BJS Open最新文献

Background: Nipple-sparing mastectomy (NSM) is a surgical option offering both oncological safety and cosmetic benefits. However, the oncological safety of NSM in carriers of BRCA1/2 pathogenic variants/likely pathogenic variants (PV/LPV) with breast cancer and the role of risk-reducing mastectomy remain underexplored, especially in Asian populations. This study evaluated the safety and effectiveness of NSM in BRCA1/2 PV/LPV carriers and assessed the preventive impact of contralateral risk-reducing NSM (RRNSM) on cancer incidence.

Methods: This multicentre retrospective study included women aged 20-80 years who underwent NSM for therapeutic or risk-reducing purposes and received germline BRCA1/2 tests between May 2006 and June 2022 across 19 institutions in Korea. Patients with distant metastasis at diagnosis were excluded. Information on demographics, the clinical characteristics of patients and tumours, surgical details, and follow-up outcomes was collected from a review the medical records of each participating institution. The primary outcome was the oncological safety of NSM, assessed by comparing ipsilateral local recurrence rates between patients with and without BRCA1/2 PV/LPV. The secondary outcome was cancer incidence in patients who underwent contralateral RRNSM versus those who did not.

Results: In all, 787 women underwent 906 NSMs, with a median (interquartile range) follow-up of 59.3 (44.0-82.8) months. Among the participants, 186 (23.6%) were BRCA1/2 PV/LPV carriers. Ipsilateral local recurrence rates were comparable between BRCA1/2 PV/LPV carriers and non-carriers (6.4 versus 7.4%, respectively). The 5-year local recurrence-free survival rates did not differ significantly between BRCA1/2 PV/LPV carriers and non-carriers (92.2% versus 93.2%, respectively; P = 0.87). Contralateral breast cancer occurred in 4.5% of patients with BRCA1/2 PV/LPV who did not undergo contralateral RRNSM, whereas no cases of contralateral breast cancer were reported among patients who underwent RRNSM regardless of BRCA1/2 status.

Conclusions: This study highlights NSM as a safe and effective surgical option for BRCA1/2 PV/LPV carriers with breast cancer, as well as a risk-reducing strategy. Further prospective studies are needed to confirm these findings and evaluate long-term outcomes.

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: Extremity trauma is a common and significant injury sustained by military and civilian casualties of war. Civilian management has evolved, adopting a multidisciplinary orthoplastics approach. Accurate and timely management of open fractures and complex war wounds is required to minimize complications and optimize outcomes. The Lower Limb Debridement for Operations Working Group is part of the UK Defence Medical Services and aimed to provide updated guidelines to support deployed surgeons, given the modern nature of conflict.

Methods: The working group formed a panel of military consultants (attendings) in Trauma and Orthopaedics and Plastics and Reconstructive Surgery. The literature was systematically reviewed for new evidence. A modified Delphi technique was adopted, and an initial survey was circulated to the working group to gain its opinion on current guidance. Responses were used by the steering group chairs to formulate updated guidance on combat wound management. A consensus meeting with consultants (attendings) was then used to agree the final guidance.

Results: Eight previous recommendations were removed and 21 new recommendations were formed, providing updated guidelines. Recommendations relate to timing, location, and technique of wound excision including irrigation and requirements for wound closure.

Conclusions: Civilian and military combat casualties require well prepared surgeons and evidence-based guidance to save life and limb. These recommendations represent a consensus, utilizing up-to-date literature and expert opinions of both orthopaedic and plastic surgeons. In large-scale combat operations, NHS surgeons working in the UK may be required to treat large numbers of patients repatriated from conflict. These guidelines may form a useful part of their preparation.

Background: Emerging evidence supports axillary de-escalation in patients with clinically node-positive breast cancer with low-volume residual disease following neoadjuvant chemotherapy, avoiding axillary node clearance in selected patients. Targeted axillary dissection, which retrieves a known metastatic, clipped node alongside standard sentinel node biopsy aims to reduce false-negative rates. This study evaluated axillary surgery after neoadjuvant chemotherapy across NHS Greater Glasgow and Clyde, and examined 10-year trends.

Methods: Patients with node-positive breast cancer receiving neoadjuvant chemotherapy between 2017 and 2024 were identified from multidisciplinary team records. Clinicopathological and surgical data were collected. Outcomes were compared using χ2 tests and logistic regression. Additional data from 2015-2016 were extracted from the Regional Cancer Registry.

Results: Of 498 patients, primary axillary surgery included Magseed®-localized targeted axillary dissection (27.5%), wire-localized targeted axillary dissection (0.4%), non-localized targeted axillary dissection (7.0%), sentinel node biopsy (14.3%), and axillary node clearance (50.8%). The clipped node retrieval rate was 100% with Magseed®-localized and 91.4% with non-localized targeted axillary dissection; sentinel node concordance rates were 85.8 and 66.7%, respectively. Completion axillary node clearance was undertaken in 27 patients (11.0%) and was associated with an increased risk of complications including seroma, restricted shoulder movement, and wound infection, compared with de-escalated surgery (odds ratio (OR) 2.88, 95% confidence interval (CI) 1.28 to 6.49; P = 0.011) and upfront axillary node clearance (OR 1.86, 95% CI 1.27 to 2.72; P = 0.001). Use of axillary de-escalation increased over 10 years, surpassing 50% recently (χ²(4) = 25.3, P < 0.001).

Conclusion: Targeted axillary dissection enables safe de-escalation of axillary surgery in patients with low-volume residual disease. Localization enhances clipped node retrieval. Completion axillary node clearance carries higher morbidity, reinforcing the need for careful patient selection.

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.

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.