The research, conducted at the Children’s Hospital of Chongqing Medical University and published in BMC Pediatrics, followed 280 infants who underwent surgery for post-necrotizing enterocolitis intestinal stricture between January 2017 and December 2025. Of these, 194 received a primary anastomosis, in which surgeons remove the damaged segment and immediately join the two healthy ends of the bowel together. The remaining 86 underwent a staged enterostomy, a two-step approach in which the bowel is brought out through the abdominal wall as a temporary stoma, allowing the intestine to heal before a second operation reconnects it. Because surgeons tend to choose the staged approach for sicker, more fragile babies, a simple comparison of outcomes between the two groups would be deeply misleading.

To overcome that bias, the research team turned to propensity score matching, a statistical technique designed to mimic the balance of a randomized trial using observational data. Each infant treated with a primary anastomosis was paired with an infant treated with a staged enterostomy who had a nearly identical profile of baseline characteristics, with exact matching by sex and a caliper width of 0.2 standard deviations of the logit of the propensity score. After this careful pairing, 73 matched pairs remained, and all absolute standardized mean differences fell to 0.17 or lower, indicating that the two groups were well balanced on the measured variables. This allowed the investigators to compare the two operations on far more equal footing than previous studies had managed.

The results paint a nuanced picture. In the matched cohort, primary anastomosis took slightly longer in the operating room, with a median operative duration of 96 minutes compared with 90 minutes for staged enterostomy, a difference that was statistically significant. Yet that extra time under anesthesia appeared to buy a faster overall recovery. Infants who received the single-stage operation began enteral feeding at the same point as their staged counterparts, a median of seven days after surgery, but they went home sooner: the median postoperative hospital stay was 15 days after primary anastomosis versus 18 days after staged enterostomy, a difference that reached statistical significance.

Complication data added further weight to the case for the one-stage repair, though with important caveats. Individual major adverse events, including anastomotic leakage, the complication surgeons fear most when reconnecting bowel, were uncommon in both groups and did not differ significantly between the operations. However, when the researchers looked at the composite rate of early postoperative complications, meaning any of several early problems occurring together, the primary anastomosis group fared better, with 4.1 percent experiencing such events compared with 15.1 percent in the staged enterostomy group, a difference that was statistically significant. For parents agonizing over the choice, that gap in overall early complications may prove as meaningful as the difference in hospital stay.

To translate these findings into something clinicians can actually use, the team went a step further and built a risk prediction model. Using multivariable logistic regression, they identified factors that predicted a prolonged postoperative length of stay, which they operationally defined as 19 days or longer, corresponding to the 75th percentile of their cohort rather than a validated universal clinical cutoff. In this analysis, staged enterostomy itself emerged as an independent predictor of prolonged hospitalization, carrying an adjusted odds ratio of 2.94, with a 95 percent confidence interval of 1.52 to 5.71 and a P value of 0.001. In plain terms, even after accounting for measured baseline differences between the patients, undergoing the staged procedure nearly tripled the odds of an extended stay.

The prediction model itself showed acceptable discrimination, achieving an area under the receiver operating characteristic curve of 0.780, with a 95 percent confidence interval of 0.736 to 0.854. An area of 0.5 would indicate performance no better than chance, while 1.0 would represent perfect discrimination, so a value near 0.78 suggests the model can meaningfully separate infants likely to have short recoveries from those likely to face prolonged hospitalization. The authors were careful, however, to label the model preliminary. They explicitly cautioned that it should not be implemented in routine clinical practice until it has undergone external multicenter validation, a standard safeguard in the fast-moving field of clinical prediction tools, where models that perform well on their own data often falter when applied to new populations.

The study’s design carries both strengths and limitations that readers should keep in mind. As a single-center retrospective cohort, it reflects the practice patterns and patient population of one major Chinese children’s hospital, and its findings may not generalize everywhere. Propensity score matching can only balance the variables that were measured; unmeasured differences, such as the precise condition of the bowel at the time of surgery or subtle markers of illness severity that influenced the surgeon’s choice, could still have influenced the results. The researchers followed the STROBE reporting guidelines for observational studies and the TRIPOD guidelines for prediction models, signaling attention to transparency, but the inherent constraints of retrospective data remain.

Perhaps the most important message from the authors is one of balance rather than triumph. While primary anastomosis was associated with a shorter initial postoperative hospitalization and a lower composite rate of early complications among selected infants, staged enterostomy remains a necessary and sometimes lifesaving option when immediate reconnection of the bowel is unsuitable, for instance when tissue viability or the infant’s overall condition makes a one-stage repair too risky. The decision, the study suggests, should rest on careful patient selection rather than a blanket preference for either operation. Surgeons reading the paper will likely see it as support for attempting primary anastomosis in stable, well-selected infants, while retaining the staged approach as a vital fallback.

For the broader community of neonatologists, pediatric surgeons, and families of NICU graduates, the study arrives at a moment of growing interest in long-term outcomes after necrotizing enterocolitis. As survival from the acute illness improves, the management of its late sequelae, strictures chief among them, becomes an increasingly common clinical challenge. This research, funded without any specific grant from public, commercial, or not-for-profit agencies and approved by the hospital’s institutional review board with informed consent waived due to its retrospective design, offers a rigorous template for how such questions can be answered with real-world data. Larger, multicenter efforts will be needed to confirm the findings and validate the prediction model, but for now the study gives surgical teams concrete numbers to weigh: a few extra minutes in the operating room, roughly three fewer days in the hospital, and a lower rate of early complications for the infants healthy enough to undergo a single-stage repair.

Subject of Research: Surgical management of post-necrotizing enterocolitis intestinal stricture in infants

Article Title: Primary anastomosis versus staged enterostomy for post-necrotizing enterocolitis intestinal stricture in infants: a propensity score-matched cohort study and prediction model

Article References: Wang, Y., Chen, P., Feng, W., Wang, Y., Liu, W., & Guo, Z. (2026). Primary anastomosis versus staged enterostomy for post-necrotizing enterocolitis intestinal stricture in infants: a propensity score-matched cohort study and prediction model. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07657-x

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07657-x

Keywords: necrotizing enterocolitis, intestinal stricture, primary anastomosis, staged enterostomy, infants, pediatric surgery, propensity score matching, length of stay, prediction model, BMC Pediatrics, neonatal surgery, anastomotic leakage

The study, published in Annals of Gastroenterological Surgery, drew on the nationwide Ta-Ta-Mi registry, which captured 706 patients who underwent TaTME at 26 institutions affiliated with the Japan Society of Laparoscopic Colorectal Surgery. From this pool, 679 patients with primary rectal cancer were eligible for the current analysis, all operated on between January 2012 and December 2019. The researchers focused on tumors whose distal edge lay within 12 centimeters of the anal verge—the mid and low rectum, where surgical access is most difficult and where total mesorectal excision, the meticulous removal of the fatty envelope surrounding the rectum, is critical for local tumor control.

TaTME was developed specifically to overcome the limitations of conventional laparoscopic pelvic dissection, which becomes notoriously awkward in male patients, obese patients, and those with narrow pelvises or low-lying tumors. By entering through the anus and working upward, surgeons gain improved visualization and instrument maneuverability in the deepest part of the pelvis. A network meta-analysis of 29 randomized controlled trials involving 6,237 patients previously found broadly comparable perioperative and oncological outcomes across open, laparoscopic, robotic, and transanal approaches, though laparoscopic surgery carried a higher risk of circumferential resection-margin involvement than the transanal route. What remained unclear, however, was how neoadjuvant therapy—now increasingly given as total neoadjuvant therapy, or TNT, to boost pathological complete response rates—changes the picture for TaTME specifically.

To answer that question, the research team employed propensity score matching, a statistical technique designed to mimic randomization in observational data. Patients who received neoadjuvant therapy were matched one-to-one with those who went straight to surgery, balancing the groups on age, sex, body mass index, American Society of Anesthesiologists physical status, the tumor markers CEA and CA19-9, previous abdominal surgery, and clinical tumor stage. After matching, 294 patients—147 in each arm—formed the comparison cohort, with standardized mean differences confirming good balance across nearly all prespecified covariates. The primary endpoint was severe postoperative complications, defined as Clavien–Dindo grade III or higher, a scale that grades complications from mild deviations to life-threatening events requiring invasive intervention.

The headline result was striking in its clarity on one front and its ambiguity on another. Severe complications occurred in 12.2 percent of the non-neoadjuvant group and 10.9 percent of the neoadjuvant group—an adjusted odds ratio of 0.90 with a confidence interval spanning 0.44 to 1.85, far from statistical significance. Sensitivity analyses using conventional multivariable logistic regression, Firth logistic regression, and marginal standardization on the full cohort of 676 patients likewise found no significant association. Yet the researchers were careful to note that the confidence intervals remained wide, meaning clinically relevant benefit or harm could not be excluded. The overall severe complication rate of 11.6 percent in the matched cohort sits comfortably within the 10 to 15 percent range reported in previous multicenter trials, lending external consistency to the findings.

Operative time told a different story. Patients who had received neoadjuvant therapy spent a median of 510 minutes in the operating room, compared with 382 minutes for those who had not—an adjusted mean difference of nearly 130 minutes, highly statistically significant. This association persisted even after accounting for body mass index, operative procedure, lateral pelvic lymph node dissection, and abdominal approach, with neoadjuvant therapy independently associated with a 14 percent increase in operative time. Even among patients who did not undergo lateral lymph node dissection, a procedure that itself dramatically lengthens surgery, neoadjuvant therapy remained linked to a 13.9 percent longer operation. The researchers attribute the delay to treatment-associated tissue edema, fibrosis, and less distinct anatomical planes—changes that make the deep pelvic dissection inherently more laborious, though residual confounding cannot be ruled out.

The multivariable analysis of the full cohort painted a richer portrait of what drives operative duration. Male sex, higher body mass index, previous abdominal surgery, more advanced clinical T stage, lateral lymph node dissection, abdominoperineal resection, and an open surgical approach all independently lengthened the operation, while a two-team transanal approach—simultaneous abdominal and perineal dissection—shortened it by nearly 18 percent. Notably, bilateral lateral lymph node dissection added more than 50 percent to operative time, underscoring just how much the extent of nodal surgery shapes the surgical workload, yet the absence of a significant interaction between neoadjuvant therapy and lymph node dissection extent suggests the two effects operate independently.

Pathological findings revealed the biological footprint of preoperative treatment. Lymphatic invasion was significantly less frequent in the neoadjuvant group—23.8 percent versus 43.5 percent—and venous invasion showed an even starker reduction, 38.8 percent versus 64.6 percent, both with p values below 0.001. These changes reflect the known treatment-related pathological response to neoadjuvant therapy, in which chemotherapy and radiation systematically eradicate tumor cells that have invaded lymphatic and blood vessels. Tumor budding grades also differed, with no BD3 cases in the neoadjuvant group compared with 10 in the non-neoadjuvant arm. No significant differences emerged in p/ypT category, p/ypN status, perineural invasion, or tumor differentiation.

Perhaps most clinically reassuring were the resection-margin results. Distal margin positivity was vanishingly rare in both groups—0.7 percent each—and circumferential resection-margin involvement, defined as a tumor-to-margin distance of 1 millimeter or less, occurred in 7.8 percent of evaluable non-neoadjuvant patients and 5.7 percent of neoadjuvant patients, a non-significant difference. This matters because fibrosis and tissue edema after neoadjuvant therapy could theoretically obscure the dissection plane and increase the risk of an inadequate margin. In this multicenter cohort treated at experienced centers, TaTME after neoadjuvant therapy showed no such penalty.

An unexpected observation was that anastomotic leakage—the leakage of bowel contents from a surgical connection—occurred in only 3.4 percent of neoadjuvant patients undergoing low anterior or intersphincteric resection, compared with 11.7 percent of non-neoadjuvant patients. The authors caution that this finding is exploratory: tumor regression after neoadjuvant therapy may facilitate distal rectal transection and reconstruction, but differences in patient selection, anastomotic technique, and perfusion assessment that were not captured in the database could also explain the gap, and the absolute number of leakage events was small. The regimen-specific analysis, comparing neoadjuvant chemotherapy, chemoradiotherapy, total neoadjuvant therapy, and radiotherapy alone, found no statistically significant differences in severe complications or operative time after adjustment, though the descriptive data suggested radiotherapy alone produced the longest operations.

The study carries important limitations that temper its conclusions. As a retrospective observational analysis, treatment assignment was not randomized, and the neoadjuvant group included only patients who ultimately proceeded to TaTME—those who developed disease progression or severe toxicity before surgery were not captured, meaning the findings apply to selected surgical candidates rather than the complete treatment strategy. Neoadjuvant regimen selection, lymph node dissection criteria, and sphincter-preserving indications were not standardized across institutions, the interval between treatment completion and surgery was unavailable, and pathological assessment was performed locally without centralized review. All participating centers were experienced Japanese institutions, which may limit generalizability to other healthcare systems.

Nevertheless, the nationwide multicenter design and the depth of clinical, operative, and pathological data represent substantial strengths, and the consistency of the severe-complication findings across multiple statistical approaches strengthens confidence in the central message. For surgeons and patients weighing the timing of therapy before transanal rectal cancer surgery, the evidence suggests that preoperative neoadjuvant treatment, while adding meaningful time under anesthesia, does not appear to compromise the safety profile or the quality of the oncological resection in experienced hands. As total neoadjuvant therapy continues to expand globally in the pursuit of higher pathological complete response rates and improved systemic disease control, these findings provide a practical foundation for surgical planning in the era of increasingly intensive preoperative treatment.

Subject of Research: Short-term surgical outcomes of transanal total mesorectal excision for rectal cancer with and without preoperative neoadjuvant therapy

Article Title: Short‐Term Outcomes of Transanal Total Mesorectal Excision for Rectal Cancer: A Multicenter Propensity Score‐Matched Analysis Comparing Patients With and Without Preoperative Neoadjuvant Therapy

Article References: Shima, T., Hamamoto, H., Matsuda, T., Takemasa, I., Tanaka, K., Mukai, T., Watanabe, J., Lee, S.-W., Yamamoto, S., Naitoh, T., & Ta‐Ta‐Mi Study Group Collaborators from the Japan Society of Laparoscopic Colorectal Surgery (2026). Short‐Term Outcomes of Transanal Total Mesorectal Excision for Rectal Cancer: A Multicenter Propensity Score‐Matched Analysis Comparing Patients With and Without Preoperative Neoadjuvant Therapy. Annals of Gastroenterological Surgery, Article ags3.70298. https://doi.org/10.1002/ags3.70298

Image Credits: AI Generated

DOI: 10.1002/ags3.70298

Keywords: rectal cancer, transanal total mesorectal excision, neoadjuvant therapy, total mesorectal excision, propensity score matching, surgical outcomes, anastomotic leakage, Clavien-Dindo complications, chemoradiotherapy, total neoadjuvant therapy, operative time, circumferential resection margin

Minimally invasive esophagectomy, or MIE, replaces the large incisions of conventional open surgery with thoracoscopic and laparoscopic techniques, aiming to reduce trauma to the chest and abdominal wall while still removing the esophagus and reconstructing the digestive tract. Since the first reported case by Cuschieri and colleagues in 1992, the approach has spread rapidly around the world. In Japan, where esophageal cancer remains one of the more common and lethal malignancies, the proportion of esophagectomies performed minimally invasive rose from just 2 percent in 1996 to 57 percent by 2016, according to national surgical registries. That steep adoption curve reflects advances in instrumentation, the widespread uptake of the prone position for the thoracic phase, and insurance coverage introduced in 2002.

Yet esophagectomy in any form remains one of the most demanding operations in gastrointestinal surgery, and MIE demands even greater technical skill. The operation requires mobilizing the esophagus deep within the mediastinum, performing extensive lymph node dissection near the recurrent laryngeal nerves and airway, and then fashioning a new conduit from the stomach. Given these challenges, the question of whether hospitals that rarely perform the procedure achieve comparable results has been a persistent concern for surgeons and policymakers alike.

The scientific lineage of the volume-outcome question stretches back to 1979, when Luft and colleagues first documented that surgical mortality declines as hospital case volume rises across a range of procedures. Begg and colleagues focused specifically on esophagectomy in 1998, followed by Swisher, van Lanschot, and Birkmeyer, each using different volume thresholds but each reaching the same directional conclusion: the lowest-volume hospitals consistently posted the highest death rates. Japanese investigators, including Kazui and later Nishigori, confirmed similar patterns in national data. What remained unknown was whether these findings, based on open surgery or mixed populations, applied to MIE performed exclusively.

To answer that question, the research team turned to the National Clinical Database, a rigorously audited nationwide registry developed in cooperation with Japan’s surgical board certification system. The database enforces standardized definitions of morbidity and mortality and maintains continuous data verification. The investigators included patients with thoracic esophageal cancer who underwent transthoracic subtotal esophagectomy with reconstruction, defining MIE as either a totally thoracoscopic and laparoscopic approach or a hybrid combining thoracoscopy with open laparotomy. Of the 22,712 eligible cases, 9,739, or 42.9 percent, were performed minimally invasively.

Hospitals were stratified into five categories by their average annual esophagectomy volume, counting both open and minimally invasive operations to capture total institutional experience: very low (1 to 5 cases per year), low (6 to 10), medium (11 to 20), high (21 to 40), and very high (41 or more). The distribution was heavily skewed. Nearly three quarters of all hospitals fell into the very low category, while only 26 institutions performed 41 or more esophagectomies annually. Meanwhile, MIE adoption rose steadily with volume, from 27.9 percent of operations at very low-volume hospitals to roughly 45 to 50 percent at the higher-volume tiers, suggesting that minimally invasive techniques concentrated early in busier centers.

The raw outcomes were unambiguous. Overall operative mortality for MIE across the study period was 2.1 percent, but it ranged from 1.2 percent at very high-volume hospitals to 3.9 percent at very low-volume centers. After adjusting for patient age, comorbidities, American Society of Anesthesiologists class, preoperative therapy, and tumor stage using hierarchical logistic regression, patients at very low-volume hospitals faced 2.70 times the odds of death compared with those at very high-volume hospitals, a difference that was highly statistically significant. Medium-volume hospitals also showed a modest but significant elevation in risk, with an odds ratio of 1.70, while the differences at low and high-volume hospitals did not reach statistical significance.

Intriguingly, the overall complication rate, which averaged 40.9 percent, varied far less across hospital tiers, from 38.7 percent at the busiest centers to 44.2 percent at the least busy, and the adjusted analysis found no significant volume effect on total complications. This dissociation between complications and mortality points toward what surgical health services researchers call failure to rescue: the capacity of an institution to recognize and effectively manage a complication once it arises. Prior work by Abdelsattar and colleagues found that 21.2 percent of patients with major complications died before discharge at low-volume hospitals, compared with 13.4 percent at high-volume hospitals, a gap attributed to differences in evidence-based care processes and structural resources such as dedicated surgical intensive care units and multidisciplinary teams.

The complication-specific analyses sharpened this picture. Anastomotic leakage, one of the most feared complications of esophageal reconstruction, was significantly more likely at very low-volume hospitals, with an adjusted odds ratio of 2.23 relative to very high-volume centers, and remained elevated at both low and high-volume tiers. Atelectasis was also significantly more common at very low-volume hospitals. By contrast, rates of postoperative pneumonia, recurrent laryngeal nerve paralysis, and chylothorax showed no significant volume association, hinting that the core technical execution of MIE has become fairly standardized across Japan. Consistent with that interpretation, operative time and intraoperative blood loss were broadly similar across hospital tiers, while postoperative length of tellingly fell from a median of 30 days at very low-volume hospitals to 21 days at very high-volume centers, a difference the authors attribute partly to more effective perioperative management.

The study period itself was a deliberate choice. Between 2012 and 2015, Japanese esophageal surgery was undergoing its steepest transition toward minimally invasive techniques, with institutional experience varying enormously. The authors argue this transitional window makes the volume effect especially visible. Their analysis also situates the findings within an international debate over volume thresholds. The Leapfrog Group in the United States progressively raised its recommended minimum to 20 esophagectomies per year by 2018, while Japanese researcher Fujita and colleagues identified fewer than 5 cases per year as the risky threshold in an earlier national analysis, a figure closely matching the present study’s definition of very low-volume hospitals.

The implications for policy are nuanced rather than simplistic. Centralizing all MIE to a handful of high-volume centers could save lives, but it would impose geographic burdens on patients in rural regions and may be impractical in a country with a dispersed hospital network. The authors suggest alternative safeguards: paying close attention to surgeon-level volume, which Birkmeyer and colleagues showed explains nearly half of the hospital volume effect on mortality, and ensuring that operations and perioperative care are led by board-certified esophageal surgery specialists. In Japan, senior surgeons at high-volume hospitals frequently supervise less experienced colleagues, and multidisciplinary conferences may spread expertise beyond the operating surgeon, which could explain why earlier Japanese studies found hospital volume mattered while individual surgeon volume did not.

The authors acknowledge important limitations. The registry did not capture institutional factors such as hospital size, intensive care staffing, or the presence of certified esophageal surgeons, any of which could mediate the volume-outcome relationship. Long-term survival, the ultimate measure of cancer care, was not assessed, although prior meta-analytic work by Brusselaers and colleagues suggests high-volume settings confer an 18 to 25 percent survival advantage that persists even after excluding early postoperative deaths. Residual confounding from patient frailty and nutritional status also cannot be excluded despite extensive risk adjustment.

Even with those caveats, the central message lands with force. Patients facing minimally invasive esophagectomy at hospitals that perform the operation only a handful of times a year, roughly once every two to three months, carry a substantially elevated risk of dying from the procedure itself. As minimally invasive esophagectomy continues its global march toward becoming the default approach for esophageal cancer, this study of nearly ten thousand Japanese patients offers a data-driven benchmark: somewhere around five cases a year, institutional experience appears to cross a line separating acceptable outcomes from avoidable deaths.

Subject of Research: The relationship between hospital surgical volume and postoperative outcomes of minimally invasive esophagectomy for esophageal cancer

Article Title: Relationship Between Hospital Volume and Outcomes of Minimally Invasive Esophagectomy for Esophageal Cancer: Analysis of the National Clinical Database in Japan

Article References: Ozawa, S., Kumamaru, H., Kitagawa, Y., Koyanagi, K., Oguma, J., Udagawa, H., Miyata, H., Toh, Y., & Matsubara, H. (2026). Relationship Between Hospital Volume and Outcomes of Minimally Invasive Esophagectomy for Esophageal Cancer: Analysis of the National Clinical Database in Japan. Annals of Gastroenterological Surgery, 10(5), 1518-1526. https://doi.org/10.1002/ags3.70229

Image Credits: AI Generated

DOI: 10.1002/ags3.70229

Keywords: esophageal cancer, minimally invasive esophagectomy, hospital volume, surgical mortality, National Clinical Database, failure to rescue, anastomotic leakage, postoperative complications, thoracic surgery, Japan, volume-outcome relationship, surgical outcomes