World Journal of Surgery最新文献

Background: Biliary anastomotic strictures (BAS) after liver transplant (LT) are a significant contributor to post-transplant morbidity. Although surgical technique has been proposed as a risk factor, accurate evaluation of technique has been limited by inherent bias in conventional definitions for BAS. This study aimed to evaluate the incidence of clinically significant BAS (csBAS) with absorbable suture material and variable anastomotic suture technique in patients undergoing LT with duct-to-duct (DD) anastomosis.

Methods: A retrospective medical record review was conducted of adult patients undergoing LT at a single center between January 1st, 2000 and December 31st, 2023. Suture technique included continuous or interrupted alone, or a combined technique (continuous to posterior wall, interrupted anteriorly), while suture material was either absorbable or non-absorbable suture. Primary endpoint was the incidence of csBAS using a previously introduced surrogate marker, extended biliary dilatation programs (EBDP). Secondary endpoints included time to csBAS, incidence of bile leak, intervention rates with csBAS, and graft failure. Univariable and multivariable analyses were performed to identify independent associations with csBAS. Graft survival with csBAS was assessed using a Kaplan-Meier curve.

Results: A total of 842 patients underwent 864 LTs with DD anastomosis, of which 123 LTs (14.2%) developed csBAS. The mean age and follow up time were 53.3 ± 11.3 years and 7.0 ± 5.0 years, respectively. Year of transplant (p < 0.01), donor age (p = 0.01), suture material (p = 0.05) and suture technique (p = 0.01) were associated with csBAS on univariable analysis. On multivariable analysis, only donor age (adjusted OR 1.01, 95% CI 1.00-1.03, p = 0.03) was found to be independently associated, while absorbable suture material, suture technique and year of transplant were not associated. No difference was seen in bile leaks or graft failure with absorbable suture material nor anastomotic technique. No significant association was observed with time to csBAS, nor between csBAS and graft failure.

Conclusion: Variable suture technique and suture material during DD reconstruction are associated with comparable outcomes following LT.

Background: Whipple's pancreaticoduodenectomy (PD) is a highly complex hepato-pancreato-biliary (HPB) procedure associated with substantial morbidity and cost. Although postoperative complications are known to increase healthcare expenditures, few studies have explored the association between preoperative factors and healthcare costs. This study evaluated the predictive value of baseline patient characteristics and preoperative laboratory tests in estimating index admission charges for Whipple's PD.

Methods: A retrospective review of 375 patients who underwent open PD (2018-2023) at a high-volume, non-university tertiary care center was conducted. Preoperative demographics, comorbidities, laboratory values, and index admission hospital charges were analyzed. Univariate logistic regression identified significant predictors of charges, and the Kruskal-Wallis test was used to assess the relationship between cumulative preoperative indicators and charges.

Results: Six preoperative laboratory values were significantly associated with increased charges: white blood cell count, hemoglobin, serum albumin, platelet count, prothrombin time, and hemoglobin A1c. A significant association was found between the cumulative preoperative indicators and hospital charges (p = 0.001). Patients with three or more unfavorable preoperative indicators incurred significantly higher charges compared to those with fewer than three indicators (p < 0.001).

Conclusion: Preoperative laboratory tests, many of which are modifiable, are significant predictors of hospital charges in patients undergoing PD. A higher cumulative burden of adverse preoperative indicators is associated with higher financial charges. These findings support the use of preoperative risk stratification and optimization to enhance value-based care, guide resource allocation, and mitigate financial toxicity in high-risk surgical patients.

Purpose: Pancreatic injuries are rare but are associated with high morbidity and mortality, particularly when diagnosis or treatment is delayed. However, the optimal timing for surgical intervention remains unclear. This study aimed to assess the impact of surgical timing on outcomes of hemodynamically stable patients with blunt pancreatic trauma using data from the Trauma Quality Improvement Program (TQIP).

Methods: This retrospective study analyzed TQIP data (2017-2019) for hemodynamically stable patients with blunt pancreatic injuries who underwent pancreatic surgery. Outcomes including mortality, complications, hospital length of stay (LOS), intensive care unit (ICU) LOS, and ventilator days were evaluated based on the time (in hours) from emergency department (ED) arrival to surgery. Patients were categorized into two groups based on surgical timing: within 48 h or beyond 48 h of ED arrival. Multivariate logistic regression was performed to identify independent predictors of complications.

Results: Among the 703 patients included in the study, a longer interval from ED arrival to surgery was linearly associated with increased hospital LOS, ICU LOS, and duration of mechanical ventilation. Multivariable analysis revealed that delayed surgery (> 48 h) was an independent predictor of complications (Odds Ratio = 3.831; p = 0.002). Interestingly, mortality rates did not differ significantly between the early and delayed intervention groups. Furthermore, a subgroup analysis of patients treated within the initial 48-h window showed that the precise timing of surgery within this period did not significantly impact complication rates (p = 0.256).

Conclusions: Pancreatic surgery delayed beyond 48 h significantly increases the risk of complications and prolongs hospitalization. When performed within this time frame, additional delay appears to have minimal impact, allowing time for thorough evaluation and surgical planning.

Background: International support for surgery and healthcare in low-resource settings is primarily channeled through partnerships. To be truly impactful, such partnerships must endure long enough to mature, however longevity appears to be rare. Analysis of the challenges faced by successful long-term partnerships and how they were overcome may offer useful lessons for newer and aspiring global health partnerships.

Methods: The surgical training collaboration between the Royal College of Surgeons in Ireland and the College of Surgeons of East, Central, and Southern Africa has continued for 18 years and has delivered significant benefits for both partner institutions. Challenges faced by the collaboration and solutions to these challenges were elicited from key stakeholders in each college through an inductive approach.

Results: Challenges and solutions reported were grouped under four domains: power, operational capacity, changing needs, and maximizing impact. A set of governance structures are proposed to mitigate power disparities between partners and between individuals. Leveraging nonclinical staff members to support development of back-office systems increases local operational capacity to effectively engage in partnership activities. Constant change is a challenge for partnerships, which must both be accepted and planned for. The impact of work done through partnerships can be multiplied by expanding the collaboration to other comparable or synergistic institutions and making resources available open access.

Conclusions: The RCSI/COSECSA collaboration program demonstrates that, over time, global health partnerships can play a transformational role in improving health outcomes in low-resource settings, while also benefitting high-income partners. Analysis of the development of the collaboration offers practical strategies for the development of other global health partnerships.

Background: Ultrasound (US) is the first-line imaging test for suspected pediatric acute appendicitis (AA), yet false-negative examinations remain a concern and may delay diagnosis. Clinical and inflammatory factors may influence this risk but have not been well defined. The aim of this study was to identify predictors of false-negative US in children with suspected AA.

Method: We conducted a prospective cohort study from 1 January 2022 to 31 October 2025 including children presenting with suspected AA whose initial abdominal US was negative. Multivariable logistic regression identified independent predictors of false-negative US.

Results: Among 1174 children evaluated, 610 had a negative US and were included in the analysis. Of these, 54 were ultimately diagnosed with AA (false-negative US). The median age was 10 years and males accounted for 51.3% of the cohort. On univariable analysis, male sex, symptom duration > 48 h, Pre-hospital antibiotic administration, admission temperature > 38°C, Alvarado score ≥ 5, white blood cell count > 10 × 10⁹/L, and C-reactive protein (CRP) ≥ 10 mg/L were significantly associated with false-negative findings. In multivariable analysis, three factors remained independently predictive: Alvarado score ≥ 5 (OR 10.53; 95% CI 4.49-24.70; p < 0.001), symptom duration > 48 h (OR 4.54; 95% CI 2.18-9.45; p < 0.001), and CRP ≥ 10 mg/L (OR 2.25; 95% CI 1.03-4.92; p = 0.042).

Conclusion: False-negative US occurred in 8.9% of children with suspected AA. Higher Alvarado scores, prolonged symptoms, and elevated CRP were independently associated with missed AA despite negative imaging.

Introduction: Major Burns are life-threatening injuries that cause approximately 2500 deaths per year in Brazil. The Brazilian healthcare system has 80 hospitals with Burn Care Units (BCUs). However, non specialized hospitals also manage major burn injuries. The aim of this study was to evaluate differences in burn management and outcomes between BCUs and hospitals without BCUs.

Methods: Patients with an ICD-10 code for a burn injury were identified in a Brazilian discharge database (DATASUS) from 2015 to 2023, were categorized by total body surface area (TBSA). Hospitalizations were compared based on whether they occurred in a BCU or not, adjusting for TBSA, age, and sex.

Results: From 2015 to 2023, there were 22,627 burn injury hospitalizations in Brazil. Of these, 14,187 (62.71%) were treated in Burn Care Units (BCUs), 6553 (28.96%) in non-BCU hospitals with plastic surgery services, and 1887 (8.34%) in non-BCU hospitals without plastic surgery. Mean TBSA was highest in non-BCUs with plastic surgery (42.0%) compared to BCUs (35.2%) and non-BCUs without plastic surgery (34.4%; p < 0.001). Mortality occurred in 9.87% of hospitalizations at BCUs, 7.78% at non-BCUs with plastic surgery, and 4.45% at non-BCUs without plastic surgery. After adjusting for TBSA, age, and sex, non-BCU facilities showed lower odds of mortality (non-BCU with plastic surgery: aOR 0.49, 95% CI 0.44-0.56; non-BCU without plastic surgery: aOR 0.36, 95% CI 0.28-0.47; both p < 0.001). Transfers to other facilities occurred in 1.28% (182/14,187) of BCUs, 16.26% of non-BCUs with plastic surgery, and 29.61% (559/1887) of non-BCUs without plastic surgery. Surgical management rates were highest in BCUs, intermediate in non-BCUs with plastic surgery, and lowest in non-BCUs without plastic surgery.

Conclusion: Hospitalizations in BCUs were associated with lower transfer rates and higher rates of surgical intervention. However, BCUs also reported higher mortality rates, suggesting that they likely provided care to the most severely injured burn patients until their final outcomes, whether recovery or death. Despite non-BCUs with plastic surgery treating burns with higher mean TBSA, BCUs had higher mortality, suggesting that BCUs receive patients with unmeasured risk factors beyond TBSA and serve as referral centers for the most complex cases.

Background: Biologic mesh has historically been used for ventral hernia repairs (VHR) in contaminated fields in an off-label fashion due to early evidence suggesting that they may be able to withstand these conditions more favorably than synthetic mesh. This study aims to compare outcomes of two non-crosslinked porcine acellular dermal matrices-XenMatrix (Bard, Covington, GA) and Strattice (LifeCell Corporation, Bridgewater, NJ) used in VHR.

Methods: Patients who were undergoing elective open VHR were randomized to receive either XenMatrix or Strattice mesh (randomized controlled trial-RCT cohort). An additional cohort of patients were recruited in a retrospective observational study cohort. Surgical site occurrence (SSO) was the primary outcome evaluated with hernia recurrence being a secondary outcome measure. Simple and multivariate logistic regression analyses were conducted separately for the RCT and observational cohorts.

Results: Forty-six patients were randomized into the RCT cohort, and an additional 20 patients were recruited into the observational study cohort. There was no difference in baseline characteristics between the two mesh groups in both the RCT and observational cohorts. In the RCT cohort, the 6-week SSO rate was significantly higher for XenMatrix (36.7%) than Strattice (6.3%) (p = 0.03), and on multivariate analysis, XenMatrix was associated with higher 6-week SSO risk than Strattice [OR: 19.5 (95% CI: 2.3-523.7) and p = 0.02]. However, in the observational cohort, the rate of 6-week SSO was similar for both XenMatrix (50.0%) and Strattice (33.3%) (p = 0.46) as well in the multivariate analysis [OR: 6.6 (95% CI: 0.4-324.6) and p = 0.23]. Finally, random effect meta-analysis of 6-week risk of SSO of both RCT and observational cohort showed that XenMatrix is associated with higher 6-week SSO risk than Strattice [OR: 12.5 (95% CI: 1.8-89.2) and I² = 0% p = 0.012].

Conclusion: Our study showed that XenMatrix may be associated with higher risk of early SSO compared to Strattice. This underscores the importance of more head-to-head mesh comparison to optimize outcomes following VHR.

Trial registration: NCT02228889 (www.

Clinicaltrials: gov).

The aim of this pilot study is to summarize evidence from the implementation of prehospital whole blood programs in rural Colorado with focus on the feasibility and safety of whole blood in rural areas with prolonged transport times to definitive care.