Search Results (879)

Background/Objectives: Colorectal anastomotic leak (CAL) is one of the most severe postoperative complications in colorectal surgery, impacting patient morbidity and mortality. Current risk assessment methods rely on clinical and intraoperative factors, but no real-time predictive tool exists. This study aimed to develop an artificial intelligence model based on intraoperative laparoscopic recording of the anastomosis for CAL prediction. Methods: A convolutional neural network (CNN) was trained with annotated frames from colorectal surgery videos across three international high-volume centers (Instituto Português de Oncologia de Lisboa, Hospital das Clínicas de Ribeirão Preto, and Royal Liverpool University Hospital). The dataset included a total of 5356 frames from 26 patients, 2007 with CAL and 3349 showing normal anastomosis. Four CNN architectures (EfficientNetB0, EfficientNetB7, ResNet50, and MobileNetV2) were tested. The models’ performance was evaluated using their sensitivity, specificity, accuracy, and area under the receiver operating characteristic (AUROC) curve. Heatmaps were generated to identify key image regions influencing predictions. Results: The best-performing model achieved an accuracy of 99.6%, AUROC of 99.6%, sensitivity of 99.2%, specificity of 100.0%, PPV of 100.0%, and NPV of 98.9%. The model reliably identified CAL-positive frames and provided visual explanations through heatmaps. Conclusions: To our knowledge, this is the first AI model developed to predict CAL using intraoperative video analysis. Its accuracy suggests the potential to redefine surgical decision-making by providing real-time risk assessment. Further refinement with a larger dataset and diverse surgical techniques could enable intraoperative interventions to prevent CAL before it occurs, marking a paradigm shift in colorectal surgery. Full article

Background: Acute kidney injury (AKI) frequently occurs following major liver resection, adversely affecting both short- and long-term outcomes. This study aimed to determine the incidence of AKI post-hepatectomy and identify relevant pre- and intraoperative risk factors. Our secondary objectives were to develop a predictive score for postoperative AKI and assess the associations between AKI, chronic kidney disease (CKD), and 1-year mortality. Methods: This was a retrospective study in a cancer referral center in Marseille, France, from 2018 to 2022. Results: Among 169 patients, 55 (32.5%) experienced AKI. Multivariate analysis revealed several independent risk factors for postoperative AKI, including age, body mass index, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, time to liver resection, intraoperative shock, and bile duct reconstruction. Neoadjuvant chemotherapy was protective. The AKIMEBO score was developed, with a threshold of ≥15.6, demonstrating a sensitivity of 89.5%, specificity of 76.4%, positive predictive value of 61.8%, and negative predictive value of 94.4%. AKI was associated with increased postoperative morbidity and one-year mortality following major hepatectomy. Conclusion: AKI is a common complication post-hepatectomy. Factors such as time to liver resection and intraoperative shock management present potential clinical intervention points. The AKIMEBO score can provide a valuable tool for postoperative risk stratification. Full article

Introduction: Sarcopenia is a systemic condition linked to increased morbidity and mortality in older adults. Point-of-Care Ultrasound (POCUS) offers a rapid, bedside method to assess muscle mass. This study evaluates the diagnostic accuracy of POCUS compared to Dual-energy X-ray Absorptiometry (DXA), the gold standard method, and explores its prognostic value in old patients undergoing surgery for hip fractures. Patients and Methods: In this prospective, single-center study, 126 patients aged ≥ 70 years and hospitalized with hip fractures were included. Sarcopenia was defined according to the revised 2018 EWGSOP2 criteria. Muscle mass was assessed by the Appendicular Skeletal Muscle Mass Index (ASMI) using DXA and by the thickness of the rectus femoris (RF) muscle using POCUS. Results: Of the 126 included patients, 52 had both DXA and POCUS assessments, and 43% of them met the diagnostic criteria for sarcopenia or severe sarcopenia. RF muscle thickness measured by POCUS was significantly associated with ASMI (R² = 0.30; p < 0.001). POCUS showed a fair diagnostic accuracy in women (AUC 0.652) and an excellent accuracy in men (AUC 0.905). Optimal diagnostic thresholds according to Youden’s index were 5.7 mm for women and 9.3 mm for men. Neither RF thickness, ASMI, nor sarcopenia status predicted mortality or major postoperative complications. Conclusions: POCUS is a promising, accessible tool for diagnosing sarcopenia in old adults with hip fractures. Nonetheless, its prognostic utility remains uncertain and should be further evaluated in long-term studies. Full article

Background: Post-hepatectomy liver failure (PHLF) is the most worrisome complication after a major hepatectomy and is the leading cause of postoperative mortality. The most important predictor of PHLF is the future liver remnant (FLR), the volume of the liver that will remain after the hepatectomy, representing a major concern for hepatobiliary surgeons, radiologists, and patients. Therefore, an accurate preoperative assessment of the FLR and the prediction of PHLF are crucial to minimize risks and enhance patient outcomes. Recent radiomics and deep learning models show potential in predicting PHLF and the FLR by integrating imaging and clinical data. However, most studies lack external validation and methodological homogeneity and rely on small, single-center cohorts. This review outlines current CT-based approaches for surgical risk stratification and key limitations hindering clinical translation. Methods: A literature analysis was performed on the PubMed Dataset. We reviewed original articles using the subsequent keywords: [(Artificial intelligence OR radiomics OR machine learning OR deep learning OR neural network OR texture analysis) AND liver resection AND CT]. Results: Of 153 pertinent papers found, we underlined papers about the prediction of PHLF and about the FLR. Models were built according to machine learning (ML) and deep learning (DL) automatic algorithms. Conclusions: Radiomics models seem reliable and applicable to clinical practice in the preoperative prediction of PHLF and the FLR in patients undergoing major liver surgery. Further studies are required to achieve larger validation cohorts. Full article

Colorectal cancer (CRC) remains a leading cause of cancer morbidity and mortality worldwide, especially in older adults where frailty complicates treatment outcomes. Multimodal prehabilitation—comprising nutritional support, physical exercise, and psychological interventions—has emerged as a promising strategy to enhance patients’ resilience before CRC surgery. Clinical studies demonstrate that prehabilitation significantly reduces postoperative complications, shortens hospital stays, and improves functional recovery. Nutritional interventions focus on counteracting malnutrition and sarcopenia through tailored dietary counseling, protein supplementation, and immunonutrients like arginine and glutamine. Physical exercise enhances cardiorespiratory fitness and muscle strength while modulating immune and metabolic pathways critical for surgical recovery. Psychological support reduces anxiety and depression, promoting mental resilience that correlates with better postoperative outcomes. Despite clear clinical benefits, the molecular mechanisms underlying prehabilitation’s effects—such as inflammation modulation, immune activation, and metabolic rewiring—remain poorly understood. This review addresses this knowledge gap by exploring potential biological pathways influenced by prehabilitation, aiming to guide more targeted, personalized approaches in CRC patient management. Advancing molecular insights may optimize prehabilitation protocols and improve survival and quality of life for CRC patients undergoing surgery. Full article

Background/Objectives: Hip fractures are highly prevalent worldwide, primarily affecting frail elderly patients. Frailty increases the risk of complications like postoperative delirium, which negatively impacts outcomes, including morbidity and mortality. Current recommendations favor a multidisciplinary approach and effective pain control, often using preoperative peripheral nerve blocks. We aimed to evaluate a multimodal approach’s efficacy in reducing postoperative delirium and complications in geriatric hip fracture patients. Methods: This study was conducted between March 2020 and June 2022. A total of 144 patients evaluated prior to the implementation of an optimized clinical pathway protocol (OCPP) were compared to 117 patients evaluated following its implementation. The protocol included early preoperative evaluation, streamlined medication adjustments, prompt surgical intervention and fascia iliaca compartment block (FICB) for analgesia. In addition, early patient mobilization and resumption of oral intake were promoted. The primary outcome was the incidence of delirium during hospitalization. Secondary outcomes were a composite of 30-day mortality or major complications, duration of stay, hospital readmission after discharge and 1-year mortality. Results: The OCPP intervention significantly reduced the incidence of postoperative delirium from 44% to 29% (a 33% relative reduction; p = 0.017), the rate of major complications or death was 14.5% in OCPP group and 25.7% in the control group (p = 0.02). Significantly more patients in the OCPP group were mobilized within 24 h (74.4% vs. 41.3% in the control group, p < 0.001). The median time to ambulation was also shorter in the OCPP group: 65 h (IQR: 39–115) compared to 72 h (IQR: 48–119.75) in the control group (p = 0.028). No differences were observed on hospital stay and 1-year mortality. Conclusions: Among patients undergoing hip fracture repair the implementation of a OCPP significantly reduced the incidence of postoperative delirium and the rate of major complications or death. This improvement was associated with significantly earlier patient mobilization and ambulation. The OCPP was not associated with a lower hospital stay and lower rate of one-year mortality. Full article

Background/Objectives: Neo-adjuvant chemotherapy (NACT) is increasingly utilized in Western countries for the treatment of gastric cancer (GC). While its oncologic benefits are well established, its impact on surgical safety and long-term outcomes remain a matter of debate. This study evaluates the real-world effect of NACT on perioperative and oncologic outcomes in a high-volume Western center. Methods: Data from 254 patients who underwent gastrectomy with D2 lymphadenectomy for GC between March 2016 and January 2024 were prospectively collected and retrospectively analyzed. Patients were categorized into an upfront surgery group (n = 144, 56.7%) and a NACT group (n = 110, 43.3%). The primary outcome was to compare the two study groups in terms of perioperative outcomes, as well as overall (OS) and disease-free survival (DFS). Multivariate analyses were conducted to identify factors associated with perioperative complications and long-term survival. Results: Patients in the NACT group were younger (median age 65 vs. 72 years; p = 0.001) and had fewer comorbidities. NACT was associated with a higher incidence of proximal tumors (54–49.1% vs. 37–25.7%; p = 0.001), diffuse-type tumors (27–45.8% vs. 39–31.7%; p = 0.03), and lymph-node metastases (82–74.1% vs. 84–58%; p = 0.007). No significant differences were observed in median hospital stay (9 (7–16) and 10 (8–22) days for the upfront and NACT groups, respectively; p = 0.26), post-operative mortality (11–7.6% and 5–4.5% for the upfront and NACT groups, respectively; p = 0.32), and major complications (30–20.8% and 23–20.9% for the upfront and NACT groups, respectively; p = 0.99). Among patients receiving NACT, the FLOT regimen was associated with a lower rate of complications (12–16.2% vs. 11–30.5% in the non-FLOT cohort; p = 0.05) and reoperations (4–5.4% vs. 8–22.2% in the non-FLOT group; p = 0.008). Tumor location was identified as an independent predictor of perioperative complications (OR 4.7, 95% C.I.: 1.56–14.18; p = 0.006), while non-FLOT regimens were independently associated with higher reoperation rates (OR 0.22, 95% C.I.: 0.06–0.86; p = 0.003). Five-year OS was comparable between the two groups (44.6% in the NACT group vs. 47.7% in the upfront surgery group; p = 0.96). N+ status (OR 2.5, 95% C.I. 1.42–4.40; p = 0.001) and R+ margins (OR 1.89, 95% C.I. 0.98–3.65; p = 0.006) were negative independent prognostic factors for DFS. Conclusions: Although several selection biases limit the generalizability of our findings, our results suggest that NACT prior to gastrectomy for GC does not increase postoperative morbidity and mortality in appropriately selected patients. However, its use in elderly and polymorbid patients should be carefully considered to determine the safest and most effective therapeutic approach, particularly in selecting the appropriate chemotherapy regimen, to minimize the risk of postoperative complications requiring surgical reintervention. Full article

Infections with multidrug-resistant (MDR) organisms remain a significant cause of morbidity and mortality among liver transplant recipients, despite advances in surgical techniques and immunosuppressive therapy. This prospective observational study aimed to evaluate the impact of targeted perioperative antibiotic prophylaxis against MDR Gram-negative bacteria on postoperative infections and mortality in liver transplant recipients. Seventy-nine adult patients who underwent liver transplantation and were admitted to the ICU for more than 24 h postoperatively were included. Demographics, disease severity scores, comorbidities, and lengths of ICU and hospital stay were recorded. Colonization with carbapenem-resistant Gram-negative bacteria was assessed via preoperative and postoperative cultures from the blood, urine, rectum, and tracheal secretions. Patients were divided into two groups: those with MDR colonization or infection who received targeted prophylaxis and controls who received standard prophylaxis. Infectious complications (30.4%) occurred significantly less frequently than non-infectious ones (62.0%, p = 0.005). The most common infections were bacteremia (22.7%), pneumonia (17.7%), and surgical site infections (2.5%), with most events occurring within 15 days post-transplant. MDR pathogens isolated included Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa. Although overall complication and mortality rates at 30 days and 3 months did not differ significantly between groups, the targeted prophylaxis group had fewer infectious complications (22.8% vs. 68.5%, p = 0.008), particularly bacteremia (p = 0.007). Infection-related mortality was also significantly reduced in this group (p = 0.039). These findings suggest that identification of MDR colonization and administration of targeted perioperative antibiotics may reduce septic complications in liver transplant patients. Further prospective studies are warranted to confirm benefits on outcomes and resource utilization. Full article

Background/Objectives: Despite advancements in surgery, esophagectomy remains one of the most challenging and complex gastrointestinal surgical procedures, burdened by significant perioperative morbidity and mortality rates, as well as high financial costs. Recognizing the need for standardized care provided by a multidisciplinary healthcare team, the EUropean PErioperative MEdical Networking (EUPEMEN) initiative developed a dedicated protocol for perioperative care of patients undergoing esophagectomy, aiming to enhance recovery, reduce morbidity, and homogenize care delivery across European healthcare systems. Methods: Developed through a multidisciplinary European collaboration of five partners, the protocol incorporates expert consensus and the latest scientific evidence. It addresses the entire perioperative pathway, from preoperative preparation to hospital discharge and postoperative recovery, emphasizing patient-centered care, risk mitigation, and early functional restoration. Results: The implementation of the EUPEMEN esophagectomy protocol is expected to improve patient outcomes through a day-by-day structured prehabilitation plan, meticulous intraoperative management, and proactive postoperative rehabilitation. The approach promotes reduced postoperative complications, earlier return to oral intake, and shorter hospital stays, while supporting multidisciplinary coordination. Conclusions: The EUPEMEN protocol for esophagectomy provides a comprehensive guideline framework for optimizing perioperative care in esophageal surgery. In addition, it serves as a practical guide for healthcare professionals committed to advancing surgical recovery and standardizing clinical practice across diverse care environments across Europe. Full article

Background and Objectives: Postoperative pancreatic fistula and post-hepatectomy liver failure remain significant complications after HPB surgery; however, superficial surgical site infection (SSI) is the most frequent wound-related complication. Closed-incision negative-pressure wound therapy (ciNPWT) has been proposed to reduce superficial contamination, yet no liver-focused quantitative synthesis exists. We aimed to evaluate the effectiveness and safety of prophylactic ciNPWT after hepatopancreatobiliary (HPB) surgery. Methods: MEDLINE, Embase, and PubMed were searched from inception to 30 April 2025. Randomized and comparative observational studies that compared ciNPWT with conventional dressings after elective liver transplantation, hepatectomy, pancreatoduodenectomy, and liver resections were eligible. Two reviewers independently screened, extracted data, and assessed risk of bias (RoB-2/ROBINS-I). A random-effects Mantel–Haenszel model generated pooled risk ratios (RRs) for superficial SSI; secondary outcomes were reported descriptively. Results: Twelve studies (seven RCTs, five cohorts) encompassing 15,212 patients (3561 ciNPWT; 11,651 control) met the inclusion criteria. Device application lasted three to seven days in all trials. The pooled analysis demonstrated a 29% relative reduction in superficial SSI with ciNPWT (RR 0.71, 95% CI 0.63–0.79; p < 0.001) with negligible heterogeneity (I² 0%). Absolute risk reduction ranged from 0% to 13%, correlating positively with the baseline control-group SSI rate. Deep/organ-space SSI (RR 0.93, 95% CI 0.79–1.09) and 90-day mortality (RR 0.94, 95% CI 0.69–1.28) were unaffected. Seven studies documented a 1- to 3-day shorter median length of stay; only two reached statistical significance. Device-related adverse events were rare (one seroma, no skin necrosis). Conclusions: Prophylactic ciNPWT safely reduces superficial SSI after high-risk HPB surgery, with the greatest absolute benefit when baseline SSI risk exceeds ≈10%. Its influence on deep infection and mortality is negligible. Full article

Background/Objectives: Upper tract urothelial carcinoma (UTUC) is often complicated by intravesical recurrence and cancer progression following radical nephroureterectomy (RNU). Identifying reliable prognostic biomarkers remains crucial for optimizing postoperative surveillance. The goal of this study was to assess the prognostic value of the De Ritis ratio (AST/ALT) in predicting bladder recurrence and oncologic outcomes in patients with clinically localized UTUC undergoing RNU. Methods: This retrospective study analyzed 87 patients treated with RNU between 2018 and 2025. Preoperative De Ritis ratios were calculated, and an optimal cut-off value of 1.682 was determined using ROC analysis. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were analyzed using the Kaplan–Meier and Cox regression methods. Logistic regression was used to identify independent predictors of bladder recurrence. Results: A high De Ritis ratio was significantly associated with increased bladder recurrence and worse RFS and CSS, but not OS. Multivariate analysis confirmed that an elevated De Ritis ratio, current smoking, positive surgical margins, and synchronous bladder cancer were the independent predictors of bladder recurrence. The De Ritis ratio demonstrated strong discriminatory performance (AUC: 0.807), with good sensitivity and specificity for predicting recurrence. Conclusions: The De Ritis ratio is a simple, cost-effective preoperative biomarker that may aid in identifying UTUC patients at higher risk for intravesical recurrence and cancer-specific mortality. Incorporating this ratio into clinical decision-making could enhance risk stratification and guide tailored follow-up strategies. Full article

Background: Down syndrome (DS) is associated with unique anatomical and physiological characteristics that complicate the perioperative management of infants undergoing cardiac surgery. While ventricular septal defect (VSD) repair is commonly performed in this population, detailed data comparing perioperative outcomes in DS versus non-syndromic infants remain limited. Methods: This retrospective matched study analysed 100 infants (50 with DS and 50 without DS) who underwent isolated VSD closure between January 2021 and January 2025. Patients were matched by age and surgical date. Intraoperative anesthetic management, complications, postoperative outcomes, and mortality were compared between groups. Results: DS patients had lower age, weight, and height at surgery. They required significantly smaller endotracheal tube sizes, more intubation and vascular access attempts. The DS group had significantly lower rates of extubation in the operating room and experienced longer durations of mechanical ventilation and ICU stay. However, no significant differences were observed in total hospital stay or mortality between groups. Conclusions: Although DS infants present with increased anesthetic complexity and respiratory challenges, they do not exhibit higher surgical mortality following isolated VSD closure. Tailored perioperative strategies may improve respiratory outcomes in this high-risk group. Full article

Background and Objectives: Urothelial bladder carcinoma includes a spectrum of malignant lesions with heterogeneous molecular, biological, and clinical features and a variable risk of progression from non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive disease (MIBC) and ultimately to metastatic urothelial carcinoma (mUC). Sarcopenia, a condition secondary to a catabolic state, is characterized by progressive loss of skeletal muscle mass and function and is highly prevalent across all stages of bladder cancer. This review aims to synthesize current evidence regarding the clinical impact of sarcopenia and its dynamic changes throughout the disease course. Materials and Methods: A narrative literature review was conducted using PubMed, Scopus, and Cochrane databases, incorporating the most relevant published sources. Search terms included “bladder carcinoma”, “sarcopenia”, “body composition”, “NMIBC”, and “MIBC”. Case reports and congress abstracts were excluded. Results: In NMIBC treated with intravesical Bacillus Calmette–Guérin (BCG), sarcopenia has been shown to have a negative predictive value in some studies. Among patients receiving neoadjuvant chemotherapy (NAC) for MIBC, sarcopenia has been associated with increased toxicity, dose reductions, and treatment delays. In the context of radical surgery, sarcopenia correlates with increased postoperative mortality and a higher rate of severe complications. In mUC, low muscle mass is a negative prognostic factor regardless of treatment type and is associated with chemotherapy-related hematologic toxicity, although it does not appear to predict immune-related adverse events (irAEs). Conclusions: Sarcopenia is a highly prevalent and clinically relevant phenotype of urothelial bladder cancer patients, impacting prognosis, treatment response, and chemotherapy toxicity. Incorporating sarcopenia with other relevant components of body composition (BC) and systemic inflammatory markers may facilitate the development of more robust risk scores. Current evidence is primarily limited by the retrospective design of most studies. Future prospective research is needed to clarify the prognostic role of sarcopenia and support its integration into routine clinical decision-making. Full article

Background/Objectives: Metastatic spine disease (MSD) affects a significant proportion of patients with advanced malignancies and often necessitates surgical intervention to preserve neurological function, alleviate pain, and maintain spinal stability. While oncologic spine surgery is ideally performed in a planned, semi-elective setting, a substantial number of patients require unplanned (urgent or emergent) surgery due to acute deterioration. The impact of surgical planning status on postoperative outcomes following metastatic spine tumor surgery remains underexplored. This study aimed to compare the patient characteristics and short-term outcomes of those undergoing planned versus unplanned surgery for spinal metastases. Methods: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2018 to 2023. Patients with disseminated cancer undergoing tumor surgery were identified. Case types were grouped into planned (elective) and unplanned (urgent or emergent). The primary endpoint was failure to rescue (FTR); secondary endpoints included 30-day major complications, 30-day mortality, and length of hospital stay. Univariable and multivariable regression analyses were performed. Results: A total of 2147 patients met our inclusion criteria, out of whom 60% (n = 1284) underwent planned and 40% (n = 863) underwent unplanned surgery. Patients in the unplanned surgery group had a significantly higher prevalence of severe hypoalbuminemia, severe anemia, and ASA class IV status (p ≤ 0.001 for all). For our primary endpoint, a multivariable analysis showed a significant association between unplanned surgery and FTR (OR 2.11 [95% CI 1.24 to 3.56]; p = 0.005). Significant associations were also found with 30-day mortality (OR 1.84 [95% CI 1.25 to 2.72]; p = 0.002) and length of hospital stay (β 2.7 [95% CI 1.97 to 3.43]; p < 0.001). However, unplanned surgery could not independently predict 30-day major complications (OR 1.21 [95% CI 0.97 to 1.51]; p = 0.08). Conclusions: Our study found that unplanned surgery for spinal metastases was associated with significantly higher rates of FTR, 30-day mortality, and extended hospital stay, independent of other covariates. These findings highlight the importance of the timely identification of patients requiring surgery and the potential benefits of semi-elective care. Full article

Background/Objectives: Postoperative acute respiratory distress syndrome (ARDS) is a recognized complication with reported prevalence rates of up to 20% and highly variable mortality. However, there is limited published evidence comparing the outcomes of postoperative ARDS with those of medical ARDS. We aimed to evaluate the prevalence, hospital mortality, and healthcare costs of postoperative ARDS in Spain between 2000 and 2022 and to compare them with those of medical ARDS. Methods: We performed a nationwide, registry-based study of all hospitalizations for postoperative ARDS in Spain between 1 January 2000 and 31 December 2022 using the Minimum Basic Data Set (MBDS) Registry. Results: We identified a total of 93,192 ARDS patients, of which 40,601 had postoperative ARDS. The postoperative ARDS prevalence varied between 0.05 and 0.22%, accounting for 45–50% of total ARDS cases recorded during the study period. Hospital mortality was lower in postoperative ARDS compared with medical ARDS during the first phase (2000–2015) (47.0% vs. 49.9%, p < 0.001) and converged during the second phase (2017–2022) (42.7% vs. 43.2%, p = 0.413). Postoperative ARDS was associated with a longer hospital stay and 1.5 times higher healthcare costs compared with medical ARDS. During the COVID-19 pandemic, mortality rates declined but costs peaked in both groups. The incidence of digestive tract infection was higher in postoperative ARDS. Conclusions: The prevalence of postoperative ARDS remained stable, except during the COVID-19 pandemic, and its hospital mortality declined and equalized with that of medical ARDS. However, the costs associated with postoperative ARDS remained significantly higher. Full article