Trending Topics in Gastroenterology | GastroAGI

Mesh Fixation and Chronic Groin Pain: BJS Open | July 2026

Introduction: Chronic postoperative inguinal pain (CPIP) remains one of the most important long-term complications after laparoscopic groin hernia repair, despite lower rates than with open surgery. Whether different mesh types and fixation methods influence the risk of persistent pain remains uncertain, and comparative real-world evidence has been limited. Why was this study needed?: . CPIP significantly affects long-term quality of life after inguinal hernia repair. . The optimal combination of mesh type and fixation technique remains controversial. . Large comparative studies evaluating commonly used mesh–fixation combinations are lacking. . Identifying the safest and most cost-effective strategy could improve surgical outcomes. Results: This nationwide Swedish registry study evaluated over 15,000 patients undergoing unilateral laparoscopic groin hernia repair, with more than 10,500 providing 1-year patient-reported outcomes. Among 12 commonly used mesh–fixation combinations, three strategies were associated with the lowest risk of chronic postoperative inguinal pain: heavyweight flat mesh without fixation, lightweight flat mesh fixed with fibrin glue, and lightweight self-gripping mesh with micro-hooks. Heavyweight flat mesh without fixation performed as well as the other low-pain strategies while avoiding fixation devices altogether, making it the simplest and least expensive approach. Clinical Impact: These findings support selecting mesh–fixation strategies that minimize chronic pain without compromising repair quality. Heavyweight flat mesh without fixation appears to be a practical default option, combining low chronic pain risk with lower procedural complexity and cost. The results also reinforce previous registry evidence demonstrating acceptable recurrence rates with non-fixation techniques. Bottom Line: Heavyweight flat mesh without fixation was associated with one of the lowest risks of chronic postoperative inguinal pain after laparoscopic groin hernia repair, supporting it as a simple, effective, and cost-efficient default strategy.

Collateral-Based PD Without Venous Reconstruction: Indian J Gastroenterol | July 2026

Introduction: Venous involvement is common in locally advanced pancreatic cancer and often necessitates superior mesenteric-portal vein resection with reconstruction during pancreaticoduodenectomy. However, reconstruction may not always be feasible because of extensive venous disease or unfavorable anatomy. This technique letter describes an alternative surgical strategy that exploits well-developed collateral venous circulation to enable safe resection without venous reconstruction in carefully selected patients. Why was this study needed?: Some patients have non-reconstructible mesenteric venous anatomy, limiting the feasibility of standard venous reconstruction. Abandoning curative surgery in these patients may deny potentially beneficial treatment. Well-developed collateral venous pathways may provide adequate mesenteric venous drainage after resection. Practical technical guidance for this uncommon but challenging surgical scenario is limited. Results: The authors describe the technical principles of performing pancreaticoduodenectomy without venous reconstruction in patients with unreconstructible mesenteric venous anatomy but robust collateral circulation. Careful preoperative imaging is essential to identify collateral venous pathways and assess their adequacy before surgery. In appropriately selected patients, preservation of these collateral channels can maintain venous drainage and allow safe tumor resection without the need for complex vascular reconstruction. The report emphasizes meticulous operative planning and individualized decision-making rather than broad application of this technique. Clinical Impact: This technique expands the surgical options for a highly selected subgroup of patients with locally advanced pancreatic cancer who would otherwise be considered unsuitable for resection. It highlights the importance of detailed vascular assessment and multidisciplinary planning and underscores that successful outcomes depend on surgical expertise and careful patient selection in high-volume hepatopancreatobiliary centers. Bottom Line: Pancreaticoduodenectomy without venous reconstruction may be feasible in carefully selected patients with locally advanced pancreatic cancer and well-developed collateral venous circulation, offering a potential alternative when conventional venous reconstruction is not possible.

Robotic vs Open Pancreatoduodenectomy: BMJ | July 2026

Introduction: Pancreatoduodenectomy remains one of the most complex abdominal operations. Robotic pancreatoduodenectomy (RPD) has been proposed to improve postoperative recovery, but robust randomized evidence has been limited. The PORTAL trial compared robotic and open pancreatoduodenectomy in high-volume expert centers. Why was this study needed? • High-quality randomized evidence comparing robotic and open pancreatoduodenectomy has been limited. • Previous minimally invasive studies raised concerns regarding safety and learning curves. • Whether robotic surgery improves recovery without compromising oncological outcomes remained uncertain. • The higher costs of robotic surgery require justification through meaningful clinical benefits. • Evidence was needed to guide future surgical practice and recommendations. Results: • Robotic pancreatoduodenectomy significantly accelerated postoperative functional recovery, resulting in earlier discharge despite a longer operative time. • Postoperative complications, 90-day mortality, and oncological outcomes were comparable between robotic and open surgery, confirming the safety of the robotic approach in experienced centers. • Robotic surgery incurred higher hospital costs, highlighting the importance of careful patient selection, institutional expertise, and procedural volume. Clinical Impact: This landmark phase III randomized trial demonstrates that robotic pancreatoduodenectomy can safely enhance postoperative recovery when performed by experienced surgeons in high-volume centers. However, the increased financial cost means that widespread implementation should be guided by institutional expertise, case volume, and healthcare resource availability. Bottom Line: Robotic pancreatoduodenectomy offers faster recovery with similar safety and oncological outcomes compared with open surgery, but at a higher cost. In expert, high-volume centers, it represents an effective minimally invasive alternative, although broader adoption should remain selective and value-based.

Adapting Military Resilience to Modern Surgery by SOSC: An of Surgery | July 2026

Introduction: Surgery is an inherently high-stress profession, where complications, patient deaths, and difficult decisions can lead to burnout, moral injury, and mental health disorders. Inspired by the US Marine Corps' Combat and Operational Stress Control (COSC) program, this Perspective introduces Surgical Operational Stress Control (SOSC)—a structured framework designed to enhance surgeon resilience and sustain long-term performance. Key Takeaways: • Surgeons experience moral injury, burnout, and psychological stress similar to military personnel operating in high-pressure environments. • SOSC adapts the military's proven five-step resilience model: Strengthen, Mitigate, Identify, Treat, and Reintegrate. • The framework emphasizes early recognition of stress, encouraging intervention before temporary distress progresses to chronic burnout or mental illness. • Peer support, mentorship, shared decision-making, and open conversations about stress are central to building a resilient surgical culture. • SOSC promotes structured reintegration after major complications or emotional distress, reducing stigma and facilitating a safe return to clinical practice. • The model encourages hospitals and surgical training programs to move beyond wellness initiatives toward proactive, system-based resilience programs. • Incorporating SOSC into surgical education may improve surgeon well-being, reduce medical errors, strengthen teamwork, and enhance patient care. Clinical Impact: Surgeon well-being directly influences clinical performance and patient safety. By adapting battle-tested military principles, SOSC provides a practical framework to recognize stress early, support recovery, and foster a healthier surgical workforce. It shifts the focus from treating burnout to preventing it through structured organizational support. Bottom Line: Resilient surgeons deliver safer care. The proposed Surgical Operational Stress Control (SOSC) model offers a practical roadmap to identify, manage, and recover from occupational stress, ensuring surgeons remain healthy, effective, and "in the fight" throughout their careers.

Vascular Resection for Pancreatic Cancer: Annals of Surgery | June 2026

Introduction: As surgical techniques and perioperative therapies have advanced, vascular resection during pancreatic cancer surgery has become increasingly common in selected patients with locally advanced disease. This study evaluated the long-term outcomes of venous and arterial resections in patients undergoing curative-intent surgery for pancreatic ductal adenocarcinoma (PDAC). Why was this study needed? The oncologic benefit of vascular resection, particularly arterial resection, remains controversial because of concerns regarding increased operative risk and uncertain survival benefit. What did the study show? • The study analyzed 715 patients undergoing curative-intent surgery over 10 years at a high-volume pancreatic center. • Venous resection was performed in 30% of patients, while arterial resection was required in 12%. • Patients undergoing venous resection had shorter recurrence-free and overall survival than those without vascular resection. • After adjustment for other prognostic factors, vascular resection itself was not an independent predictor of overall survival. • Arterial resection achieved oncologic outcomes comparable to standard resection but was associated with significantly higher 90-day postoperative mortality. • Perioperative chemotherapy and chemoradiotherapy significantly improved recurrence-free and overall survival. • Node-negative disease and absence of perineural invasion were strong predictors of favorable long-term outcomes. Clinical Impact: Vascular resection should not be considered a contraindication to curative surgery in carefully selected patients with PDAC. Successful outcomes depend on multidisciplinary management, effective perioperative therapy, and performance in experienced high-volume centers. Take-Home Message: Vascular resection can safely expand surgical options for selected patients with pancreatic cancer. While arterial resection carries higher perioperative risk, careful patient selection and modern multimodality therapy can achieve oncologic outcomes comparable to standard pancreatic resection.

Drain Management After Pancreatoduodenectomy: BJS Open | June 2026

Introduction: Optimal drain management after pancreatoduodenectomy (PD) remains critical for preventing postoperative pancreatic fistula (POPF) while supporting enhanced recovery. This study proposes a dynamic, risk-adapted algorithm based on intraoperative risk and postoperative biochemical markers. Why was this study needed? Current drain removal protocols largely rely on early drain fluid amylase (DFA) levels using a one-size-fits-all approach. However, these strategies may not be reliable in patients at high intrinsic risk of POPF, particularly those with a soft pancreas and small pancreatic duct. What did the study show? • High-risk PD (soft pancreas and duct ≤3 mm) had significantly higher POPF rates than non-high-risk PD. • Early DFA was highly predictive in low-risk patients but was considerably less reliable in high-risk patients. • For non-high-risk PD, safe drain removal on POD 3 was guided by low POD 1 and POD 3 DFA along with normal serum amylase/lipase. • For high-risk PD, delaying drain removal until POD 5 improved safety. • In high-risk patients, combining POD 5 DFA with C-reactive protein provided better prediction of clinically relevant POPF than DFA alone. • The proposed algorithm individualizes drain management according to each patient's fistula risk rather than applying a uniform protocol. Clinical Impact: Drain management after pancreatoduodenectomy should be individualized. Early drain removal remains appropriate for low-risk patients, whereas high-risk patients benefit from delayed removal guided by serial biochemical assessment, potentially reducing POPF-related complications. Take-Home Message: A risk-stratified, dynamic drain management strategy is superior to a one-size-fits-all approach after pancreatoduodenectomy. Tailoring drain removal according to intraoperative risk and postoperative biomarkers can improve patient safety while supporting enhanced recovery.

Diverticulitis Peaks During Warmer Months : JAMA Surg | Apr 2026

Introduction: Diverticulitis is a common cause of acute abdominal hospitalization and contributes substantially to healthcare utilization worldwide. While seasonal variation has been recognized in several gastrointestinal and surgical conditions, whether diverticulitis follows a reproducible temporal pattern has remained uncertain. Understanding such trends could provide insight into disease triggers and help guide preventive strategies and healthcare planning. Problem Statement: The factors precipitating acute diverticulitis are incompletely understood. If seasonal fluctuations exist, they may point toward modifiable environmental, dietary, microbial, or behavioural influences that contribute to disease onset. Clarifying these patterns could improve both mechanistic understanding and resource allocation. Summary: This systematic review evaluated global evidence on seasonal variation in diverticulitis incidence and hospital admissions, encompassing more than one million cases across four continents. The analysis demonstrated a remarkably consistent pattern, with most studies reporting peak rates during summer or autumn and the lowest incidence during winter. Importantly, a reversal of this pattern between the Northern and Southern Hemispheres strongly supports the existence of true seasonality rather than random variation. The magnitude of seasonal fluctuation was substantial, with peak periods showing noticeably higher admission rates than trough periods. Several potential explanations were proposed, including dehydration during warmer weather, seasonal dietary changes, alterations in gut microbiota, immune system modulation, and variations in vitamin D exposure. Notably, while the incidence of diverticulitis varied by season, disease severity did not appear to follow the same pattern, suggesting that environmental factors may influence disease onset rather than progression. These findings provide compelling evidence that diverticulitis is influenced by seasonal factors and highlight the potential role of modifiable environmental and lifestyle exposures. From a clinical perspective, awareness of predictable seasonal peaks may assist healthcare systems in anticipating increased demand. Future prospective studies incorporating patient-level environmental, dietary, and biological data are needed to better define the mechanisms underlying this seasonal phenomenon and identify opportunities for prevention.

Avoid Treating Asymptomatic Postoperative Hypertension : JAMA Surg | Jun 2026

Introduction: Postoperative hypertension is frequently encountered in hospitalized surgical patients and often triggers immediate clinical intervention. Elevated blood pressure readings after surgery may result from pain, anxiety, fluid shifts, medication changes, or physiological stress responses. In many institutions, routine monitoring systems and standing medication orders can prompt treatment even when patients have no symptoms or evidence of end-organ injury. Problem Statement: Despite its common occurrence, the routine treatment of asymptomatic postoperative hypertension remains controversial. Acute blood pressure reduction in the absence of symptoms may expose patients to unnecessary risks, yet reflexive treatment continues to occur because of institutional practices, automated alerts, and concerns about elevated blood pressure measurements. Summary: This review challenges the common practice of administering as-needed antihypertensive medications for asymptomatic postoperative hypertension. The authors highlight that current evidence and clinical practice guidelines do not support routine treatment of elevated blood pressure in the absence of symptoms or hypertensive emergencies. Importantly, unnecessary blood pressure lowering may result in adverse outcomes, including hypotension, reduced organ perfusion, and other treatment-related complications. The review emphasizes that many episodes of postoperative hypertension are transient and related to reversible perioperative factors rather than uncontrolled chronic hypertension requiring urgent intervention. The authors identify several system-level drivers of overtreatment, including nursing notifications triggered by preset blood pressure thresholds, routine availability of as-needed antihypertensive orders, and limited familiarity with perioperative blood pressure management principles. Rather than focusing on isolated blood pressure measurements, clinicians should assess the overall clinical context and evaluate patients for symptoms or signs of end-organ dysfunction before initiating therapy. The review concludes that postoperative hypertension should generally be treated only when symptomatic or associated with hypertensive emergencies. Reducing unnecessary interventions and modifying institutional triggers for treatment may improve patient safety while avoiding the harms associated with excessive blood pressure reduction in the postoperative setting. Overall, the article advocates for a more measured and evidence-based approach to postoperative blood pressure management.

Gluteal Flap Reduces Costs After APR : BJS Open | Jun 2026

Introduction: Perineal wound complications remain a major source of morbidity after abdominoperineal resection (APR) for rectal cancer. Delayed wound healing can result in prolonged outpatient care, increased healthcare utilization, impaired quality of life, and higher overall treatment costs. The gluteal turnover flap has been proposed as a reconstructive technique to improve perineal healing, but its economic value has not been fully established. Problem Statement: While surgical innovations may improve clinical outcomes, their adoption increasingly depends on demonstrating cost-effectiveness. It remains unclear whether the additional operative effort required for gluteal turnover flap reconstruction translates into meaningful reductions in healthcare costs and patient burden compared with conventional primary closure. Summary: This cost-effectiveness analysis of the multicenter BIOPEX-2 randomized trial evaluated gluteal turnover flap closure versus primary perineal closure following APR for rectal cancer. The study demonstrated that gluteal turnover flap reconstruction was associated with significantly lower overall healthcare costs during follow-up. Cost savings were primarily driven by reductions in outpatient care requirements, specialized wound management, and home healthcare utilization, reflecting improved wound-related outcomes. Although patients who developed perineal wound complications reported substantially poorer health-related quality of life, overall quality-of-life measures were similar between the randomized groups. This likely reflects the lower frequency of wound complications among patients undergoing flap reconstruction. Importantly, the gluteal turnover flap achieved these economic benefits without compromising patient-reported outcomes. The findings suggest that preventing wound complications not only improves clinical recovery but also reduces downstream healthcare expenditure. From both a patient and healthcare system perspective, the gluteal turnover flap represents a high-value intervention that can lessen the burden of postoperative wound care after APR. Overall, this randomized trial provides strong evidence that gluteal turnover flap closure is a cost-saving strategy and supports its broader implementation as a preferred approach for perineal wound reconstruction in appropriately selected rectal cancer patients undergoing APR.

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 analysed, 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 tumours, 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 emphasise 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.