Targeting intratumoral microbiome: the MONARCH Trial takes aim at anaerobes in rectal cancer

“They’re called ‘trials’ for a reason” a very experienced clinical academic once told me during a difficult oversight meeting for a study I was leading. This randomised controlled trial (RCT) of an intervention used during emergency bowel surgery was struggling with recruitment rates after the pandemic and we were discussing ways to get things back on track. With some intensive efforts from all involved – and a fair amount of stress - we did manage to finish participant recruitment. Unperturbed, I even took on co-leadership of another emergency perioperative trial, CAMELOT, exploring rectus sheath catheter infusions for post-laparotomy analgesia.

Many of those interested in research and quality improvement for patients undergoing emergency surgery have felt compelled by the obvious health burden: 30,000 emergency laparotomy cases each year in the UK, with a 10% mortality rate at one month after surgery. The latter seems to have stubbornly plateaued after an initial improvement soon after our national audit rolled out. Yet most perioperative research is still directed at those undergoing elective surgery, with much lower overall risks. This is clearly a patient group that remains under-served, and with a lot to gain from even small improvements in postoperative outcomes. But formally evaluating new treatments in this setting is not without challenge.

PROTECT is a national platform trial designed to deliver multiple multi-centre randomised and non-randomised comparisons in adult surgical patients. Individual trial components will span phase II to phase IV, depending on the specific research question.

The study will be conducted across NHS surgical services and will include patients aged 18 years and over undergoing care within an NHS surgical pathway.

In the complex world of vascular surgery, where “high risk” is basically our love language, one topic continues to spark the debate: the uncomplicated type B aortic dissection. “Uncomplicated” may sound reassuring, but don’t be fooled. In reality, “uncomplicated” may just mean not yet complicating your life. These patients represent the calm before the storm, leaving clinicians to weigh whether it’s better to follow a conservative approach or go in early and do something heroic (and preferably endovascular).

Once upon a time, all type B dissections were approached as ticking time bombs — open surgery, big incisions and lots of drama. Outcomes, however, were far from ideal. As evidence emerged that doing less often yielded better results, the field shifted direction. Medical therapy became the dominant approach; enter the era of “let’s control the blood pressure and hope for the best.” Today, medical therapy — mainly antihypertensives and analgesics — remains the cornerstone for managing uncomplicated type B dissections.

Short-term survival left everyone quite satisfied: in-hospital survival was about 90%. Long-term results, however, were less pleasing. Survival drops to around 79% at five years, with approximately one-third of these initially “uncomplicated” patients eventually requiring intervention – procedures that are technically more challenging in the chronic phase with higher procedural risks. Turns out, “uncomplicated” is more complicated than it sounds.