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Background: In the absence of a commonly accepted definition, conversion surgery is generally considered as surgical resection with the intent of prolonging survival after non-surgical induction therapy in patients with upfront unresectable disease at diagnosis. Despite the heterogeneity of possible targets, conversion surgery is a quickly evolving concept, with commonalities for upper gastrointestinal (UGI) and hepato-pancreato-biliary (HPB) malignancies.

Methods: A comprehensive narrative review of the most recent and relevant literature was conducted by experts in the field of different UGI and HPB tumours.

Results: The increased interest of the surgical scientific community in the concept of conversion surgery can be explained by the continuous improvements in non-surgical therapies aimed at controlling the systemic tumour burden and the local extension of cancer, supported by improvements in surgical outcomes for advanced resections in expert centres. The toolbox of the surgical oncologist seeking conversion in the case of unresectable UGI and HBP tumours is large and includes (but is not limited to) systemic chemotherapy, (chemo)radiation, targeted therapy/immunotherapy, locoregional ablation techniques, intra-arterial therapies, liver hypertrophy induction techniques, treatments of underlying medical conditions, and prehabilitation.

Conclusions: Conversion surgery represents a powerful instrument to prolong the survival of patients with unresectable UGI and HPB malignancies. However, most of the available evidence is of a low level and at very high risk of selection bias. Alongside a profound understanding of (and respect for) the biology of cancer, which remains key to selecting appropriate patients and avoiding non-therapeutic surgeries, a commonly accepted definition is urgently needed to standardize practice, monitor outcomes, and improve the quality of research.

Background: The majority of women undergoing risk-reducing mastectomy have implant-based breast reconstruction, with capsular contracture being one of the most common complications. The primary aim of this study was to establish the national incidence rate of severe capsular contracture requiring surgery following risk-reducing mastectomy with implant-based breast reconstruction. The secondary aim was to establish the incidence rate of other complications and associated risk factors.

Methods: Women undergoing implant-based breast reconstruction following risk-reducing mastectomy were identified from the Swedish Breast Implant Register. Data were extracted from the Swedish Breast Implant Register and the National Patient Register on women undergoing implant-based breast reconstruction from 2014 to 2021. The primary outcome was severe capsular contracture corresponding to Baker grade III-IV requiring surgery, and the secondary outcomes were other complications observed perioperatively.

Results: In total, 656 women with 1095 implant-based breast reconstructions were included in the analysis. Median follow-up was 3.5 (interquartile range 1.5-5.4) years. Capsular contracture was observed in 39 of 1095 breasts (3.6%), and the cumulative incidence increased from 1.9% at 1 year to 4.7% after 5 years. Stratified by implant type, the estimated risk of capsular contracture increased for patients with a permanent tissue expander compared with a permanent fixed-volume implant (adjusted hazard ratio 19.33, 95% confidence interval 3.92 to 95.43; P < 0.001).

Conclusion: This study has highlighted that the risk of developing severe capsular contracture requiring surgery seems to differ between implant types, emphasizing the need for further investigation regarding permanent tissue expanders. Moreover, the continuous increase in capsular contracture incidence rates over 5 years underscores the importance of long-term follow-up.

Background: The aim of this study was to compare the postoperative analgesic effects of ultrasound-guided intercostal nerve block and transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy.

Methods: Patients undergoing laparoscopic cholecystectomy for chronic cholecystitis with gallstones were randomly allocated to ultrasound-guided T7-11 intercostal nerve block or subcostal transversus abdominis plane block (both with 40 ml 0.3% ropivacaine). The primary outcome was the dose of tramadol required for remedial analgesia 24 h after surgery. The secondary outcomes included visual analogue scale scores at different time points after surgery, the time of initial use of tramadol for postoperative analgesia, patient satisfaction with postoperative pain control, the time to flatus, and the incidence of postoperative adverse events.

Results: A total of 64 patients were included. Compared with the transversus abdominis plane block group, the intercostal nerve block group had lower visual analogue scale scores at 3 h after surgery (mean(s.d.) of 2.4(0.8) versus 1.6(0.6)), 6 h after surgery (mean(s.d.) of 2.2(0.3) versus 1.4(0.6)), and 8 h after surgery (mean of 1.7(0.5) versus 1.3(0.4)) (P < 0.001, P < 0.001, and P = 0.002 respectively), a lower dose of tramadol for remedial analgesia within 24 h after surgery (median of 100 (interquartile range 0-100) versus 50 (interquartile range 0-50) mg) (P = 0.012), and a significantly delayed time of initial use of tramadol for postoperative analgesia (mean(s.d.) of 9.1(7.5) versus 14.6(8.3) h) (P = 0.015). The incidences of postoperative dizziness and postoperative nausea and vomiting were higher in the transversus abdominis plane block group (47% and 69% respectively) than in the intercostal nerve block group (19% and 41% respectively) (P = 0.032 and 0.035 respectively). Patient satisfaction with postoperative analgesia was higher in the intercostal nerve block group than in the transversus abdominis plane block group (P = 0.037). The time to flatus was similar between the two groups (P > 0.050).

Conclusion: Compared with ultrasound-guided subcostal transversus abdominis plane block, ultrasound-guided T7-11 intercostal nerve block with 0.3% ropivacaine provides better postoperative analgesia, requires a lower dose of tramadol for remedial analgesia 24 h after surgery, and significantly delays the time of initial use of tramadol for postoperative analgesia.

Background: Surgical site infection after laparotomy is a major postoperative complication. The efficacy of prophylactic laparotomy wound irrigation to reduce surgical site infection rates remains controversial. This study evaluates the impact of antiseptic wound irrigation on surgical site infection prevention.

Methods: A systematic review and meta-analysis, following PRISMA 2020, included randomized clinical trials and observational studies (published after 1999) comparing antiseptic or saline irrigation versus saline or no irrigation before laparotomy closure in adult patients with surgical site infection as the primary outcome. Databases searched included MEDLINE, EMBASE, Cochrane Library, and Google Scholar (September 2024). Risk of bias was assessed using RoB 2 and ROBINS-I; Grading of Recommendations Assessment, Development, and Evaluation evaluated evidence certainty.

Results: Eighteen studies (6368 patients) reported an overall surgical site infection rate of 14.7%. Thirteen studies compared antiseptic with saline irrigation, showing no significant effect (relative risk 0.80, 95% confidence interval 0.58 to 1.09; P = 0.159) with very low evidence certainty. Excluding laparoscopic cases and high-risk bias studies revealed a favourable effect for antiseptic irrigation (relative risk 0.75, 0.64 to 0.87; P < 0.001) with moderate certainty. Three studies compared antiseptic with no irrigation, and four compared saline with no irrigation. Meta-analysis indicated reduced surgical site infection rates with any irrigation (antiseptic or saline) versus no irrigation (relative risk 0.52, 0.37 to 0.74; P < 0.001) with moderate certainty.

Conclusion: Wound irrigation (antiseptic or saline) likely reduces surgical site infection rates after laparotomy. Evidence comparing antiseptic versus saline is uncertain but suggests a potential benefit after excluding the high risk of bias studies. Further high-quality, standardized trials are needed.

Background: Surgical interventions for pancreatic cancer are complex due to numerous interacting components. This complexity can make the design and conduct of randomized clinical trials (RCTs) challenging due to variations in how surgical interventions are delivered across centres and surgeons. Quality assurance (QA) methods, such as those described within the CONSORT recommendations for non-pharmacological interventions (CONSORT-NPT), attempt to mitigate this. The extent of the adoption of such QA methods in RCTs evaluating surgical interventions for pancreatic cancer is unclear.

Methods: A systematic review was conducted on multicentre RCTs evaluating surgical interventions for pancreatic cancer. Data were extracted within four QA domains described within the CONSORT-NPT checklist: surgical intervention description, standardization, adherence, and clinician and unit expertise.

Results: Of 2374 studies identified, 45 were eligible for inclusion in this review. Thirty-eight RCTs (84%) described the intervention and 20 (44%) attempted to standardize techniques. Information about permitted flexibility in surgical interventions was described in 14 RCTs (31%). Fourteen studies (31%) described methods used to measure adherence to the intervention, with intra-operative photographs/videos (ten studies) being the most common. Nineteen studies (42%) detailed surgeon or unit expertise, and six (13%) used credentialing criteria.

Conclusion: Although most RCTs described the intervention, reporting on standardization, adherence, and expertise was often lacking. This may affect RCT results and compromise the extent to which observed differences in clinical outcomes are due to the actual intervention being delivered. More rigorous application and reporting of QA measures are needed to improve confidence in the results of future RCTs, which may, in turn, enhance implementation in clinical practice.

Background: Compliance with enhanced recovery after surgery (ERAS) protocols in gastrectomy, including urinary catheter management, remains poor. This study evaluated the feasibility of immediate urinary catheter removal after radical gastrectomy.

Methods: This was a non-inferiority randomized clinical trial performed at a university-affiliated hospital in China. Patients undergoing radical gastrectomy were randomized in a 1 : 1 ratio to either immediate removal (IR) or early removal (ER) of the urinary catheter. The randomization sequence was computer generated; the investigators and patients were not blinded to group allocation. ERAS protocols were applied in all patients. The primary outcome measure was postoperative urinary retention with a non-inferiority margin of 10% to compare IR with ER. Secondary outcomes were patient comfort, patient anxiety, and depression. Data were analysed using intention-to-treat analysis.

Results: Initially, 248 patients were assessed for eligibility for this study. Data were analysed for 92 patients in the IR group and 89 patients in the ER group. The incidence of postoperative urinary retention was 4.4% and 3.4% in the IR and ER groups, respectively (P = 0.733; 1.0% difference, 95% confidence interval -4.6 to 6.6%). Patient comfort levels were significantly higher in IR than ER group (mean(standard deviation) Kolcaba General Comfort Questionnaire score 74.9(7.6) versus 72.5(8.0), respectively; P = 0.041).

Conclusion: IR of the urinary catheter after gastrectomy is feasible under ERAS perioperative care protocols. It does not increase the incidence of postoperative urinary retention and can provide a more comfortable postoperative experience. Successful IR implementation probably relies on multimodal analgesia and goal-directed fluid therapy.

Registration number: NCT06718114 (http://www.clinicaltrials.gov).

Background: The primary aim of this study was to establish the incidence of implant-related operations and revisions after delayed implant-based breast reconstruction over a 20-year period.

Methods: This study is an ancillary study to the Gothenburg Breast Reconstruction Study (GoBreast; NCT03963427). The first included patient was operated on in 2003, and the last was operated on in 2011. All breast reconstructions were delayed procedures. The Kaplan-Meier method was used to estimate the time until implant loss. Log-rank tests (Mantel-Haenszel) were used for comparisons. A Cox proportional hazards model was used for multivariable analysis, and hazard ratios were estimated.

Results: The study included 881 implants and 603 patients. The mean follow-up for the implants was 8.2 years. With regard to first implants, 17% had at least one unplanned procedure with implant failure. If all implants are pooled together, the 20-year implant survival rate is 57% (95% confidence interval 54 to 61%). Most implants were lost during the first 2 years, but the cumulative risk of implant loss increased steadily with time. When different surgical methods were compared, implant survival was statistically lower for direct-to-implant than for the other techniques (P < 0.001).

Conclusion: About half of the implants in delayed breast reconstructions in this study survived for up to two decades without any additional surgery. Serial implant revisions seem more common than single implant revisions; if the first implant needed revision, there was a tendency for the second implant to also require revision.

Background: Sentinel lymph node biopsy provides information about disease staging and the need for adjuvant therapy. The consequences of a false-negative result are potentially severe. The risk of a false-negative result should be quantified. The aims of this study were to estimate the sensitivity of sentinel lymph node biopsy based on studies following up patients for at least a mean or median of 5 years, appraise the risk of bias, and provide negative predictive value estimates across a range of pretest probabilities.

Methods: Ovid MEDLINE and Embase databases were searched from inception to 28 May 2025. Studies were screened independently and in duplicate, with a third author resolving conflicts. All original comparative and non-comparative English language research studies were included if the sensitivity of sentinel lymph node biopsy was calculable and participants had been followed up for a mean or median of 5 years. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Sensitivity estimates were calculated and pooled by random-effects meta-analysis. A negative predictive value curve was plotted using the pooled sensitivity estimate and a range of plausible pretest probabilities.

Results: Fourteen studies with 8447 patients were included. The pooled sensitivity estimate was 0.85 (95% confidence interval 0.80 to 0.88). The negative predictive value estimates fell between 0.93 and 0.97, depending on pretest probability. Existing negative predictive value estimates are at risk of positive bias.

Conclusion: Sentinel lymph node biopsy is a sensitive test used to rule out lymph node metastasis in cutaneous melanoma. Clinicians can use negative predictive value estimates to counsel patients about the probability of false-negative results, for example, by offering reassurance to patients with thin melanomas and negative sentinel lymph node biopsy.

Background: Cholecystectomy is a common procedure with a notable risk of iatrogenic bile duct injury. Understanding the factors contributing to bile duct injury and the effectiveness of preventative measures is crucial for improving surgical outcomes. This meta-analysis aimed to identify and synthesize high-quality evidence on risk factors and mitigating measures associated with bile duct injury after cholecystectomy.

Methods: Following the PRISMA guidelines, a comprehensive literature search was conducted across multiple databases. Included studies reported on adult patients undergoing cholecystectomy with relevant risk factors for bile duct injury. Meta-analyses of unadjusted and adjusted risk estimates were conducted with a random-effects model to account for heterogeneity. The study period across all included studies spanned from 1989 to 2016.

Results: The review included 31 studies comprising 6 513 599 cholecystectomies and 18 259 bile duct injuries. The primary risk factors identified were male sex (adjusted odds ratio 1.27, 95% confidence interval 1.13 to 1.39) and acute cholecystitis (adjusted odds ratio 1.74, 1.27 to 2.39). The critical view of safety was inconsistently documented and not statistically linked to reduced bile duct injury. Intraoperative cholangiogram's routine use did not show a statistically significant association with reduced incidence of bile duct injury (adjusted odds ratio 0.92, 0.70 to 1.23).

Conclusion: Male sex and acute cholecystitis significantly increase the risk of bile duct injury after cholecystectomy. Risk stratification for these patients before surgery would ultimately aid the shared decision-making consent process.

Background: Neoadjuvant chemotherapy is increasingly used in patients with locally advanced gallbladder cancer (LAGBC). This study investigated factors affecting clinical benefit response (CBR) to neoadjuvant chemotherapy for LAGBC.

Methods: All consecutive patients with LAGBC following neoadjuvant chemotherapy, from January 2013 to December 2022, were analyzed for clinical and radiological responses as well as survival outcomes. CBR rates, resectability, and their impact on survival were evaluated. In addition, factors predicting CBR were identified and a predictive nomogram model was developed.

Results: Of 401 patients with LAGBC undergoing neoadjuvant chemotherapy, 303 (75.5%) exhibited a CBR. The median overall survival (OS) in patients with a CBR was 25 months, compared with 8.5 months for those without a CBR. Factors predicting a worse CBR rate included age ≥ 55.5 years (hazard ratio (HR) 2.17; 95% confidence interval (c.i.) 1.29 to 3.65), Eastern Cooperative Oncology Group (ECOG) performance status ≥ 1 (HR 2.5; 95% c.i. 1.117 to 5.59), platelet count ≥ 468 × 109/l (HR 2.86; 95% c.i. 1.12 to 6.74), tumour (T) size ≥ 2.1 cm (HR 3.4; 95% c.i. 1.70 to 6.80), T stage ≥ T3 (HR 3.26; 95% c.i. 1.22 to 8.74), and a systemic immune-inflammation index (SII) ≥ 1265.90 (HR 2.34; 95% c.i. 1.27 to 4.30). Of the patients with a CBR, 86% underwent curative surgical resection, with median OS improved to 29.54 months, compared with 11.86 months for those without resection (P < 0.01).

Conclusion: A CBR was achieved in 75.5% of patients, with curative surgical resection in 86%. A CBR was associated with improved OS. Anatomical (T size, T stage) and immune-inflammation markers (platelet count, SII) were found to predict a CBR, and could help identify responders to neoadjuvant chemotherapy. This could have implications for treatment strategies, but requires validation in further prospective studies.