INTRODUCTION: Supervised Exercise Therapy (SET) is recommended as first-line treatment for intermittent claudication. We hypothesized that oxidative stress from long-term intermittent leg ischaemia is harmful and that re...INTRODUCTION: Supervised Exercise Therapy (SET) is recommended as first-line treatment for intermittent claudication. We hypothesized that oxidative stress from long-term intermittent leg ischaemia is harmful and that revascularization mitigates this risk. The aim of this hypothesis-driven systematic review and meta-analysis was to evaluate the long-term mortality rate and clinical outcomes comparing SET with early revascularization in patients with intermittent claudication. METHODS: RCTs comparing SET and early revascularization with >12 months follow-up and reporting mortality rates were included. Medline, Embase, Cochrane Central, ClinicalTrials.gov, and WHO ICTRP were searched using a modified PICO (PICS) framework. Risk-of-bias was assessed using the Cochrane Risk-of-Bias Tool. Meta-analyses applied hazard ratios, incidence rate ratios (IRR), or odds ratios as appropriate. PROSPERO registration: CRD42024536634. RESULTS: Some nine cohorts from seven RCTs (1113 patients) were included. Meta-analysis of HR (two cohorts) displayed higher mortality rates with SET compared to early revascularization (HR: 1.83; 95% c.i.: 1.10 to 3.04; P = 0.02). Intention-to-treat IRR analysis (eight cohorts) displayed an IRR of 1.28; 95% c.i.: 0.91 to 1.79; P = 0.16. A worst-case post-hoc sensitivity analysis assuming all losses to follow-up as deaths presented higher mortality rate with SET (IRR: 1.29; 95% c.i.: 1.04 to 1.61; P = 0.02). SET reduced initial revascularizations by 60.3%, but 34.8% crossed over, resulting in over twice the need for subsequent revascularization (OR: 2.30; 95% c.i.: 1.71 to 3.11; P < 0.001). No differences were found for amputation, myocardial infarction, or stroke. Risk-of-bias was deemed high, and certainty of evidence ranged from low to very low. CONCLUSION: Early revascularization may improve long-term survival compared to SET, although interpretation is limited by risk-of-bias and incomplete data in published studies.
BACKGROUND: Superiority of robotic inguinal hernia repair compared with a laparoscopic minimally invasive approach remains unproven. The aim of this study was to evaluate postoperative pain after laparoscopic totally ext...BACKGROUND: Superiority of robotic inguinal hernia repair compared with a laparoscopic minimally invasive approach remains unproven. The aim of this study was to evaluate postoperative pain after laparoscopic totally extraperitoneal repair (TEP) compared with robotic transabdominal preperitoneal repair (rTAPP). METHODS: This was a prospective, patient- and investigator-blinded, two-group, single-centre RCT conducted at a tertiary Swiss healthcare institution including 182 patients undergoing elective primary inguinal hernia repair. Patients were randomized 1 : 1 and stratified according to BMI and unilateral or bilateral hernia to either TEP or rTAPP. Surgery took place between March 2022 and November 2024. The primary endpoint was postoperative pain while coughing 24 h after surgery. Surgical workload (assessed using the National Aeronautics and Space Administration (NASA) Task Load Index (TLX)) was also recorded. RESULTS: In total, 91 patients (93% male, mean(s.d.) age of 56.8(15.2) years, mean(s.d.) BMI of 24.8(3) kg/m2, and 22% with bilateral hernias) were randomized to TEP and 91 patients (95% male, mean(s.d.) age of 55.1(14.5) years, mean(s.d.) BMI of 24.6(2.9) kg/m2, and 21% with bilateral hernias) were randomized to rTAPP. Primary outcome data were available for 90 TEP patients and 88 rTAPP patients. The median postoperative pain while coughing on a numeric rating scale 24 h after surgery was 5 (interquartile range (i.q.r.) 2-7) after TEP and 4 (i.q.r. 2-7) after rTAPP (P = 0.431, Cohen's d = 0.12). The mean(s.d.) operating time for unilateral hernias was 64.2(19.2) min for TEP and 80.3(20.9) min for rTAPP (P < 0.001). Ten (11%) postoperative complications occured after TEP and nine (10%) after rTAPP (P > 0.999). The mean(s.d.) NASA raw TLX score was 34.0(17.2) after TEP and 18.4(10.7) after rTAPP (P < 0.001). CONCLUSION: rTAPP demonstrated no superiority over TEP regarding postoperative pain and complication rates. rTAPP was associated with a reduced surgeon workload at the expense of a longer operating time. REGISTRATION NUMBER: NCT05216276 (http://www.clinicaltrials.gov).
Daly GR, Dowling GP, Hembrecht S
… +40 more, O'Grady S, Hegarty A, Roche T, Orsi G, Pierre A, Calpin GG, Neary C, Hehir CM, Hill GJ, O'Brien A, Duggan WP, Davey MG, Stephens IJB, Kennedy ND, Brennan O, Hayes C, Al Azzawi M, Balasubramanian I, McGuire A, Zaborowski AM, Reynolds IS, Loughlin P, Allen M, Power C, Butt A, Boland MR, McCawley N, Burke JP, Robb WB, Mastrosimone A, Arumugasamy M, Prins H, Beddy D, Kerin MJ, McNamara DA, Kearney D, Sorensen J, Curley GF, Abd El Wahab S, Hill ADK
BACKGROUND: Transversus abdominis plane (TAP) block has been shown to be an effective technique in providing postoperative analgesia across a range of intra-abdominal surgeries. Laparoscopic-assisted transversus abdomini...BACKGROUND: Transversus abdominis plane (TAP) block has been shown to be an effective technique in providing postoperative analgesia across a range of intra-abdominal surgeries. Laparoscopic-assisted transversus abdominis plane (LTAP) block is a recent advancement of this technique. The aim of this trial was to evaluate the effectiveness of LTAP block compared with port-site infiltration (PSI) of local anaesthetic in patients undergoing laparoscopic appendicectomy. METHODS: A single-blinded RCT was performed across three academic hospitals. Patients were randomized 1 : 1 to receive LTAP block or PSI. The primary outcome was postoperative pain, assessed using a visual analogue scale (VAS). Secondary outcomes were postoperative opioid requirements, length of hospital stay (LOS), time to mobilization, and quality of life (QoL) after hospital discharge. RESULTS: In total, 85 of 87 patients (97.7%) in the LTAP group and 82 of 84 patients (97.6%) in the control (PSI) group were eligible for analysis. The VAS pain scores were statistically significantly lower overall in the LTAP group compared with the control (PSI) group on time-weighted analysis after laparoscopic appendicectomy (-1.7 (95% c.i. -2.06 to -1.34); P < 0.001). The difference-in-difference analysis showed that the mean VAS score for the LTAP group statistically significantly improved at 6 h (-1.63 (95% c.i. -2.55 to -0.70); P = 0.001) and 12 h (-2.06 (95% c.i. -2.92 to -1.20); P < 0.001) with no difference at 24 h (-0.68 (95% c.i. -1.55 to 0.19); P = 0.125). This is in comparison with the PSI group at 6 h (3.72 (95% c.i. 3.27 to 4.17); P < 0.001), 12 h (3.37 (95% c.i. 2.89 to 3.87); P < 0.011), and 24 h (1.57 (95% c.i. 1.13 to 2.01); P < 0.001). There was a significant reduction in oxycodone requirements in the LTAP group (1.2 versus 0.8; P = 0.032). CONCLUSION: LTAP block significantly improved early postoperative analgesia outcomes in patients undergoing laparoscopic appendicectomy and holds promise as part of an effective postoperative analgesic regimen. REGISTRATION NUMBER: NCT05427266 (http://www.clinicaltrials.gov).
Rubio-Alarcón C, Georgiadis A, Franken IA
… +41 more, Wang H, van Nassau SCMW, Schraa SJ, van der Kruijssen DEW, van Rooijen K, Linders TC, Delis-van Diemen P, Alkemade M, Bolijn A, Tijssen M, Lemmens M, Meiqari L, Ketelaars SLC, Closa-Mosquera A, van Dongen MMW, Lanfermeijer M, Lissenberg-Witte BI, Bosch LJW, Bisschop-Snetselaar T, Adriaans BC, Greer A, Riley D, White JR, Greco C, Cox L, Fox J, Victor K, Leech C, Angiuoli SV, Kok NFM, Punt CJA, van den Broek D, Koopman M, Meijer GA, Velculescu VE, Roodhart JML, Coupé VMH, Sausen M, Vink GR, Fijneman RJA, Other Members of the PLCRC-MEDOCC Group
BACKGROUND: Circulating tumour DNA (ctDNA) is a promising biomarker to guide clinical decision-making. The aim of this study was to investigate the prognostic value of postoperative ctDNA in patients with stage III colon...BACKGROUND: Circulating tumour DNA (ctDNA) is a promising biomarker to guide clinical decision-making. The aim of this study was to investigate the prognostic value of postoperative ctDNA in patients with stage III colon cancer who received adjuvant chemotherapy (ACT). METHODS: PROVENC3 was a multicentre prospective study of patients who underwent resection of pathological stage III colon cancer. Blood samples were collected at a median of 13 (interquartile range 4-20) days after resection. The presence of minimal residual disease was determined using Labcorp® Plasma Detect™, a novel tumour-informed whole genome sequencing (WGS) ctDNA test. The primary endpoint was 3-year time to recurrence (TTR). ctDNA status was further combined with pathological risk status to investigate the combined prognostic value. RESULTS: The median follow-up of the 209 patients who were included was 40 months. In total, 28 patients (13%) had detectable ctDNA after surgery. Postoperative ctDNA-positive patients had a worse TTR compared with ctDNA-negative patients (HR 6.2 (95% c.i. 3.4 to 11.2); P < 0.001). Of all ctDNA-positive patients, 36% did not develop recurrences during 3-year follow-up. Detectable ctDNA after ACT was associated with worse TTR (HR 7.9 (95% c.i. 3.9 to 15.9); P < 0.001). ctDNA status combined with pathological risk classification resulted in a 3-year recurrence risk that varied from 82% for pathological high-risk (pT4/N2) ctDNA-positive patients to 7% for pathological low-risk (pT1-3 N1) ctDNA-negative patients (HR 28.5 (95% c.i. 10.5 to 77.2); P < 0.001). CONCLUSION: Postoperative ctDNA detection using a tumour-informed WGS test improves prognosis stratification in stage III colon cancer and may help to personalize adjuvant treatment.
Guo W, Rong D, Zhang H
… +18 more, Zhang L, Zhuang H, Peng H, Wu X, Gong K, Wang W, Li Z, Fu W, Zhang X, Guo M, Chang G, Dai X, Zuo J, Guo Y, Chen B, Zhang L, Zhang T, Zhang H
BACKGROUND: Aortic arch pathologies are complex to treat. Alternatives include open surgery, hybrid surgery (endovascular aortic stent-grafting and open surgical debranching procedures) and total endovascular solutions w...BACKGROUND: Aortic arch pathologies are complex to treat. Alternatives include open surgery, hybrid surgery (endovascular aortic stent-grafting and open surgical debranching procedures) and total endovascular solutions with branched stent-grafts. Branched stent-grafts are the mainstream approach for endovascular repair, but they are primarily available only as dedicated custom-made devices. The aim of this study was to evaluate the safety and effectiveness of a non-customized modular aortic arch stent-graft. METHOD: This trial was led by the Chinese PLA General Hospital and 16 additional aortic centres in China. All included patients were treated with a non-customized modular inner branched stent-graft (Endonom Medtech, Hangzhou, China). The study endpoints were 30-day death and stroke, technical success, clinical success, early and late complications, reintervention, and death during follow-up. Follow-up via clinical examination and CT angiography scan were scheduled post surgery at 1, 6, and 12 months, and annually thereafter. RESULTS: From June 2021 to December 2024, a total of 88 patients were enrolled in this study. Technical success rate was 100%. The mean follow-up was 28.6 ± 11.7 months. The overall 30-day mortality rate was 3%, and the 30-day stroke rate was 9%. Overall survival was 91% ± 3%, 86% ± 4%, and 81% ± 4% at 12, 24, and 36 months respectively. A total of 10 patients developed endoleaks, none of which required reintervention. CONCLUSION: Modular branched stent-graft repair for aortic arch disease is feasible and with comparative rates of safety with custom made branched endovascular stent-grafts, hybrid techniques and open surgery. Long-term comparative effectiveness studies are required to establish whether it is superior to alternative interventions.
BACKGROUND: Second victim syndrome (SVS) is characterized by negative psychological and psychosomatic effects on a healthcare provider after an adverse care event. The aim of this systematic review and meta-analysis was...BACKGROUND: Second victim syndrome (SVS) is characterized by negative psychological and psychosomatic effects on a healthcare provider after an adverse care event. The aim of this systematic review and meta-analysis was to characterize the symptoms of SVS experienced by surgeons and factors affecting their impact, as well as understand common coping strategies that surgeons employ to deal with them. METHODS: A systematic review of five electronic databases was conducted without restrictions on publication date or language in January 2025. Second victim syndrome, surgeon, and adverse event and their synonyms were used as search terms. Records were screened, quality assessed, and data extracted by two independent researchers. Both qualitative and quantitative studies were included and narratively synthesized. A meta-analysis was performed using a random effects model to calculate the overall prevalence rates of symptoms and coping methods. RESULTS: A total of 36 papers were included in the analysis from 6629 retrieved records. Anxiety (56.3% (95% c.i. 45.8% to 66.3%)), guilt (53.8% (95% c.i. 41.3% to 65.8%)), sadness (48.3% (95% c.i. 34.6% to 62.3%)), and sleep disturbance (50.5% (95% c.i. 38.4% to 62.5%)) were the most commonly reported symptoms. Talking to either colleagues (72.5% (95% c.i. 65.6% to 78.4%)) or family/friends (52.0% (95% c.i. 40.6% to 63.2%)) were the most commonly employed coping strategies. The sex and level of experience of the surgeon and the severity of the event were identified as potential predictors of deleterious impact. CONCLUSION: SVS significantly impacts surgeons' global well-being, leading to burnout and attrition. Effective interventions require a multifaceted approach, including peer support, resilience training, and institutional changes that normalize emotional responses, encourage disclosure, and address barriers to seeking help. Targeted support for at-risk groups may also be necessary.
Karelis A, Adam D, Piazza M
… +12 more, Tinelli G, Gallito E, Matsagkas M, Mees B, Mani K, D'Oria M, Mansour W, Cieri E, Kölbel T, Sonesson B, Dias NV, PEACE Contributors
BACKGROUND: Chimney endovascular aneurysm repair (chEVAR) techniques have been described to manage a group of patients who are unsuitable for either open aortic aneurysm surgery or a variety of standard endovascular repa...BACKGROUND: Chimney endovascular aneurysm repair (chEVAR) techniques have been described to manage a group of patients who are unsuitable for either open aortic aneurysm surgery or a variety of standard endovascular repair techniques. The aim of this study was to assess the long-term clinical outcomes of chEVAR in emergency settings for patients with abdominal aortic aneurysms that have complex morphology. METHODS: This was a multicentre retrospective study that included all consecutive patients undergoing urgent chEVAR with at least one chimney/parallel graft up to June 2021. Outcomes that were captured included 30-day mortality, long-term overall survival, aneurysm-related mortality, chimney-related complications, and target vessel patency. RESULTS: Some 118 patients (mean(s.d.) age of 77(8) years; 72.0% male) underwent urgent or emergency chEVAR, 78 (66.1%) due to aortic rupture. The mean(s.d.) number of chimneys used per patient was 1.6(0.7). Technical success was achieved in 90.6% of patients, with a 30-day mortality rate of 17.7%. The mean follow-up was 4(3) years. Estimated overall survival was 69 ± 5% at 3 years, 45 ± 6% at 5 years, and 32 ± 6% at 7 years. Freedom from aneurysm-related mortality was 58 ± 6% at 5 years and 53 ± 6% at 7 years. In patients surviving the perioperative 30-day interval, freedom from aneurysm-related mortality was 73 ± 6% at 5 years and 66 ± 7% at 7 years. Primary target vessel patency at 5 and 7 years was 87 ± 4%, with renal arteries most frequently affected. Late reinterventions occurred in 16.1% of patients, mostly for type Ia endoleaks (8 of 25 reinterventions (32%)) and type Ib endoleaks (5 of 25 reinterventions (20%)). CONCLUSION: In this Parallel Endografting And Chimney Endovascular (PEACE) registry study, chEVAR was associated with a high rate of technical success and acceptable early outcomes, but, in the longer term, was associated with high rates of reintervention and mortality. It appears to represent a reasonable alternative technique for patients presenting as an emergency with complex aortic aneurysm morphology when standard open and endovascular techniques are not feasible.
BACKGROUND: Liver surgery carries a high risk of complications due to the complex interplay of patient-related factors, disease characteristics, and liver function. Expertise is essential for healthcare professionals man...BACKGROUND: Liver surgery carries a high risk of complications due to the complex interplay of patient-related factors, disease characteristics, and liver function. Expertise is essential for healthcare professionals managing hepatobiliary patients. This European consensus provides evidence-based guidance on selected aspects of peri- and postoperative care. METHODS: A modified Delphi process was used to achieve consensus, with a 70% agreement threshold. The expert panel comprised hepatobiliary surgeons, anaesthetists, hepatologists, a specialist nurse, and a physiotherapist. A systematic literature search was conducted in PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases. Six topics were addressed: thromboprophylaxis; perioperative antibiotics; prehabilitation/nutrition/mobilization; bile leak including bilioenteric anastomosis leaks; post-hepatectomy haemorrhage; and post-hepatectomy liver failure (PHLF). Evidence appraisal and statement development followed Scottish Intercollegiate Guidelines Network methodology. A patient representative reviewed the guideline. RESULTS: Searching the literature yielded 204 included publications from an initial 6514. Thirty-two statements were formulated with a median evidence level of 2. Evidence strength varied by topic with noticeably lower evidence levels in complex surgery settings and less prevalent conditions. In some topics, study heterogeneity and specific inclusion criteria resulted in conditional recommendations, despite high-level evidence. Notably, the weakest evidence was found for perioperative thromboprophylaxis and PHLF management. Strong recommendations were formulated for prehabilitation, early postoperative mobilization, and avoidance of routine drain use. Several evidence gaps warranting multicentre studies were identified. CONCLUSION: Optimizing peri- and postoperative care after liver resection remains challenging. Standardizing key practices and addressing evidence gaps through collaborative research are vital to improve outcomes.
Norton J, Janda AM, Howie E
… +18 more, Pohl N, Abahuje E, Harrington SD, Popov V, Bauer TM, Borges P, Querejeta Roca G, Mathis MR, Strobel RJ, Airhart A, Pham N, Harari R, Awtry JA, Pagani FD, Dias RD, Likosky DS, Yule S, Video Assessment of CaRdiac Surgery QualITY (VARSITY) Surgery Group
BACKGROUND: Deficiencies in non-technical skills (NTS) such as leadership and communication can lead to intraoperative inefficiency and error. However, the relationship between these skills and patient-level outcomes has...BACKGROUND: Deficiencies in non-technical skills (NTS) such as leadership and communication can lead to intraoperative inefficiency and error. However, the relationship between these skills and patient-level outcomes has yet to be synthesized. The aim of this study was to systematically review the evidence examining the relationship between intraoperative NTS and clinical outcomes. METHODS: The PubMed, Embase, CENTRAL, CINAHL, and PsycINFO databases were searched for relevant studies published between inception and 1 November 2024. Eligible studies assessed NTS of operating room personnel, were conducted in non-simulated environments, and reported clinical outcomes. NTS were categorized into five core domains including leadership and communication. Patient-level outcomes comprised eight clinical measures including mortality and postoperative complications. RESULTS: Of 6313 screened studies, 21 met the inclusion criteria. Included studies represented 8536 participants performing 251 180 procedures across 13 specialties. Eleven observational studies assessed NTS of surgical personnel via study participants or observers. Ten interventional studies introduced NTS team training initiatives. Twelve of 21 studies (57%) incorporating 247 036 of all procedures (98.4%) reported significant improvements in clinical outcomes. Nine of 11 observational studies (82%) reported significant improvement in clinical outcomes compared with 3 of 10 interventional studies (30%). No studies demonstrated a significant deterioration in clinical outcomes associated with improved NTS. CONCLUSION: Published evidence shows a significant link between intraoperative NTS and patient-level outcomes. These findings reinforce the value of behavioural assessment in surgery, support evidence-based team training, and underscore the need to embed NTS into regulatory frameworks to improve surgical quality and safety worldwide.
INTRODUCTION: Gastric cancer incidence, risk factors, and survival outcomes differ significantly between Japan and the United States. These disparities have led to the belief that gastric cancer represents biologically d...INTRODUCTION: Gastric cancer incidence, risk factors, and survival outcomes differ significantly between Japan and the United States. These disparities have led to the belief that gastric cancer represents biologically distinct diseases across regions. However, direct genomic comparisons of tumours from these populations have not been performed. The aim of this study was to compare the genomic and clinical characteristics of gastric cancers in patients from the US and Japan following curative-intent resection. METHODS: A retrospective cohort study of patients who underwent curative-intent gastrectomy between 2010 and 2019 at Memorial Sloan Kettering (MSK, n = 142) and Fujita Health University (FHU, n = 108), with ≥5 years of follow-up, was conducted. Tumour samples underwent targeted sequencing. Clinical and genomic data were compared between unmatched and propensity score-matched (PSM) cohorts, matched by age, sex, clinical T/N-category, and tumour location (n = 58 each). RESULTS: Commonly altered genes included TP53 (60%), ARID1A (17%), ERBB2 (14%), CCNE1 (13%), and KRAS (12%). MSK tumours showed higher rates of microsatellite instability (MSI-high; 22.4% versus 5.2%, P = 0.013) and KMT2D mutations (18% versus 5%, P < 0.05). Otherwise, gene- and pathway-level alterations were similar across unmatched, microsatellite stable only, and PSM cohorts. Five-year overall survival in PSM cohorts was comparable (MSK 60% versus FHU 69.4%, P = 0.548). Peritoneal recurrence was more common in the MSK cohort (47% versus 34%), but recurrence patterns were not associated with distinct genomic profiles. CONCLUSION: After adjustment for clinical covariates, US and Japanese gastric cancers exhibit comparable genomic landscapes and survival, supporting the relevance of clinical trial data across geographic settings.
Abbassi F, Ramser M, Pfister M
… +41 more, Staiger RD, Kim SJ, Park JW, van de Laar BCT, Gonzalez M, Perano V, Camilleri G, Merino D, Dourado J, Wignakumar A, Shigeta K, Mansur Duarte de Miranda Marques T, Leonard D, Lee KY, Saklani A, Brown KGM, Butti F, Raguz I, Schena CA, Kitaguchi D, Winter DC, Ito M, de'Angelis N, Hahnloser D, Vu J, Desouza A, Siew BE, Tan KK, Kartheuser A, Aguiar S, Okabayashi K, Brown CJ, Wexner S, Biondo S, Miskovic D, Spinelli A, Vaccaro CA, Consten ECJ, Min BS, Puhan MA, Turina M