The rapid advancement of generative artificial intelligence (gen-AI) has prompted interest in whether it can recognize and respond to individual clinical backgrounds in treatment decision-making. To explore this, we developed a virtual patient model for lymphedema and conducted an observational study to examine what treatments AI would recommend, whether the recommendations were individualized, and what tendencies the AI exhibited.
Methods
A virtual cohort of 100 patients with secondary upper extremity lymphedema following breast cancer surgery was constructed using generative pre-trained transformer-4 omni (GPT-4o). For each virtual patient, six clinical questions, based on the Japanese Lymphedema Guidelines 2024, were submitted to the AI to elicit individualized recommendations. The answers obtained were compared with guidelines-defined recommendation levels to assess concordance, deviation, and treatment tendencies, analyzed by patient factors.
Results
Multivariate analysis demonstrated that GPT-4o-generated recommendations were tailored to individual patient characteristics. They showed high concordance with guideline-defined recommendations for conservative care but greater variability and bias toward invasive options in surgical contexts.
Conclusion
The preference of gen-AI for invasive treatments may reflect an overestimation of the benefits of performing treatments rather than withholding them, especially in invasive treatments. This bias shows a limitation of current gen-AI in complex decisions. Our reproducible simulation framework identified this bias and variability, clarifying both strengths and limitations of gen-AI. This type of AI-on-AI observational study may help improve the accuracy of AI and support its future role in clinical care.
背景：生成式人工智能（gen-AI）的快速发展引起了人们对其能否在治疗决策中识别和响应个体临床背景的兴趣。为了探索这一点，我们开发了一个淋巴水肿的虚拟患者模型，并进行了一项观察性研究，以检查AI会推荐什么治疗方法，这些建议是否个体化，以及AI表现出什么倾向。方法：使用生成式预训练变压器-4 omni （gpt - 40）构建100例乳腺癌手术后继发上肢淋巴水肿患者的虚拟队列。对于每个虚拟患者，根据日本淋巴水肿指南2024，将六个临床问题提交给人工智能，以引出个性化建议。将得到的答案与指南定义的推荐水平进行比较，以评估一致性、偏差和治疗倾向，并根据患者因素进行分析。结果：多变量分析表明，gpt - 40产生的建议是针对个体患者的特征量身定制的。它们与指南定义的保守治疗建议高度一致，但在手术环境下更大的变异性和偏向于侵入性选择。结论：gen-AI对侵入性治疗的偏好可能反映了对进行治疗而不是不进行治疗的益处的高估，特别是在侵入性治疗中。这种偏见显示了当前gen-AI在复杂决策中的局限性。我们的可重复模拟框架确定了这种偏差和可变性，阐明了gen-AI的优势和局限性。这种人工智能对人工智能的观察性研究可能有助于提高人工智能的准确性，并支持其未来在临床护理中的作用。
{"title":"Virtual patient modeling for generative-AI-assisted treatment decision-making in lymphedema care: AI tends to favor more aggressive treatment","authors":"Yuki Tsujimoto , Makoto Shiraishi , Hiroki Yamanaka , Haesu Lee , Mutsumi Okazaki , Naoki Morimoto","doi":"10.1016/j.ejso.2026.111391","DOIUrl":"10.1016/j.ejso.2026.111391","url":null,"abstract":"<div><h3>Background</h3><div>The rapid advancement of generative artificial intelligence (gen-AI) has prompted interest in whether it can recognize and respond to individual clinical backgrounds in treatment decision-making. To explore this, we developed a virtual patient model for lymphedema and conducted an observational study to examine what treatments AI would recommend, whether the recommendations were individualized, and what tendencies the AI exhibited.</div></div><div><h3>Methods</h3><div>A virtual cohort of 100 patients with secondary upper extremity lymphedema following breast cancer surgery was constructed using generative pre-trained transformer-4 omni (GPT-4o). For each virtual patient, six clinical questions, based on the Japanese Lymphedema Guidelines 2024, were submitted to the AI to elicit individualized recommendations. The answers obtained were compared with guidelines-defined recommendation levels to assess concordance, deviation, and treatment tendencies, analyzed by patient factors.</div></div><div><h3>Results</h3><div>Multivariate analysis demonstrated that GPT-4o-generated recommendations were tailored to individual patient characteristics. They showed high concordance with guideline-defined recommendations for conservative care but greater variability and bias toward invasive options in surgical contexts.</div></div><div><h3>Conclusion</h3><div>The preference of gen-AI for invasive treatments may reflect an overestimation of the benefits of performing treatments rather than withholding them, especially in invasive treatments. This bias shows a limitation of current gen-AI in complex decisions. Our reproducible simulation framework identified this bias and variability, clarifying both strengths and limitations of gen-AI. This type of AI-on-AI observational study may help improve the accuracy of AI and support its future role in clinical care.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111391"},"PeriodicalIF":2.9,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146017786","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-13DOI: 10.1016/j.ejso.2026.111396
Charlotte E. Terry, James M. Halle-Smith, Nabeel Merali, Ravi Marudanayagam, Nikolaos Chatzizacharias, Bobby V.M. Dasari, David C. Bartlett, Syed S. Raza, Adam E. Frampton, Robert P. Sutcliffe, Keith J. Roberts
Background
Evidence suggests that the biliary microbiome influences the progression of pancreatic ductal adenocarcinoma (PDAC) in patients undergoing adjuvant chemotherapy. Specifically, Gammaproteobacteria (GPB) has been shown to have the potential to develop mutations which can metabolise gemcitabine into an inactive form. This study hypothesised that GPB influences survival in patients with PDAC undergoing adjuvant gemcitabine-based chemotherapy following surgery.
Methods
This was a retrospective study of patients undergoing pancreatoduodenectomy from 2010 to 2020. Associations between patient and tumour characteristics, survival data, and results of intraoperative bile cultures (GPB + or GPB-) were investigated. Analysis of patients matched by chemotherapy regimen and numbers of cycles of adjuvant therapy was also performed. Survival was analysed using Kaplan–Meier curves and Cox regression analysis.
Results
Analysis of 313 patients revealed that adjuvant gemcitabine-based therapy improved overall survival (OS). Patients who receive gemcitabine-based chemotherapy with a GPB + biliary culture had a shorter OS compared to those who were GPB-, and a median survival of 17.9 vs 26.2 months, P = 0.002. After matching for key chemotherapy variables, survival was greater in the GPB- group 26.8 vs 19.8 months, P = 0.016. This association was not seen among patients who received no adjuvant therapy or non-gemcitabine based therapy.
Conclusion
Patients receiving gemcitabine-based chemotherapy after surgery are likely to have reduction in OS if they have a biliary culture positive for GPB.
{"title":"Colonization of bile with gammaproteobacteria is associated with reduced survival after surgery for pancreatic cancer in patients receiving gemcitabine-based adjuvant chemotherapy","authors":"Charlotte E. Terry, James M. Halle-Smith, Nabeel Merali, Ravi Marudanayagam, Nikolaos Chatzizacharias, Bobby V.M. Dasari, David C. Bartlett, Syed S. Raza, Adam E. Frampton, Robert P. Sutcliffe, Keith J. Roberts","doi":"10.1016/j.ejso.2026.111396","DOIUrl":"10.1016/j.ejso.2026.111396","url":null,"abstract":"<div><h3>Background</h3><div>Evidence suggests that the biliary microbiome influences the progression of pancreatic ductal adenocarcinoma (PDAC) in patients undergoing adjuvant chemotherapy. Specifically, <em>Gammaproteobacteria (GPB)</em> has been shown to have the potential to develop mutations which can metabolise gemcitabine into an inactive form. This study hypothesised that GPB influences survival in patients with PDAC undergoing adjuvant gemcitabine-based chemotherapy following surgery.</div></div><div><h3>Methods</h3><div>This was a retrospective study of patients undergoing pancreatoduodenectomy from 2010 to 2020. Associations between patient and tumour characteristics, survival data, and results of intraoperative bile cultures (GPB + or GPB-) were investigated. Analysis of patients matched by chemotherapy regimen and numbers of cycles of adjuvant therapy was also performed. Survival was analysed using Kaplan–Meier curves and Cox regression analysis.</div></div><div><h3>Results</h3><div>Analysis of 313 patients revealed that adjuvant gemcitabine-based therapy improved overall survival (OS). Patients who receive gemcitabine-based chemotherapy with a GPB + biliary culture had a shorter OS compared to those who were GPB-, and a median survival of 17.9 vs 26.2 months, P = 0.002. After matching for key chemotherapy variables, survival was greater in the GPB- group 26.8 vs 19.8 months, P = 0.016. This association was not seen among patients who received no adjuvant therapy or non-gemcitabine based therapy.</div></div><div><h3>Conclusion</h3><div>Patients receiving gemcitabine-based chemotherapy after surgery are likely to have reduction in OS if they have a biliary culture positive for GPB.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111396"},"PeriodicalIF":2.9,"publicationDate":"2026-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146017190","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-12DOI: 10.1016/j.ejso.2026.111403
Julia V.C. Lytchiér , Melis I. Okur , Wiktor Rutkowski , Hildur Helgadottir , Alberto Falk Delgado
Introduction
Neoadjuvant immune checkpoint inhibitors (ICI) have recently entered clinical practice in management of melanoma, yet its impact on surgical outcomes remains unclear.
This study evaluated the influence of neoadjuvant ICI on postoperative complications, surgical metrics, adjuvant treatment delay and survival in patients with stage III-IV melanoma following therapeutic lymph node dissections.
Material and methods
This retrospective cohort included patients that underwent surgery for nodal recurrence between 2019 and 2024. Patient characteristics, adverse events of ICI, surgical metrics, postoperative complications, postponement of adjuvant therapy, number of outpatient visits as well as survival were analyzed.
Results
81 patients were included, 19 patients received anti-PD-1 monotherapy followed by surgery and 62 patients underwent upfront surgery. Surgical duration was longer in the neoadjuvant group (p < 0.001), regardless of site and lymph nodes removed. Complications were observed in 63.2 % in neoadjuvant patients vs. 80.6 % in upfront patients (p = 0.13). The number of nurse outpatient visits was higher for neoadjuvant patients (p = 0.02) and increased with the number of removed lymph nodes (p = 0.05). The neoadjuvant patients started adjuvant therapy at median 6.0 weeks after surgery compared to 9.1 weeks in upfront (p < 0.001). At one year the overall survival was 100 % (95 % CI 100 - 100 %) in the neoadjuvant group and 90.3 % (95 % CI 83.3–98.0 %) in upfront surgery (P = 0.04).
Conclusion
Neoadjuvant ICI did not increase postoperative complications. It was associated with prolonged surgical duration and increased follow-up visits, but also shorter time until starting adjuvant treatment.
{"title":"Surgical complications after therapeutic lymph node dissection in stage III–IV melanoma: impact of neoadjuvant immunotherapy","authors":"Julia V.C. Lytchiér , Melis I. Okur , Wiktor Rutkowski , Hildur Helgadottir , Alberto Falk Delgado","doi":"10.1016/j.ejso.2026.111403","DOIUrl":"10.1016/j.ejso.2026.111403","url":null,"abstract":"<div><h3>Introduction</h3><div>Neoadjuvant immune checkpoint inhibitors (ICI) have recently entered clinical practice in management of melanoma, yet its impact on surgical outcomes remains unclear.</div><div>This study evaluated the influence of neoadjuvant ICI on postoperative complications, surgical metrics, adjuvant treatment delay and survival in patients with stage III-IV melanoma following therapeutic lymph node dissections.</div></div><div><h3>Material and methods</h3><div>This retrospective cohort included patients that underwent surgery for nodal recurrence between 2019 and 2024. Patient characteristics, adverse events of ICI, surgical metrics, postoperative complications, postponement of adjuvant therapy, number of outpatient visits as well as survival were analyzed.</div></div><div><h3>Results</h3><div>81 patients were included, 19 patients received anti-PD-1 monotherapy followed by surgery and 62 patients underwent upfront surgery. Surgical duration was longer in the neoadjuvant group (p < 0.001), regardless of site and lymph nodes removed. Complications were observed in 63.2 % in neoadjuvant patients vs. 80.6 % in upfront patients (p = 0.13). The number of nurse outpatient visits was higher for neoadjuvant patients (p = 0.02) and increased with the number of removed lymph nodes (p = 0.05). The neoadjuvant patients started adjuvant therapy at median 6.0 weeks after surgery compared to 9.1 weeks in upfront (p < 0.001). At one year the overall survival was 100 % (95 % CI 100 - 100 %) in the neoadjuvant group and 90.3 % (95 % CI 83.3–98.0 %) in upfront surgery (P = 0.04).</div></div><div><h3>Conclusion</h3><div>Neoadjuvant ICI did not increase postoperative complications. It was associated with prolonged surgical duration and increased follow-up visits, but also shorter time until starting adjuvant treatment.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111403"},"PeriodicalIF":2.9,"publicationDate":"2026-01-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146024138","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-10DOI: 10.1016/j.ejso.2026.111402
Qiang Wang , Lei Xu , Binghua Li , Karteek Popuri , Mirza Faisal Beg , Guojie Bai , Yunhua Tan , Anrong Wang , Torkel B. Brismar
Objective
This study aimed to evaluate the added value of volumetric body composition metrics to traditional scoring systems, Clinical Risk Score (CRS) and Tumor Burden Score (TBS), for improving risk stratification and prognosis prediction in patients with colorectal liver metastases following hepatectomy.
Methods
The information of 186 patients with colorectal liver metastases was retrospectively collected. AI-powered automated measurement of volumetric body composition was conducted on preoperative CT images (L1-L4), including skeletal muscle (SKM), subcutaneous adipose tissue (SAT), visceral adipose tissue, and intramuscular adipose tissue. A rule-based body composition signature was developed. Kaplan-Meier plots were adopted to depict overall survival (OS), disease-free survival (DFS) and hepatic-specific DFS of different risk groups.
Results
SKM and SAT were identified as significant indicators for OS with HR of 0.63 (95 % CI: 0.42–0.94) and 0.59 (95 % CI: 0.37–0.92), respectively. They were selected for developing body composition signature (BCS) (low SKM and low SAT: high risk; high SKM and high SAT: low risk; the others: medium risk). There was a significant difference among the three subgroups in OS, DFS, and hepatic DFS (all log-rank p < 0.05). When incorporated into CRS and TBS, the composite systems (CRS-BCS and TBS-BCS) improved patient risk stratification for the three survival outcomes (all log-rank p < 0.05). The composite systems had a higher time-dependent AUC than their standalone counterparts for OS, DFS and hepatic DFS.
Conclusion
Incorporating preoperative volumetric body composition signature into CRS and TBS can enhance risk stratification and prognosis prediction in CRLM patients undergoing hepatectomy.
{"title":"Improved risk stratification in patients with colorectal liver metastases by incorporating volumetric body composition analysis","authors":"Qiang Wang , Lei Xu , Binghua Li , Karteek Popuri , Mirza Faisal Beg , Guojie Bai , Yunhua Tan , Anrong Wang , Torkel B. Brismar","doi":"10.1016/j.ejso.2026.111402","DOIUrl":"10.1016/j.ejso.2026.111402","url":null,"abstract":"<div><h3>Objective</h3><div>This study aimed to evaluate the added value of volumetric body composition metrics to traditional scoring systems, Clinical Risk Score (CRS) and Tumor Burden Score (TBS), for improving risk stratification and prognosis prediction in patients with colorectal liver metastases following hepatectomy.</div></div><div><h3>Methods</h3><div>The information of 186 patients with colorectal liver metastases was retrospectively collected. AI-powered automated measurement of volumetric body composition was conducted on preoperative CT images (L1-L4), including skeletal muscle (SKM), subcutaneous adipose tissue (SAT), visceral adipose tissue, and intramuscular adipose tissue. A rule-based body composition signature was developed. Kaplan-Meier plots were adopted to depict overall survival (OS), disease-free survival (DFS) and hepatic-specific DFS of different risk groups.</div></div><div><h3>Results</h3><div>SKM and SAT were identified as significant indicators for OS with HR of 0.63 (95 % CI: 0.42–0.94) and 0.59 (95 % CI: 0.37–0.92), respectively. They were selected for developing body composition signature (BCS) (low SKM and low SAT: high risk; high SKM and high SAT: low risk; the others: medium risk). There was a significant difference among the three subgroups in OS, DFS, and hepatic DFS (all log-rank p < 0.05). When incorporated into CRS and TBS, the composite systems (CRS-BCS and TBS-BCS) improved patient risk stratification for the three survival outcomes (all log-rank p < 0.05). The composite systems had a higher time-dependent AUC than their standalone counterparts for OS, DFS and hepatic DFS.</div></div><div><h3>Conclusion</h3><div>Incorporating preoperative volumetric body composition signature into CRS and TBS can enhance risk stratification and prognosis prediction in CRLM patients undergoing hepatectomy.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111402"},"PeriodicalIF":2.9,"publicationDate":"2026-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146017536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Accurate identification of locally advanced rectal cancer (LARC) is crucial for treatment planning, yet conventional Magnetic resonance imaging (MRI) assessment remains subjective and experience-dependent, leading to inconsistent staging and suboptimal treatment decisions. An objective approach for preoperative risk stratification in rectal cancer patients, as an alternative to conventional MRI-based LARC identification, is therefore critically needed.
Method
We retrospectively analyzed 294 rectal adenocarcinoma patients from three cohorts who underwent preoperative MRI and surgery. Dynamic contrast-enhanced (DCE) MRI based and clinical features were analyzed for correlation with pathology and by Cox regression for feature selection, then used to build survival prediction models. Model performance was compared against MRI- and pathology-based LARC status for predicting postoperative 3-year disease-free survival (DFS). Mediation analysis assessed whether pathological characteristics mediated imaging-clinical feature effects on DFS.
Results
The kinetic DCE-MRI feature Washout inversely correlated with pathological T-stage. Preoperative carcinoembryonic antigen (CEA) (HR 1.02; 95 %CI: 1.001–1.039) and Washout (HR 0.014; 95 %CI: 0.001–0.332) were independent predictors of 3-year DFS. High-risk patients identified by the models had significantly worse survival than low-risk patients (p < 0.01). The models outperformed conventional MRI-based assessment (AUC 0.757–0.819 vs 0.600–0.672; C-index 0.755–0.774 vs 0.586–0.673). T/N stage partially mediated effects of CEA (17.7 %) and Washout (51.1 %) on DFS.
Conclusion
The developed models provide an objective, valuable tool for preoperative risk stratification as alternative to subjective LARC identification, enhancing preoperative risk stratification.
准确识别局部晚期直肠癌（LARC）对于治疗计划至关重要，然而传统的磁共振成像（MRI）评估仍然是主观的和依赖经验的，导致分期不一致和治疗决策不理想。因此，迫切需要一种客观的方法来对直肠癌患者进行术前风险分层，以替代传统的基于mri的LARC识别。方法回顾性分析3组294例直肠腺癌患者的术前MRI和手术资料。基于动态对比增强（DCE） MRI和临床特征分析与病理的相关性，并通过Cox回归进行特征选择，然后用于建立生存预测模型。将模型性能与基于MRI和病理的LARC状态进行比较，以预测术后3年无病生存（DFS）。中介分析评估病理特征是否介导影像学-临床特征对DFS的影响。结果动态DCE-MRI特征Washout与病理性t分期呈负相关。术前癌胚抗原（CEA） （HR 1.02; 95% CI: 1.001-1.039）和冲洗（HR 0.014; 95% CI: 0.001-0.332）是3年DFS的独立预测因子。模型识别出的高危患者生存率明显低于低危患者（p < 0.01）。模型优于传统的基于mri的评估（AUC 0.757-0.819 vs 0.600-0.672； c指数0.755-0.774 vs 0.586-0.673）。T/N期部分介导CEA（17.7%）和Washout（51.1%）对DFS的影响。结论所建立的模型为术前风险分层提供了一种客观、有价值的工具，可替代主观的LARC识别，加强术前风险分层。
{"title":"Clinical-radiological predictive model for preoperative risk stratification in rectal adenocarcinoma","authors":"Youfan Zhao , Zhongwei Chen , Yuguo Wei , Jiejie Zhou , Yaru Wei , Ying Zhu , Xiang Li , Yanyan Li , Ziyi Chen , Jiashan Zhan , Meihao Wang","doi":"10.1016/j.ejso.2026.111398","DOIUrl":"10.1016/j.ejso.2026.111398","url":null,"abstract":"<div><h3>Background</h3><div>Accurate identification of locally advanced rectal cancer (LARC) is crucial for treatment planning, yet conventional Magnetic resonance imaging (MRI) assessment remains subjective and experience-dependent, leading to inconsistent staging and suboptimal treatment decisions. An objective approach for preoperative risk stratification in rectal cancer patients, as an alternative to conventional MRI-based LARC identification, is therefore critically needed.</div></div><div><h3>Method</h3><div>We retrospectively analyzed 294 rectal adenocarcinoma patients from three cohorts who underwent preoperative MRI and surgery. Dynamic contrast-enhanced (DCE) MRI based and clinical features were analyzed for correlation with pathology and by Cox regression for feature selection, then used to build survival prediction models. Model performance was compared against MRI- and pathology-based LARC status for predicting postoperative 3-year disease-free survival (DFS). Mediation analysis assessed whether pathological characteristics mediated imaging-clinical feature effects on DFS.</div></div><div><h3>Results</h3><div>The kinetic DCE-MRI feature Washout inversely correlated with pathological T-stage. Preoperative carcinoembryonic antigen (CEA) (HR 1.02; 95 %CI: 1.001–1.039) and Washout (HR 0.014; 95 %CI: 0.001–0.332) were independent predictors of 3-year DFS. High-risk patients identified by the models had significantly worse survival than low-risk patients (<em>p</em> < 0.01). The models outperformed conventional MRI-based assessment (AUC 0.757–0.819 vs 0.600–0.672; C-index 0.755–0.774 vs 0.586–0.673). T/N stage partially mediated effects of CEA (17.7 %) and Washout (51.1 %) on DFS.</div></div><div><h3>Conclusion</h3><div>The developed models provide an objective, valuable tool for preoperative risk stratification as alternative to subjective LARC identification, enhancing preoperative risk stratification.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111398"},"PeriodicalIF":2.9,"publicationDate":"2026-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145975084","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Immunotherapy (IO) has been associated with better outcomes in locally advanced non-small cell lung cancers (NSCLCs). In 2017, our center introduced compassionate use of immunotherapy for stage III NSCLC as follows: neoadjuvant chemotherapy combined to perioperative immunotherapy and surgery for resectable NSCLCs (PERIOPERATIVE) and chemo-radiation therapy followed by immunotherapy (PACIFIC) for non-resectable NSCLCs. We report the outcomes and complications of 78 patients.
Methods
IWe reviewed all stage III NSCLC patients treated in the Center or Thoracic Surgery of Romandie (CURCT) between 2017 and 2023 with chemo-immunotherapy and surgery and radiation therapy using our prospectively collected database. We compared groups using Stata®.
Results
Intention to treat population consisted in 52 PERIOPERATIVE and 26 PACIFIC patients. PERIOPERATIVE patients were significantly younger (64 [60–71]vs73 [67–80], p = 0.0001) and had better lung diffusion capacity compared to PACIFIC patients (%predicted DLCO: 74 ± 18vs48 ± 26, p = 0.0008). Complications over the course of therapy occurred in more than 50 % of patients but remained manageable in both groups. Forty-two of 52 PERIOPERATIVE (81 %) and 18 of 26 (69 %) PACIFIC patients completed the entire treatment plan. There was no 30-day mortality. Complete pathological response (pCR) occurred in 11 of the 50 operated PERIOPERATIVE patients (22 %) and was associated with a 100 % 5-year survival. Overall, 5-year survival was of 78 % and 30 % in the PERIOPERATIVE and PACIFIC groups respectively.
Conclusion
The inclusion of immunotherapy in the management of stage III NSCLC has been associated with improved patient outcomes. Real life data suggests that patient complications are frequent but manageable and that patient dropout is low.
免疫治疗（IO）与局部晚期非小细胞肺癌（nsclc）的更好预后相关。2017年，我中心对III期非小细胞肺癌开展了富有同情心的免疫治疗，可切除的非小细胞肺癌（围手术期）采用新辅助化疗联合围手术期免疫治疗，不可切除的非小细胞肺癌（围手术期）采用化疗+放疗+免疫治疗（PACIFIC）。我们报告了78例患者的结果和并发症。方法：我们回顾了2017年至2023年间在罗曼迪胸外科中心（CURCT）接受化疗免疫治疗、手术和放疗的所有III期NSCLC患者，使用我们前瞻性收集的数据库。我们使用Stata®进行组间比较。结果意向治疗人群围手术期52例，太平洋期26例。围手术期患者明显更年轻（64 [60-71]vs73 [67-80], p = 0.0001），与太平洋患者相比，肺弥散能力更好（预测DLCO百分比：74±18vs48±26，p = 0.0008）。超过50%的患者在治疗过程中出现并发症，但在两组中都是可控的。52例围手术期患者中有42例（81%）和26例太平洋患者中有18例（69%）完成了整个治疗计划。没有30天死亡率。50例围手术期患者中有11例（22%）出现完全病理反应（pCR）， 5年生存率为100%。总的来说，围手术期和太平洋组的5年生存率分别为78%和30%。结论：在III期NSCLC的治疗中纳入免疫治疗与改善患者预后相关。现实生活中的数据表明，患者并发症频繁但可控，患者退学率很低。
{"title":"Real-world outcomes of stage III NSCLCs managed by surgery or definitive radiation therapy in the era of immunotherapy","authors":"Etienne Abdelnour-Berchtold , Louis-Emmanuel Chriqui , Laetitia Zermatten , Sotirios Papadopoulos , Celine Forster , Arpad Hasenauer , Benoit Bedat , Matthieu Zellweger , Remy Kinj , Nuria Mederos , Michel Christodoulou , Alfredo Addeo , Frederic Triponez , Wolfram Karenovics , Michel Gonzalez , Thorsten Krueger , Solange Peters , Hasna Bouchaab , Jean Yannis Perentes","doi":"10.1016/j.ejso.2026.111401","DOIUrl":"10.1016/j.ejso.2026.111401","url":null,"abstract":"<div><h3>Objectives</h3><div>Immunotherapy (IO) has been associated with better outcomes in locally advanced non-small cell lung cancers (NSCLCs). In 2017, our center introduced compassionate use of immunotherapy for stage III NSCLC as follows: neoadjuvant chemotherapy combined to perioperative immunotherapy and surgery for resectable NSCLCs (PERIOPERATIVE) and chemo-radiation therapy followed by immunotherapy (PACIFIC) for non-resectable NSCLCs. We report the outcomes and complications of 78 patients.</div></div><div><h3>Methods</h3><div>IWe reviewed all stage III NSCLC patients treated in the Center or Thoracic Surgery of Romandie (CURCT) between 2017 and 2023 with chemo-immunotherapy and surgery and radiation therapy using our prospectively collected database. We compared groups using Stata®.</div></div><div><h3>Results</h3><div>Intention to treat population consisted in 52 PERIOPERATIVE and 26 PACIFIC patients. PERIOPERATIVE patients were significantly younger (64 [60–71]vs73 [67–80], p = 0.0001) and had better lung diffusion capacity compared to PACIFIC patients (%predicted DLCO: 74 ± 18vs48 ± 26, p = 0.0008). Complications over the course of therapy occurred in more than 50 % of patients but remained manageable in both groups. Forty-two of 52 PERIOPERATIVE (81 %) and 18 of 26 (69 %) PACIFIC patients completed the entire treatment plan. There was no 30-day mortality. Complete pathological response (pCR) occurred in 11 of the 50 operated PERIOPERATIVE patients (22 %) and was associated with a 100 % 5-year survival. Overall, 5-year survival was of 78 % and 30 % in the PERIOPERATIVE and PACIFIC groups respectively.</div></div><div><h3>Conclusion</h3><div>The inclusion of immunotherapy in the management of stage III NSCLC has been associated with improved patient outcomes. Real life data suggests that patient complications are frequent but manageable and that patient dropout is low.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111401"},"PeriodicalIF":2.9,"publicationDate":"2026-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146074763","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-09DOI: 10.1016/j.ejso.2026.111400
Shizheng Mi , Fangli Xiong , Xinyan Li , Qiuping Ren
Background
Liver cancer has a high recurrence rate (up to 70 %) after hepatectomy, which significantly compromises long-term survival. No study has comprehensively compiled and externally validated Cox models for postoperative relapse.
Methods
We systematically searched the relevant articles from PubMed and Web of Science databases. Patients with hepatocellular carcinoma who underwent curative resection in the Department of Liver Surgery, West China Hospital of Sichuan University were retrospectively recruited and followed up regularly. Level 1 and Level 2 validation were conducted for the Cox models according to Royston-Altman approach. Kaplan-Meier curves were generated for each Level-2 validation.
Results
Our cohort was used to externally validate ten of the sixteen studies. The calibration slope (γ) of the five Cox models based on the Prognostic Index were 0.240, 0.383, 0.484, 0.634 and 1.129 in Level 1 validation and −0.030, 0.252, 0.264, 0.289 and 0.627 in Level 2 validation. Only one model effectively distinguished the recurrence risk between high and low-risk groups in Level 2 validation.
Conclusions
Without refitting the model, an optimal model was identified in both Level 1 and Level 2 validation. Our research methodology may be applicable to external validation studies across different regions and institutions.
背景：肝癌肝切除术后复发率高（高达70%），严重影响长期生存。目前还没有研究全面编制并外部验证了术后复发的Cox模型。方法：系统检索PubMed和Web of Science数据库的相关文章。回顾性收集四川大学华西医院肝外科行根治性肝癌切除术的患者，并定期随访。根据Royston-Altman方法对Cox模型进行一级和二级验证。每个Level-2验证生成Kaplan-Meier曲线。结果：我们的队列用于外部验证16项研究中的10项。基于Prognostic Index的5种Cox模型的校正斜率（γ）在一级验证中分别为0.240、0.383、0.484、0.634和1.129，在二级验证中分别为-0.030、0.252、0.264、0.289和0.627。在二级验证中，只有一个模型有效区分了高、低风险组的复发风险。结论：在不修改模型的情况下，在一级和二级验证中都确定了最优模型。我们的研究方法可能适用于不同地区和机构的外部验证研究。
{"title":"External validation of hepatocellular carcinoma recurrence model after surgery using the Royston-Altman approach","authors":"Shizheng Mi , Fangli Xiong , Xinyan Li , Qiuping Ren","doi":"10.1016/j.ejso.2026.111400","DOIUrl":"10.1016/j.ejso.2026.111400","url":null,"abstract":"<div><h3>Background</h3><div>Liver cancer has a high recurrence rate (up to 70 %) after hepatectomy, which significantly compromises long-term survival. No study has comprehensively compiled and externally validated Cox models for postoperative relapse.</div></div><div><h3>Methods</h3><div>We systematically searched the relevant articles from PubMed and Web of Science databases. Patients with hepatocellular carcinoma who underwent curative resection in the Department of Liver Surgery, West China Hospital of Sichuan University were retrospectively recruited and followed up regularly. Level 1 and Level 2 validation were conducted for the Cox models according to Royston-Altman approach. Kaplan-Meier curves were generated for each Level-2 validation.</div></div><div><h3>Results</h3><div>Our cohort was used to externally validate ten of the sixteen studies. The calibration slope (γ) of the five Cox models based on the Prognostic Index were 0.240, 0.383, 0.484, 0.634 and 1.129 in Level 1 validation and −0.030, 0.252, 0.264, 0.289 and 0.627 in Level 2 validation. Only one model effectively distinguished the recurrence risk between high and low-risk groups in Level 2 validation.</div></div><div><h3>Conclusions</h3><div>Without refitting the model, an optimal model was identified in both Level 1 and Level 2 validation. Our research methodology may be applicable to external validation studies across different regions and institutions.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111400"},"PeriodicalIF":2.9,"publicationDate":"2026-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146017542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-09DOI: 10.1016/j.ejso.2026.111399
Jacquelyn E. Fitzgerald , Avery C. Bechthold , Omari Whitlow , Olivia Monton , J. Nicholas Odom , Kimberly E. Kopecky
Background
Values elicitation, the structured process of clarifying what matters most to patients, is essential to patient-centered care in surgical oncology. This study examined how surgeons elicit, document, and incorporate patient values into surgical decision-making in clinical practice.
Methods
We conducted a 26-question international online survey (May–June 2025) assessing self-reported values elicitation practices among surgical oncologists, focusing on timing, methods, documentation, communication, and preparedness. The survey was distributed through professional networks using convenience and snowball sampling methods, wherein participants were recruited directly or referred by peers. Descriptive statistics summarized responses, and free-text answers were thematically analyzed.
Results
Ninety-one surgical oncologists responded to the survey. Most were male (n = 40, 56 %) and White (n = 52, 74 %), specializing in gastrointestinal (n = 32, 44 %), breast (n = 24, 33 %), or skin/soft tissue (n = 24, 33 %) oncology. Most reported eliciting patient values (n = 69, 87 %) and initiating values conversations (n = 52, 73 %). Surgeons reported documenting values (n = 55, 77 %) in the electronic health record and communicating them during tumor boards (n = 50, 83 %). Most surgeons (n = 48, 67 %) reported that patient values influenced recommendations in fewer than 25 % of cases. Nearly all (n = 69, 97 %) reported navigating treatment recommendations that conflicted with patients’ values. Narrative responses identified three strategies: direct questioning, goals-of-care framing, and shared decision-making dialogue. Time constraints (n = 50, 70 %) and limited training (n = 19, 27 %) were key barriers. Most (n = 66, 93 %) felt prepared, yet 78 % (n = 56) desired additional training.
Conclusions
While values elicitation was widely reported by surgical oncologists, it often did not influence surgical recommendations. Findings highlight the need to re-evaluate approaches and training for integrating patient values in surgical decision-making.
{"title":"Values elicitation among surgical oncologists: Findings from an international survey","authors":"Jacquelyn E. Fitzgerald , Avery C. Bechthold , Omari Whitlow , Olivia Monton , J. Nicholas Odom , Kimberly E. Kopecky","doi":"10.1016/j.ejso.2026.111399","DOIUrl":"10.1016/j.ejso.2026.111399","url":null,"abstract":"<div><h3>Background</h3><div>Values elicitation, the structured process of clarifying what matters most to patients, is essential to patient-centered care in surgical oncology. This study examined how surgeons elicit, document, and incorporate patient values into surgical decision-making in clinical practice.</div></div><div><h3>Methods</h3><div>We conducted a 26-question international online survey (May–June 2025) assessing self-reported values elicitation practices among surgical oncologists, focusing on timing, methods, documentation, communication, and preparedness. The survey was distributed through professional networks using convenience and snowball sampling methods, wherein participants were recruited directly or referred by peers. Descriptive statistics summarized responses, and free-text answers were thematically analyzed.</div></div><div><h3>Results</h3><div>Ninety-one surgical oncologists responded to the survey. Most were male (n = 40, 56 %) and White (n = 52, 74 %), specializing in gastrointestinal (n = 32, 44 %), breast (n = 24, 33 %), or skin/soft tissue (n = 24, 33 %) oncology. Most reported eliciting patient values (n = 69, 87 %) and initiating values conversations (n = 52, 73 %). Surgeons reported documenting values (n = 55, 77 %) in the electronic health record and communicating them during tumor boards (n = 50, 83 %). Most surgeons (n = 48, 67 %) reported that patient values influenced recommendations in fewer than 25 % of cases. Nearly all (n = 69, 97 %) reported navigating treatment recommendations that conflicted with patients’ values. Narrative responses identified three strategies: direct questioning, goals-of-care framing, and shared decision-making dialogue. Time constraints (n = 50, 70 %) and limited training (n = 19, 27 %) were key barriers. Most (n = 66, 93 %) felt prepared, yet 78 % (n = 56) desired additional training.</div></div><div><h3>Conclusions</h3><div>While values elicitation was widely reported by surgical oncologists, it often did not influence surgical recommendations. Findings highlight the need to re-evaluate approaches and training for integrating patient values in surgical decision-making.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111399"},"PeriodicalIF":2.9,"publicationDate":"2026-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145975083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-09DOI: 10.1016/j.ejso.2026.111395
Jun Suh Lee , Gianluca Cassese , Yoo-Seok Yoon , Ho-Seong Han , Boram Lee , Yesong Park , Jin-Young Jang , Wooil Kwon , Chang-Sup Lim
Background
The optimal transection level (TL) during distal pancreatectomy (DP) for pancreatic tail cancer remains unclear. This study evaluated the effect of TL on survival and glucose metabolism.
Methods
We retrospectively reviewed 320 patients undergoing DP between 2000 and 2018 at three centers. Patients were grouped as proximal transection (PT, n = 264) or distal transection (DT, n = 56) relative to the aorta. Perioperative, oncologic, and metabolic outcomes were compared, including a propensity score–matched analysis.
Results
Operation time and blood loss were greater in PT, which also yielded more lymph nodes (14 vs. 10, P < 0.01), though R0 resection and nodal positivity were similar. In the matched cohort, disease-free survival (17.7 vs. 15.3 months, P = 0.76) and overall survival (27.0 vs. 30.9 months, P = 0.64) did not differ between PT and DT. Multivariable analysis confirmed no association of TL with survival. Among non-diabetic patients, PT was associated with a greater rise in HbA1c at 1 year (0.57 % vs. 0.16 %; P = 0.056), suggesting impaired glycemic control.
Conclusions
Transection level does not influence oncologic outcomes in DP for pancreatic tail cancer but may affect postoperative glucose regulation.
背景：胰腺癌远端胰腺切除术（DP）的最佳横断水平（TL）尚不清楚。本研究评估了TL对生存和葡萄糖代谢的影响。方法回顾性分析了2000年至2018年在三个中心接受DP治疗的320例患者。患者被分为相对于主动脉的近端横断（PT, n = 264）或远端横断（DT, n = 56）。围手术期、肿瘤学和代谢结果进行比较，包括倾向评分匹配分析。结果PT组手术时间更长，出血量更大，淋巴结数量也更多（14比10，P < 0.01），但R0切除和淋巴结阳性相似。在匹配的队列中，PT和DT的无病生存期（17.7个月vs 15.3个月，P = 0.76）和总生存期（27.0个月vs 30.9个月，P = 0.64）没有差异。多变量分析证实TL与生存无关联。在非糖尿病患者中，PT与1年HbA1c升高相关（0.57% vs. 0.16%; P = 0.056），提示血糖控制受损。结论胰尾癌术后胰液横切水平不影响预后，但可能影响术后血糖调节。
{"title":"Impact of pancreatic transection level on survival outcomes and glycemic control following distal pancreatectomy for pancreatic tail cancer: A multicenter cohort study","authors":"Jun Suh Lee , Gianluca Cassese , Yoo-Seok Yoon , Ho-Seong Han , Boram Lee , Yesong Park , Jin-Young Jang , Wooil Kwon , Chang-Sup Lim","doi":"10.1016/j.ejso.2026.111395","DOIUrl":"10.1016/j.ejso.2026.111395","url":null,"abstract":"<div><h3>Background</h3><div>The optimal transection level (TL) during distal pancreatectomy (DP) for pancreatic tail cancer remains unclear. This study evaluated the effect of TL on survival and glucose metabolism.</div></div><div><h3>Methods</h3><div>We retrospectively reviewed 320 patients undergoing DP between 2000 and 2018 at three centers. Patients were grouped as proximal transection (PT, n = 264) or distal transection (DT, n = 56) relative to the aorta. Perioperative, oncologic, and metabolic outcomes were compared, including a propensity score–matched analysis.</div></div><div><h3>Results</h3><div>Operation time and blood loss were greater in PT, which also yielded more lymph nodes (14 vs. 10, P < 0.01), though R0 resection and nodal positivity were similar. In the matched cohort, disease-free survival (17.7 vs. 15.3 months, P = 0.76) and overall survival (27.0 vs. 30.9 months, P = 0.64) did not differ between PT and DT. Multivariable analysis confirmed no association of TL with survival. Among non-diabetic patients, PT was associated with a greater rise in HbA1c at 1 year (0.57 % vs. 0.16 %; P = 0.056), suggesting impaired glycemic control.</div></div><div><h3>Conclusions</h3><div>Transection level does not influence oncologic outcomes in DP for pancreatic tail cancer but may affect postoperative glucose regulation.</div></div>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"Article 111395"},"PeriodicalIF":2.9,"publicationDate":"2026-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145975082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-08DOI: 10.1016/j.ejso.2026.111385
Florian Primavesi, Iveta Urban, Daniela Rappold, Manuel Tiefenthaler, Jürgen Simharl, David Baumgartner, Stefan Petritsch, Michael Schausberger, Daniela Luger, Klaus Bogner, Claudia Bartsch, Karin Kreuzhuber, Jutta Stadler, Rafael Diaz-Nieto, Hassan Malik, Florian Ponholzer, Tilman Königswieser, Christian Dopler, Stefan Stättner
Introduction: Minimally-invasive surgery (MIS - including laparoscopy and robotics) and enhanced recovery after surgery (ERAS®) programs reduce complications and improve functional outcome for cancer patients. Their combined impact on liver surgery cohorts remains unclear.
Materials and methods: This Austrian single centre cohort study assesses the stepwise implementation of laparoscopy, robotic-assisted-surgery (RAS), and an audited ERAS® certification. Three periods (17 months each; January 2020 to 06/2024) were compared: P1 (pre-RAS/pre-ERAS®), P2 (RAS/ERAS®-like), and P3 (RAS/ERAS®). Outcomes included intensive-care and overall length-of-stay ((ICU-)LOS), 90-day-morbidity, mortality, post-hepatectomy liver failure, haemorrhage (PHLF/PHH), and bile leakage (BL). Textbook outcome after liver surgery (TOLS) was evaluated in cancer patients (definition: no blood loss >1000 ml, MIS-conversion, PHLF/BL, severe morbidity/mortality, readmission, and R1-margin).
Results: Over the three periods n = 225 patients showed comparable demographics, underlying liver disease, preoperative chemotherapy, and major resection rates. MIS (RAS) increased from 31.1 % (0 %), to 71.1 % (52.6 %), and 77.3 % (45.6 %; p < 0.001), with less conversions (21.1 %, to 3.7 %, and 5.9 %; p = 0.030). Decreasing median blood-loss (400 ml-200 ml in P3; p = 0.002) led to low transfusion rates (P3: 5.7 %). Median LOS/ICU-LOS decreased from 9/3 days, to 6/2, and 5/1 days (p < 0.001), overall (severe) 90-day-morbidity from 54.1 % (29.5 %), to 39.5 % (14.5 %), and 35.2 % (14.8 %) (p = 0.022/p = 0.011). PHLF reduced from 13.1 %, to 1.3 %, and 5.7 % (p = 0.009). TOLS rates enhanced from 37.9 %, to 68.2 %, and 70.8 % (p = 0.002). MIS was an independent predictor of lower (severe) morbidity and LOS.
Conclusions: Implementing MIS/RAS and ERAS® in an established hepatobiliary unit significantly improves blood-loss, (ICU-)LOS, morbidity, and PHLF. This ultimately leads to substantially increased TOLS rates in common oncological indications.
{"title":"Stepwise implementation of robotics and a certified enhanced recovery program significantly improves multiple outcome metrics in a liver surgery unit.","authors":"Florian Primavesi, Iveta Urban, Daniela Rappold, Manuel Tiefenthaler, Jürgen Simharl, David Baumgartner, Stefan Petritsch, Michael Schausberger, Daniela Luger, Klaus Bogner, Claudia Bartsch, Karin Kreuzhuber, Jutta Stadler, Rafael Diaz-Nieto, Hassan Malik, Florian Ponholzer, Tilman Königswieser, Christian Dopler, Stefan Stättner","doi":"10.1016/j.ejso.2026.111385","DOIUrl":"https://doi.org/10.1016/j.ejso.2026.111385","url":null,"abstract":"<p><strong>Introduction: </strong>Minimally-invasive surgery (MIS - including laparoscopy and robotics) and enhanced recovery after surgery (ERAS®) programs reduce complications and improve functional outcome for cancer patients. Their combined impact on liver surgery cohorts remains unclear.</p><p><strong>Materials and methods: </strong>This Austrian single centre cohort study assesses the stepwise implementation of laparoscopy, robotic-assisted-surgery (RAS), and an audited ERAS® certification. Three periods (17 months each; January 2020 to 06/2024) were compared: P1 (pre-RAS/pre-ERAS®), P2 (RAS/ERAS®-like), and P3 (RAS/ERAS®). Outcomes included intensive-care and overall length-of-stay ((ICU-)LOS), 90-day-morbidity, mortality, post-hepatectomy liver failure, haemorrhage (PHLF/PHH), and bile leakage (BL). Textbook outcome after liver surgery (TOLS) was evaluated in cancer patients (definition: no blood loss >1000 ml, MIS-conversion, PHLF/BL, severe morbidity/mortality, readmission, and R1-margin).</p><p><strong>Results: </strong>Over the three periods n = 225 patients showed comparable demographics, underlying liver disease, preoperative chemotherapy, and major resection rates. MIS (RAS) increased from 31.1 % (0 %), to 71.1 % (52.6 %), and 77.3 % (45.6 %; p < 0.001), with less conversions (21.1 %, to 3.7 %, and 5.9 %; p = 0.030). Decreasing median blood-loss (400 ml-200 ml in P3; p = 0.002) led to low transfusion rates (P3: 5.7 %). Median LOS/ICU-LOS decreased from 9/3 days, to 6/2, and 5/1 days (p < 0.001), overall (severe) 90-day-morbidity from 54.1 % (29.5 %), to 39.5 % (14.5 %), and 35.2 % (14.8 %) (p = 0.022/p = 0.011). PHLF reduced from 13.1 %, to 1.3 %, and 5.7 % (p = 0.009). TOLS rates enhanced from 37.9 %, to 68.2 %, and 70.8 % (p = 0.002). MIS was an independent predictor of lower (severe) morbidity and LOS.</p><p><strong>Conclusions: </strong>Implementing MIS/RAS and ERAS® in an established hepatobiliary unit significantly improves blood-loss, (ICU-)LOS, morbidity, and PHLF. This ultimately leads to substantially increased TOLS rates in common oncological indications.</p>","PeriodicalId":11522,"journal":{"name":"Ejso","volume":"52 3","pages":"111385"},"PeriodicalIF":2.9,"publicationDate":"2026-01-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146131595","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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