Trending Topics in Gastroenterology | GastroAGI

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.