The Clavien-Dindo classification of surgical complications: five-year experience

[Holmium Laser Enucleation of the Prostate (HoLEP) Compared to Robot-Assisted Simple Prostatectomy (RASP): A Propensity Score Matched Analysis]

This study investigates and compares the clinical safety and efficiency of Holmium Laser Enucleation of the Prostate (HoLEP) and robot-assisted transvesical enucleation of the prostate (RASP) for the treatment of benign prostatic hyperplasia (BPH) with large prostate volumes in a tertiary care centre. Perioperative data were collected from 39 patients who underwent RASP at our centre between 2015 and 2021. Propensity score matching was performed based on prostate volume, patient age, and body mass index (BMI), comparing these patients with 721 individuals treated with HoLEP at our clinic. An analysis was performed of preoperative parameters, including prostate volume, age, BMI, PSA level, IPSS score, and IIEF score, as well as intra- and postoperative parameters, including operative time, resected tissue weight, postoperative catheterization duration, length of hospital stay, haemoglobin decrease, transfusion rate, postoperative urinary retention, Clavien-Dindo classification (CDC), and the Comprehensive Complication Index (CCI). A statistically significant advantage was observed in favour of HoLEP regarding operative time (114.5 vs. 153.5 minutes; p<0.001), catheterization duration (2.6 vs. 7.4 days; p<0.001), and length of hospital stay (2.9 vs. 8.8 days; p<0.001). No statistically significant difference was found in terms of haemoglobin decrease or transfusion rate. The overall complication rate was lower in the HoLEP group, but the difference did not reach statistical significance (p=0.051). However, regarding the severity of complications, a statistically significant disadvantage for RASP was observed based on the CDC (p=0.027), while the CCI did not show a statistically significant difference between the cohorts (p=0.098). Both HoLEP and RASP proved to be effective and safe for the treatment of BPH with large prostate volumes. Compared to RASP, HoLEP demonstrated advantages in terms of catheterization duration and length of hospital stay. No statistically significant differences were observed regarding the overall complication rate.

Subtotal Gastrectomy for Clinical Stage I Remnant Gastric Cancer

BACKGROUND

Subtotal gastrectomy (SG) is a surgical option for early remnant gastric cancer (RGC). However, reports evaluating the feasibility and oncological safety of SG for RGC are limited. Here, we aimed to evaluate the short- and long-term outcomes of SG for RGC.

METHODS

We conducted a multi-institutional retrospective cohort study and compared the outcomes between SG and completion gastrectomy (CG) of patients with clinical stage I RGC. The short- and long-term outcomes, body weight change, and serum albumin level at 1 year postoperatively were evaluated.

RESULTS

Twenty-two and 202 patients in the SG and CG groups, respectively, were included in the analysis. The risk ratios (95% confidence interval [CI]) were 0.90 (0.27, 2.22) and 0.51 (0.33, 2.47) for the overall and severe complications, respectively. No anastomotic leakage was observed in the SG group, while 6.4% of the CG group had anastomotic leakage (p = 0.62). The 3-year relapse-free survival rates were 79.8% and 78.8% in the SG and CG groups, respectively (hazard ratio [95% CI], 0.87 [0.31, 2.40]; p = 0.80). The median body weight changes at 1 year postoperatively from the preoperative level were significantly less in the SG group (96.4% and 90.4% in the SG and CG groups, respectively; p = 0.021), and the median serum albumin changes at 1 year postoperatively were + 0.01 and -0.04 g/dL, respectively (p = 0.551).

CONCLUSION

SG might be one of the potential options for clinical stage I RGC, if the proximal margin is secured.

A randomized controlled trial of a digital lifestyle intervention involving postoperative patients with colorectal cancer

Few studies have investigated quality of life (QoL) improvements in patients with colorectal cancer or the benefits of digital healthcare interventions. This randomized controlled trial assessed the impact of mobile applications on postoperative QoL in patients scheduled for curative surgery for colorectal cancer. Patients were randomized into three intervention groups (each using a different mobile application for postoperative lifestyle management) and a control group. QoL was evaluated using the European Quality of Life-5 Dimensions (EQ-5D), with physical and metabolic parameters and fat/muscle areas measured preoperatively, and every six months postoperatively. At six months, no significant differences in the EQ-5D scores from baseline were observed across groups. Intervention Group C showed a significant increase in skeletal muscle area compared to the control group (P = 0.046). Overall, mobile application use had a minimal effect on postoperative health-related QoL, warranting further research on their efficacy and compliance rates. Trial registration: CRIS.nih.go.kr: KCT0005447. Registration date: June 23, 2020.

Acute paraesophageal hernia with gastric volvulus. Results of surgical treatment: a systematic review and meta-analysis

INTRODUCTION

Acute gastric volvulus (AGV), is an uncommon complication of large paraesophageal hernias (PEH), resulting in closed-loop obstruction that may lead to incarceration and strangulation. The aim of this study was to summarize the evidence on clinical characteristics, surgical treatment, postoperative complications (POC), recurrence, and 30-day mortality (30DM), in patients undergoing surgery for AGV secondary to PEH.

METHODS

A systematic review including studies on AGV secondary to PEH was conducted. Searches were performed in WoS, Embase, Medline, Scopus, BIREME-BV and SciELO. Primary outcomes included POC, 30DM and recurrence. Secondary outcomes comprised publication date, study origin and design, number of patients, volvulus type, hospital stay length, treatments; and methodological quality (MQ) of studies assessed using MInCir-T and MInCir-Pr2 scales. Descriptive statistics, weighted averages (WA), least squares logistic regression for comparisons, and meta-analysis of POC prevalence and HM were applied.

RESULTS

Of 1049 studies 171 met selection criteria, encompassing 15,178 patients. The WA age of patients was 75.3 ± 13.9 years, with 51.3% female. Most studies originated from USA (31.6%), with 52.6% published in the last decade. The WA of hospital stay was 7.9 ± 5.3 days. Among patients, 32.0% experienced POC, 7.6% required reinterventions and HM was 5.7%. MQ scores averaged 8.9 ± 2.3 (MInCir-T) and 13.4 ± 5.4 (MInCir-Pr2). When comparing 1990-2014 and 2015-2024 periods, there were significant differences in age, reinterventions, readmissions and recurrence rates.

CONCLUSIONS

Despite surgical and resuscitative advancements, AGV prognosis remains poor, with high POC rates, prolonged hospitalization and significant 30DM. These findings emphasize the importance of early diagnosis and timely intervention for acute PEH to improve surgical outcomes.

Comparative outcomes of laparoscopic and open surgery in inflammatory bowel disease in pediatric and young adult patients: a systematic review and meta-analysis

BACKGROUND

Pediatric inflammatory bowel disease (IBD), encompassing Crohn's disease, ulcerative colitis, and indeterminate colitis, often necessitates surgical intervention in cases of severe or refractory disease. Although biologic therapies have significantly reduced the need for surgery, operative management remains essential for certain patients. The choice between laparoscopic (laparoscopy group [LG]) and open conventional surgery (open group [OG]) continues to be a subject of debate. This meta-analysis aimed to compare the postoperative outcomes of LG and OG in pediatric patients with IBD.

METHODS

We conducted a meta-analysis of observational studies comparing LG and OG outcomes in pediatric patients with IBD. Key outcomes analyzed included major and minor postoperative complications, reoperations, readmissions, operative time, and length of hospital stay.

RESULTS

Seven studies met the inclusion criteria, analyzing 3417 patients, with 1399 (41%) undergoing OG and 2018 (59%) undergoing LG. Our analysis revealed no significant differences in major postoperative complications, reoperation, and readmissions between LG and OG (P = .114, P = .082, and P = .641, respectively). However, LG was associated with shorter hospital stays (6.04 vs 8.35 days; P < .05). Conversions from LG to open surgery amounted to a total of 153 (7.57%). Open surgery had a significantly shorter operative time (173.8 vs 195.5 min; P = .005).

CONCLUSION

Both laparoscopic and open conventional surgeries are safe, effective, and reliable in managing pediatric IBD. Although open surgery offers shorter operative times, laparoscopy reduces hospital stay and minor postoperative complications. The choice of approach depends on the surgeon's experience and patient-specific factors.

A Comparison of Machine Learning-Based Models and a Simple Clinical Bedside Tool to Predict Morbidity and Mortality After Gastrointestinal Cancer Surgery in the Elderly

Frailty in the elderly population is associated with increased vulnerability to stressors, including surgical interventions. This study compared machine learning (ML) models with a clinical bedside tool, the Gastrointestinal Surgery Frailty Index (GiS-FI), for predicting mortality and morbidity in elderly patients undergoing gastrointestinal cancer surgery. In a multicenter analysis of 937 patients aged ≥65 years, the performance of various predictive models including Random Forest (RF), Least Absolute Shrinkage and Selection Operator (LASSO), Stepwise Regression, K-Nearest Neighbors, Neural Network, and Support Vector Machine algorithms were evaluated. The overall 30-day mortality and morbidity rates were 6.1% and 35.7%, respectively. For mortality prediction, the RF model demonstrated superior performance with an AUC of 0.822 (95% CI 0.714-0.931), outperforming the GiS-FI score (AUC = 0.772, 95% CI 0.675-0.868). For morbidity prediction, all models showed more modest discrimination, with stepwise regression and LASSO regression achieving the highest performance (AUCs of 0.652 and 0.647, respectively). Our findings suggest that ML approaches, particularly RF algorithm, offer enhanced predictive accuracy compared to traditional clinical scores for mortality risk assessment in elderly cancer patients undergoing gastrointestinal surgery. These advanced analytical tools could provide valuable decision support for surgical risk stratification in this vulnerable population.

Preoperative carbohydrate loading reduces perioperative insulin resistance and hastens functional recovery of remnant liver after living donor hepatectomy: An open-label randomized controlled trial

OBJECTIVE

This study aimed to assess the effect of preoperative carbohydrate (CHO) loading on perioperative insulin resistance (PIR) and outcomes after live donor hepatectomy. The primary objective of the trial was to compare PIR on postoperative day (POD) 2 between preoperative oral carbohydrate (CHO) loading and overnight fasting groups. The secondary objectives were to compare the functional recovery of the remnant liver, incidence of postoperative nausea and vomiting (PONV) up to 72 h after surgery, inflammatory markers, and length of hospital stay (LOS) between both groups.

BACKGROUND

Preoperative fasting increases perioperative insulin resistance (PIR). Insulin resistance has deleterious effects on liver regeneration following partial hepatectomy.

METHODS

Single-center, open-label, randomized controlled trial. After exclusion, 70 donors were recruited (35 from each group). Donors in the intervention arm received 50 g of maltodextrin at 10 PM the night before surgery and 25 g of maltodextrin 2 h before anesthesia induction on the day of surgery, whereas those in the control arm followed a minimum of 6 h of overnight fasting. The PIR was assessed using the Homeostatic Model for Assessment of Insulin Resistance (HOMA-IR).

RESULTS

Baseline and intraoperative parameters were comparable between the two groups. CHO loading provided better postoperative glycemic control (p < 0.01) and reduced PIR by > 50% (p < 0.01) compared to preoperative fasting. Although postoperative complications, inflammatory markers, and LOS were comparable between the groups, there was a significant attenuation of postoperative nausea (p = 0.01) and vomiting (p = 0.013) with early soft diet tolerance (p = 0.002) in the CHO group. In addition, preoperative carbohydrate loading accelerated functional recovery of the remnant liver, with earlier normalization of serum bilirubin levels (p = 0.002).

CONCLUSION

CHO supplementation is safe and effective in shortening preoperative fasting during donor hepatectomy without significant postoperative risks. It can be considered a standard of care in donor surgery ERAS (Enhanced Recovery After Surgery) protocols for live donor liver transplantations.

REGISTRATION NUMBER

NCT05293444 ( www.

CLINICALTRIALS

gov ).

The impact of ERAS protocol on laparoscopic sleeve gastrectomy and one anastomosis gastric bypass (OAGB): analysis of length of stay (LOS), complications, and readmission

Enhanced Recovery After Surgery (ERAS) protocols have transformed care in bariatric surgery, leading to faster recovery and shorter hospital stay. This study evaluates the impact of ERAS protocols on laparoscopic sleeve gastrectomy (SG) and one anastomosis gastric bypass (OAGB), focusing on key elements such as length of stay (LOS), postoperative complications, and readmission rates. A retrospective data analysis was conducted on patients who underwent SG or OAGB under an ERAS protocol from 2021 to 2024 evaluating a total of 181 patients in both groups. Data on LOS, complications, and readmissions were collected and compared between the two groups. The results indicate that the implementation of ERAS protocols significantly reduces LOS for both SG and OAGB patients, with average reductions of 1.2 days and 1.5 days, respectively. Additionally, the complication rates and readmission rates were found to be lower in patients undergoing these procedures with ERAS protocols compared to historical controls (Kehlet in Br J Anaesth 78:606-617, 1997; Stenberg et al. in World J Surg 46:729-751, 2022). This study highlights the effectiveness of ERAS in optimising recovery and reducing hospital costs in bariatric surgery. In the UK, only about 50% of bariatric units use a formal Enhanced Recovery After Surgery (ERAS) pathway. Using these protocols is important for improving patient outcomes by reducing complications and shortening hospital stays (Stenberg et al. in World J Surg 46:729-751, 2022).

A simplified stent-bridging pancreaticogastrostomy during pancreaticoduodenectomy: How I do it

BACKGROUND

Pancreaticoduodenectomy (PD) remains the standard approach for benign or malignant disease in the pancreatic head and periampullary regions. Despite attempts of diverse pancreatic anastomosis, no reliable pancreatic anastomosis has been recommended.

METHODS

Between July 2023 to December 2023, a novel method of pancreaticogastrostomy (PG) using a stent bridging the remnant pancreas and the stomach were applied to drain the pancreatic juice into the gastric cavity in 12 consecutive open and laparoscopic cases. The surgical details and postoperative outcomes were analyzed to evaluate this method.

RESULTS

The mean operation time was 318 ± 51.60 min. The mean time for the stent-bridging PG was 25.90 ± 4.86 min. No incidence of grades B or C postoperative pancreatic fistula (POPF) or anastomotic failure was occurred during the median follow-up period of 10.20 ± 1.55 months.

CONCLUSION

The stent-bridging PG had the advantages of safety, simplicity and promising efficacy by complete diversion of pancreatic juice and minimal manipulation of the pancreatic remnant under open or laparoscopic PD, proving its value as an alternative technique for mitigating the risk of POPF. By understanding the standardized procedures, surgeons can achieve consistent and reproducible results in complex pancreatic anastomosis. However, further evaluation with clinical trials is required to validate its real benefits.

Predictors of difficulty in robotic splenic flexure mobilization during rectal cancer surgery

PURPOSE

In surgery for rectal cancer, splenic flexure mobilization is sometimes necessary to ensure a tension-free colorectal anastomosis with adequate blood supply. Splenic flexure mobilization is regarded as a challenging and risky maneuver, but there are no clear indicators of its difficulty in rectal cancer surgery. This study evaluated the impact of clinical and anatomical factors, including splenic flexure height measured qualitatively on the basis of vertebral level using computed tomography, on the difficulty of splenic flexure mobilization during rectal cancer surgery.

METHODS

The enrolled patients underwent robotic splenic flexure mobilization during rectal surgery for primary rectal cancer at Shizuoka Cancer Center in Japan between December 2011 and March 2022. All patients were scheduled to undergo splenic flexure mobilization preoperatively, and all procedures were carried out following a standardized approach. Linear regression analysis was conducted to determine the clinical and anatomical factors significantly influencing the operative time of the abdominal phase, which is defined as the duration from lymph node dissection around the inferior mesenteric artery to the mobilization of the sigmoid and descending colon, including the splenic flexure.

RESULTS

The median operative time for the abdominal phase was 88 min (range, 39-179 min). Univariate analysis revealed that the following variables were significantly correlated with a prolonged abdominal phase: higher body mass index, larger visceral fat area, and higher splenic flexure. In a multiple linear regression analysis, only higher splenic flexure remained significantly associated with a longer abdominal phase (p < 0.01).

CONCLUSIONS

Splenic flexure height measured on the basis of vertebral level using computed tomography may be useful for predicting the difficulty of robotic splenic flexure mobilization in surgery for rectal cancer.

Association of health literacy and general self-efficacy with emergency department visits for unclear abdominal pain after bariatric surgery

INTRODUCTION

Emergency department visits are common following bariatric surgery and may be partially preventable. Health literacy and general self-efficacy are factors that may influence health-seeking behaviors in these patients. This study aimed to assess whether health literacy and general self-efficacy are associated with an increased frequency of emergency department visits after bariatric surgery.

METHODS

Patients who underwent bariatric surgery at a single hospital from 2018 to 2020 were evaluated for their health literacy and general self-efficacy levels before surgery. Data on emergency department visits within the patient's residential region were evaluated over a three-year period, with repeated emergency department visits for abdominal pain as the primary outcome.

RESULTS

During the follow-up period, 69 of 231 patients (29.9%) had at least one emergency department visit for abdominal pain, and 20 patients (8.7%) had three or more visits. Inadequate functional health literacy (OR 5.56, 95% CI 1.80-17.19, p = 0.003) and inadequate communicative and critical health literacy (OR 10.48, 95% CI 3.13-35.08, p < 0.001) were both significantly associated with an increased risk of repeated emergency department visits over the three-year period. No significant association was found between low general self-efficacy and the frequency of emergency department visits.

CONCLUSIONS

Inadequate health literacy is associated with an increased risk of repeated emergency department visits for abdominal pain following bariatric surgery.

The impact of frailty on functional recovery and discharge dispositions in patients undergoing urgent neurosurgical care

Frailty indices have emerged as robust predictors of morbidity and mortality following neurosurgical interventions. However, their impact on long-term functional and cognitive outcomes remains insufficiently characterised. This study evaluated the prognostic significance of frailty in patients undergoing emergency neurosurgical care and subsequent neurorehabilitation. Based on a cumulative deficit model, a validated 34-item Frailty Index (FI) was applied retrospectively to patients admitted for acute neurosurgical care at a tertiary academic centre and transferred to a specialised neurological rehabilitation facility. Perioperative clinical data, postoperative complications, and discharge dispositions were analysed. A total of 236 patients (median age: 64 years) were included, with 75 (31.8%) classified as "Fit," 87 (36.9%) as "Semi-fit," and 74 (31.4%) as "Frail." Only 13 (17.6%) frail patients returned home post-rehabilitation, compared to 64 (85.3%) fit and 61 (70.1%) semi-fit patients (p = 0.0006). Multivariable logistic regression confirmed FI as an independent predictor of unfavourable discharge destinations (hospital or nursing home vs. home; adjusted odds ratio: 3.615, 95% CI: 1.655-5.580; p = 0.0094). Frailty significantly influences postoperative recovery, predicting greater disability, lower neurological and cognitive function, and unfavourable discharge outcomes. Incorporating frailty assessment into routine emergency practice and research protocols may refine risk stratification and inform clinical decision-making for acutely ill patients undergoing neurosurgical interventions.

Effectiveness of an Enhanced Recovery After Surgery (ERAS) Program in Hip Arthroplasty in a Developing Country: A Propensity Score-Matched Study from Vietnam

Background

Delayed recovery and adverse outcomes frequently follow hip arthroplasty, often due to comorbidities in elderly patients and the invasive nature of the surgery. Although Enhanced Recovery After Surgery (ERAS) programs are widely recommended in developed nations, their effectiveness in developing countries remains under-researched.

Objective

This study aims to evaluate the effectiveness of the ERAS program in improving outcomes for patients undergoing hip arthroplasty.

Patients and Methods

This retrospective observational study was conducted at a single university medical center. Propensity score matching was employed to ensure comparability between the ERAS and routine care groups. The primary outcome measured was the post-operative length of stay. Secondary outcomes focused on rates of complications. Tertiary outcomes included other clinical events and symptoms.

Results

The study initially enrolled 769 participants and retained 548 after matching. In the primary outcome, the ERAS group had a shorter length of stay, with a median of 6.1 compared to 7.0 days (Hodges-Lehmann estimate of 0.9 days, 95% confidence interval of 0.2 to 1.0 days, p<0.001). In secondary outcomes, the ERAS group showed lower incidences of composite complications (25.6% vs 33.6%, p=0.040) and respiratory complications (6.9% vs 13.1%, p=0.023). In tertiary outcomes, the ERAS group had lower rates of constipation (27.0% vs 38.3%, p=0.006) and perioperative hyponatremia (21.5% vs 29.6%, p=0.040). No statistically significant differences were observed in the remaining outcomes.

Conclusion

The ERAS program improved patient outcomes by reducing length of stay and complications for those undergoing hip arthroplasty in our country. Therefore, this study confirms the effectiveness of ERAS programs and advocates for their broader implementation in similar healthcare settings.

Prophylactic abdominal drainage for pancreatic surgery

RATIONALE

This is the fourth update of a Cochrane review first published in 2015 and last updated in 2021. The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial.

OBJECTIVES

To assess the benefits and harms of routine abdominal drainage after pancreatic surgery; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.

SEARCH METHODS

We searched CENTRAL, MEDLINE, three other databases, and five trials registers, together with reference checking and contact with study authors, to identify studies for inclusion in the review. The search dates were 20 April 2024 and 20 July 2024.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) in participants undergoing pancreatic surgery comparing (1) drain use versus no drain use, (2) different types of drains, or (3) different schedules for drain removal. We excluded quasi-randomised and non-randomised studies.

OUTCOMES

Our critical outcomes were 30-day mortality, 90-day mortality, intra-abdominal infection, wound infection, and drain-related complications.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess the risk of bias in RCTs.

SYNTHESIS METHODS

We synthesised the results for each outcome using meta-analysis with the random-effects model where possible. We used GRADE to assess the certainty of evidence for each outcome.

INCLUDED STUDIES

We included 12 RCTs with a total of 2550 participants. The studies were conducted in North America, Europe, and Asia and were published between 2001 and 2024. All studies were at overall high risk of bias.

SYNTHESIS OF RESULTS

We considered the certainty of the evidence for intra-abdominal infection for the comparison of early versus late drain removal following pancreaticoduodenectomy to be moderate, downgraded due to indirectness. We considered the certainty of the evidence for the other outcomes to be low or very low, mainly downgraded due to high risk of bias, inconsistency, indirectness, and imprecision. Drain use versus no drain use following pancreaticoduodenectomy We included two RCTs with 532 participants randomised to the drainage group (N = 270) and the no drainage group (N = 262) after pancreaticoduodenectomy. The evidence is very uncertain about the effect of drain use on 30-day mortality (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.07 to 3.66; 2 studies, 532 participants), 90-day mortality (RR 0.25, 95% CI 0.06 to 1.15; 1 study, 137 participants), intra-abdominal infection rate (RR 0.85, 95% CI 0.21 to 3.51; 2 studies, 532 participants), and wound infection rate (RR 0.85, 95% CI 0.55 to 1.31; 2 studies, 532 participants) compared with no drain use. Neither study reported on drain-related complications. Drain use versus no drain use following distal pancreatectomy We included two RCTs with 626 participants randomised to the drainage group (N = 318) and the no drainage group (N = 308) after distal pancreatectomy. There were no deaths at 30 days in either group. The evidence is very uncertain about the effect of drain use on 90-day mortality (RR 0.16, 95% CI 0.02 to 1.35; 2 studies, 626 participants), intra-abdominal infection rate (RR 1.20, 95% CI 0.60 to 2.42; 1 study, 344 participants), and wound infection rate (RR 2.12, 95% CI 0.93 to 4.87; 2 studies, 626 participants) compared with no drain use. Neither study reported on drain-related complications. Active versus passive drain following pancreaticoduodenectomy We included three RCTs with 441 participants randomised to the active drain group (N = 222) and the passive drain group (N = 219) after pancreaticoduodenectomy. The evidence is very uncertain about the effect of an active drain on 30-day mortality (RR 1.24, 95% CI 0.30 to 5.07; 2 studies, 321 participants), intra-abdominal infection rate (RR 0.58, 95% CI 0.06 to 5.43; 3 studies, 441 participants), and wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; 2 studies, 321 participants) compared with a passive drain. None of the studies reported on 90-day mortality. There were no drain-related complications in either group (1 study, 161 participants; very low-certainty evidence). Early versus late drain removal following pancreaticoduodenectomy We included three RCTs with 557 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 279) and the late drain removal group (N = 278) after pancreaticoduodenectomy. Low-certainty evidence suggests that early drain removal may result in little to no difference in 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; 3 studies, 557 participants) and wound infection rate (RR 1.07, 95% CI 0.47 to 2.46; 3 studies, 557 participants) compared with late drain removal. Moderate-certainty evidence shows that early drain removal probably results in a slight reduction in intra-abdominal infection rate compared with late drain removal (RR 0.45, 95% CI 0.26 to 0.79; 3 studies, 557 participants). Approximately 58 (34 to 102 participants) out of 1000 participants in the early removal group developed intra-abdominal infections compared with 129 out of 1000 participants in the late removal group. There were no deaths at 90 days in either study group (2 studies, 416 participants). None of the studies reported on drain-related complications.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of drain use compared with no drain use on 90-day mortality, intra-abdominal infection rate, and wound infection rate in people undergoing either pancreaticoduodenectomy or distal pancreatectomy. The evidence is also very uncertain whether an active drain is superior, equivalent, or inferior to a passive drain following pancreaticoduodenectomy. Moderate-certainty evidence suggests that early drain removal is probably superior to late drain removal in terms of intra-abdominal infection rate following pancreaticoduodenectomy for people with low risk of postoperative pancreatic fistula.

FUNDING

None.

REGISTRATION

Registration: not available. Protocol and previous versions available via doi.org/10.1002/14651858.CD010583, doi.org/10.1002/14651858.CD010583.pub2, doi.org/10.1002/14651858.CD010583.pub3, doi.org/10.1002/14651858.CD010583.pub4, and doi.org/10.1002/14651858.CD010583.pub5.

Effects of an opioid-free care pathway vs. opioid-based standard care on postoperative pain and postoperative quality of recovery after laparoscopic bariatric surgery: A multicentre randomised controlled trial

BACKGROUND

Opioid-free anaesthesia (OFA) may enhance postoperative recovery after bariatric surgery, but its combined effect with opioid-free interventions has not been studied.

OBJECTIVES

To compare postoperative pain and recovery after laparoscopic bariatric surgery with a total opioid-free care pathway and conventional opioid-based treatment.

DESIGN

A multicentre nonblinded controlled trial.

SETTING

Two university hospitals in Sweden.

PATIENTS

Adult patients scheduled for laparoscopic bariatric surgery were enrolled between May 2019 and November 2023. Of 837 patients screened, 112 were randomised, and 110 were included in the analysis: 55 in the intervention and 55 in the control group.

INTERVENTIONS

Patients were randomised to an opioid-based standard care (control group) or to an opioid-free care pathway (intervention group), including intraoperative OFA and postoperative first-line transcutaneous electrical nerve stimulation (TENS) treatment.

MAIN OUTCOME MEASURES

The primary outcome was the change in patient-reported postoperative pain intensity on a numerical rating scale (NRS) from arrival in the postanaesthesia care unit (PACU) until discharge to the surgical ward. Key secondary outcomes were postoperative pain intensity, in-hospital opioid consumption, and postoperative quality of recovery scale (PQRS) scores.

RESULTS

There was no difference between the groups regarding the changes in pain intensity from arrival in PACU until discharge to the ward, with mean ± SD changes in NRS of 3.20 ± 3.01 (intervention) vs. 3.15 ± 2.25 (control); mean difference (MD) 0.04 [(95% confidence interval (CI), -1.00 to 1.08); P = 0.97], and pain intensity at 24 h (P = 0.078), 72 h (P = 0.060), and 3 months (P = 0.30) postoperatively. The intervention group had a significantly lower opioid consumption in the PACU; mean morphine equivalents 6.08 ± 12.31 vs. 51.1 ± 14.9 mg; MD -45.0 (95% CI, -50.1 to -39.8) mg; P < 0.0001; and during the hospital stay MD -40.3 (95% CI, -54.4 to -25.9) mg; P < 0.0001. Total PQRS scores did not differ significantly over the 3-month follow-up.

CONCLUSION

The opioid-free care pathway offers patients pain relief and recovery outcomes comparable to conventional opioid-based care and reduces opioid use after laparoscopic bariatric surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03756961.

Ejaculatory function after robotic waterjet ablation for the treatment of benign prostatic hyperplasia: a systematic review

Robotic waterjet ablation (RWJA), known by the trade name of Aquablation, is a minimally invasive, heat-free technique for treating benign prostatic hyperplasia (BPH) that offers comparable efficacy to transurethral resection of the prostate (TURP). Unlike TURP, RWJA utilizes targeted tissue mapping, potentially enhancing the preservation of sexual function, particularly antegrade ejaculation. This systematic review evaluated sexual outcomes following RWJA, emphasizing ejaculatory dysfunction and antegrade ejaculation preservation. A literature search conducted through January 1, 2025, in PubMed, Embase, and Cochrane databases identified 15 studies involving 1533 patients. Preservation rates of antegrade ejaculation post-RWJA ranged from 72 to 99.6%. Erectile function remained stable across all reviewed studies. Notably, a randomized controlled trial comparing RWJA to TURP demonstrated significantly lower rates of ejaculatory dysfunction in the RWJA group, maintained for up to five years. Despite promising findings indicating durable preservation of ejaculatory function, there remain limitations due to a scarcity of randomized controlled trials and limited long-term follow-up beyond 12 months. Future comparative studies evaluating RWJA against other minimally invasive BPH treatments are needed to further validate these findings and better define the sexual function outcomes associated with this innovative procedure.

Performing robot-assisted minimally invasive esophagectomy for patients with a narrow mediastinum and left-shifted esophagus for esophageal squamous cell carcinoma presents further challenges

BACKGROUND

Several studies have compared robot-assisted minimally invasive esophagectomy (RAMIE) with conventional minimally invasive surgery (C-MIE). However, the anatomical factors that may make certain patients more suitable for RAMIE remains unclear. This study compared the surgical outcomes of RAMIE with those of C-MIE in patients with narrow mediastinum and left-shifted esophagus.

METHODS

Between January 2017 and December 2023, 260 patients with esophageal squamous cell carcinoma (ESCC) who underwent MIE (C-MIE or RAMIE) at Kobe University Hospital were included in the study. We developed a new index to assess the narrow mediastinum and left-shifted esophagus at the tracheal bifurcation level using computed tomography imaging. Cox proportional hazards regression analyses were performed to identify the prognostic factors.

RESULTS

Patients with a narrow mediastinum and left-shifted esophagus had a higher incidence of recurrent laryngeal nerve (RLN) palsy and fewer lymph nodes dissections than other patients (p = 0.026 and p = 0.051, respectively). In the entire cohort, the operative time in the RAMIE group was longer than that in the C-MIE group (< 0.0001). No significant differences in other variables, including RLN palsy, were observed between the two groups. Among patients with narrow mediastinum and left-shifted esophagus, RAMIE was associated with longer operative time and fewer lymph nodes dissected from the left and right sides of the upper mediastinum compared to C-MIE (p < 0.0001, 0.0001, and 0.0001, respectively). Regarding the RLN palsy, there was no significant difference (p = 0.79).

CONCLUSIONS

There are challenges in performing RAMIE in patients with a narrow mediastinal and left-shifted esophagus. Therefore, establishing an effective procedure for these patients is important.

Total neoadjuvant therapy for locally advanced rectal cancer

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effectiveness and safety of total neoadjuvant therapy versus standard therapy in individuals with locally advanced rectal cancer.

Is there a role for the sentinel lymph node in endometrial atypical hyperplasia? Insights from an ESGO-accredited Institution

INTRODUCTION

This study investigates the outcomes of patients with premalignant endometrial findings on biopsy who underwent hysterectomy with sentinel lymph node (SLN) excision and were subsequently diagnosed with endometrial cancer (EC). It aims to highlight the role of nodal assessment in guiding postoperative treatment strategies. Additionally, the study compares surgery complication rates between patients who underwent SLN mapping and those who did not.

METHODS

This retrospective, observational, single-center study was conducted at Udine Hospital between April 2021 and July 2024. 63 patients diagnosed with atypical hyperplasia on endometrial biopsy who underwent hysterectomy and bilateral salpingo-oophorectomy, with or without SLN mapping, were included. All procedures were performed using minimally invasive surgery.

RESULTS

Of the 63 patients, 35 (55.6 %) had confirmed atypical hyperplasia on uterine pathology, while 23 (36.5 %) were diagnosed with EC on final pathology. Of the patients who underwent SLN mapping, 18 (43 %) received a final diagnosis of EC and were accurately staged and treated accordingly. In contrast, within the group of patients treated without SLN mapping, 5 (24 %) were diagnosed with EC on final pathology and didn't receive proper staging. No nodal metastases were found in both groups. There was no statistically significant difference in operating time and complication rates between the two groups (with or without SLN mapping), further supporting the procedure's safety.

CONCLUSIONS

This study's findings underscore the significance of incorporating SLN mapping into hysterectomy and bilateral salpingo-oophorectomy for patients with atypical hyperplasia. This approach enhances accurate staging for patients diagnosed with endometrial cancer on final pathology.

Does Size Outweigh Number in Predicting Survival After Pulmonary Metastasectomy for Soft Tissue Sarcoma? Insights from a Retrospective Multicenter Study

BACKGROUND

Pulmonary metastasectomy (PM) is the most frequently performed local ablative therapy for leiomyosarcoma (LMS), synovial sarcoma (SyS), and undifferentiated pleomorphic sarcoma (UPS). This study aimed to assess surgical feasibility, outcome, and clinical prognostic factors, as well as the value of a peri-interventional systemic therapy.

METHODS

This multicenter retrospective study enrolled 77 patients with LMS, SyS, or UPS who underwent first-time complete resection of isolated lung metastases between 2009 and 2021. Disease-free survival (DFS), overall survival (OS), and clinical prognostic factors were analyzed.

RESULTS

After the first PM, the median DFS was 7.4 months, and the median OS was 58.7 months. A maximal lesion diameter greater than 2 cm was associated with reduced DFS in both the univariable (hazard ratio [HR], 2.29; p = 0.006) and multivariable (HR, 2.60; p = 0.005) analyses. The univariable analysis identified a maximal lesion diameter greater than 2 cm as an adverse prognostic factor for OS (HR, 5.6; p < 0.001), whereas a treatment-free interval longer than 12 months was associated with improved OS (HR, 0.42; p = 0.032). The addition of systemic therapy was associated with a trend toward improved DFS for patients with lesions larger than 2 cm (HR, 0.29; p = 0.063). Severe postoperative complications (grade ≥IIIa) occurred in 2 % of the patients.

CONCLUSION

The size of resected lung metastases might be a more relevant prognostic factor than their number for patients with LMS, SyS, or UPS. For patients with lung metastases larger than 2 cm in maximal diameter, additional systemic therapy may be warranted.

Predictive value of modified frailty index-5 to major complications after videothoracoscopic pulmonary resections

Although minimally invasive methods have become widespread, pulmonary resections due to lung cancer continue to be an important cause of postoperative morbidity. Herein, we have investigated the predicting efficacy of modified frailty index-5 (MFI-5) for postoperative complications in patients who underwent pulmonary resection by VATS for non-small cell lung cancer (NSCLC). We retrospectively reviewed the data of patients who underwent VATS lobectomy/segmentectomy for NSCLC. MFI-5 score was calculated according to hypertension, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, and functional independence status. Major postoperative complications were determined based on Clavien-Dindo classification. The predictive efficacy of MFI-5 score for major complications was tested by univariate and multivariate logistic regression analysis. A total of 336 patients were included in the study. The mean age was 65.6 ± 9.8 years. MFI-5 score was zero in 126 (37.5%) patients and positive in 210 patients. The major complication rate was 25.9%. Multivariate analysis showed that 2 and higher MFI-5 score significantly predicted the presence of postoperative major complications (p: 0.004, OR: 4.3, 1.58-12.5 95% CI). The MFI-5 score can significantly predict the presence of major postoperative complications, including 30-day mortality, in patients undergoing VATS pulmonary resection for NSCLC. Clinical registration 2024-324, approved by Gazi University Local Ethics Committee.

Perioperative Oral decontamination and ImmunoNuTrition (POINT) to prevent postoperative pulmonary complications in elderly patients scheduled for elective non-cardiac surgeries: protocol for a multicentre, randomised controlled trial

INTRODUCTION

Elderly patients are known to be vulnerable to postoperative pulmonary complications (PPCs), especially pneumonia. Apart from elder age, preoperative pulmonary diseases, anaemia, malnutrition, dysphagia and frailty may all be contributing factors to PPCs. Poor oral hygiene is a risk factor for PPC as well, as oropharyngeal microflora might be introduced to the lower respiratory tract following endotracheal intubation for general anaesthesia during surgery. Immune regulation, nutrition supplementation and improvement of oropharyngeal microflora might regulate immune and stress response and can be beneficial to elderly patients exposed to surgical stress. In this study, we will explore the effects of perioperative oral decontamination and immunonutrition supplementation on the incidence of postoperative pneumonia in high-risk elderly surgical patients.

METHODS AND ANALYSIS

This study is a multicentre, two-by-two factorial randomised controlled trial evaluating the efficacy of immunonutrition supplementation and oral chlorhexidine decontamination. A total of 592 patients aged 65 years and older who are scheduled for elective non-cardiac surgeries in seven tertiary hospitals in China will be recruited. Patients will be excluded if they have contraindications to the intervention. Patients will be randomised into four groups in a 1:1:1:1 ratio (oral decontamination vs routine oral care, immunonutrition supplementation vs routine nutrition advice). The primary outcome is the incidence of PPCs within 7 days after surgery. The secondary outcomes are the incidence of postoperative pneumonia, infectious complications, Comprehensive Complication Index, postoperative functional recovery, length of hospital stay and hospital expenses. Intention to treat principles will be applied to all outcomes. Descriptive analysis will be used to compare patients' baseline characteristics. Logistic regression will be used to compare the incidence of PPCs within 7 days after surgery between different groups.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Research Ethics Committee of Peking Union Medical College Hospital (I-23PJ953). All participants will provide written informed consent. Study results will be published in peer-reviewed journals and presented at academic conferences.

TRIAL REGISTRATION NUMBER

NCT05971810.

Tips and tricks of spinal cord biopsy: insights from a multicenter series of 61 patients

PURPOSE

Whenever the radiological and clinical presentation of diffuse spinal cord lesions pose diagnostic and therapeutic dilemmas, the role of primary spinal cord biopsies (SCB) can represent a crucial surgical step to guide further management. However, the benefits of SCB comes with the risks of significant neurological worsening and potentially non-diagnostic findings. An evidence-based algorithm to assess the appropriateness of SCB and its chances of successful diagnosis is currently lacking.

METHOD

A multicenter retrospective study was conducted across 8 tertiary neurosurgery European centers and included all patients undergoing primary SCB between January 2005 and December 2020. The main objective of this study was to assess the positive diagnostic rate, while the secondary objective was to evaluate the rate of neurological deterioration.

RESULTS

Histological diagnoses were obtained in 91.8% (56/61) of cases. Lesions spanning more than three spinal levels were significantly associated with non-diagnostic biopsies (p = 0.03). Neurological deterioration occurred in 47.5% (29/61) of patients, with 48,3% recovering within three weeks. Independent risk factors for postoperative deterioration included low-grade glioma (LGG) (p = 0.005) and lymphoma (p = 0.007). Intraoperative Ultrasound (IoUS) was significantly associated with reduced postoperative deficits (p = 0.030). Surprisingly, preoperative clinical and radiological diagnoses differed from histopathological findings in 47.5% of cases.

CONCLUSION

SCB are relatively safe and effective diagnostic procedures despite their inherent risk of significant perioperative neurological worsening. The decision to undertake a primary SCB should always be made in a multidisciplinary setting after careful review of clinical and diagnostic findings.

Risk factors for postoperative anastomotic leakage in obstructive left colonic carcinoma

Anastomotic leakage (AL) is one of the most severe complications of colon carcinoma surgery. This study aims to investigate the related factors of AL and evaluate the independent risk factors in predicting AL after one-stage resection and primary anastomosis (RPA) for obstructive left colonic carcinoma (OLCC) patients. The demographic and clinical data, intra-operative indexes, pathologic characteristics, and ileocecal valve status shown on CT of the patients with OLCC who submitted to one-stage RPA were retrospectively analyzed. They were divided into AL group and no AL group. All indexes of the two groups were compared and the independent risk factors for AL were investigated. Receiver operating characteristic (ROC) curve analysis was used to explore the ability of the statistically significant parameters to predict AL. A total of 141 patients (AL group, 15; no AL group, 126) were enrolled. There were no statistical differences in these indexes between the two groups except for BMI (P = 0.001), ALB (P = 0.020), lymphatic metastasis (P = 0.027), and ileocecal valve status (P < 0.001). BMI, ALB, and ileocecal valve status shown on CT were the independent risk factors for AL. A BMI and ALB cutoff value of 22.2 kg/m2 and 27.9 g/L showed the area under the curve (AUC 0.765; 95% CI 0.686-0.832 and 0.684; 95% CI 0.601-0.760) in predicting AL, separately. Higher BMI, lower ALB, and incontinent ileocecal valve shown on preoperative CT may indicate an increased risk of postoperative AL after one-stage RPA for OLCC patients.

Effect of Low Thoracic Paravertebral Block via the Arcuate Ligament Under Direct Visualization on the Quality of Postoperative Recovery After Laparoscopic Donor Nephrectomy for Living-Donor Kidney Transplantation: Study Protocol for a Prospective, Blinded, Randomized Controlled Clinical Trial

Introduction

Laparoscopic donor nephrectomy (LDN) is the standard procedure for donor nephrectomy for living kidney transplantation. Compared with traditional open surgery, the laparoscopic techniques have been developed to significantly reduce postoperative pain and accelerate postoperative recovery; however, most donors still experience more than moderate pain after surgery. Ensuring maximum perioperative safety and postoperative pain control for donors remains a top priority for LDN. Our group reported a novel blockade technique that allows local anesthetic to be injected directly to reach the low thoracic paravertebral space under direct laparoscopic observation via the arcuate ligament to achieve somatic and visceral pain analgesia; this technique has been successfully applied to patients undergoing retroperitoneal laparoscopic nephrectomy. We hypothesized that compared with the transversus abdominis plane (TAP) block, low thoracic paravertebral block (TPVB) via the arcuate ligament under direct vision would reduce the consumption of postoperative opioids and improve the quality of postoperative recovery of donors after LDN.

Methods/Analysis

This study is a prospective blind, randomized, controlled clinical trial with a concealed allocation of donors scheduled to undergo elective LDN 1:1 to receive either a low TPVB via the arcuate ligament under direct vision or a TAP block. This study will recruit a total of 82 living kidney donors. The primary outcome is the 15-item recovery quality scale (QoR-15) score at 24 hours after surgery.

Ethics and Dissemination

This trial was approved by the Ethics Committee of Beijing Friendship Hospital, Capital Medical University. This trial study protocol was approved on 30 November 2024. The trial started recruiting patients after being registered on the Chinese Clinical Trial Registry.

Trial Registration Number

ChiCTR2400094612.

Thoracoscopic Repair of Recurrent CDH is Associated with a Significantly Lower Complication Rate and Shorter ICU and Hospital Stay: A Prospective, Propensity Score-Matched Analysis

Congenital diaphragmatic hernia (CDH) is a malformation that significantly impacts neonatal morbidity and mortality. Recurrence after surgical repair remains a potentially life-threatening long-term complication. Conventionally, recurrent CDH has been managed through open surgery. However, thoracoscopic repair (TR) represents a novel alternative for recurrent CDH as it has reduced the length of hospital stay and mortality rate in the primary CDH repair.A prospective, propensity score-matched analysis was conducted on pediatric patients who underwent recurrent CDH repair at the University Hospital Mannheim between 2013 and 2023, to compare the outcomes of laparotomy versus TR. Patients were categorized based on the surgical technique employed. Comparative analysis, including propensity scoring, encompassed outcome measures such as duration of ICU and hospital stays, rate of complications, and operative duration.In total, 703 patients were treated for CDH, of whom 69 children underwent laparotomy (56) or TR (16) for CDH recurrence. After propensity score matching, TR group demonstrated a significantly shorter duration of surgery (178 [93-311] versus 225 [113-450] min, p = 0.042), reduced ICU stay (0 [0-10] versus 1 (0-69) days, p = 0.011), and decreased overall hospital stay (6 [3-34] versus 12 [7-40] days, p = 0.001). Moreover, the postoperative complications were significantly lower in the TR group (21.43% versus 73.68%, p = 0.003).TR for recurrent CDH repair is associated with shorter operation times, reduced ICU and overall hospital stays, and fewer complications compared with laparotomy. These findings suggest that TR may be preferable for the management of recurrent CDH, warranting larger randomized controlled studies to confirm the long-term safety and efficacy of this approach.

Comparative Analysis of Laparoscopic Sleeve Gastrectomy with and Without Prior Endoscopic Intragastric Balloon Insertion: Examining Stomach Volumetry, Histopathologic Changes, Hormonal Levels, and Postoperative Outcomes

BACKGROUND

The effects of prior intragastric balloon (IGB) placement on stomach volumetry, surgical technique, and outcomes in laparoscopic sleeve gastrectomy (LSG) patients are unclear.

METHODS

This prospective cohort study analyzed stomach histology, gastric volume, and hormonal markers in 90 LSG patients (45 with prior IGB, 45 without). We assessed stomach wall thickness, fibrosis, smooth muscle density, and ghrelin-positive cells, along with intraoperative parameters like stapler cartridge use and operative time. Postoperative outcomes, including weight loss and food tolerance (FT), were compared between groups at 6 months and 1 year.

RESULTS

In the 6th month and 1st year, the two groups had no differences in weight, BMI, and %TWL before and after the Inverse Propensity Score-Weighted adjustment. The IGB group had significantly increased muscular thickness, smooth muscle cell count, and fibrosis (p < 0.001) but similar mucosa thickness and inflammation. Preoperative stomach and resected specimen volumes were higher in the IGB group (p < 0.001). Both groups showed slight increases by 1 year, with no significant FT differences. Furthermore, no significant difference in postoperative complications was noted. Hormonal changes were observed, including lower leptin levels in the IGB group throughout.

CONCLUSION

While prior intragastric balloon (IGB) placement induces significant volumetry changes and hormone levels, it does not affect surgical outcomes-including postoperative complications, weight loss, resolution of associated medical problems, the duration of IGB placement, or the interval between IGB removal and LSG surgery-compared to those without IGB.

Long-term health-related quality of life in oral cancer survivors following microvascular tongue reconstruction

BACKGROUND

Evaluation of long-term health-related quality of life (HRQOL) is essential for optimization of functional and psychological outcomes in head and neck cancer survivors. However, few studies have assessed long-term HRQOL in survivors following microvascular tongue reconstruction.

METHODS

A retrospective, cross-sectional study was performed, including all consecutive patients who underwent microvascular reconstruction following tongue cancer resection between 2010 and 2020. The primary outcome was HRQOL, assessed using the FACE-Q Head and Neck Cancer Module at least 3 years after surgery. Patients were grouped by the extent of the resection: partial or hemiglossectomy versus (sub)total glossectomy. Multivariable analyses were performed between clinical variables and HRQOL.

RESULTS

Overall, 77 of 108 invited patients with a microvascular tongue reconstruction could be included with a mean follow-up of 7.9 years (SD 2.6) after surgery. Partial or hemiglossectomy was performed in 66 patients (86 %) and (sub)total glossectomy in 11 patients (14 %). In the long-term, mostly functional domains (eating, oral competence, salivation, speech and swallowing) and psychological domains of eating distress and speaking distress were affected. In multivariable analyses, postoperative radiotherapy was associated with worse speech (p = 0.002) and swallowing function (p = 0.027). (Sub)total glossectomy was significantly associated with worse speech (p = 0.011). Older age at surgery was significantly associated with poorer oral competence (p = 0.004). Females had significantly lower scores for the domain of swallowing (p = 0.044).

CONCLUSION

Long-term survivors after tongue reconstruction mainly report functionally-related HRQOL deficits. These long-term results can serve to enhance symptom management and may aid in managing patient expectations regarding long-term HRQOL.

The Effect of Fungal Nutraceutical Supplementation on Postoperative Complications, Inflammatory Factors and Fecal Microbiota in Patients Undergoing Colorectal Cancer Surgery with Curative Intent: A Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Background/Objectives: The combination of different fungal extracts could be beneficial to cancer patients due to their role in gut microbiota modulation and anti-inflammatory activity. The study aimed to evaluate whether fungal extract supplementation reduces postsurgical complications in patients with colorectal cancer undergoing curative surgery. Methods: Patients were randomized to receive the nutraceutical Micodigest 2.0 or a placebo until surgery. Surgical complications were evaluated using the Clavien-Dindo classification. We also assessed the effect of the nutraceutical on gut microbiota composition, inflammatory response, nutritional status, and quality of life. A subanalysis based on surgery type (robotic vs. non-robotic) was performed. Results: We included 46 patients who met the inclusion criteria, with 27 randomized to the intervention group and 19 to the placebo group, receiving treatment for three (2-4) weeks. Non-robotic surgery was performed in 35 (76.1%) patients. We found non-significant differences in postoperative complications (Micodigest 2.0: 25.9%, placebo: 26.3%; p = 0.9). In non-robotic surgery, we identified a non-significant reduction in postoperative complications (Micodigest 2.0: 25.0%, placebo: 36.4%; p = 0.7), as well as a significant increase in lymphocyte levels and a reduction in the neutrophil-to-lymphocyte ratio (p = 0.02). Micodigest 2.0 supplementation was also associated with significant changes in gut microbiota composition, as indicated by a decreased relative abundance of the phyla Firmicutes (p = 0.004) and Actinobacteria (p = 0.04). Conclusions: Micodigest 2.0 supplementation was associated with non-significant reductions in postoperative complications and significant modifications in gut microbiota composition. Limitations: The trial did not reach the calculated sample size.

Risk factors associated with delayed union after open reduction and plate fixation for humeral diaphyseal fractures

BACKGROUND

The risk factors related to delayed union in humeral diaphyseal fractures (HDFs) following surgical osteosynthesis remain unclear. Therefore, this study aimed to evaluate radiological outcomes and the risk factors associated with delayed union in a retrospective cohort of patients who underwent open reduction and plate fixation (ORPF) for acute HDFs.

MATERIALS AND METHODS

Consecutive patients with AO/OTA 12-A and AO/OTA 12-B fractures who underwent ORPF using standard compression techniques between 2017 and 2020 were enrolled in the study. Demographic data, along with serial medical records and radiographs, were collected. The included patients were divided into two groups: the timely union (union occurring within 6 months postoperatively) and the delayed union group (union occurring between 6 and 12 months postoperatively). Differences between the groups were examined, and logistic regression was subsequently applied for risk factor analysis.

RESULTS

Sixty-five cases were included in the study, consisting of 34 males and 31 females, with a median age of 38.9 years. Among these, 45 cases (69.2%) were classified in the timely union group, while 20 cases (30.8%) were classified in the delayed union group. Overall, 30 cases (46.2%) demonstrated secondary bony union. Significant differences were observed between groups in terms of fracture pattern, immediate postoperative fracture gap, union pattern, and complication rate (p < 0.05 for all comparisons). Multivariate logistic regression analysis revealed that the use of interfragmentary screw and the presence of postoperative complications were independent predictors of delayed union, with an adjusted odds ratio of 0.14 and 5.76, respectively.

CONCLUSIONS

In ORPF for acute HSFs, 30 out of 65 cases demonstrated secondary bone union despite the use of standard compression techniques. The application of interfragmentary screws significantly reduces the risk of delayed union. Conversely, the presence of postoperative complications is associated with an increased likelihood of delayed union.

LEVEL OF EVIDENCE

3 Trial Registration All procedures were approved by the institutional review board of the authors' hospital (IRB nos. A-ER-112-395 and IRB20230089).

Surgical and Infectious Complications Following Kidney Transplantation: A Contemporary Review

Kidney transplantation significantly improves outcomes in patients with end-stage renal disease; however, postoperative complications remain a substantial concern. This review summarizes the incidence, risk factors, and management strategies for common complications after kidney transplantation. Reported incidence varies widely due to differences in definitions, diagnostic methods, and study designs. Ureteral stenosis occurs in 2.8-18.0% of recipients, vesicoureteral reflux in 0.5-86%, and urinary leakage in 1.1-7.2%. Lymphatic complications, including lymphocele and lymphorrhea, range from 0.6% to 35.2%, with one-third of complications requiring intervention. The incidence of urinary tract infections ranges from 20 to 43%, while asymptomatic bacteriuria is reported in up to 53% of recipients. Surgical site infections have a median incidence of 3.7%, and incisional hernias develop in 2.5-10% of cases, depending on follow-up duration. Vascular complications affect approximately 10% of recipients, with renal artery stenosis and thrombosis being the most prevalent. Neurologic complications, such as femoral nerve palsy and immunosuppression-related neurotoxicity, though less frequent, can impair recovery. Management strategies vary depending on severity, ranging from observation to surgical intervention. Preventive measures-including optimized ureteral stenting protocols, early catheter removal, careful immunosuppression, and appropriate antimicrobial use-play a crucial role in reducing complication risk. Despite advances in transplantation techniques and perioperative care, these complications continue to affect graft survival and patient outcomes. Further research is needed to standardize definitions and establish evidence-based protocols.

Management of Anticoagulant and Antiplatelet Therapy in Elective Degenerative Lumbosacral Spine Surgery: A Clinical Study on 578 Elderly Patients

BACKGROUND AND OBJECTIVES

Managing anticoagulant and antiplatelet therapy in elderly patients with high cardiovascular risk undergoing degenerative lumbosacral spine surgery is a complex challenge. Balancing the reduction of thromboembolic events and minimizing bleeding risks requires tailored perioperative strategies. This study evaluates the outcomes of a standardized management approach for such therapies in this vulnerable population.

METHODS

A retrospective analysis was conducted on 578 patients aged 60 years or older undergoing elective surgery for lumbar spinal stenosis, lumbar disc herniation, or spondylolisthesis. Patients were categorized into three groups based on their antithrombotic regimen: no therapy (Group A), primary prevention therapy (Group B), and secondary prevention therapy (Group C). Perioperative bridging with enoxaparin or low-dose aspirin was applied where indicated. Clinical outcomes, including surgical duration, blood loss, postoperative complications (Clavien-Dindo scale), and hospitalization length, were assessed.

RESULTS

No significant differences were observed in intraoperative blood loss or surgical duration across groups. Hospitalization duration was shorter in Group B compared with Group A for lumbar stenosis ( P = .01) and in Group C compared with Group A for disc herniation ( P < .01). Complications were predominantly Grade I or II, with no major bleeding or cardiovascular events recorded. The management demonstrated safety and efficacy in maintaining cardiovascular protection while controlling bleeding risks.

CONCLUSION

This study highlights the feasibility of individualized perioperative management of antithrombotic therapy in high-risk patients undergoing elective degenerative spine surgery. The findings support the development of standardized management strategies to optimize surgical outcomes without compromising patient safety. Further prospective studies are needed to refine these strategies.

Efficacy and safety of robotic-assisted versus endoscopic-assisted axillary lymph node dissection in node-positive breast cancer: a retrospective comparative study

BACKGROUND

Robotic surgery is increasingly being adopted for breast cancer treatment. However, robust clinical evidence regarding its effectiveness and safety remains limited. This retrospective cohort study aimed to compare the surgical quality and short-term outcomes of robotic-assisted axillary lymph node dissection (R-ALND) and endoscopic-assisted axillary lymph node dissection (E-ALND) in patients with node-positive breast cancer. Here, we report the short-term outcomes of this trial.

METHODS

This single-center retrospective study compared the short-term efficacy and safety of R-ALND and E-ALND in patients with node-positive breast cancer. Patients who underwent surgery at the Sixth Affiliated Hospital of Sun Yat-sen University between January 2022 and October 2024 were included. Clinical and pathological characteristics, surgical outcomes, and postoperative complications were analyzed.

RESULTS

A total of 56 patients were included, with 29 undergoing E-ALND and 27 undergoing R-ALND. The R-ALND group demonstrated significantly shorter operative times (43.37 ± 12.40 min vs. 60.10 ± 19.37 min, p < 0.001) and lower mean intraoperative blood loss (3.26 ± 2.40 ml vs. 9.24 ± 4.29 ml, p < 0.001). Postoperatively, the R-ALND group exhibited better upper limb function and sensation, as evidenced by significantly lower DASH scores at 1-month (10.87 ± 1.35 vs. 14.64 ± 3.49, p < 0.001) and 3-month (6.68 ± 1.86 vs. 9.24 ± 2.74, p < 0.001) follow-ups. Additionally, the R-ALND group had fewer postoperative complications, including a reduced incidence of sensory disturbances, burning sensations, and numbness in the upper limb.

CONCLUSION

Compared with E-ALND, R-ALND significantly reduces intraoperative blood loss and postoperative complications, with less impact on upper limb function and sensory outcomes. These findings indicate that R-ALND may provide better clinical benefits for patients requiring axillary lymph node dissection in the management of breast cancer.

B.T.C.H. nephrolithometry score: a novel scoring system to predict stone-free rate and complexity for ultrasound-guided percutaneous nephrolithotomy

Background

The existing scoring systems for percutaneous nephrolithotomy fail to adequately consider the influence of renal anatomy, leading to limited predictive accuracy. This study introduces and validates a novel B.T.C.H. nephrolithometry score, designed to better predict stone-free rates and complexity for ultrasound-guided percutaneous nephrolithotomy.

Methods

B.T.C.H. nephrolithometry score evaluates four variables including stone burden, type of renal pelvis, calyces involved, and hydronephrosis. 134 patients who underwent ultrasound-guided percutaneous nephrolithotomy at Beijing Tsinghua Changgung Hospital were retrospectively analyzed. The inter-observer agreement was assessed using the linearly weighted kappa coefficient. The accuracy in predicting the stone-free rate was evaluated using receiver operating characteristic curve analysis. Spearman's correlation analysis and Kendall's W test were employed to examine the correlation between the scores of each scoring system and operative time, the number of tracts and CDC scores.

Results

The overall stone-free rate was 52.99%. The stone-free rates in low (4-8 points), medium (9-12 points), and high (13-15 points) B.T.C.H. scores were 91.9, 24.6, and 0%, respectively. The B.T.C.H. nephrolithometry score had an AUC of 0.909 for predicting stone-free rate, outperforming both the GSS (AUC = 0.761) and the S.T.O.N.E. nephrolithometry score (AUC = 0.763). The B.T.C.H. nephrolithometry score were positively correlated with operative time, the number of tracts and CDC scores.

Conclusion

B.T.C.H. nephrolithometry score is a suggested novel scoring system for ultrasound-guided percutaneous nephrolithotomy, which had superior prediction of stone-free rate and positive correlation with operative time, the number of tracts, and postoperative CDC scores.

Comprehensive comparison of technical performance, surgical outcomes, and oncologic prognosis between remnant gastric cancer and primary upper-third gastric cancer in the era of minimally invasive surgery: A pooled analysis of 3 prospective trials

BACKGROUND AND OBJECTIVE

To compare the technical performances and short- and long-term outcomes of laparoscopic total gastrectomy for remnant gastric cancer and primary upper gastric cancer.

METHODS

This prospective study (FUGES-004 study) enrolled 50 remnant gastric cancer patients who underwent laparoscopic total gastrectomy at Fujian Medical University Union Hospital between June 2016 and June 2020 (ClinicalTrials.gov identifier: NCT02792881). Propensity score matching (1:2) was used to select upper gastric cancer patients who underwent laparoscopic total gastrectomy in the FUGES-001 and FUGES-002 studies. Technical performance was assessed using the General Error Reporting Tool, Objective Structured Assessment of Technical Skills (OSATS), and Intraoperative Complication Classification.

RESULTS

After matching, 46 remnant gastric cancer and 92 upper gastric cancer patients were included in the final analysis. Abdominal adhesions in the epigastrium, central abdomen, and bowel-to-bowel regions were more severe in the remnant gastric cancer group (P < .001). The remnant gastric cancer group had more technical errors and intraoperative adverse events (especially grade I bleeding) during surgery (P < .05). However, the Objective Structured Assessment of Technical Skills scores were comparable between the remnant gastric cancer and upper gastric cancer groups (30.8 vs 31.0, P = .799). Although the severe postoperative complication rates were similar between the 2 groups (P = .333), the postoperative complication rate was significantly higher in the remnant gastric cancer group (28.3% vs 7.6%, P = .001). Additionally, the long-term oncologic outcomes (including 3-year disease-free survival, overall survival, and recurrence pattern) were comparable between the remnant gastric cancer and upper gastric cancer groups (log-rank P > .05).

CONCLUSIONS

Although the long-term oncologic outcomes were comparable between the groups, the remnant gastric cancer group had more intraoperative errors and adverse events and higher postoperative complication rates than the upper gastric cancer group. For complex remnant gastric cancer cases, laparoscopic total gastrectomy may serve as an effective therapeutic option. However, experienced surgeons at high-volume centers should exercise caution when performing laparoscopic total gastrectomy and implement more rigorous perioperative management strategies.

Advancing Maxillary Reconstruction: A Systematic Review and Meta-Analysis of the Evolving Role of the Scapular Free Flap

Background/Objectives: This systematic review and meta-analysis evaluates the surgical, functional, and aesthetic outcomes of scapular free flaps in maxillary reconstruction. The primary objective is to assess early surgical complications, fistula formation, donor site morbidity, dental restoration, normal dietary intake, aesthetic compromise, and eye-related issues. Secondary objectives include total free flap necrosis, the need for revision procedures, and functional performance of the upper limb. Methods: A systematic review was conducted following the PRISMA guidelines. Eligible studies were identified by searching PubMed/MEDLINE, Cochrane Library, Scopus, and Google Scholar, with the last search conducted on 10th February 2025. Inclusion criteria were studies reporting on patients undergoing maxillary reconstruction with scapular free flaps, and which provided data on at least one of the primary or secondary outcomes. A single-arm meta-analysis was performed to assess the outcomes of scapular free flap reconstruction. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale, with two independent reviewers performing the assessment. Results: From an initial search of 310 articles, 6 studies were included in the qualitative and quantitative synthesis, encompassing 231 patients with a mean age of 52.9 years (95% CI 44.9-60.8). Early general surgical complications occurred in 24% (95% CI 13-40) of patients, while 12% (95% CI 4-31) experienced fistula formation. Donor site morbidity was reported in 10% (95% CI 6-17) of cases, with a mean DASH score of 10.49, indicating low upper limb impairment. Dental rehabilitation was achieved in 56% (95% CI 42-70), and 52% (95% CI 31-72) of patients resumed a normal diet. Aesthetic compromise was observed in 27% (95% CI 9-58), and 36% (95% CI 28-44) reported eye-related issues. Conclusions: Scapular free flap is a reliable option for maxillary reconstruction with favourable outcomes, particularly in complex composite defects requiring both bone and soft tissue reconstruction. However, the evidence is limited by risk of bias, significant heterogeneity, and imprecision due to the small number of studies and participants. Larger, more robust trials are needed to confirm these findings.

Enhanced recovery and comparable long-term outcomes in reduced-port robotic distal gastrectomy versus conventional laparoscopic distal gastrectomy: A propensity score-matched analysis of single-center experience

INTRODUCTION

Reduced-port robotic distal gastrectomy (REPRODG) combines reduced-port surgery with robotic assistance to further optimize surgical outcomes. While the advantages of both reduced-port and robotic approaches over conventional laparoscopic surgery remain controversial, evaluating these techniques together may reveal potential benefits not observed when assessed separately. This study aimed to compare the surgical and oncologic outcomes of REPRODG to those of conventional laparoscopic distal gastrectomy (CLDG).

MATERIALS AND METHODS

We conducted a retrospective analysis of 1865 patients with gastric cancer who underwent either REPRODG or CLDG between January 2015 and December 2018. Utilizing 1:1 propensity score matching, we compared short- and long-term outcomes between the groups.

RESULTS

A total of 174 matched pairs of REPRODG and CLDG patients were analyzed. The REPRODG group demonstrated a shorter hospital stay (p = 0.006) and faster time to the first flatus (p = 0.001), and a lower incidence of pulmonary complications (p = 0.044) compared to the CLDG group. No significant differences were observed in overall and recurrence-free survival between the two groups (p = 0.739 and 0.564, respectively).

CONCLUSIONS

This study suggests that REPRODG may provide better short-term surgical outcomes to CLDG, particularly faster postoperative recovery, while maintaining comparable oncologic outcomes. Integrating robotic technology into reduced-port distal gastrectomy may further optimize postoperative recovery.

Surgeons' prioritization of emergency abdominal surgery and its impact on postoperative outcomes

BACKGROUND

Emergency general abdominal surgery (EGS) is associated with high morbidity and mortality. Timely intervention and effective triage systems are crucial to improve outcomes. This study evaluates the impact of surgeons' prioritization and adherence to a triage protocol on postoperative outcomes.

METHODS

Single-center retrospective analysis of patients undergoing EGS at Bern University Hospital from 03/2015-12/2022. Patients were categorized into four triage levels based on the urgency of surgery (level 1 within 1 h, level 2 within 6 h, level 3 within 12 h, and level 4 within 24 h). "Protocol violation" was defined in cases where the delay to surgery exceeded the triage level. Primary endpoint included complications according to Clavien-Dindo classification in patients with versus without "protocol violation".

RESULTS

A total of 1'947 patients were included. The mean overall delay from admission to surgery was in triage level 1 69.5 ± 127.5 min., in triage level 2 206.5 ± 178.0 min., in triage level 3 350.6 ± 282.6 min. and in triage level 4 693.4 ± 354.8 min.. Triage levels 1 and 2 correlated significantly with increased complication rates compared to triage level 3 and 4 (64% vs. 43% vs. 11% vs. 10%, p < 0.001). Similarly, mortality rates decreased significantly from triage level 1 through 4 (26% vs. 7% vs. 1% vs. 2%, p < 0.001). "Protocol violation" occurred in a total of 13% of patients with decreasing proportions from triage level 1 to 4 (37% vs. 13% vs. 12% vs. 0%, p < 0.001). "Protocol violation" did not statistically affect overall morbidity and mortality in most of the diagnoses. In patients with intestinal ischemia or abdominal abscesses, mortality was significantly higher in patients with "protocol violation". In contrast, in patients suffering from acute inguinal hernias or gastrointestinal bleeding, morbidity was significantly higher in patients without "protocol violation". A significantly shorter hospital length of stay (HLOS) was shown in triage level 2 and triage level 3 when patients were treated without "protocol violation" (8.6 ± 10.0 days vs. 13.5 ± 17.3 days, p = 0.022 and 5.3 ± 8.7 days vs. 6.4 ± 6.7 days, p < 0.001, respectively).

CONCLUSION

Surgeons' triage levels significantly correlated with mortality and morbidity. Moreover, "protocol violation" resulted in higher mortality in patients suffering from mesenteric ischemia and abdominal abscesses and resulted in prolonged HLOS. Further incorporating objective parameters into triage decisions in the EGS population may enhance prioritization accuracy, patient safety and resource utilization.

Significance of Naples prognostic score for postoperative complications after colorectal cancer surgery

PURPOSE

The Naples prognostic score (NPS) is a sensitive scoring system that reflects both inflammatory and nutritional status. This study examined the significance of NPS in predicting postoperative complications following colorectal cancer surgery.

METHODS

The present study included data from 443 patients who underwent curative resection for colorectal cancer. The patients were classified into low NPS (score 0-2) and high NPS (score 3-4) groups. We retrospectively investigated the relationship between NPS and postoperative complications (Clavien-Dindo classification ≥ II).

RESULTS

Among all patients, 57 (13%) developed postoperative complications. A total of 340 patients (77%) were categorized into the low NPS group and 103 (23%) were categorized into the high NPS group. A multivariate analysis identified that high NPS (P < 0.001), tumor location in the rectum (P = 0.025), longer operation time (P = 0.027), and greater blood loss (P = 0.004) were independent risk factors for postoperative complications. Furthermore, high NPS was significantly associated with older age (P < 0.001), higher American Society of Anesthesiologists physical status score (P = 0.029), advanced T stage (P < 0.001), N stage (P = 0.036), and longer length of hospital stay (P < 0.010).

CONCLUSIONS

NPS is a strong predictor of poor outcomes in patients undergoing curative resection for colorectal cancer, suggesting the importance of systemic inflammation and the nutritional status.

First-in-Human Linear Magnetic Jejuno-Ileal Bipartition: Preliminary Results with Incisionless, Sutureless, Swallowable Technique

BACKGROUND

Minimally invasive surgery may be further advanced with the novel biofragmentable magnetic anastomosis compression system. Two magnets may be swallowed, or placed by flexible endoscopy, in a side-to-side magnetic jejuno-ileostomy (MagJI) bipartition for weight and type 2 diabetes (T2D) reduction. MagJI markedly reduces the major complications of enterotomy, stapling/suturing, and retained foreign materials.

METHODS

This was a prospective first-in-human investigation of feasibility, safety, and preliminary efficacy in adults with body mass index (BMI, kg/m2) ≥ 30.0- ≤ 40.0. After serial introduction via swallowing or endoscopy, linear magnets were laparoscopically guided to the distal ileum and proximal jejunum where they were aligned. Magnets fused over 7-21 days forming jejuno-ileostomy.

PRIMARY ENDPOINTS

feasibility and severe adverse event (SAEs) incidence (Clavien-Dindo grade); secondary endpoints: weight, T2D reduction.

RESULTS

Between 3-1 - 2024 and 6-30 - 2024, nine patients (mean BMI 37.3 ± 1.1) with T2D (all on T2D medications; mean HbA1C 7.1 ± 0.2%, glucose 144.8 ± 14.3 mg/dL) underwent MagJI. Mean procedure time: both magnets swallowed, 86.7 ± 6.3 min; one magnet swallowed with second delivered endoscopically, 113.3 ± 17.0 min. Ninety-day feasibility confirmed in 100.0%: 0.0% bleeding, leakage, infection, mortality. Most AEs grade I-II; no SAEs. At 6-month radiologic confirmation, all anastomoses were patent. Excess weight loss 17.5 ± 2.8 kg; mean BMI reduction 2.2 ± 0.3, HbA1C 6.1 ± 0.1% (p < 0.01), glucose 115.5 ± 6.5 mg/dL (p = 0.19); 83.0% dropped below 6.5% HbA1C and had markedly reduced anti-T2D medications.

CONCLUSIONS

The swallowable, biofragmentable magnetic anastomosis system appeared to be feasible and safe in achieving incisionless, sutureless jejuno-ileostomy. The first-in-human MagJI procedure may offer minimally complicated anastomosis creation and moderate MBS weight loss and T2D reduction.

Anatomically resectable versus biologically borderline resectable pancreatic cancer definition: refining the border beyond anatomical criteria and biological aggressiveness

BACKGROUND

The anatomically resectable pancreatic ductal adenocarcinoma treatment sequence is still debated. Heterogeneity in patient characteristics within this group may explain literature discrepancies. To overcome these limits, a biologically borderline resectable pancreatic ductal adenocarcinoma category has been analysed according to institutional criteria. The aim of this study was to examine the characteristics and outcomes of patients with biologically borderline resectable pancreatic ductal adenocarcinoma and determine whether they represent a distinct clinical and prognostic subgroup.

METHODS

Data from all consecutive patients who underwent surgical resection for pancreatic ductal adenocarcinoma between 2015 and 2022 were retrospectively analysed. Biologically borderline resectable disease was classified by the presence of one or more of the following: carbohydrate antigen 19-9 ≥200 U/ml, cancer-related symptoms lasting >40 days, and radiological suspicion of regional lymph node metastases at diagnosis.

RESULTS

In total, 886 patients were included in the study and divided into anatomically borderline resectable (266 patients (30%)) and anatomically resectable (620 patients (70%)), which was further divided into resectable (R; 397 patients (64%)) and biologically borderline resectable (223 patients (36%)). Neoadjuvant treatment was administered in 245 patients (92.1%) in the anatomically borderline resectable group, 82 patients (20.7%) in the R group, and 135 patients (60.5%) in the biologically borderline resectable group. After a median follow-up of 45 (95% c.i. 42 to 48) months, the median disease-specific survival in the biologically borderline resectable group was 40 months compared with 59 months in the R group (P < 0.001) and 40 months in the anatomically borderline resectable group (P = 0.570). In the upfront surgery cohort, the median disease-specific survival was worse for biologically borderline resectable patients compared with R patients (27 versus 54 months respectively, P < 0.001). Biologically borderline resectable was also independently associated with worse disease-specific survival, together with age, tumour size at diagnosis, and anatomically borderline resectable. The same, except for age, were also predictors of worse event-free survival.

CONCLUSION

Despite their identical anatomical appearance, resectable and biologically borderline resectable pancreatic ductal adenocarcinoma represent two distinct prognostic entities, warranting separate evaluation and, potentially, different treatment approaches.

Resection of 4 or more pulmonary segments increases the risk of non-cancer-related mortality

OBJECTIVES

This study retrospectively analysed the effect of the number of resected pulmonary segments on surgical outcomes of patients with non-small-cell lung cancer undergoing anatomical pulmonary resection.

METHODS

We examined patients who underwent lobectomy or segmentectomy for non-small-cell lung cancer between January 2016 and June 2021. We compared the surgical outcomes between the ≤3 segment group (group A) and the ≥4 segment group (group B). Lung functions were evaluated by comparing the preoperative and 6-month postoperative periods. Comprehensive preoperative status, including osteoporosis, sarcopenia and lung function, was incorporated into the propensity score matching analysis.

RESULTS

Propensity score matching for 420 patients yielded 310 for evaluation (1:1 matching), with a median follow-up of 57.6 months. Fifty-four patients (17.5%) died (17 from lung cancer and 37 from other diseases), and 50 patients (16.1%) experienced cancer recurrence. The 2 groups had no significant differences in surgical outcomes, including operation time, blood loss and postoperative complications. However, group B showed the worst reduction in vital capacity and forced expiratory volume in 1 s (all P < 0.05). Additionally, there were no significant differences in cancer recurrence or lung cancer mortality between the groups, although group B was significantly associated with increased deaths from other causes (P = 0.007, Gray's test; adjusted subdistribution hazard ratio 2.392; 95% confidence interval 1.170-5.167). Subgroup analyses revealed adverse effect modification in male patients regarding non-cancer-related deaths (P-value for interaction = 0.044).

CONCLUSIONS

The ≥4 segment group exhibited poorer postoperative pulmonary function and more deaths from other causes, indicating the need for careful postoperative management.

Risk factors for postoperative complications in patients with pulmonary tuberculosis

BACKGROUND

The risk factors associated with postoperative complications following pulmonary resection in individuals with tuberculosis remain incompletely understood.

METHODS

We conducted a retrospective analysis of baseline data-including sex, age, BMI, comorbidities, previous COVID-19 status, smoking history, respiratory function, ASA grade, affected lung lobe, and operative factors-in patients who underwent surgical treatment at Wuhan Pulmonary Hospital between January 2018 and September 2022.

RESULTS

This study included 204 patients diagnosed with pulmonary tuberculosis (PTB) who underwent surgery at our hospital between January 2018 and September 2022. Of these, 138 cases (67.6%) were male and the median age was 49 years. Postoperative complications were observed in 63 patients, representing an incidence rate of 30.9% (63/204). The most commonly reported complications were prolonged air leak (PAL; 29 cases), postoperative pleural effusion (PE; 23 cases), post-resectional space (PRS; 27 cases), pneumonia (9 cases), and hemorrhage (5 cases). Multivariate analysis identified male sex (odds ratio [OR]: 2.322, 95% confidence interval [CI] 1.015-5.313, p = 0.046), severe adhesion grade (OR 4.304, 95% CI 1.710-10.830, p = 0.002), and longer operative time (OR 1.007, 95% CI 1.003-1.011; p = 0.001) as significant risk factors for postoperative complications. For PAL specifically, male sex (OR 4.003, 95% CI 1.111-14.421, p = 0.034), severe adhesion grade (OR 3.943, 95% CI 1.313-11.839, p = 0.014), and longer operative time (OR 1.005, 95% CI 1.001-1.009, p = 0.016) were significant risk factors. Significant risk factors for postoperative PE included severe adhesion grade (OR 6.078, 95% CI 1.318-28.026, p = 0.021) and longer operative time (OR 1.005, 95% CI 1.000-1.010, p = 0.043). Blood transfusion (OR 4.493, 95% CI 1.270-15.888, p = 0.020) was identified as a significant risk factor for PRS.

CONCLUSIONS

Male gender, severe adhesions, and prolonged operative time were identified as significant risk factors for postoperative complications. Specifically, risk factors for postoperative PAL included male sex, severe adhesions, and longer operative time. Severe adhesions and prolonged operative time were also associated with an increased risk of postoperative PE. Intraoperative blood transfusion emerged as a significant risk factor for PRS. This finding helps us identify problems, improve operations, and reduce potential postoperative complications.

Direct-acting antivirals lower mortality and recurrence in HCV-related hepatocellular carcinoma post liver resection: A multicenter international study

BACKGROUND

The impact of treatment on hepatitis C virus with direct-acting antivirals on 90-day postoperative outcomes, overall survival, and recurrence-free survival in patients after liver resection for hepatocellular carcinoma is unknown.

METHODS

We conducted a multicenter retrospective study. Adults who underwent liver resection for hepatitis C virus-related hepatocellular carcinoma between January 2000 and December 2018 were included from 7 international institutions. Groups included direct-acting antiviral treated, non-direct-acting antiviral treated, and untreated hepatitis C virus infection. We used a multivariable model to evaluate the association between receipt of preoperative direct-acting antivirals and 90-day postoperative major complications (Clavien-Dindo class ≥III).

RESULTS

We identified 738 patients, including 206 (28%) direct-acting antiviral treated, 241 (33%) non-direct-acting antiviral treated, and 291 (39%) untreated patients. The sustained virologic response rate was 92% in the direct-acting antiviral and 71% in the non-direct-acting antiviral treatment groups. The median follow-up was 7.6 years (95% confidence interval 6.1, 8.6) after surgery for the entire cohort. Patients who received direct-acting antiviral therapy had better 5-year overall and recurrence-free survival than those without antiviral therapy (adjusted hazard ratio [95% confidence interval]: 0.26 [0.19, 0.35] and 0.52 [0.43, 0.64], respectively). Patients who received direct-acting antiviral therapy had better 5-year overall and recurrence-free survival than those who received non-direct-acting antiviral therapy (adjusted hazard ratio [95% confidence interval]: 0.49 [0.36, 0.66] and 0.78 [0.63, 0.96], respectively). There was no significant association between preoperative direct-acting antiviral therapy and 90-day postoperative major complications (adjusted odds ratio 0.34, 95% confidence interval 0.08, 1.01).

CONCLUSION

Direct-acting antiviral therapy is associated with improved 5-year overall and recurrence-free survival, without significantly increased risk of 90-day postoperative complications, in patients undergoing liver resection for hepatitis C virus-related hepatocellular carcinoma.

Compliance and Toxicity of Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer: A Systematic Review and Network Meta-analysis

PURPOSE

The individual chemotherapy- and radiotherapy-related toxicities between induction (iTNT) and consolidation total neoadjuvant therapy (cTNT) remain unclear. This network meta-analysis (NMA) comparing iTNT, cTNT, and traditional neoadjuvant chemoradiation (nCRT) evaluated the comparative treatment-related toxicities and compliance of the TNT schemas.

METHODS

A systematic review of randomized clinical trials and nonrandomized studies of interventions was performed as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. A Bayesian NMA was conducted, and odds ratios (OR) with 95% credible intervals (CrI) are reported for all outcomes.

RESULTS

Eighteen studies including 5730 patients were identified. iTNT ranked highest on rate of rectal bleeding (cTNT: OR 0.23 95% CrI 0.05-0.93; nCRT: OR 0.33, 95% CrI 0.09-0.96), proctitis (cTNT: OR 0.2, 95% CrI 0.06-0.55; nCRT: OR 0.2, 95% CrI 0.06-0.51), and postoperative diarrhea (cTNT: OR 0.37, 95% CrI 0.18-0.73; nCRT: OR 0.33, 95% CrI 0.15-0.71); cTNT ranked highest on rate of vomiting (iTNT: OR 0.24, 95% CrI 0.05-0.96; nCRT: OR 0.29, 95% CrI 0.06-0.89) and a higher rate of lymphopenia than iTNT (iTNT: OR 0.56, 95% CrI 0.34-0.99). Radiotherapy compliance was highest in cTNT (iTNT: OR 0.23, 95% CrI 0.05-0.72; nCRT: OR 0.18, 95% CrI 0.04-0.58). There was no difference in overall toxicity and mortality, chemotherapy compliance, and remaining individual system-based toxicities and postoperative complications.

CONCLUSIONS

Across all treatment strategies, iTNT had higher radiation-related gastrointestinal toxicities and postoperative diarrhea; cTNT had higher vomiting and lymphopenia rates. While no treatment strategy was superior in chemotherapy compliance, radiotherapy compliance was ranked highest in cTNT.

Enhanced short-term outcomes after full robotic-assisted minimally invasive Ivor Lewis procedure compared to the hybrid approach

Since its introduction in the early 2000s, full robotic-assisted esophagectomy has remained a niche technique due to debated short-term outcomes. While some studies have reported improved postoperative outcomes with fully minimally invasive approaches compared to open or hybrid esophagectomy, the high rate of postoperative anastomotic leaks stands as a significant limitation. This study evaluates the short-term outcomes of robotic-assisted esophagectomy. We prospectively collected data on patients undergoing robotic-assisted Ivor Lewis esophagectomy for esophageal cancer at our center from January 2017 to October 2024. All patients underwent a robotic abdominal approach and were divided into two groups based on the thoracic approach: open thoracotomy (Hybrid-RAMIE) or robotic thoracoscopy (Full-RAMIE). We compared patients' characteristics and short-term postoperative outcomes. A total of 59 consecutive patients were included (27 in the Hybrid-RAMIE and 32 in the Full-RAMIE). Patients' characteristics were comparable. Both groups showed similar rates of severe morbidity (CD ≥ 3) although the rate of life-threatening complications (CD ≥ 4) was significantly lower in the Full-RAMIE group. The Hybrid-RAMIE group exhibited a significantly higher rate of grade IV complications (22.2%) compared to the Full-RAMIE group (0%, p = 0.005), primarily due to severe pulmonary infections. In the Full-RAMIE group, the majority of complications were grade IIIb, predominantly anastomotic leaks (29%). Most were managed non-operatively, and this rate declined significantly after the learning curve. Our findings indicates that Full-RAMIE is associated with better postoperative outcomes, including a lower risk of severe pulmonary infections. The anastomotic leak rate for Full-RAMIE significantly declined to 6% after the learning curve was surpassed.

Impact of pectoralis major muscle mass decrease after lobectomy on the prognosis of lung cancer

BACKGROUND

Low preoperative skeletal muscle mass is a negative prognostic factor for non-small cell lung cancer. However, the clinical significance of postsurgical skeletal muscle loss remains unclear. We investigated the impact of a postoperative decrease in pectoralis major muscle mass on long-term outcomes.

METHODS

A retrospective evaluation was conducted on 460 patients with pathological stage I-II non-small cell lung cancer who underwent lobectomy. Patients were categorized into two groups based on whether they did or did not show a decrease in pectoralis major muscle mass 12 months postoperatively, using a muscle mass change rate of 0.94 as the cutoff.

RESULTS

The group showing a decrease in muscle mass (n = 126) exhibited a higher incidence of chronic obstructive pulmonary disease than the group showing no decrease in muscle mass (n = 334). The median rate of change in the muscle mass of the pectoralis major was 1.00. The median follow-up period was 42.8 months. Overall survival was significantly lower in the group showing a decrease in muscle mass than in the group showing no decrease in muscle mass (P < .001). Multivariable Cox regression analysis revealed that a decrease in pectoralis major muscle mass after surgery was an independent prognostic factor for overall survival (hazard ratio, 1.05; 95% confidence interval, 1.03-1.06; P < .001).

CONCLUSIONS

A decrease in pectoralis major muscle mass following lobectomy is associated with poor prognosis in patients with non-small cell lung cancer.

Laparoscopic vs robot-assisted gastrectomy in gastric cancer patients with prior abdominal surgery: a propensity-matched analysis

No studies have compared the efficacy of laparoscopic gastrectomy (LG) and robot-assisted gastrectomy (RG) for gastric cancer (GC) patients with a history of abdominal surgery (HAS). This is the first study in this field to identify complication-related factors and compare survival outcomes using propensity score matching (PSM) and a competing risk model (CRM). A retrospective cohort study was conducted on GC patients with HAS who underwent radical LG or RG. PSM was applied to achieve baseline balance. Univariate and multivariate regression analyses were performed to identify factors independently associated with complications. CRM adjusted by inverse probability of censoring weighting (IPCW) was used to analyze overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS) across different TNM stages. PSM with a 3:1 ratio ensured baseline balance while minimizing sample loss (LG n = 87, RG n = 29). RG was associated with a significantly longer surgery duration but a lower incidence of overall and Clavien-Dindo (CD) grade ≥ 2 complications. Multivariate analysis identified RG (OR, 95% CI: 0.02, 0.01-0.15), surgery duration (OR, 95% CI: 1.01, 1.00-1.01), and lymphadenectomy extent (OR, 95% CI: 2.81, 1.16-7.25) as independent factors associated with overall complications. Likewise, RG (OR, 95% CI: 0.06, 0.01-0.38), surgery duration (OR, 95% CI: 1.01, 1.00-1.02), and tumor size (OR, 95% CI: 1.02, 1.00-1.04) were independently associated with CD grade ≥ 2 complications. Kaplan-Meier analyses based on IPCW-adjusted CRM showed no significant differences in OS, CSS, and DFS between RG and LG across TNM stages. RG may efficiently reduce complications compared to LG but offers no survival benefit, suggesting a potential advantage in perioperative safety for GC patients with HAS.

Impact of en bloc extended R0 resections on oncological outcome of locally advanced adrenocortical carcinoma

In locally advanced adrenocortical carcinoma (ACC) (ENSAT stage III - S-III) R0 surgery, involving en bloc extended resections, is the only potential curative treatment. We evaluated oncological outcomes and complications rate in S-III patients who underwent extended resection in comparison with stage I/II (S-I/II). Among 1098 adrenalectomies over 27 years (1997 -2024) in a tertiary referral center, medical records of ACC patients were reviewed, excluding stage IV and not-multivisceral resections in S-III patients. Forty-eight patients met the inclusion criteria: 6 S-I (12.5%), 36 S-II (75%) and 6 S-III (12.5%) patients. The latter patients' cohort underwent multivisceral en bloc resections (3 total nephrectomies, one renal vein thrombectomy, one splenopancreasectomy associated with total nephrectomy, left hemicolectomy and omentectomy, one liver S6-S7-S8 resection). Open adrenalectomy was scheduled in all S-III patients. Minimally-invasive approach was scheduled in 21 (50%) S-I/II patients. Conversion to open adrenalectomy was registered in 5 out these 21 patients. Locoregional and distant disease recurrences were registered in 19% of S-I/II vs 33.3% of S-III patients and 28.6% of S-I/II vs 66.7% of S-III patients, respectively (p = 0.420, p = 0.064). Postoperative complications were observed in 21.4% of S-I/II patients and 16.7% of S-III patients (p = 0.788). Kaplan-Meier DFS and OS curves were comparable among the two groups (p = 0.255, p = 0.459, respectively). After univariable analysis, hyperfunction and chemotherapy were significantly associated with locoregional disease recurrence (p = 0.02, p = 0.04, respectively). OS and DFS of S-III ACC patients undergoing extended en bloc R0 resections were comparable to those of S-I/II patients, without increased postoperative morbidity.

How do early geriatric intervention and time to surgery influence each other in the management of proximal hip fractures?

INTRODUCTION

Time to surgery (TTS) increases mortality risk in old patients with proximal femur fractures (PFFs). Orthogeriatric care pathways reduce mortality and length of stay, but the interaction between TTS and geriatric intervention remains unclear.

OBJECTIVE

To identify organisational variables-including geriatric intervention-that are predictive of 90-day mortality and explore their interactions with TTS.

MATERIALS AND METHODS

This retrospective study included 7756 PFFs aged over 60 who underwent surgery between 2005 and 2017. Organisational factors influencing 90-day mortality (main outcome) were identified in an administrative database using log-rank tests. Variables such as a mobile geriatric team (MGT) intervening in the emergency department were screened. Selected variables were included in a Cox model alongside TTS and the AtoG score, a validated multidimensional prognostic tool (from 0 no comorbidity to ≥5). Statistical interactions between TTS and organisational variables were calculated.

RESULTS

MGT was one of the rare organisational variables with a protective effect: hazard ratio (HR) = 0.81, CI 95% [0.68-0.98], P = 0.03. MGT's strongest effect was for TTS up to 1 day (HR = 0.70, CI95% [0.53-0.92], P = 0.01) and then decreased beyond 2 days (HR = 0.97, CI95% [0.73-1.3], P = 0.08). In patients with an AtoG score ≤ 2, MGT was the strongest parameter: HR = 0.76, CI95% [0.60-0.93], P = 0.03, while the HR for TTS was 1.01 CI 95% [0.99; 1.02], P = 0.15. In patients with an AtoG>2, there was a synergic interaction between MGT and reduced TTS (P = 0.05).

CONCLUSION

Geriatric intervention modulated the effect of TTS on 90-day mortality up to a TTS of 2 days. MGT had a positive impact on both vulnerable and earthier patients.