World Journal of Surgery最新文献

Background: The Clavien-Dindo (CD) classification, derived in elective surgery, limits complications to deviations from the post-operative course. The interpretation of this definition has not been examined. The application of the CD definition to emergency general surgery (EGS) is limited as many EGS patients have a pre/non-operative component of care allowing under-capture of adverse events that are relevant to quality of surgical care. This study aimed to explore how surgeons interpret and define complications across elective and EGS settings.

Methods: We conducted a cross-sectional survey of 76 general surgeons across four Melbourne public hospitals. With reference to 43 clinical vignettes spanning pre-operative, intra-operative, post-operative, post-discharge, and non-operative care domains respondents indicated whether events constituted complications under the CD classification.

Results: The response rate was 72% and 93% of respondents reported EGS experience. Acceptance of individual events ranged from 15% (post-operative fever) to 100% (intra-operative neuropraxia). There was broad acceptance that events occurring during pre-operative and non-operative care could be classified as complications. Minor physiological changes and events not requiring intervention were often disregarded as complications. Perceived accountability influenced responses, with complications more likely to be recognized when linked directly with surgical care. Agreement on classification was only fair (Fleiss' Kappa = 0.254), indicating only fair concordance in complication classification.

Conclusions: This study demonstrates significant variability in the classification of surgical complications within EGS, highlighting the limitations of current frameworks particularly in the acute contexts. Incorporating surgeon perspectives into refined classification systems may improve audit accuracy, better capture the complexity of EGS, and ultimately enhance patient care.

Area under the receiver operating characteristic curve for the Activity Measure for Post-Acute Care (AM-PAC) model and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) risk calculator model to predict discharge to postacute care.

Introduction: Operative management of gastroduodenal ulcers (GDUs) and vagotomy are increasingly rare due to success of medical therapy. Given sociodemographic factors could impact perception of medical therapy adherence and operative management, we sought to investigate the influence of sociodemographic factors on likelihood of vagotomy for patients with GDUs.

Methods: The 2012-2017 Nationwide Inpatient Sample was queried for adults admitted with GDUs and gastric or duodenal operations. To assess sociodemographic associations, univariable and multivariable comparisons were made between operations with vagotomies and those without.

Results: A total of 80,980 weighted discharges and 4230 (5.2%) vagotomies were identified. In univariable comparisons, vagotomies were more likely in earlier years, among younger patients, among patients without insurance coverage, and with lower median income. In the adjusted multivariable logistic model, lower median income (OR 1.50 [1.19, 1.90] for lowest vs. highest quartile) and younger age (OR 0.69 [0.48, 0.98] for Age 80+ vs. Age 18-39) were associated with higher odds of vagotomy.

Conclusions: Vagotomy remains a rare operative treatment for GDUs. Lower household income and Medicaid or self-pay insurance were significantly associated with performing vagotomy for GDUs. These findings suggest that socioeconomic status may play a role in operative decision-making for these conditions.

Background: The healthcare sector contributes approximately 4%-10% to overall greenhouse gas emissions. Within this percentage, the contribution of operating rooms is significant and cannot be overlooked. This study aims to construct a knowledge mapping related to research on the carbon footprint in operating rooms.

Methods: A comprehensive search was conducted in the Web of Science Core Collection database on May 1, 2025, using the keywords "operating room" OR "operating theater" OR "perioperative area" AND "carbon footprint", without applying any time restrictions. The search was limited to the fields of title, abstract, keyword plus, and author keywords. The analysis was performed using the Bibliometrix-Biblioshiny package in R software (version 4.2.2). The results were presented through key information, a word cloud, trend topics, and a thematic map.

Results: Publications were produced between 2013 and 2025, with an average publication age of 2.14 years and an annual publication growth rate of 28.83%. The majority of publications originated from the United States and the United Kingdom. Aside from keywords, the most frequently studied topic (n = 32, 14%) and the topic showing ongoing development was "sustainability." Topics such as "greenhouse gases," "surgical waste," "gas emission," and "decarbonization" had developed but remained isolated subjects.

Conclusion: This bibliometric study comprehensively analyzes the scientific discourse, trends, and developments prevailing in carbon footprint research in operating rooms without any time constraints. Identifying the limitations and orientations of current research is expected to serve as a reference for researchers interested in the carbon footprint in operating rooms.

Aim: Postoperative C-reactive protein (CRP) levels are good predictors of anastomotic leak (AL) following colorectal surgery, with postoperative day-3 CRP thresholds ranging between 162 and 195 mg/L in open and laparoscopic resections. This study aims to determine a cut-off CRP value that predicts ALs following robotic colorectal surgery and identifies patients suitable for safe early discharge.

Methods: A single-center retrospective analysis of patients who underwent an elective robotic colorectal resection, with primary anastomosis, between February 2017 and December 2024, was conducted. Primary outcome measure was clinically and radiologically confirmed AL (graded). Data were analyzed using IBM SPSS v30.0.0.

Results: Seven hundred eighty-four elective robotic colorectal resections with anastomosis were performed. Median age was 69 years (IQR 60-77), 448 male, 336 female, and BMI 27.5 (IQR 24.4-31.1), indication for surgery was cancer in 681 (86.9%) patients. 51 (6.5%) patients had an AL, of which 12/51 (23.5%) had a grade ≥ 3 leak. A POD-3 CRP level of 136.0 mg/L (73% sensitivity, 79% specificity, and AUC 0.788) and POD-4 CRP level of 94.4 mg/L (84% sensitivity, 62% specificity, and AUC 0.806) were predictive of AL. At POD-5, a cut-off CRP of 243 mg/L (88% sensitivity, 73% specificity, and AUC 0.818) was predictive of ALs requiring re-operation and/or escalation to level 2-3 care. Male sex, colo-rectal anastomoses, and resections performed before 2020 were associated with higher AL rates.

Conclusion: Postoperative CRP levels have high predictive value in early detection and exclusion of AL, facilitating early patient discharge under the enhanced recovery after surgery (ERAS) pathways. CRP thresholds in robotic colorectal resections are lower than previously reported thresholds in open and laparoscopic surgery.

Introduction: This clinical practice guideline from the Explosive Weapons Trauma Care Collective (EXTRACCT) group reviews current best practice for the management of ocular trauma in conflict-affected regions, where explosive weapons are used and healthcare infrastructure is limited.

Methods: An expert literature review of current practice is presented with practical resource-adapted guidelines constructed through expert consensus from ophthalmologists, emergency care providers and allied health professionals with field experience.

Results: The guideline provides recommendations for the assessment, classification and management of major and minor ocular injuries encountered in low-resource settings, particularly during conflict. Guidance is written for frontline healthcare workers who may be addressing such injuries in the absence of specialist ophthalmology expertise and equipment. Dosing of ophthalmic therapeutics is provided.

Conclusion: Actionable context-appropriate strategies to manage ocular trauma caused by explosive weapons can reduce vision loss and improve patient outcomes where specialized ophthalmic care is scarce.

Background: The use of perioperative bridging therapy remains a topic of debate due to its associated risks and benefits. Therefore, we sought to characterize the association of bridging therapy with thrombotic and bleeding events following a major surgical procedure.

Method: Patients who underwent surgical procedures between 2022 and 2024 were identified using Epic Cosmos database in this retrospective cohort study. Bridging therapy (BT) was defined by the receipt of low molecular weight heparin (LMWH) or unfractionated heparin within 5 days before surgery. Thrombotic and bleeding events within 30-day following surgery were examined using entropy balancing (EB) and multivariable regression models.

Results: Among 36,699 patients (i.e., pneumonectomy: n = 5829, 15.9%, esophagectomy: n = 434, 1.2%, gastrectomy: 4574, 12.5%, pancreatectomy: n = 983, 2.7%, hepatectomy: n = 946, 2.6%, biliary resection: n = 7034, 19.2%, and colectomy: n = 16,899, 46.0%), most were male (n = 19,418, 52.9%) with a mean age of 70 years (standard deviation: ± 13 years); 59.9% (n = 21,831) of patients received bridging therapy before a major surgical procedure. Following surgery, 4.6% (1673) of patients had VTE, 1.7% (n = 625) had CVA, and 12.3% (n = 4532) had bleeding. Following EB weighting, patients who received bridging therapy had 16% lower odds of CVA (OR: 0.84, 95% CI 0.71-0.99) and 12% lower odds of VTE (OR: 0.88, 95% CI 0.80-0.97); there was no difference in incidence of major bleeding events (OR: 0.97, 95% CI 0.91-1.03).

Conclusion: Roughly one in two patients undergoing surgery received bridging therapy. Bridging therapy was associated with reduced risk of thrombotic complications and no increase in major bleeding events.

Background: Surgical site infections (SSIs) are a leading cause of postoperative morbidity, particularly in low- and middle-income countries (LMICs). The influence of operative timing on SSI risk remains unclear in these settings. This study aimed to assess the association between case timing and SSIs following emergency gastrointestinal surgery at a tertiary hospital in Kenya.

Method: We performed a retrospective cohort study of adult patients undergoing emergency gastrointestinal operations between January 2016 and December 2019. Procedures were categorized by timing: weekday daytime (08:00-16:59) versus off-peak (weeknights, weekends, and holidays). The primary outcome was SSI. Multivariable logistic regression adjusted for wound classification, procedure type, and the Africa Surgical Outcomes Study (ASOS) risk score. Sensitivity analyses evaluated duration of illness, prior care, operative duration, presence of perforation, year of admission, admission to the intensive care unit, and number of surgeons.

Results: Of 400 patients included, 58 (14.5%) developed an SSI. SSI occurred in 19.9% of weekday cases versus 11.7% of off-peak cases (p = 0.029). In adjusted analysis, weekday operations were associated with increased odds of SSI (OR 2.0, 95% CI 1.1-3.6, and p = 0.024). Dirty wound classification and small intestine and colorectal cases were also associated with increased SSI rates in the model. The observed SSI rate was significantly lower than the 28.6% rate predicted by GlobalSurg data for middle-HDI countries (p < 0.001).

Conclusion: Contrary to findings from high-income settings, emergency operations performed during off-peak hours were associated with fewer SSIs than weekday cases. This may reflect workflow differences or lower operating room traffic. The findings support ongoing efforts to optimize perioperative systems and challenge assumptions about off-hour surgical care in LMICs.

Background: Access to guideline-concordant global-standard breast cancer care remains limited in many low- and middle-income countries (LMICs), where high-cost technologies for diagnostics, surgical diagnosis and treatment (such as radioisotope mapping, ICG fluorescence, and intraoperative margin assessment) are not widely available. The BRIDGE Course (Breast Surgery Resource Integration & Development for Global Excellence) was designed as a short, virtual educational program to educate and update surgeons with validated, low-cost techniques that ensure oncologic safety while addressing resource constraints.

Methods: A 7-h online course was designed and conducted in September 2025 with participation from international and national faculty. Content emphasized pragmatic adaptations of global guidelines, including triple assessment, surgical decision-making for mastectomy versus breast conservation, sentinel lymph node biopsy (SLNB) using methylene blue and fluorescein torch, and low-cost oncoplastic approaches. Pre- and post-course surveys assessed baseline practice, perceived barriers, satisfaction, confidence, and intent to implement. Descriptive statistics were analyzed.

Results: Seventy-five participants completed the pre-course survey and 66 completed the post-course survey. At baseline, mastectomy was the most common primary operation (30.7%), whereas only 20% predominantly performed breast-conserving surgery; SLNB was mainly performed using methylene blue (68.5%). Reported barriers included lack of resources, training gaps, and patient mindset. Post-course, ≥ 85% of participants reported improved confidence across all domains: triple assessment (83% strongly agreed), mastectomy versus BCS decision-making (74%), SLNB with low-cost tracers (66%), and complication management (60%). Implementation intent was high, with nearly all (96%) planning to adopt at least one new technique and all intending to share knowledge with colleagues or trainees.

Conclusion: The BRIDGE Course successfully enhanced knowledge and confidence in resource-adapted breast cancer surgery, with strong intent to implement and improve practices. Such short, focused virtual programs may serve as a scalable model for narrowing disparities in breast cancer care across LMICs.