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Background: There has been an increasing number of single-centre studies describing the long-term outcomes of patients with Hirschsprung disease. This study aimed to systematically review the literature on long-term bowel, urological, and sexual functional outcomes, fertility and quality of life in adults with Hirschsprung disease.

Methods: A PROSPERO-registered systematic review of the English literature was conducted for studies published up to July 2025 that reported functional outcomes beyond childhood (≥16 years) for patients who had undergone surgery for Hirschsprung disease. Centres were contacted individually for secondary analyses of patient-level data on bowel function score, Gastrointestinal Quality of Life Index, and Short Form 36 questionnaire. Data were analysed and compared with those from healthy controls in the studies retrieved and from a reference healthy population. Hirschsprung disease clinical and surgical variables were correlated with these outcomes of interest in a patient-level analysis.

Results: Fifty-three manuscripts fulfilled the inclusion criteria of 4277 papers retrieved. Patients with Hirschsprung disease had a greater likelihood of constipation (odds ratio 9.27, 95% confidence interval (c.i.) 4.78 to 18.06) and soiling (odds ratio 2.76, 1.96 to 3.89) compared with healthy controls. They scored lower on the Gastrointestinal Quality of Life Index (mean difference -5.21, 95% c.i. -9.53 to -0.89; P = 0.020). There were no significant differences in Short Form 36 domain scores except for physical functioning (mean difference -6.30, -8.74 to -3.87; P < 0.001). At a patient level, longer-segment disease (P < 0.001) and redo pull-through surgery (P = 0.002) were associated with a poorer bowel function score. Short form 36 scores were lower in women across six of eight domains; similarly, Gastrointestinal Quality of Life Index scores were lower in women (P < 0.001) and in patients with longer-segment disease (P < 0.001).

Conclusion: Among patients with Hirschsprung disease, women, those with longer-segment disease, and patients who underwent redo surgery may be at risk of poorer quality of life.

Background: Surgery provides definitive management of many age-related diseases, relieving symptoms or extending life. Age-related physiological decline, multimorbidity, and frailty predispose older people to postoperative complications and incomplete functional recovery, with resultant health and social care costs. These age-related conditions can be optimized using Comprehensive Geriatric Assessment (CGA), thus mitigating perioperative risk to improve clinical outcomes with cost-effectiveness. National organizations advocate CGA-based services for older surgical patients. However, there is variation in the provision of CGA-based perioperative medicine for older people undergoing surgery (POPS) services across the UK National Health Service, resulting in inequitable access for older surgical patients at higher risk, unnecessary deaths, complications, and financial cost. The aim of the POPS Scale Up (POPS-SUp) study is to determine whether CGA-based POPS services can be implemented at scale to cost-effectively improve clinical outcomes for older patients undergoing surgery.

Methods: A mixed-methods hybrid implementation-effectiveness interrupted time series study will examine the use of a coproduced implementation strategy to embed CGA-based POPS services at scale in the UK. Co-primary implementation-effectiveness outcomes will be used, namely reach and length of hospital stay, respectively. Evaluation will include an embedded process evaluation, quantitative evaluation of clinical effectiveness and cost-effectiveness, and qualitative appraisal of patient and staff experience. The proposed analysis is to embed a process evaluation using real-time framework analysis, enabling iterative refinement and evaluation of the implementation strategy. Accepted interrupted time series analysis will be used to examine and compare outcomes per participating site. A predefined dissemination strategy has been co-designed with patients/carers, clinical community of practice, and organizational bodies.

Conclusion: The anticipation is that POPS-SUp will have impact at the individual (patient and clinician), organizational, and policy levels in the perioperative setting, but with additional potential application to other clinical settings.Registration numbers: ISRCTN 45327 (https://www.isrctn.com/); NIHR 157443 (https://www.nihr.ac.uk/).

Background: Robotic-assisted surgery is expanding globally. The UK's National Institute for Health and Care Excellence recently cautioned due to a paucity of high-quality evidence. To address this, a systematic review, meta-analysis, and meta-regression were undertaken to evaluate the quality and safety of robotic-assisted gastrectomy (RAG) versus conventional approaches for gastric cancer.

Methods: Systematic searches were conducted on MEDLINE, Embase, Web of Science, and Scopus (2 May 2025) for studies comparing RAG to open or laparoscopic gastrectomy up to 30 April 2025. Primary outcomes were Clavien-Dindo grade ≥ II complications (CD ≥ II; safety) and margin-positive resections (quality). Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions and Cochrane Risk of Bias v2.0 tools. Heterogeneity and evidence certainty were evaluated using meta-regression and GRADE assessment.

Results: In all, 90 studies (65 296 patients) were included; only three studies were randomized clinical trials and 72 were from East Asia. In 44 studies (12 102 patients) RAG was associated with significantly lower CD ≥ II complications (odds ratio (OR) 0.74; 95% confidence interval (c.i.) 0.64 to 0.86); heterogeneity was low (I2 = 21.4%). Seven studies had a low risk of bias. From 35 studies on margin status, RAG had fewer R1 resections (OR 0.74; 95% c.i. 0.51 to 1.07); heterogeneity was moderate (I2 = 34.0%). Adoption year, industry funding, extent of resection, and tumour stage were identified as sources of heterogeneity. Three studies were at low risk of bias. Certainty was very low for both outcomes.

Conclusion: Although there may be potential benefits of robotic-assisted surgery, cautious adoption is warranted given the current uncertainty. Safe adoption requires standardized training, competency benchmarks, and limiting industry involvement. High-quality evaluation through randomized trials and parallel health economics is urgently needed to inform future policy and practice.

Introduction: Patients presenting with right-sided obstructing colon cancers (ROCCs) typically undergo emergency surgical resection. Emerging evidence suggests using a bridge-to-surgery (BTS) approach with a stoma or stent reduces mortality and perioperative morbidity while not effecting long-term survival. The aim of this scoping review was to provide a comprehensive report of the recent literature reporting the management of ROCC.

Methods: Systematic searches were conducted of the Embase, MEDLINE, and CENTRAL databases for studies published between 2000 and 2025. Searches were uploaded to the Covidence review tool and dual screened (abstract and full text) against prespecified inclusion criteria. Key data extraction points were: study characteristics, interventions used, patient and oncological descriptors, and outcomes reported. Data are reported descriptively as per PRISMA-ScR guidance.

Results: Twenty-seven studies were identified: 22 primary research studies and 5 systematic reviews. Primary research studies were predominantly retrospective cohorts (20), with nine single-centre studies. Emergency resection was the most common intervention (7528, 75.4%), ahead of a colonic stent as a BTS (2289, 22.9%) and defunctioning stoma as a BTS (114, 1.1%). Of note, the vast majority of patients treated with a stent were from a single paper. There were 76 different descriptors reported, with 61 reported in fewer than five studies. In all, 70 perioperative, 8 stent-specific, and 21 oncological outcomes were reported. The focus was on perioperative outcomes, with only two oncological outcomes reported in five or more studies. Of the five included systematic reviews, four compared emergency resection to BTS and reported favourable outcomes of the BTS approach.

Conclusion: Current available evidence is non-randomized and limited by retrospective study design. Although BTS appears favourable, studies are poorly powered, meaning the current evidence is insufficient to support BTS approaches.

Background: The timing of antibacterial prophylaxis in the hour before incision is unsettled due to inadequate clinical outcome data. The aim of this study was to determine whether the timing of antibacterial prophylaxis in the hour before surgery influences the surgical site infection (SSI) rate in orthopaedic and cardiac surgery procedures.

Methods: Prospective SSI surveillance was undertaken in all 20 publicly funded hospitals in New Zealand for patients undergoing hip and knee arthroplasties and cardiac surgery procedures. The timing of antibacterial prophylaxis was recorded, in minutes (min), with respect to incision time. Patients were followed for 90 days after surgery. Standard definitions for SSIs were used. The SSI rate with respect to the timing of antibacterial prophylaxis was analysed in 10-minute periods. Cefazolin was the prophylactic antibiotic used in vast majority of patients.

Results: The timing of prophylaxis, recorded in minutes, against incision time was available for 66 292 procedures. For all procedures, the lowest SSI rate was for prophylaxis given 21-30 min before surgery, with higher rates for prophylaxis given ≥ 31 min or more before incision. After multivariable analysis, the risk for SSI increased during the time period but only remained significant when prophylaxis was given 51-60 min before incision (odds ratio 1.7; 95% confidence interval 1.3 to 2.3) or earlier (odds ratio 2.01; 95% confidence interval 1.33 to 3.04).

Conclusion: The SSI rates for prophylaxis increased if antibacterial prophylaxis was given more than 50 min before incision. The results may not be applicable to non-clean procedures or non-antibacterial prophylaxis. More outcome data are required before firm recommendations can be made for fine-tuning antibacterial prophylaxis within the 60 minutes before clean surgery.

Background: Gastro-oesophageal reflux disease (GORD) has a global prevalence of 14% and significantly impairs quality of life. Treatment for GORD is rapidly evolving due to advances in pharmacotherapy, surgical techniques, and new interventional approaches and devices. There are also ongoing refinements in patient selection for interventional therapy. This article reviews the latest developments.

Methods: An expert narrative review was conducted of the most recent literature.

Results: As a non-operative treatment, potassium-competitive acid blockers have emerged as an alternative to proton pump inhibitors (PPIs), receiving legislative approval in several countries, owing to their longer duration of acid suppression and higher rates of healing GORD complications. Surgically, research has continued to refine patient selection, perioperative decision-making, and intraoperative facets of laparoscopic fundoplication and hiatus hernia repair. Robotic antireflux surgery is also increasingly being performed internationally, with comparable clinical outcomes to laparoscopic approaches. Moreover, novel endoscopic techniques (antireflux mucosal ablation, antireflux mucosectomy surgery, transoral incisionless fundoplication, and the Medigus Ultrasonic Surgical Endostapler procedure) and devices (RefluxStop™ and LINX™) are being evaluated to treat GORD with varying levels of success. This review discusses the technical rationale, latest trial outcomes, potential pitfalls, and future considerations for these novel therapies.

Conclusion: GORD is a highly prevalent disorder incurring significant morbidity. Although PPIs and laparoscopic fundoplication remain the current standards for the pharmacological and surgical treatment of GORD, novel drugs, approaches, techniques, and devices have emerged to tackle this important health issue. Their future utility will need to be proven against the current standards of care, and their success will enable personalized treatment for patients with GORD.

Background: Healthcare systems in Europe vary in funding, accessibility, and spending per capita, potentially influencing patient access to advanced surgical techniques. This study aimed to provide a snapshot of the utilization of minimally invasive surgery for elective inguinal hernia repair across Europe.

Methods: This was a secondary analysis of an international, prospective observational study of inguinal hernia repairs conducted between 30 January and 21 May 2023. Adults undergoing elective inguinal hernia repair in Europe were included in the present analysis. The four European regions according to the United Nations geoscheme (Southern, Eastern, Northern, and Western Europe) were compared. A multilevel multivariable logistic regression model was used to explore factors associated with use of minimally invasive surgery.

Results: A total of 8355 patients from 254 hospitals across 23 European countries were included: 5590 from Southern, 587 from Eastern, 1541 from Northern, and 637 from Western Europe. Most hospitals were public (88.8%) and tertiary level (49.9%). Patient and hernia characteristics were generally similar, except Western Europe reported higher rates of bilateral hernias (25.9% versus 14.1% overall). Minimally invasive surgery was performed in 26.0% of patients, 70.6% in Western, 37.9% in Northern, 46.5% in Eastern, and 15.4% in Southern Europe. Multivariable regression showed significant regional disparities. Multivariable regression also identified bilateral hernias (adjusted odds ratio 14.33 (95% confidence interval 11.76 to 17.47), surgeons with experience of ≥ 201 procedures (odds ratio 3.54, 2.75 to 4.54), and private hospitals (odds ratio 2.80, 1.03 to 7.65) as factors associated with greater use of minimally invasive surgery.

Conclusion: Significant disparities in minimally invasive surgery for elective inguinal hernia repair exist across Europe. Targeted initiatives should especially prioritize Southern Europe to ensure equitable access to advanced techniques.

Background: Anastomotic leakage (AL) remains a critical complication following oesophagectomy, with inadequate perfusion of the conduit identified as a major contributing factor. Although indocyanine green (ICG) fluorescence angiography has been used intraoperatively to assess conduit blood flow, the clinical utility of objective ICG fluorescence indicators for anastomotic site determination has not been well established. This study investigated the association between ICG fluorescence intensity, measured using a new quantitative blood flow assessment technique, and the incidence of AL in patients undergoing gastric conduit reconstruction.

Methods: Prospective analysis of patients who underwent subtotal oesophagectomy with gastric conduit reconstruction between July 2023 and May 2024. Intraoperative real-time perfusion was assessed using the SPY-PHI imaging system in conjunction with SPY-QP software. Quantitative fluorescence intensity measurements were obtained at the terminal branch of the right gastroepiploic artery and the planned anastomotic site.

Results: Of 100 included patients, AL occurred in nine patients. Although there was no significant difference in ICG enhancement time between the AL and non-AL groups, fluorescence intensity at both the end of the right gastroepiploic artery (75 versus 101%; P = 0.004) and the anastomotic line (67 versus 90%; P = 0.009) was significantly lower in patients who developed AL. Multivariable analysis identified tumour location in the upper oesophagus and fluorescence intensity ≤ 90% at the anastomotic site as independent predictors of AL, with odds ratios of 6.99 (P = 0.023; 95% confidence interval (c.i.) 1.31 to 37.30) and 12.50 (P = 0.004; 95% c.i. 2.15 to 72.9), respectively.

Conclusion: Quantitative ICG fluorescence intensity assessment facilitates objective intraoperative evaluation of gastric conduit perfusion and may support optimal anastomotic site selection, potentially reducing AL risk.

Background: Epidural analgesia can improve early postoperative recovery after renal transplantation. Abdominal wall blocks (transversus abdominis plane (TAP) and rectus sheath (RS)) combined with patient-controlled intravenous analgesia (PCIA) have also been shown to enhance postoperative recovery. However, it remains unclear whether these techniques are as effective as epidural analgesia (EP).

Methods: In this single-centre randomized non-inferiority clinical trial, participants undergoing renal transplantation were randomly assigned to receive either a TAP + RS block (combined with PCIA) or EP alone. The primary outcome was Quality of Recovery-15 (QoR-15) scores on postoperative day (POD) 1. Secondary outcomes included haemodynamics, indices of postoperative renal function, time to interventions, and postoperative pain scores.

Results: Ninety participants were included in the analysis. The TAP + RS group demonstrated non-inferiority to the EP group in terms of the mean(standard deviation) total QoR-15 score on POD1 (90.6(5.0) versus 92.4(6.4); mean difference, -1.8; 95% confidence interval -4.2 to 0.6; P < 0.001 for non-inferiority). QoR-15 scores on POD3 and POD7 and indices of postoperative renal function were comparable between the two groups, with no group-time interactions. The EP group had significantly lower mean arterial pressure and intraoperative opioid consumption, as well as shorter times to eye opening and extubation, than the TAP + RS group. However, the intervention time was longer in the EP group (P < 0.001).

Conclusion: TAP + RS block combined with PCIA demonstrated non-inferiority to EP for postoperative QoR-15 scores after kidney transplantation. TAP + RS block offers a potentially more convenient and favourable alternative to EP, helping maintain haemodynamic stability, postoperative renal function, and a low complication profile.

Registration number: ChiCTR2200056455 (https://www.chictr.org.cn).

Background: Sarcopenia has been associated with adverse outcomes in numerous malignancies. The prevalence and prognostic significance of sarcopenia in patients with breast cancer receiving neoadjuvant chemotherapy (NAC) is uncertain. This study assessed the prevalence and effect of sarcopenia on the response to NAC, as well as on operative and oncological outcomes.

Methods: Consecutive patients with breast cancer receiving NAC with curative intent between 2010 and 2015 at a single tertiary referral centre were included. Lean body mass and skeletal muscle index (SMI) were determined by analysing axial computed tomography scans taken at L3, with sarcopenia defined as SMI < 38.5cm2/m2. Univariable and multivariable linear, logistic, and Cox proportional hazards regression analyses were performed.

Results: Among 258 patients (mean age 49.5 (SD11.1) years and BMI 27.6(5.7) kg/m2), 24 (12.2%) exhibited sarcopenia. Sarcopenia was not associated with molecular subtype (P = 0.746) nor clinical tumour size (P = 0.960). On multivariable analysis, sarcopenia did not predict complete pathological response (P = 0.069), nodal positivity after NAC (P = 0.442), or Sataloff tumour response to NAC (P = 0.898). Sarcopenia did not predict the length of hospital stay (P = 0.716) nor the Comprehensive Complication Index (P = 0.242) after surgery. Lower lean body mass independently predicted overall survival (hazard ratio (HR) 0.92; 95% confidence interval [c.i.] 0.85 to 0.99; P = 0.028) and invasive disease-free survival (HR 0.93; 95% c.i. 0.87 to 1.00; P = 0.049), but not disease-specific survival (P = 0.070).

Conclusion: Sarcopenia was not associated with clinicopathological parameters and did not affect the response to NAC nor postoperative complications. Lower lean body mass was associated with reduced overall and invasive disease-free survival in patients with breast cancer receiving NAC.