Researchers led by Mouad Elganga, a medical student at the Temerty Faculty of Medicine at the University of Toronto, pooled evidence from 38 studies encompassing 7,507 patients to determine whether mobile app-based home monitoring improved recovery after surgery. The answer was nuanced. Patients enrolled in app-based monitoring programs had a 22 percent lower risk of major postoperative complications and a 22 percent lower risk of emergency room visits compared with those receiving standard postoperative care. Hospital readmissions fell by 15 percent. Yet the technology itself was not the active ingredient: readmissions dropped only in programs where a physician, surgeon or nurse actually reviewed the information patients submitted and could intervene when warning signs appeared. Programs that collected data without clinician review showed no reduction in readmissions at all.

The programs varied considerably in design, but most shared a common architecture. Patients completed daily check-ins on a smartphone or web portal, reporting symptoms such as pain, fever, nausea and the appearance of their surgical wounds. Some programs layered in wearable fitness trackers or Bluetooth-enabled devices, including blood pressure cuffs, thermometers and pulse oximeters that measure blood oxygen levels. This stream of patient-generated data, in principle, gives surgical teams a continuous window into recovery that traditional follow-up, typically a single office visit one to two weeks after discharge, simply cannot provide.

Elganga emphasized that the app alone is not a safety net. “Just using an app may not make recovery safer,” he said. “The biggest benefit occurs when a clinician is actually reviewing what patients send and can act on it. Patients should ask: ‘Who is looking at this information, how quickly will they respond and what happens if something looks wrong?'” The framing is a practical one for patients navigating an increasingly digital health care landscape, where remote monitoring offerings are proliferating faster than the evidence base can evaluate them.

One finding deserves particular scrutiny. The total number of complications did not significantly decline across the pooled studies, which suggests that app-based monitoring may not prevent postoperative problems from arising in the first place. What it appears to do is catch concerning symptoms before they escalate into major complications requiring emergency care, intensive care admission, readmission, an additional procedure or reoperation. In other words, the intervention seems to function less as a shield and more as an early warning system, converting problems that would have surfaced in the emergency department into issues that can be addressed with a phone call, a prescription adjustment or an earlier clinic visit.

The patient experience data adds an important dimension to the clinical outcomes. Patients in the monitoring programs reported less pain and anxiety, better physical function, improved quality of life and greater satisfaction with their care. That combination is notable because pain and anxiety after discharge are not merely comfort issues; uncontrolled pain can limit mobility, which in turn raises the risk of blood clots and pulmonary complications, while anxiety can deter patients from reporting symptoms that matter. A monitoring system that reassures patients while keeping clinicians informed may reinforce recovery along several pathways at once.

The vulnerable window the research targets is well understood in surgical care. Complications such as surgical site infections, bleeding, blood clots and opioid-related adverse events often emerge in the first days to weeks after discharge, precisely when the intensity of clinical oversight falls off sharply. Traditional postoperative care typically consists of discharge instructions, a phone number to call and a scheduled follow-up appointment, leaving patients and families to interpret symptoms on their own. Remote monitoring attempts to extend the hospital’s surveillance reach into the home, and the pooled evidence now suggests that this extension can measurably reduce serious outcomes when it is coupled with clinical responsiveness.

For health systems weighing an investment in app-based monitoring, the findings point to a clear implementation principle: the technology is only as valuable as the clinical workflow built around it. The authors suggest that systems considering such programs should focus not only on the software and devices but also on ensuring that clinicians review patient-submitted information and respond promptly to concerning symptoms. That means staffing, protocols and response-time commitments, not just an app download at discharge. Programs that treat monitoring as a data collection exercise, without a human loop that can act on the data, appear to deliver little measurable benefit.

Patients, too, have a role in making these programs work. The researchers recommend that patients ask who is monitoring the information they submit and what the protocol is if something looks wrong. When a clinician is actively reviewing the data, using the app consistently, completing daily check-ins even on good days, may help the care team identify problems before they become emergencies. Consistency matters because intermittent reporting creates blind spots in exactly the period when complications are most likely to develop.

The research was presented at the ANESTHESIOLOGY 2026 annual meeting, and the society notes that meeting news releases may contain updated data that was not originally available at the time abstracts were submitted. As with any pooled analysis presented at a scientific meeting, the findings await the full scrutiny of peer review and publication, and the heterogeneity of the 38 included programs, from simple symptom check-ins to multi-device remote monitoring, means the results should be interpreted as a broad signal rather than a prescription for any single app. Still, the central message is likely to shape how hospitals design postoperative care in the years ahead: remote monitoring can make the transition from hospital to home safer, but the clinician reviewing the data, not the technology collecting it, is what makes the difference.

Subject of Research: A pooled analysis of 38 studies presented at the ANESTHESIOLOGY 2026 annual meeting found that mobile app-based postoperative monitoring was associated with fewer serious complications, emergency room visits and readmissions, with benefits dependent on clinician review of patient-submitted data.

Article Title: Mobile app monitoring may reduce serious complications after surgery, new study finds

Article References: Mobile app monitoring may reduce serious complications after surgery, new study finds. Original publication (Bibliographic details unavailable.)

Image Credits: AI Generated

DOI: Not provided

Keywords: postoperative care, remote patient monitoring, mobile health apps, surgical complications, hospital readmission, ANESTHESIOLOGY 2026, patient safety, telemedicine, Mobile, monitoring, reduce, serious

The study, led by Charlotta L. Wenzelberg and colleagues at Lund University and Skåne University Hospital in Malmö, Sweden, followed patients who had undergone elective open colorectal cancer surgery through a midline incision between 2017 and 2021. The researchers tracked two clinically meaningful time points, one year and three years after the operation, using CT scans performed at 12 plus or minus 3 months and 36 plus or minus 3 months to diagnose incisional hernia with radiological precision rather than relying on physical examination alone. Of the 160 patients originally randomized in the parent trial, 134 were eligible for the one-year follow-up, and 119 of them, or 89 percent, completed the questionnaires. At three years, 81 of the remaining 101 patients, or 80 percent, filled out the same instruments, with 78 patients answering on both occasions.

The technical backbone of the assessment rested on two complementary questionnaires. The first, the EQ-5D-5L developed by the EuroQol Group, is a generic health-related quality of life instrument that probes five dimensions: mobility, self-care, usual activities, pain and discomfort, and anxiety and depression. Each dimension is graded on five levels, from no problems to extreme problems, generating one of 3,125 possible health states that can be converted into a single index value between 1, the best imaginable health, and 0, the worst. The instrument also includes a visual analogue scale on which patients rate their overall health from 0 to 100. The second tool was a slightly modified version of the Ventral Hernia Pain Questionnaire, a disease-specific instrument consisting of 19 questions that cover the intensity, frequency and duration of pain, its impact on daily activities and medication use, work limitation, subsequent operations and patient satisfaction. Pain was graded on a seven-point scale, with grades 1 and 2 defined as ignorable and grade 3 or worse as non-ignorable.

The results were striking in their consistency. At one year, the mean EQ-5D-5L scores showed no significant difference between patients with and without an incisional hernia, with a p-value of 0.276. At three years the picture was the same, with a p-value of 0.404. Mean scores for every dimension hovered between 1 and 1.7, corresponding to problems between none and slight, and the distribution of responses did not deviate from Swedish population characteristics except for a possibly larger share of patients reporting lower levels in the usual activities and pain and discomfort dimensions. The mean EQ-VAS scores, 78 at one year and 77 at three years, matched the Swedish norm of 76.1 almost exactly. Even when the researchers excluded small hernias under 2 centimeters, which lack fascial extrusion and were presumed less clinically significant, the remaining larger hernias were not found to be an independent risk factor for impaired quality of life.

The disease-specific questionnaire told a similarly reassuring story. Non-ignorable pain right now was reported by just 5.0 percent of patients at one year and 1.2 percent at three years, while the corresponding figures for non-ignorable pain over the last week were 3.4 percent and 2.5 percent. Sensation of stiffness in the abdominal wall was present in 11.0 percent at one year and 7.4 percent at three years, and other discomforting symptoms were reported by 11.9 percent and 6.3 percent respectively. Pain was generally occasional or occurred several times a week, lasted minutes to hours, had low impact on daily activities and hardly ever required analgesic medication. No patient was on sick leave because of pain at the time of follow-up, a finding partly explained by the fact that 55 percent of the cohort was retired at one year and 70 percent at three years.

Perhaps most intriguingly, patients were largely content with the outcome of their operation despite visible reminders of the surgery. About 23.5 percent regarded their scar as cosmetically disturbing at one year and 19.8 percent at three years, and roughly 10 percent experienced the appearance of their abdominal wall as somehow socially limiting at both time points. Yet 87.1 percent were satisfied with the result of their operation at one year, rising to 92.5 percent at three years. There were no differences at any follow-up occasion between the two surgical closure groups in the parent trial, one closed with a Reinforced Tension Line suture combined with the small bite 4:1 technique using polypropylene, the other with standard small bite 4:1 closure using polydioxanone, nor between patients with and without hernia.

The risk factor analysis, conducted with multivariable linear regression using the EQ-5D index as the outcome, produced the study’s most consequential finding. Incisional hernia, recurrence of colorectal cancer or new malignant disease, and the presence of a stoma were included as predefined potential risk factors. None emerged as an independent risk factor at one year. But at three years, the presence of a stoma was identified as an independent risk factor for impaired general quality of life, with a regression coefficient of minus 0.070, a 95 percent confidence interval of minus 0.117 to minus 0.022, and a p-value of 0.004. In the cohort, 68 of 119 patients, or 57 percent, had a stoma at one year and 40 of 78, or 51 percent, at three years. This aligns with a systematic review concluding that living with a colostomy negatively influences overall quality of life among colorectal cancer ostomates.

The findings contradict a body of previous research suggesting that incisional hernia does impair quality of life. A Danish register study indicated an additional decrease in quality of life among colorectal cancer patients who developed a hernia, measured with the disease-specific EORTC QLQ-C30 questionnaire. Other studies using the SF-36 instrument found reduced physical function in hernia patients, though not reduced general health, possibly due to limited statistical power. Randomized trials of hernia repair have shown improved and normalized quality of life after surgical correction, and abdominal wall reconstruction has been associated with significant overall improvement measured with the EQ-5D-5L. The Swedish authors suggest a possible explanation: general quality of life is a broad construct covering far more than abdominal wall symptoms, and colorectal cancer patients carry many other factors that affect their overall perception of health, so the presence or absence of a hernia may simply not dominate in this respect.

The study’s strengths include its prospective design, standardized inclusion criteria within a randomized controlled trial, and two recruiting centres, with ethics approval from the Regional Ethics Committee at Lund University and registration at ClinicalTrials.gov under NCT03390764. But the authors are candid about limitations. Quality of life and abdominal wall symptoms were secondary aims of the parent trial, and no power calculation was performed for these outcomes, raising the risk that the analysis was under-powered. A significant portion of patients were lost to follow-up, partly due to pandemic travel restrictions. And no preoperative questionnaire data exist, preventing evaluation of changes in quality of life from before surgery, a deliberate choice made because patients were enrolled the day before their operation, when preoperative anxiety was believed to distort questionnaire results.

The broader implication is that the surgical community may need to recalibrate how it weighs the incisional hernia threat in colorectal cancer patients, at least when it comes to patient-reported outcomes. The authors conclude that further studies are warranted in which quality of life assessment constitutes the primary aim, ideally with a single widely accepted assessment tool, which a 2021 systematic review noted is still lacking for abdominal wall hernia patients. Until then, the Rein4CeTo1 data suggest that for patients facing colorectal cancer surgery, the hernia that so often follows may be less of a burden on daily life than convention holds, while the stoma that many must live with remains the more decisive factor in how they feel three years on.

Subject of Research: Quality of life after incisional hernia following colorectal cancer surgery

Article Title: Impact of incisional hernia on quality of life after colorectal cancer surgery – results of the Rein4CeTo1 randomized clinical trial

Article References: Wenzelberg, C. L., Rönnow, C.-F., Petersson, U., & Rogmark, P. (2026). Impact of incisional hernia on quality of life after colorectal cancer surgery – results of the Rein4CeTo1 randomized clinical trial. Journal of Abdominal Wall Surgery, 5, Article 17039. https://doi.org/10.3389/jaws.2026.17039

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.17039

Keywords: colorectal cancer, incisional hernia, quality of life, stoma, abdominal wall surgery, patient-reported outcomes, Rein4CeTo1, surgical complications, Impact, incisional, hernia, quality

The case involved a patient several months out from a robotic extended totally extraperitoneal repair of an umbilical extraction-site hernia following robotic prostatectomy, combined with plication of diastasis recti, the separation of the rectus abdominal muscles. Roughly four months after the operation, the patient noticed a dense, fixed, distinctly abnormal palpable mass along his midline. The operating surgeon reviewed the imaging with a colleague, and both were unsettled by the finding. Mesh calcification seemed unlikely, and the focal, linear character of the mass did not match typical mesh-related complications. With growing uncertainty, the surgeon called a fellowship mentor, who responded without hesitation that the finding was heterotopic ossification and suggested searching the International Hernia Collaboration, a private Facebook group where surgeons connect and advance knowledge in abdominal wall surgery.

Within minutes, the search produced nine distinct posts, four of them describing nearly identical presentations after minimally invasive repair, accompanied by more than 150 comments from surgeons across the globe. These discussions detailed operative findings, technical pearls, recurrence patterns, and practical management strategies. Surgeons described encountering rigid, bone-like structures along midline repairs after minimally invasive hernia surgery, structures often mistaken initially for mesh calcification or recurrence. Only after this collective consultation did the surgeon turn to the published literature, and what emerged was sparse, dated, and almost entirely rooted in the era of open laparotomy.

Heterotopic ossification refers to the formation of bone in soft tissues where bone does not normally exist. It has long been considered a rare complication of abdominal wall surgery, most often noted in scar tissue after large laparotomies associated with trauma and vascular surgery. Yet it may be more common than assumed. Radiographic case series have reported an incidence of up to 25 percent after laparotomy, most commonly after vertical incisions and located within the linea alba, the fibrous band running down the midline of the abdomen. The published record, however, is dominated by isolated case reports and small series that establish only that ossification can occur in abdominal scars, offering limited insight into risk factors, prevention, or management, and no framework applicable to modern minimally invasive reconstruction.

Traditional etiologic theories have centered on two primary mechanisms. The first is intraoperative seeding of perichondral cells from the xiphoid process, the cartilaginous extension at the lower end of the sternum. The second is trauma-induced metaplasia, in which multipotent undifferentiated mesenchymal connective-tissue cells transform into bone-forming cells in response to injury. Both models fit the historical picture of ossification after open midline incisions near the xiphoid. They fit poorly with the emerging cases after minimally invasive hernia repair, which occur in the absence of laparotomy incisions, direct bone exposure, or overt surgical trauma, assuming as is often implied that minimally invasive surgery is inherently less traumatic.

A third, comparatively underemphasized hypothesis may be more relevant. Excessive suture-line tension, this theory proposes, may result in intramuscular implantation and subsequent ossification of periosteal particles avulsed from sites of muscular insertion into bone, with or without associated necrosis of the fascial margins. This mechanism, later emphasized in radiologic series, offers a plausible explanation for ossification observed along suture lines and in non-vertical incisions, including cesarean section scars. Extending this framework to minimally invasive abdominal wall reconstruction requires consideration of additional contributory factors, including chronic inflammatory signaling, mechanotransduction, the process by which cells convert mechanical forces into biochemical activity, and material-tissue interactions that may collectively create a permissive environment for ectopic bone formation.

Recurrent themes from the online discussions, including tensioned midline closures, barbed suture use, and retromuscular dissection planes, invite reconsideration of how mechanical forces, inflammation, and biomaterial interactions may contribute to ectopic bone formation. These observations do not establish causality, but they highlight hypotheses that would be difficult to generate from isolated cases alone. The value of the digital forum, the authors argue, lies not in replacing scientific validation but in sharpening the questions that merit rigorous investigation. The collective experience did more than identify the complication; it shaped the operative plan, informed contingency strategies including having rongeurs available to grasp and remove the bony tissue, guided patient counseling, and shaped intraoperative teaching for the resident, with the memorable warning that the finding is bone and it can be sharp.

The broader significance of the case extends beyond a single rare complication. The authors contend that surgeon-driven global communities, enabled by social media, function as powerful and underrecognized engines of early clinical discovery. These communities facilitate pattern recognition, identification of rare or emerging complications, and rapid hypothesis generation, often well before traditional publication pathways can respond. Through real-time and asynchronous discussion, surgeons across institutions and countries independently described clinical presentations, operative findings, and outcomes, and these isolated experiences converged into a recognizable pattern. What emerged was not anecdote alone but convergence, illustrating how surgeon-driven communities can function as early warning systems for rare or evolving complications.

The implications reach into practice, education, and research. Clinically, awareness of heterotopic ossification as a potential complication after minimally invasive abdominal wall surgery has immediate consequences for diagnosis, operative planning, and patient counseling. Surgeons must consider it in the differential diagnosis of postoperative midline masses or unexplained pain and be prepared for unexpected intraoperative findings. Educationally, such cases offer opportunities to teach trainees about rare complications, adaptive surgical decision-making, and the limitations of existing evidence when confronting novel presentations. From a research standpoint, early recognition through surgeon networks may represent the first step in identifying phenomena that warrant structured study; without that initial signal, many rare complications may never reach the threshold required for traditional investigation.

The authors are careful to note that these communities do not generate conclusions; they generate questions. They accelerate hypothesis formation and identify phenomena worthy of formal study, serving as a complementary pathway from observation to evidence. In an era where surgical techniques evolve faster than traditional publication cycles, the pathway from anecdote to evidence is not a leap but a process, and digital collaboration increasingly represents its earliest stage. Dismissing these platforms, the authors warn, risks delaying recognition of clinically meaningful complications and perpetuating knowledge gaps. Heterotopic ossification following minimally invasive abdominal wall surgery may remain rare, but as a case study in how modern surgical knowledge emerges, it makes a striking argument: integrating collective surgeon experience with rigorous academic inquiry can help the surgical community identify, contextualize, and study novel phenomena faster, and embracing that complementary pathway from online collaboration to clinical insight will be essential to advancing patient care in an increasingly connected surgical landscape.

Subject of Research: Surgery

Article Title: From online collaboration to clinical insight: identifying heterotopic ossification through a global hernia surgery network

Article References: Buie, V., & Jacob, B. P. (2026). From online collaboration to clinical insight: identifying heterotopic ossification through a global hernia surgery network. Journal of Abdominal Wall Surgery, 5, Article 16362. https://doi.org/10.3389/jaws.2026.16362

Image Credits: AI Generated

DOI: 10.3389/jaws.2026.16362

Keywords: hernia repair, heterotopic ossification, abdominal wall reconstruction, social media in surgery, minimally invasive surgery, International Hernia Collaboration, surgical complications, digital scholarship, online, collaboration, clinical, insight

The review, led by June Y. Moon, Yasir Al-Dojaily, Zahidul Islam, and Lucy Wang of New York Medical College’s Department of Dermatology, together with senior author Amor Khachemoune, systematically combed the published literature for reports on managing superficial cutaneous wound dehiscence. The search was deliberately broad, reaching beyond dermatology into other surgical specialties where wound separation has been studied in greater depth. What the authors found was sobering: after excluding a single-patient case report, the entire body of relevant comparative evidence amounted to just three studies covering 185 patients.

Those 185 patients were divided between two fundamentally different management philosophies. The first is secondary re-closure, in which a surgeon reintroduces sutures or other closure devices to bring the wound edges together again, sometimes after a period of wound preparation or delayed primary closure. The second is secondary intention healing, in which the wound is left open and allowed to fill in from the base through granulation tissue, contraction, and re-epithelialization. Each approach carries its own logic. Re-closure promises faster coverage and potentially better cosmesis but risks trapping bacteria and recreating the conditions that caused the separation. Secondary intention avoids foreign material in a potentially contaminated wound but demands weeks of dressing changes and leaves healing to the body’s slower processes.

The three studies that met the review’s criteria came from strikingly different clinical worlds. One was a randomized trial from obstetrics and gynecology, in which women with superficial dehiscence after gynecologic procedures were assigned to either secondary closure or healing by secondary intention. A second came from cardiothoracic surgery, examining superficial dehiscence after median sternotomy, the midline chest incision used to access the heart. The third was a retrospective case series in immunocompromised patients whose wounds were colonized by multidrug-resistant organisms, a population at extreme risk both from infection and from impaired healing.

Despite their differences, all three studies converged on a single descriptive finding: wounds that were re-closed healed faster than wounds left to heal by secondary intention. Two of the three studies also reported that re-closure required fewer clinic visits or fewer treatments, an outcome with real consequences for patients who face daily dressing changes over many weeks. In the sternotomy cohort, two closure failures were documented among the re-closed wounds, a reminder that suturing a previously opened wound back together does not always succeed. In the immunocompromised series, one late suture-associated abscess appeared, illustrating the infection risk that delayed closure is meant to mitigate but does not eliminate.

The authors are careful, and correctly so, to warn against over-reading these results. The studies differed substantially in design, wound characteristics, and how they reported outcomes, and none used the kind of rigorous, dermatology-specific framework that would allow confident generalization. The randomized trial did not provide detailed reporting of complications after re-closure, which makes a balanced risk assessment nearly impossible. Descriptive findings, the review emphasizes, do not establish superiority. A faster healing time in three heterogeneous, non-dermatologic cohorts is a signal worth investigating, not a treatment guideline.

For dermatologic surgeons, the gap is glaring. None of the three studies evaluated dehiscence after cutaneous surgery specifically, and none assessed cosmetic outcomes or patient satisfaction, two endpoints that matter enormously when the wound in question sits on a patient’s face, nose, or ear. Dermatologic surgery wounds differ in important ways from sternotomies or abdominal incisions: they are often smaller, frequently on sun-damaged skin with different biomechanics, frequently closed under significant tension on convex surfaces, and managed in an outpatient setting where healing is supervised by the operating surgeon rather than an inpatient team. Extrapolating from a 1992 obstetric trial or a cardiothoracic series to a nose defect after Mohs reconstruction is a leap that the evidence simply cannot yet support.

The biology of why wounds separate, and why they might behave differently when closed a second time, adds further nuance. Dehiscence usually follows a combination of factors: excessive tension across the closure, infection or hematoma beneath the surface, patient factors such as diabetes, smoking, immunosuppression, or advanced age, and mechanical forces from movement or trauma. Once the skin has opened, the wound bed is no longer a clean, surgically prepared plane. It is a contaminated, granulating surface colonized by bacteria, and the question of whether to close it becomes a question of whether the benefits of apposing the edges outweigh the risk of sealing microorganisms inside. The concept of delayed primary closure, well described in the plastic surgery literature, occupies the middle ground: the wound is managed briefly with dressings or negative pressure, then closed once it appears clean, theoretically capturing speed without sacrificing safety.

In practice, the review concludes, dermatologists currently manage dehiscence based on clinical experience, expert opinion, and extrapolation from other specialties. Many factors inform individual decisions: the size and depth of the wound, its location, the burden of contamination, the patient’s immune status and healing capacity, and the patient’s tolerance for repeated visits versus an open, healing wound. Some wounds on concave surfaces, such as the medial canthus or ear concha, are well suited to secondary intention and may heal with acceptable cosmetic results without re-closure. Others, under tension on convex surfaces, may benefit from being reapproximated once the infection risk is controlled. But the evidence base underlying any of these choices, when a wound actually opens, is essentially anecdote and judgment.

That is why the authors’ closing call for prospective dermatologic studies carries such weight. Wound dehiscence after skin surgery is common enough that well-designed trials, comparing re-closure against secondary intention with standardized measures of healing time, complication rates, cosmetic outcomes, and patient satisfaction, would be feasible and would transform a judgment-driven corner of practice into an evidence-based one. Until such trials exist, the review offers dermatologic surgeons something less satisfying but honest: a clear-eyed account of what is known, what is not, and where the field must go. When a wound separates, the surgeon’s hands may know what to do. The published literature, this review makes clear, does not yet.

Subject of Research: Evidence for managing postoperative cutaneous wound dehiscence in dermatologic surgery

Article Title: Management of postoperative cutaneous wound dehiscence: a narrative review and implications for dermatologic surgery

Article References: Moon, J. Y., Al-Dojaily, Y., Islam, Z., Wang, L., & Khachemoune, A. (2026). Management of postoperative cutaneous wound dehiscence: a narrative review and implications for dermatologic surgery. Archives of Dermatological Research, 318(1), Article 526. https://doi.org/10.1007/s00403-026-05005-8

Image Credits: AI Generated

DOI: 10.1007/s00403-026-05005-8

Keywords: wound dehiscence, dermatologic surgery, secondary re-closure, secondary intention healing, delayed primary closure, surgical complications, Mohs surgery, wound healing, systematic review, steronomy, infection risk, evidence gap

The research team followed the PRISMA 2020 reporting guidelines, the international standard for conducting and reporting systematic reviews in health care. They searched four major electronic databases, PubMed, Scopus, the Cochrane Library, and ERIC, in December 2025, casting a wide net across the medical education literature. From an initial pool of 4,233 records, only twelve studies published between 2007 and 2022 ultimately met the strict inclusion criteria. To qualify, studies had to evaluate surgical training outcomes among ophthalmology residents, covering measures such as intraoperative or postoperative complications, surgical efficiency, case-volume and learning-curve effects, surgical success, trainee competency, or the impact of simulation-based training. Research on non-residency populations or on educational interventions unrelated to surgery was excluded.

That attrition rate, from more than four thousand records to just twelve included studies, tells its own story. Despite decades of concern about how surgeons learn their craft, the evidence base for one of medicine’s most technically demanding specialties remains remarkably thin and fragmented. The twelve studies that survived screening came from the United States, the United Kingdom, India, Australia, and sub-Saharan Africa, a geographic spread that the authors note is heavily skewed toward high-income countries. Because the included studies varied so widely in their populations, interventions, and outcome measures, the team chose a narrative synthesis rather than a meta-analysis, meaning they could map the direction and consistency of reported effects but not pool them into a single summary statistic.

One of the clearest signals to emerge concerns case volume. Across the reviewed literature, higher cumulative surgical volume was consistently associated with lower complication rates, reinforcing the long-standing intuition that practice makes safer surgeons. Yet the picture is not purely mechanical. The review found that case-specific risk factors, such as the complexity of an individual patient’s pathology, independently predicted complications even after accounting for trainee experience. In other words, a resident’s hundredth cataract operation on a routine patient may be safer than a supervised first operation on an eye with a traumatized cornea or a weak lens support. This finding carries practical weight: it suggests that training programs should think not only about how many operations a resident performs, but about which operations, matched to the resident’s current level of skill and the level of supervision available.

The review also confronted a question that every surgical patient implicitly asks: is it safe to let a trainee operate? The evidence indicates that surgery performed by residents is associated with higher short-term complication rates compared with surgery performed by experienced surgeons, a result that will surprise no one. More encouraging, however, is the finding that long-term outcomes were often comparable between trainee-performed and consultant-performed procedures. This distinction between immediate and delayed results matters enormously for how training programs and patients think about the learning process. It suggests that the short-term bump in complications associated with supervised trainee surgery may not translate into lasting harm, provided that cases are appropriately selected and supervised and that patients receive adequate follow-up to catch and manage early problems.

Perhaps the most consistent and practically important finding of the entire review involves simulation. Across four studies, including two randomized controlled trials, simulation-based and virtual-reality training was consistently associated with lower complication rates and higher competence scores among trainees. Randomized controlled trials sit at the top of the evidence hierarchy, so their presence in this small literature is notable, and the fact that both pointed in the same direction strengthens confidence in the conclusion. Virtual reality cataract surgery simulators, which allow residents to practice capsule tearing, phacoemulsification, and instrument handling on a computer-generated eye with real-time feedback on tremor and tissue damage, have become increasingly sophisticated over the past two decades. The review’s findings suggest that this technology is not merely a convenient substitute for the operating room but an active driver of safer surgical performance once residents reach real patients.

The authors assessed the methodological quality of the included studies using design-specific tools. Observational studies were appraised with the Joanna Briggs Institute critical appraisal checklists, randomized controlled trials with the Cochrane Risk of Bias 2 tool, and the single instrument validation study with the COSMIN Risk of Bias checklist. Two reviewers independently screened titles, abstracts, and full texts, with disagreements resolved by consensus. This multi-tool approach reflects the heterogeneity of the underlying literature, but it also exposed a deeper problem: most of the evidence rests on observational designs, which are vulnerable to confounding and selection bias. Programs that give residents more cases may also differ in countless other ways from programs that give fewer, making it difficult to isolate the true causal effect of volume alone.

If simulation emerged as the strongest positive finding, the assessment of competency emerged as the weakest link. The review found that validated competency assessment instruments remain strikingly limited, with only one study in the entire evidence base addressing instrument validity in depth. This is a critical gap for a specialty built on microsurgical precision. Without validated tools to measure surgical competence, program directors are left to judge readiness using subjective supervisor impressions, logged case counts, or ad hoc rating scales whose psychometric properties are largely unknown. The authors highlight cataract surgery, the most common operation most ophthalmology residents will perform and the procedure on which much of the global burden of avoidable blindness depends, as an area particularly in need of validated assessment instruments.

The geographic concentration of the evidence adds a further layer of concern. With studies drawn predominantly from the United States, the United Kingdom, India, Australia, and parts of sub-Saharan Africa, the review notes that the evidence base is concentrated in high-income settings, leaving vast regions of the world where cataract surgical backlogs are greatest essentially unstudied in the medical education literature. Training conditions, case mix, supervision ratios, and available technology differ enormously between a well-funded academic center in North America and a district hospital in a low-resource setting. Findings about learning curves and complication thresholds generated in one context may simply not transfer to another, which is why the authors call for more geographically diverse, prospective research.

The overall message of the review is one of cautious optimism paired with a demanding agenda. Simulation-based training and structured, experience-matched case selection are associated with improved surgical outcomes and surgical competence among ophthalmology residents, giving training programs concrete, evidence-supported levers to pull today. At the same time, the field needs prospective studies that follow residents over time, validated assessment tools that can objectively certify competence, and research that extends beyond wealthy countries to the settings where surgical training capacity is most constrained. As virtual reality simulators become cheaper and more widespread, and as regulators and patients increasingly demand objective proof of surgical readiness, the pressure to build a rigorous educational evidence base for eye surgery will only grow. This review provides both a map of what is known and a clear picture of how much work remains.

Subject of Research: Surgical training and competency assessment in ophthalmology residency programs

Article Title: Ophthalmology residency surgical training and competency assessment: a systematic review of medical education evidence

Article References: Krungkraipetch, L., Leelawongs, S., & Krungkraipetch, K. (2026). Ophthalmology residency surgical training and competency assessment: a systematic review of medical education evidence. BMC Medical Education. https://doi.org/10.1186/s12909-026-10546-7

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10546-7

Keywords: ophthalmology residency, surgical education, competency assessment, simulation training, virtual reality, cataract surgery, case volume, learning curve, systematic review, medical education, surgical complications, BMC Medical Education

ETS is an established surgical treatment for focal hyperhidrosis, the condition in which the palms, armpits, or face sweat excessively, and it is also offered for refractory facial blushing. During the procedure, a surgeon inserts a thoracoscope through small incisions and interrupts the thoracic sympathetic chain, typically at spinal levels T2 to T4, using cauterization, resection, or titanium clips. The interruption abolishes the overactive sweating signals traveling to the target region, and most patients enjoy immediate and durable dryness where it matters most to them. But the sympathetic trunk is not a set of isolated wires serving single destinations. It is a longitudinally interconnected conduit carrying afferent and efferent signals between the brain, spinal cord, and virtually every organ below the neck, and the new study argues that cutting it inevitably perturbs far more than sweat glands in the hands.

The research team, led by surgeons at Linkou Chang Gung Memorial Hospital in Taiwan, developed a dedicated instrument called the Chang Gung Sympathetic Function Questionnaire to capture this broader picture. The 60-item survey rates each symptom on a 0 to 10 numeric scale, allowing respondents to classify complaints as none, mild, moderate, or severe, with scores of 8 or above counted as severe. Before deploying it, the team validated the questionnaire psychometrically: internal consistency was excellent across all domains, with Cronbach’s alpha values between 0.89 and 0.96, sampling adequacy was high, and exploratory factor analysis confirmed that the items clustered into the four theoretical domains the researchers had predicted, explaining 65 to 81 percent of total variance. The survey was distributed anonymously in English and Mandarin through closed online communities dedicated to hyperhidrosis support between April and August 2025.

The most striking finding concerned compensatory sweating, the phenomenon in which the body, deprived of its ability to sweat in the denervated upper regions, redirects sweat output to areas below the neck. More than 80 percent of ETS patients reported compensatory sweating in the chest, back, abdomen, buttocks, thighs, calves, or feet, and in multiple regions the severity reached the severe threshold in more than 40 percent of patients. The data also revealed that this burden grows with time: chest sweating severity correlated moderately with postoperative duration, and receiver operating characteristic analysis identified a cutoff of roughly 16.75 years after surgery as the point at which severe chest sweating became most predictable. In other words, the longer patients live with the operation, the more likely their compensatory sweating is to become disabling.

Beyond sweating, the survey documented a constellation of vascular and sensory disturbances that few patients are warned about. Facial, hand, and foot blushing were reported by 43 to 53 percent of ETS patients, compared with 15 to 29 percent of controls, suggesting persistent vasomotor dysregulation. Erythromelalgia, a condition marked by burning redness in the extremities, was present in 40 percent of patients versus 11.3 percent of controls. Hand and foot paresthesia, abnormal tingling sensations, were both more frequent and more severe after surgery, and skin complaints including itchiness, dermatitis, and discoloration were consistently worse. The researchers attribute these changes to the loss of sympathetic vasoconstrictor tone in cutaneous arterioles, which destabilizes blood flow regulation and microcirculation rather than merely drying the skin.

Perhaps the most provocative results concern the brain. After compensatory sweating, the central nervous system was the most frequently affected system in the survey. ETS patients reported markedly higher severity of cognitive complaints, including inattention, memory loss, brain fog, and a disturbing sense of loss of reality, along with affective symptoms such as anxiety, depression, loss of motivation, loss of interest, tiredness, and insomnia. For several of these items, severe ratings of 8 or above occurred in more than 30 percent of patients. Notably, some symptoms, such as sound sensitivity and tiredness, showed similar prevalence in both groups but significantly greater severity among ETS patients, suggesting that the surgery intensifies underlying central dysregulation rather than creating new symptoms from nothing.

The study offers a physiologically coherent explanation for these neuropsychological effects. The sympathetic nervous system governs arousal, vigilance, and emotional modulation, and surgical interruption of the thoracic chain alters the afferent feedback reaching the central autonomic network, a distributed set of cortical and subcortical structures including the insula, anterior cingulate cortex, amygdala, hypothalamus, and brainstem nuclei that integrates visceral signals and balances sympathetic and parasympathetic output. Physiological studies have documented parasympathetic predominance and reduced sympathetic drive after ETS, visible in heart rate variability and baroreflex sensitivity, supporting the idea of a systemic autonomic shift rather than an isolated peripheral denervation. In this framework, brain fog and mood disturbance after ETS are not imagined side effects but plausible consequences of rewiring the body’s stress and arousal circuitry.

The systemic reach of the surgery extended to the viscera as well. Cardiorespiratory complaints, including palpitations, shortness of breath, chest tightness, and chest tingling, were significantly more frequent and severe among ETS patients, each affecting more than half of respondents. Gastrointestinal symptoms such as heartburn, diarrhea, nausea, and indigestion were also elevated, consistent with the disruption of splanchnic sympathetic pathways that connect thoracic ganglia to the abdominal organs. Urogenital disturbances, particularly difficulty urinating and incomplete bladder emptying, increased markedly. Interestingly, a few symptoms moved in the opposite direction: dysmenorrhea and irregular menstrual cycles were less common in the ETS group, and shoulder and neck pain was less prevalent, though the authors caution that the ETS cohort was 70.4 percent male versus 10.1 percent of controls, so some of these apparent reductions likely reflect demographic imbalance rather than genuine protection.

The clinical implications are significant. The authors argue that the breadth of these findings supports more selective surgical techniques, such as limited ganglion resection or rami-only procedures, even though these carry a higher risk of hyperhidrosis recurrence. For patients already suffering severe complications, sympathetic trunk reconstruction, in which sural nerve or intercostal nerve grafts are used to restore continuity across the surgical gap, has emerged as the most definitive reversal option, and the Chang Gung team has pioneered robot-assisted microsurgical versions of this procedure with preliminary improvements in compensatory sweating and systemic symptoms. But reconstruction is complex surgery in its own right, and no pharmacologic or minimally invasive treatment currently exists that reliably reverses the systemic complications of ETS.

The study has limitations that temper but do not erase its message. Its cross-sectional design cannot prove causation, surgical details such as the exact level and extent of sympathectomy were self-reported and often incomplete, and recruitment through online hyperhidrosis communities may have overrepresented dissatisfied patients, potentially inflating symptom prevalence. The questionnaire has not yet been externally validated in independent cohorts, and no objective autonomic testing was performed. Even so, the sheer consistency of the signal across four symptom domains, measured against a validated instrument and a control group, makes a compelling case that ETS is not the localized procedure it is often portrayed to be. As the authors conclude, the operation produces global dysregulation of sympathetic control, and patients deserve preoperative counseling that reflects the true, multisystemic scope of what they are signing up for.

Subject of Research: Systemic adverse effects of endoscopic thoracic sympathectomy for hyperhidrosis

Article Title: The systemic adverse effects of endoscopic thoracic sympathectomy are underrecognized: a questionnaire-based study

Article References: Sung, C. W.-H., Chen, L. W.-Y., Lee, C.-H., Lu, J. C.-Y., Huang, J.-J., Chao, Y.-K., Chuang, D. C.-C., & Chang, T. N.-J. (2025). The systemic adverse effects of endoscopic thoracic sympathectomy are underrecognized: a questionnaire-based study. BMC Plastic and Reconstructive Surgery, 1(1), Article 7. https://doi.org/10.1186/s44452-025-00007-3

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00007-3

Keywords: endoscopic thoracic sympathectomy, hyperhidrosis, compensatory sweating, autonomic nervous system, sympathetic chain, brain fog, vasomotor dysregulation, questionnaire study, sympathetic trunk reconstruction, patient counseling, central autonomic network, surgical complications

The study, published in Breast Cancer Research and Treatment, retrospectively analyzed 669 patients who underwent mastectomy at Shinshu University Hospital between January 2015 and December 2022. Because 20 of those patients had synchronous bilateral disease and were operated on both sides, the analysis covered a total of 709 breasts. Post-surgical bleeding, defined in the study as hemorrhage requiring manual compression or more than 100 milliliters of bloody discharge from a surgical drain by the morning of the first postoperative day, occurred in 42 cases, or 5.9 percent of the cohort. That figure may sound modest, but bleeding after mastectomy is clinically consequential: it can force blood transfusion or reoperation, prolong hospitalization, and delay adjuvant treatment.

What makes the new work distinctive is its focus on a regional rather than a systemic measure of body composition. Surgeons have long known that a high body mass index raises the odds of wound complications, infections, and bleeding after mastectomy, but BMI is a blunt instrument. It cannot distinguish a patient whose weight comes from abundant subcutaneous fat from one carrying substantial lean muscle. Meanwhile, surgical oncology research has increasingly implicated sarcopenia, the loss of skeletal muscle mass, in poor postoperative outcomes across many solid tumors. The standard tool for quantifying muscle in these studies is the skeletal muscle index, calculated from the cross-sectional muscle area at the third lumbar vertebral level on abdominal CT, normalized to height squared.

The Japanese team saw two problems with applying that abdominal measure to breast surgery. First, patients with early-stage breast cancer rarely undergo abdominal CT, so the necessary images often simply do not exist. Second, and more fundamentally, bleeding after mastectomy does not usually start in the abdomen. It originates from small vessels in the subcutaneous tissue or on the surface of the pectoralis major muscle, the very structures exposed during the operation. A global index of trunk musculature may therefore miss the local tissue characteristics that actually determine whether those fragile vessels hold or bleed. Chest CT, by contrast, is routinely obtained for staging in breast cancer, and the pectoralis major is clearly visualized on it.

To exploit that opportunity, the researchers measured the pectoralis major muscle area on axial CT slices at the level of the second thoracic vertebra, using semiautomated delineation within attenuation thresholds of minus 29 to 150 Hounsfield units. The area, expressed in square centimeters, was divided by the patient’s height squared to yield a pectoralis major muscle index, or PMI. Two investigators performed the image analysis while blinded to all postoperative outcomes, and cutoff values for BMI and PMI were derived from receiver operating characteristic curve analysis. The resulting thresholds were 23.7 for BMI and 2.90 for PMI.

The statistical signal was striking. Patients who bled had a significantly higher mean BMI than those who did not, 26.1 versus 22.8, and a significantly lower mean PMI, 2.76 versus 3.12. Yet BMI and PMI were only weakly correlated, with a Pearson coefficient of 0.16, and PMI also correlated only weakly with the conventional lumbar skeletal muscle index. In other words, the chest muscle measurement captures information about body composition that neither BMI nor the standard systemic muscle index reflects. On multivariate logistic regression, high BMI and low PMI each remained independently associated with bleeding, alongside the type of axillary procedure performed. Patients with a high BMI and low PMI had the highest incidence of bleeding at 20.1 percent, compared with 7.4 percent for high BMI with high PMI, 4.8 percent for low BMI with low PMI, and just 1.3 percent for low BMI with high PMI.

The authors offer a mechanistic explanation rooted in surgical anatomy. In patients with a high BMI, abundant subcutaneous fat can obscure small vessels and hinder meticulous hemostasis, raising the chance that a vessel is inadequately sealed and later bleeds. In patients with a low PMI, the pectoralis major itself tends to be atrophic, which may increase the fragility of the vessels running across its surface. Excess fat and diminished local muscle thus act synergistically: the fat makes vessels harder to secure, while the wasted muscle beneath makes them more vulnerable in the first place. Notably, the team’s earlier work found that the lumbar skeletal muscle index predicted bleeding only when normalized to BMI, a pattern consistent with sarcopenic obesity, whereas the regional PMI predicted bleeding on its own, without any adjustment.

One counterintuitive finding deserves mention. Faculty surgeons, defined as board-certified specialists, accounted for a significantly higher share of the bleeding cases than residents, 59.5 percent versus 42.2 percent. The authors argue this likely reflects case allocation rather than skill: faculty were more often assigned technically demanding or high-BMI patients, and at Shinshu every resident-performed mastectomy is directly supervised by a faculty surgeon acting as first assistant. Mastectomy is also a highly standardized procedure with routine drain placement and postoperative compression protocols, which may flatten differences attributable to individual technique. In routine practice, the study suggests, patient-related factors such as BMI and PMI matter more than operator-related ones.

The study has limitations the authors themselves acknowledge. It was retrospective and conducted at a single institution, the number of bleeding events was relatively small, and the bleeding definition captured early postoperative events rather than minor or late-onset ones. Bilateral cases were analyzed as independent observations, although sensitivity analyses excluding them produced essentially unchanged results. The BMI and PMI cutoffs were derived from the same cohort they were tested on, and the population was exclusively Japanese, so external validation in larger, more diverse cohorts will be needed before the thresholds can be generalized.

Even so, the practical implication is appealingly simple. Most breast cancer patients already have a preoperative chest CT, and measuring one muscle on an existing scan adds no cost, radiation, or delay. If validated prospectively, the pectoralis major muscle index could become a routine element of perioperative risk stratification, flagging patients, particularly those with both high BMI and low PMI, who warrant especially careful intraoperative hemostasis, closer drain monitoring, and a lower threshold for early intervention. In an era when body composition is increasingly recognized as a modifiable factor in cancer care, the study adds a new twist: for mastectomy outcomes, the muscle that matters most may be the one directly under the surgeon’s hands.

Subject of Research: Pectoralis major muscle mass as a predictor of post-surgical bleeding after mastectomy in breast cancer patients

Article Title: Low pectoralis major muscle mass predicts the risk of post-surgical bleeding after mastectomy in patients with breast cancer

Article References: Iji, R., Oba, T., Miyazawa, R., Kitazawa, A., Kiyosawa, N., Katsuyama, S., Morikawa, H., Amitani, M., Chino, T., Shimizu, T., Ono, M., Natori, K., Kanai, T., & Ito, K.-I. (2026). Low pectoralis major muscle mass predicts the risk of post-surgical bleeding after mastectomy in patients with breast cancer. Breast Cancer Research and Treatment, 219(1), Article 2. https://doi.org/10.1007/s10549-026-08063-8

Image Credits: AI Generated

DOI: 10.1007/s10549-026-08063-8

Keywords: breast cancer, mastectomy, pectoralis major muscle index, post-surgical bleeding, body mass index, body composition, sarcopenia, computed tomography, surgical complications, risk stratification, perioperative care, Shinshu University

The study, conducted by Karin Falk-Brynhildsen, Carina Bååth, Dimitri Beeckman, Christine Leo Swenne, Charlotte Raepsaet and Camilla Wistrand, set out to describe Swedish operating room nurses’ self-estimated knowledge and attitudes regarding the prevention of intraoperative pressure ulcers. Using a cross-sectional design reported according to the STROBE guidelines for observational studies, the team distributed an online questionnaire by email to operating room nurses across all 21 of Sweden’s healthcare regions. Of the 2247 addresses contacted, 343 proved non-functional, leaving 1904 eligible recipients. After two reminders, 284 nurses completed the survey, a response rate of 15 percent. Data collection took place in August and September 2020 as part of a larger project developing two validated instruments tailored to the operating room: the Pressure Ulcer Knowledge Assessment Tool for the operating room, known as PUKAT 2.0 OR, and the Attitudes toward Pressure Ulcer Prevention instrument adapted for the same setting, the APuP-OR.

The scale of the clinical problem provides the context for why this matters. According to the European Pressure Ulcer Advisory Panel guidelines, surgery-related pressure ulcers occur in approximately 4 to 45 percent of surgical procedures. Recent studies have documented intraoperative incidence rates ranging from 6.2 to 16.2 percent, and one study of patients aged 65 and older reported an incidence of 18.8 percent, with operative times of 180 minutes or longer strongly associated with increased risk. Medical devices compound the danger: blood pressure cuffs, adhesive tapes, endotracheal tubes and spectral index monitors can all damage skin and mucosal surfaces, and device-related pressure ulcers have been estimated at a prevalence of around 11.8 percent, while positioning-related ulcers may reach 23.5 percent. The operating room is therefore recognised as a high-risk environment where every member of the surgical team shares responsibility for tissue protection.

The 284 respondents were an experienced and highly educated group. Their mean age was 42.8 years, 93 percent were women, and 37 percent held a master’s degree while another 33.8 percent held a professional operating room nursing degree. More than 63 percent had over 11 years of experience in healthcare, and 37.7 percent had more than 20 years. When asked to rate their own expertise using Benner’s classic proficiency levels, half identified as proficient and 38 percent as competent, with 11.3 percent claiming expert status and only two nurses describing themselves as novices. Crucially, 87 percent said that further education in pressure ulcer prevention would be beneficial, an appetite for learning that the study’s findings suggest is well founded.

The knowledge assessment told a story of two halves. In the domain of aetiology, the nurses performed impressively. More than 95 percent correctly identified the causes of pressure ulcers and understood the biomechanical consequences of a patient sliding in a semi-upright position, and 90.1 percent recognised that body weight contributes to risk. These results align with previous research emphasising the role of knowledge in delivering evidence-based care. But when the questions turned to prevention, classification and observation, performance dropped sharply. Only 38 percent correctly identified where deep tissue injuries develop during surgery, and just 41.2 percent correctly classified blisters observed on both heels after a three-hour procedure. Nearly 60 percent answered incorrectly when asked about heel protection measures for a patient already lying on a pressure-redistributing mattress, and questions about patient positioning yielded correct response rates of only around 51 to 52 percent.

The researchers applied a demanding benchmark to these results, using a 90 percent threshold for correct answers, and only 3 of the 14 knowledge items met it. Even when the cut-off was lowered to 70 percent, the number of adequate responses remained limited. The authors deliberately retained the stricter threshold, reflecting on whether adjusting the standard of what counts as sufficient knowledge in pressure ulcer prevention is appropriate at all. The finding that positioning competencies are limited is consistent with earlier work by Sørensen and colleagues, who reported similar gaps among surgical teams, and it points to a specific, teachable weakness at the heart of intraoperative care: knowing how to position a patient safely is not the same as knowing why pressure damages tissue.

Attitudes, by contrast, were overwhelmingly positive. A remarkable 94.7 percent of respondents reported feeling confident in their ability to prevent pressure ulcers, and 98.6 percent agreed that prevention should be a priority and a personally important responsibility. Fully 94 percent acknowledged the financial burden that pressure ulcers place on society. The nurses firmly rejected dismissive statements: 93.7 percent disagreed that the impact of pressure ulcers on patients is exaggerated, 96.5 percent rejected the notion that too much attention is paid to prevention, and 96.1 percent refused the idea that they bear no responsibility if an ulcer develops in their patient. Attitude scores were higher than those reported in a previous study by Khong and colleagues, suggesting Swedish operating room nurses occupy an unusually favourable motivational position.

Experience shaped confidence in measurable ways. Pairwise comparisons revealed statistically significant differences across years of operating room experience in perceived training: nurses with more than 20 years of experience felt significantly better trained than those with 5 to 10 years, with a p-value of 0.049. A similar pattern emerged for perceived confidence, with significant differences between the most experienced nurses and those with 5 to 10 years of experience, and between the 11-to-20-year group and their less experienced colleagues. Yet the study’s central paradox remains: despite this confidence and experience, overall knowledge was insufficient, and positive attitudes did not translate into consistently correct answers about prevention strategies such as surgical linen use, positioning angles and heel offloading.

The authors are candid about the limitations of their work. Self-reported data are vulnerable to recall bias and social desirability bias, and some question wording may have confused participants. The 15 percent response rate restricts generalisability, and it is possible that respondents were more interested in pressure ulcer prevention than non-respondents, which could have inflated the apparent knowledge and attitude scores. The measurement instruments themselves, while validated, showed modest internal consistency on some subscales, and the authors note that PUKAT 2.0 OR requires further refinement to capture the complexity of pre-positioning across different surgical procedures while preserving operative exposure for the surgeon.

The implications reach beyond Sweden. Because most pressure ulcers are preventable, the authors argue, raising awareness and promoting evidence-based prevention strategies across the entire operating room team is imperative, including surgeons, anaesthesiologists and nurse anaesthetists, not nurses alone. They call for systematic, evidence-based educational interventions, structured training programmes, simulation-based learning and regular competency assessments integrated into continuing professional development, alongside mixed-methods research to clarify why positive attitudes fail to produce adequate knowledge or consistent preventive action. Structured risk assessment tools, which guidelines consider the gold standard, should complement rather than replace clinical judgement. For a complication that can begin forming the moment a patient is positioned on the table, the message of this survey is clear: the will to prevent pressure ulcers is present in the operating room, but the knowledge to do so reliably still needs to be built, one training programme at a time.

Subject of Research: Operating room nurses' knowledge and attitudes regarding intraoperative pressure ulcer prevention

Article Title: Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes

Article References: Falk‐Brynhildsen, K., Bååth, C., Beeckman, D., Leo Swenne, C., Raepsaet, C., & Wistrand, C. (2026). Preventing Pressure Ulcers in the Operating Room: A National Survey of Operating Room Nurses' Knowledge and Attitudes. Nursing Open, 13(9), Article e70808. https://doi.org/10.1002/nop2.70808

Image Credits: AI Generated

DOI: 10.1002/nop2.70808

Keywords: pressure ulcers, operating room nurses, patient safety, intraoperative care, nursing knowledge, survey research, Sweden, patient positioning, surgical complications, nursing education, pressure injury prevention, cross-sectional study

Primary tumours of the liver and biliary system are genuinely rare in cats, accounting for only about 1.0 to 2.9 percent of all feline neoplasms. They can arise from hepatocytes, the biliary epithelium, neuroendocrine cells or connective tissue elements, producing a histologically diverse group of diseases with very different behaviours. Because these tumours are uncommon, most published evidence has consisted of small single-institution case series, which has made it difficult for clinicians to give owners accurate prognostic information. The new study, led by Carolyn Averil Hylton and Matteo Rossanese of the Royal Veterinary College with colleagues at Colorado State University, the University of Bologna and the San Marco Veterinary Clinic, set out to close that evidence gap by pooling cases treated between 2003 and 2024.

The cohort was dominated by domestic shorthairs, reflecting the general cat population, with a median age of 12 years and a median body weight of 4.8 kilograms. Only eight of the 76 cats were asymptomatic; in these animals a mass was discovered incidentally during investigations for unrelated problems. The rest presented with the vague, non-specific signs typical of feline hepatic disease: lethargy, reduced appetite, progressive weight loss, vomiting and abdominal distension. Advanced cases could show icterus, clotting abnormalities and excessive thirst and urination, all signs of failing liver function. The median duration of clinical signs before presentation was 29 days, a reminder of how quietly these tumours can grow in a species that hides illness well.

Diagnostic workups revealed the scale of the problem. Imaging identified hepatic masses with a median maximal diameter of 5.5 centimetres, with the largest reaching 13 centimetres, an extraordinary volume for a feline liver. The left division of the liver was involved in 40 of the 76 cases, the central division in 22 and the right division in 14. The overwhelming majority of tumours, 85.5 percent, were of the massive solitary type rather than nodular or diffuse. Biliary cystadenoma, a benign tumour of the bile duct epithelium, was the most common diagnosis with 30 cases, followed by hepatocellular carcinoma with 19, hepatocellular adenoma with 11 and biliary carcinoma with 11, alongside small numbers of haemangiosarcomas and neuroendocrine carcinomas.

Preoperative diagnosis proved as difficult as the literature suggests. Nearly two-thirds of the masses were sampled before surgery, mostly by fine needle aspiration, but cytology matched the final histopathology in only 22 of those samples, was inconclusive in 11 and flatly wrong in 9, and in two further cases the pathologists could not distinguish adenoma from carcinoma. All seven tru-cut biopsy samples, by contrast, proved accurate. The study also uncovered biochemical patterns that may help clinicians refine their suspicion. Cats with biliary carcinoma had markedly elevated total bilirubin concentrations, with a median of 191 micromoles per litre, likely reflecting mechanical obstruction of bile flow, whereas cats with biliary cystadenoma had a median bilirubin of just 3 micromoles per litre. Cats with the benign cystadenomas also had significantly lower ALT and ALP liver enzyme values than cats with malignant tumours, consistent with the greater hepatocyte injury caused by carcinomas.

All 76 cats underwent exploratory abdominal surgery performed by or under the direct supervision of board-certified veterinary surgeons, with complete liver lobectomy in 66 cases and partial lobectomy in 10. A third of the cats required resection of more than one liver lobe, an operationally significant finding that underscores how large and invasive these masses can be. The authors suggest the predominance of left-sided tumours may partly reflect surgical selection bias: left lateral masses sit away from the gallbladder, bile ducts and hepatic hilus and are easier to resect, so surgeons and owners may historically have opted for surgery mainly in that anatomically favourable setting. Still, a genuine biological predilection for the larger left hepatic parenchyma cannot be excluded.

The headline safety data are striking. Intraoperative complications occurred in 11 cats, about 15 percent, including four severe haemorrhagic events. Postoperatively, 17 cats, 22 percent, experienced complications ranging from hyperthermia and anaemia requiring transfusion to anorexia severe enough to need a feeding tube. Seven cats died as a result of perioperative complications, giving an overall mortality rate of just 9 percent, with 69 of 76 cats surviving to hospital discharge. The median hospitalisation was four days. Earlier reports had put survival to discharge as low as 40 percent, so the authors argue that improvements in diagnostics, anaesthesia and surgical technique over recent decades have fundamentally changed the risk calculus for this operation.

Survival analysis, using Kaplan–Meier curves and Cox proportional hazards modelling, showed that histological diagnosis was the only factor significantly associated with survival. Median tumour-specific survival for cats with malignant tumours was 673 days, compared with 2916 days for benign tumours, a difference that was highly statistically significant. Among the malignant subtypes, cats with hepatocellular carcinoma lived a median of 859 days and those with biliary carcinoma 387 days, while for biliary cystadenoma the median survival was never reached during follow-up, which extended to nearly eight years in some patients. Notably, incomplete surgical margins did not significantly affect survival, nor did tumour size or location, although the authors caution that the mix of benign and malignant lesions among incompletely excised tumours may have muddied that comparison.

Recurrence and metastasis rates appeared reassuringly low, at 18 and 25 percent respectively among the cats for which restaging data were available, occurring between 30 and 840 days and 30 and 435 days after surgery. However, the authors flag an important limitation: only 28 of the 69 surviving cats underwent any follow-up restaging, so the true recurrence figures remain uncertain. Only four cats received postoperative chemotherapy, too few to draw any conclusion about the value of adjunctive therapy. The retrospective design also introduces selection bias, since cats deemed inoperable, those with metastatic disease at diagnosis and those euthanised without surgery were necessarily excluded, likely inflating the reported survival times.

Even with those caveats, the study delivers a clear and clinically actionable message. Liver lobectomy for feline hepatobiliary tumours carries a low mortality rate, and even cats with hepatocellular or biliary carcinoma can achieve favourable survival measured in years rather than weeks, outcomes consistent with recent smaller studies and broadly comparable to results in dogs. The authors recommend that clinicians actively discuss surgical options with owners of cats presenting with hepatic masses rather than defaulting to palliative management on the basis of outdated expectations. They also propose that surgery should be considered for masses outside the anatomically convenient left division, and that marked bilirubin elevations may warrant heightened suspicion of biliary carcinoma when cytology is inconclusive. Larger prospective studies will be needed to identify reliable prognostic factors and define the role of chemotherapy, but for now, the message to feline practitioners is one of cautious optimism: for many cats with primary liver tumours, surgery works, and it works better than the old textbooks ever admitted.

Subject of Research: Survival and prognostic factors in cats undergoing surgery for primary non-lymphomatous hepatobiliary tumours

Article Title: Evaluation of survival and prognostic factors in cats undergoing surgery for primary non-lymphomatous hepatobiliary tumours

Article References: Hylton, C. A., Guillén, A., Altwal, J., Tremolada, G., Cinti, F., Magno, S. D., & Rossanese, M. (2026). Evaluation of survival and prognostic factors in cats undergoing surgery for primary non-lymphomatous hepatobiliary tumours. Veterinary Oncology, 3(1), Article 2. https://doi.org/10.1186/s44356-025-00053-0

Image Credits: AI Generated

DOI: 10.1186/s44356-025-00053-0

Keywords: feline, hepatobiliary tumours, liver lobectomy, veterinary oncology, hepatocellular carcinoma, biliary cystadenoma, biliary carcinoma, prognostic factors, tumour-specific survival, surgical complications, retrospective study, liver enzymes

Vocal fold paralysis occurs when the nerves supplying the vocal folds, most commonly the recurrent laryngeal nerve, are damaged or dysfunctional, leaving one or both folds unable to move properly. The condition is far more often unilateral than bilateral, and the two presentations pose fundamentally different clinical problems. Patients with unilateral vocal fold paralysis typically struggle with a breathy, weak voice, difficulty swallowing, and an elevated risk of aspiration because the paralyzed fold cannot close the glottis during speech or swallowing. Bilateral paralysis, by contrast, can be life-threatening: when both folds are immobile near the midline, the airway itself may be obstructed, sometimes constituting a surgical emergency. Most cases in adults follow iatrogenic injury during thyroid, cardiothoracic, or esophageal surgery, while malignancies of the lung and larynx, stroke, trauma, and idiopathic causes account for much of the remainder.

The therapeutic arsenal for these patients is broad and reflects the divergent goals of treatment. For unilateral paralysis, surgeons aim to reposition or bulk up the immobile fold so that it can meet its functioning partner. Temporary options include hyaluronic acid injection, while calcium hydroxylapatite provides medialization lasting roughly eighteen months on average and autologous fat around six to twelve months. When the glottal gap exceeds three millimeters, framework surgery such as type I thyroplasty, sometimes combined with arytenoid adduction, is generally preferred and achieves voice improvement in eighty to ninety percent of cases. Laryngeal reinnervation, which reroutes nerve supply such as the ansa cervicalis to the recurrent laryngeal nerve, does not restore dynamic movement but improves static competence, muscle tone, and long-term stability by preventing denervation atrophy. For bilateral paralysis, the priority shifts to enlarging the airway through posterior cordotomy, partial or subtotal arytenoidectomy, or cordectomy, procedures that achieve decannulation rates of eighty-seven to one hundred percent among tracheostomized patients, albeit with substantial revision needs.

Despite the maturity of these techniques, the evidence base for their safety has remained surprisingly thin. Most published series are small, single-center studies drawn from homogeneous patient populations, leaving clinicians without reliable, generalizable estimates of perioperative risk. The new analysis was designed to close that gap. The investigators queried the ACS-NSQIP database, a prospectively maintained registry that collects standardized perioperative data from more than six hundred participating hospitals, using diagnostic codes for vocal fold paralysis and paresis together with a comprehensive list of procedural codes covering injection laryngoplasty, framework surgery, glottis-enlarging procedures, and reinnervation. Complications were aggregated into composite outcomes: surgical complications such as infections, wound dehiscence, and bleeding; medical complications ranging from pneumonia and reintubation to stroke, cardiac arrest, and sepsis; and an overall composite that also included reoperation.

The resulting cohort closely mirrored the expected epidemiology of the disease. Of the 931 patients, 857, or ninety-two percent, had unilateral paralysis, while seventy-four, or eight percent, had bilateral disease. Mean age was about sixty years in both groups, body mass index averaged twenty-nine kilograms per square meter, and roughly fifty-five percent of patients were women, a balanced sex distribution the authors suggest may more accurately reflect the true epidemiology than the divergent ratios reported in smaller studies. The majority of patients in both groups were classified as American Society of Anesthesiologists class three, indicating severe systemic disease, underscoring that these procedures are routinely performed in medically complex individuals. Most operations, around ninety percent in each group, were completed on an outpatient basis, with mean operative times of roughly one hundred minutes.

The safety outcomes were remarkably consistent across the two diagnostic groups. The overall complication rate was 3.4 percent for unilateral cases and 2.7 percent for bilateral cases, a difference that was not statistically significant. Reoperation was required in 0.93 percent of unilateral and 1.4 percent of bilateral patients, while surgical complications occurred at nearly identical rates of about 1.5 percent in both groups. Medical complications arose in 1.4 percent of unilateral cases and none of the bilateral cases. There were no significant between-group differences in superficial or deep infections, organ space infection, wound dehiscence, bleeding, pneumonia, reintubation, prolonged ventilation, urinary tract infection, stroke, cardiac arrest, myocardial infarction, deep vein thrombosis, sepsis, or septic shock. Notably, the analysis recorded no cases of sepsis, septic shock, or organ-space infection at all, findings the authors interpret as validation of established perioperative safety protocols.

The single patient who required ventilation beyond forty-eight hours illustrates how baseline frailty, rather than the procedure itself, can drive adverse outcomes. The individual was an eighty-year-old, ASA class three patient with congestive heart failure and hypertension who experienced a cascade of postoperative events including unplanned reintubation, cardiopulmonary resuscitation, blood transfusion, reoperation, and prolonged ventilation. Although no causal inference can be drawn from a single observation, the case highlights the importance of preoperative risk stratification in this population. This concern is particularly relevant given the burden of chronic pulmonary disease in the cohort: 8.1 percent of patients had chronic obstructive pulmonary disease, yet only six cases of pneumonia, or 0.64 percent, and a single reintubation, or 0.11 percent, were observed across the entire study period, figures consistent with or better than historical single-center series.

These results arrive amid ongoing debate about the optimal timing of surgery. Because spontaneous recovery occurs in a meaningful fraction of patients, with reported remission rates for idiopathic unilateral paralysis ranging from thirty to sixty-nine percent and most evidence clustering near the lower end, guidelines generally recommend deferring definitive procedures such as injection glottoplasty or type I thyroplasty for at least six and ideally up to twelve months. Prolonged denervation, however, causes progressive atrophy of the intrinsic laryngeal muscles that can compromise eventual functional outcomes, and significant aspiration or threatened airway protection may justify earlier temporary augmentation. Currently, no diagnostic marker reliably distinguishes patients who will recover spontaneously from those who will need surgery, forcing clinicians to balance the window for neural recovery against the risk of irreversible muscular deterioration on a case-by-case basis.

The authors are careful to frame the study as a measure of safety rather than efficacy. The ACS-NSQIP database captures only thirty days of follow-up, so long-term outcomes such as sustained voice quality, swallowing function, and airway stability fall outside its scope. Nor does the registry provide granular detail on specific techniques, primary versus revision procedures, or the underlying etiology of paralysis, and the binary structure of its outcome variables may underrepresent subtler morbidities like persistent dysphonia or delayed aspiration recovery. Because the database largely reflects North American practice, the findings may not generalize fully to international settings. Nevertheless, by transcending the single-center biases that have limited prior work, the analysis establishes a dependable benchmark: thirty-day morbidity after vocal fold paralysis surgery is low, comparable between unilateral and bilateral disease, and low enough to reassure both surgeons and the patients they counsel.

Subject of Research: Thirty-day perioperative safety of surgical intervention for unilateral and bilateral vocal fold paralysis in a multicenter ACS-NSQIP cohort

Article Title: Thirty-day perioperative safety following surgical intervention for unilateral and bilateral vocal fold paralysis: a multicenter ACS-NSQIP analysis

Article References: Schaschinger, T., Hoch, C. C., Knoedler, L., Niederegger, T., Dyhr, W. J., Hundeshagen, G., Lellouch, A. G., Voss, L. J., & Voss, J. O. (2026). Thirty-day perioperative safety following surgical intervention for unilateral and bilateral vocal fold paralysis: a multicenter ACS-NSQIP analysis. BMC Plastic and Reconstructive Surgery, 2(1), Article 26. https://doi.org/10.1186/s44452-026-00039-3

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00039-3

Keywords: vocal fold paralysis, ACS-NSQIP, perioperative safety, phonosurgery, thyroplasty, injection laryngoplasty, laryngeal reinnervation, bilateral vocal fold paralysis, unilateral vocal fold paralysis, surgical complications, otolaryngology, medialization