Search Results (68)

Background: Perioperative assessment of hemostasis remains challenging, particularly in non-cardiac surgery, where the incidence of clinically significant bleeding is relatively low. Viscoelastic testing enables real-time evaluation of whole-blood coagulation, but its perioperative dynamics and agreement with conventional assays require further characterization. Methods: In this prospective single-center observational study, 53 patients undergoing major non-cardiac surgery were included in the final analysis. Hemostatic parameters were assessed preoperatively, intraoperatively at two-hour intervals, and 24 h postoperatively using ROTEM (EXTEM, INTEM, and FIBTEM) and conventional coagulation assays. Longitudinal changes and correlations between fibrinogen concentration according to Clauss and ROTEM-derived parameters were analyzed. Results: Fifty-three patients undergoing major hepatopancreatobiliary surgery completed longitudinal perioperative monitoring. Pancreaticoduodenectomy and liver resection accounted for 60.7% and 39.3% of procedures, respectively. Serial perioperative ROTEM and laboratory assessments demonstrated time-dependent changes in coagulation parameters, including decreased intraoperative fibrinogen and antithrombin III levels and shortening of INTEM clotting time. Clinically significant bleeding was infrequent, with severe intraoperative bleeding observed in 7.4% of patients. Strong correlations were confirmed between fibrinogen concentration according to Clauss and FIBTEM-derived parameters, particularly FIBTEM MCF (r = 0.811, p < 0.001), whereas the correlation with FIBTEM A10 was moderate (r = 0.574, p < 0.001). No significant association was observed between preoperative fibrinogen concentration and perioperative blood loss. Conclusions: This study provides a longitudinal characterization of perioperative coagulation dynamics and demonstrates strong agreement between fibrinogen concentration according to Clauss and ROTEM-derived parameters. The findings are primarily descriptive and highlight the methodological consistency between viscoelastic and conventional fibrinogen assessment. Further studies are required to determine their clinical relevance in perioperative management. These findings suggest that ROTEM-derived parameters may provide a rapid functional estimate of fibrinogen status in the perioperative setting, potentially supporting clinical assessment, although their role in guiding management requires further validation. Full article

Background/Objectives: This study aimed to develop a novel tumor-associated macrophage (TAM)-targeting nanoplatform to improve the solubility and bioavailability of camptothecin (CPT) and achieve active targeted drug delivery for enhanced anti-tumor immunotherapy. Methods: We constructed a sialic acid-disulfide bond-camptothecin (SA-SS-CPT) nanowire system. Sialic acid was used as a targeting ligand to specifically recognize the overexpressed Siglec-E receptor on TAMs. Upon cellular internalization, the disulfide bond was designed to respond to intracellular glutathione (GSH), enabling controlled drug release. Results: The SA-SS-CPT nanowires significantly improved CPT solubility and enabled targeted delivery to TAMs. Following GSH-responsive cleavage and CPT release, the nanowires induced DNA damage in TAMs, activating the cGAS-STING signaling pathway. This promoted TAM polarization toward the M1 phenotype, enhanced pro-inflammatory and anti-tumor immune responses, and inhibited tumor immune escape. Furthermore, SA-SS-CPT synergistically improved the efficacy of PD-L1 blockade immunotherapy, remodeling the tumor immune microenvironment. Conclusions: The SA-SS-CPT nanoplatform effectively targets TAMs, repolarizes them to an anti-tumor M1 phenotype, and activates the cGAS-STING pathway. It shows strong potential for overcoming tumor immune escape and synergizing with PD-L1 checkpoint blockade to achieve significant tumor clearance. Full article

Background: Acute pancreatitis (AP) is increasingly recognised as a disease with clinically significant long-term consequences. However, the extent to which aetiology influences the spectrum of long-term pancreatic sequelae remains unclear. This systematic review and meta-analysis evaluated long-term complications following a first episode of AP, with a protocol-defined focus on the impact of aetiology. Methods: This review evaluated eligible studies that included adults with a first episode of AP who were followed for chronic pancreatitis (CP), exocrine pancreatic insufficiency (EPI), or new-onset diabetes mellitus (NODM). A comprehensive search of PubMed, Scopus, Web of Science, and CENTRAL was conducted from January 2002 to June 2025. Risk of bias was assessed using the Newcastle–Ottawa Scale. Random-effects meta-analyses were performed to estimate pooled incidence proportions. A prespecified network meta-analysis was not feasible because outcome-specific event counts stratified by aetiology were inconsistently reported. This study satisfied PRISMA 2020 guidelines and was registered with PROSPERO (CRD420251074032). Results: Eight studies met eligibility criteria with extractable data for quantitative synthesis. Five studies (n ≈ 10,780) reported chronic pancreatitis (CP), with a pooled incidence of approximately 7–8% following a first episode of acute pancreatitis (AP) and substantial heterogeneity (I² ≈ 96%). Three studies (n = 796) reported exocrine pancreatic insufficiency (EPI), with a pooled incidence of approximately 23%, although estimates were highly heterogeneous (I² ≈ 98%). Four studies (n = 2706; 415 events) reported new-onset diabetes mellitus (NODM), with a pooled incidence of approximately 20% (I² ≈ 93%). Although aetiology-specific quantitative comparisons were not possible, narrative synthesis consistently demonstrated higher long-term risk following alcohol-associated AP, lower risk after biliary AP, and intermediate but variable outcomes in idiopathic AP. Conclusions: Clinically meaningful long-term pancreatic dysfunction is common after a first episode of acute pancreatitis, particularly new-onset diabetes mellitus. While aetiology-specific risks could not be quantified, consistent patterns suggest that aetiology shapes long-term outcomes. These findings support structured, aetiology-informed follow-up after acute pancreatitis and the need for standardised outcome reporting in future studies. Full article

Background/Objectives: Pancreatic surgery has always been associated with a variety of complications. In the current study, we analyzed more than 800 consecutive pancreatic resections and tried to find clinically relevant routine parameters that could predict adverse outcomes at an early stage. We focused on hepato-pancreato-biliary routine parameters, especially on liver enzymes, because so far there are no studies showing any correlation between postoperatively elevated liver enzymes and postoperative complications. Methods: All pancreatic resections of a tertiary care center from 2003 until 2025 were documented prospectively and analyzed retrospectively. Data analysis comprised descriptive as well as inferential statistical analyses. Results: Laboratory values from 808 consecutive resections were analyzed for the first week after surgery. Elevated aspartate aminotransferase (AST) was associated with postoperative hemorrhage on POD 1, pulmonary insufficiency on POD 1 to 4, other complications on POD 1 to 5, MODS on POD 2 to 4, and development of pneumonia on POD 3 to 5. Elevated alanine aminotransferase (ALT) was associated with pulmonary insufficiency on POD 1 to 4 and POD 6, pneumonia, and other complications on POD 3. It was also associated with MODS on POD 1 to 6. Bilirubin elevated preoperatively and on POD 1 could not really predict any complication. In this study, we can also confirm that elevated amylase and lipase can predict complications. Conclusions: This is the first study that shows a correlation between postoperatively elevated AST and ALT and the development of postpancreatectomy complications. Elevated AST and ALT, especially in combination with postoperative pancreatitis or at least elevated pancreatic enzymes, can identify patients at risk for life-threatening conditions and might be useful to decrease failure-to-rescue patients. Full article

Background: Major hepatopancreatobiliary (HPB) surgeries cause significant physical stress. In this study, we evaluated how a 4-week multimodal prehabilitation program affects perioperative outcomes across different types of HPB procedures. Methods: We conducted a retrospective cohort study of 359 patients undergoing HPB surgery (162 historical controls and 197 in the prehabilitation group). To accurately assess the clinical benefits of various procedures, patients were stratified into specific surgical groups: major and minor hepatectomy, pancreatoduodenectomy (PD), and left pancreatectomy (LP). Results: The prehabilitation program significantly improved preoperative nutrition, demonstrated by increased serum albumin levels on the day of surgery (p < 0.001), and the clinical benefits were most pronounced in pancreatic surgeries. Patients undergoing PD in the prehabilitation group had a significantly shorter median hospital stay (8 versus 13 days, p < 0.001). LP patients also experienced shorter hospital stays (5 versus 9 days, p = 0.001) and reduced blood loss (p = 0.002). For minor hepatectomies, the intervention significantly lowered the need for blood transfusions (8.3% versus 18.9%, p = 0.033). The length of stay and complication rates for major hepatectomies remained comparable between groups. Importantly, major morbidities and 90-day mortality were low and similar across all cohorts. Conclusions: Multimodal prehabilitation successfully optimizes preoperative nutrition and accelerates hospital discharge, especially after highly stressful pancreatic surgeries. Because benefits vary by surgical magnitude, prehabilitation pathways should be tailored to prioritize high-risk patients facing complex operations. Full article

Background: Vascular leiomyosarcoma (LMS) is an exceptionally rare and aggressive soft tissue sarcoma arising from the smooth muscle cells of the vascular wall. They account for approximately 0.5–2% of adult soft-tissue sarcomas and are the most frequent primary malignancy of vascular origin. Among venous sites, the inferior vena cava (IVC) is the most frequently involved, accounting for more than half of reported vascular LMS cases, with rarer occurrences in peripheral veins, including the internal saphenous vein and the external iliac vein. Case Presentation: We report a case series comprising two distinct presentations of vascular LMS involving the internal saphenous vein and the inferior vena cava, respectively. Each case highlights unique clinical manifestations, radiologic features, histopathologic diagnosis, and therapeutic challenges inherent to the involved vascular territory. Surgical resection with clear margins was the primary treatment modality, complemented by adjuvant therapies tailored according to tumor grade and extent. Literature Review: An updated literature review contextualizes these findings, detailing epidemiology, diagnostic challenges, prognostic factors, and current management approaches. It emphasizes the rarity of leiomyosarcomas originating from major venous pathways and highlights variability in clinical presentation, tumor size, growth patterns, and outcomes. Achieving complete surgical removal with negative margins continues to be the primary treatment goal and the most significant prognostic factor. Conclusions: Given the paucity of cases, our series contributes valuable insights into the clinical spectrum and multidisciplinary approach necessary for optimal outcomes in vascular LMS. Early recognition and aggressive treatment remain paramount to improving survival in this rare malignancy. Full article

Background: Enterococcus faecium bloodstream infections (EF-BSI) cause significant morbidity and mortality in solid organ transplant (SOT) recipients, with the role of vancomycin resistance (VR) remaining controversial as an independent driver. Methods: This was a retrospective cohort study including SOT recipients with EF-BSI at our institution from 2019 to 2023. We used Cox proportional hazards regression to identify predictors of 30-day all-cause mortality. A time-dependent covariate was used to model the effects of receiving targeted, effective antibiotic therapy. Results: A total of 79 patients were included (26.6%, with VR). The overall 30-day mortality was 12.7% (10/79). In univariable analysis, septic shock (Hazard Ratio, HR: 17.1, 95% CI: 3.64–80.8, p < 0.001), the need for Continuous Venovenous Hemofiltration (HR: 6.40, 95% CI: 1.85–22.1, p = 0.003), and a Pitt Bacteremia Score ≥ 2 (HR: 5.17, 95%CI: 1.10–24.3, p = 0.038) were associated with increased mortality, while source control was protective (HR: 0.20, 95% CI: 0.05–0.76, p = 0.018). In the final multivariable model, only septic shock remained an independent predictor of 30-day mortality (HR: 11.4, 95% CI: 1.63–79.5, p = 0.014). VR was not significantly associated with mortality, though the confidence interval was wide and included clinically meaningful effects (HR: 2.07, 95% CI: 0.40–10.6, p = 0.4). Conclusions: In SOT recipients with EF-BSI, 30-day mortality is overwhelmingly driven by the host’s physiological response, manifested as septic shock, rather than the VR profile of the pathogen. The early recognition of severe sepsis/septic shock and the aggressive implementation of supportive care and source control measures in this setting are crucial. Full article

The gut immune microenvironment and the liver engage in intricate information exchange via the gut–liver axis. The disruption of these interactions plays a pivotal role in the formation and exacerbation of pathological damage to the liver. The gut immune microenvironment is not an independent layer of the gut barrier; rather, it permeates and regulates all other barrier functions, serving as the core coordinator. Disruption of the immune microenvironment in the gut–liver axis drives progression across the full disease spectrum—from steatosis to hepatitis, fibrosis, and even liver cancer—through the continuous influx of immune-stimulatory signals that overwhelm the liver’s intrinsic immune regulatory mechanisms. Dysfunction of innate immunity components, amplification of inflammatory factors and key cellular signaling pathways, activation of adaptive immune T cells, and systemic effects mediated by liver-derived inflammatory factors collectively form a disordered immune microenvironment. This damages the intestinal barrier and exacerbates liver disease via the gut–liver axis, leading to further intestinal injury, thus establishing a self-reinforcing vicious cycle. Current therapeutic strategies based on modulating the gut–liver axis microenvironment remain limited, yet studies have demonstrated that suppressing gut immune cells, cytokines, and signaling pathways can help delay liver disease progression. Hopefully, future combined, precise, and cutting-edge gut immunotherapies will provide more effective strategies for liver disease treatment. Full article

Introduction: Graft and patient survival after kidney transplantation in children has increased in the past decade; however, post-transplant surgical complications occur in up to 15.4% of recipients and pose a significant threat to graft survival. Due to anatomic discrepancies in children, kidney transplantation in this population is nuanced and requires meticulous planning. This narrative review summarizes the most common postoperative surgical complications following kidney transplantation in children. Methods: PubMed and Google Scholar were queried for full-text articles that reported pediatric kidney transplantation surgical complications and their management following kidney transplantation. Results: Vascular complications can occur in approximately 1.3–13.8% of cases and are the leading cause of graft nephrectomy, with arterial stenosis and venous thrombosis being the most common. Urologic complications occur in 1.3–30% of patients and are more frequent in children due to pre-existing genitourinary abnormalities prior to transplantation. Vesicoureteral reflux is the most common urologic complication. Discussion: Surgical complications following kidney transplantation in children continue to significantly affect graft viability. Ultimately, meticulous surgical techniques and close postoperative surveillance are critical to mitigating the risk of allograft nephrectomy. Prospective studies focused on best surgical practice, techniques, prevention, and postoperative care in pediatric kidney transplant recipients are needed. Full article

Metabolic dysfunction-associated steatotic liver disease (MASLD) is strongly linked to systemic metabolic disturbances and features a lipid-driven cascade that promotes hepatic inflammation and fibrosis. Choline insufficiency contributes to disease advancement by altering phospholipid turnover and redox homeostasis; however, its spatial and temporal regulatory roles throughout MASLD progression remain insufficiently defined. A 10-week high-fat, choline-deficient (HFCD) mouse model was established, and liver pathology was evaluated at weeks 6, 8, and 10. Time-resolved assessments combined untargeted metabolomics, magnetic resonance imaging–proton density fat fraction (MRI-PDFF), serum biochemistry, histological staining, immunofluorescence, and transmission electron microscopy to characterize dynamic alterations in lipid metabolism, redox status, inflammation, and fibrogenesis. The HFCD diet produced a clear temporal sequence of liver injury. Steatosis, phosphatidylcholine depletion, and early antioxidant loss appeared by week 6. By week 8, mitochondrial structural damage and pronounced cytokine elevation were evident. At week 10, collagen deposition and α-SMA activation signaled fibrotic progression. Metabolomics indicated significant disruptions in pathways related to ATP-binding cassette (ABC) transporters, one-carbon metabolism, and the tricarboxylic acid (TCA) cycle. Using integrated analytical strategies, this study suggests that choline deficiency may be associated with a time-dependent pathological cascade in MASLD, beginning with phospholipid destabilization and extending to altered mitochondria–endoplasmic reticulum crosstalk at mitochondria-associated membranes, alongside amplified oxidative–inflammatory responses, which collectively may contribute to progressive fibrogenesis as the disease advances. Full article

Background: The management of complex hepato-pancreato-biliary (HPB) pathologies demands exceptional surgical precision. Traditional two-dimensional imaging has limitations in depicting intricate anatomical relationships, potentially complicating preoperative planning. This review explores the synergistic application of three-dimensional (3D) reconstruction and artificial intelligence (AI) to support surgical decision-making in complex HPB cases. Methods: This narrative review synthesized the existing literature on the applications, benefits, limitations, and implementation challenges of 3D reconstruction and AI technologies in HPB surgery. Results: The literature suggests that 3D reconstruction provides patient-specific, interactive models that significantly improve surgeons’ understanding of tumor resectability and vascular anatomy, contributing to reduced operative time and blood loss. Building upon this, AI algorithms can automate image segmentation for 3D modeling, enhance diagnostic accuracy, and offer predictive analytics for postoperative complications, such as liver failure. By analyzing large datasets, AI can identify subtle risk factors to guide clinical decision-making. Conclusions: The convergence of 3D visualization and AI-driven analytics is contributing to an emerging paradigm shift in HPB surgery. This combination may foster a more personalized, precise, and data-informed surgical approach, particularly in anatomically complex or high-risk cases. However, current evidence is heterogeneous and largely observational, underscoring the need for prospective multicenter validation before routine implementation. Full article

Frozen section (FS) analysis is a rapid intraoperative tool that provides real-time pathological assessment, guiding surgical decisions in gastrointestinal and hepatobiliary disease. Its main applications include confirming diagnoses, assessing resection margins, staging lymph nodes, and evaluating unexpected intraoperative findings. Drawing on a 14-year experience at Queen’s Medical Centre, Nottingham, this review highlights the strengths and limitations of FS in gastrointestinal and hepatopancreato-biliary surgery. Concordance with final paraffin diagnoses exceeded 97%, underscoring its reliability when performed under optimal conditions. FS is particularly valuable in complex scenarios such as distinguishing benign from malignant hepatic or pancreatic lesions, identifying metastatic disease, and evaluating conditions like Hirschsprung disease. Although interpretive artefacts and sampling errors remain challenges, careful technique and close clinical–pathological communication mitigate these issues. Beyond diagnosis, FS also supports molecular applications through targeted tissue selection for genomic testing. Overall, FS remains an essential adjunct to modern surgical pathology, enhancing intraoperative decision-making and contributing to precision oncology. Looking ahead, the integration of FS with artificial intelligence, telepathology, and minimally invasive surgical platforms is poised to expand its accuracy, accessibility, and impact in real-time precision surgery. Full article

Background and Objectives: Bile leak is a common complication after hepatopancreatobiliary surgery, requiring timely management to prevent life-threatening outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) is essential in treatment, but large data concerning optimal timing and technique selection are unavailable. This study evaluates whether the timing of ERCP influences healing and if different bile duct injuries affect outcomes. Materials and Methods: Data from a prospectively maintained database over 25 years (2001–2025) included 176 patients (M/F: 91/85, mean age 62) undergoing ERCP for bile leaks. Results: Most leaks followed cholecystectomy (n = 143, 81.5%). The median time from leak to ERCP was 7 days. Ten patients (5.7%) had complete common bile duct (CBD) transection—considered major leaks—requiring surgery. Among the 166 minor leaks, the cystic duct stump (40.1%) was the most common injury site, followed by the CBD (24.1%) and the gallbladder bed (15.4%). Healing occurred in 90.6%. Stent placement improved healing rates (93.9% vs. 75.9%, p = 0.007), with no difference between pig-tail and (Amsterdam) straight plastic stents (90% vs. 96%, p = 0.267). Retained CBD stones or CBD strictures did not affect outcomes. Leaks from the cystic duct stump had a 96.9% resolution rate, whereas gallbladder bed leaks healed in 88%. The median healing time was 2 days, unaffected by stent placement or ES alone (p = 0.842), but later ERCP correlated with longer healing (RR: 0.362, p < 0.001). Following a right aberrant bile leak, the time for healing was longer than in leaks from other sites. Conclusions: ERCP with stenting remains the first-line approach for minor bile leaks. Early ERCP accelerates healing, emphasizing the importance of prompt intervention. Full article

Background: Hepatopancreatobiliary (HPB) surgery is among the most complex domains in oncologic care, where decisions entail significant risk–benefit considerations. Artificial intelligence (AI) has emerged as a promising tool for improving individualized decision-making through enhanced risk stratification, complication prediction, and survival modeling. However, its role in HPB oncologic surgery has not been comprehensively assessed. Methods: This systematic review was conducted in accordance with PRISMA guidelines and registered with PROSPERO ID: CRD420251114173. A comprehensive search across six databases was performed through 30 May 2025. Eligible studies evaluated AI applications in risk–benefit assessment in HPB cancer surgery. Inclusion criteria encompassed peer-reviewed, English-language studies involving human s ubjects. Two independent reviewers conducted study selection, data extraction, and quality appraisal. Results: Thirteen studies published between 2020 and 2024 met the inclusion criteria. Most studies employed retrospective designs with sample sizes ranging from small institutional cohorts to large national databases. AI models were developed for cancer risk prediction (n = 9), postoperative complication modeling (n = 4), and survival prediction (n = 3). Common algorithms included Random Forest, XGBoost, Decision Trees, Artificial Neural Networks, and Transformer-based models. While internal performance metrics were generally favorable, external validation was reported in only five studies, and calibration metrics were often lacking. Integration into clinical workflows was described in just two studies. No study addressed cost-effectiveness or patient perspectives. Overall risk of bias was moderate to high, primarily due to retrospective designs and incomplete reporting. Conclusions: AI demonstrates early promise in augmenting risk–benefit assessment for HPB oncologic surgery, particularly in predictive modeling. However, its clinical utility remains limited by methodological weaknesses and a lack of real-world integration. Future research should focus on prospective, multicenter validation, standardized reporting, clinical implementation, cost-effectiveness analysis, and the incorporation of patient-centered outcomes. Full article

Background/Objectives: Cholecystectomy (CE) is among the most commonly performed surgical procedures worldwide. While it effectively treats gallstone disease, concerns have been raised about a potential long-term association with colorectal cancer (CRC), given overlapping risk factors and post-surgical physiological changes. Previous studies have reported inconsistent findings. This updated systematic review aimed to reassess the association between CE and CRC risk by incorporating the most recent evidence. Methods: In accordance with PRISMA 2020 guidelines, a systematic literature search was conducted in PubMed, Embase, Medline, Web of Science, and the Cochrane Library for studies published after May 2022. Eligible studies were observational cohort studies reporting relative risk estimates for CRC following CE. Data were extracted manually, and study quality was assessed using the NewcastleOttawa Scale (NOS). Only high-quality studies were included to update the systematic review. Publication bias was assessed using funnel plots and Egger’s test. Results: Out of 156 identified records, three new high-quality cohort studies met the inclusion criteria and were added to the 18 studies from the previous review, resulting in a total of 21 studies. The findings were heterogeneous: while no consistent association with overall CRC risk was observed, several studies reported an elevated risk of proximal (right-sided) colon cancer following CE. Egger’s test indicated no significant publication bias (p = 0.50). Conclusions: This updated systematic review suggests a potential association between CE and an increased risk of proximal colon cancer; however, the evidence remains inconclusive. Further prospective studies with robust confounder control and detailed tumor location-specific analyses are warranted to clarify causality and guide future screening strategies. Full article