Total neoadjuvant therapy (TNT) has become a standard treatment approach for rectal cancer, providing higher rates of pathological complete response and improved long-term survival. Glucagon-like peptide-1 receptor agoni...Total neoadjuvant therapy (TNT) has become a standard treatment approach for rectal cancer, providing higher rates of pathological complete response and improved long-term survival. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown significant advantages in weight loss, systemic metabolic regulation, and anti-inflammatory effects. Emerging evidence also points to possible anticancer properties, with observational data suggesting a lower incidence of obesity-related cancers, including colorectal cancer. This narrative review aims to examine the biological basis and potential therapeutic benefits of combining GLP-1 RAs with TNT for the management of locally advanced rectal cancer. We explore how GLP-1 RAs may affect tumour biology and treatment tolerance, including their impact on visceral fat, insulin resistance, and systemic inflammation. Preclinical and clinical data are reviewed to determine whether GLP-1-induced metabolic changes can improve the effectiveness of chemotherapy and enhance surgical and oncological results. Although evidence is evolving, the integration of GLP-1 receptor agonists into rectal cancer treatment pathways represents a promising area for further investigation, particularly in metabolically vulnerable populations.
Anyomih TTK, Agbeko AE, Aregawi AB
… +13 more, Chu K, Crawford R, Harrison EM, Kamarajah S, Li E, Meara JG, Mulliez A, Sobhy S, Sullivan R, Tissingh E, Weiser TG, Bhangu A, Nepogodiev D
BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) defined six indicators with 2030 targets to track national surgical system performance. The aim of this systematic review was to evaluate national reporting and...BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) defined six indicators with 2030 targets to track national surgical system performance. The aim of this systematic review was to evaluate national reporting and attainment of benchmarks for each indicator and to assess the quality of modelling studies used to fill data gaps. METHODS: Seven bibliographic databases (1 April 2015-24 July 2024) and government domains of 48 countries committed to National Surgical, Obstetric, and Anaesthesia Plans were searched. Records providing national estimates of any LCoGS indicator were eligible. The primary outcome was the proportion of World Bank-classified countries meeting indicator benchmarks and the secondary outcome was the quality of modelled national estimates. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD420250650890). RESULTS: Of 4245 records retrieved, 44 studies were included (35 research articles and 9 policy documents). Among 217 World Bank-classified countries, access to timely essential surgery (indicator 1) was reported for 94 countries (39% meeting benchmark), specialist surgical workforce density (indicator 2) was reported for 167 countries (50.3% meeting benchmark), surgical volume (indicator 3) was reported for 124 countries (31.5% meeting benchmark), perioperative mortality (indicator 4) was reported for 74 countries (no benchmark was set at country level), and financial risk protection indicators (indicators 5 and 6) were reported for five countries, with none meeting either benchmark. Across indicators, high-income countries were more likely to meet benchmarks. Most modelled studies lacked transparency in data sources, statistical methods, or model validation. CONCLUSION: Reporting of LCoGS indicators remains sparse and uneven, particularly in low- and middle-income countries. Without standardized, routine measurement and minimum quality standards for modelled estimates, progress towards 2030 cannot be credibly tracked. Integrating surgical metrics into national health information systems should be a policy priority.
BACKGROUND: The BASIL-3 trial demonstrated that patients with chronic limb-threatening ischaemia secondary to femoropopliteal disease who were randomized to plain balloon angioplasty (PBA) ± bare-metal stenting (BMS), dr...BACKGROUND: The BASIL-3 trial demonstrated that patients with chronic limb-threatening ischaemia secondary to femoropopliteal disease who were randomized to plain balloon angioplasty (PBA) ± bare-metal stenting (BMS), drug-coated balloon angioplasty (DCBA) ± BMS, or drug-eluting stenting (DES) had similar clinical outcomes. Herein, the in-trial health economic analysis is presented. METHODS: Cost-utility analysis (CUA) and cost-effectiveness analysis (CEA) were conducted from the perspective of the UK National Health Service (NHS) and Personal Social Services Research Unit. Patient-level resource use and health outcome data were collected from the BASIL-3 trial during 2-7 years of follow-up and were utilized to estimate incremental cost-effectiveness ratios expressed as a cost per amputation-free life-year and per quality-adjusted life-year (QALY). EQ-5D-5L was used to generate participant QALYs at baseline and during follow-up. RESULTS: In the CUA, DCBA was associated with slightly lower NHS costs (-£250.71 (95% c.i. -£4630.34 to £3652.10)), but slightly lower QALY gains (-0.007 (95% c.i. -0.116 to 0.097) QALYs) when compared with PBA. When compared with PBA, DES was less costly (-£724.52 (95% c.i. -£4975.04 to £2631.57)) and resulted in an additional 0.048 (95% c.i. -0.060 to 0.148) QALYs. CONCLUSION: In BASIL-3, the probability of DCBA and of DES being cost-effective at £20 000 per QALY was 52% and 76% respectively. At a higher willingness-to-pay threshold (£30 000 per QALY) DES may be cost-effective and further research is required to explore the economic case.
INTRODUCTION: There is little data on the occurrence of cardiovascular disease (CVD) in oesophageal cancer (OC) survivors. Risk of CVD was investigated as a composite of myocardial infarction (MI), atrial fibrillation (A...INTRODUCTION: There is little data on the occurrence of cardiovascular disease (CVD) in oesophageal cancer (OC) survivors. Risk of CVD was investigated as a composite of myocardial infarction (MI), atrial fibrillation (AF), heart failure (HF), and ischaemic stroke (IS), as well as CVD-specific death among OC survivors after surgery. METHODS: A population-based retrospective cohort study was performed using the Korean National Health Insurance Service database (2009-2022), including patients who underwent surgery for OC (n = 3996) and 1:3 propensity score-matched non-cancer controls (n = 11 988). RESULTS: A total of 3996 OC survivors and 11 988 non-cancer controls were included in this study. Among OC survivors and controls, 492 and 1599 incident CVD cases and 33 and 305 CVD-specific deaths were observed respectively. OC survivors showed a higher risk of CVD (cause-specific hazard ratio (csHR) 1.42, 95% c.i. 1.28 to 1.57) than controls, and patients who underwent chemoradiotherapy plus surgery were at the highest risk. The increased risk was most prominent within the first year after surgery (csHR 3.00, 95% c.i. 2.35 to 3.85), but persisted thereafter (csHR 1.23, 95% c.i. 1.10 to 1.38 at 1-year lag; csHR 1.23, 95% c.i. 1.08 to 1.40 at 3-year lag; csHR 1.34, 95% c.i. 1.14 to 1.57 at 5-year lag). This pattern was evident for MI and AF, but not for HF, IS, or CVD-specific death. DISCUSSION: There is an increased risk of CVD in OC survivors compared to controls. The risk of CVD varied by the outcome, treatment, and duration after surgery.
Arjona-Sanchez A, Bhatt A, Kazi M
… +9 more, Somashekar SP, Raoof M, Cortés D, Kusamura S, Van der Speeten K, Sommariva A, Alyami M, Glehen O, PSOGI Collaborators
Hallet J, Falconi M, Bennet S
… +33 more, Frilling A, Gangi A, Gaujoux S, Pommier R, Bertani E, Buerba GA, Chan J, Clarke CN, Deguelte S, Del Rivero J, Nieveen van Dijkum E, Dumitra T, Eshmuminov D, Engelsman A, Fermi F, Grozinsky-Glasberg S, Howe JR, Lamarca A, Meloche-Dumas L, Mercier F, Myrehaug S, Perinel J, De Ponthaud C, Sallinen V, Song Y, Stuart H, Janson ET, Tinguely P, Tozzi F, van Ginhoven T, Warner S, Soreide K, Partelli S
BACKGROUND: Day case elective surgery is becoming increasingly common across a range of procedures. The aim of this study was to investigate the safety of day case thyroid lobectomy, a procedure with low uptake in the UK...BACKGROUND: Day case elective surgery is becoming increasingly common across a range of procedures. The aim of this study was to investigate the safety of day case thyroid lobectomy, a procedure with low uptake in the UK. METHODS: This study analysed the Hospital Episode Statistics administrative data set for all first-time elective thyroid lobectomies performed on adults in England from 1 April 2017 to 31 March 2024. The primary outcome was 30-day emergency readmission and secondary outcomes were 30-day emergency readmission for complications and specifically for haemorrhage. The primary exposure variable was whether patients were day case patients or inpatients. Models were adjusted for the demographic and frailty characteristics of the patients. RESULTS: Over the 7-year interval, 41 518 elective thyroid lobectomies were performed by 127 different hospital trusts. The day case rate was 9.9% (4125 patients) across all hospital trusts. Rates in the 118 hospital trusts conducting >20 procedures during the 7 years varied from 0% to 74.6%. Day case surgery was associated with a lower 30-day emergency readmission rate (OR 0.73 (95% c.i. 0.56 to 0.96); P < 0.021), with no evidence of association with poorer outcomes. There was no evidence that trusts with day case rates >30% had poorer outcomes than trusts with day case rates <1%. CONCLUSION: In low-risk patients, day case thyroid lobectomy is safe.
BACKGROUND: Cognitive non-technical skills (NTS), including situation awareness and decision-making, are critical determinants of surgical outcomes. Current NTS assessments depend on expert human observation, which is re...BACKGROUND: Cognitive non-technical skills (NTS), including situation awareness and decision-making, are critical determinants of surgical outcomes. Current NTS assessments depend on expert human observation, which is resource-intensive and difficult to scale. To address this, we investigated whether surgical gestures, derived from annotated video of the surgical field, could serve as objective indicators of cognitive NTS. METHODS: A data set of 40 open-source laparoscopic appendicectomy videos was annotated for temporal (for example surgical gestures) and spatial (for example coordinates of actions) indicators of surgical NTS. Using the Non-Technical Skills for Surgeons (NOTSS) tool, 12 expert observers independently assessed decision-making (1-4) and situation awareness (1-4). Multivariable linear regression analysed video-derived indicators predictive of NTS. RESULTS: Across all videos, a total of 10 385 events were annotated, generating 87 374 data points. The mean cognitive NOTSS rating was 5.6 (s.d. 0.8) out of 8, with decision-making and situation awareness highly correlated (r = 0.8, P < 0.001). The final multivariable model explained 39.6% of the variance in expert cognitive NOTSS ratings, identifying five predictors: dexterity index, events during the final operative phase, coagulating events, dropping actions, and actions targeting the small bowel. CONCLUSION: This study provides evidence that non-technical skills can be inferred from silent video of the surgical field alone. These findings lay the foundations for scalable, automated tools to evaluate surgeons' cognitive processes offering new avenues to improve surgical training, performance and outcomes.
BACKGROUND: Total neoadjuvant treatment (TNT) results in more complete responses and less risk of distant metastasis (DM) compared with chemoradiotherapy in locally advanced rectal cancer (LARC). The best schedule and th...BACKGROUND: Total neoadjuvant treatment (TNT) results in more complete responses and less risk of distant metastasis (DM) compared with chemoradiotherapy in locally advanced rectal cancer (LARC). The best schedule and the most suitable patients are unknown. In Sweden, after the closure of the RAPIDO trial, all hospitals in five out of six healthcare regions treated LARC patients with an abbreviated RAPIDO schedule, LARCT-US. Long-term data are reported. METHODS: Between July 2016 and June 2020, LARC patients with at least one high-risk criterion for recurrence according to staging MRI (cT4, cN2, mesorectal fascia involvement <1 mm, extramural vascular involvement, lateral node involvement) received TNT consisting of 5 × 5 Gy followed by four cycles of CAPOX/six cycles of FOLFOX. RESULTS: Curatively treated patients (437 of 462) were analysed after a median of 6.5 (interquartile range 5.9-7.2) years of follow-up. cT4 was seen in 53.5%. Sixty-two patients with a cCR entered a watch-and-wait programme (21 patients with regrowth) and 375 patients underwent primary surgery. At 5 years, of the 437 patients, locoregional recurrence (LRR) occurred in 26 patients (5.9% (95% c.i. 3.7% to 8.2%)) and DM occurred in 108 patients (24.7% (95% c.i. 20.7% to 28.7%)). The distal resection margin was ≤10 mm in 8.3% of patients after a sphincter-saving procedure (a lower percentage than in RAPIDO). The 109 patients (24.9%) with a complete response (48 patients with a cCR sustained for >1 year after the start of radiotherapy and 61 patients with a pCR) had excellent outcomes (0% with LRR and 3.7% with DM). CONCLUSION: TNT consisting of 5 × 5 Gy followed by four cycles of CAPOX/six cycles of FOLFOX resulted in excellent locoregional and distant control, despite inclusion of more advanced tumours than previous TNT studies. The low LRR risk in LARCT-US could be explained by more adequate distal resection margins practiced at Swedish centres.
INTRODUCTION: Patients awaiting elective procedures often have conditions that carry a risk of medical emergencies. This study quantifies the extent and variation of emergency hospital admissions during the waiting perio...INTRODUCTION: Patients awaiting elective procedures often have conditions that carry a risk of medical emergencies. This study quantifies the extent and variation of emergency hospital admissions during the waiting period across selected specialties and procedures. METHODS: Data from the NHS England Waiting List Minimum Dataset linked to the Secondary Uses Service hospital admissions data set from 1 January 2022 to 31 December 2023 was analysed. Emergency admissions occurring while patients awaited treatment were identified and categorized from 'very likely' related to the index condition or its recognized co-morbid risks-and potentially avoidable through definitive treatment-through to 'unrelated'. RESULTS: In 2023 some 2 093 789 waits (both incomplete and complete) were recorded across 41 selected procedures spanning 11 specialties. Over a combined waiting time of 33 832 790 days, 69 322 emergency admissions occurred, accounting for 535 806 bed days. The highest emergency admission rates per 52 weeks waiting were observed for urinary stent procedures (0.71), endoscopic retrograde cholangiopancreatography (0.63), and urinary catheter care (0.55). Nine procedures had more emergency bed days during the wait than elective bed days post-treatment, with the highest emergency/elective bed day ratios for ureteric stones (4.59), colonoscopy (2.80), and ablation/cardioversion (2.05). CONCLUSION: A substantial number of patients on elective waiting lists are being admitted as emergencies during their wait, placing a burden on emergency care that would be avoided through more timely treatment. The variation in risk between specialties and pathways requires further prioritization strategies that mitigate patients' risk of associated harm, acting both within and across waiting lists, specialties, and organizations.
Tinelli G, Sica S, Tsilimparis N
… +15 more, Pichlmaier M, Neri E, Hostalrich A, Kölbel T, Sobocinski J, Di Eusanio M, Gatta E, Schanzer A, Guimbretière G, Giannarelli D, Guo MH, Tshomba Y, Massetti M, Haulon S, International multicenter post-Dissection Arch Repair Study (DARS) Group
BACKGROUND: Redo open arch repair is challenging; arch branched endovascular aortic repair (a-BEVAR) offers a less invasive alternative. However, direct comparisons are lacking. The aim of this study was to compare the o...BACKGROUND: Redo open arch repair is challenging; arch branched endovascular aortic repair (a-BEVAR) offers a less invasive alternative. However, direct comparisons are lacking. The aim of this study was to compare the outcomes of open arch repair versus a-BEVAR in patients with residual aortic dissection after ascending aorta replacement for acute Stanford type A aortic dissection. METHODS: This multicentre retrospective study included patients treated for residual dissection after type A aortic dissection in ten high-volume centres from January 2018 to May 2024. Propensity score matching (1 : 1) was used to adjust for baseline differences. Primary endpoints included 30-day mortality and stroke rates, and secondary endpoints included acute kidney injury, spinal cord ischaemia, reintervention, aortic-related mortality, and hospital length of stay. RESULTS: A total of 183 patients were included: 89 (48.6%) underwent open arch repair and 94 (51.4%) underwent a-BEVAR. After propensity score matching, there were 57 patients in each group. The 30-day mortality rate was 3.5% for open arch repair and 5.3% for a-BEVAR (P = 0.220). The stroke rate was 5.3% for open arch repair and 3.5% for a-BEVAR (P = 0.650). Open arch repair was associated with significantly higher rates of prolonged (>48 h) intubation (28.1% versus 3.5%; P < 0.001), acute kidney injury (31.6% versus 8.8%; P = 0.002), and temporary dialysis (22.8% versus 7.0%; P = 0.002). The median hospital length of stay was 21 days for open arch repair and 10 days for a-BEVAR (P < 0.001). During a median follow-up of 30 months (i.q.r. 7-49), no difference in mortality was observed (10.5% for open arch repair versus 12.3% for a-BEVAR; P = 0.770). CONCLUSION: a-BEVAR provides a less invasive alternative to open arch repair with reduced complications. Long-term studies are needed.