Search Results (27)

Background/Objectives: Acute cholecystitis is a common surgical emergency associated with significant morbidity in elderly, frail, and critically ill poor surgical candidates. Early laparoscopic cholecystectomy remains the standard of care for low-risk patients, but interventional radiology (IR) modalities have been increasingly used in high-risk patients for gallbladder decompression, source control, and/or definitive non-operative treatment. Methods: A narrative review of the literature was performed to investigate current percutaneous IR options in acute cholecystitis. Evidence from international guidelines, randomized trials, systematic reviews, meta-analyses, and experimental novel techniques were reviewed. The patient selection approaches, timing of intervention, efficacy, complications, and risk of recurrence were summarized. Results: Percutaneous cholecystostomy remains the most commonly performed IR procedure for acute cholecystitis, offering decompression and source control in patients unfit for surgery. Percutaneous gallstone extraction and gallbladder chemical ablation, or cryoablation, have been used to reduce recurrence and long-term catheter dependence with promising results, but are still limited by complications and insufficient evidence. The variability in practice patterns and the absence of standardized treatment algorithms contribute to mixed results, ranging from long-term/definitive symptom control to the prolonged dependence on indwelling catheters and readmissions for catheter-related complications. Conclusions: IR plays an important role in the management of high-risk patients with acute cholecystitis. The careful selection of patients based on disease severity, physiologic reserve, frailty, and patient-centered goals is frequently limited by institutional resources. A structured clinical decision framework to guide IR-based interventions in acute cholecystitis is of the utmost importance to achieve optimal outcomes. Future studies should focus on standardized algorithms, patient-centered outcomes, recurrence, tube-free survival, and quality of life. Full article

Background: Our aim was to evaluate the impact of obesity on operative and long-term oncological outcomes following rectal cancer surgery. Methods: Single-center retrospective review of all patients that underwent rectal resection for primary rectal adenocarcinoma between 2010 and2020. Divided into two groups based on preoperative body mass index (BMI): obese—BMI ≥ 30 kg/m², non-obese—BMI < 30 kg/m². Results: Total of 513 patients included 100 in the obese group (mean BMI 33.5 kg/m², range 30–45.6) and 413 in the non-obese group (mean BMI 24.9 kg/m², range 15.6–29.9, p < 0.001). The groups exhibited a similar age distribution (63.94 and 63.23, p = 0.59) or gender distribution (p = 0.83) between the groups. The obese group had higher conversion rates to open approach (22% versus 11.6%, p = 0.007), and longer surgeries (median 300 min, versus 260 min, p = 0.003), but similar overall postoperative complications (73% versus 64.4%, p = 0.1), 30-day readmission (19% versus 17.4%, p = 0.71), harvested lymph nodes (16 versus 14, p = 0.38), incidence of positive resection margins, 5-year overall survival (94.2% versus 88.7%, p = 0.97), and 5-year disease-free survival (70.4% versus 72%, p = 0.59). Conclusions: Obesity did not affect immediate overall surgical outcomes, surgical pathology quality indexes or long-term oncological outcomes. Full article

Background/Objectives: Congestion is a hallmark of heart failure (HF) and a major determinant of outcomes. Non-invasive tools enable detection of subclinical congestion, but their correlation and prognostic relevance remain incompletely defined. The present study aimed to assess the prevalence, evolution, interrelationships, and prognostic impact of clinical and subclinical congestion markers in patients hospitalized for HF. Methods: This single-centre, prospective cohort study included adults admitted with HF who underwent serial evaluations at admission, 72 h, pre-discharge, early outpatient follow-up and at 6 months. Clinical congestion was assessed using a standardized physical examination score. Subclinical congestion was evaluated using lung ultrasound (LUS), Venous Excess Ultrasound Score (VExUS), and Remote Dielectric Sensing (ReDS). Patients were classified according to the presence of clinical and/or subclinical congestion at discharge. The primary endpoint was a composite of all-cause mortality, HF readmission, or unscheduled visits requiring intravenous diuretics within six months. Results: Ninety-four patients (mean age 74 ± 11 years, 68% male) were included. While clinical congestion improved significantly during hospitalization, approximately 30% of patients remained clinically congested at discharge. Among clinically euvolemic patients, only 47% showed no evidence of subclinical congestion. Correlations between congestion markers were weak to moderate, suggesting complementary pathophysiological information. At discharge, pulmonary B-lines were the strongest predictor of the composite endpoint (hazard ratio [HR] 3.50, 95% CI 1.41–8.72), followed by clinical congestion (HR 2.67, 95% CI 1.13–6.30). Patients with clinical and subclinical congestion exhibited lower event-free survival. Conclusions: Subclinical congestion is common despite apparent clinical euvolemia and is associated with worse outcomes. Integrating clinical assessment with non-invasive congestion markers may improve post-discharge risk stratification in HF. Full article

Background/Objectives: Percutaneous microwave (MW) ablation is a nephron sparing treatment for localized renal cell carcinoma (RCC). We compared perioperative, renal functional, and oncologic outcomes for clinical stage 1 RCC treated with MW ablation, PN, or RN. Methods: Adults with clinical T1 kidney masses treated with MW ablation, PN, or RN from 2001–2025 were identified. Outcomes included: 90-day overall and major complication rate, 30-day readmission rate, length of hospital stay (LOS), change in renal function, local recurrence-free survival (LRFS), metastasis-free survival (MFS), and cancer-specific survival (CSS). Univariable and multivariable analyses evaluated outcomes adjusted for confounders. Results: A total of 2201 patients with renal masses ≤ 7 cm and no evidence of locally advanced or metastatic disease were treated with MW ablation (708), PN (729), or RN (764). MW ablation patients were older and more comorbid compared to both PN/RN, whereas RN patients had larger, higher-grade tumors. Ninety-day overall complications were lowest after MW ablation (8.9% vs. 20.3% PN, p < 0.001 and 8.9% vs. 19.9% RN, p < 0.001). LOS was shortest after MW ablation (median 1 day vs. 3 days PN/RN, p < 0.001 for each). Six-month eGFR decline was similar after MW ablation and PN (−5.2% and −4.7%, p = 0.84) but greater after RN (−32.9%, p < 0.001). Local recurrences were more common with MW ablation, with five-year LRFS 96.4% versus 99.7% for PN (p < 0.001). Five-year MFS (99.5% vs. 99.7%, p = 0.24) and CSS (99.3% vs. 99.7%, p = 0.71) did not differ between MW ablation and PN. Conclusions: Percutaneous MW ablation has comparable metastasis free and cancer specific survival with lower perioperative morbidity and comparable renal preservation to PN, despite worse baseline comorbidity and renal function. These findings support MW ablation as an effective nephron-sparing option for appropriately selected patients with clinical T1 RCC when performed at an experienced center. Full article

Major hepatectomy (MH) has traditionally been associated with higher R0 rates in colorectal liver metastases (CRLM), but at the cost of increased morbidity. Parenchymal-sparing hepatectomy (PSH) has emerged as an alternative approach aimed at reducing perioperative complications while preserving functional liver parenchyma without compromising oncological outcomes. We retrospectively analyzed 248 consecutive patients undergoing liver resection for CRLM between 2016 and 2025, classified as PSH (n = 215, 86.7%) or MH (n = 33, 13.3%). MH was performed more frequently in patients with greater tumor burden, including larger lesions, more numerous metastases, and bilobar disease (all p < 0.001). PSH was associated with shorter hospital stay, fewer postoperative complications, and lower 30-day readmission rate. In multivariable Cox analyses, surgical strategy was not associated with recurrence-free survival or overall survival, which were primarily driven by tumor burden. Among patients who developed liver recurrence, repeat hepatectomy was more often feasible after PSH than MH (p = 0.026), emphasizing the long-term value of preserving functional parenchyma. Overall, PSH was associated with lower postoperative morbidity, enabling earlier recovery, while facilitating future liver resections when needed in this chronically evolving disease. Full article

Background: Adjuvant therapies improve disease-free and cancer-specific survival in digestive tract malignancies. Return to intended oncological therapy (RIOT) measures how promptly patients resume these treatments after cancer resection. Because sugammadex has demonstrated superior postoperative outcomes compared to neostigmine, we hypothesize that its use may increase the likelihood and timeliness of RIOT in patients undergoing digestive tract cancer surgery. Methods: Adults (≥18 years) undergoing gastrointestinal, hepatobiliary cancer resection, or liver resection for limited metastases between January 2016 and December 2017 were retrospectively analyzed. Patients were grouped by neuromuscular blockade reversal agent (neostigmine vs. sugammadex). The primary outcome was RIOT within 90 days; secondary outcomes included RIOT within 180 days, time-to-RIOT, hospital length of stay, ICU admission, and readmissions. Results: Of 4358 records screened, 1081 met the inclusion criteria: 273 (25.2%) patients with neostigmine and 808 (74.8%) with sugammadex. Patients in the neostigmine group were slightly younger, and racial distribution differed modestly, but sex, BMI, ASA class, comorbidity, cancer type, and stage were comparable. Median reversal doses were 5 mg and 200 mg, respectively. Anesthesia duration, hospital and ICU length of stay, readmissions, and ICU use showed no significant differences. RIOT frequency was also similar across groups, except for modestly higher radiotherapy resumption with neostigmine at 90 and 180 days. Overall, perioperative and oncological outcomes were largely comparable between groups. Conclusions: Sugammadex and neostigmine showed similar RIOT rates, with only a modest difference in radiotherapy resumption. Larger studies are needed to elucidate the potential benefits of sugammadex, particularly regarding long-term oncological outcomes and treatment continuity. Full article

Objective: Textbook outcome (TO) is a multidimensional composite quality metric that integrates several desirable short-term outcomes into a single measure representing the “ideal” perioperative course. Unlike traditional indicators that focus narrowly on mortality or single complications, TO captures the complexity of cardiothoracic care, encompassing oncologic adequacy, absence of major complications, avoidance of reintervention and readmission, and timely discharge. Methods: In this systematic review, we synthesize evidence on the definition, incidence, determinants, prognostic impact, and limitations of TO across cardiothoracic surgery (lung and esophageal resections, lung transplantation, cardiac surgery, and adult heart transplantation) in accordance with the PRISMA guidelines. Results: Reported achievement rates range from 24% to 66% in thoracic series, 30% after Norwood palliation, 37–45% after adult heart transplantation, and 52% in a contemporary national cohort of lung transplantation, with wide between-center variability. Achieving TO is consistently associated with improved overall and disease-free survival, lower costs, and enhanced benchmarking. Determinants of failure include inadequate lymph node dissection, prolonged operative time, advanced comorbidity, pretransplant organ support, and socioeconomic disadvantage. Heterogeneity of definitions, limited incorporation of patient-reported outcomes, and equity concerns remain barriers to its successful use. Outside transplantation, benchmarking of TO in adult cardiac procedures (e.g., CABG/valve) remains limited and non-standardized. Conclusions: We argue for harmonized, procedure-specific core TO sets aligned with widely available registry fields, integration of equity-sensitive risk adjustment, and prospective validation. TO is poised to become a cornerstone metric of quality assessment and improvement in cardiothoracic surgery. Full article

Objectives: The purpose of this study was to determine whether concomitant tricuspid valve repair (TVr) at the time of left ventricular assist device (LVAD) implantation improves outcomes in patients with ≥moderate tricuspid regurgitation (TR) and to evaluate the prognostic value of preoperative right ventricular (RV) strain. Methods: In a retrospective analysis of 100 LVAD recipients (44 TVr; 56 No-TVr), preoperative (preop) and postoperative (postop) clinical, echocardiographic, and hemodynamic variables, including pulmonary vascular resistance (PVR) and pulmonary artery pulsatility index (PAPI), were analyzed. RV free wall strain (RV-FWS) and RV fractional area change (RV-FAC) were measured by speckle tracking. Early right heart failure (RHF) was modeled with multivariable logistic regression, and 2-year mortality was assessed with Fine–Gray competing risk regression. Preoperative and three-month measurements were compared within each of the 100 patients. Results: Baseline invasive hemodynamics, RV-FWS, and RV-FAC were similar between the TVr and No-TVr groups. TVr at the time of LVAD implantation reduced postoperative TR grade, but it did not improve RV-FWS or RV-FAC at 3 months. The No-TVr patients were more often discharged home and had lower 30-day readmissions. PVR was comparable preoperatively and at 3 months postoperatively. In adjusted analyses, preop PVR, PAPI, and TVr were not independently associated with early RHF, whereas decreased preoperative RV-FWS and lower preop RV-FAC independently predicted higher 2-year mortality. Conclusions: In LVAD recipients with ≥moderate TR, concomitant TVr lowers postoperative TR severity but does not improve early RHF, RV strain-based remodeling, or 2-year mortality. Preoperative RV deformation metrics, rather than preoperative PVR or PAPI, independently predict survival following LVAD implantation with or without TVr. Full article

Post-operative pancreatic fistula (POPF) is a serious yet far too common complication following distal pancreatectomy (DP), as it affects 20–30% of patients after DP. POPF raises the risk of other complications and causes delays to a patient’s oncologic care. In this review, we present the latest data on patient risk factors for developing POPF, such as obesity, smoking, young age, thick pancreas, lack of epidural anesthesia, hypoalbuminemia, and elevated drain amylase levels. Other risk factors that have been identified with irregular consistency include open surgical approach, non-malignant or neuroendocrine tumor pathology, simultaneous splenectomy, simultaneous vascular resection, and long operative time. We also review the consequences of POPF, which include hemorrhage, infection, delayed gastric emptying, re-operation, re-admission, delays in adjuvant chemotherapy initiation, reduced progression-free survival, and reduced overall survival. Finally, we present strategies that have been studied for avoiding POPF after DP, including reducing pressure at the sphincter of Oddi, the use of sealants and patches, optimizing pancreatic transection, strategies for post-operative drain placement, the use of post-operative somatostatin analogues, and pre-clinical studies of experimental devices and techniques that may inform future trials. This review informs readers on the current state of the art with regard to POPF after DP and sets the stage for future studies to improve patient outcomes. Full article

Background and Objectives: Reconstructive outcomes following head and neck (H&N) cancer resection in pediatric patients remain understudied, particularly regarding the comparative efficacy of free versus local tissue transfer. Materials and Methods: A retrospective review was conducted on pediatric patients undergoing malignant H&N tumor resection at a tertiary center from 2007 to 2024. Patients were stratified by reconstruction type (free vs. local flap), and outcomes assessed included flap failure, wound complications, revision rates, operative time, hospital stay, and 30-day readmission. Results: A total of 41 patients (mean age: 10.6 years) met inclusion criteria; 18 underwent free flaps and 23 received local flaps. Common diagnoses included osteosarcoma (21.9%) and rhabdomyosarcoma (12.2%). Anterolateral thigh (44.4%) and fibula (33.3%) were the most common free flaps; temporalis (21.7%) and pectoralis (13.0%) were common local flaps. Flap survival was high in both groups (94.4% vs. 100%). However, local flaps had significantly higher rates of hardware exposure (34.7% vs. 5.5%, p = 0.025) and wound dehiscence (39.1% vs. 5.5%, p = 0.045). Free flaps were associated with longer operative times (10.3 vs. 6.5 h, p = 0.011) and hospital stays (29.1 vs. 13.9 days, p = 0.036). Conclusions: While both approaches achieved high flap survival, free flaps may offer more durable reconstruction and reduce wound-related complications in complex pediatric H&N oncologic cases. Full article

Non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) often coexists with multivessel coronary artery disease (MVD), complicating treatment decisions. Current guidelines suggest complete revascularization (CR), yet robust evidence in hemodynamically stable patients remains insufficient. However, the comparative benefit of CR over incomplete revascularization (IR) in reducing ischemic events and improving cardiac function in this population is not well established. The aim of this study was to evaluate the impact of CR on all-cause mortality, cardiac death, and ischemic readmissions at 6 and 12 months, as the composite primary outcome, and to assess left ventricular ejection fraction (LVEF) improvement at discharge and hospital length of stay, as secondary outcomes. A total of 282 hemodynamically stable NSTE-ACS patients with MVD were included, of whom 218 (77.3%) underwent CR and 64 (22.7%) IR. The primary composite outcome occurred in 40.6% of IR patients versus 11.0% in the CR group at 6 months (p < 0.001), and 68.8% vs. 22.0% at 12 months (p < 0.001). CR was associated with significantly lower rates of all-cause and cardiac death, myocardial infarction, and unstable angina. Stroke incidence was similar. Event-free survival favored CR. Multivariable analysis identified CR and baseline LVEF as independent predictors of 12-month outcomes (HR for CR: 7.797; 95% CI: 3.961–15.348; p < 0.001; HR for LVEF: 0.959; CI: 0.926–0.994; p = 0.021). These findings strongly support CR as the preferred therapeutic strategy. Future prospective randomized studies are warranted to confirm the results. Full article

Introduction: The role of urethrectomy at the time of Robotic-Assisted or Open Radical Cystectomy (RARC, ORC) is controversial. Whether urethrectomy should be performed at the time of RARC/ORC or delayed up to a 3–6 month interval is unclear. We performed a retrospective cohort analysis of perioperative and survival outcomes in patients with high-risk NMIBCs or non-metastatic MIBCs at our institution who underwent either concomitant or deferred urethrectomy after RC. Materials and Methods: cTis-T1 or cT2-T4, N0-1, M0 BC patients who underwent RARC or ORC from 2009 to 2024 were reviewed. Clinical, demographic, tumour, and patient characteristics and perioperative variables were assessed across concomitant and delayed urethrectomy groups. Multivariate logistic analysis was performed to estimate the impact of significant variables on intraoperative and postoperative outcomes. Univariable Kaplan–Meier and multivariable Cox regression modelling was implemented to explore the relative effect of time of urethrectomy on progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). Results: A total of n = 58 patients (n = 47 delayed vs. n = 11 concomitant) with similar demographic characteristics were included. The concomitant urethrectomy group experienced longer operative time and greater blood loss (379 ± 65 min and 430 ± 101 mL vs. 342 ± 82 min and 422 ± 125 mL, with p = 0.049 and p = 0.028, respectively). Hospital readmission rates were higher in the concomitant urethrectomy group (36.4% vs. 8.5%, p = 0.016; OR: 17.9; 95% CI 1.2–265; p = 0.036). In Cox regression analysis, the timing of urethrectomy had no influence on PFS, CSS, or OS (all p > 0.05). Conclusions: Our study suggests that urethrectomy can be safely deferred unless urothelial disease is clearly present pre- or intraoperatively without compromising survival outcome and with the advantage of reducing surgical morbidity at the time of RC. Full article

Background/Objectives: Gram-negative bloodstream infections (GN-BSIs) in the critically ill carry significant mortality, which is exacerbated by delays in appropriate therapy. To improve the time to effective therapy, aminoglycosides are often recommended as empiric adjunctive antimicrobials. However, there is a paucity of clinical data supporting this practice. This study’s objective was to evaluate the safety and efficacy of adjunctive aminoglycosides compared to β-lactam monotherapy in patients admitted to the intensive care unit (ICU) with GN-BSI. Methods: This was a retrospective, propensity-matched cohort study of critically ill patients with GN-BSI. The primary outcome was 15-day all-cause mortality. The secondary endpoints evaluated included 30-day mortality, ICU-free survival days, 60-day relapse, 30-day readmission, development of acute kidney injury (AKI), and new resistance. Results: A total of 209 propensity-matched patients were included for analysis: 136 received β-lactam monotherapy and 73 received adjunctive aminoglycoside. The primary outcome of 15-day all-cause mortality was not significantly different between groups (17% vs. 21%; p = 0.644). Additional secondary endpoints of 30-day mortality (22% vs. 25%), ICU-free survival (12.1 vs. 12.2 days), 60-day relapse (3.3% vs. 7.4%), and 30-day readmission (23% vs. 18%) did not yield significant differences. The proportion of AKI was higher in the adjunctive aminoglycoside group but was not found to be significantly different (26.5% vs. 37%). Conclusions: The use of adjunctive aminoglycosides for GN-BSI did not affect clinical outcomes in the critically ill. Full article

Background/Objectives: Heart failure (HF) can damage organs because of poor perfusion and/or congestion. The interactions between HF and other organs have recently been studied; however, data on the interaction between HF and pancreatic exocrine function, which may affect fat and protein absorption and malnutrition, are scarce. We previously showed that the serum levels of pancreatic exocrine enzymes, as suggestive of pancreatic exocrine function, were low and associated with malnutrition or congestion in hospitalized patients with acute decompensated HF (ADHF). This study investigated the relationship between the serum levels of pancreatic exocrine enzymes and long-term outcomes in patients with ADHF. Methods: We collected serum levels of pancreatic exocrine enzymes (amylase and lipase) from patients who were admitted to the cardiac intensive care unit due to ADHF. Patients undergoing dialysis and those with neoplasms were excluded. Patients were categorized as having high or low pancreatic exocrine enzyme levels in the first quartile upon admission. The association between low serum pancreatic exocrine enzyme levels at admission and the composite of death and ADHF readmission was assessed. Results: Of the 146 patients, 37 (25.3%) and 36 (24.7%) had low amylase and lipase levels, respectively. Patients with low lipase levels showed worse cumulative event-free survival than those with high lipase levels (p < 0.001). A low lipase level was associated with worse outcomes (hazard ratio: 1.96; p = 0.012). Conclusions: These findings suggest that low serum lipase levels may be a predictor of long-term outcomes in patients with ADHF. Full article

Introduction: Peritoneal carcinomatosis presents significant treatment challenges. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) offers a promising therapeutic approach. Patient selection remains critical, and the role of age as an exclusion criterion requires further investigation. This study evaluates whether age influences postoperative outcomes in CRS-HIPEC patients. Methods: A retrospective review of a prospective comprehensive database of 271 CRS-HIPEC procedures performed between 2018 and 2023 was conducted. Logistic regression assessed the relationship between age and postoperative outcomes. Age groups (18–44, 45–69, ≥70 years) were compared based on demographic data, primary tumor site, Peritoneal Cancer Index scores, and key outcome measures. Results: Across the different age groups, there were no significant differences in PCI scores, recurrence, disease-free survival, 30-day morbidity, or mortality. Length of stay was longer in older patients (p = 0.009). Patients aged ≥70 had higher readmission rates (p = 0.041) and were more often discharged to transitional care facilities (p = 0.001). Older patients were also more likely to experience Clavien–Dindo grade III or higher complications (p = 0.008). Logistic regression confirmed these findings. Continuous age analysis yielded similar results and revealed significant differences in race and primary organ involvement. Conclusions: Age is not a significant predictor of 30-day morbidity, mortality, or survival outcomes in patients undergoing CRS-HIPEC. However, older patients require closer attention to discharge planning and readmission risk management. This study highlights the importance of comprehensive patient assessment beyond age and underscores the need for further research to better understand factors influencing outcomes in this population. Full article