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.

Imaging and interventions in vascular malformations of the gastrointestinal tract

Vascular malformations of the gastrointestinal (GI) tract are a rare yet significant cause of GI bleeding, that can present at any age and require a high index of suspicion for timely diagnosis. While the majority of lesions may be asymptomatic and detected incidentally on imaging, they may also present with anemia if there is occult blood loss, as acute GI bleeding, or as lead points for intussusception. The presence of multiple vascular malformations may be associated with underlying syndromes, such as Hereditary Hemorrhagic Telangiectasia syndrome and Klippel-Trénaunay syndrome. While luminal endoscopy is the first-line diagnostic test to evaluate overt and occult GI bleeding, imaging plays a very significant role in detecting these vascular malformations and planning the best treatment approach. In this review, we describe the various imaging findings of GI tract vascular malformations and available treatment options, focusing on endovascular interventional treatments where possible.

Pre-Treatment SEPTIN9 Gene Methylation Ratio Predicts Tumor Response to Total Neoadjuvant Therapy in Patients with Locally Advanced Rectal Cancer

Background and objective: Multiple markers have been proposed, but there are no reliable pre-treatment markers that predict tumor response to total neoadjuvant therapy in patients with locally advanced rectal cancer. The objective of this study is to evaluate the usefulness of pre-treatment SEPTIN9 gene methylation ratio as a predictor of tumor response to total neoadjuvant therapy and its correlation with tumor size and tumor stage in patients with locally advanced rectal cancer. Methods: Patients with locally advanced rectal cancer (T3/4 and/or N+ histologically confirmed rectal cancer) undergoing total neoadjuvant therapy were included. Tumor size and tumor stage were determined by magnetic resonance. SEPTIN9 gene methylation in plasmatic cfDNA was analyzed by droplet digital PCR at the time of diagnosis. After completing total neoadjuvant therapy, tumor response was assessed by magnetic resonance and proctoscopy. The correlation between pre-treatment SEPTIN9 gene methylation ratio, tumor size, tumor stage and tumor response was analyzed. Results: 39 patients with locally advanced rectal cancer were included. Pre-treatment SEPTIN9 gene methylation ratio (p = 0.033) and tumor size (p = 0.026), but not tumor stage, significantly correlated with tumor response to total neoadjuvant therapy. Pre-treatment SEPTIN9 gene methylation ratio also correlated with N stage (p = 0.040) and tumor size (p = 0.001), but not with T stage (p = 0.846). Conclusions: Pre-treatment SEPTIN9 gene methylation ratio correlates with tumor size and N stage and can predict tumor response to total neoadjuvant therapy in patients with locally advanced rectal cancer.

To cut or not to cut? Extended mesenteric excision during intestinal resection does not impact the postoperative recurrence nor the postoperative complications in Crohn's disease: a systematic review and meta-analysis

BACKGROUND

The mesentery might be involved in the pathogenesis of Crohn's disease (CD). As a result of scarce and conflicting data, it is debatable whether removal during intestinal resections could influence postsurgical outcome. We aimed to investigate the association between the extent of mesenteric excision during intestinal resections and postoperative complications and recurrence.

METHODS

We conducted a systematic search in five databases on 29 July 2024 for studies reporting outcomes in patients with CD who underwent intestinal resections with extended mesenteric excision (EME) compared with limited mesenteric excision (LME). Pooled odds ratios (ORs) with 95% confidence intervals (CI) were calculated using the random-effects model. We assessed the risk of bias using the ROBINS-I and RoB2 tool and evaluated the certainty of evidence according to the GRADE Working Group recommendations.

RESULTS

We retrieved data from six studies, covering 4590 patients. The pooled data showed no significant difference between EME and LME patients regarding surgical recurrence (OR 0.3; 95% CI 0.02-3.73; p = 0.176), overall postoperative complications (OR 0.78; 95% CI 0.33-1.82, p = 0.329), anastomotic leak (OR 0.76, 95% CI 0.09-6.85, p = 0.722), surgical site infection (OR 0.84, 95% CI 0.3-2.36, p = 0.539), reoperation rate (OR 1.09, 95% CI 0.33-3.58, p = 0.783), or hospitalization (MD - 0.33 (95% CI - 1.8 to 1.15, p = 0.53). Individual studies reported similar results regarding 6 months follow-up endoscopic recurrence. The certainty of evidence was very low and low, respectively.

CONCLUSION

Extended mesenteric excision is not statistically associated with improved postoperative complications or postoperative recurrence. Results should be interpreted cautiously because of the small number of studies; hence, randomized, long-term, controlled trials are needed.

Effectiveness of combined botulinum toxin and fissurectomy on chronic anal fissures - a systematic review

BACKGROUND

Anal fissures are a debilitating benign condition, thought to be due to the hypertonicity of the internal anal sphincter resulting in localized ischaemia inhibiting healing. There are several surgical and non-surgical treatment options for chronic anal fissures. Clinical practice surveys report a trend toward sphincter-sparing options, reserving the more successful treatment of lateral sphincterotomy, with an incontinence rate up to 10%, for refractory fissures.

METHODS

A search of MEDLINE, Cochrane Database of Systematic Reviews and EMBASE for studies assessing sphincter-sparing treatment with botulinum toxin and fissurectomy was performed following PRISMA guidelines. Outcomes assessed included healing rate, persistence, recurrence, re-intervention and incontinence rates.

RESULTS

Fifteen non-randomized studies assessed 978 patients managed with botulinum toxin and fissurectomy. The mean age was 40.8 years with a female predominance of 58.9%. Healing rate was reported on 14 of the 15 studies, with a healing rate of 81% (95% CI:0.67, 0.90). Persistence rate was reported as 15% (95% CI:0.07, 0.28) and a recurrence rate of 6% (95% CI: 0.01, 0.19). Re-intervention was required in 8% of patients with 55.1% requiring a repeat dose of botulinum toxin with or without fissurectomy. Incontinence appears to be transient with studies reporting a rate of 1% with median long-term follow up 23 months (range: 5-60 months).

CONCLUSION

Combination fissurectomy and botulinum toxin is a safe and viable sphincter sparing treatment option, with moderate success rate and negligible complications. Randomized controlled trials are required to further strengthen the evidence for its use in chronic anal fissures.

Factor analysis of postsurgical gastroparesis syndrome after right hemicolectomy for colon cancer

The present study aimed to investigate factors influencing postsurgical gastroparesis syndrome (PGS) in patients with right-sided colon cancer. In total, 260 patients who underwent complete mesocolic excision for right-sided colon cancer were included in the present analysis. Among the included patients, 69 underwent open radical right-sided colon resection, 175 underwent laparoscopic radical right-sided colon resection and 16 underwent robot-assisted radical right-sided colon resection. The occurrence of PGS was observed, and both the χ2 test and multivariate regression analysis were conducted to identify influencing factors. Among the 260 patients, 32 experienced PGS, with an incidence rate of 12.3%. Univariate analysis demonstrated that age, perioperative blood glucose levels, self-rated anxiety scale scores and surgical approach were significantly associated with PGS (P<0.05), whereas sex, surgical duration, diabetes and perioperative albumin levels were not significant factors (P>0.05). Multivariate logistic regression analysis showed that age >70 years, perioperative blood glucose ≥11.1 mmol/l, a self-rating anxiety scale score ≥50 and radical extended right-sided colon resection were risk factors for PGS occurrence. In conclusion, the occurrence of PGS in patients with right-sided colon cancer was revealed to be associated with age, perioperative blood glucose levels, self-rated anxiety scale scores and surgical approach.

Deep learning-based pelvimetry in pelvic MRI volumes for pre-operative difficulty assessment of total mesorectal excision

BACKGROUND

Specific pelvic bone dimensions have been identified as predictors of total mesorectal excision (TME) difficulty and outcomes. However, manual measurement of these dimensions (pelvimetry) is labor intensive and thus, anatomic criteria are not included in the pre-operative difficulty assessment. In this work, we propose an automated workflow for pelvimetry based on pre-operative magnetic resonance imaging (MRI) volumes.

METHODS

We implement a deep learning-based framework to measure the predictive pelvic dimensions automatically. A 3D U-Net takes a sagittal T2-weighted MRI volume as input and determines five anatomic landmark locations: promontorium, S3-vertebrae, coccyx, dorsal, and cranial part of the os pubis. The landmarks are used to quantify the lengths of the pelvic inlet, outlet, depth, and the angle of the sacrum. For the development of the network, we used MRI volumes from 1707 patients acquired in eight TME centers. The automated landmark localization and pelvic dimensions measurements are assessed by comparison with manual annotation.

RESULTS

A center-stratified fivefold cross-validation showed a mean landmark localization error of 5.6 mm. The inter-observer variation for manual annotation was 3.7 ± 8.4 mm. The automated dimension measurements had a Spearman correlation coefficient ranging between 0.7 and 0.87.

CONCLUSION

To our knowledge, this is the first study to automate pelvimetry in MRI volumes using deep learning. Our framework can measure the pelvic dimensions with high accuracy, enabling the extraction of metrics that facilitate a pre-operative difficulty assessment of the TME.

A Case Report of Metastatic Melanoma in the Transverse Colon

Colonic metastasis from melanoma is extremely rare and is often asymptomatic, complicating detection. Diagnosis requires imaging and endoscopic evaluation. Treatment typically involves surgical resection with systemic therapies like immunotherapy and targeted therapy. However, immunotherapy has increased immune-related adverse events, including gastrointestinal perforation, a rare but serious complication. This report details a case of a Caucasian male patient in his 60s with a history of excised scalp melanoma eight years prior, who developed metastatic melanoma in the transverse colon. After initiating combination immunotherapy with ipilimumab/nivolumab, he suffered a bowel perforation, necessitating palliative care. The case underscores the need for vigilant monitoring for asymptomatic gastrointestinal tract metastases in melanoma patients and careful risk assessment when considering immunotherapy. It emphasizes the challenge of balancing aggressive treatment with managing potentially severe adverse events.

Pre-operative imaging for inguinal hernia: routine or waste? A single institution perspective

INTRODUCTION

Inguinal hernia is a very common surgical problem in Australia. This study aims to assess at a single institution the perioperative use of imaging for these patients, and the accuracy of that imaging.

METHODS

Data were collected retrospectively for 215 adult patients who underwent inguinal hernia repair at a single public hospital. Clinical, operative, and imaging findings were collected and recorded.

RESULTS

The study included 215 patients who had surgery on 240 groins. 90% of patients had preoperative imaging, with 70% undergoing ultrasound, and 28% undergoing CT scan. 82% of patients who had imaging had a clinically palpable hernia. Ultrasound and CT had high sensitivity for the presence of hernia, 97.5% and 90.6%, respectively. Ultrasound was inaccurate at assessing for direct versus indirect hernia, correlating with operative findings only 62% of the time.

CONCLUSION

Data suggest that imaging is being overused for investigation of groin hernias, and imaging findings do not appear to alter operative management.

Multidisciplinary protocol to reduce surgical readmissions in Australia: American College of Surgeons National Surgical Quality Improvement Program

INTRODUCTION

Unplanned readmissions in general surgery are an important quality indicator of patient care and are associated with increased costs to healthcare services. This study aims to implement a multidisciplinary protocol in a single institution in a tertiary referral hospital to monitor and reduce unplanned readmission rates.

METHODS

A prospective cohort study using an institution-based protocol was conducted over an 18-month period including patients undergoing a general surgical procedure. The protocol included: (i) implementation of a surgical readmissions nurse-patient liaison; (ii) access to a surgical walk-in clinic; and (iii) early post-discharge phone contact. Data included demographic details, index procedure, hospital length of stay (LOS), and whether contact between patient/nurse occurred upon discharge. The primary outcome was the cause and rate of 30-day readmissions. Secondary outcomes were mortality, use of surgical clinic, emergency department presentations, and complications.

RESULTS

After protocol implementation, 874 patients underwent a general surgical procedure, with 354 (49%) being male and an overall median age of 53.0 years (interquartile range: 36.0-67.0). The overall readmission rate was 5.6% (n = 49), with a median LOS after readmission of 4 days. Compared with historical pre-protocol ACS-NSQIP data, this reflects a 30% reduction compared to that of readmission rate of 7.9%, P = 0.03.

CONCLUSION

The multidisciplinary protocol was efficacious in significantly reducing unplanned readmissions. Continued audits and monitoring of factors associated with readmissions are required to help design targeted projects that may lead to improved outcomes, lower costs, increased patient satisfaction, and better efficiency within our healthcare system.

Perianal Fistulizing Crohn's Disease: Outcomes of Surgical Repairs and Current State of Stem Cell-Based Therapies

Perianal fistulizing Crohn's disease is one of the most disabling phenotypes of Crohn's disease, due to the severe impairment in quality of life including social and personal wellbeing. A multimodal approach with patient-tailored care is the key to optimal management of this condition. Medical therapy is needed to optimize the luminal disease, and surgical intervention is required to control any associated perianal sepsis and attempt palliative or definitive fistula repair. While several medical and surgical options are available, the majority of patients continue to have symptomatic disease. Fortunately, this continues to drive novel innovations which are revolutionizing the treatment and outcomes of perianal fistulizing Crohn's disease. However, there continues to be a need for randomized trials and consistent metrics utilized for classification and treatment outcomes in order to accurately describe optimal treatment outcomes.

Short-Term Complications Following Transvaginal Sacrospinous Ligament Rectopexy: A Retrospective Cohort Study

INTRODUCTION AND HYPOTHESIS

Obstructed defecation syndrome (ODS) affects over 12% of middle-aged women, characterized by excessive straining, incomplete evacuation, and splinting. Current surgical options such as ventral mesh rectopexy, though effective, involve risks associated with mesh use and abdominal entry. This study evaluates the short-term complications of transvaginal sacrospinous ligament rectopexy.

METHODS

This retrospective cohort study was conducted at a tertiary medical center, including patients over 21 years who underwent transvaginal sacrospinous ligament suture rectopexy for ODS from January 2018 to May 2024. Demographic, intraoperative, and 30-day postoperative complication data were collected.

RESULTS

A total of 190 patients with a mean age of 62.3 years underwent transvaginal sacrospinous ligament suture rectopexy. Intraoperative complications were rare, with four rectal injuries: two occurred during posterior dissection, one due to aggressive posterior repair, and another was discovered during exploration for postoperative pain. All rectal injuries were managed successfully. One patient experienced significant intraoperative bleeding, resulting in a hematoma that required evacuation 5 days later. Postoperative urinary retention was the most common complication, affecting 29.8% of patients. This was associated with concurrent procedures, such as mid-urethral sling placement and anterior colporrhaphy. Reoperation within 30 days was necessary for six patients (3.7%): two for urinary retention due to sling-related issues, two for sacrospinous pain necessitating suture removal, and two for vaginal bleeding related to hematoma formation. No cases of surgical site infection, sepsis, or mortality were observed.

CONCLUSIONS

Transvaginal sacrospinous ligament suture rectopexy appears to be a safe alternative for ODS treatment, with low short-term complication rates.

C-reactive protein and digestive pathologies: A narrative review for daily clinical use

The aim of this narrative review is to familiarize clinicians, especially digestive surgeons, to adequately use of serum C-reactive protein as a reliable noninvasive biomarker in diverse practical clinical situations. We hope that the review will help clinicians for their decision-making when facing various digestive diseases including operative and nonoperative pathologies such as anastomotic leakage, pancreatitis, emergency situation, and digestive cancer management and prognosis.

Superselective superior rectal artery embolization in the treatment of hemorrhoidal disease

Hemorrhoids are a prevalent and benign anal disorder for which minimally invasive treatments are increasingly preferred. The UK National Institute for Health and Care Excellence clinical guideline (2010) recommends hemorrhoidal artery ligation as a treatment option for hemorrhoidal disease. Superior rectal artery embolization (SRAE) leverages this principle by using digital subtraction angiography to precisely identify and superselectively embolize the arteries supplying the hemorrhoidal region. This procedure has demonstrated favorable clinical outcomes. SRAE is minimally invasive, painless, preserves the anal sphincter and normal anal anatomy, and offers a quick recovery, establishing it as an effective minimally invasive surgical option. As a result, this technique has gained increasing clinical recognition and adoption. This article examines the efficacy and safety of superselective SRAE for hemorrhoidal disease.

Preoperative Optimization for Elective Surgery in Crohn's Disease: A Narrative Review

Crohn's disease is a chronic inflammatory bowel disease and, despite an increase in the available drug treatments, many patients will still require surgery at some point in their disease course. Stricturing and penetrating phenotypes of Crohn's disease are less likely to respond to our current medical treatment and, therefore, surgical intervention may be required. This is most commonly elective, planned surgery, thereby affording the opportunity to optimize medications, nutritional and inflammatory status, and steroid use. Poor nutritional status and previous surgery increase the risk of postoperative complications. Preoperative optimization has three main goals: reduction of postoperative complications; reduction of reoperation rates; and reduction of postoperative recurrence rates. A literature search was completed using PubMed, Embase, and Ovid using the search term "preoperative optimization in Crohn's disease", and it included both adult and pediatric studies, excluding those for perianal Crohn's disease. In this narrative review, we examine the role of nutritional intervention, medical optimization pre and postoperatively, and the role of personalized prehabilitation in the reduction of postoperative complications. We demonstrate that these may all yield better postoperative outcomes for patients with Crohn's disease undergoing elective surgery, although the evidence is somewhat limited and there is a requirement for more prospective randomized controlled trials to implement their role into standard practice or guidelines.

Angioleiomyoma originating from the ano-rectal wall presenting as a perineal mass: a case report

INTRODUCTION

Angioleiomyoma, a vascular leiomyoma is a rare, benign smooth-muscle tumor observed to occur anywhere in the body, most frequently in the lower extremities but very rarely in the digestive system. Angioleiomyoma in the hindgut is infrequent and in particular, rectal/perianal location has been observed very rarely.

CASE REPORT

We describe herein a case of a 50-year-old male patient complaining of perineal discomfort and a swelling at the level of the left ischio-rectal fossa, moderately painful. This solid mass in the left ischio-rectal space was in close relationship with the wall of the ano-rectal junction. After surgical removal and histopathology, the mass resulted an angioleiomyoma, vascular type, desmin positive, a very rare neoplasm. Extensive immune-histochemical studies are fundamental for the correct diagnosis and to rule out other mesenchymal tumors.

DISCUSSION/CONCLUSION

Angioleiomyoma is a very rare neoplasm of the gastrointestinal tract, and the fundamental problem of peri-rectal/perianal angioleiomyoma is represented by differential diagnosis from gastrointestinal stromal tumors (GISTs) and other perianal/perirectal swellings. For correct differential diagnosis, the histopathology supported by extensive immune-histochemical study adopting a panel of specific tissue markers is important. The surgical treatment is mandatory with complete excision and subsequent follow-up since local recurrence may occur.

A retrospective, observational study to examine the effect of early tumor necrosis factor inhibitor use on rates of surgery for Crohn's disease in Japan

BACKGROUND

Crohn's disease (CD) is an incurable inflammatory condition that often requires multiple surgeries, negatively impacting quality of life. As such, treatment strategies that aim to prevent damage to the bowel and reduce the burden of surgeries for patients with CD are important. This retrospective, long-term, observational study investigated whether tumor necrosis factor inhibitor (TNFi) treatment was associated with decreased rates of abdominal surgery in Japanese patients with CD.

METHODS

Patients were divided into two groups based on prior TNFi therapy (TNFi-treated and TNFi-untreated). Outcomes assessed included surgery rate, cumulative surgery-free survival rate, and time to surgery. For surgery rate, treatment groups were compared through estimation of an odds ratio (OR) with 95% confidence intervals (CIs). Cumulative surgery-free survival rate and time to surgery was calculated using Kaplan-Meier methodology and compared using log-rank tests. The primary analysis compared outcomes between the TNFi-treated and TNFi-untreated groups. Subgroup analyses compared outcomes between two subgroups of the TNFi-treated group (infliximab-treated vs. adalimumab-treated) and the TNFi-untreated group.

RESULTS

Overall, 124 patients with CD were included in the analysis (TNFi-treated: N = 86; TNFi-untreated: N = 38). Of those patients who received TNFi treatment, 62 received infliximab and 24 received adalimumab. The median (range) observation period in the TNFi-treated and TNFi-untreated groups was 4.62 (0.41-13.75) years and 8.13 (0.08-30.25) years, respectively. Median time to surgery was 3 years in the TNFi-untreated group and 6.58 years in the TNFi-treated group. A significantly lower proportion of patients in the TNFi-treated group required surgery (3/86) compared with those in the TNFi-untreated group (17/38; OR [CI]: 0.0446 [0.0120-0.1667]; P < 0.0001). Cumulative surgery-free survival rates were significantly higher in the TNFi-treated group versus the TNFi-untreated group (P < 0.0001). Compared with the TNFi-untreated group, the proportion of patients who required surgery was significantly lower with both infliximab (1/62; OR [CI]: 0.0203 [0.0025-0.1616]; P = 0.0002) and adalimumab (2/24; OR [CI]: 0.1123 [0.0231-0.5466]; P = 0.0068). Cumulative surgery-free survival rates were significantly higher in the infliximab-treated group versus the TNFi-untreated group (P < 0.0001).

CONCLUSIONS

Introduction of TNFis for the treatment of CD may lead to a reduction in surgery rates and prolong time to surgery.

Prevalence of workplace bullying among medical students: A meta-analysis and systematic review protocol

Workplace bullying is a significant issue impacting various professions, including the healthcare sector. This study presents a meta-analysis aimed at assessing the global prevalence of workplace bullying among medical students and identifying potential influencing factors. Previous research suggests that medical students experience higher rates of bullying compared to senior doctors. However, no worldwide meta-analysis has been conducted on this topic. By utilizing a reliable measurement tool, this study will offer a comprehensive analysis of the prevalence of workplace bullying among medical students. The findings are intended to inform the development of strategies to address this issue and enhance the well-being and professional development of medical students worldwide.

Enhancing Quadruple Health Outcomes After Thoracic Surgery: Feasibility Pilot Randomized Controlled Trial Using Digital Home Monitoring

BACKGROUND

Surgical recovery after hospital discharge often presents challenges for patients and caregivers. Postoperative complications and poorly managed pain at home can lead to unexpected visits to the emergency department (ED) and readmission to the hospital. Digital home monitoring (DHM) may improve postoperative care compared to standard methods.

OBJECTIVE

We conducted a feasibility study for a randomized controlled trial (RCT) to assess DHM's effectiveness following thoracic surgical procedures compared to standard care.

METHODS

We conducted a 2-arm parallel-group pilot RCT at a single tertiary care center. Adult patients undergoing thoracic surgical procedures were randomized 1:1 into 2 groups: the DHM group and the standard of care (control group). We adhered to the intention-to-treat analysis principle. The primary outcome was predetermined RCT feasibility criteria. The trial would be feasible if more than 75% of trial recruitment, protocol adherence, and data collection were achieved. Secondary outcomes included 30-day ED visit rates, 30-day readmission rates, postoperative complications, length of stay, postdischarge 30-day opioid consumption, 30-day quality of recovery, patient-program satisfaction, caregiver satisfaction, health care provider satisfaction, and cost per case.

RESULTS

All RCT feasibility criteria were met. The trial recruitment rate was 87.9% (95% CI 79.4%-93.8%). Protocol adherence and outcome data collection rates were 96.3% (95% CI 89.4%-99.2%) and 98.7% (95% CI 92.9%-99.9%), respectively. In total, 80 patients were randomized, with 40 (50%) in the DHM group and 40 (50%) in the control group. Baseline patient and clinical characteristics were comparable between the 2 groups. The DHM group had fewer unplanned ED visits (2.7% vs 20.5%; P=.02), fewer unplanned admission rates (0% vs 7.6%; P=.24), lower rates of postoperative complications (20% vs 47.5%, P=.01) shorter hospital stays (4.0 vs 6.9 days; P=.05), but more opioid consumption (111.6, SD 110.9) vs 74.3, SD 71.9 mg morphine equivalents; P=.08) compared to the control group. DHM also resulted in shorter ED visit times (130, SD 0 vs 1048, SD 1093 minutes; P=.48) and lower cost per case (CAD $12,145 [US $ 8436.34], SD CAD $8779 [US $ 6098.20] vs CAD $17,247 [US $11,980.37], SD CAD $15,313 [US $10,636.95]; P=.07). The quality of recovery scores was clinically significantly better than the controls (185.4, SD 2.6 vs 178.3, SD 3.3; P<.001). All 37 patients who completed the intervention answered the program satisfaction survey questionnaires (100%; 95% CI 90.5%-100%). Only 36 out of 80 caregivers responded to the caregiver satisfaction questionnaires at the end of the fourth week post hospital discharge (47.7%; 95% CI 35.7%-59.1%). Health care providers reported a 100% satisfaction rate.

CONCLUSIONS

This pilot RCT demonstrates the feasibility of conducting a full-scale trial to assess DHM's efficacy in improving postoperative care following thoracic surgery. DHM shows promise for enhancing continuity of care and warrants further investigation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04340960; https://clinicaltrials.gov/study/NCT04340960.

Perioperative management and survival outcomes following cytoreductive surgery in patients with peritoneal metastases from rectal cancer: A scoping review

BACKGROUND

Patients with rectal cancer and peritoneal metastases (PM) may have a worse prognosis and benefit from a different management than patients with colon cancer.

METHODS

A systematic literature search of MEDLINE (PubMed) and EMBASE databases was performed to identify all reported patients with rectal cancer and PM treated with cytoreductive surgery (CRS), with or without hyperthermic intraperitoneal chemotherapy (HIPEC), to investigate the proper selection criteria for this population, the optimal perioperative management, and highlight its specific oncological outcomes.

RESULTS

Twenty studies reporting on 285 patients were identified. Median age varied from 28 to 63 years, and 57.5 % of patients had synchronous disease. The use of neoadjuvant treatment was frequent, but regimens were heterogenous, consisting of radiotherapy alone, chemoradiotherapy or systemic chemotherapy. Thirty-two percent did not receive any neoadjuvant treatment. Most patients (85.6 %) received HIPEC after CRS, with mitomycin C being the most used drug. Complete cytoreduction was performed in 90.1 % of patients. Data on stoma creation and management were poorly reported. Severe complications occurred in 32.2 % of patients. Median disease-free survival ranged from 6 to 22 months, and median overall survival varied from 7 to 53.2 months.

CONCLUSION

This scoping review highlights the paucity of data available regarding the management of patients with rectal cancer and PM. It also emphasizes different issues and dilemmas regarding this specific population, especially on the use of neoadjuvant treatment, the role of HIPEC after CRS and stoma management.

Ten-Year Outcome of a Randomized Trial: Cytoreduction and HIPEC with Mitomycin C Versus Oxaliplatin for Appendiceal Neoplasm with Peritoneal Dissemination

BACKGROUND

Appendiceal cancer is a rare disease that has proven difficult to study in prospectively. Our initial report of this trial showed minor hematologic toxicity with both mitomycin C and oxaliplatin and similar 3-year survival. We now report an update of the first prospective randomized trial for appendiceal cancer with 10-year follow up.

PATIENTS AND METHODS

Patients with mucinous appendiceal neoplasms and evidence of peritoneal dissemination were enrolled in the Multicenter Randomized Trial to evaluating HIPEC for 120 min with oxaliplatin (200 mg/M2) or mitomycin C (40 mg). Overall survival and disease-free survival were calculated at 10 years and compared between the groups.

RESULTS

A total of 121 patients were included in the study. The patients were 57% female, with a mean age of 55.3 years (range 22-82 years). The disease was low grade in 71% and high grade in 29%. The average peritoneal cancer index (PCI) score was 18 (SD 10) in the mitomycin C group and 17.9 (SD 9.4) in the oxaliplatin group (p = 0.94). The 10-year survival rate was 56.2% (SE 7.2) with mitomycin C and 47.5% (SE 8.4) with oxaliplatin, p = 0.83. The 10-year progression-free survival rate in the mitomycin C group was 45.2% (SE 8.4) compared with 50.4% (SE 6.7) in the oxaliplatin group, p = 0.95. Median survival was 9.1 years after HIPEC with oxaliplatin, and median not reached for the mitomycin C group (> 5.6 years).

CONCLUSIONS

Oxaliplatin and mitomycin C have similar long-term efficacy for hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with appendiceal neoplasms and peritoneal dissemination. Long-term survival is experienced by most patients after cytoreduction surgery (CRS) and HIPEC for appendiceal neoplasms.

Rectal Artery Embolization for the Treatment of Hemorrhoidal Disease

The term "hemorrhoid" is commonly invoked to characterize the pathologic process of symptomatic hemorrhoidal disease instead of the normal anatomic structure. While often treated with conservative measures, rectal artery embolization offers a minimally invasive alternative for patients with persistent or severe symptoms. This technique involves blocking the blood supply to the hemorrhoids using embolic agents, reducing blood flow, and alleviating symptoms. This review explores the clinical evaluation, techniques, and outcomes associated with rectal artery embolization for the treatment of hemorrhoidal disease. A discussion of the pathophysiology of hemorrhoids, the anatomy of rectal arteries, and the embolization procedure is provided in detail. Additionally, the safety and efficacy of the technique, including potential complications and outcomes, are reviewed.

Current surgical practices and attitudes toward pilonidal sinus disease among Russian surgeons: A national survey

AIM

Pilonidal sinus disease (PSD), also known as pilonidal disease, is a common chronic disorder in coloproctology and general surgery. It predominantly affects young male patients and is typically located in the sacrococcygeal region. Nowadays, various approaches are used to address this condition, but no consensus on a gold standard has been established. The aim of this study was to analyse and assess current PSD practice, diagnostic and surgical approaches, training and attitudes among Russian surgeons.

METHOD

A comprehensive online survey comprising 35 structured questions was developed by the Russian Society of Colorectal Surgeons and distributed to its members. The survey targeted colorectal and general surgeons and collected data on demographics, professional experience, surgical training, PSD management practices and both elective and abscess surgery techniques. Categorical data are reported as frequencies and percentages.

RESULTS

Of the 158 respondents, the vast majority were coloproctologists and general surgeons (n = 152, 96%) with over 10 years of experience (n = 110, 69.6%) and performing 10-50 operations per year. The most popular surgical procedures were excision with midline closure (68%), open healing (62%) and marsupialization (59%). PSD-associated abscesses were managed through incision and drainage by 81 surgeons (51%). About half of surgeons had access to laser therapy for treating PSD, but sinus laser-assisted closure was used by only 16%. Most surgeons had received training in PSD surgery under specialist supervision and felt sufficiently trained.

CONCLUSION

Our findings suggest that PSD surgery in Russia has not yet shifted from midline excisions to off-midline flap procedures and minimally invasive surgery. This study calls for attention to this underprioritized group of patients and underscores the importance of developing national guidelines in Russia.

Postoperative Ileus and Nonpharmacological Nursing Interventions for Colorectal Surgery: A Systematic Review

PURPOSE

This review evaluates nonpharmacological interventions for postoperative ileus (POI) prevention and treatment.

DESIGN

We systematically reviewed articles from various databases between January 2012 and February 2023 on POI prevention in colorectal surgery patients, emphasizing nursing interventions.

METHODS

Inclusion was based on criteria such as language (English or Turkish), date range, and study type. The risk of bias was evaluated using Cochrane's RoB2 tool.

FINDINGS

Of the 3,497 articles found, 987 unique articles were considered. After title and abstract reviews, 977 articles were excluded, leaving 52 randomized controlled trials for examination. Common interventions included chewing gum, early hydration, acupuncture, and coffee consumption. Compared to control groups, intervention groups had quicker bowel function return, shorter hospital stays, fewer complications, and enhanced quality of life.

CONCLUSION

Nondrug nursing interventions post colorectal surgery can effectively mitigate POI, optimize bowel function, and boost patient satisfaction, warranting their incorporation into post-surgery care protocols.

Histopathologic Evaluation and Single-Cell Spatial Transcriptomics of the Colon Reveal Cellular and Molecular Abnormalities Linked to J-Pouch Failure in Patients with Inflammatory Bowel Disease

Background and Aims

Total abdominal colectomy (TAC) with a staged ileal pouch-anal anastomosis (IPAA) is a common surgical treatment for ulcerative colitis (UC). However, a significant percentage of patients experience pouch failure, leading to morbidity. This retrospective case-control study identified histopathological features of the TAC specimen associated with pouch failure and investigated the molecular mechanisms of this susceptibility using single-cell spatial transcriptomics.

Methods

We analyzed a cohort of 417 patients who underwent IPAA between 2000-2010 at the University of Chicago Medical Center for up to 18 years. Histological examination of TAC specimens focused on disease activity, depth of inflammation, and specific features, including granulomas and deep ulcers. A subset of patients was profiled using single-cell spatial transcriptomics to map gene expression and immune cell interactions in relation to the risk of pouch failure.

Results

The 18-year pouch failure risk was 23%, with post-procedure diagnosis of CD as a major risk factor (HR = 4.3, 95% CI: 2.3-8.1) as well as high-risk histologic features, including deep chronic inflammation (HR = 21, 95% CI: 11-41) and severe disease activity (HR = 14, 95% CI: 5.7-32) in TAC specimens. Spatial transcriptomics showed immune infiltration of T and myeloid cells, reduced myocyte-glial interactions, and cytokine signaling pathways such as IL-10, IL-1β, and type I/II interferons, associated with an increased risk of pouch failure.

Conclusion

Histological features and spatial molecular profiling are predictive of IPAA failure. These findings support the use of histologic evaluation and targeted molecular analysis of the TAC specimen to identify high-risk patients and improve IPAA outcomes.

Metabolics-Based Study on the Therapeutic Mechanism Behind the Effect of Shenhuang Plaster Applied to the Shenque Acupoint on Gastrointestinal Motility in POI Mice

BACKGROUND

Postoperative ileus (POI) is a common postoperative clinical complication that significantly affects postoperative rehabilitation and quality of life in patients and can even produce secondary complications, leading to serious consequences. External treatment using Shenhuang Plaster (SHP) (Shenque acupoint administration) has definite effects and unique advantages in the prevention and treatment of POI, but its mechanism is not completely clear. In this study, we investigated the therapeutic mechanism behind the effect of Shenhuang Plaster applied to the Shenque acupoint on gastrointestinal motility in POI mice based on metabolomics.

MATERIALS AND METHODS

C57BL/6 mice were divided into three groups: blank control (Ctrl), model (POI), and intervention (POI + SHP) groups. SHP treatment was started 3 days before modeling. We employed several behavioral tests and gastrointestinal transit function measurements and performed qRT-PCR analysis, 16S rRNA gene sequencing, and metabolomics analysis on serum metabolites.

RESULTS

We found that SHP could reduce the mRNA expression of inflammatory mediators in the smooth muscle tissue of the small intestine, regulate the structure and function of the intestinal microbiota, and modulate serum phenylalanine, carnitine, and glutamic acid levels.

CONCLUSIONS

POI mice had obvious intestinal flora disorders and metabolic disorders of amino acids and their derivatives, and there was a significant correlation between differential flora and differential metabolites. SHP could effectively regulate the concentration of intestinal flora and serum metabolites and the metabolic pathway related to amino acids in vivo and, ultimately, achieve a therapeutic purpose in POI. In this study, it was found, for the first time, that applying SHP to the Shenque acupoint could effectively regulate the serum metabolites of phenylalanine, carnitine, and glutamate, and improve postoperative intestinal motile disturbance through association with the intestinal flora.

Low skeletal muscle mass as a proxy marker of sarcopenia is a risk factor for major complications in older patients undergoing curative colon resections for colon cancer

Introduction

Various reports have confirmed that low skeletal muscle mass, a proxy marker of sarcopenia, can be a risk factor for surgical and oncological outcomes in colon cancer. We aimed to investigate the effects of skeletal muscle mass index (SMMI) on postoperative complications, overall survival (OS), and disease-free survival (DFS) in older patients with colon cancer who underwent elective curative colon resections.

Materials and methods

Patients over 65 years old with stage I-III colon cancer who underwent elective curative colon resections between January 2015 and December 2023 were included in this single-center retrospective longitudinal study. Demographics, comorbidities, laboratory data, pathological features, malignant lymph node ratio (MLNR), OS, and DFS were recorded. Controlling Nutritional Status (CONUT) Score was used to assess the nutritional status. An axial portal-phase image was obtained at the level of the third lumbar vertebra, and muscle areas were calculated. SMMI was calculated by dividing the muscle area (cm2) by the square of the patient's height (m2). Low SMMI was defined as SMMI<41 cm2/m2 in women and < 43 cm2/m2 in men with body mass index (BMI) <25 kg/m2, and as SMMI <53 cm2/m2 in patients with a BMI >25 kg/m2. Postoperative complications were classified according to the Clavien-Dindo system. Univariate and multivariate analyses were performed to investigate the factors related to the postoperative complications, OS and DFS.

Results

In total, 98 cases (mean age 75.2 ± 6.9, 55.1% male) were included in the study. The median follow-up time was 38.3 (0.5-113) months. There were 64 patients (65.3%) in the Low SMMI group and 34 patients (34.7%) in the Normal SMMI group. Logistic regression analysis demonstrated that low SMMI was associated with a higher risk of major complications, with an odds ratio of 5.3 (95% CI, 1.1-20.1; p = 0.037). Cox regression analysis revealed no significant differences in OS and DFS.

Conclusion

Low SMMI as a proxy marker of sarcopenia was found to be an independent risk factor for postoperative major complications. Additional prospective studies are warranted to obtain more reliable results.

Use of social media for academic and professional purposes by gynecologic oncologists

OBJECTIVE

To investigate the prevalence and patterns of social media use among gynecologic oncologists for professional and academic purposes.

METHODS

A prospective online survey between November and December 2022 targeted gynecologic oncology practitioners (gynecologic oncologists, surgical oncologists, medical oncologists, radiation/clinical oncologists, and onco-pathologists/pathologists). The survey, distributed via various social media platforms, included 40 questions to capture qualitative and quantitative data on social media use.

RESULTS

Of 131 respondents from 32 countries, 106 (80.9%) were gynecologic oncologists and affiliated with academic institutions (84.7%). Facebook (n=110, 83.9%), Twitter (n= 108, 82.4%), and Instagram (n=100, 76.3%) were the most used platforms. Respondents used social media to stay updated (n=101, 77.1%), network (n=97, 74%), learn about conferences and webinars (n=97, 74%), and engage in academic discussions (n=84, 64.1%). Following the COVID-19 pandemic, 100/129 (77.5%) reported increased social media use. However, only 32 (24.4%) used it to connect with patients, and concerns were raised about privacy and the need for separate professional and personal accounts. A quarter of respondents hesitated to share their opinions on social media due to the fear of controversy, with 26 (20%) experiencing cyberbullying, yet 120/130 (92.3%) believed it enabled junior professionals to express their views. Concerns about differentiating valid content, information reliability, and the professional perception of sourcing knowledge from social media were noted. Gender, age, specialty, and income level influenced patterns of social media use, with variations in preferences for platforms, content engagement, and purposes, highlighting a complex landscape of social media interaction among gynecologic oncologists.

CONCLUSION

While the use of social media among gynecologic oncologists is prevalent, particularly for academic and professional development, challenges such as cyberbullying, privacy concerns, and the need for formal training in social media navigation persist. Tailored training programs and guidelines could enhance social media's effective and ethical use in this field, promoting a safe environment for professional expression and engagement.

Single versus double stapled anastomosis in natural orifice specimen extraction (NOSE) laparoscopic anterior resection

BACKGROUND

Laparoscopic anterior resection (LAR) with Natural Orifice Specimen Extraction (NOSE) has shown benefits such as reduced pain, fewer wound complications, and improved cosmesis. In colorectal anastomosis during NOSE, double staple anastomosis (DSA) and triple stapled technique (TSA) are common. However, a novel single stapled anastomosis (SSA) technique, utilising two laparoscopically placed purse strings and only four 5 mm ports, has emerged. This study aims to compare the complications between single and double stapled anastomoses in NOSE LAR.

METHODS

A retrospective analysis of NOSE LAR data from 2011 to 2022 included patients. All patients received mechanical bowel preparation, colonoscopic instillation of betadine or chlorhexidine, and antibiotics. DSA was performed conventionally, while the SSA technique involved an additional rectal laparoscopic purse string. Fisher's exact test assessed anastomotic leak rates and the need for intraoperative revisions.

RESULTS

Analysis of 179 patients revealed 40 with SSA and 139 with DSA. Patient age ranged from 20 to 88 years, with a BMI between 22 and 46 kg/m2. Diverticulitis and malignant polyps, the most common indications. Operation duration was similar between groups (238 min in SSA, 234 min in DSA; P = 0.69). Intraoperative laparoscopic anastomotic redo was significantly higher in the SSA group (six patients) than the DSA group (five patients; P = <0.05). No anastomotic leaks occurred in the SSA group, while six occurred in the DSA group (P = 0.34). There was no significant difference in Length of Stay (LOS), (5 days in SSA versus 6 days in DSA group, P = 0.29).

CONCLUSIONS

Single stapled anastomosis in NOSE LAR appears safe for benign conditions but is more likely to necessitate intraoperative redo compared to double stapled anastomosis.

The Evidence-Based Medicine Management of Endometriosis Should Be Updated for the Limitations of Trial Evidence, the Multivariability of Decisions, Collective Experience, Heuristics, and Bayesian Thinking

Background/Objectives: The diagnosis and treatment of endometriosis should be based on the best available evidence. Emphasising the risk of bias, the pyramid of evidence has the double-blind, randomised controlled trial and its meta-analyses on top. After the grading of all evidence by a group of experts, clinical guidelines are formulated using well-defined rules. Unfortunately, the impact of evidence-based medicine (EBM) on the management of endometriosis has been limited and, possibly, occasionally harmful. Methods: For this research, the inherent problems of diagnosis and treatment were discussed by a working group of endometriosis and EBM specialists, and the relevant literature was reviewed. Results: Most clinical decisions are multivariable, but randomized controlled trials (RCTs) cannot handle multivariability because adopting a factorial design would require prohibitively large cohorts and create randomization problems. Single-factor RCTs represent a simplification of the clinical reality. Heuristics and intuition are both important for training and decision-making in surgery; experience, Bayesian thinking, and learning from the past are seldom considered. Black swan events or severe complications and accidents are marginally discussed in EBM since trial evidence is limited for rare medical events. Conclusions: The limitations of EBM for managing endometriosis and the complementarity of multivariability, heuristics, Bayesian thinking, and experience should be recognized. Especially in surgery, the value of training and heuristics, as well as the importance of documenting the collective experience and of the prevention of complications, are fundamental. These additions to EBM and guidelines will be useful in changing the Wild West mentality of surgery resulting from the limited scope of EBM data because of the inherent multivariability, combined with the low number of similar interventions.

Current approaches to the surgical management of Crohn's disease in Australia and New Zealand

PURPOSE

Given the evolving literature regarding the optimal surgical approach to mitigate post-operative recurrence of Crohn's disease (CD), this survey study aimed to elucidate the practices and preferences of colorectal surgeons in Australia and New Zealand (ANZ) in their surgical management of CD.

METHODS

Colorectal surgical consultants and fellows (n = 337) registered with the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) were invited by email in April 2022 to participate in a cross-sectional survey consisting of basic demographics and 12 questions relating to their usual surgical practice and preferred operative strategy.

RESULTS

A total of 135 responses were received (39.9%). Regarding anastomotic configuration, 47% (n = 68) preferred the side-to-side anastomosis (STSA), 19% (n = 28) the end-to-end anastomosis (ETEA), and 15% (n = 21) the Kono S anastomosis. Most respondents preferred to resect at the proximal junction of the abnormal mesentery (75%, n = 97), while radical resection of the mesentery was preferred in 10% (n = 13) and close intestinal resection through abnormal mesentery in 15% (n = 20). The preferred surgical approach was by far laparoscopic (93%, n = 125) with extraction from the midline peri-umbilical port (80%, n = 108).

CONCLUSION

Amongst participating colorectal surgeons, there was a clear consensus on the approach, where the dominant practice was laparoscopy with a midline peri-umbilical extraction. Similarly, most respondents preferred some degree of mesenteric resection. However, anastomotic configuration and technique were domains of resection in CD lacking unanimity despite clear guidelines, highlighting an area requiring further attention.

Efficacy of traditional Chinese medicine in the conservative management of complete small intestinal obstruction post-gastric cancer surgery: A case report

In this case report, we describe the successful treatment of a patient with complete small bowel obstruction following gastric cancer surgery, employing an integrated approach of traditional Chinese medicine and Western medicine. Initial treatment consisted of conventional biomedical interventions, including intestinal obstruction catheterization, but after 16 days without improvement, surgical intervention was recommended. The patient, however, refused surgery and opted for treatments based on traditional Chinese medicine. Comprehensive traditional Chinese medicine therapies such as acupuncture, moxibustion, flash cupping, oral administration of compound herbal formulas, and enemas using Chinese herbal medicine were implemented alongside modern medical care. The obstruction resolved, and the patient was discharged without requiring surgery. Follow-up revealed no recurrence of the condition. This case highlights the potential of integrating traditional Chinese medicine with Western medical practices in the conservative management of complete small bowel obstruction, offering a reference for clinical application.

The prevalence of pouch fistulas in ulcerative colitis following restorative proctocolectomy: a systematic review and meta-analysis

BACKGROUND/AIMS

One complication of restorative proctocolectomy with ileo-anal pouch anastomosis is fistula formation in the pouch. Fistulas can be associated with significant morbidity and pouch failure. We conducted a systematic review with meta- analysis to try and understand the prevalence of pouch fistulas in patients with ulcerative colitis following restorative proctocolectomy.

METHODS

The Embase, Embase Classic, and PubMed databases were searched between January 1979 and April 2022. Studies were included if there were cross-sectional, case-controlled, population-based or cohort studies reporting on prevalence of pouch fistulas in ulcerative colitis. Studies had to report the number of patients with pouch fistulas using either clinical, endoscopic, or radiological diagnosis in an adult population.

RESULTS

Thirty-three studies screened met the inclusion criteria. The pooled prevalence of developing at least 1 fistula was 0.05 (95% confidence interval [CI], 0.04-0.07). The pooled prevalence of pouch failure in patients with pouch fistula was found to be 0.24 (95% CI, 0.19-0.30). The pooled prevalence of developing a pouch fistula at 3 years, 5 years and more than 5 years was 0.04 (95% CI, 0.02-0.07), 0.05 (95% CI, 0.02-0.07), and 0.05 (95% CI, 0.02-0.10), respectively.

CONCLUSIONS

This is the first systematic review and meta-analysis to report the prevalence of pouch fistula. It also provides a pooled prevalence of pouch failure in these patients. These results can help to shape future guidelines, power future studies, and help counsel patients.

Minimum Supervision Levels Required for Pediatric Cardiology Fellowship Graduation by Pediatric Cardiology Fellowship Program Directors

Entrustable professional activities (EPAs) are "observable essential tasks expected to be performed by a physician for safe patient care in practice." Six Pediatric Cardiology (PC) EPAs and their level of supervision (LOS) scales were developed by medical educators in PC using a modified Delphi process and reviewed by the Subspecialty Pediatrics Investigator Network (SPIN). However, their general use in assessment for PC fellows for graduation requirements has yet to be studied. The objective of this study was to determine the minimum LOS required for PC fellows to graduate and compare it with the minimum LOS expected for safe and effective practice for the six PC EPAs, from the perspective of the PC Fellowship Program Directors(FPD). All Fellowship Program Directors(FPD) of ACGME-accredited PC fellowships were surveyed through SPIN between April 2017 and August 2017. For each of the PC EPAs, the FPDs were asked to indicate the minimum LOS expected for graduation and whether they would allow a fellow to graduate if this level was not achieved and the minimum LOS expected for a practicing pediatric cardiologist to provide safe and effective patient care. The minimum LOS was defined as the LOS for which no more than 20% of FPDs would want a lower level. The survey response rate was 80% (47/59). The majority of the FPDs did not require a minimum LOS of five corresponding to unsupervised practice in any of the six PC EPAs at graduation. For EPAs related to imaging, arrhythmia management, and management of cardiac problems, the minimum LOS for graduation was 3, corresponding to being "trusted to perform a task with indirect supervision for most simple and a few complex cases." For the EPAs related to interventional cardiology, heart failure pulmonary hypertension, and cardiac intensive care, the minimum LOS for graduation was 2, corresponding to being "trusted to perform a task only with direct supervision and coaching." The minimum LOS considered necessary for safe and effective practice for all but one EPA was 3. For the EPA related to the management of cardiac problems, the minimum LOS for safe practice was 4, corresponding to being "trusted to execute tasks independently except for few complex and critical cases." Most PC FPDs reported they would not require fellows to achieve the highest entrustment level for any of the six PC EPAs for graduation. It is crucial that educational programs evolve to address these essential activities during training better and that stakeholders ensure that graduating PC fellows have adequate resources and infrastructure to continue professional development as early career pediatric cardiologists.

Effectiveness of abdominal massage on chronic constipation in adults: A systematic review and meta-analysis

BACKGROUND

Chronic constipation is a common distressing symptom. Abdominal massage is a safe, noninvasive, and comfortable intervention. However, it is rarely used in formal clinical practice as its' effectiveness for chronic constipation remains unclear.

OBJECTIVE

This systematic review aimed to investigate the effectiveness of abdominal massage on defecation frequency, stool consistency, colonic transit time, constipation symptoms, quality of life, laxative use, and adverse events in adults. Additionally, we aimed to compare the effectiveness of abdominal massage in chronic constipation with different etiologies and types of abdominal massage techniques.

METHODS

Data from eight English and Chinese electronic databases until May 15, 2024, including randomized controlled trials (RCT) and quasi-experimental studies, were used. The risk of bias was assessed using the Cochrane risk-of-bias tool. Results were synthesized using a random-effect model. This study was registered on the 7th of January 2023 to the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023385243).

RESULTS

A total of 23 studies with 1431 participants were eligible for the meta-analysis. Abdominal massage statistically significantly increased weekly defecation frequency (MD = 1.59; 95 % CI 1.06, 2.11; df = 10; I2 = 82 %), decreased gut transit time (MD = -21.53 h; 95 % CI -35.94, -7.12; df = 3; I2 = 65 %), and decreased constipation symptoms (SMD = -1.06; 95 % CI -1.33, -0.80; df = 18; I2 = 79 %) as compared to the control group; however, it did not reduce laxative use (OR: 0.43, 95 % CI 0.14, 1.34, p = 0.15; I2 = 74 %). In subgroup analysis, the effectiveness of defecation frequency appeared to be greater for functional constipation (SMD = 1.23; 95 % CI 0.87, 1.60; df = 6; I2 = 86 %) as compared to opioid-induced constipation (SMD = 1.06; 95 % CI 0.61, 1.50; df = 5; I2 = 5 %) or neurogenic bowel dysfunction (SMD = 0.68; 95 % CI 0.26, 1.10; df = 4; I2 = 51 %). There were statistically significant differences in defecation frequency between the functional constipation and neurogenic bowel dysfunction groups (p = 0.075). Acupressure and aromatherapy massage had a greater effect on defecation frequency (SMD = 1.63; 95 % CI 1.06, 2.21; df = 3; I2 = 86 %) than circular massage (SMD = 0.90; 95 % CI 0.57, 1.22; df = 10; I2 = 68 %) or electric device massages (SMD = 0.83; 95 % CI 0.15, 1.51; df = 1; I2 = 82 %); however, high heterogeneity and a limited number of articles were encountered. No adverse reactions were observed in the non-neurogenic bowel dysfunction group.

CONCLUSION

This study reveals the efficacy of abdominal massage in alleviating symptoms of chronic constipation, as well as the differences in the effectiveness of different constipation types and massage techniques. Patients, caregivers, and health professionals can select abdominal massage techniques based on their effectiveness in specific type of constipation or troublesome symptoms.

TWEETABLE ABSTRACT

Abdominal massage is effective for chronic constipation, increasing defecation frequency and improving symptoms. Users can tailor massage technique to specific constipation type for optimal results. #ConstipationRelief #GutHealth.

Understanding constipation as a geriatric syndrome

Constipation is common among older adults and significantly impacts their quality of life (QoL). Prior studies have extensively detailed constipation, but conceptualization of constipation as a geriatric syndrome is lacking. In this review, we provide an overview of constipation in the geriatric population and conceptualize constipation as a geriatric syndrome given its high prevalence, under-recognized status, and association with poor QoL and adverse outcomes among older adults. The conceptualization of constipation as a geriatric syndrome, as with frailty and delirium, highlights its importance and need for a multi-faceted approach. Future research is needed to 1) better define constipation, 2) explore the multifactorial nature of constipation in older adults and relationship with other geriatric syndromes, 3) include more older adults in pharmacological and non-pharmacological interventions for constipation, and 4) curate multidisciplinary care models. Appreciating constipation as a geriatric syndrome will yield tailored management strategies, ensure timely intervention, and avoid adverse outcomes.

Endocrine surgery fellowship is necessary for competent endocrine surgical practice: perspectives from Australia and New Zealand

BACKGROUND

Currently pathways to practice in endocrine surgery vary based on location and surgical training programme. International data highlights the impact of surgeon volume on outcomes, and the importance of understanding the learning curve in developing minimum training competencies. This study aims to explore how surgeons obtain competence in endocrine surgery in Australia and New Zealand, and perceptions around competence and scope of practice.

METHODS

A web-based survey was distributed to fellows practicing endocrine surgery. Participants were invited to complete a semi-structured interview to explore key themes around competence. Thematic analysis was performed.

RESULTS

Responses from 87 surgeons, with 30% practicing primarily in a regional or rural area, showed 94% emphasized post-fellowship training to be competent in endocrine surgery. Median primary operator procedural volume learning curves were 50 thyroid, 30 parathyroid and 20 laparoscopic adrenalectomy procedures. Semi-structured interviews with 12 participants identified four major themes: (1) learning opportunities during general surgical education and training programmes alone are insufficient for consultant-level competence; (2) the importance of sufficient training to develop clinical decision-making, insight and judgement to appropriately select patients in the management of endocrine disease; (3) expected standards of clinical and technical performance are independent of practice location or context; (4) the importance of multi-disciplinary teams for complex cases including advanced cancers.

CONCLUSIONS

Practicing endocrine surgeons acknowledge formal fellowship training is required to achieve competence across technical and non-technical domains. The definition of competence and expectations regarding technical outcomes are independent of practice location or context.

Management of Chronic Constipation: A Comprehensive Review

Traditionally, the treatment of chronic constipation has focused on lifestyle modification, dietary guidance and therapy, and osmotic and stimulant laxatives. Recently, several drugs with new mechanisms of action have been introduced as treatments for chronic constipation. In Japan, polyethylene glycol and lactulose can now be administered under insurance coverage. The number of treatment options for constipation has increased dramatically. First, lifestyle modifications and dietary therapies must be implemented. If constipation does not improve sufficiently, specialized functional tests are performed to diagnose physiological subgroups. If functional tests are not available, patients are classified as having the "decreased frequency of defecation" type or the "difficult defecation" type based on the patient's symptoms, with treatment applied according to each type. Medical therapy includes osmotic laxatives, secretagogues, bile acid transporter inhibitors, probiotics, prokinetics, and Kampo medicines. The temporary use of stimulant laxatives, suppositories, enemas, and digital evacuation is also recommended. The usefulness of biofeedback is yet to be determined.

Management of Refractory Functional Gastrointestinal Disorders: What Role Should Psychiatrists Have?

Currently, it has been stated that psychiatric and psychological problems are equally paramount aspects of the clinical modulation and manifestation of both the central nervous and digestive systems, which could be used to restore balance. The present narrative review aims to provide an elaborate description of the bio-psycho-social facets of refractory functional gastrointestinal disorders, psychiatrists' role, specific psychiatric approach, and the latest psychiatric and psychological perspectives on practical therapeutic management. In this respect, "psyche," "psychiatry," "psychology," "psychiatrist," "psychotropic," and "refractory functional gastrointestinal disorders" (as the keywords) were searched in relevant English publications from January 1, 1950, to March 1, 2024, in the PubMed, Web of Science, Scopus, EMBASE, Cochrane Library, and Google Scholar databases. Eventually, the narrative technique was adopted to reach a compelling story with a high level of cohesion through material synthesis. The current literature recognizes the brain-gut axis modulation as a therapeutic target for refractory functional gastrointestinal disorders and the bio-psycho-social model as an integrated framework to explain disease pathogenesis. The results also reveal some evidence to affirm the benefits of psychotropic medications and psychological therapies in refractory functional gastrointestinal disorders, even when psychiatric symptoms were absent. It seems that psychiatrists are required to pay higher levels of attention to both the assessment and treatment of patients with refractory functional gastrointestinal disorders, accompanied by educating and training practitioners who take care of these patients.

Current status and factors associated with sexual harassment among operating room nurses: a multi-center cross-sectional study

AIMS

The purpose of this study was to investigate the prevalence of sexual harassment among operating room nurses, and to analyze the influencing factors.

BACKGROUND

Sexual harassment in the healthcare field has a high incidence and nurses are the main victims; sexual harassment not only leads to physical and mental problems, but also undermines nurses' performance and affects the quality of medical care.

METHODS

A multi-center cross-sectional study was conducted using an online survey to investigate the sexual harassment experiences of 483 operating room nurses. The survey included demographic information, personality traits (Ten-Item Personality Inventory), sexual harassment experiences (Workplace Sexual Harassment Questionnaire), negative consequences, coping strategies, and social support status.

RESULTS

63% of operating room nurses experienced sexual harassment in the past 12 months, with gender harassment predominating (56.7%), followed by unwanted sexual attention (28.6%) and sexual coercion (13.6%). Surgeons (81.20%) and married ones (66.7%) were the most common perpetrators. Most victims possess limited knowledge regarding sexual harassment laws and exhibit weak awareness of their rights protection. 47.8% remained silent after being sexually harassed; most of nurse employed passive coping strategies. Sexual harassment had the most prominent impact on the work of operating room nurses, mainly in the form of decreased work quality and efficiency (87.3%), as well as decreased work engagement (77.0%) and negative workplace pressure experience (72.2%); emotional disturbances, such as anxiety (76.6%), stigma (71.8%), and fear (71.5%); and was accompanied by sleep disorders (74.9%), headaches (56.0%) and nausea and vomiting (54.3%); as well as reduced trust in the opposite sex (83.8%) and disruption of family life (82.1%).Only 39.2% of the hospitals had sexual harassment reporting channels or methods, 30.7% had departments to deal with sexual harassment in the workplace, and 46.8% had communication discussions about psychological safety after sexual harassment. Personality traits, drinking behaviour, age, marriage, and social support were associated with sexual harassment behavior in the operating room.

CONCLUSION

The high incidence of sexual harassment in the operating room affects nurses' productivity and physical and mental health. Operating room nurses had insufficient legal knowledge about sexual harassment and lacked hospital organizational support. agreeableness and openness personality traits, alcohol consumption, age, being married, and lack of social support were influential factors of sexual harassment in the operating room.

IMPLICATIONS FOR NURSING MANAGEMENT

Healthcare organizations should encourage reporting, care for victims, and join with the police department, judiciary, and women's federation to develop reporting procedures and training programs on sexual harassment knowledge to create a safe and comfortable professional environment.

Assessment of performance feedback as a teaching-learning tool in the operating room at the National Referral Hospital, Bhutan: a prospective pre-post interventional study

BACKGROUND

Effective, efficient, and enduring feedback on performance improves and accelerates learning in medical education. Basic teaching methods like providing constructive feedback would enhance educational quality. However, briefing and debriefing culture is almost absent in our operating room. Feedback, if at all given, is traditionally negative, pointing out errors, while wanting to draw attention to strengths and success. This study aimed to examine the current status of performance feedback in the operating room and to evaluate the effect of an educational intervention "SHARP" on the quality of performance feedback.

METHODS

This was a prospective, pre-post interventional study conducted at the National Referral Hospital, in Bhutan. Surgeons (trainers) and the surgical residents (trainees) performing elective surgical cases under general anesthesia were assessed for pre-intervention and post-intervention performance feedback using a validated Objective Structured Assessment of Debriefing (OSAD) based questionnaire. A validated SHARP 5-Step Feedback tool for surgery (Setting up learning objectives, How did it go, Address concerns, Review learning points, and Plan ahead) was used as an intervention. The data were analyzed using SPSS version 23 and the paired t-test was used to compare the pre-post OSAD scores, and p < 0.05 is considered statistically significant.

RESULTS

The existing performance feedback was unacceptably low. With the 'SHARP' intervention, the post-intervention OSAD score significantly increased compared to the pre-intervention score (26.7 ± 1.72 vs. 22.0 ± 2.67 for post-intervention and pre-intervention respectively, effect size 1.9, p < 0.001). An educational tool 'SHARP' effectively improves the quality of feedback in the operating room.

CONCLUSION

The existing performance feedback is low in the operating room. Performance feedback can be efficient, effective, and enduring if a culture of structured feedback is in place. Educational tools like 'SHARP' can facilitate experiential learning in the surgical classroom.

Definitions of Incidental [18F]FDG PET/CT Findings in the Literature: A Systematic Review and Definition Proposal

Objectives: The objectives of this study were (1) to systematically review the currently used definitions of incidental 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography findings (IPFs) in the literature and (2) to propose an IPF definition. Methods: A systematic search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search was guided by the question "How is IPF defined?" and was performed in MEDLINE, Embase, and the Cochrane Library. The retrieved studies were reviewed and analyzed. The definitions of IPFs in the included studies were compiled into two sets of categories based on the description of FDG uptake and the specification of clinical factors in defining IPFs. Results: The systematic literature search identified 4852 publications accessible for title-abstract screening, which yielded 395 studies for full-text assessment. Sixty-five studies met the eligibility criteria and were included. Sixty-two percent mentioned "FDG uptake" in their definition. In 40% of the definitions, "Focal FDG uptake" was specified, while "FDG uptake in the surrounding tissue" was included in 15%. Fifty-seven percent stated that IPFs were "Unrelated to PET/CT indication". Thirty-four percent specified IPFs as "Present in other organ than PET/CT indication", whereas 20% included "No known disease related to IPF". Seventeen percent of the definitions comprised a "New finding", while 15% and 11% encompassed a "Clinical asymptomatic patient" and "Not a metastasis", respectively. Finally, 5% of the definitions included "Potential clinical significance". Conclusions: No generally accepted definition of IPFs currently exists. We propose an IPF definition based on explicit FDG uptake and clinical patient-related factors.

Beyond Obstruction: Evaluating Self-Expandable Metallic Stents (SEMSs) vs. Emergency Surgery for Challenging pT4 Obstructive Colon Cancer: Multicentre Retrospective Study

BACKGROUND/OBJECTIVES

Colon cancer presents as an obstruction in almost 30% of patients. Self-expandable metallic stents emerged as an alternative to emergency surgery, despite early controversies around their use. Improved techniques led to stent incorporation in clinical guidelines. Our objective is to compare colectomies performed after the insertion of self-expandable metallic stents versus emergency surgeries in pT4 obstructive left colon cancer, analysing postoperative and oncological outcomes.

METHODS

This is an observational retrospective multicentre study involving 50 hospitals and analysing data from patients with pT4 obstructive tumours treated for curative intent between 2015 and 2017. Patients with left-sided obstructive colon cancer were included, with exclusion criteria being palliative surgery or incomplete resection. Primary outcomes were local, peritoneal, and systemic recurrence rates, overall survival (OS), and disease-free survival (DFS). Secondary outcomes were postoperative complications and the rate of surgeries without major complications.

RESULTS

In total, 196 patients were analysed, 128 undergoing emergency surgery and 68 receiving colonic stents. Stents more frequently allowed for minimally invasive surgeries: 33.8% vs. 4.7% (p < 0.01). The stent group showed fewer major complications (Clavien-Dindo ≥ 3) at 4.5% vs. 22.4% (p < 0.01), fewer infectious complications at 13.2% vs. 23.1% (p = 0.1), and fewer organ-space infections at 3.3% vs. 15.9% (p = 0.03). No significant differences in recurrence rates, 29.4% vs. 28.1% (p = 0.8); disease-free survival, 44.5 vs. 44.3 months (p = 0.5); or overall survival, 50.5 vs. 47.6 months (p = 0.4), were found between groups.

CONCLUSIONS

Self-expandable metallic stents are a safe alternative for pT4 obstructive left colon cancer, improving postoperative outcomes without compromising short- and medium-term oncological results. Consideration of experienced clinicians and potential referral to centres with advanced stenting capabilities may enhance patient care.

Nonoperative management of rectal cancer

The management of locally advanced rectal cancer has changed drastically in the last few decades due to improved surgical techniques, development of multimodal treatment approaches and the introduction of a watch and wait (WW) strategy. For patients with a complete response to neoadjuvant treatment, WW offers an opportunity to avoid the morbidity associated with total mesorectal excision in favor of organ preservation. Despite growing interest in WW, prospective data on the safety and efficacy of nonoperative management are limited. Challenges remain in optimizing multimodal treatment regimens to maximize tumor regression and in improving the accuracy of patient selection for WW. This review summarizes the history of treatment for rectal cancer and the development of a WW strategy. It also provides an overview of clinical considerations for patients interested in nonoperative management, including restaging strategies, WW selection criteria, surveillance protocols and long-term oncologic outcomes.

Diagnostic accuracy of intraoperative pelvic autonomic nerve monitoring during rectal surgery: a systematic review

PURPOSE

Anorectal and urogenital dysfunctions are common after rectal surgery and have a significant impact on quality of life. Intraoperative pelvic autonomic nerve monitoring (pIONM) has been proposed as a tool to identify patients at risk of these functional sequelae. This systematic review aims to evaluate the diagnostic accuracy of pIONM in detecting anorectal and urogenital dysfunction following rectal surgery.

METHODS

A systematic review of articles published since 1990 was conducted using MEDLINE, Embase, CINAHL, Google Scholar, Scopus, and Web of Science. Studies describing pIONM for rectal surgery and reporting anorectal or urogenital functional outcomes were included. The risk of bias was assessed using the QUADS-2 tool. The diagnostic accuracy of pIONM was established with pooled sensitivity and specificity alongside summary receiver-operating characteristic curves.

RESULTS

Twenty studies including 686 patients undergoing pIONM were identified, with seven of these studies including a control group. There was heterogeneity in the pIONM technique and reported outcome measures used. Results from five studies indicate pIONM may be able to predict postoperative anorectal (sensitivity 1.00 [95% CI 0.03-1.00], specificity 0.98 [0.91-0.99]) and urinary (sensitivity 1.00 [95% CI 0.03-1.00], specificity 0.99 [0.92-0.99]) dysfunction.

CONCLUSIONS

This review identifies the diagnostic accuracy of pIONM in detecting postoperative anorectal and urogenital dysfunction following rectal surgery. Further research is necessary before pIONM can be routinely used in clinical practice.

PROSPERO REGISTRATION DETAILS

CRD42022313934.

Recurrence risk analysis for stage II and III colorectal cancer, and the implications of diabetes mellitus as a risk factor for the recurrence of stage III colorectal cancer

The present study investigated the risk factors for recurrence in patients with stage II-III colorectal cancer (CRC) who underwent colorectal surgery. Data from 232 patients with stage II and III CRC who underwent primary tumor resection were retrospectively analyzed. Univariate and multivariate analyses were performed to determine the risk factors for recurrence. The overall recurrence rate was 21.6% (n=50/232). Univariate Cox regression analysis identified diabetes mellitus (DM) (P=0.032) as a risk factor for recurrence. In addition, multivariate Cox regression analysis showed that DM was an independent risk factor for recurrence-free survival (RFS) (hazard ratio 2.40, P=0.016). The RFS curve obtained using the Kaplan-Meier method indicated that in patients with stage III colon cancer, the non-DM group demonstrated a significantly longer RFS than the DM group (P=0.012). In conclusion, the present study demonstrated that DM may be an independent risk factor for recurrence in patients undergoing curative resection for stage III CRC. Consequently, better postoperative therapy and careful monitoring might be required, especially in patients with stage III CRC and preoperative DM.

Returning Incidental Research Findings From 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography to Participants: A Survey of Investigators From a Clinical Trial of Rheumatoid Arthritis

OBJECTIVE

There are limited data on researchers' attitudes and beliefs on returning and managing incidental research findings from whole body 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG PET/CT) imaging.

METHODS

Site principal investigators (PIs) who enrolled participants for the Treatments Against Rheumatoid Arthritis and Effect on FDG PET/CT (TARGET) trial were surveyed.

RESULTS

Of the 28 TARGET site PIs eligible for the study, 18 consented to participate (response rate: 64%). Many site PIs returned incidental findings to participants (61%), and the most common finding that was returned was serious (but not life-threatening) and treatable (54.5%). More than half of the investigators believed that adequacy of clinical follow up (58.8%) and legal liability if incidental findings are not disclosed (55.6%) were extremely important factors in returning incidental research findings from whole body FDG PET/CT. All investigators felt very obligated to return incidental research findings if scans revealed a treatable, high-risk medical condition. Most investigators felt very obligated to disclose incidental findings with important health implications (94.4%), for which proven preventive or therapeutic interventions exist (77.8%), that provide early detection of a health problem (72.2%), if participants ask for their incidental findings (72.2%), and if scans have established validity for a particular medical condition (61.1%).

CONCLUSION

Although it is recommended that researchers report and manage incidental research findings, our data show differing views and uncertainties on what and how to return, and the extent of follow up needed to manage, incidental findings from whole body FDG PET/CT; this highlights the need for more specific and standardized guidance.

Brain health: A concern for anaesthesiologists and intensivists

Damage to the brain can have disastrous and long-lasting consequences. The European Society of Anaesthesiology and Intensive Care (ESAIC) is aware of the importance of taking good care of the brain, both of patients and of anaesthesia and intensive care unit (ICU) caregivers, and has organised a complete learning track on brain health to bring this concern to the attention of practitioners. This learning track included an online Focus Meeting on Brain Health (November 25, 2023). We here provide readers with a digest of the information that was delivered during that meeting in an opinion paper driven by the authors' own reading of the literature. It is divided according to the meeting's sessions, including how to improve the health of an injured brain, how to keep a young or old brain healthy, how to keep a healthy adult brain unimpaired, how monitoring can impact brain health in the operating room and in the intensive care unit, and how to keep the anaesthesia and ICU caregivers' brain healthy. Each part is a brief and focused summary. The main delivered messages are that the management of injured brain patients involves an adequate choice of sedation, adequate brain monitoring, and focused attention to specific points depending on the underlying pathology; that several measures can be undertaken to protect the brain of the very young needing anaesthesia; that it is possible to detect older patients at risk of postoperative neurocognitive disorders, and that dedicated perioperative management by a multidisciplinary expert team may improve their outcomes; that apparently healthy adult brains may suffer during anaesthesia; that the electroencephalogram may track peri-operative brain dysfunction, and that female patients should be given special care in this respect; that multimodal brain monitoring helps to detect pathological processes and to maintain brain homeostasis; and that burnout in anaesthesiologists can be effectively fought using personal, organisational, managerial and legal approaches.

Mesh-associated complications in minimally invasive ventral mesh rectopexy: a systematic review

BACKGROUND

Ventral mesh rectopexy (laparoscopic and robotic) is a common and well established treatment of rectal prolapse. Although described as safe and effective, complications, especially mesh-associated ones are often mentioned. Additionally, there is no consensus regarding the mesh type and fixation method as well as the materials used for this purpose. The aim of this systematic review was to identify the total amount of complications and of those the mesh-associated ones.

METHODS

Pubmed, Web of Science and Cochrane Central Register were screened for complications in general and in detail regarding the mesh(es) and a systematic review was performed.

RESULTS

Following qualitative evaluation, 40 studies were identified for further investigation. Across 6269 patients, complications were found in 9.2% (622 patients). Mesh-related complications were described in 1.4% (88 patients) of which 64.8% were erosions, 11.4% fistulas and 13.6% mesh releases. The complication rate according to the different materials were low with 1% in biological and synthetic meshes and 1.8% in not further described or mixed mesh type. Non-absorbable material to fixate the mesh was most frequently used to fixate the mesh.

CONCLUSION

Laparoscopic ventral mesh rectopexy is a safe operation with a low-complication rate, regardless of mesh type.