World Journal of Surgery最新文献

Introduction: Postoperative nutrition after pancreatoduodenectomy (PD) remains controversial. Although many centers routinely place a feeding jejunostomy tube (FJT) after PD, it is associated with morbidity. We conducted this study to compare the perioperative outcomes with and without FJT placement post-PD.

Methods: This was an open-label randomized controlled trial, in which the FJT was placed in one arm and the nasojejunal tube (NJT) in the other. All patients with periampullary neoplasm who underwent pylorus resecting PD were included in this study. The primary outcome assessed was clinically relevant delayed gastric emptying (CR-DGE), and the secondary outcomes were clinically relevant postoperative pancreatic fistula (CR-POPF), postoperative complications, and hospital stay.

Results: Forty patients were allocated to the FJT and NJT groups, and the two groups were comparable in baseline demographics, disease characteristics, and perioperative outcomes, including CR-POPF rates. The FJT group had a significantly higher CR-DGE rate (55% vs. 25%, p = 0.006), required increased use of prokinetic drugs (77.5% vs. 45%, p = 0.003), and had a longer median postoperative hospital stay (11 vs. 9 days, p = 0.007). Both groups had similar tube-related complications. In the NJT group, 22.5% of the patients with CR-DGE required parenteral nutrition. On multivariate analysis, the presence of FJT [adjusted odds ratio (aOR), 6.030 (1.431-25.402), p = 0.014] and intra-abdominal collection [aOR, 7.108 (1.026-49.224), p = 0.047] were independent risk factors for CR-DGE.

Conclusion: Post-PD placement of FJT was an independent risk factor for CR-DGE. Hence, the routine use of the FJT can be omitted after PD without compromising postoperative morbidity and nutrition.

Trial registration: The trial was registered with the Clinical Trial Register with CTRI number: CTRI/2021/02/030942 (https://ctri.nic.in/Clinicaltrials/advancesearchmain.php).

Background: Robotic adrenalectomy (RA) is increasingly adopted, but its clinical value compared with laparoscopic adrenalectomy (LA) remains unclear. We assessed perioperative outcomes and the learning curve of RA.

Methods: A bicentric retrospective study included 228 patients who underwent adrenalectomy between 2013 and 2023 (97 RA, 131 LA). Primary outcomes were intra- and postoperative complications (Clavien-Dindo, Comprehensive Complication Index, CCI). Secondary outcomes included operative time and length of stay (LOS). Subgroup analysis evaluated tumors ≥ 6 cm. RA learning curve was assessed with cumulative sum (CUSUM) analysis.

Results: Patients in the RA group had higher ASA scores, more prior abdominal surgery, and larger tumors. Overall complication rates were similar (RA 18.6% vs. LA 17.6%, p = 0.846). RA was independently associated with shorter LOS (OR 0.48; 95% CI 0.26-0.84; p = 0.012). In tumors ≥ 6 cm, RA reduced postoperative complications (5.3% vs. 35.3%, p = 0.037). CUSUM analysis showed earlier improvements in operative time (after 25 cases) and later reductions in morbidity (after ∼ 45 cases).

Conclusions: RA is a safe alternative to LA even in complex patients. It shortens LOS overall and improves outcomes in large adrenal tumors. CUSUM analysis highlights a progressive but safe learning curve, supporting the integration of RA into endocrine surgical practice.

Background: Bone mineral density (BMD) measurement at the lumbar spine, femoral neck, total hip, and distal 1/3 radius is recommended for patients with primary hyperparathyroidism (PHPT). Osteoporosis at any site justifies surgery. The distal 1/3 radius is often neglected. This study evaluated the prevalence of distal 1/3 radius measurement, the proportion of osteoporosis at this site alone, and BMD changes 1 year post-parathyroidectomy in patients with PHPT.

Methods: A total of 548 patients who underwent parathyroidectomy for PHPT between 2016 and 2024 in University Hospital Center of Nantes (France) were reviewed. Patients without pre-surgery BMD measurements at the lumbar spine or the femoral neck were excluded. BMD was assessed via dual x-ray absorptiometry before and 12-months after surgery.

Results: Four hundred patients (mean age 63.3 ± 12.3 years, 80.5% female, and 86.2% menopausal) were included. Mean baseline serum calcium was 2.76 ± 0.19 mmol/L; median PTH was 99.2 pg/mL [76.1; 138.7]. Osteoporosis was present in 47.0% of patients. Distal 1/3 radius BMD was measured in 46.2%, identifying 11.4% with forearm-only osteoporosis. They were younger (60.6 ± 13.9 vs. 67.1 ± 10.2 years, p = 0.048), less frequently menopausal (66.7% vs. 95.9%, p = 0.001) and had higher calcium levels (2.88 ± 0.18 vs. 2.73 ± 0.20 mmol/L, p = 0.002) than the other osteoporotic patients. After surgery, BMD increased significantly at the lumbar spine (+0.06 g/cm²) and the total hip (+0.03 g/cm²), in a similar way to other osteoporotic patients.

Conclusion: After measuring distal 1/3 radius BMD, performed in < 50% of PHPT patients, it was identified that 11.4% patients had forearm-only osteoporosis, who could have a bone benefit from surgery. These findings emphasize the importance of systematic measurement during PHPT evaluation.

Trial registration: NCT05469087.

Background: Iliopsoas abscess (IPA), a purulent collection in the iliopsoas compartment, is an infrequent disease that is insidious, easily overlooked, life-threatening, and rarely diagnosed early due to nonspecific symptoms and signs. The classic triad of fever, flank pain, and hip movement limitation is present in only 30% of patients. Delays in treatment are followed by increased morbidity and mortality. The microbial etiology of IPA is variable and depends on the geographical area. IPA can be primary or secondary due to the origin of the infectious focus. This review aims to outline the current stage of knowledge of IPA, to emphasize its precocious recognition, and to provide a precise diagnosis using modern imaging according to the hospital patients are seen at, in an effort to reduce the delay in the diagnosis and treatment of IPA.

Methods: A comprehensive literature search was made from 1980 to December 2024 related to IPA published in English. Key words utilized were "iliopsoas abscess," "retroperitoneal infection," "psoas muscle disorder," "pyogenic psoas abscess," and "psoas abscess." A total of 247 papers were reviewed: 120 case reports, 33 short retrospective series of less than 15 patients, 20 large series with more than 50 patients, and 7 reviews. Additionally, 72 observational studies, 2 systematic reviews, and 2 prospective studies were reviewed. The inclusion criteria encompassed original and review articles published in English.

Conclusion: Since the description of IPA with isolated cases, then small series, and recently large retrospective reviews from major hospitals worldwide, the diagnosis and treatment of IPA have improved. With modern imaging techniques (US, CAT scan, and MRI), the diagnosis of IPA has increased, but sequential use of the aforementioned methods is not standardized; besides, there is no uniform treatment for IPA so far. Current management of IPA entails broad-spectrum antibiotics plus percutaneous or surgical drainage.

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.