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

Laparoscopic common bile duct exploration for common bile duct stones after gastric surgery

BACKGROUND

Gallstone disease is common after gastric surgery and especially after weight loss from bariatric surgery. In patients with normal gastroduodenal anatomy, treatment of common bile duct stones (CBS) generally consists of, endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES), followed by cholecystectomy in a second stage. However, after gastric surgery the papilla may not be easily accessible endoscopically. The aim of our study was to evaluate the therapeutic success of single-stage laparoscopic cholecystectomy and common bile duct exploration (LCBDE) after previous gastric surgery.

METHODS

In this observational cohort study, all LCBDE in patients with previous gastric surgery between January 2014 and July 2022 were retrospectively reviewed. Gastric surgery consisted of Roux-en-Y gastric bypass, BII subtotal gastrectomy, total gastrectomy and subtotal gastrectomy with Roux-en-Y reconstruction. Outcomes of interest consisted of successful duct clearance, postoperative adverse events and CBS recurrence.

RESULTS

Forty-four patients (M/F: 22/22) underwent LCBDE after previous gastric surgery, in which simultaneous cholecystectomy was performed in 38 cases. Median (range) age 68 (25-90) years. Presence of CBS was confirmed in 38 patients (85%), a choledochal polyp in one patient (2%) and recurrence of gastric cancer in another (2%). Duct clearance was successful in 37 out of 38 patients (97%). Median (range) length of stay after LCBDE was 1 (0-12) day(s). Eight patients developed a postoperative adverse event, of which three Clavien-Dindo > 3a complications. Three patients were readmitted. At a median (range) follow-up of 60 (24-120) months, no CBS recurrences were observed.

CONCLUSIONS

LCBDE is a safe technique, with a high rate of successful duct clearance after previous gastric surgery, even after previous cholecystectomy. In experienced centers, LCBDE provides a valid alternative for complex interventional endoscopy, omitting the need for the creation of a gastro-gastric fistula.

Novel Robotic Valvuloplastic Esophagogastrostomy Technique After Proximal Gastrectomy: A Safety and Feasibility Study

BACKGROUND

Esophagogastrostomy is one of the reconstruction techniques after proximal gastrectomy, but reflux and esophagitis are significant concerns. We introduced a new robotic valvuloplasty technique (single-flap), taking advantage of robotic surgery to address these issues and simplify the technique, especially for tumors with esophageal invasion.

METHODS

Between March 2022 and March 2024, patients who underwent robotic proximal gastrectomy with the single-flap technique were included. Based on the difficulty of the surgery, patients were divided into 2 groups: one with esophageal invasion requiring anastomosis in the mediastinum and the second group with tumors in the upper third of the stomach requiring anastomosis in the abdomen.

RESULTS

A total of 22 patients were included: 13 in the esophageal invasion group and 9 in the upper stomach group. The median size of esophageal invasion was 2 cm (1 to 3 cm). The median operative time was 320 minutes (esophageal invasion 326 vs. upper stomach 280 min, P =0.51), with a median blood loss of 35 g (31 vs. 38 g, P =0.19). No postoperative mortality, anastomotic leaks, reflux symptoms, or pancreatic fistulas were observed. Eighteen patients underwent endoscopic evaluation, and no sign of esophagitis was detected. Five patients (22.7%) developed grade III strictures requiring endoscopic balloon dilation (esophageal invasion 32.1% vs. upper stomach 22.2%; P =0.96).

CONCLUSIONS

Robotic proximal gastrectomy with single-flap valvuloplastic esophagogastrostomy is a safe and feasible option for gastroesophageal junction tumors with up to 3 cm of esophageal invasion.

Comparison of Short-Term Outcomes Between Robotic-Assisted and Open Pancreatoduodenectomy: A Retrospective Cohort Study With Inverse Probability of Treatment Weighting (IPTW) Analysis

BACKGROUND

The advantages of robotic-assisted pancreatoduodenectomy (RPD) in comparison with open pancreatoduodenectomy (OPD) have not been well-established. We aimed to compare their short-term outcomes by inverse probability of treatment weighting (IPTW) analysis.

METHODS

Patients who underwent RPD/OPD at our hospital were recruited. Stabilised IPTW were performed to adjust observed covariates. Short-term outcomes were compared.

RESULTS

After IPTW, the effective sample comprised 807 patients (199 RPD, 608 OPD) with balanced clinicopathological characteristics. RPD had a longer operation time, fewer intraoperative blood loss (IBL), and lower blood transfusion rate than OPD. RPD was associated with a lower incidence of clinically relevant postoperative pancreatic fistula and reoperation but did not reach statistical significance. In pancreatic adenocarcinoma, RPD had a significantly higher number of lymph nodes examined. There were no significant differences in postoperative morbidities and length-of-stay.

CONCLUSIONS

RPD was associated with fewer IBL and transfusion rates than OPD. RPD can be considered feasible and safe.

Choroid plexus tumors in adults: a retrospective mono-institutional study

PURPOSE

Choroid plexus tumors (CPT) are rare entities, and even rarer in adulthood.

METHODS

A retrospective consecutive series of 24 adult CPT patients was reviewed.

RESULTS

We described 24 adult CPTs. Clinical onset included cerebellar signs (n = 11, 45.8%), intracranial hypertension signs (n = 8, 33.4%), cranial nerves impairment (n = 5, 20.8%), incidental findings (n = 4, 16.6%), seizures (n = 1, 4.2%), spinal signs (n = 1, 4.2%). At first diagnosis, CPT was mostly located in the ventricular system, but other locations can occur, including the spine (one case); meningeal involvement was present in one, pre-surgical hydrocephalus in one case only. CPT histological grade ranged from grade 1 (n = 17), grade 2 (n = 6), and grade 3 (n = 1). TERTp mutation was detected in 17.6% (n = 3/17). TP53 mutation in 5.9% (n = 1/17). Gross Total, Subtotal, Partial resection and Biopsy were achieved in 17 (70.8%), 3 (12.5%), 3 (12.5%) and 1 (4.2%) of patients, respectively. 76% of cases (n = 16/21) experienced clinical worsening suddenly after surgery for different reasons, and mostly gradually recovered. For three cases no data was available. Adjuvant therapy was performed only for grades 2 and 3. At recurrence, surgery, radiosurgery, radiotherapy and chemotherapy were considered. The median Overall Survival from surgery was 219.25 months (95% CI, 188.83-249.67).

CONCLUSIONS

We confirm that CPT can occur in adults and are mostly grade 1 tumors located in the ventricular system. The surgical approach is the gold standard, although 76% of clinical worsening occurred, often transient. Adjuvant treatment was limited to higher grade CPT; however, no consensus has already been achieved about adjuvant therapy.

A left-posterior approach to the superior mesenteric artery during robot-assisted pancreaticoduodenectomy

BACKGROUND

A complete dissection around the superior mesenteric artery (SMA) with artery-first concept is crucial during pancreaticoduodenectomy for periampullary cancers. The left-posterior (LP) approach to the SMA may be effective during robot-assisted pancreaticoduodenectomy (RPD), but data on its technical feasibility and clinical outcomes are limited.

METHODS

We retrospectively reviewed 83 RPD patients utilizing the LP approach, dividing them into early (n = 42) and late (n = 41) groups to assess procedural maturity. The LP approach was initiated at the first phase of resection to achieve circumferential SMA dissection from the left and posterior aspect and early vascular control through ligation of the inferior pancreaticoduodenal artery (IPDA). Postoperative short-term outcomes were compared between the two groups.

RESULTS

The late group demonstrated significantly shorter operative times (518 vs. 626 min; p < .01) and higher rates of IPDA ligation (90% vs. 71%; p = .03). The median blood loss in the late group was 50 mL (65 mL in the early group; p = .39). Lymph node retrieval number was 17 in both (p = .81), and R0 resection was achieved in all late group cases (96% in the early group; p = .35).

CONCLUSIONS

With experience from approximately 80 cases, the LP approach for RPD has enabled precise SMA dissection and early vascular control. A stable and super-magnified caudal view provided by robotic surgery is particularly advantageous for this approach.

Vascularized lymph node transfer (VLNT) versus lymphaticovenous anastomosis (LVA) for chronic breast cancer-related lymphedema (BCRL): a retrospective cohort study of effectiveness over time

PURPOSE

Microsurgical reconstruction, including vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA), have emerged as promising treatment options for chronic breast cancer-related lymphedema (BCRL). Despite their clinical relevance, the precise timelines for patient improvement following these interventions remain rather unexplored. Therefore, the goal of this study was to compare the long-term outcomes and improvement patterns over time of VLNT versus LVA to lay open potential differences and aid in personalized counseling of future patients.

METHODS

A prospectively maintained, encrypted database was analyzed for patients with chronic BCRL treated with either VLNT or LVA with a minimum follow-up of one year. Patient-specific variables, such as body weight and circumferential arm measurements at distinct locations on both arms were documented preoperatively and on regular postoperative outpatient follow-ups.

RESULTS

This study comprised 112 patients, of which 107 patients fully completed the one-year follow-up period. Both VLNT and LVA achieved significant arm size reductions. LVA showed an early peak in effectiveness within the first three months, followed by a subsequent decrease and eventual stabilization. Contrarily, VLNT exhibited a distinct pattern with two significant peaks at three and eighteen months.

CONCLUSIONS

VLNT and LVA are both effective in long-term lymphedema management, yet they demonstrate marked differences in the timing of improvement. VLNT shows a delayed but more durable response, in contrast to the greater but shorter-lasting surge in effectiveness achieved by LVA. Interestingly, VLNT demonstrates an earlier onset of therapeutic impact than previously understood.

Multimodal Prehabilitation in Head and Neck Cancer Patients Undergoing Surgery: A Feasibility Study

BACKGROUND

Head and neck cancer (HNC) incidence is increasing, and surgery is frequently indicated as curative treatment. Unfortunately, complications and long-term functional impairment are common. Recent promising results of multimodal prehabilitation in colorectal cancer surgery show improved recovery and functional outcomes. The objective of this study is to assess the feasibility of multimodal prehabilitation, which is composed of high-intensity training, a protein-enriched diet, cessation of intoxications, mental support and speech support therapy, in HNC surgery.

METHODS

A feasibility study was conducted at a large teaching hospital, Northwest Clinics, Alkmaar, the Netherlands, between July 2022 and December 2023. The primary outcome was feasibility, defined as participation, dropout and adherence rate. The secondary outcome was functional capacity 6 weeks postoperatively.

RESULTS

The participation rate was 60% (30 of 50 patients), mainly limited due to the travel distance to the physiotherapist. A dropout rate of 7% was present, as two patients discontinued prehabilitation. Of the remaining 28 patients, 27 patients (96%) attended at least six sessions at the community physiotherapist practice. All functional tests increased by prehabilitation, with the 6-min walking test being significant (p ≤ 0.05). Six weeks postoperatively, all but steep ramp tests remained higher than baseline.

CONCLUSION

Feasibility of multimodal prehabilitation in HNC surgery patients in this study is limited by its participation rate of 60%. Addressing participation, a widespread network of oncologic physiotherapists or home-based multimodal prehabilitation by an app could possibly potentiate participation. More studies are needed to assess the optimal form of multimodal prehabilitation in this challenging population.

Ciliated hepatic foregut cysts: a large retrospective single-centre series

OBJECTIVE

This study aimed to provide insight about clinical management of ciliated hepatic foregut cysts (CHFC) at a tertiary centre.

BACKGROUND

CHFC is a rare cystic lesion of the liver with malignant potential according to previous reports. However, the current recommendation to resect all cysts in fit patients is based on limited evidence.

METHODS

Retrospective observational single-centre study including all patients with radiological suspicion of CHFC at Karolinska University Hospital during the years 2015-2022. Patients were characterised, mainly descriptively, regarding baseline characteristics, radiological and histopathological data, as well as data on follow-up.

RESULTS

A total of 41 patients with suspected CHFC were identified. Of these, 23 were operated and 18 only diagnosed radiologically. Of the operated, 19 patients (83%) had a histopathological examination confirming CHCF diagnosis. No patient had dysplasia or cancer in the specimen, and no patient developed cancer during a follow-up length (from first radiology) of 82 months (3-215).

CONCLUSIONS

CHFC can be diagnosed radiologically with acceptable accuracy. No patient in this study had malignant transformation, neither in the specimens nor during follow-up. Surgical treatment of CHCF for all patients fit for surgery should probably be challenged, but further studies supporting this change of management are needed.

Is robotic pancreaticoduodenectomy non-inferior to open pancreaticoduodenectomy in patients with high PD-ROBOSCORE?

INTRODUCTION

Robotic pancreaticoduodenectomy (RPD) is associated with technical challenges that may result in intraoperative and postoperative complications. Some previous reports and the recently published PD-ROBOSCORE describe several factors associated with an increased difficulty. The aim of this study is to investigate whether difficult RPD patients have a better outcome when operated by open approach (OPD).

METHODS

All patients undergoing robotic and open PD from January 2020 to June 2024 with high PD-ROBOSCORE were included. Preoperative pancreatitis and/or cholangitis, and tumor contact with PV-SMV were also analysed. Outcomes of RPD vs OPD were compared.

RESULTS

45 RPD and 57 OPD patients with high PD-ROBOSCORE were considered for this study. Median age was 68.5 years (68 RPD vs 65 OPD; p = 0.25), median BMI was 27 kg/m2 (27 RPD vs 28 OPD; p = 0.13), 65.6% of patients were male (60.0% RPD vs 70.2% OPD; p = 0.15) and median PD-ROBOSCORE was 10 (10 RPD vs 9 OPD, p = 0.145). POPF occurred in 37.2% (40.0% RPD vs 35.1% OPD; p = 0.668), CD ≥ 3 was 25.4% (28.8% RPD vs 22.8% OPD; p = 0.477), median CCI was 20.9 (20.5 RPD vs 20.9 OPD; p = 0.752), reoperation rate was 17.6% (15.5% RPD vs 19.3% OPD; p = 0.496). Hospital stay was 15 days (16 RPD vs 13 OPD; p = 0.583). Of patients developing POPF; 76.3% had soft pancreas, 84.2% had pancreatic duct ≤ 2 mm and 97.2% had BMI ≥ 25.

CONCLUSION

RPD seems to be non-inferior to OPD in patients with increased technical complexity. Most of these complications are related to fistula risk factors (high BMI, soft pancreas and small pancreatic duct) and not directly related with other technical difficulty factors.

Treatment strategies for solitary hepatocellular carcinoma: comparative outcomes of radiofrequency ablation vs. laparoscopic liver resection based on tumor location

INTRODUCTION

The treatment of early stage hepatocellular carcinoma (HCC) has become increasingly complex. This study evaluates the effectiveness of radiofrequency ablation (RFA) versus laparoscopic liver resection (LLR) for treating solitary hepatocellular carcinoma (HCC) ≤ 3 cm, with a focus on tumor location and depth.

METHODS

We conducted a retrospective analysis of patients treated for solitary HCC ≤ 3 cm in the right liver lobe from 2004 to 2022. Tumor depth was categorized into three zones based on proximity to portal vein branches: Zone I (near first-order branches), Zone II (adjacent to second-order branches), and Zone III (near third-order branches). Outcomes were measured using overall survival (OS) and recurrence-free survival (RFS) rates.

RESULTS

Of the 662 patients, for Zone I, II, and III, 240 (65 LLR, 175 RFA); 174 (100 LLR, 74 RFA); and, 248 patients were treated (244 LLR, 4 RFA), respectively. Statistically significant differences in the treatment outcomes based on the tumor depth were observed. For Zone I, LLR demonstrated superior OS (p = 0.043) and RFS rates (p = 0.030) than did RFA. For Zone II, both treatments had comparable survival outcomes, with no statistically significant differences in the OS (p = 0.460) and RFS (p = 0.358). For Zone III, LLR was principally favored, due to easier surgical access and cleaner margins.

CONCLUSIONS

This study highlighted the importance of including tumor location and depth, in addition to the tumor size and liver function, in the management of early stage HCC. A multidisciplinary approach is essential for treatment planning and optimizing survival outcomes.

Feasibility of Image-guided Navigation with Electromagnetic Tracking During Robot-assisted Sentinel Node Biopsy: A Prospective Study

BACKGROUND AND OBJECTIVE

Image-guided surgical navigation (IGSN) can enhance surgical precision and safety. The expansion of minimally invasive surgery has increased the demand for integration of these navigation systems into robot-assisted surgery. Our objective was to evaluate the integration of electromagnetic tracking with IGSN in robot-assisted sentinel lymph node biopsy (SLNB).

METHODS

We conducted a prospective feasibility study to test the use of IGSN in SLNB. In total, 25 patients scheduled for SLNB at The Netherlands Cancer Institute were included (March 2022 to March 2023). SLNB using IGSN was performed using a standardised technique with a da Vinci robot (Intuitive Surgical, Sunnyvale, CA, USA) in four-arm configuration. Feasibility was determined as the percentage of sentinel nodes (SNs) successfully identified via IGSN. Successful SN resection was defined as SNs correctly localised via navigation and validated ex vivo with a gamma probe. Surgeon feedback on the robot-assisted IGSN workflow was evaluated using the System Usability Scale (SUS).

KEY FINDINGS AND LIMITATIONS

In accordance with the protocol, the first five patients were used for workflow optimisation, and the subsequent 20 patients were included in the analysis. IGSN led to successful identification of 91% (50/55) of the SNs. There were no complications associated with navigation. The surgeon feedback (SUS) was 60.9, with lowest scores reported for the user interface and workflow integration.

CONCLUSIONS

IGSN during robot-assisted surgery was feasible and safe. The technique allowed identification and removal of predefined small pelvic lymph nodes.

PATIENT SUMMARY

We carried out a study on the feasibility of imaging-guided navigation in robot-assisted prostate surgery. Our results show that this technique is feasible, safe, and effective.

Evaluation of 4DryField® as an Adhesion Prophylaxis in Pediatric Patients: A Propensity-Score Matched Study

INTRODUCTION

 Abdominal adhesions following surgery can lead to complications like intestinal obstruction and pelvic pain. While no molecular therapies currently target the underlying adhesion formation process, various barrier agents exist. 4DryField® has shown promise in reducing bleeding and adhesions in adults. This study aimed to assess its effectiveness in children.

METHODS

 The study examined all pediatric patients who underwent laparotomy between January 2018 and February 2022. It compared outcomes between those treated with 4DryField® and a control group. Key endpoints included surgical revision, adhesion recurrence, infections, insufficiencies, fever, C-reactive protein (CRP) levels, and time to gastrointestinal passage.

RESULTS

 In total, 233 children had surgery for bowel adhesions. After propensity score matching, 82 patients were included in the analysis: 39 in the control and 43 in the 4DryField® group. 4DryField® did not affect the readhesion rate. Children in the treatment group had significantly more complications (47 vs. 15%, p = 0.002), more often fever, and higher CRP levels.

CONCLUSIONS

 4DryField® did not show potential in reducing adhesion formation, but it was associated with significantly more complications in pediatric patients. Thus, future prospective studies are needed to evaluate the safety and effectiveness of 4DryField® in children.

Neoadjuvant gemcitabine and S-1 in pancreatic ductal adenocarcinoma: Effects on nutritional status and pancreaticoduodenectomy outcomes

BACKGROUND

With the advent of improved chemotherapy options, neoadjuvant chemotherapy has gained acceptance as a multidisciplinary treatment approach for localized pancreatic ductal adenocarcinoma. This study aimed to clarify whether neoadjuvant chemotherapy with gemcitabine and S-1 influences preoperative nutritional status and postoperative outcomes, particularly in patients undergoing highly invasive pancreatic resection.

METHODS

Patients with resectable pancreatic ductal adenocarcinoma who underwent pancreaticoduodenectomy as upfront surgery or after neoadjuvant chemotherapy with gemcitabine and S-1 between January 2015 and December 2022 were assessed. In addition to perioperative surgical outcomes, preoperative nutritional status was evaluated using serum albumin, controlling nutritional status, and prognostic nutritional index.

RESULTS

A total of 158 patients who underwent upfront pancreaticoduodenectomy and 119 who received neoadjuvant chemotherapy with gemcitabine and S-1 before pancreaticoduodenectomy were evaluated. Preoperative nutritional assessments (serum albumin, controlling nutritional status score, and prognostic nutritional index) showed no significant differences between groups, either at the initial consultation or immediately before surgery. No significant differences were observed in postoperative outcomes, including blood loss, operation time, and morbidity. The neoadjuvant chemotherapy with gemcitabine and S-1 group had a significantly greater rate of negative tumor margins (R0 resection rate 86% vs 74%, P = .018), and improved overall survival (hazard ratio, 0.41; 95% confidence interval, 0.25-0.67, P < .001) compared with the upfront pancreaticoduodenectomy group.

CONCLUSIONS

Neoadjuvant chemotherapy with gemcitabine and S-1 does not adversely impact preoperative nutritional status and enhances the effectiveness of pancreaticoduodenectomy for resectable pancreatic ductal adenocarcinoma, leading to improved pathologically curative resection rates and overall survival.

Aptis Distal Radioulnar Joint Implant: Management of Remarkable Complications

Background  The aim of an Aptis distal radioulnar joint (DRUJ) implant is to reconstruct the DRUJ in patients with a destroyed, painful DRUJ, and gross ulnar instability. The literature is scarce regarding the management of (severe) early complications related to the Aptis implant in wrists with more rare conditions, such as rheumatoid arthritis, congenital malformations, or leiomyosarcoma of the distal ulna. Purpose  This paper describes the clinical results, (severe) early complications related to the implant, revision surgery, patient satisfaction with the revision surgery, and esthetic appearance of the affected wrist in this specific cohort. Materials and Methods  Retrospective evaluation of five consecutive patients with a short-to-medium follow-up time of 32 months (range: 18-53 months) was carried out. Results  The follow-up revealed implant osseointegration failure in two cases, periprosthetic fractures in two cases, and acute carpal tunnel syndrome in one case. Three Aptis DRUJ arthroplasties were converted into a proximal Darrach. In four cases (80%), the patient was satisfied with the revision surgery due to pain reduction. In four cases (80%), the esthetic appearance of the affected wrist was found disappointing. Conclusion  This study describes remarkable complications related to the Aptis implants in wrists with more rare conditions. The implant is more likely to fail in wrists with poor bone stock, remodeling of the radius, deformation, and malformation of the radius. The range of indications for the usage of the implant to maintain wrist function may be strict. Level of Evidence  IV.

Comparing open and video endoscopic lymphadenectomy for penile cancer: a systematic review and meta-analysis of prospective studies

OBJECTIVE

To conduct the first meta-analysis using only prospective studies to evaluate whether video endoscopic inguinal lymphadenectomy (VEIL) offers advantages in perioperative outcomes compared to open IL (OIL) in patients with penile cancer.

METHODS

A systematic review with meta-analysis was conducted across multiple databases, including Cochrane Central Register of Controlled Trials (CENTRAL), the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Latin America and Caribbean Health Sciences Literature (LILACS), Scopus, Web of Science, and several trial registries up to June 2024. Only randomised controlled trials (RCTs) and prospective cohort studies were included. Data extraction focused on operative time, perioperative complications, drainage time, hospital stay, number of nodes retrieved and oncological outcomes.

RESULTS

Four prospective studies, including three RCTs and one non-randomised study, were included in the analysis, totalling 95 patients and 174 operated limbs. VEIL demonstrated significantly fewer wound infections (P < 0.001; 95% confidence interval [CI] 0.01-0.18; I2 = 0), skin necrosis (P = 0.002; 95% CI 0.04-0.49; I2 = 0), and lymphoedema (P = 0.05; 95% CI 0.09-0.99; I2 = 27%) compared to OIL. The VEIL group also had a shorter drainage period (P = 0.001; mean difference [MD] -1.94, 95% CI -3.15 to -0.74) and hospital stay (P < 0.01; MD -5.48, 95% CI -6.34 to -4.62). Pain intensity and operative time were lower in the VEIL group, contributing to fewer postoperative complications overall. Oncological outcomes showed no significant differences between the groups.

CONCLUSION

The meta-analysis indicates that VEIL offers significant advantages over OIL in terms of reducing wound infections, skin necrosis, and lymphoedema, leading to shorter hospital stays and overall improved perioperative outcomes. However, the limited sample of 95 patients across four studies underscores the need for further randomised trials and a cautious interpretation of the results, which currently support the use of VEIL in managing patients with penile cancer.

Laparoscopic suture-free partial nephrectomy using argon-beam-coagulator: Surgical technique and outcomes of a single-center, open-label randomized controlled trial

OBJECTIVE

To determine whether argon-beam-coagulation (ABC) suture-free technique results in more favorable renal function than conventional suture technique after laparoscopic partial nephrectomy.

METHODS

This study was a single-center, open-label randomized controlled study. A total of 32 patients with T1a renal tumor and R.E.N.A.L score ≤7 were recruited. The primary endpoint of the study was the absolute variation of the ipsilateral split renal function (SRF) at 12 months. The following secondary endpoints were addressed: the 1, 3, 6, and 12-months variation of eGFR; the 1, 3, 6-months variation of SRF; perioperative outcomes (including operative time, warm ischemia time, time to hemostasis, blood loss).

RESULTS

The suture-free group had a significantly shorter operative time (90.4 ± 22.0 minutes vs. 117.8 ± 23.5 minutes, p = 0.003) and warm ischemia time (9.6 ± 4.7 minutes vs. 21.3 ± 8.3 minutes, p < 0.001) than the suture group. At the last follow-up, the change of ipsilateral SRF was 7.5 ± 5.1 ml/min for the suture-free group and 13.1 ± 6.7 ml/min for the suture group (p = 0.014). The change of eGFR demonstrated a similar trend (5.5 ± 4.4 ml/min vs. 12.6 ± 6.0 ml/min, p=0.001). Multivariate linear analysis confirmed that suture-free technique was associated with a less decrease of renal function.

CONCLUSIONS

Suture-free partial nephrectomy is a feasible technique for T1a renal masses and benefits long-term SRF and eGFR compared to conventional procedure.

Role of Indocyanine Green Angiography to Assess Intra-operative Bowel Vascularity and its Association with Post-operative Outcome in Robot-assisted Rectal Resection: a Prospective Indian Cohort Study

Adequate intestinal perfusion is one of the critical factors influencing anastomotic leak (AL) in colorectal surgery. The use of indocyanine green fluoroscence angiography (ICG-FA) intra-operatively to ensure optimal perfusion is being increasingly used. This prospective study aimed to assess the role of ICG-FA in robot-assisted surgery for rectal cancer. This was a prospective cohort study carried out between July 2019 and July 2023, comprising patients undergoing elective robot-assisted rectal resection. The primary objective was to determine the role of ICG-FA in assessing bowel vascularity and in deciding the transection point of the bowel. The secondary objective was to assess the effect of ICG-FA on the post-operative outcomes, and also the effect of the various variables on the ICG staining grade. A total of 50 patients were included. Sixty percent of the patients received pre-operative radiotherapy, including short-course radiotherapy (SCRT) and long-course concurrent chemoradiation (LCRT). A change in transection line based on a less than normal ICG-FA grade was done in 11 patients (22%). Post-operatively, AL was present in 8 patients, out of whom 5 underwent re-operation. Administration of pre-operative RT was the only factor significantly associated with post-operative AL (p < 0.05). The present study showed that a change in the transection point based on the intra-operative ICG-FA was made in 22% of the patients. ICG-FA could hence be used as a potential adjunct to the operative surgeon in assessing the bowel vascularity in a minimally invasive approach like robotic or laparoscopic surgery.

Surgical Management of Postcholecystectomy Strasberg Type E4 Bile Duct Injuries

INTRODUCTION

High-biliary injuries are associated with worse outcomes. Most series do not mention failure rates specific to the injury grade. In our experience, Strasberg E4 injuries are associated with a higher failure rate. This study shares our experience with the surgical management of postcholecystectomy Strasberg E4 injuries.

PATIENTS AND METHODS

Patient demographics, radiological findings, operative details, and postoperative complications were collected for patients with Strasberg E4 injury from October 2003 to December 2020. Between 2003 and 2010, the preferred operation was Roux-en-Y hepaticojejunostomy (HJ). In cases of right lobe atrophy or an isolated right hepatic duct injury, a primary hepatic resection was considered. From 2010 onward, Strasberg E4 injuries were considered for a right hepatectomy with the left duct HJ. Patients were followed up at six monthly intervals with liver function tests and abdominal ultrasound.

RESULTS

Sixteen patients had Strasberg E4 injuries, thirteen presented with an external biliary fistula and three presented with obstructive jaundice. Nine of the ten patients who underwent HJ before 2010 developed cholangitis at a median follow-up of 14 months (2-28 months). Five of these subsequently underwent a hepatectomy, one underwent a liver transplant, and the other three underwent radiological dilatation of their anastomoses. From 2010 onward, six patients underwent an upfront right hepatectomy with left duct anastomosis. At a median follow-up of 40 months (10-74 months), 3 patients had minor derangement of liver enzymes, and none required an endoscopic or radiological intervention.

CONCLUSION

HJ in E4 injuries often produces poor long-term results. An upfront right hepatectomy with left duct anastomosis might be considered.

Statistical models versus machine learning approach for competing risks in proctological surgery

Clinical risk prediction models are ubiquitous in many surgical domains. The traditional approach to develop these models involves the use of regression analysis. Machine learning algorithms are gaining in popularity as an alternative approach for prediction and classification problems. They can detect non-linear relationships between independent and dependent variables and incorporate many of them. In our work, we aimed to investigate the potential role of machine learning versus classical logistic regression for the preoperative risk assessment in proctological surgery. We used clinical data from a nationwide audit: the database consisted of 1510 patients affected by Goligher's grade III hemorrhoidal disease who underwent elective surgery. We collected anthropometric, clinical, and surgical data and we considered ten predictors to evaluate model-predictive performance. The clinical outcome was the complication rate evaluated at 30-day follow-up. Logistic regression and three machine learning techniques (Decision Tree, Support Vector Machine, Extreme Gradient Boosting) were compared in terms of area under the curve, balanced accuracy, sensitivity, and specificity. In our setting, machine learning and logistic regression models reached an equivalent predictive performance. Regarding the relative importance of the input features, all models agreed in identifying the most important factor. Combining and comparing statistical analysis and machine learning approaches in clinical field should be a common ambition, focused on improving and expanding interdisciplinary cooperation.

Comparison of Treatment Outcomes between Graft Replacement and Aneurysmorrhaphy with Graft Preservation for Type 2 Endoleaks after Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

This study aimed to compare treatment outcomes between graft replacement and aneurysmorrhaphy with ligation of the aortic side branches for type 2 endoleaks after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms.

METHODS

We retrospectively analyzed multicenter data of patients who underwent open surgical conversion, including graft replacement or aneurysmorrhaphy with ligation of the aortic side branches (graft preservation) for the treatment of type 2 endoleaks between 2007 and 2022. The endpoints were postoperative complications, 30-day mortality, overall survival, and reintervention or sac expansion after open surgical conversion.

RESULTS

Forty patients underwent open surgical conversion (graft replacement, n = 9; graft preservation, n = 31). There were no significant differences in patient characteristics at open surgical conversion or anatomical data of the initial EVAR between the groups. The median operative time and amount of blood loss were significantly lesser in the graft preservation group than in the replacement group (179 vs. 318 min, P < 0.001, and 710 vs. 2,567 mL, P = 0.030, respectively). There was no difference in the occurrence of postoperative complications between the 2 groups (P = 0.645). No 30-day mortality was observed in any of the groups. Overall survival rate at 5 years after open surgical conversion was 85.7% in the graft replacement group and 77.8% in the graft preservation group (P = 0.789). Freedom from sac expansion or reintervention rate at 5 years after open surgical conversion was 100% in the graft replacement group and 76.0% in the graft preservation group (P = 0.239).

CONCLUSION

Aneurysmorrhaphy with ligation of the aortic side branches was less invasive treatment compared with graft replacement, although there were no differences in postoperative complications. No reintervention was needed after graft replacement; however, some patients required reintervention after graft preservation. Further studies are needed to determine the optimal surgical procedure for the treatment of type 2 endoleak.

MAMBA (Moisture Assisted Multiple BipolAr) technique vs Robo-lap approach in robotic liver resection. Is it possible a full robotic approach for parenchymal transection? A propensity score matching analysis

BACKGROUND

Robotic surgery is becoming more and more widespread. Despite its diffusion, parenchymal transection still remains a matter of debate. Up to now, in minimally invasive surgery, most of liver resection were performed laparoscopically with the support of ultrasonic dissector. The absence of robotic ultrasonic dissector is replaced by the hybrid (Robo-lap) technique in which the use of laparoscopic ultrasonic dissector is merged with the use of robotic energy devices in order to perform parenchymotomy. On the other side, some surgical groups perform liver resection using only Da Vinci energy devices, focusing on the simultaneous use of the double bipolar forceps (Maryland and bipolar) and applying the clamp-crush technique during robotic resection (MAMBA-Moisture Assisted Multiple BipolAr). Aim of our study is to compare intra- and post-operative outcomes of these two techniques.

METHODS

We collected a multicenter retrospective database, including 1070 consecutive robotic liver resection in 10 European Hospital Centers. Among these, 921 patients underwent liver resection for malignancies. Perioperative data for each patient were analyzed. Patients were also divided in two groups according to parenchymal transection technique (MAMBA vs robo-lap). Perioperative data were compared between 2 groups before and after 1:1 Propensity Score Matching.

RESULTS

755 resection were performed by MAMBA technique, 166 resection by Robo-lap. After PSM, 91 patients were included in each group. There were no significant differences between two groups regarding operative time, estimated blood loss, conversion rate, and post-operative complications.

CONCLUSION

MAMBA technique is a valid alternative in robotic liver parenchymal transection, overcoming the lack of ultrasound devices.

Patient-Surgeon Satisfaction Discrepancy following Breast Reduction Surgery: A 10-year Analysis of Aesthetic Outcomes and Quality of Life

Background

Breast reduction surgery has been recognized for its potential to improve quality of life in patients with macromastia or after unilateral oncological treatment. However, comparative analysis of different surgical techniques remains sparse. Patient-reported outcome measures have emerged as indispensable tools in assessing patient satisfaction and postoperative outcomes. Driven by the hypothesis of substantial differences between self-reported patient outcomes and professional assessments, this study aimed to compare different technical approaches, integrating both the patients' and plastic surgeons' perspectives.

Methods

A 10-year retrospective single-center cohort study was conducted to compare patient- and surgeon-reported outcomes using pre- and postoperative BREAST-Q questionnaires and aesthetic self-assessments. Outcomes and postoperative complication rates of different technical approaches were analyzed using photographic documentation.

Results

A total of 170 patients met the inclusion criteria, of which 92 agreed to further photographic documentation for aesthetic evaluation. The median follow-up duration was 4.9 years. BREAST-Q scores significantly improved across all surgical techniques, with comparable scores in both oncoplastic and nononcoplastic patients. Notably, patients reported greater satisfaction with the postoperative aesthetic outcomes than surgeons. Multivariable analysis confirmed body mass index as a significant risk factor for postoperative complications.

Conclusions

Breast reduction surgery improves both aesthetic outcomes and long-term quality of life, regardless of surgical technique or the use of oncoplastic methods. The discrepancy between patient and surgeon satisfaction highlights the need for a patient-centered approach, such as incorporating patient-reported outcome measures to evaluate postoperative results.

Free-Hand Endoscopic Full-Thickness Resection for Duodenal Subepithelial Lesions

BACKGROUND AND AIM

This work aims to evaluate the efficacy and safety of free-hand endoscopic full-thickness resection (EFTR) for duodenal subepithelial lesions (SELs).

METHODS

We performed a retrospective review of 105 patients with duodenal SELs who underwent free-hand EFTR. Free-hand EFTR means no other devices (over-the-scope clip or full-thickness resection device) are required. The preoperative baseline data, procedure-related characteristics, and postoperative outcomes were analyzed.

RESULTS

The technical success rate was 99.0%, and the en bloc resection rate was 94.2%. A total of nine (8.7%) patients experienced major postoperative adverse events (AEs). The incidence of major AEs was significantly higher for lesions with a maximum diameter ≥ 2 cm (30.4%) than for lesions with a maximum diameter < 2 cm (2.6%) (p < 0.001). There were also significant differences in the incidence of major AEs for peri-ampullary lesions (37.5%), bulb lesions (4.8%), bulb-descending junction lesions (6.7%), and descending part lesions (12.5%) (p = 0.032). Multivariable regression analyses revealed that the maximum diameter ≥ 2 cm (OR = 18.108; 95% CI = 1.881-174.281; p = 0.012) and lesions located in peri-ampullary (OR = 18.950; 95% CI = 1.219-294.648; p = 0.036) were independent risk factors for major AEs. The mean duration of the follow-up period was 36.6 ± 21.3 months, and only one patient with gastrointestinal stromal tumors recurred.

CONCLUSIONS

Free-hand EFTR is a safe and effective technique for nonampullary duodenal SELs with a maximum diameter of < 2 cm. Given the complexity of the duodenal anatomy, this procedure should be performed by experienced endoscopists.

A multicentre prospective single-arm clinical trial to evaluate the treatment outcomes of prophylactic laparoscopic lateral pelvic lymph node dissection for advanced lower rectal cancer

AIM

There has been no prospective multicentre validation of the treatment outcomes of minimally invasive lateral pelvic lymph node dissection for lower rectal cancer; hence, this prospective study aimed to evaluate the treatment outcomes of prophylactic laparoscopic lateral pelvic lymph node dissection.

METHOD

Between May 2018 and August 2021, 90 patients with Stage II-III rectal cancer were registered. The clearance range for lateral pelvic lymph node dissection included the lymph nodes around the internal iliac artery and the obturator lymph nodes, while the autonomic nerves were generally preserved. The primary outcome was the incidence of Grade III-IV postoperative complications at discharge. The secondary outcomes were surgical and pathological outcomes, urinary function, sexual function, disease-free survival and overall survival. The experience of each facility and surgeon requirements were set to maintain quality control of lateral pelvic lymph node dissection.

RESULTS

Of the 90 patients, 87 were analysed after exclusion of ineligible patients. There were 30 and 57 cases, respectively, of Stage II and III rectal cancer, among which 17 patients underwent neoadjuvant chemotherapy. The median operating time and blood loss were 472 min and 55 mL, respectively. Postoperative complications were observed in 22 patients (25.3%), and the primary outcome of Grade III postoperative complication was observed in five patients (5.7%). Eight lateral lymph nodes were harvested bilaterally, and lateral lymph node metastasis was observed in 14 patients.

CONCLUSION

Prophylactic lateral pelvic lymph node dissection can be safely performed with adequately quality-controlled laparoscopic procedures.

The Short-Term Impact of Neoadjuvant Chemotherapy on the Outcome of Patients Undergoing Pneumonectomy for Lung Cancer: Is It Acceptable Nowadays?

Objective: We aimed at assessing our experience at the European Institute of Oncology in order to evaluate the peri- and immediately post-operative impact of neoadjuvant chemotherapy in patients who underwent pneumonectomy for NSCLC. Materials and methods: We retrospectively reviewed the outcomes and medical records of patients undergoing pneumonectomy (2010-2024). We compared pre-, peri- and post-operative outcomes of patients treated with induction chemotherapy and subsequent pneumonectomy with patients who underwent surgery directly. Differences in their distribution between study arms were assessed using the chi-square test for categorical variables or the Mantel-Haenszel test for trend for ordinal variables. We tested normality of the distribution of continuous variables using the Shapiro-Wilk test. We used logistic regression to quantify the risk of various outcomes (complications, 30-day and 12-day mortality) in patients who received neoadjuvant chemotherapy. Risks were expressed as odds ratios (ORs) with 95% confidence intervals (CIs adjusted for age (<60, 60-64, 65-69, ≥70 years), sex and comorbidities (cardiovascular, pulmonary or previous cancer). Results: We observed a higher frequency of post-operative respiratory complications in patients who underwent neoadjuvant therapy and pneumonectomy compared to those who only underwent surgery (11.4% vs. 18.5%; p = 0.05). After adjustment for age, sex and comorbidities we observed a significantly higher rate of pulmonary complications (OR 1.95; 95% CI 1.09-3.47; p = 0.02), ARDS (OR 2.88; 95% CI 1.26-6.59; p = 0.02) and 30-day mortality rate (OR 8.19; 95% CI 1.33-50.3; p = 0.02) in pre-treated patients. Conclusions: It is therefore strongly recommended to study and select potentially eligible patients in an extremely meticulous way before starting the neoadjuvant treatment, and to thoroughly re-evaluate the cardiorespiratory status after inductive therapy, before surgery.

Nationwide clinical practice variation for reconstructive surgery following oral cavity cancer from the Dutch Head and Neck Audit: are we all doing the same?

Quality registries provide real-world data that can drive quality improvement, which often starts with reducing inter-hospital variation. We explored outcomes and the extent of nationwide inter-hospital variation for patients undergoing reconstructive surgery after oral cavity cancer (OCC) using the Dutch Head and Neck Audit (DHNA). Within the DHNA, we selected all OCC patients who underwent curative reconstructive surgery between 2018 and 2022. Patient, tumour, and treatment characteristics were compared, including reconstruction strategies (skin grafting, local transposition, and pedicled and free flaps). Of those treated with free flap reconstruction, postoperative complications were scored according to the Clavien-Dindo (CD) classification and labelled minor (CD 1-2) or major (CD ≥3). A total of 1383 patients were included in the analysis. Especially in the case of patients with stage I tumours (10.1%) there was a wide variation in reconstructive surgery between centres, with a preference for local transposition (42.6%). Free flaps (n = 974) were used most often in patients with a more extensive tumour load (65.4-89.2%), with the radial forearm flap the preferred technique (54.7%, range range 37.1-80.8%). Thirty-four per cent of patients treated with a free flap had postoperative complications, with 38 cases of total flap loss (overall 3.9% complications). Strategies and percentages varied widely across centres, showing high inter-hospital variation in applied techniques and outcomes, and the need for national data improvement. Level of evidence: II.

Many ways, one destination: a comprehensive review of screening and assessment tools to detect malnutrition in patients with ovarian cancer

Malnutrition is a condition of deficiency, imbalance, or excess in a person's intake of energy and/or nutrients. Despite being common in patients with cancer, it is rarely diagnosed and managed by oncologists. Weight loss or changes in body mass index may fail to capture nutritional risk in patients with ovarian cancer due to masking ascites. The European Society for Clinical Nutrition and Metabolism and American Society for Parenteral and Enteral Nutrition guidelines recommend that patients with cancer undergo formal malnutrition screening and a full specialist assessment for those identified as high risk, and this recommendation is endorsed by European Society of Gynecologic Oncology and National Comprehensive Cancer Network for patients with ovarian cancer. The goal of this review was to describe the most common screening and assessment tools, studied in patients with ovarian cancer, as they relate to patient outcomes (complications, toxicity, and survival). Several tools have been tested in research and clinical settings, including serum markers, algorithms, scores, and clinical screening and assessment methods. These include but are not limited to pre-operative albumin, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, the Glasgow prognostic score, the prognostic nutritional index, and several clinical questionnaires. There are benefits and limitations to any individual tool as described in the review. Emerging technologies may also prove useful for malnutrition detection. We advocate that gynecologic oncology practices adopt a universal standardized method of screening and assessment for malnutrition in patients with ovarian cancer. Malnutrition can dramatically impact oncologic outcomes and patient well-being. Patients with malnutrition should be offered a nutritional care plan. These patients might also benefit from pre-habilitation, an emerging concept in gynecologic oncology, but evidence on its real impact is still limited. It is imperative that future research focus on strategies to reduce nutritional risk, improve patient overall health, and support resilience to cancer and anticancer treatment.

Percutaneous Nephrolithotomy in the Management of Renal Stone: An Audit of Outcomes and Complications

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is considered one of the most significant advances in minimally invasive urologic surgery. It offers a better stone-free rate compared to other available treatment modalities of renal stones at a lower complication rate compared to open surgery. Despite the availability of extracorporeal shock wave lithotripsy and flexible ureteroscopy, PCNL remains the gold standard modality for large and complex renal stones. Here, we review our initial experience with standard PCNL in the prone position for renal stones >1.5 cm with respect to stone clearance rate and complications as seen in our patients.

PATIENTS AND METHODS

Records of 24 patients who had standard PCNL and pneumatic lithotripsy between September 2020 and September 2023 were reviewed retrospectively. All the patients who had the standard PCNL for renal stones >1.5 cm were the subjects of this study. Data on patients' demographics, indication for the surgery, location of stone, size of stone, postoperative nephrostomy placement, nephrostomy tract size, complications, duration of surgery, duration of hospital stay, and status of stone clearance were obtained, and the data were subjected to statistical analysis.

RESULTS

A total of 24 patients underwent the standard PCNL. The mean age of the patients was 47.0 ± 10.28 years (16 males and 8 females; range: 17-68 years). Flank pain was the main indication for the surgery. The mean stone size was 2.5 cm (range: 1.6-3.3 cm). The mean Hounsfield unit was 1248.2 HU (range: 927-1502HU). At a single session, we achieved 100% stone clearance in 20 (83.3%) patients. Two (8.3%) of our patients required a second session of PCNL due to intraoperative bleeding and perforation of the pelvicalyceal system necessitating termination of the procedure and insertion of nephrostomy tube. In another 2 (8.3%) patients, the stones migrated and became inaccessible. One (4.2%) patient stayed for 10 days due to persistent urine leak, which eventually stopped after the insertion of a double-J stent and administration of antibiotics. The Clavien-Dindo grading system was used to classify postoperative complications. A total of 14 (58.3%) patients had Grade I complications, while 3 (12.5%) patients had Grade II and 1 (4.2%) had Grade IIIa complications.

CONCLUSION

PCNL is an effective minimally invasive technique for the treatment of large renal stones. Our initial experience suggests that the complication rate in PCNL is well within the acceptable limit.

How has the diagnostic approach to parathyroid localization techniques evolved in the past decade? Insights from a single-center experience

The standardization of preoperative imaging in primary hyperparathyroidism is one of the current challenges of endocrine surgery. A correct localization of the hypersecretory gland by neck ultrasound and 99mTc-sestamibi (MIBI) scintigraphy are not sufficiently sensitive in some cases. In recent years, CT-4D, 18F-Fluorocholine PET/CT, and radio-guided parathyroidectomy have come into common use. The aim of this study is to evaluate the performance of 18F-Fluorocholine PET/CT after prior negative or discordant first-line imaging in patients with primary hyperparathyroidism undergoing parathyroid surgery. Monocentric observational study on patients affected by pHPT undergoing surgery from July 2009 to April 2024 at the Division of General Surgery, Cattinara Teaching Hospital of Trieste. Preoperative, intra-operative, and follow-up data were collected. The imaging methods used were neck ultrasound, 99mTc-sestamibi (MIBI) scintigraphy, and 18F-Fluorocholine PET/CT (since 2018). 172 patients were included. As first radiologic examination, neck ultrasound (US) was performed in 140 cases and 99mTc-sestamibi (MIBI) scintigraphy in 162. Ultrasound and/or scintigraphy imaging were sufficient for the identification of the gland in 127 patients (73.8%), while in 45 patients (26.2%), the localization was defined with other techniques. Particularly, three patients with negative or discordant first-line imaging underwent neck 4D-CT scan who was useful for parathyroid localization all cases (100%). Only one patient received a neck magnetic resonance (MRI) and resulted positive for preoperative localization. Starting in 2018, 29 out of 45 patients underwent 18F-FCH PET/CT yielding a positive result in 29 patients (100%). In other 16 cases (before the introduction of PET/CT in our preoperative imaging study), the preoperative localization was inconclusive and bilateral neck exploration (BNE) was necessary. The sample was homogeneous in terms of age, anthropometric characteristics, and preoperative biochemical parameters. Male/female ratio was 1:5.1. In the intra-operative site, in the cases of exclusive PET/CT positivity, in 28 cases (96.5%), a diagnostic agreement was confirmed, and the gland was macroscopically smaller or normal in size. The combination of ultrasound and MIBI scintigraphy remains the preferred imaging approach for preoperative studies of pHPT. If secondary imaging is required, 18F -FCH PET/CT stands out as the most advantageous option due to its ability to provide anatomical and functional specificity. FCH PET/CT resulted an effective imaging modality with the highest sensitivity of the available imaging techniques for localizing the hyperfunctioning parathyroid gland. Therefore, this method can be recommended in patients showing negative or inconclusive results in the conventional diagnostic imaging.

Multi-Institutional Analysis of Pancreaticoduodenectomy for Nonfamilial Periampullary Adenoma: A Novel Risk Score to Guide Shared Decision-Making

BACKGROUND

Pancreaticoduodenectomy (PD) may occasionally be indicated for complete removal of periampullary (duodenal and ampullary) adenomas (PAs). As compared with malignant indications, PD for benign or premalignant disease is often associated with increased morbidity. Although the Spigelman classification assesses malignancy risk for familial adenomatous polyposis (FAP)-related duodenal adenomas, no malignancy risk score (MRS) exists for non-FAP-related PAs. We developed an MRS for non-FAP-related PAs undergoing PD to weigh the risk of malignancy and postoperative morbidity.

STUDY DESIGN

We retrospectively analyzed patients with non-FAP-related PA who underwent PD at 8 institutions (2010 to 2022). Patient and lesion factors associated with final malignant pathology were identified using multivariable logistic regression to create MRS. Postoperative complications were assessed according to MRS.

RESULTS

Of 127 patients, 59 (46.5%) had evidence of malignancy on final pathology. The odds of malignancy were higher in patients aged 65 years or older (odds ratio [OR] 3.2, p = 0.01), having bile duct 9 mm or more (OR 3.3, p = 0.009), having preoperative symptoms (OR 7.7, p = 0.002), and having high-grade dysplasia (OR 7.5, p < 0.001). A MRS was derived ranging from 0 to 6: age 65 years or older = 1, bile duct 9 mm or more = 1, symptomatic = 2, and high-grade dysplasia = 2. Patients were stratified into low-risk (MRS 1 to 2, n = 26), intermediate-risk (MRS 3 to 4, n = 59), and high-risk groups (MRS 5 to 6, n = 26), with malignancy rates increasing with MRS (10.3%, 44.1%, and 88.2%, p < 0.001). Patients in the no- or low-risk group (MRS 0 to 2) had higher odds of major postoperative complications compared with patients in the intermediate- or high-risk group (MRS 3 or higher, OR 2.9, p = 0.047).

CONCLUSIONS

This novel MRS stratifies the risk of malignancy in non-FAP-related PAs managed with PD. This score can be used to counsel patients who may require PD for complete tumor removal about their risk of harboring malignancy and their risk of major postoperative complications.

Efficacy of Neoadjuvant Radiotherapy After Chemotherapy and the Optimal Interval from Radiotherapy to Surgery for Borderline Resectable and Resectable Pancreatic Cancer

BACKGROUND

Benefits of neoadjuvant treatment for pancreatic cancer with major vessel invasion has been demonstrated through randomized controlled trials; however, the optimal neoadjuvant treatment strategy remains controversial, especially for radiotherapy. Therefore, we aimed to evaluate the efficacy and safety of neoadjuvant radiotherapy followed by chemotherapy and the optimal time interval to undergo surgery after radiotherapy in (borderline) resectable pancreatic cancer.

METHODS

Between 2013 and 2022, patients with (borderline) resectable pancreatic cancer with vessel contact who received 5-fluorouracil with leucovorin, oxaliplatin, and irinotecan or gemcitabine and nanoparticle albumin-bound paclitaxel as initial treatment following surgery were included. Patients who received radiotherapy after chemotherapy and those who did not were matched using 1:1 nearest-neighbor propensity scores. Propensity scores were measured using the tumor size at initial image, duration of neoadjuvant chemotherapy, and responsiveness to neoadjuvant chemotherapy.

RESULTS

Of 212 patients, 166 patients were retrieved for the matched cohort. Patients who received radiotherapy had significantly better postoperative survival, local control, and R0 resection rates than those who did not. Furthermore, patients who underwent surgery within 4 weeks after completing radiotherapy had lower intraoperative blood loss and a clinically relevant postoperative pancreatic fistula rate than those who underwent surgery after more than 4 weeks.

CONCLUSIONS

In patients with (borderline) resectable pancreatic cancer with vessel contact who were scheduled for curative-intent surgery after neoadjuvant chemotherapy, additional radiotherapy was associated with better postoperative survival and local control. Furthermore, our findings suggested that scheduling surgery within 4 weeks following radiation therapy might enhance the perioperative outcomes.

The Effects of Perioperative Corticosteroids on Postoperative Complications After Pancreatoduodenectomy: A Debated Topic of Systematic Review and Meta-analysis

BACKGROUND

The intraoperative administration of corticosteroids has been shown to improve postoperative outcomes in patients undergoing surgery; however, the impact of corticosteroids on complications following pancreatoduodenectomy (PD) remains controversial.

OBJECTIVE

This study aimed to evaluate the efficacy of perioperative corticosteroids on postoperative complications after PD.

MATERIALS AND METHODS

A comprehensive search was conducted using the PubMed, Embase, and Web of Science databases for studies published prior to 1 July 2024. Of 7418 articles identified, a total of 5 studies were eligible for inclusion in this meta-analysis. The primary outcome was incidence of postoperative major complications (PMCs), while the additional outcomes were incidences of postoperative pancreatic fistulas (POPFs), infection, delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), bile leakage, reoperation, and 30-day mortality. The study was registered in the PROSPERO database (CRD42024524936).

RESULTS

Finally, 5 studies involving 1449 patients (537 with corticosteroids and 912 without corticosteroids) were analyzed. Intraoperative corticosteroids were not associated with any improvement in PMCs (p = 0.41). The incidence of POPF (p = 0.12), infectious complications (p = 0.15), or DGE (p = 0.81) were not significantly different between the two groups. No obvious differences were found in the incidence of PPH (p = 0.42), bile leakage (p = 0.68), 30-day mortality (p = 0.99), or reoperation (p = 0.26).

CONCLUSION

Perioperative corticosteroids did not significantly demonstrate any protective advantage in terms of postoperative complications after PD. This finding may serve as a reference for the perioperative use of corticosteroids in pancreatic surgery. Well-designed clinical trials are warranted in the near future in order to provide high-level evidence.

Graft Inflow Modulation by Splenic Artery Ligation for Portal Hyperperfusion Does Not Decrease Rates of Early Allograft Dysfunction in Adult Live Donor Liver Transplantation: A Randomized Control Trial

OBJECTIVE

The primary objective was to compare the rates of early allograft dysfunction (EAD) in patients undergoing elective adult live donor liver transplantation (ALDLT) with and without graft portal inflow modulation (GIM) for portal hyperperfusion. The secondary objectives were to compare time to normalization of bilirubin and International Normalized Ratio, day 14 ascitic output more than 1 L, small-for-size syndrome, intensive care unit/high dependency unit and total hospital stay, and 90-day morbidity and mortality.

BACKGROUND

GIM can prevent EAD in ALDLT patients with portal hyperperfusion.

METHODS

A single-center randomized trial with and without GIM for portal hyperperfusion by splenic artery ligation (SAL) in ALDLT was performed. After reperfusion, patients with portal venous pressure (PVP)>15 mm Hg with a gradient (PVP-central venous pressure) of ≥7 mm Hg and/or portal venous flow (PVF) >250 mL/min/100 g of liver were randomized into 2 groups: GIM and No GIM.

RESULTS

75 of 209 patients satisfied the inclusion criteria, and 38 underwent GIM. Baseline PVF and PVP were comparable between the GIM and no GIM groups. SAL significantly reduced the PVF and PVP ( P <0.001). There were no significant differences in the primary and secondary outcomes between the 2 groups. In the subgroup analysis, with a Graft to Recipient Weight Ratio ≤0.8, there were no significant differences in the primary and secondary outcomes.

CONCLUSIONS

SAL significantly decreased PVP and PVF but did not decrease rates of EAD in adult LDLT.

T1b gallbladder cancer: is extended resection warranted?

BACKGROUND

Although the prognosis for gallbladder cancer (GBCA) improves with early diagnosis and aggressive surgical treatment, the management of patients with muscle layer invasion (T1b) remains controversial. This study aimed to analyze the optimal surgical approach for these patients.

METHODS

A database was queried for patients with early T1b GBCA treated at four Chilean hospitals. Patients were prospectively treated and registered by the same surgical team at each hospital. Clinical outcomes, including survival rates according to the type of surgery, were analyzed.

RESULTS

Between 1988 and 2023, 129 Chilean patients were pathologically diagnosed with T1b GBCA. Simple cholecystectomy (SC) was performed in 86 patients (66.7 %), while extended cholecystectomy (EC) was performed in 43 patients. The overall 5-year survival rate was 83 %, with no significant difference between SC and EC patients.

CONCLUSION

Simple cholecystectomy demonstrated survival rates comparable to extended cholecystectomy for patients with T1b GBCA. More extensive resections did not improve the prognosis.

Psoas Muscle Volume Is a Useful Predictor of Postoperative Outcome in Elderly Patients With Non-Small Cell Lung Cancer

BACKGROUND

As the population ages, the number of elderly lung cancer patients has been increasing. While surgery is the best treatment for resectable lung cancer, elderly patients often have multiple comorbidities, making accurate preoperative risk assessment crucial when formulating an appropriate treatment plan. This study aims to explore how psoas muscle volume relates to postoperative outcomes in elderly lung cancer patients.

METHODS

This single-center, retrospective study included 344 elderly (≥ 75) patients who underwent complete surgical resection for non-small cell cancer between 2010 and 2023. The psoas muscle volume index (PVI, cm3/m3) was measured using a 3-dimensional imaging workstation based on preoperative computed tomography images and grouped based on the median value for each gender. Postoperative complications and survival rates were then compared between the groups.

RESULTS

The median PVI was 60.5 cm3/m3 for males and 47.7 cm3/m3 for females. The PVI-high group had significantly fewer complications (15.6%) than the PVI-low group (37.1%) (p < 0.001). The 5-year overall survival (OS) rate was higher in the PVI-high group (80.5%) than in the PVI-low group (66.7%) (p = 0.01). Multivariate analyses showed that PVI-high was an independent predictor of lower complication risk (odds ratio 0.28, p < 0.001) and an independent factor that improved OS (hazard ratio 0.60, p = 0.042).

CONCLUSIONS

PVI in elderly lung cancer patients is associated with postoperative complications and survival.

Does surgeon or hospital volume influence outcome in dedicated colorectal units?-A Viennese perspective

OBJECTIVE

A clear relationship between higher surgeon volume and improved outcomes has not been convincingly established in rectal cancer surgery. The aim of this study was to evaluate the impact of individual surgeon's caseload and hospital volume on perioperative outcome.

METHODS

We retrospectively analyzed 336 consecutive patients undergoing oncological resection for rectal cancer at two Viennese hospitals between 1 January 2015 and 31 December 2020. The effect of baseline characteristics as well as surgeons' caseloads (low volume: 0-5 cases per year, high volume > 5 cases per year) on postoperative complication rates (Clavien-Dindo Classification groups of < 3 and ≥ 3) were evaluated.

RESULTS

No differences in baseline characteristics were found between centers in terms of sex, smoking status, or comorbidities of patients. Interestingly, only 14.7% of surgeons met the criteria to be classified as high-volume surgeons, while accounting for 66.3% of all operations. There was a significant difference in outcomes depending on the treating center in univariate and multivariate binary logistic regression analysis (odds ratio (OR) = 2.403, p = 0.008). Open surgery was associated with lower complication rates than minimally invasive approaches in univariate analysis (OR = 0.417, p = 0.003, 95%CI = 0.232-0.739) but not multivariate analysis. This indicated that the center's policy rather than surgeon volume or mode of surgery impact on postoperative outcomes.

CONCLUSION

Treating center standards impacted on outcome, while individual caseload of surgeons or mode of surgery did not independently affect complication rates in this analysis. The majority of rectal cancer resections are performed by a small number of surgeons in Viennese hospitals.

Retrospective analysis of general surgery outcomes in multicenter cohorts in Saudi Arabia

General surgery outcomes remain a concern despite advancements in techniques, anesthesia, and perioperative care. Achieving consistent, high-quality results and accurately predicting risks remains challenging. This study aimed to identify factors associated with adverse outcomes through a retrospective analysis of general surgery cases across multiple centers in Saudi Arabia. A retrospective cohort study analyzed 14,635 medical records of patients who underwent general surgery across multiple centers in Saudi Arabia from 2010 to 2020. Data from the General Directorate of Health Affairs registry included demographics, comorbidities, procedure details, and outcomes. The study focused on risk factors for 30-day mortality and complications, with subgroup analyses comparing outcomes across facilities. Common surgeries included hernia repair, cholecystectomy, appendectomy, and bowel resection. The overall 30-day mortality rate was 0.74%, and the complication rate was 11.1%. Independent predictors of mortality were ASA grade III/IV, Charlson index ≥3, cardiovascular disease, dementia, renal disease, and longer procedures. Teaching hospitals had lower mortality and complication rates. Complication predictors included older age, ASA III/IV, diabetes, cardiac disease, and high-risk procedures. Evening surgeries were associated with fewer complications. This multicenter study identified patient risk factors and procedure characteristics that predict 30-day outcomes after general surgery. Older age, multiple comorbidities, and high-risk surgeries were linked to poorer outcomes. Teaching centers had better results, emphasizing the role of institutional factors. These findings can guide risk stratification and quality improvement efforts to enhance recovery and provide a foundation for future research to improve surgical practices globally.

Anatomic Factors Associated with Complications After Radical Prostatectomy: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

The role of anatomical factors in predicting outcomes after radical prostatectomy (RP) remains unclear. This review aims to evaluate the impact of various anatomical factors on the perioperative outcomes of patients undergoing RP for localized prostate cancer (PCa).

METHODS

A comprehensive literature search was conducted through January 2024 using the PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. Data were extracted and pooled for a meta-analysis, with outcomes including operative time, blood loss, transfusion rates, overall complications, and positive surgical margins (PSMs). Heterogeneity was assessed using Cochrane Q test, and subgroup analyses were conducted to explore the influence of surgical approach.

KEY FINDINGS AND LIMITATIONS

A total of 91 studies met our inclusion criteria. Among the anatomical factors, prostate volume (PV), prostate weight, and median lobe (ML) were suitable for the meta-analysis. Larger prostates were associated with increased operative time, blood loss, and complication rates, but with fewer PSMs (all p < 0.05). ML presence was not associated with a higher risk of complications. Heterogeneity was high across studies (Cochrane Q tests <0.05), reflecting inconsistent definitions and methods. In subgroup analyses, the open approach was associated with a longer operative time than robotic surgery for large prostates (p = 0.03) and a lower PSM rate (p < 0.001).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Anatomical factors, particularly PV, play a significant role in RP outcomes. Larger prostates are associated with higher complication rates but fewer PSMs. Further research with standardized outcome measures is necessary to clarify these relationships and guide clinical decision-making.

PATIENT SUMMARY

In this study, we examined how a patient's individual anatomy might affect the results of prostate surgery for cancer. We found that larger prostates tend to lead to longer surgeries and increased blood loss, but these also have a lower risk of leaving cancer cells behind. These findings could help doctors in better planning surgeries and improving patient outcomes.

Intravesical Instillation of Chemotherapy Before Radical Surgery for Upper Urinary Tract Urothelial Carcinoma: The REBACARE Trial

BACKGROUND AND OBJECTIVE

Intravesical instillation of chemotherapy (IIC) after radical surgery for upper urinary tract urothelial carcinoma (UTUC) reduces the risk of intravesical recurrence (IVR). However, compliance is low because of possible extravesical leakage after bladder cuff excision. The aim of this study was to evaluate the efficacy of preoperative IIC in reducing the risk of IVR.

METHODS

In this prospective, single-arm, multi-institutional, phase 2 clinical trial, 190 chemonaïve patients with primary UTUC without prior or concurrent bladder cancer received a single intravesical instillation of mitomycin C for 1-2 hr within 3 h before surgery. The primary endpoint was the 2-yr histologically confirmed IVR rate, with a target reduction of >40% (from 33.2% according to literature data to <20%). A historical cohort of 247 patients with UTUC who did not receive perioperative IIC served as the reference. Secondary endpoints included compliance, toxicity, and IVR-free survival, which was analyzed via multivariable Cox regression and stratified by previous diagnostic ureteroscopy (d-URS).

KEY FINDINGS AND LIMITATIONS

The 2-yr IVR rate was 24% (95% confidence interval [CI] 18-31%) on intention-to-treat analysis and 23% (95% CI 13-32%) on per-protocol analysis. Multivariable analysis revealed that d-URS was associated with higher IVR risk. In the REBACARE cohort, patients without d-URS had threefold lower IVR risk (hazard ratio 0.33, 95% CI 0.12-0.87) in comparison to the reference cohort. Compliance with preoperative instillation was 96% and no grade >2 toxicity occurred.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Preoperative IIC with mitomycin C was feasible and well tolerated and significantly reduced IVR risk for patients without d-URS. These findings suggest that preoperative IIC is a viable strategy for this subset of UTUC patients and that d-URS should be performed judiciously.

Short-term outcomes of minimally invasive total vs supracervical hysterectomy for uterine fibroids: a National Surgical Quality Improvement Program study

BACKGROUND

Uterine fibroids are the most common indication for benign hysterectomy in the United States, but data regarding the association between hysterectomy type and outcomes for this indication are lacking.

OBJECTIVE

This study aimed to describe the rate and odds of short-term (30 days) postoperative complications between patients who underwent minimally invasive total laparoscopic hysterectomy and those who underwent laparoscopic supracervical hysterectomy for uterine fibroids.

STUDY DESIGN

This was a cohort study of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. The characteristics of women who underwent total laparoscopic hysterectomy and those who underwent laparoscopic supracervical hysterectomy for uterine fibroids were identified. In addition, the risk factors associated with the occurrence of 30-day postoperative complications, defined according to the Clavien-Dindo classification, were identified. Multivariate regression analysis, including age, body mass index, race, comorbidities, American Society of Anesthesiologists classification, uterine weight, and concomitant procedures, was performed to identify the adjusted odds of postoperative complications. The co-primary outcomes were (1) the risk of a composite of any postoperative complications and (2) the risk of major postoperative complications according to surgical type.

RESULTS

Overall, 44,413 patients underwent minimally invasive total laparoscopic hysterectomy, and 6383 patients underwent laparoscopic supracervical hysterectomy. The operative time was shorter in the total laparoscopic hysterectomy group than in the laparoscopic supracervical hysterectomy group (143.0 vs 150.6 minutes, respectively; P < .001). In addition, the proportion of uterine weight of >250 g was lower in the total laparoscopic hysterectomy group than in the laparoscopic supracervical hysterectomy group (39.4% vs 45.1%, respectively; P < .001). The rates of any and major complications were higher in the total laparoscopic hysterectomy group than in the laparoscopic supracervical hysterectomy group (any complications: 6.6% vs 5.3%, respectively; P < .001; major complications: 2.7% vs 1.6%, respectively; P < .001), whereas the rates of minor complications were comparable in both groups (4.4% vs 4.1%, respectively; P = .309). In multivariate regression analysis, laparoscopic supracervical hysterectomy was independently associated with a lower risk of any (adjusted odds ratio, 0.79; 95% confidence interval, 0.70-0.88) and major (adjusted odds ratio, 0.55; 95% confidence interval, 0.44-0.69) complications than total laparoscopic hysterectomy.

CONCLUSION

Laparoscopic supracervical hysterectomy was associated with a lower risk of short-term postoperative complications in patients with uterine fibroids than total laparoscopic hysterectomy. Our findings can aid in shared decision-making before minimally invasive hysterectomy for uterine fibroids.

Risk Factors for Anastomotic Leakage: A Comprehensive Single-Center Analysis of Colorectal Anastomoses for Ovarian and Gastrointestinal Cancers

BACKGROUND

Anastomotic leakage (AL) is a major complication in colorectal surgery, particularly following rectal cancer surgery, necessitating effective prevention strategies. The increasing frequency of colorectal resections and anastomoses during cytoreductive surgery (CRS) for peritoneal carcinomatosis further complicates this issue owing to the diverse patient populations with varied tumor distributions and surgical complexities. This study aims to assess and compare AL incidence and associated risk factors across conventional colorectal cancer surgery (CRC), gastrointestinal CRS (GI-CRS), and ovarian CRS (OC-CRS), with a secondary focus on evaluating the role of protective ostomies.

PATIENTS AND METHODS

A retrospective analysis was performed on 1324 patients undergoing CRC, GI-CRS, and OC-CRS between January 2015 and December 2022. Multivariate analysis was utilized to identify preoperative, intraoperative, and postoperative variables as potential AL risk factors.

RESULTS

The overall AL rate was 3.0% (40/1324), with no significant differences among the three groups. Distinct risk factors were identified for each group: CRC (preoperative chemoradiotherapy), GI-CRS (ECOG score ≥ 2, preoperative albumin < 30 mg/dL), and OC-CRS (BMI < 18 kg/m2, pelvic lymphadenectomy, preoperative albumin < 30 mg/dL, anastomosis distance < 10 cm, postoperative anemia). Protective ostomies did not reduce AL incidence, and a notable discrepancy exists between AL risk factors and those influencing protective ostomy decisions.

CONCLUSIONS

AL, while rare, remains a serious postoperative complication in CRC and CRS. Key risk factors include preoperative nutritional status and surgical details such as blood supply and anastomosis level. Each patient group presents unique risks, which must be carefully weighed when considering protective ileostomy.

The effect of delirium on the association between frailty and postoperative major complications in elderly patients: a mediation analysis

PURPOSE

Both preoperative frailty and postoperative delirium (POD) are associated with higher risk of postoperative complications. But it is unclear if the effect of preoperative frailty on postoperative complications was mediated by POD.

METHODS

This study was a mediation analysis of a pooled database. Patients aged ≥ 60 years who underwent elective non-cardiac surgery were enrolled. Preoperative frailty was defined as the modified frailty index (mFI) ≥ 0.27. POD was assessed twice daily within the first 3 days using the Confusion Assessment Method (CAM) for patients without intubation and the CAM for intensive care unit (CAM-ICU) for intubated patients. Major complications within postoperative 30 days were screened. Mediation analysis was employed to explore the relationships between frailty, POD, and postoperative complications.

RESULTS

A total of 4684 patients were included. The prevalence of frailty was 10.4% (489/4684). In comparison with non-frail patients, frail patients had a higher incidence of POD (12.7% [62/489] vs 6.5% [271/4195], RR = 2.102, 95% CI 1.568-2.819, P < 0.001) and more postoperative complications (21.5% [105/489] vs 16.7% [701/4195], RR = 1.363, 95% CI 1.082-1.716, P = 0.008). The adjusted total and direct associations between frailty and postoperative complications were 5.8% (adjusted β, 95% CI, 1.8-9.5%; P < 0.001) and 5.0% (adjusted β, 95% CI, 1.1-8.7%; P = 0.004), respectively. A significant indirect association via POD was observed (adjusted β = 0.8%; 95% CI, 0.3-1.4%; P < 0.001), accounting for 13.8% of the total effect.

CONCLUSION

Preoperative frailty is associated with an increased risk of postoperative complications, mediated in part by early POD, in elderly patients following non-cardiac surgery. Given the modest effect size, further research is warranted to confirm these findings.

Laparoscopic versus open resection for hepatocellular carcinoma according to the procedure's complexity: real-world weighted data from a national register

BACKGROUND

Minimal access liver surgery (MALS) is considered superior to open liver resection (OLR) in reducing the perioperative risk in patients affected by hepatocellular carcinoma (HCC). No national-level comparisons exist based on procedure complexity. This study aims to compare postoperative complications, postoperative ascites (POA), and major complications (MC) between MALS and OLR.

METHODS

Data were retrieved from the Italian HE. RC.O.LE.S. registry. Patients were categorized into OLR or MALS groups and stratified by complexity grade (CP1, CP2, CP3). An inverse probability weighting (IPW) was performed to ensure balanced comparisons.

RESULTS

From 2008 to 2021, 4738 patients were included: 1596 (33.7 %) underwent MALS, and 3142 (66.3 %) underwent OLR. CP1 procedures were conducted in 2522 cases (53.2 %), CP2 in 974 cases (20.5 %), and CP3 in 1242 cases (26.2 %). For CP1, MALS was associated with reduced POA (OR 0.356, 95%CI:0.29-0.43, p < 0.001), and MC (OR 0.738, 95%CI:0.59-0.91, p: 0.006). In CP2, MALS showed association with MC (OR 0.557, 95%CI:0.37-0.82, p:0.004), but not with POA. For CP3, MALS was associated with increased MC risk (OR 1.441, 95%CI:1.10-1.88, p:0.008). Low-volume centers had significantly higher MC risks after CP2 and CP3 procedures than medium or high-volume centers.

CONCLUSION

In CP1 and CP2 procedures, MALS was proven advantageous in reducing POA and MC. Among CP3, MALS increased the risk of MC, but not among high-volume centres.

Neoadjuvant and Adjuvant Immune-based Approach for Renal Cell Carcinoma: Pros, Cons, and Future Directions

CONTEXT

Immune-oncology strategies are revolutionising the perioperative treatment in several tumour types. The perioperative setting of renal cell carcinoma (RCC) is an evolving field, and the advent of immunotherapy is producing significant advances.

OBJECTIVE

To critically review the potential pros and cons of adjuvant and neoadjuvant immune-based therapeutic strategies in RCC, and to provide insights for future research in this field.

EVIDENCE ACQUISITION

We performed a collaborative narrative review of the existing literature.

EVIDENCE SYNTHESIS

Adjuvant immunotherapy with pembrolizumab is a new standard of care for patients at a higher risk of recurrence after nephrectomy, demonstrating a disease-free survival and overall survival benefit in the phase 3 KEYNOTE-564 trial. Current data do not support neoadjuvant therapy use outside clinical trials. While both adjuvant and neoadjuvant immune-based approaches are driven by robust biological rationale, neoadjuvant immunotherapy may enable a stronger and more durable antitumour immune response. If neoadjuvant single-agent immune checkpoint inhibitors demonstrated limited activity on the primary tumour, immune-based combinations may show increased activity. Overtreatment and a risk of relevant toxicity for patients who are cured by surgery alone are common concerns for both neoadjuvant and adjuvant strategies. Biomarkers helping patient selection and treatment deintensification are lacking in RCC. No results from randomised trials comparing neoadjuvant or perioperative immune-based therapy with adjuvant immunotherapy are available.

CONCLUSIONS

Adjuvant immunotherapy is a new standard of care in RCC. Both neoadjuvant and adjuvant immunotherapy strategies have potential advantages and disadvantages. Optimising perioperative treatment strategies is nuanced, with the role of neoadjuvant immune-based therapies yet to be defined. Given strong biological rationale for a pre/perioperative approach, there is a need for prospective clinical trials to determine clinical efficacy. Research investigating biomarkers aiding patient selection and treatment deintensification strategies is needed.

PATIENT SUMMARY

Immunotherapy is transforming the treatment of kidney cancer. In this review, we looked at the studies investigating immunotherapy strategies before and/or after surgery for patients with kidney cancer to assess potential pros and cons. We concluded that both neoadjuvant and adjuvant immunotherapy strategies may have potential advantages and disadvantages. While immunotherapy administered after surgery is already a standard of care, immunotherapy before surgery should be better investigated in future studies. Future trials should also focus on the selection of patients in order to spare toxicity for patients who will be cured by surgery alone.

The Kaleidoscope of Midface Management in Apert Syndrome: A 23-Year Single-Institution Experience

BACKGROUND

This study assesses operative trends over time and outcomes of 5 osteotomy techniques used to treat the midface in Apert syndrome. Using clinical and photogrammetric data, the authors present their institution's selection rationale for correcting specific dysmorphologies of the midface in Apert syndrome based on the individual phenotype.

METHODS

The authors retrospectively reviewed patients with Apert syndrome who underwent midface distraction from 2000 through 2023. Patients were temporally divided by 2012 to assess differences in surgical approach. Postoperative facial dimension changes, surgical and perioperative characteristics, and complications data were compared across techniques.

RESULTS

A total of 39 patients with Apert syndrome underwent 41 midface distraction procedures (23 [56%] in the early cohort and 18 [44%] in the late cohort). The use of segmental osteotomies for frontofacial advancement increased from 0% before 2012 to 61% from 2012 onwards ( P < 0.001). Monobloc with bipartition was the only technique associated with decreased intercanthal distance ( P = 0.016), and Le Fort II with zygomatic repositioning achieved the greatest median change in bilateral canthal tilt of 8.7 degrees (interquartile range, 1.3, 8.7 degrees; P = 0.068). Monobloc with Le Fort II achieved the greatest median change in facial convexity of -34.9 degrees (interquartile range, -43.3, -29.2 degrees; P = 0.031). Severity of complications, stratified by Clavien-Dindo grade, was greater in transcranial than subcranial procedures, but similar between segmental and nonsegmental osteotomies ( P = 0.365).

CONCLUSIONS

In studying the midface in Apert syndrome and attempting to resolve its varying functional and aesthetic issues, the authors document an evolution toward multipiece osteotomies over time. With an appreciation for differential midface hypoplasia, segmentation is found to be associated with more effective normalization of the face in Apert syndrome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Irreversible Electroporation and Beta-Glucan-Induced Trained Innate Immunity for Treatment of Pancreatic Ductal Adenocarcinoma: A Phase II Study

BACKGROUND

Irreversible electroporation (IRE) has augmented the effects of certain immunotherapies in pancreatic ductal adenocarcinoma (PDA). Yeast-derived particulate beta-glucan induces trained innate immunity and successfully reduced murine pancreatic cancer burden. This is a phase II study to test the hypothesis that IRE may augment beta-glucan-induced trained immunity in patients with PDA.

STUDY DESIGN

In this phase II clinical trial (NCT03080974), surgical ablative IRE was performed on clinical stage III PDA followed by oral beta-glucan administration for 12 months or until disease recurrence. Peripheral blood was taken preoperative, 14 days, and every 3 months and was evaluated by mass cytometry and compared with patients who received IRE alone.

RESULTS

Thirty consecutive patients with preoperative clinical stage III PDA were treated with IRE and then initiated on oral beta-glucan postoperatively were compared with 20 patients treated with IRE alone. There were no dose-limiting toxicities with oral beta-glucan, and compliance with therapy was 96% in all patients. Seven patients (23%) developed grade 3 or 4 treatment-related adverse events at 90 days; none required a dose modification of oral beta-glucan. A median disease-free interval (DFI) was 18 months (range 6 to 48 months), with a median overall survival (OS) of 32.5 months (range 4 to 53 months). At 12 months post-IRE, immunophenotyping was demonstrated a significant effect with improvement in the IRE-beta-glucan-treated group. This also resulted in a significant decrease on naive CD4 and CD8 T cells with increased CD4 and CD8 terminal effector cells in the IRE-beta-glucan-treated group, which correlated with a significant improvement in DFI and OS (p = 0.001).

CONCLUSIONS

Combined beta-glucan with IRE-ablated PDA tumor cells elicited a potent trained response and augmented antitumor functionality at 12 months post-IRE, which translated into an improved DFI and OS.

The Actual Role of CPET in Predicting Postoperative Morbidity and Mortality of Patients Undergoing Pneumonectomy

This study aims to determine whether maximal oxygen consumption (VO2max) or predicted postoperative (ppo)-VO2max could still reliably predict postoperative complications and deaths in lung cancer patients undergoing pneumonectomy and which values could be more reliably considered as the optimal threshold. Methods: We retrospectively collected data of consecutive patients undergoing pneumonectomy for primary lung cancer at the European Oncological Institute (April 2019-April 2023). Routine preoperative assessment included cardiopulmonary exercise testing (CPET) and a lung perfusion scan. We evaluated the morbidity and mortality rates; associations between morbidity, mortality, VO2max, and ppoVO2max values were investigated through ANOVA or Fisher's exact test as appropriate. Receiver operating characteristic (ROC) curves were applied to further explore the relation between VO2max, ppoVO2max values, and 90-day mortality. Results: The cardiopulmonary morbidity rate was 32.2%; the 30-day and 90-day mortality rates were 2.2% and 6.7%. The PpoVO2max values were significantly lower in patients experiencing cardiopulmonary complications or deaths compared to the whole cohort, whereas VO2max, though showing a trend towards lower values, did not reach statistical significance. A VO2max value threshold of 15 mL/kg/min correlated significantly with 90-day mortality, while a ppoVO2max cut-off of 10 mL/kg/min was significantly associated with cardiopulmonary complications and 30-day and 90-day mortality rates. ROC curve analysis revealed ppoVO2max as a better predictor of 90-day mortality compared to VO2max. Conclusions: CPET and a lung perfusion scan are two key elements for the preoperative evaluation of patients undergoing pneumonectomy, since it provides a holistic assessment of cardiopulmonary functionality. We recommend the routine calculation of ppoVO2max, particularly when adopting a 10 mL/kg/min threshold.

Colorectal Cancer Outcomes of Robotic Surgery Using the Hugo™ RAS System: The First Worldwide Comparative Study of Robotic Surgery and Laparoscopy

Background/Objectives: The aim of the study was to compare the perioperative and oncologic outcomes of patients who underwent surgery for colorectal cancer (CRC) performed using laparoscopy or using the Medtronic Hugo™ Robotic-Assisted Surgery (RAS) system. Methods: This is a retrospective comparative single-center study of consecutive minimally invasive surgeries for CRC performed by two colorectal surgeons with extensive laparoscopic experience at the beginning of their robotic expertise. Patients were not selected for the surgical approach, but waiting lists and operating room availability determined whether the patients were in the robotic group or the laparoscopic group. The primary outcome was to compare 30-day postoperative complications according to the Clavien-Dindo classification and the Complication Comprehensive Index (CCI). The secondary outcomes included operating times, conversion rates, intraoperative complications, length of hospital stays (LOS), readmission rates, and short-term oncologic outcomes, such as the R0 resection, the number of lymph nodes harvested, the total mesorectal excision (TME) quality, and the circumferential resection margin (CRM). Results: Of the 109 patients, 52 underwent robotic and 57 laparoscopic CRC surgery. Patient demographic and clinical characteristics were similar in the two groups. There was no significant difference between the robotic and the laparoscopic groups regarding postoperative complications, the Clavien-Dindo classification, and the CCI. They also had similar operating times, conversion rates, intraoperative complications, LOSs, readmission rates, and short-term oncologic outcomes (the lymph nodes harvested, the R0 resection, TME quality, and CRM status). Conclusions: This study reports the largest cohort of CRC surgery performed using the Medtronic Hugo™ RAS system and is the first comparative study with laparoscopy. The perioperative and oncologic outcomes were similar, demonstrating that the Medtronic Hugo™ RAS system is safe and feasible for CRC as compared to laparoscopic surgery, even at the beginning of the robotic experience.

Whole stomach versus narrow gastric tube reconstruction after esophagectomy for esophageal cancer (ATHLETE trial): study protocol for a randomized controlled trial

BACKGROUND

There are two types of methods of creating a gastric conduit after esophagectomy for patients with esophageal cancer: narrow gastric tube reconstruction or whole stomach reconstruction. Whole stomach reconstruction with good blood perfusion was reported in a prospective cohort study to be safe and that it has the possibility to prevent anastomotic leakage (AL). We therefore planned a randomized controlled phase III study to investigate the superiority of whole stomach reconstruction over narrow gastric tube reconstruction after esophagectomy for esophageal cancer.

METHODS

This is a single center, two-arm, open-label, randomized phase III trial. We calculated that 65 patients in each arm of this study and total study population of 130 patients are required according to our historical data on narrow gastric tube reconstruction and prospective data on whole stomach reconstruction. In the narrow gastric tube group, a 3.5-cm-wide gastric tube is made along the greater curvature of the stomach using linear staplers. Otherwise, in the whole stomach group, after the lymphadenectomy of the lesser curvature and No.2, the stomach is cut just below the esophagogastric junction using a linear stapler. The primary endpoint of this study is the incidence of AL. Secondary endpoints are the occurrence rate of anastomotic stenosis, the occurrence rate of pneumonia, the occurrence rate of all postoperative complications, the occurrence rate of reflux esophagitis, quality of life evaluation by EORTC QLQ-C30 and EORTC OES-18, nutritional evaluation, the amount of blood loss, postoperative hospital stays, and blood flow evaluation. Complications are evaluated using the Clavien-Dindo classification (version 2.0), and those of grade II or higher are considered to be postoperative complications.

DISCUSSION

If the optimal method for creating a gastric conduit after esophagectomy is clarified, it may be possible to contribute to improving short-term and long-term surgical outcomes for patients undergoing surgery for esophageal cancer.

TRIAL REGISTRATION

The protocol of ATHLETE trial was registered in the UMIN Clinical Trials Registry as UMIN000050677 ( http://www.umin.ac.jp/ctr/index.htm ). Date of registration: March 26, 2023. Date of first participant enrollment: March 27, 2023.

Estimating the Morbidity of Robot-Assisted Radical Cystectomy Using the Comprehensive Complication Index: Data from the Asian Robot-Assisted Radical Cystectomy Consortium

Background/Objectives: The Clavien-Dindo classification (CDC) grades the most severe post-operative complication and may not comprehensively reflect cumulative surgical morbidity. Our objective was to investigate the potential incremental role of the comprehensive complication index (CCI) over the CDC in defining the quality of robot-assisted radical cystectomy (RARC). Methods: Data were extracted from the Asian RARC Consortium database. Complications were classified using the CCI (CCI = 0, CCI < 75th and ≥75th percentile) and CDC. Adverse peri-operative outcomes such as length of stay >14 days (LOS > 14 days), estimated blood loss >350 mL (EBL > 350 mL), time to solid food intake >4 days (TFI > 4 days) and 30-day readmission rates were analyzed. The area under the curve (AUC) of the receiver operating characteristic (ROC) curves for CCI and CDC were compared for the various adverse outcomes. Results: The peri-operative complication rate was 44.4%, comprising 11.6% with severe complications (CDC ≥ III). The mean CCI was 10.2 (±13.5) while median CCI was 0 (IQR 0-21). There were 7.6% of patients with >one perioperative complication. On adjusted analysis, CCI ≥ 75th percentile was significantly associated with greater LOS (>14 days) (OR 2.21, 95% CI 1.47-3.31, p < 0.001) compared to when CCI = 0. There were no significant differences in the AUC between CDC and CCI in predicting LOS > 14 days, TFI > 4 days, 30-day readmission or EBL > 350 mL. Conclusions: In our multi-institutional cohort, the CCI did not provide additional discrimination over CDC, and this is likely related to the limited number of complications that occurred per individual in the Asian RARC cohort. Hence, the perceived advantages of CCI over CDC are contextual.