Evidence map›Paper›PMID 40171564›Full record

Trial reportInternational journal of surgery (London, England)2025

Influence of surgical start time on the quality of surgery for middle and low rectal cancer: a post hoc analysis of the real trial.

Guodong He, Zhuojian Zhang, Weitang Yuan, Taiyuan Li, Bo Tang, Baoqing Jia, Yanbing Zhou, Wei Zhang, Ren Zhao, Cheng Zhang and 6 more

Abstract readRandomized Controlled TrialMulticenter StudyEquivalence Trial
PubMed Full text at PMC Publisher
In one paragraph

Trial report in International journal of surgery (London, England), 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

16 authors.

Guodong HeDepartment of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China.
Zhuojian ZhangDepartment of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China.
Weitang YuanDepartment of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzho, Henan Province, China.
Taiyuan LiDepartment of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China.
Bo TangDepartment of General Surgery, Southwest Hospital, Army Medical University, Chongqing, China.
Baoqing JiaDepartment of General Surgery, The First Medical Center, PLA General Hospital, Beijing, China.
Yanbing ZhouDepartment of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China.
Wei ZhangDepartment of Colorectal Surgery, Changhai Hospital, Navy Medical University, Shanghai, China.
Ren ZhaoDepartment of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Cheng ZhangDepartment of General Surgery, Northern Theater Command General Hospital, Shenyang, Liaoning Province, China.
Longwei ChengSecond Department of Gastrointestinal Surgery, Jilin Cancer Hospital, Changchun, Jilin Province, China.
Xiaoqiao ZhangDepartment of General Surgery, Shandong Provincial Hospital affiliated to the Shandong First Medical University, Jinan, Shandong Province, China.
Fei LiangDepartment of Biostatistics, Zhongshan Hospital Fudan University, Shanghai, China.
Ye WeiDepartment of General Surgery, Huadong Hospital Fudan University, Shanghai, China.
Qingyang FengDepartment of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China.
Jianmin XuDepartment of Colorectal Surgery, Zhongshan Hospital Fudan University, Shanghai, China.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundSurgical start time is considered to influence the quality of surgery due to surgeon fatigue. High-quality studies on middle and low rectal cancer are lacking. The analysis aims to find out the influence of surgical start time on the quality of surgery for middle and low rectal cancer, and whether robotic surgery could avoid the influence. MATERIALS AND

methodsThis study was a post hoc analysis of the REAL (robotic vs. laparoscopic surgery for middle and low rectal cancer) study, a multicenter, randomized, controlled, unblinded, parallel group, superiority trial. This analysis included the modified intention-to-treat population of the REAL study, who were divided into Group I (the surgeon's first surgery of the day), Group II (the surgeon's second surgery of the day), and Group III (the surgeon's third and subsequent surgeries of the day) based on surgical information registered in the REAL study. The primary outcome was the percentage of patients with a positive circumferential resection margin. The second outcomes were the macroscopic completeness of resection the incidence of intraoperative complications and 30-day postoperative complications.

resultsA total of 1171 patients from the REAL study were included and divided into three groups: 547 (46.7%) in Group I (the surgeon's first surgery), 420 (35.9%) in Group II (the surgeon's second surgery), and 204 (17.4%) in Group III (the surgeon's third and subsequent surgeries). There was a lower percentage of circumferential resection margin (CRM)-positive patients in Group I (3.9%) than in Group II (6.6%, unadjusted P = 0.069) and Group III (8.1%, unadjusted P = 0.027, adjusted P = 0.081). Group I also had fewer intraoperative complications (5.3%) than Group II (8.3%, unadjusted P = 0.060) and Group III (9.3%, unadjusted P = 0.046, adjusted P = 0.138). Macroscopic completeness of resection was not significantly different among the three groups (complete rate: Group I vs. Group II, 94.9% vs. 92.4%, unadjusted P = 0.254; Group I vs. Group III, 94.9% vs. 92.6%, unadjusted P = 0.334; Group II vs. Group III, 92.4% vs. 92.6%, unadjusted P = 0.488). The incidence of 30-day postoperative complications showed no significant difference among the three groups (Group I vs. Group II, 18.5% vs. 20.0%, unadjusted P = 0.547; Group I vs. Group III, 18.5% vs. 22.1%, unadjusted P = 0.268; Group II vs. Group III, 20.0% vs. 22.1%, unadjusted P = 0.551). The quality of robotic surgery was not significantly influenced by surgical start time. For laparoscopic surgery, Group I had a lower CRM positivity rate (4.3%) than Group II (9.4%, unadjusted P = 0.029, adjusted P = 0.087) and Group III (10.4%, unadjusted P = 0.031, adjusted P = 0.047).

conclusionAccording to this post hoc analysis of the REAL study, for middle and low rectal cancer surgery, surgical start time could influence surgical quality by affecting surgeon fatigue. Surgeries start later in a day bring worse quality compared to those early in a day. Robotic surgery could reduce this influence to some extent, while laparoscopic surgery is more susceptible.

Indexed as

LaparoscopyRectal NeoplasmsRobotic Surgical ProceduresAgedFemaleHumansMaleMargins of ExcisionMiddle AgedPostoperative ComplicationsTime Factorsquality of surgeryrectal cancerrobotic surgery

Identifiers

PMID40171564
PMCPMC12165524

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