World Journal of Surgery最新文献

The legacy of the anatomist surgeon John Wood has been forgotten by history. However, his life was linked to the search for a radical cure for hernias. This study aims to analyze his work, focusing on the surgical anatomy of hernias.

Background: Anastomotic leakage (AL) remains a severe complication after low anterior resection (LAR) for rectal cancer, despite advances in minimally invasive (MI) techniques. This study aimed to evaluate the impact of a surgery-focused care bundle, implemented on an enhanced recovery after surgery (ERAS)-based perioperative protocol, on preventing AL and improving postoperative outcomes in patients with MI-LAR.

Methods: In this retrospective historically controlled cohort study, a total of 306 patients who underwent MI-LAR between 2011 and 2024 were included. A late-phase cohort (n = 81) receiving the care bundle with an ERAS-based protocol (from September 2019) was compared with a historical early-phase cohort (n = 225). The surgery-focused care bundle included robot surgery, preoperative oral antibiotics, indocyanine green blood flow evaluation, diverting stoma, transanal drainage tubes, and anastomotic reinforcement. Our institutional ERAS protocol was developed in accordance with the ERAS Society guidelines. Propensity score matching (PSM) was used to adjust for baseline differences between cohorts.

Results: The AL rate significantly decreased from 14.7% (33/225) to 2.5% (2/81) after bundle implementation (p < 0.01). Post-PSM, AL rates remained significantly lower in the late-phase cohort (18.0% vs. 1.3% and p < 0.001). Severe complications (Clavien-Dindo grade ≥ 3) and surgical site infections (SSIs) were also significantly reduced, and no reoperations were required in the late-phase cohort. Multivariate analysis identified lack of care bundle (odds ratio [OR]: 6.36, 95% confidence interval [CI]: 1.42-28.4, and p = 0.01) and male sex (OR: 3.05, 95% CI: 1.24-7.52, and p = 0.01) as significant risk factors for AL.

Conclusions: Implementation of a surgery-focused care bundle, integrated within an ERAS-based perioperative framework, significantly reduced AL, severe complications, and SSIs after MI-LAR, suggesting potential long-term benefits by improving short-term postoperative outcomes.

Background: Diabetic foot is a serious complication of diabetes mellitus that generates lifelong consequences on the health and quality of life of affected patients. One of the first grading systems developed for diabetic foot was the Wagner classification system. Despite its prolonged use in the medical field, accurate clinical assessment requires an experienced evaluator to minimize errors and bias. Using infrared thermography, a technology that quantitatively measures temperature changes in areas of interest related to altered vascular flow derived from inflammatory processes, could diminish the subjective bias associated with clinical evaluation.

Objective: To determine the thermographic pattern of the different grades of the Wagner classification system for diabetic foot.

Methods: We evaluated thermographic images of 66 patients diagnosed with diabetic foot. Clinical data and infrared thermographic images were acquired at the moment of evaluation. Temperature differences (ΔT) between the first toe of the affected limb and the contralateral unaffected first toe were recorded and analyzed with computer software. The thermographic patterns were then compared with the Wagner classification system grades.

Results: A positive ΔT was observed in 36 patients in the first three Wagner grades: Wagner 0, ΔT 0.71°C ± 0.43; Wagner 1, ΔT 1.17°C ± 1.88; and Wagner 2, ΔT 2.18°C ± 2.38. Thirty patients presented negative ΔT from the third grade onward: Wagner 3, ΔT -2.66°C ± 1.14; Wagner 4, ΔT -5.92°C ± 1.75, and Wagner 5, ΔT -6.92°C ± 1.28. Then, we separate the cohort into two groups: patients who required amputation and those who required conservative management. A threshold in the ΔT value of -2.6 correctly predicted the outcome in more than 95% of patients.

Conclusions: These results suggest a potential application for thermography as an adjunctive tool in wound clinics, enabling the accurate evaluation of diabetic foot ulcers and as a predictor of patients' outcomes.

Trial registration: Registry: 08-23 by the Hospital Regional de Alta Especialidad "Dr. Ignacio Morones Prieto" Research Ethics Committee (CONBIOÉTICA-24-CEI-001-20160427).

Objectives: To test the hypotheses that intraoperative hyperlactatemia is independently associated with increased postoperative infection risk in cardiac surgery with cardiopulmonary bypass (CPB).

Methods: This study involved 4970 cardiac surgical patients with CPB from two medical centers. Intraoperative hyperlactatemia was defined as blood lactate levels exceeding 2.0 mmol/L. The main objective was to investigate the association between intraoperative hyperlactatemia and postoperative infections. Furthermore, we identified the threshold values of intraoperative peak blood lactate levels linked to a heightened risk of postoperative infection.

Results: Postoperative infections occurred in 14.49% of the patients included in the study. Patients who developed postoperative infection had significantly higher intraoperative median peak lactate levels (3.5 mmol/L vs. 2.6 mmol/L and p < 0.001). After adjusting for confounders, patients with intraoperative hyperlactatemia had roughly a 1.5-fold increased risk of developing postoperative infection (adjusted OR: 1.49; 95% CI: 1.18-1.91; and p < 0.001). Moreover, the threshold for intraoperative peak blood lactate levels that correlated with a higher risk of composite in-hospital postoperative infection was approximately 2.7 mmol/L.

Conclusions: Consistent with our hypothesis, intraoperative hyperlactatemia was independently associated with a 1.49-fold increased risk of postoperative infection in CPB-assisted cardiac surgery. Notably, maintaining intraoperative blood lactate levels below 2.7 mmol/L might lower the risk of such infections.

Background: Excessive opioid prescribing after colorectal surgery can lead to adverse events and contribute to the opioid crisis. Understanding international prescribing patterns is essential for guiding practice and future research. The Analgesia After Colorectal Surgery (ACORE) survey aimed to characterize international opioid prescribing practices after elective colorectal resection.

Method: This international cross-sectional survey followed established methodological guidelines. Eligible participants were colorectal, gastrointestinal, and general surgeons, as well as surgery trainees. Recruitment followed snowball sampling via international surgical societies' mailing lists, social media, and personal networks. The primary outcome of interest was post-discharge opioid prescribing after open and MIS elective colorectal resection. Secondary outcomes included prescription quantity in morphine milligram equivalents (MMEs). Data were analyzed using descriptive statistics and logistic regression with Bayesian model averaging.

Results: Among 817 participants, 88% were surgeons, 12% were trainees, 62% practiced in academic hospitals, and 67% had over 5 years in practice. Overall, 57% of the participants reported prescribing opioids at discharge (55% after open and 54% after minimally invasive procedures). Opioids were commonly prescribed by surgeons practicing in Australia and New Zealand (100%), Northern America (92%), Northern Europe (68%), and South-eastern Asia (71%). In contrast, they were less frequently prescribed in Eastern Europe (11%), Eastern Asia (22%), Latin America and the Caribbean (26%), Southern Europe (19%), and Northern Africa (0%). The median quantity of opioids prescribed at discharge varied widely (30-200 MMEs). In regression analysis accounting for surgeon and practice characteristics, region of practice was the only factor independently associated with opioid prescribing.

Conclusion: The extensive global variation in opioid prescribing underscores clinical equipoise and challenges the assumption that post-discharge opioids are universally necessary for patients undergoing colorectal resection.