Effects of nurse-led interventions on enhancing patient-related outcomes in colorectal cancer management throughout the cancer care continuum: A systematic review and meta-analysis

BACKGROUND

Colorectal cancer ranks third in global incidence and second in cancer-related mortality worldwide. Despite persistent challenges across the care continuum, nurses play a pivotal role in optimizing patient outcomes through tailored interventions. However, robust evidence on the clinical efficacy and optimal delivery of nurse-led interventions remains limited.

OBJECTIVE

To describe the health problems of the participants and nurse-led interventions in accordance with the Omaha System and summarize evidence on the effects of these interventions throughout the continuum from colorectal cancer screening to survivorship.

METHODS

Eight databases, namely, Web of Science, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, PubMed, Scopus, China National Knowledge Infrastructure and Wanfang Data, were searched from their inception to May 2024. Additionally, the reference lists of the included studies were examined. Content analysis was applied to identify problems and interventions based on the Omaha System. Meta-analysis and descriptive analysis were adopted. Subgroup analyses were conducted on the basis of the study design, treatment history and mode of intervention delivery.

RESULTS

Twenty-eight studies identified problems and types of nurse-led interventions. There were 13 problems in the psychosocial, physiological and health-related behaviors domains. The nurse-led interventions included teaching, guidance and counseling; case management; and treatments and procedures. Nurse-led interventions improved screening rates for colonoscopy and fecal occult blood testing (odds ratio [OR] = 2.51; 95 % confidence interval [CI]: 2.16 to 2.92; p < 0.001; OR = 6.14; 95 % CI: 1.93 to 19.47; p = 0.002), the adequacy of bowel preparation (OR = 1.69; 95 % CI: 1.40 to 2.03; p < 0.001), stoma self-efficacy (standardized mean difference [SMD] = 2.48; 95 % CI: 0.71 to 4.25; p = 0.006), and quality of life (SMD = 0.72; 95 % CI: 0.21 to 1.22; p = 0.005), and reduced the incidence of stoma complications (OR = 0.28; 95 % CI: 0.18 to 0.42; p < 0.001), anxiety (SMD = -1.19; 95 % CI: -1.40 to -0.99; p < 0.001), and depression (SMD = -1.00; 95 % CI: -1.20 to -0.79; p < 0.001). However, nurse-led interventions were ineffective in reducing distress and addressing unmet supportive care needs.

CONCLUSION

Nurse-led interventions can reduce stoma complications, anxiety and depression and increase the screening rate for colorectal cancer, the adequacy of bowel preparation, stoma self-efficiency and quality of life. Nevertheless, future rigorous research is needed to validate their effects and inform wider implementation.

REGISTRATION

PROSPERO (CRD42024505730) registered on February 18, 2024.

Scaling robotic surgery: the role, responsibilities and challenges of robotic proctorship in colorectal surgery

BACKGROUND

The adoption of robotic-assisted surgery (RAS) in colorectal procedures is growing rapidly, driven by advancements in technology and recognition of its clinical benefits. The dissemination of RAS technology relies heavily on robotic proctors, who are tasked with training and guiding their peers in adopting these advanced techniques. Despite their critical role, there is limited understanding of the training, responsibilities, and challenges faced by robotic proctors. A qualitative study was conducted using focus groups to understand the experiences, challenges, and training approaches of robotic colorectal surgery proctors in the UK and Ireland. Established proctors were invited to participate in the focus groups and to share insights into their practices, training methods, and the current state of robotic proctorship. The data were analysed thematically using NVivo software. Ten expert robotic surgeons participated in our study, with the majority working with Intuitive Surgical® platforms (n = 9, 90%). Over 60% had been robotic trainers for more than 6 years and 60% were considered high-volume proctors, having proctored over 30 surgeons, and conducted more than 20 proctored cases annually. Thematic analysis revealed eight interconnected themes: proctor selection, proctor responsibilities, proctored training, accreditation, challenges, industry-proctor partnerships, emerging technologies, and network and support. Robotic proctoring is essential for scaling RAS adoption, however, it is a complex arena, with significant gaps in training frameworks and support systems. Establishing standardised guidelines and professional support structures is critical to ensure consistency, quality, and safety in robotic surgical training.

Hand-Assisted Laparoscopic Surgery (HALS) as an Alternative to Unplanned Laparoscopic Conversion to Open Surgery (LCOS) in Colectomies for Acute Diverticulitis

BackgroundIn difficult colorectal cases, surgeons may opt for a hand-assisted laparoscopic (HALS) colectomy or attempt a laparoscopic surgery that may require an unplanned conversion to open (LCOS). We aimed to compare the clinical outcomes of these 2 types of surgeries.MethodsColectomies for acute diverticulitis with a HALS or LCOS surgery were selected from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2022 Targeted Colectomy Database. After confirming a difference in propensity scores between the cohorts, they were matched using propensity score matching (PSM) based on preoperative factors. RStudio was utilized for filtering and performing the PSM, while Minitab was used for statistical analysis.ResultsWe identified 804 HALS colectomies and 284 LCOS colectomies. After PSM, both cohorts contained 284 patients. Absolute standardized mean errors for all matched factors were less than 0.1, confirming well-balanced cohorts. Following PSM, preoperative and perioperative factors were similar between both colectomy groups. Postoperatively, HALS surgeries had a shorter average length of stay (7.67 ± 0.38 vs 10.57 ± 0.41, P < 0.001) as well as lower rates of ileus (13.73% vs 22.54%, P = 0.007) and superficial surgical site infection (2.11% vs 5.28%, P = 0.045).ConclusionTo the best of our knowledge, this is the first national database study comparing HALS and LCOS colectomies. After accounting for confounding variables, our PSM analysis showed the benefits of HALS colectomies for acute diverticulitis. Future studies may use single-center data containing risk adjustment profiles to create an even more uniform comparison.

Entrustable Professional Activities in Postgraduate General Surgery Training: A Scoping Review

OBJECTIVE

To provide an overview of the current use of Entrustable Professional Activities (EPAs) in postgraduate general surgery training internationally.

BACKGROUND

Entrustable Professional Activities (EPAs) were introduced to connect clinical competencies and the professional activities to be entrusted to trainees on graduation. The popularity of EPAs as a framework for assessment is growing globally, including in general surgery. Anecdotally, there appears to be substantial variation in how they are implemented, yet a formal comparison of their use in postgraduate general surgery training is lacking.

METHODS

A scoping review was performed based on the original 5-stage approach described by Arksey and O'Malley with the addition of protocol-specific items from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR).

RESULTS

Twenty-nine published and grey literature sources were included in the review. Entrustable Professional Activity use in postgraduate general surgery training was identified in 11 unique contexts, including from North America, South America, Europe, Asia, Africa, and Australia. There were substantial differences in the scope and number of EPAs, tools used for EPA assessment, and how EPAs were sequenced through training. Despite the wide variation, 8 distinct EPAs were common to the majority (>80%) of countries. Several articles described findings of EPA use in postgraduate general surgery training, allowing the identification of multiple barriers and facilitators to integration.

CONCLUSIONS

This review provides guidance for certification and regulatory bodies, program directors, and institutions with ambitions to implement EPAs for assessment and curricular design. In settings where EPAs are already used, the data may facilitate the refinement of programs and strategies.

Is it the right time to promote competency-based European Training Requirements in Ophthalmology? A European Board of Ophthalmology survey

PURPOSE

To report national practices and recent progress in competency-based medical education (CBME) implementation in ophthalmology across European countries.

METHODS

A 30-question online survey was emailed to European Union of Medical Specialists (UEMS) ophthalmology section delegates, European Board of Ophthalmology Diploma (EBOD) examiners and presidents of ophthalmology societies affiliated with UEMS/EBO.

RESULTS

A total of 230 ophthalmologists with an average age of 54.7 years [30-77] and from 28 countries completed the survey. Half of them had been involved as medical educators for more than 10 years. The majority (74%) exercised their educational role in a University Hospital. Ninety six percent of them dedicated less than 50% of their activity to teaching. A third dedicated more than a half of their activity to patient care. The teaching of skills reported (medical, surgical, research, attitudinal and theoretical knowledge) was significantly better applied than their assessment. While 91% of the respondents found it necessary to harmonize European Training Requirements (ETR) in ophthalmology, competency-based education concepts were rarely implemented in their country (for instance, 8% for CBME; 6% for entrustable professional activities (EPAs) and 3% for ETR).

CONCLUSIONS

Despite considerable diversity in European residency programmes, post-graduate medical education leaders in ophthalmology agree on the need to find a platform for equivalence in the content of the basic training requirements that constitute the professional identity of a practicing ophthalmologist.

Advancements in the application of botulinum toxin type a in the treatment of anorectal disorders

Botulinum toxin type A (BoNT/A) has garnered significant attention in recent years due to its unique biological properties and neuromuscular blocking effects, particularly in the field of anorectal disorders. This review discusses the application of BoNT/A in treating various conditions such as anal sphincter spasms, hemorrhoids, anal fissures, and other related ailments. We analyze the latest research findings regarding its efficacy, safety, and clinical applications, highlighting both the current state of research and the challenges that persist in this area. This synthesis aims to provide valuable insights and guidance for future studies and clinical practices involving BoNT/A in the management of anorectal diseases.

An Innovative Low Cost Technique of Hand Port Creation for Hand Assisted Laparoscopic Surgery (HALS)- the AIIMS Technique

BackgroudHand-assisted laparoscopic surgery (HALS) is a technique that integrates the use of the surgeon's hand through a hand port device. This approach combines the benefits of open surgery, such as tactile feedback, with the minimally invasive advantages of laparoscopic surgery.PurposeDespite its benefits, the average cost of a gel hand port device is around 60,000 INR, which limits its use in resource-constrained settings such as India. To address this issue, we have developed an innovative low-cost technique ("AIIMS technique"), utilizing a number 8 size surgical glove to create a functional hand port.Study DesignA low cost innovative hand port was made using number 8 size glove sutured to the anterior rectus sheath.ConclusionThis method provides a more affordable alternative, making HALS accessible in regions with limited financial resources.

The Effect of Sphincter Pressure and Anal Length on Surgical Decision in Chronic Anal Fissure

Background/Objectives: Chronic anal fissure, an anorectal condition, is characterized by internal anal sphincter fibers at the base of the fissure. The lifetime prevalence is 7-8%. Medical management and lifestyle modifications are the first-line treatments, whereas chemical or surgical internal anal sphincterectomy is an option for refractory cases. The aim of this study was to evaluate the impact of surgical anal canal length and sphincter pressure on postoperative symptom relief and continence outcomes. Methods: A total of 26 patients diagnosed with chronic anal fissures were selected for surgical treatment. Five patients voluntarily withdrew, leaving 21 cases for analysis. In patients undergoing open lateral internal sphincterotomy, anal canal length and sphincter pressure were assessed preoperatively and three months postoperatively using endoanal ultrasonography and high-resolution anal manometry. Results: Postoperatively, all patients experienced complete resolution of pain and bleeding. The expected decrease in resting pressure was not significantly associated with sex. A significant weight gain was observed postoperatively (p = 0.001). Although a significant decrease was observed in preoperative sphincter resting pressure and VAS scores, Wexner scores remained unchanged. Preoperatively and postoperatively, mean sphincter pressure was significantly lower in the spontaneous vaginal delivery group than that in the non-spontaneous vaginal delivery group (p < 0.05). Patients with short anal canal lengths had greater pressures reductions, though not statistically significant. Conclusions: Lateral internal sphincterotomy is an effective and safe treatment for chronic anal fistula when performed by experienced surgeons. Anal canal length may influence postoperative complications and surgical decisions. Larger studies are needed to confirm these findings.

Insufficiency of ileocolic anastomosis in Crohn’s disease patients – prevention and treatment

Resection of the terminal ileum and ileocecal valve remains the most commonly performed procedure in patients with Crohn's disease. However, despite radical treatment, there is a risk of disease recurrence at the site of the intestinal anastomosis in some cases. Therefore, long-term postoperative management is crucial and requires systematic clinical assessment, endoscopic surveillance, and pharmacological support when indicated. A key challenge is identifying the risk factors associated with the recurrence of anastomotic failure and defining the principles of follow-up care to prevent secondary intestinal insufficiency. This paper focuses on both surgical and non-surgical factors that may play a role in preventing complications in patients undergoing ileocecal resection, providing a comprehensive approach to postoperative management.

The 5-year outcomes and predictors of healing in chronic anal fissure treated with botulinum toxin: a retrospective analysis of 199 cases

BACKGROUND

Botulinum toxin (BT) is a nonsurgical alternative to lateral internal sphincterotomy (LIS). While there are promising results, there is still a gap in knowledge regarding long-term outcomes and the predictors for healing after BT.

METHODS

Chronic anal fissure (CAF) patients treated with 100 IU BT with a minimum 5-year follow-up were analyzed retrospectively. Patients with persistent or recurrent fissures after their first BT injection were offered either a second BT injection or LIS. Healing was defined as complete symptom resolution with fissure epithelization. The primary outcome measure was recurrence-free healing rate with BT at 5 years. Predictors of healing were assessed by logistic regression analysis.

RESULTS

The mean age was 33.8 ± 10 years, and 139 (69.5%) patients were female. The complete healing rate at 5 years was 73.8% and 26.2% for the patients that underwent LIS. Multivariate analysis for LIS likelihood revealed that female gender (odds ratio, OR: 0.48, 95% confidence intervals, CI 0.25-0.92, p = 0.028), absence of chronic constipation (OR: 0.09, 95% CI 0.03-0.25, p = < 0.0001), and shorter constipation duration (OR: 1.10, 95% CI 1.06-1.13, p = < 0.0001) were predictors for recurrent-free healing after BT at 5-years. A cutoff value of 10 months of constipation yielded an accuracy of 88% for predicting nonhealing with BT (AUC: 0.881). BT-related incontinence was mild and resolved within 2 months, while LIS resulted in 19.2% permanent incontinence at 5 years.

CONCLUSIONS

BT is an effective and safe treatment for CAF, with acceptable long-term outcomes and minimal incontinence risk. Constipation duration and gender are key predictors of healing, aiding patient selection. Male patients with prolonged constipation may benefit from earlier consideration of LIS.

Management of chronic anal fissures: should fissurectomy be performed with botulinum toxin injection?

BACKGROUND

Despite the superior success rate of lateral internal sphincterotomy for managing chronic anal fissure (CAF), there is a trend towards sphincter-preserving treatment due to the increased risk of incontinence. Botulinum toxin (BT) and fissurectomy are two sphincter-preserving options for CAF. We aim to assess if combining fissurectomy with botox treatment is superior to botulinum toxin alone in the management of CAF.

METHODS

This retrospective cohort study was conducted across two Sydney hospitals over 7 years. All patients with a CAF managed with either BT and fissurectomy (group 1) or BT only (group 2) were included. Primary outcome was healing rate defined as resolution or significant improvement of perianal symptoms at initial follow-up. Secondary outcomes were persistence, recurrence, re-intervention and faecal incontinence rate. Follow-up questionnaire was conducted to compare long-term outcomes between the two groups.

RESULTS

Fifty-seven patients met the inclusion criteria (group 1, 37; group 2, 20). Mean BT dose and injection location between the groups were similar (p = 0.259 and p = 0.427). There was a 65% response rate to the follow-up questionnaire. Median follow-up was 34.3 months (range 0.4-93). There was no difference in healing (56.7% vs. 50%, p = 0.561), recurrence (37.8% vs. 30%, p = 0.383) or re-intervention rate (13.5% vs. 20%, p = 0.888). Long-term incontinence rate was significantly higher in patients group 2 (0% vs. 10%, p = 0.010), with two patients reporting persistent flatus incontinence. Median overall satisfaction score was 3/4 (range 1-4), in both groups (p = 0.469).

CONCLUSION

Botulinum toxin with or without fissurectomy is a safe sphincter-sparing treatment option for CAF. However, the addition of fissurectomy to BT does not improve healing rates and we therefore recommend BT injection alone as a second-line treatment of CAF in patients who fail topical treatment.

Prevalence and Determinants of Academic Bullying Among Junior Doctors in Sierra Leone: Cross-Sectional Study

Background

Academic bullying among junior doctors-characterized by repeated actions that undermine confidence, reputation, and career progression-is associated with adverse consequences for mental health and professional development.

Objective

This study aimed to investigate the prevalence and determinants of academic bullying among junior doctors in Sierra Leone.

Methods

We conducted a cross-sectional survey of 126 junior doctors at the University of Sierra Leone Teaching Hospitals Complex in Freetown between January 1 and March 30, 2024. Participants were selected through random sampling. Data were collected using a semistructured, self-administered questionnaire and analyzed with descriptive statistics and multivariable logistic regression.

Results

Of the 126 participants (n=77, 61.1% male; mean age 31.9, SD 5.05 years), 86 (68.3%) participants reported experiencing academic bullying. Among those, 55.8% (n=48) of participants experienced it occasionally and 36% (n=31) of participants experienced it very frequently. The most common forms were unfair criticism (n=63, 73.3%), verbal aggression (n=57, 66.3%), and derogatory remarks (n=41, 47.7%). Consultants and senior doctors were the main perpetrators, with incidents primarily occurring during ward rounds, clinical meetings, and academic seminars. No statistically significant predictors of bullying were found for gender (odds ratio 2.07, 95% CI 0.92-4.64; P=.08) or less than 2 years of practice (odds ratio 0.30, 95% CI 0.05-1.79; P=.19).

Conclusions

Academic bullying is widespread among junior doctors at the University of Sierra Leone Teaching Hospitals Complex. It has serious consequences for their mental health and professional development. There is an urgent need for clear and culturally appropriate policies, targeted training programs, confidential reporting systems, and leadership development. Promoting ethical leadership and fostering a culture of respect can help reduce incivility and burnout, leading to a healthier work environment for junior doctors.

Incidence and Risk Factors for Incisional Hernia Following Ileostomy Takedown: A Retrospective Cohort Study

Background: Incisional hernias are a frequent complication following ileostomy closure, with rates reaching 24%. Protective ileostomies are commonly performed in colorectal surgery, but their closure presents a significant risk for abdominal wall defects. Identifying risk factors for incisional hernias at the ileostomy site is crucial for improving patient outcomes. Methods: This retrospective study analyzed data from 95 patients who underwent loop ileostomy closure at two Romanian hospitals between 2018 and 2023. Patient demographics, surgical details, and follow-up data were reviewed. Incisional hernias were diagnosed through clinical examination or radiological imaging. Statistical analyses, including univariate and multivariate regression, were performed to identify independent risk factors. Results: The incidence of incisional hernias at the ileostomy site was 13.7% (13/95). Univariate analysis identified BMI (HR 30.08; p = 0.007), previous hernia (HR 7.99; p = 0.059), radiotherapy (HR 299.15; p = 0.029), and chemotherapy (HR 0.004; p = 0.026) as significant factors. Multivariate analysis confirmed BMI > 30 kg/m2 (HR 12.27; p = 0.002) and prior hernia (HR 8.14; p = 0.007) as independent risk factors. Conclusions: Obesity and previous hernias significantly increase the risk of incisional hernias following ileostomy closure. Radiological follow-up enhances early detection, and further studies should explore the benefits of prophylactic mesh reinforcement. Optimizing patient selection and surgical technique may reduce postoperative hernia rates, improving long-term outcomes.

Optimizing Biologic Therapy for the Prevention of Post-Operative Recurrence in Crohn's Disease: Current Evidence and Future Perspectives

Crohn's disease (CD) imposes a substantial burden on patients due to its chronic, relapsing nature, often necessitating surgical intervention. However, surgery is not curative, and post-operative recurrence (POR) remains a major clinical challenge, with up to 80% of patients developing endoscopic recurrence within one year if left untreated. The pathophysiology of POR is multifactorial, involving dysregulated immune responses, gut microbiota alterations, and mucosal healing impairment, highlighting the need for targeted therapeutic strategies. This review aims to explore the current landscape of POR management, focusing on biologic therapies and emerging advanced treatments. Conventional management relies on early prophylactic therapy with anti-TNF agents such as infliximab and adalimumab, which have demonstrated efficacy in reducing endoscopic and clinical recurrence. However, newer biologics, including IL-23 inhibitors (risankizumab) and Janus kinase (JAK) inhibitors (upadacitinib), have shown promise in CD management, though their role in POR remains underexplored. The lack of direct clinical evidence for advanced biologics in POR prevention, combined with inter-individual variability in treatment response, underscores the need for further research. Future directions should focus on optimizing therapeutic strategies through personalized medicine, identifying predictive biomarkers, and conducting robust trials to establish the efficacy of novel agents in POR prevention. A tailored, evidence-driven approach is essential to improving long-term outcomes and minimizing disease recurrence in post-operative CD patients.

Entrustable professional activities for pediatric and subspecialties residency training in China

BACKGROUND AND OBJECTIVES

Outcome-based medical education is the latest focus in the past decade, and Entrustable Professional Activities(EPAs) have emerged as efficient vehicles to assess physicians. However, few studies have discussed the use of EPAs for residency training in pediatric medicine and its subspecialties. We conducted a pilot study to examine the feasibility of EPAs as a component of the clinical program of assessment in pediatric standardized residency training.

METHODS

We conducted a cross-sectional study for standardized residency training in different subspecialties within pediatric medicine at Qilu Hospital of Shandong University. Totally 65 residents and 35 directors joined in this study. An electronic EPA survey using 8 scales composed of 15 categories was distributed among residents and directors. Kruskal-Wallis test and Mann-Whitney U test were applied for comparing the self-assessments and director-assessments. Generalized estimated equation (GEE) was used to analyze the effect of postgraduate year(PGY), gender, and position on the EPA scores of director assessments.

RESULTS

A total of 401 director-assessment and 65 residents' self-assessment ( response rate 100%) questionnaires were collected, both demonstrating rising trends in scores across PGYs. Significant differences were found between PGY1 and PGY2 (p < 0.01) and between PGY1 and PGY3 (p < 0.01), but not between PGY2 and PGY3 (p > 0.01). With an effect analysis of PGY, gender, and position on EPA scores performed, PGY had a significant effect on 13 out of 15 EPA scores, while gender affected only four EPA scores significantly, and position affected only three EPA categories. Meanwhile, some EPA categories revealed significant differences across various pediatric subspecialties (p < 0.01).

CONCLUSIONS

The study findings suggest that EPA assessments is feasible among different PGYs in standardized Chinese residency training in pediatric medicine and its subspecialties. Postgraduate year had a significant impact on EPA scores, while gender and resident position also affected EPA scores to a certain extent. Improved stratified teaching programs are required for better subspecialty consistency.

An Unusual Case of Ileitis and Partial Small Bowel Obstruction Secondary to Mesh Erosion After Totally Extraperitoneal Inguinal Hernia Repair

The objectives were to highlight that: (1) mesh erosion related partial small bowel obstruction after laparoscopic totally extraperitoneal (TEP) inguinal hernia repair (IHR) as an uncommon complication can clinically and radiologically mimic ileocolic Crohn's disease in young adults; and (2) implore clinicians to consider a broad set of differential diagnosis and prompt involvement of other subspecialties, especially if preliminary investigations and treatment yield minimal results. The authors report a 34-year-old male who presented with computed tomography (CT) findings of ileitis, which was initially investigated for Crohns' disease. Due to persisting abdominal pain and negative initial investigations, he underwent a laparotomy demonstrating secondary mesh migration with erosion into distal ileum requiring bowel resection, 2.5 years after an uneventful laparoscopic right TEP IHR. The patient made an uneventful postoperative recovery and at 6 weeks follow-up, he had resolution of abdominal pains, and normal bowel function.

Catheter Injectable Multifunctional Biomaterial for the Treatment of Infected Enterocutaneous Fistulas

Enterocutaneous fistulas (ECF) are challenging to treat contributing to high morbidity and high mortality rates, significantly impacting the quality of life of the patients. Its susceptibility to antibiotic-resistant infections often leads to chronic inflammation, complicating treatment with conventional methods. Here, 18NC75-10P-1IL is reported, which is a multi-functional shear-thinning hydrogel comprised of gelatin and nanosilicates for injectability, an ionic liquid for bactericidal effects, and platelet rich fibrin fraction for pro-healing properties; this biomaterial is engineered for the treatment of ECFs. Through rigorous testing, the mechanical properties of 18NC75-10P-1IL were tailored for catheter injection to achieve durable occlusion of fistulous tracts under external pressures simulating clinical scenarios. 18NC75-10P-1IL demonstrated pro-healing effects and anti-microbial activity against highly resistant patient-derived bacteria known to be associated with ECF. Subcutaneous implantation and anorectal fistula models confirmed its biocompatibility, pro-healing, anti-inflammatory, and anti-microbial properties compared to control materials, suggesting promising potential for clinical translation in the treatment of human ECFs.

Cecal volvulus following laparoscopic cholecystectomy: A case report and literature review

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallbladder stones. Minimally invasive operations are currently preferred by surgeons and patients. Intestinal volvulus after laparoscopic cholecystectomy has been reported before, but it is still a rare complication of laparoscopic procedures, i.e., including laparoscopic cholecystectomy. To date, few cases were found specifically mentioning cecal volvulus after laparoscopic cholecystectomy; other articles had mentioned other intestinal volvulus after other laparoscopic procedures. We are reporting a case of cecal volvulus that developed in a 43-year-old woman 2 days after laparoscopic cholecystectomy, which was treated successfully with exploratory laparotomy with limited right hemicolectomy and ileocolic primary anastomosis. More studies have to be made to determine the incidence and causative relation between laparoscopic surgeries and volvulus, and volvulus should be considered in every patient who complains of postoperative abdominal pain and symptoms of intestinal obstruction.

Long-term Outcomes After Minimally Invasive Ventral Rectopexy for Rectal Prolapse Using Biological Graft Prosthesis: A 15-Year Retrospective Cohort Study

BACKGROUND

Minimally invasive ventral rectopexy has widely become the preferred prolapse procedure. However, there have been recent concerns regarding the safety of permanent synthetic mesh in the pelvis. Biological grafts have also been commonly used as an alternative prosthesis, but data on their safety and the longevity of the prolapse repair have been lacking.

OBJECTIVE

To assess the short- and long-term safety and efficacy of biological grafts in minimally invasive ventral rectopexy.

DESIGN

Retrospective cohort study using data from a prospectively collected database.

SETTINGS

Single surgeon at a single tertiary hospital in Australia.

PATIENTS

There were 366 patients with minimum 6-month follow-up undergoing minimally invasive ventral rectopexy using a biological graft between January 1, 2008, and October 5, 2023.

MAIN OUTCOME MEASURES

Overall recurrence, complications, and functional outcomes.

RESULTS

A total of 57 patients (15.6%) experienced a recurrence during the study period, with a median follow-up time of 35.5 months (range, 6-183 months). Of these, 17 (4.6%) were full-thickness recurrence. The Kaplan-Meier estimates of the overall 1-, 3-, and 5-year recurrence rates were 2.0%, 6.0%, and 16.0%, respectively. There was no statistically significant difference in recurrence for patients who presented with a full-thickness prolapse compared to those with other indications (16.8% vs 14.2%, p = 0.29). Overall, there were a total of 34 complications that occurred in 29 patients (7.9%). Nineteen patients (5.2%) required a return to theater. There was no reported graft-related complication or long-term pelvic pain. Ninety-eight percent of patients had symptomatic improvement and were satisfied with their outcome.

LIMITATIONS

Retrospective study and generalizability of the results from single surgeon experience. Late recurrences may have been missed.

CONCLUSIONS

Minimally invasive ventral rectopexy using a biological graft is both safe and effective, offering acceptable short- and long-term recurrence rates and overall complications with no graft-related morbidity. See Video Abstract .

RESULTADOS A LARGO PLAZO DESPUS DE LA RECTOPEXIA VENTRAL MNIMAMENTE INVASIVA PARA EL PROLAPSO RECTAL UTILIZANDO PRTESIS DE INJERTO BIOLGICO UN ESTUDIO DE COHORTE RETROSPECTIVO DE AOS

ANTECEDENTES:La rectopexia ventral mínimamente invasiva se ha convertido en gran medida, como el procedimiento preferido para el prolapso. Sin embargo, recientemente ha habido inquietudes con respecto a la seguridad de la malla sintética permanente en la pelvis. Los injertos biológicos también se han utilizado comúnmente como prótesis alterna, pero faltan datos sobre su seguridad y la longevidad de la reparación del prolapso.OBJETIVO:Evaluar la seguridad y eficacia a corto y largo plazo de los injertos biológicos en la rectopexia ventral mínimamente invasiva.DISEÑO:Estudio de cohorte retrospectivo que utiliza datos de una base de datos recopilada prospectivamente.AJUSTE:Un cirujano de hospital terciario en Australia.PACIENTES:366 pacientes con un mínimo de 6 meses de seguimiento sometidos a una rectopexia ventral mínimamente invasiva utilizando un injerto biológico entre el 1 de enero de 2008 y el 5 de octubre de 2023.PRINCIPALES MEDIDAS DE RESULTADO:Recurrencia general, complicaciones y resultados funcionales.RESULTADOS:Un total de 57 pacientes (15,6 %, n = 57) presentaron una recurrencia durante el período de estudio, con un tiempo de seguimiento medio de 35,5 meses (rango, de 6 a 183 meses). De estos, 17 (4,6 %) fueron recurrencias de espesor total. Las estimaciones de Kaplan-Meier de las tasas generales de recurrencia a 1, 3 y 5 años fueron del 2,0 %, 6,0 % y 16,0 %, respectivamente. No hubo una diferencia estadísticamente significativa en la recurrencia para los pacientes que presentaron un prolapso de espesor total en comparación con aquellos con otras indicaciones (16,8 % frente a 14,2 %, p = 0,29). En general, hubo un total de 34 complicaciones que ocurrieron en 29 (7,9 %) pacientes. 19 pacientes (5,2 %) necesitaron regresar al quirófano. No hubo complicaciones relacionadas con el injerto o dolor pélvico a largo plazo. El 98% de los pacientes presentaron una mejoría sintomática y se mostraron satisfechos con el resultado.LIMITACIONES:Estudio retrospectivo y generalización de los resultados a partir de la experiencia de un solo cirujano. Es posible que se hayan pasado inadvertidas las recurrencias tardías.CONCLUSIONES:La rectopexia ventral mínimamente invasiva con un injerto biológico es segura y eficaz, y ofrece tasas de recurrencia aceptables a corto y largo plazo y complicaciones generales sin morbilidad relacionada con el injerto. (Traducción - Dr. Fidel Ruiz Healy ).

Pancreatic Cancer Solitary Metastasis to Colon is a Rare Entity

Metastases in pancreatic ductal adenocarcinoma are present in over 50% of cases at the time of diagnosis, with the liver, peritoneum, and lung being some of the most common sites. By contrast, solitary distant metastasis to the colon is a rare entity but clinically significant. We report 2 cases of synchronous pancreatic ductal adenocarcinoma distant metastasis to colon along with a literature review. Our cases demonstrate the utility of colonoscopy to diagnose metastatic disease. Last, as highlighted, palliative stenting can be used in cases of complete obstruction. KEYWORDS: pancreatic cancer; metastasis; obstruction; malignant large bowel obstruction; colonoscopy.

Imposter Phenomenon, Burnout, and Suicidal Ideation Among Orthopaedic Surgery Residents

BACKGROUND

The prevalence of imposter phenomenon (IP) and its risk factors among orthopaedic surgery residents remains poorly understood. The purpose of this study was to determine the prevalence of IP, burnout, and suicidal ideation among orthopaedic surgery residents. Secondarily, we aimed to identify risk factors associated with higher levels of IP.

METHODS

An anonymous survey including the Clance Imposter Phenomenon Survey (CIPS) was distributed to orthopaedic surgery residents. CIPS scores were compared using t-tests and one-way analyses of variance, and multivariable logistic regression was used to identify risk factors.

RESULTS

Forty-two orthopaedic surgery residents were surveyed. Significant or intense IP was reported by 23 respondents (54.8%), with women (P < 0.001), those who experienced burnout within the past 5 years (P = 0.002), those who experienced suicidal ideation (P = 0.003), and those with a research year during medical school (P = 0.018) reporting higher levels of IP. Residents with a gap year before medical school were 4.85 times more likely to experience significant or intense IP (95% confidence interval, 1.063 to 22.107, P = 0.041). Among respondents, 15 (35.7%) were experiencing burnout, 26 (61.9%) experienced burnout over the past 5 years, 3 (7.1%) experienced suicidal ideation during their lifetime, and one (2.4%) experienced suicidal ideation during residency.

CONCLUSION

Significant or intense IP was reported by 54.8% of orthopaedic surgery residents, with higher levels reported by women, those with a research year during medical school, those who experienced burnout within the past 5 years, and those with a history of suicidal ideation.

Predictors of Pathologic Non-response to Neoadjuvant Approaches in Locally Advanced Rectal Cancer

BACKGROUND

Approximately 10-20% of rectal cancer patients do not respond to neoadjuvant treatment. While the current literature has focused on pathological complete response, pinpointing those who will fail to benefit entirely from neoadjuvant approaches is crucial.

OBJECTIVE

This study aimed to determine the risk factors associated with pathological non-response (pNR) to neoadjuvant treatment.

METHODS

Patients with stage II-III rectal adenocarcinoma who underwent neoadjuvant treatment followed by curative surgical resection between 2018 and 2023 at a high-volume center were retrospectively reviewed. Patients were divided into two cohorts (pNR and pathologic responder [pR]) based on their response to neoadjuvant therapy. The pNR group included patients with a Tumor Regression Score of grade 3 or those upstaged on the final pathological report.

RESULTS

Of the 405 patients included in this study, 53 (13%) were pNR and 352 (87%) were pR. Among patients treated with standard neoadjuvant chemoradiation, 12% were pNR compared with 14% among those treated with total neoadjuvant therapy. Significantly more patients in the pNR cohort had perineural (31% vs. 8%; p < 0.001) and lymphovascular (22% vs. 6%, p = 0.001) invasions when compared with the pR cohort. After adjusting for age, sex, clinical T stages, and clinical nodal status on multivariable analysis, the presence of extramural vascular invasion (EMVI) on pretreatment magnetic resonance imaging (odds ratio 2.08, 95% confidence interval 1.03-4.20, p = 0.04) was identified as a significant predictor of pNR.

CONCLUSION

EMVI was an independent risk factor of pNR in patients with rectal cancer. Identifying pretreatment factors that predict pNR to neoadjuvant therapy is crucial as it allows for better risk stratification and personalized treatment strategies.

Neoadjuvant Radiotherapy vs Up-Front Surgery for Resectable Locally Advanced Rectal Cancer

Importance

Guidelines for resectable locally advanced rectal cancer (LARC) advocate for neoadjuvant radiotherapy (NRT) followed by surgery as the standard approach. However, recent trials have reported no oncological benefits of NRT-based therapy for middle or lower rectal cancer, raising the question of whether NRT followed by surgery remains the optimal treatment approach for resectable LARC overall.

Objective

To compare the outcomes of NRT followed by surgery vs up-front surgery for resectable LARC.

Design, Setting, and Participants

This cohort study, using a target trial emulation framework with nationwide registries in Taiwan, included patients undergoing curative resection for resectable LARC (cT1-2N1-2, cT3Nany) between January 1, 2014, and December 31, 2017, with follow-up until December 31, 2020. Data were analyzed from January 1, 2024, to February 15, 2025.

Exposure

NRT.

Main Outcomes and Measures

The primary outcomes were overall survival (OS) and local recurrence (LR). The secondary outcome was intraoperative diverting stoma outcomes.

Results

A total of 4099 patients were analyzed, including 1436 patients undergoing NRT followed by surgery (median [IQR] age, 62.0 [53.0-71.0] years; 1036 [72.1%] male) and 2663 patients undergoing up-front surgery (median [IQR] age, 65.0 [56.0-74.0] years; 1626 [61.1%] male). NRT followed by surgery, compared with up-front surgery, was associated with higher 3-year OS rates (88.5% vs 85.2%; hazard ratio [HR], 0.74; 95% CI, 0.59-0.92) but higher permanent diverting stoma rates (20.6% vs 11.1%; relative risk [RR], 1.91; 95% CI, 1.62-2.25); LR rates were not significantly different (5.7% vs 6.6%; HR, 0.78; 95% CI, 0.55-1.11). Subgroup analysis revealed that compared with up-front surgery, NRT followed by surgery was associated with improved outcomes in middle or lower rectal cancer but not upper rectal cancer (OS: HR, 1.54; 95% CI, 0.82-2.90; LR: HR, 1.08; 95% CI, 0.23-5.00). NRT followed by surgery was associated with significantly increased risks of permanent diverting stomas across different tumor heights, particularly in upper rectal cancer (RR, 3.54; 95% CI, 1.44-8.69).

Conclusions and Relevance

In this cohort study of nationwide registries in Taiwan, NRT followed by surgery was associated with improved oncological outcomes for overall resectable LARC, with excessive diverting stoma nonreversal as the trade-off. However, the benefits of NRT were not observed for upper rectal cancer. These findings raise concerns about potential harm from NRT and advise caution when performing NRT for upper rectal cancer.

Malignant Bowel Occlusion: An Update on Current Available Treatments

Malignant bowel obstruction (MBO) is a critical complication occurring in patients with advanced malignancy. Current treatments are both surgical and non-surgical, the latter including medical, endoscopic, and percutaneous approaches. Surgery is still the treatment of choice for MBO. However, almost 50% of patients are unfit for surgery because of poor performance status. Given the high post-operative mortality rate and the frailty of MBO patients, the least invasive surgical intervention is recommended. Therefore, recent multidisciplinary recommendations have suggested considering less invasive interventions instead of palliative surgery. Medical therapy, aiming to alleviate symptoms, is usually only a part of the therapeutic strategy when managing patients with MBO. Percutaneous techniques, including both interventional radiology and endoscopic procedures, are safe and effective for symptom relief, but often do not allow oral diet resumption. Endoscopic techniques are achieving a more relevant role for MBO treatment, as supported by the widening of the indication to colonic intraluminal stenting in the latest update of the European guidelines. Current data support the use of colonic stenting as both a bridge to surgery and the definitive treatment of malignant colonic obstruction. The development of endoscopic ultrasound-guided anastomotic techniques may offer the possibility of widening its applications to endoscopic treatment of MBO, allowing stenosis to be overcome, and reestablishing the continuity of the gastrointestinal tract in small bowel obstructions as well. The introduction of new interventional endoscopic techniques and their progressive diffusion will add the possibility to adopt minimally invasive solutions to treat a critical condition such as MBO.

Role of pelvimetry in predicting surgical outcomes and morbidity in rectal cancer surgery: A retrospective analysis

BACKGROUND

Rectal cancer has increased in incidence, and surgery remains the cornerstone of multimodal treatment. Pelvic anatomy, particularly a narrow pelvis, poses challenges in rectal cancer surgery, potentially affecting oncological outcomes and postoperative complications.

AIM

To investigate the relationship between radiologically assessed pelvic anatomy and surgical outcomes as well as the impact on local recurrence following rectal cancer surgery.

METHODS

We retrospectively analyzed 107 patients with rectal adenocarcinoma treated with elective rectal surgery between January 1, 2017, and September 1, 2022. Pelvimetric measurements were performed using computed tomography (CT)-based two-dimensional methods (n = 77) by assessing the pelvic inlet area in mm², and magnetic resonance imaging (MRI)-based three-dimensional techniques (n = 52) using the pelvic cavity index (PCI). Patient demographic, clinical, radiological, surgical, and pathological characteristics were collected and analyzed in relation to their pelvimetric data.

RESULTS

When patients were categorized based on CT measurements into narrow and normal/wide pelvis groups, a significant association was observed with male sex, and a lower BMI was more common in the narrow pelvis group (P = 0.002 for both). A significant association was found between a narrow pelvic structure, indicated by low PCI, and increased surgical morbidity (P = 0.049). Advanced age (P = 0.003) and male sex (P = 0.020) were significantly correlated with higher surgical morbidity. Logistic regression analysis identified four parameters that were significantly correlated with local recurrence: older age, early perioperative readmission, longer operation time, and a lower number of dissected lymph nodes (P < 0.05). However, there were no significant differences between the narrow and normal/wide pelvis groups in terms of the operation time, estimated blood loss, or overall local recurrence rate (P > 0.05).

CONCLUSION

MRI-based pelvimetry may be valuable in predicting surgical difficulty and morbidity in rectal cancer surgery, as indicated by the PCI. The observed correlation between low PCI and increased surgical morbidity suggests the potential importance of a preoperative MRI-based pelvimetric evaluation. In contrast, CT-based pelvimetry did not show significant differences in predicting surgical outcomes or cancer recurrence, indicating that the utility of pelvimetry alone may be limited in these respects.

Predictive Risk Factors for Low Anterior Resection Syndrome (LARS) in Rectal Cancer-An Observational Cohort Study

Background/Objectives: The improved long-term survival of rectal cancer patients has led to a major increase in the prevalence of functional complications. Understanding which patients are prone to develop major LARS is important for their preoperative counselling and follow-up. Herein, we aimed to assess the risk factors for LARS. Methods: This is a retrospective cohort study on rectal cancer patients. All patient and tumour variables, management plan, type of neoadjuvant therapy, radiation dose to anal sphincter, and perioperative outcomes were collected from the hospital electronic databases. We quantified LARS and compared the score before and after surgery (mean follow-up of 42.2 ± 32 months). Results: A total of 182 patients were included for the final analysis. LARS was present in 43.4% (n = 79) of patients, with 14.8% (n = 27) having minor LARS and 28.5% (n = 52) having major LARS. Age (p = 0.03), male gender (p < 0.00001), smoking (p = 0.04), neoadjuvant radiotherapy (p = 0.02), rectal stump length (p = 0.008), end-to-end anastomosis (p = 0.008), and ileostomy (p = 0.002) were found to significantly increase the rate of LARS. A logistic regression model based on the above variables was able to predict major LARS with good predictive value (AUC 0.700). Conclusions: LARS is highly common after sphincter-preserving surgery, and it is significantly more common in young, male patients with a history of smoking, having mid-lower rectal cancers with neoadjuvant radiotherapy, and undergoing TME surgery with end-to-end low anastomosis and ileostomy.

Breaking Myths: Comparable Outcomes in Lymph Node Analysis Across Surgical Methods

BACKGROUND/OBJECTIVES

Colorectal cancer is the third most common cancer worldwide, making lymph node recovery critical for treatment decisions and prognosis. The relationship between body mass index (BMI) and the number of lymph nodes retrieved during laparoscopic and open surgeries remains controversial. This study aimed to evaluate whether surgical approach and BMI influence lymph node retrieval in colon cancer surgeries.

METHODS

A retrospective analysis was conducted on 560 patients who underwent colon cancer surgery at a single institution between 2018 and 2023. The average number of lymph nodes retrieved during laparoscopic and open procedures was compared. Distribution analysis using violin plots was performed to assess the pattern of lymph node yield between surgical approaches. Additionally, the impact of BMI on lymph node recovery was assessed. All surgeries were performed by a standardized surgical team using consistent fat clearance techniques.

RESULTS

The mean number of lymph nodes retrieved was 15.89 ± 0.84 for laparoscopic surgeries and 15.98 ± 0.50 for open surgeries, with no statistically significant difference (p = 0.9166). The violin plot analysis confirmed overlapping distributions between the two surgical approaches, with no significant difference (p = 0.6270). BMI also showed no significant effect on the number of lymph nodes removed during surgery. The consistency in outcomes was attributed to standardized surgical practices across all cases.

CONCLUSIONS

Laparoscopic and open surgical approaches yield comparable lymph node recovery in colon cancer surgeries, both in terms of mean values and overall distribution patterns, regardless of patient BMI. These findings emphasize the importance of standardized surgical techniques in ensuring reliable outcomes and suggest that both approaches are equally effective in meeting oncological standards for lymph node retrieval.

Contact radiotherapy for rectal cancer (CORRECT): study protocol for a multicentre randomised phase II trial

INTRODUCTION

Non-operative management of early-stage rectal cancer is increasingly recognised as a subject of significant clinical and research interest. Contact X-ray brachytherapy (CXB) offers an alternative to surgery in appropriately selected cases. Current clinical evidence suggests the use of CXB in combination with chemoradiotherapy (CRT). Although proven effective, no randomised evidence exists for the combination of CXB and short-course radiotherapy (SCRT). In this Swedish national randomised phase II trial, we aim to compare the combination of CXB with either CRT or SCRT in patients with early-to-intermediate rectal cancer.

METHODS AND ANALYSIS

A total of 110 eligible, operable patients with early-to-intermediate rectal cancer (cT1-cT3ab), with tumours measuring <5 cm in largest diameter, involving <50% of the rectal circumference, N0-N1 (≤3 nodes <8 mm in diameter), located ≤10 cm from the anal verge and MX/M0, are randomised into two arms: standard arm (A) CXB with CRT and experimental arm (B) CXB with SCRT. The contact radiotherapy for rectal cancer (CORRECT) trial aims to evaluate whether the experimental treatment is non-inferior to standard treatment with respect to the primary endpoint 2-year organ preservation rate. On demonstrating non-inferiority in oncological outcomes compared with CXB+CRT, the combination of CXB+SCRT could pave the way for establishing a new standard of care for organ preservation in early-to-intermediate rectal cancer for patients who wish to avoid surgery.

ETHICS AND DISSEMINATION

CORRECT is conducted in accordance with research ethical approval (2024-02762-01) granted by the Swedish Research Ethics Committee on 4 June 2024. Informed consent will be obtained from all trial participants. The trial results will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT06501053.

Preoperative malnutrition is a risk factor for prolonged postoperative ileus for patients undergoing gastrointestinal surgery

Background

Prolonged postoperative ileus (PPOI), a common complication after gastrointestinal (GI) surgery, seriously affects the postoperative recovery rate. However, there are few previous studies on the effect of preoperative nutritional status on the occurrence of PPOI in patients with GI cancer.

Objective

To evaluate the value of preoperative nutritional status for predicting the occurrence of PPOI in patients undergoing GI surgery.

Methods

We retrospectively analyzed the clinical data of GI cancer patients who were admitted to our hospital between June 2021 and June 2023. The nutritional status of all patients was assessed using the Nutritional Risk Screening 2002 (NRS2002) and the Patient-Generated Subjective Global Assessment (PG-SGA). The independent risk factors for PPOI identified via univariate and multivariate logistic regression analyses were used to establish nomogram for the prediction of PPOI.

Results

The clinical data of 310 patients with GI cancer who underwent surgical resection were analyzed. PG-SGA score, serum albumin concentration, hemoglobin concentration, operation time, tumor stage, and previous abdominal surgery are independent risk factors for PPOI. The nomogram developed to predict PPOI performed well [area under the curve (AUC) = 0.835]. The calibration curve showed high consistency between the observed and predicted results. The decision curve analysis (DCA) revealed that the nomogram was clinically useful. The predictive ability of this nomogram is better than that of albumin level and PG-SGA score.

Conclusion

The preoperative nutritional status of GI cancer patients has a significant effect on the occurrence of PPOI. The nomogram developed in this study accurately predicted PPOI in GI surgery patients.

Clinical course and prognostic disparities of pyoderma gangrenosum based on underlying disease: A long-term comparative study in 124 patients

BACKGROUND AND OBJECTIVES

Pyoderma gangrenosum (PG) is associated with inflammatory bowel disease (IBD), autoimmune and connective tissue diseases, and hematologic malignancies. The impact of these underlying diseases on the clinical course and outcomes of PG remains poorly understood. This study investigates the influence of systemic disease associations on the progression, treatment response, and prognosis of PG.

PATIENTS AND METHODS

This study followed a cohort of 124 patients diagnosed with PG at a multidisciplinary referral institution between 2007 and 2024. Patients were stratified into four groups: IBD-associated PG (n = 52), autoimmune and connective tissue disease-associated PG (n = 24), hematologic malignancy-associated PG (n = 15), and idiopathic PG (n = 33). Outcomes, including remission and relapse rates, were analyzed using Kaplan-Meier survival curves and Cox proportional hazards models.

RESULTS

IBD-associated PG had the most favorable outcomes, with 75% of patients achieving remission at 12 months (M12) (Hazard Ratio [HR]: 2.56; 95% Confidence Interval [95%CI]: 1.49-4.35). Autoimmune and connective tissue disease-associated PG was the most treatment-refractory, with only 8.3% achieving remission at M12 (HR: 0.21; 95% CI: 0.10-0.50). Relapse occurred in 26.1% of patients, with no significant difference across the groups (p = 0.8). Bullous PG, predominantly linked to hematologic malignancies, exhibited accelerated healing but also a high rate of malignant transformations near PG onset.

CONCLUSIONS

IBD-associated PG followed a more favorable clinical course compared to autoimmune and connective tissue diseases or hematologic conditions, highlighting the importance of tailored treatment approaches based on underlying disease associations.

Long-term outcome of prophylactic biosynthetic mesh reinforcement at the time of loop ileostomy reversal for colorectal cancer- results of a case-matched study

PURPOSE

Stoma site incisional hernia (SSIH) is a frequent complication following ileostomy closure but can be potentially decreased by prophylactic mesh reinforcement. The aim was to assess if the use of a slowly absorbable biosynthetic mesh at the time of ileostomy reversal could reduce the incidence of SSIH.

METHODS

Outcomes of consecutive patients receiving prophylactic biosynthetic mesh (poly-4-hydroxybutyrate Phasix®, BD) implantation at the time of ileostomy reversal for colorectal cancer were prospectively collected in the Club Hernie database. Outcomes were compared with those of matched patients from a historical cohort of patients undergoing ileostomy reversal without mesh augmentation.

RESULTS

A total of 100 patients underwent ileostomy reversal: 50 with biosynthetic mesh augmentation (mesh group) and 50 with standard fascial closure without mesh (control group). Mesh augmentation did not increase the operating time (mesh group 49.8 min vs. control group 60.5 min, p < 0.01), the incidence of surgical site infection (mesh group 4% vs. control group 6%, p = 1) or the length of hospital stay (mesh group 5 days vs. control group 6 days, p = 0.28). After a mean follow-up of 4 years, the rate of SSIH, diagnosed by CT scan, was significantly lower in the mesh group (mesh group 8% vs. control group 24%, p = 0.029).

CONCLUSION

Prophylactic use of a slowly absorbable biosynthetic mesh at the time of ileostomy reversal for colorectal cancer was safe and effective in reducing the rate of SSIH without increasing surgical site infection.

Trends for the Surgical Management of Rectal Prolapse in the Elderly: A Contemporary Analysis of the National Quality Improvement Program

BACKGROUND

Traditionally, the management of rectal prolapse in the elderly involved a perineal approach to repair. However, management paradigms have evolved, and the use of the transabdominal approach may be as safe as the perineal approach in elderly patients.

OBJECTIVE

To provide a contemporary analysis of early postoperative outcomes and trends in the surgical management of rectal prolapse.

DESIGN

This was a retrospective review of a large multicenter database.

SETTING

The National Surgical Quality Improvement Program captured data from 702 participating sites.

PATIENTS

All patients aged 70 years or older who underwent surgical repair of rectal prolapse from 2005 to 2022 were included for review.

INTERVENTION

Surgical approach used to treat prolapse is defined as open transabdominal, minimally invasive transabdominal, and perineal.

MAIN OUTCOME MEASURES

Temporal trends in the surgical approach used to treat rectal prolapse and rates of 30-day major and minor complications.

RESULTS

A total of 9664 patients were analyzed who underwent rectal prolapse repair via perineal (72%), minimally invasive (19%), or open approach (9%). Surgical trends demonstrated the proportion of open approaches decreased from a high of 16.5% to 8.1% and that of perineal approaches decreased from 92.9% to 67.0%. In contrast, the proportion of minimally invasive procedures increased from 0.0% to 24.9%. There were no differences in major complication rates among the 3 approaches, but a higher mortality rate was seen for the perineal approach (1.7%) than for the minimally invasive approach (0.5%), and a higher minor complication rate was seen for open (11.1%) than for minimally invasive (5.8%) and perineal (6.0%) approaches.

LIMITATIONS

This was a retrospective database study with limited details regarding surgical procedures and no long-term follow-up data beyond 30 days.

CONCLUSIONS

The minimally invasive approach appears to be the safest repair method and has gained significant popularity in recent years among the elderly population. However, the perineal approach remains the most commonly used approach despite evolving trends. See Video Abstract.

TENDENCIAS EN EL TRATAMIENTO QUIRRGICO DEL PROLAPSO RECTAL EN ANCIANOS UN ANLISIS CONTEMPORNEO DEL PROGRAMA NACIONAL DE MEJORA DE LA CALIDAD

ANTECEDENTES:Tradicionalmente, el tratamiento del prolapso rectal en los ancianos implicaba un abordaje perineal para la reparación. Sin embargo, los paradigmas de tratamiento han evolucionado, y el uso del abordaje transabdominal puede ser tan seguro como el perineal en los ancianos.OBJETIVO:Proporcionar un análisis contemporáneo de los resultados postoperatorios tempranos y las tendencias en el tratamiento quirúrgico del prolapso rectal.DISEÑO:Se trata de una revisión retrospectiva de una gran base de datos multicéntrica.ENTORNO CLINICO:El Programa Nacional de Mejora de la Calidad Quirúrgica recopiló datos de 702 centros participantes.PACIENTES:Se incluyeron para la revisión todos los pacientes ≥ 70 años de edad que se sometieron a reparación quirúrgica de prolapso rectal entre 2005 y 2022.INTERVENCIÓN:Abordaje quirúrgico utilizado para tratar el prolapso, definido como transabdominal abierto, transabdominal mínimamente invasivo y perineal.MEDIDAS DE RESULTADO PRINCIPALES:Tendencias temporales en el abordaje quirúrgico utilizado para tratar el prolapso rectal y tasas de complicaciones mayores y menores a 30 días.RESULTADOS:Se analizó un total de 9.664 pacientes sometidos a reparación de prolapso rectal mediante abordaje perineal (72%), mínimamente invasivo (19%) o abierto (9%). Las tendencias quirúrgicas demostraron que la proporción de abordaje abierto utilizado disminuyó de un máximo del 16,5% al 8,1%, y el abordaje perineal disminuyó del 92,9% al 67,0%. En cambio, la proporción de procedimientos mínimamente invasivos aumentó del 0,0% al 24,9%. No hubo diferencias en las tasas de complicaciones mayores entre los 3 abordajes, pero se observó una mayor tasa de mortalidad en el abordaje perineal (1,7%) que en el mínimamente invasivo (0,5%), y una mayor tasa de complicaciones menores en el abierto (11,1%) que en el mínimamente invasivo (5,8%) y el perineal (6,0%).LIMITACIONES:Este fue un estudio retrospectivo de base de datos con detalles limitados con respecto a los procedimientos quirúrgicos y sin datos de seguimiento a largo plazo más allá de 30 días.CONCLUSIONES:El abordaje mínimamente invasivo parece ser la reparación más segura y ha ganado una popularidad significativa en los últimos años en la población anciana. Sin embargo, el abordaje perineal sigue siendo el más utilizado a pesar de la evolución de las tendencias. (Traducción- Dr. Francisco M. Abarca-Rendon).

Comparative analysis of functional end-to-end and end-to-side anastomosis in laparoscopic right hemicolectomy for colon cancer

BACKGROUND

Despite advancements in laparoscopic right hemicolectomy for right-sided colon cancer, the choice between functional end-to-end anastomosis and end-to-side anastomosis remains a topic of debate. This study aimed to compare these 2 techniques in terms of postoperative complications and disease-free survival.

METHODS

This retrospective analysis included 1,202 patients who underwent laparoscopic right hemicolectomy for nonmetastatic colon cancer at Samsung Medical Center between January 2007 and February 2016. The patients were divided into functional end-to-end anastomosis (n = 968) and end-to-side anastomosis (n = 234) groups based on the anastomosis technique used. Patients' characteristics, oncologic results, operative outcomes, and postoperative complications were analyzed.

RESULTS

The baseline characteristics were similar between the 2 groups, except for a higher incidence of cancer obstruction in the end-to-side anastomosis group (P < .001). After matching, no significant differences were observed in operation time, blood loss, length of hospital stay, time to the first meal, or time to first flatus. Anastomotic leakage rates were comparable (functional end-to-end anastomosis 0.6% vs end-to-side anastomosis 0.4%, P > .999). The functional end-to-end anastomosis group had a higher rate of postoperative ileus (4.9% vs 1.3%, P = .017). Multivariable analysis indicated age, sex, and anastomosis type as significant predictors of postoperative ileus.

CONCLUSION

The study findings demonstrate that both functional end-to-end and end-to-side anastomosis techniques in laparoscopic right hemicolectomy are comparable in terms of operation metrics and disease-free survival. However, functional end-to-end anastomosis is associated with a higher incidence of postoperative ileus. These findings can guide surgical decision-making in the treatment of right-sided colon cancer.

Fostering an open surgical culture: strategies to eliminate inappropriate behavior in surgical practice

Surgery is a demanding and stressful profession. Unfortunately, inappropriate behavior is still not banished from the daily surgical practice and we are dealing with the negative consequences (e.g. negative working environments or burn-out). To adequately treat this type of behavior we first have to acknowledge its existence and create a proper path to discuss it inside our own ranks. The only manner to achieve this, is through an open culture. An 'open surgical culture' is the key, as it creates an environment with psychological safety and allows all involved parties to be able to speak up without fear for retaliation. Theoretical models such as Bateson's pyramid, McClelland's iceberg, and Dweck's Growth Mindset Theory can serve as valuable sources of inspiration to addressing cultural change by approaching both individual and organizational levels. Examples of cultural change attempts can be as small as discussing inappropriate behavior through pocket cards with statements of certain behavior or during national conferences, e.g. the annual meeting of the Dutch Surgical Society (Chirurgendagen). Only together we are able to achieve an open surgical culture, in order to ban mistreatment from the surgical profession. Here a roadmap to achieving an open surgical culture is presented and discussed.

SS, Bhandoria G, Chatterjee A, Deo SVS, Garach N, Guru A, Kumar N, Kumar R, Rajagopal AK, Kumar S, Mehta S, Mishra D, Pawar A, Prabhu A, Sinukumar S, Solanki S, Sharma V, Sheshadri RA, Bhatt A. The INDEPSO-ISPSM Consensus on Peritoneal Malignancies-Methodology

The numerous international guidelines on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) do not cover many clinically relevant issues for which evidence is limited and some regional issues (HIPEC in limited resource settings, age-limit for CRS, etc.). We describe the methodology of a consensus CRS and HIPEC for peritoneal malignancies carried out under the aegis of the two national societies for peritoneal oncology-INDEPSO and ISPSM. The modified Delphi technique was used with two rounds of voting. Eight key topics were selected by a working group of 29 members. Questionnaires comprising of closed-ended questions were disseminated through the online SurveyMonkey (http://www.surveymonkey.com) platform. A panel of 56 surgical, gastrointestinal, and gynecologic oncologists with a minimum of 5 years of experience with CRS-HIPEC voted on 260 questions. A consensus was reached if any of the options received 70% or more votes (> 90% = strong consensus). The response rate was 98.2% in round I and 94.6% in round II. A consensus was achieved on 80.7% questions after two rounds (43.0% after round I; 36.9% after round II). It was the highest in the enhanced recovery after surgery (ERAS) section (93.3%) and the lowest (68.0%) for ovarian cancer. A strong consensus was reached on 59 (22.6%) questions (highest for  the technical section (34.2%); lowest in the ERAS section (16.6%)). This consensus which had a high rate of participation should be a useful clinical resource for surgeons treating peritoneal malignancies in India and other regions with a similar demographic and socioeconomic background.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-02118-2.

Hybrid Open Anterior and Laparoscopic Repair Using Self-Gripping Mesh for Parastomal Hernia Following Ileal Conduit With Extensive Intra-abdominal Adhesions: A Case Report

Parastomal hernia (PSH) is the protrusion of visceral organs through an abdominal wall defect adjacent to a stoma and is one of the major complications following cystectomy and ileal conduit (IC) formation. We report a case of hybrid open anterior and laparoscopic repair using self-gripping mesh for a PSH following IC, complicated by extensive intra-abdominal adhesions. An 89-year-old man presented with recurrent episodes of small bowel obstruction (SBO) caused by PSH following IC. The patient had undergone total cystectomy with IC for urinary bladder cancer 30 years prior and had been hospitalized nine times for SBO due to PSH. The patient was referred for surgical treatment. Computed tomography revealed protrusion of the small bowel through a 10 × 7 cm hernia orifice around the IC. Considering the symptomatic PSH with a persistent risk of SBO, laparoscopic repair was planned. Laparoscopic exploration revealed extensive adhesions of the small bowel to the hernia orifice and IC, extending to the pelvis. The IC was also widely attached to the anterior abdominal wall, preventing visual assessment of the contralateral side of the conduit. Therefore, an additional transverse skin incision was made laterally and caudally to the stoma. The defect was closed anteriorly under direct vision with interrupted transfascial sutures and reinforced by onlay mesh placement using a trimmed (15 × 12 cm) self-gripping mesh (ProgripTM, Medtronic). The postoperative course was uneventful. At the 15-month follow-up, the patient was in good physical condition without hernia recurrence or SBO, except for intermittent episodes of urinary obstruction requiring drainage. Hybrid open anterior and laparoscopic repair using self-gripping mesh may be considered a surgical option for PSH following IC with extensive intra-abdominal adhesions around the stoma.

Pregnancy in Patients with Inflammatory Bowel Disease: A Narrative Review

Background

The incidence of inflammatory bowel diseases (IBDs) peaks in the fertile age of both women and men. There is a significant lack of knowledge regarding disease-specific aspects of guiding IBD patients through conception, pregnancy, and delivery in clinical routine.

Summary

Patients with IBD often remain voluntarily childless, primarily due to a lack of knowledge. Fertility is generally unaffected in IBD patients, except in those with high disease activity or who have undergone specific abdominal surgeries that may lead to changes in the abdominal cavity, such as inflammatory or postoperative adhesions. Immunosuppressive and immunomodulatory medications are generally considered safe during pregnancy and should be continued to reduce the likelihood of relapses. If flares occur, close monitoring of the mother and the fetus is mandatory, and therapeutic options (conservative, interventional, surgical) have to be weighed thoroughly. Despite advances in treatment, IBD patients remain at increased risk of preterm labor, small-for-gestational-age newborns and are at risk of C-sections, although the current literature suggests vaginal delivery is possible for most patients. C-sections are recommended in patients with active perianal disease.

Key Messages

Patients with IBD wishing to conceive should receive comprehensive preconception counseling about pregnancy-specific aspects of IBD management from an interdisciplinary team of specialists, including IBD gastroenterologists, obstetricians, and colorectal surgeons.

Age Matters: Early-Onset Rectal Cancer Exhibits Higher Rates of Pathological Complete Response: A Retrospective Analysis of the Influence of Young Age on Treatment Success in Stage II-III Rectal Cancer

BACKGROUND

The incidence of rectal cancer has decreased overall, but the incidence of early-onset rectal cancer (eoRC) has increased. Early-onset rectal cancer and late-onset rectal cancer (loRC) differ due to phenotypical, genetic characteristics, and higher stage presentations in eoRC. Thus, eoRC patients undergo more aggressive neoadjuvant treatments. This paper was designed to evaluate the impact of age on the pathological complete response rates in sporadic locally advanced rectal cancer.

METHODS

All patients with stage II-III rectal cancer who underwent neoadjuvant therapy and curative rectal resection between January 2018 and December 2023 were included and allocated to eoRC (<50 years) and loRC (≥50 years) groups based on their age at diagnosis.

RESULTS

A total of 381 patients were included (93 eoRC and 288 loRC). Preoperative radiological imaging revealed higher clinical nodal staging in the eoRC group (p = 0.002). A higher proportion of eoRC resulted in a pathological complete response compared with loRC (29% vs. 18.8%, p = 0.035). The rate of pathological complete response in eoRC and loRC did not differ between patients treated by total neoadjuvant therapy (TNT) and those treated by standard chemoradiotherapy (29.2% vs. 28.6%, p = 0.95 in eoRC and 21.7% vs. 25.9%, p = 0.097 in loRC). Multivariable analysis resulted in young age of onset (odds ratio 2.68; 95% confidence interval 1.11-6.51; p = 0.029) and KRAS wildtype (odds ratio 3.37; 95% confidence interval 1.25-9.07; p = 0.016) as being independent predictors of pathological complete response.

CONCLUSIONS

Sporadic eoRC and KRAS wildtype tumors are predictive factors for pathological complete response in stage II-III rectal cancer.

The Fate of the Rectum in Inflammatory Bowel Disease

For many patients with inflammatory bowel disease (IBD) proctocolitis, proctectomy offers symptom and disease control, albeit at the expense of a potentially morbid proctectomy. There are select situations, however, where definitively leaving an IBD rectum in situ, either in or out of intestinal continuity, may be a suitable alternative to proctectomy. This review explores the rare occasions where leaving the rectum in situ may be advisable and discusses the subsequent implications.

What is the predictive value of pretreatment MRI characteristics for achieving a complete response after total neoadjuvant treatment in locally advanced rectal cancer?

OBJECTIVES

To investigate the value of pretreatment magnetic resonance imaging (MRI) features in predicting a complete response to total neoadjuvant treatment (TNT) in locally advanced rectal cancer (LARC).

METHODS

The data of patients who received TNT were analyzed retrospectively. MRI features, including T stage, morphology, length, and volume; the presence of MR-detected extramural venous invasion (mrEMVI), the number of mrEMVI, and the diameter of the largest invaded vein; main vein mrEMVI; presence of MR-detected tumor deposits (mrTDs), the number of mrTDs, and the size of the largest mrTD; MR-detected lymph node status (mrLN); tumor distance from the anal verge; mesorectal fascia involvement (mrMRF + ); and mean apparent diffusion coefficient (ADC) values were recorded. Patients were classified as complete (CRs) or noncomplete responders (non-CRs) according to the pathological/clinical outcomes. For patients managed nonoperatively, a sustained clinical complete response for > 2 years was deemed a surrogate endpoint for complete response. The MRI parameters were categorized into three distinct groups: baseline, advanced, and quantitative features, and were analyzed using multivariable stepwise logistic regression. The ability to predict complete response was evaluated by comparing different combinations of MRI parameters, and performance on an "independent" dataset was estimated using bootstrapped leave-one-out cross-validation (LOOCV).

RESULTS

The data of 84 patients were evaluated (CRs, n = 44; non-CRs, n = 40). The optimal model, which included baseline and quantitative MRI features, achieved an area under the curve of 0.837 for predicting complete response. Selected predictors were T stage and ADC mean value. Advanced MRI features did not improve the performance of the model.

CONCLUSION

A multivariable model combining T stage and the ADC mean value can help identify LARC patients who are likely to a achieve complete response before the initiation of TNT.

Treatment of Hemorrhoidal Disease in Patients with Liver Cirrhosis: A Systematic Review

Introduction

The incidence of hemorrhoidal disease (HD) in cirrhotic patients is similar to that of general population, varying between 21% and 79%. Managing this clinical condition in these patients is challenging, due to the need to differentiate between bleeding originating from hemorrhoids or anorectal varices, and the unique hemostatic balance of each patient, which can lead to a decompensation of liver function and subsequently increase the anesthetic risk. To date, there are no systematic reviews specifically addressing this topic.

Methods

This was a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were retrieved from three electronic databases. Efficacy (symptomatic improvement, patient satisfaction, quality of life improvement, disease recurrence/need for surgery and/or hemorrhoidal prolapse reduction in anoscopy) and safety (reported adverse events) outcomes were evaluated. Data from each study were initially described individually, followed by a comparative analysis for procedures applied in multiple studies.

Results

Six studies were included - 1 randomized clinical trial (RCT), 2 prospective cohort studies, 1 retrospective cohort study, and 2 case series. The considered techniques encompassed rubber band ligation (RBL), injection sclerotherapy (IS) using 3 agents - aluminum potassium sulfate and tannic acid (ALTA), ethanolamine oleate 5% (EAO), or N-butyl-cyanoacrylate, hemorrhoidopexy, and emborrhoid technique. RBL showed great symptomatic improvement and patient satisfaction in 63% and 73% of patients, respectively, and in 90% was associated with one-grade prolapse reduction after only one session. The most frequently reported adverse events included pain (16%) and ulceration/fissure (1-17%). Concerning IS, symptomatic improvement was observed in all patients. Recurrence rates varied with the agent used (EAO: 13% at 12 months; N-butyl-cyanoacrylate: 40% at 12 months; ALTA: 18% at 5 years), and 86.7% of patients exhibited more than one-grade reduction after the initial session. The most frequent adverse event was pain (EAO: 63%; N-butyl-cyanoacrylate: 60%). Stapled hemorrhoidopexy resulted in symptomatic improvement in all patients, although associated with a recurrence rate of 25% within 4 months. With an emborrhoid technique, 80% of the patients showed clinical improvement at a 3-month follow-up, without significant adverse events, at the cost of a 40% recurrence rate.

Conclusions

All the treatment methods assessed in the included studies appear to be effective and safe in cirrhotic patients. This assumption challenges previous concerns regarding significant bleeding after office-based procedures like RBL in this population. Future research should prioritize RCT to thoroughly assess the management of HD in these patients, particularly addressing polidocanol foam sclerotherapy, a minimally invasive technique that has previously been shown to be more effective than RBL in the general population and in patients with bleeding disorders.

Predictors of pathological complete response after total neoadjuvant treatment using short course radiotherapy for locally advanced rectal cancer

BACKGROUND

Total neoadjuvant treatment (TNT) has become a standard treatment approach for locally advanced rectal cancer (LARC). Patients achieving pathological complete response (pCR) following TNT have better outcomes (overall survival, relapse free survival). However, not all patients treated for LARC with neoadjuvant treatment achieve pCR.

AIM

The aim of our study was to assess the rate and predictors of pCR.

MATERIALS AND METHODS

We performed a retrospective study at medical oncology unit in a tertiary care teaching hospital. All consecutive LARC patients without any evidence of distant metastasis who underwent neoadjuvant chemoradiotherapy and surgery between June 2020 and January 2023 were included in the research. Pathological response to neoadjuvant treatment was assessed using Mandard grading system and response was categorized as pCR or not‑pCR. Two different standardized protocols for the neoadjuvant treatment were used: the first group was treated with induction chemotherapy followed by short course radiotherapy and the second group was treated with the RAPIDO protocol. Correlation between different studied parameters and pCR was determined using univariate and multivariate logistic regression analysis.

RESULTS

The mean age of the 91 included patients (46 men and 45 women) was 58.53 ± 10.3 years. Twenty (22%) were found to have a pCR (Mandard TRG1) in the operative specimen. In univariate analysis, patients less than 60 years, continuation of chemotherapy and patients treated with the induction chemotherapy followed by short course radiotherapy showed a better pCR as compared to patients treated with Rapido protocol (p = 0.043, p = 0.0001 and p = 0.021 respectively). Patients with mucinous component had low pCR rates (p = 0.021). On logistic regression analysis, chemotherapy continuation (OR = 10.27, 95% CI = 2,14-49.32), and absence of mucinous component (OR = 12.6, 95% CI = 3.1-40.32) were significant predictors of pCR. The median survival was 37.7 months.

CONCLUSION

Mucinous component and chemotherapy interruption are associated with lower pCR rates. Integrating these factors into personalized treatment algorithms may help optimize therapeutic strategies and improve outcomes for patients with LARC.

Parastomal Hernia: direct repair versus relocation: is stoma relocation worth the risk? A comparative meta-analysis and systematic review

Parastomal hernia is a prevalent and challenging complication in patients with stomas, frequently necessitating surgical intervention. The two primary approaches to parastomal hernia repair- direct repair without relocation and stoma relocation- offer distinct benefits and drawbacks. This systematic review and meta-analysis aimed to compare the efficacy and safety of stoma relocation versus direct repair in managing parastomal hernia. Following PRISMA guidelines, we conducted a systematic review and meta-analysis of studies involving adult patients (≥ 18 years) with parastomal hernia who underwent either stoma relocation or direct repair, with a focus on clinically relevant outcomes. A comprehensive search of Web of Science, PubMed, Scopus, and Cochrane Library databases was conducted up to September 2024. Key short-term outcomes (operative time, surgical site infection, urinary tract infection, bowel obstruction, length of hospital stay, and overall complications) and long-term outcomes (re-admission, recurrence, re-operation, and mortality) were extracted. Statistical analysis included risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Six studies were included, encompassing both laparoscopic and open-surgical techniques. Direct repair was associated with a significantly shorter operative time (MD: 115 min, 95% CI: 95.71 to 134, P < 0.00001) and a reduced length of hospital stay (MD: 2 days, 95% CI: 0.40 to 3.9, P = 0.02). While reoperation rates were significantly lower in the relocation group (RR: 0.15, 95% CI: 0.03 to 0.62, P = 0.009), other outcomes-including recurrence, re-admission, and overall complication rates-showed comparable results between the two approaches. Notably, there were no significant differences in surgical site infection, urinary tract infection, bowel obstruction, or mortality rates. Direct repair may be advantageous for reducing operative time and hospital stay, whereas stoma relocation appears beneficial in reducing reoperation rates. Future research should focus on developing standardized techniques and incorporating patient-specific factors to inform optimal surgical decision-making in parastomal hernia repair.

Comparative analysis of Ferguson hemorrhoidectomy combined with doppler-guided hemorrhoidal artery ligation and Ferguson hemorrhoidectomy in hemorrhoidal disease treatment

BACKGROUND

In hemorrhoidal disease, despite the existence of numerous treatment options to alleviate symptoms, surgical intervention continues to be the gold standard. The advantages and disadvantages of many methods have been shown in numerous studies However, only a few studies have compared the effectiveness of combined methods.

AIM

To compare the results of a coloproctology clinic that switched to the Doppler-guided hemorrhoidal artery ligation (DG-HAL) + Ferguson hemorrhoidectomy (FH) technique from the FH in the treatment of hemorrhoidal disease.

METHODS

In this retrospective cohort, data from a total of 45 patients who underwent DG-HAL + FH (n = 24) and FH (n = 21) for grade III hemorrhoidal disease between 2020 and 2022 were analyzed. Demographic and clinical data, surgical duration, intraoperative blood loss, hospital stay, postoperative analgesic consumption, pain scores using the Visual Analog Scale (VAS), complications, time to return to normal activities, and the recurrence rate were compared in both groups.

RESULTS

The study included 45 patients, with 75.6% (n = 34) male and 24.4% (n = 11) female. The rate of intraoperative blood loss was higher in the FH group (P < 0.05). The VAS scores and postoperative complication rates were similar in both groups. The need for postoperative analgesics was lower in the DG-HAL + FH group (2 vs 4 days, P < 0.05), while the FH group showed a shorter time to return to normal activities (9.5 vs 6.0 days, P = 0.02). The recurrence rate (16.7% vs 0%) and Clavien-Dindo Score-1 complications (20.8% vs 9.5%, P = 0.29) were higher in the DG-HAL + FH group but were insignificant.

CONCLUSION

Our study revealed that the addition of the DG-HAL to classical hemorrhoidectomy caused less intraoperative bleeding and a lower postoperative analgesia requirement.

Protective ileostomy creation after anterior resection of the rectum (PICARR): a decision-making exploring international survey

In our previous survey of experts, surgeon's decision-making process (DMP) about protective ileostomy (PI) creation after anterior resection was investigated. Based on our previous data, a multiple choice questionnaire has been developed. The aim is to perform a quantitative analysis of the results obtained from an international survey and to describe the clinical practice worldwide. Ten questions were related to participants' demographics and, 20 questions (of which 17 Likert scale questions) investigated the DMP regarding PI creation. To evaluate the tendency of the answers in the Likert-type questions, the mean of the answers obtained was compared with the mean point of the Likert scale. The survey was completed by 1019 physicians. Neoadjuvant chemoradiotherapy and distance of the anastomosis from the anal verge ≤ 10 cm were each considered alone sufficient to justify creation of a PI, with statistically significant differences in comparison to the mean point of the scales in (p =  < 0.0001 in both cases). Total Mesorectal Excision alone was not considered a factor sufficient to create a PI (p = 0.416). Most of the participants agree to define their approach to create a PI "tailored" to patients' risk factors (p =  < 0.0001) and "influenced by my experience" in case of patients with low/moderate risk of anastomotic leakage (p =  < 0.0001). This study provides useful insights on the worldwide clinical practice regarding creation of PI following anterior resection. Given the lack of standardization and evidence-based guidelines, this analysis may be helpful to assist surgeons' practice.

Fecal Incontinence Outcomes Following Transvaginal Posterior Vaginal Wall Repair

INTRODUCTION AND HYPOTHESIS

Knowledge regarding rates of improvement of fecal incontinence (FI) after repair of posterior compartment prolapse is limited. We aimed to estimate the rate of resolution or improvement of fecal incontinence postoperatively following transvaginal posterior compartment repair.

METHODS

This was a retrospective cohort study including patients with diagnosis of fecal incontinence who underwent transvaginal posterior repair at a single academic institution between 1/2016 and 1/2022. Patients who underwent concomitant anal sphincteroplasty served as controls. The primary outcome was resolution of FI symptoms within 6-weeks postoperatively. Secondary outcomes included improvement of FI symptoms and preoperative anorectal manometry characteristics. Univariate and bivariate analysis were performed to describe and compare outcomes between groups with multivariable regression performed to address potential confounders.

RESULTS

Of 179 patients included, 91 had posterior repair alone, while 88 had concomitant anal sphincteroplasty. Demographic and clinical characteristics were similar between groups. Overall, 143 (80%) patients did not report any FI symptoms at their 6-week postoperative visit. An additional 28 (16%) reported improvement in FI symptoms. Among patients who underwent posterior repair alone, 76 (84%) had resolution of their FI compared to 67 (76%) in patients with concomitant anal sphincteroplasty (P = 0.6); 71 patients underwent anorectal manometry preoperatively. There were no significant differences in mean average resting pressures or mean maximum squeeze pressures between groups.

CONCLUSIONS

Posterior compartment repair resulted in resolution or improvement of fecal incontinence symptoms within 6-weeks postoperatively. The mechanism for FI symptoms in women with rectoceles may be independent of the anal sphincter complex.

Multi-Modal Machine Learning for Evaluating the Predictive Value of Pelvimetric Measurements (Pelvimetry) for Anastomotic Leakage After Restorative Low Anterior Resection

Background/Objectives: Anastomotic leakage (AL) remains a major complication after restorative rectal cancer surgery, with accurate preoperative risk stratification posing a significant challenge. Pelvic measurements derived from magnetic resonance imaging (MRI) have been proposed as potential predictors of AL, but their clinical utility remains uncertain. Methods: This retrospective, multicenter cohort study analyzed rectal cancer patients undergoing restorative surgery between 2013 and 2021. Pelvic dimensions were assessed using MRI-based pelvimetry. Univariate and multivariate regression analyses identified independent risk factors for AL. Subsequently, machine Learning (ML) models-logistic regression, random forest classifier, and XGBoost-were developed to predict AL using preoperative clinical data alone and in combination with pelvimetry. Model performance was evaluated using F1 scores, with the area under the receiver operating characteristic (ROC-AUC) and precision-recall curves (AUC-PR) as primary metrics. Results: Among 487 patients, the overall AL rate was 14%. Multivariate regression analysis identified distance to the anorectal junction, pelvic inlet width, and interspinous distance as independent risk factors for AL (p < 0.05). The logistic regression model incorporating pelvimetry achieved the highest predictive performance, with a mean ROC-AUC of 0.70 ± 0.09 and AUC-PR of 0.32 ± 0.10. Although predictive models that included pelvic measurements demonstrated higher ROC-AUCs compared to those without pelvimetry, the improvement was not statistically significant. Conclusions: Pelvic dimensions, specifically pelvic inlet and interspinous distance, were independently associated with an increased risk of AL. While ML models incorporating pelvimetry showed only moderate predictive performance, these measurements should be considered in developing clinical prediction tools for AL to enhance preoperative risk stratification.