GI Surgery

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.

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.

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.