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Background: Improvements in medical standards have allowed critically ill patients to benefit from liver transplantation, but defining futility arbitrarily according to one single-stage outcome could deprive patients of the potential benefits of transplantation. This study aimed to redefine futile liver transplantation by multiterm outcomes and develop a novel scoring system to predict futile liver transplantation.

Methods: This retrospective study in China enrolled patients who had liver transplantation from 3 centres between January 2015 and April 2021. Independent risk factors were identified by logistic regression analysis and used to establish risk prediction models. Kaplan-Meier survival curves were calculated to explore the association between futile score and overall survival.

Results: Of 1408 patients undergoing liver transplantation, patients at persistent high risk for mortality in the short term (3 months), mid term (1 year), and long term (3 years) were defined as the truly futile liver transplantation group. Higher donor and recipient age, hepatorenal syndrome, intensive care unit stay, need for mechanical ventilator, ABO blood group incompatibility, prolonged cold ischaemia time, increased alanine aminotransferase levels, and decreased albumin levels were independent risk factors for futility, and were used to construct a futile scoring system. The scoring system had good predictive capability, with an area under the receiver operating characteristic curve of 0.921, better than that of a previously established scoring system. Survival analysis showed that the group with a high futile risk had decreased survival.

Conclusion: This study has redefined futile liver transplantation and established a novel futile scoring system. This can be used to optimize the allocation of medical resources, especially with regard to recipient selection for liver transplantation, and increase survival prediction for selected patients.

Background: Chronic anastomotic leakage (AL) is the most common cause of pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. This study investigated factors associated with AL and successful salvage of leaking anastomoses after ileoanal pouch surgery.

Method: This multicentre retrospective cohort study included patients aged ≥ 18 years with ulcerative colitis or unclassified inflammatory bowel disease who underwent ileoanal pouch surgery between 2016 and 2021 in six European centres, with a > 12-month follow-up. The primary outcome was AL rate. Secondary outcomes included factors associated with AL occurrence, timing of AL diagnosis (early (< 21 days) versus late), AL management, AL salvage rate, and stoma-free survival.

Results: Overall, 411 patients were included, of whom 13.6% (56) had a diagnosed AL. The rate of AL was significantly higher in low-volume (less than ten procedures annually) centres (28.0% versus 12.7%; P = 0.031). Of the 56 ALs, 44 were diagnosed as early leaks and 12 were diagnosed as late leaks. A three-stage approach was associated with late diagnosis and treatment. AL was managed using various techniques, including diverting ileostomy, antibiotics, and drainage. The overall AL salvage rate was 85.4%, but increased to 92% when diagnosed and treated early (compared with 60% when diagnosed and treated late; P = 0.010). Successful AL salvage was associated with long-term stoma-free status (P = 0.002). The median follow-up was 3.8 years (range 1.0-8.1 years). The long-term stoma-free rate was 95.5% in patients with AL diagnosed and treated early, but only 41.7% when diagnosed and treated late (P < 0.001).

Conclusion: Early diagnosis and treatment of AL diminishes the negative effect of AL after ileoanal pouch surgery. Proactive anastomotic assessment enable early diagnosis and management, especially in patients undergoing a three-stage approach.

Background: In patients with rectal cancer, when it is not possible to restore bowel continuity with an anastomosis, the optimal surgical method is still a matter of debate. The aim of this trial was to determine 30-day postoperative surgical complication rates after Hartmann's procedure (HP) versus intersphincteric abdominoperineal excision (iAPE) in patients with rectal cancer who were not suitable for restorative surgery.

Methods: This multicentre randomized controlled trial (HAPIrect) was performed in Sweden and Finland between 2014 and 2021. Eligible patients with adenocarcinoma of the rectum located ≥ 5 cm from the anal verge and deemed unsuitable for anterior resection with anastomosis were randomized (1:1) intraoperatively to either HP or iAPE. The primary outcome was 30-day postoperative surgical complications. Secondary outcomes were major surgical complications (Clavien-Dindo grade ≥ IIIa), perineopelvic complications, and overall complications. Logistic regression in the intention-to-treat population was the primary method used to compare the surgical approaches.

Results: Of 194 eligible patients, 163 were randomized (80 patients to HP and 83 to iAPE). The study was closed before achieving the target accrual. The main reasons for not receiving an anastomosis were advanced age, co-morbidity, or poor anal sphincter function. Mean operating time in the HP and iAPE groups was 291 and 373 minutes, respectively. In the HP and iAPE groups, the surgical complication rate was 39% and 43%, respectively (odds ratio (OR) for HP 0.83; 95% confidence interval (c.i.) 0.44 to 1.54; P = 0.549) and the rate of major surgical complications was 14% and 11%, respectively (P = 0.573). Perineopelvic complications occurred in 21% and 30% of patients in the HP and iAPE groups, respectively (OR for HP 0.63; 95% c.i. 0.31 to 1.28; P = 0.197). The overall complication rate (including both medical and surgical complications) was 45% and 49% in the HP and iAPE groups, respectively (P = 0.574). In multivariable analysis adjusted for sex, preoperative radiotherapy, and surgical procedure, there was no statistically significant difference in surgical complications between the two groups.

Conclusion: Although the trial was underpowered and did not reach accrual, in randomized patients, both HP and iAPE are practicable surgical options for patients unsuitable for anastomosis.

Registration number: NCT01995396 (http://www.clinicaltrials.gov).

Background: This study evaluated the outcomes of colonic volvulus management in a national cohort, and identified risk factors for morbidity and mortality.

Methods: This was a multicentre national retrospective study of patients presenting with colonic volvulus between 2010 and 2019. Main outcome measures were 30-day and 1-year mortality. Multivariable regression and Kaplan-Meier analyses were used to study predictors of mortality and survival.

Results: Of the 559 patients presenting with sigmoid volvulus, 381 underwent surgery and 178 received conservative treatment. The 30-day mortality rates were 11.0% and 19.0%, respectively. Emergency surgery (P = 0.030), nursing home residence (P = 0.040), increased co-morbidity (P = 0.017), and male sex (P = 0.029) predicted postoperative 30-day mortality. Primary endoscopic detorsion followed by elective surgery during a subsequent hospital admission resulted in best survival. Of the 342 patients presenting with caecal volvulus, 340 underwent surgery. The 30-day mortality rate was 6.4%. Increased co-morbidity (P = 0.008), nursing home residence (P = 0.002), and necrotic caecum (P = 0.007) predicted 30-day mortality. At 1 year, the mortality rate among patients with sigmoid volvulus was 19.9% after surgery and 43.2% after conservative treatment. Emergency surgery (P = 0.023), nursing home residence (P = 0.009), and increased co-morbidity (P < 0.001) were associated with 1-year postoperative mortality. In patients with caecal volvulus the 1-year mortality rate was 13.1%. Increased co-morbidity (P < 0.001) and nursing home residence (P < 0.001) were predictive. Anastomotic leakage in patients with sigmoid volvulus was associated with an American Society of Anesthesiologists fitness grade of III (P = 0.032) and total colectomy (P = 0.012).

Conclusion: Surgery should be recommended for colonic volvulus where co-morbidity, patient preference, and functional status allows. Surgically unfit patients have poorer outcomes. Elective sigmoidectomy after endoscopic detorsion is preferred as it carries the lowest mortality risk. Necrotic bowel, dependency, and co-morbidities predict death for both sigmoid and caecal volvulus.

Background: Colorectal cancer (CRC) screening programmes aim to detect early, asymptomatic cancers and improve survival. This study aimed to establish the proportion of interval cancers, and the consequences with regard to stage, clinical outcome, and overall survival. Risk factors associated with interval CRCs were investigated.

Methods: The Scottish Bowel Screening Programme uses faecal immunochemical testing at a threshold of 80 µg haemoglobin per g as a positive trigger for investigation. Screening was offered to all eligible individuals in one region, from November 2017 to October 2021. Cancer registries were cross-checked to ensure complete capture of all cancers including interval CRCs. The primary outcome was rate of interval CRCs among participants with follow-up of 24 months, and its relationship to faecal immunochemical testing results, clinical variables, stage, time to diagnosis, and survival. The secondary outcome was identification of risk factors associated with interval CRCs.

Results: The Scottish Bowel Screening Programme generated 316 583 tests during the study period. Participation was 71.0% of the eligible population (212 664 patients); it was greater among women (71.9 versus 70.0%; P < 0.001) and in higher socioeconomic areas (76.9 versus 58.6%; P < 0.001). In the screened population, 546 CRCs were diagnosed within 2 years of screening. Some 289 of these patients (52.9%) had positive bowel screening. There were 257 patients with interval CRCs, who waited a median of 13 (interquartile range 7-20) months for diagnosis. Of CRCs diagnosed, 24.9% had screening faecal immunochemical test results of < 10 µg haemoglobin per g. The interval CRC rate was greater in women, older patients, and among the least socioeconomically deprived. Interval CRCs were associated with worse 2-year all-cause mortality than screen-detected CRCs (23.0 versus 10.8%; P < 0.001). Importantly, 121 of the 257 interval CRCs (47.1%) had detectable faecal immunochemical test results at 10-79 µg haemoglobin per g.

Conclusion: Patients with interval CRCs and a detectable faecal immunochemical test result below the predetermined threshold appear to be significantly disadvantaged with respect to stage at presentation and survival. Almost half of interval CRCs diagnosed within 2 years had detectable haemoglobin on screening faecal immunochemical test and would be a target for lower positivity thresholds.

Background: Standard sentinel lymph node (SLN) mapping for early breast cancer involves technetium-99m (99mTc) lymphoscintigraphy. Indocyanine green (ICG) fluorescence allows real-time visualization of lymphatics and nodes while avoiding radiation exposure and the inconvenience of 99mTc, but its inclusion in international guidelines is not widespread. This study compared efficacy and costs between ICG and 99mTc for axillary SLN lymphatic mapping.

Methods: Patients with early breast cancer and clinically negative axilla who underwent lymphatic mapping with ICG and 99mTc were enrolled in a prospective single-institution single-arm non-randomized trial (2021-2024). Data on the number of SLNs, including metastatic nodes, rate of failed mapping, costs, and the surgeon's reported ease of mapping with ICG compared with 99mTc were collected. Cost analysis used Medicare item numbers and microcosting.

Results: A total of 305 patients were enrolled, with 637 SLNs sampled. The SLN identification rate was 97.8% (95% confidence interval (c.i.) 96.3 to 98.7%) for ICG and 98.3% (95% c.i. 96.9 to 99%) for 99mTc. The mean(standard deviation (s.d.)) number of SLNs identified with ICG and 99mTc was 2.06 (1.99) and 2.07 (2.02), respectively (P = 0.871). Metastatic SLNs were identified in 70 of 305 patients (23.0%), with 83 metastatic SLNs in total. ICG identified 79 of 83 metastatic SLNs (95.2%; 95% c.i. 88.3 to 98.1%) and 99mTc identified 82 of 83 metastatic SLNs (98.8%; 95% c.i. 93.5 to 99.8%; P = 0.256). Mean(s.d.) surgeon-reported ease for using ICG and 99mTc, rated used a five-point Likert scale, was 1.67 (0.98) (95% c.i. 1.56 to 1.78) and 1.5 (0.59) (95% c.i. 1.43 to 1.57), respectively (P = 0.082). 99mTc cost an additional EUR841 (95% c.i. EUR766 to EUR917) per patient but ICG would require > 35 patients before breaking even with initial outlay equipment costs.

Conclusion: ICG fluorescence performed similarly to 99mTc lymphoscintigraphy and may be less costly over the long term.

Background: The aim of this meta-analysis was to elucidate the effects of prehabilitation (PR) on outcomes after surgery for upper gastrointestinal tract cancer.

Methods: PubMed, Web of Science, Embase, and Cochrane databases were searched from inception up to 21 May 2024 for randomized clinical trials (RCTs) and cohort studies investigating PR interventions in patients with upper gastrointestinal tract cancer. Data were synthesized using standardized mean differences (SMDs) and risk ratios (RRs) with corresponding 95% confidence intervals. Sensitivity and subgroup analyses were used to examine the robustness of the results and find possible sources of heterogeneity. Statistical analyses were performed using Review Manager 5.4 and Stata 16.0.

Results: Eight RCTs and eight cohort studies were included in the meta-analysis. Compared with the control group (no PR), the PR group had a significantly shorter postoperative length of hospital stay (SMD -0.27; 95% confidence interval (c.i.) -0.47 to -0.07; P = 0.008), a significant reduction in the occurrence of pneumonia after the surgery (RR 0.71; 95% c.i. 0.50 to 1.00; P = 0.005), and a greater improvement in the 6-minute walk distance (SMD 0.95; 95% c.i. 0.68 to 1.22; P < 0.00001). However, there were no significant differences between the control and PR groups in overall postoperative complications, anastomotic leakage, overall pulmonary complications, operative time, intraoperative blood loss, wound infection rate, in-hospital mortality, or recurrence rate (all P > 0.05).

Conclusion: For the population with upper gastrointestinal tract cancer, PR can partially lower the risk of postoperative pneumonia and promote faster postoperative recovery. Given the inherent limitations in the included studies, more large-scale RCTs are needed to verify these findings.

Background: Intraoperative autotransfusion remains underutilized in high-risk haemorrhagic oncological procedures, particularly in liver transplantation for hepatocellular carcinoma. This is because of the theoretical risk of tumour cell reinfusion and dissemination, potentially leading to reduced recurrence-free survival. The aim of this study was to evaluate the impact of intraoperative autotransfusion on recurrence-free survival during liver transplantation for hepatocellular carcinoma.

Methods: This was a retrospective study of patients receiving liver transplantation for hepatocellular carcinoma with or without intraoperative autotransfusion between 1 January 2011 and 1 January 2020 at five French hospitals, of which one used autotransfusion and four did not. Propensity score matching was used to match the cohorts with and without autotransfusion. The primary endpoint was 5-year recurrence-free survival.

Results: Some 113 patients in the study cohort (autotransfusion) were compared with 441 patients in the control cohort. The median volume of autotransfused blood was 1500 ml. Median follow-up was 84.6 months. There was no significant difference in 5-year recurrence-free survival between the cohorts (69.7% in control cohort versus 66.3% in study cohort; P = 0.241). After matching patients based on oncological criteria, the difference remained non-significant, with a 5-year recurrence-free survival rate of 67.1% in the study cohort and 77.6% in the control cohort (P = 0.174).

Conclusion: The use of autotransfusion during liver transplantation for hepatocellular carcinoma was not associated with recurrence-free survival.

Background: Oesophageal squamous cell carcinoma is the predominant histopathological subtype of oesophageal cancer across the world, representing as many as 90% of all cases; however, within Western cohorts, it is a low-prevalence disease, and, as such, appropriately powered trials to establish a standard treatment paradigm in this population remain challenging. The aim of this study was to assess current practices and compare outcomes for patients with locally advanced oesophageal squamous cell carcinoma across the UK and Ireland.

Methods: This was a retrospective multicentre cohort study of patients managed with curative intent for squamous cell carcinoma of the middle or distal oesophagus in 23 hospitals across the UK and Ireland. Consecutive patients diagnosed between 1 January 2012 and 31 December 2016 were included.

Results: This study included 1545 patients, of whom 923 (59.7%) received definitive chemoradiotherapy, 286 (18.5%) neoadjuvant chemotherapy + surgery, 218 (14.1%) neoadjuvant chemoradiotherapy + surgery, and 118 (7.6%) surgery alone. Neoadjuvant chemoradiotherapy + surgery was associated with significantly longer survival than neoadjuvant chemotherapy or definitive chemoradiotherapy (median 83.9 versus 27.8 versus 26.5 months). In propensity score-matched analysis of overall survival, patients receiving neoadjuvant chemoradiotherapy + surgery had significantly longer survival than those who had definitive chemoradiotherapy (median 56.8 versus 43.1 months; hazard ratio 0.39, 95% confidence interval 0.20 to 0.78; P < 0.001).

Conclusion: This multicentre retrospective cohort study suggests that, despite a majority of patients being treated with definitive chemoradiotherapy, patients undergoing neoadjuvant chemoradiotherapy and surgery have improved survival compared with those receiving definitive chemoradiotherapy or neoadjuvant chemotherapy + surgery. In the absence of robust Western randomized clinical trial data, neoadjuvant chemoradiotherapy + surgery should be considered the standard for well selected patients fit for surgery.