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Background: Surgical-site infection following open appendicectomy for perforated appendicitis increases length of hospital stay and treatment costs while compromising patients' quality of life. Data from randomized clinical trials (RCTs) evaluating the role of super-oxidized solution in perforated appendicitis are lacking. The study objective was to determine the effect of peritoneal and wound lavage with super-oxidized solution in reducing risk of surgical-site infection following open appendicectomy for perforated appendicitis.

Methods: In this multicentre RCT conducted between September 2020 and March 2022, patients aged 13 years and older with perforated appendicitis undergoing open appendicectomy were randomly assigned to receive peritoneal and wound lavage with either super-oxidized solution or normal saline. The primary outcome was surgical-site infection within 30 days after surgery. Randomization was computer-generated, with allocation concealment by opaque, sequentially numbered, sealed envelope. The patients, surgeons, outcome assessors and statisticians performing the analysis were blinded to treatment assigned.

Results: A total of 102 consecutive patients (51 in the super-oxidized solution group and 51 in the normal saline group) were randomized and included in the intention-to-treat analysis. The super-oxidized solution group showed a significant reduction in overall surgical-site infection (8 (15.6%) versus 19 (37.2%); relative risk (RR) 0.42; 95% c.i. 0.20 to 0.87; P = 0.014), and superficial surgical-site infection (5 (9.8%) versus 18 (35.3%); RR 0.28; 95% c.i. 0.11 to 0.69; P = 0.002), with a number-needed-to-treat of four patients. There were no adverse events in either group.

Conclusions: Peritoneal and wound lavage with super-oxidized solution is superior to normal saline in preventing surgical-site infection after open appendicectomy for perforated appendicitis.

Trial registration: ClinicalTrial.gov Identifier: NCT04512196.

Background: Antibiotics have been reported as an efficient and safe treatment option for uncomplicated acute appendicitis without an appendicolith diagnosed using computed tomography (CT). The aim of this study was to assess the association of a CT-diagnosed appendicolith and its characteristics with appendicitis severity.

Methods: A large prospective patient cohort with suspected acute appendicitis enrolled between April 2017 and November 2018 was retrospectively reviewed. The initial analysis evaluated the association of a CT-diagnosed appendicolith with complicated acute appendicitis; then, based on the availability of CT images, a subset of patients was analysed for the correlation of appendicolith characteristics with appendicitis severity. The final appendicitis assessment (uncomplicated or complicated-including perforation, gangrene, an abscess, or a tumour) was determined for all patients.

Results: Out of 3512 eligible patients, 3085 patients with appendicitis were selected and 380 patients with an appendicolith and with a CT image available for reassessment were included. Out of the 3085 patients with CT-diagnosed acute appendicitis, 1101 (35.7%) patients presented with both acute appendicitis and an appendicolith and, out of these, 519 (47.1%) had complicated acute appendicitis. In the patients without an appendicolith (1984 patients), 426 (21.5%) had complicated appendicitis (P < 0.001). Re-evaluation of CT images for 380 patients showed that a larger appendicolith diameter (OR = 1.15 (95% c.i. 1.06 to 1.25); P < 0.001), appendicolith location at the base of the appendix (55.1% versus 44.9%; P = 0.008), and heterogeneous appendiceal wall enhancement around the appendicolith (68.4% versus 31.6%; P < 0.001) were associated with an increased risk of complicated acute appendicitis.

Conclusion: The presence of an appendicolith in patients with acute appendicitis is correlated with the risk of complicated appendicitis. This risk is further increased by a larger appendicolith diameter or appendicolith location at the base of the appendix.

Background: The current gold standard for extraperitoneal locally advanced rectal cancer is total neoadjuvant therapy (TNT) followed by total mesorectal excision. This research explored the number of lymph nodes in patients with locally advanced rectal cancer after TNT and its correlation with survival.

Materials and methods: This is a post-hoc analysis based on the STELLAR trial, including patients with locally advanced rectal cancer from 16 tertiary centres who were randomized for short-term radiotherapy followed by chemotherapy (TNT group) or long-term concurrent chemotherapy group followed by total mesorectal excision between 2015 and 2018. This lymph node-related analysis is based on the TNT group. Subgroups were differentiated based on the lymph node harvest (below the median number: limited lymphadenectomy group, and greater than/equal to the median number: extended lymphadenectomy group). The primary outcomes were overall survival and disease-free survival (DFS). Correlations with clinical/pathological variables, lymphadenectomy categories and use of adjuvant chemotherapy were explored.

Results: Among the 451 patients enrolled in the STELLAR trial, 227 patients (50.3%) were assigned to the TNT group, including 29.5% females. The median number of lymph nodes retrieved in the TNT group was 11.0. Patients in the limited lymphadenectomy subgroup exhibited worse overall survival than those with extended lymphadenectomy (HR 2.95 (95% c.i. 1.47 to 5.92), P = 0.001). The overall survival was similar in the ypN0-limited and ypN1-extended subgroups (HR 0.38 (95% c.i. 0.11 to 1.30), P = 0.109). Adjuvant chemotherapy was associated with better overall survival and DFS than no adjuvant chemotherapy overall (P < 0.001) and in the limited lymphadenectomy subgroup (P < 0.001). However, there was no significant difference in overall survival or DFS with or without adjuvant chemotherapy in the extended lymphadenectomy subgroup (P = 0.887 and P = 0.192, respectively).

Conclusion: In the STELLAR trial, the median number of lymph nodes harvested was 11. In patients with limited lymphadenectomy, the use of adjuvant therapy after TNT was beneficial and correlated with better prognosis compared with patients who did not receive adjuvant chemotherapy.

Background: A surgeon experiences elevated stress levels when operating. Acute stress is linked to cognitive overload, worsening surgical performance. Chronic stress poses a significant risk to a surgeon's health. Identifying intraoperative stress may allow for preventative strategies that reduce surgeons' stress and subsequently improve patient outcomes. The aim of this study was to assess the feasibility of using heart rate variability as a marker of stress during vascular surgery.

Methods: A total of 11 senior surgeons were evaluated performing three different vascular surgery procedures. Heart rate variability metrics (low-frequency to high-frequency ratio and standard deviation of the normal-normal interval) were determined from single-lead ECG traces at predetermined procedural performance points. State-Trait Anxiety Inventory-6, a validated stress tool, was used to assess surgeon-reported stress. Subjective reports of procedural difficulty were also collected. One-way ANOVA compared heart rate variability at key performance points with baseline. Pearson's coefficient assessed correlation between heart rate variability and subjective stress.

Results: Data were collected for six carotid endarterectomies, six open abdominal aortic aneurysm repairs, and five lower limb bypasses. Heart rate variability metrics indicating markedly greater stress were observed at key performance points across all procedures. Peaks in stress were consistent across different surgeons performing the same procedure. A significant correlation was observed between heart rate variability metrics and subjective State-Trait Anxiety Inventory-6 stress reports (r = 0.768, P =<0.001). The most difficult procedural steps reported corresponded with heart rate variability metrics displaying the greatest stress.

Conclusion: Heart rate variability may be a viable approach to assess intraoperative stress and cognitive load during vascular surgery and could be used to evaluate whether a theatre intervention (for example timeout) could reduce stress in areas of surgical difficulty.

Background: Neoadjuvant endocrine therapy presents an important downstaging option with lower toxicity than neoadjuvant chemotherapy in oestrogen receptor (ER)-positive early breast cancer. Meta-analysis of the effects of neoadjuvant endocrine therapy on surgical outcomes across randomized clinical trials (RCTs) and cohort studies has not previously been performed.

Methods: A systematic review and meta-analysis was performed to evaluate the effect of neoadjuvant endocrine therapy on surgical outcomes (PROSPERO (international prospective register of systematic reviews, 2020)) compared with surgery followed by adjuvant endocrine therapy. PubMed and EMBASE were searched to identify RCT and cohort studies between 1946 and 27 March 2024. Two independent reviewers manually screened the identified records and extracted the data. Risk of bias was assessed using the Cochrane Collaboration tools and random-effects meta-analysis was done with ReviewManager.

Results: The search identified 2390 articles eligible for screening. The review included 20 studies (12 cohort and 8 RCTs); 19 were included in the meta-analysis with a total of 6382 patients. Overall, neoadjuvant endocrine therapy was associated with a lower mastectomy rate compared with surgery first (risk ratio (RR) 0.53, 95% c.i. 0.44 to 0.64). Subgroup analysis showed similar improvement in the mastectomy rate in the neoadjuvant endocrine therapy group versus control group irrespective of study type (RCT: RR 0.58, 95% c.i. 0.50 to 0.66; cohorts: RR 0.48, 95% c.i. 0.33 to 0.70). There was no difference in the mastectomy rate by duration of neoadjuvant endocrine therapy (more than 4 months: RR 0.57, 95% c.i. 0.42 to 0.78; 4 months or less than 4 months: RR 0.52, 95% c.i. 0.43 to 0.64). Most of the studies were characterized by moderate-quality evidence with significant heterogeneity.

Conclusion: Neoadjuvant endocrine therapy is associated with a reduction in mastectomy rate. Given the moderate methodological quality of previous studies, further RCTs are required.

Registration id: CRD42020209257.

Background: A surgeon's daily performance may be affected by operating room organizational factors, potentially impacting patient outcomes. The aim of this study was to investigate the link between a surgeon's exposure to delays in starting scheduled operations and patient outcomes.

Methods: A prospective observational study was conducted from 1 November 2020 to 31 December 2021, across 14 surgical departments in four university hospitals, covering various surgical disciplines. All elective surgeries by 45 attending surgeons were analysed, assessing delays in starting operations and inter-procedural wait times exceeding 1 or 2 h. The primary outcome was major adverse events within 30 days post-surgery. Mixed-effect logistic regression accounted for operation clustering within surgeons, estimating adjusted relative risks and outcome rate differences using marginal standardization.

Results: Among 8844 elective operations, 4.0% started more than 1 h late, associated with an increased rate of adverse events (21.6% versus 14.4%, P = 0.039). Waiting time surpassing 1 h between procedures occurred in 71.4% of operations and was also associated with a higher frequency of adverse events (13.9% versus 5.3%, P < 0.001). After adjustment, delayed operations were associated with an elevated risk of major adverse events (adjusted relative risk 1.37 (95% c.i. 1.06 to 1.85)). The standardized rate of major adverse events was 12.1%, compared with 8.9% (absolute difference of 3.3% (95% c.i. 0.6% to 5.6%)), when a surgeon experienced a delay in operating room scheduling or waiting time between two procedures exceeding 1 h, as opposed to not experiencing such delays.

Conclusion: A surgeon's exposure to delay before starting elective procedures was associated with an increased occurrence of major adverse events. Optimizing operating room turnover to prevent delayed operations and waiting time is critical for patient safety.

Background: Noise in the operating room has been shown to distract the surgical team and to be associated with postoperative complications. It is, however, unclear whether complications after noisy operations are the result of objective or subjective surgical difficulty or the consequence of distraction of the operating room team by noise.

Methods: Noise level measurements were prospectively performed during operations in four Swiss hospitals. Objective difficulty for each operation was calculated based on surgical magnitude as suggested by the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), duration of operation and surgical approach. Subjective difficulty and distraction were evaluated by a questionnaire filled out by the operating room team members. Complications were assessed 30 days after surgery. Using regression analyses, the relationship between objective and subjective difficulty, distraction, intraoperative noise and postoperative complications was tested.

Results: Postoperative complications occurred after 121 (38%) of the 294 procedures included. Noise levels were significantly higher in operations that were objectively and subjectively more difficult (59.89 versus 58.35 dB(A), P < 0.001) and operations that resulted in postoperative complications (59.05 versus 58.77 dB(A), P = 0.004). Multivariable regression analyses revealed that subjective difficulty as reported by all members of the surgical team, but not distraction, was highly associated with noise and complications. Only objective surgical difficulty independently predicted noise and postoperative complications.

Conclusion: Noise in the operating room is a surrogate of surgical difficulty and thereby predicts postoperative complications.

Background: Neoadjuvant treatment has shown promising results in patients with borderline resectable pancreatic ductal adenocarcinoma. The potential benefits of neoadjuvant treatment on long-term overall survival in patients with resectable pancreatic ductal adenocarcinoma have not yet been established. The aim of this study was to compare long-term overall survival of patients with resectable pancreatic ductal adenocarcinoma based on whether they received neoadjuvant treatment or underwent upfront surgery.

Methods: A systematic review including randomized clinical trials on the overall survival outcomes between neoadjuvant treatment and upfront surgery in patients with resectable pancreatic ductal adenocarcinoma was conducted up to 1 August 2023 from PubMed, MEDLINE and Web of Science databases. Patient-level survival data was extracted and reconstructed from available Kaplan-Meier curves. A frequentist one-stage meta-analysis was employed, using Cox-based models and a non-parametric method (restricted mean survival time), to assess the difference in overall survival between groups. A Bayesian meta-analysis was also conducted.

Results: Five randomized clinical trials comprising 625 patients were included. Among patients with resectable pancreatic ductal adenocarcinoma, neoadjuvant treatment was not significantly associated with a reduction in the hazard of death compared with upfront surgery (shared frailty HR 0.88, 95% c.i. 0.72 to 1.08, P = 0.223); this result was consistent in the non-parametric restricted mean survival time model (+2.41 months, 95% c.i. -1.22 to 6.04, P < 0.194), in the sensitivity analysis that excluded randomized clinical trials with a high risk of bias (shared frailty HR 0.91 (95% c.i. 0.72 to 1.15; P = 0.424)) and in the Bayesian analysis with a posterior shared frailty HR of 0.86 (95% c.i. 0.70 to 1.05).

Conclusion: Neoadjuvant treatment does not demonstrate a survival advantage over upfront surgery for patients with resectable pancreatic ductal adenocarcinoma.