Drager LD, Atsma F, Strijker D
… +9 more, van Heusden-Scholtalbers LAG, van Asseldonk MJMD, Rosenstok J, Seeger JPH, Verlaan S, Buffart LM, van Laarhoven CJHM, van den Heuvel B, F4S PREHAB Collaborative Group
BACKGROUND: Multimodal prehabilitation may improve surgical outcomes in selected populations, but its real-world effectiveness remains unclear. The aim of this study was to evaluate the effect of hospital-wide implementa...BACKGROUND: Multimodal prehabilitation may improve surgical outcomes in selected populations, but its real-world effectiveness remains unclear. The aim of this study was to evaluate the effect of hospital-wide implementation of multimodal prehabilitation on postoperative complications and length of hospital stay in a diverse surgical population. METHODS: This single-centre, non-randomized stepped-wedge study (F4S PREHAB) was conducted at Radboudumc, Nijmegen, The Netherlands from March 2019 to April 2024. Patients who underwent elective surgery across 20 clinical pathways received either standard preoperative care or multimodal prehabilitation comprising supervised exercise, nutritional support, psychological counselling, and smoking and alcohol cessation support. The primary outcome was the incidence and severity of postoperative complications within 30 days, with assessment of Clavien-Dindo (CD) grade ≥II complications and the dichotomized Comprehensive Complication Index (CCI). The secondary outcome was the length of hospital stay. Analyses used generalized linear models adjusted for time of inclusion and clinical pathway, as well as other confounders in some models. Subgroup analyses focused on patients who underwent high-risk gastrointestinal (GI) oncological surgery. RESULTS: During the study interval, 4131 patients received usual care (2660 patients) or prehabilitation (1471 patients). A total of 367 patients (24.9%) attended at least nine exercise sessions, indicating partial adherence. No significant differences between groups were found with regard to postoperative CD grade ≥II complications (adjusted risk ratio 1.02 (95% c.i. 0.90 to 1.16)) and CCI >22.6 (adjusted risk ratio 1.03 (95% c.i. 0.86 to 1.23)) or length of hospital stay (adjusted incidence rate ratio 1.04 (95% c.i. 0.92 to 1.18)). In the high-risk GI oncological surgery subgroup (1230 patients), the relative reduction in CD grade ≥II complication risk was 9%, but this was not statistically significant (adjusted risk ratio 0.91 (95% c.i. 0.75 to 1.10)). CONCLUSION: Hospital-wide implementation of multimodal prehabilitation did not reduce postoperative complications or length of hospital stay. A greater effect in high-risk patients suggests a targeted approach may be more effective. Future research should identify such patients and evaluate effectiveness of prehabilitation in this population.
BACKGROUND: Although several oesophageal squamous cell carcinoma (OSCC) studies have reported no definitive overall survival (OS) differences between neoadjuvant chemoradiotherapy (NACRT) and neoadjuvant chemotherapy (NA...BACKGROUND: Although several oesophageal squamous cell carcinoma (OSCC) studies have reported no definitive overall survival (OS) differences between neoadjuvant chemoradiotherapy (NACRT) and neoadjuvant chemotherapy (NAC), the higher pCR rate with NACRT has been viewed as a potential advantage. Beyond ongoing concerns about the validity of pCR as a surrogate endpoint, it remains uncertain whether survival differs between these modalities among patients with OSCC who achieve pCR. METHODS: An integrated analysis of individual patient data (IPD) from phase III trials evaluating perioperative therapies for resectable OSCC was conducted, emphasizing prognostic differences between NAC and NACRT, particularly among patients who achieved pCR. RESULTS: IPD from seven phase III RCTs across six countries included data for 1044 patients with OSCC (83.5% male; mean age of 62.3 years). Of these patients, 605 (58.0%) received NAC and 439 (42.0%) received NACRT, with R0 resection rates of 89.6% versus 84.7% and pCR rates of 6.9% versus 34.2% respectively. Among patients who achieved pCR (192 patients), 5-year OS was 97.5% in the NAC group and 70.4% in the NACRT group, while 5-year recurrence-free survival was 80.8% and 63.7% respectively. Multivariable analysis demonstrated a significant survival advantage for NAC among patients who achieved pCR. CONCLUSION: Among patients who achieved pCR, postoperative outcomes varied considerably by neoadjuvant treatment modality. The markedly favourable prognosis associated with pCR after NAC suggests that these patients may represent an optimal candidate cohort for future evaluation of surgery-avoidance and watch-and-wait strategies.
BACKGROUND: Surgical-site infections (SSIs) are a leading cause of postoperative morbidity, prolonged hospitalization, and significant healthcare costs. Antimicrobial dressings may mitigate SSI risk by minimizing local m...BACKGROUND: Surgical-site infections (SSIs) are a leading cause of postoperative morbidity, prolonged hospitalization, and significant healthcare costs. Antimicrobial dressings may mitigate SSI risk by minimizing local microbial burden, but their effectiveness remains uncertain. METHODS: MEDLINE, Embase, CINAHL, and Cochrane CENTRAL were searched from inception up to 5 July 2024, supplemented by searches of the grey literature and citation chasing. RCTs comparing antimicrobial dressings with any other inert dressing for closed incisional wounds after elective or emergency surgery were included. Data were extracted in duplicate, risk of bias (RoB) was assessed using the Cochrane RoB 2 tool, and certainty of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Pairwise random-effects meta-analyses were performed. The primary outcome was SSI within 30 days (90 days if prosthesis used); secondary outcomes included adverse events and costs. RESULTS: A total of 35 RCTs involving 8718 participants were included. Meta-analyses were conducted for silver (21 studies, 5504 participants), dialkylcarbamoyl chloride (DACC) (3 studies, 892 participants), and mupirocin (3 studies, 1320 participants). Compared with standard dressings, silver dressings reduced the risk of SSI by 22% (risk ratio (RR) 0.78 (95% c.i. 0.62 to 0.97); I2 = 43%; moderate-certainty evidence). DACC dressings halved the risk of SSI (RR 0.49 (95% c.i. 0.29 to 0.83); I2 = 0%; moderate-certainty evidence) compared with standard dressings. Mupirocin dressings were not associated with SSI prevention (RR 0.62 (95% c.i. 0.15 to 2.63); I2 = 67%; very low-certainty evidence). Evidence for other agents was insufficient. CONCLUSION: Silver and DACC dressings probably reduce the risk of SSI in closed surgical wounds. There is residual uncertainty over the clinical effectiveness of other antimicrobial dressings.
BACKGROUND: Surgical training relies heavily on subjective performance evaluation, which is resource-intensive and prone to assessor bias. Advances in digital surgery offer opportunities for objective assessment. While v...BACKGROUND: Surgical training relies heavily on subjective performance evaluation, which is resource-intensive and prone to assessor bias. Advances in digital surgery offer opportunities for objective assessment. While validity evidence for data-driven assessments increases, strategies for implementation in surgical training remain scarce. The aim of this study was to leverage stakeholder insights to develop an implementation framework for integrating data-driven surgical sabermetrics into training curricula. METHODS: Structured workshops were conducted at two international surgical conferences (the Association of Surgeons of Great Britain and Ireland Congress, Edinburgh, May 2025 and the International Conference on Surgical Education and Training, Edinburgh, June 2025). Delegates participated in facilitated discussions, interactive polling, and group concept-mapping exercises to explore opportunities, delivery modalities, access rights, and contextualization for surgical performance metrics. Stakeholder perceptions were used to iteratively develop an implementation framework, balancing applicability to current training pathways and capturing the nuances of data-driven insights. RESULTS: A total of 54 surgical trainees and trainers from 13 countries contributed. Opportunities centred on enhancing objective feedback, assessing non-technical skills, and tracking trainee progression. Video-based delivery and real-time feedback were prioritized for technical skills, dashboards were prioritized for non-technical and cognitive skills, and structured reports were prioritized for performance-based metrics. Supervising surgeons and training leads were identified as essential users of trainee data, with integration of multimodal data (for example surgeon physiology, case complexity) deemed essential for contextualization. CONCLUSION: This study presents an implementation framework for surgical sabermetrics in training. The framework provides practical guidance on delivery, access, and integration of performance metrics, supporting data-driven feedback to optimize trainee development, advance surgical education, and improve patient outcomes.
BACKGROUND: Recent advancements in endovascular aortic repair (EVAR) have expanded treatment to increasingly proximal aortic segments, including the thoracic and thoracoabdominal aorta as well as the arch. Coherent real-...BACKGROUND: Recent advancements in endovascular aortic repair (EVAR) have expanded treatment to increasingly proximal aortic segments, including the thoracic and thoracoabdominal aorta as well as the arch. Coherent real-world data on stroke risk after EVAR, stratified by the proximal landing zone, and the impact of perioperative stroke on mid-term survival are scarce. METHODS: A population-based multiregistry retrospective analysis was performed on prospectively collected data for all EVARs performed in Sweden between 15 May 2018 and 15 May 2023. Data were collected from the Swedish Vascular Registry (Swedvasc) and cross-referenced with the Swedish Patient Registry, the Swedish Cause of Death Registry, and the Swedish Stroke Registry. The effect of perioperative stroke on mid-term survival was analysed and the relationship between the incidence of stroke and the proximal landing zone was analysed. RESULTS: Some 4842 EVARs were performed. Perioperative stroke occurred in 1.6% (79 of 4842). Stroke risk was associated with the proximal landing zone, with a stroke rate of 22% in zone 0. In multivariable analysis, the OR for stroke in zone 0 was 41.58 (95% c.i. 18.46 to 93.70); P < 0.001. The 30-day mortality rate was 24% (19 of 79) and 3.5% (169 of 4763) for patients with and without perioperative stroke respectively. This difference persisted over time, with a 4-year survival probability of 48.6% and 72.5% for patients with and without stroke respectively (HR 2.17 (95% c.i. 1.26 to 3.72); P < 0.001). CONCLUSION: Stroke is strongly associated with the proximal landing zone, being more likely when landing proximal to the supra-aortic vessels. Perioperative stroke impacts patient survival and should be taken into consideration during patient selection, and efforts should be made to reduce the risk of stroke during proximal repair.
Gangaram Panday SSG, van der Wilk BJ, Eyck BM
… +35 more, Lagarde SM, Rosman C, Noordman BJ, Valkema MJ, Bisseling TM, Coene PLO, van Det MJ, Dekker JWT, van Dieren JM, Doukas M, van Esser S, Fiets WE, Hartgrink HH, Heisterkamp J, Holster IL, Husson O, Klarenbeek B, Kouw E, Kouwenhoven EA, Luyer MD, Mostert B, Nieuwenhuijzen GAP, Oostenbrug LE, Pierie JP, van Sandick JW, Sosef MN, Spaander MCW, Steyerberg EW, Valkema R, van der Zaag ES, Lingsma HF, van Klaveren D, van Lanschot JJB, Wijnhoven BPL, Other Members of the SANO Study Group
BACKGROUND: The SANO trial demonstrated that active surveillance after neoadjuvant chemoradiotherapy (nCRT) has non-inferior 2-year overall survival compared with standard surgery in patients with locally advanced oesoph...BACKGROUND: The SANO trial demonstrated that active surveillance after neoadjuvant chemoradiotherapy (nCRT) has non-inferior 2-year overall survival compared with standard surgery in patients with locally advanced oesophageal cancer. This aim of this study was to compare health-related quality of life (HRQoL) in both groups. METHODS: Patients with a cCR after nCRT were included and randomized within the stepped-wedge cluster-randomized SANO trial to active surveillance or surgery. HRQoL was measured using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30) and the EORTC Quality of Life Questionnaire-Oesophago-Gastric Module (QLQ-OG25) before nCRT (baseline) and at 3 (before surgery), 6, 9, 12, 16, 20, and 24 months after nCRT. Predefined endpoints included dysphagia (QLQ-OG25), as well as dyspnoea, fatigue, physical functioning, and emotional functioning (all QLQ-C30). Repeated measures analysis was used to assess between-group differences. Cohen's d (CD) >0.5 was considered clinically relevant. RESULTS: A total of 274 patients were included, with a response rate of 85.4% (234 patients responded in total; 169 active surveillance patients and 65 standard surgery patients). At 6 months after nCRT, scores for dysphagia, dyspnoea, fatigue, and physical functioning were significantly better in the active surveillance group (CD of -1.09, -0.63, -0.70, and 0.77 respectively; all P ≤ 0.001). Dysphagia remained significantly better in the active surveillance group at 9, 12, and 24 months after nCRT (CD of -0.60 (P = 0.001), -0.46 (P = 0.015), and -0.79 (P < 0.001) respectively). No differences were found for other domains. CONCLUSION: Active surveillance patients experienced less dysphagia, dyspnoea, and fatigue, as well as better physical functioning, at 6 months after nCRT compared with standard surgery patients. Dysphagia remained improved at 2 years. These results support an active surveillance approach in patients with oesophageal cancer who attain a cCR after nCRT. REGISTRATION NUMBER: NTR-6803 (Netherlands Trial Register).
BACKGROUND: Open surgery is a durable approach to thoracoabdominal aortic aneurysm (TAAA) repair. It carries a substantial risk of major perioperative complications, including death. The aim of this study was to describe...BACKGROUND: Open surgery is a durable approach to thoracoabdominal aortic aneurysm (TAAA) repair. It carries a substantial risk of major perioperative complications, including death. The aim of this study was to describe the outcomes of open repairs undertaken by the Scottish National TAAA Service since its inception 25 years ago. METHODS: Procedural details and clinical outcomes of all open TAAA repairs between 1999 and 2023 were reviewed. The primary outcome was in-hospital mortality, with secondary outcomes including overall and aneurysm-related survival, as well as rates of permanent spinal cord ischaemia (SCI), renal replacement therapy, and other major operative complications. Survival of patients requiring a thoracolaparotomy (Crawford extent I-III and V repair) versus that of patients requiring a laparotomy (Crawford extent IV repair) was assessed using Kaplan-Meier analysis. RESULTS: Of 424 patients (mean(s.d.) age 65.86(10.86) years, mean(s.d.) aneurysm diameter 63.89(17.52) mm, 5.7% with a connective tissue disorder, and 72.8% male), 148 patients underwent thoracolaparotomy and 276 underwent laparotomy. While 4.5% of operations were for ruptures, most (297 (70.0%)) were for asymptomatic TAAAs. Elective and overall in-hospital mortality were 10.1% and 13.4% respectively. Patients who underwent repair requiring a thoracolaparotomy (148 patients) were younger (mean age 59.7 years versus 69.1 years; P < 0.001), had higher 30-day mortality (23.6% versus 6.5%; P < 0.001), and had a higher rate of permanent SCI (8.8% versus 0.7%; P < 0.001) compared with those who underwent repair requiring a laparotomy. Patients who underwent extent II repairs had the highest overall and elective 30-day mortality (30.2% and 26.6% respectively) and had the highest rate of permanent SCI (14.3%). The estimated overall 5-year survival was 68.3% and the estimated elective 5-year survival was 70.2%, 67.5%, and 71.3% for the entire cohort, the extent I-III and V cohort, and the extent IV cohort respectively. CONCLUSION: Open TAAA repair is associated with significant operative risk, which varies depending on the extent of aneurysm repair.
Streit S, Wharton G, Mah J
… +15 more, van Kessel R, Prionas A, Johnston-Webber C, Boletis J, Domínguez-Gil B, Forsberg A, França A, Gardiner D, Jeurissen P, Papanicolas I, Pearcey O, Rasmussen A, Romagnoli J, Mossialos E, Papalois V
BACKGROUND: Health system performance assessment helps identify areas for improvement and guides policy initiatives. Although well-validated indicators exist for measuring organ donation and transplantation performance a...BACKGROUND: Health system performance assessment helps identify areas for improvement and guides policy initiatives. Although well-validated indicators exist for measuring organ donation and transplantation performance at the facility level, consensus on indicators for assessing national programmes is lacking. The aim of this study was to develop a comprehensive scorecard for evaluating national organ donation and transplantation programmes. METHODS: A three-step approach was used. First, a targeted literature review identified potential indicators from regulatory documents, national transplant organization reports, and databases. Second, indicators were mapped to an established transplant system framework and refined through preliminary expert consultations. Third, a modified Delphi consensus process validated the indicators. The Delphi panel comprised international experts in health policy, organ donation, transplantation, and patient representation. Participants rated 168 indicators using a five-point Likert scale across two rounds (24 experts completed round 1 and 22 experts completed round 2). Consensus for inclusion required 80% agreement. RESULTS: Of 168 indicators evaluated, 103 achieved consensus for inclusion. After consolidation of organ-specific indicators, the final set contained 84 indicators across seven domains: monitoring and reporting (8 indicators), prevention and need (9 indicators), waiting lists (11 indicators), consent (4 indicators), donation (28 indicators), transplantation (14 indicators), and follow-up (10 indicators). The indicator set incorporates established metrics such as waiting list statistics, donation rates, and complication rates alongside novel system-level indicators addressing structural factors, patient-centredness, and equity in care delivery. CONCLUSION: This validated indicator set provides a standardized tool for assessing and comparing transplant system performance across European countries, supporting performance benchmarking and evidence-informed policy development.
BACKGROUND: Open excisional haemorrhoidectomy (OEH) remains the standard treatment for advanced haemorrhoidal disease, offering low recurrence but notable postoperative pain. Transanal haemorrhoidal dearterialization (TH...BACKGROUND: Open excisional haemorrhoidectomy (OEH) remains the standard treatment for advanced haemorrhoidal disease, offering low recurrence but notable postoperative pain. Transanal haemorrhoidal dearterialization (THD) is an alternative with reduced pain but potentially higher recurrence. The aim of this trial was to compare the 1-year efficacy of both techniques using validated symptom and quality-of-life scores. METHODS: A prospective, single-centre, randomized, open-label trial was conducted in patients with grade III haemorrhoids. The primary outcome was the relative change at 12 months in Haemorrhoidal Disease Symptom Score (HDSS) and Short Health Scale adapted for Haemorrhoidal Disease (SHS-HD) from baseline. Additionally, the predefined, pragmatic composite endpoint-the clinical failure rate (CFR), defined as a ≤50% improvement in both HDSS and SHS-HD-was compared. Secondary outcomes included postoperative pain, time to return to work, complications, and reoperation. RESULTS: From August 2021 to February 2023, 50 patients were randomized (25 OEH patients and 25 THD patients). Three patients were lost to follow-up (2 THD patients and 1 OEH patient). CFR was significantly higher in the THD group (14 of 23 (61%)) versus the OEH group (2 of 24 (8%)) (P <0.001). All eigth reoperations occurred in the THD group (P = 0.001). Both procedures reduced symptom and quality-of-life scores (P = 0.002 and P < 0.001). OEH was associated with greater early postoperative pain and a longer time to return to work (median of 21 versus 14 days; P = 0.010). CONCLUSION: OEH is more effective than THD but is associated with greater early postoperative pain. REGISTRATION NUMBER: NCT06420986 (http://www.clinicaltrials.gov).
OBJECTIVE: Identifying the optimal metabolic bariatric surgery approach for patients with severe obesity with a BMI ≥50 kg/m2 remains challenging. The aim of this long-term follow-up of a randomized clinical trial (RCT)...OBJECTIVE: Identifying the optimal metabolic bariatric surgery approach for patients with severe obesity with a BMI ≥50 kg/m2 remains challenging. The aim of this long-term follow-up of a randomized clinical trial (RCT) was to compare distal long alimentary limb Roux-en-Y gastric bypass (RYGB) with standard RYGB for 10-year weight loss and nutritional outcomes. METHOD: Secondary analysis of a 10-year follow-up of an RCT with initially 113 patients (BMI 50-60 kg/m2) randomized to either standard (n = 57, 50 cm biliopancreatic/150 cm alimentary limb) or distal long alimentary limb RYGB (n = 56, 50 cm biliopancreatic/150 cm common limb) from March 2011 to April 2013 at two Norwegian hospitals. The final data collection date was 15 August 2023. The primary focus was weight loss (BMI reduction, %total weight loss) and other secondary outcomes included cardiometabolic risk factors, nutritional status, and health-related quality of life (HRQOL). RESULTS: Of 113 patients, 79 (69.9%, mean age 50 (s.d. 8.7) years, 50 (63%) females) patients were available for 10-year follow-up (41 standard RYGB, 38 distal RYGB). The 10-year mortality rate was 3.5% (4/113) and all deaths occurred after distal RYGB. One death may have been associated with the surgery in a patient with previously undiagnosed liver cirrhosis at the time of operation. Mean BMI reduction from baseline was 12.0 kg/m2 (95% c.i., 10.8 to 13.2) after standard RYGB and 14.7 kg/m2 (95% c.i., 13.5 to 15.9) after distal RYGB with a between-group difference of 2.7 kg/m2 (95% c.i., 1.0 to 4.5, P = 0.002). The mean percentage total weight loss from baseline was 23.0% (95% c.i., 20.8 to 25.2) after standard RYGB and 28.2% (95% c.i., 26.0 to 30.5) after distal RYGB, with a between-group difference of 5.3% (95% c.i., 2.1 to 8.4, P = 0.001). The distal RYGB group had higher rates of malnutrition (1/57 standard versus 5/56 distal; P = 0.12), diarrhoea (7/57 standard versus 15/56 distal; P = 0.05), and vitamin D deficiency (24/41 standard versus 32/38 distal; P = 0.01). There were no differences between the groups in the prevalence of type 2 diabetes, hypertension, dyslipidaemia, or metabolic syndrome at 10-year follow-up. Four patients underwent revisional surgery due to malnutrition after distal RYGB. There were no statistically significant differences in HRQOL scores between the groups at 10 years (SF-36 physical 44.2 versus 44.1, mental 50.3 versus 47.3; OWLQOL 63 versus 61; all P > 0.2). CONCLUSIONS: Distal long alimentary limb RYGB resulted in greater weight loss after 10 years with a higher risk of malnutrition, diarrhoea, and vitamin D deficiency. TRIAL REGISTRATION: Clinicaltrials.gov NCT00821197.