Journal of Surgery and Research is an open access, peer reviewed journal to provide an excellent platform for the dissemination of cutting-edge developments in surgery and its related disciplines. Journal of Surgery and Research opens a medium for the surgical specialties to share the latest developments in surgery knowledge, ideas and good practice. The Journal publishes original articles, review articles, editorials, letters to the editor, short communication, case reports in the fields of General surgery, Plastic surgery, Transplantation surgery, Oncology, Trauma, Gastrointestinal and Vascular.
Wheel-spoke injuries in a resource-limited setting: A Retrospective observational study in District General Hospital Kilinochchi, Sri Lanka
Background: Wheel-spoke injuries are a common mechanism of trauma in low- and middle-income countries, especially affecting children. These injuries although common, are easily preventable. These injuries mainly occur while travelling as a pillion rider on bicycles or motorbikes. The injuries can range from minor abrasions to degloving injuries and fractures, potentially resulting in significant tissue damage. Aim: To evaluate the injury pattern, management strategies and outcomes of wheel-spoke injuries with the aim of understanding effective preventive measures in a District General Hospital in Northern Sri Lanka. Methods: A retrospective observational study was conducted at District General Hospital Kilinochchi. Records of patients who presented with wheel-spoke injuries from June 2024 to April 2026 were traced and reviewed. Data collected were the demographics, mechanism of injury, type of injury and its severity, management undergone and its outcome. Descriptive statistics were used to summarize the data and comparative analyses were performed to assess the differences between the groups. Results: Mean age was 5.7 years. Females comprised of 59.1%. Severe injuries accounted for 9.3%. Surgical intervention required in 38.6%. On Comparative analysis, • Severity vs Surgery: p < 0.001 • Delayed presentation vs severity: p = 0.041 • Delayed presentation vs surgery: p = 0.048 • Delayed presentation vs complications: p = 0.032 Conclusion: Wheel-spoke injuries are preventable, but common and significant mechanism of injury found in certain communities. Delayed presentation significantly worsens the injury severity, need for surgical intervention and complication rates. Therefore, early presentation could be considered a critical modifiable factor in the management of patients with wheel-spoke injuries.
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Effect of Postoperative Immobilization Following Volar Plate Fixation of Distal Radius Fractures on Functional Outcomes and Wrist Stiffness: A Retrospective Cohort Study
Background: Distal radius fractures are the most common upper limb fractures specifically in the elderly population. Open Reduction Internal Fixation with Volar plating remains the preferred method for Surgical Fixation in unstable fractures. There is a common practice to keep the fracture immobilized to ensure comfort and stability. This study evaluates postoperative patient-reported outcomes and stiffness in patients undergoing ORIF who experienced prolonged casting (>14 days) in the peri operative period. Methods: This retrospective cohort study was conducted at DGH in UK. A total of 150 patients who underwent volar plate fixation for distal radius fractures between July 2024 and December 2025 were included. Patient demographics, fracture characteristics, and operative details were extracted from electronic medical records. Functional outcomes were assessed using the Patient-Rated Wrist Evaluation (PRWE) score at ≥6 months, and wrist stiffness was assessed from clinic documentation at 3 months. Results: PRWE data were available for 115 patients. Patients managed without postoperative backslab immobilisation demonstrated significantly lower PRWE scores compared with those treated with backslab immobilisation (13.47 ± 17.20 vs 21.50 ± 23.21, p = 0.036). Stiffness rates at 3 months were similar between groups (31.3% vs 34.3%, p = 0.692). Conclusions: Our Study findings support timely surgical fixation in line with BOAST guidance and advocate early postoperative mobilization without routine casting to improve outcomes & reduce healthcare burden.
A Rare Case Report of Synchronous Gastric Cancer and Jejunal Gastrointestinal Stromal Tumor
Mucinous adenocarcinoma of stomach and synchronous jejunal gist is a rare entity and here we present a case of 63 year old female with mucinous gastric adenocarcinoma in antropyloric region of stomach and gastrointestinal stromal tumor at proximal jejunum just distal to duodenojejunal flexure and the complexity faced in surgical management of the above case.
Olecranon Fractures with associated Radial Head or Coronoid Injuries and Terrible Triad Variants: A Systematic Review of Outcomes
Olecranon fractures with associated radial head or coronoid injuries, often termed “terrible triad” variants, are complex elbow injuries that pose challenges in both surgical management and functional recovery. These injuries combine bony comminution with potential ligamentous disruption, increasing the risk of instability, stiffness, and post-traumatic arthritis if inadequately addressed. This systematic review evaluated studies reporting on surgical management of such injuries, focusing on functional outcomes, union rates, complications, and rehabilitation strategies. Across included studies, comprehensive surgical treatment comprising open reduction and internal fixation of the olecranon, fixation or replacement of the radial head, and ligamentous repair when indicated. It was associated with high union rates and good to excellent functional recovery. Early intervention and structured postoperative rehabilitation further optimized motion and strength restoration. Complications were generally low and manageable. Despite favorable outcomes, heterogeneity in fracture patterns, surgical techniques, and follow-up durations limits direct comparisons. Standardized, prospective studies are needed to refine surgical strategies and rehabilitation protocols, guiding optimal care for this challenging injury subset and improving long-term elbow function.
Perioperative Anxiety and Stress Cortisol on Postoperative Pain: Pharmacological and Non-Pharmacological Management Strategies
Postoperative pain remains a significant clinical challenge associated with delayed recovery, prolonged rehabilitation, and increased healthcare utilization. Despite advances in analgesic techniques, outcomes remain variable, suggesting that non-physical factors such as perioperative stress and anxiety play an important role. A relationship between perioperative anxiety, stress, and postoperative pain was examined with emphasis on physiologic mechanisms, assessment strategies, and management approaches. A narrative review was conducted using PubMed searches of the studies published in last 25 years. Search terms included cortisol, stress, perioperative surgery, postoperative pain, sex differences, questionnaires, and therapeutic interventions. Peer-reviewed studies involving human subjects were included if they evaluated perioperative stress, cortisol dynamics, postoperative pain, or related interventions. Preoperative anxiety is consistently associated with increased postoperative pain and higher analgesic requirements. Activation of the Hypothalamic-Pituitary- Adrenal Axis and subsequent cortisol release represents a key mechanism linking stress to pain modulation; however, significant variability limits the role of cortisol as a standalone biomarker. Validated tools such as the Brief Measure of Emotional Preoperative Stress, State-Trait Anxiety Inventory, and Hospital Anxiety and Depression Scale can identify highrisk patients but remain underutilized. Sex differences are evident, with women reporting higher pain scores and stronger associations between anxiety and postoperative pain. Non-pharmacological interventions, including music therapy and perioperative communication, demonstrate modest benefit, while pharmacological strategies show variable efficacy. Perioperative stress and anxiety significantly influence postoperative pain outcomes. A multimodal, patient-centered approach incorporating structured assessment and targeted interventions may improve recovery and optimize perioperative care.
Endoscopic Evacuation of Deep Intracerebral Haemorrhage Versus Medical Treatment; A Retrospective Cohort Study
Purpose: Spontaneous deep supratentorial haemorrhage is associated with high morbidity and mortality. There is limited evidence on surgical treatment possibilities. This study evaluates the effect of acute minimally invasive surgery (MIS) using the Artemis neuro evacuation device versus medical management alone in patients with spontaneous deep intracerebral haemorrhage (ICH). Methods: Eleven patients with spontaneous ICH who underwent acute endoscopic surgery with the Artemis system were matched 1:1 with nonsurgical patients, resulting in a total of 22 patients in the study. Results: The 30-day mortality was 18% in the surgical group and 36% in the non-surgical group (RR=0.5; [95%CI = 0.11;2.19]). Overall mortality was 18% for the surgical group and 45% for the non-surgical group (RR=0.4; [95%CI = 0.10;1.64]). The mean modified Rankin Scale score was 3.82 for the surgical group and 4.45 for the non-surgical group (P=0.3761). Conclusion: Surgery using the Artemis neuro evacuation device showed a tendency to reduce 30-day mortality in patients with spontaneous basal ganglia intracerebral haemorrhage. These results support the need for a randomized controlled trial of MIS using the Artemis system compared to medical management alone.
A Rare case of Meckels diverticulum rupture with a foreign body
Introduction: Meckel’s Diverticulum (MD) is the most common congenital anomaly of gastrointestinal tract due to incomplete obliteration or persistence of proximal part of the Vitello intestinal tract. Perforation of Meckel’s diverticulum could be a rare but life-threatening complication as it can lead to generalized peritonitis which may progress to sepsis. Cases of perforation due to foreign bodies are reported with fish bone being the most common, but a perforation with a sugar cane fiber was not found in the literature reviewed. Case presentation: Most patients with MD will be asymptomatic however when symptoms occur, they often mimic acute appendicitis. A 36-year-old lady presented with periumbilical and right iliac fossa pain with examination revealing RIF tenderness with normal inflammatory markers and an ultrasound scan finding of a prominent appendix and fluid filled cecum. She underwent a diagnostic laparoscopy which revealed a perforated Meckel’s diverticulum with a foreign body which was a sugar cane fiber. The histology revealed dual pathology of appendix with peri appendicitis and Meckel’s diverticulum with pancreatic tissue within it. Conclusion: This case emphasizes on diagnostic difficulty and need of early intervention in cases of complicated Meckel’s diverticulum. Perforation of a Meckel’s diverticulum with a foreign body is rare but potentially life threatening and requires early recognition to avoid high morbidity. Resection is the main mode of management for complicated MD and that for uncomplicated depend on each case.
Robotic eTEP Versus Robotic Transversus Abdominis Release (rTAR) for Complex Ventral Hernia Repair: A Systematic Review and Meta-Analysis
Complex ventral hernia repair is an involved area in abdominal wall surgery especially among patients who have big defects, recurrent hernias or a big abdominal wall weakness. Conventional open repair surgery is considered to cause increased morbidity after surgery, and delayed recovery. Robotic surgery has recently become one of the latest forms of minimally invasive surgery that allows a surgeon to carry out a complex abdominal wall reconstruction with better visualization, known to be more dexterous in provision and better ergonomic than traditional laparoscopy. Two of the robotic methods that are today applied to the repair of ventral hernia, the robotic extended totally extraperitoneal repair (eTEP) and robotic transversus abdominis release (rTAR) have become increasingly popular. The two methods support the insertion of retromuscular mesh and seek to provide lasting repair of hernias with minimum intraperitoneal complications. The purpose of this systematic review and meta-analysis is to find the differences in perioperative and postoperative outcomes of robotic eTEP and robotic TAR in treating complex ventral hernia. To locate the studies providing the outcomes of robotic abdominal wall reconstruction methods, the thorough literature search in the large electronic databases such as PubMed, Scopus, Web of Science, and Embase was carried out. They included studies of adult patients that undergo ventral hernia repair through robotic eTEP or robotic TAR. Her mother had hernia recurrence and general postoperative complications as the primary outcomes and operation time, length of hospital stay, seroma formation and surgical site infection as the secondary outcomes. The combined evidence indicates that robotic eTEP and robotic TAR are safe and effective methods of a complex ventral hernia repair. Robotic eTEP was mostly linked with shorter operative time and less hospital stay whereas robotic TAR was more likely to be used to treat a large or complex defect because it could provide more fascial medialization. Complications and second time outcomes were similar in regards to overall complications and recurrence. Finally, robotic eTEP and robotic TAR are capable of being effective minimally invasive interventions in the repair of complex ventral hernias. The technique is to be selected personally depending on the nature of the hernia, patient and the experience of the surgeon. Additional superior comparative research works will be necessary to develop the best surgical management techniques.
The Role of Ulnar Styloid Fixation in Surgically treated Distal Radius Fractures: A Systematic Review
Distal radius fractures are frequently associated with ulnar styloid fractures, yet the clinical benefit of fixing the ulnar styloid remains uncertain. This systematic review evaluated whether ulnar styloid fixation improves pain, function, wrist mobility, or distal radioulnar joint (DRUJ) stability following surgical treatment of distal radius fractures. A comprehensive literature search of PubMed, Embase, Scopus, and the Cochrane Library was conducted according to PRISMA 2020 guidelines, including studies comparing outcomes with and without ulnar styloid fixation. Data on pain, functional scores (DASH/PRWE), wrist range of motion, and DRUJ stability were extracted, and risk of bias was assessed using ROBINS-I, AMSTAR 2, or Cochrane RoB 2 tools. Nine studies comprising 680 adult patients were included. Across these studies, routine ulnar styloid fixation did not provide significant improvement in pain, functional outcomes, or wrist mobility. Selective fixation for basal fractures associated with DRUJ instability may offer targeted benefits. Overall, the evidence suggests that routine ulnar styloid fixation is generally unnecessary, and surgical decision-making should prioritize DRUJ assessment to optimize outcomes while minimizing operative morbidity.
How healthy is “healthy”? The Gastrointestinal Quality of Life Index (GIQLI) and the “Screening Instrument for Somatoform Disorders” (SOMS) in a Non-Patient Self-Identified Healthy Cohort
The Gastrointestinal Quality of Life Index (GIQLI) is a widely used tool for assessing quality of life (QoL) in patients with gastrointestinal diseases. However, normative data from non-patient populations remain limited, particularly regarding the influence of factors such as age, gender, and somatization. This study aimed to provide normative GIQLI data from a large sample of self-identified healthy individuals and explore the impact of somatization on the GIQLI outcomes. A total of 259 participants from two German villages completed the GIQLI and the Screening Instrument for Psychosomatic Disorders (SOMS). Results showed a mean GIQLI score of 121.22, consistent with previously reported values for healthy populations. GIQLI scores were stable across age groups and genders, with slight declines observed in older participants. Notably, 6.95% of participants exhibited a high symptom burden (SSI > 17), despite selfidentifying as healthy, and demonstrated significantly lower GIQLI scores. These findings highlight the importance of accounting for baseline symptom levels in non-patient populations when interpreting QoL data. The study provides a robust dataset for future comparisons with clinical populations and underscores the interconnected nature of GIQLI dimensions. This expanded normative database enhances the utility of GIQLI in patientcentered decision-making and QoL assessments.
Predictive Value of the Red Cell Distribution Width to Albumin Ratio For Hospitalization due to Inflammatory Bowel Disease Flares
Background: Hospitalizations for inflammatory bowel disease (IBD) flares remain common despite advances in biologic therapy and outpatient monitoring. Clinicians still lack simple, low-cost tools that identify patients at imminent risk for severe flare before clinical deterioration occurs. Objective: To evaluate whether the red cell distribution width to albumin ratio (RAR), a composite biomarker derived from routine laboratory testing, predicts hospitalization for IBD flare when measured weeks to months prior to presentation. Methods: We performed a retrospective cohort study of adults with ulcerative colitis (UC) or Crohn’s disease (CD) admitted between 2021 and 2023. The most recent outpatient or emergency department RDW (%) and serum albumin (g/dL) obtained within three months prior to admission were used to calculate RAR. The primary predictor was RAR ≥4.3. The primary outcome was hospitalization for IBD flare confirmed by detailed chart review. Results: Among 41 patients (mean age 47.9 ± 18.8 years; 46.3% female), 22 (53.7%) were hospitalized for IBD flare. Mean RAR was 4.57 ± 1.93, and 16 patients had RAR ≥4.3. Elevated RAR was strongly associated with flare related hospitalization (OR 9.9, 95% CI 1.52–64.24; p=0.01). Other demographic and behavioral variables were not significantly associated with hospitalization. Conclusion: An elevated RDW to albumin ratio measured up to three months prior to presentation was strongly associated with hospitalization for IBD flare. RAR represents a pragmatic, low-cost biomarker that may enable earlier outpatient intervention and offers a promising foundation for prospective, biomarker-guided flare prevention strategies.
Efficacy of Minimally Invasive Surgery (Mis) Versus Open Surgery for Advanced Gastrointestinal Cancers
Background: Minimally invasive surgery (MIS) has obtained increasing popularity, mainly the laparoscopic and robotic approaches, for the treatment of gastrointestinal (GI) malignancies. Nevertheless, it is still controversial whether such surgeries are equally effective for advanced GI cancers as conventional open surgeries. Objective: To assess perioperative and oncological outcomes after minimally invasive surgery (MIS) or open surgery for advanced gastrointestinal cancers and to compare the two approaches. Methods: By conducting a thorough literature search in PubMed, PMC and other major databases, we identified studies in which the authors had compared MIS and open surgery for advanced gastric and colorectal cancers. Odds ratios (OR) with 95% confidence intervals (CI) were combined using the random effects models. The extent of variation due to heterogeneity was determined using the I² statistics. Results: Various studies, including randomized controlled trials and observational cohorts, were analyzed for this meta-analysis. MIS resulted in a significantly reduction of postoperative complications and comparable oncologic outcomes. For anastomotic leak, the combined OR was 0.56 (95% CI: 0.29-1.07) favouring MIS, with very low heterogeneity (I² = 7%). The results of gastric and colorectal cancers were similar in the subgroup analysis. Conclusion: When performed in highly experienced centers, MIS offers comparable oncological safety and superior perioperative outcomes compared with open surgery in patients with advanced GI cancers.
Sentinel Lymph Node in Non-Small Cell Lung Cancer: Longterm Outcomes and Immunopathological Consequences
Background: Lymph-node staging is pivotal in non-small-cell lung cancer (NSCLC). While systematic lymph-node dissection (SLND) is standard, it may blunt anti-tumour immunity. Sentinel lymph-node (SLN) mapping could deliver robust staging with less immune disruption. We assessed survival outcomes and lymph-node immune profiles associated with SLN mapping in NSCLC surgery. Methods: This retrospective study of 266 patients who underwent major lung resection with SLN identification (Dec 2020–Sep 2025) assessed overall survival (OS) and disease-free survival (DFS). Translational analyses compared immune populations in SLN vs. non-SLN and node-positive (pN+) vs. node-negative (pN0) samples, using immunohistochemistry (IHC; 10 SLN and 10 pN+ patients) and flow cytometry (FCM; 13 pN0 SLN and 4 pN+ patients). Results: SLN was detected in 80.1% of patients (213/266). In patients with NSCLC, upstaging occurred in 6.6% (11/167), with a false-negative rate of 2.6% (4/156). Median OS was 27 months for SLN pN+ and not reached for SLN pN0 (HR 9.7, 95% CI 2.61–36.22; p<0.001); median DFS was 12 months for SLN pN+ and not reached for SLN pN0 (HR 10.1, 95% CI 3.68–27.83; p<0.001). IHC and FCM demonstrated a comparable immune environment between SLNs and non-SLNs in pN0 patients for key immune compartments (CD4, CD8 T cells, memory subsets), while metastatic lymph nodes displayed disrupted architecture and altered cytotoxic Tcell markers. Conclusions: SLN micrometastasis is a strong prognostic marker. SLN mapping may provide accurate staging while preserving nodal immunity, representing a conservative alternative to SLND in early-stage NSCLC, and warrants confirmation in larger, prospective studies.
Frequency and Clinical Correlates of Low Bone Mineral Density among Adults Attending a Tertiary Care Diagnostic Center
Background: Osteoporosis is a major global public health concern that primarily affects older populations and postmenopausal women. Reduced bone mineral density (BMD), which raises the risk of fracture, is the condition's defining feature. This study aimed to ascertain the prevalence of low bone mineral density (BMD) and its clinical correlates among adults having their BMD evaluated at a tertiary care diagnostic center. Methods: A cross-sectional study was conducted at Square Hospitals Ltd., Dhaka, Bangladesh, from June 2022 to February 2023 among 826 adults who underwent dual-energy X-ray absorptiometry (DXA) scanning. BMD measurements were taken at the lumbar spine (L1-L4) and femoral neck. The participants were categorized as normal, osteopenia, or osteoporosis based on WHO criteria. Age, sex, and body mass index (BMI) were among the demographic information recorded. Data were analyzed using SPSS version 26, including Chi-square tests, correlation analyses, and multivariable logistic regression. Results: 90.8% of the population was female, and the mean age was 63.2±9.4 years. Osteoporosis was found in 30.9% of cases, and osteopenia in 50.6% of cases. 66.1% of participants had low bone mineral density at the femoral neck. While higher BMI demonstrated protective effects with a 12% reduction per unit increase (AOR=0.88, 95% CI: 0.85-0.92, p<0.001), advanced age independently increased osteoporosis odds by 5% annually (AOR=1.05, 95% CI: 1.03-1.07, p<0.001). There was no significant predictor of sex. Age-BMD correlations were negligible, and correlation analyses showed a weak positive relationship between BMI and lumbar spine BMD (r = +0.148). Conclusion: With more than 80% of the population having either osteopenia or osteoporosis, the study shows a high burden of low BMD. In tertiary care settings, age and BMI were found to be significant independent predictors, highlighting the necessity of focused screening and early intervention techniques.
Beyond Aesthetics: The Impact of Facial Non-Melanoma Skin Cancer (NMSC) Surgery on Patient Quality of Life
Facial non-melanoma skin cancer (NMSC) is the most common skin malignancy and often requires excision with reconstruction. Oncological outcomes are favorable, but effects on aesthetics and psychosocial wellbeing are less defined. We examined whether reconstructive technique influences patient-reported outcomes one year after facial NMSC surgery. Methods: In a prospective cohort at Zealand University Hospital, Denmark, patients underwent facial excision closed by either direct suturing (DS) or flap surgery (FS). Outcomes were measured with the FACE-Q Skin Cancer module: satisfaction with appearance, scar perception, cancerrelated anxiety, and quality of life. Results: Of 225 enrolled patients, 52 (23.1%) completed one-year follow-up (DS n=38; FS n=14). Mean scar satisfaction scores were 91/100 for DS and 71/100 for FS. Cancer-related anxiety was higher after FS versus DS (23 vs 14/100; p=0.005). Overall satisfaction with facial appearance did not differ significantly. Stratification suggested outcomes depended more on anatomical site than technique. A modest inverse correlation was observed between scar satisfaction and cancer worry (r=−0.34). Conclusions: Reconstructive technique influenced patient-reported outcomes, with FS associated with lower scar satisfaction and greater cancer-related anxiety. Site effects were prominent: nasal defects—often requiring flaps—had the lowest satisfaction, whereas cheek and forehead procedures showed high satisfaction irrespective of closure method.
The Effects of Vascular Tissue Transplantation and Anastomosis at Different Storage Time Periods on Tissue Repair in a Rat Ischemia Model
Vascular occlusion-induced ischemia can occur in any part of the body, causing oxygen deprivation and microvascular dysfunction, which restricts blood flow to muscles, tissues, and organs. The severity of ischemia depends on whether the vessel is partially or completely occluded, with symptoms varying based on the degree of blood flow restriction. Objectives: To study the effects of different time periods after ex vivo vascular tissue transplantation and anastomosis on tissue repair in ischemic models. Methods: Fifty male Wistar rats (Rattus norvegicus, body weight: 200- 300 g, age: 8 weeks) were obtained from the Biomedical Institute and Experimental Animal Center of the National Institute of Medical Sciences. The rats were randomly divided into two groups: Control Group (n=10): Underwent direct end-to-end vascular grafting of a 0.3-0.5 mm diameter artery in the right femur. Experimental Group (n=40): Underwent end-toend microvascular grafting using donor vessels preserved for 3 days and 7 days. Results: In the limb ischemia model, in the end-to-end anastomosis of allogeneic vascular transplantation, the tissue cell ischemia-reperfusion injury recovery ability of the vascular anastomosis preserved for 3 days was better than that of the vascular anastomosis preserved for 7 days. Conclusion: In the limb ischemia model, microvascular transplantation surgery showed different degrees of tissue edema, uneven cell distribution, tissue necrosis and other phenomena, which were more obvious in the 7 day ischemia group. When selecting vascular transplantation anastomosis, through our comparative study, it is best to choose blood vessels with a shelf life of less than 3 days.
Risk-Stratified Use of Topical and Infiltrative Local Anesthetics in High- Risk Dermatologic Surgery
Local anesthetics are fundamental to dermatologic practice, yet their safety profile requires nuanced understanding in high-risk contexts including end-arterial sites, barrier-compromised skin, and scenarios predisposing to systemic toxicity. This narrative review synthesizes contemporary evidence across these three interacting domains to provide an integrated, risk-stratified framework for clinical decision-making. Regarding endarterial territories, over two decades of clinical evidence encompassing more than 200,000 digital and acral injections has effectively dismantled the historical dogma against epinephrine use in digits, nose, ear, and penis, demonstrating an excellent safety profile when dilute concentrations are used in patients with adequate perfusion, with phentolamine providing reliable rescue for rare, prolonged vasoconstriction. In barriercompromised skin (e.g. burns, ulcers, and inflammatory dermatoses) topical anesthetics function as absorption amplifiers, with dramatically accelerated systemic uptake that can precipitate local anesthetic systemic toxicity or prilocaine- and benzocaine-induced methemoglobinemia, particularly in infants and frail elderly patients. For large, denuded areas, dilute tumescent infiltration offers a pharmacokinetically safer alternative to high-dose topical therapy. The review details systemic toxicity risk factors, recognition, and management, emphasizing that intravenous lipid emulsion therapy has transformed severe toxicity from an often-fatal event to a manageable emergency. Special considerations for pediatric and geriatric populations, drug interactions, and cumulative dosing across modalities are addressed. The overarching conclusion is that context-sensitive risk stratification which includes integrating vascular status, barrier integrity, and host pharmacokinetics combined with office preparedness including phentolamine and lipid emulsion, enables safe local anesthesia even in traditionally high-risk dermatologic scenarios.
Congenital Common Bile Duct Agenesis: An Extremely Rare Anomaly - Two Case Reports and Review of Literature
Variations of the hepatico-pancreatic-biliary system are frequently vascular, but biliary duct deviations can occur.1 In the extra-hepatic biliary system, anomalies occur during foregut development and include accessory ducts, anomalous insertions, or agenesis. Though anomalies may be clinically silent, discovery usually occurs in symptomatic patients resulting in imaging or intraoperatively during exploration. The rarest of anomalies is common bile duct agenesis, resulting in formation of a cholecystohepatic duct, gallbladder interposition, or perhaps most appropriately, a hepaticocystic duct.2-3 We present here two cases discovered intraoperatively and an updated review on this anomaly.
Biomarkers and Diagnostic Criteria for Early Differentiation of Transfusion- Related Acute Lung Injury and Transfusion-Associated Circulatory Overload: A Systematic Review
Transfusion-related respiratory complications, including transfusionrelated acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO), are major causes of morbidity and mortality in transfused patients. Differentiating these conditions is challenging due to overlapping clinical presentations but is critical for appropriate management. This systematic review synthesizes current evidence on biomarkers and diagnostic criteria to enable early and accurate differentiation of TRALI and TACO. A comprehensive literature search identified six studies examining cardiac biomarkers (BNP, NT-proBNP), endothelial injury markers (syndecan-1), and inflammatory cytokines (IL-6, IL-8, TNF-α). NTproBNP and syndecan-1 were consistently elevated in TACO, reflecting circulatory overload and glycocalyx disruption, whereas inflammatory cytokines were associated with TRALI, indicating immune-mediated capillary leak. Integrated approaches combining biomarkers with clinical assessment and imaging improved diagnostic accuracy, particularly in overlapping cases. Limitations include small sample sizes, single-center designs, and variability in biomarker thresholds. These findings support the use of a multimarker strategy to guide early differentiation, optimize targeted interventions, and reduce misclassification. Future research should focus on prospective validation of biomarker algorithms and their impact on patient outcomes.
Stoma Intubation, Isolation and Negative Pressure Wound Therapy for Complex Stoma-Associated Wounds: New Technique and Case Series
Background: The use of negative-pressure wound therapy (NPWT) in colorectal surgery has been demonstrated for treating perineal defects, enterocutaneous fistula and stoma dehiscence. Here we describe a technique for closure of complex stoma-associated wounds using a novel commercial intubation device alongside NPWT to protect the surrounding wound from the stoma effluent. Clinically the patients were managed by an MDT approach including specialist nurse practitioners, dieticians, colorectal nurses, stoma nurses and critical care. The device has previously described for use with enterocutaneous fistula. We present two cases that have been successfully treated with this technique. Technique and Cases: The first case is of an 88 year-old women with a retracted loop ileostomy and the second a 48 year-old male with a retracted end colostomy. Both patients underwent significant emergency peristomal debridement and in both cases the commercial device was deployed to intubate the stoma. VAC foam and standard adhesive dressings were used to form a quality seal and the pressure set to 125mmHg. In both cases near complete healing was achieved to the point that standard stoma bags and management could be used. Conclusion: This is the first description of the use of an isolation device in complex stoma associated wounds. We have found the Fistula Funnel to be safe in this context.
Metabolic Pathway Alterations in Glioblastoma Stem Cells Under Hypoxia: Computational Analysis of Hypoxia-Activated Pathways
Therapy resistance in glioblastoma stem cells (GSCs) often arises in hypoxic microenvironments, yet most computational studies analyze single pathways in isolation. Here, we introduce HypoPINN-lite, a graph-based framework that integrates differential expression, enrichment analysis, and pathway interaction modeling to capture multi-pathway crosstalk under hypoxia. Applying this approach to transcriptomic profiles from GSE77307, we identified a tightly coupled metabolism–inflammation module linking glycolysis (LDHA, GLUT1), fatty acid synthesis (FASN), oxidative phosphorylation, and COX-2 signaling (PTGS2). Unlike standard enrichment, which highlights pathways independently, our framework reveals that hypoxia drives these pathways to function as a single adaptive collapse network. This convergence suggests therapeutic leverage points: disrupting both metabolic and inflammatory edges may destabilize the module and prevent adaptation. Beyond glioblastoma, HypoPINN-lite is generalizable to other cancers and stress conditions, offering a systems-level strategy to identify multi-pathway vulnerabilities invisible to traditional analyses.
Environmental Discourse in Orthopedic Surgery Publications: Are we on par with other surgical subspecialties?
Aims: The U.S. health system produces 8%-10% of national greenhouse gas (GHG) emissions with operating rooms (ORs) being the most resourceintensive area [1,2]. Orthopedic surgical cases generate significant waste from disposable procedure packs, large instrument trays, and single use instruments [2]. This study evaluates publishing trends in the top five journals with the highest impact factor within nine surgical subspecialties related to environmental stewardship and planetary health, highlighting challenges and opportunities for future research. Methods: Using the Journal of Citation Reports (JCR) Database, the five highest impact factor (IF) journals 9 surgical subspecialties were identified. Publications were reviewed over a 25-year period (1999-2024). Articles including environment and one other key word [environment, environmental impact, sustainability, carbon footprint, GHG emissions, greenhouse, climate, recycling and waste] underwent initial review. Articles were categorized and identified as primary research or review articles. Results were tabulated as n, percentages, and means. Results: Of 4,263 articles reviewed, 131 were included in the final analysis. Publications on environmental impact and sustainability surged beginning in 2019. Anesthesiology had the greatest number of publications (47/131), plastic surgery had the least (2/131) and orthopedic surgery had the second fewest publications (4). Most publications (78/131 or 60%) were review articles. Average impact factor was highest in general surgery publications (14.1) and fifth highest in orthopedic surgery (5.1). Waste audits were the most common article classification (21%) followed closely by anesthetic gases (17%). Conclusion: While orthopedic surgery is a high-volume specialty and generates significant waste and GHG emissions, it falls behind other subspecialties in publishing literature related to the environment. Public awareness of climate change has grown significantly, but the medical profession has not kept pace. The future of health systems requires a better understanding of how to protect planetary health to avoid future losses to patient and population health and well-being.
A Prospective Study on Early Postoperative Outcomes Following Laparoscopic and Open Ventral Hernia Repair
Background: Ventral hernia repair is a common surgical procedure that involves evolving approaches. Laparoscopic repair is increasingly performed due to its potential to minimize postoperative morbidity; however, evidence from Bangladesh remains limited. This study aimed to compare the early postoperative outcomes between laparoscopic and open ventral hernia repair in a tertiary-care setting. Methods: This prospective comparative study was conducted at the Shaheed Suhrawardy Medical College Hospital and Enam Medical College Hospital, Dhaka, from January 2024 to July 2025. Seventy-eight patients with ventral hernias were randomized into two equal groups: laparoscopic (n = 39) and open (n = 39). Data on the perioperative outcomes, hospital stay, return to activity and early post-operative complications were collected and analyzed using SPSS 25.0. Results: The mean operative time was longer for laparoscopic repair (110.5 ± 28.6 min vs. 85.2 ± 22.1 min, p < 0.001). However, laparoscopic repair resulted in significantly less blood loss (40 ± 25 mL vs. 120 ± 90 mL), lower pain scores, fewer analgesic doses, shorter hospital stay (2.8 ± 1.4 days vs. 5.6 ± 2.9 days) and earlier return to activity (10 days vs. 22 days). However, the mesh-related complications were collectively higher after laparoscopic repair (25.6% vs. 5.1%). Conclusion: Laparoscopic ventral hernia repair provides superior shortterm recovery benefits but carries an increased risk of wound and meshrelated complications. The choice of technique should therefore be individualized, balancing recovery advantages against the higher risk of mesh-specific morbidity.
Eosinophilic Esophagitis induced by semaglutide use: A case report
We report the case of a 46-year-old male patient undergoing treatment with a GLP-1 receptor agonist (semaglutide) for six months, who developed progressive dysphagia to solids and a retrosternal foreign body sensation. An upper endoscopy revealed impacted food at 40 cm from the dental arch, which was successfully advanced into the stomach. At the same location, three small fibrin-covered ulcers were identified. Histopathological analysis of esophageal biopsies confirmed the diagnosis of eosinophilic esophagitis. Follow-up evaluations at one and three months showed the patient remained asymptomatic, adherent to an allergen-free restrictive diet and proton pump inhibitor therapy, without resuming semaglutide and without requiring corticosteroid treatment. This case highlights the importance of recognizing potential adverse effects of pharmacological agents, even when they are rare or scarcely reported in the literature. Such awareness may improve patient outcomes and provide valuable insight for clinicians managing similar presentations.
The Growing Value of Multicentre, Prospective, Real-world Data: Early- Outcomes of 1000 Patients with the Avalus Aortic Valve
Background: As cardiac surgery becomes increasingly complex, real-world data is essential to evaluate bioprosthetic valve performance beyond controlled trials. The Avalus Clinical confidencE (ACE) registry provides real-world insights into the safety and effectiveness of the Avalus valve across diverse patient populations. Methods: The ACE registry is a prospective, multicentre, single-arm, observational study including 1000 patients undergoing surgical aortic valve replacement with the Avalus bioprosthesis in 26 European centres between 2021-2023. Exclusion criteria were age <18y and salvage surgery, which lead to a real-world study population undergoing aortic valve replacement, either isolated or combined with various other procedures. Primary endpoints included all-cause mortality and disabling stroke. Secondary endpoints assessed prosthetic valve function and major complications. Clinical status and echocardiographic performance were evaluated at discharge and at one-year follow-up. Results: In an all-comers population (mean age: 71.5±6.6years, mean EuroSCORE II: 3.4±5.8), early all-cause mortality was 1.7%. Median implanted valve size was 24mm, with 19.3% of valves being a 19 or 21mm prosthesis. Echocardiographic assessment at discharge showed a mean gradient of 11.6±5.3mmHg, with an effective orifice area of 1.98±0.61cm². Severe patient-prosthesis-mismatch (PPM) was observed in only 5.0% of patients, while 73.9% had no PPM. At one-year followup (n=703), overall mortality remained low at 3.3%, with continued stability in valve performance (mean gradient: 12.2±4.9mmHg). Functional improvement was significant, with 74% of patients improving to NYHA class I or II. Conclusions: The ACE registry shows low stroke and mortality rates in a complex real-world population, with excellent hemodynamics and minimal PPM at one-year follow-up.
Epidemiology and Management of Postoperative Infections in Hepatectomy and Pancreaticoduodenectomy
Infections remain a major source of postoperative morbidity and mortality following complex bile duct surgeries, namely hepatectomy and pancreaticoduodenectomy. Infection rates remain high—ranging from 24% to 61%—and are influenced by multiple factors, including patient comorbidities, surgical complexity, and perioperative variables such as prolonged operative time, excessive blood loss, and preoperative biliary drainage. Disruption of the biliary barrier due to drainage or stent placement promotes bile stasis, microbial colonization, and biofilm formation, facilitating the emergence of multidrug-resistant (MDR) pathogens such as Escherichia coli, Klebsiella pneumoniae, and Enterococcus species. These resistance mechanisms—such as β-lactamase production, altered membrane permeability, efflux pump activity, and target site modification— make antimicrobial therapy increasingly complex, prolonging recovery, hospitalization, and healthcare costs. Diagnosis is often challenging and relies on a combination of clinical assessment, inflammatory markers (including leukocytosis, C-reactive protein, and procalcitonin), and microbiological cultures from bile, wound, or drainage fluid. Once infection is confirmed, management requires early recognition, empirical broad-spectrum antibiotic coverage, and subsequent de-escalation based on susceptibility testing. To prevent recurrence, effective source control through interventional drainage or reoperation is essential. In select cases, antifungal therapy may be indicated, particularly in the presence of Candida coinfection associated with biliary interventions or prolonged antibiotic exposure. Preventive strategies—including optimized perioperative care, tailored antibiotic prophylaxis, nutritional optimization, and minimally invasive surgical approaches—are vital to reduce infectious risk. Future efforts should focus on refining risk stratification, advancing rapid diagnostic methods, and developing evidence-based protocols to address the growing challenge of MDR infections and improve postoperative outcomes in hepatobiliary surgery.
Management of Postoperative Infections in Hepatectomy
Pancreaticoduodenectomy. Journal of Surgery
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Efficacy of Endoscopic Vs. Surgical Management of Gastroesophageal Reflux Disease (Gerd)
Background: Various treatment methods like, medications, endoscopic procedures or surgery have been used to treat chronic and debilitating condition i.e., gastro- esophageal reflux disease (GERD). Because endoscopic and surgical treatments differ in terms of their effectiveness, safety and likelihood of recurrence, which is the better option is still up for debate. Objective: The goal of this study is to thoroughly examine and compile data from high quality studies that compare surgical and endoscopic treatment for GERD, in order to determine which treatment is superior in efficacy using statistical techniques. Methods: Articles from 2010 to 2025 were analyzed, including cohort studies, randomized controlled trials and other meta-analyses. Heterogeneity, odds ratios and confidence intervals were extracted from each study and the overall effect was measured. Results: According to the results, surgery has a 13% better outcome than endoscopic treatments, with a pooled odds ratio of 1.13 (95% CI: 1.06–1.21). However, the degree of variation between the studies was moderate to high (I² = 71.9%), indicating that the findings differed significantly between the studies. Conclusion: Transoral Incisionless Fundoplication (TIF) and Stretta are examples of more recent endoscopic procedures, which are good choices because they result in fewer complications and enable quick recovery. However, surgery is still more effective in managing GERD symptoms. Each patient's health, preference or presence of any other health issue should all be taken into consideration when selecting the best course of action for them.
Multiligament Knee Injuries in Adolescents: Distinct Patterns Based on Energy Mechanisms and Polytrauma Status
Purpose: Characterize differences in ligamentous injury patterns in adolescents with MLKIs by different mechanisms and polytrauma status, with the hypothesis that high-energy (HE) and polytrauma (PT) patients would have more severe injuries. Materials and Methods: Demographics, clinical characteristics, radiographic findings, and intraoperative variables were obtained on surgical MLKIs in the adolescent population from a single tertiary-care institution between June 2008 through October 2022. HE versus lowenergy (LE) and PT versus non-polytrauma (NPT) mechanisms were stratified. Subgroup comparisons were made based on body mass index, age, sex, number/type of ligaments injured, and surgeries performed. Statistical analysis included t-test and Chi-square analyses. Results: A total of 38 adolescent MLKI patients were included (mean age 16.0 ± 1.6 years, body mass index 24.6 ± 4.3 points, 65.8% male). There was an increased rate of posterior cruciate ligament (PCL; 77.8% vs 24.1%; P = 0.004), lateral collateral ligament (LCL; 77.8% vs 34.5%; P = 0.022), and medial patellofemoral ligament (MPFL) (44.4% vs 10.3%; P = 0.021) injuries in HE vs. LE, respectively. PT compared to NPT cases also had higher rates of LCL (83.3% vs 37.5%; P = 0.038) and MPFL (50.0% vs 12.5%; P = 0.030) injuries. Mean number of ligaments injured (excluding MPFL) were increased in HE vs. LE (3.2 ± 0.7 vs 2.2 ± 0.7; P < 0.001) and PT vs. NPT (3.2 ± 0.8 vs 2.3 ± 0.8; P = 0.014) cases, respectively. Conclusion: MLKIs resulting from HE mechanisms were associated with increased rates of PCL, LCL, and MPFL injuries, with PT patients having increased rates of LCL and MPFL injuries. HE and PT patients experienced a greater number of injured ligaments than LE and NPT patients. LCL injuries were associated with increased rates of injury in both groups and should be scrutinized in these patients during workup. Level of Evidence: Level IV: Retrospective Case Series
Predictive Factors for Mortality in Patients with Malignant Pleural effusion Undergoing Pleurodesis via Video-Assisted Thoracoscopy in Senegal
Background: This study aimed to identify predictive factors for mortality in patients undergoing pleurodesis via video-assisted thoracoscopy surgery Methods: We conducted a prospective 10-month study including 51 patients with malignant pleural effusion who underwent pleurodesis via video-assisted thoracoscopy at the Department of Thoracic and Cardiovascular Surgery, University Hospital Centre of FANN in Dakar, Senegal. Sociodemographic, clinical, and therapeutic data were collected and analyzed using R software. Kaplan-Meier survival curves and the Cox model were employed to visualize survival probabilities and identify predictive factors for mortality. Results: The mean age of patients was 50 ± 14 years, with a predominance of female patients (66.7% vs. 33.3%). The prevalence of malignant pleurisy was 49% (n = 25) for recurrent right-sided pleural effusion, 43% (n = 22) for recurrent left-sided pleural effusion, and 7.8% (n = 4) for recurrent bilateral pleurisy, with a mortality rate of 18% (n = 9). Occupational exposure (p = 0.015) and the use of traditional surgical techniques (p = 0.005) were significantly associated with reduced survival at 24 weeks. Predictive factors for mortality included sex (HR = 0.95; p = 0.02), the presence of comorbidities (HR = 0.98; p = 0.007), positive cytology (HR = 0.7; p = 0.02), and chemotherapy treatment (HR = 0.95; p = 0.04). Conclusion: Our results show that factors such as sex, the presence of comorbidities, positive cytology, and the use of chemotherapy significantly influence patient survival. It is necessary to establish a multidisciplinary approach and increase access to the most appropriate diagnostic and therapeutic methods to optimize the survival of patients with malignant pleural effusion.
Most Effective Interventions for Enhancing Neural Plasticity for Functional Recovery in Patients with Traumatic Brain Injury
Traumatic brain injury (TBI) is a major global health concern and one of the leading causes of disability worldwide. Outcomes of this injury range from full recovery to lifelong cognitive, physical, and psychological impairments. Management of TBI remains challenging due to the variety of symptoms and severity, as well as the complexity of the underlying cellular mechanisms. In addition, the lack of standardized treatment protocols contributes to the uncertainty of recovery. This article explores current evidence of the most effective interventions in improving function in patients with TBI. Acute management focuses on patient stabilization, tight control of intracranial pressure, and seizure prophylaxis. Long-term recovery, however, is dependent on a multidisciplinary approach including compensatory cognitive training with supported employment and social communication therapy, which have been shown to accelerate return to work and social reintegration. In addition, structured exercise, dietary modifications, and environmental enrichment have proven to be helpful. Novel therapeutic therapies including neuromodulation techniques and regenerative medicine strategies show promise in enhancing neuroplasticity and repairing injured neural tissue. Although encouraging, these treatments remain experimental, and no FDA approved disease modifying agents exist currently. Future progress will likely center around advancing these novel interventions as well as developing reliable biomarkers to help assess injury severity, predict prognosis, and guide individualized treatment planning.