Updates in Surgery最新文献

{"title":"Comment on: Surgery without surgeons: a national wake-up call on the state of surgical training in Italy.","authors":"Kun Wang","doi":"10.1007/s13304-026-02852-y","DOIUrl":"https://doi.org/10.1007/s13304-026-02852-y","url":null,"abstract":"","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149115176","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Delayed fluorescence on indocyanine green angiography reflects impaired red blood cell perfusion: implications for intraoperative perfusion assessment in colorectal surgery.","authors":"Tetsuro Maruyama, Shunsuke Kainuma, Toru Tochigi, Masaya Uesato, Gaku Ohira, Satoshi Endo, Shunsuke Imanishi, Hiroyuki Amagai, Atsushi Hirata, Hisahiro Matsubara","doi":"10.1007/s13304-026-02856-8","DOIUrl":"https://doi.org/10.1007/s13304-026-02856-8","url":null,"abstract":"<p><p>Indocyanine green fluorescence angiography (ICG-FA) is widely used for intraoperative perfusion assessment in colorectal surgery. Although delayed fluorescence is commonly interpreted as impaired perfusion, its underlying hemodynamic characteristics remain unclear. A porcine model of mesenteric division was used to evaluate intestinal perfusion using both ICG-FA and Blue Laser Imaging-microcirculation (BLI-M), which enables direct visualization of red blood cell (RBC) flow. Perfusion boundaries, fluorescence dynamics, and microcirculatory flow were analyzed on both mucosal and serosal surfaces. A mucosal bridge model was created to assess the role of submucosal perfusion. In regions showing delayed fluorescence on ICG-FA, no detectable RBC flow was observed on either the mucosal or serosal surfaces using BLI-M. Despite this, fluorescence gradually increased and reached levels comparable to well-perfused regions. Quantitative analysis demonstrated prolonged time to fluorescence onset and reduced slope in delayed regions, while maximum fluorescence intensity was similar across regions. These findings suggest that delayed fluorescence reflects temporal delay rather than adequate perfusion, likely due to plasma-dominant flow or extremely low-velocity microcirculation. The perfusion boundary identified by ICG-FA corresponded to mucosal perfusion rather than serosal perfusion, indicating a layer-specific discrepancy in intestinal blood flow. Delayed fluorescence on ICG-FA may represent regions with insufficient effective RBC perfusion despite preserved fluorescence intensity. Accurate identification of the initial perfusion boundary is essential, as reliance on delayed fluorescence may lead to inappropriate transection line selection and increased risk of anastomotic leakage. To our knowledge, this is the first study to provide direct experimental evidence elucidating the mechanism underlying delayed fluorescence observed in ICG-FA.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149115148","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Efficacy and safety of adjuvant targeted therapy plus immunotherapy in hepatocellular carcinoma patients with high-risk recurrence factors after hepatectomy.","authors":"Mengmeng Zhang, Lingzhi Wang, Zhongran Man, Ming Xu","doi":"10.1007/s13304-026-02857-7","DOIUrl":"https://doi.org/10.1007/s13304-026-02857-7","url":null,"abstract":"<p><p>Hepatocellular carcinoma (HCC) has postoperative recurrence rates reaching 70% at five years in high-risk patients. Despite advances in surgical technique, effective adjuvant strategies for patients undergoing radical hepatectomy remain limited. This study aimed to evaluate adjuvant tyrosine kinase inhibitors (TKIs) plus immune checkpoint inhibitors (ICIs) in HCC patients with high-risk recurrence factors after hepatectomy. We retrospectively analyzed 312 HCC patients with high-risk factors who underwent radical hepatectomy between January 2019 and December 2023. Patients were divided into an adjuvant group (n = 68) receiving TKIs plus ICIs and a control group (n = 244). Propensity score matching at a 1:2 ratio was applied. The primary endpoint was recurrence-free survival (RFS). After matching, 156 patients were included (52 adjuvant, 104 control). The median RFS was 31.8 months in the adjuvant group versus 17.2 months in the control group (P = 0.003). Adjuvant therapy was an independent protective factor for RFS (HR = 0.61, 95% CI 0.41-0.91, P = 0.014) and overall survival (HR = 0.70, 95% CI 0.52-0.95, P = 0.023). Patients with multiple tumors, maximum tumor diameter > 5 cm, microvascular invasion, and portal vein tumor thrombus showed potential differential RFS benefit. Grade ≥ 3 adverse events totaled 11 events (16%), with no grade 4 or 5 events. Postoperative adjuvant TKI plus ICI therapy significantly prolonged RFS with acceptable safety in HCC patients with high-risk recurrence factors.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149075925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of previous abdominal surgery on perioperative outcomes of laparoscopic pancreaticoduodenectomy: a propensity score matching study.","authors":"Guomeng Zhang, Jianzhang Qin, Jianhua Liu, Wenbin Wang, Haitao Lv","doi":"10.1007/s13304-026-02877-3","DOIUrl":"https://doi.org/10.1007/s13304-026-02877-3","url":null,"abstract":"<p><p>Laparoscopic pancreaticoduodenectomy (LPD) is a complex procedure. The impact of different types of previous abdominal surgeries (PAS) on its perioperative outcomes remains unclear. Clinical data of 794 LPD patients were collected and divided into major-PAS, minor-PAS, and no-PAS groups based on PAS type and extent. Patients with current or previous complicated intra-abdominal infectious conditions were excluded. Propensity score matching (PSM, 1:2:4) was performed using baseline variables. Intraoperative and postoperative outcomes were compared among groups. Multivariable logistic regression and inverse probability of treatment weighting (IPTW) were performed as sensitivity analyses, with an exploratory subgroup analysis by previous surgical approach. After PSM, 39 major-PAS, 78 minor-PAS, and 156 no-PAS patients were included. Compared with no PAS, major PAS was associated with higher rates of conversion to open surgery (p = 0.010), overall postoperative complications (p = 0.014), incision infection (p = 0.005), and abdominal infection (p = 0.009). Compared with minor PAS, major PAS was also associated with higher rates of conversion to open surgery (p = 0.010) and incision infection (p = 0.003). No significant differences were observed between the minor-PAS and no-PAS groups. Multivariable regression and IPTW analyses provided supportive findings that were generally consistent with the PSM results. Previous open surgery was associated with a higher conversion rate than previous minimally invasive surgery (p = 0.036). In carefully selected patients without documented complicated intra-abdominal infection treated at a high-volume center, minor PAS was not significantly associated with adverse perioperative outcomes after LPD, whereas major PAS was associated with higher risks of conversion to open surgery and infection-related complications.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149075858","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comment on: \"Selective non-diverting strategy after restorative rectal cancer surgery\": composite endpoint bias masks a trial-stopping safety signal.","authors":"Jian Huang","doi":"10.1007/s13304-026-02867-5","DOIUrl":"https://doi.org/10.1007/s13304-026-02867-5","url":null,"abstract":"","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149075892","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lifesaving transcordal stenting for high proximal tracheoesophageal fistulas: a conservative endoscopic approach.","authors":"Cristiano Casciani, Valentina Peritore, Vincenzo Ambrogi, Claudio Andreetti","doi":"10.1007/s13304-026-02855-9","DOIUrl":"https://doi.org/10.1007/s13304-026-02855-9","url":null,"abstract":"<p><p>Management of non-operable malignant tracheoesophageal fistulas remains challenging, particularly when the communication is located immediately below the vocal cords. We describe a customized transcordal variable-caliber silicone stent assembled intraoperatively from two commercially available stents in three patients with esophageal cancer and high proximal tracheoesophageal fistulas. Preprocedural planning combined endoscopy, contrast-enhanced CT, and three-dimensional reconstructions. All procedures were performed by rigid bronchoscopy under deep sedation with spontaneous ventilation. The devices were deployed without technical complications, achieved fistula exclusion, and allowed oral hydration within 24 h followed by gradual reintroduction of oral feeding. Follow-up was 18, 10, and 8 months. One patient required stent replacement for late prosthetic infection; no other major stent-related complications occurred. This approach provides an immediately available and intraoperatively adjustable option for selected patients with complex proximal airway anatomy when conventional single-caliber or rapidly manufactured patient-specific devices are unsuitable.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149076014","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Future surgical strategies for hepatocellular carcinoma in Italy: a strategic framework and scenario-based projection of liver transplantation and hepatic resection from 2027 onwards.","authors":"Gian Luca Grazi, Luca Tirloni, Ilenia Bartolini, Matteo Risaliti","doi":"10.1007/s13304-026-02880-8","DOIUrl":"https://doi.org/10.1007/s13304-026-02880-8","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Hepatocellular carcinoma (HCC) in Italy is undergoing a dual transition: a decline in viral (HCV/HBV) etiology following direct-acting antivirals (DAAs) and a rise in metabolic (MASLD/MASH)-related disease. Concurrently, the deceased-donor pool is being reshaped by donation after circulatory death (DCD) and machine perfusion, and neoadjuvant immune checkpoint inhibition is emerging as a possible route to transplant eligibility. This work explores, through scenario-based quantitative projections, how these forces may reshape the balance between hepatic resection and liver transplantation (LT) for HCC in Italy through 2035. This is a strategic framework supported by quantitative scenario projections, not a fully executed patient-level modelling study. Aggregate published data and registry annual reports (Piano Nazionale Esiti [PNE]; Centro Nazionale Trapianti [CNT]; European Liver Transplant Registry [ELTR]; ITA.LI.CA) and peer-reviewed literature were used; direct patient-level access to PNE and CNT datasets was not obtained. A deterministic scenario framework (conservative, baseline, expanded) was applied over 2027-2035. DCD growth was modelled with a saturating (logistic) function with an explicit carrying capacity. An explicit allocation layer bounds the HCC share of grafts by historical Italian values and does not permit it to rise as competing non-HCC demand grows. Immunotherapy-driven downstaging was parameterized from published neoadjuvant response data and treated as a promising but still-evolving input. Each headline output is reported with a scenario-based plausible range. Under the baseline scenario, total liver graft availability is projected to increase by ≈16-17% by 2035 (scenario range +11% to +23%), driven principally by a logistic rise in DCD activity toward ≈450 liver transplants/year (expanded corner ≈600/year) and by improved marginal-graft utilization via machine perfusion. Projected HCC incidence is broadly stable-to-declining overall, with a rising MASLD/MASH -related fraction offsetting the viral-related decline. Because HCC has historically represented ~44-49% of Italian LT waitlistings, while non-HCC demand (alcohol-related disease, MASLD/MASH, acute-on-chronic liver failure [ACLF]) is rising, the HCC share of grafts is constrained to ~45-50% in the scenario framework rather than assumed to expand; this yields ≈1,020-1,135 LT for HCC/year even in the expanded scenario. Immunotherapy-driven conversion from unresectable to transplantable disease is modelled conservatively (15% conservative, ~18-24% baseline, 30% only as an optimistic sensitivity extreme). Net reallocation of highly selected early-stage cirrhotic patients from resection to transplantation is estimated at ≈11-15% of the reallocatable resection pool. Within the constraints of a finite, allocation-governed graft supply and rising competing demand, a modest, highly selective shift from resection toward transplantation in early-stage cirrhotic HCC is plausi","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149075880","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A retrospective multicenter study: postoperative prognostic value of the lymphocyte-C-reactive protein ratio combined with the Ki-67 index in gallbladder cancer.","authors":"Haijian Wang, Shuqing Xu, Jianwu Liu","doi":"10.1007/s13304-026-02861-x","DOIUrl":"https://doi.org/10.1007/s13304-026-02861-x","url":null,"abstract":"<p><p>We investigated the predictive value of the lymphocyte-to-C-reactive protein ratio (LCR) and Ki-67 index for postoperative prognosis in gallbladder cancer (GBC). This study included 180 patients with GBC who underwent radical resection, with 2-year postoperative recurrence-free survival (RFS) as the primary endpoint. Patients were divided into event (70 cases) and event-free (110 cases) groups depending on the occurrence of RFS. Ki-67 expression in tumor tissues was detected by immunohistochemistry. Univariate Cox regression and least absolute shrinkage and selection operator-Cox regression were adopted to explore the correlations of LCR and Ki-67 index with postoperative RFS, with Kaplan-Meier survival analysis and receiver operating characteristic curve analysis to evaluate their impacts on postoperative RFS and assess their predictive efficacy. The event group had lower LCR and higher Ki-67 index versus the event-free group. During follow-up, 70 RFS events (38.89%) and 30 OS events (16.67%) were observed. Low LCR and high Ki-67 index were linked to shorter RFS. Multivariate Cox analysis confirmed LCR (HR = 0.144, 95%CI: 0.064-0.325, P < 0.001) and Ki-67 index (HR = 1.058, 95%CI: 1.025-1.091, P < 0.001) to be independently correlated with RFS. Their combination showed moderate predictive performance for 2-year postoperative RFS events. GBC patients with postoperative RFS events present lower preoperative LCR and higher tumoral Ki-67 index. The two biomarkers are independently related to postoperative RFS, showing certain predictive value for 2-year postoperative RFS events. They are promising tools for postoperative risk stratification and adjuvant treatment decision-making in patients with GBC.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149075950","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association of lymph node ratio with perioperative outcomes and survival in patients with early-onset gastric cancer: a multicenter retrospective cohort study.","authors":"Yingxin Wu, Gongyin Zhang, Min Peng, Jun Lu, Ju Wu, ShuoMeng Xiao, PengSen Guo, Pan Nie, Jie Liu, XinXi Yang, PeiSen Guo, HongMei Zhu, YanJun Liu","doi":"10.1007/s13304-026-02865-7","DOIUrl":"https://doi.org/10.1007/s13304-026-02865-7","url":null,"abstract":"<p><p>Early-onset gastric cancer (EOGC) represents a distinct subgroup of gastric cancer with unique clinicopathological characteristics and prognostic challenges. This multicenter retrospective cohort study aimed to evaluate the association of lymph node ratio (LNR) with perioperative outcomes and long-term survival in patients with EOGC aged <50 years. A total of 544 patients who underwent radical gastrectomy were included from six tertiary hospitals. Patients were classified into low- and high-LNR groups according to the cohort median LNR (4.5%). Intraoperative indicators, postoperative complications, short-term recovery outcomes, overall survival (OS), and disease-free survival (DFS) were compared between groups. Propensity score matching and multivariable regression analyses were performed to reduce baseline imbalance and potential confounding. During a median follow-up of 15.0 months, no significant differences were observed between low- and high-LNR groups regarding operative time, intraoperative blood loss, postoperative complications, or short-term postoperative recovery indicators. However, multivariable Cox regression analysis demonstrated that high LNR was independently associated with worse OS (HR=3.279, 95% CI 1.529-7.030, p=0.002) and DFS (HR=3.266, 95% CI 1.523-7.003, p=0.002). Kaplan-Meier analyses consistently showed poorer survival outcomes in patients with high LNR. These findings indicate that LNR is associated with long-term oncological outcomes but not with perioperative recovery in patients with EOGC. LNR may serve as a complementary prognostic marker for postoperative risk stratification; however, prospective studies with standardized thresholds and longer follow-up are required for further validation.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149064500","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prophylactic thoracic endovascular aortic repair (p-TEVAR) before radiotherapy in advanced non-small cell lung cancer: a technical note and case series.","authors":"Giovanni Zambello, Alberto Busetto, Riccardo Amatucci, Marco Damiano Pipitone, Giovanni Coppi, Reinhold Perkmann, Francesco Zaraca","doi":"10.1007/s13304-026-02827-z","DOIUrl":"https://doi.org/10.1007/s13304-026-02827-z","url":null,"abstract":"<p><p>Advanced non-small cell lung cancer (NSCLC) with thoracic aortic invasion (T4Ao) is a life-threatening condition and represents a major therapeutic challenge. Radiotherapy (RT) is often recommended for local control or palliation; however, it carries a substantial risk of vascular complications, including aortic rupture, thrombosis and pseudoaneurysm formation. Thoracic endovascular aortic repair (TEVAR) provides mechanical reinforcement of the aortic wall, potentially mitigating these risks and enabling safer administration of high-dose RT. This technical note describes our experience with prophylactic TEVAR (p-TEVAR) performed prior to RT. Three patients with cT4Ao-NSCLC completed the procedure and subsequent treatment without procedure-related vascular complications, achieving partial tumor response in two patients. Follow-up ranged from 6 to 10 months after radiotherapy, with no evidence of endoleak, graft migration, thrombosis, pseudoaneurysm, or aortic rupture. p-TEVAR may represent a feasible adjunct to radiotherapy or chemoradiotherapy in selected patients with advanced thoracic malignancies involving the aorta. This study highlights the feasibility of endovascular reinforcement and the importance of multidisciplinary decision-making.</p>","PeriodicalId":23391,"journal":{"name":"Updates in Surgery","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149064572","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}