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Background: Despite absence of level 1 evidence on the long-term oncological safety of non-operative management for rectal cancer (watch and wait), increased implementation has occurred globally over the past decades. In Sweden, a pan-national prospective non-randomized study was initiated in 2017 to assess its implementation.

Method: Patients with biopsy-proven rectal cancer receiving neoadjuvant therapy according to national guidelines in whom a clinical complete response was detected at reassessment were eligible for inclusion following informed consent. Only patients with an opportunistic watch-and-wait approach were included. Inclusion and follow-up, according to the study protocol, was managed at the participating study centres. The primary outcome measure of the study is 3-year disease-free survival. Here, the secondary short-term outcomes local regrowth rate, distant metastasis rate and outcomes after surgery for regrowth, at 6 months follow-up, are reported.

Results: Between January 2017 and February 2023, 211 patients with a clinical complete response were included in the study. Thirty-three (16%) patients developed suspicious regrowth within 6 months of inclusion. Thirty-two of 33 patients had abdominal resectional surgery for regrowth. The curative intention rate was 94% for patients with regrowth. Three patients (1.4%) developed distant metastases within 6 months of inclusion.

Conclusion: This Swedish national study on watch and wait reports regrowth rates after 6 months are in line with previous reports in the literature. Nearly all patients with early regrowth could be treated with salvage surgery and curative intent.

Background: Gastric outlet obstruction due to unresectable tumours is usually managed with a gastrojejunostomy. Unfortunately, the unsatisfactory outcomes of this procedure have led to the search for alternatives, including gastric partitioning.

Methods: Monocentric, randomized, parallel, open-label trial that included patients with obstructive, unresectable distal gastric tumours. The objective was to compare gastric partitioning to gastrojejunostomy, considering the gastric outlet obstruction scoring system scale as the main outcome. Randomization was performed using computer-generated software available online and after the application of the informed consent term, the allocation group was revealed to the surgeon before the surgical procedure.

Results: Over 7 years, 90 patients were initially randomized. After applying the inclusion and exclusion criteria, 25 patients were included in the gastrojejunostomy group and 27 in the partitioning group. Both groups were similar regarding initial clinical characteristics including sex, age, weight, clinical performance, and the acceptance of oral diet. Surgery duration, length of hospital stay, postoperative complications, and 30- and 90-day mortality rates were similar between groups. Acceptance of normal diet was more frequently reached by patients in the partitioning group (96% versus 72%; P = 0.022). During outpatient follow-up, maintenance of oral intake and weight was similar between groups. Patients in the partitioning group received more frequent red blood cell transfusions (81% versus 52%; P = 0.024). There was no difference regarding the administration of palliative chemotherapy lines and survival. In the multivariable analysis, the inability to eat a full diet (P = 0.035) and the absence of palliative chemotherapy after the procedure (P = 0.001) were associated with worse survival.

Conclusions: Gastric partitioning provided a better return of the ability to accept food orally. There was no difference regarding postoperative complications and long-term survival.

Trial registration: NCT02065803, clinicaltrials.gov.

Background: Robotic data streams allow for capture of objective performance indicators, providing the ability to quantify and analyse operator technique and movement in optimizing postoperative outcomes. This study provided proof-of-concept demonstration of how intraoperative surgeon-factors could influence post-robotic herniorrhaphy complications via machine learning analyses of objective performance indicators.

Study design: Data on robotic-assisted ventral hernia repair were retrospectively reviewed between February 2013 and November 2022 at a single academic centre. Machine learning modelling on systematic chart review data correlated perioperative patient factors, intraoperative objective performance indicators, and postoperative outcomes. Complications were classified with the Clavien-Dindo scale. Endpoints of interest included postoperative complications at discharge, at postoperative day 30, and at the last follow-up. Machine learning models employed included linear, k-nearest neighbours, support vector, decision tree, random forest, adaptive boosting, and extreme gradient boosting regression algorithms.

Results: Some 520 patients undergoing robotic ventral hernia were included. Median age of patients was 56 years with 52.7% male and median body mass index 31.9 kg/m2. 92.7% of patients had at least one medical comorbidity peoperatively. Complications occurred in 33 (6.3%) patients at time of discharge. Machine learning models demonstrated an accuracy 0.95, a precision 0.92, a recall 0.95, and a F1 0.92 of objective performance indicator predicting complications and an accuracy 0.95, a precision 0.95, a recall 0.95, and a F1 0.94 by Clavien-Dindo grade at time of discharge. Thematic analyses of top ranked factors included operator-specific objective performance indicators alongside patient factors canonically associated with hernia complications.

Conclusions: This study showed the novel application of machine learning modelling to bridge objective performance indicators and clinical patient factors to postoperative clinical outcomes, demonstrating the relevance of dynamic intraoperative surgeon factors on clinical outcomes.

Background: Contrary to the impact of screening, the effect of long-term surveillance on the quality of life of patients with an abdominal aortic aneurysm is not well known. Therefore, the aim of this study was to describe patient-reported outcomes of patients with an abdominal aortic aneurysm approaching the surgical threshold.

Methods: This multicentre, observational cohort study included patients with an abdominal aortic aneurysm with a maximum aneurysm diameter of greater than or equal to 40 mm. The EuroQol five-dimension five-level questionnaire (range -0.446 to 1, minimal clinically important difference 0.071), the Hospital Anxiety and Depression Scale questionnaire (0-21 points/subscale, minimal clinically important difference 1.7 points), and the short version of the Patient Health Questionnaire (0-6 points) were mailed to patients with an abdominal aortic aneurysm at baseline and after 1 and 2 years or until abdominal aortic aneurysm surgery/death. Linear mixed-effects models were used to describe the evolution of patient-reported outcomes over time and investigate changes attributable to clinical characteristics.

Results: In total, 291 to 294 responses to each questionnaire were available from 124 patients with an abdominal aortic aneurysm, of whom 34 underwent surgery during follow-up. The mean health-related quality of life and anxiety and depression scores over time were 0.781 (95% c.i. 0.749 to 0.814), 4.4 points (95% c.i. 3.9 to 4.9), and 4.6 points (95% c.i. 4.0 to 5.2) respectively. Anxiety and depression scores decreased in patients who underwent surgery with a mean of 2.8 (95% c.i. 1.1 to 4.6) and 2.0 (95% c.i. 0.4 to 3.6) points/year respectively, compared with patients who had not had surgery. Considering the minimal clinically important difference, patients with a primary education alone, compared with a secondary education, had higher or increasing anxiety and depression scores. Patients with a first-degree relative with an abdominal aortic aneurysm had a higher risk of clinical anxiety.

Conclusion: Although health-related quality of life, anxiety, and depression remain stable over time on average, anxiety and depression decrease in patients approaching surgery. Patients with a family history of abdominal aortic aneurysm or a primary education alone experience more anxiety and/or depression and thus might benefit from a tailored approach during surveillance.

Background: Radical gastrectomy with D2 lymphadenectomy is standard surgical protocol for locally advanced gastric cancer. The surgical experience and skill in recognizing blood vessels and performing lymph node dissection differ between surgeons, which may influence intraoperative safety and postoperative oncological outcomes. Hence, the aim of this study was to develop an accurate and real-time deep learning-based perigastric blood vessel recognition model to assist intraoperative performance.

Methods: This was a retrospective study assessing videos of laparoscopic radical gastrectomy with D2 lymphadenectomy. The model was developed based on DeepLabv3+. Static performance was evaluated using precision, recall, intersection over union, and F1 score. Dynamic performance was verified using 15 intraoperative videos.

Results: The study involved 2460 images captured from 116 videos. Mean(s.d.) precision, recall, intersection over union, and F1 score for the artery were 0.9442(0.0059), 0.9099(0.0163), 0.8635(0.0146), and 0.9267(0.0084) respectively. Mean(s.d.) precision, recall, intersection over union, and F1 score for the vein were 0.9349(0.0064), 0.8491(0.0259), 0.8015(0.0206), and 0.8897(0.0127) respectively. The model also performed well in recognizing perigastric blood vessels in 15 dynamic test videos. Intersection over union and F1 score in difficult image conditions, such as bleeding or massive surgical smoke in the field of view, were reduced, while images from obese patients resulted in satisfactory vessel recognition.

Conclusion: The model recognized the perigastric blood vessels with satisfactory predictive value in the test set and performed well in the dynamic videos. It therefore shows promise with regard to increasing safety and decreasing accidental bleeding during laparoscopic gastrectomy.

Background: Thoracic surgery is an invasive procedure and there has been a move towards minimally invasive approaches. This includes video-assisted thoracoscopic surgery. Non-intubated video-assisted thoracoscopic surgery without endotracheal intubation has been developed with a view to avoiding complications associated with intubation including tracheal injury, vocal cord injury and lung impairment due to mechanical ventilation. This study aims to compare outcomes from non-intubated 'completely tubeless' versus intubated 'partially tubeless' minimally invasive thoracic surgery.

Methods: A single-institution, prospective randomized clinical trial was conducted comparing patients who underwent minimally invasive lung completely tubeless versus partially tubeless surgery, both with enhanced recovery. The primary outcome was the short-term postoperative complication rate. Binary logistic regression analysis was performed to determine the significant predictors of severe mediastinal shift and receiver operating characteristic (ROC) curve plots were drawn.

Results: Among the 348 patients, 174 patients were assigned to the completely tubeless group and 174 patients were assigned to the partially tubeless group. There was no difference in postoperative complications including pulmonary complications, supraventricular arrhythmia, acute myocardial infarction, acute cerebral stroke, venous thromboembolism and urinary retention. The completely tubeless protocol was associated with a higher proportion of early mobilization (66.7% versus 55.7%, P = 0.047), a shorter median duration of drainage (1.0 versus 2.0 days, P = 0.002), and a shorter median duration of postoperative hospital stay (2.0 versus 3.0 days, P = 0.001). The completely tubeless group had less of a difference in white blood cell count before and after the operation (P = 0.042). Binary logistic regression analysis revealed that weight was a significant predictor of mediastinal shift in the completely tubeless group.

Conclusion: Under enhanced recovery after surgery protocols, there is no difference in postoperative complications in patients undergoing completely or partially tubeless surgery. However, patients having completely tubeless surgery have shorter durations of postoperative drainage, shorter durations of hospital stay, milder systemic inflammatory reactions, and better immune protection than patients who undergo lung resection with a partially tubeless protocol. The severity of mediastinal shift may be mainly related to body-weight.

Registration number: NCT05269784 (http://www.clinicaltrials.gov).

Background: Proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for patients with ulcerative colitis with medical refractory disease or dysplasia. The aim of this research was to describe the evolution of ileal pouch-anal anastomosis surgery and surgical outcomes over a three-decade interval in a high-volume referral centre.

Methods: All consecutive patients undergoing ileal pouch-anal anastomosis for ulcerative colitis between 1990 and 2022 at the University Hospitals of Leuven were retrospectively included. Patients were divided into three interval arms (interval A 1990-2000, interval B 2001-2010 and interval C 2011-2022). The primary outcomes of interest were anastomotic leakage at 30 days and pouch failure.

Results: Overall, 492 patients were included. The use of preoperative advanced therapies increased over time (P < 0.001). An increase in laparoscopic procedures (23.2% in interval A, 66.4% in interval B, 86.0% in interval C; P < 0.001) and a shift towards delayed ileal pouch-anal anastomosis (colectomy-first approach with delayed ileal pouch-anal anastomosis construction: 23.0% in interval A, 40.9% in interval B, 85.8% in interval C; P < 0.001) were observed. Anastomotic leakage rate decreased from 16.7% (interval A) to 8.4% (interval C) (P = 0.04). Delayed ileal pouch-anal anastomosis was the most relevant factor in limiting leakage (OR 0.49 (95% c.i. 0.27 to 0.87); P = 0.016). Median follow-up was 7.5 years (interquartile range 2.5-16). Cumulative pouch failure incidence was 8.2%, not significantly different between the three intervals (P = 0.580). Anastomotic leakage was the only significant risk factor for pouch failure (HR 2.82 (95% c.i. 1.29 to 6.20); P = 0.010).

Conclusion: Significant changes in the management of ulcerative colitis patients occurred. Despite the widespread use of advanced therapies and the expanded surgical indications, anastomotic leakage rate decreased over time. In the context of a delayed ileal pouch-anal anastomosis, diverting ileostomy could be avoided in selected cases. Anastomotic leakage remains the most relevant risk factor for pouch failure. Pouch failure incidence remained stable over the years.

Background: Comparison of quality indicators can improve quality of care. However, case-mix adjustment is deemed essential. The aim of this study was to develop and validate case-mix adjustment models and to evaluate the effect of case-mix adjustment for the quality indicators related to complications after breast cancer surgery.

Methods: Multivariable logistic regression with backward selection (P < 0.1) was used to develop case-mix models in patients undergoing breast cancer surgery (all types, breast-conserving surgery, mastectomy with or without immediate reconstruction) in the Netherlands (NABON Breast Cancer Audit). High-impact complications were defined as Clavien Dindo grade ≥3. Model performance was assessed using the area under the receiver operating characteristic curve (AUC), corrected for optimism with bootstrap validation. Observed-to-expected plots were used to visualize the difference between unadjusted and case-mix adjusted hospital performance (hospital shifts).

Results: In total 32 084 patients from 72 hospitals treated in 2021-2022 were included. A between-hospital variation in complication rates was observed for all surgeries (interquartile range 2.4-6.0%), breast-conserving surgery (interquartile range 1.4-3.4%), and mastectomy with (interquartile range 9.4-9.1%) and without reconstruction (interquartile range 3.3-9.7%). Of the considered variables, body mass index, smoking, multifocality and neoadjuvant therapy were weakly associated with complications. However, surgery type was strongly related to complications (AUC 0.70), resulting in noticeable hospital shifts in the quality indicator scores comprising all surgeries. After stratification for surgery type, no evident hospital shifts were observed after case-mix correction.

Conclusion: For valid comparison of complication rates after breast cancer surgery between hospitals, stratification by surgery type is crucial. Subsequently, the evaluated patient and tumour characteristics have a negligible effect on the hospital variation.