BJS Open最新文献

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: The relationship between surgeon volume and patient outcomes in adrenalectomy is well established in the literature and clinical guidelines. However, evidence regarding the impact of centre volume on patient outcomes remains limited. This study aimed to evaluate the effect of centre volume on patient outcomes.

Methods: This multicentre study analysed adrenalectomy procedures from the EUROCRINE® registry (2015-2024). A volume threshold was determined using receiver operating characteristic curve analysis to predict high-grade complications (Clavien-Dindo grade ≥ III). Outcomes were compared between high- and low-volume centres, and multivariable logistic regression was used to identify independent predictors of complications and death.

Results: A total of 6672 patients undergoing adrenalectomy from 99 centres across Europe were included. The optimal centre volume threshold was ≥ 36 adrenalectomies per year. Only seven centres (7%) met this threshold, accounting for 36.7% of all procedures. High-volume centres had significantly lower rates of high-grade complications (0.9 versus 2.9%; P < 0.001), conversion (2.3 versus 3.5%), and reoperation (0.7 versus 1.6%), and shorter hospital stays (median 2 versus 3 days). Multivariable analysis showed high-volume centre status to be independently protective against high-grade complications (odds ratio 0.39, 95% confidence interval 0.24 to 0.63; P < 0.001), but not postoperative mortality (odds ratio 0.69; P = 0.480). Functional benign tumours compared with malignant tumours (odds ratio 0.61, 0.39 to 0.93; P = 0.020) and minimally invasive surgery (odds ratio 0.21, 0.14 to 0.31; P < 0.001) were both associated with a significantly lower risk of high-grade complications.

Conclusion: Centre adrenalectomy volume is a key determinant of high-grade complication risk following adrenalectomy. A threshold of ≥ 36 adrenalectomies per year identifies high-performing centres. These findings support centralization of adrenal surgery to optimize outcomes and standardize care across institutions.

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.

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: 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).