Clinicopathological differences between classical schwannomas and cellular schwannomas in the retroperitoneum

This study aimed to compare clinical and pathological features of retroperitoneal classical schwannomas and cellular schwannomas. A total of 64 cases of retroperitoneal classical schwannoma and 48 cases of cellular schwannoma were studied. Histopathological analysis was performed using hematoxylin and eosin staining and immunohistochemistry. Retroperitoneal cellular schwannomas exhibited 100% (48/48) and 75% (36/48) positive expression for glial fibrillary acidic protein (GFAP) and cytokeratins (CK), respectively. Classical schwannomas showed rates of 6.25% (4/64) and 15.63% (10/64), respectively (P < .05). In classic schwannomas, 85.9% (55/64) showed a reticular pattern of positive anti-CD34 staining around tumor margins and subcapsular areas vs 52.1% (25/48) in cellular schwannomas (P < .05). Cellular schwannomas exhibited more mitotic figures than classical schwannoma (P < .05). The recurrence rate of cellular schwannomas was 10.42% (5/48), while that of classical schwannomas was 1.56% (1/64) (P < .05). Retroperitoneal cellular schwannomas commonly express GFAP and CK compared to classical schwannomas, suggesting that cellular schwannoma may originate from unmyelinated Schwann cells, while classical schwannoma may originate from myelinated Schwann cells. Anti-CD34 staining patterns may be used to distinguish between the 2 types. Retroperitoneal cellular schwannomas also show higher mitotic activity and are more prone to recurrence.

Positive impact of laparoscopic hepatectomy versus open hepatectomy on body size-corrected bleeding in obese patients

PURPOSE

Laparoscopic hepatectomy (LH) is reported to cause less bleeding than open hepatectomy (OH) in obese patients; however, there are no reports addressing this issue in terms of body size-corrected bleeding.

METHODS

The subjects of this study were 31 obese and 149 non-obese patients who underwent LH and 32 obese and 245 non-obese patients who underwent OH. Bleeding corrected for body surface area (C-BL) was compared between the obese and non-obese patients who underwent each procedure. A multivariate analysis for increased C-BL was performed using the median C-BL for each procedure.

RESULTS

The median C-BL tended to be higher in the obese patients than in the non-obese patients who underwent LH, but there was no significant difference (72 vs. 42 mL/m2, P = 0.050). However, it was significantly higher in the obese patients than in the non-obese patients who underwent OH (542 vs. 333 mL/m2, P = 0.002). In a multivariate analysis, for OH, sectionectomy or more (OR 3.20, P < 0.001) and a high BMI (OR 2.76, P = 0.018) were found to be independent risk factors, whereas for LH, a high BMI was not (OR 1.58, P = 0.301).

CONCLUSIONS

Obesity was identified as a risk factor for increased bleeding with body size correction for OH, but the risk was reduced for LH.

Primary, revisional, and endoscopic bariatric surgery: a narrative review of abdominal emergency management for general surgeons

Minimally invasive approaches like endoscopic, laparoscopic, and robotic surgery have revolutionized bariatric and metabolic surgery (MBS). Despite the safety of MBS in specialized centers, acute complications requiring emergency treatment may occur and present challenges for general surgeons, especially in community hospitals. This is further complicated by the rising popularity of bariatric surgery tourism and the increasing diversity of bariatric surgical techniques. This paper provides an updated review of the management of acute abdominal complications after minimally invasive MBS, intending to guide general surgeons in managing these patients, especially in emergency settings where specialized bariatric care may not be readily available.

Paclitaxel in colon cancer management: from conventional chemotherapy to advanced nanocarrier delivery systems

Paclitaxel, a potent chemotherapeutic agent derived from the bark of the Pacific yew tree, has demonstrated significant efficacy in the treatment of various cancers, including colon cancer. This comprehensive review delves into the conventional treatments for colon cancer, emphasizing the crucial role of paclitaxel in contemporary management strategies. It explores the intricate process of sourcing and synthesizing paclitaxel, highlighting the importance of its structural properties in its anticancer activity. The review further elucidates the mechanism of action of paclitaxel, its pharmacological effects, and its integration into chemotherapy regimens for colon cancer. Additionally, novel drug delivery systems, such as nanocarriers, liposomes, nanoparticles, microspheres, micelles, microemulsions, and niosomes, are examined for their potential to enhance the therapeutic efficacy of paclitaxel. The discussion extends to recent clinical trials and patents, showcasing advancements in paclitaxel formulations aimed at improving treatment outcomes. The review concludes with prospects in the field underscoring the ongoing innovation and potential breakthroughs in colon cancer therapy.

Do Abdominoplasties in Patients with Prior Sleeve Gastrectomy Impact De Novo Gastroesophageal Reflux Disorder and the Need for Conversion to Roux-en-Y Gastric Bypass?

Introduction: The sleeve gastrectomy (SG) often requires conversion to Roux-en-Y gastric bypass (RYGB) due to gastroesophageal reflux disorder (GERD). Many postbariatric patients seek body-contouring surgery such as abdominoplasty to remove unwanted skin and fat. Although the number of abdominoplasties performed in postbariatric patients is increasing each year, the number of conversion surgeries is increasing in accordance. This study evaluates the impact of abdominoplasties in patients with prior SG on the development of GERD and the need for conversion to RYGB. Methods: A retrospective study was conducted with 630 patients who underwent conversions from SG to RYGB at our institution between January 2014 and December 2023. Outcomes were stratified for comparison between patients with GERD as an indication for conversion and patients with inadequate weight loss as an indication for conversion. Between the two groups we compared the number of patients with post-SG abdominoplasty and the number of hiatal hernias (HH) seen during conversion surgery. A logistic regression analysis was performed to identify factors independently associated with GERD. Results: There was a statistically significant higher number of abdominoplasties in patients who underwent conversion to RYGB for GERD (29 patients, 8.6%) compared to inadequate weight loss (12 patients, 4.1%), P value .034. However, these patients also had statistically significantly more HH (98 patients, 28.9%) compared to patients with inadequate weight loss as an indication for conversion (46 patients, 15.8%), P value <.001. In the logistic regression comparing these two variables, only the presence of HH seen during surgery was found to be a significant predictor of GERD (odds ratio 2.7, confidence interval 1.7-4.1, P < .001). Conclusion: Our data shows that abdominoplasty surgery does not directly influence the development of GERD in post-SG patients. However, the presence of HH in this population significantly impacts the development of GERD, often necessitating conversion to RYGB.

Application of imaging technology for the diagnosis of malignancy in the pancreaticobiliary duodenal junction (Review)

The pancreaticobiliary duodenal junction (PBDJ) is the connecting area of the pancreatic duct, bile duct and duodenum. In a broad sense, it refers to a region formed by the head of the pancreas, the pancreatic segment of the common bile duct and the intraduodenal segment, the descending and the horizontal part of the duodenum, and the soft tissue around the pancreatic head. In a narrow sense, it refers to the anatomical Vater ampulla. Due to its complex and variable anatomical features, and the diversity of pathological changes, it is challenging to make an early diagnosis of malignancy at the PBDJ and define the histological type. The unique anatomical structure of this area may be the basis for the occurrence of malignant tumors. Therefore, understanding and subclassifying the anatomical configuration of the PBDJ is of great significance for the prevention and treatment of malignant tumors at their source. The present review comprehensively discusses commonly used imaging techniques and other new technologies for diagnosing malignancy at the PBDJ, offering evidence for physicians and patients to select appropriate examination methods.

Artificial Intelligence, the ChatGPT Large Language Model: Assessing the Accuracy of Responses to the Gynaecological Endoscopic Surgical Education and Assessment (GESEA) Level 1-2 knowledge tests

Background

In 2022, OpenAI launched ChatGPT 3.5, which is now widely used in medical education, training, and research. Despite its valuable use for the generation of information, concerns persist about its authenticity and accuracy. Its undisclosed information source and outdated dataset pose risks of misinformation. Although it is widely used, AI-generated text inaccuracies raise doubts about its reliability. The ethical use of such technologies is crucial to uphold scientific accuracy in research.

Objective

This study aimed to assess the accuracy of ChatGPT in doing GESEA tests 1 and 2.

Materials and Methods

The 100 multiple-choice theoretical questions from GESEA certifications 1 and 2 were presented to ChatGPT, requesting the selection of the correct answer along with an explanation. Expert gynaecologists evaluated and graded the explanations for accuracy.

Main outcome measures

ChatGPT showed a 59% accuracy in responses, with 64% providing comprehensive explanations. It performed better in GESEA Level 1 (64% accuracy) than in GESEA Level 2 (54% accuracy) questions.

Conclusions

ChatGPT is a versatile tool in medicine and research, offering knowledge, information, and promoting evidence-based practice. Despite its widespread use, its accuracy has not been validated yet. This study found a 59% correct response rate, highlighting the need for accuracy validation and ethical use considerations. Future research should investigate ChatGPT's truthfulness in subspecialty fields such as gynaecologic oncology and compare different versions of chatbot for continuous improvement.

What is new?

Artificial intelligence (AI) has a great potential in scientific research. However, the validity of outputs remains unverified. This study aims to evaluate the accuracy of responses generated by ChatGPT to enhance the critical use of this tool.

Survival after vascular resections in patients with borderline resectable or locally advanced pancreatic head cancer: A systematic review

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive tumors, and the most common cause of cancer-related deaths. In the past, vascular infiltration of the tumor rendered the disease unresectable. However, today, venous or arterial involvement of a PDAC is classified as borderline resectable (BR) or locally advanced (LA) disease. Pancreaticoduodenectomy (PD) with vascular resections is a promising intervention intended for complete resection of BR- and LA-PDAC. This study aims to assess the overall survival of patients undergoing PD with vascular resections, compared to those without. A PubMed search was conducted for cohort studies that included patients with BR- or LA-PDAC treated with vascular resections. The retrieved publications were screened following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. The study protocol was registered at the International Prospective Register for Systematic Reviews (PROSPERO). Sixteen cohort studies were included in our systematic review. Fourteen of them included patients undergoing PD with venous-only resections for PDAC. The 5-year overall survival rates ranged from 8.0% to 22.2% for vascular resection patients, and 4.0% to 24.3% for standard PD patients. Three cohorts included patients with PDAC and arterial and/or venous involvement who were treated with arterial resections. Their median overall survival ranged from 13.7 to 17.0 months, similar to that of patients who did not undergo vascular resections. PD with vascular resections in patients with BR- and LA-PDAC could lead to similar overall survival to that after standard PD.

Robotic or laparoscopic SLEEVE-DOR (sleeve gastrectomy with anterior Dor 180° fundoplication) for obesity: preliminary results of a series of 80 patients

Aims: Sleeve gastrectomy (SG) is currently the most performed bariatric surgery worldwide. For patients with obesity and symptomatic gastroesophageal reflux disease (GERD), the indication of SG is a matter of concern due to the possibility of worsening or de novo reflux in the postoperative follow-up. A new method, the combination of a 180-degree anterior fundoplication (SLEEVE-DOR) using only one barbed nonabsorbable suture, is proposed to allow the use of SG for this set of patients aiming to minimize the occurrence of de novo GERD. The study aims to evaluate the safety, feasibility and efficacy of SG with SLEEVE-DOR for the therapy of patients with obesity.

Methods: The study describes the largest series of SG combined with anterior hemifundoplication. Since June 2018, all patients with indications for bariatric surgery and having proton pump inhibitor (PPI) therapy for symptomatic reflux at least 6 months before surgery were prospectively documented. All operations were performed laparoscopically (45) or with a robotic DaVinci platform (35). Clinical data were collected from our bariatric center database. The primary outcomes included technical success, perioperative complications and mortality, and the resolution of symptomatic gastroesophageal reflux after the SLEEVE-DOR procedure.

Results: The procedure was successfully performed for all patients (n = 80). Mean operative time was 60.1 min. All patients started oral fluids one hour after the surgery and were discharged between 1st and 3rd postoperative day. Postoperative complications occurred in three patients, with one leak, one peritonitis due to colonic thermic lesion from adherences, and one postoperative death due to massive pulmonary embolism. Four patients claimed intractable reflux between 3 and 6 months and were later converted to a Roux-en-Y gastric bypass (RYGB). The remaining patients experienced complete resolution of reflux symptoms in the 6-month follow-up. The percentage of excess weight loss (%EWL) was 58.5% on postoperative 12 months.

Conclusions: SLEEVE-DOR with one nonabsorbable barbed suture is a safe, effective, and technically simple alternative procedure to allow the performance of SG for morbidly obese patients with preoperative mild symptomatic gastroesophageal reflux, especially for patients with severe obesity as the first step operation.

The Aging Stomach: Clinical Implications of H. pylori Infection in Older Adults-Challenges and Strategies for Improved Management

Aging is a multifactorial biological process characterized by a decline in physiological function and increasing susceptibility to various diseases, including malignancies and gastrointestinal disorders. Helicobacter pylori (H. pylori) infection is highly prevalent among older adults, particularly those in institutionalized settings, contributing to conditions such as atrophic gastritis, peptic ulcer disease, and gastric carcinoma. This review examines the intricate interplay between aging, gastrointestinal changes, and H. pylori pathogenesis. The age-associated decline in immune function, known as immunosenescence, exacerbates the challenges of managing H. pylori infection. Comorbidities and polypharmacy further increase the risk of adverse outcomes in older adults. Current clinical guidelines inadequately address the specific needs of the geriatric population, who are disproportionately affected by antibiotic resistance, heightened side effects, and diagnostic complexities. This review focuses on recent advancements in understanding H. pylori infection among older adults, including epidemiology, diagnostics, therapeutic strategies, and age-related gastric changes. Diagnostic approaches must consider the physiological changes that accompany aging, and treatment regimens need to be carefully tailored to balance efficacy and tolerability. Emerging strategies, such as novel eradication regimens and adjunctive probiotic therapies, show promise for improving treatment outcomes. However, significant knowledge gaps persist regarding the impact of aging on H. pylori pathogenesis and treatment efficacy. A multidisciplinary approach involving gastroenterologists, geriatricians, and other specialists is crucial to providing comprehensive care for this vulnerable population. Future research should focus on refining diagnostic and therapeutic protocols to bridge these gaps, ultimately enhancing clinical outcomes and reducing the burden of H. pylori-associated diseases in the aging population.

Focus on patient perspectives in climate action policies for healthcare. A German survey analysis on what patients are willing to do

Background

The healthcare sector, while dedicated to improving health, paradoxically contributes significantly to global carbon emissions, accounting for approximately 4.9% of global emissions. Despite growing public concern about climate change, few studies have explored patients' awareness and attitudes toward the environmental impact of healthcare. This study aims to assess patients' perspectives on climate change and the sustainability of healthcare practices.

Methods

A cross-sectional survey was conducted at Ludwig-Maximilians-University (LMU) Hospital in Munich, Germany. Patients were invited to participate in a voluntary, anonymous online survey via strategically placed QR codes throughout the hospital. The survey explored patients' demographic information, environmental awareness, attitudes toward climate-friendly practices in healthcare, and willingness to support sustainable initiatives. Descriptive statistics and regression analyses were used to analyze the data.

Results

A total of 399 patients completed the survey (87% completion rate). The majority of respondents (92.3%) were aware of climate change, and 82.7% reported prioritizing climate-friendly practices in their personal lives. However, 55.9% of respondents were unaware of the healthcare system's contribution to carbon emissions, and only 18.3% knew about hospitals' climate impact. Despite this, 88.2% of respondents supported environmentally friendly initiatives in hospitals, and 86.5% were open to sustainable alternatives, provided that quality standards were maintained. Participants expressed significant interest in knowing the environmental impact of their treatments, with 63.2% in favor of a Nutri-Score-like system that would display the carbon footprint of medical procedures. Among those, 54.4% indicated that such a system would influence their choice of treatment. Similarly, 62.2% of respondents were interested in knowing the environmental impact of their medications, with 65% reporting that this information would affect their medication choices. A notable proportion of patients (66.2%) indicated willingness to support sustainable healthcare through shorter hospital stays and increased follow-up visits, while 35.8% were open to paying a CO2 compensation fee for their treatments. However, 81% were unwilling to pay higher insurance premiums to support environmentally friendly practices in hospitals. Regression analyses revealed that older age groups and having children were positively associated with environmental awareness (p < 0.05). However, factors such as gender, education level, relationship status, and illness severity did not significantly impact environmental attitudes. There was a significant correlation between patients' environmental friendliness and their readiness to take climate-protective actions (p < 0.001).

Conclusion

The study highlights a gap between patients' environmental awareness and their knowledge of healthcare's carbon footprint. While patients are generally supportive of sustainable practices in healthcare, their willingness to act diminishes when personal costs or discomfort are involved. A coordinated approach involving policy changes, patient education, and market innovations is essential to promote sustainable practices in healthcare without compromising patient care quality. Further research is needed to explore strategies for bridging the gap between environmental awareness and action in healthcare settings.

Developing and validation a prognostic model for predicting prognosis among synchronous colorectal cancers patients using combined log odds ratio of positive lymph nodes: a SEER database study

PURPOSE

The aim of the study is to identify risk factors for the prognosis and survival of synchronous colorectal cancer and to create and validate a functional Nomogram for predicting cancer-specific survival in patients with synchronous colorectal cancer.

METHODS

Synchronous colorectal cancers cases were retrieved from the Surveillance, Epidemiology, and End Results database retrospectively, then they were randomly divided into training (n = 3371) and internal validation (n = 1440) sets, and a set of 100 patients from our group was used as external validation. Risk factors for synchronous colorectal cancer were determined using univariate and multivariate Cox regression analyses, and two Nomograms were established to forecast the overall survival and cancer-specific survival, respectively. We assessed the Nomogram performance in terms of discrimination and calibration. Bootstrap resampling was used as an internal verification method, and we select external data from our hospital as independent validation sets.

RESULTS

Two Nomograms are established to predict the overall survival and cancer-specific survival. In OS Nomogram, sex, age, marital status, ttumor pathological grade, AJCC TNM stage, preoperative serum CEA level, LODDS, radiotherapy and chemotherapy were determined as prognostic factors. In CSS Nomogram, age and marital status, AJCC TNM stage, tumor pathological grade, preoperative serum CEA level, LODDS, radiotherapy and chemotherapy were determined as prognostic factors.The C-indexes for the forecast of overall survival were 0.70, and the C-index was 0.68 for the training and internal validation cohort, respectively. The C-indexes for the forecast of cancer-specific survival were 0.75, and the C-index was 0.74 for the training and internal validation cohort, respectively. The Nomogram calibration curves showed no significant deviation from the reference line, indicating a good level of calibration. Both C-index and calibration curves indicated noticeable performance of newly established Nomograms.

CONCLUSIONS

Those Nomograms with risk rating system can identify high risk patients who require more aggressive therapeutic intervention and longer and more frequent follow-up scheme, demonstrated prognostic efficiency.

Recurrence rates and associated risk factors after conservative surgery for adenomyosis: a retrospective study

BACKGROUND

Conservative surgery for adenomyosis has been shown to be effective. However, risk factors for postoperative recurrence have yet to be clarified. In this study, we aimed to determine the recurrence rate after conservative surgery for adenomyosis and identify the risk factors for recurrence.

METHODS

This retrospective study was conducted in a tertiary hospital. Patients who underwent conservative surgery for adenomyosis between January 2013 and April 2023 were identified. Eligible patients were assigned to either the recurrent or non-recurrent group. Continuous and categorical variables were compared between the two groups using the Mann-Whitney U test or chi-squared test. Risk factors for recurrence were identified by Cox proportional risk analysis.

RESULTS

Data for 133 eligible patients who underwent conservative surgery for adenomyosis were analyzed. The mean follow-up duration was 52 months. The recurrence rate after conservative surgery was 39.1% (52/133). Cox proportional risk analysis identified adenomyosis involving the posterior uterine wall (hazard ratio [HR] 6.505, P = 0.018), two or more adenomyotic lesions (HR 6.310, P = 0.030), laparotomy (HR 2.490, P = 0.029), and concomitant endometriosis (HR 2.313, P = 0.036) to be risk factors for recurrence after conservative surgery. Postoperative combined progestogen therapy (HR 0.126, P < 0.001) or treatment with a gonadotropin-releasing hormone agonist (GnRHa) (HR 0.237, P = 0.004) prevented recurrence of adenomyosis.

CONCLUSION

Adenomyosis continues to have a relatively high long-term recurrence rate after conservative surgery. Patients with adenomyosis involving the posterior wall of the uterus, those with two or more adenomyotic lesions, and those with concomitant endometriosis are at high risk for recurrence after conservative surgery. Postoperative progestogen or GnRHa therapy may reduce the risk of recurrence of adenomyosis. Considering the retrospective nature of this study and its small sample size, larger prospective studies are needed to confirm its findings.

Prognostic efficacy of lymph node parameters in resected ampullary adenocarcinoma based on long-term follow-up data after adjuvant treatment

BACKGROUND

Lymph node (LN) metastasis is an important prognostic factor in the ampulla of Vater (AoV) adenocarcinoma. Various LN parameters have been proposed, but their prognostic efficacy has not been compared in the same population. We aimed to evaluate the prognostic values of LN parameters in AoV adenocarcinoma patients who underwent surgical resection and adjuvant treatment based on the long-term follow-up data.

METHODS

A total of 86 patients with surgically resected AoV adenocarcinoma followed by adjuvant treatment were analyzed. We evaluated the prognostic values of various LN parameters such as pathologic N stage, number of metastatic regional LN (LNN), LN ratio (LNR), and log odds of positive LNs (LODDS). Each LN parameter was separately analyzed using Cox regression models with the same confounders.

RESULTS

The median follow-up period was 69.4 months, and the median overall survival (OS) was 114 months. The median number of dissected LNs is 15, with an interquartile range of 8 to 25. In the univariable analyses, all LN parameters showed significant prognostic efficacy for OS, disease-free survival (DFS), and distant metastasis-free survival (DMFS). In the multivariable Cox regression analyses, LNN ≥ 2 was a statistically significant prognostic factor for OS (hazard ratio (HR) 2.10, 95% confidence interval (CI), 1.11-3.97; p = 0.022), DFS (HR 2.51, 95% CI 1.28-4.93; p = 0.007), and DMFS (HR 2.74, 95% CI 1.39-5.41; p = 0.004). LNR showed significant prognostic performance for DFS (HR 2.35, 95% CI 1.23-4.50; p = 0.010), and DMFS (HR 2.26, 95% CI 1.17-4.35; p = 0.015). N stage showed significant prognostic performance in DFS (HR 1.55 for pN1; p = 0.243 and HR 4.31 for pN2; p = 0.003), DMFS (HR 1.46 for pN1; p = 0.323 and 4.59 for pN2; p = 0.002). LODDS and the presence of LN metastasis, did not demonstrate significant prognostic value across survival outcomes.

CONCLUSIONS

LN parameters showed good long-term predictive performance in AoV adenocarcinoma patients treated with curative resection and adjuvant treatments. Among LN parameters, LNN ≥ 2 showed better prognostic value than others. Further large-scale studies are needed to validate the clinical usefulness of various LN parameters.

Patient Outcomes in Resected Combined Hepatocellular Cholangiocarcinoma (cHCC-ICC) and Intrahepatic Cholangiocarcinoma: A Single Center Study

BACKGROUND/OBJECTIVES

Combined hepatocellular cholangiocarcinoma (cHCC-ICC) is a rare malignancy that involves a combination of features of hepatocellular carcinoma and intrahepatic cholangiocarcinoma (ICC) and exhibits a more aggressive clinical course; however, its risk factors and outcomes remain largely undefined.

METHODS

This study is a single-center retrospective study of 82 patients diagnosed with ICC or cHCC-ICC who underwent surgical resection from June 2011 to January 2023. Our analysis included 70 patients with resected ICC and 12 with resected cHCC-ICC.

RESULTS

The overall survival (OS) for the entire cohort was 21.6 months, with a recurrence-free survival (RFS) of 11.8 months. The cHCC-ICC group had significantly higher levels of AST and ALT (AST median 206 U/L vs. 46 U/L; ALT median 165.5 U/L vs. 48 U/L; p = 0.012 and p = 0.013, respectively), whereas the ICC group had higher alkaline phosphatase (median 66 U/L vs. 104 U/L; p = 0.03). CA 19-9 values (76 U/mL vs. 22 U/mL; p = 0.02) were higher in the ICC group, while AFP values were higher in the cHCC-ICC group (7.3 ng/mL vs. 3.2 ng/mL; p = 0.0004). The cHCC-ICC group had a significantly higher rate of recurrence (83% vs. 47%, p = 0.028) with a significantly decreased RFS (4.7 months vs. 12.4 months; log-rank p = 0.007). In multivariate analysis, patients with resected ICC had a significantly reduced risk of recurrence by 73% compared to their counterparts (HR 0.27 [0.10-0.73], p = 0.01).

CONCLUSIONS

cHCC-ICC is a rare entity that needs to be further studied to improve patient outcomes. Further studies are warranted and may suggest the need for more aggressive initial treatment strategies in patients diagnosed with cHCC-ICC.

Pathomic and bioinformatics analysis of clinical-pathological and genomic factors for pancreatic cancer prognosis

Pancreatic cancer exhibits a high degree of malignancy with a poor prognosis, lacking effective prognostic targets. Utilizing histopathological methodologies, this study endeavors to predict the expression of pathological features in pancreatic ductal adenocarcinoma (PAAD) and investigate their underlying molecular mechanisms. Pathological images, transcriptomic, and clinical data from TCGA-PAAD were collected for survival analysis. Image segmentation using unsupervised machine learning was employed to extract features, perform clustering, and establish models. The prognostic value of pathological features and associated clinical risk factors were evaluated; the correlation between pathological features and molecular mechanisms, gene mutations, and immune infiltration was analyzed. By clustering 45 effective pathological features, we divided PAAD patients into two groups: cluster 1 and cluster 2. Significant associations with poor prognosis were found for cluster 2 in both the training group (n = 113) and validation group (n = 75) (p = 0.006), with pathological stages II-IV identified as potential synergistic risk factors (HR = 2.421, 95% CI = 1.263-4.639, p = 0.008). Subsequently, through multi-omics correlation analysis, we further revealed a close association between cluster 2 and the oxidative phosphorylation mechanism. Within the cluster 2 group, 28 oxidative phosphorylation genes exhibited reduced expression, CDKN2A gene mutations were upregulated, and there was significant downregulation of Tregs infiltration and related immune gene expression. The pathomic model constructed using machine learning serves as a valuable prognostic target for PAAD. The histopathological features cluster 2 are closely associated with the downregulation of oxidative phosphorylation levels and Tregs immune infiltration.

Risk Factors of In-Hospital Venous Thromboembolism and Prognosis After Emergent Ventral Hernia Repair

Background: The risk factors and association of venous thromboembolism (VTE) following emergent ventral hernia repair (EVHR) remains uncertain. This aim of the study aims was to establish the predictors of VTE after EVHR and its influence on the long-term outcomes. Methods: A total of 2093 patients from the MIMIC-IV database who underwent EVHR were recruited. Multivariate logistic regression and nomogram models were developed to predict in-hospital VTE and mortality. Calibration and receiver operating characteristic (ROC) curves were utilized to assess the model's effectiveness and reliability. Decision curve analysis (DCA) was performed to evaluate the net clinical benefits of the model. Results: The rate of in-hospital VTE was 1.6% (33/2093) after EVHR. Four independent potential factors were established after multivariate analysis, and the abovementioned risk factors fit into the nomogram. The prediction model presented good performance metrics (C-index: 0.857), the calibration and ROC curves demonstrated the accurate prediction power, and DCA indicated the superior net benefit of the established model. In-hospital and 1-year mortality rates were 0.8% (17/2093) and 4.1% (86/2076) after EVHR. The potential factors were included in the mortality prediction nomogram. The prediction model presented good performance metrics (C-index of 0.957 and 0.828, respectively), the calibration and ROC curves were consistent with the actual results, and DCA indicated the superior net benefit of the established model. Conclusion: The nomogram, derived from the logistic regression model, demonstrated excellent predictive performance for VTE occurrence and prognosis in patients following EVHR. This model could serve as a valuable reference for clinical decision-making regarding VTE prevention and for enhancing post-EVHR prognosis.

Comparative study of midterm outcomes between Roux-en-Y gastric bypass (RYGB), diverted one-anastomosis gastric bypass (D-OAGB), and one anastomosis gastric bypass (OAGB)

PURPOSE

Diverted one anastomosis gastric bypass (D-OAGB) is a new procedure that entails performing Roux-en-Y diversion during OAGB to preclude post-OAGB bile reflux. This study aimed to compare the mid-term outcomes of Roux-en-Y gastric bypass (RYGB) and OAGB versus D-OAGB.

METHODS

This is a retrospective study that encompassed the analysis of data from patients undergoing bypass surgeries from 2015 to May 2021. The patients' data until 2 years of follow-up were compared.

RESULTS

This study included 140 patients who underwent OAGB (n = 64), RYGB (n = 24), and D-OAGB (n = 52). In the OAGB, RYGB, and D-OAGB groups, complication rates were 3.1%, 8.3%, and 5.8%, respectively. At the 3-month and 6-month follow-ups, the OAGB and D-OAGB groups showed a statistically significant higher percentage of excess weight loss (EWL%). Otherwise, the weight measures and weight loss outcome were comparable among the three groups in the other follow-up visits (p > 0.05). There was a significantly lower number of gastroesophageal reflux disease (GERD) remission cases and a higher number of de novo GERD cases in the OAGB group.

CONCLUSION

D-OAGB demonstrated favorable outcomes, including lower early adverse events and superior weight loss results in the first 6 months post-surgery when compared to RYGB. The D-OAGB group also showed higher rates of GERD remission and lower de novo GERD occurrence than OAGB. Further research is warranted to validate these findings and expand our understanding of this innovative surgical approach.

Environmentally sustainable surgical systems

Surgeons, anaesthetists, wider surgical teams and hospital managers are a large global group that has the capacity and power to play a leadership role to contribute to change. Hospitals are a good target for improvement since they are centres of communities, linking together surrounding healthcare facilities and influencing wider determinants of the environment. District and rural hospitals are good sites to start since they serve large populations, have the least sustained energy and clean water supplies and will benefit most from quality improvement. Within hospitals, surgeons and surgical pathways are the ideal places to start decarbonising healthcare. Surgery is a high-resource activity, but it focuses on one patient at a time, allowing measures to be introduced, and their effects closely monitored. Through a mass movement, surgical teams should be able to influence policy-makers for healthcare and industry supply chains, amplifying their effect. This article describes how we can make personal, professional and organisational changes to start creating impact. Change can be hard, especially in healthcare, so this new community needs to blend carbon literacy and behavioural change techniques for success. The article is focused on the front-line team and written by clinician experts in behavioural change and sustainable practice. As such, it will not tackle the technicalities of sustainability and carbon accounting. It intends to challenge individual readers to start making changes now, and to challenge systems leaders to start making larger-scale changes urgently.

Building resilient surgical systems that can withstand external shocks

When surgical systems fail, there is the major collateral impact on patients, society and economies. While short-term impact on patient outcomes during periods of high system stress is easy to measure, the long-term repercussions of global crises are harder to quantify and require modelling studies with inherent uncertainty. When external stressors such as high-threat infectious disease, forced migration or climate-change-related events occur, there is a resulting surge in healthcare demand. This, directly and indirectly, affects perioperative pathways, increasing pressure on emergency, critical and operative care areas. While different stressors have different effects on healthcare systems, they share the common feature of exposing the weakest areas, at which point care pathways breakdown. Surgery has been identified as a highly vulnerable area for early failure. Despite efforts by the WHO to improve preparedness in the wake of the SARS-CoV-2 pandemic, measurement of healthcare investment and surgical preparedness metrics suggests that surgical care is not yet being prioritised by policy-makers. Investment in the 'response' phase of health system recovery without investment in the 'readiness' phase will not mitigate long-term health effects for patients as new stressors arise. This analysis aims to explore how surgical preparedness can be measured, identify emerging threats and explore their potential impact on surgical services. Finally, it aims to highlight the role of high-quality research in developing resilient surgical systems.

Health systems strengthening through surgical and perioperative care pathways: a changing paradigm

Global health has traditionally focused on the primary health development with disease-specific focus such as HIV, malaria and non-communicable diseases (NCDs). As such, surgery has traditionally been neglected in global health as investment in them is often expensive, relative to these other priorities. Therefore, efforts to improve surgical care have remained on the periphery of initiatives in health system strengthening. However, today, many would argue that global health should focus on universal health coverage with primary health and surgery and perioperative care integrated as a part of this. In this article, we discuss the past developments and future-looking solutions on how surgery can contribute to the delivery of effective and equitable healthcare across the world. These include bidirectional integration of surgical and chronic disease pathways and better understanding financing initiatives. Specifically, we focus on access to safe elective and emergency surgery for NCDs and an integrated approach towards the rising multimorbidity from chronic disease in the population. Underpinning these, data-driven solutions from high-quality research from clinical trials and cohort studies through established surgical research networks are needed. Although challenges will remain around financing, we propose that development of surgical services will strengthen and improve performance of whole health systems and contribute to improvement in population health across the world.

Laparoscopic versus open surgery for liver resection: a multicenter cohort study

The relative risk and benefits of Laparoscopic liver resection (LLR) are still controversial. This study aimed to evaluate perioperative and survival outcomes for three primary malignant liver tumors related outcomes following LLR. Data from three Homogeneous-High-Volume-Expert-Centers were collected. Multivariable logistic regression analysis was performed for the association between LLR, and major complications defined as Clavien-Dindo Classification grade ≥ II. Multivariable Cox proportional hazards regression was used to explore the impact of LLR on primary malignant liver tumor survival. Overall, 5886 patients underwent liver resection, of which 1991 underwent LLR. After adjusting for covariables, LLR had significantly lower rate of CDC grade ≥ II (OR = 0.56, 95% CI: 0.48-0.67, P < 0.001). Interaction analysis showed that LLR had significant association with sex, drinking status, history of abdominal surgery, and platelet count (all P < 0.05). The overall survival for each primary malignant liver tumor shown potential risk but without significantly different between LLR and OLR (all P > 0.05). LLR was associated with lower rate of major complications, especially in women, non-drinkers, those without a history of abdominal surgery, and those with normal platelet. For primary malignant liver tumors, the survival outcomes did not differ significantly between LLR and OLR.

The Role of Dicer Phosphorylation in Gemcitabine Resistance of Pancreatic Cancer

Dicer, a cytoplasmic type III RNase, is essential for the maturation of microRNAs (miRNAs) and is implicated in cancer progression and chemoresistance. Our previous research demonstrated that phosphorylation of Dicer at S1016 alters miRNA maturation and glutamine metabolism, contributing to gemcitabine (GEM) resistance in pancreatic ductal adenocarcinoma (PDAC). In this study, we focused on the role of Dicer phosphorylation at S1728/S1852 in GEM-resistant PDAC cells. Using shRNA to knock down Dicer in GEM-resistant PANC-1 (PANC-1 GR) cells, we examined cell viability through MTT and clonogenic assays. We also expressed phosphomimetic Dicer 2E (S1728E/S1852E) and phosphomutant Dicer 2A (S1728A/S1852A) to evaluate their effects on GEM resistance and metabolism. Our results show that phosphorylation at S1728/S1852 promotes GEM resistance by reprogramming glutamine metabolism. Specifically, phosphomimetic Dicer 2E increased intracellular glutamine, driving pyrimidine synthesis and raising dCTP levels, which compete with gemcitabine's metabolites. This metabolic shift enhanced drug resistance. In contrast, phosphomutant Dicer 2A reduced GEM resistance. These findings highlight the importance of Dicer phosphorylation in regulating metabolism and drug sensitivity, offering insights into potential therapeutic strategies for overcoming GEM resistance in pancreatic cancer.

Potential role of glucagon-like peptide-1 (GLP-1) receptor agonists in substance use disorder: A systematic review of randomized trials

BACKGROUND

Increasing evidence suggests that GLP-1 receptor agonists (GLP-1RA) have a potential use in addiction treatment. Few studies have assessed the impact of GLP-1RA on substance use disorder (SUD), particularly in humans. The study aimed to do systematic review of clinical trials to assess GLP-1RA's effect on reducing SUD in patients.

METHODS

The scientific literature was reviewed using the MEDLINE, Scopus and Cochrane Library databases, following PRISMA guidelines. Studies including patients with a diagnosis of SU who were treated with GLP-1RA were selected. The primary outcome was GLP-1RA's therapeutic effect on SUD, and the secondary outcomes were therapeutic effects of GLP-1RA on weight, BMI and HbA1c.

RESULTS

1218 studies were retrieved, resulting in 507 papers after title and abstract screening. Following full-text review, only 5 articles met inclusion criteria. We incorporated a total of 630 participants utilizing Exenatide (n=3) and Dulaglutide (n=2) as GLP-1RAs. Therapeutic effect of GLP-1RA on SUD was assessed in 5 studies, with 3 demonstrating a significant decrease in SUD (alcohol and nicotine). GLP-1RA's impact on body weight, BMI, and HbA1c, was reported in 3 studies. These revealed a notable reduction in these parameters among the GLP-1RA treated group.

CONCLUSION

This review will give an overview of current new findings in human studies; we suggest that the effects of GLP-1RA in SUD is a possible new option of therapy in addiction medicine.

Comparison Between Billroth II and Billroth II + Braun Anastomosis in Gastrectomy for Gastric Cancer

INTRODUCTION

Distal gastrectomy remains the predominant therapeutic approach for gastric cancer, with digestive tract reconstruction as an integral procedure. The implementation of Braun anastomosis following Billroth II anastomosis is common in distal gastrectomy. This retrospective cohort study evaluated the clinical utility of Braun anastomosis by comparing the outcomes and quality of life between Billroth II (B-II) and Billroth II with Braun (B-IIB) anastomosis in the treatment of gastric cancer.

METHODS

A retrospective cohort study examined clinical and pathological data from 377 patients who underwent distal gastrectomy for gastric cancer treatment at The Affiliated Lihuili Hospital, Ningbo University, from October 2016 to October 2021.185 patients received B-II anastomosis, while the other 192 received B-IIB anastomosis, forming the B-II and B-IIB groups, respectively. Baseline characteristics, perioperative variables, short-term and long-term complications, and nutritional indicators at 1 mo and 1 y postsurgery were compared across both groups. Additionally, gastric endoscopy results at 6 mo and 1 y postsurgery were evaluated. Quality of life at 1 y postsurgery was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30.

RESULTS

Baseline characteristics between the two groups revealed no statistically significant differences (all P > 0.05), confirming their equivalence. All 377 patients successfully underwent curative distal gastrectomy for gastric cancer without intraoperative procedural modifications. No intraoperative complications or perioperative mortality occurred. Notable differences included extended operative time (222.1 ± 41.0 vs. 199.4 ± 24.9 min, P < 0.001), reduced postoperative nasogastric tube removal time (1.8 ± 0.9 vs. 2.2 ± 1.1 d, P < 0.001), decreased average gastric drainage volume (100.7 ± 35.2 vs. 112.2 ± 32.0 mL, P = 0.001), and increased incidence of internal hernia and ileus (4.7% vs. 1.1% and 8.3% vs. 3.2%, P = 0.038 and P = 0.035) in the B-IIB group compared to the B-II group. No significant differences were observed in estimated blood loss, lymph node dissection, postoperative flatus time, transition to a semiliquid diet, length of hospital stay, or short-term and long-term complications (all P > 0.05). Nutritional assessments conducted 1 mo and 1 y postsurgery indicated no statistically significant differences in body mass index, total protein, and serum albumin levels between the two groups (all P > 0.05). Gastric endoscopy evaluations at 6 mo and 1 y postsurgery, including food residue grade, gastritis severity, extent of gastritis, and bile reflux, demonstrated no significant discrepancies between the groups (all P > 0.05). At the 1-y follow-up, neither group exhibited tumor recurrences, deaths from tumor-related diseases, postoperative complications, or other diseases. Additionally, quality of life assessments using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core revealed no significant differences across various domains or items between the groups (all P > 0.05).

CONCLUSIONS

A comparative analysis between B-II and B-IIB anastomosis demonstrated no notable variations in intraoperative parameters, postoperative nutritional outcomes, gastric endoscopic results, or postoperative quality of life. Nevertheless, incorporating Braun anastomosis can extend the duration of surgery and may elevate the likelihood of postoperative internal hernia.

Predictors of appendicectomy one year after antibiotic treatment for acute appendicitis: Insights from a prospective, multicentre, observational study

BACKGROUND

Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited include the risk of recurrent appendicitis and the risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine the long-term efficacy of antibiotic versus operative management of appendicitis.

METHOD

One-year follow-up of patients enrolled in the multicentre, COVID:HAREM cohort study during March-June 2020 was performed. Initial operative or non-operative management was determined on a case-by-case basis by the responsible surgeon. Outcomes were appendicectomy rate at 1-year, histology of removed appendix and predictors of unsuccessful antibiotic treatment.

RESULTS

A total of 625 patients who had non-operative management were included. Emergency appendicectomy had been performed by 1-year in 24% (149/625), with a median time to appendicectomy of 12 days [IQR 1-77] from presentation. Thirty-one patients had elective appendicectomy. Normal histology was reported in 6% of emergency procedures and 58% of elective ones. There were 7 malignancies and 3 neuroendocrine tumors identified at histology. All patients with malignant histology had ≥1 risk factors for malignancy at initial presentation. Faecolithiasis (hazard ratios (HR) 2.3, 95% confidence intervals (CI) 1.51-3.49) and a high Adult Appendicitis Score (AAS >16; HR 2.44, 95% CI 1.52-3.92) were independent risk factors for unsuccessful non-operative management.

CONCLUSION

At 1 year, 71% of patients managed non-operatively did not undergo an appendicectomy. Recurrence of appendicitis was associated with faecolithiasis and a high AAS. Patients at higher risk for appendiceal malignancy should have targeted follow-up. These factors should be considered when counseling patients on non-operative management.

Is YouTube a reliable source of education for the intravitreal injection procedure?

PURPOSE

This study aims to evaluate the quality of videos on YouTube that demonstrate the intravitreal injection (IVI) procedure as an educational tool.

MATERIAL AND METHODS

A search on YouTube using the keywords "intravitreal injection", "intravitreal injection procedure", "eye injection", "eye injection procedure", "dexamethasone intraocular injection", and "anti-VEGF injection" was performed on January 10, 2023. Of the first 300 videos obtained, 70 met the inclusion criteria. The videos were evaluated for content and quality using the IVI procedure checklist score, DISCERN, modified Global Quality Score (GQS), Health on the Net Foundation (HON) code, and the Journal of American Medical Association (JAMA) scores. The quality of the videos was also compared with regard to the uploading source, such as a university or training hospital, educational channels, and individual medical doctors or healthcare professionals.

RESULTS

The mean IVI procedure checklist score was 4.84±1.58, and 29 videos fulfilled more than 80% of the checklist items, indicating that only 41.4% of the videos conformed to the IVI procedure recommendations. The mean DISCERN, modified GQS, and JAMA benchmark scores were 34.75±10.46, 2.90±1.09, and 2.09±0.72, respectively, indicating poor overall video quality. The mean HON code score was 4.68±1.39, indicating moderate overall video quality. Videos uploaded by educational channels seem to be of better quality than those uploaded by others.

CONCLUSIONS

The majority of evaluated YouTube videos on the IVI procedure appear to be of low quality as an educational tool. Videos uploaded by educational channels would be preferred to gain quality information about the IVI procedure.

Ultra-low-impact laparoscopy: a new concept for a minimally invasive surgery

INTRODUCTION

Minimally invasive surgery is considered the gold standard for the treatment of gynecological diseases. Our study aims to assess the effectiveness of the new concept of ultra-low-impact laparoscopy as a combination of low-impact laparoscopy, consisting in the use of miniaturized instruments through 3-5mm ports and low-pressure pneumoperitoneum, with regional anesthesia to evaluate the perioperative outcomes.

METHODS

A cross-sectional study was performed from May 2023 to December 2023, to enroll 26 women affected by benign gynecological disease and threated by mini-invasive surgical approach. The surgical procedures were performed following the low-impact laparoscopy protocol and the regional anesthesia protocol. The postoperative pain, nausea, and vomiting and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were analyzed.

RESULTS

Operative time was within 90 min (41.1 ± 17.1 mean ± standard deviation (SD)) and no conversion to laparotomy or general anesthesia was required. According to VAS score, the postoperative pain during the whole observation time was less than 3 (mean). Faster resumption of bowel motility (6.5 ± 2.1 mean ± SD) and women's mobilization (3.1 ± 0.7 mean ± SD) were observed as well as low incidence of post-operative nausea and vomit. Early discharge and patient's approval were recorded. Intraoperatively pain score was assessed on Likert scale during all stages.

CONCLUSION

Ultra-low-impact laparoscopy showed to provide a satisfying recovery experience for patients in terms of short hospital stays, cosmetic result, and pain relief, without compromising surgical outcomes. The encouraging results lead us to recruit a greater number of patients to validate our technique as a future well-established produce.

Surgical Outcome After Distal Pancreatectomy With and Without Portomesenteric Venous Resection in Patients with Pancreatic Adenocarcinoma: A Transatlantic Evaluation of Patients in North America, Germany, Sweden, and The Netherlands (GAPASURG)

BACKGROUND

Pancreatic adenocarcinoma located in the pancreatic body might require a portomesenteric venous resection (PVR), but data regarding surgical risks after distal pancreatectomy (DP) with PVR are sparse. Insight into additional surgical risks of DP-PVR could support preoperative counseling and intraoperative decision making. This study aimed to provide insight into the surgical outcome of DP-PVR, including its potential risk elevation over standard DP.

METHODS

We conducted a retrospective, multicenter study including all patients with pancreatic adenocarcinoma who underwent DP ± PVR (2018-2020), registered in four audits for pancreatic surgery from North America, Germany, Sweden, and The Netherlands. Patients who underwent concomitant arterial and/or multivisceral resection(s) were excluded. Predictors for in-hospital/30-day major morbidity and mortality were investigated by logistic regression, correcting for each audit.

RESULTS

Overall, 2924 patients after DP were included, of whom 241 patients (8.2%) underwent DP-PVR. Rates of major morbidity (24% vs. 18%; p = 0.024) and post-pancreatectomy hemorrhage grade B/C (10% vs. 3%; p = 0.041) were higher after DP-PVR compared with standard DP. Mortality after DP-PVR and standard DP did not differ significantly (2% vs. 1%; p = 0.542). Predictors for major morbidity were PVR (odds ratio [OR] 1.500, 95% confidence interval [CI] 1.086-2.071) and conversion from minimally invasive to open surgery (OR 1.420, 95% CI 1.032-1.970). Predictors for mortality were higher age (OR 1.087, 95% CI 1.045-1.132), chronic obstructive pulmonary disease (OR 4.167, 95% CI 1.852-9.374), and conversion from minimally invasive to open surgery (OR 2.919, 95% CI 1.197-7.118), whereas concomitant PVR was not associated with mortality.

CONCLUSIONS

PVR during DP for pancreatic adenocarcinoma in the pancreatic body is associated with increased morbidity, but can be performed safely in terms of mortality.

Upregulation of HSD11B1 promotes cortisol production and inhibits NK cell activation in pancreatic adenocarcinoma

Cortisol is a glucocorticoid hormone that has immunosuppressive function. Elevated basal cortisol levels are present in patients with some kinds of cancers, but its role in the microenvironment of pancreatic adenocarcinoma (PAAD) remains unclear. This study analyzed the expression of genes involved in cortisol generation by using high-throughput sequencing data from TCGA portal and found HSD11B1 was significantly upregulated in patients with PAAD. The correlations between HSD11B1 level and the expression of 23 immunosuppressive receptors were analyzed by Spearman's correlation analysis. The function of HSD11B1 was examined in primary NK cells and PAAD cell lines. The levels of cortisol in medium and cell lysates were detected by ELISA. In vitro killing assay was used to evaluate the cytotoxicity of NK cells. Cell surface levels of CD96, Tim-3, PD-1, TIGIT, CTLA-4, NKp46, NKp30, NKD2G and LFA-1A, and intracellular levels of CD107a and IFN-γ were examined by flow cytometry. We observed that patients with higher HSD11B1 level had shorter survival time. HSD11B1 is positively correlated with the mRNA levels of 11 immunosuppressive receptors in PAAD. Higher HSD11B1 level relates to reduced abundance of activated NK cells in the tumors. HSD11B1 overexpressed NK cells exhibit exhausted phenotype with increased cortisol production, reduced viability, and reduced cytotoxicity against cancer cells. Overexpression of HSD11B1 did not change the viability of tumor cells but upregulated cortisol production. Targeting HSD11B1 by a specific inhibitor improved the NK cells responsiveness. In conclusion, HSD11B1 is upregulated in patients with PAAD, and higher HSD11B1 level is related to poor prognosis. Upregulation of HSD11B1 in NK and tumor cells increased the production and secretion of cortisol and induces NK cell exhaustion.

Therapeutic Options for Recurrence of Weight and Obesity Related Complications After Metabolic and Bariatric Surgery: An IFSO Position Statement

Obesity is a chronic disease that may require multiple interventions and escalation of therapy throughout the years. Until recently, no universal definition existed for recurrent weight gain and insufficient weight loss. Standardization of reporting is key so outcomes can be compared and data can be pooled. The recent IFSO consensus provided standard terminology and definitions that will likely resolve this in the future, and publishers will need to enforce for authors to use these definitions. This current IFSO position statement provides guidance for the management of recurrent weight gain after bariatric surgery.

Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial

BACKGROUND

Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis.

METHODS

This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems.

FUNDING

National Institute for Health and Care Research Global Health Research Unit.

Interventions to achieve environmentally sustainable operating theatres: an umbrella systematic review using the behaviour change wheel

INTRODUCTION

The healthcare sector is a major contributor to the climate crisis and operating theatres (OTs) are one of the highest sources of emissions. To inform emissions reduction, this study aimed to (i) compare the outcomes of interventions targeting sustainable behaviours in OTs using the Triple Bottom Line framework, (ii) categorise the intervention strategies using the five Rs (reduce, recycle, reuse, refuse, and renew) of circular economy, and (iii) examine intervention functions (IFs) using the Behaviour Change Wheel (BCW).

METHODS

Medline, Embase, PsychInfo, Scopus, and Web of Science databases were searched until June 2023 using the concepts: sustainability and surgery. The review was conducted in line with the Cochrane and Joanna Briggs Institution's recommendations and was registered on PROSPERO. The results were reported in line with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) (Supplemental Digital Content 1, http://links.lww.com/JS9/D210 ) guidelines.

RESULTS

Sixteen reviews encompassing 43 life-cycle analyses, 30 interventions, 5 IFs, and 9 BCW policy categories were included. 28/30 (93%) interventions successfully led to sustainability improvements; however, the environmental outcomes were not suitable for meaningful comparisons due to their using different metrics and dependence on local factors. The 'reduce' strategy was the most prolific and commonly achieved through 'education' and/or 'environmental restructuring'. However, single-session educational interventions were ineffective. Improving recycling relied on 'environmental restructuring'. More intensive strategies such as 'reuse' require multiple intervention functions to achieve, either through a sustainability committee or through an intervention package.

CONCLUSION

Policymakers must examine interventions within the local context. Comparing the outcomes of different interventions is difficult and could potentially be misleading, highlighting the need for a tool integrating diverse outcomes and contextual factors. 'Reduce' strategy guarantees environmental and financial savings, and can be achieved through 'Education' and/or 'environmental restructuring'.

Optimal results through enhanced recovery: Achieving textbook outcomes with high compliance in elective liver surgery

BACKGROUND

Existing studies suggest a positive correlation between high compliance with enhanced recovery programs (ERP) and improved outcomes. While individual outcome measures have advantages, composite benchmarks, such as textbook outcome (TO), offer a more comprehensive assessment of healthcare performance. Given the link between ERP and postoperative outcomes, this study aims to investigate the impact of ERP on TO attainment after liver surgery (LS).

METHODS

A prospective multicenter cohort of patients undergoing LS and exposed to ERP from 2016 to 2022 in France was analyzed. The primary outcome was to compare the rates of TO achieved between patients with high ERP compliance (>70%) and those with low ERP compliance (<70%) after LS.

RESULTS

A total of 706 patients were included in the study, and 217 (30.7%) achieved TO: 170 patients with high ERP compliance (24%) versus 47 patients (6.6%) with low ERP compliance attained TO (p < 0.001). High ERP compliance was associated to an increased likelihood of achieving TO [odds ratio (OR) = 1.49 (95% CI: 1.01, 2.24); p = 0.049], while cholangiocarcinoma [OR = 0.11 (95% CI: 0.02, 0.39); p = 0.003], high complexity LS [OR = 0.22 (95% CI: 0.13, 0.36); p < 0.001], intraoperative hypotension requiring vasopressors [OR = 0.29 (95% CI: 0.10, 0.68); p = 0.010], and post-operative ileus [OR = 0.08 (95% CI: 0.00, 0.37); p = 0.013] were negatively associated to the likelihood of achieving TO.

CONCLUSIONS

Patients with high ERP compliance after LS experience elevated rates of TO, compared to those with low ERP compliance.

A systematic review and meta-analysis of morbidity and pancreatic fistula after distal pancreatectomy with versus without prophylactic intra-abdominal drainage

BACKGROUND

The omission of a prophylactic intra-abdominal drainage has been under debate in pancreatic surgery due to the high-risk of complications and especially of postoperative pancreatic fistula (POPF). Recently, the second randomized controlled trial (RCT) and two propensity score-matched comparative studies assessing risks and benefits of a no-drainage policy versus prophylactic drainage after distal pancreatectomy (DP) have been published. This systematic review with meta-analysis provides an updated summary of the available evidence on this topic.

METHODS

RCTs and nonrandomized comparative studies (NCS) investigating outcomes of no drainage versus drainage after DP were searched systematically in MEDLINE, Embase, and CENTRAL. Random effects meta-analyses were performed, and the results presented as weighted odds ratios (OR) or mean differences with their corresponding 95% CI. Subgroup analyses were performed to account for interstudy heterogeneity between RCTs and NCS.

RESULTS

Two RCTs and six NCS with a total of 3610 patients undergoing DP were included of whom 1038 (28.8%) patients did not receive prophylactic drainage. A no-drainage policy was associated with significantly lower risks of POPF (OR 0.38, 95% CI: 0.25-0.56; P <0.00001), reduced major morbidity (OR 0.64, 95% CI: 0.47-0.89; P =0.008), less reinterventions (OR 0.70, 95% CI: 0.52-0.95; P =0.02), and fewer readmissions (OR 0.69, 95% CI: 0.54-0.88; P =0.003) as well as shorter length of hospital stay (mean differences -1.74, 95% CI: -2.70 to -0.78; P =0.0004). Subgroup analyses including only RCTs confirmed benefits of the no-drainage policy.

CONCLUSION

A no-drainage policy is associated with reduced POPF and morbidity and can therefore be recommended as standard procedure in patients undergoing DP.

Effectiveness of video-based teaching in surgery residents: A randomized control trial

Objective

To determine the effectiveness of video-based teaching in surgery residents by comparing it to the routine operating room traditional teaching.

Methodology

The randomized control trial was done at four institutions from September 2022 to March 2023. Interventional group underwent video-based instruction of basic surgical skills whereas the control group was taught through traditional operating room teaching. Pre and post-test mean scores were analyzed on SPSS version 20 through paired t-test. Learning gain was calculated. Supervisors' perceptions were recorded on survey form regarding direct observations and recorded video evaluations of resident skills on post-test.

Results

Out of sixty (n=60), fifty-five newly inducted surgical residents completed the study including both females (n=13) and male residents (n=42). Video intervention Group (27.93±3.72) and control group (23.07±4.62) both showed improvements in their post-test scores as compared to pretest scores of 13.68±3.25 and 13.52±3.60 respectively. Mean score difference improvement was more in video intervention group (13.9±3.8) in comparison to control group (9.5±4.3) provided both groups exhibits improvements in all seven domains of the global rating system (reflected by the p <0.0001). However, learning gain of 65% was observed in intervention group as compared to learning gain (41%) of control group. Evaluators(n=5) observed that recorded video evaluations helped to provide integrated feedback, despite being time (40%) and resource intensive (60%).

Conclusion

Video-based teaching has higher learning gain irrespective of the fact that both groups exhibit statistically significant results in all seven domains of the global rating system. Recorded video evaluation was found feasible and reliable tool for formative assessment.

Pathologic complete response following neoadjuvant chemotherapy in pancreatic ductal adenocarcinoma: Impact on survival and recurrence

BACKGROUND

Pathologic complete response after neoadjuvant treatment in pancreatic ductal adenocarcinoma is a rare occurrence. Similar to other malignancies, achieving a pathologic complete response in pancreatic ductal adenocarcinoma seems to correlate with improved survival. However, because of the rarity of such events, the true significance of pathologic complete response in pancreatic cancer remains unclear. The aim of the present study was to investigate the impact of pathologic complete response on survival and recurrence.

METHODS

In a single-center retrospective study, pathologic complete response was defined as no evidence of viable tumor cells in resected specimen entirely sampled according to a rigorous protocol and in which a residual tumor bed was identified. Disease-specific survival and disease-free survival were measured from surgery. Independent predictors for disease-specific survival and disease-free survival were examined.

RESULTS

Overall, 403 patients were included. Pathologic complete response was found in 15 patients (3.8%), after chemotherapy alone. After a median follow-up of 42 months (95% CI 38-45), 3-year disease-specific survival was 87% in pathologic complete response patients vs 43% in those without pathologic complete response (P = .014). The recurrence rate was 40% (n = 6/15) in the pathologic complete response group compared with 69.8% (n = 271/388) in those without pathologic complete response. Disease-free survival was longer in the pathologic complete response group, with higher 1- and 3-year rates compared with the no-pathologic complete response group (80% vs 60% and 48% vs 24%, respectively). Pathologic complete response was found to be an independent protective factor for disease-specific survival (P = .035) but not for disease-free survival (P = .052).

CONCLUSION

Pathologic complete response in pancreatic ductal adenocarcinoma is not synonymous of cure but ensure a prolonged survival. Nevertheless, recurrence remains a significant concern, with high rates observed even among these exceptional responders.

Human Capital and Productivity in Surgery Research Across the Globe: A Big Data Analysis Using Artificial Intelligence

INTRODUCTION

No investigation of each nation's contribution to knowledge production and human capital in surgery currently exists. Previous studies explored country-level research productivity only in few surgical subspecialties. To identify current and future leaders in surgery research, we conduct a retrospective observational study of each country's human capital and research productivity.

METHODS

A web-scraping algorithm was deployed on PubMed to retrieve information on the first and senior author of every publication in all PubMed-indexed surgery outlets-a total of 388 journals-between 2010 and 2022, according to the SCImago classification. Each country's human capital is proxied by the number of first and senior authors.

RESULTS

A total of 665,668 publications from 110 countries were reviewed. The number of publications rises over time. The United States represents 30.78% and 31.32% of global publications based on first and senior authors, respectively. Other leading contributors include the United Kingdom (5.57% and 5.69% of global first and senior author publications, respectively), China (8.84% and 8.74%), Japan (7.14% and 7.10%), and Italy (4.54% and 4.46%). The number of publications per 100K people ranges between 0.04 and 86.01, suggesting widely varying levels of research productivity relative to the population.

CONCLUSIONS

Our findings underscore the US dominance in surgery research. Countries with a higher share of first or senior authors may have greater capacity to expand their future research output. As big data research expands, we expect studies deploying artificial intelligence methodologies, such as web scraping, on data repositories to guide healthcare provision and health policy decisions to become mainstream.

Open, laparoscopic liver resection and percutaneous thermal ablation in elderly patients with hepatocellular carcinoma: outcomes and therapeutic strategy

BACKGROUND

Liver resection and percutaneous thermal ablation (PTA) are considered curative option for hepatocellular carcinoma (HCC). This study aims to compare short- and long-term outcomes between open liver resection (OLR), laparoscopic liver resection (LLR), and PTA in elderly patients with single HCC and to define a liver map for therapeutic strategy according to HCC location and size.

METHODS

A multicenter retrospective study was conducted in 10 European Hospital Center, including 239 consecutive liver resection (OLR and LLR) and PTA in elderly patients ≥ 70 years old with single HCC ≤ 30 mm. Perioperative data and long-term oncological outcomes were collected and compared between groups before and after propensity score matching.

RESULTS

A total of 239 patients were enrolled, distributed as follows: 61 in the ORL group, 88 in the LLR group, and 90 in the PTA group. The hospital stay was longer in OLR and LLR groups compared to the PTA group (6, 5 and 3 days, respectively, p < 0.05). Morbidity was lower in the PTA group compared to the OLR group (11 vs. 26%, respectively, p < 0.05). Overall survival (OS) at 5 years was significantly higher in the OLR and LLR groups compared to the PTA group (82, 81, and 34%, respectively, p < 0.001). Disease-free survival (DFS) at 5 years was also significantly higher in the ORL and LLR groups compared to the PTA group (66, 50 and 20%, respectively, p < 0.001). These results were also confirmed after a propensity score matching analysis between surgery group (OLR and LLR) and the PTA group. PTA was the most used treatment for subcapsular and deep HCC not in contact with vascular structures compared to OLR and LLR.

CONCLUSION

PTA in elderly patients ensures a shorter hospital stay and lower morbidity but worst survival compared to liver resection.

Prospective comparison of two surgical approaches for incarcerated and strangulated inguinal hernia: preperitoneal hernioplasty through the lower abdominal median incision and laparoscope (TAPP)

The optimal surgical approach of incarcerated and strangulated inguinal hernia is controversial. Retrospective studies showed that surgical approaches through lower abdominal median incision or laparoscopic are superior to the oblique inguinal incision, respectively. Whether transabdominal laparoscopic approach is superior to the lower abdominal median incision approach needs prospective research.Prospective comparative study of patients with incarcerated and strangulated groin hernia admitted to Jinshan hospital for emergency surgery from January 2018 to June 2022. They were divided into two groups according to different surgical approach. The open preperitoneal repair group (OPR) was operated through the lower abdominal median incision. Laparoscopic preperitoneal repair group (TAPP) was completed under transabdominal laparoscope. The perioperative complications and long-term results of the two groups were compared and analyzed. Eighty-two patients met the inclusion criteria, 40 in OPR group and 42 in TAPP group. Baseline data of the two groups were comparable. Thirteen cases (15.9%) of the two groups underwent intestinal resection and anastomosis. Seventy cases (90.2%) underwent the 1st stage mesh repair, including 5 cases of preperitoneal hernioplasty after intestinal resection. The average operation time of TAPP group was 13 min longer (60.7 ± 13.7 min vs 47.8 ± 19.8 min P < 0.001), and the visual analogue scale pain score at 24 h after operation was lower (3.5 ± 1.2 vs 4.4 ± 1.7 P = 0.019) than that of OPR group. There was 1 case of bladder injury (2.5%) in OPR group and 1 case of inferior abdominal artery injury (2.4%) in TAPP group. There was no difference in the rate of the 1st stage hernioplasty between the two groups. In OPR group, 2 cases (5%) extended the incision for more than 2 cm, while in TAPP group, 1 case (2.4%) converted to laparotomy. The time of hospital stay (3.2 ± 1.8 d vs 4.3 ± 2.7 d, P = 0.036) and return to normal activities (7.9 ± 2.7 d vs 11.0 ± 4.4 d, P < 0.001) were shorter in TAPP group. The rate of total postoperative complications including chronic pain, surgical-site infection, seroma, hernia recurrence and so on was 11.9% in TAPP group, which was not significantly different from 25% in OPR group (P = 0.212). There were no cases of mesh related infection and death within 30 days in both groups.TAPP is safe and feasible for the operation of acute incarcerated inguinal hernia. TAPP had better comfort and faster recovery over open preperitoneal repair for the appropriate patients with incarcerated/strangulated inguinal hernia, which can reduce acute pain, shorten hospital stay and return to normal activities earlier.

Revisional Surgery Due to Weight Regain or Insufficient Weight Loss Following One Anastomosis Gastric Bypass

INTRODUCTION

One anastomosis gastric bypass (OAGB) is a common procedure associated with satisfactory outcomes. Revisional surgery due to weight regain or insufficient weight loss (WR/IWL) after OAGB is underreported.

METHODS

A retrospective analysis of a single-bariatric surgeon database was conducted. All patients undergoing revisional surgery after OAGB due to WR/IWL were included.

RESULTS

Ten patients were included in this case series. The median time between OAGB and revisional surgery was 44.9 months. The median body mass index (BMI) was 41.6 at pre-OAGB and 38.6 at pre-revision. The median age at OAGB revision was 40 years. The median biliopancreatic limb (BPL) length at revision was 160 cm. BPL elongation was performed in three patients, conversion to Roux-en-Y gastric bypass (RYGB) with BPL elongation in three patients, RYGB without BPL elongation in three patients, and one patient underwent conversion to single anastomosis duodeno-ileal bypass with sleeve (SADI-S). Pouch resizing was performed in four patients. One patient was reoperated due to a staple line leak from pouch resizing after conversion to RYGB. At a mean postoperative follow-up of 19 months, the median BMI and total weight loss were 30 and 18%, respectively. Higher weight loss outcomes occurred with BPL elongation (average: 24.8%) and SADI-S (average: 23.4%), while conversion to RYGB, with or without elongation, showed lower weight loss outcomes (11.5% and 7.8%, respectively).

CONCLUSIONS

WR/IWL after OAGB can be encountered during follow-up. In this case series, several options of revisions were evaluated, and BPL elongation or conversion to SADI-S correlated with better weight loss outcomes.

Long-Term Outcomes of Neoadjuvant Therapy Versus Upfront Surgery for Resectable Pancreatic Ductal Adenocarcinoma

INTRODUCTION

This study aimed to compare the long-term effects of neoadjuvant therapy and upfront surgery on overall survival (OS) and progression-free survival (PFS) in patients with resectable pancreatic ductal adenocarcinoma (PDAC).

METHODS

We retrospectively analyzed 202 patients, including 167 who had upfront surgery and 35 who received neoadjuvant therapy followed by surgery. Surgical outcomes and survival rates were compared using propensity score matching to minimize selection bias.

RESULTS

Neoadjuvant therapy showed significantly longer 75% OS (72.7 months vs. 28.3 months, p = 0.032) and PFS (29.6 months vs. 13.2 months, p < 0.001) compared to upfront surgery. Additionally, neoadjuvant therapy demonstrated significant improvements in surgical outcomes, including higher R0 resection rates (74.3% vs. 49.5%, p = 0.034), reduced tumor size (22.0 mm vs. 28.0 mm, p = 0.001), and decreased lymphovascular invasion (20.0% vs. 52.4%, p = 0.001).

CONCLUSION

Our study demonstrates the potential benefits of neoadjuvant therapy for resectable PDAC. The improved survival rates, delayed disease progression, and enhanced surgical outcomes underscore the potential of neoadjuvant therapy in addressing this aggressive disease. Despite limitations such as the retrospective design and small sample size, these findings support the effectiveness of neoadjuvant therapy in improving treatment outcomes for PDAC patients in real-world settings. Further prospective studies are required to validate these results.

Postoperative Complications

Surgery under anesthesia poses a significant stress to the body, and postoperative complications occur in up to 20% of cases. An understanding of postoperative complications, including assessment of patients at risk, risk mitigation, early recognition, and evidence-based treatment, is essential to provide high-value health care. Common postoperative complications reviewed in this article include fever, cerebrovascular accident, nausea and vomiting, ileus, and urinary retention, including discussion of pathophysiology, prevention, and treatment.

Clinical Practice of Pre-Assembling and Storing of Extracorporeal Membrane Oxygenation Systems

According to the Extracorporeal Life Support Organization (ELSO) guidelines, pre-assembled and already primed extracorporeal membrane oxygenation (ECMO) systems can be safely stored for up to 30 days under specific conditions. This study gives a detailed overview of existing pre-assembly practices. An anonymous online survey was conducted among chief perfusionists at German ECMO centers. Forty-four of a total of 83 ECMO centers (53%) completed the survey. Thirty-three percent do not preassemble ECMO systems. Seventy-seven percent (n = 34) reported having preassembled ECMO systems readily available (30% dry preassembly/20% wet preassembly/27% wet preassembly with circulation). Half of the participating centers (50%) reported having a standard operating procedure (SOP) and the majority (57%) of chief perfusionists expressed a need for an evidence-based SOP. A maximum storage time for wet preassembled ECMO systems is established in 88% of departments. On average, wet preassembled systems are discarded after 20 days, which is below the ELSO's safe limit of 30 days. Overall, this survey reveals a heterogeneous approach regarding the practice of provisioning preassembled ECMO systems. The demand for an evidence-based SOP for the preassembly and storing of ECMO systems becomes evident, necessitating the determination of hygienic standards, regular training, and a reliable maximum storage period.

Impact of neoadjuvant chemoradiotherapy on pathologic response in pancreatic ductal adenocarcinoma: A systematic review and meta-analysis

BACKGROUND

The impact of chemoradiotherapy on pathologic response, resection margin, and survival benefit is still debated. The aim of this study was to compare the rate of pathologic complete response (pCR) in surgical resection following neoadjuvant chemotherapy vs. chemoradiotherapy, and secondarily, to compare the rate of R0 resection and Overall Survival (OS).

METHODS

A systematic review on MEDLINE/PubMed, Embase, Cochrane, Web of Science and Google Scholar was conducted for studies published between 2012 and 2024 (PROSPERO CRD42022341467). All studies reporting clinical outcomes of patients with Pancreatic ductal adenocarcinoma (PDAC) following neoadjuvant therapy were considered eligible for inclusion. A meta-analysis comparing the rate of pCR, R0 resection rate, and 3-year OS following Chemotherapy vs chemoradiotherapy in patients was performed. The overall quality of evidence was evaluated using a GRADE approach.

RESULTS

Out of 5194 potentially relevant studies, 29 studies were considered eligible for full-text assessment, and 11 studies were included in the systematic review and in the meta-analysis. Of these, five were retrospective single-center, five retrospective multi-center studies, and one was a phase II multi-center RCT. Overall, 1830 Chemotherapy patients and 2299 Chemoradiotherapy patients were included in the meta-analysis. A statistically significant increased rate of pCR and R0 resections were found in chemoradiotherapy patients (OR 3.58, 95 % CI 2.47-5.18, p ≤ 0.00001) (OR 1.49, 95 % CI 1.17-1.90, p = 0.001), whereas 3-year OS (OR 1.07, 95 % CI 0.84-1.36, p = 0.6) did not differ significantly.

CONCLUSIONS

Chemoradiotherapy may have a positive impact on pathologic response and R0 resection rate, whereas a survival benefit was not reported.

Importance of duodenal stump reinforcement to prevent stump leakage after gastrectomy: a large-scale multicenter retrospective study (KSCC DELICATE study)

BACKGROUND

The significance of reinforcement of the duodenal stump with seromuscular sutures and the effectiveness of reinforced staplers in preventing duodenal stump leakage remain unclear. We aimed to explore the importance of duodenal stump reinforcement and determine the optimal reinforcement method for preventing duodenal stump leakage.

METHODS

This retrospective cohort study was conducted between January 1, 2012 and December 31, 2021, with data analyzed between December 1, 2022 and September 30, 2023. This multicenter study across 57 institutes in Japan included 16,475 patients with gastric cancer who underwent radical gastrectomies. Elective open or minimally invasive (laparoscopic or robotic) gastrectomy was performed in patients with gastric cancer.

RESULTS

Duodenal stump leakage occurred in 153 (0.93%) of 16,475 patients. The proportions of males, patients aged ≥ 75 years, and ≥ pN1 were higher in patients with duodenal stump leakage than in those without duodenal stump leakage. The incidence of duodenal stump leakage was significantly lower in the group treated with reinforcement by seromuscular sutures or using reinforced stapler than in the group without reinforcement (0.72% vs. 1.19%, p = 0.002). Duodenal stump leakage incidence was also significantly lower in high-volume institutions than in low-volume institutions (0.70% vs. 1.65%, p = 0.047). The rate of duodenal stump leakage-related mortality was 7.8% (12/153). In the multivariate analysis, preoperative asthma and duodenal invasion were identified as independent preoperative risk factors for duodenal stump leakage-related mortality.

CONCLUSIONS

The duodenal stump should be reinforced to prevent duodenal stump leakage after radical gastrectomy in patients with gastric cancer.

Improving postoperative survival in cholangiocarcinoma: development of surgical strategies with a screening program in the epidemic region

BACKGROUND

The Cholangiocarcinoma Screening and Care Program (CASCAP) has been launched since 2013 to detect early-stage cholangiocarcinoma and reduce the disease death. However, the clinical utility of the CASCAP remains unclear. To compare survival outcomes between two time periods: before and after 2013, when significant changes in treatment strategies were implemented, and to evaluate the efficacy of the ultrasound-based screening program, in an Asian region endemic for cholangiocarcinoma.

METHODS

A single-center retrospective review was conducted in curative-intended resection cholangiocarcinoma from 2002 to 2021. Patents characteristics and survival outcomes were compared between 2002 and 2013 (early period) and 2014 to 2021 (later period).

RESULTS

A total of 1091 patients with intrahepatic (n = 624) or perihilar (n = 467) cholangiocarcinoma was included (early period, n = 658; later period, n = 433). Of 66 (15.2%) patients in the later period were referred by the CASCAP. The incidence of early-staged disease (Stage 0 and 1) was lower in early period compared to later period 16.0% versus 29.1% (p < 0.001); that of positive surgical margin was higher in early period 53.7% versus 40.0% (p < 0.001). A median survival time (MST) was 14 months in early and 40 months in later period (p < 0.001). Subgroup analysis by tumor location, the MST was 13 versus 60 months in early and late periods for intrahepatic tumor (p < 0.001), respectively. While MST in perihilar tumor was 18 versus 31 months in early and late periods(p < 0.001), respectively. By presentation, the MST was 51 vs. 38 months, respectively, with screening and usual presentation (p = 0.06).

CONCLUSION

Postoperative survival in CCA patients improved more than doubled during the study period. Moreover, the late period demonstrated enhanced early-stage detection, a higher rate of negative surgical margins, and improved survival outcomes.

The effect of virtual reality hypnosis (HypnoVR) in patients undergoing inguinal hernia repair under local anesthesia. A preliminary report

INTRODUCTION

Surgical procedures, even under local anesthesia, can induce significant stress and anxiety in patients. Innovative approaches to alleviate anxiety are crucial for improving patient outcomes. Sedatives and anxiolytics may alleviate this discomfort, but they can also subject patients to undesirable side effects, diminishing their overall effectiveness, and, finally, delaying discharge. We present the first case series of a patients underwent inguinal hernia surgical repair under local anesthesia using VRH (HypnoVR) to avoid use of sedatives and anxiolytics.

METHODS

12 consecutive patients were enrolled to undergo elective monolateral inguinal hernia repair surgery via an open approach using HypnoVR, at Colorectal Surgery Unit of Fondazione Policlinico Universitario Campus Bio-Medico di Roma. Vital signs (heart rate, SpO2, blood pressure) were detected for all patients before surgery, during local anesthesia, during the whole intervention and after surgery.

RESULTS

No intraoperative or postoperative complications have been recorded and only one postoperative complication occurred (seroma), which not required invasive treatment but only drug administration. All patient's vital parameters were recorded during all operative and perioperative phasis. No use of intraoperative analgesic, sedative or anxiolytic were needed. All patients were discharged no later than 3 h after surgery.

CONCLUSION

Virtual Reality Hypnosis is a promising tool for anxiety management in surgical settings. Our series highlights the positive impact of HypnoVR in reduction and management of surgical patient anxiety and discomfort, allowing to perform inguinal hernia repair using only local anesthesia, with good patients' satisfaction.