Trending Topics in Gastroenterology | GastroAGI

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.