World Journal of Surgery最新文献

Background: Timely care for open tibia fractures remains difficult in low-resource settings. We evaluated a task-sharing model in Malawi in which trained orthopedic clinical officers (OCOs) delivered external fixation supported by a remote quality assessment tool.

Methods: We conducted a prospective implementation evaluation across one central and four district hospitals (May 2023-July 2024). The intervention bundled OR refurbishment assured external fixator supply, refresher training, mentoring (on-site and remote), national guideline reinforcement, and a novel Fracture Fixation Assessment Tool for External Fixation (FFATEF). OCOs submitted postoperative radiographs and construct photographs for scoring across four domains (reduction, stability, implantation, and surgical impression; total 0-12 and satisfactory ≥ 8). Nonparametric tests compared performance by the hospital type; temporal trends were assessed with Spearman correlation.

Results: Forty-seven patients (89% male and mean age 32.3 years) were treated (central: n = 28 and district: n = 19). The central hospital managed more severe injuries (Gustilo IIIA/B 69.6% vs. 15.8%). Median FFATEF scores were higher at the central hospital (10.0 [IQR 9-11]) than district hospitals (6.0 [5, 6, 7, 8], p < 0.001). Satisfactory scores (≥ 8) occurred in 93% of central versus 32% of district cases. Central scores improved over time (ρ = 0.52; p = 0.005) whereas district scores were unchanged (ρ = 0.15; p = 0.540). Preoperative antibiotic compliance was 100% at the central versus 47% at district hospitals.

Conclusions: When embedded within integrated surgical teams and adequate infrastructure, task sharing for open fracture external fixation yielded satisfactory technical performance but lagged district-level implementation despite training. Comprehensive institutional support-mentoring intensity, equipment, supply chains, and referral adherence-is likely required for safe scale-up. Validation of FFATEF against clinical outcomes and economic evaluation of delivery models are priorities.

Background: Laparoscopic surgery has gradually gained acceptance for abdominal surgical emergencies; however, limited reports exist on laparoscopic surgery for strangulated small bowel obstruction (SSBO). We aimed to demonstrate the efficacy and feasibility of laparoscopic surgery for SSBO.

Methods: In this single-center retrospective study, patients who underwent emergency surgery for SSBO between January 2014 and December 2024 were included and divided into laparoscopy and open groups. Propensity score matching (PSM) was performed to compare the primary outcomes-intraoperative and short-term postoperative outcomes-between the groups. Logistic regression analysis was used to identify the factors associated with the conversion from laparoscopic to open surgery as secondary outcomes.

Results: A total of 123 patients were included in this study, of whom 39 (31.7%) were assigned to the laparoscopy group. After PSM, the overall rate of the Clavien-Dindo grade ≥ II postoperative complications was significantly lower in the laparoscopy than the open group (7.4% vs. 29.6%; p = 0.036). Of the 39 patients in the laparoscopy group, 10 (25.6%) were converted from laparoscopic to open surgery. The number of previous laparotomies (odds ratio: 4.036, 95% confidence interval: 1.189-13.701, and p = 0.025) and a history of gastrointestinal surgery (odds ratio: 6.125, 95% confidence interval: 1.263-29.699, and p = 0.024) were identified as factors significantly associated with conversion from laparoscopic to open surgery in patients with SSBO.

Conclusion: Our study suggests that laparoscopic surgery for SSBO is beneficial for reducing the occurrence of postoperative complications. However, laparoscopic surgery should be performed in patients with a history of multiple laparotomies or gastrointestinal surgery, considering the possibility of conversion to open surgery.

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: 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).

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.

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.