GI Surgery

Mesh Fixation and Chronic Groin Pain: BJS Open | July 2026

Introduction: Chronic postoperative inguinal pain (CPIP) remains one of the most important long-term complications after laparoscopic groin hernia repair, despite lower rates than with open surgery. Whether different mesh types and fixation methods influence the risk of persistent pain remains uncertain, and comparative real-world evidence has been limited. Why was this study needed?: . CPIP significantly affects long-term quality of life after inguinal hernia repair. . The optimal combination of mesh type and fixation technique remains controversial. . Large comparative studies evaluating commonly used mesh–fixation combinations are lacking. . Identifying the safest and most cost-effective strategy could improve surgical outcomes. Results: This nationwide Swedish registry study evaluated over 15,000 patients undergoing unilateral laparoscopic groin hernia repair, with more than 10,500 providing 1-year patient-reported outcomes. Among 12 commonly used mesh–fixation combinations, three strategies were associated with the lowest risk of chronic postoperative inguinal pain: heavyweight flat mesh without fixation, lightweight flat mesh fixed with fibrin glue, and lightweight self-gripping mesh with micro-hooks. Heavyweight flat mesh without fixation performed as well as the other low-pain strategies while avoiding fixation devices altogether, making it the simplest and least expensive approach. Clinical Impact: These findings support selecting mesh–fixation strategies that minimize chronic pain without compromising repair quality. Heavyweight flat mesh without fixation appears to be a practical default option, combining low chronic pain risk with lower procedural complexity and cost. The results also reinforce previous registry evidence demonstrating acceptable recurrence rates with non-fixation techniques. Bottom Line: Heavyweight flat mesh without fixation was associated with one of the lowest risks of chronic postoperative inguinal pain after laparoscopic groin hernia repair, supporting it as a simple, effective, and cost-efficient default strategy.

Collateral-Based PD Without Venous Reconstruction: Indian J Gastroenterol | July 2026

Introduction: Venous involvement is common in locally advanced pancreatic cancer and often necessitates superior mesenteric-portal vein resection with reconstruction during pancreaticoduodenectomy. However, reconstruction may not always be feasible because of extensive venous disease or unfavorable anatomy. This technique letter describes an alternative surgical strategy that exploits well-developed collateral venous circulation to enable safe resection without venous reconstruction in carefully selected patients. Why was this study needed?: Some patients have non-reconstructible mesenteric venous anatomy, limiting the feasibility of standard venous reconstruction. Abandoning curative surgery in these patients may deny potentially beneficial treatment. Well-developed collateral venous pathways may provide adequate mesenteric venous drainage after resection. Practical technical guidance for this uncommon but challenging surgical scenario is limited. Results: The authors describe the technical principles of performing pancreaticoduodenectomy without venous reconstruction in patients with unreconstructible mesenteric venous anatomy but robust collateral circulation. Careful preoperative imaging is essential to identify collateral venous pathways and assess their adequacy before surgery. In appropriately selected patients, preservation of these collateral channels can maintain venous drainage and allow safe tumor resection without the need for complex vascular reconstruction. The report emphasizes meticulous operative planning and individualized decision-making rather than broad application of this technique. Clinical Impact: This technique expands the surgical options for a highly selected subgroup of patients with locally advanced pancreatic cancer who would otherwise be considered unsuitable for resection. It highlights the importance of detailed vascular assessment and multidisciplinary planning and underscores that successful outcomes depend on surgical expertise and careful patient selection in high-volume hepatopancreatobiliary centers. Bottom Line: Pancreaticoduodenectomy without venous reconstruction may be feasible in carefully selected patients with locally advanced pancreatic cancer and well-developed collateral venous circulation, offering a potential alternative when conventional venous reconstruction is not possible.

Robotic vs Open Pancreatoduodenectomy: BMJ | July 2026

Introduction: Pancreatoduodenectomy remains one of the most complex abdominal operations. Robotic pancreatoduodenectomy (RPD) has been proposed to improve postoperative recovery, but robust randomized evidence has been limited. The PORTAL trial compared robotic and open pancreatoduodenectomy in high-volume expert centers. Why was this study needed? High-quality randomized evidence comparing robotic and open pancreatoduodenectomy has been limited. Previous minimally invasive studies raised concerns regarding safety and learning curves. Whether robotic surgery improves recovery without compromising oncological outcomes remained uncertain. The higher costs of robotic surgery require justification through meaningful clinical benefits. Evidence was needed to guide future surgical practice and recommendations. Results: Robotic pancreatoduodenectomy significantly accelerated postoperative functional recovery, resulting in earlier discharge despite a longer operative time. Postoperative complications, 90-day mortality, and oncological outcomes were comparable between robotic and open surgery, confirming the safety of the robotic approach in experienced centers. Robotic surgery incurred higher hospital costs, highlighting the importance of careful patient selection, institutional expertise, and procedural volume. Clinical Impact: This landmark phase III randomized trial demonstrates that robotic pancreatoduodenectomy can safely enhance postoperative recovery when performed by experienced surgeons in high-volume centers. However, the increased financial cost means that widespread implementation should be guided by institutional expertise, case volume, and healthcare resource availability. Bottom Line: Robotic pancreatoduodenectomy offers faster recovery with similar safety and oncological outcomes compared with open surgery, but at a higher cost. In expert, high-volume centers, it represents an effective minimally invasive alternative, although broader adoption should remain selective and value-based.

Adapting Military Resilience to Modern Surgery by SOSC: An of Surgery | July 2026

Introduction: Surgery is an inherently high-stress profession, where complications, patient deaths, and difficult decisions can lead to burnout, moral injury, and mental health disorders. Inspired by the US Marine Corps' Combat and Operational Stress Control (COSC) program, this Perspective introduces Surgical Operational Stress Control (SOSC)—a structured framework designed to enhance surgeon resilience and sustain long-term performance. Key Takeaways: Surgeons experience moral injury, burnout, and psychological stress similar to military personnel operating in high-pressure environments. SOSC adapts the military's proven five-step resilience model: Strengthen, Mitigate, Identify, Treat, and Reintegrate. The framework emphasizes early recognition of stress, encouraging intervention before temporary distress progresses to chronic burnout or mental illness. Peer support, mentorship, shared decision-making, and open conversations about stress are central to building a resilient surgical culture. SOSC promotes structured reintegration after major complications or emotional distress, reducing stigma and facilitating a safe return to clinical practice. The model encourages hospitals and surgical training programs to move beyond wellness initiatives toward proactive, system-based resilience programs. Incorporating SOSC into surgical education may improve surgeon well-being, reduce medical errors, strengthen teamwork, and enhance patient care. Clinical Impact: Surgeon well-being directly influences clinical performance and patient safety. By adapting battle-tested military principles, SOSC provides a practical framework to recognize stress early, support recovery, and foster a healthier surgical workforce. It shifts the focus from treating burnout to preventing it through structured organizational support. Bottom Line: Resilient surgeons deliver safer care. The proposed Surgical Operational Stress Control (SOSC) model offers a practical roadmap to identify, manage, and recover from occupational stress, ensuring surgeons remain healthy, effective, and "in the fight" throughout their careers.

Vascular Resection for Pancreatic Cancer: Annals of Surgery | June 2026

Introduction: As surgical techniques and perioperative therapies have advanced, vascular resection during pancreatic cancer surgery has become increasingly common in selected patients with locally advanced disease. This study evaluated the long-term outcomes of venous and arterial resections in patients undergoing curative-intent surgery for pancreatic ductal adenocarcinoma (PDAC). Why was this study needed? The oncologic benefit of vascular resection, particularly arterial resection, remains controversial because of concerns regarding increased operative risk and uncertain survival benefit. What did the study show? The study analyzed 715 patients undergoing curative-intent surgery over 10 years at a high-volume pancreatic center. Venous resection was performed in 30% of patients, while arterial resection was required in 12%. Patients undergoing venous resection had shorter recurrence-free and overall survival than those without vascular resection. After adjustment for other prognostic factors, vascular resection itself was not an independent predictor of overall survival. Arterial resection achieved oncologic outcomes comparable to standard resection but was associated with significantly higher 90-day postoperative mortality. Perioperative chemotherapy and chemoradiotherapy significantly improved recurrence-free and overall survival. Node-negative disease and absence of perineural invasion were strong predictors of favorable long-term outcomes. Clinical Impact: Vascular resection should not be considered a contraindication to curative surgery in carefully selected patients with PDAC. Successful outcomes depend on multidisciplinary management, effective perioperative therapy, and performance in experienced high-volume centers. Take-Home Message: Vascular resection can safely expand surgical options for selected patients with pancreatic cancer. While arterial resection carries higher perioperative risk, careful patient selection and modern multimodality therapy can achieve oncologic outcomes comparable to standard pancreatic resection.

Drain Management After Pancreatoduodenectomy: BJS Open | June 2026

Introduction: Optimal drain management after pancreatoduodenectomy (PD) remains critical for preventing postoperative pancreatic fistula (POPF) while supporting enhanced recovery. This study proposes a dynamic, risk-adapted algorithm based on intraoperative risk and postoperative biochemical markers. Why was this study needed? Current drain removal protocols largely rely on early drain fluid amylase (DFA) levels using a one-size-fits-all approach. However, these strategies may not be reliable in patients at high intrinsic risk of POPF, particularly those with a soft pancreas and small pancreatic duct. What did the study show? High-risk PD (soft pancreas and duct ≤3 mm) had significantly higher POPF rates than non-high-risk PD. Early DFA was highly predictive in low-risk patients but was considerably less reliable in high-risk patients. For non-high-risk PD, safe drain removal on POD 3 was guided by low POD 1 and POD 3 DFA along with normal serum amylase/lipase. For high-risk PD, delaying drain removal until POD 5 improved safety. In high-risk patients, combining POD 5 DFA with C-reactive protein provided better prediction of clinically relevant POPF than DFA alone. The proposed algorithm individualizes drain management according to each patient's fistula risk rather than applying a uniform protocol. Clinical Impact: Drain management after pancreatoduodenectomy should be individualized. Early drain removal remains appropriate for low-risk patients, whereas high-risk patients benefit from delayed removal guided by serial biochemical assessment, potentially reducing POPF-related complications. Take-Home Message: A risk-stratified, dynamic drain management strategy is superior to a one-size-fits-all approach after pancreatoduodenectomy. Tailoring drain removal according to intraoperative risk and postoperative biomarkers can improve patient safety while supporting enhanced recovery.

Diverticulitis Peaks During Warmer Months : JAMA Surg | Apr 2026

Introduction: Diverticulitis is a common cause of acute abdominal hospitalization and contributes substantially to healthcare utilization worldwide. While seasonal variation has been recognized in several gastrointestinal and surgical conditions, whether diverticulitis follows a reproducible temporal pattern has remained uncertain. Understanding such trends could provide insight into disease triggers and help guide preventive strategies and healthcare planning. Problem Statement: The factors precipitating acute diverticulitis are incompletely understood. If seasonal fluctuations exist, they may point toward modifiable environmental, dietary, microbial, or behavioural influences that contribute to disease onset. Clarifying these patterns could improve both mechanistic understanding and resource allocation. Summary: This systematic review evaluated global evidence on seasonal variation in diverticulitis incidence and hospital admissions, encompassing more than one million cases across four continents. The analysis demonstrated a remarkably consistent pattern, with most studies reporting peak rates during summer or autumn and the lowest incidence during winter. Importantly, a reversal of this pattern between the Northern and Southern Hemispheres strongly supports the existence of true seasonality rather than random variation. The magnitude of seasonal fluctuation was substantial, with peak periods showing noticeably higher admission rates than trough periods. Several potential explanations were proposed, including dehydration during warmer weather, seasonal dietary changes, alterations in gut microbiota, immune system modulation, and variations in vitamin D exposure. Notably, while the incidence of diverticulitis varied by season, disease severity did not appear to follow the same pattern, suggesting that environmental factors may influence disease onset rather than progression. These findings provide compelling evidence that diverticulitis is influenced by seasonal factors and highlight the potential role of modifiable environmental and lifestyle exposures. From a clinical perspective, awareness of predictable seasonal peaks may assist healthcare systems in anticipating increased demand. Future prospective studies incorporating patient-level environmental, dietary, and biological data are needed to better define the mechanisms underlying this seasonal phenomenon and identify opportunities for prevention.

Avoid Treating Asymptomatic Postoperative Hypertension : JAMA Surg | Jun 2026

Introduction: Postoperative hypertension is frequently encountered in hospitalized surgical patients and often triggers immediate clinical intervention. Elevated blood pressure readings after surgery may result from pain, anxiety, fluid shifts, medication changes, or physiological stress responses. In many institutions, routine monitoring systems and standing medication orders can prompt treatment even when patients have no symptoms or evidence of end-organ injury. Problem Statement: Despite its common occurrence, the routine treatment of asymptomatic postoperative hypertension remains controversial. Acute blood pressure reduction in the absence of symptoms may expose patients to unnecessary risks, yet reflexive treatment continues to occur because of institutional practices, automated alerts, and concerns about elevated blood pressure measurements. Summary: This review challenges the common practice of administering as-needed antihypertensive medications for asymptomatic postoperative hypertension. The authors highlight that current evidence and clinical practice guidelines do not support routine treatment of elevated blood pressure in the absence of symptoms or hypertensive emergencies. Importantly, unnecessary blood pressure lowering may result in adverse outcomes, including hypotension, reduced organ perfusion, and other treatment-related complications. The review emphasizes that many episodes of postoperative hypertension are transient and related to reversible perioperative factors rather than uncontrolled chronic hypertension requiring urgent intervention. The authors identify several system-level drivers of overtreatment, including nursing notifications triggered by preset blood pressure thresholds, routine availability of as-needed antihypertensive orders, and limited familiarity with perioperative blood pressure management principles. Rather than focusing on isolated blood pressure measurements, clinicians should assess the overall clinical context and evaluate patients for symptoms or signs of end-organ dysfunction before initiating therapy. The review concludes that postoperative hypertension should generally be treated only when symptomatic or associated with hypertensive emergencies. Reducing unnecessary interventions and modifying institutional triggers for treatment may improve patient safety while avoiding the harms associated with excessive blood pressure reduction in the postoperative setting. Overall, the article advocates for a more measured and evidence-based approach to postoperative blood pressure management.

Gluteal Flap Reduces Costs After APR : BJS Open | Jun 2026

Introduction: Perineal wound complications remain a major source of morbidity after abdominoperineal resection (APR) for rectal cancer. Delayed wound healing can result in prolonged outpatient care, increased healthcare utilization, impaired quality of life, and higher overall treatment costs. The gluteal turnover flap has been proposed as a reconstructive technique to improve perineal healing, but its economic value has not been fully established. Problem Statement: While surgical innovations may improve clinical outcomes, their adoption increasingly depends on demonstrating cost-effectiveness. It remains unclear whether the additional operative effort required for gluteal turnover flap reconstruction translates into meaningful reductions in healthcare costs and patient burden compared with conventional primary closure. Summary: This cost-effectiveness analysis of the multicenter BIOPEX-2 randomized trial evaluated gluteal turnover flap closure versus primary perineal closure following APR for rectal cancer. The study demonstrated that gluteal turnover flap reconstruction was associated with significantly lower overall healthcare costs during follow-up. Cost savings were primarily driven by reductions in outpatient care requirements, specialized wound management, and home healthcare utilization, reflecting improved wound-related outcomes. Although patients who developed perineal wound complications reported substantially poorer health-related quality of life, overall quality-of-life measures were similar between the randomized groups. This likely reflects the lower frequency of wound complications among patients undergoing flap reconstruction. Importantly, the gluteal turnover flap achieved these economic benefits without compromising patient-reported outcomes. The findings suggest that preventing wound complications not only improves clinical recovery but also reduces downstream healthcare expenditure. From both a patient and healthcare system perspective, the gluteal turnover flap represents a high-value intervention that can lessen the burden of postoperative wound care after APR. Overall, this randomized trial provides strong evidence that gluteal turnover flap closure is a cost-saving strategy and supports its broader implementation as a preferred approach for perineal wound reconstruction in appropriately selected rectal cancer patients undergoing APR.

Robotic vs Laparoscopic Rectal Cancer Surgery: BJS Open | June 2026

This large population-based Swedish study compared robotic-assisted and conventional laparoscopic rectal cancer surgery using real-world national registry data. A total of 5,874 patients undergoing minimally invasive rectal cancer resection were analysed, including more than 3,500 robotic procedures. The primary endpoint was circumferential resection margin positivity (CRM+), a key surrogate marker of oncologic quality. Robotic surgery did not reduce CRM positivity compared with conventional laparoscopy. On multivariable analysis, robotic surgery was not associated with superior short-term oncologic outcomes. One of the major advantages of robotic surgery was a significantly lower conversion rate to open surgery. Conversion occurred in approximately 9% of robotic cases compared with 16% of laparoscopic cases, representing a substantial reduction. Lower conversion rates may be particularly important in obese patients, narrow pelvises, low rectal tumours, and technically challenging operations. Unexpectedly, robotic surgery was associated with a higher rate of surgical complications. Anastomotic leak rates were higher in the robotic group than in the laparoscopic group. Robotic surgery was also associated with fewer complete total mesorectal excision (TME) specimens, an unexpected finding that warrants further investigation. The study challenges the assumption that superior technology necessarily translates into better oncologic outcomes. The findings suggest that the main benefit of robotic surgery may be technical facilitation rather than improved cancer clearance. Long-term oncologic outcomes, local recurrence rates, disease-free survival, and overall survival remain important unanswered questions. The authors emphasise that further research is needed to understand why robotic surgery reduced conversion rates but was associated with higher leakage rates and less complete TME specimens. Bottom line: In this large national cohort, robotic rectal cancer surgery reduced conversion to open surgery but did not improve circumferential margin positivity and was associated with higher anastomotic leak rates. The true value of robotic surgery may lie in technical advantages rather than superior oncologic outcomes.

Funnel-Shaped Mesh Prevents Parastomal Hernia After Colostomy : JAMA Surg | Apr 2026

Introduction: Parastomal hernia (PSH) is one of the most frequent long-term complications following permanent colostomy, often leading to discomfort, impaired stoma function, reduced quality of life, and, in some cases, the need for reoperation. Despite its high incidence, the routine use of prophylactic mesh remains controversial because of concerns regarding long-term efficacy, mesh-related complications, and patient selection. Robust long-term randomized data are therefore essential to guide clinical practice. Problem Statement: While previous studies have suggested that prophylactic mesh placement may reduce PSH formation, uncertainty persists regarding the durability of this benefit and its long-term safety. Determining whether preventive mesh can sustainably reduce hernia incidence without increasing complications is critical for optimizing stoma surgery outcomes. Summary: This 3-year follow-up analysis of the randomized Chimney Trial evaluated the effectiveness and safety of a funnel-shaped intra-abdominal mesh placed at the time of permanent colostomy creation for rectal adenocarcinoma surgery. The study demonstrated a significant and durable reduction in both radiologically confirmed and clinically diagnosed parastomal hernias among patients receiving prophylactic mesh. Importantly, when hernias did occur in the mesh group, they were substantially smaller than those observed in patients who underwent standard surgery without mesh placement. The long-term benefit was achieved without an increase in postoperative complications or other adverse outcomes, providing reassuring evidence regarding the safety of this approach. These findings are particularly important because PSH remains a major source of morbidity after permanent stoma formation and can be challenging to manage once established. By preventing both the occurrence and severity of PSH, prophylactic funnel-shaped mesh has the potential to improve long-term patient outcomes and reduce the need for future corrective procedures. The study provides some of the strongest randomized evidence to date supporting prophylactic mesh use during permanent colostomy creation. Overall, the results suggest that funnel-shaped mesh represents an effective and safe preventive strategy and should be strongly considered in patients undergoing permanent colostomy for rectal cancer surgery.

Early Enteral Feeding Reduces Complications After Whipple Surgery : JAMA Surg | Apr 2026

Introduction: Pancreatoduodenectomy remains one of the most complex abdominal operations and is associated with substantial postoperative morbidity despite advances in surgical technique and perioperative care. Nutritional support is a critical component of recovery, particularly in patients who are malnourished or at increased nutritional risk before surgery. However, the optimal postoperative feeding strategy remains controversial, with uncertainty regarding whether early enteral nutrition offers advantages over standard oral feeding. Problem Statement: Patients undergoing pancreatoduodenectomy frequently experience delayed gastric emptying, pancreatic fistula, infections, and other complications that may impair nutritional intake and recovery. Although enteral nutrition is thought to preserve gut integrity and immune function, evidence supporting its routine use after pancreatoduodenectomy has been inconsistent. Determining the most effective nutritional approach is essential for improving postoperative outcomes. Summary: The NUTRIWHI randomized clinical trial evaluated the impact of early supplemental enteral nutrition (EEN) compared with oral nutrition alone in patients undergoing pancreatoduodenectomy who were identified as being at nutritional risk. Patients receiving EEN were fed immediately after surgery through a nasojejunal tube while also following the same oral feeding protocol as the control group. The study demonstrated that EEN significantly reduced the overall burden of postoperative complications during the first 90 days after surgery. Although rates of specific complications such as postoperative pancreatic fistula, delayed gastric emptying, hemorrhage, and surgical site infection were similar between groups, patients receiving enteral supplementation experienced a more favorable overall postoperative course. These findings suggest that the benefits of EEN extend beyond preventing individual complications and instead contribute to a broader improvement in postoperative recovery. Importantly, the intervention was targeted to patients with pre-existing nutritional risk, a population particularly vulnerable to adverse surgical outcomes. While nasojejunal tube displacement occurred in some patients, no major safety concerns were identified. This study provides strong evidence that early supplemental enteral nutrition should be considered as part of routine postoperative care in nutritionally at-risk patients undergoing pancreatoduodenectomy, with the potential to meaningfully reduce the overall burden of postoperative morbidity.

Post-Hepatectomy Liver Failure: BJS | March 2026

Modern liver surgery has become remarkably safe due to advances in surgical techniques, anesthesia, perioperative care, parenchyma-sparing strategies, and minimally invasive approaches. Despite these advances, post-hepatectomy liver failure (PHLF) remains the most feared complication after major liver resection. Although overall mortality after liver surgery is now generally below 1%–2%, PHLF continues to occur in approximately 8%–12% of major hepatectomies. PHLF is the single most important predictor of postoperative mortality following liver resection. Once clinically significant PHLF develops, treatment options are limited and are largely supportive, similar to management of acute liver failure from other causes. Mortality remains extremely high, often reaching 50%–80% in severe cases. The central principle in modern hepatobiliary surgery is therefore not treatment of PHLF, but prevention of PHLF. Adequate future liver remnant (FLR) volume and function remain the cornerstone of prevention. Preoperative assessment must evaluate: Future liver remnant volume Liver function Presence of steatosis Chemotherapy-associated liver injury Cirrhosis or fibrosis Portal hypertension Volumetric assessment alone is insufficient; functional liver reserve is increasingly recognized as equally important. Strategies to increase the future liver remnant include: Portal vein embolization (PVE) Liver venous deprivation Staged hepatectomy approaches ALPPS in selected patients Parenchyma-sparing liver surgery has become an important strategy to maximize oncological clearance while preserving functional liver tissue. Intraoperative factors such as blood loss, ischemia-reperfusion injury, prolonged operative time, and transfusion requirements also influence PHLF risk. Patients with underlying chronic liver disease, steatohepatitis, obesity, diabetes, and prior chemotherapy exposure represent particularly high-risk populations. Emerging technologies including functional imaging, dynamic liver function tests, and AI-based risk prediction models may improve future patient selection. The review emphasizes that PHLF is not a single disease entity but a complex syndrome involving impaired regeneration, insufficient liver reserve, systemic inflammation, and multi-organ dysfunction. Bottom line: Post-hepatectomy liver failure remains the major life-threatening complication after liver resection. Because effective treatment is limited once PHLF develops, meticulous patient selection, accurate assessment of future liver remnant function, and parenchyma-preserving surgical strategies remain the most effective means of improving outcomes.

Robotic vs Laparoscopic Rectal Cancer Surgery: BJS Open | June 2026

This large population-based Swedish study compared robotic-assisted and conventional laparoscopic rectal cancer surgery using real-world national registry data. A total of 5,874 patients undergoing minimally invasive rectal cancer resection were analyzed, including more than 3,500 robotic procedures. The primary endpoint was circumferential resection margin positivity (CRM+), a key surrogate marker of oncologic quality. Robotic surgery did not reduce CRM positivity compared with conventional laparoscopy. On multivariable analysis, robotic surgery was not associated with superior short-term oncologic outcomes. One of the major advantages of robotic surgery was a significantly lower conversion rate to open surgery. Conversion occurred in approximately 9% of robotic cases compared with 16% of laparoscopic cases, representing a substantial reduction. Lower conversion rates may be particularly important in obese patients, narrow pelvises, low rectal tumors, and technically challenging operations. Unexpectedly, robotic surgery was associated with a higher rate of surgical complications. Anastomotic leak rates were higher in the robotic group than in the laparoscopic group. Robotic surgery was also associated with fewer complete total mesorectal excision (TME) specimens, an unexpected finding that warrants further investigation. The study challenges the assumption that superior technology necessarily translates into better oncologic outcomes. The findings suggest that the main benefit of robotic surgery may be technical facilitation rather than improved cancer clearance. Long-term oncologic outcomes, local recurrence rates, disease-free survival, and overall survival remain important unanswered questions. The authors emphasize that further research is needed to understand why robotic surgery reduced conversion rates but was associated with higher leakage rates and less complete TME specimens. Bottom line: In this large national cohort, robotic rectal cancer surgery reduced conversion to open surgery but did not improve circumferential margin positivity and was associated with higher anastomotic leak rates. The true value of robotic surgery may lie in technical advantages rather than superior oncologic outcomes.

Neurogenic Diarrhoea Common After SMA Divestment in PDAC : BJS Open | Jun 2026

Introduction: The increasing use of preoperative chemotherapy has expanded the surgical eligibility of patients with locally advanced pancreatic ductal adenocarcinoma (PDAC). Superior mesenteric artery (SMA) divestment and, in selected cases, SMA resection have become important techniques for achieving margin-negative resections in tumors involving the perivascular neural plexus. However, disruption of the autonomic nerve fibers surrounding the SMA can lead to postoperative neurogenic diarrhoea, a complication that is often difficult to manage and can significantly affect postoperative recovery and quality of life. Problem Statement: Despite growing adoption of SMA divestment procedures, data regarding the incidence, risk factors, treatment strategies, and long-term consequences of postoperative neurogenic diarrhoea remain limited. Better understanding of this complication is essential for patient counselling, perioperative planning, and postoperative management. Summary: This international multicentre study provides the largest evaluation to date of neurogenic diarrhoea following pancreatic resection with SMA divestment or resection after preoperative therapy for PDAC. The investigators found that neurogenic diarrhoea is a frequent postoperative complication, affecting approximately two-thirds of patients. The risk increased substantially with the extent of SMA dissection, with the highest rates observed after more extensive circumferential divestment and SMA resection. Management strategies varied considerably across centers and included antidiarrhoeal agents, opioid-based therapies, opium tincture, and octreotide, reflecting the absence of standardized treatment protocols. Although symptom resolution was achieved in approximately half of affected patients, neurogenic diarrhoea remained a challenging postoperative issue. Reassuringly, despite its high incidence and impact on postoperative care, neurogenic diarrhoea was not associated with worse overall survival. These findings suggest that while the complication can be burdensome, it should not discourage aggressive surgical approaches when oncologically indicated. The study highlights the importance of preoperative patient counselling, early recognition of symptoms, and structured postoperative management. It also underscores the urgent need for evidence-based treatment algorithms and prospective studies aimed at optimizing the prevention and management of neurogenic diarrhoea in patients undergoing advanced pancreatic cancer surgery.

Intercostal Trocar Facilitates Difficult Liver Resections : Ann Hepatobiliary Pancreat Surg | May 2026

Introduction: Laparoscopic liver resection (LLR) has become an established approach for the management of selected hepatic lesions, offering benefits such as reduced postoperative pain, shorter hospital stay, and faster recovery. However, lesions located in the posterosuperior (PS) liver segments remain technically challenging because of their deep anatomical location, limited visualization, and restricted instrument maneuverability. Various technical modifications have been proposed to overcome these limitations, including the use of intercostal (IC) trocars. Problem Statement: Despite increasing interest in IC trocar-assisted LLR, evidence supporting its safety and effectiveness remains limited. Concerns persist regarding potential thoracic complications, optimal port placement, and whether improved access can be achieved without compromising patient safety or oncological outcomes. Summary: This single-center study evaluated the feasibility and safety of incorporating a small intercostal trocar during laparoscopic resection of lesions located in the posterosuperior liver segments. The technique involved placement of an accessory 5-mm right intercostal port to improve surgical exposure and instrument access in anatomically difficult regions of the liver. The approach was successfully applied across a range of benign and malignant hepatic conditions, including liver adenomas, colorectal liver metastases, neuroendocrine metastasis, and hepatolithiasis. Outcomes were highly favorable, with no intraoperative complications, no conversions to open surgery, and no requirement for blood transfusion. All resections achieved negative margins, indicating satisfactory oncologic clearance, while postoperative recovery was rapid with short hospital stays. Importantly, no postoperative morbidity or mortality was observed during follow-up. These findings suggest that the addition of a small intercostal trocar may provide enhanced visualization and access to challenging posterosuperior liver segments without increasing operative risk. Although the study is limited by its small sample size and retrospective design, it supports IC trocar-assisted LLR as a practical technical adjunct for complex minimally invasive liver surgery. Larger prospective multicenter studies are needed to establish standardized indications and validate its broader clinical applicability.

Preventive IPMN Resection: UEG Journal | March 2026

Intraductal papillary mucinous neoplasms (IPMNs) are recognized precursor lesions for pancreatic cancer, and current management aims to prevent progression to invasive disease. This multinational EAHPBA-endorsed study analyzed 1,728 patients who underwent preventive pancreatic resection for IPMN without preoperative evidence of invasive cancer. Overall outcomes after surgery were excellent, with an estimated 1-year overall survival of 97%. Long-term survival remained outstanding across most pathological subgroups, including low-grade dysplasia (LGD), high-grade dysplasia (HGD), and very early invasive cancers (T1a-b). Five-year overall survival was remarkably similar for LGD, HGD, and T1a-b invasive cancers, suggesting that carefully selected patients with very early invasive disease can achieve outcomes comparable to non-invasive lesions. Only patients with T1c invasive cancer demonstrated a meaningful decline in long-term survival. Age was an important determinant of outcome. Patients aged 75 years or older had significantly worse long-term survival compared with younger individuals. A striking finding was that 63% of all resections revealed only low-grade dysplasia, meaning that most operated patients did not harbor advanced precancerous disease or invasive cancer. Additionally, 61% of patients underwent surgery without prior surveillance, suggesting that many lesions may have been resected immediately rather than monitored over time. These findings reinforce concerns regarding potential overtreatment of IPMN, particularly given the morbidity associated with pancreatic surgery. The study supports the safety and effectiveness of surgery when appropriately indicated, but highlights the urgent need for better risk stratification tools. Future management should focus on identifying which patients truly require immediate surgery versus those who can be safely monitored. Improved imaging, molecular biomarkers, cyst fluid analysis, and surveillance strategies may help reduce unnecessary resections. The results also suggest that preventing progression to T1c or more advanced invasive cancer should remain a major therapeutic goal. The study provides reassurance that delayed surgery during surveillance does not necessarily compromise outcomes if intervention occurs before significant invasive progression develops. Bottom line: Preventive IPMN resection is associated with excellent long-term survival, but the high proportion of low-grade dysplasia among resected lesions highlights substantial overtreatment. Future efforts should focus on improving patient selection and safely expanding surveillance strategies to avoid unnecessary pancreatic surgery.

Rectal Cancer Surgery Rapidly Reshapes the Gut Microbiome : BJS Open | Jun 2026

Introduction: The gut microbiome plays a fundamental role in maintaining intestinal homeostasis through its effects on metabolism, immune regulation, and resistance to pathogenic colonization. Increasing evidence suggests that disruptions in microbial composition may influence surgical recovery, infectious complications, and long-term outcomes in colorectal cancer. However, the immediate effects of rectal cancer surgery and perioperative interventions on the gut microbiome remain poorly characterized. Problem Statement: Patients undergoing rectal cancer surgery are exposed to multiple factors that can alter microbial ecology, including bowel preparation, antibiotics, selective digestive decontamination, dietary changes, and ileostomy formation. Understanding how these interventions affect the microbiome is essential for developing strategies that may improve postoperative recovery and reduce complications. However, the relative contribution of these perioperative factors has remained unclear. Summary: This analysis from the IMARI trial provides important insights into the early microbiome changes occurring after rectal cancer surgery. The investigators demonstrated that surgery itself is the dominant driver of postoperative microbial disruption, leading to a marked reduction in microbial diversity and a substantial shift in overall microbial composition. These changes were characterized by an increase in facultative anaerobic organisms, particularly Enterococcus and Klebsiella, alongside a decline in beneficial obligate anaerobic bacteria, including several members of the Firmicutes phylum. Ileostomy formation emerged as an additional major determinant of microbiome alteration, exerting a greater influence on microbial composition than selective digestive decontamination. While selective digestive decontamination affected specific bacterial taxa, its overall impact on microbial diversity was comparatively modest. These findings highlight the profound ecological consequences of rectal cancer surgery and suggest that postoperative microbial imbalance may represent a potentially modifiable factor influencing surgical outcomes. The study lays the foundation for future investigations exploring whether microbiome-directed interventions, including optimized antibiotic stewardship, nutritional strategies, probiotics, or targeted microbial therapies, can improve recovery and clinical outcomes in patients undergoing rectal cancer surgery.

Early-Onset Appendiceal Cancer: Better Outcomes but Different Biology: Journal of Gastrointestinal Cancer | June 2026

* Early-onset appendiceal cancer, defined as diagnosis before age 50, accounts for nearly one-third of appendiceal malignancies. * This NCDB analysis included more than 27,000 patients with appendiceal adenocarcinoma or neuroendocrine tumors diagnosed between 2005 and 2019. * Early-onset appendiceal cancer patients were more often female, Hispanic, and privately insured compared with late-onset patients. * The early-onset group had more favorable tumor biology, with a higher proportion of neuroendocrine tumors, low-grade disease, and stage I cancers. * Stage I disease was almost twice as common in early-onset patients compared with late-onset patients. * Early-onset patients were more frequently treated with appendectomy and minimally invasive surgery. * They were less likely to undergo hemicolectomy or receive chemotherapy, reflecting earlier stage and more favorable histology. * Five-year overall survival was significantly better in early-onset appendiceal cancer compared with late-onset disease. * Survival advantage was seen across histologic subtypes and disease stages. * Early-onset patients also had better perioperative outcomes, including shorter hospital stay, fewer positive margins, lower 30- and 90-day mortality, and fewer unplanned readmissions. * The better survival should not be interpreted as age alone being protective; it likely reflects differences in tumor type, grade, stage, insurance status, and treatment patterns. * The study highlights that appendiceal cancer in younger patients is biologically and clinically distinct from late-onset disease. * Clinicians should avoid assuming that all early-onset gastrointestinal cancers behave aggressively; appendiceal cancer appears to follow a different pattern. * However, because early-onset appendiceal cancer still represents a substantial proportion of cases, awareness and appropriate staging remain important. Bottom line: Early-onset appendiceal cancer has better survival than late-onset disease, largely because it is more often neuroendocrine, low grade, early stage, and treated with less extensive surgery.

Onlay Mesh Preferred in Ventral Hernia Repair : JAMA Surg | May 2026

Introduction: Mesh reinforcement is the standard of care for primary ventral hernia repair, yet the optimal anatomical position for mesh placement remains controversial. Common techniques include onlay, preperitoneal, retromuscular, and intraperitoneal onlay mesh (IPOM) placement. While each approach has theoretical advantages, comparative real-world evidence regarding long-term recurrence and bowel obstruction remains limited. This large nationwide Danish cohort study evaluated the impact of mesh positioning on clinically relevant postoperative outcomes. Problem Statement: Surgeons must balance recurrence prevention against procedure-related complications when selecting mesh placement techniques. However, robust population-level data comparing recurrence and bowel obstruction risks across different mesh positions are scarce, making evidence-based selection challenging. Summary: This nationwide registry-based cohort study included 17,832 adults who underwent elective primary umbilical or epigastric ventral hernia repair with mesh reinforcement between 2014 and 2025. Patients were categorized according to mesh position: onlay (8,764 patients), retromuscular (1,239), preperitoneal (4,292), and IPOM (3,537). Outcomes were assessed using national healthcare databases with long-term follow-up. Compared with onlay mesh placement, both retromuscular and IPOM techniques were associated with significantly higher risks of reoperation for hernia recurrence. Retromuscular placement increased recurrence risk by 63%, while IPOM increased risk by 38%. In contrast, preperitoneal mesh placement demonstrated recurrence outcomes comparable to onlay repair. Bowel obstruction risk also differed substantially according to mesh location. Retromuscular placement doubled the risk of bowel obstruction, whereas IPOM was associated with more than a threefold increase compared with onlay mesh placement. Preperitoneal repair again showed no significant increase in bowel obstruction risk. These findings challenge the traditional perception that retromuscular mesh placement consistently provides superior long-term outcomes. The authors suggest that factors such as mesh-related adhesions, tissue plane characteristics, and technical variability may contribute to the observed differences. Clinically, the study supports onlay and preperitoneal mesh placement as favorable options for primary ventral hernia repair when considering both recurrence and bowel obstruction risks. Preperitoneal repair may be particularly attractive because it combines low recurrence rates with a low risk of bowel obstruction. Overall, this large real-world analysis suggests that onlay and preperitoneal mesh placement provide the most favorable balance between durability and safety, whereas retromuscular and IPOM techniques may carry higher risks of recurrence and postoperative bowel obstruction requiring reoperation.

Perioperative Immune Modulation Shapes Surgical Recovery : J Cardiothorac Vasc Anesth | May 2026

Introduction Surgery induces a complex inflammatory and immunologic response involving cytokine activation, neuroendocrine stress signaling and tissue repair pathways. While controlled inflammation is necessary for healing, excessive perioperative immune dysregulation contributes substantially to postoperative morbidity. Problem Statement The perioperative impact of anesthetic techniques on immune function, inflammation and long-term postoperative outcomes remains underrecognized despite growing evidence linking anesthetic modulation to recovery trajectories and organ dysfunction. Summary This review comprehensively examines how anesthetic strategies influence the perioperative immune response and subsequently affect postoperative recovery and complications. The authors emphasize that surgical trauma activates systemic inflammatory cascades intended to facilitate tissue repair and host defense. However, exaggerated or poorly regulated inflammation can result in immune suppression, immune tolerance and multisystem organ dysfunction. A major focus of the review is the immunomodulatory role of anesthetic agents themselves. Commonly used general anesthetics such as Propofol and volatile inhalational agents exert direct effects on cytokine signaling, leukocyte activity and inflammatory pathways. The review highlights the dualistic nature of anesthetic immunomodulation. Appropriate suppression of excessive inflammation may reduce tissue injury and postoperative complications, whereas excessive immunosuppression may impair host defense, increase infection risk and potentially influence oncologic outcomes. Regional anesthesia is discussed as a potentially more immune-preserving strategy compared with general anesthesia. By attenuating neuroendocrine stress responses and reducing systemic opioid requirements, regional techniques may limit perioperative immune disruption. The article also reinforces the increasingly recognized relationship between perioperative inflammation and postoperative outcomes. Excessive inflammatory activation is associated with higher rates of postoperative pain, infection, cardiac complications, acute kidney injury, delayed mobilization and prolonged hospitalization. Importantly, the review positions perioperative immune management as a modifiable therapeutic target rather than merely a physiologic consequence of surgery. Several practical perioperative strategies are discussed, including optimization of anesthetic depth, individualized anesthetic selection, opioid-sparing approaches, anti-inflammatory therapies, nutritional support and immunomodulatory interventions. The authors also explore emerging translational areas including immune checkpoint modulation and targeted immunotherapeutic strategies within perioperative medicine, although these remain largely investigational. Clinically, the review aligns with the broader evolution of perioperative medicine toward precision anesthesiology and enhanced recovery paradigms. Modern perioperative care increasingly emphasizes physiologic optimization rather than simply intraoperative sedation and analgesia. The work is particularly relevant in high-risk populations including elderly patients, cancer surgery populations, critically ill surgical patients and those with baseline immune dysfunction. From an oncologic perspective, perioperative immune modulation may be especially important because surgical stress and immunosuppression can theoretically influence residual tumor biology, metastatic progression and antitumor immune surveillance. The review also underscores the importance of multidisciplinary perioperative management involving anesthesiologists, surgeons, intensivists, nutrition teams and rehabilitation specialists to optimize inflammatory and immune recovery. Importantly, the authors acknowledge that current evidence remains heterogeneous, with many mechanistic findings derived from experimental or translational studies rather than definitive clinical outcome trials. Future research will likely focus on biomarker-guided perioperative immune profiling, individualized anesthetic immunophenotyping and targeted anti-inflammatory strategies integrated into enhanced recovery pathways. Overall, this review highlights perioperative inflammation and immune regulation as central determinants of surgical recovery, emphasizing that anesthetic choice and perioperative immune modulation may substantially influence postoperative complications, organ dysfunction and long-term outcomes.

Surgical Necrosectomy Retains a Key Role in WON : Ann Surg | May 2026

Introduction Walled-Off Pancreatic Necrosis remains one of the most challenging complications of severe pancreatitis. Over the last decade, minimally invasive and endoscopic step-up approaches have increasingly replaced open surgery, with Direct Endoscopic Necrosectomy emerging as a dominant strategy for retrogastric collections. Problem Statement Although endoscopic necrosectomy is widely adopted, comparative real-world data evaluating surgical transgastric approaches versus endoscopic techniques for retrogastric pancreatic necrosis remain limited. Summary This retrospective Stanford cohort study compared outcomes between Laparoscopic Transgastric Necrosectomy and direct endoscopic necrosectomy in patients with retrogastric walled-off necrosis. The investigators analyzed 106 patients treated over more than a decade, with similar baseline demographics and pancreatitis severity characteristics between groups. Importantly, both approaches demonstrated comparable overall safety profiles, including similar complication, mortality and 30-day readmission rates. A key finding was procedural efficiency. Although total procedural time was similar between approaches, complete debridement was achieved after a single intervention far more frequently with laparoscopic transgastric necrosectomy, whereas endoscopic therapy more commonly required multiple sessions. This observation is clinically important because repeated necrosectomy sessions increase procedural burden, healthcare utilization, cumulative sedation exposure and prolonged hospitalization. The study also demonstrated a significant interaction between disease severity and hospital length of stay. In patients with higher APACHE-II scores, laparoscopic transgastric necrosectomy was associated with shorter hospitalization compared with endoscopic management. These findings challenge the increasingly simplistic perception that endoscopic therapy should universally replace surgical intervention in pancreatic necrosis management. Instead, the data support a more individualized strategy in which patient physiology, necrosis burden, anatomical characteristics and anticipated procedural efficiency guide modality selection. The work is particularly relevant because retrogastric necrosis occupies a unique anatomical niche where both endoscopic and minimally invasive surgical transgastric access are technically feasible. Importantly, the study also highlights the maturation of minimally invasive pancreatic surgery. Contemporary laparoscopic necrosectomy differs substantially from historical open necrosectomy approaches traditionally associated with major morbidity. The reduced need for repeat interventions after laparoscopic treatment may reflect superior mechanical debridement capability, particularly in patients with dense necrotic burden or organized debris less amenable to endoscopic clearance. At the same time, the study reinforces the continued importance of multidisciplinary pancreatitis programs integrating advanced endoscopy, pancreatic surgery, interventional radiology and critical care expertise. The authors appropriately acknowledge that endoscopic approaches remain highly effective and less invasive for many patients. However, the results suggest that surgical transgastric necrosectomy should not be viewed merely as salvage therapy after endoscopic failure. Clinically, these findings may be particularly relevant for patients with extensive necrosis, high physiologic severity scores or anticipated need for multiple endoscopic sessions. The study also contributes to the evolving debate regarding optimal endpoint definitions in necrotizing pancreatitis intervention, where “procedural success” increasingly includes treatment burden, reintervention frequency and resource utilization rather than technical success alone. Limitations include the retrospective single-center design and potential selection bias regarding procedural allocation. Nevertheless, the long study period and contemporary multidisciplinary expertise provide meaningful real-world insight. Overall, this study supports laparoscopic transgastric necrosectomy as a safe, efficient and clinically relevant option for retrogastric pancreatic necrosis, reinforcing the continuing role of minimally invasive surgical approaches alongside advanced endoscopic therapy in modern pancreatic necrosis management.

Transanal Irrigation Improves LARS Outcomes : BJS | May 2026

Introduction Low Anterior Resection Syndrome is a major long-term complication following sphincter-preserving rectal cancer surgery and is characterized by fecal urgency, incontinence, clustering, fragmentation and impaired quality of life. Despite its substantial functional burden, effective long-term treatment strategies remain limited. Problem Statement Evidence supporting the use of Transanal Irrigation for severe low anterior resection syndrome remains limited, particularly from randomized multicenter studies evaluating long-term feasibility, bowel function and quality-of-life outcomes. Summary This international multicenter randomized clinical trial evaluated transanal irrigation versus best supportive care in patients with major low anterior resection syndrome persisting at least one year after rectal surgery. The study demonstrated substantial improvement in bowel function among patients treated with transanal irrigation. At 12 months, patients receiving irrigation showed dramatically lower LARS and Wexner incontinence scores compared with standard supportive management, indicating clinically meaningful improvement in continence and bowel control. Importantly, the benefits extended beyond symptom scores alone. Patients undergoing transanal irrigation also achieved significantly better quality-of-life outcomes and higher bowel function instrument scores, reinforcing the broader functional and psychosocial impact of improved bowel regulation. A notable strength of the study was the high treatment adherence observed throughout follow-up. Three-quarters of patients continued daily irrigation at 12 months, suggesting that transanal irrigation is not only effective but also practically acceptable for long-term use in motivated patients. The safety profile was favorable, with only minor procedure-related adverse events reported. No major complications were observed, supporting the relative procedural safety of structured irrigation protocols in experienced settings. The findings are clinically important because LARS remains one of the most underrecognized survivorship complications following rectal cancer treatment. While oncologic outcomes have improved substantially with sphincter-preserving surgery, many patients continue to experience severe functional disability despite technically successful resections. The study also reinforces the concept that bowel dysfunction after rectal surgery should be approached proactively rather than accepted as an unavoidable postoperative consequence. Structured rehabilitation strategies may significantly improve long-term survivorship quality. Mechanistically, transanal irrigation likely improves symptoms by facilitating predictable bowel emptying, reducing stool fragmentation and minimizing urgency episodes. This restoration of bowel control may substantially reduce anxiety and social limitation associated with unpredictable defecation patterns. The trial further highlights the need for dedicated multidisciplinary LARS pathways integrating colorectal surgeons, gastroenterologists, pelvic floor specialists and continence teams. Early identification and escalation to advanced supportive therapies may prevent chronic deterioration in quality of life. Although the study size was modest, the magnitude and consistency of benefit across multiple functional endpoints provide strong support for transanal irrigation as an important therapeutic option in severe LARS. Future work will need to better define optimal patient selection, timing of initiation, long-term durability and integration with other rehabilitative approaches including pelvic floor therapy, neuromodulation and dietary interventions. Overall, this randomized multicenter trial demonstrates that transanal irrigation is feasible, safe and highly effective for severe low anterior resection syndrome, producing substantial improvements in bowel function, continence and quality of life compared with best supportive care.

Prophylactic Negative-Pressure Wound Therapy Reduces Surgical Site Infection After Major Abdominal Surgery : BJS Open | May 2026

Introduction Surgical Site Infection remains one of the most common complications after major abdominal and thoracic surgery, contributing substantially to postoperative morbidity, prolonged hospitalization, reintervention and healthcare expenditure. High-risk procedures such as emergency laparotomy and open cardiothoracic surgery are particularly vulnerable to wound complications. Prophylactic Negative-Pressure Wound Therapy has emerged as a potential strategy to reduce postoperative wound morbidity, although prior clinical trial results have been inconsistent. Problem Statement The effectiveness of prophylactic negative-pressure wound therapy in reducing surgical site infection and improving postoperative outcomes after major thoracic and abdominal surgery remains uncertain because of heterogeneous trial data and variable study quality. Summary This systematic review and meta-analysis evaluated randomized trials investigating prophylactic negative-pressure wound therapy following open abdominal and thoracic surgery, providing one of the largest contemporary syntheses of evidence in this field. Across more than 12,000 patients from 45 randomized trials, negative-pressure wound therapy significantly reduced the incidence of surgical site infection compared with standard dressings. The magnitude of benefit was substantial, with approximately a 50% relative reduction in infection risk observed overall. Importantly, the beneficial effect appeared consistent across commonly used commercial systems, suggesting that the therapeutic principle rather than a specific proprietary device likely underlies the observed reduction in wound complications. Negative-pressure therapy was additionally associated with shorter hospital stay, reinforcing the broader clinical and economic relevance of reducing postoperative wound morbidity. Even modest reductions in length of stay may translate into major cumulative healthcare savings at a population level, particularly in high-volume abdominal surgery pathways. However, the analysis also demonstrated important limitations. Negative-pressure wound therapy did not significantly reduce organ-space infection, wound dehiscence or reoperation rates. This suggests that the primary benefit is likely confined predominantly to superficial or deep incisional wound complications rather than broader intra-abdominal septic processes. The thoracic surgery evidence base remained notably limited, with only three studies included and no statistically significant reduction in infection demonstrated in this subgroup. Consequently, extrapolation of abdominal surgery findings to thoracic procedures should be performed cautiously. A particularly important methodological observation was the detection of publication bias. After statistical correction using trim-and-fill analysis, the magnitude of benefit was attenuated though still remained significant. This finding suggests that earlier enthusiasm regarding prophylactic negative-pressure therapy may partly overestimate the true effect size. The study therefore supports a more nuanced clinical approach rather than universal adoption. Selective use in high-risk patients appears most justifiable, particularly in individuals with obesity, diabetes, contaminated surgery, immunosuppression, emergency laparotomy or other established wound-healing risk factors. The findings also reflect the growing emphasis on perioperative optimization and complication prevention within modern surgical practice. Reducing surgical site infection not only improves immediate postoperative recovery but may also influence downstream oncologic treatment timelines, readmissions and patient quality of life. Importantly, the authors highlight persistent deficiencies in reporting patient-reported outcomes and long-term wound-related endpoints. Future studies will need to better evaluate pain, mobility, scar quality, device tolerance and cost-effectiveness to fully define the clinical value of prophylactic negative-pressure systems. From a mechanistic standpoint, negative-pressure therapy likely improves wound healing through multiple pathways including reduction of dead space, fluid removal, enhanced perfusion and stabilization of the incision environment. However, the relative contribution of these mechanisms in closed surgical incisions remains incompletely understood. Overall, this large meta-analysis supports prophylactic negative-pressure wound therapy as an effective strategy for reducing surgical site infection and shortening hospital stay after major abdominal surgery. Nevertheless, evidence of publication bias and limited long-term outcome data support a selective risk-based implementation strategy rather than routine universal use across all surgical populations.

Liver Margin Positivity Emerges as a Major Determinant of R1 Resection in Perihilar Cholangiocarcinoma : Ann Surg | May 2026

Introduction Perihilar Cholangiocarcinoma remains one of the most technically challenging hepatobiliary malignancies to treat surgically. Achieving an R0 resection is critical because microscopic residual disease strongly influences recurrence and long-term survival. While ductal margins are routinely assessed, the significance and optimal evaluation of the liver margin have remained poorly defined despite it representing the largest surgical margin in major hepatectomy specimens. Problem Statement The prevalence, spatial distribution and clinical relevance of positive liver margins in resected perihilar cholangiocarcinoma are incompletely understood, and standardized pathological assessment strategies for liver margins are lacking. Summary This multicenter study investigated the status of liver margins in resected perihilar cholangiocarcinoma using serial whole-mount digital large-section analysis, providing important new insights into patterns of microscopic residual disease and margin assessment methodology. The study demonstrated that liver margin positivity is substantially underrecognized using conventional small-section pathology techniques. When assessed using whole-mount digital large sections, the liver margin R1 rate approached 39%, compared with only 6% using conventional small-section evaluation alone. This striking discrepancy highlights the limitations of traditional sampling approaches in accurately characterizing microscopic residual disease within the liver transection plane. Importantly, patients classified as R0 in the discovery cohort undergoing more comprehensive liver margin assessment experienced superior overall survival and recurrence-free survival, emphasizing the major prognostic implications of accurate margin characterization. A particularly notable finding was the spatial clustering of microscopic carcinoma near the proximal ductal margin. Approximately 95% of carcinoma involvement within the liver margin was located within 20 mm of the proximal ductal margin, suggesting a biologically and surgically meaningful zone of highest residual disease risk. The investigators further identified a proximal ductal margin distance below 5 mm as an independent predictor of liver margin positivity. Patients with narrow proximal ductal clearance were significantly more likely to harbor occult liver margin involvement, reinforcing the interconnected anatomy of ductal and parenchymal spread in perihilar cholangiocarcinoma. Clinically, the study has important implications for both surgery and pathology workflows. The findings suggest that current routine pathology approaches may significantly underestimate true R1 rates in perihilar cholangiocarcinoma, potentially leading to inaccurate prognostication and postoperative treatment planning. The proposed examination strategy focusing on a 20 mm radius around the proximal ductal margin provides a practical framework for standardized liver margin assessment. This targeted approach may improve diagnostic yield while remaining operationally feasible within routine pathology practice. From a biological perspective, the work also illustrates the infiltrative growth characteristics of perihilar cholangiocarcinoma. Microscopic extension beyond visibly apparent tumor boundaries into adjacent hepatic parenchyma may partly explain the persistently high recurrence rates observed even after apparently curative surgery. The study additionally highlights the growing role of digital pathology and whole-mount sectioning in hepatobiliary oncology. Advanced pathological mapping techniques may increasingly refine understanding of tumor spread patterns and improve surgical margin interpretation. These findings may also influence operative strategy. Awareness that narrow proximal ductal margins strongly correlate with occult liver margin involvement could affect intraoperative decision-making regarding extent of resection and frozen-section interpretation. Importantly, the work raises broader questions regarding the definition of true oncologic radicality in perihilar cholangiocarcinoma. Conventional binary R0/R1 classification may not fully capture the complexity of microscopic parenchymal extension patterns in this disease. Overall, this multicenter study identifies liver margin positivity as a major and previously underappreciated contributor to R1 resection in perihilar cholangiocarcinoma. Whole-mount digital large-section pathology substantially improves detection of occult residual disease and supports a standardized focused assessment strategy centered around the proximal ductal margin region.

Anastomotic Leak Drives Major Clinical and Economic Burden After Left-Sided Colorectal Surgery : BJS Open | June 2026

Introduction Anastomotic Leak remains one of the most feared complications following Colorectal Surgery. Beyond its immediate morbidity and mortality implications, anastomotic leak substantially disrupts recovery pathways, prolongs hospitalization and frequently necessitates reintervention. While the clinical consequences are well recognized, large-scale real-world economic data quantifying the healthcare burden of anastomotic leak within national healthcare systems have remained limited. Problem Statement The true healthcare resource utilization and economic impact of anastomotic leak after left-sided colorectal surgery in England has not been comprehensively characterized using contemporary real-world population data. Summary This large retrospective matched-cohort study analyzed outcomes of nearly 37,000 patients undergoing left-sided colorectal surgery in England using the Hospital Episode Statistics database. The investigators compared patients with and without anastomotic leak after exact matching for key demographic and operative variables, allowing robust estimation of the independent burden associated with leak development. The study demonstrated that anastomotic leak imposes profound clinical and financial consequences. Patients developing leaks experienced markedly higher inpatient costs, with adjusted excess costs exceeding €11,000 per patient. This substantial economic burden likely reflects prolonged admissions, intensive care utilization, radiologic and surgical interventions, antibiotic therapy, nutritional support and repeat hospitalizations. Hospital length of stay was dramatically prolonged among patients with leaks, with an additional cumulative hospitalization duration approaching 16 days. This finding underscores how anastomotic failure fundamentally alters postoperative recovery trajectories and consumes significant healthcare resources. Importantly, the incidence of clinically significant leaks requiring intervention was 5.6%, reinforcing that anastomotic leak remains a relatively common major complication despite advances in minimally invasive surgery, enhanced recovery pathways and perioperative optimization. The study also differentiated between major and minor leaks, highlighting the spectrum of clinical severity associated with anastomotic failure. Even less severe leaks contributed substantially to healthcare utilization, emphasizing that the burden of leak extends beyond catastrophic surgical emergencies alone. Clinically, the findings reinforce that prevention of anastomotic leak should remain a central quality priority in colorectal surgery. Strategies including meticulous surgical technique, perfusion assessment, tension-free anastomosis, selective diversion, nutritional optimization and careful patient selection may have major downstream economic as well as clinical benefits. The work is particularly important because it provides robust real-world national data rather than estimates derived from small institutional series. By leveraging a large population database, the study captures the broader systemic impact of leak complications across routine clinical practice. The findings additionally have major implications for healthcare policy and value-based surgical care. Anastomotic leak prevention programs may yield substantial cost savings at a population level, supporting investment in perioperative optimization pathways, intraoperative perfusion technologies and specialized colorectal surgical services. From an oncologic perspective, the burden of leak extends beyond immediate postoperative morbidity. Anastomotic leaks may delay adjuvant chemotherapy initiation, impair long-term functional outcomes and potentially worsen oncologic survival, although these endpoints were not specifically examined in this analysis. The study further highlights the importance of standardized leak definitions and surveillance systems within colorectal surgery quality programs. Reliable benchmarking of leak incidence and associated costs is essential for institutional performance improvement and comparative outcomes assessment. Overall, this nationwide English real-world study demonstrates that anastomotic leak after left-sided colorectal surgery is associated with major increases in healthcare utilization, prolonged hospitalization and substantial economic burden. The findings strongly reinforce the critical importance of leak prevention, early recognition and optimized perioperative colorectal surgical care pathways.

Nationwide Prehabilitation Reduces Complications After CRC Surgery : JAMA Surg | May 2026

Introduction Colorectal Cancer surgery remains associated with substantial postoperative morbidity despite advances in minimally invasive techniques and enhanced recovery pathways. Increasing attention has focused on prehabilitation strategies aimed at optimizing physical fitness, nutritional status and psychological resilience before surgery. However, prior prehabilitation studies have been limited by small sample sizes, selective enrollment and heterogeneous protocols, leaving uncertainty regarding real-world effectiveness at a national scale. Problem Statement Whether standardized multimodal prehabilitation improves postoperative outcomes in unselected colorectal cancer populations across diverse healthcare systems has remained unclear. Large implementation-based data evaluating broad clinical applicability have been lacking. Summary This nationwide multicenter Dutch cohort study evaluated the real-world impact of a standardized four-week supervised multimodal prehabilitation program among nearly 2,400 patients undergoing elective colorectal cancer resection across 18 hospitals. Patients participating in prehabilitation were propensity-score matched with historical controls to minimize baseline differences in operative and clinical risk factors. The multimodal program incorporated high-intensity exercise training, nutritional optimization, psychological counseling and targeted management of comorbidities including anemia, frailty and smoking cessation. Importantly, the intervention was implemented broadly across unselected surgical candidates rather than only highly motivated or frail subgroups, enhancing generalizability. Participation in prehabilitation was associated with significant reductions in overall postoperative complications. Both medical and surgical complications were reduced, with particularly notable decreases in nonsurgical medical morbidity. Hospital stay was shortened by approximately one day, while readmission and intensive care admission rates were also lower in the prehabilitation cohort. One of the most clinically important observations was that benefit occurred consistently across age groups and ASA classifications. Older patients and those with higher perioperative risk derived similar improvements, suggesting that prehabilitation may improve physiologic reserve irrespective of baseline frailty or comorbidity burden. Mechanistically, the findings support the concept that improving preoperative functional capacity enhances resilience against surgical stress responses. High-intensity exercise may improve cardiopulmonary reserve and metabolic flexibility, while nutritional optimization likely supports immune competence, wound healing and muscle preservation. Psychological support and smoking cessation may additionally reduce perioperative inflammatory and neuroendocrine stress pathways. The study is particularly impactful because it demonstrates successful nationwide implementation of a uniform prehabilitation strategy within routine clinical practice rather than highly controlled experimental settings. This suggests that multimodal prehabilitation can be feasibly integrated into standard colorectal cancer care pathways at scale. Importantly, the observed reduction in complications likely extends beyond simply lowering complication incidence. Enhanced physiologic reserve may also mitigate severity and improve recovery trajectories when complications occur, a concept increasingly recognized as central to perioperative oncology care. The findings further reinforce the growing paradigm shift from procedure-centered surgery toward patient-centered physiologic optimization. As oncologic surgery becomes increasingly multidisciplinary, prehabilitation may emerge as a core component of perioperative cancer management alongside enhanced recovery protocols and minimally invasive techniques. Overall, this large nationwide implementation study demonstrates that standardized multimodal prehabilitation is associated with meaningful reductions in postoperative morbidity and healthcare utilization after colorectal cancer surgery across broad patient populations. The results strongly support incorporation of structured prehabilitation programs into routine colorectal surgical oncology practice.

Polidocanol Foam Enhances Recovery After Hemorrhoidectomy : Dis Colon Rectum | May 2026

Polidocanol Foam Enhances Recovery After Hemorrhoidectomy : Dis Colon Rectum | May 2026 Introduction Hemorrhoids remain one of the most common anorectal disorders worldwide. For grade IV hemorrhoidal disease, the Milligan-Morgan Hemorrhoidectomy continues to be regarded as the surgical gold standard because of its durable efficacy. However, postoperative pain, bleeding and delayed return to normal activity remain major limitations. Polidocanol foam sclerotherapy has shown efficacy in lower-grade hemorrhoidal disease, but evidence supporting its adjunctive use in advanced grade IV disease has been limited. Problem Statement Despite excellent long-term control, conventional open hemorrhoidectomy is frequently associated with substantial postoperative morbidity and prolonged recovery. Whether adjunctive foam sclerotherapy can meaningfully improve postoperative recovery and symptom control after excisional surgery for advanced hemorrhoidal disease remains uncertain. Summary This randomized open-label single-center trial evaluated the addition of 3% polidocanol foam sclerotherapy to standard Milligan-Morgan hemorrhoidectomy in patients with grade IV hemorrhoidal disease. Thirty-six patients were randomized equally to combined therapy versus conventional surgery alone. The primary endpoint was recovery time measured by return to normal daily activity and work. Patients receiving adjunctive polidocanol foam demonstrated significantly faster postoperative recovery, returning to normal activities nearly six days earlier than patients undergoing hemorrhoidectomy alone. Combined therapy was also associated with lower postoperative bleeding severity, reduced analgesic requirements and improved hemorrhoidal symptom scores during early postoperative follow-up. Importantly, no adverse events or continence deterioration were observed, and patient satisfaction remained high in both treatment groups. The findings suggest that adjunctive foam sclerotherapy may reduce postoperative vascular congestion and inflammation following excisional hemorrhoidectomy, thereby improving early healing and reducing symptomatic recovery burden. The absence of increased complications is particularly notable given concerns regarding tissue necrosis or impaired wound healing with combined interventions. Although limited by its small sample size, short follow-up duration and single-center nonblinded design, this study provides encouraging early evidence supporting integration of 3% polidocanol foam into surgical management strategies for advanced hemorrhoidal disease. Larger multicenter trials with long-term follow-up will be necessary to confirm durability, recurrence rates and broader reproducibility of these findings.

Autologous PRP Shows Promise for Complex Anal Fistulas : Dis Colon Rectum | May 2026

Introduction Management of complex Anal Fistula remains challenging because durable fistula closure must be balanced against preservation of anal sphincter function. Conventional fistulotomy is often unsuitable in complex disease because of the risk of postoperative fecal incontinence, prompting increasing interest in minimally destructive sphincter-preserving therapies. Platelet-Rich Plasma has emerged as a biologically active regenerative strategy with potential to promote fistula healing while minimizing tissue injury. Problem Statement Current sphincter-preserving procedures for complex anal fistulas often demonstrate variable healing rates, technical complexity or substantial recurrence risk. Evidence supporting standalone autologous platelet-rich plasma therapy without adjunctive surgical closure techniques has remained limited, particularly in large heterogeneous real-world cohorts. Summary This retrospective Swedish referral-center study evaluated 90 consecutive patients with complex anal fistulas treated using a staged autologous platelet-rich plasma protocol. Patients underwent detailed preoperative evaluation with endoanal three-dimensional ultrasonography, which fully replaced pelvic MRI within the treatment pathway. Initial examination under anesthesia with seton placement was followed by delayed fistula occlusion using autologous PRP after approximately three months. Clinical and ultrasonographic healing was achieved in 63% of patients after a single PRP closure procedure. Repeat minimally invasive treatments further improved outcomes, with an additional 11% healing after a second procedure and another 7% after a third intervention, resulting in an overall closure rate exceeding 80% following repeated therapy. Importantly, no postoperative anal incontinence or procedural complications were reported, emphasizing the sphincter-preserving safety profile of the approach. The study included a broad spectrum of fistula types and patient demographics without major exclusion criteria, supporting potential generalizability to complex real-world practice. Statistical analysis suggested that patient age was not a significant determinant of healing outcome. The authors also highlighted the practical advantages of the technique, noting its relative technical simplicity, low tissue destructiveness and repeatability compared with more invasive reconstructive procedures. Although limited by its retrospective single-surgeon design and absence of a control group, the study provides encouraging evidence supporting autologous PRP as a safe and potentially effective minimally invasive treatment option for complex anal fistulas. The findings further reinforce growing interest in biologically regenerative sphincter-preserving therapies within colorectal surgery and suggest that repeat PRP application may substantially improve cumulative fistula healing rates without compromising continence.

Liver Margin Status in pCCA : Ann Surg | May 2026

Introduction Achieving margin-negative resection remains one of the major determinants of long-term outcomes in perihilar cholangiocarcinoma (pCCA). While proximal and distal ductal margins are routinely evaluated, the liver margin (LM) represents the largest and least standardized resection margin in pCCA surgery. This multicenter study investigated the prevalence, spatial distribution and prognostic significance of LM positivity using serial whole-mount digital large-section (WDLS) pathology. Problem Statement Among 227 patients undergoing major hepatectomy for pCCA, WDLS-based assessment identified LM R1 resection in 38.6% of cases, substantially higher than conventional small-section analysis alone. Standard pathology underestimated positive LM involvement, detecting only approximately 6% of R1 cases. Importantly, patients classified as true R0 by WDLS demonstrated superior overall survival and recurrence-free survival compared with conventionally assessed controls. Spatial mapping revealed that 95% of carcinoma involvement occurred within 20 mm of the proximal ductal margin (P-DM), and a P-DM distance <5 mm independently predicted LM positivity. Summary This study establishes liver margin positivity as a major contributor to occult R1 resection in pCCA and demonstrates that conventional sampling substantially underestimates residual microscopic disease. WDLS significantly improved diagnostic accuracy and refined pathological risk stratification. The authors propose a practical LM assessment strategy focused on systematic examination within a 20 mm radius surrounding the proximal ductal margin, particularly in patients with a P-DM distance <5 mm. These findings may redefine pathological evaluation standards in pCCA and improve surgical quality assessment, prognostication and postoperative management.

Early-Onset Pancreatic Cancer Shows Aggressive Molecular Biology : Br J Surg | May 2026

Introduction The global rise in early-onset gastrointestinal malignancies has become a major oncologic concern, with pancreatic ductal adenocarcinoma (PDAC) increasingly being diagnosed in patients younger than 50 years. Although younger patients are generally presumed to tolerate aggressive multimodality treatment better, the biological behavior of early-onset pancreatic cancer (EOPC) remains poorly understood. Problem Statement Existing studies evaluating outcomes in EOPC have produced conflicting results, and the molecular mechanisms underlying disease aggressiveness in younger patients remain unclear. Whether EOPC differs biologically from late-onset PDAC has important implications for prognosis, surveillance and therapeutic decision-making. Summary This large multicenter translational study demonstrated that surgically resected EOPC is associated with significantly earlier postoperative recurrence and more aggressive molecular characteristics compared with late-onset PDAC. Despite receiving adjuvant chemotherapy more frequently and completing treatment more often than older patients, individuals with EOPC experienced shorter disease-free survival and remained at increased risk of recurrence after resection. Importantly, these poorer outcomes could not be explained by conventional clinicopathological factors such as tumor stage, nodal burden, margin status or differentiation grade. Transcriptomic analysis revealed enrichment of squamous (basal-like) molecular subtype signatures in EOPC, including increased expression of aggressive genes such as S100A2, TP63 and MYC-related proliferative pathways, alongside downregulation of GATA6, a marker associated with the more favorable classical pancreatic subtype. Gene programs linked to cell proliferation, squamous differentiation, inflammation and metabolic reprogramming were significantly enriched in younger patients, supporting a biologically aggressive phenotype. Additionally, immune-related gene pathways appeared relatively suppressed in EOPC, although major differences in immune cell infiltration were not definitively demonstrated. Germline mutations were not more common in younger patients, suggesting that inherited predisposition alone does not explain disease biology. Collectively, the findings challenge the assumption that younger age predicts favorable pancreatic cancer outcomes and instead support EOPC as a distinct high-risk biological subtype that may require intensified surveillance, earlier systemic therapy optimization and prioritization for biomarker-driven clinical trials.

Financial Toxicity After Complex GI Surgery : Ann Surg | May 2026

Introduction Financial toxicity (FT) has emerged as an important yet underrecognized consequence of modern cancer care. Patients undergoing major gastrointestinal (GI) surgery frequently face substantial economic stress related to hospitalization, prolonged recovery, loss of income and ongoing medical expenses. Although FT has been studied in oncology, its impact in complex GI surgical populations and its relationship with patient-reported quality-of-life outcomes remain insufficiently explored. Problem Statement Patients undergoing pancreatic, hepatobiliary and other complex GI procedures often experience prolonged treatment pathways involving multimodal therapy and intensive postoperative care. However, limited data exist regarding the prevalence of FT in GI surgery and its influence on emotional and social well-being. Better identification of vulnerable patients is essential to enable timely financial and psychosocial support interventions. Summary This prospective study evaluated FT among patients undergoing major GI surgery using validated patient-reported outcome instruments. Nearly one-third of patients experienced clinically significant FT, highlighting the substantial economic burden associated with complex surgical care. Pancreatic resections constituted the largest subgroup, reflecting the intensive treatment requirements of these patients. Importantly, FT demonstrated a meaningful association with emotional and social well-being, emphasizing that financial strain extends beyond economic hardship and directly affects overall quality of life. Single marital status emerged as an independent predictor of FT, suggesting that limited social support networks may increase vulnerability to financial distress. Interestingly, patients not receiving chemotherapy or radiation therapy also showed higher odds of FT, potentially reflecting differences in insurance coverage, employment disruption or access to coordinated oncologic care. The study reinforces the growing recognition that financial health represents a critical component of perioperative outcomes. The authors propose that preoperative identification of high-risk patients may facilitate early referral to financial counseling, social work and supportive care services. Overall, this work highlights FT as a clinically relevant and measurable postoperative burden in GI surgery, supporting the integration of financial risk assessment into multidisciplinary surgical oncology care pathways.

Minimally Invasive Surgery Provides Durable Relief in Thoracic Esophageal Diverticula : Journal of Gastrointestinal Surgery | May 2026

Introduction Mid- and distal thoracic esophageal diverticula are uncommon but clinically significant disorders that frequently present with dysphagia, regurgitation and aspiration-related symptoms. Surgical management has evolved substantially over the past two decades, with minimally invasive approaches increasingly replacing traditional thoracotomy-based procedures to reduce perioperative morbidity while maintaining symptomatic benefit. Problem Statement Despite growing adoption of minimally invasive surgery for thoracic esophageal diverticula, long-term outcome data remain limited because of the rarity of the condition and the heterogeneity of operative strategies. Questions persist regarding durability of symptom relief, recurrence rates and the importance of adjunctive esophageal myotomy in optimizing postoperative outcomes. Summary This large single-center experience demonstrates that minimally invasive surgery is an effective and safe treatment strategy for symptomatic mid- to distal thoracic esophageal diverticula. Most patients presented with clinically significant dysphagia, and underlying esophageal motility disorders—particularly achalasia—were frequently identified, supporting the concept that diverticula are often secondary to functional outflow abnormalities. Minimally invasive thoracoscopic and laparoscopic approaches achieved excellent symptomatic improvement, with nearly 90% of patients reporting complete resolution of dysphagia early after surgery. Although some patients experienced recurrent or residual symptoms during longer follow-up, overall dysphagia severity remained substantially improved compared with preoperative status. The study also highlights the importance of concomitant myotomy, which was performed in most patients and likely contributed to favorable functional outcomes by addressing the underlying motility disorder. Postoperative esophageal leak remained the most important complication, although rates were acceptable and mortality was absent. Importantly, only a minority of patients with recurrent diverticula required reoperation, suggesting that radiographic recurrence does not necessarily correlate with clinically significant failure. Overall, the findings support minimally invasive surgery as the preferred approach for symptomatic thoracic esophageal diverticula, providing durable symptom relief with relatively low morbidity in experienced centers.

Robotic Groin Hernia Repair Shows No Long-Term Recurrence Advantage | JAMA Surgery

Introduction Robotic-assisted groin hernia repair has rapidly expanded across surgical practice in the United States, driven by increasing adoption of minimally invasive techniques and perceived technical advantages such as enhanced visualization and improved surgeon ergonomics. Despite this growth, robust population-level evidence comparing long-term outcomes of robotic, laparoscopic and open approaches remains limited. Problem Statement Although robotic surgery is increasingly used for groin hernia repair, it remains unclear whether this technology improves long-term durability compared with established laparoscopic and open techniques. Given the substantial costs and rapid dissemination of robotic platforms, understanding whether robotic repair meaningfully reduces recurrence is essential for evaluating its true clinical value. Summary This large Medicare-based cohort study found that robotic-assisted groin hernia repair was associated with slightly higher long-term operative recurrence rates compared with laparoscopic and open approaches, without demonstrating a clinically meaningful advantage in repair durability. Over five years of follow-up, recurrence rates remained low across all surgical techniques, but laparoscopic repair consistently showed the lowest recurrence risk, while robotic-assisted repair demonstrated the highest cumulative recurrence incidence. Importantly, these findings remained stable across multiple sensitivity analyses, including elective versus emergent repairs, unilateral versus bilateral procedures and varying levels of surgeon robotic utilization. The study highlights the rapid expansion of robotic-assisted hernia surgery despite limited evidence of superior long-term outcomes and raises important questions regarding technology adoption driven more by market forces and procedural diffusion than by demonstrable clinical benefit. The authors emphasize that recurrence rates alone may not fully capture the value of robotic surgery and suggest that future evaluation should incorporate broader outcomes such as recovery, conversion rates, patient experience and healthcare utilization. Overall, the findings challenge assumptions that robotic repair offers superior long-term effectiveness for groin hernia surgery and reinforce the need for evidence-based adoption of surgical innovation.

Younger Adults Face Higher Intra-Abdominal Risk After Colectomy for Diverticular Disease | Journal of Gastrointestinal Surgery

Introduction Diverticular disease has traditionally been considered a condition of older adults, but its incidence in younger populations has risen substantially over recent decades. As colectomy is increasingly performed in younger patients with diverticular disease, understanding age-specific postoperative risk has become essential to guide surgical decision making and patient counselling. Problem Statement Younger patients undergoing colectomy for diverticular disease are often perceived as lower-risk surgical candidates because they generally have fewer comorbidities and better overall physiological reserve. However, whether younger age confers a true postoperative advantage remains uncertain, particularly with respect to clinically significant intra-abdominal complications following colectomy. Summary This large national surgical outcomes study challenges the assumption that younger patients experience better postoperative outcomes after colectomy for diverticular disease. Using NSQIP data from nearly 40,000 patients, the authors found that although younger adults had a generally healthier baseline profile, they did not experience lower overall postoperative risk compared with older patients. Notably, age younger than 50 years independently increased the risk of major intra-abdominal complications, including anastomotic leak and organ-space surgical site infection. While older patients had slightly higher readmission rates overall, younger patients who were readmitted returned earlier, suggesting a distinct postoperative risk pattern in this group. These findings indicate that younger age should not be viewed as inherently protective in the perioperative setting and that colectomy in younger patients carries meaningful risk despite fewer traditional comorbidities. The study provides important evidence to support more balanced patient counselling and reinforces the need for individualized surgical decision making rather than age-based assumptions in diverticular disease management.

Robot-Assisted Esophagectomy vs Conventional MIE: Annals of Surgical Oncology | April 2026

Introduction Surgical management of Esophageal cancer continues to evolve, with minimally invasive techniques improving perioperative outcomes. A newer concept—total mesoesophageal excision (TME)—aims to enhance oncologic clearance. The integration of robotic surgery with TME (RATME) is proposed to further refine precision and outcomes compared to conventional minimally invasive esophagectomy (MIE). Problem Statement It remains unclear whether robot-assisted esophagectomy combined with TME offers meaningful advantages over conventional minimally invasive approaches in terms of surgical and oncologic outcomes. Summary This multicenter retrospective study compared robot-assisted TME esophagectomy (RATME) with other minimally invasive approaches. The robotic TME group had longer operative times but demonstrated important perioperative advantages, including reduced blood loss, shorter postoperative hospital stay, and lower complication rates. Additionally, the TME approach resulted in a higher lymph node yield, suggesting improved oncologic clearance. Although overall survival and disease-free survival were not significantly different across groups, trends toward lower recurrence and mortality were observed in the RATME group. The key takeaway is that robot-assisted TME appears to enhance surgical precision and short-term outcomes, with potential long-term benefits. However, the trade-off includes longer operative time, and further studies are needed to confirm survival advantages. Key Takeaways: Better surgery today may translate into better cancer outcomes tomorrow—but stronger evidence is still needed.

Pyloroplasty During MIE/RAMIE: Annals of Surgery | April 2026

Introduction Minimally invasive esophagectomy (MIE) and robot-assisted MIE (RAMIE) are standard approaches in the treatment of Esophageal cancer. One debated step during surgery is whether to perform pyloroplasty, a procedure intended to improve gastric emptying after esophageal resection. Despite widespread use, high-quality evidence supporting or refuting its benefit has been limited, especially in the modern minimally invasive era. Problem Statement There is a lack of level-1 evidence to determine whether adding pyloroplasty during MIE or RAMIE improves postoperative outcomes. Summary This phase III randomized controlled trial provides important evidence supporting the use of pyloroplasty during minimally invasive esophagectomy. The study used an adaptive design and demonstrated that patients undergoing pyloroplasty had better short-term outcomes compared to those without it. The primary composite outcome—pneumonia or anastomotic leak requiring surgery—occurred less frequently in the pyloroplasty group (18%) compared to the no-pyloroplasty group (27%). The trial was stopped early once predefined superiority criteria were met, indicating a high probability that pyloroplasty improves short-term outcomes. Clinically, this suggests that pyloroplasty may reduce postoperative complications, particularly respiratory and anastomotic issues, in patients undergoing MIE or RAMIE. However, long-term outcomes and quality-of-life data are still awaited. Key takeaway: Adding pyloroplasty during minimally invasive esophagectomy improves short-term surgical outcomes and may be considered a beneficial adjunct procedure.

Micronutrients and Thyroid Recovery After Sleeve Gastrectomy: AJS | April 2026

Introduction Bariatric surgery, particularly sleeve gastrectomy, is increasingly recognized not only for weight loss but also for its metabolic benefits, including improvement in endocrine disorders such as hypothyroidism. While many patients experience normalization of thyroid function after surgery, predicting which patients will achieve thyroid-stimulating hormone (TSH) remission remains unclear. Emerging evidence suggests that micronutrient status—especially vitamin D and vitamin B12—may play a role in endocrine recovery and metabolic regulation. Problem Statement There is a lack of reliable preoperative predictors to identify which hypothyroid patients will achieve TSH remission after sleeve gastrectomy. Summary This study demonstrates that preoperative levels of vitamin D and vitamin B12 are strong predictors of TSH remission following sleeve gastrectomy. Patients with higher baseline levels of these micronutrients had significantly higher rates of remission at both 6 and 12 months. Notably, up to 77.5% of patients achieved TSH normalization by 12 months, with many able to reduce or discontinue levothyroxine therapy, and none requiring dose escalation. Importantly, micronutrient levels outperformed traditional predictors such as age, sex, and BMI, highlighting a potentially modifiable factor in preoperative optimization. Both vitamin D and B12 showed strong predictive accuracy, suggesting a clinically meaningful role in patient selection and counseling. From a practical standpoint, this study supports routine assessment and correction of micronutrient deficiencies before bariatric surgery. It also opens the possibility that optimizing nutritional status may enhance endocrine recovery, moving toward a more personalized and proactive perioperative strategy.

Predicting Perineural Invasion in CRC: Surgery | April 2026

Perineural invasion (PNI) is a well-recognized adverse prognostic factor in colorectal cancer (CRC), associated with aggressive tumor biology, higher metastatic potential, and poor survival outcomes. However, PNI is typically identified only after surgical resection on histopathology. The ability to predict PNI preoperatively could significantly influence risk stratification, surgical planning, and decisions regarding neoadjuvant or adjuvant therapy. Problem Statement Currently, there is no reliable preoperative tool to predict perineural invasion in colorectal cancer. This limits the ability to identify high-risk patients early and incorporate this critical prognostic factor into multidisciplinary decision-making before definitive treatment. Summary This large SEER-based case-control study involving over 223,000 CRC patients identified key predictors of PNI, including male sex, tumor location (left colon and rectum), poor differentiation, nodal involvement (N1/N2), and elevated carcinoembryonic antigen levels. PNI was present in 13.1% of cases and was strongly associated with worse 5-year overall and cancer-specific survival, as well as increased liver and lung metastases. The derived Cleveland Clinic Florida PNI prediction score demonstrated excellent negative predictive value (93%), making it particularly useful to rule out PNI preoperatively. This model has potential clinical utility in guiding personalized treatment strategies and improving multidisciplinary planning in colorectal cancer.

Vasculobiliary Injury in Laparoscopic and Open Cholecystectomy HPB | 2026

Introduction Vasculobiliary injury is one of the most serious complications associated with cholecystectomy, particularly when a bile duct injury is accompanied by injury to the hepatic artery or portal vein. These combined injuries are clinically important because vascular compromise can worsen the biliary injury, extend its level, impair healing after reconstruction, and in severe cases lead to liver ischemia, infarction, abscess formation, or hepatic atrophy. This review was undertaken to clarify the definition of vasculobiliary injury, examine its mechanisms, and outline its clinical implications and management. Summary This review defines vasculobiliary injury as a combined injury involving both a bile duct and a hepatic artery and/or portal vein, with the bile duct damage resulting from operative trauma, ischemia, or both. The authors show that the most common form is injury to the right hepatic artery associated with bile duct injury. In these cases, arterial damage may silently worsen the biliary injury by making it extend higher than the gross mechanical injury initially suggests. The review also highlights that right hepatic artery injury rarely causes major problems when isolated, but becomes clinically significant when combined with bile duct injury because collateral blood flow is disrupted. This combination increases the risk of biliary ischemia, anastomotic failure, restricture, and in about 10% of patients, slow infarction of the right liver. Injuries involving the portal vein or the proper or common hepatic artery are much rarer but far more dangerous, often leading to rapid hepatic necrosis and high mortality. The authors recommend routine vascular imaging when early biliary repair is being considered and advise that patients with portal vein or major hepatic artery injuries should be referred urgently to tertiary hepatopancreatobiliary centers. Conclusion The key clinical message of this review is that vasculobiliary injury should not be viewed as a simple extension of bile duct injury, but as a distinct and more dangerous entity that demands early recognition, careful vascular assessment, and specialized management. Right hepatic artery injury is the commonest pattern, whereas portal vein and major hepatic artery injuries are the most devastating. The review strongly supports delayed biliary reconstruction in selected ischemic injuries and emphasizes referral to expert centers for optimal outcomes.

Autologous Fat Injection for Pouch-Related Fistulae: UEG Journal — December 2025

Introduction Ileal pouch–anal anastomosis (IPAA) is the standard restorative surgery for patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) after colectomy. Although IPAA significantly improves the quality of life, long-term complications remain common. One of the most challenging complications is pouch-related fistulae (PRF), occurring in approximately 5–10% of patients. These fistulae can cause persistent discharge, infections, and may ultimately lead to pouch failure and permanent ileostomy. Management of PRF is difficult, and no consensus exists regarding optimal therapy. Traditional surgical approaches often risk sphincter damage and recurrence. Recently, regenerative strategies such as mesenchymal stem cell therapy have shown promise. Autologous adipose tissue injection (AATI), which contains stromal vascular fraction and stem-cell–like components, offers a simpler and minimally invasive alternative. Summary This prospective cohort study evaluated autologous adipose tissue injection (AATI) for the treatment of pouch-related fistulae in patients with IPAA. Participants: 21 patients with 29 PRF Follow-up: Median 16 months Key findings: 48% fistula healing after a single injection 69% healing after repeated injections 14% additional patients showed partial improvement with reduced fistula secretion Minimal complications and good procedural tolerance Healing varied by fistula type: Anastomosis-cutaneous fistulae: highest success (100%) Pouch-vaginal fistulae: lowest response rates Clinical Implications Autologous adipose tissue injection appears to be a safe, minimally invasive, and sphincter-preserving treatment for pouch-related fistulae. The encouraging healing rates suggest that AATI may represent a promising regenerative approach, although larger controlled studies are required before widespread adoption.

LIR!C Trial: Lancet Gastroenterol Hepatol, 2026

Introduction Management of localised ileocaecal Crohn’s disease traditionally prioritises medical therapy, particularly anti-TNF agents such as infliximab. However, the original LIR!C randomised trial demonstrated that laparoscopic ileocaecal resection could be an effective alternative to infliximab, providing comparable quality-of-life outcomes in patients with immunomodulator-refractory, non-stricturing ileal Crohn’s disease. Given the increasing interest in early surgical intervention as a disease-modifying strategy, the present study evaluated the long-term (10-year) outcomes of patients enrolled in the LIR!C trial, focusing on therapy-free remission and sustained clinical remission. Summary This retrospective follow-up study included 129 patients (90%) from the original LIR!C randomised trial, with 66 patients undergoing ileocaecal resection and 63 receiving infliximab therapy. The median follow-up duration was 11 years. The 10-year therapy-free remission rate was significantly higher in the surgical group compared with the infliximab group: 35.8% after ileocaecal resection 13.2% after infliximab (difference 22.6%, p=0.0038) Despite this difference, the overall clinical remission rates at 10 years were similar between groups: 36.5% with surgery vs 28.4% with infliximab (HR 0.79; p=0.27). Exploratory analyses suggested an age-dependent effect, with younger patients benefiting more from early surgery. For example, the estimated 10-year clinical remission was 54% in a 20-year-old patient undergoing resection vs 24% with infliximab. Conclusion Long-term results from the LIR!C cohort show that ileocaecal resection provides significantly higher therapy-free remission rates than infliximab, while overall clinical remission remains comparable. These findings support early laparoscopic ileocaecal resection as a viable and potentially advantageous treatment option in selected patients with localised ileal Crohn’s disease, particularly in younger individuals.

Broad-Spectrum Antibiotic Prophylaxis May Improve Outcomes After Pancreatoduodenectomy: Annals of Surgery, March 2026

Introduction Pancreatoduodenectomy (Whipple procedure) is a complex surgical operation performed for pancreatic and periampullary diseases. Despite advances in surgical techniques and perioperative care, the procedure continues to carry significant postoperative morbidity, largely driven by infectious complications. Surgical site infections (SSI), intra-abdominal infections, and sepsis frequently arise from postoperative pancreatic fistula (POPF) or biliary contamination, particularly in patients who undergo preoperative biliary drainage. Bacterial colonisation of bile ducts—commonly involving Enterococcus, Klebsiella, and Enterobacter species—increases the risk of postoperative infection and subsequent mortality. Because infection remains a major contributor to postoperative mortality after pancreatoduodenectomy, perioperative antibiotic prophylaxis is routinely recommended. Traditionally, cephalosporins have been used as standard prophylaxis. However, emerging evidence suggests that these antibiotics may inadequately cover the spectrum of pathogens present in contaminated bile, especially in patients with biliary stents. This has led to increasing interest in broad-spectrum penicillin-based antibiotics, such as piperacillin–tazobactam, which provide enhanced coverage against Gram-negative organisms and Enterococcus species. Summary of the Meta-analysis This systematic review and meta-analysis evaluated whether broad-spectrum penicillin-based antibiotics (BS-AB) improve outcomes compared with cephalosporin-based prophylaxis (CE-AB) in patients undergoing pancreatoduodenectomy. The analysis included 12 studies (1 randomized controlled trial and 11 nonrandomized studies) encompassing 12,469 patients, of whom 35.3% received BS-AB and 64.7% received CE-AB. Broad-spectrum prophylaxis was associated with significantly improved postoperative outcomes. The incidence of surgical site infections was markedly reduced with BS-AB (OR 0.53; 95% CI 0.32–0.86). Similarly, the risk of postoperative pancreatic fistula was lower (OR 0.62; 95% CI 0.47–0.81). Mortality was also significantly reduced in the BS-AB group (OR 0.56; 95% CI 0.34–0.95). Patients receiving broad-spectrum prophylaxis experienced a trend toward shorter hospital stays, approximately 2 days less than those receiving cephalosporins. Subgroup analysis demonstrated even stronger benefits among patients with preoperative biliary drainage, where broad-spectrum antibiotics significantly reduced SSI, POPF, and mortality. Conclusion Broad-spectrum penicillin-based antibiotic prophylaxis appears to reduce infectious complications, pancreatic fistula, and mortality after pancreatoduodenectomy, particularly in patients with biliary stents. These findings suggest that broad-spectrum regimens may represent a new standard for perioperative prophylaxis in pancreatic surgery, though further high-quality randomized trials are needed to confirm these results and balance benefits against risks such as antimicrobial resistance.

Metachronous CRC Risk in Lynch Syndrome: Clinical Gastroenterolo and Hepatolo, March 2026

Introduction Lynch syndrome (LS) is the most common hereditary colorectal cancer (CRC) syndrome, caused by germline mutations in DNA mismatch repair genes (MLH1, MSH2, MSH6, PMS2, EPCAM). Individuals with LS have a markedly increased lifetime risk of CRC and frequently develop metachronous colorectal cancer after treatment of the first tumor. Surgical strategy—segmental (partial) colectomy vs extended colectomy—is therefore a critical decision that must balance cancer prevention with postoperative quality of life. Summary This multicenter cohort study from the German Consortium for Familial Intestinal Cancer analysed 852 patients with Lynch syndrome who underwent surgery for primary CRC to determine risk factors for metachronous CRC. Over a median follow-up of 7.9 years, 21.1% of patients developed a second colorectal cancer. Key findings included: Partial colectomy showed a trend toward a higher risk of metachronous CRC compared with extended colectomy in high-risk LS carriers (HR 3.78; borderline significance). Male sex significantly increased risk (HR 2.16). Older age at first CRC diagnosis modestly increased risk (HR 1.03 per year). Left-sided primary tumors were associated with higher metachronous risk (HR 1.53). Surveillance colonoscopy adherence did not significantly reduce risk in this analysis. Key Message Metachronous CRC remains common in Lynch syndrome despite surveillance. Risk varies according to sex, age, tumor location, and possibly extent of surgery, supporting a personalized surgical strategy rather than a uniform recommendation for extended colectomy in all patients.

GLP-1 Drugs vs Bariatric Surgery: JAMA Surgery | March 2026

Introduction The introduction of second-generation GLP-1 receptor agonists such as semaglutide and tirzepatide has transformed obesity treatment. These medications produce substantial weight loss and metabolic improvements, approaching outcomes traditionally achieved with metabolic and bariatric surgery (MBS). With their rapid adoption in clinical practice, questions have emerged regarding whether the increasing use of GLP-1 therapies is influencing the utilisation of bariatric surgery. Summary This large population-level study analysed electronic health record data from Epic Cosmos, including over 31 million patients eligible for bariatric surgery between 2017 and 2025. Researchers examined trends in prescriptions of GLP-1 receptor agonists and the rate of bariatric surgery among eligible patients. Key findings include: GLP-1 prescription rates increased dramatically, from 0.22% in late 2018 to 24.17% by mid-2025. Bariatric surgery rates initially increased, peaking in 2022, but declined sharply afterwards. By 2025, MBS use had fallen by 46.4% compared with 2022 levels. The decline was more pronounced for sleeve gastrectomy than for Roux-en-Y gastric bypass. Surgery rates declined across patient groups regardless of diabetes status, though the decline was less pronounced in patients with a BMI ≥55. Despite the rise in pharmacologic therapy, 75.8% of surgery-eligible patients received neither GLP-1 therapy nor bariatric surgery, suggesting significant undertreatment of severe obesity. Key Message The rapid adoption of GLP-1 receptor agonists is associated with a decline in bariatric surgery utilisation, signalling a shift in obesity management. However, because bariatric surgery remains the most durable treatment for severe obesity, future care pathways will likely require integrated pharmacologic and surgical strategies tailored to patient needs.

Early Thrombus Removal in Iliofemoral DVT: Annals of Surgery | February 2026 | DOI: 10.1097/SLA.0000000000006765

Introduction Iliofemoral deep vein thrombosis (IF-DVT) carries a high risk of post-thrombotic syndrome (PTS), a chronic and disabling complication that significantly impairs quality of life. Early thrombus removal strategies—either lytic (catheter-directed thrombolysis and pharmacomechanical techniques) or non-lytic (mechanical thrombectomy)—have been developed to reduce PTS beyond standard anticoagulation, but concerns about bleeding risk have led to conflicting guideline recommendations. Summary This PRISMA-guided systematic review and meta-analysis evaluated 20 studies comparing early thrombus removal strategies with anticoagulation alone in patients with acute (<28 days) IF-DVT. The pooled rate of PTS was 24.5% with lytic therapies and 40.4% with anticoagulation alone, translating to a number needed to treat (NNT) of 6 to prevent one case of PTS and 15 to prevent moderate-severe PTS. Non-lytic mechanical thrombectomy showed a PTS rate of 18.8%, though evidence was limited to a single observational study. However, lytic therapies were associated with significantly higher odds of major bleeding compared with anticoagulation alone (OR 4.9), with a number needed to harm (NNH) of 33. Notably, no major bleeding events were reported with purely mechanical thrombectomy. Mortality and DVT recurrence rates were not significantly different across groups. Overall, early thrombus removal reduces PTS risk but increases nonfatal major bleeding when lytics are used. Mechanical thrombectomy appears safer regarding bleeding, yet robust randomised efficacy data remain limited. Careful patient selection, balancing bleeding risk and long-term morbidity, is essential.

Staging Laparoscopy in Gastric Cancer: Surgical Oncology Feb. 2026

Introduction Radiographically occult peritoneal carcinomatosis (PC) is a well-recognised challenge in gastric and Siewert III gastroesophageal junction adenocarcinoma. Current guidelines recommend staging laparoscopy (SL) before neoadjuvant systemic therapy (NST) to prevent understaging and inappropriate treatment. Problem Statement Despite clear recommendations, real-world adherence to SL remains uncertain. Missing occult peritoneal metastases may expose patients to unnecessary chemotherapy, surgery, and delayed palliative care. Study Findings In this multi-institution retrospective analysis of 205 non–stage IV patients (2010–2022), 63% received NST. However, only 29.8% underwent staging laparoscopy before NST. Among those who had SL, 38% were upstaged due to peritoneal metastases—80% with gross PC and 20% with positive cytology. Among patients proceeding to surgery after NST, recurrence occurred in 33.7%, with the peritoneum as the most common site (38.5%), highlighting the clinical relevance of missed peritoneal disease. Conclusion SL is significantly underutilised before NST in gastric cancer. Given that nearly 4 in 10 patients undergoing SL were upstaged, improving compliance is critical. Enhanced adherence to SL—or development of better non-invasive detection strategies—may prevent futile therapy and optimise treatment selection in gastric cancer.

ROGER Trial- BJS Feb.26

The ROGER randomised clinical trial compared robotic transabdominal preperitoneal repair (rTAPP) with laparoscopic totally extraperitoneal repair (TEP) for elective primary inguinal hernia. In this single-centre, patient- and investigator-blinded Swiss RCT, 182 patients were randomised 1:1 (mostly male, mean age ~56 years, BMI ~25 kg/m²). The primary endpoint was postoperative pain while coughing at 24 hours. Results showed no significant difference in pain between approaches (median score 5 for TEP vs 4 for rTAPP, P = 0.431). Postoperative complication rates were also similar (11% vs 10%). However, key differences emerged: Operating time was significantly longer with rTAPP (80 vs 64 minutes for unilateral repairs). Surgeon workload, measured using the NASA Task Load Index, was substantially lower with rTAPP (mean 18 vs 34, P < 0.001). Thus, while robotic repair did not improve early postoperative pain or reduce complications, it significantly reduced perceived surgical workload—at the cost of longer operative time. Clinical takeaway: For patients, outcomes are equivalent. For surgeons, robotics may improve ergonomics and reduce fatigue. The decision to adopt robotic repair may therefore depend more on institutional resources and surgeon factors than on short-term patient benefit.

Delayed Leak Recognition After Colon Resection - JAMA Surgery Feb 26

Anastomotic leak remains a leading driver of morbidity and mortality after colon resection. This large Veterans Affairs Surgical Quality Improvement Program cohort study evaluated whether the timing of leak recognition is linked to failure to rescue (FTR)—death after a complication. Because direct leak timing is difficult to capture in administrative data, the authors used organ space surgical site infection (OSSI) as a pragmatic proxy for anastomotic leak and classified OSSI as early (before or without sepsis) or delayed (diagnosed after sepsis began). Across more than 39,000 colon resections, OSSI occurred in a small but clinically meaningful subset. When OSSI was diagnosed after sepsis onset, outcomes were substantially worse than when identified earlier: patients experienced more downstream complications, higher reoperation rates, longer hospitalisations, and markedly higher FTR. In other words, mortality clustered not simply around the presence of a leak proxy, but around progression to sepsis before the leak was recognised. The practical message is clear: preventing “failure to rescue” after colon resection may depend as much on early detection and timely escalation as on leak prevention alone. This supports quality initiatives focused on rapid recognition of early clinical deterioration, standardised postoperative surveillance, prompt imaging when suspicion arises, and streamlined pathways for source control—aimed at intervening before sepsis develops.

Molecular Residual Disease and Recurrence in Rectal Cancer- Ann. Sur Jan.26

The study titled "Molecular Residual Disease and Recurrence in Rectal Cancer" published in Annals of Surgery on January 26 explores the prognostic utility of circulating tumor DNA (ctDNA) as a biomarker for recurrence and treatment response in patients with rectal cancer undergoing upfront surgery. The research focuses on understanding the role of ctDNA in predicting disease-free survival (DFS) and guiding adjuvant chemotherapy (ACT) decisions in patients who did not receive neoadjuvant therapy prior to surgery. Rectal cancer poses unique challenges due to its anatomical location and the complexity of its treatment. While neoadjuvant therapy is often utilized, some patients undergo upfront surgery followed by ACT. The study investigates how postoperative ctDNA testing can provide insights into molecular residual disease (MRD) and help predict recurrence risk and the effectiveness of ACT. The findings of the study reveal that ctDNA is a robust biomarker for assessing recurrence risk and evaluating the benefit of ACT. Patients who tested positive for ctDNA after surgery had a significantly higher likelihood of recurrence compared to those who were ctDNA-negative. Moreover, ctDNA-positive patients demonstrated a clear benefit from ACT, suggesting that ctDNA status can guide treatment decisions more effectively. Conversely, ctDNA-negative patients did not show a significant advantage from ACT, highlighting the importance of personalized treatment approaches based on ctDNA results. The study also examined ctDNA dynamics over time, revealing that patients who remained ctDNA-positive or converted from ctDNA-negative to positive were at a higher risk of recurrence compared to those who consistently tested ctDNA-negative. These findings underscore the utility of ctDNA testing as a minimally invasive tool for real-time monitoring of tumor burden and treatment response. In conclusion, postoperative ctDNA testing is a valuable biomarker for predicting recurrence risk and guiding adjuvant therapy decisions in rectal cancer patients undergoing upfront surgery. This approach has the potential to improve clinical outcomes by enabling tailored treatment strategies based on molecular insights.

Reevaluating Intraoperative Neck Margin Revision After Neoadjuvant Therapy in Pancreatic Cancer

The study titled **"Reevaluating Intraoperative Neck Margin Revision After Neoadjuvant Therapy in Pancreatic Cancer"** explores the oncologic benefits of revising a positive pancreatic neck margin during pancreatoduodenectomy (PD) after neoadjuvant therapy for pancreatic ductal adenocarcinoma (PDAC). This research is critical in understanding whether intraoperative frozen section analysis and subsequent margin revision improve survival or recurrence outcomes in patients undergoing surgery for this aggressive cancer. ### Key Findings: 1. **Study Design and Patient Groups**: - The study analyzed patients treated with neoadjuvant therapy followed by PD across three academic centers. - Patients were categorized into three groups based on final margin status and surgical technique: - **Complete Resection Achieved En Bloc**: Entire tumor removed in one piece with clear margins. - **Complete Resection Achieved Through Additional Non–En Bloc Resection**: Positive neck margin revised intraoperatively to achieve a negative margin. - **Incomplete Resection**: Positive margin left unrevised. 2. **Tumor Characteristics and Disease Aggressiveness**: - Patients requiring additional neck margin resection or left with incomplete resection tended to have more aggressive disease features, such as larger tumors and poorer response to neoadjuvant therapy. 3. **Survival and Recurrence Outcomes**: - Complete en bloc resection was associated with the most favorable survival outcomes. - Revising a positive neck margin to a negative margin through additional resection did **not** improve overall survival or recurrence-free survival compared to leaving an incomplete resection. - Margin status was not identified as an independent predictor of survival or recurrence outcomes in multivariable analysis. 4. **Implications for Surgical Practice**: - Routine intraoperative neck margin revision after neoadjuvant therapy does **not** provide meaningful oncologic benefits. - This challenges the traditional assumption that margin revision improves surgical outcomes and suggests it should not be systematically recommended in the postneoadjuvant setting. ### Clinical Significance: The findings highlight the importance of tailoring surgical approaches to individual patient and tumor characteristics rather than relying on routine margin revision. Patients undergoing neoadjuvant therapy often present with biologically aggressive disease, and achieving clear margins through revision may not alter the underlying tumor biology or improve long-term outcomes. Therefore, the focus should shift to optimizing systemic therapy and ensuring access to adjuvant treatment when appropriate. ### Conclusion: The study provides valuable insights for surgeons and oncologists managing pancreatic cancer patients after neoadjuvant therapy. It underscores the need to reconsider the role of intraoperative neck margin revision, emphasizing that achieving a negative margin through additional resection does not necessarily translate into improved survival or reduced recurrence. These findings advocate for a more nuanced approach to surgical decision-making in the context of postneoadjuvant pancreatoduodenectomy.

Perioperative Use of Tranexamic Acid

The perioperative use of tranexamic acid (TXA) has been extensively studied in various surgical contexts, including general surgery, to evaluate its efficacy in reducing blood loss, the need for transfusion, and major bleeding events, as well as its safety profile concerning thromboembolic events and mortality. ### Key Findings on Perioperative Use of Tranexamic Acid: 1. **Reduction in Blood Loss**: - TXA has been shown to significantly reduce intraoperative blood loss. In a systematic review and meta-analysis of 26 randomized clinical trials (RCTs) involving 6976 patients, TXA use was associated with a mean reduction of 35.85 mL in intraoperative blood loss compared to placebo. 2. **Reduced Need for Transfusion**: - The use of TXA was linked to a 25% reduction in the risk of requiring blood transfusions during or after surgery (Risk Ratio [RR], 0.75). This suggests that TXA can effectively minimize the need for blood products in the perioperative setting. 3. **Lower Risk of Major Bleeding Events**: - TXA use was associated with a 28% reduction in the risk of major bleeding events (RR, 0.72). This highlights its role in improving hemostasis during surgical procedures. 4. **No Significant Increase in Thromboembolic Events**: - Concerns about TXA increasing the risk of venous thromboembolism (VTE) were not substantiated in the meta-analysis. The risk of VTE remained comparable between TXA and placebo groups (RR, 1.09). 5. **No Increase in Mortality**: - TXA did not significantly affect mortality rates (RR, 1.08), indicating that its perioperative use is safe in terms of survival outcomes. 6. **Impact on Length of Stay**: - While TXA was associated with a slight reduction in hospital length of stay, the difference was not statistically significant. ### Considerations and Subgroup Analyses: - **Procedure-Specific Efficacy**: - The benefits of TXA were not consistent across all types of general surgical procedures. For example, in abdominal surgeries, the reductions in blood loss and transfusion requirements observed in the overall analysis were not significant. - In hepatobiliary surgeries, TXA was particularly effective in reducing major bleeding events (RR, 0.59). - **Heterogeneity in Results**: - The systematic review noted some heterogeneity in outcomes, which may reflect differences in surgical procedures, patient populations, and TXA dosing regimens. ### Safety Profile: - TXA was not associated with increased risks of thromboembolic events, such as deep vein thrombosis (DVT) or pulmonary embolism (PE), which have historically been concerns with antifibrinolytic agents. - No significant increase in mortality was observed, further supporting the safety of TXA use in perioperative settings. ### Clinical Implications: - **Individualized Decision-Making**: - While TXA has demonstrated efficacy and safety in reducing perioperative bleeding, its use should be tailored to the specific surgical procedure and patient characteristics. - Factors such as the type of surgery, baseline risk of bleeding, and patient comorbidities should guide the decision to use TXA. - **Potential for Broader Use**: - TXA may be a valuable tool in reducing the need for blood transfusions and improving surgical outcomes, particularly in procedures with a high risk of bleeding. However, its benefits may not be universal across all types of general surgery. ### Conclusion: The perioperative use of tranexamic acid is associated with significant reductions in blood loss, transfusion requirements, and major bleeding events, without an increased risk of thromboembolic complications or mortality. However, its benefits may vary depending on the type of surgery and patient population, necessitating a case-by-case approach to its use.

Intrathecal Morphine for Enhanced Recovery After Laparoscopic Colorectal Surgery

Intrathecal Morphine (ITM) has been evaluated as a component of multimodal pain management to enhance recovery after laparoscopic colorectal surgery within the framework of Enhanced Recovery After Surgery (ERAS). Postoperative pain, particularly visceral pain, is a significant challenge to early mobilization and optimal recovery following minimally invasive colorectal procedures. The study in question investigates whether adding ITM to transversus abdominis plane block (TAPB) improves postoperative recovery outcomes. ### Study Design: - **Type:** Prospective, double-blind randomized clinical trial. - **Participants:** 252 adult patients undergoing elective laparoscopic colorectal surgery. - **Intervention:** Patients were randomized to receive either ITM (3 μg/kg) or intrathecal saline placebo, with both groups receiving TAPB using liposomal bupivacaine. - **Primary Outcome:** Quality of recovery at 24 hours, assessed via the Quality of Recovery-15 (QoR-15) score. - **Secondary Outcomes:** Postoperative pain levels, opioid consumption, gastrointestinal recovery, adverse events, and length of hospital stay. ### Key Findings: 1. **Improved Recovery Quality:** - Patients receiving ITM combined with TAPB demonstrated significantly better recovery at 24 hours, with higher QoR-15 scores. - Clinically meaningful improvements were observed across multiple recovery domains. 2. **Pain Management:** - The ITM group experienced lower postoperative pain scores compared to the control group. - Reduced opioid requirements were noted, which is particularly beneficial as opioid-related adverse effects can hinder recovery. 3. **Enhanced Functional Recovery:** - Faster ambulation and earlier return of bowel function were observed in the ITM group. - Gastrointestinal recovery was significantly improved, supporting quicker progression through postoperative milestones. 4. **Adverse Effects:** - Nausea, vomiting, and dizziness were less frequent among patients receiving ITM. - Pruritus (itching) was more common in the ITM group but was generally manageable and non-serious. 5. **Length of Hospital Stay:** - While specific data regarding hospital stay duration is not detailed, the faster recovery and reduced complications suggest potential for earlier discharge. ### Conclusion: The study concludes that intrathecal morphine, when combined with TAPB, significantly enhances early postoperative recovery and analgesia after laparoscopic colorectal surgery. This approach aligns well with the principles of ERAS by promoting early mobilization, reducing opioid-related side effects, and improving overall recovery quality. Despite a higher incidence of pruritus, ITM's benefits outweigh this manageable side effect, making it an effective addition to multimodal pain management strategies. ### Clinical Implications: - ITM combined with TAPB offers a promising strategy for addressing postoperative pain and recovery challenges in laparoscopic colorectal surgery. - Incorporating ITM into ERAS protocols may improve patient outcomes, reduce opioid dependency, and expedite recovery timelines. - Careful monitoring and management of pruritus are necessary to optimize patient comfort and satisfaction. This study highlights the importance of multimodal analgesia in surgical recovery and supports ITM as a valuable tool for enhancing patient care in minimally invasive colorectal procedures.

Multi-Omics Analysis of Ileal Mucosa and Mesentery Before and After Ileocecal Resection in Crohn’s Disease

The multi-omics analysis of ileal mucosa and mesentery before and after ileocecal resection in Crohn’s disease (CD) provides valuable insights into how surgical intervention influences the disease at both microbial and metabolic levels. This study employs an integrated approach to analyze paired samples from patients with active and remission-stage CD, focusing on the spatial changes in the microbiome and metabolome within the ileal mucosa and mesentery. ### Key Findings: #### 1. **Microbial Alterations**: - **Improved Microbial Health**: Ileocecal resection is associated with a significant improvement in microbial health in both the ileal mucosa and mesentery. - **Reduction in Dysbiosis**: Post-surgery, there is a decrease in dysbiosis (microbial imbalance), with restoration of microbial diversity and balance. - **Decline in Proinflammatory Bacteria**: Bacterial taxa previously linked to epithelial barrier disruption, immune activation, and inflammation are significantly reduced after surgery. - **Gut–Mesentery Axis**: The study highlights that microbial changes are not limited to the intestinal lumen but extend into the mesenteric tissues, emphasizing the role of the gut–mesentery axis in CD pathogenesis. #### 2. **Metabolic Alterations**: - **Shifts in Metabolic Pathways**: Postoperative changes in metabolic profiles are observed, particularly in pathways related to: - Lipid metabolism - Amino acid metabolism - Immune signaling - Gut barrier function - **Microbe–Metabolite Interactions**: Specific altered metabolites correlate with microbial changes, suggesting an interplay between microbes and metabolites that contributes to mucosal healing and immune regulation. - **Key Pathways**: Tryptophan metabolism and lipid signaling emerge as critical pathways potentially involved in promoting postoperative remission. #### 3. **Spatial Analysis**: - The study provides a spatially resolved view of changes in both the ileal mucosa and mesentery. This dual analysis reveals that the mesentery, often overlooked in CD research, plays a significant role in the pathogenesis and remission of the disease. #### 4. **Therapeutic Implications**: - **Early Surgical Intervention**: The findings support the therapeutic value of early ileocecal resection in selected CD patients, as it leads to microbial and metabolic improvements associated with disease remission. - **Microbiome-Based Strategies**: Insights from this study may inform the development of microbiome-targeted therapies or precision treatments to manage CD more effectively. ### Significance of the Study: This is the first study to comprehensively map the microbiome and metabolome changes in both the ileal mucosa and mesentery before and after ileocecal resection. By integrating microbial and metabolic data, the research provides a deeper understanding of the biological mechanisms underlying postoperative remission in CD. It highlights the importance of considering the mesentery as an integral component of CD pathogenesis and remission, paving the way for novel therapeutic strategies aimed at restoring gut and mesenteric health. In summary, the multi-omics analysis underscores the complex interplay between gut microbiota, host immunity, and metabolism in Crohn’s disease and demonstrates how surgical intervention can modulate these interactions to promote remission.

Comparison of the efficacy and safety of super-selective and selective transcatheter arterial embolization in non-variceal gastrointestinal bleeding

The comparison of the efficacy and safety between super-selective and selective transcatheter arterial embolization (TAE) for managing non-variceal gastrointestinal bleeding (NVGIB) reveals nuanced findings that depend on the type of bleeding (upper vs. lower gastrointestinal bleeding) and procedural considerations. Here is a detailed breakdown of the study's findings: ### **Efficacy** 1. **Immediate Hemostasis**: - Both super-selective and selective TAE were technically feasible and successfully achieved immediate hemostasis during angiography, demonstrating their effectiveness as rescue therapies for NVGIB refractory to endoscopic treatment. 2. **Early Rebleeding**: - **Upper Gastrointestinal Bleeding**: Super-selective embolization was associated with a **lower likelihood of early rebleeding** compared to selective embolization. This suggests that precise targeting of smaller, distal vessels closer to the bleeding source improves short-term bleeding control in upper gastrointestinal bleeding. - **Lower Gastrointestinal Bleeding**: No clear superiority was observed between the two techniques in terms of rebleeding risk. However, procedural factors such as embolic material selection appeared to influence outcomes more significantly in lower gastrointestinal bleeding. 3. **Long-Term Bleeding Control**: - Both techniques showed broadly similar results in terms of long-term bleeding control, indicating that the choice between super-selective and selective embolization may not significantly affect outcomes over extended periods. 4. **Need for Additional Interventions**: - There was no significant difference between the two approaches in terms of requiring further interventions for bleeding recurrence, highlighting that other factors—such as bleeding severity and transfusion requirements—might play a more critical role in predicting recurrence. ### **Safety** 1. **Complication Rates**: - The overall complication rates were comparable between super-selective and selective embolization, indicating that both techniques are generally safe when performed correctly. 2. **Intestinal Ischemia**: - Patients with lower gastrointestinal bleeding were found to be **more vulnerable to intestinal ischemia**, emphasizing the importance of careful procedural planning, especially when using selective embolization targeting larger arterial branches. Super-selective embolization may reduce the risk of ischemia by sparing collateral blood supply, but this was not definitively proven in the study. 3. **Embolic Material**: - The choice of embolic material was particularly relevant in lower gastrointestinal bleeding, as it influenced both rebleeding risk and the need for further treatment. This underscores the importance of tailoring embolization strategies to individual patient anatomy and clinical conditions. 4. **Mortality**: - Mortality rates were similar between the two techniques, suggesting that the embolization strategy itself does not significantly impact survival outcomes. ### **Key Takeaways** 1. **Upper Gastrointestinal Bleeding**: - Super-selective embolization is preferred due to its lower likelihood of early rebleeding, offering better short-term bleeding control. - However, long-term outcomes, complication rates, and mortality are similar between the two techniques. 2. **Lower Gastrointestinal Bleeding**: - Neither technique showed clear superiority in terms of efficacy, but the risk of intestinal ischemia is higher, requiring careful procedural planning. - The choice of embolic material plays a critical role in influencing outcomes, and individualized decisions based on vascular anatomy and bleeding severity are essential. 3. **General Observations**: - Greater transfusion requirements were more closely associated with bleeding recurrence, reflecting the severity of bleeding rather than the choice of embolization technique. - Both techniques are safe and effective when performed by experienced interventional radiologists, but super-selective embolization may offer advantages in specific scenarios, particularly for upper gastrointestinal bleeding. ### **Conclusion** Super-selective TAE demonstrates greater efficacy in reducing early rebleeding for upper NVGIB and should be considered the preferred approach in these cases. For lower NVGIB, individualized decision-making based on bleeding severity, vascular anatomy, and embolic material selection is critical, as neither technique shows clear superiority. Both approaches are generally safe, but careful planning is essential to minimize complications like intestinal ischemia, particularly in lower gastrointestinal bleeding.

Anastomotic leakage after radical esophagectomy for ESCC

Anastomotic leakage is a serious and potentially life-threatening complication following radical esophagectomy for esophageal squamous cell carcinoma (ESCC). It occurs when the surgical connection (anastomosis) between the esophagus and the stomach or intestine fails to heal properly, leading to leakage of gastric or intestinal contents into surrounding tissues. Below is a detailed analysis based on available data: ### Incidence - The incidence of anastomotic leakage among ESCC patients is high, reported at **21.5%** in the study cohort. - This highlights the need for vigilant monitoring and preventive strategies, especially in high-risk patients. ### Risk Factors 1. **Age**: - Older patients are at significantly higher risk due to reduced organ reserve and poorer healing capacity. Age-related physiological changes impair tissue repair processes. 2. **Anastomosis Location**: - **Cervical anastomosis** carries a much higher risk compared to thoracic anastomosis. - Increased tension and weaker perfusion at the cervical site contribute to the higher leakage rates. Additionally, longer gastric conduits required for cervical anastomosis can compromise blood flow and healing. 3. **Postoperative Red Blood Cell (RBC) Count**: - Lower postoperative RBC counts are associated with impaired oxygen delivery to tissues, which is essential for healing. Anemia exacerbates tissue hypoxia and increases leakage risk. 4. **Postoperative Neutrophil-to-Lymphocyte Ratio (NLR)**: - Elevated NLR is a strong predictor of leakage. High NLR reflects systemic inflammation, which can impair tissue repair and healing. A cutoff value of **14.62** was identified as a threshold for heightened risk. 5. **Nutritional Status**: - Poor nutritional status, indicated by low albumin levels and compromised immune indices, is associated with increased risk of leakage. Adequate nutrition is critical for postoperative recovery and tissue repair. 6. **Inflammatory Stress**: - Excessive postoperative inflammation, as evidenced by high NLR, negatively affects healing at the anastomotic site, increasing the likelihood of leakage. ### Predictive Tools - A **nomogram model** was developed to predict anastomotic leakage risk in ESCC patients. - This clinical scoring tool incorporates dynamic postoperative parameters (such as RBC count and NLR) along with other patient-specific factors. - The model demonstrated strong accuracy, achieving an **AUC of 0.870**, making it highly reliable for risk prediction. - It outperformed earlier models, offering superior predictive strength and aiding personalized patient management. ### Detection and Monitoring - Early diagnosis is critical for managing anastomotic leakage effectively. - Imaging studies, such as contrast-enhanced CT or esophagography, are typically performed around postoperative day 7 to detect leaks. - Laboratory monitoring of inflammatory markers (e.g., NLR) and oxygen delivery indicators (e.g., RBC count) plays a vital role in early detection. ### Management Strategies 1. **Postoperative Monitoring**: - Dynamic postoperative parameters (RBC count, NLR) are emphasized for timely detection and intervention. 2. **Supportive Care for High-Risk Patients**: - High-risk patients may benefit from early supportive strategies, including: - Oxygen therapy to improve tissue oxygenation. - Antibiotics to prevent or manage infections resulting from leakage. - Delayed oral feeding to reduce stress on the anastomotic site and promote healing. 3. **Preventive Measures**: - Patients with high postoperative NLR (>14.62) or low RBC counts should be closely monitored and managed proactively to prevent complications. - Nutritional optimization pre- and post-surgery can improve outcomes. ### Implications for Personalized Management - The findings from this study emphasize the importance of personalized management for ESCC patients undergoing radical esophagectomy. - Risk prediction tools, such as the nomogram, can help prioritize intensive monitoring and early interventions for vulnerable patients. - Biomarkers like NLR and RBC counts serve as valuable indicators for guiding postoperative care and tailoring treatment strategies. ### Summary Anastomotic leakage after radical esophagectomy for ESCC is a multifactorial complication influenced by age, anastomosis location, nutritional status, postoperative inflammation, and oxygen delivery. The development of a highly accurate nomogram model and the identification of dynamic postoperative markers (e.g., NLR, RBC count) enable early detection, risk stratification, and personalized management. Early supportive strategies, close monitoring, and preventive measures are critical for improving outcomes and reducing the burden of this serious complication.

Refractory esophageal anastomotic stricture

**Refractory Esophageal Anastomotic Stricture** A refractory esophageal anastomotic stricture refers to a narrowing of the esophagus at the site of surgical anastomosis (the junction created after esophageal surgery, such as esophagectomy) that does not respond adequately to conventional treatments like balloon dilation. These strictures are often caused by excessive scar tissue formation during the healing process, leading to a persistent narrowing that significantly impacts swallowing and quality of life. A stricture is considered "refractory" when it fails to improve despite repeated attempts at treatment, typically after three or more endoscopic balloon dilations (EBDs) without achieving sustained relief of symptoms. Patients with refractory strictures often experience persistent dysphagia (difficulty swallowing) and require frequent medical interventions. --- ### **Causes of Refractory Esophageal Anastomotic Strictures** 1. **Fibrotic Scar Tissue Formation**: Excessive healing response after esophageal surgery leads to dense fibrotic tissue that narrows the lumen of the esophagus. 2. **Anastomotic Tension**: High tension at the surgical site can increase the risk of stricture formation. 3. **Ischemia**: Poor blood supply to the anastomotic site can impair healing and lead to scar formation. 4. **Radiation Therapy**: Prior radiation treatment for esophageal cancer can exacerbate scarring and strictures. 5. **Infection or Inflammation**: Chronic inflammation or infection at the surgical site may contribute to the development of strictures. --- ### **Management Strategies for Refractory Esophageal Anastomotic Strictures** The primary goal of managing these strictures is to improve swallowing function and reduce the need for repeated interventions. Common strategies include: #### 1. **Endoscopic Balloon Dilation (EBD)** - This is the first-line treatment for esophageal strictures. A balloon is inserted into the narrowed segment and inflated to widen the lumen. - While effective for many patients, some strictures are refractory and require additional interventions. - Repeated EBD is often needed for refractory cases. #### 2. **Steroid Injection** - Triamcinolone or other corticosteroids are injected directly into the stricture site during endoscopy. - Steroids help reduce inflammation and inhibit scar tissue formation, prolonging the effects of dilation. - This is often combined with EBD to enhance outcomes. #### 3. **Radial Incision and Cutting (RIC)** - RIC is a newer technique where radial incisions are made into the scar tissue using an endoscopic knife. - The goal is to release the fibrotic bands causing the stricture and improve swallowing. - RIC is typically combined with steroid injections to prevent recurrence. #### 4. **Stent Placement** - In cases where strictures are extremely resistant to other treatments, self-expanding metal or plastic stents may be placed to keep the esophageal lumen open. - However, stents are associated with complications like migration, pain, and tissue overgrowth. #### 5. **Surgical Revision** - In rare cases, when endoscopic methods fail, surgical intervention may be required to reconstruct the anastomosis or bypass the stricture. #### 6. **Adjunctive Therapies** - Anti-reflux medications (e.g., proton pump inhibitors) can reduce inflammation and promote healing. - Nutritional support, such as enteral feeding, may be necessary for patients with severe dysphagia. --- ### **How This Study Helps** This randomized multicenter trial provides critical insights into the management of refractory esophageal anastomotic strictures by comparing two advanced treatment strategies: **EBD + steroid injection** and **RIC + steroid injection**. The study's findings clarify the relative effectiveness and safety of these approaches, helping guide clinical decision-making. Key contributions include: 1. **Safety Confirmation**: - Both EBD and RIC, when combined with steroid injection, were found to have very low rates of serious complications (3.1%). This confirms that either approach can be safely performed in patients with refractory strictures. 2. **Effectiveness Comparison**: - The study demonstrated that **RIC does not offer better outcomes than EBD**. Restricture-free survival was similar between the two groups (10.6 weeks for EBD vs. 8.7 weeks for RIC), and the number of additional balloon dilations required was nearly identical. - These findings suggest that EBD + steroid injection remains the **standard and preferred treatment** for refractory esophageal anastomotic strictures. 3. **Clinical Implications**: - Since RIC offers no significant advantage over enhanced balloon dilation, clinicians can continue to rely on EBD + steroid injection as the first-line treatment. This avoids the need for adopting more invasive or complex techniques like RIC unless absolutely necessary. 4. **Cost-Effectiveness**: - EBD is a widely available and cost-effective procedure when compared to RIC. The study reinforces its role as the most practical option for managing refractory strictures. 5. **Future Directions**: - The study highlights the need for further research into novel treatments or adjunctive therapies that might improve outcomes for patients with refractory strictures. --- ### **Conclusion** Refractory esophageal anastomotic strictures are challenging to manage due to their persistence and impact on swallowing. This study demonstrates that **EBD + steroid injection remains the gold standard** for treatment, as it is equally effective and safe compared to RIC + steroid injection. These findings provide reassurance to clinicians and patients that enhanced balloon dilation continues to be the most reliable approach for managing this condition.

Hemorrhoidal Disease

Hemorrhoidal disease is a common medical condition that affects approximately 10 million people in the United States. It can significantly impair quality of life due to symptoms such as rectal bleeding, pain, anal irritation, and tissue prolapse. Hemorrhoids are swollen and inflamed blood vessels in the rectal and anal area, and they are categorized into three types: internal, external, and mixed hemorrhoids. ### **Classification of Hemorrhoids:** 1. **Internal Hemorrhoids:** These occur above the dentate line (a boundary in the anal canal). They are typically painless but can cause rectal bleeding, discomfort, and prolapse (when the hemorrhoid protrudes out of the anal canal). 2. **External Hemorrhoids:** These occur below the dentate line and are covered by sensitive skin. They can cause significant pain, especially when engorged or thrombosed (when a blood clot forms within the hemorrhoid). 3. **Mixed Hemorrhoids:** A combination of internal and external hemorrhoids. ### **Grades of Internal Hemorrhoid Prolapse:** Internal hemorrhoids are further classified into grades based on the severity of prolapse: - **Grade I:** Hemorrhoids remain inside the anal canal and do not protrude. - **Grade II:** Hemorrhoids protrude during bowel movements but retract spontaneously. - **Grade III:** Hemorrhoids protrude and require manual reduction to return inside the anal canal. - **Grade IV:** Hemorrhoids are irreducible and remain protruded outside the anal canal. ### **Symptoms:** - **Internal Hemorrhoids:** Rectal bleeding, discomfort, and prolapse are the main symptoms. Bleeding is often painless and may appear as bright red blood on toilet paper or in the toilet bowl. - **External Hemorrhoids:** These cause significant rectal pain, especially when thrombosed, and may also present with swelling and irritation. ### **Management Strategies:** #### **1. First-Line Management:** The initial treatment for hemorrhoidal disease focuses on lifestyle modifications: - **Dietary Fiber:** Increasing fiber intake helps soften stool and reduces the risk of straining during bowel movements. - **Hydration:** Drinking adequate water supports regular bowel movements. - **Avoiding Straining:** Patients are advised to avoid prolonged sitting on the toilet or excessive straining. #### **2. Role of Phlebotonics:** Phlebotonics, such as flavonoids, are medications that may help reduce symptoms like bleeding, rectal pain, and swelling. However, their benefits are often temporary, and up to 80% of patients experience symptom recurrence within 3 to 6 months after discontinuing treatment. #### **3. Office-Based Treatments:** If conservative therapy fails, office-based procedures are recommended for grade I to III internal hemorrhoids. These include: - **Rubber Band Ligation:** A rubber band is placed around the base of the hemorrhoid to cut off its blood supply, causing it to shrink and fall off. This procedure relieves symptoms in 89% of cases, although 20% may require repeat sessions. - **Sclerotherapy:** A chemical solution is injected into the hemorrhoid to shrink it. It provides short-term relief in 70–85% of patients, but only about one-third benefit long-term. - **Infrared Coagulation:** Heat is applied to the hemorrhoid to promote tissue scarring and shrinkage. It is effective in 70–80% of patients. #### **4. Surgical Treatment:** Surgery is reserved for severe cases where office-based therapies fail or for mixed hemorrhoidal disease. The most common surgical procedure is **excisional hemorrhoidectomy**, which involves removing the hemorrhoids. While recurrence rates are low (2–10%), the recovery period is longer, typically lasting 9–14 days. #### **5. Management of Thrombosed External Hemorrhoids:** Thrombosed external hemorrhoids rarely require surgery unless the thrombosis causes severe pain. Management depends on timing: - **Within 72 Hours:** Outpatient clot evacuation can reduce pain and recurrence. - **Beyond 72 Hours:** Medical therapy is preferred, including stool softeners and topical/oral analgesics (e.g., 5% lidocaine) to manage pain. ### **Conclusion:** Hemorrhoidal disease is a common and treatable condition with a wide range of management options based on severity. Early intervention with lifestyle changes can alleviate symptoms and prevent progression, while office-based procedures and surgery provide effective solutions for more advanced cases. For thrombosed external hemorrhoids, timely intervention can significantly improve outcomes. If you suspect hemorrhoidal disease, consult a healthcare professional for proper diagnosis and treatment tailored to your specific needs.

Ileal J-pouch interposition

### Ileal J-Pouch Interposition: A Detailed Explanation **Definition:** Ileal J-pouch interposition is a surgical procedure in which a segment of the small intestine (ileum) is shaped into a J-shaped reservoir (pouch) and used to replace or bypass a damaged or non-functional section of the large intestine. This pouch is then connected to the remaining viable colon and the anal canal to restore bowel continuity and maintain functionality. --- ### **Purpose of Ileal J-Pouch Interposition:** The procedure is typically performed as a salvage option in patients where standard surgical techniques, such as direct coloanal anastomosis, are not feasible. This could be due to factors like insufficient colonic length, poor blood supply (ischemia), or complications following initial colorectal surgery. In the case presented, ileal J-pouch interposition was used as an alternative to permanent stoma formation for a patient with a failed coloanal anastomosis after low rectal cancer surgery. --- ### **Failed Coloanal Anastomosis in Low Rectal Cancer:** **Coloanal anastomosis** is a surgical technique in which the colon is directly connected to the anal canal after resection of the rectum, often performed in patients with low rectal cancer. A **failed coloanal anastomosis** refers to complications that prevent the anastomosis (surgical connection) from functioning properly. These complications may include: 1. **Ischemia**: Inadequate blood supply to the anastomosis site, leading to tissue necrosis. 2. **Anastomotic Leakage**: Breakdown of the connection, causing leakage of intestinal contents. 3. **Rectovaginal Fistula**: An abnormal connection between the rectum and vagina, leading to fecal contamination. 4. **Stricture Formation**: Narrowing of the anastomosis, obstructing bowel movements. 5. **Infection**: Postoperative infections that compromise healing. In this case, the patient developed ischemia, anastomotic leakage, and a rectovaginal fistula, making the initial coloanal anastomosis non-viable. --- ### **Factors Contributing to Failed Anastomosis:** Several factors can lead to a failed coloanal anastomosis, including: 1. **Poor Blood Supply (Ischemia):** - Inadequate perfusion to the anastomotic site, often due to vascular compromise during surgery. 2. **Tension on the Anastomosis:** - Excessive tension on the connection due to insufficient colonic length or improper surgical technique. 3. **Infection:** - Postoperative infections can impair healing and lead to complications such as leakage or fistula formation. 4. **Patient-Related Factors:** - Conditions like diabetes, smoking, malnutrition, or prior radiation therapy can impair wound healing. 5. **Technical Errors:** - Errors in surgical technique, such as poor alignment or inadequate suturing, can compromise the anastomosis. 6. **Underlying Disease:** - Aggressive or advanced cancer, inflammation, or other conditions affecting bowel integrity can increase the risk of failure. --- ### **How Ileal J-Pouch Interposition Helps:** When a coloanal anastomosis fails, ileal J-pouch interposition offers a viable alternative to permanent stoma formation. Here’s how it works and why it’s effective: 1. **Restores Bowel Continuity:** - A segment of the ileum is used to create a J-shaped pouch, which acts as a reservoir for stool. This pouch is then interposed between the remaining viable colon and the anal canal, effectively bypassing the damaged section. - This restores the continuity of the gastrointestinal tract, allowing the patient to defecate normally without the need for a permanent stoma. 2. **Improves Functional Outcomes:** - The ileum has good compliance and reservoir capacity, which helps regulate stool consistency and frequency. - In this case, the patient achieved good bowel control with only 1–2 bowel movements per day and minimal urgency or leakage. 3. **Avoids Permanent Stoma:** - For many patients, a permanent colostomy (stoma) significantly impacts quality of life. Ileal J-pouch interposition provides an alternative that preserves anal sphincter function and natural defecation. 4. **Addresses Ischemia:** - The ileum is supplied by the superior mesenteric artery, which is often unaffected by the ischemia that compromises the colon. This ensures adequate blood supply to the interposed segment. 5. **Customizable Length:** - The length of the ileal segment can be tailored to bridge the gap between the remaining colon and the anal canal, ensuring a tension-free anastomosis. 6. **Functional Advantages:** - The J-pouch design mimics the rectum’s reservoir function, helping to maintain continence and regulate stool passage. - The procedure has shown outcomes comparable to those of ileal pouches used in ulcerative colitis surgeries. 7. **Postoperative Bowel Management:** - In this case, an appendicostomy was created for Malone Antegrade Continence Enema (ACE), allowing the patient to manage bowel function through regular irrigation. --- ### **Key Technical Considerations:** Successful ileal J-pouch interposition depends on: 1. **Adequate Mesenteric Length:** - The ileal segment must have sufficient length and mobility to reach the anal canal without tension. 2. **Tension-Free Anastomosis:** - Ensures proper healing and reduces the risk of complications like leakage or stricture. 3. **Good Perfusion:** - The ileal segment must have a robust blood supply to ensure viability and prevent ischemia or necrosis. --- ### **Outcomes of Ileal J-Pouch Interposition:** 1. **Long-Term Safety:** - In the reported case, the patient experienced no complications such as pouchitis, stricture, or obstruction over five years of follow-up. 2. **Oncologic Safety:** - Regular surveillance with colonoscopies, CT scans, and tumor markers confirmed no cancer recurrence. 3. **Functional Success:** - The patient achieved good bowel control with minimal symptoms of low anterior resection syndrome (LARS) and a high quality-of-life score. 4. **Patient Satisfaction:** - The procedure allowed the patient to avoid a permanent stoma and maintain a high quality of life. --- ### **Limitations and Future Directions:** 1. **Single-Patient Case Report:** - The results may not be generalizable to all patients. 2. **Lack of Objective Functional Testing:** - No manometry or other detailed studies were performed to assess pouch function. 3. **Need for Further Research:** - Multicenter studies are needed to compare ileal J-pouch interposition with other salvage techniques and evaluate long-term outcomes. --- ### **Conclusion:** Ileal J-pouch interposition is a technically feasible and functionally effective salvage option for patients with failed coloanal anastomosis due to ischemia or insufficient colonic length. It provides a viable alternative to permanent stoma formation, offering promising long-term oncologic and functional outcomes. However, further research is needed to validate its efficacy and safety in larger patient populations.

Two-Stage Hepatectomy for Irresectable Hepatic Tumor

Two-Stage Hepatectomy (TSH) is an advanced surgical strategy designed to treat patients with irresectable hepatic tumors, particularly those with colorectal liver metastases (CRLM), which were previously deemed inoperable due to the extent or distribution of the disease. Below is a detailed explanation of the process, feasibility, risks, outcomes, and its potential as a curative approach: ### **Overview of Two-Stage Hepatectomy:** TSH is a stepwise surgical approach used for patients with multinodular or bilobar liver metastases. Many of these patients cannot undergo a single-stage resection due to insufficient remaining liver volume, which is critical for postoperative liver function. The two-stage procedure allows for safe and complete resection of tumors while ensuring that the liver has sufficient time to regenerate between surgeries. ### **Rationale for TSH:** - **Challenge:** Patients with bilobar or extensive liver metastases often have insufficient functional liver reserve to tolerate a single, extensive resection. - **Solution:** TSH involves two surgeries. The first surgery removes the maximum number of tumors while preserving liver parenchyma to allow regeneration. The second surgery is performed after the liver has sufficiently regenerated to remove the remaining tumors. ### **Patient Selection and Study Population:** - Out of 634 patients with colorectal liver metastases (CRLM) treated between 1992 and 1999, 398 had irresectable disease. - Only 16 patients (4%) became eligible for TSH after receiving systemic chemotherapy, and 13 of these patients successfully completed both stages. - Key eligibility factors included: - Disease control with systemic chemotherapy. - Absence of extrahepatic metastases (except for select cases of resectable pulmonary metastases). ### **Chemotherapy as a Bridge to Surgery:** - All patients underwent systemic chemotherapy before surgery to stabilize or shrink tumors, making resection feasible. The regimens primarily included 5-fluorouracil (5-FU) combined with oxaliplatin or irinotecan. - Chemotherapy continued during the interval between the two surgeries to prevent tumor progression. ### **Surgical Strategy:** 1. **First Stage:** - The goal was to perform tumor debulking by resecting the maximum number of tumors while preserving enough liver parenchyma for regeneration. - Techniques included partial hepatectomy or lobar clearance guided by intraoperative ultrasound. 2. **Second Stage:** - After a median interval of 4 months (range: 2–14 months), the second surgery was performed. - This stage typically involved a more extensive resection (e.g., removal of >3 liver segments) to eliminate the remaining tumors. - Portal vein embolization (PVE) was used in 6 patients to induce hypertrophy of the future liver remnant (FLR) and ensure safe resection in the second stage. - Cryosurgery was used in one patient for non-resectable lesions. ### **Feasibility and Success Rates:** - The complete two-stage procedure was feasible in 81% (13 out of 16) of selected patients. - Three patients (19%) were unable to proceed to the second stage due to disease progression during the interval period. ### **Morbidity and Mortality:** - **Morbidity:** - Postoperative complications occurred in 31% of patients following the first stage and 45% after the second stage. - Common complications included transient ascitic leaks, perihepatic collections, and one case of bowel obstruction. - **Mortality:** - No deaths were reported after the first stage. - Two patients (15%) died after the second stage due to postoperative liver failure, highlighting the increased complexity and physiological burden of the second surgery. ### **Survival Outcomes:** - The median overall survival was 44 months from diagnosis and 31 months from the second hepatectomy. - The 3-year overall survival rate following TSH was 35%. - Four patients (31%) achieved long-term disease-free survival, remaining disease-free at 7, 22, 36, and 54 months post-procedure. - Patients who completed both stages of TSH lived significantly longer than those who could not proceed to the second stage, confirming the potential curative benefit of this approach. ### **Tumor Recurrence:** - Tumor recurrence occurred in 7 of 13 patients (54%), with the majority being hepatic recurrences within an average of 8 months after the second surgery. - Repeat hepatectomy was feasible in select cases, and some patients achieved prolonged survival or disease-free status despite recurrence. ### **Key Predictive Factors for Success:** - Strict patient selection is critical for TSH success. - The following factors were identified as important predictors of positive outcomes: - Effective disease control with chemotherapy. - Absence of extrahepatic metastases (except resectable pulmonary metastases). - Adequate liver hypertrophy and function between stages. ### **Clinical Implications:** - TSH significantly increased the resection rate among initially irresectable patients, from 37% to 54% in the study population. - The approach offers a potentially curative option for patients who would otherwise be limited to palliative care with systemic chemotherapy. - Integration of systemic chemotherapy and techniques such as portal vein embolization enhances the safety and success of the procedure. ### **Conclusion:** Two-Stage Hepatectomy, when combined with systemic chemotherapy and advanced surgical techniques, represents a transformative approach for select patients with irresectable colorectal liver metastases. Despite the risks associated with the procedure, the potential for long-term survival and even cure makes it a viable option for appropriately selected patients.

Sleeve Gastrectomy and Anemia

Sleeve gastrectomy (SG) has been shown to have a positive impact on anemia recovery in patients with obesity who undergo bariatric surgery. According to the findings from a retrospective cohort study conducted in Ontario, Canada, SG was associated with greater odds of anemia recovery compared to Roux-en-Y gastric bypass (RYGB). Specifically, the adjusted odds ratio (aOR) for recovery with SG was 1.41, indicating that patients who underwent SG were more likely to experience hematologic improvement than those who underwent RYGB. ### Key Details About SG and Anemia Recovery: 1. **Recovery Rates**: - Among 1664 adults with obesity and preexisting anemia who underwent bariatric surgery, nearly 60% recovered from anemia within 6 months post-surgery. - Recovery rates continued to improve over time, reaching 59.8% at 1 year and 69.7% at 5 years post-surgery. 2. **Impact of Procedure Type**: - Sleeve gastrectomy demonstrated better odds of anemia recovery compared to Roux-en-Y gastric bypass. - This suggests that the type of bariatric surgery plays a significant role in hematologic recovery, with SG being the preferred option for patients with preexisting anemia. 3. **Patient Characteristics**: - Neither preoperative body mass index (BMI) nor weight loss at 6 months was found to influence anemia outcomes. - Instead, patient characteristics and the type of surgery were identified as more critical determinants of anemia recovery. 4. **Why SG May Be Preferred**: - SG may be less likely to cause malabsorption of nutrients, particularly iron, which is essential for hemoglobin production and anemia recovery. - In contrast, RYGB is associated with a higher risk of nutrient deficiencies due to its bypass of portions of the gastrointestinal tract, which could exacerbate anemia. 5. **Clinical Implications**: - Bariatric surgery provides a net benefit for patients with obesity and anemia. - Sleeve gastrectomy may be the preferred surgical option for candidates with preexisting anemia, as it offers a greater likelihood of hematologic recovery. ### Conclusion: Sleeve gastrectomy is an effective bariatric surgery option for improving anemia outcomes in patients with obesity. Its association with higher recovery rates compared to Roux-en-Y gastric bypass highlights its potential as the preferred choice for individuals with preexisting anemia. This information can help guide surgical decisions and optimize patient outcomes in this population.

J- Pouch

### J-Pouch: Overview and Key Details A **J-pouch**, or **ileal pouch–anal anastomosis (IPAA)**, is a surgical procedure primarily performed for patients with **ulcerative colitis (UC)** or certain other conditions affecting the colon, such as familial adenomatous polyposis (FAP). It is a restorative surgery designed to allow patients to avoid a permanent ileostomy after the removal of the colon and rectum. The J-pouch serves as a stool reservoir, mimicking the function of the removed rectum. --- ### **Surgical Process** The creation of a J-pouch is typically performed in **three stages**, especially for acutely ill patients, to ensure the best outcomes and reduce complications: #### **Stage 1: Total Colectomy with End Ileostomy** - **Procedure**: The entire colon is removed, and an end ileostomy is created. This allows the patient to recover and regain health before constructing the pouch. - **Purpose**: - Restores the patient’s health. - Allows optimization of nutrition. - Enables tapering off steroids and correction of anemia. - **Duration**: The surgery takes about **3–4 hours**. - **Hospital Stay**: Approximately a **week**. - **Recovery Time**: Around **6 weeks**. #### **Stage 2: Proctectomy with Pouch Construction and Diverting Loop Ileostomy** - **Procedure**: The rectum is removed, the J-pouch is constructed from the small intestine, and a temporary diverting loop ileostomy is created to protect the new pouch while it heals. - **Duration**: Surgery takes **3–4 hours**. - **Hospital Stay**: About **a week**. - **Recovery Time**: Around **6 weeks**. #### **Stage 3: Ileostomy Closure** - **Procedure**: The temporary diverting ileostomy is closed, allowing stool to pass through the new J-pouch. - **Duration**: Surgery takes about **1 hour**. - **Hospital Stay**: Shorter than the previous stages. - **Recovery Time**: Around **6 weeks**. --- ### **Advantages of the J-Pouch** - **Restorative Function**: Avoids the need for a permanent ileostomy. - **Quality of Life**: Allows patients to pass stool through the anus, maintaining a more normal bowel function. --- ### **Outcomes and Success Rates** - **Long-Term Pouch Survival**: Exceeds **90%**, making it a highly successful procedure. - **Complications**: - **Pouchitis**: A common complication, involving inflammation of the pouch. - **Crohn’s-like Changes**: Occur in **10–15%** of cases. - **Better Outcomes at High-Volume Centers**: Evidence suggests that outcomes are significantly better when the surgery is performed at specialized, high-volume centers. Centralization of care is supported by systematic reviews. --- ### **Challenges and Considerations** - **Contraindications**: Not all patients are suitable candidates for a J-pouch. Patient preference and medical factors play a critical role. - **Complications to Avoid**: - Long rectal cuff. - Small pouch reservoir. - **Optimization Before Surgery**: - Nutritional support. - IV iron therapy. - Steroid tapering. - Perioperative venous thromboembolism (VTE) prophylaxis. - Multidisciplinary review. --- ### **Ileostomy vs. J-Pouch** While the J-pouch avoids a permanent ileostomy, patients with an ileostomy may face their own set of challenges, including: - Skin irritation. - Parastomal hernia. - Fertility and pelvic nerve concerns. Patients are advised to consult **ostomy nurses preoperatively** to understand all options and prepare for potential outcomes. --- ### **Conclusion** The J-pouch is a highly effective surgical solution for patients with ulcerative colitis and other conditions requiring colon removal. While the procedure is complex and requires multiple stages, it offers a high rate of long-term success and improved quality of life. However, it requires careful patient selection, optimization of health prior to surgery, and specialized surgical expertise to ensure the best outcomes.