Frontiers in Surgery最新文献

Congenital diaphragmatic hernia (CDH) is a life-threatening developmental anomaly where abdominal organs herniate into the thoracic cavity, impairing fetal lung growth and subsequent postnatal lung function. Despite advances in treatment, the morbidity and mortality of CDH remain significant. Currently, the most well-established fetal intervention is fetoscopic endoluminal tracheal occlusion (FETO), which promotes lung expansion and development by temporarily blocking the egress of lung fluid. However, treatment outcomes remain variable, which underscores the need for robust animal models to investigate novel therapies. The fetal sheep model is particularly valuable due to physiological similarities to human infants in lung development and anatomy. However, its successful implementation requires substantial veterinary and surgical expertise. In this paper, we outline the surgical protocol, refinements, and perioperative challenges in establishing a fetal sheep model of CDH to test a novel therapy. A diaphragmatic defect was surgically created via fetal thoracotomy at 80 days of gestation using a maternal caudal ventral midline laparotomy. Fetal tracheal occlusion with treatment administration was performed via a maternal left flank laparotomy at 108 days, followed by euthanasia then delivery at 136 days. Initial surgeries experienced complications such as maternal incisional dehiscence and herniation. These were mitigated through changes in surgical approach, closure techniques, and enhanced postoperative care. Veterinary oversight was critical in optimizing maternal well-being, minimizing stress, and improving recovery outcomes. This refined model provides a reproducible, welfare-centred approach integrating essential veterinary contributions to support translational pediatric surgery research in CDH.

Objective: The complex anatomy of anterior communicating artery aneurysms (ACoA) makes microsurgical clipping challenging. This study assessed the clinical value of 3D printed models based on digital subtraction angiography (DSA) in the surgical management of ACoA aneurysms, with a comprehensive analysis of ruptured and unruptured cases.

Methods: A prospective cohort study was conducted from 2022 to 2023, involving 60 patients with ACoA aneurysms. The study included both ruptured (n = 42) and unruptured (n = 18) aneurysms. Patients were divided into two groups: a control group (n = 30) using traditional 2D DSA imaging and 3D rotational angiography displays and a model group (n = 30) utilizing 3D printed models. Patient characteristics, including comorbidities such as hypertension, smoking status, and diabetes, as well as Hunt and Hess scores for ruptured cases, were recorded. For ruptured cases, Fisher grades, Hunt and Hess scores, and presence of hydrocephalus were documented. Primary outcomes included residual aneurysm neck, parent artery stenosis, and modified Rankin Scale (mRS) at 14 days post-surgery. Secondary outcomes encompassed intraoperative complications, diagnostic accuracy, operative duration, and perioperative clinical parameters. Temporary clip usage and duration were recorded, and intraoperative vessel patency was verified using Doppler ultrasonography and indocyanine green video angiography.

Results: At 14 days postoperatively, the model group demonstrated significantly lower rates of residual aneurysm neck (0% vs. 20%, p = 0.012) and parent artery stenosis (3.33% vs. 23.33%, p = 0.026). Fewer patients in the model group had mRS ≥ 3 (10% vs. 33.33%, p = 0.028). Intraoperative complications were reduced in the 3D model group (6.67% vs. 26.67%, p = 0.038), with significantly shorter operation duration (264.47 ± 52.27 vs. 313.10 ± 59.90 min, p = 0.001). The model group had higher preoperative diagnostic accuracy (93.33% vs. 70%, p = 0.02) With the aid of 3D models, surgical precision and outcomes are improved.

Conclusion: 3D printed models derived from DSA imaging significantly enhance the surgical management of ACoA aneurysms, offering improved diagnostic accuracy, reduced complications, and better functional outcomes. The average production time of 2-8 h and cost of approximately $120 USD per model make this approach feasible even for time-sensitive cases. These findings highlight the potential of patient-specific 3D models as a valuable adjunct in the management of complex ACoA aneurysms.

Purpose: Robot-assisted surgery (RAS) has established itself as a minimally invasive approach in colorectal surgery, although evidence on its integration with Enhanced Recovery After Surgery (ERAS®) protocols in older patients remains limited. This study aims to describe short-term outcomes of RAS combined with a perioperative treatment according to the ERAS® protocols in patients ≥70 years.

Methods: This retrospective analysis of a prospectively maintained database includes all patients aged ≥70 years who underwent robotic colorectal resections at two German colorectal cancer centers between January 2019 and April 2024, managed perioperatively according to the ERAS® protocols. Primary endpoints were the patients' short-term perioperative outcomes, including duration of surgery, conversion rate, postoperative Intermediate-Care-Unit (IMC) admission, postoperative complications according to Clavien-Dindo, anastomotic leak and reoperation rate, length of hospital stay, and compliance to ERAS® guidelines. Results are presented descriptively without a comparator arm.

Results: A total of 161 patients (99 colon resections and 62 rectal resections) were included over the study period. Median duration of surgery was 153 (IQR: 130-197) minutes for colon and 243 (IQR: 120-467) minutes for rectal resections. Conversion rates were 1% and 4.8% respectively. Postoperative IMC admission was required in 9.1% (9 Patients) after colon and 12.9% (8 Patients) after rectal-resections, based on individual clinical assesement. Anastomotic leaks occurred in 7 cases (7%) following colon resections, with a total reoperation rate of 10%. Among rectal resections, the anastomotic leakage rate was 9.7% (6 cases) with a total reoperation rate of 16.1%. ERAS® compliance was 91.3% for colon- and 85% for rectal resections. Within the rectal cohort, postoperative complications were associated with a substantially lower perioperative ERAS® compliance compared to patients without complications (73.3% vs. 90.7%). Hospital stay was 5 days (IQR: 4-6 days) for colon- and 6 days (IQR: 5-11 days) for rectal resections. The 30-day readmission rate was 4% (4 cases) for colon and 8% (5 cases) for rectal resections.

Conclusion: The integration of RAS colorectal surgery within ERAS® protocols appears feasible and is associated with acceptable short-term outcomes in elderly and comorbid patients. Nonetheless, these results should be interpreted as descriptive observations rather than inferential evidence.

Objective: Based on an analysis of large-scale retrospective case data, this study aimed to identify the risk factors associated with the development and postoperative complications of complicated acute appendicitis (CAA) in elderly patients (>60 years).

Methods: A total of 296 elderly patients diagnosed with acute appendicitis (AA) who underwent appendectomies at our hospital between January 2020 and January 2025 were enrolled in this study. These patients were categorized into either the CAA group (n = 113) or the uncomplicated acute appendicitis (UCAA) group (n = 183), based on the severity of their clinical presentation. Subsequently, univariate and multivariate logistic regression analyses were performed to identify the risk factors associated with the onset of CAA and its postoperative complications.

Results: The elderly patients in the CAA group exhibited a higher risk of postoperative complications and intensive care unit (ICU) admission, as well as prolonged hospitalization, compared to those in the UCAA group. Preoperative abdominal pain lasting more than 3 days [odds ratio (OR) = 3.159, P = 0.038], the presence of abdominal muscle tension (OR = 2.297, P = 0.007), appendiceal fecalith (OR = 2.697, P = 0.002), temperature ≥ 37.45 °C (OR = 2.968, P = 0.001), neutrophil percentage ≥ 82.7% (OR = 2.593, P = 0.010), and C-reactive protein (CRP) level ≥ 4.3 mg/L (OR = 3.256, P < 0.001) were identified as independent risk factors associated with the development of CAA. The incidence of postoperative complications in the elderly patients in the CAA group was 31%, which was significantly higher than the 6.0% observed in the UCAA group. An analysis based on the data from the patients with CAA indicated that the presence of nausea/vomiting (OR = 3.629, P = 0.033), white WBC ≥ 14.24 × 10⁹/L (OR = 3.825, P = 0.021), neutrophil percentage ≥ 84.3% (OR = 11.165, P = 0.012), and open appendectomy (OR = 5.799, P = 0.002) were independent risk factors for postoperative complications.

Conclusions: Abdominal signs and symptoms, the presence of appendicoliths, body temperature, and the levels of neutrophils and CRP were associated with the occurrence of CAA, while surgical approaches and the levels of WBCs and neutrophils were associated with postoperative complications. This study explored the risk factors associated with CAA and its postoperative complications in elderly patients, thereby offering valuable insights for the clinical management and treatment of AA in this population.

Introduction: Pedicle screws are used in spinal surgery and have yielded favorable postoperative outcomes. Despite this, the optimal timing for their removal remains controversial. This study presents a case report of a patient with Parkinson's disease who experienced rapid vertebral fracture and spinal cord compression after pedicle screw removal. We outlined the patient's management, and follow up and discuss consideration for screw removal.

Case presentation: A 58-year-old woman with an 8-year history of Parkinson's disease underwent lumbar surgery (L4-L5 oblique lumbar interbody fusion, L5-S1 transverse lumbar interbody fusion, and T12-L4 posterolateral lumbar fusion), including pedicle screw implantation at a local hospital 3 years prior for degenerative lumbar spondylolisthesis and lumbar spinal stenosis. She presented with lower back pain and bilateral lower limb numbness for 7 months. The patient was diagnosed with failed back surgery syndrome and underwent posterior fixation removal, interbody fusion cage removal, decompression, fusion with bone grafting, and new internal fixation (L4-S2). However, 3 months postoperatively, the lower back pain recurred and worsened by the fourth month, accompanied by lower limb weakness. Subsequently, the patient was diagnosed with L2 and L3 vertebral fractures and spinal cord injury.

Results: With appropriate treatment including total L2 laminectomy with decompression, intertransverse bone grafting, L2 vertebroplasty, pedicle screw-rod fixation (T11-S2), and T11 screw tract augmentation, the patient exhibited a satisfactory prognosis at the 2-year follow-up.

Anal canal carcinoma is a rare malignancy, accounting for less than 3% of gastrointestinal tumors. Recurrent anal canal carcinoma, which occurs in less than 1% of cases, is often accompanied by severe complications. Surgery plays a crucial role in improving patients' quality of life and controlling systemic paraneoplastic syndromes. This article reports a case of a 52-year-old female patient with recurrent anal canal squamous cell carcinoma (pT4bN0M0, Stage IIIB) 7 months after comprehensive treatment, complicated by rectovaginal fistula (RVF) and hypercalcemia of malignancy (HCM). Following multidisciplinary team (MDT) discussions, an innovative approach combining free omental packing with gracilis myocutaneous flap was adopted for the treatment of an isolated sacrococcygeal recurrent tumor after anal canal squamous cell carcinoma surgery. A tumor mass with a maximum diameter of 12.5 cm was completely resected. Postoperative pathological examination confirmed that no cancer cells were detected in multiple biopsies of the free resection margin, achieving R0 resection. After surgery, the patient's serum calcium level and serum squamous cell carcinoma antigen (SCC) returned to normal. Meanwhile, the bilateral combined myocutaneous flaps survived completely, RVF symptoms disappeared, the patient's quality of life was significantly improved, and the survival prognosis was enhanced.

Objective: To systematically evaluate the efficacy and safety of radiofrequency thermocoagulation target in the treatment of lumbar disc herniation.

Methods: Clinical randomized controlled trials (RCTs) on RFTT for LDH were collected by searching databases including CNKI (China National Knowledge Infrastructure), Wanfang Data, VIP Database, PubMed, Cochrane Library, and Web of Science. The search period spanned from the establishment of each database to December 8, 2023. Two reviewers independently screened the literature and extracted data in accordance with the inclusion and exclusion criteria. The risk of bias of the included studies was assessed using the Cochrane Handbook 5.3.0 risk of bias assessment tool. Review Manager 5.4 software was used to analyze outcomes including total effective rate, Visual Analog Scale (VAS) score, Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), and safety indicators.

Results: A total of 89 relevant studies involving 10, 079 participants were included, with 5,046 in the experimental group and 5,033 in the control group. The final analysis reviewed 89 studies, covering 10,079 participants. Among them, 5,046 participants were assigned to the experimental group and received the specific intervention, while the remaining 5,033 participants were in the control group and received conventional treatment. The analysis results showed that the total effective rate, JOA score, and ODI of the experimental group were significantly higher than those of the control group, indicating that the therapeutic effect of the experimental group was more pronounced than that of the control group. The incidence of adverse reactions was relatively consistent between the two groups, and most adverse reactions could be resolved through self-resolution without the need for intervention.

Conclusion: In the treatment of LDH, radiofrequency thermocoagulation targeted surgery combined with conventional treatment is more effective than conventional treatment alone. It can better improve patients' quality of daily life and work ability, and this therapeutic approach significantly enhances patients' daily living quality and work capacity. However, due to the small sample size of the included studies and the low quality of relevant literature, the results of this study still require verification by more large-sample, multi-center, and high-quality clinical randomized controlled trials.

Total laparoscopic hysterectomy (TLH) for enlarged uteri presents a significant challenge for surgeons due to limited surgical field exposure, increasing the risk of injury to the bowel, bladder, ureters, and blood vessels. To minimize these intraoperative complications, a surgical approach known as "The Ship Theory" has been developed at our center. According to this concept, the uterus is likened to a large vessel moored within the pelvis. As its supporting ligaments ("anchors") are progressively released, the uterus gains mobility, allowing it to migrate into the abdominal cavity. This enhanced mobility improves visualization and facilitates surgical access, enabling a safer and more effective TLH for large uteri. Using this approach, we successfully performed this procedure on a 51-year-old female patient with uterine leiomyomas and metrorrhagia. Preoperative imaging revealed a uterus measuring 189 × 158 × 148 mm. Institutional review board and ethics committee approval was obtained. The total operative time was approximately 90 min, with an estimated blood loss of less than 50 mL. The patient was discharged 48 h postoperatively without complications. This technical report demonstrates that the application of a minimally invasive surgical technique for uteri with significant spatial constraints-as outlined in "The Ship Theory"-is not only feasible but can be successfully executed when performed in a systematic and structured manner.

Background: Cervical disc herniation at the C2-3 level, resulting in cervical spondylotic myelopathy (CSM), is an uncommon clinical entity. The diagnostic and therapeutic complexity escalates when this pathology coexists with non-contiguous multilevel cervical disc degenerative disease (CDDD). Due to the segmental variability in pathological features, the clinical manifestations of such cases are highly heterogeneous, thereby necessitating a highly individualized treatment strategy. Hybrid surgery (HS), which integrates cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF), offers a tailored approach for the management of multilevel degenerative cervical pathology. The unique anatomical features and surgical technical challenges at the C2-3 level impose significant constraints on treatment options. This article presents a case of non-contiguous three-level hybrid surgery involving CDA at C2-3 and ACDF at C4-5 and C5-6, and discusses the feasibility of this technique for upper cervical disc pathology.

Case presentation: A 62-year-old female was admitted with a 6-month history of neck and right upper limb pain, numbness, and gait instability, which had been unresponsive to conservative management. DR revealed loss of the normal cervical lordosis. CT showed no significant osteophyte formation or bony canal stenosis. MRI demonstrated a large disc extrusion at C2-3 causing spinal cord compression, and disc herniations at C4-5 and C5-6 with nerve root impingement. Based on clinical and imaging findings, a diagnosis of multilevel cervical spondylopathy (C2-3, C4-5, and C5-6 disc herniation) was established. The patient underwent anterior cervical discectomy followed by artificial disc arthroplasty (CDA) at C2-3, and anterior cervical discectomy and fusion (ACDF) at C4-5 and C5-6, successfully completing a non-contiguous three-level hybrid surgical procedure.

Results: Postoperative symptoms were significantly alleviated. At the 12-month follow-up, pain and gait disturbance had largely returned to normal. MRI confirmed adequate decompression of neural compression, DR demonstrated satisfactory range of motion (ROM) at C2-3, and CT revealed satisfactory bone healing at the fused segments.

Conclusion: CDA serves as an effective alternative for C2-3 disc pathology, achieving neural decompression while preserving segmental mobility. The HS provides a valuable surgical option for the precise treatment of non-contiguous multilevel degenerative disease.

Background: Nonpigmented villonodular synovitis (non-PVNS) is a benign yet locally aggressive proliferative disorder affecting the synovium. The occurrence of non-PVNS following knee joint replacement is exceedingly rare.

Case presentation: This study investigated synovial mechanisms driving aseptic loosening in bilateral total knee arthroplasty failure over a 14-year period. Radiographic and pathologic analysis tracked sequential failure progression bilaterally. Initial radiographs documented progressive left-knee loosening (2009-2016). Subsequent intraoperative and histologic evaluation (H&E staining) confirmed synovial hyperplasia without PVNS features as the primary mechanism. Post-revision imaging showed immediate left-knee stabilization. However, long-term follow-up revealed sustained left-knee stability (2019) but emergent right-knee loosening (2023), demonstrating interlimb heterogeneity and recurrence risk. Pathologic examination of the revised right knee identified an analogous synovial hyperplasia mechanism (non-PVNS).

Conclusion: Final post-revision radiographs validated successful stabilization following both revisions. This longitudinal bilateral case uniquely demonstrates synovial hyperplasia as a replicable driver of aseptic loosening independent of PVNS, highlights heterogeneous progression kinetics and recurrence risk between limbs despite unilateral intervention, and confirms the consistent efficacy of revision arthroplasty for this specific pathology.