Effects of a Preoperative Patient-Controlled Analgesia Education Program Using Smart Learning in Laparoscopic Cholecystectomy Patients

BACKGROUND

Patients undergoing laparoscopic cholecystectomy develop severe postoperative pain, and this acute pain often becomes chronic.

OBJECTIVES

This study determines the effects of preoperative education on patient-controlled analgesia (PCA) through smart learning in patients using PCA after undergoing laparoscopic cholecystectomies.

DESIGN

We conducted a quasi-experimental study with a nonequivalent control group pretest-posttest design.

PARTICIPANTS

A total of 60 adult patients aged 20-65 years, admitted for laparoscopic cholecystectomy at a hospital in Korea, participated in a smart learning training program.

METHODS

The concept of smart learning, which integrates learning content and solutions with the fourth industrial revolution using mobile devices such as smartphones and media tablets was applied in this study. This smart learning training program comprised three phases: (1) prebriefing, where patients accessed PCA knowledge via a program created by researchers and accessible using a mobile web device (e.g., smartphone or an iPad), with training covering pain characteristics, PCA effects, precautions, and usage methods; (2) simulation, where patients learned using PCA with a machine; (3) debriefing, where patients reviewed their knowledge and skills.

RESULTS

Comparing the pain between the experimental and control groups, the pain decreased significantly in both the experimental (Z = -4.40, p < .001) and control groups (Z = -4.41, p < .001), with no significant difference between groups (Z = -1.00, p = .319). Preoperative knowledge significantly increased in both the experimental (Z = -4.74, p < .001) and control groups (Z = -3.55, p < .001), with a significant difference between groups (Z = -6.05, p < .001). Total satisfaction with pain control was higher in the experimental group than in the control group.

CONCLUSIONS

A structured educational program on PCA use is an effective nursing intervention. PCA educational programs using smart learning could help patients undergoing laparoscopic cholecystectomy understand postoperative pain, promote efficient PCA use, and enhance their satisfaction with pain control.

"What really matters to the patients?": assessing the impact of wound healing on the quality of life in patients undergoing incisional hernia repair

PURPOSE

We aim to evaluate the impact of surgical wound complications in the first 30 postoperative days after incisional hernia repair on the long-term quality of life of patients. In addition, the impact of the surgical technique and preoperative comorbidities on the quality of life of patients will also be evaluated.

METHOD

Prospective cohort study, which evaluates 115 patients who underwent incisional hernioplasty between 2019 and 2020, using the onlay and retromuscular techniques. These patients were initially assessed with regard to surgical wound outcomes in the first 30 postoperative days (surgical site infection (SSI) or surgical site occurrence (SSO)), and then, assessed after three years, through a specific quality of life questionnaire, the Hernia Related Quality of Life Survey (HerQLes).

RESULTS

After some patients were lost to follow-up during the study period, due to death, difficulty in contact, refusal to respond to the questionnaire, eighty patients were evaluated. Of these, 11 patients (13.8%) had SSI in the first 30 postoperative days and 37 (46.3%) had some type of SSO. The impact of both SSI and SSO on quality of life indices was not identified. When analyzing others variables, we observed that the Body Mass Index (BMI) had a significant impact on the patients' quality of life. Likewise, hernia size and mesh size were identified as variables related to a worse quality of life outcome. No difference was observed regarding the surgical techniques used.

CONCLUSION

In the present study, no relationship was identified between surgical wound outcomes (SSO and SSI) and worse quality of life results using the HerQLes score. We observed that both BMI and the size of meshes and hernias showed an inversely proportional relationship with quality of life indices. However, more studies evaluating preoperative quality of life indices and comparing them with postoperative indices should be carried out to evaluate these correlations.

Preoperative risk evaluation and optimization for patients with liver disease

The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.

Comparison of laser and traditional lancing devices for capillary blood sampling in patients with diabetes mellitus and high bleeding risk

PURPOSE

Despite the importance of self-monitoring blood glucose (SMBG) for management of diabetes mellitus (DM), frequent blood sampling is discouraged by bleeding risk due to dual-antiplatelet agent therapy (DAPT) or thrombocytopenia.

METHODS

We compared the bleeding time (BT) of sampling by using a laser-lancing-device (LMT-1000) and a conventional lancet in patients with DM and thrombocytopenia or patients undergoing DAPT. BT was measured using the Duke method, and pain and satisfaction scores were assessed using numeric rating scale (NRS) and visual analog scale (VAS). The consistency in the values of glucose and glycated-hemoglobin (HbA1c) sampled using the LMT-1000 or lancet were compared.

RESULTS

The BT of sampling with the LMT-1000 was shorter than that with the lancet in patients with thrombocytopenia (60s vs. 85s, P = 0.024). The NRS was lower and the VAS was higher in laser-applied-sampling than lancet-applied sampling in the DAPT-user group (NRS: 1 vs. 2, P = 0.010; VAS: 7 vs. 6, P = 0.003), whereas the group with thrombocytopenia only showed improvement in the VAS score (8 vs. 7, P = 0.049). Glucose and HbA1c sampled by the LMT-1000 and lancet were significantly correlated in both the DAPT-user and the thrombocytopenia groups.

CONCLUSION

The LMT-1000 can promote SMBG by shortening BT in subject with thrombocytopenia and by increasing satisfaction score, as well as by showing reliable glucose and HbA1c value.

Development of Indocyanine Green/Methyl-β-cyclodextrin Complex-Loaded Liposomes for Enhanced Photothermal Cancer Therapy

Photothermal therapy (PTT) is a promising cancer therapeutic approach due to its spatial selectivity and high potency. Indocyanine green (ICG) has been considered a biocompatible PTT agent. However, ICG has several challenges to hinder its clinical use including rapid blood clearance and instability to heat, light, and solvent, leading to a loss of photoactivation property and PTT efficacy. Herein, we leveraged stabilizing components, methyl-β-cyclodextrin and liposomes, in one nanoplatform (ICD lipo) to enhance ICG stability and the photothermal therapeutic effect against cancer. Compared to ICG, ICD lipo displayed a 4.8-fold reduction in degradation in PBS solvent after 30 days and a 3.4-fold reduction in photobleaching after near-infrared laser irradiation. Moreover, in tumor-bearing mice, ICD lipo presented a 2.7-fold increase in tumor targetability and inhibited tumor growth 9.6 times more effectively than did ICG without any serious toxicity. We believe that ICD lipo could be a potential PTT agent for cancer therapeutics.

Artificial intelligence-assisted decision making: Prediction of optimal level of distal mesorectal margin during transanal total mesorectal excision (taTME) using deep neural network modeling

BACKGROUND

With steep posterior anorectal angulation, transanal total mesorectal excision (taTME) may have a risk of dissection in the wrong plane or starting higher up, resulting in leaving distal mesorectum behind. Although the distal mesorectal margin can be assessed by preoperative MRI, it needs skilled radiologist and high-definition image for accurate evaluation. This study developed a deep neural network (DNN) to predict the optimal level of distal mesorectal margin.

METHODS

A total of 182 pelvic MRI images extracted from the cancer image archive (TCIA) database were included. A DNN was developed using gender, the degree of anterior and posterior anorectal angles as input variables while the difference between anterior and posterior mesorectal distances from anal verge was selected as a target. The predictability power was assessed by regression values (R) which is the correlation between the predicted outputs and actual targets.

RESULTS

The anterior angle was an obtuse angle while the posterior angle varied from acute to obtuse with mean angle difference 35.5°±14.6. The mean difference between the anterior and posterior mesorectal end distances was 18.6±6.6mm. The developed DNN had a very close correlation with the target during training, validation, and testing (R=0.99, 0.81, and 0.89, P<0.001). The predicted level of distal mesorectal margin was closely correlated with the actual optimal level (R=0.91, P<0.001).

CONCLUSIONS

Artificial intelligence can assist in either making or confirming the preoperative decisions. Furthermore, the developed model can alert the surgeons for this potential risk and the necessity of re-positioning the proctectomy incision.

The efficacy and safety of combined therapy with endobronchial tamponade and bronchial artery embolization for massive hemoptysis

BACKGROUND

Massive hemoptysis is characterized by its life-threatening nature, potentially leading to airway obstruction and asphyxia. The objective of this study was to evaluate the clinical effectiveness of combining endobronchial tamponade with bronchial artery embolization (BAE) in the treatment of massive hemoptysis.

METHODS

Between March 2018 and March 2022, a total of 67 patients with massive hemoptysis who underwent BAE were divided into two groups: the combination group (n = 26) and the BAE group (n = 41). Technical and clinical success rates were assessed, and adverse events were monitored following the treatment. Blood gas analysis and coagulation function indicators were collected before and after the treatment, and recurrence and survival rates were recorded during the follow-up period.

RESULTS

All patients achieved technical success. There were no significant differences in the clinical success rate, recurrence rates at 3 and 6 months, and mortality rates at 3 months, 6 months, and 1 year between the combination group and the BAE group. However, the hemoptysis recurrence rate at 1 year was significantly lower in the combination group compared to the BAE group (15.4% vs. 39.0%, P = 0.039). No serious adverse events were reported in either group. After treatment, the combination group showed higher levels of arterial partial pressure of oxygen (PaO2), oxygenation index (PaO2/FiO2), fibrinogen (FIB), and D-dimer (D-D) compared to the BAE group (P < 0.05). Multivariate regression analysis demonstrated a significant correlation between combined therapy and hemoptysis-free survival.

CONCLUSION

Combination therapy, compared to embolization alone, exhibits superior efficacy in improving respiratory function, correcting hypoxia, stopping bleeding, and preventing recurrence. It is considered an effective and safe treatment for massive hemoptysis.

Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer

BACKGROUND

Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus.

MATERIALS AND METHODS

This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up.

RESULTS

In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001).

CONCLUSION

Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

Para-aortic lymph node dissection with or without nerve-sparing in gynecological malignancies

OBJECTIVE

Para-aortic lymph node dissection (PALND) is a widely used treatment that causes many complications. This study is to evaluate the efficacy and safety of nerve-sparing para-aortic lymph node dissection (NSPALND) by comparing it with conventional PALND in gynecological malignancies and to prove whether locating the superior hypogastric plexus (SHP) can help reveal the para-aortic nerves.

METHODS

This is a retrospective study of the patients who underwent para-aortic lymphadenectomy from January 2020 to December 2022 at Zhejiang Cancer Hospital. All of them were divided into NSPALND and PALND groups according to whether or not nerve-sparing was performed. The surgical, functional and oncological outcomes were evaluated.

RESULTS

There were 43 patients enrolled, of which, 20 patients underwent NSPALND and 23 patients underwent PALND. The para-aortic nerves were successfully revealed by locating the SHP in all 20 cases of NSPALND. The post-operative anal exhaust time in the NSPALND group was significantly shorter than that in the PALND group (2.5 vs. 4 days, p=0.006), and the incidence of acute intestinal obstruction in the NSPALND group was significantly lower than that in the PALND group (10% vs. 39%, p=0.029). There was no difference between the two groups in terms of catheterization duration, urinary retention, dysuria, as well as the number of lymph nodes removed and the para-aortic recurrence rate.

CONCLUSION

NSPALND can significantly reduce the rate of acute intestinal obstruction and improve post-operative intestinal function. Locating the SHP and using it as an anatomical landmark to reveal the para-aortic nerves is feasible. Its exact clinical value needs to be further studied.

Predicting lymph node metastasis in colorectal cancer patients: development and validation of a column chart model

Lymph node metastasis (LNM) is one of the crucial factors in determining the optimal treatment approach for colorectal cancer. The objective of this study was to establish and validate a column chart for predicting LNM in colon cancer patients. We extracted a total of 83,430 cases of colon cancer from the Surveillance, Epidemiology, and End Results (SEER) database, spanning the years 2010-2017. These cases were divided into a training group and a testing group in a 7:3 ratio. An additional 8545 patients from the years 2018-2019 were used for external validation. Univariate and multivariate logistic regression models were employed in the training set to identify predictive factors. Models were developed using logistic regression, LASSO regression, ridge regression, and elastic net regression algorithms. Model performance was quantified by calculating the area under the ROC curve (AUC) and its corresponding 95% confidence interval. The results demonstrated that tumor location, grade, age, tumor size, T stage, race, and CEA were independent predictors of LNM in CRC patients. The logistic regression model yielded an AUC of 0.708 (0.7038-0.7122), outperforming ridge regression and achieving similar AUC values as LASSO regression and elastic net regression. Based on the logistic regression algorithm, we constructed a column chart for predicting LNM in CRC patients. Further subgroup analysis based on gender, age, and grade indicated that the logistic prediction model exhibited good adaptability across all subgroups. Our column chart displayed excellent predictive capability and serves as a useful tool for clinicians in predicting LNM in colorectal cancer patients.

Insight into COVID-19 associated liver injury: Mechanisms, evaluation, and clinical implications

COVID-19 has affected millions worldwide, causing significant morbidity and mortality. While predominantly involving the respiratory tract, SARS-CoV-2 has also caused systemic illnesses involving other sites. Liver injury due to COVID-19 has been variably reported in observational studies. It has been postulated that liver damage may be due to direct damage by the SARS-CoV-2 virus or multifactorial secondary to hepatotoxic therapeutic options, as well as cytokine release syndrome and sepsis-induced multiorgan dysfunction. The approach to a COVID-19 patient with liver injury requires a thorough evaluation of the pattern of hepatocellular injury, along with the presence of underlying chronic liver disease and concurrent medications which may cause drug-induced liver injury. While studies have shown uneventful recovery in the majority of mildly affected patients, severe COVID-19 associated liver injury has been associated with higher mortality, prolonged hospitalization, and greater morbidity in survivors. Furthermore, its impact on long-term outcomes remains to be ascertained as recent studies report an association with metabolic-fatty liver disease. This present review provides insight into the subject by describing the postulated mechanism of liver injury, its impact in the presence of pre-existing liver disease, and its short- and long-term clinical implications.

CT evaluation of bowel wall enhancement in pneumatosis intestinalis: preventing non-therapeutic laparotomies

PURPOSE

To evaluate the diagnostic performance of bowel wall enhancement for diagnosing concomitant bowel ischemia in patients with parietal pneumatosis (PI) diagnosed at abdominal CT.

MATERIALS AND METHODS

From January 1, 2012 to December 31, 2021, 226 consecutive patients who presented with PI on abdominal CT from any bowel segment were included. Variables at the time of the CT were retrospectively extracted from medical charts. CT examinations were blindly analyzed by two independent radiologists. The third reader classified all disagreement of bowel enhancement in three categories: (1) normal bowel enhancement; (2) doubtful bowel wall enhancement; (3) absent bowel wall enhancement. Multivariable logistic regression analysis was performed. Concomitant bowel ischemia was defined as requirement of bowel resection specifically due to ischemic lesion in operated patients and death from bowel ischemia in non-operated patients.

RESULTS

Overall, 78/226 (35%) patients had PI associated with concomitant bowel ischemia. At multivariate analysis, Only absence or doubtful bowel wall enhancement was associated with concomitant bowel ischemia (OR = 167.73 95%CI [23.39-4349.81], P < 0,001) and acute mesenteric ischemia associated with PP (OR = 67.94; 95%CI [5.18-3262.36], P < 0.009). Among the 82 patients who underwent a laparotomy for suspected bowel ischemia, rate of non-therapeutic laparotomy increased from 15/59 (25%), 2/6 (50%) and 16/17 (94%) when bowel wall enhancement was absent, doubtful and normal respectively.

CONCLUSION

Absence of enhancement of the bowel wall is the primary feature associated with concomitant bowel ischemia. It should be carefully assessed when PI is detected to avoid non-therapeutic laparotomy.

A comprehensive exploration of gallbladder health: from common to rare imaging findings

This comprehensive review explores a wide range of imaging findings associated with the gallbladder (GB), from anatomic variants to rare diseases. Through an in-depth review of diagnostic modalities including ultrasound, magnetic resonance cholangiopancreatography, CT, and MRI, we aim to highlight the crucial role of imaging techniques in diagnosing GB disorders, as congenital anomalies, inflammatory diseases, neoplasms, and surgical complications. Employing a detailed analysis and comparison of imaging findings across various modalities, this review seeks to improve diagnostic accuracy for GB-related pathologies, facilitating optimal patient management.

Synchronous liver metastasis at initial diagnosis of adrenal pheochromocytoma by CT: A case report

Pheochromocytoma is a tumor of the sympathetic nervous system, characterized by atypical symptoms and signs. Pheochromocytoma metastases can be found in various tissues and organs. However, synchronous metastasis at the initial diagnosis of pheochromocytoma is rare. The present study described a case with synchronous liver metastasis at the initial diagnosis of adrenal pheochromocytoma based on imaging findings. A 41-year-old woman presented with liver pain and fatigue for 1 month. Physical examination showed increased blood pressure and heart rate with sinus tachycardia. Laboratory examination revealed normal levels of liver tumor markers and increased levels of serum or urine epinephrine and norepinephrine. CT examination revealed a large cystic solid mass in the right lobe of the liver and right adrenal gland, and the solid part of the mass was enhanced after enhancement. The pathological diagnosis was pheochromocytoma of the right adrenal gland with liver metastasis. The patient underwent right hepatectomy and right adrenal tumor resection. During the postoperative follow-up, the patient's blood pressure and catecholamine levels were within the normal range. Three years after surgery, the CT examination revealed multiple liver metastases. Chemotherapy was administered to the patient. A year later, re-examination revealed an increase and enlargement of the metastases, and the mass of the right adrenal gland remained similar to the previous one. After 6 months of follow-up, the patient succumbed to recurrence and metastasis. Preoperative diagnosis of metastatic pheochromocytoma is challenging. This case mainly emphasizes that imaging findings can help the clinical diagnosis of metastatic pheochromocytoma.

Reviewing the impact of obesity on inflammatory bowel disease and considerations for optimizing management

PURPOSE OF REVIEW

This review examines the complex relationship between obesity and inflammatory bowel disease (IBD), encompassing their potentially shared pathogenesis, the impact of obesity on the natural history and treatment outcomes of IBD, and the management of obesity in the patient with IBD.

RECENT FINDINGS

Obesity represents a state of chronic inflammation that may not only contribute to IBD pathogenesis, but also influence disease progression, complications, and response to treatment. Increased visceral adiposity may carry negative prognostic implications for disease and treatment-specific outcomes. Antiobesity medications, endoscopic bariatric therapies, and even bariatric surgery may be effective and well tolerated in selected patients with IBD.

SUMMARY

The intersection of obesity and IBD presents a significant clinical challenge, with obesity influencing the natural history of IBD and potentially affecting treatment efficacy. As obesity prevalence among IBD patients rises, a tailored approach to management is crucial, taking into account the individualized risks and benefits of various treatment strategies, including lifestyle interventions, pharmacotherapy, endoscopic procedures, and bariatric surgery.

Molecular differentiation between complete and incomplete responders to neoadjuvant therapy in rectal cancer

Background

Neoadjuvant chemoradiotherapy (nCRT) is the standard treatment for locally advanced rectal cancer, but only 20-40% of patients completely respond to this treatment.

Methods

To define the molecular features that are associated with response to nCRT, we generated and collected genomic and transcriptomic data from 712 cancers prior to treatment from our own data and from publicly available data.

Results

We found that patients with a complete response have decreased risk of both local recurrence and future metastasis. We identified multiple differences in DNA mutations and transcripts between complete and incomplete responders. Complete responder tumors have a higher tumor mutation burden and more significant co-occurring mutations than the incomplete responder tumors. In addition, mutations in DNA repair genes (across multiple mechanisms of repair) were enriched in complete responders and they also had lower expression of these genes indicating that defective DNA repair is associated with complete response to nCRT. Using logistic regression, we identified three significant predictors of complete response: tumor size, mutations within specific network genes, and the existence of three or more specific co-occurrent mutations. In incompletely responder tumors, abnormal cell-cell interaction and increased cancer associated fibroblasts were associated with recurrence. Additionally, gene expression analysis identified a subset of immune hot tumors with worse outcomes and upregulated of immune checkpoint proteins.

Conclusions

Overall, our study provides a comprehensive understanding of the molecular features associated with response to nCRT and the molecular differences in non-responder tumors that later reoccur. This knowledge may provide critical insight for the development of precision therapy for rectal cancer.

A pilot study of virtual liver segment projection technology in subsegment-oriented laparoscopic anatomical liver resection when indocyanine green staining fails (with video)

BACKGROUND

Precision surgery for liver tumors favors laparoscopic anatomical liver resection (LALR), involving the removal of specific liver segments or subsegments. Indocyanine green (ICG)-negative staining is a commonly used method for defining resection boundaries but may be prone to failure. The challenge arises when ICG staining fails, as it cannot be repeated during surgery. In this study, we employed the virtual liver segment projection (VLSP) technology as a salvage approach for precise boundary determination. Our aim was to assess the feasibility of the VLSP to be used for the determination of the boundaries of the liver resection in this situation.

METHODS

Between January 2021 and June 2023, 12 consecutive patients undergoing subsegment-oriented LALR were included in this pilot series. The VLSP technology was utilized to define the resection boundaries at the time of ICG-negative staining failure. Routine surgical parameters and short-term outcomes were evaluated to assess the safety of VLSP in this procedure. In addition, its feasibility was assessed by analyzing the accuracy between the predicted resected liver volume (PRLV) and actual resected liver volume (ARLV).

RESULTS

Of the 12 enrolled patients, the mean operation time was 444.58 ± 101.70 min (range 290-570 min), with a mean blood loss of 125.00 ± 96.53 ml (range 50-400 mL). One patient (8.3%) was converted to laparotomy for subsequent parenchymal transection, four (33.3%) received blood transfusions and four (33.3%) had postoperative complications. All patients received an R0 resection. The Pearson correlation coefficient (r) between PRLV and ARLV was 0.98 (R2 = 0.96, p < 0.05), and the relative error (RE) was 8.62 ± 6.66% in the 12 patients, indicating agreement.

CONCLUSION

Failure of intraoperative ICG-negative staining during subsegment-oriented LALR is possible, and VLSP may be an alternative to define the resection boundaries in such cases.

Evaluation of the short-term complications of intracorporeal anastomosis in right-sided colectomy

INTRODUCTION

The benefits of intracorporeal anastomosis in laparoscopic colorectal cancer surgery remain unclear. Therefore, we aimed to investigate the short-term postoperative outcomes of intracorporeal anastomosis.

METHODS

We retrospectively analyzed 87 patients who underwent laparoscopic surgery for right-sided colon tumors using a colon database.

RESULTS

Of the 87 patients, 23 underwent intracorporeal anastomosis and 64 underwent extracorporeal anastomosis. Intraoperative bleeding, wound length, exhaust gas, preoperative white blood cell count, and C-reactive protein (postoperative day 1) were higher in the extracorporeal anastomosis group than in the intracorporeal anastomosis group. The incidence of wound infection was higher in the intracorporeal anastomosis group than in the extracorporeal anastomosis group. In the irrigation water bacterial culture collected after anastomosis, the positive group had a higher white blood cell count on postoperative day 1 and higher C-reactive protein levels on postoperative day 3 than did the negative group. Patients who underwent chemical preparation had lower C-reactive protein levels on postoperative day 1 than did the group who did not undergo chemical preparation.

CONCLUSION

Despite the advantages of intracorporeal anastomosis in terms of wound length and intraoperative bleeding, the risk of infection may increase during the introduction phase. Fever and inflammatory responses are significantly elevated in culture-positive cases.

Absorbable versus Nonabsorbable Sutures for Facial Skin Closure: A Systematic Review and Meta-analysis of Clinical and Aesthetic Outcomes

When repairing facial wounds, it is crucial to possess a thorough understanding of suitable suture materials and their evidence base. The absence of high-quality and comprehensive systematic reviews poses challenges in making informed decisions. In this study, we conducted a review of the existing literature and assessed the quality of the current evidence pertaining to the clinical, aesthetic, and patient-reported outcomes associated with absorbable and nonabsorbable sutures for facial skin closure. The study was registered on Prospective Register of Systematic Reviews. We conducted searches on Embase, Ovid, and PubMed/MEDLINE databases. Only randomized controlled trials (RCTs) were eligible for inclusion in this study. Additionally, the risk of bias in the randomized studies was assessed using Cochrane's Risk of Bias Tool. The study included a total of nine RCTs involving 804 participants with facial injuries. Among these injuries, absorbable sutures were utilized in 50.2% (403 injuries), while nonabsorbable sutures were employed in 49.8% (401 injuries). The analysis of cosmesis scales revealed no statistically significant difference between absorbable and nonabsorbable sutures regarding infections ( p  = 0.72), visual analog scale ( p  = 0.69), wound dehiscence ( p  = 0.08), and scarring ( p  = 0.46). The quality of the included studies was determined to have a low risk of bias. Absorbable sutures can be considered a suitable alternative to nonabsorbable sutures, as they demonstrate comparable aesthetic and clinical outcomes. Future high-quality studies with a level I evidence design and cost-effectiveness analysis are necessary to enhance clinician-patient shared decision-making and optimize the selection of suture materials. Level of evidence is I, risk/prognostic study.

Local Excision Versus Radical Resection for Grade 2 Rectal Neuroendocrine Tumors: A Multicenter Propensity Score-Matched Analysis

BACKGROUND

Studies on grade 2 rectal neuroendocrine tumors are limited, and the optimal treatment for these tumors is not well established.

OBJECTIVE

We aimed to compare the oncologic results of local excision versus radical resection for the treatment of grade 2 rectal neuroendocrine tumors.

DESIGN

Retrospective multicenter propensity score-matched study to minimize heterogeneity between groups and focus on the differences between surgery strategies.

SETTINGS

Seventeen large-scale Chinese medical centers participated in this study.

PATIENTS

A total of 144 patients with pathologically confirmed grade 2 rectal neuroendocrine tumors were retrospectively analyzed.

MAIN OUTCOME MEASURES

Cancer-specific survival and relapse-free survival were assessed to compare surgery strategies.

RESULTS

A total of 144 patients with grade 2 rectal neuroendocrine tumors were enrolled in this study. Twenty-seven patients underwent endoscopic resection, 55 underwent transanal excision, 50 underwent radical resection, and 12 underwent palliative surgery or biopsy for distant metastasis. Of the 50 patients who underwent radical resection, 30 (60.0%) had clinically positive lymph nodes on the basis of the histopathology results. The optimal cutoff value for tumor size to predict cancer-specific survival was 1.5 cm. In patients with grade 2 rectal neuroendocrine tumors of ≤1.5-cm size, there were no significant differences in cancer-specific survival and relapse-free survival between local excision and radical resection groups ( p > 0.05). In patients with grade 2 rectal neuroendocrine tumors of >1.5-cm size, relapse-free survival was significantly lower in the local excision group than in the radical resection group ( p = 0.04).

LIMITATIONS

The nature of retrospective reviews and a relatively short follow-up period are limitations of this study.

CONCLUSIONS

Grade 2 rectal neuroendocrine tumors have a nonnegligible rate of lymph node metastasis. Local excision is a feasible choice for tumors of ≤1.5 cm size without metastasis, whereas radical resection is more beneficial in those of >1.5 cm size. See Video Abstract .

ESCISIN LOCAL VERSUS RESECCIN RADICAL PARA TUMORES NEUROENDOCRINOS RECTALES GRADO ANLISIS MULTICNTRICO CON PUNTUACIN DE PROPENSIN COINCIDENTE

ANTECEDENTES:Los estudios sobre los tumores neuroendocrinos rectales de grado 2 son limitados y el tratamiento óptimo para estos tumores no está bien establecido.OBJETIVO:Comparar los resultados oncológicos de la escisión local versus la resección radical para el tratamiento de tumores neuroendocrinos rectales grado 2.DISEÑO:Estudio multicéntrico retrospectivo emparejado por puntuación de propensión para minimizar la heterogeneidad entre grupos y centrarse en la diferencia entre estrategias quirúrgicas.ESCENARIO:Diecisiete centros médicos chinos de gran tamaño participaron en este estudio.PACIENTES:Se analizaron retrospectivamente un total de 144 pacientes con tumores neuroendocrinos rectales grado 2 patológicamente confirmados.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron la supervivencia específica del cáncer y la supervivencia libre de recaída para comparar las estrategias quirúrgicas.RESULTADOS:En este estudio se inscribieron un total de 144 pacientes con tumores neuroendocrinos rectales grado 2. Veintisiete pacientes se sometieron a resección endoscópica, 55 a escisión transanal, 50 a resección radical y 12 a cirugía paliativa o biopsia por metástasis a distancia. De los 50 pacientes que se sometieron a resección radical, 30 (60,0%) tenían ganglios linfáticos clínicamente positivos según los resultados histopatológicos. El valor de corte óptimo para el tamaño del tumor para predecir la supervivencia específica del cáncer fue de 1,5 cm. En pacientes con tumores neuroendocrinos rectales grado 2 ≤ 1,5 cm, no hubo diferencias significativas en la supervivencia específica del cáncer y la supervivencia libre de recaída entre los grupos de escisión local y resección radical ( p >0,05). En pacientes con tumores neuroendocrinos rectales grado 2 > 1,5 cm, la supervivencia libre de recaída fue significativamente menor en el grupo de escisión local que en el grupo de resección radical ( p = 0,04).LIMITACIONES:La naturaleza de la revisión retrospectiva y el período de seguimiento relativamente corto son limitaciones de este estudio.CONCLUSIONES:Los tumores neuroendocrinos rectales grado 2 tienen una tasa no despreciable de metástasis en los ganglios linfáticos. La escisión local es una opción factible para tumores ≤ 1,5 cm sin metástasis, mientras que la resección radical es más beneficiosa en aquellos > 1,5 cm. (Traducción-Dr. Felipe Bellolio ).

Impact of Operative Approach on Acute Kidney Injury Risk Prediction Models for Colectomy

INTRODUCTION

Acute kidney injury (AKI) is a serious postoperative complication associated with increased morbidity and mortality. Identifying patients at risk for AKI is important for risk stratification and management. This study aimed to develop an AKI risk prediction model for colectomy and determine if the operative approach (laparoscopic versus open) alters the influence of predictive factors through an interaction term analysis.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed from 2005 to 2019. Patients undergoing laparoscopic and open colectomy were identified and propensity score matched. Multivariable logistic regression identified significant preoperative demographic, comorbidity, and laboratory value predictors of AKI. The predictive ability of a baseline model consisting of these variables was compared to a proposed model incorporating interaction terms between operative approach and predictor variables using the likelihood ratio test, c-statistic, and Brier score. Shapley Additive Explanations values assessed relative importance of significant predictors.

RESULTS

252,372 patients were included in the analysis. Significant AKI predictors were hypertension, age, sex, race, body mass index, smoking, diabetes, preoperative sepsis, Congestive heart failure, preoperative creatinine, preoperative albumin, and operative approach (P < 0.001). The proposed model with interaction terms had improved predictive ability per the likelihood ratio test (P < 0.05) but had no statistically significant interaction terms. C-statistic and Brier scores did not improve. Shapley Additive Explanations analysis showed hypertension had the highest importance. The importance of age and diabetes showed some variation between operative approaches.

CONCLUSIONS

While the inclusion of interaction terms collectively improved AKI prediction, no individual operative approach interaction terms were significant. Including operative approach interactions may enhance predictive ability of AKI risk models for colectomy.

Genotype-histotype-phenotype correlations in hyperinsulinemic hypoglycemia

Hyperinsulinemic hypoglycemia (HH) of pancreatic origin includes congenital hyperinsulinism (CHI), insulinoma, insulinomatosis, and adult-onset non-insulinoma persistent hyperinsulinemic hypoglycemia syndrome (NI-PHHS). In this review, we describe the genotype-histotype-phenotype correlations in HH and their therapeutic implications. CHI can occur from birth or later on in life. Histologically, diffuse CHI shows diffuse beta cell hypertrophy with a few giant nuclei per islet of Langerhans, most frequently caused by loss-of-function mutations in ABCC8 or KCNJ11. Focal CHI is histologically characterized by focal adenomatous hyperplasia consisting of confluent hyperplastic islets, caused by a paternal ABCC8/KCNJ11 mutation combined with paternal uniparental disomy of 11p15. CHI in Beckwith-Wiedemann syndrome is caused by mosaic changes in the imprinting region 11p15.4-11p15.5, leading to segmental or diffuse overgrowth of endocrine tissue in the pancreas. Morphological mosaicism of pancreatic islets is characterized by occurence of hyperplastic (type 1) islets in one or a few lobules and small (type 2) islets in the entire pancreas. Other rare genetic causes of CHI show less characteristic or unspecific histology. HH with a predominant adult onset includes insulinomas, which are pancreatic insulin-producing endocrine neoplasms, in some cases with metastatic potential. Insulinomas occur sporadically or as part of multiple endocrine neoplasia type 1 due to MEN1 mutations. MAFA mutations may histologically lead to insulinomatosis with insulin-producing neuroendocrine microadenomas or neuroendocrine neoplasms. NI-PHHS is mainly seen in adults and shows slight histological changes in some patients, which have been defined as major and minor criteria. The genetic cause is unknown in most cases. The diagnosis of HH, as defined by genetic, histological, and phenotypic features, has important implications for patient management and outcome.

Evaluation of the genetic basis of familial-associated early-onset hematologic cancers in an ancestral/ethnically diverse population

Genetic predisposition to hematologic malignancies has historically been addressed utilizing patients recruited from clinical trials and pedigrees constructed at major treatment centers. Such efforts leave unexplored the genetic basis of variations in risk by race/ethnic group shown in population-based surveillance data where cancer registration, compulsory by law, delivers universal enrollment. To address this, we performed exome sequencing on DNA isolated from newborn bloodspots derived from sibling pairs with early-onset cancers across California in which at least one of the siblings developed a hematologic cancer, using unbiased recruitment from the full state population. We identified pathogenic/likely pathogenic (P/ LP) variants among 1,172 selected cancer genes that were private or present at low allele frequencies in reference populations. Within 64 subjects from 32 families, we found 9 LP variants shared between siblings, and an additional 7 such variants in singleton children (not shared with their sibling). In 8 of the shared cases, the ancestral origin of the local haplotype that carries P/LP variants matched the dominant global ancestry of study participant families. This was the case for Latino sibling pairs on FLG and CBLB, non-Latino White sibling pairs in TP53 and NOD2, and a shared GATA2 variant for a non-Latino Black sibling pair. A new inherited mutation in HABP2 was identified in a sibling pair, one with diffuse large B-cell lymphoma and the other with neuroblastoma. Overall, the profile of P/LP germline variants across ancestral/ethnic groups suggests that rare alleles contributing to hematologic diseases originate within their race/ethnic origin parental populations, demonstrating the value of this discovery process in diverse, population-based registries.

Current state of minimally invasive general surgical practice in Africa: A systematic review and meta-analysis of the laparoscopic procedures performed and outcomes

BACKGROUND

Minimally invasive surgery, including laparoscopy and robotics, has significantly improved general surgical (GS) practice globally. While robot-assisted GS practice is yet to be adopted in the majority of Africa, laparoscopy has been utilized to improve surgical outcomes. This study aims to review the laparoscopic GS procedures (LGSPs) performed and evaluate outcomes such as conversion to open surgery, morbidity, and mortality in Africa.

METHODS

Four databases (PubMed, Google Scholar, WoS, and AJOL) were searched, identifying 8022 publications. Following screening, 40 studies across Africa that reported LGSPs (n ≥ 2) performed and outcomes met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% CI of conversion, morbidity, and mortality.

RESULTS

A total of 6381 procedures performed in 15 African countries were analyzed in this study. Majority, 72.89%, of the procedures were performed in Senegal, South Africa, and Nigeria. The major procedures performed were cholecystectomy (37.09%), appendicectomy (33.36%), and diagnostic laparoscopy (9.98%). The meta-analysis revealed a conversion rate of 5% [95% CI: 4, 7]. Adhesion (28.13%), hemorrhage (16.67%), technical difficultly (12.50%), and equipment failure (11.46%) were the predominant indications for conversion. Surgical site infection (42.75%) was the major cause of morbidity. The prevalences of morbidity and mortality were 7% [95% CI: 5, 10] and 0.12% [95% CI: 0, 0.29], respectively.

CONCLUSION

A wide range of basic and advanced LGSPs were performed. The outcomes obtained indicate successful implementation of the laparoscopic approach. Importantly, this study serves as a foundational work for further research on minimally invasive surgery in Africa.

Surgical quality assessment of critical view of safety in 283 laparoscopic cholecystectomy videos by surgical residents and surgeons

INTRODUCTION

Surgical quality assessment has improved the efficacy and efficiency of surgical training and has the potential to optimize the surgical learning curve. In laparoscopic cholecystectomy (LC), the critical view of safety (CVS) can be assessed with a 6-point competency assessment tool (CAT), a task commonly performed by experienced surgeons. The aim of this study is to determine the capability of surgical residents to perform this assessment.

METHODS

Both surgeons and surgical residents assessed unedited LC videos using a 6-point CVS, a CAT, using an online video assessment platform. The CAT consists of the following three criteria: 1. clearance of hepatocystic triangle, 2. cystic plate, and 3. two structures connect to the gallbladder, with a maximum of 2 points available for each criterion. A higher score indicates superior surgical performance. The intraclass correlation coefficient (ICC) was employed to assess the inter-rater reliability between surgeons and surgical residents.

RESULTS

In total, 283 LC videos were assessed by 19 surgeons and 31 surgical residents. The overall ICC for all criteria was 0.628. Specifically, the ICC scores were 0.504 for criterion 1, 0.639 for criterion 2, and 0.719 for the criterion involving the two structures connected to the gallbladder. Consequently, only the criterion regarding clearance of the hepatocystic triangle exhibited fair agreement, whereas the other two criteria, as well as the overall scores, demonstrated good agreement. In 71% of cases, both surgeons and surgical residents scored a total score either ranging from 0 to 4 or from 5 to 6.

CONCLUSION

Compared to the gold standard, i.e., the surgeons' assessments, surgical residents are equally skilled at assessing critical view of safety (CVS) in laparoscopic cholecystectomy (LC) videos. By incorporating video-based assessments of surgical procedures into their training, residents could potentially enhance their learning pace, which may result in better clinical outcomes.

Fluorescence and tracers in surgery: the coming future

The revolution that we are seeing in the world of surgery will determine the way we understand surgical approaches in coming years. Since the implementation of minimally invasive surgery, innovations have constantly been developed to allow the laparoscopic approach to go further and be applied to more and more procedures. In recent years, we have been in the middle of another revolutionary era, with robotic surgery, the application of artificial intelligence and image-guided surgery. The latter includes 3D reconstructions for surgical planning, virtual reality, holograms or tracer-guided surgery, where ICG-guided fluorescence has provided a different perspective on surgery. ICG has been used to identify anatomical structures, assess tissue perfusion, and identify tumors or tumor lymphatic drainage. But the most important thing is that this technology has come hand in hand with the potential to develop other types of tracers that will facilitate the identification of tumor cells and ureters, as well as different light beams to identify anatomical structures. These will lead to other types of systems to assess tissue perfusion without the use of tracers, such as hyperspectral imaging. Combined with the upcoming introduction of ICG quantification, these developments represent a real revolution in the surgical world. With the imminent implementation of these technological advances, a review of their clinical application in general surgery is timely, and this review serves that aim.

Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2)

BACKGROUND

Management of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL.

METHODS

Patients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included.

RESULTS

A total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients.

CONCLUSION

The incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.

Trends in preoperative carbohydrate load practice: A systematic review

BACKGROUND

The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice.

METHODS

A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume.

RESULTS

A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377).

CONCLUSION

Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.

Traumatic perforated duodenal diverticulum after a fight, a case report

INTRODUCTION

Fewer than 200 cases of Perforated Duodenal Diverticulum ("PDD") have been reported in the literature. The percentage of caused by trauma is generally very low and similar to rates recorded for duodenal injuries caused by trauma in the absence of diverticula (3 %-5 %). As a rare cause of abdominal pain after trauma, perforated duodenal diverticula are seldom diagnosed preoperatively. Despite preoperative CT scan demonstrating duodenal perforation, a diverticular origin is often only identified intraoperatively.

PRESENTATION OF CASE

A 36-year-old man was admitted to the emergency department with severe upper abdominal pain that began after blunt trauma by a kick to his upper abdomen during a fight. A duodenal injury was identified by CT. Exploratory laparotomy then revealed a retroperitoneal perforation of a diverticulum located at the second segment of the duodenum.

DISCUSSION

A review of the literature found few cases reporting perforated duodenal diverticulum secondary to trauma. Most cases identified the diverticulum at intraoperative exploration, with most approaches being through open surgery.

CONCLUSION

Perforation of a duodenal diverticulum secondary to trauma is an extremely rare event, which is why it is often overlooked in the differential diagnosis of acute abdomen. As the presenting signs are often suggestive of duodenal perforation without a clear notion of duodenal diverticula at CT scan, a surgical approach and exploration is most frequently described. In our experience, the management of traumatic PDD aligns with the literature favoring the open surgical approach.

A bifid gallbladder? A challenging laparoscopic cholecystectomy

INTRODUCTION

The modern-day gold standard treatment of acute cholecystitis is laparoscopic surgery. It is, however, associated with a higher risk of bile duct injury (0.1 %-1.5 %) when compared to the open approach.

CASE PRESENTATION

We report a case of a patient with an acute cholecystitis in which we performed a laparoscopic cholecystectomy. We faced a destabilizing anatomy with what looked like the gallbladder and an unidentified mass, interpreted as a possible common bile duct cyst. Careful dissection allowed us to determine that what looked like a common bile duct cyst was a dilatation of "Hartmann's pouch" due to a large gallstone.

DISCUSSION

Laparoscopic cholecystectomy reduces length of hospitalization and enhance intra-operative and postoperative morbidity compared with open cholecystectomy. It may increase the risk of bile duct injury, notably in an acute setting due to inflammation and an unclear anatomy. Hartmann's pouch with the infundibulum can sometimes unexpectedly be present beneath the common hepatic duct. In order to avoid bile duct injury, notably in an acute setting, a surgical technique was developed, the Critical View of Safety. It is a method whose sole aim is to secure identification of the cystic structures.

CONCLUSION

Understanding the anatomy allowed for an ultimately safe laparoscopic cholecystectomy. It is strongly advised that, in the event of atypical anatomy, a second opinion is asked of another and/or more experimented surgeon.

The utility of intraperitoneal drain placement after laparoscopic appendectomy for perforated appendicitis in postoperative intraperitoneal abscess prevention

BACKGROUND

Perforated appendicitis is associated with postoperative development of intraperitoneal abscess. Intraperitoneal drain placement during appendectomy is thought to reduce the risk of developing postoperative intraperitoneal abscess. The aim of this study was to determine whether intraperitoneal drainage could reduce the incidence of intraperitoneal abscess formation after laparoscopic appendectomy for perforated appendicitis.

METHODS

This is a retrospective study of all patients (aged 7 and above) who were diagnosed with perforated appendicitis and subsequently underwent laparoscopic appendectomy between January 2018 and December 2022 at two government hospitals in the state of Kuwait. Demographic, clinical, and perioperative characteristics were compared between patients who underwent intraoperative intraperitoneal drain placement and those who did not. The primary outcome was the development of postoperative intraperitoneal abscess. Secondary outcomes included overall postoperative complications, superficial surgical site infection (SSI), length of stay (LOS), readmission and postoperative percutaneous drainage.

RESULTS

A total of 511 patients met the inclusion criteria between 2018 and 2022. Of these, 307 (60.1%) underwent intraoperative intraperitoneal drain placement. Patients with and without drains were similar regarding age, sex, and Charlson Comorbidity Index (CCI) (Table 1). The overall rate of postoperative intraperitoneal abscess was 6.1%. Postoperatively, there was no difference in postoperative intraperitoneal abscess formation between patients who underwent intraperitoneal drain placement and those who did not (6.5% vs. 5.4%, p = 0.707). Patients with intraperitoneal drains had a longer LOS (4 [4, 6] vs. 3 [2, 5] days, p < 0.001). There was no difference in the overall complication (18.6% vs. 12.3%, p = 0.065), superficial SSI (2.9% vs. 2.5%, p = 0.791) or readmission rate (4.9% vs. 4.4%, p = 0.835).

CONCLUSIONS

Following laparoscopic appendectomy for perforated appendicitis, intraperitoneal drain placement appears to confer no additional benefit and may prolong hospital stay.

Impact of hepatic artery variation on surgical and oncological outcomes in robotic pancreaticoduodenectomy

BACKGROUND

In patients with hepatic artery variation (HAV), feasibility and justification of robotic pancreatoduodenectomy (RPD) for periampullary lesions have been not been well established.

METHODS

A total of 600 patients with periampullary lesions receiving RPD or open pancreaticoduodenectomy (OPD) were identified from our prospectively collected computer database. Surgical outcomes, oncological radicality, and survival outcomes after RPD in HAV ( +) and (-) patients were compared.

RESULTS

The incidence of HAV was 16%, including 12.7% in patients with RPD and 23.0% in those with OPD. In the HAV ( +) group, vascular injury rate had no statistical difference between the RPD (3.7%) and OPD (9.1%) patients, P = 0.404. Among the RPD patients, those with HAV ( +) had longer operation time (8.5 ± 2.5 vs. 7.7 ± 2.0 h, P = 0.013) and higher vascular injury (3.8% vs. 0.6%, P = 0.024) when compared with the HAV (-) patients. There was no significant difference between the HAV ( +) and (-) patients with RPD regarding blood loss, open conversion, vascular resection, and surgical mortality and morbidity. There was no survival difference between the HAV ( +) and (-) patients with pancreatic head adenocarcinoma after RPD. There was no survival difference between RPD and OPD in the HAV ( +) group.

CONCLUSIONS

When compared with OPD, RPD is feasible and justifiable without increasing vascular injury rate for patients with HAV ( +). Hepatic artery variation has no negative impact on surgical, oncological, and survival outcomes following an RPD, if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Acute Small-bowel Obstruction: An Appraisal of Common Etiology and Management at the Federal Medical Centre, Keffi, North-central Nigeria

BACKGROUND

Acute small intestinal obstruction is a common surgical emergency in the sub-Saharan region. Over the decades, complicated inguinal hernias have been identified as a leading cause. However, we observed from our clinical practice that complicated inguinal hernias were not the most common etiology.

AIMS AND OBJECTIVES

This study aimed to evaluate the common etiology of acute small bowel obstruction in the study center and compare our findings with that from other centers and existing literature.

MATERIALS AND METHODS

This was a retrospective, cross sectional study carried out over a period of five years (January 2017 to December 2021). This study looked at the patients presenting with acute, mechanical, small bowel obstruction that did not respond to conservative treatment in our hospital facility. Relevant information were extracted from patients' clinical details and entered into the proforma prepared for this study.

RESULTS

A total of 147 patients were recruited into this study out of which 85(57.8%) were males and 62 (42.2%) were females (M:F=1.44:1). Majority (80.3%) of the patients that presented with post-operative bowel adhesion had previous appendectomy. Simple bowel obstruction was seen in 93 (63.3%) patients while strangulated obstruction and gangrenous bowel were seen in 26 (17.7%) patients and 22 (15.0%) patients respectively. Majority (47.6%) of the patients had adhesiolysis done while others had bowel resection.

CONCLUSION

The common cause of acute small bowel obstruction as observed in this study is post-operative adhesions arising from previous appendectomy and laparotomies.

Patients With Moderate to Severe Liver Cirrhosis Have Significantly Higher Short-Term Complication Rates Following Total Knee Arthroplasty: A Retrospective Cohort Study

BACKGROUND

Liver cirrhosis is associated with increased perioperative morbidity. Our study used the Model for End-Stage Liver Disease (MELD) score to assess the impact of cirrhosis severity on postoperative outcomes following total knee arthroplasty (TKA).

METHODS

A retrospective review identified 59 patients with liver cirrhosis who underwent primary TKA at a large, urban, academic center from January 2013 to August 2022. Cirrhosis was categorized as mild (MELD < 10; n = 47) or moderate-severe (MELD ≥ 10; n = 12). Modified Clavien-Dindo classification was used to grade complications, where grade 2+ denoted significant intervention. Hospital length of stay, nonhome discharge, and mortality were collected. A 1:1 propensity matching was used to control for demographics and selected comorbidities.

RESULTS

Moderate-severe cirrhosis was associated with significantly higher rates of intrahospital overall (58.33 versus 16.67%, P = .036) complications, 30-day overall complications (75 versus 33.33%, P = .042), and 90-day overall complications (75 versus 33.33%, P = .042) when compared to matched mild cirrhosis patients. Compared to matched noncirrhotic controls, mild cirrhosis patients had no significant increase in complication rate or other outcomes (P > .05).

CONCLUSIONS

Patients with moderate-severe liver cirrhosis are at risk of short-term complications following primary TKA. Patients with mild cirrhosis have comparable outcomes to matched noncirrhotic patients. Surgeons can use MELD score prior to scheduling TKA to determine which patients require optimization or higher levels of perioperative care.

Neoadjuvant immunotherapy in microsatellite instability-high (MSI-H) duodenal adenocarcinoma leads to pathological complete response and paves the way for new strategies

Duodenal adenocarcinoma is a rare digestive cancer, often diagnosed at a late stage and harbours a poor prognosis. The arrival of immunotherapy has changed the prognosis of many neoplasia, including digestive adenocarcinomas with MSI-H status. Hereby, we describe three cases of MSI-H locally advanced duodenal adenocarcinoma who received neoadjuvant treatment with a PD1 inhibitor, pembrolizumab. A partial metabolic and endoscopic response was observed in all patients after 2 cycles. Duodenopancreatectomy was performed at the end of treatment (4-6 cycles), and anatomopathological analysis demonstrated pathological complete response in all patients. Our case series paves the way for prospectively exploring neoadjuvant immunotherapy in duodenal MSI-H adenocarcinoma and raises the question of organ sparing surgery in case of complete clinical response as observed in gastric and colo-rectal adenocarcinomas.

Evaluating frailty using the modified frailty index for colonic diverticular disease surgery: analysis of the national inpatient sample 2015-2019

BACKGROUND

Frailty has been associated with increased postoperative mortality and morbidity; however, the use of the modified frailty index (mFI-11) to assess patients undergoing surgery for diverticular disease has not been widely assessed. This paper aims to examine frailty, evaluated by mFI-11, to assess postoperative morbidity and mortality among patients undergoing operative intervention for colonic diverticular disease.

METHODS

We used data from the Healthcare Cost and Utilization Project National Inpatient Sample (October 1, 2015-December 31, 2019). ICD-10-CM codes were utilized to identify a cohort of adult patients with a primary admission diagnosis of diverticulitis. mFI-11 items were adapted to correspond with ICD-10-CM codes. Patients were stratified into robust (mFI < 0.27) and frail (mFI ≥ 0.27) groups. Primary outcomes were in-hospital postoperative morbidity and mortality. Secondary outcomes included system-specific postoperative complications, length of stay (LOS), total admission cost, and discharge disposition. Multivariable regression models were fit.

RESULTS

Of the 26,826 patients, there were 24,194 patients with mFI-11 < 0.27 (i.e., robust) and 2,632 patients with mFI-11 ≥ 0.27 (i.e., frail). Adjusted analysis showed significant increases in postoperative mortality (aOR 2.16, 95% CI 1.38-3.38, p = 0.001) and overall postoperative morbidity (aOR 1.84, 95% CI 1.65-2.06, p < 0.001). LOS was higher in the frail group (MD 1.78 days, 95% CI 1.46-2.11, p < 0.001) as well as total cost (MD $25,495.19, 95% CI $19,851.63-$31,138.75, p < 0.001).

CONCLUSION

In the elective setting, a high mFI-11 (i.e., presence of the variables comprising the index) could alert clinicians to the possibility of implementing preoperative optimization strategies. In the emergent setting, a high mFI-11 may help guide prognostication for these vulnerable patients.

Long- vs short-segment Barrett's esophagus-derived adenocarcinoma: clinical features and outcomes of endoscopic submucosal dissection

BACKGROUND

The incidence of Barrett's esophageal adenocarcinoma (BEA) is increasing, and endoscopic submucosal dissection (ESD) has been frequently performed for its treatment. However, the differences between the characteristics and ESD outcomes between short- and long-segment BEA (SSBEA and LSBEA, respectively) are unclear. We compared the clinicopathological characteristics and short- and long-term outcomes of ESD between both groups.

METHODS

We retrospectively reviewed 155 superficial BEAs (106 SSBEAs and 49 LSBEAs) treated with ESD in 139 patients and examined their clinicopathological features and ESD outcomes. SSBEA and LSBEA were classified based on whether the maximum length of the background mucosa of BEA was < 3 cm or ≥ 3 cm, respectively.

RESULTS

Compared with SSBEA, LSBEA showed significantly higher proportions of cases with the macroscopically flat type (36.7% vs. 5.7%, p < 0.001), left wall location (38.8% vs. 11.3%, p < 0.001), over half of the tumor circumference (20.4% vs. 1.9%, p < 0.001), and synchronous lesions (17.6% vs. 0%, p < 0.001). Compared with SSBEA, regarding ESD outcomes, LSBEA showed significantly longer resection duration (91.0 min vs. 60.5 min, p < 0.001); a lower proportion of submucosal invasion (14.3% vs. 29.2%, p = 0.047), horizontal margin negativity (79.6% vs. 94.3%, p = 0.0089), and R0 resection (69.4% vs. 86.8%, p = 0.024); and a higher proportion of post-procedural stenosis cases (10.9% vs. 1.9%, p = 0.027). The 5-year cumulative incidence of metachronous cancer in patients without additional treatment was significantly higher for LSBEA than for SSBEA (25.0% vs. 0%, p < 0.001).

CONCLUSIONS

The clinicopathological features of LSBEA and SSBEA and their treatment outcomes differed in many aspects. As LSBEAs are difficult to diagnose and treat and show a high risk of metachronous cancer development, careful ESD and follow-up or eradication of the remaining BE may be required.

Long-term cardiovascular risk reduction after gastric cancer surgery: a nationwide cohort study

BACKGROUND

Gastrectomy for gastric cancer is associated with postoperative changes in cardiovascular risk factors, however, the impact of gastrectomy on cardiovascular events remains unclear. The authors assessed the incidence of cardiovascular events between patients undergoing gastrectomy or endoscopic resection for gastric cancer, and the general population.

MATERIALS AND METHODS

This retrospective nationwide cohort study included patients with gastric cancer undergoing gastrectomy ( n =37 698), endoscopic resection ( n =2773), and matched control population ( n =161 887) between 2004 and 2013. The authors included patients without a history of cancer other than gastric cancer, myocardial infarction, or ischemic stroke. The primary outcome was the incidence of major adverse cardiovascular events (MACE) such as acute myocardial infarction, revascularization, or acute ischemic stroke, in patients with gastric cancer.

RESULTS

Among patients who underwent gastrectomy for gastric cancer, 2.9% (4.69 per 1000 person-years) developed novel MACE within the 1-year follow-up period. The gastrectomy group demonstrated a significantly decreased risk for MACE than the control population [hazard ratio (HR), 0.65; 95% CI: 0.61-0.69; P <0.001). Among the patients undergoing endoscopic resection for gastric cancer, 5.4% (8.21 per 1000 person-years) developed novel MACE within the 7-year follow-up period. The risk for MACE in the endoscopic resection group was not significantly different from the control population.

CONCLUSION

Patients with gastric cancer who have undergone gastrectomy exhibit a reduced risk of cardiovascular diseases in comparison to the general population. In contrast, the risk for cardiovascular diseases in patients with gastric cancer who underwent endoscopic resection did not demonstrate a significant difference in cardiovascular risk in comparison to the general population.

Point/Counterpoint #1: Chemotherapy Alone Is a Sufficient Preoperative Treatment for Rectal cancer

ABSTRACT

For decades, the standard neoadjuvant therapy regimen for locally advanced rectal cancer consisted of chemoradiation, surgical resection, and consideration of adjuvant systemic therapy. Additional data have emerged suggesting neoadjuvant systemic therapy as a reasonable alternative to chemoradiation in selected patients. In addition, a total neoadjuvant therapy approach integrating both chemotherapy and chemoradiation results in superior cancer outcomes and the potential for consideration of nonoperative management in patients with a clinical complete response. Despite a multitude of therapeutic pathways for the management of rectal cancer, what is clear, however, is the importance of a multidisciplinary approach with shared patient and provider decision-making.

Long-term survival outcomes of robotic total gastrectomy for locally advanced proximal gastric cancer: a prospective study

BACKGROUND

Robotic gastrectomy is a safe and feasible approach for gastric cancer (GC); however, its long-term oncological efficacy remains unclear. The authors evaluated the long-term survival outcomes and recurrence patterns of patients with locally advanced proximal GC who underwent robotic total gastrectomy (RTG).

METHODS

This prospective study (FUGES-014 study) enrolled 48 patients with locally advanced proximal GC who underwent RTG between March 2018 and February 2020 at a tertiary referral teaching hospital. Patients who underwent laparoscopic total gastrectomy (LTG) in the FUGES-002 study were enrolled in a 2:1 ratio to compare the survival outcomes between RTG and LTG. The primary endpoint of the FUGES-014 study was postoperative 30-day morbidity and has been previously reported. Here, the authors reported the results of 3-year disease-free survival (DFS), 3-year overall survival (OS), and recurrence patterns.

RESULTS

After propensity score matching, 48 patients in the RTG and 96 patients in the LTG groups were included. The 3-year DFS rates were 77.1% (95% CI: 66.1-89.9%) for the RTG and 68.8% (95% CI: 60.1-78.7%) for the LTG groups ( P =0.261). The 3-year OS rates were not significantly different between the groups (85.4 vs. 74.0%, P =0.122). Recurrence occurred in nine patients (18.8%) in the RTG and 27 (28.1%) patients in the LTG groups ( P =0.234). Recurrence patterns and causes of death were similar between the groups ( P >0.05).

CONCLUSIONS

The oncological outcome of RTG was noninferior to that of LTG. Thus, RTG might be an alternative surgical treatment for locally advanced proximal GC.

Visualization of Risk Factors and Predictive Models for Early Death of Neonatal Gastric Perforation

A retrospective analysis was performed from May 2003 to October 2021 at our hospital. One hundred and eleven neonates diagnosed with gastric perforation were categorized into non-survivor and survivor groups based on prognosis. The mortality rate was 23.42%. Logistic regression was used to analyze the factors influencing the early neonatal death. The non-survivor groups showed more abdominal distension, vomiting, hypoxia, acidosis, hyperkalemia, and coagulation abnormalities. Serum potassium concentration (odds ratio [OR] 2.148, P = .043) was an independent risk factor; however, arterial partial pressure of oxygen (OR 0.977, P = .024), bicarbonate (OR 0.779, P = .023), and platelet count (OR 0.986, P = .014) had protective effects on neonatal death. Based on this, a visualized nomogram prediction model was constructed, patients who had a nomogram score of more than 163.787 was considered to have high risks of mortality, the area under the curve of this was up to 0.828 (95% confidence interval [0.733, 0.923]), the sensitivity was 80.0%, and the specificity was 76.9%.

Pancreatoscopy-Guided Endotherapies for Pancreatic Diseases

Per-oral pancreatoscopy (POP) is a pancreas-preserving modality that allows for targeted pancreatic duct interventions, particularly in cases where standard techniques fail. POP specifically has an emerging role in the diagnosis, risk stratification, and disease extent determination of main duct intraductal papillary mucinous neoplasms (IPMNs). It has also been successfully used for laser ablation of IPMNs in poor surgical candidates, lithotripsy for complex stone disease, and laser stricturoplasty. As experience with POP increases beyond select referral center practices, further studies validating POP efficacy with long-term follow-up will help clarify when POP-guided intervention is most beneficial in relation to surgical intervention.

Xanthogranulomatous appendicitis presenting asymptomatically 3 years after surgery for hilar cholangiocarcinoma: A case report

INTRODUCTION

Xanthogranulomatous appendicitis (XGA) is a rare condition involving chronic inflammation of the appendix that is often difficult to distinguish from malignancy using imaging because of the formation of a heterogeneous mass with indistinct borders. Herein, we present a case of XGA with unusual clinical manifestations.

PRESENTATION OF CASE

A 78-year-old female patient underwent radical resection of hilar cholangiocarcinoma with extended right hepatic lobectomy and biliary reconstruction. Three years postoperatively, she presented with an irregular mass in the right lateral pelvis, which was observed on computed tomography. The patient had not experienced recent clinical symptoms and did not present with abdominal tenderness. Routine blood tests did not indicate an increased inflammatory response; however, carcinoembryonic antigen levels continued to increase. Although disseminated recurrence of hilar cholangiocarcinoma and appendiceal carcinoma were suspected, XGA was diagnosed via laparoscopic appendectomy.

DISCUSSION

XGA generally presents with symptoms of acute or chronic appendicitis, and is diagnosed incidentally during surgery. Hilar cholangiocarcinoma has a high recurrence rate, even after radical resection, and disseminated recurrence usually requires chemotherapy. In the present case, XGA was not suspected preoperatively because of the lack of physical symptoms and increased levels of tumor markers during follow-up for hilar cholangiocarcinoma. There have been no reports of XGA with such a confusing clinical course, thus confirming the difficulty in preoperatively diagnosing XGA.

CONCLUSION

The preoperative diagnosis of XGA is difficult to differentiate from malignancy because of its clinical and imaging findings. We diagnosed the patient with XGA using laparoscopic surgery.

The Potential Mechanism of Remission in Type 2 Diabetes Mellitus After Vertical Sleeve Gastrectomy

In recent years, there has been a gradual increase in the prevalence of obesity and type 2 diabetes mellitus (T2DM), with bariatric surgery remaining the most effective treatment strategy for these conditions. Vertical sleeve gastrectomy (VSG) has emerged as the most popular surgical procedure for bariatric/metabolic surgeries, effectively promoting weight loss and improving or curing T2DM. The alterations in the gastrointestinal tract following VSG may improve insulin secretion and resistance by increasing incretin secretion (especially GLP-1), modifying the gut microbiota composition, and through mechanisms dependent on weight loss. This review focuses on the potential mechanisms through which the enhanced action of incretin and metabolic changes in the digestive system after VSG may contribute to the remission of T2DM.

Laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis in a patient with situs inversus totalis: A case report

Situs inversus complicates diagnosis and treatment due to the mirrored organ placement in relation to normal anatomy. This report describes a 78-year-old female patient with situs inversus totalis who underwent laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis. Utilizing the "French mirror technique" for port placement, the surgeon adeptly mirrored standard maneuvers with a 2-mm needle forceps in the left hand and a 5-mm forceps in the right in a reversed anatomical setting. This technique maintained familiar hand movements, despite the patient's unique anatomy. The surgeon applied transcystic ductal bile duct exploration, using choledochoscopy for duct exploration and a basket catheter for stone removal. Laparoscopic cholecystectomy and common bile duct exploration through the transcystic ductal route are viable and effective for patients with situs inversus.

Peri-operative, oncological and functional outcomes of robotic versus transanal total mesorectal excision in patients with rectal cancer: A systematic review and meta-analysis

BACKGROUND

Comparative outcomes of robotic low anterior resection (rTME) and trans-anal total mesorectal excision (TaTME) in patients with low rectal cancer were evaluated.

METHODS

A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies of rTME versus TaTME for low rectal cancer were included. Primary outcomes were postoperative complications, including anastomotic leak, surgical site infection, and Clavien-Dindo complication rate. Total operative time, conversion to open surgery, intra-operative blood loss, intensive therapy unit (ITU) and total hospital length of stay (LOS), oncological outcomes and functional outcomes were the other evaluated outcome parameters.

RESULTS

A total of 12 studies with a total number of 3025 patients divided between rTME (n = 1881) and TaTME (n = 1144) groups were included. There was no significant difference between the two groups for total operative time (P = 0.39), conversion to open surgery (P = 0.29) and intra-operative blood loss (P = 0.62). Clavien-Dindo ≥ 3 complication rate (P = 0.47), anastomotic leak (P = 0.89), rates of re-operation (P = 0.62) and re-admission (P = 0.92), R0 resections (P = 0.52), ITU LOS (P = 0.63) and total hospital LOS (P = 0.30) also showed similar results between the two groups. However, the rTME group had higher rates of total harvested lymph nodes (P = 0.04) and complete total mesorectal excision (TME) resections (P = 0.05). Albeit with a limited dataset, the Wexner and low anterior resection syndrome (LARS) scores showed better functional results in the rTME group compared with the TaTME group (P = 0.0009 and P = 0.00001, respectively).

CONCLUSION

Compared with TaTME, rTME seems to provide better functional outcomes, higher lymph node yield and more complete TME resections with a similar post-operative complications profile.

Association of Clinicopathological Factors With MMP13 (rs2252070) Gene Polymorphism in Swedish Patients With Colorectal Cancer

BACKGROUND/AIM

Matrix metalloproteinase 13 (MMP13) has been reported to be involved in tumor development and progression, including of colorectal cancer (CRC). This study aimed at evaluating whether the MMP13 rs2252070 gene polymorphism is associated with clinicopathological factors and its influence on long-term survival in Swedish patients with CRC.

PATIENTS AND METHODS

A total of 723 patients with CRC were genotyped using TaqMan single nucleotide polymorphism assays based on polymerase chain reaction.

RESULTS

Assessing clinicopathological factors, we demonstrated that having the G/G genotype for MMP13 rs2252070 was significantly associated with poor differentiation, higher serum level of carcinoembryonic antigen and higher lymph node status. Moreover, the presence of a G allele was significantly related to larger tumor size in rectal cancer but had a significantly protective role against mucinous cancer, perineural invasion and lymphovascular invasion. Kaplan-Meier analysis showed no difference between genotypes regarding cancer-specific survival.

CONCLUSION

Our findings highlight the potential of MMP13 rs2252070 polymorphism as a useful predictor of poor differentiation, serum level of carcinoembryonic antigen, lymph node status, tumor size, mucinous cancer, perineural invasion and lymphovascular invasion in patients with CRC.

Large retrorectal spindle cell sarcoma: A case report and brief review of the literature

Large retrorectal tumors are rare and often a diagnostic and surgical challenge due to their anatomical location. We report the case of a 55-year-old patient with weight loss and changed bowel habits, where digital rectal examination revealed a retrorectal mass raising suspicion of a tumor. Magnetic resonance imaging (MRI) and computed tomography (CT) showed a large retrorectal tumor and histopathology after surgical resection showed undifferentiated spindle cell sarcoma. This tumor type has not been previously reported as the etiology of large retrorectal tumors. We discuss the implications of diagnostic imaging, especially MRI, in the approach to diagnosis and surgical treatment of retrorectal tumors with reference to the scientific literature and previously reported cases of retrorectal tumors.