World Journal of Surgery最新文献

Background: Low- and middle-income countries are currently experiencing a significant shortage of physicians trained in anesthesia. This shortage has been widely attributed to multifactorial causes, including limited local training capacity, workforce migration, underfunded health education systems, and poor national workforce planning. Therefore, the present study aimed to evaluate the state of postgraduate anesthesia training in Ecuador focusing on the structure of current programs and the competencies of their senior residents.

Methods: A cross-sectional study was conducted in two-phases. During the first phase, we mapped and characterized accredited anesthesiology residency programs based on the information available on the webpage of the Ecuadorian Higher Education Council. During the second phase, we administered two surveys. First, we invited the medical directors of universities with active anesthesiology programs to fill out a survey developed by the Society for Education in Anesthesia's ad hoc Committee for Resident Evaluation. Then, we assessed self-perceived senior residents' competencies for anesthesia care defined by the Accreditation Council for Graduate Medical Education. A five-point Likert scale was used to determine whether the competency was met using a 70% cutoff value.

Results: Seven universities in Ecuador offer postgraduate anesthesiology programs, ranging from 4 to 32 residents per cohort, with a total training capacity of 112 residents. Findings from both program directors (n = 4) and senior residents (n = 27) revealed deficiencies in resident evaluation processes, including low faculty-to-resident ratios and limited resident involvement in evaluation committees. Deficiencies in competency development were observed particularly in pain management; only 48.5% of those evaluated reported competence in managing complex pain at the perioperative level. Likewise, lack of competence was reported in using echocardiography for patient monitoring and revealing medical errors or complications with competence values at 14.8% and 33.3%, respectively.

Conclusions: Ecuador has a limited number of postgraduate anesthesiology programs, contributing to a shortage of anesthesia-trained physicians. Exacerbating this issue, within these programs, there are significant gaps in resident evaluation and competency development. Addressing these issues would improve the quality of anesthesiology training and enhance patient care and safety in Ecuador.

Objectives: To test the hypotheses that intraoperative hyperlactatemia is independently associated with increased postoperative infection risk in cardiac surgery with cardiopulmonary bypass (CPB).

Methods: This study involved 4970 cardiac surgical patients with CPB from two medical centers. Intraoperative hyperlactatemia was defined as blood lactate levels exceeding 2.0 mmol/L. The main objective was to investigate the association between intraoperative hyperlactatemia and postoperative infections. Furthermore, we identified the threshold values of intraoperative peak blood lactate levels linked to a heightened risk of postoperative infection.

Results: Postoperative infections occurred in 14.49% of the patients included in the study. Patients who developed postoperative infection had significantly higher intraoperative median peak lactate levels (3.5 mmol/L vs. 2.6 mmol/L and p < 0.001). After adjusting for confounders, patients with intraoperative hyperlactatemia had roughly a 1.5-fold increased risk of developing postoperative infection (adjusted OR: 1.49; 95% CI: 1.18-1.91; and p < 0.001). Moreover, the threshold for intraoperative peak blood lactate levels that correlated with a higher risk of composite in-hospital postoperative infection was approximately 2.7 mmol/L.

Conclusions: Consistent with our hypothesis, intraoperative hyperlactatemia was independently associated with a 1.49-fold increased risk of postoperative infection in CPB-assisted cardiac surgery. Notably, maintaining intraoperative blood lactate levels below 2.7 mmol/L might lower the risk of such infections.

Background: Continuous monitoring of vital signs using wearable devices may improve early detection of postoperative complications and reduce nursing workload. Evidence from real-world clinical implementation remains limited. This study aimed to answer the question: does the implementation of wearable monitoring in surgical wards reduce nursing workload and is it feasible and acceptable to staff?

Methods: A prospective, single-center implementation study was conducted on a surgical ward in a large teaching hospital. Nursing workload was assessed using the Integrated Workload Scale (IWS), and usability was evaluated using the system usability scale (SUS). Additionally, staff attitudes were measured with the evidence-based practice attitude scale (EBPAS). Manual spot checks of vital signs were monitored before and after the implementation of wearable devices (viQtor) for continuous monitoring of heart rate, respiratory rate, and oxygen saturation.

Results: Nursing workload decreased significantly with mean IWS scores dropping from 5.46 ± 1.18 to 3.87 ± 1.38 (p < 0.001). A 62.7% reduction in manual spot checks was observed (from 4686 expected to 1748 performed, p < 0.001) corresponding to a time saving of 10.1 min per patient per day. The SUS score improved from 74.2 ± 10.1 to 86.0 ± 5.2 (p = 0.025). No significant differences were observed in EBPAS scores over time (p = 0.43).

Conclusions: Implementation of remote wearable monitoring in surgical wards is feasible, reduces nursing workload, and demonstrates high usability and acceptance among staff. These findings highlight the potential of wearable technology for more efficiency of postoperative care.

Trial registration: ClinicalTrials.gov: NCT06574867, prospectively registered on 27 August 2024.

Introduction: The efficacy of Billroth II with Braun (BIIB) anastomosis in laparoscopic distal gastrectomy remains uncertain. We aimed to perform a systematic review and meta-analysis comparing BIIB with Roux en Y (RY) for distal laparoscopic gastrectomy.

Methods: We systematically searched PubMed, Embase, and Cochrane for studies comparing BIIB versus RY in adult patients undergoing distal gastrectomy. We computed risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes, with 95% confidence intervals (CIs). Heterogeneity was assessed with I² statistics. Statistical analyses were performed using R software, version 4.2.3.

Results: We included 10 studies, comprising a total of 1377 patients. BIIB was associated with a lower anastomotic time (MD 7.82 min; 95% CI -11.99 to -3.65; p = 0.0002; I² = 99%), intraoperative blood loss (MD -17.88 mL; 95% CI -31.00 to -4.76; p = 0.0076; I² = 91%), and operative time (MD -21.67 min; 95% CI -28.62 to -14.72; p < 0.01; I² = 80%). Also, BIIB group was associated with a higher incidence of bile reflux when compared to the RY group (RR 3.10; 95% CI 1.75 to 5.50; p < 0.0001; I² = 74%). There were no significant differences between BIIB and RY for anastomotic leakage rate, number of retrieved lymph nodes, gastritis, residual food, time to first exhaust, length of hospital stay, time to liquid diet, and adverse events.

Conclusion: In adult patients undergoing distal gastrectomy, BIIB was associated with a shorter operative, anastomotic time, and intraoperative blood loss, with an increased incidence of bile reflux. BIIB may be an easier and feasible alternative to RY, especially in patients who should avoid excessive exposure to anesthesia.

Introduction: Definitive second-line treatment for pediatric Graves' disease (GD) includes radioiodine ablation (RAI) or thyroidectomy. The current treatment practice in pediatric GD patients is a contentious issue as the decision to consider either of the treatment options depends on preferences of patients, physicians, and access to surgical care and radioactive iodine treatment. This systematic review and meta-analysis were performed to compare the cure and relapse rates of RAI versus surgery as definitive therapy in children with Graves' Disease.

Methods: A comprehensive search on Cochrane library, Embase, PUBMED, MEDLINE (via Pubmed), and ClinicalTrials.gov for English articles published on definitive treatment of GD in children since 1985 to 2023 was performed. The data were extracted and meta-analyzed for efficacy and safety outcomes, risk of bias (ROB), and certainty of evidence summated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) instrument.

Results: Twenty-nine (26 retrospective and 3 prospective) studies with a total of 1861 children and a mean age of 13.15 years with a mean follow up of 8 years were evaluated in the systematic review. Among these, 1061 children received RAI therapy, whereas 800 underwent thyroidectomy and were evaluated in the pooled analysis. 755 were excluded as details pertaining to definite treatment was not available. Studies were of low to moderate risk of bias. The pooled analysis suggests that RAI had significantly lower cure rate in children compared to children who underwent thyroidectomy (RR 0.89; 95% CI 0.81-0.99; p = 0.03). In subgroup analysis of patients from 19 studies who underwent surgery, total thyroidectomy (2%) was more effective than subtotal thyroidectomy (13%) in preventing recurrent hyperthyroidism (p = 0.001; moderate quality evidence). Hypothyroidism rates after RAI and surgery were similar (RR 0.97; 95% CI 0.67-1.40; p = 0.88). There were no significant adverse outcomes reported such as secondary malignancy or quality of life after RAI. Following TT, adverse effects seen were permanent hypoparathyroidism (0.6%) and temporary recurrent laryngeal nerve palsy (5.1%).

Conclusion: Thyroidectomy appears to be more effective than RAI in effecting cure in Graves' disease in children following failed remission with antithyroid medication therapy. However, access to thyroidectomy may not be universally available and RAI is an option in these children.

Background: Gastric cancer continues to pose a significant global health burden, with gastrectomy being the primary curative treatment. However, the increased performing of laparoscopic gastrectomy (LG) has been associated with a rising incidence of postoperative internal hernia (IH), particularly Petersen's hernia (pH), which may lead to bowel strangulation and necrosis. This meta-analysis aimed to compare the incidence of IH following LG versus open gastrectomy (OG) and to evaluate the preventive effect of Petersen's space closure on pH occurrence.

Methods: A systematic review and meta-analysis were conducted using PubMed and Embase to identify studies published in the past 25 years that reported IH or pH after gastrectomy for gastric cancer. Eligible studies compared (1) the incidence of IH between LG and OG or (2) the incidence of pH between closure and nonclosure of Petersen's space. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model.

Results: Five studies comparing LG and OG demonstrated a significantly higher risk of IH in the LG group (OR 2.81, 95% CI: 1.40-5.62). A subgroup analysis limited to total gastrectomy showed a nonsignificant trend toward increased IH risk after LG (OR 6.12). Additionally, five studies showed that closure of Petersen's space significantly reduced the risk of pH (OR 5.73, 95% CI: 1.59-20.67).

Conclusion: Laparoscopic gastrectomy is associated with an increased risk of internal hernia compared to open surgery for gastric cancer. The preventive closure of Petersen's space should be considered mandatory, particularly during Roux-en-Y reconstruction after gastrectomy.

Background: Operative intervention for deep burn injury confers a survival advantage compared to healing by secondary intention and dressings alone. Mortality benefits from early surgery may not extend to resource-restricted environments. There are major deficiencies in the delivery of advanced burn care in low-resource settings. This study aimed to compare two different operative approaches in the same setting for deep burn injury.

Methods: We conducted a prospective, observational study at Grey's Hospital in Pietermaritzburg. The first system applied a triage strategy to ensure priority patients received early excision, while the second system provided no excision and performed skin grafting only once spontaneous eschar separation had occurred. The primary outcome was mortality.

Results: The Priority System included 191 admissions with 158 operative admissions. The Conservative System included 199 admissions with 174 operative admissions. The groups were similar in age, total body surface area and sex. Mortality was higher in the Priority versus Conservative System (10.8% vs. 4.6%, p = 0.039), with significantly higher acute kidney injury and ICU admission rates but lower sepsis rates. The time from injury to first surgery, and injury to discharge were significantly longer in the Conservative System.

Conclusion: In a single, low-resource institution, spontaneous eschar separation and delayed skin grafting improved mortality outcomes compared to a triage system providing early excision and subsequent grafting for a group of high-risk patients. Conservative surgical approaches should be considered where resource restrictions prevent early excision and simultaneous closure. Early excision without immediate closure does not provide mortality benefit.