BACKGROUND: The pace of surgical innovation appears ever faster. Innovation is being freed from the design constraints of the opposable digits of a surgeon's hand through the use of programmable binary digits. Surgeons m...BACKGROUND: The pace of surgical innovation appears ever faster. Innovation is being freed from the design constraints of the opposable digits of a surgeon's hand through the use of programmable binary digits. Surgeons must be the drivers of change and central to the application of innovations. We should collaborate with industry, engineers and scientists to think out of the box but must consider also expense, environmental impact, equity, and ethics. But we should not be blinded by shiny technology: innovation without impact is mere noise. The ultimate considerations are the diagnosis and management of surgical disease, of improving the care of our patients. METHODS: Expert surgeons, scientists and engineers across the world were identified and invited to describe areas of innovation within surgery. They were given free rein to review their areas of expertise and to discuss both current and future applications of technology within surgical care. RESULTS: The Commission spans multiple surgical specialties and scientific domains. It reviews translational genomics, including the role of ctDNA, alongside microbiomic and proteomic applications in improving the diagnosis, treatment and monitoring of surgical disease. Applications to enhance surgical procedures are described, from medical micro/nanorobots for minimally invasive interventions, sensory-enriched surgery with visual optimization and molecular image-guidance to intelligent and semiautomated instruments. The expansion and broad influence of artificial intelligence in surgical writing, training and simulation, diagnosis and robotics is widely described. The role of surgical innovation and technology in driving personalized care for benign and malignant surgical disease from genomic profiling to bespoke surgical and non-surgical treatment pathways and surveillance is considered. CONCLUSION: The future of surgery is poised to become more precise, personalized, and effective. Collaboration with engineers, data scientists, and industry partners not only represents an exciting opportunity for surgeons to participate in team science but is critical to focus innovation goals on optimizing patient care and outcomes.
BACKGROUND: Postoperative mortality is the third leading cause of death worldwide and disproportionately affects patients in low- and middle-income countries (LMICs). Although many deaths are potentially preventable, evi...BACKGROUND: Postoperative mortality is the third leading cause of death worldwide and disproportionately affects patients in low- and middle-income countries (LMICs). Although many deaths are potentially preventable, evidenced-based interventions remain limited. The aim of this systematic review was to consolidate randomized trial evidence on interventions designed to reduce postoperative mortality in LMICs. METHODS: Medical databases from database inception to February 2025 were systematically searched for randomized trials evaluating interventions in any aspect of the patient pathway from admission to discharge that were designed to reduce postoperative mortality within 90 days of surgery in LMIC patients. Eligible studies included elective and emergency operations across all surgical specialties. The protocol was preregistered in PROSPERO, the international prospective register of systematic reviews (CRD42024604760). RESULTS: From 10 877 search results, some 18 trials involving 95 521 patients were included. Three were multicountry trials and half were conducted in China. Trials spanned multiple specialties, with only 4 of 18 assessed as having a low risk of bias. Four trials showed a significant reduction in mortality, although the interventions were largely context specific (two neurosurgical trials centred on operative technique in China, one Brazilian trial investigating patient blood management, and one study evaluating maternal death reviews and implementation of best practice after caesarean deliveries in Senegal and Mali). Adherence to interventions was generally high and similar between simple and complex interventions (93.6% versus 96.8% respectively), although adherence varied substantially across trials. CONCLUSION: Few RCTs have targeted postoperative mortality in LMICs and no intervention demonstrated consistent effectiveness across multiple contexts. To maximize clinical impact, future research should prioritize the development of interventions in regions with the greatest need, particularly sub-Saharan Africa, and ensure they are co-developed with LMIC interest holders and evaluated across diverse clinical environments.
BACKGROUND: Thoracic epidural analgesia (TEA) remains the 'gold standard' for postoperative pain management after major open surgery, but is potentially associated with hypotension, urinary retention, and delayed recover...BACKGROUND: Thoracic epidural analgesia (TEA) remains the 'gold standard' for postoperative pain management after major open surgery, but is potentially associated with hypotension, urinary retention, and delayed recovery. Rectus sheath catheters (RSCs) offer a simple regional alternative that avoids sympathetic blockade while maintaining somatic analgesia. The aim of this review was to compare analgesic efficacy, complications, recovery, patient satisfaction, and costs between RSCs and TEA in open surgical procedures. METHODS: This systematic review was registered with PROSPERO, the international prospective register of systematic reviews (registration number: CRD420251234467). A systematic PubMed search was conducted to identify studies comparing continuous wound infusion via RSCs with TEA in adult patients undergoing open abdominal, pelvic, thoracic, or vascular surgery. RCTs, as well as prospective and retrospective comparative studies, were included. A meta-analysis was performed for randomized trials. RESULTS: In total, 31 studies (21 prospective and 10 retrospective) involving 2162 patients were included. RSCs and TEA did not differ significantly with respect to postoperative pain (standardized mean difference -0.35 (95% c.i. -2.01 to 1.32)) or opioid consumption (standardized mean difference -0.32 (95% c.i. -1.71 to 1.07)). No differences were observed in recovery of bowel function, urinary retention, time to mobilization, or length of hospital stay. RSCs significantly reduced the risk of hypotension compared with TEA (risk ratio 0.40 (95% c.i. 0.26 to 0.60)) and were associated with lower costs with savings ranging from $500 to $6632 per case. Subgroup analyses suggested less urinary retention and earlier mobilization with RSCs in non-visceral surgery and non-laparotomy incisions. CONCLUSION: RSCs provide analgesia comparable to TEA with fewer complications, facilitating earlier recovery and potential cost savings. Considering the growing shift toward fast-track surgery, RSCs represent a pragmatic and resource-efficient alternative for postoperative pain management in open surgical procedures.
Denost Q, Ghouti L, Tuech JJ
… +13 more, Rouanet P, Germain A, Rio E, Faucheron JL, Jafari M, Cotte E, Mineur L, De Chaisemartin C, Lefevre JH, Merdrignac A, Sitta R, Frison E, Vendrely V
BACKGROUND: Some patients report experiencing various systemic symptoms after surgical placement of a (polypropylene (PP)) mesh implant, including fatigue, arthritis, and myalgia. As these complaints could resemble syste...BACKGROUND: Some patients report experiencing various systemic symptoms after surgical placement of a (polypropylene (PP)) mesh implant, including fatigue, arthritis, and myalgia. As these complaints could resemble systemic symptoms of autoimmune disease (AID), there are concerns that mesh implants could induce such disorders. The aim of this study was to identify the incidence of AID after mesh implantation, compared with controls in whom no mesh was implanted. METHODS: In this national retrospective cohort study, approximately 4 million people insured with Dutch health insurer Coöperatie VGZ were screened for operative procedure reimbursements for inguinal and incisional hernia repair, between January 2015 and January 2019. Patients who underwent cholecystectomy were included as controls, as no mesh is implanted during this procedure. Patients were followed from 2 years before surgery to 3 years after surgery. The primary outcome was the difference in the incidence of AID after mesh implantation, compared with surgery without mesh. Propensity score matching for age, sex, and socioeconomic status was performed to reduce selection bias. RESULTS: The cohort included 19 464 inguinal/incisional hernia patients (86.0% male) and 18 259 cholecystectomy patients (31.8% male). After matching, both groups consisted of 1500 patients. The incidence of new AID during follow-up was not statistically different between the two groups (1.1% for the intervention group and 1.5% for the control group; P = 0.520). CONCLUSION: Based on this cohort study, mesh implants do not increase the medium-term risk of developing AID.
BACKGROUND: The increase in incidence of early-onset pancreatic cancer (EOPC) is of concern and poorly understood. The aim of this study was to investigate the clinical outcomes of surgically resected patients with EOPC...BACKGROUND: The increase in incidence of early-onset pancreatic cancer (EOPC) is of concern and poorly understood. The aim of this study was to investigate the clinical outcomes of surgically resected patients with EOPC and the potential molecular heterogeneity between EOPC and late age-onset disease. METHODS: A retrospective cohort study was conducted, with clinical, pathological, and survival outcome data obtained from two large independent prospective cohorts curated by the Australian Pancreatic Genome Initiative (APGI) and the West of Scotland Pancreatic Unit (Glasgow Royal Infirmary) between 1997 and 2022. Patients were categorized into two age groups (<50 and ≥50 years) at time of diagnosis. Clinicopathological features and survival outcomes, in addition to gene expression and tumour microenvironment data, were compared between groups. RESULTS: In total, 851 patients were identified, of whom 68 (8%) were aged <50 years. EOPC was associated with significantly earlier recurrence after surgery (median disease-free survival (DFS) 10.9 versus 14.2 months; P = 0.011) and there was no statistically significant difference in disease-specific survival (median 19.9 versus 23.8 months; P = 0.117). There were no differences in validated clinicopathological variables to account for the shorter DFS in the EOPC group. Despite an increased proportion of patients with EOPC receiving adjuvant chemotherapy (P = 0.032), DFS was significantly worse (DFS 12.6 versus 16.0 months; P = 0.022). EOPC demonstrated enrichment of genes associated with more aggressive molecular pathology and the squamous (basal-like) molecular subtype of pancreatic ductal adenocarcinoma, including S100A2 (P < 0.001) and TP63 (P = 0.044), and down-regulation of GATA6 (P = 0.016). CONCLUSION: EOPC is associated with a shorter time to recurrence and more aggressive, adverse molecular pathology.
BACKGROUND: Wound complications after breast surgery are common and contribute to morbidity and healthcare costs. The economic value of prophylactic incisional negative-pressure wound therapy (iNPWT) remains uncertain. T...BACKGROUND: Wound complications after breast surgery are common and contribute to morbidity and healthcare costs. The economic value of prophylactic incisional negative-pressure wound therapy (iNPWT) remains uncertain. This study evaluated the effectiveness and cost-effectiveness of iNPWT in preventing postoperative wound complications (freedom from complication) following breast surgery through a systematic review and meta-analysis. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched without any restrictions up to 5 March 2025. Randomized trials and prospective or retrospective cohort studies comparing prophylactic iNPWT with standard dressings were included. Two reviewers independently extracted data, assessed risk of bias (RoB 2, ROBINS-I), and graded evidence certainty (GRADE). Random-effects meta-analyses were performed, and cost-effectiveness modelling focused on surgical site infection (SSI). RESULTS: Twenty-nine studies including 4904 patients (1817 iNPWT; 3087 controls) were analysed. iNPWT was associated with higher rates of wound dehiscence prevention (RR 1.07, 95% c.i. 1.03 to 1.12), SSI prevention (RR 1.05, 95% c.i. 1.01 to 1.09), and skin necrosis prevention (RR 1.07, 95% c.i. 1.01 to 1.15). No significant differences were observed for seroma, nipple-areolar complex necrosis, or haematoma. Across outcomes, heterogeneity was substantial and 95% prediction intervals crossed the null, indicating uncertainty in the direction of effect in future settings. Evidence certainty ranged from low to moderate. Cost modelling suggested that iNPWT may be cost-saving only in settings with high SSI-related costs. CONCLUSIONS: Current evidence does not establish consistent clinical benefit of prophylactic iNPWT in breast surgery. Cost-effectiveness appears limited to high-risk or high-cost contexts, supporting selective use.
Perry WRG, Brown KGM, Burns E
… +18 more, Denost Q, Frizelle F, Glover TE, Glyn T, Graham RP, Heriot A, Merchea A, Quyn A, Sagar P, Solomon MJ, Thomas G, Tiernan JP, Turner GA, Warrier S, Wood V, Presacral Tumour Working Group, Jenkins JT, Dozois EJ
BACKGROUND: Presacral tumours are rare and heterogeneous lesions arising within a complex anatomical space, resulting in variability in diagnosis and management. Increasing incidental detection and evolving surgical and...BACKGROUND: Presacral tumours are rare and heterogeneous lesions arising within a complex anatomical space, resulting in variability in diagnosis and management. Increasing incidental detection and evolving surgical and oncological strategies have highlighted the need for contemporary guidance. The aim of this study was to establish an international expert consensus on the optimal diagnosis and management of presacral tumours. METHODS: An international panel of colorectal surgeons from high-volume units was convened. Evidence- and practice-based statements were developed after domain-based literature reviews and refined through five online and two in-person meetings. Consensus was achieved using a modified Delphi process with anonymous voting. RESULTS: In total, 16 colorectal surgeons participated in the study. Ten domains were identified resulting in the development of 22 statements based on expert opinion and retrospective studies. After two rounds, unanimous (100%) agreement was achieved for all statements. High-resolution MRI with structured synoptic reporting is endorsed as central to risk stratification. Selective image-guided transperineal or parasacral biopsy is recommended for high-risk lesions where histology would alter management. Complete surgical resection is defined as the operative goal, with approach tailored to tumour biology and anatomy; minimally invasive surgery is considered appropriate in selected cases. Non-operative surveillance is supported for carefully selected asymptomatic, low-risk cystic lesions. Postoperative surveillance is recommended in a risk-adapted manner according to histopathology and margin status. CONCLUSION: This international consensus provides a pragmatic, risk-stratified framework for the multidisciplinary diagnosis and management of presacral tumours. These recommendations aim to reduce practice variation, support decision-making in specialized centres, and inform future prospective collaborative research.
Achalasia is a rare, progressive oesophageal motility disorder defined by impaired lower oesophageal sphincter relaxation and absent peristalsis, leading to dysphagia, regurgitation, chest pain, weight loss, and increase...Achalasia is a rare, progressive oesophageal motility disorder defined by impaired lower oesophageal sphincter relaxation and absent peristalsis, leading to dysphagia, regurgitation, chest pain, weight loss, and increased long-term risks of aspiration and malignancy. Management has evolved from open surgical myotomy to minimally invasive laparoscopic and robotic techniques and, more recently, peroral endoscopic myotomy (POEM). This review summarizes contemporary diagnostic strategies, including high-resolution manometry, timed barium oesophagram, endoscopy, and emerging applications of impedance planimetry, and critically appraises current endoscopic and surgical therapies. The review compares outcomes of pneumatic dilation, botulinum toxin injection, minimally invasive Heller myotomy with fundoplication, POEM, POEM with fundoplication, and newer approaches for advanced disease such as peroral oesophageal plication and oesophagectomy, integrating data from randomized trials and long-term cohort studies. Key issues, including post-treatment gastro-oesophageal reflux, cancer surveillance, and management of recurrent or refractory symptoms, are addressed. Treatment selection is emphasized as individualized, incorporating manometric subtype, oesophageal morphology, patient co-morbidity, institutional expertise, procedural durability, complication profiles, and evolving guideline recommendations across international expert consensus groups. Contemporary multimodal therapy enables durable symptom control and meaningful quality-of-life improvement for most patients, while ongoing innovation and longer-term follow-up will continue to refine treatment algorithms and standards of care.
McClements J, Lee WT, Koh A
… +51 more, Sellappan H, Blackburn L, Brooks A, Nixon G, Merali N, Frampton A, Safavi D, Davidson B, Feretis M, Dasari BVM, Chin SL, Karavias D, Rowcroft A, Lucocq J, Harrison EM, Morrison-Jones V, Welsh F, Pathanki A, Marangoni G, Bruno P, Skipworth J, Colucci N, Kosmoliaptsis V, O'Leary L, Malik H, Hamadalnile A, Menon K, Patel W, Bekheit M, Tanno L, Silva M, Brown C, Kumar N, Triance J, Shah N, Alsaoudi T, Bhardwaj N, Nassar H, Mownah O, Yeung KTD, Bhogal R, Blanco-Colino R, Farid S, Aljaberi R, Pandanaboyana S, Abdelmohsin O, Aroori S, Evans D, Athwal T, Lodge JPA, Gomez D
INTRODUCTION: To provide contemporary, real-world data on the management approaches and survival outcomes of patients with incidental gallbladder cancer (GBC) following cholecystectomy in the United Kingdom. The secondar...INTRODUCTION: To provide contemporary, real-world data on the management approaches and survival outcomes of patients with incidental gallbladder cancer (GBC) following cholecystectomy in the United Kingdom. The secondary aim was to identify prognostic factors associated with survival. METHODS: Patients diagnosed with incidental GBC following cholecystectomy between January 2014 and December 2022 across 24 centres were included. Data collected comprised demographics, treatment details, histopathological findings and survival outcomes. RESULTS: During the study period, 285 patients had incidental GBC. Median follow-up was 31 months, with 5-year disease-free (DFS) and overall (OS) survival of 41.5% and 45.1%, respectively. Of the 193 (67.7%) patients who underwent liver resection, most (97.9%) underwent segment 4B/5 resection. Patients with incidental GBC who underwent liver resection had significantly improved DFS (51 vs 15 months, p<0.001) and OS (72 vs 26 months, p<0.001) compared with those who did not. In addition, patients who completed adjuvant chemotherapy had better DFS (35 vs 15 months, p=0.021) and OS (47 vs 26 months, p=0.009) compared to those who did not. On multivariable analysis, nodal metastases were independently associated with poorer DFS (HR 2.04, 95% CI 1.30-3.20, p=0.002), while advanced tumour (T3-T4) stage (HR 1.70, 95% CI 1.04-2.77, p=0.034) and nodal metastases (HR 2.15, 95% CI 1.33-3.48, p=0.002) predicted poorer OS. CONCLUSION: Patients who underwent liver resection after incidental GBC had significantly better survival than those who did not proceed to further surgery. Adverse tumour biology was associated with poorer survival.
BACKGROUND: The prognostic relevance of multifocal and multicentric breast cancer remains unclear and current staging systems do not consider focality. The aim of this study was to explore whether women with multifocal b...BACKGROUND: The prognostic relevance of multifocal and multicentric breast cancer remains unclear and current staging systems do not consider focality. The aim of this study was to explore whether women with multifocal breast cancer have less favourable tumour characteristics and worse survival compared with women with unifocal breast cancer. METHODS: Patient and tumour characteristics were obtained from Breast Cancer Database Sweden 3.0, which includes data for all Swedish women diagnosed with invasive breast cancer between 2008 and 2019 and who underwent surgery. Overall and breast cancer-specific survival rates were calculated using the Kaplan-Meier method and multivariable analysis was used to identify independent predictors of survival using the Cox proportional hazard model. RESULTS: A total of 71 419 women were included in the study: 59 445 (83.2%) had unifocal breast cancer, 7286 (10.2%) had multifocal breast cancer with two invasive foci, and 4688 (6.6%) had multifocal breast cancer with three or more invasive foci. Multifocal breast cancer was associated with higher clinical T and N categories compared with unifocal breast cancer. The median follow-up time was 5.96 (interquartile range 3.078.80) years. The breast cancer-specific 10-year survival rates were 86.1% for women with multifocal breast cancer with three or more foci, 86.5% for women with multifocal breast cancer with two foci, and 88.4% for women with unifocal breast cancer. In a multivariable analysis adjusted for patient and tumour characteristics, the HR for breast cancer-specific death was 1.17 (95% c.i. 1.03 to 1.32) for women with multifocal breast cancer with three or more foci compared with women with unifocal breast cancer. There was no statistically significant difference in overall survival between the three groups. CONCLUSION: The present study suggests that focality provides prognostic information that is additional to that provided by traditional tumour characteristics.
BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists have anti-inflammatory and immunomodulatory properties beyond glycaemic control. The impact of GLP-1 receptor agonists on burn injury outcomes remains unexplo...BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists have anti-inflammatory and immunomodulatory properties beyond glycaemic control. The impact of GLP-1 receptor agonists on burn injury outcomes remains unexplored. The aim of this study was to assess the potential impact of prior GLP-1 receptor agonist exposure on mortality, infectious complications, and critical care utilization in burn patients. METHODS: Using the TriNetX US Collaborative Network, adult patients with thermal burns ≤20% total body surface area (TBSA) between 1 January 2018 and 8 November 2025 were identified. Patients with documented GLP-1 receptor agonist use within 1 year before burn injury were propensity score matched with controls for age, sex, race, co-morbidities, TBSA, BMI, and haemoglobin A1c (HbA1c). Outcomes included 1-year mortality, infectious complications, critical care utilization, and wound management outcomes. Sensitivity analyses examined 6-month and 3-year exposure windows. RESULTS: After matching, 8307 patients per cohort were included. GLP-1 receptor agonist exposure was associated with 54% reduced odds of mortality (OR 0.46, P < 0.001), 35% reduced intensive care unit admission (OR 0.65, P < 0.001), and 62% reduced intubation (OR 0.38, P < 0.001). Infectious complications were significantly decreased, including sepsis (32% reduction), pneumonia (24% reduction), and methicillin-resistant Staphylococcus aureus (MRSA) infection (27% reduction). The odds of broad-spectrum antibiotic use decreased 21%. Benefits persisted across all exposure windows. The 3-year cohort demonstrated a 27% increase in hypertrophic scarring (OR 1.27, P = 0.031). CONCLUSION: Prior GLP-1 receptor agonist use was associated with a significant decrease in mortality, infectious complications, and critical care utilization among burn patients, independent of metabolic factors like BMI. These findings warrant prospective studies to optimize perioperative management strategies in this patient population.