World Journal of Surgery最新文献

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: Surgical site infections (SSIs) are a leading cause of postoperative morbidity, particularly in low- and middle-income countries (LMICs). The influence of operative timing on SSI risk remains unclear in these settings. This study aimed to assess the association between case timing and SSIs following emergency gastrointestinal surgery at a tertiary hospital in Kenya.

Method: We performed a retrospective cohort study of adult patients undergoing emergency gastrointestinal operations between January 2016 and December 2019. Procedures were categorized by timing: weekday daytime (08:00-16:59) versus off-peak (weeknights, weekends, and holidays). The primary outcome was SSI. Multivariable logistic regression adjusted for wound classification, procedure type, and the Africa Surgical Outcomes Study (ASOS) risk score. Sensitivity analyses evaluated duration of illness, prior care, operative duration, presence of perforation, year of admission, admission to the intensive care unit, and number of surgeons.

Results: Of 400 patients included, 58 (14.5%) developed an SSI. SSI occurred in 19.9% of weekday cases versus 11.7% of off-peak cases (p = 0.029). In adjusted analysis, weekday operations were associated with increased odds of SSI (OR 2.0, 95% CI 1.1-3.6, and p = 0.024). Dirty wound classification and small intestine and colorectal cases were also associated with increased SSI rates in the model. The observed SSI rate was significantly lower than the 28.6% rate predicted by GlobalSurg data for middle-HDI countries (p < 0.001).

Conclusion: Contrary to findings from high-income settings, emergency operations performed during off-peak hours were associated with fewer SSIs than weekday cases. This may reflect workflow differences or lower operating room traffic. The findings support ongoing efforts to optimize perioperative systems and challenge assumptions about off-hour surgical care in LMICs.

Background: Robotic adrenalectomy (RA) is increasingly adopted, but its clinical value compared with laparoscopic adrenalectomy (LA) remains unclear. We assessed perioperative outcomes and the learning curve of RA.

Methods: A bicentric retrospective study included 228 patients who underwent adrenalectomy between 2013 and 2023 (97 RA, 131 LA). Primary outcomes were intra- and postoperative complications (Clavien-Dindo, Comprehensive Complication Index, CCI). Secondary outcomes included operative time and length of stay (LOS). Subgroup analysis evaluated tumors ≥ 6 cm. RA learning curve was assessed with cumulative sum (CUSUM) analysis.

Results: Patients in the RA group had higher ASA scores, more prior abdominal surgery, and larger tumors. Overall complication rates were similar (RA 18.6% vs. LA 17.6%, p = 0.846). RA was independently associated with shorter LOS (OR 0.48; 95% CI 0.26-0.84; p = 0.012). In tumors ≥ 6 cm, RA reduced postoperative complications (5.3% vs. 35.3%, p = 0.037). CUSUM analysis showed earlier improvements in operative time (after 25 cases) and later reductions in morbidity (after ∼ 45 cases).

Conclusions: RA is a safe alternative to LA even in complex patients. It shortens LOS overall and improves outcomes in large adrenal tumors. CUSUM analysis highlights a progressive but safe learning curve, supporting the integration of RA into endocrine surgical practice.

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.

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.

Background: A growing number of emergency general surgery (EGS) admissions comprise of adults age 65 years and older, who are more likely to experience missed or delayed diagnoses, and subsequently worse postoperative outcomes. We aimed to ascertain the perspectives of clinicians on the diagnostic challenges unique to older adults with EGS conditions and strategies to improve feedback.

Methods: In this qualitative study, semi-structured focus groups were conducted with frontline clinicians with experience in providing high volume care to older adult EGS patients to explore diagnostic challenges, tools, and feedback strategies. Questions focused on clinical gaps and approaches, tools, and the mechanisms in place to provide feedback on patient diagnosis and assessment. Focus groups were transcribed and qualitatively analyzed using an inductive approach.

Results: Twenty-two clinicians participated in one of six focus groups. Clinicians reported three key diagnostic challenges: nontextbook presentations, comorbidities, and older-age specific complications. Nondiagnostic factors remained high priorities including functional health status, patient preferences, family involvement, and health related social needs. Practical tools addressing these gaps included the use of multidisciplinary expertise, surgical risk calculators, cognitive assessments, functional health assessments, and protocols guiding goals of care discussions. Participants shared barriers and facilitators for implementation of these tools.

Conclusion: Frontline clinicians identified several high priority considerations unique in EGS for older adults. To address these, context-specific tools and strategies were detailed and inform ongoing work to incorporate feedback and solutions into frontline settings. Future work in quality improvement should incorporate these high priority areas into existing quality improvement frameworks.

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: This clinical practice guideline from the Explosive Weapons Trauma Care Collective (EXTRACCT) group reviews current best practice for the management of ocular trauma in conflict-affected regions, where explosive weapons are used and healthcare infrastructure is limited.

Methods: An expert literature review of current practice is presented with practical resource-adapted guidelines constructed through expert consensus from ophthalmologists, emergency care providers and allied health professionals with field experience.

Results: The guideline provides recommendations for the assessment, classification and management of major and minor ocular injuries encountered in low-resource settings, particularly during conflict. Guidance is written for frontline healthcare workers who may be addressing such injuries in the absence of specialist ophthalmology expertise and equipment. Dosing of ophthalmic therapeutics is provided.

Conclusion: Actionable context-appropriate strategies to manage ocular trauma caused by explosive weapons can reduce vision loss and improve patient outcomes where specialized ophthalmic care is scarce.