BACKGROUND: Chronic post-operative inguinal pain (CPIP) is a significant complication following inguinal hernia repair. Evidence on the surgical factors associated with CPIP remains mixed and modern generations are often...BACKGROUND: Chronic post-operative inguinal pain (CPIP) is a significant complication following inguinal hernia repair. Evidence on the surgical factors associated with CPIP remains mixed and modern generations are often turning to social media and artificial intelligence (AI) tools to seek answers. The concordance between these emerging information sources and empirical evidence is yet unknown. METHODS: An augmented evidence review was performed to integrate three sources around a unifying question: "What are the key tips to minimize postoperative chronic groin pain when performing inguinal hernia repair (any approach)?" The sources compared were empiric evidence (Abdominal Core Health Quality Collaborative [ACHQC]), social media evidence on the International Hernia Collaboration [IHC] Facebook group, and Artificial Intelligence evidence from Open Evidence [OE]. RESULTS: The ACHQC analytic cohort included 4,385 patients. Laparoscopic TEP (β 0.40; p=0.032) and robotic TAPP (β 0.64; p=0.003) were associated with statistically higher 6-month pain scores compared to open repair. No significant differences in pain were observed across fixation subtypes at any time point postoperatively. Nerve identification remained statistically significant at 6-month (β 0.66 p=0.001) and 1 year postoperatively (β 0.67, p=0.01). The social media poll had 238 votes, identifying minimization of traumatic mesh fixation as the most important strategy. AI generated 16 references across surgical approach, nerve management, mesh type and fixation method. CONCLUSION: The three sources demonstrated moderate but incomplete alignment of information. As technology-driven information sources become integrated into surgical decision-making, surgeons should remain vigilant of data source shortcomings and structured frameworks evaluating concordance between these sources are essential.
BACKGROUND: Traditional metrics for anal fistula surgery prioritise healing and continence, largely ignoring intimacy and psychosocial well-being. Addressing a critical literature gap, this novel systematic review and ex...BACKGROUND: Traditional metrics for anal fistula surgery prioritise healing and continence, largely ignoring intimacy and psychosocial well-being. Addressing a critical literature gap, this novel systematic review and exploratory meta-analysis is the first to mathematically evaluate the gender-specific impacts of fistula surgery and seton placement on sexual function. METHODS: A PRISMA-compliant search of PubMed, Embase, Scopus, and Cochrane databases identified studies utilising validated sexual indices [International Index of Erectile Function (IIEF) for males, Female Sexual Function Index(FSFI)] and targeted quality-of-life surveys for cryptoglandular or Crohn 's-associated fistulas. This study uniquely pooled continuous pre- and postoperative functional data using Standardised Mean Differences(SMD). RESULTS: Eighteen studies were included. Systematic review established a stark, previously unquantified gender dimorphism in surgical recovery. Definitive surgical cure yielded highly significant improvements in IIEF(male) by eradicating chronic suppuration(p<0.001). Conversely, FSFI(female) showed negligible improvement or active deterioration, frequently complicated by anterior-track dyspareunia. Furthermore, this review quantifies the "Seton Paradox" - while loose setons successfully mitigate sepsis, cross-sectional pooling demonstrated they inflict severe, statistically significant impairment on female sexual function (p=0.02) and drive high rates of body-image avoidance across both genders. Crucially, the synthesis of patient-reported data exposed a systemic failure in informed consent, revealing that 79% of patients never received pre-operative sexual counselling. CONCLUSIONS: Anal fistula surgery inflicts a profound, gender-dimorphic toll on sexual function. As the first systematic review to objectively highlight this disparity and quantify the psychological burden of chronic setons, these findings mandate a clinical paradigm shift. Proactive counselling regarding dyspareunia, body image, and intimacy must become a mandatory component of preoperative informed consent.
BACKGROUND: Textbook outcome (TO) is a composite measure of surgical quality, but existing definitions in colon surgery predate the widespread adoption of minimally invasive surgery and contemporary, perioperative recove...BACKGROUND: Textbook outcome (TO) is a composite measure of surgical quality, but existing definitions in colon surgery predate the widespread adoption of minimally invasive surgery and contemporary, perioperative recovery pathways. We sought to redefine TO using a contemporary and data-driven length-of-stay (LOS) standard and evaluate its incidence, temporal trends, and predictors after elective colectomy. METHODS: We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2022. Adult patients undergoing elective colectomy were included. TO was defined as LOS ≤ 3 days and the absence of 30-day morbidity, mortality, readmission, or reoperation. The LOS threshold was informed by cohort-level LOS distribution analysis, demonstrating a modal LOS of 3 days. Trends in TO achievement and factors associated with TO were analyzed using multivariable logistic regression. RESULTS: Among the 139,064 patients included, 44.5% achieved TO. TO rates improved significantly from 29.3% in 2012 to 50.2% in 2022 (P <.001), with rates plateauing after 2019. Minimally invasive approaches were strongly associated with TO, particularly robotic (odds ratio [OR], 8.30; 95% CI, 7.90-8.73) and laparoscopic (OR, 4.21; 95% CI, 4.03-4.39) surgery. Reduced odds of TO were associated with age > 80 years (OR, 0.46; 95% CI, 0.43-0.48), frailty index ≥ 3 (OR, 0.48; 95% CI, 0.42-0.55), nonhome discharge (OR, 0.21; 95% CI, 0.19-0.23), indication of bleeding (OR, 0.53; 95% CI, 0.38-0.72), and ostomy creation (OR, 0.52; 95% CI, 0.49-0.55), all P <.001. CONCLUSION: A contemporary TO definition incorporating LOS ≤ 3 days identifies a rigorous and clinically relevant recovery benchmark after elective colectomy. TO achievement improved substantially over the study period. Minimally invasive approaches, particularly robotic surgery, were strongly associated with TO achievement, whereas advanced age, frailty, and nonhome discharge were associated with a lower likelihood of TO. Our contemporary TO definition may provide a patient-centered framework for evaluating perioperative recovery quality and contextualizing outcomes in modern colon surgery.
BACKGROUND: Clinical influence of end-stage renal disease (ESRD) in patients undergoing hepatectomy for malignancy remains to be fully understood. METHODS: From a clinical dataset of surgery for hepatic malignancies, out...BACKGROUND: Clinical influence of end-stage renal disease (ESRD) in patients undergoing hepatectomy for malignancy remains to be fully understood. METHODS: From a clinical dataset of surgery for hepatic malignancies, outcomes of patients who were receiving hemodialysis (HD) at the time of surgery (HD group; n=29) and those who were not (non-HD group; n=2,008) were compared. RESULTS: Multivariate analysis confirmed that the risk of blood loss >1000mL (odds ratio [OR], 3.02), likely need for blood transfusion (OR, 4.53), risk of any postoperative complications (OR, 2.55), risk of major postoperative complications (OR, 4.03), and 90-day mortality (OR, 19.00) were higher in the patients who were on HD. Patients of the HD group also showed a tendency towards worse survival, with the major cause of death classified as non-cancer-related death. Competing-risks regression analysis showed ESRD on HD was associated with non-cancer-related death (hazard ratio, 5.19), while it was not correlated with increased risk of cancer-specific mortality. CONCLUSIONS: Hepatectomy for malignancies in patients undergoing HD was associated with an increased risk of perioperative morbidity and mortality. While ESRD/HD was not significantly associated with increased cancer-specific mortality in our limited cohort, the worse survival observed in the patients with ESRD was mainly attributable to non-cancer-related death.
BACKGROUND: The Cardiovascular-Kidney-Metabolic (CKM) staging system integrates metabolic, cardiovascular and renal disease burden and may better capture perioperative risk. However, its relevance to morbidity and mortal...BACKGROUND: The Cardiovascular-Kidney-Metabolic (CKM) staging system integrates metabolic, cardiovascular and renal disease burden and may better capture perioperative risk. However, its relevance to morbidity and mortality following hepatectomy has not been well established. METHODS: We conducted a retrospective cohort study using the Nationwide Inpatient Sample (2016-2021), including adults undergoing major hepatectomy. Patients were categorized by CKM stage (0/1, 2/3, and 4a). The primary outcome was in-hospital mortality. Secondary outcomes included major postoperative complications (Clavien-Dindo ≥III), prolonged length of stay (≥75th percentile) and non-home discharge. Multivariable generalized estimating equation models adjusted for patient, procedural, and hospital characteristics were used. RESULTS: The cohort included 3,988 patients: 65.3% CKM 0/1, 15.8% CKM 2/3, and 18.9% CKM 4a. After adjustment, CKM stage 4a was independently associated with increased in-hospital mortality (aOR 1.84, 95% CI 1.28-2.66), prolonged length of stay (aOR 2.28, 95% CI 1.87-2.79), and non-home discharge (aOR 1.88, 95% CI 1.45-2.43). Major postoperative complications (Clavien-Dindo ≥III) increased stepwise across CKM stages (19.7%, 33.2%, and 38.7%; p<0.001). In sensitivity analyses excluding isolated diagnoses of diabetes and chronic kidney disease, Stage 4a remained strongly associated with mortality (aOR 2.74, 95% CI 1.11-6.76). CONCLUSIONS: Advanced CKM stage, particularly stage 4a, is independently associated with adverse short-term outcomes after major hepatectomy. CKM staging may enhance perioperative risk stratification and resource planning in hepatobiliary surgery.
BACKGROUND/PURPOSE: Enhanced-view totally extraperitoneal (eTEP) repair enables minimally invasive retromuscular and preperitoneal mesh placement while avoiding contact with intraperitoneal mesh. Reported complication ra...BACKGROUND/PURPOSE: Enhanced-view totally extraperitoneal (eTEP) repair enables minimally invasive retromuscular and preperitoneal mesh placement while avoiding contact with intraperitoneal mesh. Reported complication rates differ depending on the definition and data source. We developed an augmented evidence review (AER) to address "What are key tips to avoid common eTEP complications?" METHODS: The AER integrated three evidence streams (1) empiric; the Abdominal Core Health Quality Collaborative (ACHQC), including elective adult eTEP-consistent ventral hernia repairs with 30-day follow-up (N=8,434; Oct 2013-Dec 2025); (2) social media; an International Hernia Collaboration (IHC) expert poll ranking prioritized eTEP hazards; and (3) AI; Open Evidence synthesis with manual source verification. Outcomes were classified as consequential (readmission, reoperation, SSI, SSO/I, prolonged LOS) versus non-consequential/burden. Adjusted analyses compared TAR versus no TAR and robotic versus laparoscopic approaches. RESULTS: The incidence of 30-day outcomes was as follows: readmission 2.4%, reoperation 1.3%, SSI 1.1%, any SSO 9.5%, and SSO/I 1.8%. Defect width showed strong graded associations with adverse outcomes, with SSO/I rising from 0.5% (<4cm) to 4.6% (>10cm). In adjusted models, TAR was strongly associated with LOS ≥2 days (OR 3.51, 95% CI 2.96-4.16) but not with readmission or reoperation. After adjustment, the laparoscopic approach was not independently associated with the primary consequential endpoints compared with the robotic approach. The IHC poll prioritized posterior-layer disruption with intraparietal/internal herniation (29%), crossover-related linea alba injury (27%), midline bulging (23%), and trocar-exit bleeding (18%). Open Evidence synthesis identified plane discipline and posterior-layer closure as primary prevention strategies, concordant with IHC poll priorities. CONCLUSION: In a large cohort of elective minimally invasive surgery (MIS) extraperitoneal sublay procedures, 30-day high-consequence events were uncommon, and most postoperative issues reflected non-procedural wound occurrences. Defect width is the primary risk factor. Registry outcomes, expert polling and AI synthesis all support eTEP as a safe and effective approach when performed with disciplined plane control and mechanism-based prevention strategies.
BACKGROUND: Systemic inflammation may predict poor postoperative outcomes after gastrointestinal cancer surgery. This study aimed to evaluate the association between preoperative neutrophil-to-lymphocyte ratio and postop...BACKGROUND: Systemic inflammation may predict poor postoperative outcomes after gastrointestinal cancer surgery. This study aimed to evaluate the association between preoperative neutrophil-to-lymphocyte ratio and postoperative complications after colon carcinoma resection. METHODS: This study retrospectively analyzed all patients who underwent curative colon carcinoma resection at a single tertiary center in Finland between 2014 and 2024. The patients were stratified into low and high (≥ 4.0) neutrophil-to-lymphocyte ratio groups. Ninety-day postoperative complications and their severity were recorded. Associations between neutrophil-to-lymphocyte ratio and complications were evaluated using multivariable logistic regression models. RESULTS: Of the 573 included patients, 232 (40.5%) experienced complications within 90 days and 8 (1.4%) died. A high (≥ 4.0) neutrophil-to-lymphocyte ratio, observed in 101 (17.6%) patients, was associated with a significantly increased risk of severe (Clavien-Dindo IV-V) postoperative complications (OR 3.48, 95% c.i. 1.57-7.75), a higher overall complication burden measured with Comprehensive Complication Index (mean 17.3 vs 10.7; P = 0.012) and a greater incidence of medical complications (33.7% vs 21.4%; P = 0.008). In the multivariable analyses, the high preoperative neutrophil-to-lymphocyte ratio remained an independent predictor of postoperative complications. CONCLUSION: Preoperative neutrophil-to-lymphocyte ratios ≥ 4.0 were associated with higher risk of 90-day complications, particularly severe and nonsurgical events, after colon cancer resection.
Hepatic artery infusion chemotherapy (HAIC) is a form of liver directed therapy for primary and metastatic cancers of the liver. Following the discovery that the hepatic artery supplies the majority of blood flow to hepa...Hepatic artery infusion chemotherapy (HAIC) is a form of liver directed therapy for primary and metastatic cancers of the liver. Following the discovery that the hepatic artery supplies the majority of blood flow to hepatic tumors, studies have investigated the use of chemotherapeutics via this route as not only palliative, but therapeutic treatment. HAIC was initially designed exclusively for patients with unresectable colorectal liver metastasis (CRLM), however there is an emerging role for HAIC in patients with resectable CRLM and unresectable intrahepatic cholangiocarcinoma (ICC). The use of HAIC has become more prevalent over the last decade with more centers nation and worldwide developing HAI programs. Here, we review the history and origin of HAIC along with its evolution and outcomes of current applications.
INTRODUCTION: Financial hardship is common in cancer care and may extend beyond medical costs to threaten basic needs such as housing and utilities. Nationally representative data comparing inability to pay mortgage, ren...INTRODUCTION: Financial hardship is common in cancer care and may extend beyond medical costs to threaten basic needs such as housing and utilities. Nationally representative data comparing inability to pay mortgage, rent, or utility bills and threatened utility shutoff among adults with gastrointestinal (GI) cancer versus adults without GI cancer are limited. METHODS: We analyzed 2022-2023 Behavioral Risk Factor Surveillance System data for adults aged >=18 years. GI cancer history and treatment status were identified using Cancer Survivorship Module items and categorized as no GI cancer, current treatment, or treatment completed. Outcomes were inability to pay mortgage, rent, or utility bills and threatened utility shutoff in the prior 12 months. Survey-weighted multivariable models adjusted for demographic and socioeconomic factors and were stratified by employment status and housing tenure. RESULTS: Among 63,753 adults, 1,870 (3.0%) reported GI cancer, including 420 (0.7%) undergoing current treatment and 1,450 (2.3%) with completed treatment. Inability to pay mortgage, rent, or utility bills was reported by 21.0% (n=88) of those undergoing current treatment and 14.8% (n=215) of those with completed treatment compared with 8.2% (n=5,100) of adults without GI cancer (p=0.01). Threatened utility shutoff was reported by 13.1% (n=55) and 10.0% (n=145), respectively, versus 5.8% (n=3,600) among adults without GI cancer (p=0.02). Among renters who were not employed, current GI cancer treatment was associated with higher odds of inability to pay mortgage, rent, or utility bills (aOR 3.40; 95% CI 2.20-5.40) and threatened utility shutoff (aOR 3.30; 95% CI 2.30-4.90) compared with renters without GI cancer. CONCLUSION: Self-reported GI cancer, particularly current treatment, was associated with elevated inability to pay mortgage, rent, or utility bills and threatened utility shutoff, with the highest burden among renters who were not employed.
BACKGROUND: Minimally invasive esophagectomy has significant benefits in operative outcomes compared with open approaches. The myriad of techniques have precluded the recommendation of a standard approach. The use of the...BACKGROUND: Minimally invasive esophagectomy has significant benefits in operative outcomes compared with open approaches. The myriad of techniques have precluded the recommendation of a standard approach. The use of the robotic approach has increased steadily. This study sought to evaluate trends and identify milestones in the learning curve for robotic-assisted esophagectomy. METHODS: We prospectively followed all patients who underwent robotic-assisted esophagectomy performed by a single surgeon between 2010 and 2022. Clinicopathologic factors and surgical outcomes were recorded and compared across successive cohorts. To identify key inflection points in the learning curve, cumulative sum (CUSUM) analysis combined with structural change detection regression was applied. All statistical tests were 2-sided, and P <.05 was considered statistically significant. RESULTS: We identified 323 patients who underwent robotic-assisted esophagectomy between 2010 and 2022. The median operative time was 340 min. CUSUM analysis demonstrated cutoff points at cases 90, 140, and 175. The learning curve was divided into phases, and cases were stratified as follows: learning/consolidation (cases 1-90), proficient (cases 91-140), second learning curve (cases 141-175), and expert (cases 176+). Operative time significantly decreased in the proficient phase (P <.001), increased significantly during the second learning curve (P <.001), and then decreased again when expertise was achieved (P <.001). The increase in operative time after case 140 coincided with an increase in Charlson-Deyo comorbidity scores (P <.001) and higher tumor stage (P =.005), indicating patients at a higher risk. Clavien-Dindo grade III to V postoperative complications also increased after case 140. CONCLUSION: For surgeons proficient in minimally invasive esophagectomy, the learning curve for a robotic-assisted procedure appears to be near proficiency after 90 cases. However, as more complex cases are undertaken, there appears to be an additional learning curve that is surpassed after 175 cases.
BACKGROUND: While endocrine insufficiency after distal pancreatectomy (DP) has been extensively studied, data on pancreatic exocrine insufficiency (PEI) following DP remain limited. This study aimed to evaluate the chara...BACKGROUND: While endocrine insufficiency after distal pancreatectomy (DP) has been extensively studied, data on pancreatic exocrine insufficiency (PEI) following DP remain limited. This study aimed to evaluate the characteristics and clinical relevance of PEI after DP. METHODS: 184 patients who underwent DP between June 2013 and December 2022 were retrospectively analyzed. Demographics, perioperative parameters and postoperative outcomes were evaluated. Follow-up time was 24 months. RESULTS: Postoperative de-novo PEI occurred in 48.4% of patients. Patients who developed PEI had a lower BMI (24.2 vs. 26.1kg/m², p = 0.016), more postoperative complications (48.4% vs. 66.3%, p = 0.02), a higher prevalence of malignant disease (69.7% vs. 55.8%, p = 0.07), particularly pancreatic ductal adenocarcinoma (48.3% vs. 29.5%, p = 0.02). Multivariate analysis identified a longer operative time (OR 1.407, 95% CI 1.096 -1.807, p = 0.007) and major complications (Clavien-Dindo > II; OR 3.153, 95% CI 1.569-6.337, p = 0.007) as independent predictors for the development of postoperative PEI. Lower preoperative BMI also showed an effect on new onset postoperative PEI (OR 0.887, 95% CI 0.814-0.966, p = 0.006). CONCLUSION: PEI is frequent and its development is influenced by individual patient factors, the extent of resection, and the postoperative course. These findings underscore the importance of PEI as one key parameter in pancreatic surgery.
BACKGROUND: Postoperative delirium is a common complication among older adults undergoing surgery and is associated with increased morbidity, mortality, and healthcare utilization. Although routine screening is recommend...BACKGROUND: Postoperative delirium is a common complication among older adults undergoing surgery and is associated with increased morbidity, mortality, and healthcare utilization. Although routine screening is recommended for high-risk patients, screening practices after colectomy remain poorly characterized. METHODS: We performed a retrospective cohort study using 2024 American College of Surgeons National Surgical Quality Improvement Program data. Adults aged 75 years and older undergoing inpatient colectomy were included. Primary outcomes were postoperative delirium screening and positive screening results. Multivariable logistic regression was used to identify factors associated with screening and positive screening results. Secondary outcomes included hospital length of stay and 30-day readmission. RESULTS: Among 13,729 patients, 8,153 (59.3%) underwent postoperative delirium screening. Of screened patients, 986 (12.1%) had a positive screening result. Factors independently associated with screening included higher American Society of Anesthesiologists class, emergent surgery, fall history, and dementia. Among screened patients, factors associated with positive screening results included American Society of Anesthesiologists class IV-V, underweight body mass index, preoperative sepsis, fall history, dementia, and open operations. Patients with positive screening results had significantly longer length of stay. Hospital-level variation in screening was substantial, and 30.5% of hospitals screened fewer than 25% of eligible patients. CONCLUSION: Postoperative delirium screening occurred in only 59.3% of older adults undergoing colectomy and varied widely across hospitals. Among screened patients, more than 1 in 10 had a positive screening result, which was associated with longer hospital stay. Standardized screening may improve detection in this high-risk population.