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Background: This study aimed to compare preperitoneal ventral mesh patch with barbed suture in ventral hernia repair, evaluating recurrence rates and complications, and to assess the safety of preperitoneal patch placement.

Methods: In this randomized clinical trial, adult patients undergoing ventral hernia repair at Karlskoga Hospital between 2020 and 2023 were randomized 1 : 1 to either a ventral mesh patch repair group or a non-absorbable barbed suture repair group, blinded to patients and outcome assessors. The primary outcome was recurrence detected at clinical examination and CT verification 1 year after surgery. Pain (measured on a visual analogue scale and using the Ventral Hernia Pain Questionnaire), nausea, and surgical site events (including wound infection, haematoma and seroma) were assessed 4 h, 1 week, 1 month, and 4 years after operation.

Results: Of 256 eligible patients, 209 were screened, and 205 were randomized to ventral mesh patch repair (103) or barbed suture repair (102). The hernia recurrence rate at 1 year was lower in the ventral patch repair group (1.9 versus 5.9%), although this was not statistically significant (P = 0.14). The surgical site infection rate at 1 month was significantly lower in the ventral patch group (0.9 versus 6.9%; P = 0.02). At 1 month, the ventral patch repair group had higher 'pain right now' scores on the Ventral Hernia Pain Questionnaire (P = 0.02), although this difference had disappeared by 1 year.

Conclusion: Preperitoneal ventral hernia patch repair is a safe and effective technique with a recurrence rate not statistically significant from that after barbed suture repair. Although postoperative pain scores at 1 month were higher after ventral patch repair, this difference had disappeared by 1 year.

Background: Laparoscopic liver resection has been associated with less morbidity than, and similar global outcomes to, open liver resection. There is no robust evidence that these outcomes lead to similar clinical outcomes in patients aged over 80 years. The aim of this study was to analyse the short-term outcomes between open and laparoscopic liver resection in patients over 80 years old.

Methods: A retrospective analysis was undertaken. The study population comprised patients aged ≥ 80 years who underwent laparoscopic or open liver resection between January 2014 and December 2019, and who presented with resectable malignant tumours. The primary outcome was postoperative morbidity, according to Dindo-Clavien grading. Cox regression models were used to compute hazard ratios and 95% confidence intervals. Propensity score matching (1 : 1) was performed to balance the two groups according to independent prognostic factors for morbidity.

Results: A total of 988 patients were analysed from 34 centres (16 from Asia, 14 from Europe and 4 from America): 487 in the open group and 501 in the laparoscopic group. Independent risk factors associated with severe morbidity were the open approach (hazard ratio 1.59, 95% confidence interval 1.19 to 2.11; P < 0.001), Charlson Co-morbidity Index score > 7 (HR 1.69, 1.26 to 2.27; P < 0.001), more than one resected tumour (hazard ratio 1.55, 1.13 to 2.11; P = 0.006), major hepatectomy (hazard ratio 1.86, 1.22 to 2.83; P = 0.003), and Iwate score ≥ 7 (hazard ratio 1.43, 1.02 to 2.01; P = 0.03). Before propensity score matching, severe morbidity, length of intensive care unit stay, 90-day mortality, length of hospital stay, and readmission were better in the laparoscopic group (P < 0.050). These observations were confirmed after propensity score matching.

Conclusion: The laparoscopic approach is a safe procedure for elderly patients, with better morbidity and mortality outcomes than the open approach, and should be considered as a default option.

Background: Axillary node clearance is the current standard of care in patients with node-positive breast cancer undergoing primary surgery, despite a lack of evidence to demonstrate survival benefit and high rates of life-changing morbidity. Targeted axillary dissection (TAD) may be a safe alternative to axillary node clearance, but there is no agreement how primary TAD should be performed. TADPOLE-TOGETHER aimed to use international consensus methods to agree the key components of primary TAD to promote standardized introduction and evaluation of the technique within the TADPOLE trial.

Methods: A scoping review and key stakeholder interviews were used to generate a longlist of possible procedure steps for inclusion in the Delphi questionnaire. Two rounds of an international online survey were then used to agree the mandatory, optional, and prohibited steps of TAD, together with any standardization and training required. The final approach to primary TAD was agreed at an online consensus meeting.

Results: Thirteen potential steps of a TAD procedure were identified from the literature and expert interviews, together with information regarding standardization and training. Some 244 surgeons with global representation participated in the Round 1 survey, of whom 161 (66.0%) participated in Round 2. Seven mandatory steps of primary TAD, including localization and removal of the involved node, combined with a sentinel node biopsy, were agreed upon and ratified by 42 surgeons from the UK, Europe, and Asia who attended the consensus meeting.

Conclusion: Robust international consensus methods have been used to agree how primary TAD should be performed, promoting safe and transparent introduction and evaluation of the technique.

Background: Hiatal hernia (HH) after oesophagectomy is a potentially life-threatening complication, more commonly observed after minimally invasive procedures. The aim of the study was to compare the incidence of HH after open versus minimally invasive oesophagectomy (MIO) for cancer, to identify risk factors for its onset, and analyse the technical differences between the approaches.

Methods: This was a retrospective study of patients who underwent transthoracic oesophagectomy for cancer over a 15-year period. Open and minimally invasive procedures were compared according to demographics, and operative and perioperative parameters. MIO included both laparoscopic and robotic operations. Risk factors for HH after oesophagectomy were analysed by calculating odds ratios of uni- and multivariable generalized linear models.

Results: A total of 898 patients operated on between 2008 and 2023 were included in the study. HH was observed in 1 of 490 patients (0.2%) in the open group and in 21 of 408 patients (5.2%) in the minimally invasive group (P < 0.001). At multivariable analysis, patients with an ASA score of II and III within the MIO group had a significantly lower risk of HH compared with ASA I subjects (P = 0.002 and P < 0.001, respectively). Omentectomy was performed in all open procedures but in none of the MIO.

Conclusion: The rate of HH was significantly lower in patients who underwent open oesophagectomy. Omentectomy may prevent postoesophagectomy HH as it was the only additional technical difference between the groups. Multicentric randomized clinical trials are needed to assess whether omentectomy during MIO may reduce the occurrence of paraconduit HH.

Background: Failure to rescue (FTR) is the mortality rate among patients with complications, and is a quality indicator for surgical care. FTR has been inconsistently defined in the literature, with potential impacts on reported rates and hospital benchmarking. This study examined the impact of differences in the FTR definition on hospital rankings.

Methods: A retrospective population-based cohort study of patients undergoing gastrointestinal or hepatopancreatobiliary cancer resection from 2005 to 2020 was performed using linkage of the New Zealand Cancer Registry and National Minimum Dataset. FTR was defined as the mortality rate among patients with any of 19 postoperative complications. Five FTR definitions commonly used in the literature were adapted for comparison. Risk-adjusted rates were compared between hospitals using each definition, as well as for in-hospital and 90-day outcomes.

Results: In total, 31 199 patients were included from 20 hospitals, with 1517 90-day deaths (4.9%). The 90-day FTR rate with all 19 complications included was 10.4% (1517 of 14 646). The FTR definition affected hospital rankings, with the Bland-Altman 95% limits of agreement ranging between 4 and 11 position differences. There were 847 in-hospital deaths, and the in-hospital FTR rate was 5.8% (847 of 14 516). Hospital rankings were affected by the timing of outcome measurement; 95% limits of agreement ranged from 5 to 8 position differences compared with 90-day outcomes.

Conclusion: The definition and timing of FTR measurement affected hospital rankings. This may have important ramifications for FTR as a quality indicator when benchmarking institutional performance.

Background: Faecal immunochemical test (FIT) results triage urgent suspicion of colorectal cancer (USoC) referrals to investigation. As FIT detects microscopic blood, its role in patients with per rectal bleeding (PRB) is controversial. Patients are encouraged to submit sample stools without evident bleeding. The positivity rate, colorectal cancer (CRC) detection accuracy, and benefits from repeated FITs in patients with rectal bleeding are unknown.

Methods: A prospective dataset of USoC referrals for CRC was interrogated for referral symptoms, FIT results, and colorectal investigation outcomes. These were linked to South-East Scotland Cancer Network data to ensure complete CRC outcome data. A FIT result of 10 µg Hb/g or more was considered positive. The primary outcome of interest was diagnostic performance of FIT in patients with PRB compared with symptoms excluding PRB, including sensitivity, specificity, and negative predictive value (NPV). Secondarily, the impact of double FITs in these cohorts was investigated.

Results: A total of 5686 patients completed a FIT and subsequent colorectal investigation, and 2130 (37.5%) of these had PRB as a referral symptom. FIT positivity was higher in patients with PRB compared with no PRB (34.7% versus 18.6%; P < 0.001). When two successive FITs were completed, the positivity rate rose to 43.5%. Significant bowel pathology (CRC, advanced adenoma, inflammatory bowel disease (IBD)) was more prevalent in patients with PRB. The majority of CRCs in the PRB group were located distally (PRB 94.1% versus no PRB 51.5%; P < 0.001). The sensitivity for CRC was significantly greater in those with PRB compared with no PRB (98.0% (95% confidence interval (c.i.) 95.1-99.2) versus 82.5% (95% c.i. 74.6-88.9)), with respective NPVs of 99.8% and 99.4%. Double FITs increased CRC sensitivity in the non-PRB group, removing the difference in sensitivity between the two groups observed with one test (PRB 100% (95% c.i. 92.3-100) versus no PRB 92.9% (95% c.i. 79.4-97.8)). The NPV for CRC in PRB when two FITs were complete was 100% (99.0-100).

Conclusion: Rectal bleeding makes up one-third of USoC referrals to secondary care. The FIT positivity rate is 34.7% and it has a high sensitivity for CRC. Patients with PRB with two negative FITs have a negligible CRC prevalence.

Objective: To assess the effectiveness and safety of a normothermic artery bypass and visceral-anastomosis-first (NABV) strategy for thoracoabdominal aortic aneurysm repair.

Methods: From July 2017 to September 2024, a retrospective analysis was conducted on early postoperative complications in two groups of patients undergoing thoracoabdominal aortic aneurysm repair. The analysis compared patients treated with a new strategy with those treated with deep hypothermic circulatory arrest, clarifying the protective effects of the new strategy on visceral organs, particularly the spinal cord.

Results: A total of 182 patients were included in the study; 73 in the NABV group and 109 in the DHCA group. After inverse probability of treatment weighting, the NABV group had lower incidences of spinal cord deficit, pulmonary complications, and gastrointestinal insufficiency, a shorter duration of mechanical ventilation, and a shorter hospital stay. Body mass index ≥ 24.0 (odds ratio 3.099, 95% confidence interval (c.i.) 1.051 to 9.142; P = 0.004) and coronary artery disease (odds ratio 4.848, 95% c.i. 1.169 to 20.102; P = 0.030) were independent risk factors for spinal cord deficit in the entire cohort, in contrast to the NABV strategy (odds ratio 0.283, 95% c.i. 0.039 to 0.806; P = 0.025), which was a protective factor. The multivariable Cox regression analyses identified smoking history (hazard ratio 2.61, 95% c.i. 1.12 to 6.05; P = 0.026) as an independent risk factor for overall survival.

Conclusion: The treatment of thoracoabdominal aortic aneurysm through open surgery is still an important method and remains difficult. The NABV strategy, as a safe and reproducible technique, minimizes the risk of complications associated with spinal cord injury when implemented at experienced medical centres. To better evaluate the clinical outcomes of this surgical approach, long-term follow-up and further prospective cohort studies are necessary.

Background: Faecal immunochemical testing has rapidly been established as the first-line triage for patients with symptoms suspicious for colorectal cancer. However, the reported low compliance of test returns issued from primary care is concerning. This article reports the real-world impact of implementation of a double-faecal immunochemical testing pathway for symptomatic referrals into routine clinical practice.

Methods: All eligible referrals between November 2021 and October 2022 were sent two faecal immunochemical tests via the faecal immunochemical testing interface office. Colorectal investigations were instigated if either test result was ≥10 µg haemoglobin per g. Referrals with double-negative results were reviewed by consultants who decided whether symptoms merited further investigation. Cancer registry follow-up data were cross-checked, and a further electronic registry allowed capture of re-referrals.

Results: Some 5425 patients were triaged using double-faecal immunochemical testing, with 5116 (94.3%) completing at least 1 and 4607 (84.9%) both faecal immunochemical tests. The positivity of one test was 20.8%, rising to 27.8% where both tests were completed. The number of referred patients undergoing colorectal investigation fell from 90% before faecal immunochemical testing-directed pathways to 56.6% owing to a reduction in investigating patients with double-negative results. The double-faecal immunochemical testing pathway had a sensitivity of 94.3% for the detection of colorectal cancer, with 37.5% of cancers with a negative first test being detected by the second. Only 3.3% of patients triaged through the double-faecal immunochemical testing pathway were re-referred.

Conclusion: The double-faecal immunochemical testing pathway demonstrated high test return rates, a reduction in unnecessary investigations, and colorectal cancer detection rates similar to preimplementation rates.

Introduction: The management of faecal incontinence (FI) remains challenging and further treatment modalities are urgently needed. The aim of this study was to assess the efficacy of a novel artificial bowel sphincter (SimplyFI anal band), which is implanted around the anal sphincter complex to enhance continence.

Methods: An exploratory prospective multicentre study based on the IDEAL 2b framework was conducted in patients with FI unresponsive to conservative treatment. Participants underwent SimplyFI implantation, followed by assessments at 1 week and 1, 3, 6, and 12 months after implantation. Intraoperative and postoperative complications were recorded. Functional improvement and quality of life were measured using the St Mark's incontinence score (SMIS) and the Faecal Incontinence Quality of Life Scale (FIQLS).

Results: Eighteen patients were included in the study (17 women, 1 man). The median operating time was 27 (range 13-60) min, with a median hospital stay of 2 (range 1-5) days. One intraoperative complication occurred without affecting the outcome. One patient (5.6%) underwent band removal due to anal discomfort without signs of infection. Relative to baseline, significant improvements were seen at 12 months in median scores for both the SMIS (from 16.5 to 12.5; P = 0.013) and the FIQLS (from 2.0 to 2.6; P = 0.006). Anorectal manometry showed a significant increase in the anal resting pressure from preoperative values to 3 months after implantation (median 15.5 versus 19.0 mmHg, respectively; P = 0.037); however, the increase in anal resting pressure was no longer seen at the 12-month follow-up.

Conclusion: In this exploratory study of 18 patients, the SimplyFI anal band appears to be safe with short-term improvement in function. Future studies with longer follow-up periods are needed to better define the role of this new treatment modality. Registration number: NCT05708612 (http://www.clinicaltrials.gov).