World Journal of Surgery最新文献

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.

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.