was undertaken that included patients who underwent pancreatoduodenectomy between 2008 and 2022. Three approaches were used to assess the two complication scores: the Spearman rank test, yielding the correlation coefficient (r), the area under the curve with 95% confidence intervals, and a mixed-effects model and a generalized mixed-effects model that yielded odds ratios and β-coefficients.

Results: A total of 596 patients were included. The CCI and Clavien-Dindo classification demonstrated no correlation with 90-day mortality (r = - 0.021, 0.618; and r = -0.003, P = 0.951) but a significant correlation with length of hospital stay (r = 0.620, P < 0.001; and r = 0.605, P < 0.001) and with 90-day readmission rate (r = 0.148, P < 0.001; and r = 0.120, P = 0.005). The accuracy of the CCI was superior to that of the Clavien-Dindo classification for length of hospital stay dichotomized at the 75th (P = 0.022) and 90th (P < 0.001) percentiles. The CCI significantly improved the effect of the Clavien-Dindo classification (random effect, P < 0.001) in the mixed-effects and generalized mixed-effects logistic regression analyses.

Conclusion: Compared with the Clavien-Dindo classification, the CCI appeared to be more accurate in terms of its association with a prolonged hospital stay and 90-day readmission rate. The CCI should complement the Clavien-Dindo classification in clinical and research settings.

Background: Malignant bowel obstruction in patients with stage IV gastrointestinal cancer represents a challenging scenario, with a lack of patient-centred outcome data to guide decisions. This study evaluated the association between days at home, and malignant bowel obstruction palliation treatment strategy in this subgroup of patients.

Methods: This population-based retrospective cohort study included adults with stage IV gastrointestinal cancer admitted for malignant bowel obstruction between 2010 and 2019. Patients with stage IV gastrointestinal cancer treated with curative intent were excluded. The primary exposure was treatment strategy at first admission with malignant bowel obstruction divided into surgical, procedural (percutaneous or endoscopic), and supportive care. The primary outcome of interest was days at home over 90 days. Multivariable quantile regression was used to evaluate the association between treatment strategy and days at home over 90 days adjusted for cancer and patient factors. Quantile plots were used to examine this association across the distribution of days at home over 90 days.

Results: Of 12 923 patients admitted, 4642 were selected: 2076 (44.7%) received surgical, 310 (6.7%) procedural, and 2256 (48.6%) supportive care. Those who had surgical treatment had the highest median days at home over 90 days of 67 (interquartile range 23-80) days, followed 45 (7-78) days with procedural treatment, and 31 (0-76) days with supportive care. After adjusting for patient and cancer factors, surgical treatment was associated with an increase in median days at home over 90 days of 20 (95% confidence interval 15-24) days and procedural treatment with an increase of 14 (6-22) days. The directionality of these findings was stable across the distribution of days at home over 90 days, and stable in sensitivity analysis after exclusion of deaths.

Conclusion: Surgical and procedural treatment were associated with increased days at home over 90 days. These findings can support decision-making and expectation setting in patients eligible for surgical and procedural treatments.

Background: Chyle leak is a significant complication after pancreatic resection, associated with increased morbidity and mortality. Data on its incidence, risk factors, and treatment are inconsistent. Robotic pancreatic resections are increasingly performed and assumed to be associated with fewer complications than open surgery. This study evaluated the incidence, risk factors, and therapeutic strategies for chyle leak after both open and robotic pancreatic surgery.

Methods: A scoping literature review was conducted across multiple databases to identify studies that included patients who underwent open or robotic pancreatic resection and experienced chyle leak as defined by the International Study Group on Pancreatic Surgery. The search period extended from database inception until 27 August 2025.

Results: In all, 58 studies published between 2007 and 2025 (30 039 patients) were included in the analysis. The pooled incidence of chyle leak after pancreatic resection was 8.0%. Procedure-specific pooled incidences of chyle leak were 9.5% after partial pancreatoduodenectomy, 8.4% after pylorus-preserving pancreatoduodenectomy, 6.9% after distal pancreatectomy, 1.7% after enucleation, and 6.2% after total pancreatectomy. In seven comparative studies (6339 patients), the pooled incidence of chyle leak was 10% after robotic pancreatoduodenectomy and 12% after open pancreatoduodenectomy.

Conclusion: Chyle leak is an important complication following pancreatic resection. Despite advances in surgical techniques, the risk remains substantial, with no clinically significant difference in the rate of chyle leak between robotic and open pancreatoduodenectomy resections.