World Journal of Surgery最新文献

Background: Anastomotic leakage (AL) remains a severe complication after low anterior resection (LAR) for rectal cancer, despite advances in minimally invasive (MI) techniques. This study aimed to evaluate the impact of a surgery-focused care bundle, implemented on an enhanced recovery after surgery (ERAS)-based perioperative protocol, on preventing AL and improving postoperative outcomes in patients with MI-LAR.

Methods: In this retrospective historically controlled cohort study, a total of 306 patients who underwent MI-LAR between 2011 and 2024 were included. A late-phase cohort (n = 81) receiving the care bundle with an ERAS-based protocol (from September 2019) was compared with a historical early-phase cohort (n = 225). The surgery-focused care bundle included robot surgery, preoperative oral antibiotics, indocyanine green blood flow evaluation, diverting stoma, transanal drainage tubes, and anastomotic reinforcement. Our institutional ERAS protocol was developed in accordance with the ERAS Society guidelines. Propensity score matching (PSM) was used to adjust for baseline differences between cohorts.

Results: The AL rate significantly decreased from 14.7% (33/225) to 2.5% (2/81) after bundle implementation (p < 0.01). Post-PSM, AL rates remained significantly lower in the late-phase cohort (18.0% vs. 1.3% and p < 0.001). Severe complications (Clavien-Dindo grade ≥ 3) and surgical site infections (SSIs) were also significantly reduced, and no reoperations were required in the late-phase cohort. Multivariate analysis identified lack of care bundle (odds ratio [OR]: 6.36, 95% confidence interval [CI]: 1.42-28.4, and p = 0.01) and male sex (OR: 3.05, 95% CI: 1.24-7.52, and p = 0.01) as significant risk factors for AL.

Conclusions: Implementation of a surgery-focused care bundle, integrated within an ERAS-based perioperative framework, significantly reduced AL, severe complications, and SSIs after MI-LAR, suggesting potential long-term benefits by improving short-term postoperative outcomes.

Aim: This systematic review and meta-analysis aimed to synthesize current evidence on the effect of metabolic and bariatric surgery on osteoarthritis (OA) diagnosis, pain, stiffness, and functional outcomes.

Method: A systematic search was conducted in PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library for studies published between January 2000 and July 2025. Eligible studies included adult patients undergoing any form of bariatric surgery who had either a documented diagnosis of OA before and after surgery or a quantitative assessment of OA-related symptoms using validated instruments such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Data were pooled using random-effects models, and heterogeneity was assessed using the I² statistic.

Results: Twelve studies published between 2007 and 2024 met the inclusion criteria, encompassing 12,000 participants across prospective and retrospective cohorts. The pooled odds ratio for OA diagnosis after surgery compared with preoperative status was 0.21 (95% CI: 0.11-0.41), indicating a 79% reduction in OA likelihood. Significant improvements were observed in WOMAC pain, stiffness, and physical function scores at 6 and 12 months postoperatively, with overall pooled mean differences of -20.80 (95% CI: -32.74 to -8.86) and -17.12 (95% CI: -25.28 to -8.96), respectively. Heterogeneity was substantial across studies (I² > 75%).

Conclusions: Metabolic and bariatric surgery is associated with significant reductions in osteoarthritis diagnosis and improvements in OA-related pain and physical function. These findings suggest that surgical weight loss may provide meaningful benefits for joint health in patients with obesity.

Background: Anatomical variations in pulmonary vein (PV) drainage are critical considerations during right upper or middle lobectomy, as unrecognized aberrant veins can increase surgical risks. Although such variations have been described in anatomical and radiologic studies, surgically verified data under a standardized thoracoscopic approach remain limited. This study investigates the prevalence and patterns of aberrant venous drainage from the right middle lobe (RML) and right lower lobe (RLL) into the right upper pulmonary vein (RUPV).

Methods: A total of 213 patients undergoing right upper or middle lobectomy between March 2019 and April 2021 were reviewed from the prospectively collected database. Intraoperative findings documented aberrant venous drainage patterns, including accessory veins and segmental vein variations. We performed video-assisted thoracoscopic surgery (VATS) using a fissure-first, hilum-last to visualize the PV anatomy.

Results: Aberrant venous drainage was observed in 60 patients (28%). Variant drainage from the RML to the RUPV was present in 44 patients (20.7%), whereas drainage from the RLL to the RUPV was found in 22 patients (10.3%). The most common pattern involved accessory veins from the RML draining into various branches of the RUPV, noted in 49 patients (61% of cases with aberrant veins). Accessory veins from the RLL were identified in 20 patients (25%). Superior segmental veins of the RLL drained into the RUPV instead of the right inferior pulmonary vein in 3 patients (1.4%). These frequencies are broadly comparable to those reported in previous anatomical and radiologic series.

Conclusion: Aberrant venous drainage from the RML and RLL to the RUPV is relatively common and largely consistent with prior anatomical and radiologic descriptions. These findings, based on surgically verified mapping under a standardized VATS approach, confirm and refine existing knowledge and underscore the need for meticulous intraoperative assessment and careful review of preoperative imaging to avoid vascular complications. Future studies should explore multi-institutional data and long-term outcomes to further optimize surgical strategies.

Background: Paravertebral analgesia may be a safe and adequate alternative to epidural analgesia during and after minimally invasive Ivor Lewis esophagectomy and may be associated with a lower incidence of post-thoracotomy pain syndrome, side effects, and complications. The aim of this study is to monitor the transition from epidural to paravertebral analgesia after minimally invasive Ivor Lewis esophagectomy and to compare both techniques through the transition period.

Methods: In this single-center retrospective study, patients undergoing elective minimally invasive Ivor Lewis esophagectomy between January 2016 and November 2023 were included. All patients with paravertebral analgesia since the introduction of paravertebral analgesia in 2020 were included and case-matched with patients receiving epidural analgesia from the period before. Data were obtained from electronic patient files. The primary endpoint was the amount of additional analgesia medication needed and patient pain scores within 4 days postoperatively. Secondary endpoints were postoperative complications, requirement of vasopressor support, analgesia side effects and complications, and the length of ICU stay.

Results: Baseline characteristics were similar for both analgesia groups. The paravertebral patients noted significant higher NRS scores. However, no difference in requirement of rescue analgesia was observed between the paravertebral and epidural analgesia groups. In addition, more patients in the epidural analgesia group reported insufficiency of analgesia. Patients receiving epidural analgesia had a longer ICU stay, were more likely to develop hypotension, and required significantly more vasopressor. Moreover, when vasopressors were needed, the dosage of vasopressors was higher in this group. More obstipation and hypotension were described in the epidural analgesia group. The epidural analgesia group also showed more pulmonary complications, such as pleural fluid, and mediastinitis. No statistical difference was found in (technical) analgesia complications.

Interpretation: From the onset of the transition from epidural to paravertebral analgesia after minimally invasive Ivor Lewis esophagectomy, paravertebral analgesia is as adequate as epidural analgesia but is superior in respect to vasopressor use and concomitant duration of ICU stay.

Background: Emergency laparotomy and its perioperative care is associated with high morbidity and mortality. At our institution, 30-day mortality was approximately 12% in 2013-2017. We introduced a perioperative protocol for emergency laparotomies in 2019.

Method: Retrospective cohort of emergency laparotomies 2019-2022. Reoperations, trauma and converted laparoscopies (appendectomy and cholecystectomy) were excluded. Primary outcome was mortality at 30, 90, and 180 days. Secondary outcomes were postoperative complications (Clavien-Dindo; CD) and hospital-based outcomes.

Results: Six hundred eighty-two patients undergoing emergency laparotomy were included. Age was 72 (IQR 23) years and 66.4% (n = 453) were aged ≥ 65 years 56.6% (n = 386) were ASA class III or IV and 6.5% (n = 44) were not living at home at admission. The most frequent surgical findings were bowel obstruction (64.2%; n = 438) and gastrointestinal perforations (n = 134; 19.4%). Stoma creation (29.9%; n = 204), adhesiolysis (28.6%; n = 195), and anastomosis (27.4%; n = 187) were common. Mortality at 30 days was 6.9% (n = 47), 90 days 11.0% (n = 75), and 180 days 12.8% (n = 87). Mortality was higher for patients ≥ 80 years than < 65 years (23.9% vs. 4.4%; p < 0.001). Mortality predictors were admission not from home (p = 0.043), disseminated cancer (p < 0.001), and septic shock (p = 0.003) or systemic inflammatory response syndrome (p = 0.017). CD IIIb-IVb occurred in 81 patients (11.9%). ICU admission was 16.6% (n = 113) and LOS 8 (IQR 7) days.

Conclusions: Mortality and complication rates after the introduction of a perioperative emergency laparotomy protocol were low despite a comorbid aged-patient cohort. Particular focus on the elderly, frail, and septic patients considered for emergency laparotomy is recommended.

Objective: Effective postoperative pain control is essential in ambulatory hernia surgery. This pilot randomized controlled trial aimed to evaluate the efficacy, safety, and feasibility of topical EMLA (eutectic mixture of local anesthetics) cream as adjunct postoperative analgesia following open inguinal hernioplasty under local anesthesia.

Methods: A prospective, double-blind, randomized controlled trial was conducted at Hospital Canselor Tuanku Muhriz, UKM, from December 2023 to March 2025. Thirty-six male patients undergoing elective open inguinal hernia repair under local anesthesia were randomized to receive either EMLA (n = 18) or placebo cream (n = 18). The cream was applied topically to the surgical site every 6 h for 48 h. Pain was self-assessed using a numerical rating scale (NRS) after each application. Primary outcomes included pain scores and rescue analgesia use; secondary outcomes included feasibility and adverse events.

Results: Topical application was rated "easy" or "very easy" by all participants, with no adverse events or complications reported. In the EMLA group, pain scores significantly decreased across all post-application time points compared to baseline (p < 0.05), whereas no significant changes were observed in the placebo group. Between-group analysis showed significantly lower pain scores in the EMLA group starting from 6 h postoperatively (p < 0.001). No participants in either group required rescue analgesia.

Conclusion: Topical EMLA cream is a feasible adjunct for postoperative pain control following open inguinal hernia repair under local anesthesia. Although no infections or adverse events occurred in this pilot cohort, the study is underpowered to detect rare complications such as surgical site infection; therefore, safety conclusions should be interpreted with caution. The clinically meaningful reduction of 2-3 points in pain scores supports further validation in larger, adequately powered trials using an inert placebo.

Aim: To compare the sentinel lymph node (SLN) identification proportions using Indocyanine green with the standard radio colloid-blue dye method.

Background: Radioisotope and blue dye are standard agents for performing sentinel lymph node (SLN) biopsy in breast cancer. Limited centers offering nuclear medicine services along with the short half-life of technetium and the hazards associated with radioactive materials contribute to the low acceptability of SLNB.

Methods: This randomized controlled trial conducted between September 2022 and May 2024 compared SLN identification proportions of radioisotope-blue dye [Group A] with Indocyanine Green (ICG) [Group B]. Sample size of 70 (35 in each arm) was calculated. Upfront operable node negative early breast cancer patients were included in the study. Clinico-demographic data, number and type of SLN, and time taken were recorded. Chi-squared/Fisher exact tests were used to compare proportions between two groups. p value of less than 0.05 was considered to represent statistical significance.

Results: Seventy patients were randomized to either group (35 in Group A and 35 in group B). The clinico-demographics and the tumor characteristics were similar between both the groups. SLN identification rate (IR) was 100% in group A and 97.14% in group B. Median of 3 lymph nodes were identified in Group A and Group B. Median operative time for SLNB was 12 min in both the groups.

Conclusions: Indocyanine green (ICG) fluorescence offers comparable sentinel node identification rate when compared to current standard of radioisotope and blue dye.

Trial registration: This study is registered under Clinical Trials Registry-India (CTRI) vide registration no. CTRI/2022/09/045719.