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Background: Healthcare systems in Europe vary in funding, accessibility, and spending per capita, potentially influencing patient access to advanced surgical techniques. This study aimed to provide a snapshot of the utilization of minimally invasive surgery for elective inguinal hernia repair across Europe.

Methods: This was a secondary analysis of an international, prospective observational study of inguinal hernia repairs conducted between 30 January and 21 May 2023. Adults undergoing elective inguinal hernia repair in Europe were included in the present analysis. The four European regions according to the United Nations geoscheme (Southern, Eastern, Northern, and Western Europe) were compared. A multilevel multivariable logistic regression model was used to explore factors associated with use of minimally invasive surgery.

Results: A total of 8355 patients from 254 hospitals across 23 European countries were included: 5590 from Southern, 587 from Eastern, 1541 from Northern, and 637 from Western Europe. Most hospitals were public (88.8%) and tertiary level (49.9%). Patient and hernia characteristics were generally similar, except Western Europe reported higher rates of bilateral hernias (25.9% versus 14.1% overall). Minimally invasive surgery was performed in 26.0% of patients, 70.6% in Western, 37.9% in Northern, 46.5% in Eastern, and 15.4% in Southern Europe. Multivariable regression showed significant regional disparities. Multivariable regression also identified bilateral hernias (adjusted odds ratio 14.33 (95% confidence interval 11.76 to 17.47), surgeons with experience of ≥ 201 procedures (odds ratio 3.54, 2.75 to 4.54), and private hospitals (odds ratio 2.80, 1.03 to 7.65) as factors associated with greater use of minimally invasive surgery.

Conclusion: Significant disparities in minimally invasive surgery for elective inguinal hernia repair exist across Europe. Targeted initiatives should especially prioritize Southern Europe to ensure equitable access to advanced techniques.

Background: Anastomotic leakage (AL) remains a critical complication following oesophagectomy, with inadequate perfusion of the conduit identified as a major contributing factor. Although indocyanine green (ICG) fluorescence angiography has been used intraoperatively to assess conduit blood flow, the clinical utility of objective ICG fluorescence indicators for anastomotic site determination has not been well established. This study investigated the association between ICG fluorescence intensity, measured using a new quantitative blood flow assessment technique, and the incidence of AL in patients undergoing gastric conduit reconstruction.

Methods: Prospective analysis of patients who underwent subtotal oesophagectomy with gastric conduit reconstruction between July 2023 and May 2024. Intraoperative real-time perfusion was assessed using the SPY-PHI imaging system in conjunction with SPY-QP software. Quantitative fluorescence intensity measurements were obtained at the terminal branch of the right gastroepiploic artery and the planned anastomotic site.

Results: Of 100 included patients, AL occurred in nine patients. Although there was no significant difference in ICG enhancement time between the AL and non-AL groups, fluorescence intensity at both the end of the right gastroepiploic artery (75 versus 101%; P = 0.004) and the anastomotic line (67 versus 90%; P = 0.009) was significantly lower in patients who developed AL. Multivariable analysis identified tumour location in the upper oesophagus and fluorescence intensity ≤ 90% at the anastomotic site as independent predictors of AL, with odds ratios of 6.99 (P = 0.023; 95% confidence interval (c.i.) 1.31 to 37.30) and 12.50 (P = 0.004; 95% c.i. 2.15 to 72.9), respectively.

Conclusion: Quantitative ICG fluorescence intensity assessment facilitates objective intraoperative evaluation of gastric conduit perfusion and may support optimal anastomotic site selection, potentially reducing AL risk.

Background: Epidural analgesia can improve early postoperative recovery after renal transplantation. Abdominal wall blocks (transversus abdominis plane (TAP) and rectus sheath (RS)) combined with patient-controlled intravenous analgesia (PCIA) have also been shown to enhance postoperative recovery. However, it remains unclear whether these techniques are as effective as epidural analgesia (EP).

Methods: In this single-centre randomized non-inferiority clinical trial, participants undergoing renal transplantation were randomly assigned to receive either a TAP + RS block (combined with PCIA) or EP alone. The primary outcome was Quality of Recovery-15 (QoR-15) scores on postoperative day (POD) 1. Secondary outcomes included haemodynamics, indices of postoperative renal function, time to interventions, and postoperative pain scores.

Results: Ninety participants were included in the analysis. The TAP + RS group demonstrated non-inferiority to the EP group in terms of the mean(standard deviation) total QoR-15 score on POD1 (90.6(5.0) versus 92.4(6.4); mean difference, -1.8; 95% confidence interval -4.2 to 0.6; P < 0.001 for non-inferiority). QoR-15 scores on POD3 and POD7 and indices of postoperative renal function were comparable between the two groups, with no group-time interactions. The EP group had significantly lower mean arterial pressure and intraoperative opioid consumption, as well as shorter times to eye opening and extubation, than the TAP + RS group. However, the intervention time was longer in the EP group (P < 0.001).

Conclusion: TAP + RS block combined with PCIA demonstrated non-inferiority to EP for postoperative QoR-15 scores after kidney transplantation. TAP + RS block offers a potentially more convenient and favourable alternative to EP, helping maintain haemodynamic stability, postoperative renal function, and a low complication profile.

Registration number: ChiCTR2200056455 (https://www.chictr.org.cn).

Background: Sarcopenia has been associated with adverse outcomes in numerous malignancies. The prevalence and prognostic significance of sarcopenia in patients with breast cancer receiving neoadjuvant chemotherapy (NAC) is uncertain. This study assessed the prevalence and effect of sarcopenia on the response to NAC, as well as on operative and oncological outcomes.

Methods: Consecutive patients with breast cancer receiving NAC with curative intent between 2010 and 2015 at a single tertiary referral centre were included. Lean body mass and skeletal muscle index (SMI) were determined by analysing axial computed tomography scans taken at L3, with sarcopenia defined as SMI < 38.5cm2/m2. Univariable and multivariable linear, logistic, and Cox proportional hazards regression analyses were performed.

Results: Among 258 patients (mean age 49.5 (SD11.1) years and BMI 27.6(5.7) kg/m2), 24 (12.2%) exhibited sarcopenia. Sarcopenia was not associated with molecular subtype (P = 0.746) nor clinical tumour size (P = 0.960). On multivariable analysis, sarcopenia did not predict complete pathological response (P = 0.069), nodal positivity after NAC (P = 0.442), or Sataloff tumour response to NAC (P = 0.898). Sarcopenia did not predict the length of hospital stay (P = 0.716) nor the Comprehensive Complication Index (P = 0.242) after surgery. Lower lean body mass independently predicted overall survival (hazard ratio (HR) 0.92; 95% confidence interval [c.i.] 0.85 to 0.99; P = 0.028) and invasive disease-free survival (HR 0.93; 95% c.i. 0.87 to 1.00; P = 0.049), but not disease-specific survival (P = 0.070).

Conclusion: Sarcopenia was not associated with clinicopathological parameters and did not affect the response to NAC nor postoperative complications. Lower lean body mass was associated with reduced overall and invasive disease-free survival in patients with breast cancer receiving NAC.

Background: This study aimed to compare preperitoneal ventral mesh patch with barbed suture in ventral hernia repair, evaluating recurrence rates and complications, and to assess the safety of preperitoneal patch placement.

Methods: In this randomized clinical trial, adult patients undergoing ventral hernia repair at Karlskoga Hospital between 2020 and 2023 were randomized 1 : 1 to either a ventral mesh patch repair group or a non-absorbable barbed suture repair group, blinded to patients and outcome assessors. The primary outcome was recurrence detected at clinical examination and CT verification 1 year after surgery. Pain (measured on a visual analogue scale and using the Ventral Hernia Pain Questionnaire), nausea, and surgical site events (including wound infection, haematoma and seroma) were assessed 4 h, 1 week, 1 month, and 4 years after operation.

Results: Of 256 eligible patients, 209 were screened, and 205 were randomized to ventral mesh patch repair (103) or barbed suture repair (102). The hernia recurrence rate at 1 year was lower in the ventral patch repair group (1.9 versus 5.9%), although this was not statistically significant (P = 0.14). The surgical site infection rate at 1 month was significantly lower in the ventral patch group (0.9 versus 6.9%; P = 0.02). At 1 month, the ventral patch repair group had higher 'pain right now' scores on the Ventral Hernia Pain Questionnaire (P = 0.02), although this difference had disappeared by 1 year.

Conclusion: Preperitoneal ventral hernia patch repair is a safe and effective technique with a recurrence rate not statistically significant from that after barbed suture repair. Although postoperative pain scores at 1 month were higher after ventral patch repair, this difference had disappeared by 1 year.

Background: Laparoscopic liver resection has been associated with less morbidity than, and similar global outcomes to, open liver resection. There is no robust evidence that these outcomes lead to similar clinical outcomes in patients aged over 80 years. The aim of this study was to analyse the short-term outcomes between open and laparoscopic liver resection in patients over 80 years old.

Methods: A retrospective analysis was undertaken. The study population comprised patients aged ≥ 80 years who underwent laparoscopic or open liver resection between January 2014 and December 2019, and who presented with resectable malignant tumours. The primary outcome was postoperative morbidity, according to Dindo-Clavien grading. Cox regression models were used to compute hazard ratios and 95% confidence intervals. Propensity score matching (1 : 1) was performed to balance the two groups according to independent prognostic factors for morbidity.

Results: A total of 988 patients were analysed from 34 centres (16 from Asia, 14 from Europe and 4 from America): 487 in the open group and 501 in the laparoscopic group. Independent risk factors associated with severe morbidity were the open approach (hazard ratio 1.59, 95% confidence interval 1.19 to 2.11; P < 0.001), Charlson Co-morbidity Index score > 7 (HR 1.69, 1.26 to 2.27; P < 0.001), more than one resected tumour (hazard ratio 1.55, 1.13 to 2.11; P = 0.006), major hepatectomy (hazard ratio 1.86, 1.22 to 2.83; P = 0.003), and Iwate score ≥ 7 (hazard ratio 1.43, 1.02 to 2.01; P = 0.03). Before propensity score matching, severe morbidity, length of intensive care unit stay, 90-day mortality, length of hospital stay, and readmission were better in the laparoscopic group (P < 0.050). These observations were confirmed after propensity score matching.

Conclusion: The laparoscopic approach is a safe procedure for elderly patients, with better morbidity and mortality outcomes than the open approach, and should be considered as a default option.

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.