World Journal of Surgery最新文献

Purpose: Glucagon-like peptide-1 (GLP-1) receptor agonist medications are revolutionizing approaches to weight loss, including in the neoadjuvant setting. Obesity poses a challenge to the hernia surgeon, as an independent modifiable risk factor for hernia occurrence which also connotates a higher risk of post-operative morbidity, complications, and recurrence. This is the first review to investigate the neoadjuvant potential of GLP-1 receptor agonists to result in weight loss prior to elective abdominal wall hernia surgery in obese patients.

Methods: A computer-assisted search of Medline, PubMed, and EMBASE was conducted to identify studies reporting on the utility of GLP-1 receptor agonist medications in neoadjuvant weight loss prior to abdominal wall hernia surgery.

Results: A total of three retrospective studies were included in this narrative study. In this study, GLP-1 receptor agonists have been found to contribute to either statistically significantly greater weight loss and BMI reductions, or at least equivalent outcomes, in the pre-operative setting prior to elective abdominal wall hernia repair, when compared to conventional lifestyle modifications alone. However, neoadjuvant GLP-1 receptor agonists have not been shown to be superior to pre-operative bariatric surgery in effecting weight loss and BMI reduction. GLP-1 receptor agonists have also been found to be associated with an earlier surgery date if weight loss is the barrier to surgery, when compared to both lifestyle modifications and bariatric surgery. Crucially, GLP-1 receptor agonists have not been shown to lead to more complications or hernia recurrences in terms of post-operative outcomes. These results are limited by the relative paucity of data, the heterogeneity of the included studies, and the absence of long-term outcomes.

Conclusion: There may be a promising role for GLP-1 receptor agonists in the neoadjuvant approach to abdominal wall hernia repair, by inducing and accelerating pre-operative weight loss without a negative impact on post-operative outcomes. Only limited conclusions can yet be drawn at this stage and large-scale prospective studies, ideally in a randomized controlled setting, are necessary to investigate this finding further.

Background: Diabetic foot is a serious complication of diabetes mellitus that generates lifelong consequences on the health and quality of life of affected patients. One of the first grading systems developed for diabetic foot was the Wagner classification system. Despite its prolonged use in the medical field, accurate clinical assessment requires an experienced evaluator to minimize errors and bias. Using infrared thermography, a technology that quantitatively measures temperature changes in areas of interest related to altered vascular flow derived from inflammatory processes, could diminish the subjective bias associated with clinical evaluation.

Objective: To determine the thermographic pattern of the different grades of the Wagner classification system for diabetic foot.

Methods: We evaluated thermographic images of 66 patients diagnosed with diabetic foot. Clinical data and infrared thermographic images were acquired at the moment of evaluation. Temperature differences (ΔT) between the first toe of the affected limb and the contralateral unaffected first toe were recorded and analyzed with computer software. The thermographic patterns were then compared with the Wagner classification system grades.

Results: A positive ΔT was observed in 36 patients in the first three Wagner grades: Wagner 0, ΔT 0.71°C ± 0.43; Wagner 1, ΔT 1.17°C ± 1.88; and Wagner 2, ΔT 2.18°C ± 2.38. Thirty patients presented negative ΔT from the third grade onward: Wagner 3, ΔT -2.66°C ± 1.14; Wagner 4, ΔT -5.92°C ± 1.75, and Wagner 5, ΔT -6.92°C ± 1.28. Then, we separate the cohort into two groups: patients who required amputation and those who required conservative management. A threshold in the ΔT value of -2.6 correctly predicted the outcome in more than 95% of patients.

Conclusions: These results suggest a potential application for thermography as an adjunctive tool in wound clinics, enabling the accurate evaluation of diabetic foot ulcers and as a predictor of patients' outcomes.

Trial registration: Registry: 08-23 by the Hospital Regional de Alta Especialidad "Dr. Ignacio Morones Prieto" Research Ethics Committee (CONBIOÉTICA-24-CEI-001-20160427).

Background: Amid increasing global concerns regarding antimicrobial resistance, the routine use of prophylactic antibiotics in anorectal surgery has been questioned. In practice, prescribing practices vary widely among surgeons, highlighting the need for stronger evidence-based guidance. The aim of this study is to perform a systematic, critical assessment of the current literature to determine the role of prophylactic antibiotics in elective anorectal surgery.

Methods: A comprehensive search of studies published between January 1980 and June 2025 was performed using PubMed, Embase, and Cochrane Library. The primary outcome was surgical site infection (SSI); secondary outcomes included systemic infection, wound dehiscence, abscess formation, bleeding, and recurrence. Study quality was assessed using the Cochrane RoB 2.0 tool for randomized controlled trials (RCTs) and the ROBINS-I tool for observational studies. The certainty of evidence was evaluated using the GRADE approach.

Results: Nine studies including 2317 participants were included, and five were eligible for meta-analysis. Overall, prophylactic antibiotics were not associated with a significant reduction in postoperative infectious or wound-related complications in RCTs (RR 0.76, 95% CI 0.43-1.33, and p = 0.66, moderate GRADE certainty of evidence) or observational studies (RR 0.60 (95% CI 0.01-48.4) and p = 0.53, very low certainty). All studies concluded that routine antibiotic prophylaxis may be unnecessary in anorectal surgery.

Conclusion: Current evidence does not support the routine use of prophylactic antibiotics in uncomplicated anorectal procedures. However, the certainty of evidence is limited by small sample sizes, methodological heterogeneity, and limited number of available studies. Large-scale randomized trials are required to strengthen this evidence base.

Trial registration: The review protocol was registered in the PROSPERO database CRD420251159850.

Introduction: Healthcare financing models significantly impact health outcomes across many diseases in high-income countries (HICs). In low or middle-income countries (LMICs), where financial vulnerabilities are much higher, little is known about the relationship between payment mechanisms and emergency care outcomes. This study aimed to quantify the association between trauma care payment mechanisms and inpatient mortality.

Methods: We conducted analysis of data from in four facilities in province Sindh, Pakistan (two urban and two rural sites) collected between May 2023 and February 2025. The outcomes were inpatient mortality and length of stay (LOS). We compared patients with out-of-pocket (OOP) expenses with no-OOP. We calculated adjusted odds ratio with a 95% confidence interval for OOP after controlling for age, sex, injury severity (Kampala Trauma Score [KTS]), blood transfusion, procedure, comorbidity, and setting. We also applied propensity score matching (PSM) on age, sex, mechanism of injury, injury severity (KTS), and setting.

Results: Most of the 3572 enrolled patients were young (median age 35 years and IQR 25-50) males (81.95%) and a third paid OOP for hospital care (n = 978 and 37.38%). The overall mortality rate was 4.85%, with a significantly higher mortality rate among the OOP group compared to the no-OOP group (10.02% vs. 2.89%; AOR 3.14: 95% CI 1.93, 5.10). Additionally, the hospital LOS (median 4 vs. 9 days and p value < 0.001) and mean survival time of patients (22.81 days vs. 28.67 and p value < 0.001) were lower for the OOP group than no-OOP group. The odds ratio after PSM showed a weak significant independent association between OOP and mortality (OR 1.05; 95% CI 1.02, 1.08).

Conclusion: Patients who paid OOP for injury care had greater mortality, suggesting that alternative financing strategies could improve outcomes in LMICs. Additionally, OOP was associated with shorter LOS, highlighting the need to improve universal health coverage for complete injury care.

Background: Timely care for open tibia fractures remains difficult in low-resource settings. We evaluated a task-sharing model in Malawi in which trained orthopedic clinical officers (OCOs) delivered external fixation supported by a remote quality assessment tool.

Methods: We conducted a prospective implementation evaluation across one central and four district hospitals (May 2023-July 2024). The intervention bundled OR refurbishment assured external fixator supply, refresher training, mentoring (on-site and remote), national guideline reinforcement, and a novel Fracture Fixation Assessment Tool for External Fixation (FFATEF). OCOs submitted postoperative radiographs and construct photographs for scoring across four domains (reduction, stability, implantation, and surgical impression; total 0-12 and satisfactory ≥ 8). Nonparametric tests compared performance by the hospital type; temporal trends were assessed with Spearman correlation.

Results: Forty-seven patients (89% male and mean age 32.3 years) were treated (central: n = 28 and district: n = 19). The central hospital managed more severe injuries (Gustilo IIIA/B 69.6% vs. 15.8%). Median FFATEF scores were higher at the central hospital (10.0 [IQR 9-11]) than district hospitals (6.0 [5, 6, 7, 8], p < 0.001). Satisfactory scores (≥ 8) occurred in 93% of central versus 32% of district cases. Central scores improved over time (ρ = 0.52; p = 0.005) whereas district scores were unchanged (ρ = 0.15; p = 0.540). Preoperative antibiotic compliance was 100% at the central versus 47% at district hospitals.

Conclusions: When embedded within integrated surgical teams and adequate infrastructure, task sharing for open fracture external fixation yielded satisfactory technical performance but lagged district-level implementation despite training. Comprehensive institutional support-mentoring intensity, equipment, supply chains, and referral adherence-is likely required for safe scale-up. Validation of FFATEF against clinical outcomes and economic evaluation of delivery models are priorities.