World Journal of Surgery最新文献

Background: Low- and middle-income countries are currently experiencing a significant shortage of physicians trained in anesthesia. This shortage has been widely attributed to multifactorial causes, including limited local training capacity, workforce migration, underfunded health education systems, and poor national workforce planning. Therefore, the present study aimed to evaluate the state of postgraduate anesthesia training in Ecuador focusing on the structure of current programs and the competencies of their senior residents.

Methods: A cross-sectional study was conducted in two-phases. During the first phase, we mapped and characterized accredited anesthesiology residency programs based on the information available on the webpage of the Ecuadorian Higher Education Council. During the second phase, we administered two surveys. First, we invited the medical directors of universities with active anesthesiology programs to fill out a survey developed by the Society for Education in Anesthesia's ad hoc Committee for Resident Evaluation. Then, we assessed self-perceived senior residents' competencies for anesthesia care defined by the Accreditation Council for Graduate Medical Education. A five-point Likert scale was used to determine whether the competency was met using a 70% cutoff value.

Results: Seven universities in Ecuador offer postgraduate anesthesiology programs, ranging from 4 to 32 residents per cohort, with a total training capacity of 112 residents. Findings from both program directors (n = 4) and senior residents (n = 27) revealed deficiencies in resident evaluation processes, including low faculty-to-resident ratios and limited resident involvement in evaluation committees. Deficiencies in competency development were observed particularly in pain management; only 48.5% of those evaluated reported competence in managing complex pain at the perioperative level. Likewise, lack of competence was reported in using echocardiography for patient monitoring and revealing medical errors or complications with competence values at 14.8% and 33.3%, respectively.

Conclusions: Ecuador has a limited number of postgraduate anesthesiology programs, contributing to a shortage of anesthesia-trained physicians. Exacerbating this issue, within these programs, there are significant gaps in resident evaluation and competency development. Addressing these issues would improve the quality of anesthesiology training and enhance patient care and safety in Ecuador.

Introduction: The efficacy of Billroth II with Braun (BIIB) anastomosis in laparoscopic distal gastrectomy remains uncertain. We aimed to perform a systematic review and meta-analysis comparing BIIB with Roux en Y (RY) for distal laparoscopic gastrectomy.

Methods: We systematically searched PubMed, Embase, and Cochrane for studies comparing BIIB versus RY in adult patients undergoing distal gastrectomy. We computed risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes, with 95% confidence intervals (CIs). Heterogeneity was assessed with I² statistics. Statistical analyses were performed using R software, version 4.2.3.

Results: We included 10 studies, comprising a total of 1377 patients. BIIB was associated with a lower anastomotic time (MD 7.82 min; 95% CI -11.99 to -3.65; p = 0.0002; I² = 99%), intraoperative blood loss (MD -17.88 mL; 95% CI -31.00 to -4.76; p = 0.0076; I² = 91%), and operative time (MD -21.67 min; 95% CI -28.62 to -14.72; p < 0.01; I² = 80%). Also, BIIB group was associated with a higher incidence of bile reflux when compared to the RY group (RR 3.10; 95% CI 1.75 to 5.50; p < 0.0001; I² = 74%). There were no significant differences between BIIB and RY for anastomotic leakage rate, number of retrieved lymph nodes, gastritis, residual food, time to first exhaust, length of hospital stay, time to liquid diet, and adverse events.

Conclusion: In adult patients undergoing distal gastrectomy, BIIB was associated with a shorter operative, anastomotic time, and intraoperative blood loss, with an increased incidence of bile reflux. BIIB may be an easier and feasible alternative to RY, especially in patients who should avoid excessive exposure to anesthesia.

Introduction: Definitive second-line treatment for pediatric Graves' disease (GD) includes radioiodine ablation (RAI) or thyroidectomy. The current treatment practice in pediatric GD patients is a contentious issue as the decision to consider either of the treatment options depends on preferences of patients, physicians, and access to surgical care and radioactive iodine treatment. This systematic review and meta-analysis were performed to compare the cure and relapse rates of RAI versus surgery as definitive therapy in children with Graves' Disease.

Methods: A comprehensive search on Cochrane library, Embase, PUBMED, MEDLINE (via Pubmed), and ClinicalTrials.gov for English articles published on definitive treatment of GD in children since 1985 to 2023 was performed. The data were extracted and meta-analyzed for efficacy and safety outcomes, risk of bias (ROB), and certainty of evidence summated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) instrument.

Results: Twenty-nine (26 retrospective and 3 prospective) studies with a total of 1861 children and a mean age of 13.15 years with a mean follow up of 8 years were evaluated in the systematic review. Among these, 1061 children received RAI therapy, whereas 800 underwent thyroidectomy and were evaluated in the pooled analysis. 755 were excluded as details pertaining to definite treatment was not available. Studies were of low to moderate risk of bias. The pooled analysis suggests that RAI had significantly lower cure rate in children compared to children who underwent thyroidectomy (RR 0.89; 95% CI 0.81-0.99; p = 0.03). In subgroup analysis of patients from 19 studies who underwent surgery, total thyroidectomy (2%) was more effective than subtotal thyroidectomy (13%) in preventing recurrent hyperthyroidism (p = 0.001; moderate quality evidence). Hypothyroidism rates after RAI and surgery were similar (RR 0.97; 95% CI 0.67-1.40; p = 0.88). There were no significant adverse outcomes reported such as secondary malignancy or quality of life after RAI. Following TT, adverse effects seen were permanent hypoparathyroidism (0.6%) and temporary recurrent laryngeal nerve palsy (5.1%).

Conclusion: Thyroidectomy appears to be more effective than RAI in effecting cure in Graves' disease in children following failed remission with antithyroid medication therapy. However, access to thyroidectomy may not be universally available and RAI is an option in these children.

Background: Continuous monitoring of vital signs using wearable devices may improve early detection of postoperative complications and reduce nursing workload. Evidence from real-world clinical implementation remains limited. This study aimed to answer the question: does the implementation of wearable monitoring in surgical wards reduce nursing workload and is it feasible and acceptable to staff?

Methods: A prospective, single-center implementation study was conducted on a surgical ward in a large teaching hospital. Nursing workload was assessed using the Integrated Workload Scale (IWS), and usability was evaluated using the system usability scale (SUS). Additionally, staff attitudes were measured with the evidence-based practice attitude scale (EBPAS). Manual spot checks of vital signs were monitored before and after the implementation of wearable devices (viQtor) for continuous monitoring of heart rate, respiratory rate, and oxygen saturation.

Results: Nursing workload decreased significantly with mean IWS scores dropping from 5.46 ± 1.18 to 3.87 ± 1.38 (p < 0.001). A 62.7% reduction in manual spot checks was observed (from 4686 expected to 1748 performed, p < 0.001) corresponding to a time saving of 10.1 min per patient per day. The SUS score improved from 74.2 ± 10.1 to 86.0 ± 5.2 (p = 0.025). No significant differences were observed in EBPAS scores over time (p = 0.43).

Conclusions: Implementation of remote wearable monitoring in surgical wards is feasible, reduces nursing workload, and demonstrates high usability and acceptance among staff. These findings highlight the potential of wearable technology for more efficiency of postoperative care.

Trial registration: ClinicalTrials.gov: NCT06574867, prospectively registered on 27 August 2024.

Background: Medullary thyroid carcinoma (MTC) frequently presents with lymph node metastases (LNMs), and the extent of lymph node (LN) surgery remains controversial. The desmoplastic stromal reaction (DSR) has emerged as a potential histopathological predictor of metastatic spread.

Methods: We retrospectively analyzed 63 patients with sporadic MTC treated between 2016 and 2025 at four tertiary centers. Histopathological specimens were re-evaluated for DSR, which was graded as absent, low, moderate, or high. Clinicopathological features, biochemical markers, and oncologic outcomes were compared across groups.

Results: DSR was absent in 27.0% and present in 73% tumors. DSR positivity was significantly associated with higher calcitonin (Ctn) and carcinoembryonic antigen (CEA) levels, increased LNM (87% vs. 0%), lymphovascular invasion, advanced nodal stage, and stage IV disease. Biochemical cure was achieved in 94.1% of DSR-negative patients compared with 56.5% of DSR-positive patients. The extent of tumor desmoplasia levels correlated with higher metastatic burden.

Conclusion: DSR negativity reliably identifies an indolent subgroup with negligible metastatic risk, whereas increasing desmoplasia stratifies patients into higher-risk categories. The incorporation of DSR alongside established biomarkers such as Ctn may refine surgical decision-making and may help tailor the extent of LN dissection in sporadic MTC.

Background: Postoperative morbidity remains a significant concern following the surgical treatment of pediatric liver hydatid disease, particularly in endemic regions. The aim of this study was to identify independent predictors of postoperative morbidity in pediatric liver hydatid disease in order to improve preoperative risk assessment.

Methods: This retrospective observational study included consecutive pediatric patients who underwent surgical treatment for liver hydatid disease at Hedi Chaker University Hospital, Sfax, Tunisia, between 1 July 2010 and 30 June 2025. Postoperative morbidity was defined as any complication occurring within 30 days after surgery.

Results: A total of 117 children were included. The median age was 8 years, with a nearly equal sex distribution (59 males and 58 females). The median Sun Pediatric Comorbidity Index (SPCI) was 1 [IQR, 0-2]. The mean cyst size was 8 ± 2.4 cm, with right lobe involvement observed in 83 patients (70.9%). Concomitant extrahepatic hydatid disease was identified in 23 children (19.7%). Postoperative complications occurred in 25 patients (21.4%). In multivariate analysis, three factors were independently associated with postoperative morbidity: SPCI ≥ 3 (OR 5.748, 95% CI 1.696-19.482; p = 0.005), cyst size > 8 cm (OR 5.020, 95% CI 1.172-21.513; p = 0.030), and concomitant extrahepatic hydatid disease (OR 6.355, 95% CI 1.710-23.620; p = 0.006).

Conclusion: Postoperative morbidity after pediatric liver hydatid surgery remains frequent. Beyond cyst size, pediatric comorbidity burden and multisite hydatid disease emerge as novel and independent predictors of adverse postoperative outcomes.