Ann Surg Oncol
· 2026 Jun · PMID 42298080
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BACKGROUND: Anatomic segmentectomy 8 of the liver is among the most technically demanding procedures, primarily because of the deep intraparenchymal location and marked anatomic variability of the segment 8 Glissonean pe...BACKGROUND: Anatomic segmentectomy 8 of the liver is among the most technically demanding procedures, primarily because of the deep intraparenchymal location and marked anatomic variability of the segment 8 Glissonean pedicle (G8) and the inherently curved configuration of the intersegmental planes. The cranial hepatic vein-guided approach (HVGA) combined with indocyanine green (ICG) fluorescence imaging offers a rational and reproducible strategy for achieving accurate anatomic resection. METHODS: The authors performed robotic anatomic segmentectomy 8 using a stepwise strategy integrating three complementary elements: (1) cranial root-side exposure of the middle hepatic vein (MHV) to establish a stable anatomic axis, (2) intersegmental vein (ISV)-guided localization of G8 exploiting the consistent anatomic relationship between the ISV between segments 5 and 8 and the G8 root, and (3) ICG-negative staining for real-time delineation of the segment 8 portal territory. RESULTS: The operative time was 180 min, with an estimated blood loss of 10 mL. No intraoperative transfusion was required. The Pringle maneuver was applied intermittently for a cumulative duration of 45 min. A 30-mm hepatocellular carcinoma was resected with a clear surgical margin of 11 mm. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. CONCLUSIONS: Robotic anatomic segmentectomy 8 using a cranial HVGA integrated with ICG fluorescence imaging enables precise identification of G8 and accurate navigation along the curved intersegmental planes of S8. This three-element integrated strategy provides an anatomically grounded, reproducible framework for safe and complex robotic anatomic segmentectomy.
Bae SJ, Lee J, Do SI
… +5 more, Kim EY, Park CH, Park YL, Yun JS, Lee KH
Ann Surg Oncol
· 2026 Jun · PMID 42298079
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BACKGROUND: Adjuvant treatment decisions in ER+/HER2- breast cancer depend on accurate distinction between pN1 and pN2/3 disease. As sentinel lymph node biopsy (SLNB) increasingly replaces axillary lymph node dissection...BACKGROUND: Adjuvant treatment decisions in ER+/HER2- breast cancer depend on accurate distinction between pN1 and pN2/3 disease. As sentinel lymph node biopsy (SLNB) increasingly replaces axillary lymph node dissection (ALND), patients with apparent pN1 disease may be understaged. We evaluated preoperative imaging and developed a composite risk score to identify patients for whom completion ALND might be omitted. METHODS: We retrospectively analyzed 160 ER+/HER2- patients with 1-3 positive sentinel nodes who underwent completion ALND after upfront surgery. Four imaging modalities were assessed for pN2/3 (≥4 positive nodes). A five-item composite score (SLN ≥ 2, lymphovascular invasion, tumor ≥2 cm, Ki-67 ≥20%, multifocality; range 0-5) underwent bootstrap validation and decision curve analysis (DCA). RESULTS: All four preoperative imaging modalities failed to predict pN2/3 under-staging (NPV 80-86%; all p ≥ 0.885). Overall, 17.5% harbored true pN2/3 on completion ALND. Low-risk patients (score ≤1; 32% of cohort) had a pN2/3 rate of only 3.9% (NPV 96.1%; sensitivity 92.9%) versus 23.9% in high-risk patients (p = 0.0015). DCA showed net benefit over a treat-all strategy across clinically relevant thresholds, corresponding to ~14 fewer unnecessary ALNDs per 100 patients. CONCLUSIONS: Preoperative imaging showed limited sensitivity for pN2/3 under-staging and should not alone guide omission of completion ALND. A five-item composite score identified a low-risk subgroup (NPV 96.1%) in whom completion ALND might be omitted without compromising monarchE or RxPONDER decisions; prospective external validation is required before routine adoption.
Sun J, Xiong Y, Qiu J
… +4 more, Zheng Y, Ji S, Ye C, Shen Z
Ann Surg Oncol
· 2026 Jun · PMID 42295674
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BACKGROUND: Locally advanced thymic epithelial tumors (TETs) may extend into the adjacent brachiocephalic vein (BCV), creating major technical challenges for resection. While BCV reconstruction is traditionally considere...BACKGROUND: Locally advanced thymic epithelial tumors (TETs) may extend into the adjacent brachiocephalic vein (BCV), creating major technical challenges for resection. While BCV reconstruction is traditionally considered after tumor removal, its true clinical value compared with simple transection remains unclear. PATIENTS AND METHODS: Consecutive patients with TETs involving the BCV who underwent surgical resection at Shanghai Pulmonary Hospital between January 2013 and March 2023 were retrospectively analyzed. Perioperative details, 30-day morbidity, and long-term outcomes were systematically assessed. Inverse probability of treatment weighting (IPTW) was applied to improve baseline comparability between groups. RESULTS: A total of 51 patients were enrolled in the final cohort and were categorized into the transection group (n = 22) or the reconstruction group (n = 29), according to the surgical management of BCV. Compared with the reconstruction group, the transection group had a significantly lower transfusion rate (9.1% versus 37.9%, P = 0.025). However, both 30-day morbidity (40.9% versus 48.3%, P = 0.601) and long-term morbidity (22.7% versus 27.6%, P = 0.693) showed no significant differences. Similarly, recurrence-free survival and overall survival did not differ significantly between the two groups (P = 0.731 and P = 0.882, respectively). After IPTW adjustment, transfusion rates remained significantly higher in the reconstruction group (37.3% versus 5.9%, P = 0.005), whereas no other short- or long-term outcomes differed significantly between the groups. CONCLUSIONS: Despite its technical complexity, BCV reconstruction did not confer additional short- or long-term benefits compared with transection. Therefore, BCV transection may be a more practical surgical approach for selected patients with locally advanced TETs.
Hierl AN, Imamura T, Badgwell BD
… +2 more, Mansfield PF, Ikoma N
Ann Surg Oncol
· 2026 Jun · PMID 42289640
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BACKGROUND: Locally advanced gastroesophageal junction (GEJ) tumors are surgically challenging, requiring balance between R0 resection and preserving quality of life. Total gastrectomy has been the standard approach, but...BACKGROUND: Locally advanced gastroesophageal junction (GEJ) tumors are surgically challenging, requiring balance between R0 resection and preserving quality of life. Total gastrectomy has been the standard approach, but function-preserving strategies are increasingly used to mitigate the nutritional and hormonal consequences associated with complete stomach removal.Proximal gastrectomy (PG) with esophagogastric anastomosis preserves gastric volume but is frequently complicated by severe reflux and anastomotic strictures. Double-tract reconstruction (DTR) has emerged as an alternative. Recent meta-analyses have demonstrated that DTR reduces reflux and stricture rates compared with esophagogastric anastomosis while maintaining 5-year overall survival comparable with total gastrectomy. Fig. 1 Port placement and external retraction for robotic proximal gastrectomy METHODS: This study demonstrated robotic PG-DTR and en bloc distal pancreatectomy with splenectomy (DPS) for a 70-year-old man with Siewert type II GEJ adenocarcinoma. RESULTS: After a favorable response to neoadjuvant FOLFOX chemotherapy, the patient underwent resection. The case was completed in less than 6 h. Pathology showed a 6.3-cm, moderately differentiated T4bN2 adenocarcinoma. Despite advanced-stage disease and indications of peritoneal spread, the patient had prompt recovery (Fig. 1). Key considerations included careful patient selection after preoperative chemotherapy and achievement of R0 resection with meticulous mediastinal and oncologic lymph node dissection. For optimal functional outcomes and prevention of internal hernias, the authors perform hand-sewn esophagojejunostomy, appropriate spacing between the esophagojejunostomy and gastrojejunostomy, upright fixation of the remnant stomach, and closure of the hiatal, mesenteric, and Petersen defects. CONCLUSION: This case demonstrates that PG-DTR and en bloc DPS are feasible and may provide functional benefits for select patients who have locally advanced GEJ tumors with direct pancreatic invasion. The robotic approach may enhance postoperative recovery, supporting early resumption of systemic therapy.
Wen ZL, Ren H, Niu PH
… +9 more, Zhang XJ, Fei H, Jing DS, Li ZF, Adili D, Nie HX, Zhou L, Liu DC, Zhao DB
Ann Surg Oncol
· 2026 Jun · PMID 42289639
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BACKGROUND: The optimal extent of gastrectomy after neoadjuvant therapy for Siewert II/III gastric adenocarcinoma remains unclear. The objective of this study was to compare survival after proximal versus total gastrecto...BACKGROUND: The optimal extent of gastrectomy after neoadjuvant therapy for Siewert II/III gastric adenocarcinoma remains unclear. The objective of this study was to compare survival after proximal versus total gastrectomy and to assess the prognostic impact of distal nodal station metastasis (nos. 4d, 5, 6, and 12a). PATIENTS AND METHODS: We retrospectively analyzed 824 patients with Siewert II/III gastric adenocarcinoma who received neoadjuvant chemotherapy and underwent proximal gastrectomy (PG) or total gastrectomy (TG) at three Chinese centers (2010-2025). Following propensity score matching, survival analysis was performed on a balanced cohort of 518 patients. Overall survival (OS) and progression-free survival (PFS) were assessed using Kaplan-Meier analysis and Cox regression. RESULTS: PG and TG achieved comparable OS and PFS (OS P = 0.54; PFS P = 0.86), with consistent findings across Siewert subtype, pathologic T stage, and TNM stage strata. No significant differences were observed in N0 or N subgroups. Survival remained similar between procedures regardless of neoadjuvant response or immunotherapy exposure. Metastasis to distal lymph node stations increased with advancing ypTNM stage, particularly in stage III disease. In multivariable analyses, gastrectomy type was not an independent prognostic factor (P = 0.117), whereas advanced pathological stage independently predicted worse survival (all P < 0.05). Other clinicopathologic variables were not independently associated with outcome. CONCLUSIONS: PG provides survival comparable to TG after neoadjuvant therapy. The distal key station exhibits a significantly higher metastatic incidence in patients with stage III gastric cancer.
Tomita K, Adams AM, Takayama M
… +15 more, Pan C, Shen SE, Wang X, Wang XS, Williams LA, Arvide EM, To C, Gamboa A, Maxwell JE, Snyder RA, Kim MP, Tzeng CD, Lee JE, Katz MHG, Ikoma N
Ann Surg Oncol
· 2026 Jun · PMID 42289638
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BACKGROUND: Detailed longitudinal data on symptom recovery after pancreatectomy and determinants of delayed recovery remain limited. This study prospectively characterized symptom trajectories and defined symptom-based r...BACKGROUND: Detailed longitudinal data on symptom recovery after pancreatectomy and determinants of delayed recovery remain limited. This study prospectively characterized symptom trajectories and defined symptom-based recovery using patient-reported outcomes. METHODS: The study included 185 patients who underwent pancreatectomy between October 2020 and September 2025 (pancreatoduodenectomy [n = 106], distal pancreatectomy [n = 79]). Of the 185 patients, 121 (65%) underwent a robotic approach. The MD Anderson Symptom Inventory (MDASI) was completed preoperatively at seven postoperative time points through postoperative month (POM) 6. The top five symptoms and top three interference items were identified using mean postoperative day 3 scores. Composite symptom and interference scores were defined as the mean scores of those top items for each. Recovery was defined when both composite scores achieved ≤ 3 of 10 points. Cumulative recovery rates were compared by surgery type and approach, and cluster analysis was performed to identify patients with delayed recovery and contributing factors. RESULTS: The top symptoms were pain, fatigue, sleep disturbance, drowsiness, and bloating, and the top interference items were general activity, working, and walking. Symptom recovery followed three phases: acute improvement (POD 3 to 14), a plateau (POD 14 to POM 1), and persistent recovery extending to POM 6. Fatigue persisted longest. Overall cumulative recovery rates were 68.1% on POM 1, 78.6% on POM 3, and 86.9% on POM 6. In cluster analysis, postoperative complications predicted delayed recovery, whereas surgery type and approach did not. CONCLUSIONS: Early symptom burden improved over time, with changes varying by time point, but fatigue often persisted. Prevention of postoperative complications appears to be a key strategy for improving symptom recovery regardless of surgical approach.
Zhou W, Guan H, Yao J
… +6 more, Yang C, Ni W, Liu Y, Zheng M, Guo B, Li G
Ann Surg Oncol
· 2026 Jun · PMID 42289637
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BACKGROUND: This study aimed to investigate the pathologic and clinical features of local recurrence after partial nephrectomy (PN) for renal cell carcinoma (RCC), with particular emphasis on recurrence location and its...BACKGROUND: This study aimed to investigate the pathologic and clinical features of local recurrence after partial nephrectomy (PN) for renal cell carcinoma (RCC), with particular emphasis on recurrence location and its association with pathologic upstaging and salvage surgical management. METHODS: The study retrospectively analyzed 55 patients who experienced ipsilateral local recurrence after PN and subsequently underwent secondary surgical treatment between January 2014 and March 2025. Based on imaging, intraoperative findings, and gross pathology, recurrences were classified as original-site recurrence (tumor bed or resection margin) or non-original-site recurrence (distant ipsilateral renal parenchyma). Baseline characteristics, perioperative variables, pathologic findings at secondary surgery, and renal functional outcomes were compared between the two groups. Pathologic upstaging was defined as a higher pathologic T stage of the recurrent tumor compared with the primary tumor. RESULTS: Of the 55 patients, 32 (58.2 %) had original-site recurrence, and 23 (41.8 %) had non-original-site recurrence. Baseline demographic and perioperative characteristics at initial surgery were comparable between the groups. However, original-site recurrence was significantly associated with pathologic upstaging compared with non-original-site recurrence (84.3 % vs 21.7 %; p < 0.001). Recurrent tumors in the original-site group also showed more advanced pathologic stage at secondary surgery (p < 0.001). This difference influenced salvage treatment selection (p = 0.003): radical nephrectomy was more frequently performed in the original-site group (81.2 % vs 47.8 %), whereas repeat partial nephrectomy was more common in the non-original-site group (47.8 % vs 9.4 %). Cancer-specific mortality and secondary recurrence were numerically higher in the original-site group, although the differences were not statistically significant. Long-term renal functional outcomes were similar between the groups. CONCLUSIONS: Local recurrence after PN is biologically heterogeneous. Original-site recurrence is strongly associated with pathologic upstaging and more aggressive disease, often requiring radical salvage surgery. In contrast, non-original-site recurrence tends to show less aggressive pathology and may be more suitable for repeat nephron-sparing surgery. Recurrence location may therefore be an important factor in postoperative risk stratification and secondary surgical decision-making.
Chang JG, Park IJ, Kim YI
… +4 more, Lee JL, Yoon YS, Kim CW, Lim SB
Ann Surg Oncol
· 2026 Jun · PMID 42289636
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PURPOSE: Peritoneal metastasis (PM) following curative resection for colorectal cancer (CRC) remains difficult to detect and is associated with limited therapeutic options. This study aimed to assess recurrence patterns...PURPOSE: Peritoneal metastasis (PM) following curative resection for colorectal cancer (CRC) remains difficult to detect and is associated with limited therapeutic options. This study aimed to assess recurrence patterns of PM after curative CRC surgery and to identify associated risk factors. METHODS: A retrospective cohort study included 4695 patients with pathologically confirmed T3 or T4 CRC who underwent curative resection at a tertiary center from January 2012 to December 2020. Recurrence site distribution, cumulative incidence of recurrence, cumulative incidence of peritoneal metastasis (CIPM), and risk factors for PM were analyzed by T stage. RESULTS: Of 4,695 patients, 749 had T4 CRC, with a higher recurrence rate than T3 cases (30.6% vs. 11.9%). In T4 CRC, PM was the most common recurrence site (10.9%), surpassing lung (9.6%) and liver (7.1%) metastases. Peritoneal metastasis rates were highest in right-sided T4 colon cancers (15.7%). The 5-year CIPM was significantly higher in T4 than in T3 (11.5% vs. 1.8%, p < 0.001). Stratified analysis showed a higher cumulative incidence of PM in T4N0 disease compared with T3N+ disease (7.4% vs. 2.9%, p < 0.001). Independent risk factors for PM included T4 stage (hazard ratio 4.47; 95% confidence interval 3.15-6.35), nodal positivity (hazard ratio 2.41; 95% confidence interval 1.60-3.63), advanced age, preoperative obstruction, right-sided cancer, signet ring cell carcinoma, and perineural invasion. CONCLUSIONS: Pathologic T4 CRC exhibits a distinct recurrence pattern characterized by a predominance of peritoneal metastasis. These findings may inform future surveillance protocols and treatment planning.
Aw K, Lau R, Wong B
… +12 more, Riad K, Lee A, Li H, Grose E, Brandts-Longtin O, Abed A, Stevenson J, Sheikh R, Chen R, Goulet C, Johnson-Obaseki S, Nessim C
Ann Surg Oncol
· 2026 Jun · PMID 42289633
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Kawashima J, Sahara K, Yuza K
… +23 more, Endo Y, Cauchy F, Aucejo F, Marques HP, Lopes R, Rodriguea A, Hugh T, Shen F, Maithel SK, Groot Koerkamp B, Popescu I, Kitago M, Weiss MJ, Martel G, Pulitano C, Aldrighetti L, Poultsides G, Ruzzente A, Bauer TW, Gleisner A, Homma Y, Endo I, Pawlik TM
Ann Surg Oncol
· 2026 Jun · PMID 42289631
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INTRODUCTION: The oncologic impact of lymph node dissection (LND) for intrahepatic cholangiocarcinoma (iCCA) remains unclear. We hypothesized that the prognostic relevance of LND may vary according to tumor burden. There...INTRODUCTION: The oncologic impact of lymph node dissection (LND) for intrahepatic cholangiocarcinoma (iCCA) remains unclear. We hypothesized that the prognostic relevance of LND may vary according to tumor burden. Therefore, this study sought to evaluate the interaction between tumor burden and adequate LND among patients who underwent curative-intent resection for iCCA. METHODS: Patients who underwent curative-intent liver resection for iCCA were identified from a large international multi-institutional database. Overall survival (OS) was evaluated using multivariable Cox regression models that included an interaction term between tumor burden score (TBS) and adequate LND. RESULTS: Among 1,558 patients, 872 (56.0%) underwent LND and 322 (20.7%) underwent adequate LND, defined as retrieval of at least six lymph nodes. The median TBS was 6.1 (interquartile range [IQR] 4.1-8.6). On multivariable Cox regression analysis, a significant interaction was observed between TBS and adequate LND (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.87-0.95, p < 0.001). Among 542 (34.8%) patients with TBS < 5.0, adjusted OS did not differ according to adequate LND status (HR 1.23, 95% CI 0.86-1.76, p = 0.265). In contrast, among 1,016 (65.2%) patients with TBS ≥ 5.0, adequate LND was associated with improved adjusted OS (HR 0.65, 95% CI 0.51-0.82, p < 0.001). Similar findings were observed for recurrence-free survival (RFS). CONCLUSIONS: The prognostic relevance of adequate LND in patients undergoing curative-intent resection for iCCA appears to vary according to tumor burden. Adequate LND was associated with improved OS and RFS among patients with high TBS, but not among those with low TBS.
Acker RC, Sharpe JE, Williams S
… +6 more, Landau SI, Rowe J, Fraker D, Karakousis GC, Wachtel H, Kelz RR
Ann Surg Oncol
· 2026 Jun · PMID 42289630
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BACKGROUND: Team dynamics influence team performance and patient outcomes in surgery, yet data on resident-led teams are scarce. This study aimed to compare patient outcomes across resident-led teams in complex surgical...BACKGROUND: Team dynamics influence team performance and patient outcomes in surgery, yet data on resident-led teams are scarce. This study aimed to compare patient outcomes across resident-led teams in complex surgical oncology. We hypothesized that patient outcomes would vary by team assignment. METHODS: This was a retrospective cohort study of resident-led teams who contributed more than 10 surgical oncology operations (colectomy, hepatectomy, pancreatectomy, or thyroidectomy) to the National Surgical Quality Improvement Project registry at a single university-based hospital (2018-2025). The primary outcome was presence of any adverse event, including mortality and postoperative complications. Length of stay and 30-day readmissions were also examined. Mixed-effects regression estimated expected outcome probabilities for each patient. For each team, observed-minus-expected (O-E) outcome rates were calculated to assess performance. RESULTS: In total, 145 teams cared for a median of 22 patients (interquartile interval 16- 27; n = 2919). Five teams demonstrated poor performance based on risk-adjusted adverse event rates (O-E rates: 6.9% and 22.3%). A total of 13 teams had significantly longer risk-adjusted length of stays than expected (O-E between 0.4 and 3.5 days), and seven teams had shorter risk-adjusted length of stays than expected (O-E between -1.1 and -0.7 days). Three teams had higher risk-adjusted readmission rates than expected (O-E between 4.9% and 6.8%). Two teams performed poorly across all three outcomes. CONCLUSIONS: Variation in team performance can be measured using valid and reliable risk-adjusted patient outcomes in complex surgical oncology. This may provide meaningful feedback with benchmarking to identify teams that require more supervision.