BACKGROUND: Subtotal cholecystectomy (SC) is a possible bailout procedure to prevent bile duct injuries (BDIs) when a critical view of safety cannot be obtained during cholecystectomy (CC). METHODS: This retrospective st...BACKGROUND: Subtotal cholecystectomy (SC) is a possible bailout procedure to prevent bile duct injuries (BDIs) when a critical view of safety cannot be obtained during cholecystectomy (CC). METHODS: This retrospective study analyzed 17,299 CCs performed by 111 surgeons across 12 hospitals within 1 large healthcare system using multilevel propensity-weighted logistic regression to model the risk of SC and reinterventions, accounting for patient-, surgeon-, and hospital-level factors. RESULTS: Among 157 SC cases, 94 (60%) were performed by just 8 surgeons, who collectively accounted for only 13% of all CCs. In addition, 136 cases (87%) of SC were concentrated in 3 hospitals, accounting for 31% of all CCs. Surgeons with increasing experience performing SC were significantly more likely to perform the procedure (odds ratio [OR], 1.13; P =.004). Conversely, the more CCs a surgeon performed, the lower the likelihood of performing an SC (OR, 0.998; P <.001). Fellowship training and years of experience were not significant independent predictors. The 30-day disease-specific reintervention rate after SC was 22.3%. There was no detectable increase in reinterventions among surgeons or hospitals who had never or rarely performed SC. In addition, 6 major BDIs requiring reconstruction were identified after CC (BDI rate of 0.03%). Surgeon-level variability, not hospital-level variability, explained the residual clustering of SC use, accounting for 16% of the adjusted residual. CONCLUSION: SC use was primarily surgeon driven, even after accounting for patient factors that were independently associated with SC. These findings challenge SC's role as a universal bailout and call for curbing its discretionary overuse.
BACKGROUND: The magnetic compression technique (MCT) is a novel surgical operation that leverages the "noncontact" magnetic forces to address challenging clinical issues. The underlying mechanisms of different healing ef...BACKGROUND: The magnetic compression technique (MCT) is a novel surgical operation that leverages the "noncontact" magnetic forces to address challenging clinical issues. The underlying mechanisms of different healing efficacy in gastroenteric anastomosis between MCT and traditional suturing techniques are still unclear. METHODS: A total of 20 male Sprague-Dawley rats, weighing 200 to 240 g, were randomly and equally divided into the traditional suturing (control [Con]) and MCT groups. The anastomosis construction time, survival rates, and postoperative complications were compared. Specimens were collected, and RNA sequencing was performed 2 weeks after surgery. Simultaneously, the burst pressure and histological characteristics were compared between the 2 groups. RESULTS: The anastomosis time of the MCT group was significantly shorter than that of the Con group (6.20 ± 1.51 vs 15.70 ± 2.43 min, respectively; P <.001). The survival rate was significantly higher in the MCT group than in the Con group (100% vs 80%, respectively). No postoperative complications were observed in the MCT group. The burst pressure and histological characteristics suggested that the MCT group had a more durable, smoother, and fatter surface; complete mucosal migration; less inflammation infiltration; and continuous submucosal layers. The transcriptomics indicated that the biological characteristic of the MCT group was mainly enriched in energy metabolism, especially lipid metabolism. The evaluated expression of Nfil3 and Pdk4 could serve as key metabolic molecules regulating anastomotic healing. CONCLUSION: The MCT presented significant advantages in multiple dimensions, including simplicity, safety, and low postoperative complications. A novel insight was provided that MCT facilitated energy metabolism and further promoted anastomotic healing.
BACKGROUND: Colorectal cancer survivors frequently experience persistent fatigue, psychological distress, and reduced health-related quality of life (HRQoL) after treatment. Exercise is increasingly recognized as an effe...BACKGROUND: Colorectal cancer survivors frequently experience persistent fatigue, psychological distress, and reduced health-related quality of life (HRQoL) after treatment. Exercise is increasingly recognized as an effective nonpharmacologic intervention, but the comparative efficacy of different modalities remains uncertain. This study aimed to evaluate and rank the effects of exercise interventions on HRQoL, fatigue, depression, and anxiety in colorectal cancer survivors through a systematic review and network meta-analysis. METHODS: Five databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar) were searched from inception to October 30, 2025. Eligible randomized controlled trials included adult colorectal cancer survivors receiving structured exercise interventions-such as aerobic exercise (AE), resistance training (RT), combined AE plus RT (AE + RT), yoga, qigong, tai chi, or multicomponent programs-compared with usual care or alternative exercise modalities. Primary outcomes were HRQoL, fatigue, depression, and anxiety assessed after the intervention. Standardized mean differences (SMDs) and 95% CIs were pooled using random-effects models, and comparative rankings were estimated using the surface under the cumulative ranking curve (SUCRA). RESULTS: A total of 22 trials (n = 1676) met the inclusion criteria. Overall, exercise significantly improved HRQoL (SMD, 0.48; 95% CI, 0.28-0.67) and reduced fatigue (SMD, -0.44; 95% CI, -0.70 to -0.19), depression (SMD, -0.29; 95% CI, -0.48 to -0.10), and anxiety (SMD, -0.29; 95% CI, -0.42 to -0.15). Subgroup analyses indicated greater effects with supervised or tele-supervised, moderate-intensity programs (3-5.9 metabolic equivalents of task) in 30- to 60-min sessions, 3 to 4 times weekly for 9 to 23 weeks. Network meta-analysis ranked RT highest for improving HRQoL (SUCRA, 91.8%), and AE + RT most effective for reducing fatigue, depression, and anxiety (SUCRA, 81.7%-82.4%). CONCLUSION: Exercise significantly enhances HRQoL and psychological well-being in colorectal cancer survivors, with optimal benefits observed from moderate-intensity, supervised, or tele-supervised programs. AE + RT seems the most effective for symptom relief, whereas RT provides the greatest gains in global quality of life.
BACKGROUND: The Charlson Comorbidity Index (CCI) is widely used in surgical research to summarize patients' baseline comorbidities. However, large surgical databases, such as the American College of Surgeons National Sur...BACKGROUND: The Charlson Comorbidity Index (CCI) is widely used in surgical research to summarize patients' baseline comorbidities. However, large surgical databases, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), lack key CCI components, limiting its applicability. Developing a modified CCI (mCCI) using available ACS-NSQIP variables could improve baseline risk stratification for patients undergoing pancreatoduodenectomy (PD). This study aimed to define such an mCCI and evaluate its performance compared with that of the conventional CCI. METHODS: This was a 2-phase retrospective study that included patients who underwent PD. In the derivation phase, our institutional ACS-NSQIP database (2015-2021) was used to construct the mCCI, with scores reweighted to the observed 14-point maximum. The Spearman rank correlation was used to evaluate the relationship between CCI and mCCI. The nationwide ACS-NSQIP database (2022) was used for external validation. Unadjusted logistic regression models were constructed to predict discharge disposition and postoperative complications. Model discrimination was evaluated using area under the receiver operating characteristic curve (AUC)/receiver operating characteristic curve analysis with AUCs compared with the DeLong test. RESULTS: A total of 333 institutional and 4867 national patients who underwent PD were included. In the derivation cohort, the mCCI was strongly correlated with the CCI (r = 0.85; P <.001). For discharge disposition, both indices yielded an AUC of 0.74. For postoperative complications, AUCs were 0.50 for CCI and 0.55 for mCCI. Similar trends were observed in external validation. No significant differences were found in the discriminatory capacities between the models. CONCLUSION: mCCI is a reasonable alternative to account for baseline comorbidities in patients undergoing PD using the ACS-NSQIP database. Further studies should refine weighting schemes across diverse populations to optimize mCCI performance.
BACKGROUND: Survivors of digestive system cancers frequently experience depression, anxiety, fatigue, and impaired health-related quality of life (HRQoL). Exercise has emerged as a promising adjunctive therapy. However,...BACKGROUND: Survivors of digestive system cancers frequently experience depression, anxiety, fatigue, and impaired health-related quality of life (HRQoL). Exercise has emerged as a promising adjunctive therapy. However, the optimal modality and prescription remain unclear. This study aimed to evaluate the effects of exercise on psychological outcomes and HRQoL, to rank the relative efficacy of different modalities, and to identify optimal exercise characteristics through subgroup analyses. METHODS: PubMed, Embase, CENTRAL, Web of Science, and Google Scholar were searched until August 31, 2025, for randomized controlled trials (RCTs) of exercise interventions in adult survivors of digestive system cancers. Eligible comparators included usual care, no intervention, or alternative exercise. The primary outcomes were HRQoL, fatigue, depression, and anxiety, which were measured using validated instruments. The standardized mean differences (SMDs) with 95% CIs were used as effect estimates. Pairwise meta-analyses were performed with random-effects models, and Bayesian network meta-analysis was used to compare exercise modalities. Subgroup analyses were used to examine moderators, including cancer type, exercise intensity, frequency, session duration, and intervention length. RESULTS: A total of 38 RCTs that involved 3255 participants were included. The exercise group significantly had improved HRQoL (SMD, 0.43 [95% CI, 0.27-0.59]) and reduced fatigue (SMD, -0.52 [95% CI, -0.72 to -0.32]), depression (SMD, -0.37 [95% CI, -0.58 to -0.15]), and anxiety (SMD, -0.33 [95% CI, -0.44 to -0.21]) compared with the control group. Network meta-analysis indicated that mind-body exercise (such as yoga or tai chi) was most effective for HRQoL (SMD, 0.68 [95% CI, 0.22-1.14]) and depression (SMD, -0.55 [95% CI, -0.95 to -0.16]), resistance training for fatigue (SMD, -0.79 [95% CI, -1.35 to -0.23]), and combined training (CT) for anxiety (SMD, -0.38 [95% CI, -0.53 to -0.23]). Subgroup analyses showed that moderate-intensity, moderate-frequency, and medium-to-long interventions produced the most consistent benefits. CONCLUSION: Exercise interventions significantly improved HRQoL and reduced depression, anxiety, and fatigue in survivors of digestive system cancers. Mind-body exercise (eg, yoga or tai chi) demonstrated the greatest benefits for HRQoL and depression, resistance training best alleviated fatigue, and CT reduced anxiety. Moderate-intensity, sustained programs achieved the most consistent benefits, supporting individualized exercise prescriptions in survivorship care.
BACKGROUND: Pancreaticoduodenectomy (PD) is the only curative option for localized pancreatic head and periampullary malignancies. However, PD is associated with significant perioperative morbidity. Perioperative fluid m...BACKGROUND: Pancreaticoduodenectomy (PD) is the only curative option for localized pancreatic head and periampullary malignancies. However, PD is associated with significant perioperative morbidity. Perioperative fluid management has emerged as an important modifiable factor influencing surgical outcomes in PD. METHODS: In this qualitative review, PubMed/Medline searches were performed between March and August 2025 to review the terms "pancreaticoduodenectomy," "fluid management," "Enhanced Recovery After Surgery," "complications," and related terms. RESULTS: Historically, liberal fluid administration was favored to compensate for third-space losses, but contemporary evidence has linked excessive fluid volumes to complications, such as postoperative pancreatic fistula, anastomotic edema, and increased inflammatory responses. Recent studies, including those utilizing Enhanced Recovery After Surgery (ERAS) protocols, indicate the possible benefit of more restrictive fluid regimens, finding that restrictive fluids are associated with reduced overall complications, lower cardiopulmonary morbidity, and shorter post-operative hospital stays, amongst others. However, overly restrictive strategies may risk hypoperfusion, driving the necessity for a delicate balance between restrictive fluid administration and physiologic demand. CONCLUSIONS: Goal-directed fluid therapy protocols offer a promising approach to PD fluid management by individualizing fluid delivery, minimizing complications, and improving perfusion metrics, resulting in a more effective restrictive fluid approach. Despite these advancements, heterogeneity in study designs, fluid management definitions, and monitoring tools limits a clear consensus. Future research should prioritize multicenter randomized controlled trials, standardized protocols, and long-term outcome assessments to refine evidence-based, patient-centered fluid management strategies in PD.
BACKGROUND: Proximal gastrectomy with conventional esophagogastrostomy is frequently associated with postoperative complications, including significant reflux esophagitis. This study aimed to evaluate a modified reconstr...BACKGROUND: Proximal gastrectomy with conventional esophagogastrostomy is frequently associated with postoperative complications, including significant reflux esophagitis. This study aimed to evaluate a modified reconstruction technique that combines gastric tube (GT) formation with overlap anastomosis and partial fundoplication. METHODS: Between January 2021 and January 2024, 29 consecutive patients diagnosed with early-stage proximal gastric cancer underwent laparoscopic proximal gastrectomy using our novel reconstruction method. The surgical protocol included the creation of a GT conduit, overlap esophagogastric anastomosis, and partial fundoplication procedure. Perioperative outcomes and postoperative follow-up data were prospectively collected. RESULTS: The cohort demonstrated a mean operative time of 239 ± (SD) 50 min and a median estimated blood loss of 50 mL (IQR, 20-150). Lymph node dissection yielded a median count of 25 nodes (IQR, 9-66). Postoperative complications included 1 case (3.4%) of anastomotic leakage requiring conservative management. Mild reflux symptoms (heartburn) were transiently observed in 2 patients (6.9%), both resolving with short-term proton pump inhibitor therapy. Endoscopic evaluation at the 3-month follow-up revealed grade A or B reflux esophagitis (Los Angeles classification) in 2 patients (6.9%). Nutritional parameters (serum albumin and total protein levels) showed expected postoperative declines during the initial 3-month period, followed by progressive recovery to preoperative baseline values by 6 months postoperatively (P <.05 for longitudinal comparison). CONCLUSION: Our preliminary findings suggest that GT reconstruction with overlap anastomosis and partial fundoplication is a technically feasible and safe approach for proximal gastrectomy, demonstrating acceptable short-term functional outcomes with mitigated reflux complications.
Moreira JE, Ivanoff I, Santillán Pazmiño M
… +12 more, Martín P, Milesi V, Stringa P, Giannou AD, Cúneo L, Ogresta F, Castro A, Pellegrino Damelio A, Eleta M, Gentilini MV, Rumbo M, Gondolesi GE
BACKGROUND: Primary abdominal wall closure after intestinal and multivisceral transplants remains a challenge. Avascular transplant of the abdominal rectus fascia (TxARF) has emerged as an alternative to reduce postopera...BACKGROUND: Primary abdominal wall closure after intestinal and multivisceral transplants remains a challenge. Avascular transplant of the abdominal rectus fascia (TxARF) has emerged as an alternative to reduce postoperative morbidity and mortality. This study aimed to evaluate tissue and immunological responses to TxARF in a rat model without immunosuppression. METHODS: A total of 34 TxARFs were performed in rats (17 isogenic [ISO] and 17 allogeneic [ALLO]), with recipients sacrificed at 30 and 120 days after surgery. Serum and graft samples were analyzed for donor-specific antibodies (DSAs), elasticity, cellular analysis by flow cytometry, histopathology, and immunohistochemistry for CD3+ cells. RESULTS: Muscle fiber loss was observed at 30 days, with collagen content significantly higher in ALLO (55.97 ± 3.68) and ISO (33.13 ± 3.85) groups than controls (3.78 ± 0.47) (P <.0001). The lateral portions of the grafts showed more large blood vessels, whereas the medial areas had small vessels. The ALLO group exhibited increased resistance to stretching and elasticity loss. Despite the lack of immunosuppression, CD3+ levels in all groups were similar to controls, with only 1 animal showing a positive DSA response. CONCLUSION: Long-term changes include muscle fiber replacement with fibrosis and loss of elasticity, especially in the alloreactive group. No significant immune response occurred, confirming the fascia's low immunogenicity.
BACKGROUND: This study aimed to describe contemporary outcomes on index hospitalization and 1-year outcomes from index discharge in patients with diverticulitis. METHODS: This population-based retrospective cohort study...BACKGROUND: This study aimed to describe contemporary outcomes on index hospitalization and 1-year outcomes from index discharge in patients with diverticulitis. METHODS: This population-based retrospective cohort study included adult residents of Ontario, Canada, who presented to the emergency department (ED) with diverticulitis (January 2017 to March 2022). For individuals hospitalized at the time of index ED presentation, the risks of urgent surgery, percutaneous drainage, and mortality were reported. After index presentation discharge (from the ED or hospital with an intact colon), the cumulative incidences of unplanned hospitalization, urgent surgery, and scheduled surgery were reported at 30 days and 1 year, accounting for competing risks. RESULTS: Of 24,759 patients presenting to the ED with diverticulitis, 6263 (25%) were hospitalized, and 5379 (23%) required no intervention. However, a minority of patients required surgery (555 [2.2%]) and percutaneous drainage (329 [1.3%]). After index presentation discharge, the cumulative incidences of unplanned hospitalization, urgent surgery, and scheduled surgery were 2.00% (95% CI, 2.10%-2.40%), 0.60% (95% CI, 0.50%-0.70%), and 0.06% (95% CI, 0.03%-0.09%) at 30 days and 7.00% (95% CI, 6.70%-7.30%), 1.30% (95% CI, 1.20%-1.50%), and 1.50% (95% CI, 1.30%-1.60%) at 1 year, respectively. People managed with percutaneous drainage at index presentation were at higher 1-year risk: 44% (95% CI, 29%-39%) unplanned hospitalization and 11% (95% CI, 8%-14%) urgent surgery. CONCLUSION: For most patients, the disease course 1 year from index discharge remains benign, with only a small minority of patients requiring hospitalization or surgery. These outcome estimates can guide patient counseling, including the appropriateness of scheduled colectomy for diverticulitis.
Ushimaru Y, Omori T, Yamamoto K
… +17 more, Yamamoto K, Masuike Y, Yanagimoto Y, Matsuura N, Sugase T, Kanemura T, Mori R, Kitakaze M, Kubo M, Fukuda Y, Komatsu H, Miyo M, Sueda T, Kagawa Y, Gotoh K, Kobayashi S, Miyata H
BACKGROUND: Stage IV gastric cancer remains challenging to treat despite recent advances in systemic therapy. Among patients with favorable responses to chemotherapy, conversion surgery aiming for R0 resection has shown...BACKGROUND: Stage IV gastric cancer remains challenging to treat despite recent advances in systemic therapy. Among patients with favorable responses to chemotherapy, conversion surgery aiming for R0 resection has shown promise in improving survival. Immune checkpoint inhibitors (ICIs) have become a key component of systemic treatment, but their prognostic impact in the setting of conversion surgery remains unclear. METHODS: This retrospective single-center study included 98 patients with gastric cancer who received platinum-based doublet chemotherapy followed by minimally invasive surgery. Patients were stratified into ICI (n = 41) and non-ICI groups (n = 57). Perioperative outcomes, progression-free survival (PFS), and overall survival (OS) were evaluated using Kaplan-Meier analysis and Cox regression models. RESULTS: The median operative time was 345 min, and the median blood loss was 5 mL. R0 resection was achieved in 79.6% of cases, and the median hospital stay was 7 days. Clavien-Dindo grade ≥ II complications occurred in 12.2% of patients. ICI-treated patients had significantly longer PFS (hazard ratio [HR], 0.418; P =.0008) and OS (HR, 0.437; P =.024). R0 resection was independently associated with improved PFS (HR, 0.179; P <.0001) and OS (HR, 0.231; P <.0001). Multivariate analysis identified pathological N status, R0 resection, and ICI use as independent predictors of PFS. CONCLUSION: Among patients who underwent conversion surgery in this real-world cohort, those treated with ICI-based chemotherapy demonstrated more favorable long-term outcomes than those treated with chemotherapy alone. Although our findings do not demonstrate a causal relationship of ICI therapy on resectability, they suggest that ICI-based chemotherapy may be associated with improved survival in appropriately selected patients with human epidermal growth factor receptor 2-negative stage IV gastric cancer. Prospective studies are warranted to clarify optimal indications and perioperative strategies for integrating ICI-based regimens into conversion treatment.
BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. The advent of tyrosine kinase inhibitors (TKIs), such as imatinib, has significantly improved c...BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. The advent of tyrosine kinase inhibitors (TKIs), such as imatinib, has significantly improved clinical outcomes in patients with GISTs by delaying metastasis and prolonging survival. However, most patients eventually develop resistance to TKIs, limiting long-term disease control. Immunotherapy has demonstrated durable responses in various solid tumors and has emerged as a potential treatment strategy for TKI-refractory GISTs. This study aimed to systematically evaluate the efficacy and safety of immunotherapy in patients with advanced or recurrent GIST, particularly those who have failed previous TKI therapy, to inform future clinical decision-making and research directions. METHODS: A systematic literature search of PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov was conducted for studies published before June 23, 2025. The inclusion criteria focused on immunotherapy interventions in patients with histologically confirmed GIST. Study selection, data extraction, and risk of bias assessments were performed independently by 2 reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Joanna Briggs Institute checklist was used for quality appraisal. Random-effects models were used to pool estimates of clinical benefit rate (CBR), objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). Generalized linear mixed models (GLMM) were used to account for cohorts with extreme values. This review protocol was registered with the International Registry of Systematic Reviews (registration number: CRD42024496866). RESULTS: A total of 9 studies involving 169 patients were included. The pooled CBR was 41.69% (95% CI, 26.99%-58.03%), and the ORR was 16.49% (95% CI, 6.25%-36.91%), both with moderate to high heterogeneity. GLMM adjustments, which incorporated additional extreme value cohorts, yielded a corrected CBR of 46.39% (95% CI, 28.85%-64.88%) and ORR of 13.23% (95% CI, 4.21%-34.56%). The pooled median PFS across 7 cohorts was 6.11 months (95% CI, 2.63-9.59), and the OS, which was calculated using 2 models, ranged from 15.53 to 17.01 months, depending on the data imputation strategy. CONCLUSION: This meta-analysis suggests that immunotherapy provides modest yet clinically meaningful efficacy in patients with advanced or treatment-refractory GIST. Despite considerable heterogeneity among studies, the observed trends in response and survival outcomes support immunotherapy as a viable treatment option. Further large-scale, biomarker-driven clinical trials are warranted to validate these findings and guide personalized therapeutic strategies.
BACKGROUND: Preoperative esophagogastroduodenoscopy (EGD) is a key component of revisional bariatric surgery workup. However, the completeness and surgical relevance of reports may vary depending on whether the examinati...BACKGROUND: Preoperative esophagogastroduodenoscopy (EGD) is a key component of revisional bariatric surgery workup. However, the completeness and surgical relevance of reports may vary depending on whether the examination is performed by a gastroenterologist or a bariatric surgeon. This study aimed to compare the diagnostic completeness and surgical relevance of preoperative EGD reports performed by gastroenterologists with that performed by bariatric surgeons in candidates for revisional bariatric surgery. METHODS: This was a retrospective study that reviewed 88 patients who underwent revisional bariatric surgery after sleeve gastrectomy (SG) or gastric bypass (GB) between January 2024 and April 2025 in 2 bariatric centers in France. Patients were divided into 2 groups: group G (endoscopy by gastroenterologists [n = 44]) and group S (endoscopy by bariatric surgeons [n = 44]). Each report was evaluated using a standardized checklist of surgery-relevant items. The primary endpoint was the Completeness Index (CoI; percentage of mandatory items documented). The secondary endpoints included use of objective measurements, classification of sleeve dilation, documentation of bile reflux, and structured reporting. RESULTS: In the SG subgroup (n = 48), reports by surgeons achieved higher CI scores than those of gastroenterologists (93.5% ± 10.3% vs 69.6% ± 10.6%, respectively; P <.0001). Sleeve dilation classification and bile reflux were consistently documented by surgeons but rarely by gastroenterologists. In the GB subgroup (n = 40), surgeon-performed reports also showed greater completeness than gastroenterologist-performed reports (88.7% ± 11.4% vs 41.2% ± 9.1%, respectively; P <.0001), with more frequent documentation of pouch size, anastomosis diameter, and configuration. Both groups described anatomical landmarks, such as the esophagogastric junction, comparably. CONCLUSION: Surgeon-performed EGD provides more complete, surgery-oriented information than gastroenterologist-performed examinations, particularly regarding sleeve morphology, pouch size, and anastomotic configuration. Structured reporting and collaboration are essential for optimizing preoperative evaluation in revisional bariatric surgery.