Temporal trends in gender, etiology, severity and outcomes of acute pancreatitis in a third-tier Chinese city from 2013 to 2021

BACKGROUND

To evaluate temporal trends in gender, etiology, severity, outcomes, cost and median length of stay (MLS) in patients with acute pancreatitis (AP) in a third-tier Chinese city.

METHODS

Patients with AP admitted to a university hospital between January 2013 and December 2021. Relationships between etiology, prevalence of severe acute pancreatitis (SAP) and survey years were investigated by joinpoint regression analysis.

RESULTS

A total of 5459 (male 62.3%) patients with AP were included. Between January 2013 and December 2021, we observed: (a) the prevalence of biliary diseases-related AP was stable, while the prevalence of hypertriglyceridemia (HTG)-associated AP (Ptrend = 0.04) and alcohol-associated AP (Ptrend < 0.0001) both increased; (b) there was an increase in crude prevalence of SAP from 4.97% to 12.2% between 2013 and 2021 (Ptrend < 0.0001); (c) compared to female populations, male gender had a higher prevalence of AP; (d) there was a decrease in MLS from 11 days to 8 days (Ptrend < 0.0001) and in median cost of hospitalization (MCH) for all patients (from 20,166 to 12,845 YUAN) (Ptrend < 0.0001); (e) the overall in-hospital mortality rate was 1.28% (70/5459) for patients with AP. There was no statistically significant in the time trend of mortality during the study period (Ptrend = 0.5873). At multivariate analysis, survey year was associated with prevalence of SAP after adjustment by age and biliary diseases (OR: 1.07; 95% CI: 1.03-1.12). Based on the stratification by severity of disease, the decrease of MLS and MCH was more significant in non-SAP vs. SAP patients.

CONCLUSIONS

Over the observational period, the proportion of male patients with AP, prevalence of age-adjusted rate of HTG and alcohol-associated AP and SAP increased, while MLS and MCH for all patients decreased, and the time trend of mortality of AP was stable.

HUGO™ system robotic eTEP technique for ventral hernia repair. A step-by-step medial bottom-up approach

This study describes an innovative robotic extended totally extraperitoneal (eTEP) technique for ventral hernia repair via a medial bottom-up approach using the new HUGO™ system. The surgical steps and a novel setup guide for this approach are detailed. A 78-year-old male with an incisional umbilical hernia and concomitant rectus diastasis was treated using the HUGO™ system. The system's modular design enabled a customized surgical approach. Robotic eTEP repair was performed via a medial bottom-up approach, and robotic trocars were placed in the hypogastric region. Single docking was sufficient. The procedure lasted 180 min, with no intraoperative complications. The patient's postoperative recovery was uneventful, and a normal diet was resumed on the first postoperative day. The postoperative hospital stay was 7 days. Satisfactory outcomes without complications were observed during follow-up. This study introduced a novel robotic eTEP approach for abdominal wall hernia repair using the HUGO™ system, highlighting the medial bottom-up technique and an innovative docking configuration. The medial bottom-up robotic eTEP approach using the HUGO™ system is a feasible and promising technique for abdominal wall hernia repair. To evaluate long-term outcomes and broader applicability among surgeons experienced in robotic and retromuscular hernia repair, further studies are warranted.

Gender impact on pancreatic neuroendocrine neoplasm (PanNEN) prognosis according to survival nomograms

PURPOSE

Personalizing care and outcome evaluation are important aims in the field of NEN and nomograms may represent useful tools for clinicians. Of note, gender difference is being progressively more considered in NEN care, as it may also impact on survival. This systematic review aims to describe and analyze the available nomograms on pancreatic NENs (PanNENs) to identify if gender differences are evaluated and if they could impact on patients' management and prognosis.

METHODS

We performed an electronic-based search using PubMed updated until June 2024, summarizing the available evidence of gender impact on PanNEN survival outcomes as emerges from published nomograms.

RESULTS

34 articles were identified regarding prognostic nomograms in PanNEN fields. The most included variables were age, tumor grade, tumor stage, while only 5 papers (14.7%) included sex as one of the key model variables with a significant impact on patients' prognosis. These 5 studies analyzed a total of 18,920 PanNENs. 3 studies found a significant impact of sex on overall survival (OS), whereas the remaining 2 studies showed no significant impact of sex on OS.

CONCLUSIONS

Gender difference is being progressively more considered in PanNEN diagnosis, care and survival. Nomograms represent a potentially useful tool in patients' management and in outcomes prediction in the field of PanNENs. A key role of sex in the prognosis of PanNENs has been found in few models, while definitive conclusions couldn't be drawn. Future studies are needed to finally establish gender impact on PanNEN prognosis.

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.

Cost-effectiveness of robotic compared with laparoscopic rectal resection. Results from the Spanish prospective national trial ROBOCOSTES

OBJECTIVE

The costs related to robotic surgery are known to be greater than those associated with laparoscopy. However, the potential for better outcomes of the former could lead to a cost-effectiveness advantage. The aim of this study is therefore to highlight the difference in cost-effectiveness between robotic and laparoscopic rectal resection.

METHODS

This is an observational, multicenter, national prospective study (ROBOCOSTES). From 2022, for 1 year, all consecutive patients undergoing minimally invasive rectal resection were included. Quality-adjusted life year and cost data were prospectively collected. The primary aim was to assess the cost-effectiveness of robotic rectal resection and laparoscopic rectal resection . Secondary aims included clinical outcomes and quality of life.

RESULTS

Overall, 182 patients underwent rectal resection (152 anterior and 30 abdominoperineal excisions) at 14 centers, of whom 95 received robotic rectal resection and 87 laparoscopic rectal resection. Robotic rectal resection was associated with lesser blood loss (58.55 ± 51.68 vs 131.68 ± 191.92, P < .001), lower pain score at day 1 (-1.04 visual analog scale, P < .001) and day 7 (-0.81, P < .001) after surgery, and with fewer hospital readmissions (2.1% vs 15%, P = .005) compared with laparoscopic rectal resection. The overall costs of robotic rectal resection (including hospitalization) were 919.66 euros greater compared with laparoscopic rectal resection, but quality-adjusted life years in the robotic rectal resection group were better than laparoscopic approaches to rectal resection both at 30-day (0.8914 vs 0.8139) and 90-day (0.9573 vs 0.8740) follow-up. At a willingness-to-pay threshold of 20,000 and 30,000 euros, there was an 84.38% and 89.36% probability that robotic rectal resection was more cost-effective than laparoscopic rectal resection.

CONCLUSION

This study showed that robotic rectal resection, even if associated with greater direct costs in the short term, outperforms laparoscopic rectal resection in terms of quality-adjusted life years and should therefore be preferred where available.

Association between accelerometer-measured light-intensity physical activity and tumor regression for male patients with esophageal cancer receiving neoadjuvant therapy: a retrospective cohort study

BACKGROUND

Physical activity has the potential to promote tumor regression in patients with esophageal cancer receiving neoadjuvant chemotherapy (NAC); however, the benefits of light-intensity physical activity (LIPA) are unclear. This study aimed to investigate the impact of LIPA on tumor regression in male patients with esophageal cancer during NAC and its optimal cutoff value.

METHODS

This retrospective single-center observational study included all male patients who underwent NAC or curative esophagectomy. We assessed the physical activity of patients using an accelerometer and calculated the time spent on LIPA. Tumor regression was defined as grade ≥ 1b according to the Japanese classification of esophageal cancer. The impact of LIPA on tumor regression was analyzed using multivariate analysis, and the optimal cutoff value was identified using the receiver operating characteristic curve.

RESULTS

Sixty-nine male patients with esophageal cancer who underwent NAC were analyzed. The mean age was 68 years, mean body mass index was 22.4, and 80% of the patients were diagnosed with clinical stage 3 or 4 disease. Every extra 30-min increase in LIPA during the treatment phase was associated with tumor regression (adjusted OR 1.41 [1.02-2.04]). The optimal cutoff value of LIPA was 156.11 min/day, and patients with rich LIPA (≥ 156.11 min/day) were less likely to suffer from anorexia and malnutrition during NAC.

CONCLUSION

This study demonstrated that LIPA during NAC has a potential of promoting tumor regression with a cutoff value of 156.5 min/day. Further clinical research is required to determine the prognostic benefits of LIPA in patients receiving NAC.

Comparative Assessment of Outcomes: Abdominal Drain Versus No Abdominal Drain After Left Pancreatectomy-A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement postpancreatectomy.

BACKGROUND

Left pancreatectomy (LP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like postoperative pancreatic fistula (POPF). While routine abdominal drainage following LP has been standard practice, recent evidence suggests potential benefits of omitting this approach.

METHODS

A comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding nine studies comprising 15,817 patients. Data were extracted from randomized and nonrandomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios were calculated with 95% CIs, and a P value of <0.05 was considered statistically significant.

RESULTS

A total of 13,081 patients underwent drain placement after left pancreatectomy, and 2736 patients were included in the no-drain group. Out of the total, 45.1% (n=7140) patients were male, with 45.9% (n=6012) males in the drain group and 41.2% (n=1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥III complications, was significantly lower in the no-drain group [relative risk (RR): 0.77, 95% CI: 0.64-0.93, P =0.006]. Similarly, lower rates of postoperative pancreatic fistula (POPF) (RR: 0.51, 95% CI: 0.38-0.67, P <0.00001), readmission (RR: 0.75, 95% CI: 0.59-0.96, P =0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70-0.95, P =0.009) were observed in the no-drain group. In addition, a shorter length of hospital stay was noted in this group [mean difference (MD): -1.65, 95% CI: -2.50 to -0.81, P =0.0001].

CONCLUSIONS

Omitting routine drainage after a left pancreatectomy is associated with reduced complications and shorter hospital stays, supporting its potential benefits in improving postoperative outcomes.

Central pancreatectomy: An uncommon but potentially optimal choice of pancreatic resection

Benign, premalignant or low-grade malignant pancreatic tumors are increasingly diagnosed owing to the widespread uptake of cross-sectional imaging. Surgical excision is a potential treatment option for these tumors. Pancreatoduodenectomy and distal pancreatectomy are the standard resections for tumors located in the pancreatic head-neck or body-tail, respectively, and not uncommonly sacrifice a significant amount of healthy pancreatic parenchyma. Central pancreatectomy (CP) is a parenchyma-sparing procedure, initially performed by Dagradi and Serio in 1982, in a patient with pancreatic neck insulinoma. Since then, an increasing number of cases are being performed worldwide, either via open or minimally invasive surgical access. Additionally, pancreatic enucleation is reserved for tumors < 3 cm, without involvement of the main pancreatic duct. CP remains an alternative approach in selected cases, albeit in the presence of some controversies, such as its use in early pancreatic ductal adenocarcinoma or metastatic deposits to the central aspect of the pancreas from other malignancies. In recent years, clarity is lacking as regards indications for CP, and despite accumulating evidence in favor of limited resections for suitable pancreatic tumors, no evidence-based consensus guidelines are yet available. Nevertheless, it appears that appropriate patient selection is of paramount importance to maximize the advantages of preservation of endocrine and exocrine pancreatic functions as well as to mitigate the risks of higher complication rates. In this comprehensive review, we explore the role of CP in the treatment of lesions located in the neck and proximal body of the pancreas.

Early versus delayed laparoscopic cholecystectomy for gallbladder perforation

BACKGROUND

Gallbladder perforation occurs in 2% to 11% of patients with acute cholecystitis, with associated mortality estimated to be at 12% to 42%. Because of its low incidence, the data on management remain sparse. There is a lack of evidence to suggest whether early or delayed cholecystectomy is superior in the treatment of perforated cholecystitis. We hypothesize that an early definitive operation is associated with decreased total hospital length of stay (THLOS).

METHODS

Using the National Surgical Quality Improvement Program database from the American College of Surgery, we identified patients who underwent laparoscopic cholecystectomy for gallbladder perforation on an urgent or emergent basis from 2012 to 2021. We divided them into those who underwent early (<2 days from the date of admission to the date of operation) and delayed cholecystectomy (≥2 days from the date of admission to the date of operation). Our primary outcome was the THLOS. We created multivariate regression models to assess for the association of early versus delayed operation and THLOS.

RESULTS

The THLOS was found to be 2.94 days longer in the delayed group compared with the early group (p < 0.05). In those who did not present with sepsis on admission, the THLOS was noted to be 4.71 days longer in the delayed group compared with the early group (p < 0.05). Early versus delayed operation was not associated with a difference in the postoperative length of stay, 30-day postoperative complications, rate of readmission, and reoperation, regardless of preoperative sepsis status.

CONCLUSION

Early laparoscopic cholecystectomy for gallbladder perforation is associated with decreased THLOS, and there were no other differences in outcomes compared with delayed laparoscopic cholecystectomy. Patients with gallbladder perforation would likely benefit from an early operation within 2 days of admission.

LEVEL OF EVIDENCE

Therapeutic/Care management; Level IV.

Computational fluid dynamics for vascular assessment in hepatobiliopancreatic surgery: a pilot study and future perspectives

INTRODUCTION

In major hepatobiliopancreatic surgery, an accurate preoperative planning is essential. Postoperative impaired blood supply due to arterial disease or variants can cause postoperative complications. Computational fluid dynamics has previously been successful in revealing distinct features of haemodynamic disturbances. The purpose of our study is to describe the feasibility of a computational fluid dynamics model to predict hepatic artery flow and its variations following gastroduodenal (GDA) or common hepatic (CHA) artery ligation.

MATERIAL AND METHODS

This is a pilot study including 20 patients undergoing robotic pancreaticoduodenectomy at a single centre. Preoperative images and intraoperative vascular flows were used to the computational model. Three scenarios of the hepatic artery were analysed: (1) without any clamps, (2) clamped GDA and (3) clamped CHA. Patients 1 to 15 were used to develop the model, and patients 15 to 20 were used for model validation. Finally, the model was tested in 3 abnormal cases: celiac trunk stenosis (2) and replaced right hepatic artery (1).

RESULTS

The selected methodology proved to be reproducible, with the CFD model demonstrating 100% accuracy in predicting blood flow redistribution after gastroduodenal artery (GDA) clamping and 80% accuracy following common hepatic artery (CHA) clamping. The model accurately simulated reversed GDA flow in cases of celiac trunk stenosis and displayed independent flow distribution in patients with anatomical variations, even without prior specific model training.

CONCLUSION

The developed computational model accurately predicts flow variations in the proper hepatic artery in case of gastroduodenal artery and common hepatic artery clamping. Further studies are needed to validate this methodology.

Salvage of a Liver Allograft From Procurement Injury: A Case Report on the Reconstruction of the Suprahepatic Inferior Vena Cava With Donor Iliac Vein

Organ procurement injury is an underreported yet preventable cause of allograft loss. In cases where procurement injury occurs, innovative methods for reconstruction are necessary to minimize organ discard rates given the nationwide organ shortage. The liver and suprahepatic inferior vena cava (IVC) are particularly vulnerable to injury during multiorgan procurements when multiple procurements teams are present. We report an extreme case of suprahepatic IVC injury and our method for repair that resulted in successful transplantation and adequate post-transplant graft function.

Single-cell analysis reveals that GFAP+ dedifferentiated Schwann cells promote tumor progress in PNI-positive distal cholangiocarcinoma via lactate/HMGB1 axis

Distal cholangiocarcinoma (dCCA) is a highly lethal malignancy that accounts for approximately 40% of patients with primary cholangiocarcinoma. Remarkable cellular heterogeneity and perineural invasion (PNI) are two typical features of dCCA. Deciphering the complex interplay between neoplastic and neural cells is crucial for understanding the mechanisms propelling PNI-positive dCCA progression. Herein, we conduct single-cell RNA sequencing on 24,715 cells from two pairs of PNI-positive dCCA tumors and adjacent tissues, identifying eight unique cell types. Malignant cells exhibit significant inter- and intra-tumor heterogeneity. We delineate the compositional and functional phenotypes of five Schwann cell (SC) subsets in PNI-positive dCCA. Moreover, our analyses reveal two potential cell subtypes critical to forming PNI: NEAT1+ malignant cells characterized by hypoxic propensity and GFAP+ dedifferentiated SCs featuring hypermetabolism. Further bioinformatics uncover extensive cellular interactions between these two subpopulations. Functional experiments confirm that lactate in the hypoxic tumor microenvironment can induce GFAP-dedifferentiation in SCs, which promotes cancer cell invasion and progression through upregulating HMGB1. Taken together, our findings offer a thorough characterization of the transcriptional profile in PNI-positive dCCA and unveil potential therapeutic targets for dCCA PNI.

Robotic distal pancreatectomy using the Warshaw technique demonstrated superior short-term prognosis compared to the laparoscopic approach: propensity-matched cohort study

BACKGROUND

Minimally invasive spleen-preserving distal pancreatectomy (SPDP) presents technical challenges and remains a topic of debate. This study seeks to compare the splenic preservation techniques, especially the Kimura and Warshaw methods, with distal pancreatectomy with splenectomy (DPS) and to examine factors influencing short-term patient prognostic outcomes.

METHODS

A retrospective analysis was undertaken of all consecutive cases of minimally invasive distal pancreatectomy, both with and without spleen preservation, conducted at our center from January 2020 to May 2024. The study assessed the impact of demographic characteristics, operative variables, oncologic pathology review, and postoperative outcomes on patients' prognosis. Propensity score matching (PSM) was conducted at a 1:1 ratio. Both univariate and multivariate analyses were performed to identify risk factors affecting the preservation of the spleen and splenic vessels during distal pancreatectomy.

RESULTS

The research encompassed data from 490 consecutive patients who underwent minimally invasive distal pancreatectomy. Among the groups with planned spleen-preserving operations, after PSM, the incidence of Clavien-Dindo classification (CDC) ≥ III (6.3% vs. 0.7%, p = 0.010), postoperative pancreatic hemorrhage (4.2% vs. 0%, p = 0.039) and readmission within 90 days (4.2% vs. 0%, p = 0.039) was significantly higher in the Kimura group. Meanwhile, the Kimura group demonstrated a significantly lower incidence of splenic infarction (6.3% vs. 31.3%, p < 0.01) compared to the Warshaw group. Grouped by the minimally invasive methods, the robotic-SPDP (R-SPDP) group exhibited a lower rate of splenic infarction (7.6% vs. 27.5%, p < 0.01), as well as reduced operative time (145 vs. 175 min, p < 0.01) and postoperative hospital stay (6 vs. 8 days, p < 0.01), compared to the laparoscopic-SPDP (L-SPDP) group. An analysis of the minimally invasive technique revealed that the SPDP group experienced a lower rate of pleural effusion (5.6% vs. 16.8%, p = 0.009) than the DPS group after PSM analysis. Univariate analysis identified tumor diameter, operative time, Warshaw technique, and laparoscopic procedure as prognostic factors for the occurrence of splenic infarction. The Warshaw technique and laparoscopic approach were identified as independent prognostic factors for splenic infarction in multivariate analysis.

CONCLUSIONS

Both techniques have demonstrated efficacy in minimally invasive SPDP. Our findings indicate that the robotic-assisted Warshaw approach may offer enhanced efficiency and safety.

A modified multi-angle suture training module for laparoscopic training curriculum on emergency intestinal surgery

BACKGROUND

Intestinal perforation and intestinal obstruction are common emergency surgeries in clinics which often require intestinal resection and anastomosis. Most intestinal anastomosis can be completed by laparoscopy. The wound closure module In the Fundamentals of Laparoscopic Surgery (FLS) program is traditionally used for laparoscopic suture and knotting training. However, many young surgeons tend to focus on practicing suture techniques from certain or a limited range of angles. This narrow approach increases the difficulty of complex suturing and knotting in clinical scenarios such as laparoscopic intestinal anastomosis.

METHODS

To address this issue, we designed a multi-angle suture module specifically for suture and knotting training. Thirty-six second-year surgical residents were recruited for the study. Twelve residents were randomly divided at a 1:1 ratio into the traditional suture group and the multi-angle suture group according to their basic laparoscopic surgical ability. After training, they were required to perform laparoscopic end-to-end anastomosis surgery on isolated swine intestines.

RESULTS

The operation times, goal scores and surgical performance scores of the surgeries were collected and compared. Trainees who used the multi-angle suture training module shortened the operation time (3375.7 ± 1000 s vs. 4678.2 ± 684.7, p = 0.008) and achieved better surgical effects (operation performance score: 8.2 ± 1.5 vs. 6.83 ± 1.3, p = 0.041) in end‒end intestine anastomosis surgery than did those who used the traditional suture training module.

CONCLUSIONS

The multi-angle suture training module effectively improved the laparoscopic suture skills of trainees and is therefore a better choice for laparoscopic suture and knotting training before doing laparoscopic intestinal anastomosis.

International multicentre validation of the left pancreatectomy pancreatic fistula prediction models and development and validation of the combined DISPAIR-FRS prediction model

BACKGROUND

Every fifth patient undergoing left pancreatectomy develops a postoperative pancreatic fistula (POPF). Accurate POPF risk prediction could help. Two independent preoperative prediction models have been developed and externally validated: DISPAIR and D-FRS. The aim of this study was to validate, compare, and possibly update the models.

METHODS

Patients from nine high-volume pancreatic surgery centres (8 in Europe and 1 in North America) were included in this retrospective cohort study. Inclusion criteria were age over 18 years and open or minimally invasive left pancreatectomy since 2010. Model performance was assessed with discrimination (receiver operating characteristic (ROC) curves) and calibration (calibration plots). The updated model was developed with logistic regression and internally-externally validated.

RESULTS

Of 2284 patients included, 497 (21.8%) developed POPF. Both DISPAIR (area under the ROC curve (AUC) 0.62) and D-FRS (AUC 0.62) performed suboptimally, both in the pooled validation cohort combining every centre's data and centre-wise. An updated model, named DISPAIR-FRS, was constructed by combining the most stable predictors from the existing models and incorporating other readily available patient demographics, such as age, sex, transection site, pancreatic thickness at the transection site, and main pancreatic duct diameter at the transection site. Internal-external validation demonstrated an AUC of 0.72, a calibration slope of 0.93, and an intercept of -0.02 for the updated model.

CONCLUSION

The combined updated model of DISPAIR and D-FRS named DISPAIR-FRS demonstrated better performance and can be accessed at www.tinyurl.com/the-dispair-frs.

Machine learning for the rElapse risk eValuation in acute biliary pancreatitis: The deep learning MINERVA study protocol

BACKGROUND

Mild acute biliary pancreatitis (MABP) presents significant clinical and economic challenges due to its potential for relapse. Current guidelines advocate for early cholecystectomy (EC) during the same hospital admission to prevent recurrent acute pancreatitis (RAP). Despite these recommendations, implementation in clinical practice varies, highlighting the need for reliable and accessible predictive tools. The MINERVA study aims to develop and validate a machine learning (ML) model to predict the risk of RAP (at 30, 60, 90 days, and at 1-year) in MABP patients, enhancing decision-making processes.

METHODS

The MINERVA study will be conducted across multiple academic and community hospitals in Italy. Adult patients with a clinical diagnosis of MABP, in accordance with the revised Atlanta Criteria, who have not undergone EC during index admission will be included. Exclusion criteria encompass non-biliary aetiology, severe pancreatitis, and the inability to provide informed consent. The study involves both retrospective data from the MANCTRA-1 study and prospective data collection. Data will be captured using REDCap. The ML model will utilise convolutional neural networks (CNN) for feature extraction and risk prediction. The model includes the following steps: the spatial transformation of variables using kernel Principal Component Analysis (kPCA), the creation of 2D images from transformed data, the application of convolutional filters, max-pooling, flattening, and final risk prediction via a fully connected layer. Performance metrics such as accuracy, precision, recall, and area under the ROC curve (AUC) will be used to evaluate the model.

DISCUSSION

The MINERVA study aims to address the specific gap in predicting RAP risk in MABP patients by leveraging advanced ML techniques. By incorporating a wide range of clinical and demographic variables, the MINERVA score aims to provide a reliable, cost-effective, and accessible tool for healthcare professionals. The project emphasises the practical application of AI in clinical settings, potentially reducing the incidence of RAP and associated healthcare costs.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT06124989.

An Online Preoperative Screening Tool to Optimize Care for Patients Undergoing Cancer Surgery: A Mixed-Method Study Protocol

BACKGROUND/OBJECTIVE

Despite surgery being the primary curative treatment for cancer, patients with compromised preoperative physical, nutritional, and psychological status are often at a higher risk for complications. While various screening tools exist to assess physical, nutritional, and psychological status, there is currently no standardised self-reporting tool, or established cut-off points for comprehensive risk assessment. This study aims to develop, validate, and implement an online self-reporting preoperative screening tool that identifies modifiable risk factors in cancer surgery patients.

METHODS

This mixed-methods study consists of three distinct stages: (1) Development-(i) a scoping review to identify available physical, nutritional, and psychological screening tools; (ii) a Delphi study to gain consensus on the use of available screening tools; and (iii) a development of the online screening tool to determine patients at high risk of postoperative complications. (2) Testing-a prospective cohort study determining the correlation between at-risk patients and postoperative complications. (3) Implementation-the formulation of an implementation policy document considering feasibility.

CONCLUSIONS

The timely identification of high-risk patients, based on their preoperative physical, nutritional, and psychological statuses, would enable referral to targeted interventions. The implementation of a preoperative online screening tool would streamline this identification process while minimising unwarranted variation in preoperative treatment optimisation. This systematic approach would not only support high-risk patients but also allow for more efficient provision of surgery to low-risk patients through effective risk stratification.

Construction and validation of a nomogram for predicting survival in diabetic patients with severe acute pancreatitis: A retrospective study from a tertiary center

BACKGROUND

There is currently a lack of nomograms specifically designed for predicting the risk of death in diabetic patients with severe acute pancreatitis (SAP). The objective of this study was to develop a nomogram tailored to diabetic patients with SAP to predict overall survival.

METHODS

Diabetic patients diagnosed with SAP between January 1, 2018 and December 31, 2023 were included in the study. Risk factors were identified through least absolute shrinkage and selection operator regression analysis. Subsequently, a novel nomogram model was developed through multivariable logistic regression analysis. The predictive performance of the nomogram was evaluated using metrics such as the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

A total of 206 patients were included in the analysis, with 171 in the survival group and 35 in the deceased group. Multivariate logistic regression indicated that age, platelet, total bilirubin, and potassium were independent prognostic factors for the survival of diabetic patients with SAP. The nomogram demonstrated a performance comparable to sequential organ failure assessment ( P = 0.570). Additionally, the calibration curve showed satisfactory predictive accuracy, and the DCA highlighted the clinical application value of the nomogram.

CONCLUSION

We have identified key demographic and laboratory parameters that are associated with the survival of diabetic patients with SAP. These parameters have been utilized to create a precise and user-friendly nomogram, which could be an effective and valuable clinical tool for clinicians.

Role of Minimally Invasive Reoperation for Postoperatively Diagnosed T2 Gallbladder Cancer: Multicenter Retrospective Cohort Study

BACKGROUND

Although T2 gallbladder cancer (GBC) incidentally diagnosed after cholecystectomy requires additional resection, the surgical approaches are technically difficult due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed. In this study, we sought to compare the surgical and oncologic outcomes of open and minimally invasive reoperation for postoperatively diagnosed T2 GBC.

STUDY DESIGN

Patients who underwent open (110) and laparoscopic (38) reoperation for T2 GBC between November 2004 and October 2022 at 5 tertiary referral centers were included in this multicenter retrospective cohort study. The short- and long-term outcomes were compared between the 2 groups.

RESULTS

There were no differences in clinicopathologic characteristics between the open and laparoscopic groups. Liver resection was more frequent in the open group (101 [91.8%] vs 21 [55.3%], p < 0.001). Compared with open operation, laparoscopic reoperation was associated with shorter postoperative hospital stay (9.0 [8.0 to 10.0] vs 6.0 [3.8 to 8.3] days, p < 0.001) and a lower postoperative complication rate (24 [21.8%] vs 1 [2.6%], p = 0.013). Among patients who underwent liver resection, the postoperative hospital stay was shorter in the laparoscopic group (9.0 [8.0 to 10.0] vs 6.0 [4.0 to 9.0] days, p = 0.004). The 5-year disease-free survival (66.7% vs 76.1%, p = 0.749) and overall survival (75.2% vs 73.7%, p = 0.789) rates were not significantly different between the 2 groups.

CONCLUSIONS

The results indicate that laparoscopic reoperation for postoperatively diagnosed T2 GBC has favorable postoperative outcomes and similar oncologic safety compared with open operation.

Operative management and outcomes of gallbladder cancer in Australia: a multi-institutional, retrospective, observational cohort analysis

BACKGROUND

Data on optimal extent of resection for various stages of gallbladder cancer are lacking. This study aims to evaluate disease-free (DFS) and overall survival (OS) after simple (SC) versus radical cholecystectomy (RC) for gallbladder cancer in the Australian context, and assesses factors associated with post-operative morbidity.

METHODS

Multi-centre, retrospective cohort analysis including all gallbladder cancer patients who underwent resection across six Australian institutions between January 2010 and January 2020.

RESULTS

Of 63 patients included, 31 underwent SC and 32 had RC. Liver and other organ resection correlated with prolonged median DFS (41.9 vs. 13.1 months, HR 0.492 [95% CI 0.245-0.987], P = 0.042) and OS on univariate analysis of all patients (55.8% survived five years follow-up at study conclusion vs. median 18.4 months, HR 0.66 [95% CI 0.446-0.972], P = 0.036) but failed to demonstrate effect on multivariable analysis (OS HR 0.31 [95% CI 0.09-1.04], P = 0.057). RC was associated with a higher 30-day complication rate (n = 21 [65.6%] vs. n = 15 [48.4%], P = 0.310) compared to SC, although not statistically significant. There was no significant difference in the major morbidity rate (Clavien-Dindo ≥ Grade III) observed after SC (n = 7 [22.6%]) compared with RC (n = 6 [18.7%], P = 0.754). Neoadjuvant therapy was not utilized and adjuvant treatment used infrequently.

CONCLUSION

Extended gallbladder cancer resection was associated with prolonged OS and DFS but also considerable post-operative morbidity. Further studies are warranted to determine the optimal extent of surgical resection by stage of gallbladder cancer.

Perspectives of the medical oncologist regarding adjuvant chemotherapy for pancreatic cancer: An international expert survey and case vignette study

INTRODUCTION

Adjuvant chemotherapy improves survival in patients with resected pancreatic ductal adenocarcinoma (PDAC). The decision to initiate chemotherapy involves both patient and physician factors, decision-specific criteria, and contextual considerations. This study aimed to assess medical oncologists' views on adjuvant chemotherapy following pancreatic resection for PDAC.

METHODS

An online survey and case vignette study were distributed to medical oncologists via the Dutch Pancreatic Cancer Group (DPCG), International Hepato-Pancreato-Biliary Association (IHPBA) and related networks.

RESULTS

A total of 91 oncologists from 14 countries participated, 46 % of whom treated more than 40 new PDAC patients annually, with a median experience of 15 years. Significant discrepancies were noted in their recommendations for adjuvant chemotherapy across case vignettes. In patients over 70, 17 % advised against chemotherapy, while 31 % said age was not a factor. Oncologists with less than 10 years of experience and those in non-academic settings were less likely to recommend adjuvant therapy. While 87 % agreed mFOLFIRINOX is the preferred adjuvant treatment, consensus on individual cases was lacking. The recommended interval between surgery and chemotherapy ranged from 3 to 26 weeks, with varying reasons for withholding treatment, primarily due to postoperative recovery and performance status.

CONCLUSIONS

Our study revealed substantial variation among oncologists in counseling on adjuvant chemotherapy after PDAC resection. This emphasizes the need for more patient involvement in decision-making and improving shared decision-making.

Initial Management of Acute Pancreatitis

The initial management of acute pancreatitis (AP) is continually evolving. Goal-directed moderate fluid resuscitation is now preferred over more aggressive strategies. Antibiotics should be administered only when there is a proven or highly probable infection rather than for prophylactic purposes. Urgent endoscopic retrograde cholangiopancreatography would be beneficial for patients with acute cholangitis. Same-admission cholecystectomy for mild biliary PA is safe, efficiently prevents relapse, and is associated with lower costs compared with interval cholecystectomy. Ongoing research into novel pharmacologic treatments and strategies is essential for further advancements in AP management.

The Value of Blood T Cell Frequencies for Risk Prediction of Postoperative Complications in Pancreatic Cancer Surgery

Objective

To quantify and characterize preoperative blood T cells in patients with pancreatic ductal adenocarcinoma (PDAC), who underwent tumor resection, and to determine their relevance as biomarkers for postoperative pancreas-specific complications.

Background

Pancreas-specific complications after pancreatic surgery are associated with a high morbidity and mortality, which both deprive patients of adjuvant chemotherapy. Noninvasive biomarkers for risk prediction of postoperative complications are missing, and the role of blood T cells for preoperative risk stratification is unknown.

Methods

The preoperative frequency of blood T cell subsets was analyzed for 73 patients with PDAC, who underwent proximal pancreatectomy. Patients were screened for postoperative complications such as pancreatic fistula, postpancreatectomy hemorrhage, and postpancreatectomy acute pancreatitis. The frequency of CD8+, conventional CD4+, and regulatory T cells, as well as the differentiation state of each T cell subset in the peripheral blood of patients with PDAC, was analyzed.

Results

Of 73 patients with PDAC, 19.2% developed pancreas-specific complications. The occurrence of postoperative complications was independent of the type of resection performed (Whipple procedure vs pylorus-preserving pancreaticoduodenectomy). Neither the frequency of CD8+, conventional CD4+, and regulatory T cells nor the state of T cell differentiation in the peripheral blood was associated with postoperative pancreas-specific complications. Notably, a significantly lower preoperative bilirubin serum level was observed in patients, who developed postpancreatectomy hemorrhage after proximal pancreatectomy (P =0.001).

Conclusions

A low preoperative bilirubin serum level was associated with a higher risk for postpancreatectomy hemorrhage after proximal pancreatectomy. However, the preoperative blood T cell frequency does not predict postoperative pancreas-specific complications.

Development and Validation of a Preoperative Prediction Model for Neoplastic Gallbladder Polyps

Aims/Background The primary goal in evaluating gallbladder polypoid lesions (GPLs) is to identify neoplastic polyps (NP). Numerous studies have investigated risk factors for NP. This study aimed to develop a practical preoperative prediction model for NP using simple and easily accessible clinical variables. Methods We retrospectively analyzed clinical data from patients with GPLs who underwent cholecystectomy at Lanzhou University Second Hospital between January 2018 and September 2022. A total of 621 cases were included and randomly assigned into a training set (70%) and an internal validation set (30%). An external validation set was established using data from 117 patients treated at other centers between January and December 2023. Univariate logistic analyses were performed, followed by backward stepwise multivariate logistic regression analysis for variables with p< 0.2 to identify significant variables associated with NP. These predictors were included in the final logistic regression model and visualized as a nomogram model. The discrimination, calibration, and clinical utility of the model were evaluated. Results Age (odd ratio (OR) = 1.06, 95% CI = 1.03-1.09, p= 0.0001), polyp size (OR = 19.01, 95% CI = 6.48-55.79, p < 0.0001), polyp number (OR = 0.25, 95% CI = 0.12-0.56, p = 0.0006), gallbladder wall thickness (OR = 1.57, 95% CI = 1.02-2.41, p= 0.0385), and polyp echo characteristics (OR = 0.41, 95% CI = 0.19-0.85, p = 0.0169) were identified as independent influencing factors for NP. The area under the curve (AUC) of the nomogram model in the training, internal validation, and external validation sets were 0.886 (95% CI, 0.841-0.930), 0.836 (95% CI, 0.753-0.919), and 0.867 (95% CI, 0.743-0.978), respectively. Calibration curves for the three datasets showed Brier scores of 0.079, 0.092, and 0.070, all below 0.25, indicating good calibration. Decision curve analysis (DCA) and clinical impact curve (CIC) analysis suggested that a threshold probability of 0.6 provided the most significant clinical benefit. Conclusion This prediction model, incorporating easily accessible variables, demonstrated excellent performance in the identification of NP and contributed to clinical decision-making in GPL management.

Palliative biliodigestive bypass for unresectable pancreatic malignancy at Kilimanjaro Christian medical centre: a retrospective cross-sectional study

BACKGROUND

Pancreatic cancer is a common and deadly cancer, ranking as the 14th most common cancer worldwide and the 7th leading cause of cancer-related deaths. Advanced pancreatic malignancy frequently presents with biliary and gastric outlet obstruction and palliative open interventions are often required, especially in low-income countries where endoscopic surgical bypass methods are often unavailable. This study aimed to describe the demographic and clinical characteristics of patients undergoing biliodigestive bypass for pancreatic malignancy.

METHODS

This was a hospital-based retrospective observational study at the tertiary hospital in northern Tanzania. We included 53 patients who underwent double or triple bypass surgery for pancreatic malignancy between January 2019 to December 2022 at Kilimanjaro Christian Medical Centre (KCMC), Tanzania. Data was collected from medical records, analyzing demographics, comorbidities, pre-surgery and surgery details, and post-surgery outcomes. Descriptive statistics were used to summarize continuous variables as mean with standard deviation and categorical variables as percentages.

RESULTS

53 patients were analyzed, with a mean age of 63.2 years and a male to female ratio of 1.03:1. Jaundice was the most common presentation (77.4%). Of the patients, 74.5% had comorbidities, and the majority (81.1%) were uninsured. 50.9% of patients had a length of hospital stay shorter than 5 days, and 88.3% resumed normal oral intake. Palliation failure was observed in 22.6% of patients. The median survival time for the entire cohort of patients was 65 days. Patients with palliation failure had a significantly shorter mean survival time than those without complications (14.17 vs. 90 days, p = 0.001).

CONCLUSION

Bypass surgery remains a treatment of choice for palliating symptoms in patients with advanced pancreatic cancer. This study highlights the importance of prompt diagnosis of pancreatic tumors, especially in low-income countries, to achieve better outcomes.

Open versus laparoscopic oncologic resection for gallbladder cancer after index cholecystectomy: international multicenter comparative study

BACKGROUND

Liver resection and lymphadenectomy is a standard procedure in patients with incidental gallbladder cancer. Data regarding laparoscopic approach in this setting are scarce. The aim of this study was to compare laparoscopic and open approach in this population.

METHODS

This was a multicenter retrospective study including 177 patients. The primary outcome measure was overall survival (OS). The secondary outcomes measures were recurrence-free survival (RFS), lymph node yield, operative time, postoperative complications and length of hospital stay.

RESULTS

Surgery was laparoscopic in 60 (33.9%), including 18 conversions (30.0%). By intention to treat analysis, 3 and 5 year OS were 72.1% and 51.8% after laparoscopic surgery compared to 62.8% and 36.2% after open surgery (p = 0.201). 3- and 5-year RFS were 29.1% and 19.4% after laparoscopic surgery and 28.7% and 19.1% after open surgery (p = 0.697). Severe (grade ≥ 3 ) complications (p = 0.032) and Comprehensive Complication Index (CCI; p = 0.027) were both significantly higher after laparoscopic surgery (p = 0.032), although length of hospital stay was significantly shorter after laparoscopic procedures both on intention-to-treat (median 6 vs. 8 days; p = 0.004) and per protocol analysis (median 6 vs. 8 days; p = 0.004).

CONCLUSIONS

Laparoscopic approach is feasible in patients with gallbladder cancer and may shorten the duration of hospital stay.

SYNOPSIS

This retrospective cohort study suggests that laparoscopic liver resection is feasible in patients with gallbladder cancer and may shorten the duration of hospital stay. Minimally invasive procedures should be performed by surgeons experienced in laparoscopic liver surgery.

Predictive variables for intraoperative blood loss and surgical time in resection of malignant soft tissue tumors without reconstruction

BACKGROUND

Procedural techniques such as dissection and separation of blood vessels or nerves from the tumor for preserving limbs and functions involves high surgical difficulty. We hypothesized the relation of vessel and/or nerve preservation to surgical time and blood loss, accurately reflecting surgical difficulty. In this study, we elucidated the variables affecting surgical time and intraoperative bleeding in patients with malignant soft tissue tumors who did not undergo any reconstruction after tumor resection.

METHODS

We included 153 patients with malignant oft tissue tumors in the trunk (n = 72), thigh (n = 68), and upper arm (n = 13) at nine institutions. We analyzed the possible predictive variables affecting surgical time and intraoperative bleeding.

RESULTS

Overall, the study included 153 patients (85 men and 68 women) with a mean age of 65 years. The tumors were primary soft tissue sarcoma (STS) (n = 114), local recurrent STS (n = 25), and soft tissue metastasis (n = 14). The median number of participating surgeons was three. The mean and median surgical time were 144.6 and 123 min, respectively. The mean and median intraoperative bleeding were 157.1 and 55 mL, respectively. Tumor size, depth, dissection and separation of blood vessels from the tumor, dissection and separation of nerve from the tumor, and the number of participating surgeons were significantly related to the surgical time and intraoperative bleeding.

CONCLUSIONS

The procedure of dissection and separation of blood vessels and nerves from the tumor were related to surgical time and intraoperative bleeding in patients with malignant soft tissue tumors, especially large and deep tumors.

Prehabilitation Strategies: Enhancing Surgical Resilience with a Focus on Nutritional Optimization and Multimodal Interventions

Surgery imposes significant physiological and psychological stress, often leading to complications, delayed recovery, and prolonged hospital stays. Prehabilitation, a proactive strategy to optimize patients' resilience before surgery, has emerged as a transformative approach in perioperative care. Nutritional prehabilitation specifically addresses metabolic dysregulation, muscle loss, and immune suppression caused by surgical stress. This review highlights the critical role of nutritional prehabilitation within a multimodal framework, integrating exercise, psychological support, and emerging technologies. Although some evidence supports the effectiveness of prehabilitation in enhancing functional outcomes and improvements in rates of complications and mortality, its implementation faces challenges such as resources, lack of standardized protocols, and variability across healthcare settings, highlighting the need for greater standardization. Physical training as part of prehabilitation also improves mood, fosters patient engagement, and instills a sense of control over the disease process. These psychosocial benefits, alongside enhanced patient-reported outcomes and qualitative measures, reflect the holistic value of prehabilitation. Emerging technologies, such as wearable devices and telemedicine, offer scalable and personalized solutions for delivering prehabilitation, particularly in resource-limited settings. Future research should prioritize refining protocols, exploring long-term outcomes, and addressing the unique needs of high-risk populations. By emphasizing a proactive approach to perioperative care, this review aims to highlight the potential of nutritional prehabilitation as a foundational component of multimodal strategies designed to optimize surgical resilience, empower patients, and transform surgical recovery into a proactive and patient-centered journey.

Exercise Guidelines in Pancreatic Cancer Based on the Dietz Model

Pancreatic and gastrointestinal cancers are associated with debility, frailty, and chemotherapy regiments with significant toxicity. Practical exercise guidelines to combat these ailments and optimize functional status are lacking. We present a model for exercise for these cancers based on the Dietz framework for rehabilitation in cancer. The Dietz framework for rehabilitation describes four phases of rehabilitation including preventative (prehabilitation), restorative, supportive, and palliative. We present practical guidelines for exercise at each phase. Prehabilitation seeks to optimize functional performance typically prior to surgical resection and may occur concurrently with neoadjuvant therapy. Restorative rehabilitation occurs following the development of a physical deficit such as after surgery and may utilize skilled therapies in the inpatient, subacute, outpatient, and home settings to address functional impairments. Supportive rehabilitation occurs during stable disease or remission and depends on the frequent monitoring of functional status and particularly the development of chemotherapy-induced neuropathy to ensure timely exercise interventions. Palliative rehabilitation occurs at the end stage of life and shifts to a focus on patient comfort and safety. Exercise is a critical component of treatment in cancer demonstrating numerous quality-of-life benefits. The customization of exercise recommendations to individual patients based on their functional status and phase in treatment is essential for safety and adherence.

Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper

BACKGROUND

Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries.

AIM

This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings.

METHODS

Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval.

RESULTS

ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection.

CONCLUSIONS

Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.

Minimal Invasive Pancreatoduodenectomy: A Comprehensive Systematic Review and Metanalysis of Randomized Controlled Clinical Trials

BACKGROUND

The role of a minimally invasive approach (MI) in patients who underwent pancreatoduodenectomy (PD) remained unclear.

METHODS

A systematic search of randomized controlled trials was conducted. A random-effects meta-analysis was conducted, reporting risk ratio (RR) or mean difference (MD). The primary endpoints were the morbidity, mortality, and R1 rate. The secondary endpoints were clinically relevant postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), biliary fistula, reoperation, length of stay (LOS), time to functional recovery (TFR), and readmission.

RESULTS

The meta-analysis includes seven studies and 1428 patients: 618 (46.5%) in the OPD arm and 711 (53.5%) in minimally invasive pancreaticoduodenectomy (MIPD). The mortality rate was 2.9% for MIPD and 2.6% for OPD (RR 1.11 [range 0.53-2.29]). The major morbidity rate was 29.4% for MIPD and 25.6% for OPD (RR 1.11 [range 0.53-2.29]). The R1 rate was 6.2% for MIPD and 7% for OPD (RR 0.80 [0.54-1.20]). The operative time, comprehensive complication index score, POPF, PPH, DGE, biliary fistula, reoperation, readmission, LOS, TFR, and harvested lymph nodes were similar. Greater than 25% of heterogeneity was observed for major morbidity, operative time, POPF, LOS, TFR, and harvested lymph nodes. No publication bias was registered.

CONCLUSIONS

Minimally invasive pancreaticoduodenectomy was not superior to OPD and provided marginal advantages in short-term results. Further efforts should be addressed to clarify the impact of learning curve in MIPD results and the economic sustainability of MIPD, particularly robotic approach.

Prehabilitation in surgery - an update with a focus on nutrition

PURPOSE OF THE REVIEW

Since the introduction of the prehabilitation concept for optimizing functional capacity before surgery 20 years ago, evidence and interest has grown considerably. This review summarizes the recent evidence and proposes questions for prehabilitation with special regard to the nutritional component.

RECENT FINDINGS

Several meta-analyses of multimodal prehabilitation (exercise, nutrition, and psychological support) have been published recently. These reviews suggest that preoperative conditioning can improve functional capacity and reduce the complication rate for many patient groups (risk of bias: moderate to low). A prerequisite is the identification of high-risk patients using suitable screening and assessment tools. Additionally, there are currently no standardized, clear recommendations for the organization and implementation of prehabilitation programs. The programs vary greatly in duration, content, and outcome measurement. Although the preoperative nutrition interventions enhanced outcomes consistently, there was no clear evidence for which nutritional intervention should be applied to whom over consistent time frame four to six weeks (timeframe consistent with most prehabilitation programs).

SUMMARY

To advance our understanding of which prehabilitation interventions work best, how they work, and for whom they work best, additional low risk of bias and adequately powered trials are required. Nevertheless, our review presents evidence that prehabilitation should be offered before major surgery on a risk-stratified basis.

Effect of differences in vascular anatomy on surgical outcomes of left pancreatectomy: a retrospective study

BACKGROUND

Minimally invasive left pancreatectomy (MILP) is increasingly performed worldwide, necessitating the need for improved understanding of vascular anatomy during surgery. However, the effect of differences in vascular anatomy on surgical outcomes remains unclear. In this study, we aimed to evaluate the effect of vascular anatomical variations on surgical outcomes and identify factors that influence open and minimally invasive surgery (MIS) outcomes.

METHODS

This was a single-center retrospective study involving 123 patients who underwent left pancreatectomy (LP). We analyzed the correlation between vascular anatomical variations, namely, (i) the root of the splenic artery (SpA; types 1 and 2), (ii) the parent artery of the dorsal pancreatic artery, (iii) confluence patterns of the left gastric vein, and (iv) the inferior mesenteric vein, and surgical outcomes. We also performed a risk analysis of prolonged operation time, considering surgery-related factors.

RESULTS

SpA type 2 was only significantly associated with longer operation time (p < 0.01) in LP procedures. In all LP cases, the pancreatic resection line (above the portal vein: odds ratio [OR] 3.47; 95% confidence interval [CI] 1.69-11.18; p < 0.01), the SpA type (type 2; OR 2.77; 95% CI 1.16-6.94; p = 0.02), and surgery type (MIS; OR 5.24; 95% CI 2.17-14.00; p < 0.001) were independently associated with prolonged operation times. In open-LP cases, high body mass index (> 24 kg/m2; OR 7.24; 95% CI 1.89-36.34; p < 0.01), tumor location (pancreatic body; OR 6.89; 95% CI 1.79-33.79; p < 0.01), and the SpA type (type 2; OR 5.86; 95% CI 1.72-24.65; p < 0.01) showed significant association with prolonged operations. In MILP cases, sex (male; OR 9.07; 95% CI 2.61-38.65; p < 0.001) and the pancreatic resection line (above the portal vein; OR 4.12; 95% CI 1.18-17.08; p = 0.03) showed significant associations.

CONCLUSIONS

SpA type 2 may negatively affect surgical outcomes. Therefore, it is important to recognize and approach vascular anatomy appropriately. MIS, especially robotic surgery, may be effective in mitigating the negative effects of variations in vascular anatomy.

Pancreatic exocrine insufficiency after pancreatic resection: a systematic review

INTRODUCTION

Pancreatic exocrine insufficiency (PEI) is a condition defined by a reduction in pancreatic exocrine activity that impairs normal digestion. Despite established guidelines recommendations, precise diagnosis of PEI after pancreatic resection are infrequently achieved. This review aims to provide a comprehensive overview of the methodology and accuracy of diagnostic tools available for evaluating PEI after pancreatic resection.

METHODS

A review of PEI diagnostic tests was conducted using a combined text and MeSH search strategy to identify relevant articles focused on post-pancreatectomy PEI diagnosis.

RESULTS

The literature search yielded 4,874 records, and 30 studies were included in the analysis, with a total of 2,305 patients. The reported frequency of PEI across the included studies varied widely, though more than two-thirds of included papers reported an incidence of PEI above 65% in patients who underwent pancreatoduodenectomy or distal pancreatectomy. The faecal elastase-1 (FE-1) test was the most frequently used test for diagnosing post-pancreatectomy PEI. Six studies compared the diagnostic accuracy of FE-1 with faecal fat tests or 13 C breath tests, finding no significant differences. Five studies reported on micronutrient deficiencies.

CONCLUSION

The FE-1 test is the most commonly used diagnostic tool for post-pancreatectomy PEI; however, well-designed studies comparing the diagnostic accuracy of various tests for PEI are lacking. Additionally, few studies report on micronutrient deficiencies, variations in anthropometric data or PEI-related patient-reported outcomes. Future studies should aim to establish a gold standard for diagnosis and severity assessment of post-pancreatectomy PEI and provide guidance for tailored pancreatic enzyme replacement therapy.

Nodal Downstaging of Esophageal Cancer After Neoadjuvant Therapy: A Cohort Study and Meta-Analysis

BACKGROUND

In esophageal cancer, the ypN0 status after induction therapy could be categorized into two primary groups: "natural N0" (cN0/ypN0) and "down-staged N0" (cN+/ypN0). The assessment of cN status is typically based on clinical imagination or pathological regression. However, there is no standardized method for evaluating cN/ypN status. This study aims to investigate the prognosis of patients with cN+/ypN0 using both assessment methods through a cohort study and meta-analysis.

METHODS

A prospectively maintained database encompassing esophageal cancer patients undergoing induction therapy followed by radical esophagectomy was comprehensively reviewed. The prognostic significance of cN+/ypN0 across two evaluation methods was quantified. Additionally, a meta-analysis using data from previous studies was conducted.

RESULTS

578 patients were identified from the cohort analysis, with 342 classified as ypN0 and 236 as ypN+. When evaluated with clinical imagination, patients with cN+/ypN0 had survival outcomes comparable to those with natural N0 but significantly better than those with ypN+ (p < 0.001). Using pathological nodal regression, cN+/ypN0 patients showed superior overall survival compared to ypN+ patients (p = 0.0043), although their disease-free survival was notably inferior to that of natural N0 patients (p = 0.0088). A meta-analysis of 20 previous studies confirmed the prognostic value of cN+/ypN0 status in both clinical imagination and pathological regression.

CONCLUSIONS

For esophageal cancer patients receiving neoadjuvant, cN+/ypN0 status, assessed through both clinical imagination and pathological regression, serves as a significant prognostic factor. It holds precedence over ypN+ yet falls short of the natural N0. The pre-treatment categorizations warrant recognition as a novel and pertinent staging metric.

Is end-to-end or side-to-end anastomotic configuration associated with risk of positive intraoperative air leak test in left-sided colon and rectal resections for colon and rectal cancers?

BACKGROUND

Anastomotic leak after colorectal resection is associated with morbidity, mortality, and poor bowel function. Minimal data exist on the relationship between anastomotic technique, intraoperative leak test, and subsequent clinical leak, particularly on the utility of performing end-to-end anastomosis (EEA) vs non-EEA (NEEA) to avoid postoperative leaks. This study aimed to analyze potential associations between anastomotic construction, intraoperative anastomotic assessments, and clinical leak.

METHODS

This was a retrospective cohort study comparing anastomotic techniques used in patients with colorectal cancer who underwent left-sided colorectal resections with colorectal or coloanal anastomoses at a tertiary care center. The outcomes were rates of intraoperative air leak, incomplete anastomotic donuts, and postoperative clinical leak. Univariate and multivariate analyses were performed to evaluate the potential association between anastomotic technique and intraoperative anastomotic assessments and subsequent leak.

RESULTS

Among 844 patients, 27 (3.2%) had intraoperative leak, 6 (0.7%) had incomplete donuts, and 27 (3.2%) experienced clinical leak. Of note, 500 patients (59.2%) had EEAs, and 344 patients (40.7%) had NEEAs. There were no significant differences in demographics or comorbidities between groups (P >.05) or rates of incomplete donuts (P =.07). EEA was associated with significantly more intraoperative air leaks than NEEA on univariate analysis (4.9% vs 1.2%, respectively; P =.005) and multivariate analysis (odds ratio [OR], 3.6; 95% CI, 1.01-12.50; P =.049). There was no difference in postoperative clinical leak between the groups on univariate analysis (3.0% in EEA vs 3.5% in NEEA; P =.69) or multivariate analysis (OR, 0.97; 95% CI, 0.40-2.34; P =.94).

CONCLUSION

EEA is associated with higher rates of intraoperative air leak than NEEA, even after adjusting for potential confounders.

Circulating tumor cells in solid malignancies: From advanced isolation technologies to biological understanding and clinical relevance in early diagnosis and prognosis

Circulating tumor cells (CTCs) are shed from primary tumors and travel through the body via circulation, eventually settling to form micrometastases under favorable conditions. Numerous studies have identified CTCs as a negative prognostic indicator for survival across various cancer types. CTCs mirror the current heterogeneity and genetic and biological state of tumors, making their study invaluable for understanding tumor progression, cell senescence, and cancer dormancy. However, their isolation and characterization still poses a major challenge that limits their clinical translation. A wide array of methods, each with different levels of specificity, utility, cost, and sensitivity, have been developed to isolate and characterize CTCs. Moreover, innovative techniques are emerging to address the limitations of existing methods. In this review, we provide insights into CTC biology addressing spectra of markers employed for molecular analysis and functional characterization. It also emphasizes current label-dependent and label-independent isolation procedures, addressing their strengths and limitations. SIGNIFICANCE: A comprehensive overview of CTC biology, their molecular and functional characterization, along with their current clinical utility will help in understanding the present-day extent to which the clinical potential of CTCs is getting tapped in personalized medicine.

The impact of the muscle mass-to-fat ratio on the prognosis of patients undergoing pancreaticoduodenectomy for pancreatic cancer

To evaluate the relationship between the muscle mass-to-fat ratio (MMFR) at the third lumbar spine (L3) and overall survival (OS) as well as related complications after pancreaticoduodenectomy (PD) for pancreatic cancer. Patients who underwent PD for pancreatic cancer between March 2017 and May 2023 at the Second Affiliated Hospital of Soochow University were included. Muscle mass and fat content at the L3 were measured by computed tomography. The specific formula that was used to calculate the MMFR was total abdominal muscle area/(subcutaneous adipose tissue area + visceral adipose tissue area), and the optimal cutoff values of the MMFR based on receiver operating characteristic curves were 0.688 for males and 0.382 for females. Patient characteristics were collected, and multivariate analyses were used to evaluate the impact of the MMFR on prognosis. Kaplan-Meier survival curves and log-rank tests were used to compare OS between the high-MMFR and low-MMFR groups. On the basis of the optimal cutoff values, 191 patients were divided into two groups, with 91 patients in the low-MMFR group and 100 patients in the high-MMFR group. The incidence of POPF was significantly greater in the low-MMFR group than in the high-MMFR group. According to multivariate analysis, the MMFR was an independent factor associated with POPF and OS. Patients with low MMFRs had significantly shorter OS and a greater POPF incidence than did those with high MMFRs. The MMFR is an independent predictor of POPF and affects the OS of patients undergoing PD for pancreatic cancer.

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

Preoperative body composition measured by bioelectrical impedance analysis can predict pancreatic fistula after pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula (POPF) remains one of the most severe complications after pancreatic surgery. The methods for predicting pancreatic fistula are limited. We aimed to investigate the predictive value of body composition parameters measured by preoperative bioelectrical impedance analysis (BIA) on the development of POPF.

METHODS

A total of 168 consecutive patients undergoing pancreatic surgery from March 2022 to December 2022 at our institution were included in the study and randomly assigned at a 3:2 ratio to the training group and the validation group. All data, including previously reported risk factors for POPF and parameters measured by BIA, were collected. Risk factors were analyzed by univariable and multivariable logistic regression analysis. A prediction model was established to predict the development of POPF based on these parameters.

RESULTS

POPF occurred in 41 of 168 (24.4%) patients. In the training group of 101 enrolled patients, visceral fat area (VFA) (odds ratio [OR] = 1.077, P = 0.001) and fat mass index (FMI) (OR = 0.628, P = 0.027) were found to be independently associated with POPF according to multivariable analysis. A prediction model including VFA and FMI was established to predict the development of POPF with an area under the receiver operating characteristic curve (AUC) of 0.753. The efficacy of the prediction model was also confirmed in the internal validation group (AUC 0.785, 95% CI 0.659-0.911).

CONCLUSIONS

Preoperative assessment of body fat distribution by BIA can predict the risk of POPF after pancreatic surgery.

Perioperative and recurrence-free survival outcomes after laparoscopic hepatectomy for colorectal cancer liver metastases using indocyanine green fluorescence imaging: an inverse probability treatment weighted analysis

BACKGROUND

Colorectal cancer (CRC) frequently metastasizes to the liver, significantly worsening patient outcomes. While hepatectomy offers the best curative option for colorectal liver metastases (CRLM), margin recurrence remains a major challenge post-surgery. Intraoperative ultrasound (IOUS) aids tumor identification and margin determination, but its limitations in laparoscopic surgery necessitate additional methods. Indocyanine green fluorescence imaging (ICGFI) has emerged as a promising tool for tumor localization and margin assessment in CRLM. However, existing studies lack large cohorts and long-term outcomes. This study evaluates perioperative and long-term results of ICGFI-assisted laparoscopic hepatectomy in CRLM patients.

METHOD

A retrospective cohort study was performed on CRLM patients who underwent liver resection at our single center. The study population was divided into three groups: the L-ICG group (laparoscopic hepatectomy with ICGFI), the L-Non-ICG group (laparoscopic hepatectomy without ICGFI), and the open group (open liver resection). Robust statistical methods including multiple imputations and inverse probability of treatment weighting (IPTW) were employed to minimize bias.

RESULTS

A total of 340 CRLM patients who underwent hepatectomy were analyzed. The L-ICG group had a higher rate of neoadjuvant therapy and smaller tumor sizes compared to the open group. The L-ICG group also demonstrated shorter operative times, less blood loss, and a higher microscopically margin-negative (R0) resection rate than other two groups. Recurrence occurred in 70% of patients, with 77% being intrahepatic. Margin recurrence was significantly lower in the L-ICG group compared to the L-Non-ICG group (15.3% vs. 45.7%, p = 0.001). Median recurrence-free survival and overall survival did not differ significantly among groups after IPTW adjustment.

CONCLUSION

ICGFI improves R0 resection rates, perioperative outcomes, and reduces margin recurrence in CRLM patients undergoing laparoscopic hepatectomy, though it does not significantly impact OS or RFS.

Development and validation of an explainable machine learning model for mortality prediction among patients with infected pancreatic necrosis

Background

Infected pancreatic necrosis (IPN) represents a severe complication of acute pancreatitis, commonly linked with mortality rates ranging from 15% to 35%. However, the present mortality prediction tools for IPN are limited and lack sufficient sensitivity and specificity. This study aims to develop and validate an explainable machine learning (ML) model for death prediction among patients with IPN.

Methods

We performed a prospective cohort study of 344 patients with IPN consecutively enrolled from a large Chinese tertiary hospital from January 2011 to January 2023. Ten ML models were developed to predict 90-day mortality in these patients. A benchmarking test, involving nested resampling, automatic hyperparameter tuning and random search techniques, was conducted to select the ML model. Sequential forward selection method was employed to select the optimal feature subset from 31 candidate subsets to simplify the model and maximize predictive performance. The final model was internally validated with the 1000 bootstrap method and externally validated using an independent cohort of 132 patients with IPN retrospectively collected from another Chinese tertiary hospital from January 2018 to January 2023. The SHapley Additive exPlanations (SHAP) method was employed to interpret the model in terms of features importance and features effect. The final model constructed with optimal feature subset was deployed as an interactive web-based Shiny app.

Findings

Random survival forest (RSF) model showed the best predictive performance than other 9 ML models (internal validation, C-index = 0.863 [95% CI: 0.854-0.875]; external validation, C-index = 0.857 [95% CI: 0.850-0.865]). Multiple organ failure, Acute Physiology and Chronic Health Examination II (APACHE II) score ≥20, duration of organ failure ≥21 days, bloodstream infection, time from onset to first intervention <30 days, Bedside Index of Severity in Acute Pancreatitis score ≥3, critical acute pancreatitis, age ≥ 50 years, and hemorrhage were 9 most important features associated with mortality. Furthermore, SHAP algorithm revealed insightful nonlinear interactive associations between important predictors and mortality, identifying 9 features pairs with high interaction SHAP value and clinical significance. Two interactive web-based Shiny apps were developed to enhance clinical practicability: https://rsfmodels.shinyapps.io/IPN_app/ for cases where the APACHE II score was available and https://rsfmodels.shinyapps.io/IPNeasy/ for cases where it was not.

Interpretation

An explainable ML model for death prediction among IPN patients was feasible and effective, suggesting its superior potential in guiding clinical management and improving patient outcomes. Two publicly accessible web tools generated for the optimized model facilitated its utility in clinical settings.

Funding

The Natural Science Foundation of Hunan Province (2023JJ30885), Postdoctoral Fellowship Program of CPSF (GZB20230872), The Youth Science Foundation of Xiangya Hospital (2023Q13), The Project Program of National Clinical Research Center for Geriatric Disorders of Xiangya Hospital (2021LNJJ19).

Clinical Significance of Grade A Small-for-size Syndrome After Living Donor Liver Transplantation Utilizing the New Definition of Diagnostic Criteria: An International Multicenter Study

BACKGROUND

New diagnostic criteria have recently been established to classify small-for-size syndrome (SFSS) after living donor liver transplantation into 3 groups based on severity. This study aimed to evaluate the clinical impact of grade A SFSS and identify the mortality risk.

METHODS

We collected data from 406 patients diagnosed with grade A SFSS after living donor liver transplantation. Grade A SFSS is characterized by total bilirubin >5 mg/dL on postoperative day (POD) 7 or total bilirubin >5 mg/dL or ascites >1 L/d on POD 14. After propensity score matching, 193 patients were categorized into the up-trend group, down-trend group, and ascites group, with 43 patients (22.3%) in the up-trend group (total bilirubin on POD 7 < POD 14), 107 patients (55.4%) in the down-trend group (total bilirubin on POD 7 > POD 14), and 43 patients (22.3%) in the ascites group (only satisfying ascites criteria).

RESULTS

There was no significant difference in survival between patients with grade A SFSS and those without SFSS ( P  = 0.152). The up-trend group showed a higher 90-d mortality rate than the down-trend and ascites groups ( P  = 0.025). The 1-y survival rate differed significantly between the groups (87.6%, 91.9%, and 97.7%, respectively; P  = 0.044). The independent risk factors for survival were up-trend of total bilirubin, recipient age (65 y and older), model for end-stage liver disease score (≥30), and ABO incompatibility. Patients with ≥2 risk factors had worse survival rates than those with none and only 1 risk factor ( P  < 0.001).

CONCLUSIONS

Although the survival rate was comparable between the grade A SFSS and non-SFSS cohorts, the up-trend group showed worse survival. Aggressive interventions should be considered for up-trend patients with risk factors.

Prehabilitation Outcomes in Surgical Oncology Patients Undergoing Major Abdominal Surgery: A Meta-analysis of Randomized Control Trials

BACKGROUND

Prehabilitation has been increasingly utilized to optimize perioperative outcomes. In this study, we aim to evaluate the impact of uni- and multimodal prehabilitation on functional capacity and postoperative outcomes among surgical oncology patients undergoing major abdominal surgery.

PATIENTS AND METHODS

Three electronic databases (PubMed, Embase, Cochrane) were systematically searched up until December 2023. We included randomized controlled trials comparing prehabilitation to standard of care in surgical oncology patients undergoing major abdominal surgery. Our primary outcome was functional capacity as measured by the 6-min walk distance (6MWD). Secondary outcomes include postoperative complications, emergency readmissions, and length of stay (LOS). We stratified our findings to determine the impact of uni- versus multimodal prehabilitation on outcomes.

RESULTS

We included 27 studies with 2532 surgical oncology patients. Overall, patients undergoing prehabilitation demonstrated a significant improvement in preoperative functional capacity compared to those without prehabilitation (mean difference in 6MWD 28.32 meters [m], 95% CI 15.26, 41.39, p < 0.01). Prehabilitation was also associated with significantly lower odds of postoperative complications (odds ratio [OR] 0.60, 95% CI 0.46, 0.78, p < 0.01). There was no difference in emergency readmission (OR 0.90, 95% CI 0.59, 1.38, p = 0.61) or LOS (mean difference -0.42 days, 95% CI -1.01, 0.16, p = 0.15). Comparing uni- versus multimodal prehabilitation, multimodal prehabilitation was associated with greater improvements in functional capacity (6MWD 37.35 m versus 13.38 m) and lower odds of postoperative complications (OR 0.61, 95% CI 0.45, 0.82, p < 0.01 versus OR 0.63, 95% CI 0.36, 1.11, p = 0.10) CONCLUSION: Prehabilitation improves functional capacity and reduces postoperative complications among surgical oncology patients undergoing major abdominal surgery.

Pancreatic Neuroendocrine Neoplasms: Classification and Novel Role of Endoscopic Ultrasound in Diagnosis and Treatment Personalization

The incidence and prevalence of pancreatic neuroendocrine neoplasms are steadily increasing. These tumors are highly heterogeneous, with treatment options ranging from observation to surgery, and various medical therapies. The choice of treatment is influenced by factors such as tumor stage, grade (proliferative activity), and the presence of hormone-related syndromes. Endoscopic ultrasound (EUS) is becoming increasingly valuable for assessing pancreatic neuroendocrine neoplasms, offering detailed morphological, vascular, and functional information through techniques such as contrast enhancement and elastography. It also allows biopsies that are useful for both histopathological and molecular analyses. These tumors are highly heterogeneous, with treatment options ranging from observation to various medical therapies and surgery. Recent data suggest that small, non-functioning PanNENs with low proliferation rates may be safely monitored, whereas more aggressive or functioning tumors typically require surgery. EUS-guided ablation is a promising alternative for patients with functional pancreatic neuroendocrine neoplasms who are unsuitable for surgery, although randomized trials are needed. In non-resectable pancreatic neuroendocrine neoplasms, treatment options include somatostatin analogs, targeted therapies (e.g., everolimus, sunitinib), chemotherapy, and radioligand therapy. This review discusses key factors in planning personalized treatment strategies for pancreatic neuroendocrine neoplasms.

Difficulty score for the treatment of multiple gingival recessions with the Modified Coronally Advanced Tunnel technique: a preliminary reliability study

OBJECTIVES

The purpose of this study was to propose a new difficulty score for the treatment of multiple gingival recessions (GRs) with Modified Coronally Advanced Tunnel (MCAT), and to test the score's reliability.

MATERIAL AND METHODS

A difficulty score was developed for the assessment and grading of 13 relevant anatomical parameters at baseline. Six experienced dental practitioners evaluated existing GRs in three patients. The scale was assessed at two levels: for each single tooth, and seven days later for whole quadrants. Accuracy was estimated using Fleiss' kappa statistics and intraclass correlation coefficients (ICC) to determine the inter- and intra-examiner agreement.

RESULTS

During the evaluation of individual teeth, all parameters exhibited very good to excellent agreement, with Fleiss' kappa statistics ranging between 0.74 and 1. Only recession type, CEJ detectability, and cervical step displayed minor variations. The total MCAT score also produced a minor discrepancy (kappa = 0.78). During the evaluation of whole quadrants, excellent reproducibility was recorded for individual parameters (kappa 0.9-1). Minor variation was observed for recession type and CEJ detectability. Excellent reliability in the total MCAT scores was noted between examiners (kappa = 0.9). Overall intra-examiner agreement values were very high (0.75-1).

CONCLUSIONS

The reliability of the proposed difficulty score was assessed between very good and excellent. Some difficulties arose in the evaluation of recession type, CEJ detectability and cervical step.

CLINICAL RELEVANCE

The presented score may be considered for assessing the difficulty of multiple GRs treatment using MCAT in order to improve the process of clinical decision-making.

The role of exercise-based prehabilitation in enhancing surgical outcomes for patients with digestive system cancers: a meta-analysis

BACKGROUND

Prehabilitation is a crucial component of tumor rehabilitation that attempts to improve patients' preoperative health, although its efficacy in treating patients with cancers of the digestive system is still up for debate.

METHODS

The records from PubMed (MEDLINE), Embase, Web of Science, Cochrane Library, EBSCO, Scopus, CNKI and Wan fang database up to November 2024 were systematically searched. The Cochrane Collaboration tool was employed for evaluating the risk of bias in each study, and the PRISMA 2020 checklist provided by the EQUATOR network was utilized.

RESULTS

Through quality analysis, 20 articles were included, involving 1719 patients. Although its effect on severe complications is still unknown, the prehabilitation significantly decreased overall postoperative complications when compared to standard care, with a risk ratio (RR) of 0.74 (95% CI: 0.65 to 0.84). Despite not shortening the postoperative hospital stay (MD: -0.13, 95% CI: -0.29 to 0.03), prehabilitation demonstrated notable improvements in the 6-minute walk distance (6MWD), with preoperative gains (MD: 25.87, 95% CI: 14.49 to 37.25) and sustained benefits at 4 weeks postoperatively (MD: 22.48, 95% CI: 7.85 to 37.12). However, no significant differences in 6MWD were observed at 6 or 8 weeks postoperatively. The average improvement in 6MWD from baseline to preoperative was 28.99 (95% CI: 10.89 to 47.08, P = 0.002), and from 4 weeks postoperative to baseline, it was 25.95 (95% CI: 6.84 to 45.07, P = 0.008), with no significant change at 8 weeks. The acceptance and completion rates of prehabilitation were commendably high at 61% (95% CI: 47-75%) and 90% (95% CI: 87-93%), respectively, alongside a relatively low dropout rate of 10% (95% CI: 7% to13%).

CONCLUSIONS

Prehabilitation reduces postoperative complications and improves short-term physical function in digestive surgery patients, with good patient acceptance; however, the long-term effects are unknown due to a lack of follow-up data.

REGISTRATION

It was registered with the International Prospective Register of Systematic Reviews (PROSPERO) with the identification code CRD42022361100.

Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials

OBJECTIVE

To estimate the relative efficacy of individual and combinations of prehabilitation components (exercise, nutrition, cognitive, and psychosocial) on critical outcomes of postoperative complications, length of stay, health related quality of life, and physical recovery for adults who have received surgery.

DESIGN

Systematic review with network and component network meta-analyses of randomised controlled trials.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science were initially searched 1 March 2022, and updated on 25 October 2023. Certainty in findings were assessed using the Confidence in Network Meta-Analysis (CINeMA) approach.

MAIN OUTCOME MEASURES

To compare treatments and to compare individual components informed by partnership with patients, clinicians, researchers, and health system leaders using an integrated knowledge translation framework. Eligible studies were any randomised controlled trial including adults preparing for major surgery who were allocated to prehabilitation interventions or usual care, and where critical outcomes were reported.

RESULTS

186 unique randomised controlled trials with 15 684 participants were included. When comparing treatments using random-effects network meta-analysis, isolated exercise (odds ratio 0.50 (95% confidence interval (CI) 0.39 to 0.64); very low certainty of evidence), isolated nutritional (0.62 (0.50 to 0.77); very low certainty of evidence), and combined exercise, nutrition, plus psychosocial (0.64 (0.45 to 0.92); very low certainty of evidence) prehabilitation were most likely to reduce complications compared with usual care. Combined exercise and psychosocial (-2.44 days (95% CI -3.85 to -1.04); very low certainty of evidence), combined exercise and nutrition (-1.22 days (-2.54 to 0.10); moderate certainty of evidence), isolated exercise (-0.93 days (-1.27 to -0.58); very low certainty of evidence), and isolated nutritional prehabilitation (-0.99 days (-1.49 to -0.48); very low certainty of evidence) were most likely to decrease length of stay. Combined exercise, nutrition, plus psychosocial prehabilitation was most likely to improve health related quality of life (mean difference on Short Form-36 physical component scale 3.48 (95% CI 0.82 to 6.14); very low certainty of evidence) and physical recovery (mean difference in meters on the six min walk test 43.43 (95% CI 5.96 to 80.91); very low certainty of evidence).When comparing individual components using component network meta-analysis, exercise and nutrition were the individual components most likely to improve all critical outcomes. The certainty of evidence for all comparisons across all outcomes was generally low to very low due to trial level risk of bias and imprecision; however, results for exercise and nutritional prehabilitation were robust with exclusion of high risk of bias trials.

CONCLUSIONS

Consistent and potentially meaningful effect estimates suggest that exercise prehabilitation, nutritional prehabilitation, and multicomponent interventions including exercise may benefit adults preparing for surgery and could be considered in clinical care. However, multicentre trials that are appropriately powered for high priority outcomes and that have a low risk of bias are required to have greater certainty in prehabilitation's efficacy.

REGISTRATION

International prospective registry of systematic reviews CRD42023353710.