World Journal of Surgery最新文献

Introduction: Children living in conflict or post-conflict zones are frequently exposed to explosive injuries, with thousands killed and injured every year. The clinical practice guideline from the Explosive Weapons Trauma Care Collective (EXTRACCT) group provides a review of current best practice for the resuscitation of a child who has sustained a blast injury in low-resource settings.

Methods: An expert literature review of current practice was undertaken.

Results: The guideline relates to the specific considerations of pediatric resuscitation of a child with a blast injury in low-resource settings. It aims to provide guidance to all health care professionals working in resource-constrained, secondary-level healthcare contexts. It takes into consideration clinical decision-making and treatment algorithms where resource availability is limited with respect to equipment and materials, subspecialist expertise, and critical care capabilities.

Conclusion: The strength of the CPG recommendations is limited by a lack of data on pediatric blast victims. Future work is required, including establishing a blast injury victim registry and clinical trials on blast injury management strategies.

Background/aims: The HALP score, a scoring method that has demonstrated effectiveness in inflammatory clinical conditions and is increasingly used in clinical practice, can be utilized to distinguish between complicated and uncomplicated cases of acute appendicitis. Additionally, it may serve as a reference for initiating medical treatment at an earlier stage.

Materials and methods: Patients who were diagnosed with acute appendicitis and operated on were included. Patients who underwent conventional open appendectomy and laparoscopic appendectomy as surgical procedures were examined retrospectively by scanning their files. Preoperative CBC and biochemistry values of the patients were recorded by scanning their files retrospectively. From here, preoperative hemoglobin-albumin-lymphocyte-platelet (HALP) Score [hemoglobin (g/L) × albumin (g/L) × lymphocyte count (/L)]/platelet count (/L)], neutrophil-lymphocyte ratio (NLR) [neutrophil count (/L)/lymphocyte count (/L)] and platelet-lymphocyte ratio (PLR) [platelet count (/L)/lymphocyte count (/L)] were calculated manually.

Results: There were statistically significant differences between patients with and without complications in terms of preoperative WBC, neutrophil counts and lymphocyte counts in the preoperative period (p values; 0.015, < 0.006 and < 0.004, respectively). There was no statistically significant difference in terms of other preoperative blood values (p > 0.05). There was a statistically significant difference between the groups in terms of NLR, PLR, and HALP score calculated from preoperative CBC parameters.

Conclusion: HALP score is an important biomarker, like other biomarkers, in the early diagnosis of complications, initiating antibiotic therapy earlier, gaining time during transport, and preventing complications that may arise due to exacerbation of the disease.

Trial registration: NCT07002671.

Background: Enhanced recovery after surgery (ERAS) has been hypothesized to improve surgical outcomes following colorectal surgery; however, the long-term sustainability of improvement remains unclear.

Materials and methods: A comprehensive ERAS program was implemented for patients undergoing colorectal surgery at Johns Hopkins Hospital (JHH) in 2014. This study investigated inpatient elective colorectal surgery outcomes at JHH during three two-year postimplementation periods (2014-19) relative to a two-year baseline (2012-2013) via pre-post analyses and using difference-in-differences (DID) regression comparing JHH with a national sample of > 700 hospitals participating in the National Surgical Quality Improvement Program (NSQIP). Length of stay (LOS) was evaluated using multivariable zero-truncated negative binomial regression, whereas Surgical Site Infections (SSIs) and readmission rates were analyzed using multivariable logistic regression. Analyses controlled for ASA score, procedure type, age, sex, race, and surgical approach.

Results: The study included 1851 patients at JHH and 303,175 patients from the national sample. In pre-post analyses comparing JHH from baseline (2012-2013) to the final period (2018-2019), statistically significant improvements were seen for SSIs with a 4.4% reduction (OR 0.54 and 95% CI 0.35-0.86) and for readmissions with a 5.6% reduction (OR 0.57 and 95% CI 0.39-0.85), while LOS was statistically unchanged (0.41 days reduction; IRR 0.93 and 95% CI 0.85-1.01). DID analyses showed statistical equivalence for SSIs (OR 0.80 and 95% CI 0.51-1.26), greater improvement for readmission rates at JHH (OR 0.62 and 95% CI 0.42-0.92), and lower improvement for LOS at JHH (IRR 1.17 and 95% CI 1.07-1.27).

Conclusions: ERAS implementation at JHH was associated with sustained improvement that was comparable (SSIs) or superior (readmissions) to national improvement trends over a period of 6 years (postimplementation), suggesting ERAS adoption in colorectal surgery is warranted for long-term outcomes improvement. Results were suggestive of a tradeoff between readmission rates and LOS.

Background: Although prior long-term studies have demonstrated benefits of metabolic and bariatric surgery (MBS) in patients with type 2 diabetes (T2D) and obesity, we aimed to further substantiate these associations using a large cohort with 10 years of follow-up.

Methods: Surgery and nonsurgery groups were formed, and 1:1 propensity score matching was performed based on baseline characteristics including age, sex, body mass index (BMI ≥ 30 kg/m²), and comorbidities to reduce confounding. The primary endpoint was all-cause mortality; secondary endpoints included major adverse cardiovascular events (MACEs) and major adverse kidney events (MAKEs) over 10 years. Cox proportional hazards models provided hazard ratios (HRs) with 95% confidence intervals (CIs), and Kaplan-Meier curves illustrated survival.

Results: Among 36,666 matched patient pairs (n = 73,332), all of whom had T2D and obesity, MBS was associated with significantly lower risks of all-cause mortality (HR 0.67 and 95% CI 0.63-0.71), MACEs (HR 0.67 and 95% CI 0.64-0.70), and MAKEs (HR 0.80 and 95% CI 0.76-0.84). Subgroup and sensitivity analyses confirmed these findings, and E-values supported the robustness of our findings, suggesting that it would require unmeasured confounders of substantial magnitude to nullify the observed associations.

Conclusion: These results suggest durable associations with improved survival and reduced risks of cardiovascular and kidney outcomes, supporting MBS as a potentially effective treatment strategy for patients with type 2 diabetes and obesity. Continued prospective studies are warranted to further validate these associations and inform clinical decision-making in this high-risk population.

Laparoscopic surgery is widely accepted for uncomplicated Crohn's disease (CD) because it offers faster recovery, less pain, and better cosmesis. In complex CD with fistulas or abscesses, however, dense adhesions and fragile tissue make surgery technically demanding and increase postoperative morbidity. Most previous studies comparing laparoscopic and open surgery were limited by selection bias and lacked multivariate adjustment. Robust evidence on the safety of laparoscopy and predictors of postoperative complications remains scarce.

Background: Traumatic brain injury (TBI) and hemorrhage are leading causes of trauma death and disability worldwide. The concurrence of hemorrhage and brain injury carries a two-fold increase in mortality and clinical management of patients with concurrent TBI and hemorrhage is challenging. Tranexamic acid (TXA) has been shown to reduce mortality from hemorrhage and TBI independently, however there is sparse evidence on the potential benefit of TXA in patients with both non-head hemorrhage and TBI.

Methods: We conducted a secondary database analysis of EpiC, a multicenter, prospective cohort of trauma patients in South Africa. We compared the morbidity and mortality of patients experiencing both non-head hemorrhage and TBI who received TXA within 3-h post-injury versus similarly injured patients who did not receive TXA. Inverse probability treatment weighting (IPTW) was implemented followed by a multivariable logistic regression to evaluate 7-day mortality. Secondary outcomes included the worst 7-day sequential organ failure assessment (SOFA) and neurologic recovery assessed by Glasgow Outcomes Score Extended (GOSE).

Results: A total of 656 patients were included in the analysis. 132 (20%) received TXA within 3 h and 544 (80%) did not. For the primary outcome of 7-day mortality, treatment with TXA was associated with a 22% reduction in odds of death (mOR, 0.78, 95% CI, 0.62-0.98). TXA-treated patients had significant lower odds of SOFA > 4 or death (mOR, 0.71; 95%CI, 0.53-0.95) and non-significantly reduced odds of poor functional status at 3 months (GOSE < 7 or death) (mOR, 0.89; 95% CI, 0.68-1.18). Treatment with TXA within 2 h was associated with a 27% reduction in odds of 7-day mortality (mOR, 0.73; 95%CI, 0.61-0.86).

Conclusions: In this study, the administration of TXA within 3 h to patients with concurrent hemorrhage and TBI was associated with a 22% reduction in mortality at 7 days. The mortality benefit was slightly larger when TXA was given within 2 h. TXA treatment was also associated with lower risk of organ failure. These results support a growing body of evidence that TXA is an effective intervention to reduce mortality and morbidity after traumatic injury.

Background: The Clavien-Dindo (CD) classification, derived in elective surgery, limits complications to deviations from the post-operative course. The interpretation of this definition has not been examined. The application of the CD definition to emergency general surgery (EGS) is limited as many EGS patients have a pre/non-operative component of care allowing under-capture of adverse events that are relevant to quality of surgical care. This study aimed to explore how surgeons interpret and define complications across elective and EGS settings.

Methods: We conducted a cross-sectional survey of 76 general surgeons across four Melbourne public hospitals. With reference to 43 clinical vignettes spanning pre-operative, intra-operative, post-operative, post-discharge, and non-operative care domains respondents indicated whether events constituted complications under the CD classification.

Results: The response rate was 72% and 93% of respondents reported EGS experience. Acceptance of individual events ranged from 15% (post-operative fever) to 100% (intra-operative neuropraxia). There was broad acceptance that events occurring during pre-operative and non-operative care could be classified as complications. Minor physiological changes and events not requiring intervention were often disregarded as complications. Perceived accountability influenced responses, with complications more likely to be recognized when linked directly with surgical care. Agreement on classification was only fair (Fleiss' Kappa = 0.254), indicating only fair concordance in complication classification.

Conclusions: This study demonstrates significant variability in the classification of surgical complications within EGS, highlighting the limitations of current frameworks particularly in the acute contexts. Incorporating surgeon perspectives into refined classification systems may improve audit accuracy, better capture the complexity of EGS, and ultimately enhance patient care.