Abe Fingerhut

Aim: Anastomotic leakage is a well‐known complication following colorectal surgery, however, there is limited knowledge about patients' experiences with leaks across the care pathway, from initial diagnosis and treatment to long‐term recovery. To explore patients' experiences of anastomotic leakage following colorectal resection and identify patient‐reported priorities relevant to standardized reporting. Methods: Qualitative descriptive study reported using the COnsolidated criteria for REporting Qualitative research. Online semi‐structured interviews were conducted with patients from five countries (Australia, Canada, Netherlands, United Kingdom, and United States). Ten participants (six males, median age 53 [range 39–65 years]) who experienced an anastomotic leak following a colorectal resection. Themes and subthemes emerging from thematic analysis until saturation were reached. Results: Four main themes were identified: (1) physical impact, (2) emotional impact, (3) coping mechanisms, and (4) anastomotic leak care. Within these themes, participants detailed their lived experience during the different phases of the care pathway: diagnosis, treatment, early and late recovery. Additionally, participants indicated the elements of anastomotic leak care that they deemed most important, including preoperative education, communication, support from medical staff and peers, sharing of information, aftercare, shared decision‐making, and case management. Conclusions: Patients having experienced a colorectal anastomotic leak reported a physical and emotional impact, applied different coping strategies, and emphasized the importance of clear communication, comprehensive care, and sustained attention beyond the early postoperative and treatment phase.

Objective. To evaluate the methodology of Trial Sequential Analysis as a tool for developing and critically appraising of clinical guidelines on the model of midline ventral hernias. Material and methods. Systematic searching for international guidelines on the management of ventral hernias was conducted in the PubMed, EMBASE, Scopus, Web of Science, CINAHL, and Cochrane Library databases up to May 01, 2023. Searching depth was 5 years. Quality of systematic reviews was assessed using a Critical Appraisal Sheet from the Oxford Center for Evidence-Based Medicine. TSA was performed using Copenhagen Trial Unit (Centre for Clinical Intervention Research, Denmark) software. We analyzed sensitivity of models using relative risk reduction rates. Results. We analyzed 3 international guidelines on the management of primary and incisional ventral hernias: the International Endohernia Society (IEHS, 2019), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES, 2016), and the European Hernia Society (EHS, 2023). Systematic reviews in all guidelines had high quality. The IEHS (2019) and SAGES (2016) guidelines synthesized evidence without meta-analytical processing, whereas the EHS (2023) guideline incorporated meta-analysis. Our supplementary TSA calculations demonstrated that EHS (2023) guideline evidence base is sufficiently powered to identify diabetes mellitus and surgical site infection as key risk factors of incisional hernia following midline laparotomy. Alloplastic mesh appeared to be a preventive factor against hernia recurrence compared with suture repair. Nonetheless, optimal mesh placement technique remains inconclusive. Conclusion. To ensure necessary evidence base for updated guidelines on midline ventral hernias, further protocol studies are needed, including international collaboration. An alternative option for achieving a larger sample size, but with lower evidence base, could be research of surgical registries.

Radiotherapy is a well-recognized risk factor of acute leakage after colorectal surgery. However, its relationship with delayed leakage remains unclear. The aim of this systemic review and meta-analysis was to determine its association with delayed anastomotic leakage (DAL) after rectal surgery. A comprehensive literature search was conducted across seven international databases (PubMed, Embase, Cochrane CENTRAL, ClinicalKeys, EBSCOhost-CINAHL, Web of Science, and Google Scholar), five Chinese/Taiwanese databases, the ProQuest Dissertations, and three Grey literature databases. All studies that reported DAL where radiotherapy and nonradiotherapy study groups were included. The random-effect model was used to combine data. Data were presented as odds-ratios (ORs) with 95% confidence intervals (CI). The main outcome measured was DAL. Six comparative series involving a total of 4991 patients were analyzed. DAL was identified in 323 cases, occurring between 22 and 2059 days post-operation. The results revealed a statistically significant increase in the risk of DAL following radiotherapy (OR = 5.208; 95% CI = 3.241-8.371; p < 0.001). Heterogeneity was observed across the included studies (Cochran Q = 12.769 (p=0.026), I2=60.844%, Tau2 = 0.188, predictive interval (PI) = 5.208, 95% PI = 1.313-20.665). Radiotherapy is a potential risk factor for DAL after anterior resection and low anterior resection.

The Japanese Research Society for Cancer of the Colon and Rectum (JSCCR) advocates D3 regional lymph node (LN) dissection during colectomy in patients with locally advanced tumors¹. However, the concept of ‘complete mesocolic excision (CME) with central ligation’, introduced by Hohenberger et al., proposed routine infrapyloric and gastroepiploic LNs (IGLN) dissection rather than D3 lymphadenectomy for locally advanced right-sided transverse colon cancer (LARTCC) and hepatic flexure colon cancer (LAHFCC)^2,3. The debate over routine or selective IGLN dissection reflects the lack of clinical relevance of IGLN metastasis in the literature as none of the previous studies provide solid evidence⁴. Neither the JSCCR¹ nor the American Society of Colorectal Surgeons recommend routine IGLN dissection⁵. Thus, we conducted a standardized study to determine the prevalence of IGLN metastasis and to assess the feasibility, safety, and prognostic relevance of IGLN dissection for patients with LARTCC and LAHFCC.

Annals of Laparoscopic and Endoscopic Surgery goes visual

Subgroup analysis aims to identify subgroups (usually defined by baseline/demographic characteristics), who would (or not) benefit from an intervention under specific conditions. Often performed post hoc (not pre-specified in the protocol), subgroup analyses are prone to elevated type I error due to multiple testing, inadequate power, and inappropriate statistical interpretation. Aside from the well-known Bonferroni correction, subgroup treatment interaction tests can provide useful information to support the hypothesis. Using data from a previously published randomized trial where a p value of 0.015 was found for the comparison between standard and Hemopatch® groups in (the subgroup of) 135 patients who had hand-sewn pancreatic stump closure we first sought to determine whether there was interaction between the number and proportion of the dependent event of interest (POPF) among the subgroup population (patients with hand-sewn stump closure and use of Hemopatch®), Next, we calculated the relative excess risk due to interaction (RERI) and the “attributable proportion” (AP). The p value of the interaction was p = 0.034, the RERI was − 0.77 (p = 0.0204) (the probability of POPF was 0.77 because of the interaction), the RERI was 13% (patients are 13% less likely to sustain POPF because of the interaction), and the AP was − 0.616 (61.6% of patients who did not develop POPF did so because of the interaction). Although no causality can be implied, Hemopatch® may potentially decrease the POPF after distal pancreatectomy when the stump is closed hand-sewn. The hypothesis generated by our subgroup analysis requires confirmation by a specific, randomized trial, including only patients undergoing hand-sewn closure of the pancreatic stump after distal pancreatectomy.Trial registration: INS-621000-0760.