World Journal of Surgery最新文献

Background: Major emergency abdominal surgery (MEAS) has high morbidity and mortality rates. With an aging and frail population, understanding the impact of frailty on postoperative complications is crucial.

Methods: This prospective cohort study was conducted at a major university hospital in Denmark from October 1, 2020, to January 1, 2024. A total of 733 patients undergoing MEAS were assessed for frailty using the clinical frailty scale (CFS) at admission and grouped into low (CFS 1-3), moderate (CFS 4-6), and high (CFS 7-9) frailty categories. Postoperative complications were classified by the Clavien-Dindo score and comprehensive complication index (CCI) until discharge.

Results: Patients with CFS one to three had 140 complications per 100 patients, CFS four to six had 267 complications per 100 patients, and CFS seven to nine had 297 complications per 100 patients (p < 0.001). Increased frailty was associated with higher severity of complications (Clavien-Dindo score). Median CCI scores were 8.7 (CFS 1-3), 29.6 (CFS 4-6), and 38.2 (CFS 7-9) (p < 0.001). The cumulative risk of complications was higher in patients with CFS four to six and seven to nine.

Conclusion: Higher frailty scores correlate with an increased number and severity of complications as well as a greater overall burden of postoperative complications. The clinical frailty scale is effective for preoperative identification of high-risk patients.

Trial registration: The study was approved by the Capital Region of Denmark (P-2020-1166 and R-21038079) and the Danish Data Protection Agency (P-2021-431).

The shortage of surgeons in rural hospitals is a serious problem in Japan. In this study, we investigated the potential contribution of surgical telementoring systems to improving surgical skills and resolving the shortage of surgeons in rural hospitals. The conference room at Tokushima University was connected to the operating room at Miyoshi Hospital, a rural hospital approximately 75 km away, via a virtual private network. Telementoring was conducted for surgeries performed at Miyoshi Hospital from Tokushima University using ADMENIC ANNOTATOR (Carina Corporation). A questionnaire using the NASA Task Load Index was completed by two surgeons who received remote instruction. The surgeries when using the surgical telementoring system had significantly better "mental", "performance", and "frustration" scores compared with those performed without using the system. In a questionnaire about the surgical telementoring system, both surgeons did not notice a communication delay and indicated that annotation and voice instruction was easier to understand than voice only. In addition, fifty fifth-year medical students completed a questionnaire. After experiencing the surgical telementoring system, the number of students who responded favorably to working in a rural hospital increased from 22 (44%) to 31 (62%) (p < 0.01). Surprisingly, 10 of the 27 students who were not interested in becoming a surgeon indicated that they were now interested in becoming a surgeon (p < 0.01). This study suggests that the introduction of a surgical telementoring system in rural hospitals may help improve the skills of rural surgeons and contribute to eliminating the maldistribution and shortage of surgeons in the future.

Background: Some patients with gastroesophageal reflux (GERD) experience extraesophageal symptoms, which are considered due to laryngopharyngeal reflux (LPR). Most studies evaluating fundoplication for LPR report outcomes from individuals who also have typical esophageal GERD symptoms. Information is limited for patients with LPR but no GERD symptoms. To determine whether LPR patients benefit from fundoplication outcomes were determined for individuals with LPR ± GERD and also those without LPR.

Methods: Patients undergoing fundoplication from 1997 to 2015 were identified and divided into three symptom groups: LPR only, LPR and GERD, and GERD only. Heartburn, dysphagia, and satisfaction were assessed using 0-10 analog scores and compared at short (1-2 years) and later (5 years) follow-up.

Results: 2204 patients underwent fundoplication. 24 patients had LPR only, 130 patients had LPR and GERD, and matched to 1319 patients with GERD only. At 1-2 years follow-up, the LPR only group had lower satisfaction scores than those with GERD symptoms (± concurrent LPR) (7.00 ± 3.49 vs. 8.41 ± 2.42, p = 0.019, and mean ± s.d.). At 1-2 years, 68.1% of the LPR only group had a good outcome (satisfaction score: 7-10) versus 84.6% with LPR and GERD and 84.1% with GERD only.

Conclusion: At 1-2 years follow-up, patients with LPR only were less satisfied following fundoplication compared with patients with typical GERD (±LPR). However, some patients with LPR only did benefit and might be considered for surgery if appropriately counseled. Outcomes were similar for patients with LPR and typical GERD and those with only typical symptoms.

Introduction: Active surveillance (AS) for low-risk papillary thyroid carcinoma (PTC) is acknowledged as a valid management strategy. While older age is identified as a favorable factor for progression, long-term evidence is scarce and lifelong monitoring has been deemed essential. This study investigated progression patterns and tumor calcification under long-term AS and explored the possibility of ending follow-up.

Materials and methods: A total of 650 patients with low-risk PTC who chose AS were enrolled. Progression was defined as either tumor enlargement (≥3 mm from initiation) or development of clinically apparent lymph node metastasis.

Results: The median observation period was 8 years; 45.2% were under surveillance for ≥10 years. Overall, 80 patients (12.3%) exhibited progression. Median age and observation period at the time of progression were 55 and 4 years, respectively. Only 2 patients showed progression after 15 years of follow-up and 5 patients showed progression after reaching 80 years old. Among 71 patients experiencing tumor enlargement, surgery was performed immediately in 32 patients. The remaining 39 patients continued surveillance, but only 5 demonstrated ongoing enlargement thereafter. Of 40 surgeries due to progression, 36 were conducted within the first 10 years. The degree of calcification correlated with age and observation periods. No progression occurred after the development of rim calcification.

Conclusions: Progression during AS was extremely rare in older patients with long-term surveillance and in tumors with rim calcification. It may be feasible to consider ending scheduled surveillance visits for these patients. Instances of progression halting after enlargement are not uncommon.

Background: The erector spinae plane block (ESPB) and quadratus lumborum block (QLB) are two novel interfascial plane block techniques with possible analgesic effects for both incisional and visceral pain. However, the results of the intercomparison of the two techniques for analgesia after abdominal surgery remain controversial.

Methods: A systematic literature search was performed on five databases for randomized controlled trials comparing the analgesic efficacy of ESPB and QLB in abdominal surgery. The primary outcome was the 24 h postoperative intravenous IV morphine-equivalent consumption. A meta-analysis was performed using a random-effects model, with subgroup analyses based on the types of surgery and approaches of QLB.

Results: The 24 h postoperative IV morphine-equivalent consumption was lower in patients receiving ESPB than in those receiving QLB (MD -2.307 mg; 95% CI ‒4.577 to -0.038; p = 0.046; and I² = 96.5%), though the reduction did not reach clinically meaningful difference. Static and dynamic pain at different postoperative time points, the time to first rescue analgesia, and the incidence of PONV showed no significant difference between the two groups. However, the QLB group demonstrated a significantly prolonged time in performing the block compared to the ESPB group (MD -2.985 min; 95% CI -4.608 to -1.363; p < 0.001; and I² = 97.5%).

Conclusions: Based on the available evidence from a systematic search of databases, the single-shot ESPB exhibits similar analgesic effects as QLB in abdominal surgery. The incidence of PONV was similar between the two techniques, with no block-related complications identified though QLB might be a more technically challenging approach than ESPB.

Introduction: Surgical care in first-referral hospitals (FRHs) in low- and middle-income countries (LMICs) is poorly characterized. Inguinal hernia repair can act as a good tracer condition. This study aimed to evaluate the variation in hernia repair across different hospital types in LMICs.

Methods: We conducted a secondary analysis of an international prospective cohort study of hernia surgery. Data was collected from consecutive patients undergoing primary inguinal hernia repair between 30 January and May 21, 2023. We characterized patients from LMICs, comparing first-referral, secondary, and tertiary hospitals. Emergency surgery, financing methods, mesh use, and complications were defined as key performance measures relevant for FRHs. A multilevel logistic regression model was used to test associations between complications and hospital type.

Results: This analysis included 8155 patients undergoing hernia repair across 328 hospitals in 55 LMICs. Most patients were male (89.8%, 7324/8155), of working age (mean age 41.6, SD 25.3). Emergency surgery rates were similar across first-referral, secondary and tertiary hospitals (11.1%, 10.9%, and 9.6%, respectively). Patients in FRHs were most likely to experience out-of-pocket payments (31.4%, 9.4%, and 17.4%). They also had lower rates of mesh use (71.9%, 82.1%, and 84.1%) and higher postoperative complication rates (19.1%, 12.5%, and 14.0%), although complications were similar after adjustment (adjusted odds ratio 1.71, 95% CI 0.83-3.54, p = 0.148).

Discussion: This sample of FRHs is capable of delivering simple elective surgery, reducing the burden on subsequent referral hospitals. To scale these surgical pathways, FRHs need support to increase the use of mesh and ensure cost protection for patients.

Background: Hemorrhoidectomy is considered as the most effective approach for patients with grade III and grade IV hemorrhoids; the operative procedure may be associated with significant postoperative pain and other complications. Several surgical techniques and devices have been developed to overcome these postoperative problems.

Objective: To compare perioperative and postoperative outcomes of hemorrhoidectomy performed with the LigaSure and the conventional Milligan-Morgan hemorrhoidectomy among Nigerian patients with symptomatic hemorrhoids.

Methodology: All consenting adult patients who fulfilled the inclusion criteria were randomized to either conventional Milligan-Morgan or LigaSure hemorrhoidectomy. Outcome measures were the duration of the procedure, estimated blood loss, and resolution of symptoms, which were assessed using the Sodergren hemorrhoids severity score (SHSS). Postoperative pain was evaluated using the visual analog scale (VAS), and the short-term recurrence rate was also checked at 3 months. Data were analyzed using the computer software IBM SPSS version 23.

Results: Fifty-two patients were randomized equally into the two arms. The median blood loss in the LigaSure group was 10.0 mL, whereas the median blood loss in the Milligan-Morgan group was 26.5 mL, (p = 0.0001). The median postoperative pain at 2 weeks using the VAS was 5.5 in the LigaSure group, and in the Milligan-Morgan group, it was 6.0 (p = 0.002). The mean duration of surgery in the LigaSure group was 18.04 min and 34.19 min in the Milligan-Morgan group (p = 0.0001).

Conclusion: LigaSure hemorrhoidectomy is faster and associated with less blood loss compared to conventional Milligan-Morgan hemorrhoidectomy.

Aims: The aims of this study are to determine the long-term overall survival (OS) after surgically treated malignant struma ovarii (MSO) and to evaluate prognostic effect of adjuvant thyroid-related therapy (ATRT) in this setting.

Methods: A systematic review in compliance with Preferred Reporting Items for Systematic reviews and Meta-Analyses standards was conducted. MEDLINE, CINAHL, CENTRAL, Scopus, trial registries, and gray literature were searched. Due to rarity of the disease, all case reports including patients with surgically treated MSO were pooled to create a single cohort which was then compared with the eligible case series. The OS and survival time were primary outcomes. The OS was determined using Kaplan-Meier survival statistics, and the predictors of OS were determined using the stepwise Cox proportional-hazards regression model.

Results: The study included 376 patients (95 from case reports and 281 from case series). The median age was 44 years; 79% (75/95) were symptomatic. In terms of ATRT, 39% (37/95) received thyroidectomy, 28% (27/95) radioactive iodine, 28% (27/95) hormone suppression therapy, and 55% (52/95) received no therapy. Recurrence occurred in 27% (26/95) with the median time to recurrence of 4 years. The pooled OS was 91% at 10 years and 87% at 20 years. The OS was not predicted by age (p = 0.320), symptomatic status (p = 0.371), follicular histology (p = 0.934), metastatic disease (p = 0.981); omentectomy (p = 0.523), total thyroidectomy (p = 0.371), radioactive iodine therapy (p = 0.285), and thyroid hormone therapy (p = 0.994).

Conclusions: Surgically treated MSO may have excellent long-term prognosis with or without ATRT. It is possible that thyroid-specific treatments in MSO constitute overtreatment, with no demonstrable survival benefit. Limitations in the evidence base limit the ability to produce definitive conclusions.