Effect of Inspiratory Plus Expiratory Neuromuscular Electrical Stimulation on Diastasis Recti Abdominis in Postpartum

BACKGROUND

The treatment of postpartum diastasis recti abdominis requires a comprehensive approach that considers the integrated function of the core muscle group, rather than focusing solely on the isolated stimulation of the rectus abdominis.

PURPOSE

To investigate the effects of inspiratory plus expiratory neuromuscular electrical stimulation in patients with postpartum rectus abdominis separation.

METHODS

Sixty patients diagnosed with postpartum Diastasis Recti Abdominis (DRA) were randomly assigned, using a random number table, to either a control group (n = 30) or an intervention group (n = 30). Both groups participated in a standardized postpartum rehabilitation program for 4 weeks, consisting of daily 20-min treatment sessions, 5 days per week. The control group received electrical stimulation targeting the rectus abdominis muscles, whereas the intervention group underwent inspiratory plus expiratory neuromuscular electrical stimulation. To assess the outcomes, a blinded assessor utilized high-frequency ultrasound to measure the separation distance of the rectus abdominis, the thickness of the transversus abdominis, and the thickness of the diaphragm both pre- and post-intervention. Additionally, the diaphragm thickening ratio was calculated.

RESULTS

At baseline, no significant differences were observed between the two groups. However, following the 4-week intervention, both groups demonstrated significant reductions in rectus abdominis separation (p < 0.05). Notably, the intervention group exhibited significantly greater improvements in rectus abdominis separation at the supra-umbilical and umbilical regions compared with the control group (p = 0.040 and p < 0.001, respectively). Furthermore, the intervention group showed significant increases in diaphragm thickening ratio and transversus abdominis thickness (p = 0.025 and p < 0.001, respectively) relative to the control group.

CONCLUSION

The addition of inspiratory plus expiratory neuromuscular electrical stimulation to conventional postpartum rehabilitation significantly improves outcomes in patients with postpartum DRA. Overall, these findings provide evidence for a novel therapeutic approach that targets both abdominal muscle function and respiratory mechanics, offering a promising direction for the management of DRA in postpartum women.

Behavioral Responses to Healthcare Funding Decisions and Their Impact on Value for Money: Evidence From Australia

Value for money is fundamental to health insurance schemes given insurers must choose which treatments to fund. Assessing value for money ex ante is challenging, however, because costs and outcomes depend on how treatments are used. Estimates often rely on evidence from early randomized controlled trials conducted prior to regulatory approval, where provider and patient behaviors are tightly controlled. This approach ignores how different supply conditions and incentives in practice influence behaviors. This paper considers how provider and patient incentives can differ between trial and practice settings and analyses how healthcare use changed when new prostate cancer treatments were funded on the public health insurance scheme in Australia. We find evidence that doctors treated patients with worse prognosis compared to the trials, patients ceased prior treatment and switched to the new treatments earlier than expected, and treatment duration was longer than expected. These and other behavioral responses reduced value for money ex post. Our findings suggest that health insurers should carefully consider the supply conditions and incentives in practice when funding new treatments.

Effects of conservative approaches for treating diastasis recti abdominis in postpartum women: A systematic review and meta-analysis

BACKGROUND

Verify the effects of conservative approaches for treating diastasis recti abdominis in postpartum women.

METHODS

PubMed, Embase, CENTRAL, CINAHL, SportDiscus, LILACS, and PEDro were searched, until March 15, 2024. The methodological quality of randomized clinical trials (RCTs) was assessed using the PEDro scale. Meta-analyses were conducted using the mean difference (MD) between groups for interrectus distance (IRD) in millimeters (mm).

RESULTS

After screening, 34 RCTs were included in the systematic review, of which 21 presented a low risk of bias. Very low certainty evidence demonstrated significant effects for IRD reduction in favor of abdominal exercises versus no intervention (MD = -6.82 mm) and for abdominal exercises plus multi-interventions versus abdominal exercises only (MD = -3.56 mm). Subgroup analyses demonstrated that significant IRD reduction occurs only with isotonic abdominal exercises (MD = -3.78 mm) and that the best co-intervention with abdominal exercises is electrical stimulation (MD = -4.43 mm).

CONCLUSION

Isotonic abdominal exercises, especially when combined with electrical stimulation, represent the best conservative treatment option for improving postpartum diastasis recti abdominis. However, due to the very low certainty of the evidence, these results should be interpreted with caution, and further well-designed RCTs with high methodological quality are needed to confirm these findings.

Risk factors and outcomes for early returns to the operating room following abdominal wall hernia repairs

Background

Risks of re-operation in ventral hernias in non-American populations and recurrence have been studied extensively. However, data on early risk factors for reoperation in North America are still lacking. The most recent NSQIP study, analyzing risk factors for reoperation of ventral hernias was extracted from 2005-2008 data. Since then, there have been major advances in ventral hernia repair techniques. Here, we identify risk factors and indications for re-operation within 30 days.

Methods

NSQIP ACS data from 2020-2022 were used in our analysis. Additional procedures that posed significant morbidity and mortality were excluded. Risk factors were analyzed with univariate and multivariable models to determine association with re-operation within 30 days. ICD10 codes for re-operation were also analyzed.

Results

Of 56,260 patients, 2.38 % returned to the OR within 30 days. Higher ASA, male gender, surgical site infection (SSI), smoking, ascites, age group > 70, dialysis patients, open surgeries and dehiscence were significantly associated with re-operation whereas outpatient surgery was protective in univariate and multivariable models (p < 0.01). The most common indications for re-operation were surgical site occurrence (SSO) and recurrence of hernia. Mortality was significantly higher in the reoperation group, 3.29 %, compared to those patients that did not require early reoperation (0.36 %, p < 0.01).

Conclusions

Mortality and early reoperation rates have decreased in the past decade in the U.S, which could be attributed to advancement in ventral hernia repair techniques. Our analysis of risk factors for reoperation supports findings in the broader literature. This study also suggests that SSO and recurrence of hernia are leading diagnoses for early reoperation.

MEsh FIxation STudy in Laparoendoscopic Repair of M3 Inguinal Hernias: Multicenter, Double-blind, Randomized Controlled Trial-MEFISTO Trial

OBJECTIVE

To evaluate the efficacy of non-fixation versus fixation of meshes in laparoendoscopic repair of M3 inguinal hernias in terms of recurrence, postoperative pain, and surgical complications.

BACKGROUND

International guidelines recommend mesh fixation for large M3 inguinal hernias during laparoendoscopic repairs due to high recurrence rates. However, emerging experimental and registry data suggest that anatomically shaped, rigid, and three-dimensional (3D) meshes may maintain stability without fixation. This study aimed to address this knowledge gap through a multicenter randomized controlled trial.

METHODS

The MEsh FIxation STudy trial is a prospective, multicenter, double-blind, randomized controlled trial conducted in 12 surgical centers. A total of 204 patients with M3 inguinal hernias were randomized into 2 groups: a "non-fixation" group using 3D, rigid, anatomic meshes. "Fixation" group using flat lightweight meshes fixed with tissue adhesive. The primary outcome was the recurrence rate at 12 months. The secondary outcomes included postoperative pain (Visual Analog Scale) and surgical site occurrence. Data were analyzed using appropriate statistical methods for noninferiority studies.

RESULTS

The recurrence rate at 12 months was 3.1% and 2.1% in the non-fixation and fixation groups respectively ( P = 0.6847). No differences were observed in pain at discharge, 7 to 10 days postsurgery, or 12 months postsurgery. No significant differences were found in surgical complications or operative times between groups.

CONCLUSIONS

Non-fixation of 3D meshes is noninferior to fixation of flat lightweight meshes for M3 inguinal hernia repair. These findings support the potential revision of international hernia management guidelines to incorporate non-fixation approaches with appropriate mesh types.

Extra-abdominal CT imaging indicates increased severity of illness in advanced age patients requiring emergency abdominal surgery

BACKGROUND

Abdominal sepsis frequently causes neurologic and pulmonary dysfunction among geriatric patients, We hypothesize that patients with abdominal sepsis who undergo extra-abdominal imaging have a greater burden of illness.

METHODS

Patients 65 years and older that underwent emergency abdominal surgery for sepsis were divided into those with abdominal only(AbdCT) versus abdominal and extra-abdominal(ExtraCT) imaging.

RESULTS

ExtraCT patients(N ​= ​30) compared to AbdCT(N ​= ​97) had higher rates of dementia(13.3 ​% versus 3.3 ​%; p ​= ​0.03), diabetes(93.3 ​% versus 60.1 ​%; p ​< ​0.01 and COPD(70 ​% versus 29.9 ​%; p ​< ​0.01) but lower rates of abdominal pain as chief complaint (23.3 ​% versus 81.4 ​%; p ​< ​0.01) and higher rates of being qSOFA positive (33.3 ​% vs 7.2 ​%; p ​< ​0.05). Importantly, time to OR was not different between groups. ExtraCT patients had higher rates of 30-day mortality (33.3 ​% vs 5.2 ​%; p ​< ​0.01). Extra-abdominal CT imaging was associated with increased risk of mortality (OR ​= ​5.4; 95 %CI ​= ​1.4-20.1).

CONCLUSIONS

ExtraCT among geriatric patients with abdominal emergencies is a marker of severity of illness and should guide end-of-life decision making.

PErioperative respiratory care aNd outcomes for patients underGoing hIgh risk abdomiNal surgery (PENGUIN): a randomised international internal pilot trial

Background

Infections are a common complication of abdominal surgery in low- and middle-income countries (LMICs). The role of a high fraction of inspired oxygen (FiO2) and chlorhexidine mouthwash in preventing post-operative infections is unconfirmed.

Methods

Internal pilot phase of an international outcome assessor-blinded, 2x2 factorial randomised trial of patients aged ≥10-years undergoing midline laparotomy in LMIC hospitals. The main trial objectives are to compare the clinical effectiveness of preoperative 0.2% chlorhexidine mouthwash in preventing pneumonia versus no mouthwash, and 80-100% perioperative FiO2 to prevent surgical site infection (SSI) versus 21-35% FiO2. This 12-month internal pilot assessed feasibility of hospital site opening, patient recruitment, intervention adherence, patient follow-up and safety. Patients were randomised in a 1:1:1:1 ratio to the four intervention group combinations and followed up for 30 days.

Results

We recruited 927 patients from seven hospitals in India and South Africa over 12 months from November 2020. There were 907 adults (97.8%) and 20 children aged ten or over (2.2%): 89/927 (9.6%) patients died. Site opening reached 70% of our target (7/10) hospitals, and patient recruitment 107% (927/870). 917/927 (99%) patients in the mouthwash arm, and 840/927 (91%) patients in the oxygen arm received the allocated intervention. Lower adherence to the oxygen intervention related mainly to clinically necessary FiO2 increases in the 21-35% FiO2 arm. 30-day follow-up was completed appropriately for 924/927 (99%) patients. and was performed by a masked assessor for all patients. There were no reported safety events.

Conclusion

This pilot showed the feasibility and safety of a major phase III trial in post-operative infection prevention in LMICs.

Trial registration

ClinicalTrials.gov NCT04256798.

From the operating room: Surgeons' views on difficult laparoscopic cholecystectomies

Backgrounds/Aims

Assessing surgical difficulty in laparoscopic cholecystectomy (LC) is challenging due to variations in surgeon proficiency and institutional protocols. This study evaluates surgeons' perspectives on procedural difficulty and examines how intraoperative findings and preoperative imaging contribute to refining difficulty assessment criteria.

Methods

A cross-sectional survey was conducted among 50 laparoscopic surgeons in India, providing insights into tolerances for surgical duration and blood loss, reasons for conversion, and predictors of complexity. Responses were analyzed using SPSS, with statistical significance set at p < 0.05.

Results

Among surveyed surgeons, 82.0% were male, and 78.0% worked in private institutions and 52.0% had performed over 1,000 LCs. Conversion to open surgery was primarily influenced by significant blood loss (68.0%) and biliary injury (94.0%). While 38.0% preferred surgeries under 60 minutes, 26.0% imposed no time constraints. Key intraoperative challenges included dense adhesions, cholecysto-enteric fistulas, and fibrosis. Less experienced surgeons reported greater challenges with scarring adhesions and anatomical variations, but no significant differences were found for other factors like edematous or necrotic changes. Preoperative imaging was considered essential by most surgeons.

Conclusions

This study underscores the limited reliability of traditional parameters for assessing difficulty in LC. Surgeons highlighted the importance of objective intraoperative findings and preoperative imaging in predicting surgical challenges. Factors such as adhesions, fibrosis, and anatomical variations significantly impact LC difficulty, with decisions regarding conversion to open surgery largely driven by individual judgment rather than experience. Standardized grading systems incorporating these factors could improve surgical planning, reduce complications, and enhance patient outcomes.

Comparison of the efficiency of ultrasound-guided ESPB and TAPB on postoperative analgesia: a system review and meta-analysis

Background

This meta-analysis systematically evaluates the analgesic efficacy of two regional anesthesia techniques - transversus abdominis plane block (TAPB) and erector spinae plane block (ESPB) in abdominal surgical procedures.

Methods

This PRISMA-compliant meta-analysis systematically queried PubMed, Embase, Web of science, and Cochrane library. Eligible studies were controlled clinical trials comparing ESPB and TAPB for postoperative analgesia, documenting pain scales, opioid use, and safety outcomes. Methodological rigor was evaluated per Cochrane criteria, with quantitative synthesis conducted via RevMan 5.4 using effect magnitudes (SMD/MD) and risk ratios (RR). Evidence certainty was graded using GRADE methodology.

Result

Pooled data from 21 RCTs (n = 1,293 patients) revealed better pain control during the 24-h postoperative period in the ESPB groups (2-h: MD = -0.68, 95% CI [-1.04, -0.32], p < 0.05). Also, postoperative opioid consumption was significantly reduced in the ESPB group (MD = -1.25; 95% CI [-1.66 to -0.85]; p < 0.05). No significant differences were observed in complication occurrence (RR = 1.13, 95% CI [0.75, 1.71], p > 0.05).

Conclusion

Current evidence indicates that ESPB demonstrates superior postoperative analgesic efficacy and reduced opioid requirements compared to TAPB, while maintaining comparable safety profiles.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42021275992.

Predictive model for recurrence of incisional hernia constructed by CT abdominal wall imaging features

BACKGROUND

The recurrence rate after incisional hernia surgery is the most important concern for patients and surgeons, which not only causes pain to the patient but also adds additional medical costs. This study aims to investigate CT imaging features based on abdominal wall mechanics for recurrence after incisional hernia surgery.

MATERIALS AND METHODS

We collected data from patients who were diagnosed with incisional hernia and underwent hernia repair from January 2017 to January 2022 in Shanxi Provincial People's Hospital. Based on Laplace's equation, an equation for spherical wall pressure, we further measured the preoperative abdominal wall thickness and abdominal wall radius of the patients by CT and measured the abdominal wall muscle area and visceral fat area at the third lumbar level by using Slice-O-Matic 5.0 software, and the sarcopenia index was further obtained by dividing the muscle area by the square of the height. Then, we analyzed their relationship with the postoperative recurrence of incisional hernia.

RESULTS

By univariate and multifactorial analyses, we found that excessive visceral adiposity, high BMI and sarcopenia were independent risk factors for incisional hernia recurrence. In further stratified analysis, we also found that patients with combined sarcopenia had a higher probability of recurrence. Our results found that visceral fat was a higher risk factor for incisional hernia recurrence than BMI.

CONCLUSION

This study was a retrospective study. Based on the Laplace equation, sarcopenia and visceral fat are independent risk factors for recurrence after incisional hernia.

Comparison of open and laparoscopic inguinal hernia repair in the elderly patients: a randomized controlled trial

PURPOSE

It is well known that inguinal hernia repair in geriatric patients carries a higher risk of postoperative complications compared to younger patients. One of the key factors influencing these complications is the surgical technique employed. However, there is limited knowledge regarding the impact of laparoscopy on elderly patients. This prospective randomized study aims to compare the outcomes of laparoscopic and open hernia repair techniques in this patient population.

METHODS

Between April 2023 and April 2024, 120 consecutive patients aged 65 years and older with inguinal hernia were randomly assigned to one of two groups: the laparoscopic TEP group (n = 60) and the open (Lichtenstein) procedure group (n = 60). The study was registered at ClinicalTrials.gov (NCT06417346). The primary outcome of this study was the comparison of postoperative complication rates. Secondary outcomes included comparisons of hernia types, operative times, postoperative pain levels, and recurrence rates.

RESULTS

A total of 120 patients were followed up for 12 months. The mean age was 71.7 ± 6.5 years in the open group and 69.6 ± 3.9 years in the TEP group (p = 0.18). The mean operative time was 35.8 ± 7.8 min in the open group and 36.3 ± 8.7 min in the TEP group (p = 0.92). The mean time to return to normal daily activities was 10.6 ± 4.3 days in the open group and 7.5 ± 2.4 days in the TEP group (p < 0.001). On postoperative day 1, the VAS score was 3.7 ± 1.3 in the open group and 2.9 ± 1.1 in the TEP group (p < 0.001). At the end of the first month, the VAS score was 2.6 ± 1.0 in the open group and 1.7 ± 0.9 in the TEP group (p < 0.001). Chronic pain was observed in 6 patients (10%) in the open group and 1 patient (1.7%) in the TEP group (p = 0.05). No complications occurred in 51 patients (85%) in the open group and 52 patients (86.7%) in the TEP group (p = 0.84). Recurrent inguinal hernia was detected in 4 patients (6.7%) in the open group and 1 patient (1.7%) in the TEP group (p = 0.17).

CONCLUSION

Based on the data obtained from our study, laparoscopic inguinal hernia repair in elderly patients was found to offer advantages such as faster recovery, reduced postoperative and chronic pain, without an increase in complications. Given these benefits, laparoscopic hernia repair can be considered a safe and preferable approach for elderly patients.

TRIAL REGISTRATION

Clinical trials number: NCT06417346.

Vacuum-assisted closure or primary closure with relaparotomy on-demand in patients with secondary peritonitis: a systematic review and meta-analysis

BACKGROUND

Secondary peritonitis is a serious condition with significant morbidity and mortality. Its management requires emergency laparotomy for source control. Vacuum-assisted closure (VAC) and primary abdominal closure (PAC) are the main strategies for managing the laparostomy after source control. Despite the increasing use of VAC, concerns persist regarding its complications and long-term outcomes compared with PAC.

METHODS

This systematic review followed PRISMA 2020 and MOOSE. The Cochrane Risk of Bias (RoB 2) tool, MINORS and GRADE framework assessed study quality and evidence certainty. The protocol was registered in PROSPERO (CRD42022304724). A comprehensive search of MEDLINE, Embase, and the Cochrane Library from January 2004 to August 2024 identified studies reporting postoperative outcomes following VAC or PAC after laparotomy for secondary peritonitis. The included studies had to report at least two key outcomes: mortality, postoperative complications, incisional hernia, secondary fascial closure, and hospital or intensive care unit (ICU) length of stay.

RESULTS

Thirty-three studies including 4,520 patients were analyzed. Mortality was 31.1% in VAC and 22.2% in PAC (p = 0.327). Postoperative complications were higher with VAC (71.0% vs. 39.3%, p = 0.001). Incisional hernia rates were similar (21.3% vs. 20.8%, p = 0.958). Secondary fascial closure rate was significantly lower with VAC (58.1% vs. 85.9%, p < 0.001). VAC patients had longer ICU stays (21.1 vs. 9.7 days, p = 0.04), while hospital stay did not differ. Most studies had a high risk of bias, and GRADE assessment showed low to very low evidence certainty.

CONCLUSION

VAC therapy was associated with more postoperative complications, a lower fascial closure rate, and a longer ICU length of stay compared with PAC. Thirty-day mortality rates did not differ between the approaches. However, most of studies included were subject to serious risk of bias and a low level of certainty in evidence.

Perspectives of clinicians and screening candidates on shared decision-making in prostate cancer screening with the prostate-specific antigen (PSA) test: a qualitative study (PROSHADE study)

OBJECTIVE

The objective of this study is to analyse the perspectives of screening candidates and healthcare professionals on shared decision-making (SDM) in prostate cancer (PCa) screening using the prostate-specific antigen (PSA) test.

DESIGN

Descriptive qualitative study (May-December 2022): six face-to-face focus groups and four semistructured interviews were conducted, transcribed verbatim and thematically analysed using ATLAS.ti software.

SETTING

Data were obtained as part of the project PROSHADE (Decision Aid for Promoting Shared Decision Making in Opportunistic Screening for Prostate Cancer) to develop a tool for SDM in PCa screening with PSA testing in Spain.

PARTICIPANTS

A total of 27 screening candidates (three groups of men: 40-50 years old; 51-60 years old and 61-80 years old), 25 primary care professionals (one group of eight nurses and two groups of physicians: one with more and one with less than 10 years of experience), and four urologists. Focus groups for patients and healthcare professionals were conducted separately.

MAIN OUTCOME MEASURES

Participants' perceptions of shared decision-making related to PSA opportunistic screening, including their understanding, preferences, and attitudes.

RESULTS

Three themes were generated: (1) perceptions of SDM, (2) perceptions of PSA testing and (3) perceptions of SDM regarding PCa screening. Theme 1: screening candidates valued SDM when it included clear information and empowered them. There was consensus with primary care health professionals on this point, although their knowledge and implementation of SDM varied. Theme 2: candidates were divided on PSA testing; some trusted it for early detection, while others expressed scepticism due to concerns about false positives and invasive procedures, reflecting gaps in accessible information. Theme 3: professionals across primary and specialised care stressed the need for standardised SDM protocols. Primary care physicians were particularly concerned that PSA decisions align with scientific evidence and urologists recognised SDM as valuable in PSA testing only if it was adequately explained to each patient. Barriers to implementing SDM included insufficient coordination across care levels, lack of consensus-driven protocols and limited clinical time.

CONCLUSIONS

While patients expect comprehensive information, primarily based on practice to achieve empowerment, healthcare professionals face obstacles such as limited time and insufficient coordination between primary care and urology. All stakeholders agree on the importance of evidence-based tools to reinforce effective SDM and enhance collaboration across urologists and primary care in the context of PSA testing.

Sarcopenia and adverse surgical outcomes following cholecystectomy

PURPOSE

Postoperative complications and mortality following cholecystectomy persist despite the procedural simplicity. We utilized a nationwide administrative database from Taiwan and conducted propensity score matching (PSM) to investigate the association between sarcopenia and major postoperative complications.

PATIENTS AND METHODS

This retrospective cohort study analyzed data from the Taiwan National Health Insurance Research Database from 2016 to 2020. Patients who underwent elective cholecystectomy under general anesthesia for gallstone disease were included. They were categorized into two groups: those with sarcopenia and those without. The cohorts were matched at a 1:4 ratio using PSM.

RESULTS

PSM yielded a final cohort of 13,330 surgical patients (10,664 without sarcopenia and 2666 with sarcopenia). Multivariate logistic regression demonstrated that sarcopenia was significantly associated with higher 30 day mortality (adjusted odds ratio [aOR] = 2.26, 95% confidence interval [CI] 1.61-3.18) and major complications, including acute renal failure (aOR = 1.71, 95% CI 1.02-2.84), pneumonia (aOR = 1.68, 95% CI 1.22-2.31), stroke (aOR = 1.13, 95% CI 1.06-1.57), and overall complications (aOR = 1.23, 95% CI 1.07-1.41). Sarcopenia also increased the risk of 90-day mortality (aOR = 2.09, 95% CI 1.58-2.76) and 90-day major complications, including acute renal failure (aOR = 1.61, 95% CI 1.01-2.56), pneumonia (aOR = 1.70, 95% CI 1.30-2.21), stroke (aOR = 1.28, 95% CI 1.04-1.58), and overall complications (aOR = 1.24, 95% CI 1.09-1.41).

CONCLUSIONS

We found that sarcopenia is an independent risk factor for increased postoperative complications and mortality following cholecystectomy. These findings highlight the importance of preoperative sarcopenia assessment to improve surgical outcomes.

Recurrence after implementation of an updated intraoperative protocol for totally extraperitoneal (TEP) inguinal hernia repair in a high-volume clinic - a retrospective cohort study

PURPOSE

Although the recurrence rate after inguinal hernia repair is low, it remains an important postoperative outcome. To further reduce this rate, modifiable risk factors should be addressed. This study assessed reoperations for recurrence-like complaints following adjustments to the intraoperative protocol aimed at preventing recurrent inguinal hernias. These adjustments included fixating mesh in large unilateral direct defects and large bilateral hernias, and thoroughly reducing inguinal lipomas.

METHODS

Elective totally extraperitoneal (TEP) repairs in adults performed between January 1, 2013, and October 25, 2023, were retrospectively included. The cohort was subsequently divided into two groups based on the timing of their TEP repair: before (pre-implementation) or after (post-implementation) the protocol adjustments. The primary outcome was reoperation for recurrence-like complaints following the initial TEP repair. Secondary outcomes included mesh fixation and lipoma reduction.

RESULTS

A total of 12,878 TEP repairs in 12,507 patients were included (pre-implementation: 5,454; post-implementation: 7,424). Reoperation rate decreased from 0.97% pre-implementation to 0.65% post-implementation (p = 0.630). Following protocol implementation, mesh fixation for unilateral hernias significantly increased from 3.2% to 5.4% (p < 0.001), and for bilateral hernias from 9.8% to 16.3% (p < 0.001). Lipoma reduction was similar between the groups (unilateral: 32.3-32.6%, p = 0.625; bilateral: 36.0-38.1%, p = 0.288).

CONCLUSION

The adjusted intraoperative protocol demonstrated a non-significant declining trend of reoperations for recurrence-like complaints. Lipoma reduction was already well-implemented. While mesh fixation increased, it had no significant effect on the recurrence rate, so careful selection of hernias requiring fixation warrants attention.

Association of Trainee Gender With Critically-Ill Trauma Patient Outcomes

INTRODUCTION

Recent research has shown that female attending surgeons have slightly better outcomes than male attending surgeons. We aimed to evaluate if this gender difference extends to trainees caring for critically-ill trauma patients.

METHODS

The trauma registry at a level 1 academic trauma center was reviewed from October 2015 to December 2021. All patients admitted with an injury severity score ≥25 were included. The trauma team members for each patient were determined by the past resident and fellow call schedules. Teams with two female (female/female) or two male (male/male) trainees were included in the analysis. Primary outcome was mortality. Secondary outcomes included hospital and intensive care unit length of stay, return to intensive care unit, readmission, infectious complications, and venous thromboembolism.

RESULTS

1909 patients met inclusion criteria; of which, 625 were on an FF or MM team. Median age was 37 y and 80% were male. The mortality on female/female teams was 22.7%, compared to 25.5% on male/male teams, P = 0.496. There were also no differences between teams for any of the secondary outcomes.

CONCLUSIONS

There was no statistically significant difference in mortality rates for severely injured trauma patients based on whether the trainees on their team were men or women. As gender discrimination still exists in the field of surgery, studies like this that demonstrate similar or better outcomes for female surgeons can help to dissipate bias.

Uncovering variation in cholecystitis treatment: protocol and statistical analysis plan for a nationwide observational study - the Dutch Cholecystitis Snapshot Study (Dutch CHESS)

INTRODUCTION

Cholecystitis is a highly prevalent disease that imposes a substantial burden on the healthcare system. Despite strong underlying evidence, guideline adherence in the treatment of cholecystitis remains low. Moreover, important gaps in knowledge persist that must be addressed to optimise existing guidelines. The primary aim is to assess the nationwide variation in cholecystitis treatment and identify opportunities to improve guideline adherence. Secondary aims include determining the best cystic duct closure method; the best model to predict concomitant choledocholithiasis; the optimal treatment for cholecystitis lasting 7 days or more at diagnosis and the optimal strategy for gallbladder drainage and post-drainage care.

METHODS AND ANALYSIS

The Dutch CHESS is a multicentre observational cohort study, including 67 out of 69 Dutch hospitals. From 1 April to 30 September 2024, all patients diagnosed with cholecystitis (Tokyo Guidelines definition) will be prospectively identified. Data on patient characteristics, treatment and outcome (with 6-month follow-up) will be collected to address the primary and secondary aims. For the primary aim, guideline adherence is defined as the percentage of patients who undergo early cholecystectomy for cholecystitis lasting 0-7 days. Current adherence, nationally and for each individual hospital, along with predictors of adherence, will be determined. The adherence of each hospital will be set against the national average and best practices. To further support improvement, the impact of guideline adherence on total hospital stay and morbidity will be determined. Three months after performance feedback to the participating hospitals, the impact on local practice will be assessed through questionnaires. Subgroup analyses and statistical methods for addressing both the primary and secondary aims are predefined in this protocol.

ETHICS AND DISSEMINATION

The Medical research Ethics Committees United reviewed the protocol and decided that the Dutch Medical Research Involving Human Subjects Act is not applicable (reference Number: W23.225). Approval was obtained from the institutional review board and board of directors at each participating hospital. Results will be disseminated through peer-reviewed publications and conference presentations.

STUDY REGISTRATION NUMBER

ClinicalTrials.gov, NCT06349863; Pre-results.

Beyond the Basics: Recommended Approach to Severe Acute Pancreatitis Management in the Critical Care Setting

Acute Pancreatitis (AP) poses a significant healthcare burden globally. While most cases present with a mild course, approximately one-fifth progress to severe forms characterized by severe pancreatitis and systemic complications, leading to a mortality rate of up to 40%. Effective management of severe acute pancreatitis necessitates a multidisciplinary approach involving gastroenterologists, interventional radiologists, intensive care teams, and surgeons. The advances in treatment modalities, including early hydration, nutrition, and pain control, have led to a decrease in the morbidity and long-term complications associated with severe acute pancreatitis down to 20%. In this review, we focus on the management challenges and outcomes associated with the difficult condition of severe acute pancreatitis.

The relationship between renal cell carcinoma pathological types and perirenal fat area

INTRODUCTION

To explore whether there is a relationship between perirenal fat area (PFA) and the pathological types of renal cell carcinoma (RCC).

METHODS

Two hundred ninety-seven cases of RCC patients were included in our study, which is a retrospective analysis. Based on pathological type, we divided the 297 RCC patients into two groups: the clear cell renal cell carcinoma (ccRCC) group (236 cases) and the non-clear cell renal cell carcinoma (non-ccRCC) group (61 cases). Computed tomography (CT) images at the renal vein level were used to measure PFA. A multivariate logistic regression model was employed to examine the connection between various pathological types of RCC and PFA.

RESULTS

Significant differences were observed between ccRCC and non-ccRCC patients in PFA (P = 0.007), contralateral PFA (P = 0.011), weight (P = 0.002), BMI (P < 0.001), pathological stage 1 (P = 0.010), and pathological stage 2 (P = 0.002). To study the link between pathological subtypes and PFA, a multivariate logistic regression model was employed. Stratifying patients by tumor location in the kidney, the multivariate logistic regression analysis showed that when the tumor is located outside the polar lines of the kidney (OPLK), for every 1 cm2 increase in PFA, the probability of developing ccRCC increases by 5% [1.05 (1.01, 1.10) P = 0.0153]. Furthermore, after stratifying patients by tumor location and pathological stage, it was found that in T1 stage patients with tumors located OPLK, for every 1 cm2 increase in PFA, the probability of developing ccRCC increases by 6% [1.06 (1.01, 1.11) P = 0.0300].

CONCLUSION

When the tumor is located OPLK in T1 stage patients, PFA is positively correlated with ccRCC. Perirenal adipose tissue may be a risk factor for ccRCC.

Reoperation for Recurrence After Groin Hernia Repair in Adolescents: A Nationwide Register-Based Cohort Study

BACKGROUND

Although mesh-based repairs are used in adults to reduce the risk of recurrence, their necessity in adolescents remains debated. Nonmesh repairs are often preferred in younger patients to avoid potential long-term complications, but data on recurrence rates in this age group are limited. We aimed to assess the rate of reoperation for recurrence following primary groin hernia repair in adolescents aged 10-19 years.

METHODS

This was a register-based cohort study covering three decades (1992-2022), utilizing data from the Danish National Patient Register linked to data from the Danish Civil Registration System, ensuring comprehensive nationwide coverage and complete follow-up. The cumulative rate of reoperation for recurrence was estimated at 10 years of follow-up. Cox proportional hazards regression analysis was used to compare the risk of reoperation for recurrence between mesh and nonmesh repairs. Outcomes included reoperation for recurrence, readmission, and mortality.

RESULTS

Among the 2404 included groins, most were male (80%), and the median age was 16 (IQR, 12-19) years. Most (99%) groin hernias were inguinal, and few (1%) were femoral. Of the inguinal repairs, 35% were mesh, 64% were nonmesh, and 1% were unspecified repairs. The follow-up time was median 16 (IQR, 9-21) years. The cumulative rate of reoperation for recurrence across all inguinal repairs was 3.8% (95% CI, 3.0-4.9) after 10 years of follow-up. For older adolescents aged 15-19 years, the cumulative rate of reoperation for recurrence after mesh and nonmesh repair was 2.7% (95% CI, 1.6-4.6) and 4.1% (95% CI, 2.6-6.7), respectively. Nonmesh repair had a higher adjusted hazard ratio of reoperation for recurrence compared with mesh repair (adjusted hazard ratio, 2.11; 95% CI, 1.05-4.23). For femoral repairs, most (67% [18/27]) were open nonmesh repairs, and few were reoperated for recurrence.

CONCLUSION

The cumulative rate of reoperation for recurrence was low in adolescents. These findings suggest that nonmesh repair may be sufficient for primary groin hernia repair in adolescents, potentially avoiding the need for mesh implantation.

Ligation of the intersphincteric fistula fract (LIFT) in complex anorectal fistulas: retrospective analysis of the outcomes in a tertiary hospital

Anal fistula treatment remains a surgical challenge. This study focuses on the efficiency and safety of the Ligation of Intersphincteric Fistula Tract (LIFT) procedure for high intersphincteric anorectal fistulas, aiming to identify prognostic factors for success and complications. A retrospective chart review was conducted on all patients who underwent LIFT procedure at a tertiary referral hospital between January 2013 and January 2021. The primary endpoint was the success rate of fistula closure, confirmed with clinical investigation. Secondary endpoints included postoperative complications, reintervention and self-reported incontinence. Logistic regression analyses were performed for assessing prognostic factors for fistula closure and postoperative complications. Ninety-two patients were included in the study; after a median follow-up of 19.3 months, fistula closure was achieved in 71% (n = 65) and in 89% (n = 82) after reinterventions. 46% (n = 42) reported persistent symptoms, although 83% of which (n = 32/42) had succesful fistula tract closure by clinical evaluation. One patient developed incontinency for gas. Smoking emerged as a significant risk factor for fistula closure failure, OR = 6.75, 95% CI = [1.65, 27.69], p = 0.030. Wound dehiscence was the most common complication, occuring in 25% (n = 23). Prolonged oral antibiotics demonstrated a significant protective effect against wound dehiscence, OR = 0.31, 95% CI = [0.10, 0.96], p = 0.036. The LIFT procedure is an efficient and safe treatment for complex perianal fistula. Patient satisfaction emerged as a crucial treatment goal, as patients can remain symptomatic after fistula closure. Emphasizing smoking cessation is integral to the treatment approach. The findings suggest prolonged antibiotic treatment as a potential preventive measure for wound dehiscence.

Comparison of Long-Term Outcomes Between Conversion to Open and Laparoscopic Subtotal Cholecystectomy in the Difficult Gallbladder: A Single-Center Retrospective Study

BackgroundA difficult laparoscopic cholecystectomy (LC) confers an increased risk of bile duct injury. Traditionally, surgeons convert to open cholecystectomy (OC) as a bailout procedure for safer dissection. Laparoscopic subtotal cholecystectomy (LSC) has recently gained favor with comparable short-term complication rates, but differences in long-term outcomes remain unknown. We sought to compare long-term biliary outcomes between OC and LSC.Study DesignWe performed a single-center retrospective cohort study of adults who underwent non-elective LC converted to OC or LSC due to difficult dissection from 1/1/2015 to 12/31/2019. The primary outcome was a composite measure of postoperative biliary events, and we used time-to-event analysis to compare the 2 groups. We evaluated secondary outcomes using Chi-squared or independent t-tests as appropriate.ResultsOf 1089 patients who underwent non-elective LC, 68 (6%) underwent a bailout procedure (30 OC vs 38 LSC). There were no differences in demographics or comorbidities between the groups. Most patients (84%) had acute cholecystitis. Average follow-up times were 40 ∓ 29 months in OC and 54 ∓ 21 months in LSC. Biliary events occurred in 13 total patients (19%) with OC most commonly suffering bile leak (17%) and LSC most commonly having choledocholithiasis (11%). Kaplan-Meier analysis demonstrated no significant difference in biliary events between the groups (P = 0.71). Secondary outcomes were all similar between groups, except LSC had a shorter length of stay (2.9 ∓ 2.3 vs 5.1 ∓ 3.6 days, P = 0.002).ConclusionsOC and LSC demonstrated comparable long-term biliary outcomes. In a difficult LC, surgeons may perform either bailout procedure to safely manage the gallbladder.

Transcutaneous electrical acupoint stimulation combined with core stability training in postpartum women with diastasis rectus abdominis

BACKGROUND

Diastasis rectus abdominis (DRA) women experience discomfort signs, which had a negative impact like an impairment of the quality of life and functional capacities of women. Transcutaneous electrical acupoint stimulation (TEAS) and core muscle training (CMT) have provided increasing evidence as an important strategy for DRA. Here, we aimed to evaluate the effect of transcutaneous electrical acupoint stimulation (TEAS) combined with core muscle training (TEAS + CMT) in postpartum women with DRA.

METHODS

A total of 96 postpartum women with DRA were randomly assigned to three groups: control (waiting-list group), treatment group 1 (CMT), and treatment group 2 (TEAS + CMT), with 32 participants in each group. Ultimately, 90 participants completed the study (30 in each group). The control group received conventional postpartum natural recovery. Treatment group 1 underwent CMT once daily, five times per week, for four consecutive weeks (one treatment course). Treatment group 2 received TEAS + CMT following the same schedule. Changes in interrectus distance (IRD), waistline (WL), body mass index (BMI), lumbago (measured by the Short-Form McGill Pain Questionnaire [SF-MPQ]), and quality of life (assessed via SF-36) were evaluated before and after treatment.

RESULTS

At the end of treatment, each group showed notable reductions in IRD, WL, and BMI(P < 0.05), in with the most significant improvements observed in treatment group 2 (P < 0.05). Lumbago scores (SF-MPQ) distinctly decreased each group (P < 0.05), while quality of life scores (SF-36) evidently improved (P < 0.05), with treatment group 2 showing the most pronounced effects (P < 0.05).

CONCLUSION

TEAS + CMT may improve DRA of postpartum women, reduce WL and BMI, alleviate lumbago, and improve quality of life.

Simulation of gastroscopy and endoscopic retrograde cholangiopancreatography for medical student education

BACKGROUND

Simulation training has become part of medical student education, however endoscopy simulators have mostly been reserved for speciality training. Evidence suggests that simulation training has the potential to educate future doctors about endoscopy procedures and improve their communication with patients. Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic procedure that is technically challenging and poorly understood by medical students. This study aimed to investigate whether simulating gastroscopy and ERCP using an anatomical model of the upper gastrointestinal tract improves procedural knowledge, confidence, and performance in medical students.

METHODS

Students completed three attempts at gastroscopy and one attempt at ERCP using the model. Participants rated knowledge and confidence relating to endoscopic procedures before and after completing the simulation. Students also reported their attitudes towards endoscopic simulation training after their participation.

RESULTS

There was a significant increase in self-perceived knowledge of the purpose of and steps involved in endoscopy (P < 0.001), gastrointestinal anatomy (P = 0.003), and biliary system anatomy (P = 0.002) after using the simulator. Participants also reported significantly increased skills confidence in performing gastroscopy and duodenoscopy (P < 0.001), including in their ability to explain endoscopic procedures to a patient (P < 0.001). All participants agreed (5%) or strongly agreed (95%) that simulation training is a useful addition to their learning, and that they would like more simulation training in the medical curriculum.

CONCLUSION

Simulation training is an effective and engaging method of promoting procedural awareness and understanding of basic endoscopic procedures in medical students, with the potential to improve doctor-patient interactions in early clinical practice.

Development and validation of a machine learning-based risk model for metastatic disease in nmCRPC patients: a tumor marker prognostic study

BACKGROUND

Nonmetastatic castration-resistant prostate cancer (nmCRPC) is a clinical challenge due to the high progression rate to metastasis and mortality. To date, no prognostic model has been developed to predict the metastatic probability for nmCRPC patients. In this study, we developed and externally validated a machine-learning model capable of calculating risk scores and predicting the likelihood of metastasis in nmCRPC patients.

PATIENTS AND METHODS

A total of 2716 nmCRPC patients were included in this study. The training and testing datasets were derived from SPARTAN (NCT01946204) and ARAMIS (NCT02200614), respectively. Regarding metastasis-free survival as the endpoint, we subjected 13 clinical features to 10 machine-learning models and their combinations to predict metastasis. Model performance was assessed through accuracy (AUC), calibration (slope and intercept), and clinical utility (DCA). The risk score calculated by the model and risk factors based on eight identified variates were used for metastatic risk stratification.

RESULTS

The final prognostic model included eight prognostic factors, including novel hormone therapy application, Gleason score, previous treatments received (both surgery and radiotherapy, or neither), Race (White), PSA doubling time (PSADT), hemoglobin (HGB), and lgPSA. The prognostic model resulted in a C-index of 0.724 (95% CI 0.700-0.747) in internal validation and relatively good performance through tAUC (>0.70 at 3-month intervals between 6 and 39 months) in external validation. In the risk score stratifying strategy, compared with the low-risk group, the metastasis HRs for medium- and high-risk groups were 1.72 (95% CI 1.39-2.12) and 4.43 (95% CI 3.66-5.38); as for risk factor count, the HRs are 1.98 (95% CI 1.50-2.61) and 4.17 (95% CI 3.16-5.52), respectively.

CONCLUSIONS

In this study, we developed and validated a machine learning prognostic model to predict the risk of metastasis in nmCRPC patients. This model can assist in the risk stratification of nmCRPC patients, guide follow-up strategies, and aid in selecting personalized treatment intensities.

Faculty Characteristics and Surgery Trainee Attrition

This cohort study examines correlations between underrepresented-in-medicine and female faculty representation, retention, and promotion and general surgery resident attrition at a national level.

MR Imaging of Perianal Fistulas: A Review of Fundamentals, Complications, and Post-Therapy Imaging

MR imaging is the gold standard for diagnosis, providing detailed evaluation of perianal fistulas. MR imaging aids in detecting, classifying, and monitoring fistulas and guiding treatment. Detailed radiology reports, incorporating patient history and disease-specific considerations, are essential for effective management and improved clinical outcomes. This review overviews fundamental high-yield concepts to aid radiologists in interpreting MR imaging for perianal fistulas with multiple case examples.

Is it Safe to Perform Concomitant Cholecystectomy in Patients With Confirmed Gallbladder Disease Undergoing Metabolic and Bariatric Surgery? An Updated Meta-Analysis

INTRODUCTION

Obesity is a global public health issue, and metabolic and bariatric surgery (MBS) remains most effective intervention for achieving and maintaining long-term weight loss. However, rapid weight loss following MBS increases the risk of gallstone formation. Concomitant cholecystectomy (CC) during MBS has been proposed to mitigate this risk, but recent studies present conflicting evidence regarding its safety and efficacy, leaving no clear consensus.

METHODS

We conducted a meta-analysis by systematically searching MEDLINE, Cochrane Central, Embase, and ClinicalTrials.gov for studies comparing CC plus BS versus BS alone. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Statistical analyses were performed with Review Manager v5.4 and RStudio v4.3.3.

PROSPERO ID

CRD42023480360.

RESULTS

We included 26 studies encompassing 656,830 patients with confirmed gallstones, among whom 34,409 (5.2%) underwent CC.The mean age was 41.5 years, and 79.2% were female. Patients undergoing CC + MBS had increased postoperative bleeding (OR 1.31; 95% CI 1.06-1.62; p = 0.01), wound complications (OR 1.61; 95% CI 1.34-1.95; p < 0.01), respiratory complications (OR 1.49; 95% CI 1.13-1.95; p < 0.01), and anastomotic complications (OR 1.86; 95% CI 1.28-2.70; p < 0.01). No significant differences in operation time, rates of postoperative mortality, length of hospital stay, and vein thrombosis were found between groups.

CONCLUSION

CC during MBS increases operative time and postoperative complications, though only anastomotic complications are clinically significant. Therefore, CC should be reserved for high-risk or symptomatic patients and avoided in bariatric procedures involving an anastomosis due to the elevated risk of complications.

HSD3B1, prostate cancer mortality and modifiable outcomes

Androgen receptor stimulation by testosterone and dihydrotestosterone is crucial for prostate cancer progression. Despite the initial effectiveness of androgen deprivation therapy (ADT), castration-resistant prostate cancer eventually develops in most men. A common germline missense-encoding polymorphism in HSD3B1 increases extra-gonadal androgen biosynthesis from adrenal precursors owing to increased availability of the encoded enzyme 3β-hydroxysteroid dehydrogenase 1 (3βHSD1) - hence, it is called the adrenal-permissive enzyme. This mechanism explains the more rapid progression to castration-resistant prostate cancer in men who inherit this allele than in men without it via sustained androgen receptor activation despite ADT. Multiple clinical studies, including data derived from prospective phase III studies, have linked adrenal-permissive allele inheritance to inferior clinical responses to ADT and increased mortality, but reversal is possible with upfront adrenal androgen blockade. The adrenal-permissive allele exhibits divergent frequencies across various groups worldwide, which could contribute to differences in clinical outcomes among these populations. Large-scale data from the Million Veteran Program have shown homozygous HSD3B1 adrenal-permissive allele inheritance to be an independent biomarker of prostate cancer-specific mortality. Together, these observations support the integration of HSD3B1 into germline testing and clinical trials as it might help to identify groups at increased likelihood of benefiting from early, intensified, AR-targeting interventions. Lastly, 3βHSD1 is a promising target for pharmacological inhibition, which enables new strategies for systemic prostate cancer therapy.

Is the annual hospital volume associated with recurrence and chronic postoperative inguinal pain (CPIP) syndrome after inguinal hernia repair in laparo-endoscopic or open mesh technique (Lichtenstein)?

BACKGROUND

In major surgery, several studies have shown a correlation between high annual hospital volume (hospital caseload) and better outcome. Therefore, centralization is recommended. However, in inguinal hernia surgery the data are limited.

METHODS

The study is based on a retrospective analysis of prospective data from the German Herniamed Registry collected between 2009 and 2018. Out of the total of 731,982 patients operated on in 737 institutions, patients who had undergone inguinal hernia repair in Lichtenstein or in laparo-endoscopic (TAPP/TEP) technique were included. Hospitals were divided into three annual caseload categories: Low volume: ≤ 75 cases; middle volume: 76-199 cases; high volume: ≥ 200 cases. The relationship between hospital volume and the outcome parameters was analyzed using multivariable binary logistic models.

RESULTS

222,487 patients were enrolled in analysis, with 70.4% hernias operated on in laparo-endoscopic technique and 29.6% cases in open mesh technique. Overall, the outcome after laparo-endoscopic repair was significantly favorable except for the intraoperative complications (worse) and recurrence rate (no significant difference). Descriptive and multivariable analysis identified a long operating time as the main factor associated with an unfavorable outcome. In low-volume hospitals the risk was higher for intraoperative complications as well as for postoperative complications in both techniques. There was a significantly favorable association between the recurrence rate and hospital volume but only after laparo-endoscopic repair. Patients who were operated on in a low-volume center experienced significantly less pain across all three pain categories, independently of the technique used.

CONCLUSIONS

While hospital volume has a favorable association with most outcome parameters, this varied in accordance with the operative technique used. In contrast to open surgery, laparo-endoscopic surgery in a low-volume hospital (≤ 75) has the disadvantage of a higher recurrence rate. Long operating time is the most detrimental factor, proving that surgeon proficiency is of paramount importance. However, chronic postoperative inguinal pain (CPIP) syndrome is significantly less frequent in patients operated on in low-volume hospitals; this result is difficult to explain but may be due to a closer patient-surgeon relationship in these institutions.

Transcystic Laparoscopic Common Bile Duct Exploration: When to Bail

BACKGROUND

Transcystic laparoscopic common bile duct exploration (LCBDE) is a procedure considered in the management of common bile duct stones. In many ways it is superior to alternatives such as endoscopic retrograde cholangiopancreatography (ERCP); however, surgeons who have limited experience in CBDE are often reluctant to persist in difficult cases with concerns regarding increasing complication rates and waste of theater time. This study aims to provide an evidence-based approach to identify points to aid early abandonment ("bail").

METHODS

Review of all LCBDE performed in a single center from September 2008 to September 2022 was performed. Statistical analysis was performed on success and failure groups, with relevant undesirable outcomes chosen for further analysis to identify factors to be used as a guide to bail.

RESULTS

A total of 952 patients were identified for analysis. Females represented 63.8% (609) of the cohort. Success was reported in 89.2% (849) of procedures. Those in whom the cystic duct could not be cannulated with the choledochoscope, those that progressed to choledochotomy, those with a prolonged operative time, and those who had adverse outcomes were selected as undesired outcomes. Factors of age, higher ASA, preoperative ERCP, and those with preoperatively identified stones or larger stones at operation were associated with higher rates of an undesired outcome.

CONCLUSION

Older and more comorbid patients, those who underwent preoperative ERCP, and those with preoperatively or operatively identified large stones are factors that should prompt those surgeons who are developing their LCBDE experience to consider bailing early.

Rectus abdominis muscle atrophy, prophylactic mesh, and stoma placement: retrospective findings from a prospective multicenter trial

PURPOSE

The primary aim of this study was to investigate whether rectus abdominis muscle atrophy is associated with a lower risk of developing parastomal hernia. Secondary objectives were to assess whether the use of prophylactic mesh is a risk factor for rectus abdominis muscle atrophy and whether the position of the stoma within the rectus abdominis muscle affects the risk of parastomal hernia.

METHODS

This retrospective study analysed patients from a prospective, randomised, multicentre trial in which rectal cancer patients were randomised to stoma creation with or without prophylactic mesh. Computed tomography at 12 months was evaluated to identify parastomal hernia, rectus abdominis muscle atrophy and position of stoma in the rectus abdominis muscle.

RESULTS

Out of 149 patients, rectus abdominis muscle atrophy was observed in 9% and parastomal hernia in 42% of patients. There was no association between rectus abdominis muscle atrophy and parastomal hernia (p = 0.80; RR 1.07; CI 0.62-1.86), nor between prophylactic mesh and rectus abdominis muscle atrophy (p = 0.19; RR 2.00; CI 0.7-5.73). Stoma placement within the rectus abdominis muscle also showed no association with parastomal hernia development (p = 0.69; RR 0.97; CI 0.81-1.15).

CONCLUSION

This study found no statistically significant association between rectus abdominis muscle atrophy and parastomal hernia. The use of prophylactic mesh was not a risk factor for rectus abdominis muscle atrophy, and stoma placement within the rectus abdominis muscle was not associated with parastomal hernia. The previously reported association between prophylactic mesh, rectus abdominis muscle atrophy, and parastomal hernia was not confirmed in this cohort.

Optimal surgical and anesthetic approaches for inguinal hernia repair in octogenarians and nonagenarians: a multicenter cohort study in Japan

PURPOSE

We aimed to develop treatment strategies for older patients with inguinal hernia considering adequate adjustment for operative risks and a comparison that accounts for differences in surgical and anesthetic approaches.

METHODS

This retrospective cohort study included 1935 patients aged ≥ 80 years diagnosed with inguinal hernia at 21 facilities in Japan between January 2019 and December 2023. We compared surgical approaches performed under general anesthesia and separately analyzed anesthetic approaches in patients who underwent open surgery. Analysis was conducted using the inverse probability of treatment weighting method to adjust for confounding factors.

RESULTS

Of the 1935 patients, 841 underwent laparoscopic surgery (LS), while 1094 underwent open surgery (OS) with general anesthesia (GA) in 373, spinal anesthesia (SA) in 401, and local anesthesia (LA) in 320. Overall postoperative complication rates of Clavien-Dindo Grade II or higher were comparable between surgical approaches under GA (LS: 3.8% vs. OS: 3.4%; risk ratio [RR]: 1.10; 95% confidence interval [CI]: 0.57, 2.10). Comparisons of anesthetic approaches among patients with OS showed that complication rates were lower in the LA group ([LA: 1.5% vs. GA: 3.5%; RR: 0.43; 95% CI: 0.13, 1.42] and [LA: 1.1% vs. SA: 3.6%; RR: 0.29; 95% CI: 0.10, 0.90]). The LS group had a lower incidence of chronic pain than that in the OS group (LS: 1.7% vs. OS: 3.2%; RR: 0.53; 95% CI: 0.21, 1.30).

CONCLUSION

Laparoscopic inguinal hernia repair is a feasible option for octogenarians and nonagenarians. When general anesthesia is avoided, open surgery using local anesthesia is preferred.

Long-Term Postoperative Outcomes by Surgeon Gender and Patient-Surgeon Gender Concordance in the US

Importance

Evidence suggests that physician gender and patient-physician gender concordance have the potential to improve patient outcomes, especially for female patients. However, whether long-term outcomes differ by surgeon gender and patient-surgeon gender concordance has not been studied in the US.

Objective

To compare long-term postoperative outcomes by surgeon gender and patient-surgeon gender concordance.

Design, Setting, and Participants

A population-based cross-sectional study was conducted based on 100% Medicare fee-for-service claims data from 2016 through 2019. Data analysis was performed between October 17, 2023, and January 28, 2025. The study took place at acute care hospitals in the US. Participants included Medicare fee-for-service beneficiaries aged 65 to 99 years who underwent 1 of 14 elective or emergent surgeries.

Exposures

Surgeon gender and patient-surgeon gender concordance.

Main Outcomes and Measures

Ninety-day and 1-year postoperative mortality, readmission, and complication rates were compared by surgeon gender and patient-surgeon gender concordance. The study team adjusted for patient and surgeon characteristics and hospital fixed effects, effectively comparing patients within the same hospital.

Results

Among 2 288 279 patients who underwent surgery, 129 528 were operated on by female surgeons (5.7%) and 2 158 751 were by male surgeons (94.3%). Patients treated by female surgeons experienced a lower long-term mortality rate compared with those treated by male surgeons (adjusted 90-day mortality rates, 2.6% for female surgeons vs 3.0% for male surgeons; adjusted risk difference [aRD], -0.3 percentage points [pp]; 95% CI, -0.5 pp to -0.2 pp; P < .001), similarly for both female and male patients. For female patients, the patient-surgeon gender concordance was associated with lower long-term readmission (adjusted 90-day readmission rates, 7.3% vs 7.7%; aRD, -0.4 pp; 95% CI, -0.7 pp to -0.2 pp; P = .001) and complication rates (adjusted 90-day complication rates, 12.2% vs 12.8%; aRD, -0.5 pp; 95% CI, -0.9 pp to -0.2 pp; P = .005). For male patients, long-term readmission and complication rates did not differ between patients treated by female vs male surgeons. Similar patterns were found between 90-day and 1-year patient outcomes.

Conclusions and Relevance

In this study, both female and male patients treated by female surgeons experienced lower long-term postoperative mortality rates compared with those treated by male surgeons. Patient-surgeon gender concordance was associated with lower long-term readmission and complication rates for female patients, but not for male patients. These patterns were observed only for elective procedures and may not be generalizable to other populations, such as younger patients.

Prevention of infection in aortic or aortoiliac peripheral arterial reconstruction

BACKGROUND

Peripheral arterial disease (PAD) results from the narrowing of arteries. Aortic aneurysms - abnormal dilatations in artery walls - are a related concern. For severe cases, arterial reconstruction surgery is the treatment option. Surgical site infections (SSIs) are a feared and common complication of vascular surgery. These infections have a significant global healthcare impact. Evaluating the effectiveness of preventive measures is essential.

OBJECTIVES

To assess the effects of pharmacological and non-pharmacological interventions, including antimicrobial therapy, antisepsis, and wound management, for the prevention of infection in people undergoing any open or hybrid aortic or aortoiliac peripheral arterial reconstruction.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform, LILACS, and ClinicalTrials.gov up to 11 November 2024.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with a parallel (e.g. cluster or individual) or split-body design, and quasi-RCTs, which assessed any intervention to reduce or prevent infection following aortic or aortoiliac procedures for the treatment of aneurysm or PAD. There were no limitations regarding age and sex.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third review author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE.

MAIN RESULTS

We included 21 RCTs with 4952 participants. Fifteen studies were assessed as having a high risk of bias in at least one domain, and 19 studies had an unclear risk of bias in at least one domain. We analysed 10 different comparisons for eight different outcomes. The comparisons were antibiotic versus placebo or no treatment; short-duration antibiotics (≤ 24 hours) versus long-duration antibiotics (> 24 hours); different types of systemic antibiotics (one versus another); antibiotic-bonded implant versus standard implant; Dacron graft versus stretch polytetrafluoroethylene graft; prophylactic closed suction drainage versus undrained wound; individualised goal-directed therapy (IGDT) versus fluid therapy based on losses, standard haemodynamic parameters and arterial blood gas values (standard care); comprehensive geriatric assessment versus standard preoperative care; percutaneous versus open-access technique; and negative pressure wound therapy (NPWT) versus standard dressing. The primary outcomes were graft infection rate and SSI rate. The secondary outcomes included all-cause mortality, arterial reconstruction failure rate, re-intervention rate, amputation rate, pain resulting from the intervention, and adverse events resulting from the interventions to prevent infection. We did not assess all the outcomes across the different comparisons. The main findings are presented below. Antibiotic versus placebo or no treatment (five studies) Very low-certainty evidence from five included studies suggests that antibiotic prophylaxis reduces SSI (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.71; 5 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNT) 9). With very low- to low-certainty evidence, there was little or no difference between the groups in the other assessed outcomes (graft infection rate, all-cause mortality, re-intervention rate, and amputation rate). We did not quantitatively assess other outcomes in this comparison. Short duration antibiotics (≤ 24 hours) versus long duration antibiotics (> 24 hours) (three studies) Very low-certainty evidence from three included studies suggests that there is little or no difference in graft infection rate (RR 2.74, 95% CI 0.11 to 65.59; 1 study, 88 participants) or SSI rate (RR 3.65, 95% CI 0.59 to 7.71; 1 study, 88 participants) between short- and long-duration antibiotic prophylaxis. We did not quantitatively assess other outcomes in this comparison. Different types of systemic antibiotics (one versus another) (seven studies) We grouped seven studies comparing one antibiotic to another into three subgroups that compared different classes of antibiotics amongst themselves. We found little or no difference between the groups analysed. Graft infection rate: beta-lactams versus cephalosporins (RR 0.36, 95% CI 0.02 to 8.71; 1 study, 88 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 5.00, 95% CI 0.24 to 103.05; 1 study, 238 participants; low-certainty evidence); one cephalosporin versus another (RR not estimable, CI not estimable; 1 study; 69 participants; very low-certainty evidence); SSI rate: beta-lactams and cephalosporins (RR 0.27, 95% CI 0.03 to 2.53; 2 studies, 229 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 2.17, 95% CI 0.65 to 7.23; 2 studies, 312 participants; very low-certainty evidence); and one cephalosporin versus another (RR 1.26, 95% CI 0.21 to 7.45; 3 studies, 625 participants; very low-certainty evidence). We could extract all-cause mortality data for the glycopeptide versus cephalosporin comparison; there was little or no difference between groups (RR 1.33, 95% CI 0.30 to 5.83; 1 study, 238 participants; low-certainty evidence). We did not quantitatively assess other outcomes in this comparison.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that the use of prophylactic antibiotics may prevent SSIs in aortic or aortoiliac peripheral arterial reconstruction. We found no superiority amongst specific antibiotics or differences in extended antibiotic use (over 24 hours) compared with shorter use (up to 24 hours), with low-certainty evidence. For other interventions, very low- to moderate-certainty evidence showed little or no difference across various outcomes. We advise interpreting these conclusions with caution due to the limited number of events in all groups and comparisons.

Challenges in studying neuroanatomy in sub-Saharan Africa: The case of Cameroon

Introduction

Quality education is key in addressing the skilled neurological workforce gap in Africa. However, many medics are scared of the neurological sciences because of the challenges faced in medical schools in studying the neurosciences. Understanding its state and educational challenges is crucial for fostering interest in neurosurgery and related specialities on the continent.

Research question

What are the current state, challenges, and solutions to improve neuroanatomy education in Cameroon, Africa in miniature?

Materials and methods

A cross-sectional study using an 11-item electronic survey was conducted among medical students from all nine medical schools in Cameroon. Data were analysed using descriptive statistics and independent t-tests, with significance set at p < 0.05.

Results

Among 220 respondents, 40.1 % and 35.0 % respectively, reported cranial nerves/brainstem and neurovascular anatomy to be the most challenging, with a mean comprehension score of 5.83/10. Faculty predominantly relied on PowerPoint lectures (83.2 %), while most students supplemented learning with YouTube videos (77.7 %). 63.9 % of the respondents perceived classroom teaching alone to limit their understanding of neuroanatomy, and 85.8 % of students reported the time allocated for neuroanatomy teaching to be inadequate. The usage of cadaver dissection (69.5 %), and neurosimulation practicals (66.4 %) were the most recommended tools by students to improve neuroanatomy teaching.

Discussion and conclusion

Challenges in neuroanatomy education in Cameroon are perceived to arise from insufficient hands-on learning, time constraints, and limited access to specialised faculty. These suggest interactive teaching, increased curriculum time, and diverse resources as potential improvements, though further research is needed to assess their effectiveness and ultimately improve understanding, fostering a stronger neurological workforce.

Development and Validation of a Bovine Left Displaced Abomasum Reduction Model and Rubric

Left displaced abomasum (LDA) is a common condition in dairy cattle where the abomasum dilates and migrates to the left side of the abdomen. This condition causes significant economic losses for farmers and can result in life-threatening complications, so it is critical that veterinary students be taught to surgically correct a LDA before graduating and entering food animal practice. Models have been successfully used to teach students to perform other surgical procedures, but limited models exist to teach surgical skills to prospective dairy veterinary students. This study sought to develop and validate a bovine LDA reduction model and scoring rubric using a validity framework consisting of content evidence (expert opinion), internal structure evidence (reliability of rubric scores), and evidence showing the relationship with other variables (comparing expert to novice performance). Experienced veterinarians (n = 12) and novice veterinary students (n = 30) surgically deflated and reduced the model's LDA while being recorded. Videos were scored by a blinded expert. Participants completed a survey afterward. All veterinarians reported that the model was suitable for use in teaching and assessing students, offering content evidence for validation. Scores produced by the checklist had good reliability (α = .886), offering internal structure evidence. Veterinarians achieved higher checklist (p = .025) and global rating scores (p = .005) than students, offering relationship with other variables evidence. The development and use of food animal models promotes students' development of competence in performing food animal procedures, leading to better qualified new graduates entering food animal practice. The use of models also protects animal welfare during students' training.

IPOM versus eTEP as minimally invasive approaches for ventral/incisional hernias: a systematic review and meta-analysis

PURPOSE

Enhanced-view totally extraperitoneal (eTEP) repair of ventral hernias is an emerging modality that places synthetic mesh in the retrorectus space and obviates its fixation. We aimed to compare outcomes between eTEP and minimally invasive intraperitoneal onlay mesh (IPOM) repair techniques.

METHODS

A PRISMA-compliant meta-analysis searching PubMed, EMBASE and CENTRAL databases from January 2010 till August 2024, was performed. All studies comparing IPOM versus eTEP were included. The primary objective was postoperative pain at day 7 (POD7) whereas secondary objectives included operative time, length of stay (LOS), intraoperative and postoperative complications and recurrence. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed.

RESULTS

Twelve studies (3 randomized, 9 observational) capturing 868 patients (452 IPOM, 416 eTEP) were included. Most hernias were primary ventral (n = 806). Most studies (10/12) adopted a laparoscopic approach whilst two employed robotic techniques. IPOM was associated with significantly higher pain scores at POD7 (VAS; visual analog scale; MD 3.01, 95%CI = 1.28-4.75, p = 0.0007), longer LOS (MD 0.65 days, 95%CI = 0.27-1.04, p = 0.001) but shorter operative time (MD - 53.69 min, 95%CI = - 69.65- - 37.73, p < 0.00001). However, there was no differences in intraoperative (OR 2.04, 95%CI = 0.81-5.17, p = 0.13), postoperative (OR 1.15, 95%CI = 0.54-2.46, p = 0.72) complications or recurrence (OR 2.08, 95%CI = 0.79-5.46, p = 0.14). On sensitivity analyses, comparing laparoscopic IPOM with defect closure (IPOM +) versus eTEP, similar results prevailed.

CONCLUSIONS

IPOM(+) is associated with more postoperative pain at one week and a longer hospital stay. However, no differences were observed in complications or recurrence between the two techniques.

A systematic review of the predictive factors for the recurrence of acute pancreatitis

PURPOSE

Acute Pancreatitis (AP) is a prevalent clinical pancreatic disorder characterized by acute inflammation of the pancreas, frequently associated with biliary or alcoholic events. If not treated with cholecystectomy after the first episode, patients may experience a recurrence of AP, with consequent need for emergency surgery and increased risk of death. Analyzing the risk factors that may contribute to the recurrence of Biliary and Alcoholic Pancreatitis (BAP and AAP), future research can be driven toward new solutions for preventing and treating this pancreatic disease.

METHODS

A systematic review was conducted selecting studies from BiomedCentral, PubMed, Scopus and Web of Science by two independent reviewers. Publications were considered only if written in English in the time interval between January 2000 and June 2024 and investigated the risk factors for the recurrence of BAP and AAP. At the end of the selection, a quality assessment phase was conducted using the PROBAST tool.

RESULTS

In this systematic review, 8 articles were selected out of 6.945, involving a total sample of 11.271 patients of which 38.77% developed recurrence episodes. 37.5% of the included studies focus on recurrent acute biliary pancreatitis (RBAP), while 62.5% are dedicated to recurrent acute alcoholic pancreatitis (RAAP). The risk factors for the recurrence of AP showed a clear differentiation between the alcoholic and biliary etiology. Most of the considered studies adopted a retrospective design, characterized by a susceptibility to potential methodological biases. However, the trend indicated a more recent increase in prospective studies, together with a greater focus on identifying and understanding the possible risk factors associated with the recurrence of acute pancreatitis (RAP). This result highlighted the progress in the scientific approach toward a more rigorous and systematic assessment of the causes and dynamics that influence the recurrence of the disease.

CONCLUSION

Studies highlighted the importance of lifestyle factors, clinical complications, and surgical interventions that can impact the risk of biliary or alcoholic recurrent acute pancreatitis. Increased and systematic adoption of artificial intelligence-based tools could significantly impact future knowledge relating to the risks of recurrence and relative possibilities of prevention.

The difficult laparoscopic cholecystectomy: a narrative review

BACKGROUND/PURPOSE

Laparoscopic cholecystectomy is one of the most commonly performed general surgical procedures. Difficult laparoscopic cholecystectomy is associated with increased operative time, hospital stay, complication rates, open conversion, treatment costs, and mortality. This study aimed to provide a comprehensive literature review on difficult laparoscopic cholecystectomy.

METHODS

A literature search was conducted for articles published in English up to June 2024 using common databases including PubMed/MIDLINE, Web of Science, Google Scholar, and ScienceDirect. Keywords included "safe laparoscopic cholecystectomy", "difficult laparoscopic cholecystectomy", "acute cholecystitis", "prevention of bile duct injuries", "intraoperative cholangiography," "bailout procedure," and "subtotal cholecystectomy". Only clinical trials, systematic reviews/meta-analyses, and review articles were included. Studies involving children, robotic cholecystectomy, single incision laparoscopic cholecystectomy, open cholecystectomy, and cholecystectomy for indications other than gallstone disease were excluded.

RESULTS/DISCUSSION

Emergency laparoscopic cholecystectomy for acute cholecystitis is ideally performed within 72 h of symptom onset, with a maximum window of 7-10 days. Intraoperative cholangiography can help clarify unclear biliary anatomy and detect bile duct injuries. In the "impossible gallbladder", laparoscopic cholecystostomy or gallbladder aspiration may be considered. When dissection of Calot's triangle is deemed hazardous or impossible, the fundus-first approach allows for completion of the procedure with either total cholecystectomy or subtotal cholecystectomy. Subtotal cholecystectomy is effective in preventing bile duct injuries, can be performed laparoscopically, and is currently the best available bailout approach for difficult laparoscopic cholecystectomy.

CONCLUSION

Difficult laparoscopic cholecystectomy is a common clinical scenario that requires a judicious approach by experienced surgeons in appropriate settings. When difficult laparoscopic cholecystectomy is encountered, various bailout strategies are available. Currently, subtotal cholecystectomy is likely the most effective bailout approach.

Risk factors for incarceration in groin hernia: a prospective observational study

PURPOSE

Groin hernia is one of the most common benign pathologies requiring surgical intervention. Incarcerated groin hernia is a cause of serious morbidity and mortality. In our study, we aimed to identify the risk factors for incarceration in patients with groin hernia and to better understand the factors associated with incarceration, we studied patients who applied to our clinic for groin hernia and underwent surgery.

METHODS

A prospective observational study was performed, including all patients who applied to the general surgery out patient clinic or emergency department at Bakirköy Dr Sadi Konuk Training & Research Hospital and were diagnosed with groin or incarcerated groin hernia and underwent hernia repair surgery. Patients were divided into two groups; elective surgery and emergency surgery (incarcerated hernia). Multivariate logistic regression was performed to identify risk factors for incarceration.

RESULTS

The study was performed with a total of 654 cases between January 2021 and February 2023. Of these, 79.4% (n = 519) had elective surgery and 20.6% (n = 135) had emergency surgery. Increase in defect width, which was determined according to the EHS classification, was significantly associated with an incarcerated hernia (ODDS ratio 4.463 and 17.636, respectively). Additionally, female gender, femoral hernia type, chronic cough, and chronic constipation were found to be independent risk factors for incarceration.

CONCLUSION

Female gender, chronic cough, chronic constipation, femoral hernia type, and increased defect diameter are independent risk factors for urgent surgery and therefore incarceration in groin.

TRIAL REGISTRATION NUMBER

The ClinicalTrials.gov ID number of the study is NCT04785430.

Changing patterns in joint replacement surgery in the hand in Sweden: a population-based study of 5382 patients

Over a 16-year period (2008-2023), data from the Swedish National Patient Register reveal shifting trends in operation for hand joint replacements linked to demographic, healthcare and surgical advances. Among 5382 identified cases, 63% were women, with the incidence peaking in the 65-74 age bracket, highlighting a marked gender gap in middle and older age groups. Regional analyses indicate significant disparities, as Örebro and Halland had rates exceeding 10 per 100,000, while Stockholm and Blekinge fell below 5 per 100,000. The adoption of total prostheses without cement declined by 22%, reflecting changing surgical preferences. Predictive modelling anticipates an overall decline in incidence by 2035, with gender-specific rates converging over time. These findings highlight the need for targeted healthcare policies that address inequities and minimize unwarranted variations in treatment. Standardized care programmes that support evidence-based surgical decision-making could reduce the incidence of both over- and under-treatment.Level of evidence: III.

Analysis of the incidence of post-cholecystectomy diarrhea and its influencing factors in Hainan Province

BACKGROUND AND AIMS

Cholecystectomy is one of the most common surgical procedures for the treatment of diseases associated with gallstones, and the incidence of post-cholecystectomy diarrhea (PCD) has attracted attention in recent years. The aim of this study was to assess the prevalence of PCD in patients with gallstones and to analyze the factors influencing it.

METHODS

Between August 2022 and December 2024, there were 3385 cases of gallstones diagnosed by abdominal ultrasound or CT examination and laparoscopic cholecystectomy in tertiary hospitals in Hainan Province. All participants in this study were followed up by telephone within 1 year postoperatively and by telephone survey using a standardized questionnaire. The incidence of PCD was calculated, and the relevant components of the follow-up were analyzed by one-way and multifactorial logistic regression using SPSS 26.0 statistical software.

RESULTS

Four hundred seventy-nine patients (14.2%) developed PCD after undergoing laparoscopic cholecystectomy. Univariate analysis showed that age, BMI, dietary patterns, history of diabetes, alcohol consumption, gallstones and fatty liver disease were associated with the development of PCD ( P < 0.05). Binary logistic regression analysis showed that age (OR = 0.532, P = 0.010), BMI (OR = 40.615, P < 0.001), dietary patterns (OR = 0.635, P = 0.013), and history of diabetes (OR = 0.263, P < 0.001) were independent risk factors.

CONCLUSION

The incidence of PCD in Hainan Province is 14.2%. Over 50 years old, BMI, dietary pattern and history of diabetes were independent risk factors for the occurrence of PCD.

Non-programmed rehospitalizations after cholecystectomy

Cholecystectomy is one the most frequent procedures in digestive surgery. While the operation is generally associated with low rates of morbidity and mortality, frequency of occurrence can vary considerably according to surgical indication, time elapsed between symptom appearance and surgical intervention, anatomical area under treatment, and the experience of the different centers. Rehospitalization after cholecystectomy remains potentially problematic in numerous units, due in part to the ongoing development of day hospital treatment and short-term hospitalization. The objective of this update is to assess not only the rate, causes and risk factors of non-programmed hospitalizations subsequent to cholecystectomy, but also the available ways and means of prevention and management in the patient's best interests.

Exercises to treat diastasis rectus abdominis and improve abdominal function: Two case reports

BackgroundThese two case reports describe the rehabilitation program of exercises in two male participants aged 19 and 21 with diastasis rectus abdominis.ObjectiveThis paper aims to improve high inter-rectus distance, lumbar pain, abdominal and lumbopelvic function, Due to the lack of literature, this paper looks to provide clinicians with guidance in the rehabilitation of this injury.MethodsBoth cases participated in a multimodal program that included lumbopelvic stabilization, strengthening, and hypopressive exercises. Sociodemographic, clinical and muscular information was collected, as well as ultrasound measurements at three points: above the umbilicus, below the umbilicus, and at the midpoint between the xiphoid process and the umbilicus. Specific maneuvers and functional tests were used to assess changes in abdominal muscles.ResultsThe results showed improvements in both clinical and ultrasound scores. In terms of improvement in inter-rectus distance, case 1 had a reduction of 25% above the umbilicus and case 2 showed a 23.9% improvement in inter-rectus distance at the midpoint.ConclusionsIt is concluded that a combination of superficial contractions and isometric exercises may be effective in reducing inter-rectus distance and improving abdominal function, suggesting the need for further research in this area.

Toys in the bedroom: use of sexual devices in partnered sexual activity is associated with higher female orgasmic intensity, arousal, and sexual satisfaction and is not related to psychopathologies

BACKGROUND

Sex devices are tools that can improve the sexual health of users, but their effects on sexual outcomes in partnered intercourse have rarely been evaluated.

AIM

The aim of this study was to assess the relationship between partnered and solitary use of sex devices and different sexual health outcomes among sexually active women aged 18-35 in a heterosexual relationship.

METHODS

The cross-sectional descriptive study was conducted with 361 participants between May and June 2023 recruited through a social media campaign. Female sexual function was measured with the Female Sexual Function Index and the Orgasmometer-F. The Generalized Anxiety Disorder scale, the Patient Health Questionnaire and the Dark Future Scale were used to investigate psychological health. Statistical analysis was performed with the statistical software R; the significance level for statistical analyses was set as P < 0.05.

OUTCOMES

The outcomes of the study include female sexual function and orgasmic intensity, as well as measures of symptoms of anxiety, depression, and uncertainty for the future.

RESULTS

Compared to those who only used sex devices for solitary masturbation, women using sex devices in the context of partnered intercourse had higher arousal and satisfaction scores (P = 0.042 and P = 0.004, respectively), as well as higher subjective perception of orgasmic intensity over the last 6 months (P = 0.005) and in partnered sexual intercourse in the last 4 weeks (P = 0.002). Conversely, orgasmic intensity during masturbation in the last 4 weeks was higher among solitary users (P < 0.001). No significant difference was found between the two study groups for all other outcome measures.

CLINICAL IMPLICATIONS

The use of sex devices in the context of partnered intercourse is associated with increased sexual function and more intense orgasmic experience.

STRENGTHS & LIMITATIONS

The study investigates a novel topic, on a large sample size, by using several validated instruments to measure sexual functioning of participants. However, a definite cause-effect relationship cannot be established due to the study design. Self-report bias and lack of clinical data on study participants are further limitations. Additionally, being a study limited to heterosexual, sexually active women involved in a relationship, results cannot be generalized to all women.

CONCLUSION

The study found an association between better sexual functioning and use of sex devices in partnered intercourse.

Pulmonary and functional hallmarks after SARS-CoV-2 infection across three WHO severity level-groups: an observational study

Background

The manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection range from flu-like symptoms to severe lung disease. The consequences of this inflammatory process impact overall function, which can be detected through both short- to long-term assessments. This study aimed to assess the pulmonary functional and structural characteristics of post-SARS-CoV-2 infection in patients with mild/moderate, severe, and critical clinical presentations.

Methods

An observational, analytical, and cross-sectional study was conducted between 2020 and 2022, including participants with a confirmed diagnosis of coronavirus disease (COVID)-19, with mild/moderate (G1), severe (G2), and critical (G3) clinical presentations, all evaluated at least 3 months after acute infection. Spirometry, impulse oscillometry, fractional exhaled nitric oxide (FeNO), chest computed tomography, the 6-min walk test (6MWT), hand grip strength, maximum inspiratory pressure, and maximum expiratory pressure were assessed.

Results

We enrolled 210 participants aged 18-70 years, 32.6% of whom were male, with older age observed in G3. The participants were grouped as follows: G1 (42.3%), G2 (25.7%), and G3 (31.9%). Percentage of predicted X5 differed between G1 and G2, being higher in G1. The percentage of predicted forced vital capacity (FVC) according to the Global Lung Function Initiative and its z-score were higher in G1. The FVC by Pereira was lower in G3 compared to G1. The percentage of predicted forced expiratory volume in 1 s (FEV1) by Pereira was also lower in G3. The Tiffeneau (FEV1/FVC) index was different among groups, increasing with disease severity. The percentage of predicted forced expiratory flow rate at 25-75% (FEF25-75%) of the FVC and FeNO were both higher in G2 than G1. Chest computed tomography revealed the presence of interstitial abnormalities, associated with disease severity. The respiratory muscle strength evaluation showed an association between higher maximum expiratory pressure values in G3 compared to G1, but no association with maximum inspiratory pressure was observed. The 6MWT distance covered decreased with increasing severity, with a lower percentage of predicted values in G3 compared to G1. The right-hand grip strength was also lower in G3 compared to G1.

Conclusion

Alterations in pulmonary and functional markers were observed in post-COVID-19 evaluations, increasing with disease severity, as seen in G2 and G3. These findings highlight the complexity of post-COVID-19 functional assessments, given the long-term pulmonary sequelae and the consequent impairment of functional capacity.