World Journal of Surgery最新文献

Objective: To describe surgical indications, procedures and outcomes in patients operated for Zollinger-Ellison syndrome (ZES) in multiple endocrine neoplasia type 1 (MEN1) using a large nationwide cohort.

Background: Management of ZES in MEN1 remains controversial.

Methods: All patients with ZES diagnosed through the MEN1 AFCE/GTE network from 1985 to 2015.

Results: Among 233 ZES patients, 66 (28%) were operated for ZES-related gastrinomas. Thirty-three (51%) procedures aimed to remove gastrinomas and associated pancreatic neuroendocrine tumors (pNET(s)) with appropriate resection. Thirty-two procedures (49%) aimed to remove gastrinomas alone (ZES group). Survival was decreased in patients metastatic at ZES diagnosis (p < 0.001). Fifteen-year survival among non-metastatic patients was not significantly better in operated patients (82% vs. 70%, p = 0.2). Perioperative mortality was nil. Metastatic lymph nodes were found in 30/42 lymphadenectomies (71%). The choice between pancreaticoduodenectomy versus duodenal focused surgery in the ZES group was associated with pre-operative detection of adenopathies (p > 0.001), leading to more frequent lymphadenectomies (p < 0.01). Previous pancreatic surgeries (30%) may have influenced the choice of ZES procedures. Gastrin levels were more frequently normalized when the duodenum and the head of pancreas were removed versus more localized duodenal surgeries (p < 0.01).

Conclusion: The high rate of invaded nodes in lymphadenectomies in MEN1 patients operated for ZES, the absence of operative mortality, and the decreased survival in metastatic patients are indirect arguments for surgery. Pancreaticoduodenectomy may be indicated in young and fit individuals to better control hypergastrinemia and to prevent metastatic progression in the ZES group. Gastrinoma removal is justified when associated with large pNETs.

Background: Fully resorbable biosynthetic mesh composed of poly-4-hydroxybutyrate (P4HB), have been designed for incisional hernia (IH) repair, including in contaminated surgical fields. While existing studies have demonstrated its safety and efficacy in the short term, comprehensive long-term data, particularly after complete mesh resorption, remain scarce.

Methods: This multicenter European registry analysis investigates the incidence of short- and long-term complications following IH repair with Phasix (P4HB) or Phasix ST (P4HB with hydrogel barrier; BD, Warwick, RI, USA) mesh. Adult patients from registries in France, Greece, Germany, and Spain were included and stratified using the Ventral Hernia Working Group (VHWG) classification. The primary endpoint was the incidence of long-term mesh-related complications one to five years post-implantation, after mesh resorption. Secondary endpoints included short-term complications and hernia recurrence.

Results: A total of 790 patients underwent incisional hernia repair with P4HB mesh, with a median follow-up of 38 months (IQR 36-48). Long-term follow-up beyond 24 months was available in 57% of patients. The majority of complications occur during the first 6 months. Long-term mesh-related morbidity remained low, with mesh infection occurring in 2% of patients and chronic pain in 3%-5%, even after complete mesh resorption. Rates of enterocutaneous fistula and mesh explantation were rare. Long-term complication profiles varied by hernia complexity, comorbidity burden, and mesh position, with higher ASA class associated with increased risk of mesh infection and chronic pain. The overall hernia recurrence rate was 22%, with recurrence increasing after the expected resorption period and stabilizing thereafter. Higher recurrence risk was independently associated with VHWG grade III-IV (HR of 2.55 and 2.49), obesity (HR 1.41), and intraperitoneal mesh placement (HR 2.72).

Conclusion: P4HB mesh demonstrated a favorable long-term safety profile after complete resorption, with low rates of mesh-related complications, even in high-risk patients. Hernia recurrence remains an important secondary outcome and is strongly influenced by patient risk factors and surgical technique. These findings support a tailored, risk-stratified approach to the use of biosynthetic meshes in IH repair.

Background: Enhanced Recovery After Surgery (ERAS) programs are increasingly recognized as effective pathways to improve perioperative outcomes, yet their implementation across Latin America and the Caribbean remains poorly mapped. Understanding current strategies, clinical results, and economic implications is essential to identify regional gaps and guide evidence-based surgical improvement.

Methods: This scoping review followed Joanna Briggs Institute (JBI) methodology and PRISMA-ScR reporting guidelines. Searches were conducted in MEDLINE/PubMed, Web of Science, LILACS, and CENTRAL, complemented by gray literature and reference screening. Eligible studies were investigations evaluating perioperative optimization interventions in any surgical population within Latin America and the Caribbean. Data extraction included study characteristics, ERAS components, implementation strategies, clinical outcomes, and economic impact.

Results: Forty-five studies published between 2006 and 2025 were included, predominantly from Brazil (n = 28), Mexico (n = 9), Argentina (n = 4), and Chile (n = 3). Most studies implemented multimodal perioperative pathways, with the most frequent ERAS strategies being preoperative fasting abbreviation (n = 26), early refeeding (n = 22), early mobilization (n = 22), opioid-sparing anesthesia (n = 19), preoperative education (n = 16), and restrictive intravenous fluids (n = 16). Clinical outcomes consistently demonstrated reductions in postoperative length of stay and complications. Only five studies reported economic data, all focused on hospital-level costs, showing decreased expenditures primarily driven by shorter hospitalization.

Conclusions: ERAS initiatives are increasing across Latin America and the Caribbean, with evidence suggesting reductions in hospital stay and costs. Nevertheless, adoption remains uneven and concentrated in a few countries. Expanding implementation will require addressing structural disparities and generating stronger economic and implementation-focused evidence to support broader regional uptake.

Background/aim: There has been a drive on improving outcomes after Emergency Laparotomy (EmLap) due to the National Emergency Laparotomy Audit (NELA). This has focused mainly on preoperative and intraoperative management with less emphasis on other perioperative aspects. We aimed to assess the prevalence of anemia in EmLap patients and its management in a perioperative period, exploring the gaps in anemia care.

Methods: A retrospective cohort study of prospectively maintained database of 1055 EmLap patients (2016-2019) from a UK tertiary center was performed. Data were extracted from the NELA database, POLO study, electronic records (Welsh Clinical Portal). Statistics were performed in SPSS v27.

Results: Among 740 patients, 77% underwent open surgery, with mean age of 61.9 years (range 18-98), median age of 65 years, and roughly equal sex distribution (female 54%). The median preoperative NELA risk was 3.6% (IQR 1.1-9.8). Over a quarter of patients (28.6%) were anemic on admission. Anemic patients had significantly longer hospital stays (median 12 days; >/ = 11 days, p = 0.008) and higher stoma formation rates (54.1% moderate anemia vs. 34.3% nonanemic; p = 0.002). Three-quarters of patients (74.2%) were anemic at discharge (median Hb: 108 g/L, range: 74-129 g/L) but only 12% were treated with oral or IV iron or blood transfusion; only 10% had anemia reported in their discharge letters with appropriate follow-up and management plan.

Conclusions: Anemia in patients undergoing emergency laparotomy is significantly under-recognized and inadequately managed at discharge, despite recognized increased morbidity. A structured pathway for continuing anemia treatment and discharge planning is urgently needed to improve outcomes.

Background: Postoperative pain after bariatric surgery is a significant clinical challenge, with approximately 61.4% of patients reporting persistent pain. Intraperitoneal local anesthetic instillation (IPLA) has been proposed as a strategy to reduce pain and opioid-related adverse effects. However, as its effectiveness in bariatric procedures remains controversial, this meta-analysis was conducted to clarify the role of IPLA in this setting.

Methods: This systematic review and meta-analysis was conducted following PRISMA guidelines and was prospectively registered in PROSPERO. We performed a comprehensive search in Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science for randomized controlled trials (RCTs) IPLA instillation with a control group in patients undergoing bariatric surgery. The primary outcomes were postoperative pain intensity, need for rescue analgesia, and supplementary opioid consumption. Secondary outcomes included postoperative nausea and vomiting (PONV), nausea, vomiting, and shoulder pain. Data were synthesized using a random-effects model to calculate Risk Ratios (RR) for binary outcomes and Standardized Mean Differences (SMD) and Mean Differences (MD) for continuous outcomes. The methodological quality of the trials was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool.

Results: The analysis included 13 randomized controlled trials with a total of 1205 participants, of whom 624 were in the intraperitoneal local anesthetic (IPLA) group and 581 were in the control group. The pooled results showed that IPLA significantly reduced postoperative pain intensity (SMD: -0.96, 95% CI -1.72 to -0.20; p = 0.01) and the need for rescue analgesia (RR: 0.52, 95% CI 0.31-0.89). However, there was no significant difference in postoperative opioid consumption (SMD: -0.56, 95% CI -1.13 to 0.01; p = 0.05). Additionally, no significant effects were found for the incidence of postoperative nausea and vomiting (PONV) or shoulder pain. High heterogeneity was noted in most of the analyses.

Conclusion: IPLA reduces postoperative pain in bariatric surgery but does not decrease opioid consumption or adverse events. A suggested reduction in rescue analgesia was not robust. Due to high heterogeneity, the findings' clinical applicability is limited, highlighting the need for standardized trials.

Trail registration: PROSPERO protocol CRD420251085223-July 2025.

Background: Trauma care is a central component of humanitarian medical response in conflict zones. However, essential operational knowledge-referral pathways, triage practices, logistical coordination, and team leadership-remains largely undocumented and inconsistently applied. The absence of structured learning mechanisms perpetuates fragmentation and impedes quality improvement across missions. Our study aimed to capture and analyze the field-based experiences of humanitarian health professionals to define practical, system-oriented requirements for effective trauma care in conflict settings.

Methods: We conducted a qualitative, exploratory study grounded in 19 in-depth, semi-structured interviews with experienced humanitarian health professionals. Participants were purposively sampled for their experience across prehospital care, hospital-based trauma response, and humanitarian coordination. Thematic analysis was used to identify structural patterns, operational challenges, and field-informed strategies that shape trauma care delivery in conflict-affected contexts. Reporting of this study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results: Participants described trauma care in conflict settings as dependent on interlocking requirements of six interdependent domains. Effective coordination was portrayed not as a technical function but as a relational one, built on trust, preparedness, and shared ownership across agencies and communities. Information exchange needed to be ethically governed, technically reliable, and tailored to fragile environments, relying on simplicity, redundancy, and low-tech tools co-developed with local actors. Prehospital care and transport systems were seen as decisive and in need of deliberate design, rooted in safety mapping, role-adapted responder models, and integration with local infrastructure. Workforce competence extended beyond clinical skills to include cross-functional agility, cultural literacy, and ethical resilience. Education and training were considered incomplete unless they prepared staff with conflict-specific competencies, supported by structured, simulation-based training for both expatriate and local staff. Finally, the absence of embedded operational research was viewed as a critical gap, with respondents calling for real-time learning systems that inform both frontline response and long-term planning.

Conclusion: Trauma care in modern conflict cannot rely on improvisation or technical skill alone. It must be underpinned by ethical, resilient and locally grounded systems. Our study highlights the operational knowledge of field practitioners, offering a foundation for building trauma care systems that are integrated, resilient, locally anchored, and worthy of the people they aim to serve.

Background: Sinus laser-assisted closure (SiLaC) demonstrates favorable outcomes for primary sacrococcygeal pilonidal sinus disease (SPSD), yet its efficacy in recurrent disease remains undefined. This study compared long-term outcomes following SiLaC in primary versus recurrent SPSD, hypothesizing that recurrent disease would predict inferior results.

Methods: This retrospective cohort study analyzed 267 consecutive patients undergoing SiLaC at a single center (July 2019-August 2022), stratified by disease status: primary (n = 214) versus recurrent (n = 53). The primary outcome, disease recurrence, was assessed using Kaplan-Meier analysis; secondary outcomes included healing rates, healing time, and complications. Univariable risk factor analysis was performed. Follow-up through telephone interviews and review of medical records achieved a 90.3% completion rate at a median of 4.0 years (IQR: 3.6-5.0 years).

Results: Recurrence rates were significantly higher in recurrent versus primary disease (RR 1.76, 95%CI: 1.30-2.40, p = 0.001), with 12-month rates of 34.8% versus 16.8% respectively. At the final follow-up, the recurrence rate was 34.6% for primary disease and 60.8% for recurrent disease. The time to recurrence was accelerated in recurrent cases (median, 11.4 vs. 14.0 months, p < 0.05). Despite comparable initial healing rates (75.4% primary, 68.0% recurrent), recurrent disease required 10 additional days for complete healing (56 vs. 46 days, p < 0.001). Sequential SiLaC procedures, when necessary, achieved final healing rates exceeding 90% in both groups with minimal complications (5.8%). Three factors predicted recurrence: recurrent disease status in all patients; within recurrent cases, symptom duration greater than 38 weeks (RR 2.14) and four or more medial openings (RR 2.07); all p < 0.05.

Conclusion: SiLaC demonstrated acceptable recurrence rates for primary SPSD comparable to other minimally invasive techniques at long-term follow-up, but significantly poorer outcomes in recurrent disease. Therefore, SiLaC may be considered a feasible first-line option for primary SPSD, while recurrent cases require careful patient selection and consideration of alternative treatments.

Anastomotic failure remains the leading source of morbidity after pancreatoduodenectomy, particularly in patients with a soft pancreas and a small main pancreatic duct. In this high-risk setting, reconstruction is frequently compromised by geometric mismatch between the duct and an oversized jejunal enterotomy, as well as by eccentric duct anatomy that limits safe circumferential suturing. Conventional duct-to-mucosa techniques rely on tissue traction and precise stitch placement, which may be mechanically unstable in fragile glands. We developed a Seldinger-inspired, stent-centered pancreaticojejunostomy designed to address these limitations through geometry preservation and structural stabilization. Instead of cutting the jejunum, the enterotomy is created by controlled puncture and sequential dilation. A biodegradable intraductal stent is introduced over a guidewire, establishing duct-jejunal coaxial alignment. External stabilization is achieved using Blumgart-based fixation and serosal-capsular closure, avoiding ductal traction and circumferential duct-to-mucosa suturing. This technique was applied in a consecutive feasibility series of 15 high-risk patients (soft pancreas and main duct ≤ 3 mm) undergoing minimally invasive pancreatoduodenectomy. The procedure was completed robotically in 14 cases and laparoscopically in one, with no conversions or intraoperative complications. Biochemical pancreatic fistula occurred in 3 patients (20%), with no clinically relevant fistulas. No major complications (Clavien-Dindo ≥ III) or 90-day mortality were observed. By transforming a fragile duct-bowel interface into a geometry- and structure-supported reconstruction, this approach appears technically feasible and associated with encouraging short-term safety signals in a highly selected high-risk cohort. These findings should be interpreted as preliminary feasibility data and require validation in larger, multi-operator series.