Langenbeck's Archives of Surgery最新文献

Background: Osseointegration represents an innovative technique within the field of limb amputation. The management of a permanent stoma through the residuum presents significant challenges, primarily due to the insufficient literature and limited surgical techniques available. This study aims to unravel soft tissue management strategies that seek to enhance surgical outcomes.

Methods and results: It is a retrospective study containing a total of 406 patients (251transfemoral and 155 transtibial) amputees who underwent (264 trans-femoral and 177 transtibial) osseointegration at Macquarie University Hospital and Norwest Private Hospital were systematically evaluated over the period spanning from December 2010 to December 2023. Out of a total of 264 transfemoral cases, 87(32.9%) cases necessitated stump refashioning surgery. In transtibial osseointegration, 37/177 cases (20.9%) of stump refashioning events were observed among the cohort.

Conclusion: This study describes the surgical technique and the importance of careful soft tissue management in stump refashioning. It addresses issues of stoma pain, overhanging soft tissue, and infections to prevent potential complications and improve quality of life.

Purpose: Accurate localisation of hyperfunctioning parathyroid glands is crucial for successful parathyroid surgery. In patients with inconclusive imaging, intraoperative bilateral internal jugular venous sampling (BIJVS) has been reported; but its utility remains unclear. The purpose of the review is to evaluate published techniques and reported effectiveness of BIJVS in parathyroid surgery.

Methods: PubMed, Ovid and Cochrane databases were searched for articles on intraoperative BIJVS in parathyroid surgery. All original English language human studies reporting on lateralisation rates, diagnostic accuracy or cure rates following use of intraoperative BIJVS were included. Exclusion criteria included case reports, reviews, IJV sampling in non-parathyroid pathology and IJV sampling for confirming cure. Data on patient numbers, definitions used for lateralisation and correlation with clinical outcomes were extracted by one reviewer and cross-checked by a second reviewer. The review was prospectively registered on the Open Science Framework (OSF; DOI: https://doi.org/10.17605/OSF.IO/TSQA6 ).

Results: Of 753 screened, 12 studies including 502 patients where BIJVS was performed were included. Lateralisation definitions were reported in 7 studies. Among studies with relevant data, lateralisation gradient was defined as ranging from 5 to 20% and lateralisation rates varied from 51 to 100%. The positive and negative predictive values ranged from 76 to 100% (6 studies) and 0-53% respectively (3 studies). Reported cure rates following BIJVS guided surgery were high (> 98%), but the definition for cure was only reported in 8 studies.

Conclusions: BIJVS can aid localisation in parathyroid surgery. A significant lateralisation gradient may permit unilateral surgery, but a lack of gradient does not imply bilateral disease. However, the absence of a standard definition for lateralisation and inconsistent reporting limits widespread adoption of this technique.

Background: The association between intraoperative lactate levels and postoperative prognosis following emergency surgery remains inconclusive. We aimed to investigate the prognostic significance of intraoperative lactate levels in predicting in-hospital mortality.

Methods: This single-center, retrospective, observational study was conducted at Peking Union Medical College Hospital from 2017 to 2023. Intraoperative peak lactate levels were analyzed using a restricted cubic spline (RCS) model, with in-hospital mortality designated as the primary outcome. Secondary outcomes were length of stay, ICU stay, and ventilation duration. Prespecified subgroup analyses (by ASA grade and surgery type) and a sensitivity analysis excluding in-hospital deaths for secondary endpoints were performed.

Results: Among the 2,452 patients included in the study, 161 died postoperatively. Both univariate and multivariate regression analyses demonstrated that the intraoperative peak lactate level was associated with perioperative mortality (odds ratio [OR] 1.306, 95% CI 1.262-1.352, P < 0.001; OR 1.249, 95% CI 1.185-1.318, P < 0.001). The association was consistent across surgery types and appeared stronger in patients with higher ASA grade. The restricted cubic spline model indicated higher intraoperative peak lactate levels were nonlinearly associated with increased in-hospital mortality. Length of hospital stay (LOS), LOS in the intensive care unit (ICU), and duration of mechanical ventilation exhibited a nonlinear (inverted U-shaped) pattern relationship with intraoperative peak lactate levels, with an initial increasing trend followed by a subsequent decline as peak lactate concentrations rose.

Conclusions: Intraoperative peak lactate levels showed a dose-dependent nonlinear association with increased in-hospital mortality following emergency surgery and play a significant role in predicting postoperative mortality in noncardiac emergency surgery patients.

Trial registration: Not applicable.

Introduction: Rapid discharge protocols have gained progressive popularity even in thyroid surgery due to the superimposable risks of complications compared to inpatient management and for the subsequent increased surgical volume. The aim of this study is to evaluate results, benefits and complications' rates of a rapid discharge in postoperative day 1 (POD1 - overnight thyroidectomy) among patients submitted to total thyroidectomy at our surgical clinic.

Materials and methods: Single centre retrospective analysis of 729 patients submitted to total thyroidectomy between 2016 and 2024; 402 patients who are scheduled for discharge on POD 1 and 327 patients discharged after a minimum of 72 hours observation (POD 3). Data concerning postoperative complications (POC) at 24 hours, 10 and 30 days were collected. Patients' satisfaction about the rapid discharge protocol was also registered.

Results: We registered no significative differences between incidence of complications at 24h, 10-days or 30-days re-evaluations in POD1 and POD3 groups. Graves' Disease represents the main context in which early postoperative (24h) and overall complications occurred. The 94.6% of POD1 patients reported a global satisfaction in the rapid discharge scenario.

Conclusions: POD1 patients are not exposed to additional postoperative risk with overnight thyroidectomy following total thyroidectomy, given accurate patient selection. Early and overall complications are more frequently observed in patients with Graves' disease. Overnight thyroidectomy, combined with thorough perioperative patient education, received widespread appreciation among our surgical cohort.

Purpose: The indication for surgical treatment of rectus diastasis (RD) without a coexisting hernia remains controversial. Although guidelines exist, the lack of robust data allows only weak recommendations. This study aimed to provide comprehensive nationwide data on the surgical management of RD without hernia.

Methods: This retrospective observational multicenter study analyzed anonymous data from the German nationwide hospital discharge dataset (2010-2023). Patients with coexisting hernia or under 18 years were excluded. The primary endpoint was the annual number of RD surgeries without hernia. Secondary endpoints included trends over 13 years, patient demographics, mesh use, and early postoperative complications.

Results: A total of 2,768 cases were identified (mean age 46.2 ± 13.2 years; 76.2% female). The annual case number ranged from 120 to 253, with no consistent trend. A mesh was used in 28.0% (n = 775), while 72.0% underwent reconstruction without documented mesh. Data on surgical approach (open vs. minimally invasive) were not available. The overall early complication rate was 6.9%, with bleeding and wound infections most common. Male patients had significantly higher complication rates. Major limitations include potential coding bias, underreporting, and missing data on surgical technique.

Conclusion: This is the first real-world big data analysis of RD repair without hernia in Germany. On average, 198 procedures are performed annually with a low complication rate. The findings support surgical treatment in selected symptomatic cases and emphasize the need for standardized coding and prospective registry data.

Background and objectives: In canonical knowledge, long-segment intraspinal schwannomas (SCHs) require laminectomies at all involved levels for complete exposure. To evaluate a minimally invasive, limited-exposure strategy for gross total resection (GTR) of multi-level intraspinal SCHs.

Methods: A retrospective analysis was conducted on 11 patients with intraspinal SCHs involving ≥ 3 vertebral segments who underwent laminectomy confined to critical vertebrae, achieving gross total resection without full exposure of all involved levels. The surgical approach involved focused laminectomy targeting critical vertebrae, intracapsular decompression, and meticulous microsurgical dissection. Follow-up included clinical assessments and MRI evaluations at 3 months and 1-year post-surgery.

Results: The cohort comprised 4 females and 7 males, with a median age of 50 years. Lesions were predominantly located in the cervical spine. Ten cases exhibited cystic lesions, while one presented a fully solid tumor. The average surgical time was 119 ± 15.6 minutes. Laminectomy was performed within 2 levels (6 cases) or 1 level (5 cases). All patients achieved complete symptom resolution at discharge, with no perioperative complications. During a mean follow-up of 23.5 ± 13.0 months, no cases of postoperative spinal instability or tumor recurrence were identified.

Conclusion: For long-segment intraspinal SCHs, particularly cystic lesions, minimizing the number of laminectomy levels to achieve GTR is technically feasible and clinically safe.

Background and objectives: Esophagojejunal (EJ) leakage is a serious complication following total gastrectomy for gastric cancer. While several nutritional and treatment-related risk factors have been described, the role of Candida esophagitis (CE) in anastomotic failure has not been previously investigated.

Methods: This retrospective cohort study included 268 patients with gastric adenocarcinoma who underwent total gastrectomy with EJ anastomosis. The study was conducted between March 2021 and March 2025 at a tertiary referral center. CE was diagnosed by histopathologic examination of proximal esophageal margins submitted during surgery. Univariable and multivariable logistic regression analyses were performed to determine predictors of EJ leakage. Best subsets variable selection using Akaike's Information Criterion (AIC) and the Bayesian Information Criterion (BIC) guided final model development.

Results: Among the 268 patients, 48 (17.9%) developed EJ leakage. Multivariable analysis identified CE (OR: 2.19, p = 0.043), hypoalbuminemia (< 3.5 g/dL) (OR: 3.08, p = 0.007), BMI ≥ 25 kg/m² (OR: 3.68, p = 0.004), and administration of neoadjuvant therapy (OR: 2.34, p = 0.024) as independent predictors of EJ leakage. Additional analyses of diagnostic timing indicated that CE detected only on permanent histology (delayed treatment) was associated with higher odds of leak (adj OR 3.62; 95%CI: 1.42-9.23; p = 0.007), whereas CE detected on intraoperative frozen section was not.

Conclusion: CE was associated with increased odds of EJ leakage after adjustment, but causality cannot be inferred from this retrospective study. The finding that delayed CE diagnosis was linked to higher leak risk suggests diagnostic timing may matter. Prospective validation of targeted esophageal assessment and timed antifungal strategies is warranted. Elevated BMI, hypoalbuminemia, and neoadjuvant therapy also contributed to higher odds of EJ leakage.

Background: Peritoneal dialysis catheter (PDC) dysfunction significantly impacts patient survival. While individual risk factors are known, a practical tool that integrates multi-dimensional predictors-including surgical, anatomical, and postoperative parameters-for early risk stratification is lacking. This study evaluates open versus laparoscopic catheterization techniques and aims to develop such a predictive model.

Methods: A retrospective cohort study analyzed 462 end-stage renal disease patients undergoing first PDC implantation (2022-2024). Data included clinical characteristics, surgical method (open/laparoscopic), and dysfunction events. Multivariate COX regression identified independent risk factors, and a nomogram was developed. Model performance was assessed via ROC and calibration curves, with Bootstrap validation.

Results: Among 462 patients (324 modeling, 138 validation) with a median follow-up of 30.7 months, laparoscopic catheterization was associated with a significantly lower risk of dysfunction compared to the open approach (18% vs. 27%; hazard ratio [HR] 2.188, 95% CI 1.263-3.791, p = 0.005). Multivariate analysis identified five independent predictors of catheter dysfunction: history of abdominal surgery (HR 6.924, p < 0.001), open catheterization (HR 2.188, p = 0.005), diabetes (HR 2.373, p = 0.016), albumin < 30 g/L (HR 0.865, p < 0.001), and blood potassium < 4 mmol/L (HR 1.479, p = 0.015). The developed nomogram integrating these predictors showed outstanding discriminative performance, with C-indices of 0.953 (95% CI 0.940-0.967) in the modeling cohort and 0.951 (95% CI 0.929-0.972) in the validation cohort. Time-dependent ROC analysis further confirmed its predictive accuracy, with 1- and 2-year AUCs of 0.957/0.979 and 0.921/0.988 in the modeling and validation sets, respectively. Calibration curves showed close alignment between predicted and observed outcomes across both cohorts. The nomogram provides a clinically useful tool for individualized risk assessment and postoperative management.

Conclusions: Laparoscopic catheterization reduces dysfunction risk. The presented nomogram is unique in its integration of readily available surgical, comorbidity, and nutritional metrics into a single, visual tool. It facilitates early identification of high-risk patients, thereby aiding individualized surgical planning and targeted postoperative monitoring to improve PDC longevity.

Purpose: This study aims to identify UK general surgical trainees' perceptions, attitudes, and perceived barriers to EBM training and assessment so that interventions by general surgery educators to improve integration of EBM are informed by stakeholder data.

Method: A mixed-method survey was developed by adapting the validated McColl and BARRIERS questionnaires, informed by a scoping review and focus group discussions. Ethical approval was obtained (University of Sheffield - 056808). The survey was distributed through social media, surgical society newsletters, and deanery mailing lists, adhering to the CHERRIES checklist.

Results: The survey yielded 101 responses, 53 of which were complete (65% male, 35% female). A quarter of the 53 respondents did not hold higher academic degrees. Most participants (61%) worked in district general hospitals, with the highest response rates from Yorkshire and West Midlands. Attitudes towards EBM were predominantly positive from trainees (50.3%), with most of the respondents indicating their ability to understand and explain EBM terminology. However, they perceived their senior colleagues to be less enthusiastic about EBM (41.5%). Barriers to developing EBM competencies included lack of time, excessive evidence volume, limited access to resources, inadequate critical appraisal skills and limited opportunities for application during clinical practice. Existing postgraduate assessment strategies were deemed adequate for EBM by most of the trainees.

Conclusion: The surveyed UK General surgical trainees exhibit positive attitudes towards EBM but face barriers in its application within their training. One way of addressing this issue is through research informed targeted curricular interventions.