World Journal of Surgery最新文献

Background: Many studies have supported delayed appendectomy because the risk of perforation does not appear to increase until beyond 24-48 h of hospitalization. This study aimed to examine the natural time progression of perforation in acute appendicitis to find if it complements studies that recommend delayed appendectomy.

Methods: Between first of January 2018 and 30th of March 2020, 1274 patients, 40 years or younger, were suspected of appendicitis at the National University Hospital of Iceland. N = 658 of these had appendicitis of which 105 did perforate. The patients' medical records were examined for duration of symptoms and length of hospital stay, whereas perforation and abscess formation were assessed from CT, ultrasounds, surgical reports, and histopathology reports. Duration of symptoms and hospital stay were categorized, and their relationship with the other variables, primarily perforation, was analyzed with chi square, Spearman's correlation, and t-test statistics.

Results: Few perforations occurred during the first 24 h of symptoms (2.4%) and few abscesses before 48 h (1.7%). Thereafter, the rate of perforations relative to the rate at 0-24 h were 6.4, 14.7, 20.2, and 27.1 for 24-48, 48-72, 72-96, and 96+ hours respectively, (χ² = 120 and p < 0.001). Furthermore, there was a significant correlation between increased duration of symptoms and prolonged hospital stay in patients with appendicitis (rho = 0.36 and p < 0.001).

Conclusions: There was a clear correlation between the duration of symptoms and the incidence of perforated appendicitis. However, there was not a sharp increase in perforation and abscess formation until after 24 and 48 h of symptoms, respectively. Our study indicates that delayed appendectomy needs more careful evaluation after this time window has elapsed, focusing exclusively on the time since hospitalization would be insufficient.

Background: Evidence regarding the feasibility and outcomes of enhanced recovery after surgery (ERAS) programs in patients undergoing simultaneous colorectal resection and hepatectomy remains limited. This study aimed to evaluate the impact of ERAS implementation on perioperative and oncologic outcomes in patients undergoing simultaneous colorectal resection and hepatectomy for synchronous colorectal liver metastases.

Methods: A single-center retrospective cohort study was conducted involving 100 consecutive patients who underwent elective simultaneous colorectal resection and hepatectomy before (n = 50) and after (n = 50) ERAS implementation. Outcomes included postoperative complications, length of stay, hospital cost, disease-free survival, and overall survival.

Results: The mean age was 63 years, and 55% were male. Rectal cancer was the primary tumor in 38 patients, and 18 patients required major hepatectomy. Baseline characteristics and operative details were comparable between the ERAS and conventional care groups. ERAS implementation significantly reduced postoperative complications (22% vs. 42% and p = 0.032) and time to tolerate a solid diet (3 vs. 5 days and p = 0.001). Median postoperative length of stay was shorter in the ERAS group (6 days [IQR 5-9] vs. 8 days [IQR 6-16] and p = 0.005). Average hospital cost was slightly lower with ERAS (4815 USD vs. 5298 USD and p = 0.446). Five-year overall and disease-free survival rates were similar between groups (86.7% vs. 88.9%; p = 0.583 and 44.4% vs. 48.9%; p = 0.724, respectively).

Conclusions: ERAS implementation in simultaneous colorectal resection and hepatectomy resulted in shorter hospitalization, faster bowel recovery, and a modest reduction in cost, while maintaining comparable long-term oncologic outcomes.

Background: The classification of oncological resectability for hepatocellular carcinoma (HCC) has been established, requiring validation of treatment outcomes for hepatectomy and systemic chemotherapy.

Methods: The study evaluated treatment outcomes in 978 patients who underwent hepatectomy and 222 patients with HCC who received first-line systemic chemotherapy (atezolizumab plus bevacizumab, lenvatinib, or durvalumab plus tremelimumab).

Results: Among three factors defining patients with borderline resectable 1 (BR1) and 2 (BR2), macrovascular invasion factor was associated with significantly worse prognosis in a hepatectomy group (BR1: 34.2 vs. 63.4 months, p = 0.04; BR2: 14.4 vs. 20.9 months, p = 0.004). In contrast, in the systemic chemotherapy group, none of the three factors affected prognosis in either BR1 or BR2 patients. In BR2 patients undergoing hepatectomy, those with a single risk factor had significantly better outcomes than those with 2-3 factors (20.1 vs. 12.6 months, p < 0.001). Similarly, in the entire systemic chemotherapy cohort, patients with a single risk factor had better outcomes than those with 2-3 (22.6 vs. 11.9 months, p = 0.001). However, among chemotherapy responders (per modified Response Evaluation Criteria in Solid Tumors), prognosis did not significantly differ between those with one factor and those with 2-3 factors (25.4 vs. 24.5 months, p = 0.502).

Conclusion: Macrovascular invasion significantly impacted prognosis in patients undergoing hepatectomy, for both BR1 and BR2, whereas any of the tumor factors did not affect the prognosis of patients receiving systemic chemotherapy. Tumor burden correlated with prognosis in the entire cohort but not in chemotherapy responders, suggesting effective treatment may overcome poor prognostic indicators.

Background: Although minimally invasive surgery (MIS) is thought to reduce the surgical risks in both initial and repeat hepatectomy patients, the actual clinical impact of the MIS-oriented surgical approach on their clinical course is not fully understood.

Method: The clinical records of 1138 consecutive patients who had undergone hepatectomy were retrospectively reviewed, and the clinical significance of an MIS-oriented approach was analyzed.

Results: The analysis of the records of the 752 patients who had undergone an initial hepatectomy showed that MIS was associated with a lower risk of postoperative morbidity and that it was also correlated with a milder grade of adhesions observed during the next surgery. The severity of adhesions was scored according to the TORAD v2.0, and an analysis of the records of 386 repeat hepatectomy patients revealed that both the grade of adhesion and MIS were associated with a risk of postoperative morbidity at the time of the repeat hepatectomy (odds ratio, 1.60 per +1 point of the TORAD v2.0; and odds ratio, 0.09 for MIS).

Conclusion: MIS is associated with a lower surgical risk in both initial and repeat hepatectomy patients because of its less invasiveness and lower probability of being followed by severe adhesion formation.

New technologies, processes, or care models that substantially change practice are critical for surgical progress, patient care, and organizational efficiency.

Background: Gastrointestinal (GI) cancers are a major global health challenge due to their high incidence, mortality, and surgical complication rates. Preoperative physical, nutritional, and psychological vulnerabilities increase the risk of adverse surgical outcomes. Despite this, there is currently no validated, self-report screening tool integrating assessment across all three domains. This scoping review aims to identify and describe existing preoperative screening tools used to assess modifiable physical, nutritional, and psychological domains in adult patients undergoing elective GI cancer surgery.

Methods: We conducted this scoping review in accordance with Arksey and O'Malley's framework and PRISMA-ScR guidelines. Searches were performed across MEDLINE, EMBASE, CINAHL, EBM, and PsycINFO date limited from January 2000 to March 2025. Studies were included if they evaluated preoperative screening tools for physical, nutritional, and/or psychological assessment in adult patients undergoing GI cancer surgery. Data on tool characteristics, domains assessed, administration time, and psychometric properties were extracted and synthesized descriptively.

Results: From 2825 initial records, 121 studies were included, encompassing 77 unique screening tools. These were categorized as physical (n = 21), nutritional (n = 16), and psychological (n = 40) tools. Most tools were brief (1-15 items).

Conclusions: Although most screening tools are brief, feasible for self-administration, and freely accessible, none integrated all three domains. Substantial heterogeneity in tools highlights the need for a comprehensive, validated multidomain preoperative screening tool for this population.

Background: Various differences in the healthcare system have been described between the United States (US) and Japan; however, the impact on clinical outcomes, particularly in severely injured older trauma patients, is not fully understood. We aimed to compare clinical outcomes of severely injured older trauma patients between the US and Japan using a nationwide trauma database in each country.

Methods: This is a retrospective study using the National Trauma Data Bank (NTDB) and Japan Trauma Data Bank (JTDB) from 2017 to 2021. The two datasets were queried for patients aged ≥ 60 years with severe injuries (injury severity score > 15). We excluded patients who were dead on arrival (DOA) and had missing outcome data. The primary outcome was in-hospital mortality, and the secondary outcomes were hospital length of stay (HLOS) and disposition after hospital discharge.

Results: A total of 268,013 NTDB and 29,998 JTDB patients were included for the analysis. The overall in-hospital mortality rate in the NTDB was significantly higher compared to the JTDB (14.4% vs. 10.5% p < 0.001). The median hospital length of stay was significantly longer in the JTDB than the NTDB (22 vs. 7 days, p < 0.001). The rate of prolonged hospital stay, exceeding 50 days, was significantly higher in the JTDB (16.5% vs. 1.2%, p < 0.001). In the 60-69 age group, there was a significant difference in the proportion of patients that were discharged home between the JTDB and NTDB (36.0% vs. 46.7%, p < 0.001). In both datasets, the proportions of patients discharged to home in the 80-89 age group were significantly lower compared to those in younger age groups (p < 0.001, respectively) with more patients transferred to another hospital in the JTDB and more discharged to hospice or other facilities in the NTDB.

Conclusions: The results in this study suggest that there are significant outcome differences in severely injured older trauma patients between the US and Japan. Future research is warranted to identify underlying mechanisms of the outcome differences.

Background: Thermal ablation is increasingly used for selected benign and low-risk thyroid nodules, yet some patients still require thyroidectomy for regrowth, persistent symptoms, or new oncologic concern. The surgical and pathological impact of ablation-induced remodeling remains incompletely defined. We aimed to characterize postablation thyroidectomy outcomes and identify histological correlates of perioperative morbidity.

Methods: We conducted a single-center retrospective cohort study of patients undergoing thyroidectomy after radiofrequency or ethanol ablation (2021-2025). Clinical and ablation-related variables were collected, and intraoperative neuromonitoring was routinely used. Primary outcomes were recurrent laryngeal nerve (RLN) palsy, reoperative hematoma, and hypoparathyroidism. Surgical specimens underwent blinded dual-pathologist assessment with semiquantitative scoring of sclerosis, necrosis, and residual viability, from which a maturation index was derived. Associations with complications were analyzed using nonparametric methods. Outcomes were descriptively compared with a contemporaneous nonablated cohort for contextual purposes.

Results: Thirty-one patients were included. Postoperative complications occurred in 22.6% of ablated cases. Histological analysis demonstrated moderate sclerosis (19.2%), necrosis (14.6%), and high residual viability (66.1%), with frequent pericapsular inflammatory changes and preserved capsule integrity. Sclerosis was the only parameter significantly associated with postoperative complications (30.0% vs. 16.9% and p = 0.008), whereas nodule size, ablation-to-surgery interval, and incidental carcinoma were not predictive. The maturation index increased with time after ablation but did not discriminate complication risk. Exploratory fibrosis-weighted metrics suggested potential risk thresholds, although these findings remain hypothesis-generating given the limited sample size.

Conclusions: Thyroidectomy after prior ablation is feasible in experienced centers but may be technically demanding and associated with modestly increased procedural complexity. Mature sclerosis represents the principal histological correlate of perioperative morbidity, linking fibrotic remodeling to operative risk. These findings support centralization of postablation thyroid surgery in high-volume units with routine neuromonitoring and specialized pathology and highlight the need for larger prospective studies to validate fibrosis-based risk stratification tools.

Background: The Asian Breast Surgery Forum (ABSF) is a training and knowledge-sharing platform that advocates for multidisciplinary collaborations among participants. Based on the Extension for Community Healthcare Outcomes (ECHO) model, the forum aims to foster virtual case-based learning and skill-building to democratize access to specialty care.

Methods: With Malaysia as its hub, the ABSF has engaged medical experts from Thailand, Japan, South Korea, Taiwan, Singapore, China, Vietnam and India. The paired samples t-test was used to determine if there were significant differences (p < 0.05) in participants' engagement and learning outcomes. The Chi-square test (goodness-of-fit and test of independence) was used to determine significant differences in post-session survey questions.

Results: Between 2023 and 2025, ABSF had conducted 15 sessions, connecting 400 participants from 61 cities in 24 countries. The paired samples t-test found significant difference in the level of comfort/preparedness in using the knowledge gained (p < 0.001). Goodness-of-fit analysis highlighted meaningful differences in participants' perceptions across key aspects. In the test of independence, fulfillment of learning objectives was closely aligned with pre-session expectations [χ²(4) = 17.20, p = 0.002], indicating that the likelihood of fulfillment was significantly varied between objective categories. Overall feedback achieved a 100% satisfaction rate and a net promoter score (NPS) of 68.

Conclusion: Most participants found the sessions to be highly relevant, with nearly all agreeing that the balance between lectures and interactivity was optimal. Through feedback and integration of cutting-edge techniques, the forum could continue leveraging digital platforms to enhance healthcare outcomes.