International journal of surgery最新文献

Background: Animal models are essential for investigating the pathobiology of anastomotic leakage (AL). To be clinically meaningful, AL must occur despite a technically adequate anastomosis and reflect a phenotype relevant to surgical practice. This feasibility pilot study aimed to develop a clinically relevant porcine AL model by combining a Western diet (WD), segmental ischemia, perioperative antibiotic prophylaxis (PAP), and luminal exposure to pathogenic bacteria under optimal surgical conditions.

Methods: Twenty-one female domestic pigs were randomized into four groups. Group 1 received standard chow, PAP, and underwent a stapled colorectal anastomosis. Group 2 received WD, PAP, and perioperative luminal exposure to viable human and murine pathogens via colonoscopy. Group 3 received the same treatment with added ischemia-reperfusion (I/R) injury. Group 4 served as a negative control, receiving all exposures with autoclaved pathogens. Animals underwent a technically optimal stapled colorectal anastomosis. Healing was assessed clinically, endoscopically, and macroscopically on postoperative days 3 and 7.

Results: Gross healing (P = 0.0027) and adhesion scores (P = 0.0067) differed significantly between groups, with the highest scores in pigs exposed to WD, I/R, and viable pathogens. These changes did not reach the threshold of clinically overt anastomotic failure (Clavien-Dindo grade III), and endoscopic scores showed no significant intergroup differences. A strong association was observed between gross healing and adhesion scores (r = 0.909).

Conclusion: While the model did not progress to clinically overt AL (Clavien-Dindo grade III), it reproducibly induced subclinical impairment of anastomotic healing under compounded perioperative stress. These findings support its feasibility and biological relevance for studying early determinants of anastomotic integrity prior to clinical failure.

Background: The enhanced recovery after surgery (ERAS) protocol has been demonstrated to improve patient outcomes; however, its efficacy has not been prospectively evaluated in randomized controlled trials (RCTs) for patients undergoing laparoscopic sacrocolpopexy (LSC). This study aimed to develop a multidisciplinary ERAS protocol specifically for LSC and to systematically evaluate its clinical efficacy and benefits following implementation.

Materials and methods: In this prospective RCT conducted between September 2023 and February 2024, 80 patients undergoing LSC were randomized to either ERAS protocol (Group E) or conventional perioperative care (Group C). Primary outcomes included postoperative length of stay (LOS) and hospitalization costs, with secondary outcomes assessing recovery parameters, complication rates, pain scores, vital signs, and laboratory markers.

Results: Implementation of the ERAS protocol significantly reduced median postoperative LOS [77.00 (69.00-87.00) h vs. 46.50 (40.00-50.00) h; median difference: 31.00 h, 95% CI: 26.00-36.00; P < 0.001]. The ERAS group showed statistically significant improvements in multiple recovery metrics: earlier urinary catheter removal (median reduction 12 hours), quicker resumption of oral intake (18 hours), faster return of bowel function (8 hours), and earlier ambulation (4 hours) (all P < 0.001). Group E exhibited significantly improved 7-day QoR-15 scores (P = 0.002), reduced pain scores, decreased opioid use, lower postoperative white blood cell counts, and fewer episodes of postoperative nausea and vomiting. The 30-day readmission and emergency department visit rates in both group were zero.

Conclusion: This RCT establishes that implementation of an ERAS protocol for LSC significantly enhances postoperative recovery, reduces pain and complications, decreases opioid use while attenuating surgical stress responses. The 40.26% reduction in (LOS) meets the minimum clinically important difference threshold, indicating a clinically meaningful improvement. Additionally, the 30-day readmission and ED visit rates remained zero, further confirming the safety of the ERAS protocol in low-risk women.

Background: To evaluate the efficacy and safety of an all-inside, all-suture meniscal repair device for arthroscopic meniscal repair (AMR).

Materials and methods: Patients with vertical longitudinal full-thickness meniscus tears undergoing AMR were randomly assigned to the intervention group (all-inside, all-suture meniscal repair device) or the control group (all-inside meniscal repair system). The primary efficacy endpoint was the Lysholm Knee Score (LKS) at 6 months postoperatively. Secondary efficacy endpoints included: (1) the immediate device success rate at intraoperatively; (2) LKS at 3 and 12 months postoperatively; (3) Tegner activity score (TAS) and visual analogue scale (VAS) of pain at 3, 6, and 12 months postoperatively; (5) Meniscus repair status evaluated by magnetic resonance imaging (MRI) at 6 and 12 months postoperatively. Adverse events (AEs) and device deficiencies were recorded to assess safety. Final follow-up for 12 months was completed in April 2024.

Results: A total of 94 patients from 5 tier-A centers in China were randomized (intervention group: n = 48; control group: n = 46). Primary outcome analysis included 91 patients (intervention group: n = 45; control group: n = 46). LKS improved significantly from baseline in both groups at 6 months (both P < 0.001), with no between-group difference in absolute scores (mean ± standard deviation: 90.85 ± 8.70 vs 90.96 ± 11.52, P = 0.503). However, covariance analysis revealed greater LKS improvements in the intervention group (mean ± standard deviation: 30.17 ± 1.65 vs 23.87 ± 1.93, P = 0.015). Safety analysis showed no significant difference in the incidence of surgery-related AEs between the groups (17.02% vs 17.39%, P = 1.000).

Conclusion: The all-inside, all-suture meniscal repair device demonstrated comparable efficacy and safety to the controlled all-inside meniscal repair device for arthroscopic repair of vertical longitudinal full-thickness meniscus tears over 12 months. Moreover, it showed superior early improvement in knee function recovery and can be considered an alternative for AMR.

Background: Hematoma expansion or rebleeding after decompressive craniectomy (DC) is a critical determinant of poor prognosis in traumatic brain injury (TBI). However, reliable and interpretable tools for early risk prediction remain limited.

Methods: We retrospectively analyzed a bicentric cohort (training/internal validation, n = 880; external validation, n = 302). Preoperative clinical and computed tomography variables were collected. Missing data were addressed by multiple imputation with chained equations, and features were selected through LASSO and collinearity screening. Five machine-learning algorithms (logistic regression, elastic net, support vector machine, random forest, XGBoost) were optimized using Bayesian tuning and compared. Rubin's rules integrated performance estimates across imputations. Shapley Additive Explanations (SHAP) was employed for model interpretability, and the best-performing model was implemented as an online predictive tool.

Results: The XGBoost model achieved the best discrimination and calibration [pooled area under the receiver operating characteristic curve (AUC) 0.868, 95% confidence interval (CI) 0.794-0.943; area under the receiver operating characteristic curve precision-recall curves (AUPRC) 0.769] and outperformed other methods in decision-curve analysis. External validation confirmed robust generalizability (AUC 0.847, 95% CI 0.793-0.900; AUPRC 0.758). At the predefined threshold, accuracy reached 83.4%, sensitivity 75.6%, and specificity 86.6%. Eleven preoperative predictors were retained, with age, admission Glasgow Coma Scale, anticoagulant/antiplatelet use, hypertension, and basal cistern status as the most influential factors. SHAP visualizations enhanced transparency at both the population and individual levels.

Conclusion: We developed and externally validated an interpretable XGBoost-based model for the early prediction of hematoma expansion or rebleeding after DC in patients with TBI. This tool offers practical clinical value for perioperative decision-making and targeted monitoring.

Introduction: Sleeve gastrectomy (SG) has been a widely performed metabolic and bariatric surgery (MBS) procedure. However, complications and suboptimal long-term outcomes have prompted the exploration of alternatives. Single anastomosis sleeve jejunal bypass (SASJ), a variation of SASI, was systemically developed in Taiwan for its surgical advantages and promising clinical performance. This study aimed to report the 2-year outcomes of SASJ compared to SG.

Patients and methods: A retrospective multicenter study was conducted across five MBS centers between 2022 and 2023. Adults undergoing primary SASJ or SG were included; revision surgeries were excluded. SG was performed using a 36Fr bougie. SASJ was done with the following details: total bowel length (TBL) measured, the bilio-pancreatic (B-P) limb was set to 40% of TBL, and a common channel (CC) length of 350 cm. Anthropometric data, serum biochemistry, and perioperative outcomes were collected and analyzed.

Results: A total of 1479 patients were included (SASJ, n = 770; SG, n = 709). SASJ achieved significantly greater % total weight loss (%TWL) at 2 years compared to SG (34.0% vs 30.1%, P < 0.001). Both procedures effectively reduced fasting glucose, while SASJ more significantly improved HbA1c and cholesterol levels. Triglyceride improvements were similar between groups. Hemoglobin and albumin levels were slightly lower in the SASJ group at 2 years yet remained within normal limits. Re-admission and re-operation rates were comparably low in both groups.

Conclusion: SASJ - with appropriate CC length - delivers superior 2-year weight loss and metabolic outcomes than SG, with a minor nutritional and hemoglobin trade-off. Its favorable profile warrants long-term evaluation and broader clinical consideration.

Background: Emerging evidence suggests a potential association between nonalcoholic fatty liver disease (NAFLD) and stroke risk, but data from US outpatient populations remain inconclusive. This study aimed to evaluate this association in a nationally representative adult cohort.

Methods: A cross-sectional analysis was conducted using data from the National Health and Nutrition Examination Survey (NHANES) cycles 1999-2020. NAFLD was defined by the United States Fatty Liver Index (≥30). Stroke history was self-reported. Multivariable logistic regression models adjusted for sociodemographic factors, metabolic syndrome, and survey weights. Subgroup and sensitivity analyses were performed to assess robustness.

Results: Among 13 422 participants (mean age 47.141 years; 50.948% female), 40.426% had NAFLD. Stroke prevalence was significantly higher in the NAFLD group (4.087 vs. 2.215%, P < 0.001). NAFLD was independently associated with stroke in unadjusted (OR 1.804, 95% CI 1.508-2.157, P < 0.001) and demographically adjusted models (OR 1.420, 95% CI 1.171-1.721, P < 0.001). In Model 3, after adjusting for metabolic syndrome, the association was not statistically significant (OR 1.193, 95% CI 0.958-1.485, P = 0.116). In the subgroup analysis, the association between the two diseases was significant in participants aged 50-65 years (OR 1.654, 95% CI 1.044-2.622) and those without hypertension (OR 2.077, 95% CI 1.211-3.328). The connection remained significant in models applying inverse probability weighting (OR 1.611, 95% CI 1.400-1.853, P < 0.001) and continued to exist after non-Hispanic Black participants were excluded (OR 1.290, 95% CI 1.006-1.656, P = 0.045).

Conclusions: This study reveals a significant association between NAFLD and stroke, especially in adults aged 50-65 and those without hypertension. These findings suggest that NAFLD is associated with vascular risk; further prospective research is needed to determine whether it should be incorporated into cardiovascular risk assessments. Longitudinal research is needed to confirm whether treating NAFLD reduces stroke incidence.