GI Surgery

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.

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.

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.

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.

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.

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.