Frontiers in Surgery最新文献

Objective: This study aimed to retrospectively analyze myomectomy cases performed in our clinic using laparotomic and laparoscopic techniques, and to compare the effects of both surgical approaches on various clinical and surgical outcomes.

Materials and methods: Patient records of myomectomy operations performed between 2015 and 2025 at the Department of Obstetrics and Gynecology, Balıkesir University Faculty of Medicine, were reviewed. A total of 213 patients were included, comprising 140 laparoscopic and 73 laparotomic cases. The data such as patient age, number and size of removed myomas, preoperative and postoperative hemoglobin levels, postoperative additional analgesic requirements, length of hospital stay and complication rates will be analyzed to evaluate the advantages of each method in terms of patient comfort and surgical efficacy.

Results: The mean age of patients undergoing laparoscopic myomectomy was significantly higher than those in the laparotomic group (p < 0.001). The laparoscopic group demonstrated a significantly shorter hospital stay compared to the laparotomic group (p < 0.001). Preoperative and postoperative hemoglobin levels did not differ significantly between the groups. The number of removed myomas was similar; however, the mean myoma diameter was significantly larger in the laparotomic group (p < 0.001). Postoperative opioid use was significantly higher in the laparotomic group (p = 0.01). Larger and more numerous myomas were independently associated with a higher likelihood of laparotomy over laparoscopy (p < 0.001). Among laparoscopic cases, only four required conversion to laparotomy (%2,9) and a single bladder injury was observed.

Conclusion: Laparoscopic myomectomy provides considerable advantages over laparotomic myomectomy, including reduced hospital stay and lower postoperative analgesic requirements. While laparotomy remains preferable for larger myomas, laparoscopic approaches yield comparable outcomes in terms of hemoglobin levels and complication rates. With appropriate patient selection, laparoscopic myomectomy is a preferred surgical method due to its positive impact on patient recovery, comfort and overall surgical efficacy.

Introduction: Primary ventral abdominal wall hernias, especially when complicated by concomitant rectus abdominis diastasis, pose a complex challenge for surgeons. The retro-muscular Rives-Stoppa technique is a well-established and effective repair method. However, a rare but severe complication is the development of an interparietal hernia.

Case presentation: We present the case of a 57-year-old male with an epigastric hernia and diastasis recti who underwent an open retro-muscular Rives-Stoppa repair. Postoperatively, he developed a series of non-specific symptoms including mild discomfort, nausea, and vomiting, without clear signs of hernia recurrence. On postoperative day four, his condition worsened with projectile bilious vomiting and acute kidney injury. A CT scan revealed an incarcerated interparietal hernia containing small bowel between the posterior rectus sheath and the mesh. He underwent an emergency reoperation to reduce the bowel and repair the defect. The patient had an uneventful recovery and was discharged on postoperative day seven.

Discussion: Interparietal hernias are a rare complication of the Rives-Stoppa repair, resulting from dehiscence of the posterior rectus sheath. This can lead to incarcerated bowel without the external signs of a recurrent hernia, delaying diagnosis. High clinical suspicion and a low threshold for CT imaging are crucial. We review the current literature, highlighting the scarcity of reported cases and the various surgical approaches, which include open, laparoscopic, or expectant management.

Conclusion: Although uncommon, interparietal hernia should be considered in any patient who fails to thrive after a Rives-Stoppa repair. This case emphasizes the need for prompt diagnosis and a tailored management strategy to prevent severe morbidity.

Traditionally, in extraperitoneal robot-assisted radical prostatectomy (EP-RARP), a pneumo-Retzius is obtained by using a CO₂ insufflation pressure of 12-15 mmHg. However, EP surgery is associated with an increase in CO₂ absorption and consequent hypercapnia and acidosis. This study aimed to compare the effect of low CO₂ pressure (8 mmHg) with the conventional gas pressure in EP-RARP. We enrolled patients with low-risk prostate cancer who had undergone total nerve-sparing RARP using our PERUSIA (Posterior, Extraperitoneal, Robotic, Under Santorini, Intrafascial, Anterograde) technique. The exclusion criteria were the presence of chronic lung disease, a positive biopsy core from the anterior zone, or a shift to a transperitoneal approach. Cardiopulmonary parameters were measured at the induction of anesthesia (T0); at 5 (T1) and 60 (T2) minutes after starting CO_₂ insufflation; and immediately after dorsal venous complex dissection before urethro-vesical anastomosis (T3). Data from 120 consecutive patients were retrospectively analyzed from a prospectively maintained database. Patients were divided into two groups based on the CO₂ insufflation pressure (8 vs. 12 mmHg). No significant differences were detected in mean operative time, time required for trocar positioning, mean estimated blood loss, or complications between the two groups. The only significant difference was in the partial pressure of carbon dioxide, which was higher at T3 in Group 2 (p=0.005), with a consequent reduction in arterial pH. However, no significant difference (p = 0.44) was found regarding acidosis between the two groups at all timepoints. RARP has become a standard procedure in urological surgery for the treatment of localized prostate cancer. However, the CO₂ insufflation required to create a surgical workspace may lead to cardiopulmonary complications, especially in patients with pre-existing respiratory conditions. This study compared the effects of a lower insufflation pressure (8 mmHg) vs. the standard pressure (12 mmHg) during EP-RARP. The findings suggest that using a low and constant pressure can reduce CO₂ absorption into the bloodstream without increasing intraoperative or postoperative complications. This approach may expand eligibility for EP-RARP to include patients with chronic pulmonary diseases by enhancing the safety and tolerability of the procedure.

Background: Anastomotic leakage (AL) represents one of the most serious complications in gastrointestinal surgery, with reported incidence rates of up to 26%. Despite advancements in surgical techniques, early detection of AL remains challenging, and no reliable real-time monitoring system is currently available. In this study, we investigated a resorbable polydioxanone (PDO) membrane as a potential substrate for future sensor integration, aiming to facilitate real-time monitoring of anastomotic healing.

Methods: In eight German Landrace pigs, 34 ileal side-to-end stapler anastomoses were examined: GM1 (n = 7), GM2 (n = 10), and controls (n = 17). Membrane stability was monitored after implantation, while adhesion formation, burst pressure, and histology were assessed on postoperative day 7.

Results: Both membrane geometries showed robust stability, with good anchorage of the large spokes within the anastomosis. Geometry 1 (GM1) exhibited higher burst pressure than Geometry 2 (GM2) (193 ± 43.6 vs. 155 ± 65.5 mmHg, p = 0.02). Compared with controls (167 ± 42.3 mmHg), neither GM1 (p = 0.053) nor GM2 (p = 0.379) differed significantly. Adhesions occurred in all groups, without significant differences. Histological evaluations showed typical granulation tissue and fibrosis, with granulocytic inflammation more common in GM1 without affecting anastomotic stability.

Conclusion: This proof-of-concept study demonstrates that the PDO membrane can be safely incorporated into stapled anastomoses without compromising anastomotic healing. The membrane provides a stable, biocompatible platform suitable for future sensor integration, supporting the development of a diagnostic intraanastomotic device.

Background: Patients with advanced colorectal cancer (CRC) with primary tumor stage T3 or T4 are at increased risk of peritoneal metastasis. The safety and feasibility of combining radical resection with intraoperative intraperitoneal perfusion chemotherapy (IPC) using raltitrexed in this population warrant further investigation.

Methods: In this single-center, exploratory randomized controlled trial, 60 patients with advanced CRC (T3, T4) scheduled for laparoscopic radical resection were randomly assigned to receive either intraoperative raltitrexed IPC (n = 30) or surgery alone (control, n = 30). The primary endpoints were safety and feasibility. Toxicity profiles (hematologic, renal, hepatic), postoperative complications within 14 days, and procedural feasibility were compared between groups. Short-term tumor marker levels [carcinoembryonic antigen [CEA] and carbohydrate antigen 19-9 [CA19-9]] were assessed as exploratory endpoints, measured preoperatively and at three months postoperatively, with recurrence or metastasis events recorded within the same period.

Results: The IPC procedure was successfully completed in all assigned patients, confirming procedural feasibility. No significant between-group differences were observed in postoperative hematological toxicity, nephrotoxicity, or complication rates. Transaminase elevations (ALT/AST) on postoperative day seven were transient and mild in both cohorts, with a more marked yet clinically manageable increase in the IPC group. At the three-month follow-up, no significant between-group differences were found in tumor marker levels or recurrence rates. Within-group analyses, however, demonstrated a significant decrease in CEA in the IPC group [mean change: -2.23 ± 4.68 ng/mL (95% CI: 0.48-3.98); P = 0.014] and a significant increase in CA19-9 in the control group [mean change: +3.33 ± 7.07 U/mL (95% CI: 0.69-5.97); P = 0.015].

Conclusions: For patients with advanced CRC (T3/T4), laparoscopic radical resection combined with intraoperative raltitrexed IPC is feasible and exhibits an acceptable short-term safety profile. Observed short-term changes in tumor markers are considered exploratory findings and require validation in subsequent, large-scale prospective studies with extended follow-up periods.

Objective: This study aims to compare the effects of sleeve gastrectomy (SG), duodenojejunostomy (DJOS), and their combination (DJOS + SG) on glucose regulation and pancreatic histomorphology and function in Zucker diabetic fatty (ZDF) rats, using artificial intelligence (AI)-assisted tissue analysis to assess morphological alterations.

Methods: Forty-five male ZDF rats were randomized into three surgical groups (SG, DJOS, DJOS + SG). Oral glucose tolerance tests (OGTT) and insulin levels were assessed at 1, 3 and 6 months post-surgery. Pancreatic tissue was analyzed histologically and immunohistochemically for β-cell mass, PCNA and PDX-1 expression. QuPath software enabled AI-based quantification of acinar, adipose, and fibrotic tissue.

Results: DJOS and DJOS + SG improved glucose tolerance and increased fasting insulin compared to SG. Both bypass groups demonstrated greater β-cell mass and clustering, elevated PCNA and PDX-1 expression, and more acinar tissue. SG was associated with reduced β-cell presence and increased pancreatic adiposity.

Conclusion: Malabsorptive (DJOS) or combination bariatric procedures (DJOS + SG) significantly enhance glycemic control in the rat model. These effects are accompanied by increased β-cell numbers and clustering, as well as enhanced β-cell proliferation and differentiation. Furthermore, acinar glandular tissue is increased, while pancreatic adiposity is reduced following bypass surgery.

Background: Spinal cord reperfusion injury of the cervical spine is a rare but severe postoperative complication, typically occurring after the decompression of chronically compressed spinal cord tissue. The report aims to present a case of early postoperative spinal cord reperfusion injury that was successfully managed, and to discuss its underlying pathogenesis, treatment strategies, and clinical outcomes.

Case report: A 63-year-old middle-aged male was admitted with a 3-month history of neck and shoulder pain accompanied by numbness and pain in both upper limbs. MRI and clinical evaluations revealed cervical spinal canal stenosis with radiculopathy. The patient underwent anterior cervical discectomy and fusion (ACDF), with no intraoperative complications noted. 2 h after the operation, when the patient regained consciousness, it was found that the muscle strength of both lower limbs was grade 1, that of both upper limbs was grade 2, and the skin sensation of the lower limbs was gradually fades. However, four hours after surgery, upon regaining consciousness, the patient developed complete quadriplegia and loss of skin sensation, with progressive worsening. An emergency MRI ruled out intracranial pathology but revealed spinal cord edema at the surgical site. Based on the clinical course and imaging findings, spinal cord reperfusion injury was suspected. The patient was immediately transferred through the emergency "green channel" for urgent posterior cervical laminoplasty to achieve expanded decompression, accompanied by intraoperative and postoperative high-dose corticosteroid therapy. One day after the second surgery, the patient's muscle strength improved to Grade 3. Following two months of postoperative treatment and rehabilitation, the patient made a full recovery and was discharged. Follow-up MRI demonstrated substantial resolution of spinal cord edema and restoration of spinal cord morphology. This case illustrates that early recognition of spinal cord reperfusion injury and timely, appropriate intervention can significantly improve neurological outcomes, providing valuable insight for the management of similar cases.

Conclusion: Spinal cord reperfusion injury after cervical spine surgery is rare, but once it occurs, it requires a high level of clinical vigilance. Identifying the underlying cause, making a rapid diagnosis, and initiating timely surgical intervention combined with corticosteroid pulse therapy are essential to preventing irreversible neurological damage.

Aim: This study aims to evaluate the feasibility and effectiveness of a modified multi-modal prehabilitation program for Chinese patients with colorectal cancer during their preoperative hospital stay. The impact on perioperative physiological function, postoperative recovery, and overall outcomes was assessed.

Design: A prospective, randomized controlled trial.

Methods: A prospective, randomized controlled trial was conducted with 200 patients (100 experimental, 100 control) at a tertiary hospital in Shanghai. The experimental group received a modified multi-modal prehabilitation program, including inspiratory muscle training, aerobic exercise, nutritional supplementation, and psychological support, while the control group received standard perioperative care. Primary outcomes were assessed using the 6-Minute Walk Test (6MWT) on the day before surgery and 30 days postoperatively. Secondary outcomes included postoperative hospital stay duration, time to first flatus, ambulation, oral intake, and incidence of postoperative complications.

Results: The experimental group showed significantly greater improvements in 6MWT performance compared to the control group both before surgery (400.40 m vs. 383.25 m, P < 0.01) and 30 days postoperatively (375.40 m vs. 336.85 m, P = 0.03). Additionally, the experimental group had a shorter postoperative hospital stay (7.91 days vs. 9.06 days, P < 0.01) and earlier recovery milestones (P ≤ 0.01) compared to the control group. The incidence of postoperative complications was slightly lower in the experimental group, though not statistically significant.

Clinical trial registration: https://www.chictr.org.cn/, Identifier ChiCTR2200055764.

Background: Fenestrated and/or branched endovascular aortic repair (f/bEVAR) has evolved a reliable alternative to treat complex aortic aneurysms. The aim of this study was to analyze the evolution of f/bEVAR in a large German vascular department by investigating temporal changes in patient selection, surgical strategies, and clinical outcomes.

Methods: Retrospective cohort study of consecutive patients undergoing f/bEVAR between 2007 and 2023 at TUM University Hospital in Munich (Klinikum rechts der Isar, Technical University of Munich). To assess for temporal changes, the cohort was divided into three time periods (date of operation: 2007-2016; 2017-2020; 2021-2023). The primary outcome was in-hospital death. Statistical analyses included univariate analyses, Kaplan-Meier survival analyses, and Kruskal-Wallis tests for group comparisons.

Results: A total of 176 patients (median age 75 years; 80% male) were included. Over time (early phase vs. recent phase), an increase in the proportion of octogenarians was observed (14 vs. 31%; p = 0.042) and the mean number of incorporated vessels increased from 3.7 to 4.0 (p < 0.001). Mean operative time decreased from 321 to 241 min (p = 0.002) and intraoperative contrast volume was reduced (398 vs. 190 mL; p = 0.001). Length of intensive care unit stay (8.1 vs. 2.7 days; p < 0.001) and in-hospital rates of acute kidney injury (16 vs. 4.7%; p = 0.034) and respiratory failure (18 vs. 0%; p = 0.001) declined, while non-significant trends were found for in-hospital mortality (8.8% vs. 1.6%; p = 0.062) and the paraplegia rate (8.8% vs. 1.6%, p = 0.062). Longer operating time (per 10 min; OR 1.06; 95% CI 1.02-1.11; p = 0.003) and occurrence of a major adverse event (OR 37.4; 95% CI 4.52-4,869; p < 0.001) were associated with death until discharge. Kaplan-Meier analyses showed, that patients treated in the early phase had lower survival probability compared to those in the recent phase (p = 0.024).

Conclusion: This retrospective analysis demonstrates a continuous improvement in clinical outcomes associated with f/bEVAR over the past two decades. The findings underscore the increasing reliability and effectiveness of endovascular treatment approaches.

Objective: To explore the efficacy of quadruple nerve decompression in treating painful diabetic peripheral neuropathy (PDPN) of lower extremity, and to evaluate its clinical value in pain relief and sensory recovery.

Method: A retrospective analysis was performed on 26 PDPN patients (45 sides), all of whom underwent quadruple nerve decompression, including release of the common peroneal nerve (CPN), superficial peroneal nerve (SPN), deep peroneal nerve (DPN), and tibial nerve (TN). Changes in the Visual Analog Scale (VAS) score, two-point discrimination (TPD), sensory nerve conduction velocity (SCV), and Toronto Clinical Scoring System (TCSS) score were evaluated by comparing preoperative values with those at an average of 30.46 months postoperatively. Statistical analysis was conducted using the paired t-test.

Results: Postoperative VAS scores were significantly reduced, from 7.31 ± 1.62 to 2.51 ± 1.47 (P < 0.001), with 93.3% of limbs achieving at least 50% pain relief. TPD showed significant improvement, decreasing from 13.80 ± 3.01 mm to 7.49 ± 2.07 mm (P < 0.001), and 68.9% of patients returned to normal levels. The proportion of nerves showing an SCV improvement of ≥5 m/s ranged from 64.4% to 75.6%. TCSS scores shifted from all being grade III before surgery to mild or moderate in 93.3% of cases. No severe complications were observed postoperatively.

Conclusion: Significant pain relief and improvement in sensation and nerve function have been achieved in patients with PDPN through quadruple nerve decompression, which addresses multiple potential nerve entrapment sites. This procedure, building upon existing evidence, demonstrates sustained efficacy in pain relief and sensory recovery over a median 30-month follow-up, offering a refined surgical option for patients with refractory PDPN who have failed conservative management.