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Background: Axillary node clearance is the current standard of care in patients with node-positive breast cancer undergoing primary surgery, despite a lack of evidence to demonstrate survival benefit and high rates of life-changing morbidity. Targeted axillary dissection (TAD) may be a safe alternative to axillary node clearance, but there is no agreement how primary TAD should be performed. TADPOLE-TOGETHER aimed to use international consensus methods to agree the key components of primary TAD to promote standardized introduction and evaluation of the technique within the TADPOLE trial.

Methods: A scoping review and key stakeholder interviews were used to generate a longlist of possible procedure steps for inclusion in the Delphi questionnaire. Two rounds of an international online survey were then used to agree the mandatory, optional, and prohibited steps of TAD, together with any standardization and training required. The final approach to primary TAD was agreed at an online consensus meeting.

Results: Thirteen potential steps of a TAD procedure were identified from the literature and expert interviews, together with information regarding standardization and training. Some 244 surgeons with global representation participated in the Round 1 survey, of whom 161 (66.0%) participated in Round 2. Seven mandatory steps of primary TAD, including localization and removal of the involved node, combined with a sentinel node biopsy, were agreed upon and ratified by 42 surgeons from the UK, Europe, and Asia who attended the consensus meeting.

Conclusion: Robust international consensus methods have been used to agree how primary TAD should be performed, promoting safe and transparent introduction and evaluation of the technique.

Background: Hiatal hernia (HH) after oesophagectomy is a potentially life-threatening complication, more commonly observed after minimally invasive procedures. The aim of the study was to compare the incidence of HH after open versus minimally invasive oesophagectomy (MIO) for cancer, to identify risk factors for its onset, and analyse the technical differences between the approaches.

Methods: This was a retrospective study of patients who underwent transthoracic oesophagectomy for cancer over a 15-year period. Open and minimally invasive procedures were compared according to demographics, and operative and perioperative parameters. MIO included both laparoscopic and robotic operations. Risk factors for HH after oesophagectomy were analysed by calculating odds ratios of uni- and multivariable generalized linear models.

Results: A total of 898 patients operated on between 2008 and 2023 were included in the study. HH was observed in 1 of 490 patients (0.2%) in the open group and in 21 of 408 patients (5.2%) in the minimally invasive group (P < 0.001). At multivariable analysis, patients with an ASA score of II and III within the MIO group had a significantly lower risk of HH compared with ASA I subjects (P = 0.002 and P < 0.001, respectively). Omentectomy was performed in all open procedures but in none of the MIO.

Conclusion: The rate of HH was significantly lower in patients who underwent open oesophagectomy. Omentectomy may prevent postoesophagectomy HH as it was the only additional technical difference between the groups. Multicentric randomized clinical trials are needed to assess whether omentectomy during MIO may reduce the occurrence of paraconduit HH.

Background: Failure to rescue (FTR) is the mortality rate among patients with complications, and is a quality indicator for surgical care. FTR has been inconsistently defined in the literature, with potential impacts on reported rates and hospital benchmarking. This study examined the impact of differences in the FTR definition on hospital rankings.

Methods: A retrospective population-based cohort study of patients undergoing gastrointestinal or hepatopancreatobiliary cancer resection from 2005 to 2020 was performed using linkage of the New Zealand Cancer Registry and National Minimum Dataset. FTR was defined as the mortality rate among patients with any of 19 postoperative complications. Five FTR definitions commonly used in the literature were adapted for comparison. Risk-adjusted rates were compared between hospitals using each definition, as well as for in-hospital and 90-day outcomes.

Results: In total, 31 199 patients were included from 20 hospitals, with 1517 90-day deaths (4.9%). The 90-day FTR rate with all 19 complications included was 10.4% (1517 of 14 646). The FTR definition affected hospital rankings, with the Bland-Altman 95% limits of agreement ranging between 4 and 11 position differences. There were 847 in-hospital deaths, and the in-hospital FTR rate was 5.8% (847 of 14 516). Hospital rankings were affected by the timing of outcome measurement; 95% limits of agreement ranged from 5 to 8 position differences compared with 90-day outcomes.

Conclusion: The definition and timing of FTR measurement affected hospital rankings. This may have important ramifications for FTR as a quality indicator when benchmarking institutional performance.

Background: Faecal immunochemical test (FIT) results triage urgent suspicion of colorectal cancer (USoC) referrals to investigation. As FIT detects microscopic blood, its role in patients with per rectal bleeding (PRB) is controversial. Patients are encouraged to submit sample stools without evident bleeding. The positivity rate, colorectal cancer (CRC) detection accuracy, and benefits from repeated FITs in patients with rectal bleeding are unknown.

Methods: A prospective dataset of USoC referrals for CRC was interrogated for referral symptoms, FIT results, and colorectal investigation outcomes. These were linked to South-East Scotland Cancer Network data to ensure complete CRC outcome data. A FIT result of 10 µg Hb/g or more was considered positive. The primary outcome of interest was diagnostic performance of FIT in patients with PRB compared with symptoms excluding PRB, including sensitivity, specificity, and negative predictive value (NPV). Secondarily, the impact of double FITs in these cohorts was investigated.

Results: A total of 5686 patients completed a FIT and subsequent colorectal investigation, and 2130 (37.5%) of these had PRB as a referral symptom. FIT positivity was higher in patients with PRB compared with no PRB (34.7% versus 18.6%; P < 0.001). When two successive FITs were completed, the positivity rate rose to 43.5%. Significant bowel pathology (CRC, advanced adenoma, inflammatory bowel disease (IBD)) was more prevalent in patients with PRB. The majority of CRCs in the PRB group were located distally (PRB 94.1% versus no PRB 51.5%; P < 0.001). The sensitivity for CRC was significantly greater in those with PRB compared with no PRB (98.0% (95% confidence interval (c.i.) 95.1-99.2) versus 82.5% (95% c.i. 74.6-88.9)), with respective NPVs of 99.8% and 99.4%. Double FITs increased CRC sensitivity in the non-PRB group, removing the difference in sensitivity between the two groups observed with one test (PRB 100% (95% c.i. 92.3-100) versus no PRB 92.9% (95% c.i. 79.4-97.8)). The NPV for CRC in PRB when two FITs were complete was 100% (99.0-100).

Conclusion: Rectal bleeding makes up one-third of USoC referrals to secondary care. The FIT positivity rate is 34.7% and it has a high sensitivity for CRC. Patients with PRB with two negative FITs have a negligible CRC prevalence.

Objective: To assess the effectiveness and safety of a normothermic artery bypass and visceral-anastomosis-first (NABV) strategy for thoracoabdominal aortic aneurysm repair.

Methods: From July 2017 to September 2024, a retrospective analysis was conducted on early postoperative complications in two groups of patients undergoing thoracoabdominal aortic aneurysm repair. The analysis compared patients treated with a new strategy with those treated with deep hypothermic circulatory arrest, clarifying the protective effects of the new strategy on visceral organs, particularly the spinal cord.

Results: A total of 182 patients were included in the study; 73 in the NABV group and 109 in the DHCA group. After inverse probability of treatment weighting, the NABV group had lower incidences of spinal cord deficit, pulmonary complications, and gastrointestinal insufficiency, a shorter duration of mechanical ventilation, and a shorter hospital stay. Body mass index ≥ 24.0 (odds ratio 3.099, 95% confidence interval (c.i.) 1.051 to 9.142; P = 0.004) and coronary artery disease (odds ratio 4.848, 95% c.i. 1.169 to 20.102; P = 0.030) were independent risk factors for spinal cord deficit in the entire cohort, in contrast to the NABV strategy (odds ratio 0.283, 95% c.i. 0.039 to 0.806; P = 0.025), which was a protective factor. The multivariable Cox regression analyses identified smoking history (hazard ratio 2.61, 95% c.i. 1.12 to 6.05; P = 0.026) as an independent risk factor for overall survival.

Conclusion: The treatment of thoracoabdominal aortic aneurysm through open surgery is still an important method and remains difficult. The NABV strategy, as a safe and reproducible technique, minimizes the risk of complications associated with spinal cord injury when implemented at experienced medical centres. To better evaluate the clinical outcomes of this surgical approach, long-term follow-up and further prospective cohort studies are necessary.

Background: Faecal immunochemical testing has rapidly been established as the first-line triage for patients with symptoms suspicious for colorectal cancer. However, the reported low compliance of test returns issued from primary care is concerning. This article reports the real-world impact of implementation of a double-faecal immunochemical testing pathway for symptomatic referrals into routine clinical practice.

Methods: All eligible referrals between November 2021 and October 2022 were sent two faecal immunochemical tests via the faecal immunochemical testing interface office. Colorectal investigations were instigated if either test result was ≥10 µg haemoglobin per g. Referrals with double-negative results were reviewed by consultants who decided whether symptoms merited further investigation. Cancer registry follow-up data were cross-checked, and a further electronic registry allowed capture of re-referrals.

Results: Some 5425 patients were triaged using double-faecal immunochemical testing, with 5116 (94.3%) completing at least 1 and 4607 (84.9%) both faecal immunochemical tests. The positivity of one test was 20.8%, rising to 27.8% where both tests were completed. The number of referred patients undergoing colorectal investigation fell from 90% before faecal immunochemical testing-directed pathways to 56.6% owing to a reduction in investigating patients with double-negative results. The double-faecal immunochemical testing pathway had a sensitivity of 94.3% for the detection of colorectal cancer, with 37.5% of cancers with a negative first test being detected by the second. Only 3.3% of patients triaged through the double-faecal immunochemical testing pathway were re-referred.

Conclusion: The double-faecal immunochemical testing pathway demonstrated high test return rates, a reduction in unnecessary investigations, and colorectal cancer detection rates similar to preimplementation rates.

Introduction: The management of faecal incontinence (FI) remains challenging and further treatment modalities are urgently needed. The aim of this study was to assess the efficacy of a novel artificial bowel sphincter (SimplyFI anal band), which is implanted around the anal sphincter complex to enhance continence.

Methods: An exploratory prospective multicentre study based on the IDEAL 2b framework was conducted in patients with FI unresponsive to conservative treatment. Participants underwent SimplyFI implantation, followed by assessments at 1 week and 1, 3, 6, and 12 months after implantation. Intraoperative and postoperative complications were recorded. Functional improvement and quality of life were measured using the St Mark's incontinence score (SMIS) and the Faecal Incontinence Quality of Life Scale (FIQLS).

Results: Eighteen patients were included in the study (17 women, 1 man). The median operating time was 27 (range 13-60) min, with a median hospital stay of 2 (range 1-5) days. One intraoperative complication occurred without affecting the outcome. One patient (5.6%) underwent band removal due to anal discomfort without signs of infection. Relative to baseline, significant improvements were seen at 12 months in median scores for both the SMIS (from 16.5 to 12.5; P = 0.013) and the FIQLS (from 2.0 to 2.6; P = 0.006). Anorectal manometry showed a significant increase in the anal resting pressure from preoperative values to 3 months after implantation (median 15.5 versus 19.0 mmHg, respectively; P = 0.037); however, the increase in anal resting pressure was no longer seen at the 12-month follow-up.

Conclusion: In this exploratory study of 18 patients, the SimplyFI anal band appears to be safe with short-term improvement in function. Future studies with longer follow-up periods are needed to better define the role of this new treatment modality. Registration number: NCT05708612 (http://www.clinicaltrials.gov).

Background: Appendiceal adenocarcinomas and low-grade appendiceal mucinous neoplasms (LAMNs) are rare tumours. Much of the existing knowledge is derived from registry-based studies, particularly the Surveillance, Epidemiology, and End Results database in the USA.

Methods: This retrospective cohort study used data from the Swedish Cancer Registry, Swedish Cause of Death Registry, and the National Patient Registry to analyse demographic characteristics and outcomes of patients diagnosed with appendiceal adenocarcinoma or LAMN between 2005 and 2019. Kaplan-Meier survivor function, multivariate Cox regression analysis, standardized mortality ratio, and net survival were used to assess survival. Incidence was estimated by direct standardization from 2005 to 2019.

Results: In all, 1159 patients with appendiceal neoplasms were included, with a mean age at diagnosis of 63.3 years. The incidence of adenocarcinomas was stable, whereas the incidence of LAMNs increased from 2012 onwards. Patients with non-mucinous adenocarcinomas who underwent colonic resection had better survival outcomes than patients treated with appendicectomy alone. For mucinous adenocarcinomas, colonic resection did not improve survival outcomes compared with appendicectomy. Patients with non-mucinous adenocarcinoma, mucinous adenocarcinoma, or LAMN who underwent cytoreductive surgery and heated intraperitoneal chemotherapy (CRS-HIPEC) had favourable overall and net survival.

Conclusion: Colonic resection increased survival only for patients with non-mucinous adenocarcinomas. Since 2012, the incidence of LAMN has increased, most likely due to changes in diagnostic and coding practices, but the incidence of appendiceal adenocarcinomas has remained stable. The survival benefit of CRS-HIPEC is observed in a very specific patient population, emphasizing the importance of careful patient selection.

Background: Surgical decision-making for breast cancer requires consideration of both treatment outcomes and health-related quality of life (HR-QoL). However, data on HR-QoL differences across surgical procedures remain limited. This study compared breast satisfaction and HR-QoL among Japanese patients with breast cancer undergoing mastectomy (MT), breast-conserving surgery (BCS), or immediate breast reconstruction (IBR).

Methods: A survey using the Japanese version of the BREAST-Q was conducted among patients with primary breast cancer who underwent surgery between August 2013 and July 2021.

Results: Of 648 patients, 577 were included in this study. The median time from surgery to questionnaire completion was 56 months. Satisfaction with breast scores was highest in patients undergoing BCS, followed by those undergoing IBR and MT. Psychosocial and sexual well-being were significantly better in patients undergoing BCS and IBR than in those undergoing MT, whereas physical well-being showed no significant differences among the three groups. In multiple regression analysis, surgical procedure was identified as the most influential factor for breast satisfaction, psychosocial well-being, and sexual well-being.

Conclusions: This multicentre Japanese study confirmed that the choice of surgical procedure is the most influential factor affecting postoperative HR-QoL, with both BCS and IBR offering advantages over MT. The findings highlight the importance of comprehensive preoperative counselling to ensure patients receive detailed information on potential HR-QoL differences.