BACKGROUND: The international consensus delineates 8 symptom complexes and 8 consequences for defining low anterior resection syndrome (LARS). This exploratory cross-sectional study aimed to evaluate the differential ass...BACKGROUND: The international consensus delineates 8 symptom complexes and 8 consequences for defining low anterior resection syndrome (LARS). This exploratory cross-sectional study aimed to evaluate the differential associations between symptom complexes and consequence severity after intersphincteric resection (ISR) for ultralow rectal cancer. METHODS: Patients were enrolled ≥12 months after diverting ileostomy reversal after ISR. The severity of the consensus-defined LARS variables was assessed using a 5-point Likert scale. Participants completed questionnaires on bowel function and condition-specific quality of life (CSQoL). RESULTS: A total of 174 patients were included (response rate: 85.3%). Our exploratory severity scores revealed a strong symptom-consequence correlation (r = 0.78). All symptom complexes demonstrated significant univariate associations between LARS consequence severity, bowel function satisfaction, and CSQoL (all P <.001), although "altered stool consistency" showed uniformly weak associations. Multivariate analysis identified 4 symptom complexes that remained independently associated with adverse consequences: "emptying difficulties" (B, 2.15 [95% CI, 1.16-3.14]; P <.001), "urgency" (B, 1.55 [95% CI, 0.62-2.48]; P =.001), "variable and unpredictable bowel function" (B, 1.46 [95% CI, 0.46-2.45]; P =.004), and "repeated painful stools" (B, 1.17 [95% CI, 0.45-1.89]; P =.002). In contrast, "altered stool consistency" exhibited a near-null independent association (B, -0.03 [95% CI, -0.88 to 0.82]; P =.944). CONCLUSION: Of note, 4 specific symptom complexes, including "emptying difficulties," "urgency," "variable bowel function," and "repeated painful stools," were independently associated with adverse LARS consequences after ISR. However, "altered stool consistency" showed no such independent association, which warrants further investigation.
BACKGROUND: Gastric submucosal tumors (G-SMTs) refer to protuberant lesions originating from the muscularis mucosae, submucosa, or muscularis propria. Endoscopic resection (ER) has been adopted as a treatment option for...BACKGROUND: Gastric submucosal tumors (G-SMTs) refer to protuberant lesions originating from the muscularis mucosae, submucosa, or muscularis propria. Endoscopic resection (ER) has been adopted as a treatment option for G-SMTs. However, the indications for ER remain inconsistent across guidelines. This study aimed to provide further clinical evidence supporting the role of ER in the management of G-SMTs. METHODS: This retrospective study included 531 of 949 patients with G-SMTs undergoing ER between June 2015 and June 2024. Baseline and lesion characteristics were collected. Among patients diagnosed as having gastrointestinal stromal tumors (GISTs), clinical features were compared in patients who achieved complete ER (ER0) with incomplete ER (ER1). Follow-up information was available for a subset of patients and was used to evaluate recurrence outcomes. RESULTS: The mean age of patients was 56.4 ± 11.0 years, and the mean tumor size was 1.56 ± 0.97 cm. The mean procedural time for patients was 58 ± 32 min. Postoperative pathological evaluation revealed that GISTs and leiomyomas were the most common pathological types, accounting for 53.7% and 32.8% of cases. To evaluate the risk factors associated with piecemeal resection of GISTs, the patients were divided into 2 groups (ER0 and ER1). On univariate analysis, larger tumor size (P <.001), extraluminal growth pattern (P =.031), and high-risk grade (P =.02) were significantly associated with incomplete resection, whereas multivariable analysis identified tumor size as the only independent risk factor (odds ratio, 3.389; 95% CI, 1.799-6.385; P <.001). During follow-up, only 2 patients experienced recurrence, and overall recurrence-free survival remained high. CONCLUSION: ER is a safe and effective therapeutic method for specific G-SMTs. For GISTs, tumor size is the main factor associated with incomplete resection.
BACKGROUND: Split liver transplantation (SLT) can expand the donor pool by generating 2 grafts from 1 organ. However, SLT only consists of <5% of United States liver transplants. Factors determining adequate SLT prognosi...BACKGROUND: Split liver transplantation (SLT) can expand the donor pool by generating 2 grafts from 1 organ. However, SLT only consists of <5% of United States liver transplants. Factors determining adequate SLT prognosis remain understudied. METHODS: A retrospective study of adult deceased-donor liver transplant recipients (January 2015 to September 2025) was conducted using the United Network for Organ Sharing/Organ Procurement and Transplantation Network database. The primary outcome was graft survival (GS) at 3 and 12 months. SLT recipients were analyzed by graft laterality, splitting technique, graft-to-recipient weight ratio (GRWR), and graft weight-to-standard liver volume (GW/SLV) ratio. Propensity score matching (PSM; 1:1) was used to compare SLT with whole liver transplantation (WLT), followed by sensitivity analyses. RESULTS: Among 840 SLT recipients, right lobe graft (RLG) demonstrated superior 12-month GS over left lobe graft (LLG) (91.7% vs 79.6%, respectively; P <.001), GRWR ≥ 0.8 outperformed GRWR < 0.8 (91.4% vs 85.3%, respectively; P =.045), and GW/SLV ≥ 0.45 outperformed GW/SLV < 0.45 (91.3% vs 83.0%, respectively; P =.032). Using propensity score-matched analysis, SLT demonstrated lower GS than WLT at 3 months (93.7% vs 96.6%, respectively; hazard ratio [HR], 1.89; P =.03) and 12 months (89.8% vs 93.4%, respectively; HR, 1.60; P =.03). Sensitivity analyses revealed that this difference was driven by LLG (3-month HR, 6.62; 12-month HR, 4.03; both P <.001), GRWR < 0.8 (3-month HR, 4.39; P =.008; 12-month HR, 2.98; P =.02), and recipients aged ≥55 years (3-month HR, 2.05; P =.047; 12-month HR, 1.86; P =.03). RLG, GRWR ≥ 0.8, GW/SLV ≥ 0.45, and recipients aged <55 years demonstrated outcomes comparable with those of WLT. CONCLUSION: Within the SLT cohort, RLG, GRWR ≥ 0.8, and GW/SLV ≥ 0.45 were associated with superior early GS. Compared with the detrimental GS difference of WLT, the detrimental GS difference of SLT was attenuated with RLG, younger recipients, and adequately matched grafts.
BACKGROUND: Gastrointestinal stromal tumors (GISTs) arising in the bowel exhibit substantial clinical and biological heterogeneity. They are commonly analyzed as a single entity, which obscures important site-specific di...BACKGROUND: Gastrointestinal stromal tumors (GISTs) arising in the bowel exhibit substantial clinical and biological heterogeneity. They are commonly analyzed as a single entity, which obscures important site-specific disparities. This study aimed to evaluate demographic profiles, clinicopathological characteristics, treatment patterns, and their association with survival according to anatomical location. METHODS: This was a retrospective population-based cohort study conducted using the Surveillance, Epidemiology, and End Results database (2000-2022). Patients were stratified by anatomical location: small intestine, colon, and rectum. The primary outcome was 5-year cancer-specific survival (CSS). RESULTS: A total of 5760 patients with bowel GISTs were identified. Most tumors were located in the small intestine (85%), followed by the rectum (8.5%) and colon (6.6%). Patients with colonic tumors were older and had a markedly higher proportion of Black patients than those with tumors in other sites. Rectal GISTs had the highest 5-year CSS (86.5%), followed by the small intestine (81.0%), whereas colonic GISTs had the lowest 5-year CSS (67.2%). In multivariate analysis, colonic location was not an independent predictor of poor survival, whereas rectal location was independently associated with improved survival (hazard ratio, 0.31; P =.026). Surgical resection, with or without systemic therapy, was associated with markedly improved survival across most sites. Patients with rectal GISTs achieved a high 5-year CSS even with systemic therapy alone (77.7%). CONCLUSION: Bowel GISTs are a heterogeneous group with distinct profiles based on anatomical location. Although colonic GISTs have poorer unadjusted outcomes, rectal GISTs exhibit a consistent survival advantage, likely due to earlier detection and high therapy responsiveness. Site-specific risk stratification is essential for optimizing management.
BACKGROUND: The increasing adoption of incomplete cholecystectomy in severe cholecystitis has created a growing population of patients who later develop recurrent symptoms from remnant gallbladder or cystic duct patholog...BACKGROUND: The increasing adoption of incomplete cholecystectomy in severe cholecystitis has created a growing population of patients who later develop recurrent symptoms from remnant gallbladder or cystic duct pathology. Reoperative cholecystectomy is definitive but technically challenging, and the role of robotic surgery in this setting remains poorly defined. METHODS: A retrospective cohort study was performed of adult patients undergoing robot-assisted completion or remnant cholecystectomy for recurrent gallbladder disease at a single tertiary institution between 2022 and 2024. Perioperative outcomes were evaluated, and institutional primary cholecystectomy outcomes were used as a contextual comparator. RESULTS: Twenty-one patients underwent robotic reoperative cholecystectomy. The median age was 41 years, and most patients were female and obese. All had radiographic evidence of remnant biliary pathology. The median operative time was 166 min, with no intraoperative complications or conversions to open surgery. The median postoperative length of stay was 0 days, with most patients discharged the same day. One patient experienced a 30-day major complication managed nonoperatively. There were no 90-day readmissions or mortalities, and all patients reported symptom resolution. DISCUSSION: In this single-institution series, robotic reoperative cholecystectomy was safe and effective, with minimal morbidity, very short hospital stays, and universal symptom resolution. When performed at experienced centers, robotic reoperative cholecystectomy represents an effective definitive strategy for recurrent gallbladder disease after incomplete cholecystectomy.
BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder with multifactorial pathogenesis. Owing to the chronic nature of the disease and the long-term side effects of medical therapy, surgical interventio...BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disorder with multifactorial pathogenesis. Owing to the chronic nature of the disease and the long-term side effects of medical therapy, surgical interventions have gained popularity. RefluxStop is a newly introduced minimally invasive technique for treating GERD. This meta-analysis aimed to build high-level evidence on the effectiveness and safety of the RefluxStop procedure. METHODS: This systematic review and meta-analysis analysed the results of primary studies reporting clinical outcomes of RefluxStop. RESULTS: Of 188 screened articles, 5 studies involving 296 patients were included. Most patients (99.7%) underwent laparoscopic RefluxStop procedures. Preoperative dysphagia was noted in 23.6% of patients. Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores were reported in 4 studies using different scoring versions. In 169 patients, the pooled preoperative mean GERD-HRQL score was 27.96, which improved to 3.89 postoperatively. The overall complication rate was 15.2%, with surgical emphysema being the most common (40.0%). Device-related complications occurred in 4 patients, including migrations, slippage, and gastric penetration. Of note, 2 cases had incorrect device placement. Patient satisfaction was high (93.9% in 3 studies), and 2 mortalities occurred due to unrelated medical causes. CONCLUSION: RefluxStop shows promising results with significant improvement in GERD-HRQL scores postoperatively. The overall complication rate was 15.2%. Excluding cases with surgical emphysema, which were all self-limiting, the complication rate was 9.1%, and the major complication rate (Clavien-Dindo grades 3 and 4) was 3.0%. Further studies are needed to assess the long-term safety and effectiveness of RefluxStop.
BACKGROUND: Multivisceral resection (MVR) in pancreatic ductal adenocarcinoma (PDAC) involves en bloc resection of adjacent organs due to direct invasion. Despite its clinical significance, adjacent organ invasion is not...BACKGROUND: Multivisceral resection (MVR) in pancreatic ductal adenocarcinoma (PDAC) involves en bloc resection of adjacent organs due to direct invasion. Despite its clinical significance, adjacent organ invasion is not included as a determinant in the American Joint Committee on Cancer (AJCC) staging or National Comprehensive Cancer Network resectability criteria. This study aimed to evaluate the safety and efficacy of MVR vs standard resection. METHODS: This study analyzed 1222 patients who underwent surgery for PDAC at a tertiary institution between 2009 and 2019. Patients with stage IV disease, recurrent operations, incomplete data, or MVR performed for double primary malignancy were excluded. Propensity score matching (PSM) was performed at a 1:2 ratio, matching for operation type and AJCC T/N stages. Short- and long-term outcomes were compared between the 2 groups. RESULTS: Before PSM, 42 MVR cases and 1099 standard resections demonstrated similar postoperative hospital stay lengths (11.4 vs 12.6 days, respectively; P =.094), major complications (23.8% vs 19.0%, respectively; P =.566), and clinically relevant postoperative pancreatic fistula (11.9% vs 6.6%, respectively; P =.310). However, compared with standard resections, MVR showed poorer long-term outcomes, including 2-year overall survival rate (2YSR; 49.9% vs 33.3%, respectively; P =.006), 2-year disease-free survival rate (2YDFSR; 25.9% vs 11.3%, respectively; P =.018), and 2-year local recurrence rate (2YLRR; 30.9% vs 41.3%, respectively; P =.319). After PSM, both groups maintained similar short-term outcomes and showed no statistical difference in 2YSR (P =.143), 2YDFSR (P =.279), and 2YLRR (P =.362). CONCLUSION: MVR demonstrates comparable short- and long-term outcomes to standard resection and should be considered for selected patients with suspected organ invasion. Our findings reinforce current staging and resectability criteria and support surgical decision-making for PDAC.
BACKGROUND: Recurrence of colorectal cancer (CRC) after curative-intent treatment is largely driven by minimal residual disease (MRD). Circulating tumor DNA (ctDNA) offers a noninvasive approach to detect MRD and tailor...BACKGROUND: Recurrence of colorectal cancer (CRC) after curative-intent treatment is largely driven by minimal residual disease (MRD). Circulating tumor DNA (ctDNA) offers a noninvasive approach to detect MRD and tailor adjuvant therapy and surveillance. METHODS: This scoping review synthesized prospective cohorts, interventional/randomized trials, and real-world registries on ctDNA-based MRD testing in resected CRC, comparing tumor-informed vs plasma-only (mutation- and/or methylation-based) assays. RESULTS: Postoperative ctDNA positivity strongly predicts recurrence and often precedes radiologic relapse by 3 to 10 months. Tumor-informed assays provide high specificity and analytical sensitivity, whereas plasma-only assays enable tissue-free, faster testing but often require serial sampling. In stage II colon cancer, ctDNA-guided management reduced the use of chemotherapy without compromising recurrence-free survival. ctDNA dynamics add prognostic resolution. Clearance after adjuvant therapy is associated with excellent outcomes, whereas persistent positivity signals a very high relapse risk. Escalation approaches tested to date (eg, intensified chemotherapy or trifluridine/tipiracil) have not shown definitive disease-free survival gains in patients with a positive ctDNA. Implementation data indicate that ctDNA can influence treatment and surveillance decisions. However, barriers include assay variability, optimal timing, counseling, and reimbursement. CONCLUSION: ctDNA-based MRD testing is a robust prognostic tool and a practical framework for biology-guided postoperative CRC care. Ongoing phase III trials should establish standardized algorithms and effective MRD-directed therapies.
Ishida J, Toyama H, Nanno Y
… +13 more, Mizumoto T, Lee D, Akita M, Arai K, Yoshida T, So S, Urade T, Fukushima K, Komatsu S, Asari S, Yanagimoto H, Kido M, Fukumoto T
BACKGROUND: Portomesenteric vein (PMV) resection is performed for pancreatic ductal adenocarcinoma with venous invasion. However, positive transection margins may lead to local recurrence. This study aimed to evaluate wh...BACKGROUND: Portomesenteric vein (PMV) resection is performed for pancreatic ductal adenocarcinoma with venous invasion. However, positive transection margins may lead to local recurrence. This study aimed to evaluate whether routine intraoperative frozen section analysis (FSA) reduces positive PMV transection margins. METHODS: This retrospective study reviewed patients who underwent pancreatectomy with PMV resection at Kobe University Hospital from 2010 to 2020. Routine FSA of the PMV transection margin was introduced in 2017. Clinicopathological factors and the incidence of positive PMV transection margins were compared between patients who underwent FSA (PMV frozen [+]) and those who did not (PMV frozen [-]). Cox regression was used to assess the prognostic effect of margin status. RESULTS: A total of 115 patients were included (57 in the PMV frozen [+] group and 58 in the PMV frozen [-] group). The rate of positive PMV transection margins was significantly lower in the PMV frozen (+) group than in the PMV frozen (-) group (1.8% vs 17.2%, respectively; P =.003). Multivariate logistic regression analysis demonstrated that intraoperative FSA of the PMV transection margin was an independent factor associated with a reduced risk of positive PMV transection margins on final pathological diagnosis (odds ratio, 13.7 [95% CI, 1.61-116.7]; P =.017). However, the positive PMV transection margin was not associated with overall survival (hazard ratio, 0.96 [95% CI, 0.31-2.50; P =.937). CONCLUSION: Routine FSA of the PMV transection margin markedly reduces positive PMV transection margins after pancreatectomy. However, the prognostic effect of a positive PMV transection margin remains unclear. Larger prospective studies are needed to determine its prognostic relevance.
BACKGROUND: Enhanced Recovery After Surgery (ERAS) is an established strategy for improving recovery after surgery. Although the overall benefits are well-documented, the specific patient- and disease-related factors tha...BACKGROUND: Enhanced Recovery After Surgery (ERAS) is an established strategy for improving recovery after surgery. Although the overall benefits are well-documented, the specific patient- and disease-related factors that are mitigated by ERAS to achieve these outcomes remain unclear. This study aimed to determine which factors influencing postoperative hospital stay are neutralized by ERAS implementation. METHODS: This retrospective multicenter cohort study included 3 groups: ERAS (tertiary hospital [n = 635]), tertiary non-ERAS (non-ERAS; tertiary hospitals without ERAS [n = 4001]), and secondary non-ERAS (secondary hospitals without ERAS [n = 837]). Factors analyzed included patient variables (age, sex, body mass index, American Society of Anesthesiologists score, and comorbidities), disease factors (tumor location, TNM stage, perforation, and obstruction), surgical factors (operative time, blood loss, and approach), institutional factors (ERAS protocol and hospital classification), and postoperative complications. RESULTS: The mean postoperative hospital stay (postoperative day [POD]) was significantly shorter in the ERAS group (4.74 ± 1.62 days) than in the tertiary non-ERAS (8.73 ± 5.95 days) and secondary non-ERAS (12.71 ± 11.48 days) groups (P <.001). Multivariate analysis showed that patient- and disease-related factors did not significantly affect POD in the ERAS group, whereas multiple patient-, disease-, and surgeon-related factors significantly influenced POD in the non-ERAS groups. Propensity score-matched analysis demonstrated that ERAS significantly reduced POD compared with same-level tertiary non-ERAS care (4.65 ± 1.55 vs 8.41 ± 3.84 days, respectively; reduction of 3.76 days; P <.001) and cross-level secondary non-ERAS care (4.65 ± 1.55 vs 10.98 ± 7.73 days, respectively; reduction of 6.34 days; P <.001). CONCLUSION: ERAS significantly reduces postoperative hospital stay in patients who underwent surgery for colorectal cancer by mitigating the adverse influence of patient and disease factors. These findings support the role of ERAS in standardizing recovery outcomes across diverse patient populations and clinical settings.
BACKGROUND: This study aimed to assess and compare the application of stapled and handsewn anastomoses in video-assisted thoracoscopic and laparoscopic McKeown esophagectomy for the treatment of esophageal cancer (EC). M...BACKGROUND: This study aimed to assess and compare the application of stapled and handsewn anastomoses in video-assisted thoracoscopic and laparoscopic McKeown esophagectomy for the treatment of esophageal cancer (EC). METHODS: This retrospective study included patients with EC who were treated at our hospital from 2019 to 2022. After a series of preoperative examinations and preparations, strict quality control indicators were formulated and surgical indications documented (cT1-3N0-2M0) based on current international EC surgery protocols. Patients were divided into either a stapled anastomosis group (stapled anastomosis [n = 79]) or a handsewn anastomosis group (handsewn anastomosis [n = 40]) based on the anastomosis technique used. The incidence of postoperative complications and short-term postoperative quality of life were compared between the 2 groups. With these data, it was possible to assess the reliability of the by-layer anastomosis in cervical thoracoscopic, McKeown thoracoscopic, and laparoscopic approaches. RESULTS: There were no significant differences in age, sex, tumor location, or cancer stage between the 2 groups (P >.05). Statistically significant differences were obtained concerning the incidence of postoperative anastomotic leakage and stenosis between the handsewn anastomosis group and the stapled anastomosis group (P <.05), with the former group showing lower rates of these complications. CONCLUSION: The incidence of anastomosis-related complications is lower with manual layer-to-layer anastomosis, a relatively safe surgical procedure for McKeown esophagectomy.