BJS Open最新文献

Background: Laparoscopic (transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP)) and Lichtenstein procedures are the most commonly used approaches for primary unilateral inguinal hernia repair. However, only limited long-term data are available to compare the outcomes of these techniques, particularly from large cohorts. The aim of this study was to evaluate the long-term results of Lichtenstein and laparoscopic primary unilateral hernia repairs based on data from the Herniamed registry.

Methods: All patients registered in the Herniamed registry were included between 5 January 2009 and 4 October 2024. At the 5-year follow-up, a propensity score matched analysis was performed comparing Lichtenstein versus TEP, Lichtenstein versus TAPP, and TEP versus TAPP.

Results: In all, 109 130 patients with primary unilateral inguinal hernia and 5-year follow-up data were included in the study. Propensity score matching revealed 21 889, 27 439, and 29 475 matched pairs for comparisons of Lichtenstein versus TEP, Lichtenstein versus TAPP, and TEP versus TAPP, respectively. Lichtenstein repair had more general complications compared with TEP (1.2 versus 0.9%; P = 0.002), postoperative complications (3.4 versus 1.7%; P < 0.001), complication-related reoperations (1.0 versus 0.5%; P < 0.001), pain on exertion (6.7 versus 4.2%; P < 0.001), pain at rest (3.2 versus 2.3%; P < 0.001), pain requiring treatment (1.8 versus 1.3%; P < 0.001), and seroma (1.2 versus 0.9%; P < 0.001); discordant cases in matched-pair analyses. However, intraoperative complications were lower for Lichtenstein compared with TEP procedure (0.8% versus 1.0%; P = 0.038). Lichtenstein repair had more general complications compared with TAPP (1.2 versus 0.9%; P = 0.002), postoperative complications (3.5 versus 1.9%; P < 0.001), complication-related reoperations (1.0 versus 0.5%; P < 0.001), pain on exertion (6.3 versus 4.1%; P < 0.001), pain at rest (3.1 versus 2.2%; P < 0.001), and pain requiring treatment (1.8 versus 1.3%; P < 0.001).

Conclusion: In the evaluation of long-term results, laparoscopic techniques have advantages over the Lichtenstein procedure in primary unilateral inguinal hernia repair with regard to postoperative complications and chronic pain.

Background: Major lower extremity amputations are frequently performed for end-stage peripheral arterial disease and progressive diabetic foot complications. Wound complications after amputation affect up to one-third of limbs. The patient cohort undergoing amputation are typically high risk for poor wound healing, often with unmodifiable risk factors in an urgent clinical setting. Incisional negative pressure wound therapy (NPWT) has been shown to reduce wound complications in other high-risk populations. This randomized controlled trial investigates whether prophylactic NPWT reduces wound complications in patients after major amputation compared with standard dry dressings.

Methods: This protocol describes a prospective, multicentre, randomized controlled trial with an internal pilot recruiting patients undergoing major lower extremity amputation for any indication. Limbs will be randomized to receive either a single-use NPWT device on their closed surgical incision or a dry dressing. The primary clinical outcome is the rate of wound complications. Secondary outcomes include reoperation rates, length of hospital stay, cost-effectiveness of NPWT, and patient-reported quality of life. Follow-up will continue to 6 months after surgery. The initial pilot phase has a recruitment target of 96 limbs, whereas an estimated 728 patients will be required to power a definitive trial adequately.

Discussion: This trial aims to supplement the existing poor-quality data on this important aspect of care and equip healthcare professionals to make cost-effective decisions regarding postoperative wound management.

Background: The increasing detection of non-palpable breast lesions has made accurate preoperative localization essential to optimize breast-conserving surgery. Although multiple localization methods exist, there is still a lack of robust, large-scale, multicentre evaluations comparing different techniques.

Methods: The LOCALIZATION01 study compares real-world data from 13 breast units in Italy and Switzerland on the impact of localization techniques on breast-conserving surgery for non-palpable lesions between 2016 and 2024. Four localization techniques were compared: wire-guided (WGL), radio-guided (ROLL), magnetic seed (MSL), and carbon (CL). The main outcomes were margin status, calculated resection ratio, postoperative complications, and surgical time. Subgroup analyses were performed for body mass index, lesion morphology and histopathology.

Results: In total, 3241 patients were enrolled (ROLL 985, MSL 592, WGL 1079, and CL 585). ROLL achieved the highest rate of negative surgical margins, significantly outperforming MSL, WGL, and CL (97.5% versus 94.7% versus 94.5% versus 90.6%, respectively; P < 0.05). CL was associated with the highest postoperative complications rate (16.7%) versus ROLL (4.1%), MSL (4.5%), and WGL (2.1%) (P < 0.0001). The surgical time for MSL was significantly shorter when compared with WGL (46 versus 70 minutes (min); P < 0.0001) and CL (55 min; P < 0.0001). WGL had the most favourable calculated resection ratio (2.4), followed by MSL (2.6), ROLL (2.7), and CL (3.0). Multivariable analysis identified CL as an independent predictor of positive margins (odds ratio 1.82; P = 0.004), whereas ROLL was protective (odds ratio 0.45; P = 0.009).

Conclusion: ROLL and MSL outperformed WGL and CL across multiple endpoints. CL data revealed objective limitations that suggest caution in its use. A personalized approach considering lesion morphology, body mass index, and logistics is recommended.

Background: Tumour deposits are an important prognostic factor in colorectal cancer. In tumour node metastasis (TNM)8, the definition became stricter as TNM7's previous requirement for absence of lymphatic tissue was expanded to also include nerve and vascular tissue. TNM8 has been criticised for its limited prognostic value. This study aimed to compare prognostic differences for patients with colorectal cancer with tumour deposits staged with TNM7 and TNM8.

Methods: This national retrospective cohort study included patients with colorectal cancer who underwent surgical resection in 2011-2014 and 2017-2019. Exclusion criteria were metastatic stage IV disease, non-radical or non-curative surgery, unstated tumour deposit status, or early (≤ 30 days) mortality. Univariable, multivariable, and interaction term Cox regression analyses examined differences in overall survival and distant metastasis between TNM7 and TNM8 stagings. Multivariable models were adjusted for age, gender, American Society of Anesthesiologists score, number of positive lymph nodes, TNM stage, neoadjuvant, and adjuvant treatment.

Results: Of 19 413 patients operated on during 2011-2014 and 15 027 during 2017-2019, 23 966 were included. The TNM7 cohort had 1225 (9.5%) patients with tumour deposits, and the TNM8 cohort had 1407 (12.7%). There was an improved 5-year distant metastasis-free survival for patients with tumour deposits (hazard ratio 2.35 (95% confidence interval 2.14 to 2.58)) in the TNM8 cohort, but no benefit in overall survival, compared with patients in the TNM7 cohort. Interaction analysis revealed no prognostic difference associated with tumour deposit status between the two TNM editions.

Conclusion: Despite increased complexity, the revised definition of tumour deposits in TNM8 did not enhance prognostic ability compared with TNM7.

Background: Low cardiorespiratory fitness (CRF) has been demonstrated to be associated with increased perioperative morbidity and mortality. However, evidence regarding the effect of prehabilitation on CRF and postoperative outcomes remains inconclusive.

Methods: A systematic review and meta-analysis were conducted in accordance with the PRISMA statement encompassing randomized clinical trials (RCTs) published in PubMed and Web of Science up to June 2025 on the effects of prehabilitation with exercise, measured using the 6-minute walk test, for adult patients undergoing surgery. The primary objective was to examine the effect of prehabilitation based on physical exercise on the preoperative physical condition of adults scheduled to undergo elective surgery, measured as the change in the 6-minute walk distance (6MWD). Factors associated with changes in the 6MWD and the effect of prehabilitation on postoperative CRF were analysed, as were the length of hospital stay and mortality. Effect sizes and their 95% confidence interval (c.i.) were estimated with a random-effects model.

Results: Of 107 RCTs screened, 21 were included in the analysis, comprising 1649 patients (828 undergoing prehabilitation) across several specialities, the most prevalent being cardiac (501 patients), colorectal (423 patients), and thoracic surgery (364 patients). The prehabilitation group exhibited a greater improvement in the 6MWD before surgery (mean difference (MD) 29 m; 95% c.i. 14 to 42 m; P < 0.001; I2 = 84%) and in the first month after surgery (MD 22 m; 95% c.i. 0 to 43 m; P = 0.05; I2 = 92%). A greater proportion of patients in the prehabilitation group had a clinically significant improvement in the 6MWD both before (odds ratio (OR) 2.66; 95% c.i. 1.76 to 4.0; P < 0.001; I2 = 53%) and after (OR 2.59; 95% c.i. 1.05 to 6.35; P = 0.04; I2 = 69%) surgery. There were no differences between the groups in length of hospital stay (MD -0.24; 95% c.i. -0.65 to 0.17; P = 0.25; I2 = 25%) or mortality (OR 0.71; 95% c.i. 0.26 to 1.92; P = 0.5; I2 = 0%).

Conclusion: Prehabilitation involving physical exercise before surgery was associated with an improvement in preoperative CRF. However, no differences were observed between the groups in length of hospital stay or postoperative mortality. The improvement in CRF persists in the postoperative period, suggesting a potential benefit for patient recovery.

Background: Early triage for massive transfusion (MT) is essential in trauma care but most existing scoring systems rely on in-hospital data. To address this limitation, a machine learning model using only prehospital variables to predict MT and stratify mortality risk was developed and externally validated.

Methods: Data from the Korean Trauma Data Bank from 19 trauma centres (2017-22) was used for model development and internal validation, with 2023 data for patients from four additional centres used for external validation. Trauma cases were identified using S or T codes from the Korean Classification of Diseases, 7th edition. MT was defined as ≥ 5 units packed red blood cells within 4 hours or ≥ 10 units within 24 hours. Machine learning models were trained using 21 prehospital variables, with a final ensemble model constructed from the top-performing algorithms. Model interpretability was assessed using Shapley additive explanations (SHAP), and the association between predicted probability tertiles (T1-T3) and in-hospital mortality was evaluated using logistic regression.

Results: In all, 227 567 patients were included in the development cohort and internal validation cohort, with 8867 patients in the external validation cohort. The soft-voting ensemble model, combining random forest and AdaBoost, showed high predictive performance, with area under the receiver operating characteristic curve values of 0.837 (internal validation) and 0.837 (external validation). SHAP analysis identified accident type as the most influential predictor, followed by consciousness level, and circulatory assistance. Higher model probability was associated with increased in-hospital mortality (adjusted odds ratios (95% confidence intervals) 2.34 (2.16 to 2.55), 2.70 (2.49 to 2.92), and 3.53 (3.25 to 3.83) for T1, T2, and T3, respectively).

Conclusion: A prehospital ensemble learning model to predict MT was developed and validated, and its predictions were significantly associated with in-hospital mortality. However, this study is limited by the inclusion of a single ethnicity, and future research needs to integrate data from multiple populations to enhance generalizability.