Frontiers in Surgery最新文献

Bone defect following debridement for calcaneal osteomyelitis presents both a clinical challenge to surgeons and a significant burden to patients. A 68-year-old male patient sustained multiple injuries, including bilateral calcaneal fractures, due to a fall from height. He underwent open reduction and internal fixation (ORIF) for bilateral calcaneal fractures and left fibular fracture at an external institution. Two months postoperatively, sinus tracts developed at the bilateral incision sites, leading to a diagnosis of bilateral calcaneal infection. The patient subsequently received multiple debridement procedures and antibiotic-loaded bone cement implantation. In our management, we performed one-stage eggshell debridement and vascularized fibular grafting immediately after removing the antibiotic-loaded bone cement. At the final follow-up, radiological evaluations revealed satisfactory graft integration and stable positioning. The postoperative Maryland Foot Score was 85 for the left foot and 90 for the right foot, indicating favorable functional recovery, with the patient reporting high satisfaction. This case suggests that one-stage eggshell debridement combined with vascularized fibular grafting, performed after the removal of antibiotic-loaded bone cement following initial debridement for calcaneal infection, can provide reliable stability and achieve favorable clinical outcomes.

Background: Non-intubated uniportal video-assisted thoracoscopic surgery (NI-UVATS) has emerged as an alternative to conventional intubated approaches, yet its applicability across diverse patient populations and procedure types remains undefined. We evaluated perioperative outcomes of NI-UVATS vs. intubated UVATS (I-UVATS) in an unrestricted cohort.

Methods: This retrospective cohort study analyzed 289 consecutive VATS procedures (January 2017-June 2025) at a single center. Patients underwent either I-UVATS (n = 166) or NI-UVATS (n = 123) based on surgeon and anesthesiologist preference. Primary outcome was serious complications (composite of mortality, reintubation, pneumonia, or reoperation). Secondary outcomes included 30-day mortality, length of stay, and procedure-specific complications. Propensity score matching (1:1) was performed to address baseline imbalances. Post-hoc stratification by procedural complexity was conducted.

Results: After propensity score matching, 98 patients in each group were analyzed. Despite matching, significant procedural heterogeneity persisted: anatomical resections comprised 36.7% of I-UVATS vs. 5.1% of NI-UVATS procedures (p < 0.001). For low-complexity procedures (n = 118), serious complications occurred in 10.8% I-UVATS vs. 7.4% NI-UVATS (p = 0.545). For medium-complexity procedures (decortications, n = 37), serious complications were comparable (16.0% I-UVATS vs. 16.7% NI-UVATS, p = 0.959). The limited number of NI-UVATS anatomical resections (n = 5) precluded meaningful comparison for high-complexity procedures. Operative time was longer in NI-UVATS (median 52 vs. 37 min, p = 0.042). Overall serious complications occurred in 14.3% I-UVATS vs. 11.2% NI-UVATS patients (p = 0.522). Thirty-day mortality was 12 (12.2%) in I-UVATS vs. 7 (7.1%) in NI-UVATS (p = 0.240), and surgery-related mortality at 1 year was 10 (10.2%) vs. 15 (15.3%), respectively (p = 0.291).

Conclusions: NI-UVATS demonstrated safety and feasibility for low-to-medium complexity thoracic procedures within current real-world selection patterns. The marked procedural imbalance (36.7% vs. 5.1% anatomical resections) reflects contemporary practice where surgeons reserve NI-UVATS for lower-complexity interventions. These findings support NI-UVATS implementation for appropriately selected patients undergoing diagnostic and pleural procedures, while anatomical resections remain predominantly performed under intubation. Procedure-specific randomized trials are needed to define the role of NI-UVATS in complex resections.

A 62-year-old man presented with bilateral posterior shoulder dislocations 2 months after sustaining an accidental electric shock while fishing. Imaging confirmed chronic locked posterior dislocations with reverse Hill-Sachs lesions and large humeral head articular defects (approximately 60% on the left and 55% on the right), together with partial-thickness supraspinatus and subscapularis tendon tears. The patient underwent staged reverse total shoulder arthroplasty. At the 12-month follow-up, he was free from pain with a markedly improved active range of motion (forward flexion, 130°; abduction, 100°) and excellent functional outcomes (constant score: 86, left shoulder; 83, right shoulder; ASES, 90). This case supports reverse shoulder arthroplasty as a viable option for a chronic bilateral posterior shoulder dislocation with substantial humeral head defects.

Background: No large-scale study has compared the outcomes of soft-tissue endoscopic surgery (SOFTES) with conventional open surgery (OS) for vascular anomalies and benign soft tissue tumors. We aimed to compare the operative safety, efficacy, and outcomes of the two approaches for soft tissue lesions.

Methods: Patients (n = 414) undergoing SOFTES or OS in two centers were retrospectively reviewed. Propensity score matching was used to minimize selection bias and group differences. The treatment outcomes were compared between the two groups.

Results: After matching, 150 patients (SOFTES: 75; OS: 75) were included. Compared with the OS group, the estimated blood loss in the SOFTES group was significantly lower [20 mL (1-500) vs. 50 mL (5-600); p = 0.001]; however, the operative duration was significantly longer [223 minutes (35-490) vs. 173 minutes (37-494); p = 0.008]. Major complications were not observed. The incidence of focal burn of skin in the SOFTES group was higher than that in the OS group (p = 0.048). The incidences of superficial peroneal nerve injury, postoperative bleeding, persistent lymph drainage, local sensory paralyses (<5 cm²), surgical site infection, hematoma/seroma, and residual mild pain were not significantly different between the two groups. However, the incidence of wound dehiscence [n = 0 (0.00%) vs. n = 7 (9.33%); p = 0.010] and flap necrosis [n = 1 (1.33%) vs. n = 11 (14.67%); p = 0.005] was significantly higher in the OS group than in the SOFTES group. Residual pain was cured or significantly improved. All patients achieved resolution of contracture had normal or near-normal joint motion.

Conclusions: Endoscopic surgery is a safe and effective treatment option for various vascular anomalies and benign soft tissue tumors in selected patients. This paradigm shift has many advantages in terms of clinical outcomes and reduces postoperative complications.

Introduction and aim: Medial closing wedge distal femoral osteotomy (MCW-DFO) is a surgical technique used to treat symptomatic valgus knee deformity. This retrospective study aims to evaluate the reliability of Patient-Specific Instrumentation (PSI) in reproducing preoperative planning and to assess preliminary clinical and radiographic outcomes in patients treated with MCW-DFO using the PSI technique compared to conventional instrumentation. This research was conducted within the framework of the Italian National Recovery and Resilience Plan (PNRR), Mission 6-Health, as part of the PNRR-MAD-2022-12375978-PEARL Project, supporting the development of precision-based surgical strategies to prevent early osteoarthritis progression.

Materials and methods: Between 2012 and 2023, 34 patients underwent MCW-DFO, of whom 16 were treated with NewClip Technics PSI and met the study's inclusion and exclusion criteria. Preoperative planning was performed using TraumaCad® software, identifying preoperative and planned mechanical femorotibial angle (mFTA) and mechanical lateral distal femoral angle (mLDFA) values. Postoperative measurements were obtained to determine the difference between planned and achieved alignment as an index of surgical reproducibility.

Results: The difference between planned and postoperative values for mFTA and mLDFA angles differed significantly between the two groups. In the PSI group, mean postoperative values differed from planned values by 0.46° for mFTA and 0.66° for mLDFA. In contrast, in the conventional instrumentation group, the difference exceeded 2° for both angles.

Conclusions: The PSI technique proved to be significantly more reliable than traditional instrumentation in adhering to preoperative planning in MCW-DFO. The integration of patient-specific technologies represents a precision-surgery approach consistent with PNRR objectives, potentially improving alignment accuracy and contributing to joint preservation strategies in patients at risk of early osteoarthritis.

Background: Zero-P VA device is a unique zero-profile device comprising only two integrated variable-angle screws which may provide inferior mechanical stability compared with other types of devices. There is a lack of comprehensive clinical and radiological evidence comparing the plate-cage construct (PCC) and the Zero-P VA device in single-level anterior cervical discectomy and fusion (ACDF).

Methods: We retrospectively reviewed consecutive patients who underwent single-level ACDF using either the Zero-P VA device (50 cases) or the PCC (51 cases). Clinical outcomes were evaluated using the Visual Analogue Scale (VAS) and Japanese Orthopaedic Association (JOA) scores. Radiological outcomes were assessed using standard lateral cervical x-ray films. Data were recorded preoperatively, immediately postoperatively, and at 3- and 12-month follow-up visits.

Results: VAS and JOA scores, cervical alignment, segmental angle, and surgical segment height were all significantly improved postoperatively in both groups. However, in the Zero-P VA group, the segmental angle and anterior height of the surgical segment at 3 and 12 months decreased significantly compared with immediate postoperative values and were significantly lower than those observed in the PCC group. The rate of segmental kyphosis was significantly higher in the Zero-P VA group at the 12-month follow-up (12% vs. 0%, p < 0.05), while fusion rates were comparable.

Conclusion: The Zero-P VA device provides short-term clinical outcomes comparable to those of the PCC for single-level ACDF. However, it is associated with inferior radiological outcomes, specifically greater loss of segmental lordosis and anterior surgical segment height. The surgeon's choice of implant therefore involves a clinical trade-off between the established surgical advantages of a zero-profile system and the superior radiological stability offered by the PCC.

The field of abdominal wall hernia surgery is transitioning from a traditional focus on anatomical repair to a more comprehensive model centered on functional reconstruction. This paradigm shift expands the primary goal from mere defect closure to the restoration of abdominal wall integrity, dynamic stability, and physiological function. This perspective article examines this progression and highlights the critical role of integrating functional reconstruction with structured perioperative management to enhance long-term surgical outcomes and patient quality of life. We explore the clinical impact of technical innovations-including minimally invasive component separation, advanced prosthetic materials, and robotic-assisted techniques-alongside the implementation of individualized perioperative care pathways. Multidisciplinary collaboration is emphasized as a foundational framework for delivering personalized treatment. Several challenges remain, including optimal material selection, comparative evaluation of surgical approaches, and health economic assessments. Addressing these issues requires robust prospective studies to strengthen the evidence base. Future directions should prioritize the development of standardized functional assessment tools, the integration of artificial intelligence in surgical planning, and the incorporation of function-oriented principles into surgical education and practice. Through these advancements, abdominal wall hernia surgery can fully evolve into a patient-centered specialty focused on achieving sustainable, long-term benefits.

Background: Internal hernias are a rare but critical cause of small bowel obstruction, with paraduodenal hernias being the most common subtype. They pose a significant diagnostic challenge due to non-specific symptoms and can lead to catastrophic outcomes like bowel strangulation.

Objectives: This report details a case of acute small bowel obstruction secondary to a paraduodenal Treitz hernia to highlight the diagnostic and therapeutic challenges and discuss key management decisions.

Case presentation: A 53-year-old male, smoker, with no surgical history, presented with severe progressive abdominal pain, vomiting, and constipation. Examination revealed abdominal tenderness and rigidity. Laboratory findings showed leukocytosis with neutrophilia, a markedly elevated creatine kinase and C-reactive protein. CT scan confirmed a small bowel obstruction with a tight transition point. An initial laparoscopic exploration was converted to open laparotomy due to poor visualization, revealing a non-strangulated paraduodenal Treitz hernia, which was successfully reduced. The patient's postoperative course was uncomplicated, with a rapid return to a liquid diet by postoperative day one.

Conclusion: This case underscores that internal hernias must be considered in patients with small bowel obstruction and no prior abdominal surgery. Timely CT imaging is crucial for diagnosis, and surgical flexibility, with a readiness to convert to open laparotomy, is essential for safe management and optimal outcomes.

Objective: To construct an artificial intelligence (AI) model based on Computed Tomography (CT) imaging and evaluate its efficacy in preoperatively predicting infected upper urinary tract calculi.

Methods: Clinical data from December 2023 to February 2025 for patients diagnosed with urinary tract calculi at the Affiliated Hospital of Hebei University were collected. Postoperative analysis of stone composition defined stones containing more than 25% struvite and/or carbonate apatite as infectious stones, with the remainder being non-infectious stones. Labelimg software was utilized to annotate the stone locations in CT images by manually outlining the stone contours. Stratified random sampling was performed at the patient level to divide the 465 enrolled patients into training, validation, and test sets at a 7:1:2 ratio (326, 47 and 92 patients, respectively), with all CT images of each patient assigned to the corresponding dataset to avoid data overlap. We documented the model's Average Precision (AP), Mean Average Precision (mAP), and Mean Recall (mR). Additionally, CT images from patients diagnosed with urinary tract calculi from December 2021 to February 2023 at our hospital were randomly selected to evaluate the model's clinical efficacy.

Results: Of the 465 patients enrolled, 134 were classified in the infectious stone group and 331 in the non-infectious stone group. The model's mAP for infectious stones in the training and validation sets was 95.3% and 95.0%, respectively. The mAP was lower at 62.4% for stones smaller than 32 × 32 pixels, and 81.3% for stones larger than this size. Of the 935 CT images analyzed from December 2021 to February 2023, the RetinaNet model achieved an accuracy of 85.17%, sensitivity of 72.78%, specificity of 93.09%, and positive and negative predictive values of 87.04% and 84.27%, respectively for predicting infectious stones. The kappa test demonstrated significant consistency between the model and infrared spectroscopy analysis (kappa value of 0.679).

Conclusion: The RetinaNet model based on CT imaging shows high specificity for predicting infectious upper urinary tract calculi, supporting its clinical value in identifying suspected cases preoperatively. However, its moderate sensitivity precludes reliable standalone ruling-out of infectious stones. When combined with routine laboratory tests (e.g., urine routine and culture), this AI model acts as a valuable complementary preoperative tool, providing auxiliary guidance for treatment strategy formulation and surgical decision-making in patients with urinary tract calculi.

Introduction: Living-donor kidney transplantation (LDKT) is the gold standard for end-stage renal disease. Traditionally, the left kidney is preferred for its longer vein. However, the "donor safety first" principle, combined with the transition to laparoscopic and robotic donor nephrectomy, has increased the frequency of using right-sided grafts or encountering "iatrogenically" shortened veins due to mechanical stapling. In this study, we report our preliminary experience evaluating the efficacy of cryopreserved vascular grafts for renal vein lengthening in LDKT to overcome anatomical vascular length limitations.

Methods: All LDKT in this series were performed using a robotic-assisted laparoscopic approach. All procedures were carried out by a dedicated and experienced surgical team thanks to a cross-institutional partnership involving two regional University Hospitals. When necessary, cryopreserved venous allografts were employed to ensure adequate renal vein length. All transplants were carried out using a standard retroperitoneal approach in the iliac fossa.

Results: From June 2024 to October 2025, nine living-donor kidney transplants were performed. The donor cohort included 7 females and 2 males with a median age of 58 years (IQR 51-69), while the recipient cohort included 4 females and 5 males with a median age of 39 years (IQR 23-55). Cryopreserved venous allografts were used in 5/9 LDKT (55.5%), following right kidney procurement. Cold ischemia time was higher in grafts requiring vascular extension than in those without elongation (median 139 min [IQR 130-141] vs. 115 min [IQR 107-121], respectively; p < 0.05). Rewarming time was also longer in the vessel extension group (median 38 min [IQR 37-40] vs. 33.5 min [IQR 31-35], respectively; p = 0.6). No intraoperative or high-grade postoperative complications were observed. At a median follow-up of 10 months (IQR 8-17), there were no deaths or graft losses. The median serum creatinine level at last follow-up was 1.6 mg/dL (IQR 1.2-1.7).

Conclusion: Renal vein lengthening with cryopreserved vascular grafts is a valuable tool in modern transplantation, addressing short veins-common in right-sided grafts and after laparoscopic or robotic stapling-and complex recipient venous anatomy. By enabling safer anastomoses, this technique supports excellent graft function while preserving donor safety.