BACKGROUND: A lack of response to neoadjuvant chemoradiotherapy (nCRT) has been described as a surrogate of aggressive tumor biology leading to poor oncologic outcomes in locally advanced rectal cancer (LARC). However, t...BACKGROUND: A lack of response to neoadjuvant chemoradiotherapy (nCRT) has been described as a surrogate of aggressive tumor biology leading to poor oncologic outcomes in locally advanced rectal cancer (LARC). However, there is a paucity of data on this association for patients with LARC undergoing pelvic exenteration (PE). METHODS: The National Cancer Database was queried for adults with cT4 rectal adenocarcinoma between 2006 and 2021. The following 3 groups were identified: upfront PE, nCRT with neoadjuvant rectal (NAR) score of <8 followed by PE, and nCRT with an NAR score of ≥8 followed by PE. The NAR score is a validated endpoint that incorporates cT, pT, and pN to calculate treatment efficacy. RESULTS: Of 942 patients, 73% were <65 years old, 57% female, 84% White with a median follow-up of 40 months (0-201); 5% underwent upfront PE, 82% nCRT with an NAR score of ≥8%, and 13% nCRT with an NAR score of <8. Overall, 15% had positive margins. On univariable analysis, compared with an NAR score of <8, upfront PE and an NAR score of ≥8 were significantly associated with increased odds of a positive surgical margin. Five-year overall survival (OS) was 84% for an NAR score of <8, 55% for an NAR score of ≥8%, and 28% for upfront PE. After adjustment, upfront PE (hazard ratio [HR], 5.10; 95% CI, 2.69-9.65) and NAR score of ≥8 cohorts (HR, 2.23; 95% CI, 1.31-3.79) experienced worse OS. CONCLUSION: In this US-based cohort of LARC undergoing PE, tumor regression after nCRT was strongly associated with lower rates of positive margins and better OS, confirming its significant relevance in the selection and management of these patients.
BACKGROUND: Although current guidelines recommend harvesting ≥12 lymph nodes (LNs) for rectal cancer staging, its appropriateness after neoadjuvant chemoradiotherapy (nCRT) remains debated. This study evaluated the progn...BACKGROUND: Although current guidelines recommend harvesting ≥12 lymph nodes (LNs) for rectal cancer staging, its appropriateness after neoadjuvant chemoradiotherapy (nCRT) remains debated. This study evaluated the prognostic value of harvested LNs (HLNs) after nCRT. METHODS: We retrospectively analyzed 1596 patients who underwent radical surgery for rectal cancer after nCRT at 2 tertiary hospitals between April 2004 and December 2021. Patients were categorized by the number of HLNs (≥12 vs <12). Clinicopathologic outcomes and recurrence were compared, and multivariable analyses were performed to identify factors associated with recurrence and survival. RESULTS: Less than 12 HLNs were found in 321 patients (20.1%), and ≥12 in 1275 (79.9%). No significant differences were observed in age, sex, tumor height, resection margins, or circumferential resection margin involvement. The ≥12 HLNs group showed more advanced ypT, ypN, and overall stage, with higher rates of venous and perineural invasion. Completeness of postoperative chemotherapy was comparable. However, the <12 HLNs group demonstrated a higher recurrence rate (24.6% vs 18.8%; P = .026). In multivariate analysis, <12 HLNs were identified as independent risk factors for overall survival (OS) (hazard ratio [HR], 1.624; P = .002) and disease-free survival (HR, 1.297; P = .047). Kaplan-Meier analysis showed 5-year OS was significantly lower in the <12 HLNs group than the ≥12 HLNs group (83.1% vs 86.1%; P = .003). CONCLUSION: Harvesting fewer than 12 LNs was significantly associated with worse OS and remains an independent prognostic factor of rectal cancer after nCRT.
Choi B, Abbasi A, Ali UA
… +13 more, Ge Y, Imahiyerobo T, Testerman E, Marra V, Autencio K, Jabi O, Khoshknabi D, Zoccali MB, Bakes D, Su LC, Shen B, Church J, Kiran RP
BACKGROUND: Enterocutaneous fistula (ECF) is a serious condition that can be challenging to treat with high recurrence and mortality rates. This study reports the characteristics and outcomes of a large series of patient...BACKGROUND: Enterocutaneous fistula (ECF) is a serious condition that can be challenging to treat with high recurrence and mortality rates. This study reports the characteristics and outcomes of a large series of patients with ECF, aiming at evaluating the rate and factors associated with successful surgical management. METHODS: Data were obtained from a prospectively maintained database at an academic institution. All patients who underwent repair of an ECF between 2013 and 2025 were included. Clinical characteristics, operative details, and postoperative outcomes were evaluated. Primary outcomes were fistula recurrence and mortality. Secondary outcomes were intra- and postoperative complications. Regression analysis was used to identify independent risk factors for the primary outcomes. RESULTS: A total of 93 patients (52% female) underwent surgery with a median age of 58 years (IQR, 44.2-66.6) and a body mass index (BMI) of 23.4 kg/m (IQR, 20.4-27.8). The proximate cause of fistula formation was spontaneous in 12 patients (13%), whereas the remainder were postoperative; 16 patients (17%) had underlying Crohn's disease. Twenty-two patients (24%) had a recurrence; hence, 76% had a successful repair. The median time to fistula recurrence was 85 days (IQR, 53-372). Mortality occurred in 5 patients (5%). The most common postoperative complications were intra-abdominal or pelvic abscess (19%) and transfusion (28%). Patients with fistula recurrence, compared with patients with no recurrence, had similar age, BMI, etiology (inflammatory bowel disease [IBD] vs non-IBD), American Society of Anesthesiologists class, sex, race, and comorbidities. A significantly longer length of stay was observed in the recurrence group (18.5 vs 8 days; P < .01). Postoperative complications were similar except for anastomotic leak, which was higher in the recurrence group (22.7% vs 7.0%; P = .053). In the multivariable logistic regression analysis, recurrence was independently associated with high-output fistula (odds ratio [OR], 6.62; 95% CI, 1.38-31.80; P = .018), preoperative stoma use (OR, 4.36; 95% CI, 1.17-16.27; P = .029), wound class overall (P = .015), primary repair (OR, 4.55; 95% CI, 1.10-18.85; P = .037), and intraoperative transfusion (OR, 7.72; 95% CI, 1.46-40.74; P = .016). CONCLUSION: Surgery for ECF can be accomplished with good rates of healing in experienced centers. Recurrence seems to be associated with fistula severity, operative complexity, and intraoperative burden, underscoring the importance of careful patient optimization and meticulous operative management.
BACKGROUND: Temporary fecal diversion (FD) is performed selectively in patients with rectovaginal fistulas (RVFs). This study aimed to identify the factors associated with FD in the treatment of RVF and determine whether...BACKGROUND: Temporary fecal diversion (FD) is performed selectively in patients with rectovaginal fistulas (RVFs). This study aimed to identify the factors associated with FD in the treatment of RVF and determine whether FD is associated with increased recurrence-free survival. METHODS: A retrospective review of females who underwent repair of an RVF was performed. Patients were divided into 2 groups based on the use of FD. Recurrence was defined as evidence of RVF on clinical examination or imaging after at least 2 previous follow-ups, with healing noted. RESULTS: A total of 158 patients underwent 424 surgical procedures, of whom 100 (63.3%) underwent FD and 58 (36.7%) did not. Patients were comparable in terms of age, body mass index, diabetes mellitus, smoking history, inflammatory bowel disease history, and fistula etiology. Patients in the FD group required a median of 3 repairs (IQR, 1-5) (P <.005). Interposition flaps were more common in the FD group than in the non-FD group: gracilis flap (13 [13%] vs 2 [3%]; P =.05) and Martius flap (17 [17%] vs 2 [3%]; P =.01). There were no significant differences in healing or recurrence rates. Multivariate analysis revealed an increased number of previous attempted repairs associated with the use of FD (P <.001). The cumulative 5-year Kaplan-Meier cure rates were 72.7% (95% CI, 61.0%-87.0%) in the FD group and 64.3% (95% CI, 48.0%-86.0%) in the non-FD group (P =.38). CONCLUSION: Multiple previous RVF repairs and interposition flap repairs were associated with the use of FD. Selecting high-risk patients for FD before re-repair may allow the recurrence rate to be similar to that of lower-risk nondiverted patients.
BACKGROUND: Obesity is a major contributor to atherosclerotic cardiovascular disease (ASCVD) through adverse effects on blood pressure, lipid metabolism, and glucose regulation. Metabolic and bariatric surgery (MBS) prod...BACKGROUND: Obesity is a major contributor to atherosclerotic cardiovascular disease (ASCVD) through adverse effects on blood pressure, lipid metabolism, and glucose regulation. Metabolic and bariatric surgery (MBS) produces durable cardiometabolic improvement, but procedures differ in their metabolic effects. Whether these differences translate into meaningful variation in integrated cardiovascular risk reduction remains uncertain. We compared changes in estimated cardiovascular risk after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD-DS). METHODS: We conducted a retrospective cohort study of adults undergoing primary MBS at a tertiary academic center. Patients were required to have complete clinical and laboratory data at baseline and 1 year after surgery. Ten-year and lifetime ASCVD risk estimates were calculated using pooled cohort equations. Primary outcomes were absolute changes in estimated 10-year and lifetime cardiovascular risk at 1 year. Secondary outcomes included percent total body weight loss (TBWL%) and changes in blood pressure and lipid parameters. RESULTS: The cohort included 2642 patients (699 SG, 1813 RYGB, and 130 BPD-DS). At 1 year, the mean 10-year cardiovascular risk decreased by 0.33 after SG, 0.93 after RYGB, and 1.58 after BPD-DS (P = .006). The mean lifetime cardiovascular risk decreased by 3.24, 7.67, and 10.49, respectively (P < .001). TBWL% was 23.6%, 31.0%, and 36.8%, respectively (P < .001). CONCLUSION: MBS is associated with significant cardiovascular risk reduction, with greater benefit observed after more metabolically intensive procedures.
BACKGROUND: Perioperative opioid overdose (OD) is a rare but serious complication. However, data on OD risk factors and outcomes after gastrointestinal (GI) surgery remain limited. This study aimed to define the risk fac...BACKGROUND: Perioperative opioid overdose (OD) is a rare but serious complication. However, data on OD risk factors and outcomes after gastrointestinal (GI) surgery remain limited. This study aimed to define the risk factors and outcomes of opioid OD after major GI surgery. METHODS: Data on opioid OD were extracted from the National Inpatient Sample (2016-2019), which included adults who underwent major GI surgery. Patients were categorized into opioid OD and non-OD cohorts; outcomes included in-hospital complications, mortality, length of stay (LOS), and hospitalization costs. Multivariate regression analyses were performed to estimate the association between opioid OD and outcomes. RESULTS: Among 1,562,770 patients in the weighted population, 1434 (0.1%) experienced perioperative opioid OD. Compared with patients without OD, those with opioid OD were predominantly female (807,450 [51.7%] vs 940 [65.5%], respectively; P<.001) and more likely to have Medicaid insurance (152,555 [9.8%] vs 230 [16.0%], respectively; P<.001). The incidence of opioid OD declined from 0.12% in 2016 to 0.07% in 2019. On adjusted analyses, compared with colectomy, esophagectomy (adjusted odds ratio [AOR], 3.78 [95% CI, 2.01-7.11]), hepatectomy (AOR, 2.08 [95% CI, 1.13-3.83]), and pancreatectomy (AOR, 1.90 [95% CI, 1.10-3.26]) were associated with higher odds of OD, emergency admissions (AOR, 1.99 [95% CI, 1.49-2.67]), and drug abuse disorder (AOR, 4.51 [95% CI, 3.11-6.55]). Opioid OD was associated with higher odds of renal complications (AOR, 2.77 [95% CI, 2.07-3.72]), longer LOS (+2.97 days [95% CI, +1.67 to +4.28]), and increased costs (+$14,320 [95% CI, +$9110 to +$19,520]). CONCLUSION: Opioid OD was associated with substantial morbidity, prolonged hospitalization, and increased costs. Temporal decline with persistent risk among vulnerable individuals highlights the need for systematic perioperative substance screening and structured stewardship programs in major GI surgery care.
BACKGROUND: The management of multiple bilobar colorectal liver metastases (BCRLMs) continues to evolve, and the optimal strategy remains controversial. This was a systematic review that analyzed the outcomes of differen...BACKGROUND: The management of multiple bilobar colorectal liver metastases (BCRLMs) continues to evolve, and the optimal strategy remains controversial. This was a systematic review that analyzed the outcomes of different surgical strategies for BCRLMs. METHODS: A systematic literature search that included MEDLINE, Embase, and the Cochrane Library was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and registered in the International Prospective Register of Systematic Reviews. This review included studies reporting surgery for BCRLMs (January 2010 to August 2025) according to 5 strategies: two-stage hepatectomy (TSH), associated liver partitioning and portal vein ligation for staged hepatectomy (ALPPS), parenchymal-sparing hepatectomy (PSH), one-stage hepatectomy with ablation (OSHA), and liver transplantation (LT). RESULTS: A total of 34 studies that reported the outcomes of 2756 patients were included (TSH [20 studies; 1813 patients], ALPPS [11 studies; 272 patients], PSH [2 studies; 142 patients], OSHA [3 studies; 279 patients], and LT [8 studies; 250 patients]). BCRLMs treatment has mostly synchronous presentation (82.3%). Patients who underwent ALPSS showed a higher rate of extrahepatic disease (EHD), whereas those who underwent LT had no EHD. Patients who underwent LT had the highest rate of preoperative chemotherapy (100%) and a higher median number of lesions (n = 11). However, the patients who underwent LT were less likely to be females. Mutational status (KRAS or BRAF) was reported in <40% of patients. The overall 90-day postoperative mortality rate was 4.0%. However, patients who underwent LT had a lower 90-day postoperative mortality rate (0.8%). The overall R1 resection rate was 18.9%. However, patients who underwent PSH had a higher R1 resection rate (55.7%). The median overall survival (OS) and disease-free survival (DFS) estimates were similar across strategies (TSH: 41 vs 15 months, respectively; ALPPS: 44 vs 11 months, respectively; PSH: 45 vs 9 months, respectively; OSHA: 47 vs 10 months, respectively; LT: 60 vs 19 months, respectively), but LT showed higher OS and DFS estimates. CONCLUSION: The outcomes of patients with BCRLMs differed across surgical strategies that showed high variability across countries, centers, and eras. Therefore, there is a need for a common definition of BCRLMs and guidelines for managing patients, including a transplantation option.
Matto MA, Luketich JD, Levy RM
… +6 more, Lloyd G, Awais O, Witek T, Christie NA, Ajabshir N, Alicuben ET
J Gastrointest Surg
· 2026 Jun · PMID 41990992
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PURPOSE: This study aimed to investigate the outcomes of minimally invasive surgery for mid- to distal thoracic esophageal diverticula (TED). METHODS: This was a retrospective review of patients who underwent surgery for...PURPOSE: This study aimed to investigate the outcomes of minimally invasive surgery for mid- to distal thoracic esophageal diverticula (TED). METHODS: This was a retrospective review of patients who underwent surgery for symptomatic TED. Patients with Zenker diverticulum were excluded. Demographic information and operative details were recorded. Dysphagia score was defined using the Knyrim scoring system (0 = no dysphagia, 1 = hard solids, 2 = soft solids, 3 = liquids, and 4 = saliva). The follow-up included clinical encounters, barium esophagram in all patients, and endoscopy in those who developed postoperative symptoms. RESULTS: From September 2001 to September 2024, there were 91 patients with a median follow-up of 19 months. Of note, 79 patients (86.8%) presented with dysphagia. Achalasia was identified in 27 patients. Surgical approaches included thoracoscopy (58.2%), laparoscopy (31.9%), or both (8.8%). Myotomy was performed in 85.7% of patients. There were no perioperative mortalities. The median hospital length of stay was 6 days. Of note, 6 patients had an esophageal leak postoperatively, and 4 patients required intervention. Of the 26 patients with a residual or recurrent diverticulum, only 4 required reoperation. At the first postoperative visit, all patients reported an improvement in their dysphagia scores, and 88.6% of patients reported no dysphagia. At a median follow-up of 19 months, 30 patients reported some degree of dysphagia, but overall, the dysphagia scores remained significantly improved compared with those in the preoperative period (P <.001). CONCLUSION: Minimally invasive treatment of symptomatic, mid- to lower TED resulted in significant improvement in dysphagia scores and low morbidity.
Hu A, Gallant B, Reddington H
… +7 more, Ballinger Z, Maykel J, Aulet T, Sturrock P, Peponis T, Lou F, Alavi K
J Gastrointest Surg
· 2026 Apr · PMID 41990991
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BACKGROUND: Minimally invasive surgical approaches, including laparoscopic and robotic techniques, have been shown to improve the outcomes in colorectal cancer resection by decreasing pain, hospital length of stay, and p...BACKGROUND: Minimally invasive surgical approaches, including laparoscopic and robotic techniques, have been shown to improve the outcomes in colorectal cancer resection by decreasing pain, hospital length of stay, and perioperative mortality. However, broader adoption of robotics faces several barriers. This study aimed to evaluate national trends in robotic colorectal surgery using the National Cancer Database (NCDB). METHODS: Patients with stage I to III colon and rectal adenocarcinomas who underwent resection (2010-2021) were identified. Trends in surgical approaches (open, laparoscopic, and robotic) were analyzed. Multivariate logistic regression identified factors associated with the adoption of robotics. RESULTS: A total of 537,627 colon and 116,763 rectal resections were included. Robotics were used in 61,640 (11.5%) colon and 30,569 (26.1%) rectal cases. For colon cancer, the adoption of robotics increased by +2.4% annually, nearly equaling open surgery by 2021 (26.7% vs 27.2%). For rectal cancer, adoption of robotics increased by +4.28% annually, surpassing both laparoscopic and open approaches by 2018. Robotic surgery was predominantly performed in metropolitan centers (87.2%) compared with rural areas (1.5%). Regionally, the adoption of robotics was the highest in the West North Central (+5.0%/y) and West South Central (+3.3%/y) regions and the lowest in New England (+1.3%/y). Compared with New England, all regions were more likely to use robotics, with the West North Central region demonstrating the highest odds (odds ratio, 2.15 [95% CI, 1.95-2.38]). CONCLUSION: Robotic colorectal cancer surgery has expanded substantially over the past decade, with marked regional and institutional disparities. Understanding these patterns may inform targeted educational initiatives and promote nationwide equitable adoption of robotic surgery.
BACKGROUND: Localized pancreatic cancer is generally treated with curative intent multidisciplinary care. However, the survival effect of treatment recommendations versus actual treatment receipt in older adults has not...BACKGROUND: Localized pancreatic cancer is generally treated with curative intent multidisciplinary care. However, the survival effect of treatment recommendations versus actual treatment receipt in older adults has not been well characterized. This study aimed to quantify survival differences by treatment recommendation and receipt among adults aged ≥65 years with localized pancreatic cancer. METHODS: A population-based cohort study was conducted using data from 17 Surveillance, Epidemiology, and End Results registries including adults aged ≥65 years diagnosed with localized pancreatic cancer from 2000 to 2022. Treatment was categorized according to recommendation and receipt. Relative survival was estimated using the Ederer II method and cancer-specific mortality using Fine-Gray competing risk models. RESULTS: Among 4409 patients (56.6% female, 73.3% non-Hispanic White), the 5-year relative survival was substantially higher for patients who underwent surgical resection (ages of 65-74 years: 25.6% [95% CI, 22.4-29.2]; ages of 75-84 years: 18.5% [95% CI, 15.3-22.3]) than for individuals without a surgery recommendation (2.0% [95% CI, 1.2-3.2]) or those recommended surgery but not treated (0.1% [95% CI, 0.0-1.3]). Compared with nonreceipt or refusal of therapy, receipt of surgery (adjusted hazard ratio [AHR], 0.26 [95% CI, 0.23-0.30]), radiotherapy (AHR, 0.82 [95% CI, 0.67-1.00]), and chemotherapy (AHR, 0.67 [95% CI, 0.63-0.72]) were associated with lower cancer-specific mortality. The risk of death after an early pancreatic cancer diagnosis was lower among males (AHR, 0.24 [95% CI, 0.20-0.29]) and was the lowest among non-Hispanic Asian/Pacific Islander patients (AHR, 0.21 [95% CI, 0.10-0.41]). CONCLUSION: Receipt of recommended treatment-particularly surgical resection-was associated with improved survival and reduced cancer-specific mortality. The discordance between treatment recommendation and receipt relative to differences in sex and race/ethnicity highlight the need for equitable, individualized treatment decision-making beyond chronological age.
BACKGROUND: Hepatocellular carcinoma (HCC) is a leading indication for liver transplantation (LT). However, post-transplant recurrence remains a major challenge. Liquid biopsy biomarkers, including circulating cell-free...BACKGROUND: Hepatocellular carcinoma (HCC) is a leading indication for liver transplantation (LT). However, post-transplant recurrence remains a major challenge. Liquid biopsy biomarkers, including circulating cell-free DNA (cfDNA) and circulating tumor DNA (ctDNA), have emerged as promising tools for dynamic risk stratification, minimal residual disease (MRD) detection, and personalized surveillance. Despite increasing evidence supporting their prognostic value, the integration of cfDNA and ctDNA into transplant algorithms remains limited. METHODS: This was a targeted literature review that synthesized data from studies evaluating cfDNA and ctDNA in patients who underwent curative-intent hepatectomy or LT for HCC. The roles of cfDNA and ctDNA in pretransplant biological risk assessment, perioperative monitoring, and post-transplant MRD detection were examined. Moreover, this study evaluated logistical, methodological, operational, and ethical barriers to widespread adoption, including assay performance variability, workflow constraints, and infrastructure limitations. RESULTS: Elevated preoperative cfDNA levels and postoperative ctDNA positivity consistently predicted aggressive tumor biology, early recurrence, and reduced survival. Tumor-informed, tumor-naïve, and methylation-based ctDNA assays demonstrated high sensitivity for detecting recurrence, often 3 to 8 months before radiographic progression, and provided prognostic discrimination beyond alpha-fetoprotein and traditional morphologic criteria. However, translation into clinical practice is hindered by heterogeneity in testing platforms (droplet digital polymerase chain reaction, next-generation sequencing, and methylation assays), differences in detection thresholds (variant allele frequency of 0.01%-1%), lack of standardized protocols for sampling and analysis, limited reimbursement pathways, 7 to 14-day turnaround times, and poor integration with electronic medical records. CONCLUSION: cfDNA and ctDNA offer transformative opportunities to enhance biologically informed LT selection, enable early recurrence detection, and support precision-guided postoperative management. Standardized protocols and large-scale prospective validation are essential for achieving routine clinical integration and realizing the full potential of liquid biopsy in transplant oncology.