PURPOSE: The incidence of diverticular disease in younger adults has been on the rise over the past decades. This study aimed to evaluate the association between age and postoperative outcomes for patients undergoing col...PURPOSE: The incidence of diverticular disease in younger adults has been on the rise over the past decades. This study aimed to evaluate the association between age and postoperative outcomes for patients undergoing colectomy for diverticular disease. METHODS: A retrospective analysis was performed using the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files between 2016 and 2020. Adults aged ≥18 years who underwent colectomy for diverticular disease were included. Demographic, perioperative, and postoperative variables were analyzed between patients aged <50 and ≥50 years. A multivariable logistic regression was used to identify independent predictors of major intra-abdominal complications, defined as positive when either anastomotic leak or organ/space surgical site infections were present. RESULTS: A total of 39,729 patients met the inclusion criteria. Younger individuals comprised 23% of the cohort, were less often female (36% vs 61%; P <.001), had a higher mean body mass index (32 vs 29; P <.001), and were more likely to be smokers (28% vs 18%; P <.001). Readmissions were more frequent in older patients (8.5% vs 7.5%; P =.002); however, the median time to first readmission occurred earlier in younger patients (12 vs 15 days; P <.001). In multivariable analysis, among other factors, age younger than 50 years independently increased the risk of major intra-abdominal complications (odds ratio, 1.14; 95% CI, 1.02-1.27). CONCLUSION: Despite their overall healthier profile, younger patients experience comparable postoperative risk rates with older patients and are at an increased risk of severe intra-abdominal complications. These findings provide insights that add to patient-physician shared decision making.
BACKGROUND: Patients post-gastroesophageal cancer surgery frequently present with clinical features of malabsorption and are often treated empirically with pancreatic enzyme replacement therapy (PERT). Primary aim was to...BACKGROUND: Patients post-gastroesophageal cancer surgery frequently present with clinical features of malabsorption and are often treated empirically with pancreatic enzyme replacement therapy (PERT). Primary aim was to objectify the presence of fat malabsorption in patients after gastroesophageal surgery and, secondary, to measure exocrine pancreatic function. METHODS: Eligible patients were those who underwent gastroesophageal cancer surgery (2017-2021), were at least six months post-surgery, maintained an oral diet, and showed no evidence of recurrent disease. Treatment with PERT was ceased prior to this study. Fecal fat balance test (coefficient of fat absorption, CFA (%)) was used to measure absorption of fat. The CFA was determined by collecting feces over three days to measure daily fecal fat excretion (g/d), along with a four-day (weighted) nutritional diary, to establish the average daily fat intake (g/d). Fat malabsorption was defined as a CFA <85%. Exocrine pancreatic function was measured using fecal elastase-1 (FE-1). RESULTS: We included 90 patients (50 after esophagectomy with gastric tube reconstruction and 40 after (sub)total gastrectomy with Roux-en-Y reconstruction). Fecal analysis were conducted at a median of 17 months (IQR 11-28) post-surgery. A CFA <85% was found in 24% of patients after gastric tube reconstruction, accompanied by low levels of FE-1 in 33%. After Roux-en-Y reconstruction a CFA <85% was present in 43%, of which 71% had low levels of FE-1. CONCLUSION: Fat malabsorption is common after gastrectomy with Roux-en-Y reconstruction and after esophagectomy with gastric tube reconstruction, partly accompanied by reduced FE-1 levels. Clinicians should remain alert to malabsorption during follow-up and an empirical trial with PERT can be considered, although further studies are needed to evaluate its effects on absorption, symptoms, and quality of life.
BACKGROUND: Esophagectomy remains the primary curative treatment of esophageal cancer, and the anastomotic technique is a crucial determinant of postoperative outcomes. Although circular stapled esophagogastrostomy (CSE)...BACKGROUND: Esophagectomy remains the primary curative treatment of esophageal cancer, and the anastomotic technique is a crucial determinant of postoperative outcomes. Although circular stapled esophagogastrostomy (CSE) is widely used, side-overlap esophagogastrostomy (SOE) has recently been adapted for intrathoracic reconstruction. METHODS: This retrospective study included 105 patients who underwent Ivor-Lewis esophagectomy. The short-term clinical outcomes were compared between the SOE group and the CSE group. RESULTS: No significant differences were observed between the SOE and CSE groups in operative duration (189.0 ± 49.9 vs 200.2 ± 48.3 min, respectively; P =.246), estimated blood loss (110 mL [IQR, 150-90] vs 120 mL [IQR, 150-100], respectively; P =.354), or number of lymph nodes harvested (19.0 [IQR, 23.0-16.0] vs 17.5 [IQR, 21.0-15.8], respectively; P =.285). The overall postoperative complication rate was similar (18.2% in the SOE group vs 22.0% in the CSE group; P =.625). However, patients in the SOE group reported significantly lower pain scores on postoperative days (PODs) 1 and 2 (POD1: 3.49 ± 0.79 in the SOE group vs 4.04 ± 0.95 in the CSE group; P =.002; POD2: 2.73 ± 0.65 in the SOE group vs 3.06 ± 0.62 in the CSE group, P =.009). The incidence of severe gastroesophageal reflux (Reflux Disease Questionnaire ≥ 12) was significantly lower in the SOE group than in the CSE group (14.5% vs 34.0%, respectively; P =.019). Dysphagia symptoms were less frequent in the SOE group than in the CSE group (9.1% vs 24.0%, respectively; P =.038). CONCLUSION: Intrathoracic SOE is a safe and feasible alternative to CSE for patients with Siewert type I/II adenocarcinoma of the esophagogastric junction undergoing esophagectomy. SOE offers comparable operative safety while reducing postoperative pain, severe reflux, and dysphagia, suggesting functional advantages in short-term recovery.
BACKGROUND: Hiatal hernia (HH) is an often overlooked cause of chronic anemia, and the therapeutic role of surgical HH repair (HHr) in these cases remains underexplored. Thus, we assessed the prevalence of anemia and vis...BACKGROUND: Hiatal hernia (HH) is an often overlooked cause of chronic anemia, and the therapeutic role of surgical HH repair (HHr) in these cases remains underexplored. Thus, we assessed the prevalence of anemia and visible Cameron lesions in patients undergoing primary HHr, explored associations with hernia size, and evaluated objective postoperative improvements. METHODS: This retrospective, observational study used a prospectively maintained surgical database at a high-volume tertiary referral center to identify patients with anemia or upper gastrointestinal bleeding who underwent HHr between September 2016 and March 2024. Adults who underwent HHr with (i) preoperative anemia (hemoglobin <13.0 g/dL for men or <12.0 g/dL for women), (ii) endoscopic evidence of Cameron lesions, (iii) documented anemia in medical records, or (iv) documented history of iron deficiency anemia-related therapies were included. Patients with prior foregut procedures or other identifiable sources of blood loss were excluded. The primary endpoints were the rates of postoperative transfusion-level anemia and iron deficiency anemia-related therapies. RESULTS: Among 448 patients who underwent primary HHr, 132 (29.5%) were included. The rates of anemia-related findings increased with HH size as follows: small, 7.3%; moderate, 28.7%; large, 58.4%; and intrathoracic stomach, 44.7%. Significant reductions were seen in postoperative rates of transfusion-level anemia (15.2% to 0%; P =.004) and anemia-related medical therapies (50.8% to 2.2%; P <.001). CONCLUSION: Anemia and/or visible Cameron lesions are common in patients undergoing HHr and increase with hernia size. HHr significantly reduces transfusion-level anemia and the need for anemia-related therapies. Early surgical referral should be considered, as medical treatment alone may not address the underlying causes.
BACKGROUND: Achalasia is classified into 3 manometric subtypes with variable treatment response. Guidelines recommend per oral endoscopic myotomy (POEM) over laparoscopic Heller myotomy (LHM) for the treatment of achalas...BACKGROUND: Achalasia is classified into 3 manometric subtypes with variable treatment response. Guidelines recommend per oral endoscopic myotomy (POEM) over laparoscopic Heller myotomy (LHM) for the treatment of achalasia type III. However, there is limited evidence directly comparing these operations. We aimed to compare the treatment response to POEM vs LHM in type III achalasia. METHODS: We conducted a retrospective, case-control review of patients undergoing primary myotomy for type III achalasia or achalasia variants with type III features. The primary outcome was symptomatic response assessed using the Eckardt score (ES) with a score of ≤3 classified as success. The secondary outcome was the need for reintervention(s) within 3 years. RESULTS: There were 46 patients, of whom 16 underwent POEM, and 30 underwent LHM. The groups were similar in demographics, preoperative ESs, and rates of preoperative endoscopic interventions. Both groups had median myotomy lengths of 6 cm (4 cm esophageal and 2 cm gastric). After myotomy, both groups had similar rates of success (14/16 POEM vs 26/30 LHM, P =.94). The primary persisting symptom was dysphagia in both groups. Reinterventions occurred in 4/16 (25%) of POEM patients who underwent 9 reinterventions compared with 5/30 (16.7%) LHM patients who underwent 6 reinterventions (P =.49). Most patients in both groups had symptomatic improvement after their last reintervention. CONCLUSION: Patients with type III achalasia had similar improvements after undergoing POEM or LHM. There was no difference in reintervention rates between the groups. Patients undergoing reintervention after POEM were more likely to undergo multiple reinterventions.
de Pascale S, Rosati R, Bagnardi V
… +15 more, Cossu A, Ferrari G, Frassoni S, Giacopuzzi S, Gualtierotti M, Moletta L, Morino M, Pallabazzer G, Realis Luc M, Rebecchi F, Santi S, Valmasoni M, Weindelmayer J, Fumagalli Romario U, Società Italiana per lo Studio delle Malattie dell’Esofago (Italian Society for Study of Esophageal Diseases)
BACKGROUND: Esophagogastric junction adenocarcinoma (EGJA) is characterized by a high recurrence rate after esophagectomy, which significantly affects patient survival. This study aimed to identify the risk factors contr...BACKGROUND: Esophagogastric junction adenocarcinoma (EGJA) is characterized by a high recurrence rate after esophagectomy, which significantly affects patient survival. This study aimed to identify the risk factors contributing to early recurrence (ER) within 12 months after Ivor Lewis esophagectomy (ILE) in patients with EGJA. METHODS: A retrospective multicenter analysis was conducted across 7 high-volume Italian centers that included 594 patients with Siewert type I and II EGJAs who underwent ILE between January 2018 and December 2022. The clinicopathologic characteristics and postoperative outcomes were analyzed. ER was defined as cancer recurrence within 12 months after surgery. Univariate and multivariate analyses were performed to identify the independent risk factors for ER. RESULTS: The overall recurrence rate was 41.2% (245/594), with ER occurring in 24.4% (145/594) of patients. The 1-year overall survival rate was 87.7%, and the 1-year recurrence-free survival (RFS) rate was 70.6%. The median RFS was 32.1 months. Multivariate Cox regression analysis identified lower body mass index (hazard ratio [HR], 0.95; P =.009), poor or absent response to neoadjuvant treatment based on the Mandard classification (HR, 2.26; P =.013), and advanced stage (HR, 2.24; P <.001) as independent significant risk factors for ER in EGJA. CONCLUSION: Identifying prognostic factors associated with ER allows for the stratification of a subgroup of patients with poor oncological outcomes who require a personalized treatment approach, distinct from the standard multimodal treatment.
BACKGROUND: Esophagectomy traditionally involves delayed oral feeding (DOF) due to anastomotic leakage concerns. Enhanced Recovery After Surgery protocols favor early feeding, but its safety remains controversial. This s...BACKGROUND: Esophagectomy traditionally involves delayed oral feeding (DOF) due to anastomotic leakage concerns. Enhanced Recovery After Surgery protocols favor early feeding, but its safety remains controversial. This study compared early oral feeding (EOF) and DOF after esophagectomy. METHODS: PubMed, Embase, and Scopus were systematically searched from inception of the study to October 2025 for randomized controlled trials comparing EOF (0-3 days) and DOF (≥5 days) after esophagectomy. The primary outcomes were anastomotic leakage and pneumonia. The secondary outcomes included complications, hospital outcomes, gastrointestinal (GI) recovery, and quality of life (QOL). Effect sizes were calculated as mean differences (MDs) or standardized MDs (SMDs) for continuous variables and risk ratios (RRs) for dichotomous variables, with 95% CIs, using Review Manager (version 5.4; Cochrane Collaboration). RESULTS: A total of 13 trials involving 1468 patients were included in the study. Early feeding showed no increase in anastomotic leakage (RR, 0.89 [95% CI, 0.55-1.45]; I² = 0%), with consistent safety across anastomotic locations and surgical approaches. Early feeding significantly reduced pneumonia (RR, 0.66 [95% CI, 0.47-0.92]; P =.01) and accelerated GI recovery: time to first bowel movement (MD, -0.50 days [95% CI, -0.55 to -0.46]; P <.00001) and first flatus (MD, -0.61 days [95% CI, -0.95 to -0.26]; P =.0006). Hospital stay was reduced by 1.89 days (95% CI, -3.06 to -0.72; P =.002) with lower medical expenses (SMD, -1.19 [95% CI, -2.07 to -0.30]; P =.009). QOL improved: global health status (MD, 9.08 [95% CI, 3.88-14.29]; P =.0006), dysphagia (MD, -6.15 [95% CI, -9.97 to -2.34]; P =.002), pain (MD, -3.60 [95% CI, -5.32 to -1.89]; P <.00001), and swallowing difficulties (MD, -1.39 [95% CI, -1.53 to -1.26]; P <.00001). CONCLUSION: EOF after esophagectomy seems safe and effective, reducing complications while accelerating recovery. However, further high-quality multicenter trials are needed to validate these findings.
PURPOSE: This study aimed to investigate whether preoperative nutritional status and physical fitness after prehabilitation are associated with surgical outcomes, functional capacity, fatigue, and quality of life after e...PURPOSE: This study aimed to investigate whether preoperative nutritional status and physical fitness after prehabilitation are associated with surgical outcomes, functional capacity, fatigue, and quality of life after esophagectomy. METHODS: This multicenter, observational cohort study included patients with esophageal cancer who underwent curative treatment and multimodal prehabilitation as part of standard care. Preoperative assessments included body mass index (BMI), risk of malnutrition, exercise capacity, handgrip strength (HGS), upper leg muscle function, physical activity level, and fatigue, after finishing prehabilitation. Differences in preoperative parameters between patients with and without postoperative overall or pulmonary complications were analyzed using independent samples t-tests. Associations between preoperative parameters and length of hospital stay, postoperative functional capacity, fatigue, and quality of life were examined using multivariable linear regression models. RESULTS: A total of 168 patients were included in the study, with a mean age of 65.9 ± 8.6 years and 78.0% of the patients being male. A higher preoperative BMI was associated with more overall complications (P =.029). Better preoperative exercise capacity and upper leg muscle function were associated with less pulmonary complications (P <.045) and better postoperative functional capacity (P <.032). Less preoperative fatigue was associated with better postoperative functional capacity, quality of life, and less fatigue (P ≤.001). Risk of malnutrition, HGS, and physical activity level were not significantly associated with postoperative outcomes. CONCLUSION: BMI, exercise capacity, upper leg muscle function, and fatigue seem to be important factors in the preoperative assessment before esophagectomy in terms of postoperative complications, postoperative functional capacity, fatigue, and quality of life. During prehabilitation, specific attention is needed for patients with a high BMI, low fitness level, and high fatigue.
BACKGROUND: Gastroparesis is a debilitating disorder, and surgical therapy can provide meaningful improvement in patients who remain symptomatic despite medical treatment. However, patients often present with variable di...BACKGROUND: Gastroparesis is a debilitating disorder, and surgical therapy can provide meaningful improvement in patients who remain symptomatic despite medical treatment. However, patients often present with variable disease severity, and the influence of demographic and socioeconomic factors on this variability and on postoperative outcomes remains poorly defined. This study aimed to evaluate the effect of demographic status and socioeconomic status (SES) on preoperative characteristics and postoperative outcomes in patients who underwent surgery for medically refractory gastroparesis. METHODS: All patients who underwent surgical treatment of medically refractory gastroparesis between 2012 and 2024 at a tertiary foregut center were retrospectively analyzed. Demographics, gastroparesis etiology, gastric emptying, and Gastroparesis Cardinal Symptom Index (GCSI) scores were compared across sex, race, age, and SES groups. SES classification was derived from zip code-level United States census data. Surgical procedures included pyloroplasty, gastric peroral endoscopic pyloromyotomy, and gastric electrical stimulation. RESULTS: A total of 387 patients were included (82.4% female; mean age of 51.3 ± 15.6 years). Idiopathic (62.3%) and diabetic (23.9%) etiologies predominated. Overall, GCSI total score improved significantly (median: 3.1 [IQR, 2.5-3.9] to 2.4 [IQR 1.6-3.3]; P <.001), and gastric retention at 4 h decreased (29.0% [IQR, 17.0%-44.9%] to 8.0% [IQR, 1.0%-24.0%]; P <.001). African American patients presented with higher baseline GCSI total score (median: 4.3 [IQR, 3.3-4.8] vs 3.1 [IQR, 2.4-3.8]; P =.011) and continued to report higher postoperative symptom scores (GCSI total score: 3.1 vs 2.4; P =.031). Similarly, patients with low SES demonstarted a trend toward more severe preoperative symptoms and higher gastric retention but achieved postoperative improvement comparable with those with higher SES. A significant correlation between preoperative gastric emptying at 4-hour retention and GCSI total score was observed only in men, both preoperatively (r = 0.46; P =.049) and postoperatively (r = 0.60; P =.025). Younger patients were less likely to have symptom resolution (P =.035). CONCLUSION: Surgical treatment achieved durable improvement in medically refractory gastroparesis, with similar postoperative gains across SES groups. Persistent symptoms in African American and younger patients and sex-specific differences in symptom-motility correlation suggest multifactorial mechanisms beyond motility alone.