BMC Surgery最新文献

Background: Incisional hernia is the most common long-term complication after abdominal surgery, including minimally invasive colorectal procedures. In Japan, fascial closure of small midline incisions is generally performed using interrupted suturing, but high-quality evidence comparing continuous barbed suturing with interrupted suturing is limited. Continuous closure may reduce the risk of incisional hernia; however, robust randomized data in laparoscopic and robot-assisted colorectal surgery are lacking. This study aims to determine whether continuous barbed suturing is superior to conventional interrupted suturing in preventing incisional hernia after minimally invasive colorectal cancer surgery.

Methods: The HIBISCUS trial is a multicenter, prospective, open-label, randomized controlled study comparing continuous barbed suturing with interrupted monofilament suturing for fascial closure of mini-laparotomy incisions. Eligible adults with colorectal cancer undergoing elective laparoscopic or robot-assisted resection will be randomized 1:1 to continuous closure using a barbed absorbable suture (STRATAFIX Symmetric PDS Plus; bite width of 5 mm and stitch spacing of 5 mm) or interrupted closure using a monofilament absorbable suture (PDS Plus; bite width of 8 mm and stitch spacing of 8 mm). Only board-certified surgeons who complete a standardized pre-trial suturing competency assessment will be allowed to participate. The primary endpoint is the incidence of incisional hernia within 18 months after surgery, assessed mainly by scheduled abdominal CT imaging, with clinical examination as complementary. Secondary endpoints include fascial closure time, postoperative wound complications (including surgical site infection (SSI)), postoperative wound pain, and reoperation or readmission. All CT images will be independently reviewed by two blinded specialists. Based on power calculations, 422 patients will be enrolled.

Discussion: This trial will be the first randomized study to directly compare continuous barbed suturing with conventional interrupted suturing for small midline incisions in minimally invasive colorectal surgery. By standardizing suturing parameters and requiring surgeon competency verification, the HIBISCUS trial is designed to yield high-quality evidence on optimal fascial closure technique. The results are expected to influence clinical practice, inform guideline development, and contribute to the global standardization of abdominal wall closure practices.

Trial registration: This study is registered in the Japan Registry of Clinical Trials (jRCT1040250129). Registration date: November 21, 2025.

Background: The "male-female health-survival paradox" describes women's longer lifespan despite a greater burden of non-fatal chronic conditions-a phenomenon rarely examined in surgical settings. This study investigated whether this paradox exists in a national cohort of frail patients undergoing hip replacement and explored its underlying mechanisms. We hypothesized that in this cohort: (1) female patients would be less healthy, presenting with a higher prevalence of frailty, older age, and a higher Charlson Comorbidity Index (CCI); and (2) frail men would experience higher in-hospital mortality.

Methods: A retrospective cohort study was conducted using the US National Inpatient Sample (2005-2014) A frailty-defining diagnosis cluster was employed to identify frail individuals. Sex-based differences in demographics, comorbidities, and in-hospital outcomes (mortality, complications, length of stay, costs) were analyzed using multivariable logistic regression, including interaction terms and sex-stratified models.

Result: Among 29,063 frail patients, 64% were female. Despite being significantly older (median age 81 vs. 77 years, p < 0.001) and having a higher CCI burden, frail women had significantly lower in-hospital mortality than men (3% vs. 5%, p < 0.001). Comorbidity patterns differed markedly: women had higher rates of rheumatoid arthritis, depression, and hypothyroidism, while men had more congestive heart failure, diabetes, and renal failure (all p < 0.001). After adjustment, male sex remained an independent predictor of mortality (Adjusted OR 1.31, 95% CI 1.15-1.49, p < 0.001), primarily driven by significant interactions between male sex and life-threatening conditions such as heart failure and renal failure.

Conclusion: The male-female health-survival paradox is evident in frail patients undergoing hip replacement. These findings highlight the need for sex-tailored preoperative optimization, with particular emphasis on cardiovascular and metabolic risk management in frail male patients.

Background: Incisional hernia is the most common long-term complication following abdominal surgery, resulting in considerable morbidity and the need for reoperation. The effectiveness of the small-bite fascial closure technique in reducing incisional hernia rates has been demonstrated; however, outside of elective settings, evidence is scarce regarding mixed elective and emergency populations. This prospective observational cohort study aimed to evaluate factors associated with incisional hernia at 12 months and to assess the association between closure technique and hernia formation.

Methods: We prospectively enrolled consecutive adults undergoing midline laparotomy from May 2021 to June 2023. Patient information including intraoperative parameters, such as the closure technique employed, that is, small-bite versus conventional, incision and suture length, and the suture-to-wound length ratio were recorded. Occurrence of incisional hernia was confirmed clinically and ultrasonographically after 12 months. Secondary outcomes included early wound complications and hospital stay duration. Independent predictors were identified using univariate and multivariate logistic regression analyses.

Results: Of the 231 patients enrolled, 217 completed 12-month follow-up (76 small-bite, 141 conventional). Incisional hernia developed in 3 patients (3.9%) with small-bite and 31 (22.0%) with conventional closure (p = 0.001). Early wound complications occurred in 16.6% overall and were significantly less frequent with small-bite closure (8.6% vs. 20.9%, p = 0.018). In the multivariate model, emergency surgery (OR = 5.74, p = 0.011), comorbidities (OR = 6.03, p = 0.001), and early wound complications (OR = 16.59, p < 0.001) were independent predictors for incisional hernia, whereas the protective effect of small-bite technique was not significant (OR = 0.47, p = 0.325). The small-bite technique independently diminished the risk of postoperative early wound complications by 74% (adjusted OR = 0.26, p = 0.045).

Conclusions: The major independent predictors for incisional hernia development were emergency surgery, comorbidity, and early wound complications. The small-bite closure technique significantly reduced the occurrence of early wound complications and demonstrated a favorable but not statistically significant effect regarding hernia prevention.

Trial registration: ClinicalTrials.gov NCT07340918 (Retrospectively registered).

Background: Proximal gastrectomy (PG) for proximal gastric cancer (PGC) is associated with complications such as gastroesophageal reflux. The double-flap technique (DFT) has been proposed as an effective anti-reflux reconstruction method. This systematic review aims to compare the safety and short-term outcomes of DFT versus other reconstruction methods for proximal gastrectomy.

Methods: The present meta-analysis was conducted, following PRISMA guidelines. Studies comparing DFT with other reconstruction methods for proximal gastric cancer were included. Outcomes assessed included surgical parameters (operative time and intraoperative blood loss), postoperative reflux incidence (subjective reflux symptoms, objective evaluation using endoscopy and proton pump inhibitor (PPI) intake), and other short-term postoperative indicators (postoperative complications and length of postoperative hospital stay). Data were extracted from PubMed, Web of Science, EMBASE, and the Cochrane Library through June 1st, 2025. Risk of bias was assessed using the Newcastle-Ottawa Scale. We performed meta-analyses using Review Manager 5.4, presenting mean differences (MD) and odds ratios (OR) with 95% confidence intervals (CI).

Results: A total of 11 retrospective studies were included in this meta-analysis. Qualitative analysis showed DFT had anastomotic leakage, stricture, and pancreatic fistula rates of 1.4%, 5.9%, and 1.8%, respectively. Postoperatively, 17.4% of patients took PPIs, and 3.4% reported subjective reflux symptoms. One year after surgery, during follow-up endoscopy, 5.1% of patients were found to have gastroesophageal reflux (Los Angeles classification grade B or higher). Meta-analysis results showed that the DFT group had significantly longer operative times but reduced intraoperative blood loss compared to the esophagojejunostomy (EJ) groups. Postoperative complication rates, including anastomotic leakage and stricture, were similar across the double tract reconstruction (DTR) group and other esophagogastrostomy (EG) groups. While no significant differences were found in reflux symptoms or esophagitis at the 1-year follow-up, DFT was associated with significantly reduced PPI usage, especially compared to the EG group.

Conclusions: DFT is a safe and effective method for reconstructing the digestive tract following PG, offering a balance between surgical complexity and favorable short-term outcomes. Although it does not fully eliminate reflux, its reduced PPI dependency and acceptable complication profile make it a promising option. Further large-scale randomized trials are needed to confirm these findings.

Trial registration: The protocol was prospectively registered on the PROSPERO website as CRD42025636187 on January 9th, 2025.

Background: Pelvic adhesions are a common consequence of prior abdominal surgery, endometriosis, malignancy, or infection, often leading to infertility, chronic pelvic pain, and surgical complications. Reliable preoperative prediction of these adhesions can guide surgical planning and minimize risks. The sonographic "sliding sign" has shown promise in detecting intra-abdominal adhesions, yet its routine use remains limited. This study aims to evaluate the diagnostic accuracy of both transvaginal and transabdominal ultrasonographic assessments of the sliding sign in predicting intra-abdominal adhesions prior to gynecologic endoscopic surgery.

Methods: This retrospective cohort study included 262 women who underwent gynecologic endoscopic surgery at a tertiary care center in 2024. Patients with body mass index (BMI) > 35 were excluded. Both transabdominal and transvaginal ultrasonographic evaluations of the sliding sign were performed preoperatively by a single experienced physician, while operative outcomes were recorded by a blinded observer. Adhesion status, operative time, hospital stay, and surgical complications were analyzed. Statistical methods included Chi-square, Fisher's Exact test, Mann-Whitney U test, and receiver operating characteristic (ROC) curve analysis.

Results: Intra-abdominal adhesions were confirmed in 56 patients (21.4%). Absence of the sliding sign was significantly associated with the presence of adhesions (p < 0.001). Transvaginal sonography yielded a sensitivity of 77%, specificity of 100%, and area under curve (AUC) of 0.884. Transabdominal sonography demonstrated higher accuracy, with a sensitivity of 96%, specificity of 100%, and AUC of 0.982. The combination of both methods matched the diagnostic performance of transabdominal ultrasound alone. Adhesions were significantly associated with previous abdominal surgery (p < 0.001), endometriosis (p = 0.01), hypotrophic or keloid scars (p < 0.001), obliteration of the Douglas pouch (p < 0.001), longer hospital stay (p = 0.006), and increased rates of hemorrhage (p = 0.003) and bladder injury (p = 0.03).

Conclusion: Preoperative ultrasonographic evaluation of the sliding sign is a highly accurate, non-invasive, and practical tool for predicting intra-abdominal adhesions. Both transabdominal and transvaginal sonography offers superior sensitivity and should be considered in routine preoperative assessments. Integration of this method into standard preoperative protocols may help reduce complications, optimize surgical planning, and improve patient outcomes in gynecologic endoscopic procedures.