Concept Of Surgical Treatment Research Articles

Novel concepts for surgical treatment of pancreatic cancer

Novel concepts for surgical treatment of pancreatic cancer

Foot surgery for internal offloading in diabetic foot syndrome (DFS) - therapy and prevention

Offloading for DFS must not mean immobilisation. The independence of those affected must not be significantly restricted by the treatment outside of emergency situations. Surgical options, which must be adapted to the degree of mobility of the affected person, can be helpful here. Entities are subgroups of DFS that are defined by their location. They provide easy access to the biomechanical causes of wounds, the prognosis and the surgical treatment concepts. There are often surgical alternatives to amputations and the fear of complications is not justified, as the main complication is usually the amputation itself. Neuropathy-related postoperative treatment cancellations during ulcer offloading must be safely ruled out.

Risk-benefit analysis of surgical treatment strategies for cystic craniopharyngioma in children and adolescents.

Treatment strategies for craniopharyngiomas are still under debate particularly for the young population. We here present tumor control and functional outcome data after surgical treatment focusing on stereotactic and microsurgical procedures for cystic craniopharyngiomas in children and adolescents. From our prospective institutional database, we identified all consecutive patients less than 18 years of age who were surgically treated for newly-diagnosed cystic craniopharyngioma between, 2000 and, 2022. Treatment decisions in favor of stereotactic treatment (STX) or microsurgery were made interdisciplinary. STX included aspiration and/or implantation of an internal shunt catheter for permanent cyst drainage. Microsurgery aimed for safe maximal tumor resections. Study endpoints were time to tumor recurrence (TTR) and functional outcome including ophthalmological/perimetric, endocrinological, and body-mass index (BMI) data. 29 patients (median age 9.9 yrs, range 4-18 years) were analyzed. According to our interdisciplinary tumor board recommendation, 9 patients underwent stereotactic treatment, 10 patients microsurgical resection, and 10 patients the combination of both. Significant volume reduction was particularly achieved in the stereotactic (p=0.0019) and combined subgroups (p<0.001). Improvement of preoperative visual deficits was always achieved independent of the applied treatment modality. Microsurgery and the combinational treatment were associated with higher rates of postoperative endocrinological dysfunction (p<0.0001) including hypothalamic obesity (median BMI increase from 17.9kg/m2 to 24.1kg/m2, p=0.019). Median follow-up for all patients was 93.9 months (range 3.2-321.5 months). Recurrent tumors were seen in 48.3% and particularly concerned patients after initial combination of surgery and STX (p=0.004). In here, TTR was 35.1 ± 46.9 months. Additional radiation therapy was found indicated in 4 patients to achieve long-lasting tumor control. In children and adolescents suffering from predominantly cystic craniopharyngiomas, stereotactic and microsurgical procedures can improve clinical symptoms at low procedural risk. Microsurgery, however, bears a higher risk of postoperative endocrine dysfunction. A risk-adapted surgical treatment concept may have to be applied repeatedly in order to achieve long-term tumor control even without additional irradiation.

Local negative pressure technique in abdominal surgery: advantages, disadvantages, controversial issues

A literature review of studies on the use of local negative pressure technique (vacuum therapy) in abdominal surgery is presented. The article highlights modern approaches to its use in emergency pathology of the abdominal cavity and retroperitoneal space. The mechanisms of action, advantages and disadvantages of the local negative pressure technique, as well as the main morphofunctional aspects of its application are discussed in detail. Data from recent clinical studies and meta-analyses are summarized, and the effectiveness of using vacuum-assisted laparostomy within the framework of the «damage control» concept in multi-stage surgical treatment of injuries and urgent abdominal diseases accompanied by abdominal sepsis is demonstrated. The use of local negative pressure techniques can reduce postoperative mortality, as well as shorten the length of hospital treatment of patients. However, despite the obvious positive effect on the course of the wound process, vacuum therapy carries the risk of developing serious complications, the most dangerous of which are bleeding and perforation of hollow organs. In addition, it requires very expensive equipment and consumables, as well as training of medical personnel. Thus, the use of vacuum therapy requires a sound approach and a clear understanding of the technical features of its implementation. However, the indications for the use of local negative pressure in abdominal surgery have not yet been clarified, which undoubtedly hinders the wider introduction of this promising technique into clinical practice.

Radical Hysterectomy or Total Mesometrial Resection-Two Anatomical Concepts for Surgical Treatment of Cancer of the Uterine Cervix.

A radical hysterectomy is the standard method of surgical treatment for patients with early-stage cancer of the uterine cervix. It was first introduced more than 100 years ago. Since then, various and many different radical procedures, which diverge in terms of radicality, have been described. Inconsistencies are clearly seen in practical anatomy, which were defined as surgically created artifacts. Moreover, the disparity of the procedure is most notable regarding the terminology of pelvic connective tissues and spaces. Despite these controversies, the procedure is widely performed and implemented in the majority of guidelines for the surgical treatment of cancer of the uterine cervix. However, a different and unique concept of surgical treatment of cervical cancer has been reported. It is based on ontogenetic anatomy and maps any tissue in the mature organism according to its embryologic development. The clinical implementation of this theory in the context of early cervical cancer is total mesometrial resection. The present article aims to describe and compare the anatomical and surgical basics of a radical hysterectomy (type C1/C2) and total mesometrial resection. Discrepancies regarding the terminology, resection lines, and surgical planes of both procedures are highlighted in detail. The surgical anatomy of the pelvic autonomic nerves and its surgical dissection is also delineated. This is the first article that compares the discrepancy of classic anatomy and ontogenic anatomy regarding surgical treatment of cancer of the uterine cervix. Clinical data, oncological outcome, and neoadjuvant and adjuvant treatment regarding both procedures are not the topic of the present article.

Current status of metabolic and bariatric surgery in Beijing: results of an initial survey

Objectives: To investigate the current status of metabolic and bariatric surgery (MBS) in Beijing's hospitals and to provide evidence to promote homogenization of medical development, standardizing clinical behavior, and continuously improving medical quality. Methods: This survey was conducted in September 2022 to investigate 27 hospitals in Beijing that had conducted MBS through a questionnaire survey. The questionnaire includes basic information from medical institutions, departmental information and MBS implementation, and statistical description of the results was performed. Results: At present, 27 hospitals in Beijing had carried out MBS and participated in quality control, among which 4 hospitals had established independent departments for MBS. The total number of beds for MBS was 234, and the number of doctors engaged in the specialty of MBS was 126. Among the 27 hospitals, 22 hospitals had weight-reduction and metabolic specialty clinics or multidisciplinary teams. Eleven hospitals had established 14 positions of case manager. In 2021, 1 hospital had ≥500 surgical cases, 3 hospitals had 200 to <500, 2 hospitals had 100 to <200, 3 hospitals had 50 to <100, 6 hospitals had 20 to <50, and 12 hospitals had less than 20. Twenty-six hospitals performed sleeve gastrectomy, 16 hospitals performed Roux-en-Y gastric bypass, 3 hospitals performed one anastomosis gastric bypass, 1 hospital performed biliopancreatic diversion with duodenal switch, 1 hospital performed single anastomosis duodeno-ileal bypass with sleeve gastrectomy. Six hospitals performed revisional surgery after MBS and 4 hospitals performed robotic-assisted MBS. Additionally, 15 hospitals had joined the Greater China Metabolic and Bariatric Database. Conclusions: MBS in Beijing is in the process of development. It is still necessary to clarify the position and role of surgery in the treatment of obesity and metabolic diseases, determine the concept and goal of surgical treatment of related diseases, and establish the corresponding surgical standards.

Recognition of empty pelvic syndrome and its prevention and treatment

With the development of existing surgical techniques, equipment and treatment concepts, more and more medical centers begin to carry out extensive resection for recurrent pelvic malignant tumors or those with multivisceral invasion. Exenteration may facilitate curative resection and improve the outcome of the patients. Therefore, pelvic exenteration has gradually become the standard of care for locally advanced pelvic malignancies. At present, pelvic exenteration leads to high intraoperative and postoperative complications and mortality, and therefore compromise the safety and long-term quality of life. Cumulating evidences suggest remnant cavity after exenteration might trigger the pathophysiological process and cause downstream complications which can be defined as empty pelvis syndrome. The literature related to empty pelvic syndrome was summarized, the possible cause of empty pelvic syndrome was analyzed. After the pelvic exenteration, the closed pelvic residual cavity formed continuous negative pressure with the gradual absorption of air in the cavity, bacterial propagation, and accumulation of fluid, which had an impact on the distribution of organs in the abdominal and pelvic cavity. At the same time, whether physical processes also play a role in the occurrence of empty pelvic syndrome remains to be explored. It is concluded that the diagnosis is mainly based on the patient's medical history, clinical manifestations and radiological findings, and the history of pelvic exenteration is the most important indicator in the diagnosis. In terms of prevention measures, we should identify the high-risk groups of the occurrence of empty pelvic syndrome, and then take accurate and individualized preventive measures. Various new biomaterials have more advantages in preventive pelvic cavity filling than traditional human tissue filling. Mesentery plays an important role in the morphology, peristalsis and arrangement of the small intestine. More attention should be paid to reducing the ectopic placement of the small intestine into the pelvic cavity by protecting the mesentery structure and restoring or rebuilding the mesentery morphology. In terms of treatment measures, there is still a lack of standard treatment pathway for empty pelvic syndrome.

Vacuum-assisted laparostomy in severe abdominal trauma and urgent abdominal pathology with compartment syndrome, peritonitis and sepsis: Comparison with other options for multistage surgical treatment (systematic review and meta-analysis)

Background. The concept of multistage surgical treatment of patients has been established in surgery rather recently and therefore the discussions on the expediency of using a particular surgical technique in a specific situation still continue. Vacuum-assisted laparostomy is being widely implemented into clinical practice for the treatment of abdominal compartment syndrome, severe peritonitis and abdominal trauma, but the indications and advantages of this method are not clearly defined yet.The aim of the study. To conduct a systematic review and meta-analysis on the comparison of the effectiveness of vacuum-assisted laparostomy with various variants of relaparotomy and laparostomy without negative pressure therapy in the treatment of patients with urgent abdominal pathology and abdominal trauma complicated by widespread peritonitis, sepsis or compartment syndrome.Material and methods. A systematic literature search was conducted in accordance with the recommendations of “Preferred Reporting Items for Systematic Reviews and Meta-Analyses”. We carried out the analysis of non-randomized (since January 2007 until August 6, 2022) and randomized (without time limits for the start of the study and until August 6, 2022) studies from the electronic databases eLibrary, PubMed, Cochrane Library, Science Direct, Google Scholar Search, Mendeley.Results. Vacuum-assisted laparostomy causes statistically significant shortening of the time of treatment of patients in the ICU and in hospital and a decrease in postoperative mortality compared to other variants of laparostomy without vacuum assistance.Conclusion. To obtain data of a higher level of evidence and higher grade of recommendations, it is necessary to further conduct systematic reviews and meta-analyses based on randomized clinical studies.

Robot-assisted transmediastinal esophagectomy: The path of concept and practice

The technique and concept of surgical treatment of esophageal cancer are constantly progressing. Using a combination of transcervical mediastinoscopy and robotic systems, this approach facilitates upper mediastinal operations without the need for thoracic manipulation. Its potential advantages comprise shorter operation times, reduced postoperative pain, shorter hospital stays, and fewer pulmonary complications. Additionally, patients unfit for traditional thoracic surgery might benefit from this approach. This article aims to introduce and share the surgical techniques and prospects of robot-assisted transmediastinal esophagectomy.

Achievements and Prospects for Vascular Surgery in Treatment of Vertebrobasilar Insufficiency

Vertebrobasilar insufficiency (VBI) remains an important problem in the modern medicine since approximately every fourth cerebral infarction occurs in the posterior circulation of the brain. These strokes are accompanied by severe consequences and a high risk of repeated events. The article presents the current concepts for surgical treatment of lesions of the subclavian (ScA) and vertebral (VA) arteries responsible for the development of VBI. In the open surgical treatment of symptomatic lesion of the ScA, primarily of occlusion one, extrathoracic interventions prevail in the form of carotid-subclavian bypass and carotid-subclavian transposition. According to our analysis, the results of carotid-subclavian transposition prove to be more preferable. In the endovascular intervention on the ScA, balloon angioplasty is used with possible stenting. In the analysis, we found no differences in the long-term patency between angioplasty and stenting, although the extent of technical success was higher in the group of stenting. In case of stenosis of the ScA, the world medicine gives priority to endovascular methods. To date, there are no sharply defined criteria permitting to choose between the open and endovascular interventions for treatment of the ScA occlusion, although a probable technical failure of endovascular revascularization and higher long-term patency give priority to open surgery. As for symptomatic stenosis of VA, to date there is no evidence of the advantage of stenting over conservative therapy. Thus, surgical intervention should rather be used in case the drug treatment is ineffective. The same can be said about the open reconstruction of the VA, except for the cases of contraindications for stenting of the VA, for example, its tortuosity.

Influence of different sphincter-preserving surgeries on postoperative defecation function

Advances in surgical techniques and treatment concept have allowed more patients with low rectal cancer to preserve sphincter without sacrificing survival benefit. However, postoperative dysfunctions such as fecal incontinence, frequency, urgency, and clustering often occur in patients with low rectal cancer. The main surgical procedures for low rectal cancer include low anterior rectum resection (LAR), intersphincteric resection (ISR), coloanal anastomosis (Parks) and so on. The incidence of major LARS after LAR is up to 84.6%. The postoperative function of ISR is even worse than LAR. Moreover, the greater the extent of resection ISR surgery, the worse the postoperative function. There are few studies on the function of Parks procedure. Current evidence suggests that the short-term function of Parks procedure is inferior to LAR, but function can gradually recovered over time. Colorectal surgeons have attempted to improve postoperative defecation by modifying bowel reconstructions. Current evidence suggests that J pouch or end-to-side anastomosis during LAR does not reduce the incidence of defecation disorders. Pouch reconstruction during ISR cannot reduce the incidence of severe LARS either. In general, the protection of postoperative defecation function in patients with low rectal cancer still has a long way to go.

Exploring Surgeons', Nurses', and Patients' Information Seeking Behavior on Medical Innovations: The Case of 3D Printed Biodegradable Implants in Breast Reconstruction.

To explore information seeking behavior on medical innovations. While autologous and alloplastic options for breast reconstruction are well established, it is the advent of the combination of 3D printing technology and the biocompatible nature of a highly porous biodegradable implants that offers new treatment options for the future. While this type of prosthesis is not yet clinically available understanding how patients, surgeons, and nurses take up new medical innovations is of critical importance for efficient healthcare provision. Using the largest ever combined sample of breast cancer patients (n = 689), specialist surgeons (n = 53), and breast care nurses (n = 101), we explore participants preference for a new surgical treatment concept rooted in 3D printed and biodegradable implant technologies in the context of breast reconstruction. We find that patients overwhelmingly favor information from a successful patient of the proposed new technology when considering transitioning. Surgeons and nurses instead favor regulatory body advice, peer-reviewed journals, and witnessing the procedure performed (either in person or online). But while 1 in 4 nurses nominated talking to a successful patient as an information source, not a single surgeon chose the same. Our multinomial logit analysis exploring patient preference (controlling for individual differences) showed statistically significant results for both the type of surgical treatment and choice to undergo reconstruction. Women who underwent a type of mastectomy procedure (compared with lumpectomy patients) were more likely to choose a former patient than a surgeon for seeking information relating to a new breast implant technology. Further, women who chose to undergo a reconstruction procedure, compared with those who did not, where more likely to prefer a surgeon for information relating to a new breast implant technology, rather than a successful patient. For medical professionals, we find no statistically significant relationship between medical professionals' preference and their age, nor the number of other medical professionals they work with daily, nor the average number of breast procedures performed in their practice on a weekly basis. As our findings show large variation exists (both within our patient group and compared with medical professionals) in where individuals favor information on new medical innovations, future behavioral research is warranted.

Evaluation of results of combined treatment in patients with disseminated ovarian cancer

Background. According to the modern concept of surgical treatment of ovarian cancer (OC) it is necessary to perform cytoreductive surgery (CRS) without residual tumor in order to achieve more favorable oncological prognoses. However, the possibilities of achieving it with a disseminated process (stages IIIIV) are limited, and therefore, for some patients, neoadjuvant chemotherapy (NACT) is the optimal initial treatment.&#x0D; Aim. To compare the duration of progression-free survival (PFS) of patients with advanced OC after treatment, as well as to assess the value of the prognostic nutritional index (PNI) in predicting this outcome.&#x0D; Materials and methods. We conducted a retrospective cohort study of 78 patients with stages IIIIV OC, who received combined treatment between January 2016 and March 2020 (54 patients after primary CRS (PCRS)+platinum-based chemotherapy (CT), 24 patients after NACT+interval CRS (ICRS)+postoperative CT. The predictive value of the PNI was calculated.&#x0D; Results. The complete PCRS is associated with increased PFS: after complete PCRS 3211.21 months (95% confidence interval CI 10.0953.97); after optimal PCRS 223.46 months (95% CI 15.2128.79); after suboptimal PCRS 147 months (95% CI 0.2827.72). Performing a complete ICRS is associated with decreased PFS compared to PCRS, even if the complete CRS is achieved: after complete ICRS 143.34 months (95% CI 7.4620.54); after optimal ICRS 172.16 months (95% CI 12.7721.23); after suboptimal ICRS 7 months. PNI27.86 correlates with an increased probability of complete PCRS in patients with advanced PCR (AUC 94.3, sensitivity 80%, specificity 91.7%; p0.001).&#x0D; Conclusion. Achieving complete PCRS in patients with disseminated OC leads to an improvement in the oncological outcome. The prognostic value of pre-treatment calculation of PNI has been revealed: an increased PNI is associated with more favorable perioperative outcomes. Objective criteria should be developed for a strictly reasoned refusal to carry out the first stage of surgical treatment due to the obviously less favorable prognosis of the tactics of "NACT+ICRS+CT".

Changing the concept of surgical treatment of the brachial plexus traumatic injuries

Objective: the objective of this study was to retrospectively analyze the change in the surgical strategy (SS) of brachial plexus injuries (BPI), the outcomes of different SS and the factors that influenced the establishing process of a new SS in a single surgical centre in Kyiv, Ukraine. Materials and Methods. 148 patients (mean age 29.5) received 76 neurolysis (N), 14 grafting (G) and 58 nerve transfer (NT) surgeries after a mean 7.4 months following BPI. 29 patients received NT of n. phrenicus, 7 –ulnar nerve fascicles, 9 – lateral pectoral nerve, 7 – medial pectoral nerve to musculocutaneous nerve aimed to restore active elbow flexion. Six other patients received NT of ipsilateral extraplexal motor nerves. The follow-up period included neurological examination (MRC Scale), electromyographic examination and angular deviation in the elbow joint during recovered active elbow flexion. 148 patients were retrospectively divided into two groups A (102 patients, received surgeries from surgical team #1) and B (46 patients, received surgeries from surgical team #2). The SS used in each group and its change with time was analyzed during the 6-year span. Results. 41 patients (70.7%) showed recovery of effective power (Ep) (M4-5) of biceps brachii muscle (BB) after NT. 14 patients (18.4%) showed recovery of Ep of BB after N. 4 patients (28.6%) showed recovery of Ep of BB after G. Overall Group A patients received 55 NT, Group B – 3 NT. The number of NT among Group A patients increased in 2013-2019 from 31% to 100% with overall efficacy of NT increased from 50% to 83%. Conclusions. SS of BPI changed only for Group A patients – N was completely replaced by NT in 2019. For Group B patients N remained SS of choice. The establishing of new SS was influenced by four factors (time, anatomy of injury, donor nerves, radiological findings). The factors being processed, allowed us to define optimal time, effective donors and non-reliability of radiology at BPI. We state that it is only matter of own experience, based on the thorough analysis of the technique, that brings positive outcomes after new SS has been adopted.

Venous Flap Reconstruction following Wide Local Excision for Primary Cutaneous Malignancies in Extremities.

Background:Cutaneous malignancies in the extremities are relatively common, and radical treatment such as ray amputation was performed for certain advanced skin cancer cases in the past. The concept of surgical treatment of primary cutaneous malignant tumor has gradually changed, and preservation of the extremity by performing the appropriate excision and reconstruction became possible. Various reconstructive methods after the resection of malignant tumors such as skin grafts, local flaps, and free flaps, including perforator flaps have been noted. Due to limitations and some disadvantages of these reconstructive materials for extremities, the arterialized venous flap arose as an alternative method. The arterialized venous flap, which has arterial inflow through an afferent vein perfusing the flap and venous outflow through the efferent veins, is considered to function as a great reconstructive material for distal extremities. Although efficacy of this flap has been noted in the past, usage of the flap considering the oncological aspects and application of the flap to the toes and feet have never been reported.Methods:Thirteen reconstructive cases from October 2005 to October 2016 using venous flaps after excision of primary cutaneous malignancy in the distal extremities were performed in our institution.Results:For all cases, satisfactory functional and cosmetic outcomes were observed.Conclusions:Reconstruction using the arterialized venous flap is considered a reliable and versatile method. Careful application of this flap satisfies functional, cosmetic, and oncological aspects of all distal extremities with cutaneous malignancy.

РОЛЬ И ЗНАЧЕНИЕ ПЕРЕНОСА НЕРВА ПРИ НЕВОССТАНОВИМЫХ ПОВРЕЖДЕНИЯХ НЕРВОВ ВЕРХНЕЙ КОНЕЧНОСТИ

Objective: To share the experience of using nerve transfer in the irreparable upper limb nerve damage. Methods: An analysis was made of various transfers (neurotization surgery) in 32 patients with upper limb nerve damage aged 22 to 59 years (27 males, 5 females). Nerve injuries were localised at the level of the forearm (18), shoulder (11) and brachial plexus (3). Surgical repair was aimed at restoring sensitivity and movement in 22 and 10 cases, respectively. For sensitive neurotization, the cutaneous branches of the radial nerve (RN), the dorsal branch of the ulnar nerve (UN), the superficial branch of the UN, and the cutaneous nerves of the forearm were more often used. Motor neurotization was achieved using the branches of the anterior interosseous nerve (AIN), thoracodorsal nerve (TDN), muscular branches of the UN, intercostal nerves (ICNs), and terminal and muscular branches of the brachial and cervical plexuses, respectively. Results: Long-term outcomes were evaluated between years 1 and 8. Sensitivity was restored to S3 grade (protective sensitivity), and motor strength reached M3-M4 grades according to British Medical Research Council (MRC) scale. Conclusion: Nerve transfer in irreparable nerve damage allows expanding the boundaries of reconstructive surgery. Furthermore, it opens new horizons for future scientific research to improve modern surgical treatment concepts of peripheral nerve injuries. Keywords: Upper limb nerve injury, irreparable damage to the upper limb nerves, neurotization, nerve displacement, nerve transfer.

Current State of the Posterior Malleolus Osteosynthesis Concept in Patients with Ankle Fractures (Literature Review)

Summary. The problem of posterior malleolus (PM) fractures osteosynthesis remains the subject of scientific debate, despite extensive experience in surgical treatment and a large number of biomechanical and clinical studies.&#x0D; Objective: to analyze current literary concepts of surgical treatment of PM in patients with ankle fractures.&#x0D; Results and Сonclusions. The available literature does not provide a complete understanding of the problem of surgical treatment of PM fractures. The current consensus suggests that restoring the anatomy of the articular surface of the tibial plateau and concomitant damage to the medial and lateral structures of the ankle joint, along with ensuring its stability, is the key to the successful treatment of РМ injuries. The lack of high-quality recommendations and a unified protocol for the choice of treatment tactics, as well as a sufficiently high percentage of unsatisfactory results determine the need to improve the existing principles of surgical treatment.

Study on the Effect of Accelerated Rehabilitation Surgery Concept in Surgical Treatment of Elderly Coronary Heart Disease

Study on the Effect of Accelerated Rehabilitation Surgery Concept in Surgical Treatment of Elderly Coronary Heart Disease

Nerve entrapment around elbow

Entrapment neuropathy around elbow is a common cause of disability across all age groups. The major nerves that traverse the elbow are ulnar, median and radial nerves and their branches. Cubital tunnel syndrome leading to ulnar nerve compression can often present with significant pain, paresthesia or weakness. Median and Radial nerve compression around the elbow, albeit less frequent, can also lead to significant morbidity and must be kept in the differential diagnosis when dealing with patients complaining of persistent pain around the elbow and weakness of forearm/hand muscles. Electrodiagnostic studies can be a useful adjunct to clinical examination, to help localize the site and quantify the grade of compression. Management should involve a trial of conservative treatment and failing that, surgical treatment should be considered. We hereby provide an overview of nerve entrapments around the elbow including their applied anatomy, etiology, clinical assessment and overview of the current concepts in surgical treatment.

Risk of the Watch-and-Wait Concept in Surgical Treatment of Intraductal Papillary Mucinous Neoplasm

The natural history of intraductal papillary mucinous neoplasms (IPMNs) remains uncertain. The inconsistencies among published guidelines preclude accurate decision-making. The outcomes and potential risks of a conservative watch-and-wait approach vs a surgical approach must be compared. To provide an overview of the surgical management of IPMNs, focusing on the time of resection. This cohort study was conducted in a single referral center; all patients with pathologically proven IPMN who received a pancreatic resection at the institution between October 2001 and December 2019 were analyzed. Preoperatively obtained images and the medical history were scrutinized for signs of progression and/or malignant features. The timeliness of resection was stratified into too early (adenoma and low-grade dysplasia), timely (intermediate-grade dysplasia and in situ carcinoma), and too late (invasive cancer). The perioperative characteristics and outcomes were compared between these groups. Timeliness of resection according to the final pathological findings. The risk of malignant transformation at the final pathology. Of 1439 patients, 438 (30.4%) were assigned to the too early group, 504 (35.1%) to the timely group, and 497 (34.5%) to the too late group. Radiological criteria for malignant conditions were detected in 53 of 382 patients (13.9%), 149 of 432 patients (34.5%), and 341 of 385 patients (88.6%) in the too early, timely, and too late groups, respectively (P < .001). Patients in the too early group underwent more parenchyma-sparing resections (too early group, 123 of 438 [28.1%]; timely group, 40 of 504 [7.9%]; too late group, 5 of 497 [1.0%]; P < .001), while morbidity (too early group, 112 of 438 [25.6%]; timely group, 117 of 504 [23.2%]; too late group, 158 of 497 [31.8%]; P = .002) and mortality (too early group, 4 patients [0.9%]; timely, 4 [0.8%]; too late, 13 [2.6%]; P = .03) were highest in the too late group. Of the 497 patients in the too late group, 124 (24.9%) had a previous history of watch-and-wait care. Until the biology and progression patterns of IPMN are clarified and accurate guidelines established, a watch-and-wait policy should be applied with caution, especially in IPMN bearing a main-duct component. One-third of IPMNs reach the cancer stage before resection. At specialized referral centers, the risks of surgical morbidity and mortality are justifiable.