World Journal of Surgery最新文献

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.

Background: Laparoscopic surgery has gradually gained acceptance for abdominal surgical emergencies; however, limited reports exist on laparoscopic surgery for strangulated small bowel obstruction (SSBO). We aimed to demonstrate the efficacy and feasibility of laparoscopic surgery for SSBO.

Methods: In this single-center retrospective study, patients who underwent emergency surgery for SSBO between January 2014 and December 2024 were included and divided into laparoscopy and open groups. Propensity score matching (PSM) was performed to compare the primary outcomes-intraoperative and short-term postoperative outcomes-between the groups. Logistic regression analysis was used to identify the factors associated with the conversion from laparoscopic to open surgery as secondary outcomes.

Results: A total of 123 patients were included in this study, of whom 39 (31.7%) were assigned to the laparoscopy group. After PSM, the overall rate of the Clavien-Dindo grade ≥ II postoperative complications was significantly lower in the laparoscopy than the open group (7.4% vs. 29.6%; p = 0.036). Of the 39 patients in the laparoscopy group, 10 (25.6%) were converted from laparoscopic to open surgery. The number of previous laparotomies (odds ratio: 4.036, 95% confidence interval: 1.189-13.701, and p = 0.025) and a history of gastrointestinal surgery (odds ratio: 6.125, 95% confidence interval: 1.263-29.699, and p = 0.024) were identified as factors significantly associated with conversion from laparoscopic to open surgery in patients with SSBO.

Conclusion: Our study suggests that laparoscopic surgery for SSBO is beneficial for reducing the occurrence of postoperative complications. However, laparoscopic surgery should be performed in patients with a history of multiple laparotomies or gastrointestinal surgery, considering the possibility of conversion to open surgery.

Background: A growing number of emergency general surgery (EGS) admissions comprise of adults age 65 years and older, who are more likely to experience missed or delayed diagnoses, and subsequently worse postoperative outcomes. We aimed to ascertain the perspectives of clinicians on the diagnostic challenges unique to older adults with EGS conditions and strategies to improve feedback.

Methods: In this qualitative study, semi-structured focus groups were conducted with frontline clinicians with experience in providing high volume care to older adult EGS patients to explore diagnostic challenges, tools, and feedback strategies. Questions focused on clinical gaps and approaches, tools, and the mechanisms in place to provide feedback on patient diagnosis and assessment. Focus groups were transcribed and qualitatively analyzed using an inductive approach.

Results: Twenty-two clinicians participated in one of six focus groups. Clinicians reported three key diagnostic challenges: nontextbook presentations, comorbidities, and older-age specific complications. Nondiagnostic factors remained high priorities including functional health status, patient preferences, family involvement, and health related social needs. Practical tools addressing these gaps included the use of multidisciplinary expertise, surgical risk calculators, cognitive assessments, functional health assessments, and protocols guiding goals of care discussions. Participants shared barriers and facilitators for implementation of these tools.

Conclusion: Frontline clinicians identified several high priority considerations unique in EGS for older adults. To address these, context-specific tools and strategies were detailed and inform ongoing work to incorporate feedback and solutions into frontline settings. Future work in quality improvement should incorporate these high priority areas into existing quality improvement frameworks.

Background: PANP has been applied in laparoscopic radical rectal cancer resection, significantly reducing the incidence of genitourinary dysfunction; however, it has not eliminated sexual and urinary dysfunction. Prospective trials focusing on genitourinary function as a primary outcome are rare. To confirm the protective effect on sexual and urinary function in laparoscopic radical resection of rectal cancer with pelvic autonomic nerve preservation (PANP), and explore the risk factor of postoperative sexual dysfunction.

Methods: A prospective, single-center, single-arm trial was conducted on male patients with rectal adenocarcinoma suitable for laparoscopic surgery with PANP at Sun Yat-sen Memorial Hospital, Sun Yat-sen University. Patients with normal genitourinary function were included, and the primary outcome was the change in sexual function 6 months after the operation.

Results: Of 91 patients enrolled, 70 underwent a laparoscopic operation. Six months after the operation, 5 patients were lost to follow-up, and the IIEF-5 and IPSS scores were 22.85 ± 3.66 versus 24.10 ± 1.21 (p = 0.003) and 2.11 ± 2.06 versus 1.89 ± 1.86 (p = 0.018), respectively, compared with preoperative values. Five patients (7.69%) suffered from sexual disorders, and 2 patients (3.08%) developed moderate urinary dysfunction. The majority of the autonomic nerve system was visible and preserved intraoperatively. Quality of TME was complete in 94.29% (66/70) and partially complete in 5.71% (4/70) of patients, respectively. Positive CRM in this study was 2.86% (2/70), and positive distal resection margin was 1.43% (1/70). The mean postoperative hospital stay was 7.80 ± 2.44 days. Surgical procedure, distance of tumor to AV, clinical TNM stage, nCRT, stoma, and completeness of the autonomic nervous system were risk factors of postoperative sexual dysfunction in univariate analysis; however, none of them was an independent risk factor in multivariate analysis.

Conclusions: PANP in laparoscopic radical rectal resection effectively preserves sexual and urinary function without compromising oncological outcomes. It is safe and feasible in high-flow centers and for experienced surgeons.

Background: Excessive opioid prescribing after colorectal surgery can lead to adverse events and contribute to the opioid crisis. Understanding international prescribing patterns is essential for guiding practice and future research. The Analgesia After Colorectal Surgery (ACORE) survey aimed to characterize international opioid prescribing practices after elective colorectal resection.

Method: This international cross-sectional survey followed established methodological guidelines. Eligible participants were colorectal, gastrointestinal, and general surgeons, as well as surgery trainees. Recruitment followed snowball sampling via international surgical societies' mailing lists, social media, and personal networks. The primary outcome of interest was post-discharge opioid prescribing after open and MIS elective colorectal resection. Secondary outcomes included prescription quantity in morphine milligram equivalents (MMEs). Data were analyzed using descriptive statistics and logistic regression with Bayesian model averaging.

Results: Among 817 participants, 88% were surgeons, 12% were trainees, 62% practiced in academic hospitals, and 67% had over 5 years in practice. Overall, 57% of the participants reported prescribing opioids at discharge (55% after open and 54% after minimally invasive procedures). Opioids were commonly prescribed by surgeons practicing in Australia and New Zealand (100%), Northern America (92%), Northern Europe (68%), and South-eastern Asia (71%). In contrast, they were less frequently prescribed in Eastern Europe (11%), Eastern Asia (22%), Latin America and the Caribbean (26%), Southern Europe (19%), and Northern Africa (0%). The median quantity of opioids prescribed at discharge varied widely (30-200 MMEs). In regression analysis accounting for surgeon and practice characteristics, region of practice was the only factor independently associated with opioid prescribing.

Conclusion: The extensive global variation in opioid prescribing underscores clinical equipoise and challenges the assumption that post-discharge opioids are universally necessary for patients undergoing colorectal resection.