Trending Topics in Gastroenterology | GastroAGI

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.