Updates in Surgery

Few studies have assessed the clinical implications of the combination of different prognostic indicators for overall survival (OS) and disease-free survival (DFS) of resected hepatocellular carcinoma (HCC). This study aimed to evaluate the prognostic factors in HCC patients for OS and DFS outcomes and establish a nomogram-based prognostic model to predict the DFS of HCC. A multicenter, retrospective European study was conducted through the collection of data on 413 consecutive treated patients with a first diagnosis of HCC between January 2010 and December 2020. Univariate and multivariate Cox regression analyses were performed to identify all independent risk factors for OS and DFS outcomes. A nomogram prognostic staging model was subsequently established for DFS and its precision was verified internally by the concordance index (C-Index) and externally by calibration curves. For OS, multivariate Cox regression analysis indicated Child–Pugh B7 score (HR 4.29; 95% CI 1.74–10.55; p = 0.002) as an independent prognostic factor, along with Barcelona Clinic Liver Cancer (BCLC) stage ≥ B (HR 1.95; 95% CI 1.07–3.54; p = 0.029), microvascular invasion (MVI) (HR 2.54; 95% CI 1.38–4.67; p = 0.003), R1/R2 resection margin (HR 1.57; 95% CI 0.85–2.90; p = 0.015), and Clavien–Dindo Grade 3 or more (HR 2.73; 95% CI 1.44–5.18; p = 0.002). For DFS, multivariate Cox regression analysis indicated BCLC stage ≥ B (HR 2.15; 95% CI 1.34–3.44; p = 0.002) as an independent prognostic factor, along with multiple nodules (HR 2.04; 95% CI 1.25–3.32; p = 0.004), MVI (HR 1.81; 95% CI 1.19–2.75; p = 0.005), satellite nodules (HR 1.63; 95% CI 1.09–2.45; p = 0.018), and R1/R2 resection margin (HR 3.39; 95% CI 2.19–5.25; < 0.001). The C-Index of the nomogram, tailored based on the previous significant factors, showed good accuracy (0.70). Internal and external calibration curves for the probability of DFS rate showed optimal consistency and fit well between the nomogram-based prediction and actual observations. MVI and R1/R2 resection margins should be considered as significant OS and DFS predictors, while satellite nodules should be included as a significant DFS predictor. The nomogram-based prognostic model for DFS provides a more effective prognosis assessment for resected HCC patients, allowing for individualized treatment plans.

Although bile leakage is a major postoperative complication after hepatobiliary surgery, the associated risk factors for pediatric patients remain poorly defined. Here, we intend to identify the perioperative risk factors for bile leakage in pediatric patients with choledochal cysts following Roux-en-Y hepaticojejunostomy. A multicenter case–control study investigating the risk factors for bile leakage was conducted among 1179 eligible pediatric patients with choledochal cysts following Roux-en-Y hepaticojejunostomy between January 2009 and December 2019. There were 267 cases with bile leakage, and approximately four control patients were identified for each case. Multivariable logistic regression was performed to identify the risk factors, including perioperative variables. According to univariable analysis, bile leakage was associated with severe cholangitis (p = 0.012), low albumin levels (p = 0.010), anemia (p = 0.002) and laparoscopic surgery (p = 0.004). Multivariable analysis showed that a low level of preoperative albumin (ALB) (odds ratio [OR] = 1.11; 95% CI 1.02–1.19; p = 0.016), worse symptoms (severe cholangitis) (OR = 1.16; 95% CI 1.01–1.26; p < 0.001), and a previous hepatobiliary procedure (OR = 1.32; 95% CI 1.09–1.63; p = 0.036) were independent factors that were associated with bile leakage. This study identified potential risk factors for bile leakage in patients following Roux-en-Y hepaticojejunostomy that should be targeted for interventions to reduce the occurrence of the condition.

ERAS protocol and indocyanine green fluorescence angiography (ICG-FA) represent the new surgical revolution minimizing complications and shortening recovery time in colorectal surgery. As of today, no studies have been published in the literature evaluating the impact of the ICG-FA in the ERAS protocol for the patients suitable for colorectal surgery. The aim of our study was to assess whether the systematic evaluation of intestinal perfusion by ICG-FA could improve patients outcomes when managed with ERAS perioperative protocol, thus reducing surgical complication rate. This is a retrospective case–control study. From March 2014 to April 2017, 182 patients underwent laparoscopic colorectal surgery for benign and malignant diseases. All the patients were enrolled in ERAS protocol. Two groups were created: Group A comprehended 107 patients managed within the ERAS pathway only and Group B comprehended 75 patients managed as well as with ERAS pathway plus the intraoperative assessment of intestinal perfusion with ICG-FA. Two board-certified laparoscopic colorectal surgeons jointly performed all procedures. Six (5.6%) clinically relevant anastomotic leakages (AL) occurred in Group A, while there was none in Group B, demonstrating that ICG-FA integrated in the ERAS protocol can lead to a statistically significant reduction of the AL. Mean operative time between the two groups was not statistically significant. In five cases (6.6%), the demarcation line set by the fluorescence made the surgeon change the resection line previously marked. The prevalence of all other complications did not differ statistically between the two groups. Our study confirms that combination between ICG and ERAS protocol is feasible and safe and reduces the anastomotic leakage, possibly leading to consider ICG-FA as a new ERAS item.

Ligation of the intersphincteric fistula tract has been recently employed as definitive treatment of anal fistulas. However, it carries a potential risk of continence impairment, fistula recurrence, and repeated operations. This study aimed to assess postoperative outcomes related to this procedure and evaluate the potential influence of preoperative and intraoperative features. Patients who underwent LIFT procedure between June 2012 and September 2021 were retrospectively analyzed. Patients were divided according to whether they developed fistula recurrence and on the history of a surgery prior to the LIFT. Preoperative features, postoperative outcomes, and risk factors adverse outcomes were analyzed. Forty-eight patients were included, of which 25 received primary LIFT, being the high transsphincteric fistula pattern the most frequent (62.5%). The median follow-up was 13.3 months, with a recurrence rate of 20.8%, of which the majority presented an intersphincteric fistula pattern (50%); and continence impairment rate of 16.7%. A higher prevalence of diabetes (p = 0.026) and a trend towards a higher prevalence of patients with a history of high transsphincteric fistula (0.052) were observed in the group with fistula recurrence. The history of diabetes and the operation time with a cut-off value ≥ 69 min showed a trend as a risk factors for developing fistula recurrence (0.06) and postoperative continence impairment (0.07), respectively. The LIFT procedure seems to be safe in terms of morbidity, with a reasonable incidence of recurrences, showing better results when it is primarily performed. Preoperative characteristics should be considered as they may impact outcomes.

Laparoscopic techniques have been widely used in pancreatic surgery, such as laparoscopic pancreaticoduodenectomy (LPD) and laparoscopic central pancreatectomy (LCP). Laparoscopic pancreaticojejunostomy (LPJ) is a common procedure for LPD and LCP, and is also the most critical. The quality of LPJ is associated with the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). Although LPJ technology has been greatly improved, CR-POPF cannot be completely avoided especially to soft pancreas, which is an important reason for the high risk of laparoscopic pancreatic surgery. To date, there is a lack of standard LPJ approaches. Here, we report a U-shaped suture reinforcement for soft pancreatic section combined with penetrating pancreaticojejunostomy (PPJ) technique, called U-PPJ. Twenty-three patients with soft pancreas who underwent laparoscopic pancreatic surgery adopting U-PPJ method between 2017 and 2022 were enrolled (LPD = 19, LCP = 4). Preoperative, intraoperative and postoperative indexes were collected and analyzed. The results showed that all patients treated with U-PPJ were discharged without drainage tube or a small amount of exudate in the drainage tube does not require clinical treatment, but only needs to be removed after 2 days of observation. The average operation time was 417.35 min. The intraoperative blood loss was 171.74 ml. The pancreatic duct diameter was 3.41 mm. The average postoperative hospitalization days were 11.83 days. The average postoperative drainage tube removal time was 13.26 days. The incidence of postoperative B-grade pancreatic fistula was 4.3%, and no C-grade pancreatic fistula occurred. In our experience, U-PPJ can be completed by a skilled surgeon in less than 20 min. U-PPJ is safe, reliable, convenient and has a low incidence of CR-POPF in soft pancreas, which is worthy of clinical application. It also provides more options for laparoscopic pancreatic surgery. Since this is a retrospective study with a small number of cases, more prospective multicenter studies are needed to further verify its safety and efficacy.

Several regimens of oral and intravenous antibiotics (OIVA) have been proposed with contradicting results, and the role of mechanical bowel preparation (MBP) is still controversial. This study aims to assess the effectiveness of oral antibiotic prophylaxis in preventing Surgical Site Infections (SSI) in elective colorectal surgery. In a multicentre trial, we randomized patients undergoing elective colorectal resection surgery, comparing the effectiveness of OIVA versus intravenous antibiotics (IVA) regimens to prevent SSI as the primary outcome (NCT04438655). In addition to intravenous Amoxicillin/Clavulanic, patients in the OIVA group received Oral Neomycin and Bacitracin 24 h before surgery. MBP was administered according to local habits which were not changed for the study. The trial was terminated during the COVID-19 pandemic, as many centers failed to participate as well as the pandemic changed the rules for engaging patients. Two-hundred and four patients were enrolled (100 in the OIVA and 104 in the IVA group); 3 SSIs (3.4%) were registered in the OIVA and 14 (14.4%) in the IVA group (p = 0.010). No difference was observed in terms of anastomotic leak. Multivariable analysis indicated that OIVA reduced the rate of SSI (OR 0.21 / 95% CI 0.06–0.78 / p = 0.019), while BMI is a risk factor of SSI (OR 1.15 / 95% CI 1.01–1.30 p = 0.039). Subgroup analysis indicated that 0/22 patients who underwent OIVA/MBP + vs 13/77 IVA/MBP- experienced an SSI (p = 0.037). The early termination of the study prevents any conclusion regarding the interpretation of the data. Nonetheless, Oral Neomycin/Bacitracin and intravenous beta-lactam/beta-lactamases inhibitors seem to reduce SSI after colorectal resections, although not affecting the anastomotic leak in this trial. The role of MBP requires more investigation.

Postoperative neck hematomas following thyroidectomy occur in up to 6.5% of cases. It is unclear whether the use of energy vessel sealant devices effects the rate of PNH. We hypothesized use of an EVSD to be associated with decreased risk of PNH in patients undergoing thyroidectomy. The 2016–2017 American College of Surgeons Thyroidectomy database was queried for patients undergoing thyroidectomy with and without EVSDs. A multivariable logistic regression analysis was performed to evaluate for risk of PNH. From 11,355 patients undergoing thyroidectomy, an EVSD was used for 7460 (65.7%) patients. Age distribution was similar between the two groups (52 vs. 53-years old, p = 0.467). Compared to patients without EVSD used, patients with EVSD used had higher rates of comorbid hypertension (40.6% vs. 34.8%, p < 0.001) and diabetes (14.2% vs. 11.5%, p < 0.001); however, a lower rate of PNH (1.4% vs. 2.4%, p < 0.001). After adjusting for known risk factors for PNH including age, prior neck surgery, and comorbidities, EVSD use was associated with a decreased risk of PNH (OR 0.453, 95% CI 0.330–0.620, p < 0.001). The strongest associated risk factors for PNH were hypertension (OR 1.823, 95% CI 1.283–2.591, p = 0.001) and toxic goiter (OR 1.837, 95% CI 1.144–2.949, p = 0.012). When compared to standard vessel ligation, EVSD use was associated with a lower risk of PNH in patients undergoing thyroidectomy. The strongest associated risk factor for PNH was toxic goiter. Future prospective research is needed to confirm these findings and if corroborated, then increased use of an EVSD should be employed.

Gan là cơ quan rắn phổ biến thứ hai thường bị tổn thương trong chấn thương bụng kín. Các chấn thương gan được phân loại theo Thang điểm Tổn thương của Hiệp hội Mỹ về Phẫu thuật Chấn thương. Việc lựa chọn Quản lý Không Phẫu thuật dựa trên tình trạng lâm sàng tổng quát của bệnh nhân kết hợp với hình ảnh CT. Đến nay, chưa có hướng dẫn đồng thuận nào về tiêu chí lựa chọn bệnh nhân phù hợp cho những người có thể hưởng lợi từ chụp mạch và thuyên tắc mạch. Hoại tử gan lớn là một tình trạng lâm sàng của tổn thương gan mở rộng và là biến chứng phổ biến nhất sau thuyên tắc mạch. Một lượng lớn gan hoại tử cần điều trị, nhưng chưa rõ liệu kỹ thuật tốt hơn là cắt lọc kết hợp với các thủ tục thoát mạch qua da hay cắt bỏ triệt để. Một tổng quan có hệ thống về tài liệu đã được thực hiện bằng cách tìm kiếm máy tính trong cơ sở dữ liệu như Medline cho các bài báo đã xuất bản về việc sử dụng thuyên tắc mạch trong bệnh nhân chấn thương có tổn thương gan và về biến chứng phổ biến nhất, hoại tử gan lớn. Tổng quan hệ thống được thực hiện theo các khuyến nghị của hướng dẫn PRISMA cập nhật năm 2020. Tổng cộng có 3643 bệnh nhân được đưa vào nghiên cứu, bị chấn thương gan và 1703 (47%) được điều trị bằng Quản lý Không Phẫu thuật; thuyên tắc mạch được thực hiện trong 10% các trường hợp với tỷ lệ thay đổi từ 2 đến 20%. Bệnh nhân phát triển các biến chứng khác nhau. Hoại tử gan chiếm 16% với tỷ lệ từ 0 đến 42%. 74% bệnh nhân đã trải qua quản lý phẫu thuật với tỷ lệ tử vong là 11%. Các chấn thương gan mức độ cao gây ra những thách thức đáng kể cho các bác sĩ phẫu thuật chăm sóc bệnh nhân chấn thương. Nhiều bệnh nhân có thể được quản lý thành công mà không cần phẫu thuật. Ở những bệnh nhân ổn định huyết động học có đỏ động mạch, không có tổn thương khác cần phẫu thuật ngay, thuyên tắc mạch chọn lọc và siêu chọn lọc các nhánh động mạch gan là một kỹ thuật hiệu quả. Tuy nhiên, những liệu pháp này không phải không có biến chứng và hoại tử gan lớn là biến chứng phổ biến nhất trong các chấn thương mức độ cao.