World Journal of Surgery最新文献

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.

Purpose: To evaluate predictive models for complicated acute appendicitis (CAA) and provide insights into their performance, bias, and clinical applicability.

Materials and methods: PubMed, Embase, and Google Scholar were searched up to December 31, 2024. Eligible studies included those with clearly defined predictors and reported model performance metrics. A bivariate random-effects model was applied to pool sensitivity and specificity while estimating the SROC curves. Bias was assessed using the PROBAST tool.

Results: A total of 20 studies focusing on the development and validation of emerging predictive models for complicated AA were included. These models demonstrated pooled sensitivities of 0.840, 0.840, and 0.787, specificities of 0.825, 0.768, and 0.707, and AUCs of 0.897, 0.867, and 0.811 in training, internal validation, and external validation datasets, respectively. PROBAST assessment revealed low risk of bias in participants, predictors, and outcomes across most studies, but a consistently high risk of bias in the analysis domain.

Conclusion: Emerging prediction models for CAA show promising potential but face major challenges in external validation and clinical implementation. Future research should prioritize methodologically robust model development, including prespecified sample size estimation, proper imputation strategies, multivariable predictor selection, and both internal and external validation.

Introduction: Initiatives in workforce training and education have emerged as a key strategy to address the critical shortage of skilled surgical providers in low and middle-income countries (LMICs). Nonetheless, the scope and distribution of these initiatives remain poorly characterized within the global surgery literature. This bibliometric review identifies the most highly cited studies on international surgical workforce development to clarify current trends, synthesize areas of consensus, and highlight persistent gaps that limit sustainable capacity building.

Methods: A bibliometric analysis was conducted using Web of Science to identify the top 50 publications related to global initiatives in surgical workforce development. We employed a comprehensive search strategy to analyze citation trends, authorship patterns, geographic distribution, and institutional collaborations. The most frequently cited articles, journals, and research topics were also assessed to measure the scholarly impact of surgical workforce development efforts. We also examined the duration, training approaches, and stated objectives of each initiative to clarify the major themes represented in the literature.

Results: A total of 50 publications were identified from 2000 to 2025. All publications were published within the last 10 years, reflecting a growing academic interest in global surgical education. Plastic surgery, neurosurgery, and multispecialty training programs were the most frequently represented domains, with notable emphasis on reconstructive procedures, microsurgical training, and cleft care. Authorship trends revealed a predominance of contributors from high-income countries, highlighting an imbalance in knowledge production and a need to elevate LMIC-led research. Although many initiatives were categorized as "ongoing," nearly 25% spanned less than 1 year, indicating an opportunity for improvement in the continuity and sustainability of workforce impact. Across studies, there was a clear consensus that long-term training partnerships and locally led educational models offered the most durable impact, yet few publications evaluated outcomes beyond the program period.

Conclusion: This bibliometric study offers insight into global surgical training programs, highlighting increasing research output, international collaboration, and concentrated efforts within select specialties. Findings point to an urgent need to strengthen long-term program sustainability, expand LMIC authorship leadership, and develop standardized metrics to assess educational and clinical outcomes. Advancing global surgical efforts will require establishing best practices for surgical mentorship and sustainable training models as well as promoting equitable research partnerships and enhancing LMIC representation.

Cohort study of 777 patients (1238 sides at risk) shows that both oxidized regenerated cellulose and gelatin sponge (topical hemostatic agents) are safe to use in thyroidectomy. Adverse events are nil and the incidence of RLN palsy and permanent hypoparathyroidism are low.

Introduction: Learning laparoscopic surgery in LMICs is hindered by the dearth of technically skilled surgeons. A self-directed, low-cost simulation-based training could bridge this gap. To evaluate the effectiveness of such a program, we assessed the differences in knowledge, laparoscopic skills, and self-ratings between simulation-trained and simulation-naive residents.

Methods: This study involved Cameroonian surgery residents from a program with 3 years of laparoscopic simulation training on the ALL-SAFE platform (Group A) and residents from another training program without simulation exposure (Group B). All participants completed cognitive and psychomotor portions of a novel case-based laparoscopic cholecystectomy module. We used Kruskal-Wallis tests to compare the groups' pre- and post-training test scores, confidence and competence, time to task, and psychomotor skill via checklist and global assessments of submitted videos.

Results: Twenty-six participants, including 14 in Group A and 12 in Group B, completed the module. Both groups reported similar pre-course confidence (p ≥ 0.63) and competence (p ≥ 0.21). They also had similar pretest scores, but Group A's posttest scores were improved (M = 89.29 and p = 0.005) over B's (M = 77.50 and p = 0.28). Group B checklist scores trended slightly lower (p = 0.22) and significantly lower on global assessment (p < 0.001). Group A's mean task completion time was 28.46 (12.00) minutes whereas group B's was 51.83 (16.36); p < 0.001, and d = 1.41. Group B self-ratings were higher than peers' ratings, whereas Group A self-ratings were similar or lower; p = 0.02, and r = 0.35.

Conclusion: Long-term simulation-based training improved cognitive and psychomotor skills, suggesting that a self-directed, low-cost simulation-based training may help learners develop proficiency in laparoscopy.