World Journal of Surgery最新文献

Background: Preemptive and preventative methods have been suggested to decrease pain by blocking nociceptive inputs to tissues. Preemptive analgesia has the potential to enhance postoperative recovery in patients undergoing colorectal surgery. This study aimed to evaluate the efficacy and safety of preemptive versus postoperative analgesia in this population.

Methods: We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library from inception to December 2024, and updated the search in May 2025, to identify randomized controlled trials (RCTs) comparing preemptive analgesia with postoperative analgesia in adult patients undergoing colorectal surgery. The primary outcomes were opioid consumption within 24 h, visual analog scale (VAS) pain score at rest at 24 and 48 h postoperatively. Secondary outcomes included adverse events, length of hospital stay, surgery duration (minutes), and postoperative nausea and vomiting (PONV). The Cochrane Risk of Bias 2.0 tool was used to assess risk of bias, and the strength of evidence was graded using the GRADE approach.

Results: We identified a total of 2739 records. Seven studies involving 625 patients (312 preemptive and 313 postoperative) met the inclusion criteria. Preemptive analgesia decreased VAS scores at 24 h compared to postoperative analgesia (MD -0.45, 95% CI: -0.89 to -0.01, p = 0.04). However, significant heterogeneity was observed among included studies. Additionally, there was no difference between the two groups regarding VAS at 48 h (MD -0.17, 95% CI -0.43 to 0.09, p = 0.21) and opioid consumption at 24 h (MD -21.17, 95% CI 48.18-5.85, p = 0.12).

Conclusion: The findings indicate that preemptive analgesia did not decrease opioid consumption at 24 h; however, it decreased VAS score at 24 h without any difference in VAS at 48 h, length of hospital stay, incidence of PONV, or other adverse events when compared to postoperative analgesia alone in colorectal surgery.

Trial registration: The study is registered in PROSPERO under the registration number CRD420250636020.

Background: The aging population's increased need for surgical capacity, the rise in modifiable risk factors such as deconditioning and malnutrition linked to postoperative complications, and deconditioning from cancer therapies highlight the crucial role of prehabilitation. Growing evidence supports the effectiveness of multimodal prehabilitation programs, which include preoperative physical exercise, nutrition, and psychological support for patients undergoing cancer surgery. Despite this, definitive recommendations on the optimal prehabilitation intervention remain elusive. Therefore, the primary objective of this study is to describe current prehabilitation practices for patients undergoing cancer surgery across international cancer centers.

Methods: In this cross-sectional study, an online survey was conducted between November 2023 and February 2024 to gather information from international, multidisciplinary participants with knowledge of or interest in prehabilitation. The survey included questions about prehabilitation uptake, current prehabilitation practices, and barriers to implementation. The responses were categorized by World Bank region and bank income class to provide insights into prehabilitation practices across international cancer centers.

Results: A total of 1409 respondents, representing 663 hospitals across South Asia, East Asia and Pacific (n = 40, 6%), Europe and Central Asia (n = 134, 20.2%), North America, Latin America and Caribbean (n = 19, 2.9%), Middle East and North Africa (n = 380, 57.3%), and Sub-Saharan Africa (n = 90, 13.6%), completed the survey. Prehabilitation was described as the standard of care for all cancer patients in 21.1% of the surveyed hospitals, whereas 29.9% of the hospitals provided prehabilitation only to a selected cohort of patients with cancer. The main barriers to implementing prehabilitation as standard of care were lack of institutional funding and resources (39.4%) and low institutional interest (10.6%). The most frequently provided types of prehabilitation included nutrition (36.2%), physical exercise (29.7%), and psychological interventions (23.8%).

Conclusion: This study identified significant variation in prehabilitation practices across hospitals globally. Among the surveyed hospitals, 21.1% reported providing prehabilitation as standard of care for all cancer patients. The main barriers to the widespread adoption of prehabilitation are the lack of institutional funding and resources. Evidence from future prehabilitation trials and the establishment of international guidelines and recommendations may enhance the uptake of prehabilitation globally.

Background: Existing tools to evaluate surgical care and trauma systems in low-resource settings contain a large number of variables that may limit feasibility of their use in low-resource conflict settings (LRCS). Further, such tools do not emphasize damage control capabilities, which are particularly relevant for explosive ordnance casualties. To address these needs, we developed a revised version of the existing International Assessment of Capacity for Trauma (INTACT) tool, INTACT-Blast (INTACT-B). We then piloted this tool at regional health facilities in an LRCS in the Sahel.

Methods: INTACT-B was developed by synthesizing expert opinion with a narrative review of existing LMIC trauma and surgical capacity assessment tools as well as U.S. Department of Defense Joint Trauma System Clinical Practice Guidelines. This instrument was then piloted across regional and district hospitals in Burkina Faso with functional surgical services.

Results: Thirty-six regional and district health facilities in Burkina Faso were included in the INTACT-B pilot, with required less than 15 min for data entry. Both material (e.g., equipment and infrastructure) and training needs were identified. Only 30.6% of facilities reported the ability to perform damage control laparotomy, with differences between regional and district facilities (70.0% vs. 15.4%, respectively). Although 75.0% had blood banks, only 44.4% had access to tranexamic acid and 33.3% to tourniquets and hemostatic dressings. Imaging equipment was limited (38.5% of district facilities had a functioning X-ray machine). Fewer than half of facilities were capable of performing essential war surgery interventions, such as chest tube placement and amputation (both 47.2%) or fasciotomy (33.3%), with the most significant gaps at district facilities. No facilities either at the regional or district level reporting vascular repair capabilities including intravascular shunt.

Conclusion: The INTACT-B tool provides a feasible instrument for evaluating trauma care capacity and capability in LRCS. Significant needs both with respect to material resources, infrastructure, and training were identified in the study setting. Information generated through use of the INTACT-B tool may help guide efforts to strengthen regional and district health facilities closer to point-of-injury, which holds potential to reduce preventable death among local casualties in LRCS.

Background: Anal sphincteroplasty (AS) was considered standard treatment for fecal incontinence (FI) associated with sphincter injury; however, long-term outcomes have been disappointing. Sacral neuromodulation (SNM) has proven effective for FI secondary to anal sphincter defects. This review aimed to assess outcomes of SNM in FI associated with anal sphincter defects and to compare outcomes to AS.

Methods: A PRISMA-compliant systematic review inquired PubMed and Scopus through January 2025 for studies that assessed SNM in FI secondary to anal sphincter defects. The primary outcome was continence improvement and change in baseline incontinence scores; overall complications were the secondary outcome. Random-effect meta-analyses were used to calculate pooled outcomes and odds of continence improvement after SNM compared to AS.

Results: Ten studies incorporating 779 patients (93.9% female; median age 54.5 years) were included. SNM was performed in 503 (64.5%) and AS in 265 (34%) patients. The weighted mean reduction in incontinence scores after SNM was 8.53 points (95% CI: 6.11, 10.96, p < 0.001) and the pooled rate of continence improvement was 66.7% (95% CI: 52.2%-81.1%). Previous sphincteroplasty, external sphincter defects > 120°, and low resting anal pressure were significantly associated with less continence improvement. Pooled complication and device removal rates were 18.5% (95% CI: 8.7%-28.2%) and 9.1% (95% CI: 3.4%-14.7%), respectively. SNM was associated with better continence improvement than AS (OR: 1.68, p = 0.006) with similar odds of complications (OR: 0.73, p = 0.763).

Conclusions: SNM was associated with a good improvement in FI associated with anal sphincter defects. However, a longer follow-up is required to ascertain these mid-term outcomes. There are not enough data to date to draw solid conclusions regarding the comparison between SNM and sphincteroplasty in patients with sphincter lesions.

We describe a novel "Sleeve Colonoscopy" technique, a pragmatic approach to preserving surgical sterility during cases where on-table colonoscopy or enteroscopy is required. The sleeve of a readily available surgical gown is used to create a barrier between the sterile surgical field and the endoscopy equipment path via a colotomy or enterotomy.