World Journal of Surgery最新文献

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.

Background: Patients with differentiated thyroid carcinoma have a 10 year survival rate of more than 95%. However, the existence of spinal metastases significantly reduces overall survival. In this study, we review the epidemiology and outcomes of patients with thyroid malignancies with spinal metastases.

Method: A retrospective analysis was conducted on 44 patients with thyroid malignancy and spinal metastases treated at our institution from 2008 to 2021, evaluating the outcome parameters by analyzing demographic, clinical and radiological profiles.

Results: The median age upon presentation was 58 years (range - 35 to 80 years). 54.5% had single-level involvement. The thoracic spine exhibited the highest incidence of involvement, followed by the transitional zones and lumbar spine. The most common presenting features were spinal and radicular pain followed by myelopathy. In 77.3% of cases, the pathology was identified as the follicular variant of papillary thyroid carcinoma. A total of 81.8% of patients underwent total thyroidectomy, with 84% receiving iodine ablation and 61.3% undergoing locoregional radiotherapy. Surgical intervention for spinal metastases was performed in 18 individuals (40.9%). There was significant improvement in the postoperative Visual Analog Scale (VAS) score in the operated group (p-value of 0.000). Overall, no significant difference was observed in the OS and PFS between the operated and non-operated groups except for the subset of patients who underwent postoperative radiation therapy (p-value of 0.013).

Conclusion: Vertebral metastasectomy in primary thyroid malignancies is associated with significant pain relief. Patients who receive postoperative radiotherapy perform better than patients who either undergo metastasectomy or radiation therapy.

Aim: The tubercle of Zuckerkandl (TZ) is considered to be the fusion point of the ultimabranchial body and the median thyroid body. We aimed to evaluate the frequency of TZ and its relationship with other anatomical variations and recurrent laryngeal nerve (RLN) paralysis.

Material and methods: Data regarding the thyroid lobe and RLN of patients with thyroidectomy between June 2016 and December 2019 were retrospectively evaluated. TZ is classified according to its dimensions as follows: category 0; invisible, category 1; thickening only the lateral to thyroid lobe, category 2; ≤1 cm, and category 3; >1 cm. Categories 2 and 3 were accepted as TZ.

Results: In 627 patients, 1011 necks and thyroid lobes were evaluated. TZ was found as 58.9% in categories 0 and 1, 18.7% in category 2%, and 22.4% in category 3. In the presence of TZ, the RLN was located posteromedially in 95.2% and laterally in 4.8%. RLN entrapment in the Berry ligament region was significantly higher in categories 2 and 3 compared to category 1 (25.4% vs. 28% vs. 17.3% and p < 0.0001). There was no significant difference in RLN paralysis based on the presence and size of TZ or the relationship between RLN and TZ.

Conclusion: TZ is not rare and can be observed in 41.1% of thyroid lobes. It should be noted that the likelihood of RLN entrapment in the Berry region is higher in categories 2 and 3. Therefore, performing TZ dissection without applying traction to the thyroid lobe and mapping RLN could contribute to better RLN preservation.

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.

Objectives: Acute liver failure poses a significant challenge in surgical critically ill patients. Treatments typically focus on physiological support and alleviation of hepatic insult. This study aims to evaluate the role of high-volume plasma exchange (HVPE) in surgical critically ill patients with medical jaundice and hepatic failure.

Method: A retrospective review was conducted on surgical critically ill patients with hepatic failure unresponsive to conventional therapy, excluding those with obstructive jaundice. HVPE was considered for patients with persistent hyperbilirubinemia (> 10 mg/dL) and coexisting conditions such as coagulopathy, hyperammonemia, more than Grade II hepato-encephalopathy, or exacerbated sepsis/septic shock status or multiple organ failure. Patients were categorized into standard medical treatment (SMT) and SMT + HVPE groups. Demographics and laboratory data were collected for analysis.

Result: A total of 117 patients were enrolled, with 79 in the SMT group and 38 in the SMT + HVPE group. There were no significant differences in laboratory data and MELD score upon admission. Before treatment, patients in the SMT + HVPE group exhibited higher levels of T-bil., D-bil., and sugar than the SMT group. After treatment, the SMT + HVPE group showed lower serum D-bil. and AST levels but higher levels of albumin and platelets compared to the SMT group. The SMT + HVPE group demonstrated significantly lower delta T-bil., delta D-bil., and higher delta platelet levels. The survival rate was 31.6% (12/38) in the SMT + HVPE group and 1.3% (1/79) in the SMT group. The in-hospital mortality rate in the SMT + HVPE group was lower than that in the SMT group, with a hazard ratio of 0.42 in the crude model and 0.34 (95% CI = 0.20-0.60 and p = 0.0002) in the adjusted model.

Conclusion: Our findings suggest that HVPE improves survival rates in surgical critically ill patients with medical jaundice and hepatic failure. However, due to its retrospective nature, further studies were warranted.

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.

Background: Application of enhanced recovery after surgery (ERAS) pathways in robotic lobectomy have been associated with decreased length of stay (LOS). We evaluated differences in patient characteristics and achievements of ERAS benchmarks by discharge groups at a tertiary referral center.

Materials and methods: We performed a retrospective analysis of a prospectively maintained ERAS database of patients undergoing robotic lobectomy for pulmonary malignancy. Patients were trifurcated into LOS groups, postoperative day 1, 2-3, and 4+. Preoperative and perioperative variables, ERAS achievement, complications, and readmissions were analyzed.

Results: Between October 2018 and August 2022, 145 consecutive patients were reviewed. Eighty-two (56.6%) were discharged on POD 1, 50 (34.5%) on POD 2-3, and 13 (9.0%) on POD 4+. Patients achieving POD 1 discharge were associated with better preoperative pulmonary function (FEV₁ p = 0.023 and DLCO p = 0.007) and shorter operative times (p < 0.001). Most air leaks (n = 30, 54.5%) were resolved by discharge; however, 25 (17.2%) were discharged with a chest tube. The POD 1 discharge group ambulated earlier (p = 0.005) and experienced no inpatient complications. Multivariate analysis reveals that operative time, time to first ambulation, and postoperative day 1 air leak were negatively associated with POD 1 discharge. Those who experienced a minor inpatient complication ambulated 5.8 h later than those who did not.

Conclusion: Utilization of ERAS principles can facilitate POD 1 discharge in the majority of patients undergoing robotic assisted lobectomy without an increase in complications or readmissions. Early ambulation and chest tube removal are modifiable elements of ERAS associated with POD 1 discharge.