World J Surg
· 2026 Jun · PMID 42093135
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OBJECTIVE: Various analgesic techniques have been employed for pain management in pancreatoduodenectomy (PD). However, the optimal technique remains unclear. This network meta-analysis seeks to appraise the efficacy and...OBJECTIVE: Various analgesic techniques have been employed for pain management in pancreatoduodenectomy (PD). However, the optimal technique remains unclear. This network meta-analysis seeks to appraise the efficacy and adverse effects of different analgesic techniques. METHODS: Cochrane, Embase, Web of Science, and PubMed databases were searched up to January 10, 2025. Clinical studies on pain control following PD were included. Primary search terms included PD and pain. Two reviewers separately screened studies, extracted data, and evaluated the risk of bias. A third reviewer resolved their dissents. The risk of bias was assessed via the NIH quality assessment tool. Data analysis was carried out via R version 4.4.1. The primary outcome was postoperative opioid consumption, and the secondary outcomes included pain scores at 24 and 48 h after surgery and postoperative nausea and vomiting (PONV). Effect sizes were presented as standardized mean differences (SMD), mean differences (MD), and relative risk (RR). RESULTS: A total of 10 studies were included, including five randomized controlled trials and five cohort studies, involving a total of 975 patients. The network meta-analysis revealed that compared to epidural block with other analgesia, parecoxib-IV was most effective in reducing opioid consumption after surgery (SMD: -3.7, 95% CI: [-4.3, -4.1]). Additionally, wound infiltration (WI), transversus abdominis plane (TAP) block, electrical muscle stimulation, and intrathecal morphine (ITM) + TAP can substantially reduce opioid consumption after surgery. For pain scores, parecoxib-IV was most effective in controlling postoperative pain at rest (MD: -0.32, 95% CI: [-4.9, -0.15]). Regarding PONV, WI (RR: 0.70, 95% CI: [0.51, 0.94]) and acetaminophen-IV (RR: 0.35, 95% CI: [0.099, 0.94]) were linked to fewer adverse events. CONCLUSIONS: Compared with epidural block, intravenous parecoxib was ranked as the most effective intervention for reducing postoperative opioid consumption. WI, TAP block, electrical muscle stimulation, and ITM + TAP also demonstrated superior effects in reducing opioid consumption relative to epidural analgesia. Regarding secondary outcomes, intravenous parecoxib was the most effective in reducing postoperative pain scores at rest, while both WI and intravenous acetaminophen were associated with a lower incidence of PONV. These findings suggest that alternative analgesic strategies, particularly intravenous parecoxib, may offer advantages over epidural block. Given the limited number of studies currently included, these conclusions need to be further validated by future high-quality research. TRIAL REGISTRATION: PROSPERO registration: https://www.crd.york.ac.uk/prospero/ (CRD: 420251030763).
Witthøft C, Ahmed U, Á Lakjuni Guttesen E
… +2 more, Rosenberg J, Baker JJ
World J Surg
· 2026 Jun · PMID 42089832
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BACKGROUND: Recurrence and chronic pain remain significant challenges in incisional hernia repair, and evidence on the optimal mesh placement is limited. This review aimed to determine whether there is a difference in th...BACKGROUND: Recurrence and chronic pain remain significant challenges in incisional hernia repair, and evidence on the optimal mesh placement is limited. This review aimed to determine whether there is a difference in the risk of recurrence and chronic pain based on mesh placement in patients undergoing incisional hernia repair. METHODS: Studies with adults undergoing elective incisional hernia repair for defects < 10 cm were included. PubMed, Embase Ovid, and Cochrane CENTRAL were searched on August 18, 2025. RCTs were assessed with Cochrane's Risk of Bias tool, version 2. Cohort studies were evaluated with Cochrane's Risk Of Bias In Non-randomized Studies of Interventions, version 2. Meta-analyses and a network meta-analysis were conducted to compare recurrence rates across placements. The protocol was pre-registered in PROSPERO (CRD420251148033). RESULTS: Twenty-two studies with 10,832 patients were included. Crude recurrence rates were highest for preperitoneal (12.8%) and lowest for retromuscular (3.0%) mesh positions. In the network meta-analysis, retromuscular (RR 0.3, 95% CI 0.1-0.8) and intraperitoneal (RR 0.4, 95% CI 0.2-0.9) placements were significantly associated with a lower risk of recurrence compared with onlay. However, the certainty of evidence was very low due to high risk of bias and heterogeneity, limiting confidence in these estimates. Four studies reported chronic pain, but substantial heterogeneity precluded meta-analysis. CONCLUSION: Retromuscular mesh placement may reduce recurrence compared with onlay mesh. However, these findings were limited by clinical and statistical heterogeneity across studies. Reports on chronic pain were few and heterogeneous, needing further research on the link between chronic pain and mesh placement.
Jain AJ, Dekker EN, Prakash L
… +5 more, Arvide EM, Chiang YJ, Snyder RA, Katz MHG, Tzeng CD
World J Surg
· 2026 Jun · PMID 42089830
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Independent predictors of Venous Thromboembolism (VTE) within the first 45 post-operative days on multivariate analyses.Independent predictors of Venous Thromboembolism (VTE) within the first 45 post-operative days on multivariate analyses.
Etemad S, Celie KB, Turk M
… +8 more, Dutton J, Diaz J, Adeniyi A, Bustamante A, Imran NI, Magee W, Dwyer A, Yao C
World J Surg
· 2026 Jun · PMID 42084213
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BACKGROUND: The shift to electronic health records has improved care but remains limited in low- and middle-income countries (LMICs) due to infrastructure and funding challenges. Operation Smile International (OSI) previ...BACKGROUND: The shift to electronic health records has improved care but remains limited in low- and middle-income countries (LMICs) due to infrastructure and funding challenges. Operation Smile International (OSI) previously relied on paper records, limiting quality improvement, research, and follow-up. In 2020, OSI launched a hybrid paper-electronic health record (hPHR) system tailored to LMIC needs. METHODS: Through stakeholder interviews and user-centered design, the team identified key system gaps and developed a hPHR. The hPHR uses Optical Mark Recognition and QR-coded patient IDs to enable digital data capture in low-connectivity environments. Forms were tailored to clinical disciplines and aligned with global standards. Piloted across OSI sites, the system was iteratively refined based on user feedback. RESULTS: From 2021 to 2025, OSI deployed its hPHR system in 350 surgical programs across 23 countries. Implemented with local teams, each deployment involved virtual planning, customized forms, and on-site training for staff and volunteers. The hPHR system documented data from 9686 patients and 5239 operations - mostly cleft repairs. In some countries, abbreviated systems were used to fit local workflows. All data were securely uploaded for analysis, with dashboards built in Power BI to support quality improvement, research, and planning aligned with global surgical care indicators. CONCLUSIONS: The Operation Smile hybrid hPHR is a scalable, sustainable solution for surgical documentation in low-resource settings. Despite ongoing challenges, the hPHR offers a practical bridge between paper and electronic systems, advancing health data capacity in LMICs.
World J Surg
· 2026 Jun · PMID 42084191
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BACKGROUND: The integration of Extended Reality Simulation (XR), which incorporates Virtual and Augmented Reality, is increasingly growing within surgical education. The advantages of faster skill acquisition, immersive...BACKGROUND: The integration of Extended Reality Simulation (XR), which incorporates Virtual and Augmented Reality, is increasingly growing within surgical education. The advantages of faster skill acquisition, immersive operative environments and feedback opportunities have been noted in the research thus far. The primary educational theory supporting XR simulation is Kolb's Experiential Learning Theory. However, a comprehensive qualitative systematic review of the literature that explores surgical trainees' experiences is currently lacking and was therefore conducted. METHODS: Three major databases-Medline, Embase and Mendeley-were searched primarily for qualitative and mixed-methods studies published in the past 5 years, which explored surgical trainees' experiences with XR. The search strategy followed PRISMA reporting guidelines and was conducted between January and May 2025. Initial search results yielded 330 articles, and following the inclusion criteria and full-text review, 11 papers were selected for final critical appraisal. This was conducted using the Modified Mixed Methods Appraisal Tool. Nvivo 14 was utilized to code and tabulate the data. An Interpretivist paradigm was used to approach the qualitative findings and subsequently draw the contextual subtext of the educational experiences of XR. Braun and Clarke's six-stage model was used to subsequently identify sub-themes, themes and thematic relationships. Theme development was further refined and reflected on a thematic map to highlight key relationships and cross-over amongst shared sub-themes. RESULTS: Three major themes and six sub-themes emerged from the thematic analysis: "Integration of XR into Surgical Education," "Mentorship, Collaboration and Reflective Practice," and "Challenges in Accessibility, Equity and Usability." The three major themes highlighted the potential for XR in the surgical curriculum, the benefits of mentorship and collaboration, and the challenges to accessibility that XR both addresses and faces. CONCLUSION: This qualitative systematic review highlights XR's potential to support surgical trainees in enhancing their operative confidence, procedural understanding and self-reflection. The barriers faced by XR, including socioeconomic differences and technological issues, currently limit widespread usage; however, strategic investments and careful integration with the surgical curriculum would encourage a greater user base and should be considered by educators.
Desmond B, Silva M, Wong DJ
… +35 more, Watson DI, Duong CP, Bright T, Aly A, Lee M, Chan K, Smith G, Chan DL, Merrett N, Gananadha S, Lam YH, Kanhere H, Smithers M, Bozin M, Read M, Mori K, Johnson MA, Wong E, Martin SA, Ooi G, Al-Habbal Y, Liew CH, Bohmer R, Daruwalla J, Ballal M, Ranjan R, MacCormick AD, Pattison S, Evennett N, Robertson J, Tan J, Gordon A, Bann S, Liu DS, SPACE‐FLOT ANZ Investigators
World J Surg
· 2026 Jun · PMID 42080546
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BACKGROUND: In Australian and Aotearoa New Zealand (ANZ), it is unclear whether minimally invasive transthoracic Ivor Lewis esophagectomy (MIO) is superior to open techniques with regards to perioperative and oncological...BACKGROUND: In Australian and Aotearoa New Zealand (ANZ), it is unclear whether minimally invasive transthoracic Ivor Lewis esophagectomy (MIO) is superior to open techniques with regards to perioperative and oncological outcomes. Most evidence on this topic have been derived from high-volume centers prior to the advent of perioperative FLOT chemotherapy. How these findings are applicable to the ANZ context, where oesophagectomies are typically performed in low-moderate volume centers, is unknown. This study compares perioperative outcomes and long-term survival between patients undergoing transthoracic open versus hybrid and total MIO following neoadjuvant FLOT chemotherapy across multiple ANZ centers. METHODS: Retrospective analysis of transthoracic oesophagectomies undertaken between 2017 and 2022 following neoadjuvant FLOT chemotherapy from 22 ANZ centers. The primary endpoint was the rate of major (Clavien-Dindo grade ≥ 3) postoperative complication. Secondary endpoints included nodal yield, surgery time, length-of-stay, and rates of perioperative complications, positive resection margins, ICU readmissions, in-hospital mortality, 30-day hospital readmissions, textbook outcome, adjuvant chemotherapy delivered, as well as disease free (DFS) and overall survival (OS). RESULTS: Open esophagectomy, hybrid MIO and total MIO was performed in 155 (62.5%), 61 (24.6%), and 32 (12.9%) patients, respectively. From open to total MIO, there was a stepwise decrease in the rate of major postoperative complications (Open: 38.7%, hybrid MIO: 29.5%, total MIO: 15.6%, p = 0.032). This was associated with reduced length-of-stay [Median(IQR), Open: 14 (11-23), hybrid MIO: 13 (11-23), total MIO: 10 (8-12), p = 0.031], and lower rates of pulmonary (Open: 49.0%, hybrid MIO: 42.6%, total MIO: 28.1%, p = 0.031), cardiac (Open: 20.0%, hybrid MIO: 6.6%, total MIO: 3.1%, p = 0.006), sepsis (Open: 18.7%, hybrid MIO: 8.2%, total MIO: 3.1%, p = 0.022), and wound (Open: 12.3%, hybrid MIO: 3.3%, total MIO: 0.0%, p = 0.019) complications. No significant differences were observed in other perioperative endpoints. Moreover, institutional factors including enhanced recovery after surgery programs and hospital case volume interacted with surgical technique to influence postoperative complication rates. Importantly, adjusted DFS and OS were comparable between the three groups. CONCLUSIONS: In ANZ, MIO was associated with fewer complications and comparable survival compared to open transthoracic esophagectomy. These findings support the safety of MIO in lower-volume settings in the era of perioperative FLOT chemotherapy.
Wang S, Fu Y, Hezhou
… +3 more, Yang J, Fan Y, Liu Y
World J Surg
· 2026 Jun · PMID 42060375
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BACKGROUND: Pancreaticoduodenectomy (PD) is a high-risk complex surgery with a high incidence of postoperative ischemic complications, and celiac axis stenosis (CAS) can reduce visceral blood supply and further increase...BACKGROUND: Pancreaticoduodenectomy (PD) is a high-risk complex surgery with a high incidence of postoperative ischemic complications, and celiac axis stenosis (CAS) can reduce visceral blood supply and further increase this risk by causing collateral circulation ligation during surgery. Hepatic artery variations (HAV) are common anatomical abnormalities, but the combined impact of CAS and HAV on postoperative complications of PD remains insufficiently studied, and the relevant clinical evidence is scarce. METHODS: From January 2015 to June 2025, we retrospectively analyzed the clinical data of patients who underwent PD at two institutions. Based on preoperative arterial-phase contrast-enhanced computed tomography with sagittal reconstructions, CAS was categorized into four groups: no stenosis (< 30%), Grade A (30%-< 50%), Grade B (50%-≤ 80%), and Grade C (> 80%). HAV were classified according to the Michels classification and further subclassified into three types based on blood supply origin. Both univariate and multivariate logistic regression analyses were conducted to examine the associations between CAS (whether isolated or with concomitant HAV) and perioperative complications. RESULTS: A total of 1187 eligible patients were included, among whom 108 (9.1%) were diagnosed with CAS. Of the CAS cohort, 55 (50.9%) had Grade A stenosis, 36 (33.3%) had Grade B stenosis, and 17 (15.7%) had Grade C stenosis; 82 (75.92%) had extrinsic CAS and 26 (24.07%) had intrinsic CAS. Univariate and multivariate analyses identified that severe CAS (> 80%) and HAV Type III were independent risk factors for bile leakage (CAS > 80%: OR = 6.05, 95% CI = 2.23-16.44, P = 0.023; HAV Type III: OR = 3.12, 95% CI = 1.13-8.62, P = 0.028), postoperative liver dysfunction (CAS > 80%: OR = 4.97, 95% CI = 2.13-11.57, P = 0.017; HAV Type III: OR = 2.53, 95% CI = 1.06-6.05, P = 0.037), and postpancreatectomy hemorrhage (PPH; CAS > 80%: OR = 6.02, 95% CI = 2.38-15.22, P = 0.042; HAV Type III: OR = 3.05, 95% CI = 1.18-7.87, P = 0.043). Increasing CAS severity was associated with higher rates of abdominal infection and Clavien-Dindo ≥ 3 complications. In patients with CAS, Type III HAV was associated with a higher bile leakage and PPH rate, but no significant differences in other complications were observed among HAV subtypes. CONCLUSION: Severe CAS (> 80%) is an independent risk factor for postoperative bile leakage, postoperative liver dysfunction and PPH. HAV Type III further increases the risk of these complications in PD patients with CAS.
Bwambale CL, Acire T, Kakooza J
… +4 more, Mukiibi E, Akankwansa P, Lewis CR, Mugenyi M
World J Surg
· 2026 Jun · PMID 42059367
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BACKGROUND: Blunt abdominal trauma (BAT) causes significant preventable deaths worldwide, with death rates 2-5 times higher in low- and middle-income countries (LMICs). Focused assessment with sonography for trauma (FAST...BACKGROUND: Blunt abdominal trauma (BAT) causes significant preventable deaths worldwide, with death rates 2-5 times higher in low- and middle-income countries (LMICs). Focused assessment with sonography for trauma (FAST) is standard but limited by operator skill and poor detection of certain injuries. The clinical abdominal scoring system (CASS), a simple bedside tool, could aid in quick risk assessment in low-resource areas, but needs thorough review. The objective of this review is to synthesize evidence on the diagnostic accuracy, clinical value, and practical use of CASS in BAT care, focusing on varied resource settings. METHODS: We searched PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar from January 2011 to October 2025 for studies using CASS in adult BAT. Relevant articles were selected based on predefined criteria, quality was assessed using QUADAS-2 and CASP tools, and findings were narratively summarized due to study differences. RESULTS: Six CASS studies (n = 1510 patients) showed sensitivity of 80%-100% (median 90%) and specificity of 60%-88% (median 74%) for predicting surgery in BAT. CASS plus FAST reached an AUC of 0.94. Practical use reduced decision time by 60% and CT scans by 57%. Limitations included single-site studies, Asian focus, and no patient outcome data, with over-triage risks of 12%-40%. CONCLUSIONS: CASS offers good sensitivity for BAT triage in low-resource areas but needs broader testing in diverse groups. It works best alongside other tools in stepwise protocols but not alone. Future work should validate this scoring system in LMICs, assess long-term outcomes, and evaluate costs.
Shrestha P, Roylance J, Onon T
… +8 more, George A, Mathew J, Goldsmith P, Evans WDG, Savage K, John JB, Briggs TWR, Gray WK
World J Surg
· 2026 Jun · PMID 42033125
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BACKGROUND: We aimed to investigate the impact of rationalizing general surgery surgical tray sets at an elective surgical hub in England. METHODS: This was an analysis of data collected prospectively for a clinical qual...BACKGROUND: We aimed to investigate the impact of rationalizing general surgery surgical tray sets at an elective surgical hub in England. METHODS: This was an analysis of data collected prospectively for a clinical quality improvement project between 25th March and 20th June 2024. Baseline data on use of surgical instruments for four general surgery procedures were collected, and the items categorized as high, medium and low use. Meetings were then held with surgical and operational teams involved in delivering each procedure and a set of surgical instruments for each procedure agreed upon and a rationalized tray was formed. RESULTS: Data were collected for 39 rectal procedures, 42 open hernia repairs, 15 laparoscopic hernia repairs and 14 laparoscopic cholecystectomies. A tailored rectal procedure tray was formed with 16 items from the original 53 items small basic tray; the two trays used for open hernia repair were rationalized from 53 to 43 items (small basic tray) and 75 to 60 items (large basic tray). The same laparoscopic tray was used for hernia repairs and cholecystectomies and was rationalized from 55 to 45 items. Estimated base-case annual financial savings were £16,863 and carbon savings 42.6 kgCOe for these four procedures. Saving of up to £62,648 and 3612.9 kgCOe annually may be realized if rationalization avoids opening a second tray to obtain items not present for use on a single tray. CONCLUSIONS: Rationalization of surgical trays can reduce financial costs and carbon emissions. It may also yield co-benefits in terms of enhancing theater efficiency.
World J Surg
· 2026 Jun · PMID 42017468
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BACKGROUND: Despite the potential benefits of patient-centered care (PCC), to our knowledge, there is no research on measuring patient-centered surgical care (PCSC) particularly in sub-Saharan Africa (SSA). This study ai...BACKGROUND: Despite the potential benefits of patient-centered care (PCC), to our knowledge, there is no research on measuring patient-centered surgical care (PCSC) particularly in sub-Saharan Africa (SSA). This study aimed to develop and test the psychometric properties of a scale for measuring PCSC in hospitals offering surgical care in SSA. METHODS: A 41-item interviewer-administered questionnaire was generated and tested by surveying 422 surgical patients in four hospitals in Malawi, chosen as a case study. After exploratory factor (EFA) and confirmatory factor analysis (CFA), standard model fit indices and qualitative judgment were used to determine the composition of the final questionnaire. Convergent and discriminant validity, composite reliability (CR) and intraclass correlation coefficient (ICC) were determined. All factor analyses were conducted using Mplus software. RESULTS: The participant average age was 46 (18-84) years, 53% (223 of 422) were male and 69% (290 of 422) were elective patients. Only 18 items (out of 41) had inter-item correlations ≥ 0.3. At CFA, 9 items (out of 18) were dropped due to low correlations and poor model fit. This resulted in a 9-item scale with 3 subscales: empowerment, patient-provider relationship, and access to surgical care (EMPAC). The instrument had good psychometric properties: RMSEA = 0.075, SRMR = 0.077, CFI = 0.958, TLI = 0.937, CR = 0.81, and ICC = 0.61. Patients with a poor satisfaction score also scored low on the PCSC scale signifying criterion validity. CONCLUSION: A novel parsimonious scale for measuring PCSC, a first of its kind for SSA, was developed using standard instrument development guidelines. The scale has shown evidence for reliability and construct validity paving the way for further validation among surgical patients in similar settings. The test-retest reliability, which was conducted on a sample of only 57 participants from four different study sites, was moderate to low (ICC: 0.61) pointing to the need for further evaluation using a larger sample size.