BMC Surgery最新文献

Background: Aortoesophageal fistula (AEF) is a rare but invariably life-threatening conditio. The optimal treatment for AEF resulting from postoperative anastomotic leakage following esophageal cancer surgery remains a significant clinical challenge. Here, we report a detailed case of AEF caused by anastomotic leakage from a thoracic esophageal anastomosis after esophageal cancer resection, which was successfully managed with emergent thoracic endovascular aortic repair (TEVAR) for hemorrhage control, followed by elective surgical intervention comprising esophagogastric re-anastomosis and aortic fistula repair with a bovine pericardial patch. The patient achieved long-term survival.

Case presentation: A 68-year-old male underwent minimally invasive McKeown esophagectomy with intrathoracic esophagogastric anastomosis after neoadjuvant chemotherapy and immunotherapy for advanced esophageal squamous cell carcinoma (SCC). Postoperatively, the patient experienced fever followed by hematochezia and hematemesis. Emergency endoscopy was unsuccessful in controlling the active arterial bleeding at the inflamed anastomotic site. Enhanced CT angiography (CTA) did not reveal a definitive aortoesophageal fistula, and subsequent transarterial embolization of the right gastric artery (confirmed by procedural records) failed to control the condition. The patient developed hemorrhagic shock manifested by loss of consciousness and hypotension. A repeat enhanced CT scan revealed active contrast extravasation from the descending aorta into the gastric conduit. An emergency TEVAR was performed to stabilize the hemodynamics. On postoperative day 10, we performed surgical exploration, which confirmed resection of the esophagogastric anastomotic leak, direct repair of the aortic wall defect, and reconstruction via esophagogastric anastomosis with the remnant stomach. Intraoperatively, a stapler clip from previous endoscopic hemostasis was identified as the potential culprit for the fistula formation. Ten months after the onset of AEF, the patient continued chemotherapy and led a normal daily life.

Conclusion: This case underscores that TEVAR is an effective and life-saving hemostatic method for managing life-threatening hemorrhage from AEF. However, TEVAR alone cannot ensure long-term survival due to its inability to control the underlying infection and address the gastrointestinal defect. Long-term survival requires subsequent definitive surgical repair of both the esophageal and aortic components.

Objective: To compare the clinical outcomes of open reduction and internal fixation (ORIF) versus percutaneous multiple-trajectory screw fixation (PMSF) in the treatment of unstable pelvic fractures with severe polytrauma, and to provide a basis for optimizing surgical strategies.

Methods: A prospective study included 26 patients (January-July 2024) divided into ORIF (n = 15) and PMSF (n = 11) groups. ORIF used traditional open plating/screws, while PMSF employed fluoroscopy-guided minimally invasive screws.

Primary outcomes: operative time, blood loss, complications (infection, nerve injury), fracture reduction (Matta criteria), functional recovery (Majeed score).

Secondary outcomes: hospital stay, preoperative waiting time. Age, ISS, and Tile classification were controlled. SPSS 27.0 analyzed data (significance P < 0.05).

Results: The PMSF group demonstrated significantly shorter preoperative waiting times (124.09 ± 54.45 h vs. 260.67 ± 170.92 h, P = 0.018), less intraoperative blood loss (68.18 ± 49.96 mL vs. 510.00 ± 264.71 mL, P < 0.001), and shorter hospital stays (23.36 ± 8.64 days vs. 33.93 ± 12.54 days, P = 0.024) compared with the ORIF group. There were no significant differences in the rates of excellent/good fracture reduction (Matta criteria: PMSF 90.91% vs. ORIF 86.67%, P = 1.000) or 12-month Majeed scores (82.73 ± 7.89 vs. 75.40 ± 13.64, P = 0.125) between the two groups.

Conclusion: For patients with unstable pelvic fractures with severe polytrauma, PMSF offers a better minimally invasive treatment option over traditional ORIF in terms of reducing trauma and shortening rehabilitation periods, while achieving comparable fracture reduction quality and functional recovery. Therefore, PMSF can be considered a preferred choice for such cases.

Trial registration: This study was retrospectively registered. Chinese Clinical Trial Registry (ChiCTR2500110578; Registration date: 16/10/2025;PID:288327).

Background: Surgical resources are often shared across medical specialties, which can lead to conflicts over prioritisation during on-call hours. This study investigated factors contributing to inter-speciality conflict in the prioritisation of emergency surgical cases.

Methods: A survey on views of surgical urgency and prioritisation of 22 hypothetical cases was distributed to Swedish physicians involved in emergency surgery via posters in operating departments and administrative areas, and by email. The Kruskal-Wallis test and Dunn's post-hoc test were used to compare responses across specialties. Factors associated with daily conflicts were identified using logistic regression.

Results: Of 233 respondents, 201 (90%) reported sharing resources with other specialties. General surgeons (45%), orthopaedic surgeons (15%), and anaesthetists (15%) were the most represented. Over half reported insufficient resources for emergency surgery. Sixty-nine per cent perceived that other specialties over-prioritised their own patients. Thirty-nine respondents (17%) experienced daily conflicts over case prioritisation. Minor differences were observed in how respondents perceived their own prioritisation, that of other specialties, and the prioritisation of hypothetical cases. Daily conflicts were associated with concerns about compromised patient safety (odds ratio [OR] 8.05 and 95% confidence interval [CI] 1.6-63.5 for agreeing vs. strongly disagreeing/disagreeing), whereas greater perceived resource availability was associated with fewer conflicts (OR 0.68, 95% CI 0.48-0.96).

Conclusions: Perceived threats to patient safety and resource scarcity were associated with daily prioritisation conflicts. Although respondents frequently suspected over-prioritisation by other specialties, observed differences in prioritisation between the responsible specialty and others were small. Further research on shared prioritisation protocols and resource allocation, including international comparisons across health-care systems and cultures, is warranted.

Background: The anterior interosseous nerve (AIN) end-to-side (ETS) nerve transfer is a relatively recent treatment innovation in managing cubital tunnel syndrome (CuTS). Potential benefits must be balanced against the risks associated with the adoption of an innovative technique, evaluating procedure-specific risks, and considering additional costs in the safe delivery of care. The ETS technique has been proposed as a method of improving intrinsic muscle function in the hand in the setting of ulnar nerve compression at the elbow. The technique is controversial with emerging evidence from retrospective cohort and single-arm interventional studies to support its use. However, there is persisting uncertainty regarding the relative contributions of the decompression, collateral sprouting from intact terminal axons, and neo-innervation from the ETS transfer to any functional recovery. Given this lack of equipoise regarding the efficacy of ETS nerve transfers, a randomised controlled trial is proposed to assess recruitment, protocol compliance, subject retention, and define the sample size for a future multicentre study.

Methods: This randomised controlled trial (RCT) protocol defines a prospective, single centre study of 20 patients randomised to ulnar nerve decompression with or without ETS nerve transfer, with participant blinding to treatment allocation. Anticipated follow up period is up to 24 months.

Discussion: Data from this study will be used to calculate the sample size for a future multicentre RCT evaluating SETs transfer in CuTS. It would also inform on the willingness of clinicians to randomise their patient given the current uncertainty surrounding this technique and the retention rates anticipated. Should the RCT demonstrate significant functional benefits of combining ETS nerve transfer with decompression, it could shift clinical practice toward using this dual approach, especially in patients with moderate or severe ulnar neuropathy. The findings would likely influence treatment algorithms, optimising patient outcomes, and could also spur further studies into ETS applications in peripheral nerve injuries.

Primary trial registry: ISRCTN ID Number: ISRCTN18379703, Date of Registration: 14th May 2024.