Efficiency and safety of continuous barbed suture for fascial closure in minimally invasive colorectal surgery: A propensity score-matched analysis

Efficiency and safety of continuous barbed suture for fascial closure in minimally invasive colorectal surgery: A propensity score-matched analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Efficiency and safety of continuous barbed suture for fascial closure in minimally invasive colorectal surgery: A propensity score-matched analysis Nobuhiro Naito, Hiroaki Kasashima, Tatsunari Fukuoka, Shintaro Ozawa, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8801503/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Surgical-site infections and incisional hernias remain significant challenges in colorectal cancer surgery. While minimally invasive techniques reduce surgical trauma, the optimal fascial closure method for small incisions to prevent these complications has not been definitively established. This study evaluated the efficacy of continuous barbed suturing in streamlining surgical workflow and its safety regarding postoperative complications compared to traditional simple interrupted suturing. We retrospectively analyzed 220 patients undergoing elective minimally invasive colorectal cancer surgery. To ensure a robust comparison, propensity score matching was employed to balance baseline characteristics between the continuous barbed suture and simple interrupted suture groups. Our results demonstrated that the incidences of surgical-site infections and incisional hernias, confirmed by CT imaging at 12 months, did not differ significantly between the two techniques. However, the mean fascia closure time was significantly reduced in the continuous barbed suture group (4.9 min) compared to the simple interrupted group (11.8 min) (p<0.001) (Post-PSM). These findings indicate that continuous barbed suturing for small-incision closure is safe, reliable, and significantly more efficient than conventional methods. By reducing operative stress and procedural time, this technique represents a superior alternative to traditional methods and has the potential to become the gold standard for fascial management in minimally invasive colorectal surgery. Biological sciences/Cancer Health sciences/Diseases Health sciences/Gastroenterology Health sciences/Medical research Health sciences/Oncology Colorectal cancer Minimally invasive surgery Fascial closure Barbed suture Incisional hernia Surgical workflow Introduction Minimally invasive colorectal surgery promotes recovery, yet surgical site infections (SSIs) and incisional hernias remain significant complications. While fascial closure techniques for midline laparotomies are well-debated, consensus is lacking for "mini-laparotomy" incisions (3–5 cm) used in laparoscopic or robotic surgery. Furthermore, in the restricted workspace of a mini-laparotomy, performing secure and consistent manual knot-tying can be technically demanding, potentially leading to variability in suture tension. The biomechanical stress on these small incisions differs fundamentally from traditional large incisions, potentially benefiting from barbed sutures, which distribute tension evenly without high-tension knots. However, evidence specifically evaluating barbed sutures for mini-laparotomy closure is scarce. This study evaluated the clinical outcomes of continuous barbed suturing versus conventional interrupted suturing for small-incision closure using propensity score matching, aiming to establish an efficient and safe fascial management strategy in minimally invasive colorectal surgery. Results We compared the efficacies of continuous and simple interrupted suturing for fascial closure of small incisions in patients undergoing minimally invasive (laparoscopic and robot-assisted) surgery for colorectal cancer. We applied PSM to address the potential for baseline imbalances in this retrospective study and enhance statistical reliability. Comparison of Patient Demographics and Surgical Factors: Baseline clinical characteristics, including age, Body Mass Index(BMI), and comorbidities, were well-balanced between the two groups both before and after propensity score matching (PSM) (Table I). Notably, no patients in either group were receiving preoperative steroid treatment. PSM was applied to the data for a more rigorous comparison. The post-PSM analysis confirmed the findings of the pre-PSM analysis, with no significant differences in any of the aforementioned patient characteristics between the two groups (Table I). This homogeneous dataset facilitated a more accurate and objective evaluation of the effects of each technique and helped minimize the influence of confounding factors. Comparison of Primary and Secondary Outcomes: The primary outcomes, including the incidences of SSI and incisional hernia, and the secondary outcomes, including duration of surgery, blood loss, presence of stoma, postoperative length of hospital stay, and complication rates, were compared in detail using the well-matched post-PSM dataset (Table II). To mitigate the influence of potential confounding factors, we employed PSM to balance key clinical risk factors, including BMI and preoperative steroid use, which are well-known predictors of surgical site complications. After matching, the comparison revealed that the incidences of SSI and incisional hernia were comparable between the groups. The median postoperative hospital stay was evaluated to assess the impact of the suturing technique on recovery. In the pre-matching cohort, the median length of stay was 12.0 days (range: 8–41 days) in the continuous barbed suture group and 12.0 days (range: 7–42 days) in the simple interrupted group, showing no significant difference between the two (p = 0.551). Following propensity score matching, the median hospital stay remained comparable between the groups, with 12.0 days (range: 8–41 days) in the continuous group and 12.5 days (range: 8–31 days) in the simple interrupted group (p = 0.402). These results indicate that the use of a continuous barbed suture for fascial closure does not prolong the recovery period or affect the timing of hospital discharge compared to traditional interrupted suturing. In the propensity score-matched cohort, the median operating time was 261min (range: 168–715 min) in the Continuous group and 264 min (range: 195–726 min) in the Interrupted group, with no significant difference observed between the two techniques (p = 0.871). Regarding median blood loss, no significant difference was observed between the Continuous group 3.0 g (2–750 g) and the Interrupted group 5.0 g (2–2570 g) after propensity score matching (p = 0.582). Regarding the median fascia closure time, the Continuous group was remarkably faster, requiring less than half the time of the Interrupted group (4.9 min [3.2–8.8 min] vs. 11.5 min [6.9–24.9 min]; p < 0.001). This striking disparity in efficiency was further confirmed in the propensity score-matched cohort, where the Continuous group maintained a significantly shorter closure time compared to the PSM-Interrupted group (4.9 min [3.2–8.8 min] vs. 10.2 min [6.9–24.9 min]; p < 0.001). These findings underscore the overwhelming procedural advantage of the barbed suture in streamlining the final stage of surgery. Proposed Revision: Based on the post-PSM dataset, we conducted a rigorous comparative analysis of clinical outcomes. The incidence of SSI was 1 case (3.6%) for both the continuous and simple interrupted suture groups (p = 1.00). The incidence of incisional hernia was 2 cases (7.1%) in the continuous suturing group and 3 cases (10.7%) in the simple interrupted suturing group, with no statistically significant difference (p = 1.00). Discussion The optimal method for fascial closure has long been a subject of debate in gastrointestinal surgery, as the integrity of the abdominal wall repair directly influences long-term outcomes. Traditionally, the choice between continuous and interrupted suturing has been weighed based on the biomechanical distribution of tension and procedural efficiency. While continuous suturing is often preferred for its speed, concerns regarding tension concentration—which could lead to tissue ischemia or suture failure—have led many surgeons to favor interrupted sutures, particularly in high-risk settings. Previous large-scale meta-analyses, such as that by van 't Riet et al., have compared these techniques in midline laparotomies and found no significant difference in the incidence of complications like surgical site infection (SSI) or incisional hernia 5 . However, most classical studies focus on large incisions. In the context of minimally invasive surgery, where the fascia is closed through a "mini-laparotomy," the biomechanical requirements differ. Our study focused on this specific environment, evaluating whether a continuous barbed suture (STRATAFIX®)—designed to distribute tension evenly without the need for knots—could offer a distinct advantage over traditional methods. Regarding the mechanical integrity of the closure, incisional hernia remains one of the most common complications of laparotomy, with an incidence typically reported between 2% and 10% 6 . A large-scale meta-analysis of 23 trials involving over 10,000 patients demonstrated that continuous suturing is as safe as interrupted suturing regarding the incidence of incisional hernia, while providing the advantage of reduced operative time 7 . Some reports have indicated even higher late-onset rates of 12.3% at one year and 23.2% at three years postoperatively 8 . Risk factors for incisional hernia, such as obesity and steroid use 9 , 10 , were adjusted for in our PSM analysis. Furthermore, the relationship between the suturing technique and hernia formation remains controversial; a meta-analysis by Diener et al. reported incisional hernia rates of 11.3% for continuous and 7.9% for simple interrupted sutures in elective midline laparotomy 11 . In our cohort, the continuous barbed suture group showed a trend toward a lower incidence of incisional hernia (7.1% vs. 10.7%), although this did not reach statistical significance ( p = 1.00 ). In the specific context of minimally invasive surgery, the restricted workspace of a mini-laparotomy often makes it technically challenging to maintain consistent tension and perform secure manual knot-tying. While traditional interrupted sutures rely on discrete "points" of tension (knots) that are prone to variability based on the surgeon's maneuverability, the barbed suture distributes tension along a continuous "line." This biomechanical characteristic effectively minimizes technical variability and compensates for the spatial constraints of small incisions, ensuring a more reproducible and stable fascial closure regardless of the limited working angle. The barbed mechanism potentially mitigates the risks of localized high tension and tissue ischemia—concerns typically associated with traditional running sutures—by anchoring at multiple points and ensuring uniform apposition. The barbed mechanism potentially addresses the "dead space" more effectively than traditional sutures by ensuring uniform, gap-free apposition along the entire length of the incision without the need for high-tension knots, thereby mitigating the risks of localized high tension and tissue ischemia typically associated with traditional running sutures 7 . This secure, gap-free closure is clearly visualized in our Supplementary Video 1, where the intraperitoneal view confirms the reliability of the technique even in the absence of manual tension maintenance. Our findings regarding SSI (3.6% in both groups) suggest that the fascial closure method is not the primary driver of infectious complications. SSI remains a critical challenge in perioperative management, significantly impacting hospital stay and healthcare costs 1 , 2 , 12 . Although risk factors such as advanced age, obesity, and diabetes are well-established 1 , 13 , the SSI incidence in our study was relatively low and comparable between groups. This aligns with the consensus that strict adherence to infection prevention measures, including prophylactic antibiotics and aseptic techniques, is more decisive than the specific suturing technique employed 5 . Theoretically, the knotless nature of barbed sutures offers a distinct advantage in infection control. Conventional interrupted sutures require multiple knots, which act as bulkier foreign bodies and can serve as a 'nidus' for bacterial colonization and biofilm formation. By eliminating these knots, barbed sutures potentially reduce the intra-wound bacterial load. Although our study showed equivalent SSI rates (3.6% in both groups), this suggests that while the barbed suture provides a cleaner, more streamlined closure, its clinical safety is at least non-inferior to traditional methods. This finding is particularly encouraging, as it confirms that the dramatic gain in procedural efficiency does not come at the cost of an increased infectious risk. Regarding the mean fascia closure time, the Continuous group was significantly faster than the Interrupted group (4.9 min [3.3–8.8 min] vs. 11.5min [6.9–24.9 min] ; p < 0.001 ). In this study, surgical parameters such as closure time and blood loss were analyzed using median values and non-parametric tests, as these clinical data often follow a non-normal distribution with significant outliers. This approach ensures a more robust and clinically realistic comparison of the two techniques by minimizing the influence of extreme cases. This significant difference was maintained after propensity score matching (Continuous: 4.9 min [3.2–8.8 min] vs. PSM-Interrupted: 10.2 min [6.9–24.9 min] ; p < 0.001 ). Our results reflect the overall efficiency of using barbed sutures in the final stage of the procedure, demonstrating a streamlined workflow. This efficiency is attributed to the self-anchoring, knotless mechanism, which allows for smooth procedural flow. Minimizing operative time contributes to healthcare cost savings and is a key component of Enhanced Recovery After Surgery (ERAS) protocols. For colorectal cancer patients, avoiding complications and ensuring swift recovery is paramount to starting adjuvant chemotherapy without delay—an aspect that is essential for optimizing long-term oncological outcomes 12 . While further large-scale validation is needed, the uniformity of tension distribution provided by the barbed mechanism represents a logical evolution in the closure of small incisions, where traditional knot-tying can be cumbersome and time-consuming. Limitations: This study has several limitations. First, its retrospective, single-center design may introduce selection bias. Second, the sample size after matching (n = 28 per group) is relatively small, which increases the risk of Type II error. Based on our current findings, approximately 100 cases per group would be required to statistically detect a 7% difference in hernia rates with 80% power. However, this study serves as a critical pilot evaluation, being the first to specifically demonstrate the safety and overwhelming time-saving advantages of barbed sutures for mini-laparotomy closure in colorectal surgery. While we continue to accumulate cases to increase statistical power, these preliminary findings provide immediate clinical relevance for surgical efficiency. Third, the 12-month follow-up may not capture late-onset hernias occurring years later. Finally, multi-center prospective studies, which we are currently planning, are necessary to validate these results and evaluate cost-effectiveness to standardize fascial closure in minimally invasive colorectal surgery. Continuous fascial suturing with barbed sutures for small incisions in colorectal cancer surgery is safe, effective, and significantly reduces closure time compared to interrupted sutures. By enhancing surgical efficiency and maintaining reliable abdominal wall integrity, this technique supports optimal perioperative recovery and facilitates the timely initiation of adjuvant oncological treatments. Methods Patients This retrospective cohort study included 220 patients who underwent elective surgery for colorectal cancer at the Osaka Metropolitan University Hospital between January 2024 and January 2025. All methods were performed in accordance with relevant guidelines and regulations. We compared the efficacies of continuous suture using STRATAFIX Symmetric PDS PLUS® (Ethicon, Johnson & Johnson, Livingston, Scotland, UK) for 28 of them and interrupted suture using 0-PDS Plus® (Ethicon, Johnson & Johnson, Livingston, Scotland, UK) for the remaining192 after laparatomy. We adjusted for these variables using propensity score matching (PSM) to account for potential imbalances in patient background factors. The patient demographics, cStage, surgical factors, postoperative complications, SSI, incisional hernia, and lengths of postoperative hospital stay of the post-matched groups (PSM-STRATAFIX and PSM-0PDS groups) were compared. The protocol for this study was approved by the Ethics Committee of Osaka Metropolitan University Hospital, Japan (reference number: 4182). Due to the retrospective nature of the study, the Ethics Committee of Osaka Metropolitan University Hospital waived the need for obtaining informed consent from all subjects. Procedures All the procedures were performed by experienced board-certified surgeons. The patients received prophylactic antibiotics before skin incision in accordance with the surgical infection guidelines. The intervention involved the closure of the abdominal fascia after a small incision. Fascial closure was performed using either interrupted 0-PDS Plus® or continuous STRATAFIX Symmetric PDS Plus® (both Ethicon, Johnson & Johnson, UK). The skin was closed with sutures. All data were stored in the electronic medical records, and severe adverse events were reported to the data center at Osaka Metropolitan University. The video images of the external and intraperitoneal views demonstrated secure fascial closure (Supplementary Video 1). Outcomes The primary endpoints were the incidences of incisional hernia and superficial or deep SSI, defined according to the Centers for Disease Control and Prevention/National Healthcare Safety Network 1 and Japan Nosocomial Infection Surveillance 2 criteria. SSI was assessed during hospitalization and at the first outpatient visit. Incisional hernia was defined as any abdominal wall gap or bulge at the scar area, perceptible by clinical examination or computed tomography (CT) 3 , and was evaluated 12 months postoperatively. Secondary endpoints included the length of postoperative hospital stay and the overall rate of surgical complications. Statistical Analysis We compared patients undergoing continuous versus simple interrupted suturing. To minimize selection bias, 1:1 propensity score matching (PSM) was performed with a caliper width of 0.2. Covariates included age, sex, BMI, ASA-PS score 4 , diabetes, steroid use, and cStage. After matching, the primary and secondary outcomes were compared between the two groups. The normality of continuous variables was evaluated using the Shapiro-Wilk test. Continuous variables were expressed as median (range: minimum–maximum) and compared using the Mann-Whitney U test. Categorical variables were compared using Fisher’s exact test or the chi-squared test. All analyses were performed using EZR version 1.68, with statistical significance set at p < 0.05 . AI Disclosure The authors acknowledge the use of Google Gemini, an AI-powered translation tool, for translating the original Japanese manuscript into English. This tool is used solely for linguistic assistance. The authors are solely responsible for the content, data, and conclusions of this paper. They have thoroughly reviewed and revised all AI-generated texts to ensure accuracy and alignment with the intended scientific meaning. Declarations Competing Interests: The authors declare no competing interests. Funding: This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution Conceptualization and study design: N.N, H.K, and K.MData curation and formal analysis: N.NMethodology: T.F, S.O, I.O, Y.F, Y.S, and K.KInvestigation and resources: Y.M, M.Y, T.Tamura, M.S, and T.ToyokawaWriting—original draft preparation: N.NWriting—review and editing: All authorsSupervision: K.MProject administration: T.F, H.KFinal approval of manuscript: All authors Acknowledgements: The authors thank the Department of Digestive Surgery, Graduate School of Medicine, Osaka Metropolitan University, for their valuable support. Data Availability All data generated or analyzed during this study are included in this publishedarticle and its Supplementary Information files. AI Disclosure The authors acknowledge the use of Google Gemini, an AI-powered translation tool, for translating the original Japanese manuscript into English. This tool is used solely for linguistic assistance. The authors are solely responsible for the content, data, and conclusions of this paper. They have thoroughly reviewed and revised all AI-generated texts to ensure accuracy and alignment with the intended scientific meaning. Study type: Clinical Date of submission: 2026.02.06 References Horan, T. C., Andrus, M. & Dudeck, M. A. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am. J. Infect. Control . 36 , 309–332. 10.1016/j.ajic.2008.03.002 (2008). Tsutsui, A. & Suzuki, S. Japan nosocomial infections surveillance (JANIS): a model of sustainable national antimicrobial resistance surveillance based on hospital diagnostic microbiology laboratories. BMC Health Serv. Res. 18 , 799. 10.1186/s12913-018-3604-x (2018). Muysoms, F. E. et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 19 , 1–24. 10.1007/s10029-014-1342-5 (2015). Cisneros-Perez, J. et al. The American Society of Anesthesiologists Physical Status (ASA-PS) Risk Group Classification Can Be Used to Anticipate Functional Recovery Outcomes after the Surgical Treatment of Female Urinary Incontinence with Transobturator Suburethral Tape. J. Clin. Med. 9 10.3390/jcm9082607 (2020). van 't Riet, M., Steyerberg, E. W., Nellensteyn, J., Bonjer, H. J. & Jeekel, J. Meta-analysis of techniques for closure of midline abdominal incisions. Br. J. Surg. 89 , 1350–1356. 10.1046/j.1365-2168.2002.02258.x (2002). Antoniou, G. A., Muysoms, F. E. & Deerenberg, E. B. Updated Guideline on Abdominal Wall Closure from the European and American Hernia Societies: Transferring Recommendations to Clinical Practice for Vascular Surgeons. Eur. J. Vasc Endovasc Surg. 65 , 774–777. 10.1016/j.ejvs.2023.02.009 (2023). Gupta, H. et al. Comparison of interrupted versus continuous closure in abdominal wound repair: a meta-analysis of 23 trials. Asian J. Surg. 31 , 104–114. 10.1016/S1015-9584(08)60069-X (2008). Fink, C. et al. Incisional hernia rate 3 years after midline laparotomy. Br. J. Surg. 101 , 51–54. 10.1002/bjs.9364 (2014). Bittner, R. et al. Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B. Surg. Endosc . 33 , 3511–3549. 10.1007/s00464-019-06908-6 (2019). Sugerman, H. J. et al. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am. J. Surg. 171 , 80–84. 10.1016/S0002-9610(99)80078-6 (1996). Diener, M. K., Voss, S., Jensen, K., Buchler, M. W. & Seiler, C. M. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann. Surg. 251 , 843–856. 10.1097/SLA.0b013e3181d973e4 (2010). Merkow, R. P. et al. Effect of postoperative complications on adjuvant chemotherapy use for stage III colon cancer. Ann. Surg. 258 , 847–853. 10.1097/SLA.0000000000000312 (2013). Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C. & Jarvis, W. R. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 20, 250–278; quiz 279–280, (1999). 10.1086/501620 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files file.mp4 Supplementary Video 1. Intraoperative video demonstrating the fascial closure technique using a continuous barbed suture. The first half showing the external view highlights the self-anchoring, knotless mechanism that maintains consistent tension without manual assistance, facilitating a smooth and rapid closure of the mini-laparotomy site. The second half of the video features an intraperitoneal view captured via a secondary port after fascial repair, confirming that the fascia and peritoneum are securely closed without any loosening or gapping. 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1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntraoperative video demonstrating the fascial closure technique using a continuous barbed suture. The first half showing the external view highlights the self-anchoring, knotless mechanism that maintains consistent tension without manual assistance, facilitating a smooth and rapid closure of the mini-laparotomy site. The second half of the video features an intraperitoneal view captured via a secondary port after fascial repair, confirming that the fascia and peritoneum are securely closed without any loosening or gapping.\u003c/p\u003e","description":"","filename":"file.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8801503/v1/4197eed6bec2dd101b0ea352.mp4"},{"id":102946223,"identity":"0bb47247-de8b-4d4d-9c0f-487cdf2ac251","added_by":"auto","created_at":"2026-02-18 18:42:11","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":258863,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8801503/v1/64fd00e95857d4240098c118.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficiency and safety of continuous barbed suture for fascial closure in minimally invasive colorectal surgery: A propensity score-matched analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMinimally invasive colorectal surgery promotes recovery, yet surgical site infections (SSIs) and incisional hernias remain significant complications. While fascial closure techniques for midline laparotomies are well-debated, consensus is lacking for \"mini-laparotomy\" incisions (3\u0026ndash;5 cm) used in laparoscopic or robotic surgery. Furthermore, in the restricted workspace of a mini-laparotomy, performing secure and consistent manual knot-tying can be technically demanding, potentially leading to variability in suture tension. The biomechanical stress on these small incisions differs fundamentally from traditional large incisions, potentially benefiting from barbed sutures, which distribute tension evenly without high-tension knots. However, evidence specifically evaluating barbed sutures for mini-laparotomy closure is scarce. This study evaluated the clinical outcomes of continuous barbed suturing versus conventional interrupted suturing for small-incision closure using propensity score matching, aiming to establish an efficient and safe fascial management strategy in minimally invasive colorectal surgery.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe compared the efficacies of continuous and simple interrupted suturing for fascial closure of small incisions in patients undergoing minimally invasive (laparoscopic and robot-assisted) surgery for colorectal cancer. We applied PSM to address the potential for baseline imbalances in this retrospective study and enhance statistical reliability.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Patient Demographics and Surgical Factors:\u003c/h2\u003e \u003cp\u003eBaseline clinical characteristics, including age, Body Mass Index(BMI), and comorbidities, were well-balanced between the two groups both before and after propensity score matching (PSM) (Table I). Notably, no patients in either group were receiving preoperative steroid treatment. PSM was applied to the data for a more rigorous comparison. The post-PSM analysis confirmed the findings of the pre-PSM analysis, with no significant differences in any of the aforementioned patient characteristics between the two groups (Table I). This homogeneous dataset facilitated a more accurate and objective evaluation of the effects of each technique and helped minimize the influence of confounding factors.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eComparison of Primary and Secondary Outcomes:\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes, including the incidences of SSI and incisional hernia, and the secondary outcomes, including duration of surgery, blood loss, presence of stoma, postoperative length of hospital stay, and complication rates, were compared in detail using the well-matched post-PSM dataset (Table II). To mitigate the influence of potential confounding factors, we employed PSM to balance key clinical risk factors, including BMI and preoperative steroid use, which are well-known predictors of surgical site complications. After matching, the comparison revealed that the incidences of SSI and incisional hernia were comparable between the groups. The median postoperative hospital stay was evaluated to assess the impact of the suturing technique on recovery. In the pre-matching cohort, the median length of stay was 12.0 days (range: 8\u0026ndash;41 days) in the continuous barbed suture group and 12.0 days (range: 7\u0026ndash;42 days) in the simple interrupted group, showing no significant difference between the two (p\u0026thinsp;=\u0026thinsp;0.551). Following propensity score matching, the median hospital stay remained comparable between the groups, with 12.0 days (range: 8\u0026ndash;41 days) in the continuous group and 12.5 days (range: 8\u0026ndash;31 days) in the simple interrupted group (p\u0026thinsp;=\u0026thinsp;0.402). These results indicate that the use of a continuous barbed suture for fascial closure does not prolong the recovery period or affect the timing of hospital discharge compared to traditional interrupted suturing. In the propensity score-matched cohort, the median operating time was 261min (range: 168\u0026ndash;715 min) in the Continuous group and 264 min (range: 195\u0026ndash;726 min) in the Interrupted group, with no significant difference observed between the two techniques (p\u0026thinsp;=\u0026thinsp;0.871). Regarding median blood loss, no significant difference was observed between the Continuous group 3.0 g (2\u0026ndash;750 g) and the Interrupted group 5.0 g (2\u0026ndash;2570 g) after propensity score matching (p\u0026thinsp;=\u0026thinsp;0.582). Regarding the median fascia closure time, the Continuous group was remarkably faster, requiring less than half the time of the Interrupted group (4.9 min [3.2\u0026ndash;8.8 min] vs. 11.5 min [6.9\u0026ndash;24.9 min]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This striking disparity in efficiency was further confirmed in the propensity score-matched cohort, where the Continuous group maintained a significantly shorter closure time compared to the PSM-Interrupted group (4.9 min [3.2\u0026ndash;8.8 min] vs. 10.2 min [6.9\u0026ndash;24.9 min]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings underscore the overwhelming procedural advantage of the barbed suture in streamlining the final stage of surgery.\u003c/p\u003e \u003cp\u003eProposed Revision: Based on the post-PSM dataset, we conducted a rigorous comparative analysis of clinical outcomes. The incidence of SSI was 1 case (3.6%) for both the continuous and simple interrupted suture groups (p\u0026thinsp;=\u0026thinsp;1.00). The incidence of incisional hernia was 2 cases (7.1%) in the continuous suturing group and 3 cases (10.7%) in the simple interrupted suturing group, with no statistically significant difference (p\u0026thinsp;=\u0026thinsp;1.00).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe optimal method for fascial closure has long been a subject of debate in gastrointestinal surgery, as the integrity of the abdominal wall repair directly influences long-term outcomes. Traditionally, the choice between continuous and interrupted suturing has been weighed based on the biomechanical distribution of tension and procedural efficiency. While continuous suturing is often preferred for its speed, concerns regarding tension concentration\u0026mdash;which could lead to tissue ischemia or suture failure\u0026mdash;have led many surgeons to favor interrupted sutures, particularly in high-risk settings.\u003c/p\u003e \u003cp\u003ePrevious large-scale meta-analyses, such as that by van 't Riet et al., have compared these techniques in midline laparotomies and found no significant difference in the incidence of complications like surgical site infection (SSI) or incisional hernia \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. However, most classical studies focus on large incisions. In the context of minimally invasive surgery, where the fascia is closed through a \"mini-laparotomy,\" the biomechanical requirements differ. Our study focused on this specific environment, evaluating whether a continuous barbed suture (STRATAFIX\u0026reg;)\u0026mdash;designed to distribute tension evenly without the need for knots\u0026mdash;could offer a distinct advantage over traditional methods.\u003c/p\u003e \u003cp\u003eRegarding the mechanical integrity of the closure, incisional hernia remains one of the most common complications of laparotomy, with an incidence typically reported between 2% and 10% \u003csup\u003e6\u003c/sup\u003e. A large-scale meta-analysis of 23 trials involving over 10,000 patients demonstrated that continuous suturing is as safe as interrupted suturing regarding the incidence of incisional hernia, while providing the advantage of reduced operative time \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Some reports have indicated even higher late-onset rates of 12.3% at one year and 23.2% at three years postoperatively \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Risk factors for incisional hernia, such as obesity and steroid use \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, were adjusted for in our PSM analysis. Furthermore, the relationship between the suturing technique and hernia formation remains controversial; a meta-analysis by Diener et al. reported incisional hernia rates of 11.3% for continuous and 7.9% for simple interrupted sutures in elective midline laparotomy \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In our cohort, the continuous barbed suture group showed a trend toward a lower incidence of incisional hernia (7.1% vs. 10.7%), although this did not reach statistical significance (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;1.00\u003c/em\u003e). In the specific context of minimally invasive surgery, the restricted workspace of a mini-laparotomy often makes it technically challenging to maintain consistent tension and perform secure manual knot-tying. While traditional interrupted sutures rely on discrete \"points\" of tension (knots) that are prone to variability based on the surgeon's maneuverability, the barbed suture distributes tension along a continuous \"line.\" This biomechanical characteristic effectively minimizes technical variability and compensates for the spatial constraints of small incisions, ensuring a more reproducible and stable fascial closure regardless of the limited working angle. The barbed mechanism potentially mitigates the risks of localized high tension and tissue ischemia\u0026mdash;concerns typically associated with traditional running sutures\u0026mdash;by anchoring at multiple points and ensuring uniform apposition. The barbed mechanism potentially addresses the \"dead space\" more effectively than traditional sutures by ensuring uniform, gap-free apposition along the entire length of the incision without the need for high-tension knots, thereby mitigating the risks of localized high tension and tissue ischemia typically associated with traditional running sutures \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. This secure, gap-free closure is clearly visualized in our Supplementary Video 1, where the intraperitoneal view confirms the reliability of the technique even in the absence of manual tension maintenance.\u003c/p\u003e \u003cp\u003eOur findings regarding SSI (3.6% in both groups) suggest that the fascial closure method is not the primary driver of infectious complications. SSI remains a critical challenge in perioperative management, significantly impacting hospital stay and healthcare costs \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Although risk factors such as advanced age, obesity, and diabetes are well-established \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, the SSI incidence in our study was relatively low and comparable between groups. This aligns with the consensus that strict adherence to infection prevention measures, including prophylactic antibiotics and aseptic techniques, is more decisive than the specific suturing technique employed \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Theoretically, the knotless nature of barbed sutures offers a distinct advantage in infection control. Conventional interrupted sutures require multiple knots, which act as bulkier foreign bodies and can serve as a 'nidus' for bacterial colonization and biofilm formation. By eliminating these knots, barbed sutures potentially reduce the intra-wound bacterial load. Although our study showed equivalent SSI rates (3.6% in both groups), this suggests that while the barbed suture provides a cleaner, more streamlined closure, its clinical safety is at least non-inferior to traditional methods. This finding is particularly encouraging, as it confirms that the dramatic gain in procedural efficiency does not come at the cost of an increased infectious risk.\u003c/p\u003e \u003cp\u003eRegarding the mean fascia closure time, the Continuous group was significantly faster than the Interrupted group (4.9 min [3.3\u0026ndash;8.8 min] vs. 11.5min [6.9\u0026ndash;24.9 min] ; \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e). In this study, surgical parameters such as closure time and blood loss were analyzed using median values and non-parametric tests, as these clinical data often follow a non-normal distribution with significant outliers. This approach ensures a more robust and clinically realistic comparison of the two techniques by minimizing the influence of extreme cases. This significant difference was maintained after propensity score matching (Continuous: 4.9 min [3.2\u0026ndash;8.8 min] vs. PSM-Interrupted: 10.2 min [6.9\u0026ndash;24.9 min] ; \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e). Our results reflect the overall efficiency of using barbed sutures in the final stage of the procedure, demonstrating a streamlined workflow. This efficiency is attributed to the self-anchoring, knotless mechanism, which allows for smooth procedural flow. Minimizing operative time contributes to healthcare cost savings and is a key component of Enhanced Recovery After Surgery (ERAS) protocols. For colorectal cancer patients, avoiding complications and ensuring swift recovery is paramount to starting adjuvant chemotherapy without delay\u0026mdash;an aspect that is essential for optimizing long-term oncological outcomes \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. While further large-scale validation is needed, the uniformity of tension distribution provided by the barbed mechanism represents a logical evolution in the closure of small incisions, where traditional knot-tying can be cumbersome and time-consuming.\u003c/p\u003e\n\u003ch3\u003eLimitations:\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations. First, its retrospective, single-center design may introduce selection bias. Second, the sample size after matching (n\u0026thinsp;=\u0026thinsp;28 per group) is relatively small, which increases the risk of Type II error. Based on our current findings, approximately 100 cases per group would be required to statistically detect a 7% difference in hernia rates with 80% power. However, this study serves as a critical pilot evaluation, being the first to specifically demonstrate the safety and overwhelming time-saving advantages of barbed sutures for mini-laparotomy closure in colorectal surgery. While we continue to accumulate cases to increase statistical power, these preliminary findings provide immediate clinical relevance for surgical efficiency. Third, the 12-month follow-up may not capture late-onset hernias occurring years later. Finally, multi-center prospective studies, which we are currently planning, are necessary to validate these results and evaluate cost-effectiveness to standardize fascial closure in minimally invasive colorectal surgery. Continuous fascial suturing with barbed sutures for small incisions in colorectal cancer surgery is safe, effective, and significantly reduces closure time compared to interrupted sutures. By enhancing surgical efficiency and maintaining reliable abdominal wall integrity, this technique supports optimal perioperative recovery and facilitates the timely initiation of adjuvant oncological treatments.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study included 220 patients who underwent elective surgery for colorectal cancer at the Osaka Metropolitan University Hospital between January 2024 and January 2025. All methods were performed in accordance with relevant guidelines and regulations. We compared the efficacies of continuous suture using STRATAFIX Symmetric PDS PLUS\u0026reg; (Ethicon, Johnson \u0026amp; Johnson, Livingston, Scotland, UK) for 28 of them and interrupted suture using 0-PDS Plus\u0026reg; (Ethicon, Johnson \u0026amp; Johnson, Livingston, Scotland, UK) for the remaining192 after laparatomy. We adjusted for these variables using propensity score matching (PSM) to account for potential imbalances in patient background factors. The patient demographics, cStage, surgical factors, postoperative complications, SSI, incisional hernia, and lengths of postoperative hospital stay of the post-matched groups (PSM-STRATAFIX and PSM-0PDS groups) were compared.\u003c/p\u003e \u003cp\u003e The protocol for this study was approved by the Ethics Committee of Osaka Metropolitan University Hospital, Japan (reference number: 4182). Due to the retrospective nature of the study, the Ethics Committee of Osaka Metropolitan University Hospital waived the need for obtaining informed consent from all subjects.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eAll the procedures were performed by experienced board-certified surgeons. The patients received prophylactic antibiotics before skin incision in accordance with the surgical infection guidelines. The intervention involved the closure of the abdominal fascia after a small incision. Fascial closure was performed using either interrupted 0-PDS Plus\u0026reg; or continuous STRATAFIX Symmetric PDS Plus\u0026reg; (both Ethicon, Johnson \u0026amp; Johnson, UK). The skin was closed with sutures. All data were stored in the electronic medical records, and severe adverse events were reported to the data center at Osaka Metropolitan University. The video images of the external and intraperitoneal views demonstrated secure fascial closure (Supplementary Video 1).\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary endpoints were the incidences of incisional hernia and superficial or deep SSI, defined according to the Centers for Disease Control and Prevention/National Healthcare Safety Network \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and Japan Nosocomial Infection Surveillance \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e criteria. SSI was assessed during hospitalization and at the first outpatient visit. Incisional hernia was defined as any abdominal wall gap or bulge at the scar area, perceptible by clinical examination or computed tomography (CT) \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, and was evaluated 12 months postoperatively. Secondary endpoints included the length of postoperative hospital stay and the overall rate of surgical complications.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eWe compared patients undergoing continuous versus simple interrupted suturing. To minimize selection bias, 1:1 propensity score matching (PSM) was performed with a caliper width of 0.2. Covariates included age, sex, BMI, ASA-PS score \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, diabetes, steroid use, and cStage. After matching, the primary and secondary outcomes were compared between the two groups. The normality of continuous variables was evaluated using the Shapiro-Wilk test. Continuous variables were expressed as median (range: minimum\u0026ndash;maximum) and compared using the Mann-Whitney U test. Categorical variables were compared using Fisher\u0026rsquo;s exact test or the chi-squared test. All analyses were performed using EZR version 1.68, with statistical significance set at \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAI Disclosure\u003c/h2\u003e \u003cp\u003eThe authors acknowledge the use of Google Gemini, an AI-powered translation tool, for translating the original Japanese manuscript into English. This tool is used solely for linguistic assistance. The authors are solely responsible for the content, data, and conclusions of this paper. They have thoroughly reviewed and revised all AI-generated texts to ensure accuracy and alignment with the intended scientific meaning.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting Interests:\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualization and study design: N.N, H.K, and K.MData curation and formal analysis: N.NMethodology: T.F, S.O, I.O, Y.F, Y.S, and K.KInvestigation and resources: Y.M, M.Y, T.Tamura, M.S, and T.ToyokawaWriting—original draft preparation: N.NWriting—review and editing: All authorsSupervision: K.MProject administration: T.F, H.KFinal approval of manuscript: All authors\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eThe authors thank the Department of Digestive Surgery, Graduate School of Medicine, Osaka Metropolitan University, for their valuable support.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this publishedarticle and its Supplementary Information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAI Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the use of Google Gemini, an AI-powered translation tool, for translating the original Japanese manuscript into English. This tool is used solely for linguistic assistance. The authors are solely responsible for the content, data, and conclusions of this paper. They have thoroughly reviewed and revised all AI-generated texts to ensure accuracy and alignment with the intended scientific meaning.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy type:\u003c/strong\u003e Clinical\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDate of submission:\u0026nbsp;\u003c/strong\u003e2026.02.06\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHoran, T. C., Andrus, M. \u0026amp; Dudeck, M. A. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. \u003cem\u003eAm. J. Infect. 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Hospital Infection Control Practices Advisory Committee. \u003cem\u003eInfect Control Hosp Epidemiol\u003c/em\u003e 20, 250\u0026ndash;278; quiz 279\u0026ndash;280, (1999). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1086/501620\u003c/span\u003e\u003cspan address=\"10.1086/501620\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Colorectal cancer, Minimally invasive surgery, Fascial closure, Barbed suture, Incisional hernia, Surgical workflow","lastPublishedDoi":"10.21203/rs.3.rs-8801503/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8801503/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSurgical-site infections and incisional hernias remain significant challenges in colorectal cancer surgery. While minimally invasive techniques reduce surgical trauma, the optimal fascial closure method for small incisions to prevent these complications has not been definitively established. This study evaluated the efficacy of continuous barbed suturing in streamlining surgical workflow and its safety regarding postoperative complications compared to traditional simple interrupted suturing. We retrospectively analyzed 220 patients undergoing elective minimally invasive colorectal cancer surgery. To ensure a robust comparison, propensity score matching was employed to balance baseline characteristics between the continuous barbed suture and simple interrupted suture groups. Our results demonstrated that the incidences of surgical-site infections and incisional hernias, confirmed by CT imaging at 12 months, did not differ significantly between the two techniques. However, the mean fascia closure time was significantly reduced in the continuous barbed suture group (4.9 min) compared to the simple interrupted group (11.8 min) (p\u0026lt;0.001) (Post-PSM). These findings indicate that continuous barbed suturing for small-incision closure is safe, reliable, and significantly more efficient than conventional methods. By reducing operative stress and procedural time, this technique represents a superior alternative to traditional methods and has the potential to become the gold standard for fascial management in minimally invasive colorectal surgery.\u003c/p\u003e","manuscriptTitle":"Efficiency and safety of continuous barbed suture for fascial closure in minimally invasive colorectal surgery: A propensity score-matched analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 18:42:06","doi":"10.21203/rs.3.rs-8801503/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc9c6c8e-0fd2-402d-a489-71e6804deee1","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62988410,"name":"Biological sciences/Cancer"},{"id":62988411,"name":"Health sciences/Diseases"},{"id":62988412,"name":"Health sciences/Gastroenterology"},{"id":62988413,"name":"Health sciences/Medical research"},{"id":62988414,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2026-02-20T13:56:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 18:42:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8801503","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8801503","identity":"rs-8801503","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}