Noncompressible torso hemorrhage is a leading cause of preventable death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to control hemorrhage but full aortic occlusion is limited by distal ischemia. Partial REBOA (pREBOA) allows some distal perfusion to prolong occlusion, but precise balloon titration is difficult with standard devices. The COBRA-OS 4 French (Fr) aortic occlusion catheter was evaluated in vitro and in vivo for partial REBOA. Bench-top (in vitro) and porcine (in vivo) models were used. The titration window of the device was evaluated in a non-hemorrhage porcine model and in a pulsatile aortic model. The ability of the device to maintain a targeted distal aortic pressure (20mmHg) for an extended period (3h) was tested in a porcine model of hemorrhagic shock (40% blood volume), with a corresponding in vitro experiment using a pulsatile aortic model. The COBRA-OS demonstrated a 3-4mL linear titration window with 1-1.5mL deflation volume to reach a target distal aortic pressure of 20mm Hg in vitro and in vivo. During 3h of prolonged partial REBOA, the device maintained a stable distal target with a set-and-forget strategy (21 +/- 2mmHg in vitro and 22 +/-7mmHg in vivo). The COBRA-OS 4 Fr device enabled precise, stable partial aortic occlusion in this preclinical model. This is the first demonstration of a 4 Fr REBOA catheter achieving prolonged, controlled partial occlusion in a large-animal hemorrhagic shock model, supporting the feasibility of this device for pREBOA. Basic Science, Animal study.

NCRT is a standard preoperative treatment for locally advanced RC with variable efficacy. This prospective cohort study explored HIF-1α and PD-L1 expression in RC and their impact on NCRT efficacy to provide a theoretical basis for effective predictive indicators. Patients with locally advanced rectal cancer (n=128) (cT3/T4-N0 or cTany-N1/N2) were prospectively enrolled. General clinical data were collected. Preoperative tumor and adjacent non-tumor tissues were obtained via pre-treatment biopsy, and HIF-1α/PD-L1 expression was detected by qRT-PCR. All patients underwent radical surgery after NCRT, with efficacy evaluated by pTRG. ROC analysis assessed the predictive value of HIF-1α/PD-L1 for NCRT response. Logistic regression analyzed HIF-1α/PD-L1 independent association with NCRT efficacy. The 5-year follow-up recorded survival/recurrence; Kaplan-Meier analyzed DFS/OS, and COX regression explored the independent correlation between HIF-1α/PD-L1 mRNA levels and post-NCRT DFS/OS. HIF-1α and PD-L1 were highly expressed in tumor tissues, with higher levels in NCRT-insensitive patients. Combined HIF-1α and PD-L1 showed better AUC for predicting NCRT insensitivity than either alone (AUC=0.706, sensitivity=63.24%, specificity=73.33%). For each 1-unit increase in HIF-1α and PD-L1, the risk of recurrence in patients increased by 1.567-fold (p=0.001, HR=1.567, 95% CI=1.216-2.018), and the risk of death increased by 1.725-fold (p=0.000, HR=1.725, 95% CI=1.354-2.200). HIF-1α and PD-L1 expression can serve as reliable indicators for predicting NCRT efficacy and poor prognosis in RC patients.

Thyroidectomy for Graves' disease (GD) is associated with an increased risk of intraoperative bleeding, particularly in patients with enlarged and hypervascular thyroid glands. This retrospective cohort study evaluated factors associated with intraoperative blood loss and examined the association between preoperative transarterial embolization (TAE) and surgical outcomes. A total of 199 patients with GD who underwent thyroidectomy between 2015 and 2024 were analyzed and stratified by excised thyroid weight (< 100g, 100-200g, and > 200g). Preoperative TAE was selectively performed in patients with large goiters beginning in 2021. Multivariate regression analysis identified thyroid weight (95% confidence interval [CI] 0.58-1.30, p<0.001), operative time (95% CI 0.04-1.05, p=0.035), and duration from disease onset to surgery (95% CI 2.50-17.72, p=0.010) as independent predictors of increased blood loss. In patients with thyroid glands weighing > 200g, TAE was associated with significantly lower intraoperative blood loss compared with historical controls (median 95 vs. 350mL, p=0.012), without an increase in postoperative complications. No significant benefit was observed in patients with glands weighing 100-200g. Larger thyroid gland size is associated with increased intraoperative blood loss for GD, and selective preoperative TAE may reduce bleeding in patients with markedly enlarged glands.

Postoperative pain after bariatric surgery is a significant clinical challenge, with approximately 61.4% of patients reporting persistent pain. Intraperitoneal local anesthetic instillation (IPLA) has been proposed as a strategy to reduce pain and opioid-related adverse effects. However, as its effectiveness in bariatric procedures remains controversial, this meta-analysis was conducted to clarify the role of IPLA in this setting. This systematic review and meta-analysis was conducted following PRISMA guidelines and was prospectively registered in PROSPERO. We performed a comprehensive search in Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science for randomized controlled trials (RCTs) IPLA instillation with a control group in patients undergoing bariatric surgery. The primary outcomes were postoperative pain intensity, need for rescue analgesia, and supplementary opioid consumption. Secondary outcomes included postoperative nausea and vomiting (PONV), nausea, vomiting, and shoulder pain. Data were synthesized using a random-effects model to calculate Risk Ratios (RR) for binary outcomes and Standardized Mean Differences (SMD) and Mean Differences (MD) for continuous outcomes. The methodological quality of the trials was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. The analysis included 13 randomized controlled trials with a total of 1205 participants, of whom 624 were in the intraperitoneal local anesthetic (IPLA) group and 581 were in the control group. The pooled results showed that IPLA significantly reduced postoperative pain intensity (SMD: -0.96, 95% CI -1.72 to -0.20; p=0.01) and the need for rescue analgesia (RR: 0.52, 95% CI 0.31-0.89). However, there was no significant difference in postoperative opioid consumption (SMD: -0.56, 95% CI -1.13 to 0.01; p=0.05). Additionally, no significant effects were found for the incidence of postoperative nausea and vomiting (PONV) or shoulder pain. High heterogeneity was noted in most of the analyses. IPLA reduces postoperative pain in bariatric surgery but does not decrease opioid consumption or adverse events. A suggested reduction in rescue analgesia was not robust. Due to high heterogeneity, the findings' clinical applicability is limited, highlighting the need for standardized trials. PROSPERO protocol CRD420251085223-July 2025.

New technologies, processes, or care models that substantially change practice are critical for surgical progress, patient care, and organizational efficiency.

Healthcare across Europe was affected by COVID-19 pandemic lockdowns. How different national healthcare systems coped with this impact remains unclear. Healthcare in Switzerland differs significantly from that in Scotland, for example, in terms of centralization. The aim of this study was to assess the impact of the COVID-19 pandemic on the diagnosis and surgical treatment of colorectal cancer (CRC) in contrasting healthcare systems. This retrospective cohort study was conducted in south-east Scotland and in the extended north-west of Switzerland from January 1st, 2019 to February 28th, 2023. All patients diagnosed with CRC were included. The primary outcomes were the time from CRC diagnosis to treatment and the UICC stage at diagnosis, assessed prior to, during, and following the period of lockdown. The lockdown in Scotland lasted from March 2020 to October 2020 and in Switzerland from March 2020 to April 2020. A total of 6745 patients were included (4127 from Scotland and 2618 from Switzerland). Median time from diagnosis to treatment remained unaltered during the lockdown period in both countries. However, after the lockdown, the median time from diagnosis to treatment increased from 59 to 76days in Scotland. The median number of patients who were diagnosed per annual quarter declined from 177 (IQR: 171-190) to 152 (IQR: 150-154), and the median number of who received treatment from declined from 256 (IQR: 253-259) to 203 (IQR: 186-218) during lockdown in Scotland. In multivariable logistic regression, the odds of being diagnosed with UICC stage IV increased by 42% for patients diagnosed during lockdown (95%-CI: 12%-81%). In Switzerland, the time from diagnosis to treatment increased slightly after the pandemic. However, the other effects described above were not observed in Switzerland. This descriptive study demonstrated that the impact of the pandemic on colorectal cancer care was less pronounced in Switzerland, but considerable in Scotland. Because separate subgroup analyses were conducted, direct comparisons cannot be made between Scotland and Switzerland. This trial is registered on clinicaltrials.gov as part of the EvaCol study (NCT04550156).

No abstract is available for this article.

Timely care for open tibia fractures remains difficult in low-resource settings. We evaluated a task-sharing model in Malawi in which trained orthopedic clinical officers (OCOs) delivered external fixation supported by a remote quality assessment tool. We conducted a prospective implementation evaluation across one central and four district hospitals (May 2023-July 2024). The intervention bundled OR refurbishment assured external fixator supply, refresher training, mentoring (on-site and remote), national guideline reinforcement, and a novel Fracture Fixation Assessment Tool for External Fixation (FFATEF). OCOs submitted postoperative radiographs and construct photographs for scoring across four domains (reduction, stability, implantation, and surgical impression; total 0-12 and satisfactory ≥8). Nonparametric tests compared performance by the hospital type; temporal trends were assessed with Spearman correlation. Forty-seven patients (89% male and mean age 32.3years) were treated (central: n=28 and district: n=19). The central hospital managed more severe injuries (Gustilo IIIA/B 69.6% vs. 15.8%). Median FFATEF scores were higher at the central hospital (10.0 [IQR 9-11]) than district hospitals (6.0 [5, 6, 7, 8], p<0.001). Satisfactory scores (≥8) occurred in 93% of central versus 32% of district cases. Central scores improved over time (ρ=0.52; p=0.005) whereas district scores were unchanged (ρ=0.15; p=0.540). Preoperative antibiotic compliance was 100% at the central versus 47% at district hospitals. When embedded within integrated surgical teams and adequate infrastructure, task sharing for open fracture external fixation yielded satisfactory technical performance but lagged district-level implementation despite training. Comprehensive institutional support-mentoring intensity, equipment, supply chains, and referral adherence-is likely required for safe scale-up. Validation of FFATEF against clinical outcomes and economic evaluation of delivery models are priorities.