World Journal of Surgery最新文献

Background: Appendicitis is the most prevalent surgical emergency in children. This study examined hospital infrastructure, surgical techniques, patient demographics, and hospitalization parameters to assess the provision of safe and adequate care within the Brazilian public healthcare system.

Methods: Pediatric hospitalizations for acute appendicitis in 2022 were extracted from the Brazilian national database. We included all hospitalizations for patients aged 0-16 years with a primary ICD-10 diagnosis of acute appendicitis who underwent an operation. Parameters of interest were the type of surgical approach, mortality, and total cost of hospitalization. Facilities were defined as basic-facility, full-facility, and pediatric according to the level of pediatric resources available.

Results: In 2022, there were 29,983 pediatric appendectomies due to acute appendicitis. Of these, 90.2% were open appendectomies. Most occurred in basic-facility general hospitals (53.0%), followed by full-facility (35.2%) and pediatric hospitals (11.8%). Full-facility hospitals had a higher median cost (USD126.3, IQR 99.5-154.4) compared to basic (USD96.8, IQR 87.6-130.1) and pediatric hospitals (USD103.0, IQR 91.9-117.5), though the cost difference between basic and pediatric was not significant (p = 0.367). Death was a rare event across all levels of hospital infrastructure and for all types of procedures performed.

Conclusions: The majority of hospitalizations for acute appendicitis occurred in hospitals with minimal pediatric infrastructure. Open appendectomies remain the most predominant procedure across all hospital types.

Background: Global disparities in valvular surgery services exist. Cost-effectiveness analysis (CEA) and cost-utility analysis can be used to guide national investment decisions. This scoping review aims to synthesize economic evaluations for valvular surgery by income settings and provide recommendations.

Methods: A systematic literature review identified primary CEAs or CUAs in English comparing surgical management strategies for valvular heart disease. MEDLINE, Embase, CINAHL, Web of Science, and Business Source Complete were searched using keywords "valvular surgery," "valve disease," "cost-effectiveness," and "cost-benefit analysis". Articles comparing outcomes or costs only were excluded. Search results were uploaded and screened on COVIDENCE. Variables from eligible articles were charted in a spreadsheet.

Results: Twenty articles were eligible, six from low- and middle-income countries (LMICs) and 14 from high-income countries (HICs). In HICs, the top conditions were degenerative aortic valve disease (7/14) and mitral valve disease (4/14) compared to congenital (2/6) and rheumatic heart diseases (2/6) in LMICs. HICs evaluated new technologies and techniques, whereas LMICs compared different valve types or surgery versus no intervention. Most articles used published studies (12/20) or databases (7/20) to conduct their CEA and quality-adjusted life years was the most common effectiveness measure (12/20). Comparator interventions were cost-effective in all LMIC articles and in 8/14 for HICs.

Conclusion: Economic evaluations are mostly conducted in HICs and for adult conditions. More analyses in LMICs are needed. This can be facilitated by maintaining databases, documenting costs, and implementing quality of life assessments.

Introduction: Minimally invasive surgery (MIS) has become standard of care in many high-income countries, but its adoption in low- and middle-income countries (LICs/MICs) has been impeded by resource- and training-related barriers. We hypothesized that trainees in MICs perform MIS procedures less often, and that as procedure complexity increases, the rate of MIS decreases.

Methods: A 22-question survey, distributed to representative leaders across Latin America, collected country-specific graduating trainee case requirements and volumes for four index procedures (cholecystectomy, appendectomy, inguinal hernia repair, colectomy) using MIS or open surgery (OS). USA data was obtained from the Accreditation Council for Graduate Medical Education. Kruskal-Wallis and Mann-Whitney U tests were performed to determine whether the rate of MIS differed across all countries, procedure complexity classes, and high income countries (HICs)/MICs.

Results: Seven experts (70% response rate) completed the survey, representing: Brazil, Chile, Ecuador, Guatemala, Mexico, Panama, and Paraguay. The percentage of MIS completed by trainees varied with mean and interquartile ranges as follows: cholecystectomy (60% ± 54%), appendectomy (41% ± 69%), inguinal hernia repair (19% ± 23%), colectomy (16% ± 29%). There was a significant difference in mean MIS experience across the eight countries (H = 17.6, p = 0.014) and between most complex and least complex procedures (p = 0.039). No difference was found between MICs and HICs (p = 0.786).

Conclusions: We found a significant difference of general surgery trainee exposure to MIS versus OS across the Americas, but the difference was not significantly associated with World Bank Income Groups. Different trainee experiences with MIS and OS may highlight an opportunity for international and bidirectional collaboration.

Introduction: Fibrinolytic agents (FA) activate the fibrinolytic system, converting plasminogen into plasmin to break down fibrin. Their use for irrigation of abdominal abscesses is debated, and this meta-analysis evaluates their efficacy.

Methods: We searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing FA and saline in percutaneous drainage of abdominal abscesses. Outcomes included length of hospitalization, duration of drainage, and drainage volume. We pooled mean differences (MD) and 95% confidence intervals (CI) using a random-effects model. We also performed a trial sequential analysis (TSA).

Results: We included six RCTs encompassing 299 patients. In the overall analysis, FA increased drainage volume (MD 104.25 mL; 95% CI 35.72-172.77 mL; p = 0.003; I² = 0%). In children, saline reduced hospitalization duration (MD -1.26 days; 95% CI -1.98 to -0.55 days; p = 0.0006; I² = 0%), whereas FA increased drainage volume (MD 84.66 mL; 95% CI 5.77-153.54 mL; p = 0.04; I² = 0%). In adults, FA significantly reduced hospitalization duration (MD -11.12 days; 95% CI -15.16 to -7.08 days; p < 0.00001; I² = 0%) and duration of drainage (MD -6.53 days; 95% CI -9.25 to -3.81 days; p < 0.00001; I² = 0%) while increasing drainage volume (MD 164.47 mL; 95% CI 26.16-302.78 mL; p = 0.02; I² = 0%). On TSA, the required information size was achieved only for the adult subgroup's hospitalization and drainage duration.

Conclusion: In adults, FA reduce hospitalization and drainage duration and increase drainage volume. In children, saline seems more effective in reducing hospitalization duration, while FA increase drainage volume. These findings underscore the need for age-specific treatments and further research, especially in the pediatric population.

Background: Machine learning (ML) may provide novel insights into data patterns and improve model prediction accuracy. The current study sought to develop and validate an ML model to predict early extra-hepatic recurrence (EEHR) among patients undergoing resection of colorectal liver metastasis (CRLM).

Methods: Patients with CRLM who underwent curative-intent resection between 2000 and 2020 were identified from an international multi-institutional database. An eXtreme gradient boosting (XGBoost) model was developed to estimate the risk of EEHR, defined as extrahepatic recurrence within 12 months after hepatectomy, using clinicopathological factors. The relative importance of factors was determined using Shapley additive explanations (SHAP) values.

Results: Among 1410 patients undergoing curative-intent resection, 131 (9.3%) patients experienced EEHR. Median OS among patients with and without EEHR was 35.4 months (interquartile range [IQR] 29.9-46.7) versus 120.5 months (IQR 97.2-134.0), respectively (p < 0.001). The ML predictive model had c-index values of 0.77 (95% CI, 0.72-0.81) and 0.77 (95% CI, 0.73-0.80) in the entire dataset and the validation data set with bootstrapping resamples, respectively. The SHAP algorithm demonstrated that T and N primary tumor categories, as well as tumor burden score were the three most important predictors of EEHR. An easy-to-use risk calculator for EEHR was developed and made available online at: https://junkawashima.shinyapps.io/EEHR/.

Conclusions: An easy-to-use online calculator was developed using ML to help clinicians predict the chance of EEHR after curative-intent resection for CRLM. This tool may help clinicians in decision-making related to treatment strategies for patients with CRLM.

Background: Surgical quality improvement (QI) plays a critical role in optimizing patient outcomes and reducing healthcare costs. QI programs focusing specifically on thyroid cancer surgical care are lacking. This study aimed to (a) select and introduce surgical quality indicators for thyroid cancer and (b) identify areas for QI at the state-level.

Methods: A multidisciplinary team of thyroid cancer and QI experts selected 10 thyroid cancer-specific quality indicators and assessed the quality of thyroid cancer surgical care compared to current national guidelines. Analysis of the first year (January-December 2023) of data collection was performed using descriptive statistics.

Results: The thyroid cancer quality indicators included preoperative cytology, postoperative pathology, staging, cancer size, margin status, extrathyroidal extension, lymph nodes, postoperative complications within 30 days, documented follow-up treatment, and documented surveillance plans. 112 surgeons performed 360 thyroidectomies for thyroid cancer at 51 hospitals. Preoperative cytology was not performed in 34.3% (n = 103) of cases with thyroid cancer on final pathology. When the extent of surgery was evaluated by papillary cancer size, 50.0% (n = 38) of patients with <1 cm cancers underwent total thyroidectomy, and 13.8% (n = 4) with >4 cm underwent thyroid lobectomy. Positive margins were found in 16.2% (n = 53). Postoperatively, 19.2% (n = 69) of patients lacked documented follow-up, and 18.6% (n = 67) lacked thyroid cancer surveillance plans.

Conclusions: Establishing a dedicated QI program for thyroid cancer provides a previously unharnessed opportunity to enhance the quality of thyroid cancer surgical care. Statewide surgical quality collaboratives offer a model for establishing thyroid cancer QI initiatives across diverse healthcare settings in other states and countries.

Background: Indigenous knowledge healers (IKHs) provide alternative healthcare to formal health services in rural South Africa, but there is a gap in knowledge regarding their treatment of surgical conditions. This study evaluated IKH surgical care and described their perspective of the dual health system.

Methods: A cross sectional survey of IKHs in the Madwaleni Hospital catchment of the Eastern Cape, South Africa was conducted. Topics included the training and experience of IKHs, treatment of nine common surgical conditions, referral patterns, disease origin beliefs, benefits and limitations of care, and collaborative opportunities between the two health systems.

Results: Thirty-five IKHs completed the survey. IKHs were consulted by persons with all nine surgical conditions. The most common forms of treatment were application of an ointment on the affected site (88%) and oral medication (82%). Operative treatment was only done for abscess. Referrals to the formal healthcare sector were made for all surgical conditions. IKHs reported that they were limited by their lack of training and resources to perform operations. On the other hand, they perceived the treatment of the spiritual aspect of surgical disease as a benefit of their care. Thirty-five (100%) IKHs were interested in closer collaboration with the formal health sector.

Conclusion: IKHs treat surgical conditions but refer to the formal health sector when diagnostic and operative services are needed. More research is needed to determine the potential advantages and disadvantages between the formal health sector and IKH collaboration.

Introduction: While there are no widely accepted diversity, equity, and inclusion (DEI) metrics for journals, geographic and sex diversity across a journal's editorial board may provide a surrogate measure of its commitment to DEI. We explored the association between journal quality and DEI metrics for cardiothoracic surgery (CTS) journals and investigated whether editorial diversity correlates with diversity across published articles.

Methods: We collected the following data for 30 CTS journals: country of publication (categorized by income level), journal quality metrics (citation-based metrics, e.g., impact factor (IF) or H-index), and sex and geographic representation across editorial boards and published articles. Bivariate correlations between numeric variables were assessed using Spearman's correlation.

Results: Female representation across editorial boards was 12.1%. Most editorial board members belonged to the United States (35.2%), with only 7.4% from the lower-middle-income countries and 0% from low-income countries. IF showed a strong positive correlation with female editorial representation (r = 0.70) but an inverse correlation with low- and middle-income countries (LMICs) editorial representation (r = -0.45). Female editorial representation demonstrated a significant positive correlation with female first authorship (r = 0.45), whereas LMIC editorial representation correlated strongly with LMIC corresponding authorship (r = 0.85).

Conclusion: Women and researchers from LMICs are in the minority across editorial boards of CTS journals. However, a strong correlation between journal H-index and female editorial representation indicates that top-ranked journals are spearheading efforts to improve equitable sex-based and gender representations. Similar efforts are required to ensure more global geographic representation across editorial boards and top-ranked CTS journals are the best placed to lead by example.

Introduction: Thyroid cancer is more commonly diagnosed in females, however recent research has challenged whether this finding is due to a true difference in biology or rates of diagnosis, with concerns that over-diagnosis may be a factor in differences. The rates of symptomatic versus incidental diagnosis by males and females is not well known. This study used the Australian and New Zealand Thyroid Cancer Registry (ANZTCR) to explore whether symptomatic presentation varies between sexes.

Materials and methods: Retrospective analysis on ANZTCR data between 2017 and 2022 was performed. Symptomatic cases were those with thyroid compressing symptoms, toxic goiter, Graves' disease, or abnormal laryngoscopy. Cases with asymptomatic goiter or surgeries for a thyroid nodule were classified as incidental.

Results: Among 1082 patients with differentiated thyroid cancer, 32% of males and 38% of females presented with symptomatic thyroid disease (p = 0.06). A similar rate of presentation of advanced thyroid cancer (T3/4) was seen with male and female patients (n = 70, 47% vs. n = 79, 53%). Females exhibited a higher prevalence of low-risk relapse cancers according to American Thyroid Association stratification (66.3% vs. 50.4%), whereas males exhibited a higher prevalence of high-risk relapse cancers compared to females (27.3% vs. 15.3%, p < 0.001). Regression showed symptoms were associated with more advanced T stage (OR = 1.62, p = 0.02).

Discussion: Symptomatic presentation was similar between males and females, but symptomatic presentation was associated with larger cancers.

Conclusion: This study highlights comparable rates of symptomatic detection between males and females with DTCs and symptomatic presentations were responsible for less than 40% of presentations.