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Background: According to a retrospective study at Zhongshan Hospital, external drainage of the main pancreatic duct (MPD) and common bile duct (CBD) is potentially superior over internal drainage. As yet there is no consensus regarding the optimal drainage strategy, and previous studies have not adequately addressed risk stratification for postoperative pancreatic fistula (POPF). The aim of this study is to determine the clinical advantage of external drainage of the MPD and CBD over internal drainage during pancreatoduodenectomy.

Methods: This multicentre randomized clinical superiority study is designed to compare the effects of external and internal drainage of the MPD and CBD on the incidence of postoperative complications for patients at intermediate or high risk of POPF. In all, 322 eligible patients will be recruited across six pancreatic centres and randomly assigned 1 : 1 to either an external or internal drainage group. The primary outcome is the incidence of clinically relevant POPF (Grade B/C) within 90 days after surgery. The anticipated duration of enrolment is 1 year, along with a minimum follow-up period of 2 years, with follow-up visits every 3 months.

Conclusion: This trial will provide evidence for the efficacy of simultaneous external drainage of the MPD and CBD in the management of pancreatoduodenectomy, optimizing drainage strategies for pancreatoduodenectomy and facilitating the adoption of advanced drainage technologies. Registration number: NCT06322680 (http://www.clinicaltrials.gov); ChiCTR2400086321 (https://www.chictr.org.cn).

Background: In patients with the most advanced stages of high-risk locally advanced rectal cancer (LARC), extensive resections often lead to morbidity and functional impairment. It is unclear whether these patients, despite poor prognosis, are suitable candidates for a watch-and-wait (W&W) approach in cases of a clinical complete response (cCR).

Methods: Consecutive patients with high-risk LARC who underwent total neoadjuvant therapy (TNT), followed by surgery or a W&W approach between January 2016 and February 2023, were retrospectively analysed. High-risk features included tumour invasion into the mesorectal fascia, grade 4 extramural venous invasion, enlarged lateral lymph nodes, or tumour deposits. Patients were categorized into complete response (CR) or non-CR, and stratified by W&W and surgically treated. Outcomes were regrowth, local recurrence, distant metastases (DM), regrowth-free survival, organ survival, local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), recurrence-free survival (RFS) (all death-censored), and overall survival.

Results: Of 135 patients, 29 (21.5%) achieved a cCR and entered W&W. A total of 103 patients (78.0%) underwent immediate surgery, including 15 (11.1%) with a pathological CR. Median follow-up was 42 months (range 9-76) for CR patients versus 42.5 months (range 7-82) for non-CR patients. Local recurrence and DM occurred in 1 (2.3%) and 7 patients (15.9%) in the CR group, respectively, versus 14 (15.9%) and 21 patients (23.9%) in the non-CR group, respectively. Three-year death-censored LRFS and DMFS rates were 97.6% and 82.7% in the CR group, respectively, versus 85.8% and 76.0% in the non-CR group, respectively (P = 0.016, P = 0.273). Five-year overall survival was 89.5% in the CR group versus 84.0% in the non-CR group (P = 0.131). Median follow-up was 44 months (range 16-71) in W&W patients and 42 months (range 7-82) in surgically treated patients. Among W&W patients, regrowth occurred in seven patients (24.1%) and the 3-year death-censored regrowth-free survival was 79.2%. Three-year death-censored RFS and 5-year overall survival were 71.9% and 90.9% in W&W patients, respectively, versus 72.3% and 84.2% in surgically treated patients, respectively (P = 0.680, P = 0.115).

Conclusion: A W&W approach can be considered safe and feasible for patients with high-risk LARC. Achieving a CR after TNT is associated with favourable oncological outcomes.

Background: Secondary peritonitis caused by gastrointestinal perforation is associated with significant morbidity and mortality. Effective management includes surgical source control, antibiotic therapy, and intensive resuscitation. The choice between primary abdominal closure (PAC) and vacuum-assisted closure (VAC) in the management of secondary peritonitis remains a subject of debate.

Methods: This Danish nationwide register-based cohort study included patients undergoing emergency surgery for secondary peritonitis from perforation of the small intestine, colon, or rectum between 2007 and 2021 who were treated with either PAC or VAC. Data were extracted from national registries, including the Danish Register of Cause of Death and the Danish National Patient Registry. The primary outcome was overall all-cause mortality; secondary outcomes were all-cause mortality at 30 days, 90 days, and 1 year.

Results: In all, 13 898 patients were included (1017 in the VAC group, 12 881 in the PAC group). VAC-treated patients had significantly higher Charlson Co-morbidity Index scores and were slightly younger. In the subgroup with available laboratory data, VAC-treated patients also presented with more severe biochemical derangements, including elevated C-reactive protein, leukocytes, bilirubin, and lactate, as well as lower haemoglobin, suggesting a higher baseline severity of illness. The overall risk-stratified mortality rate (RSMR) was 49.1% for VAC and 52.0% for PAC (P = 0.222). The 30-day mortality rate was 16.9% in both the VAC and PAC groups, with RSMR of 17.4% and 18.3%, respectively (P = 0.656). At 90 days, mortality was 24.3% and 22.5% in the VAC and PAC groups, respectively, with a corresponding RSMR of 23.2% and 24.2% (P = 0.437). One year after surgery, the mortality rate was 31.3% for VAC and 29.5% for PAC, with a corresponding RSMR of 30.3% and 31.6% (P = 0.346).

Conclusion: This nationwide cohort study revealed no significant differences in mortality between PAC and VAC in patients with secondary peritonitis at any of the designated time points. Demographic and laboratory data suggest that VAC-treated patients had a higher baseline severity of illness.

Background: Recent improvements in pancreatic surgery outcomes have highlighted the relevance of comprehensive quality measures, including textbook outcome. The aim of this study was to evaluate textbook outcome in patients with pancreatic neuroendocrine tumours undergoing surgical resection.

Methods: All patients undergoing surgery for pancreatic neuroendocrine tumours between 2010 and 2023 were included. Textbook outcome was defined as the absence of severe morbidity (Clavien-Dindo grade ≥ III), pancreatic fistula, bile leakage, haemorrhage, readmission, and no death. Logistic regression analysis was used to identify risk factors and Kaplan-Meier survival analysis to compare disease-free and overall survival.

Results: A total of 622 patients underwent surgery for pancreatic neuroendocrine tumours. Major morbidity occurred in 192 patients (30.9%) with an in-hospital mortality rate of 2.6% (16 patients). Rates of postoperative pancreatic fistula, haemorrhage, and readmission were 21.5, 6.4, and 10.3% respectively. Overall, a textbook outcome was achieved in 399 patients (64.1%), with a higher rate after organ-sparing versus formal resections (89 (74.8%) versus 310 (61.6%); P = 0.008). Risk factors for non-textbook outcome were older age (odds ratio 1.52, 95% confidence interval 1.05 to 2.20; P = 0.028), higher body mass index (odds ratio 1.61, 95% CI 1.15 to 2.25; P = 0.006), American Society of Anesthesiologists grade ≥ III (odds ratio 1.63, 95% CI 1.14 to 2.35; P = 0.008), and longer duration of surgery (odds ratio 1.69, 95% CI 1.17 to 2.45; P = 0.006). Patients with a textbook outcome had higher 5-year rates of disease-free (73 versus 67%; P = 0.025) and overall (88 versus 78%; P < 0.001) survival than those with a non-textbook outcome. This effect was confirmed in patients with non-functioning pancreatic neuroendocrine tumours (overall survival: 85 versus 77%; P = 0.003). In multivariable analysis, textbook outcome remained an independent predictor of survival.

Conclusion: A textbook outcome was achieved in most patients undergoing pancreatic surgery for pancreatic neuroendocrine tumours and was associated with improved long-term survival. Textbook outcome may serve as a quality control and prognostic indicator in surgery for pancreatic neuroendocrine tumours.

Background: Small bowel obstruction (SBO) due to hernia remains a prevalent surgical emergency disproportionately affecting elderly and co-morbid populations. Limited high-quality data exist to guide evidence-informed interventions for hernia-related SBO. This study explored the management and outcomes of hernia-related SBO (hSBO) for patients captured in European Society for Trauma and Emergency Surgery (ESTES) SnapSBO database.

Methods: SnapSBO is a prospective multicentre time-bound study that accrued consecutive inpatient admissions between November 2023 and May 2024. The present analysis was restricted to patients with abdominal wall hernias. Management pathways were categorized as direct to surgery (DTS), successful non-operative management (NOM), or surgery after trial of NOM (NOM-T). Outcomes of interest included complications, 30-day in-hospital mortality, length of hospital stay (LOS), and functional recovery assessed through patient-reported outcome measures (PROMs) using the PRO-diGI tool.

Results: Among 1737 patients, SBO due to abdominal wall hernia was noted in 386. The median patient age was 73 (range 16-98) years, with 64.8% of patients aged > 65 years. Primary inguinal/abdominal wall hernias were the most common (62.2%). Of the patients, 51.6% were categorized as DTS, where 17.1% required surgery after NOM-T. NOM was successful in 31.2% of patients. Parastomal hernia management led to the highest complication rate (57.1%) and prolonged postoperative LOS (mean(standard deviation) 9.1(4.8) days; P = 0.030) compared with other hernia types. Functional recovery measured in 218 patients was significantly worse in those with parastomal hernia than in those with incisional or primary inguinal hernias (mean(standard deviation) bowel function scores 68.6(22.5) versus 83.6(17.6) and 82.0(20.3), respectively; P = 0.009).

Conclusion: There is significant variability in practice and outcomes for hSBO management. Patients with parastomal hernias represent a high-risk subgroup. Future research should focus on PROMs and in developing evidence-based, context-specific guidelines for hSBO management.

Background: An increase in early-onset colorectal cancer has been observed globally, despite a decline in colorectal cancer incidence rates in many Western countries. Screening strategies for younger individuals are particularly challenging, as there are limited data on polyps in young individuals to guide clinicians. This study aimed to systematically review the current evidence surrounding polyp distribution in different age groups.

Methods: A literature search was performed in PubMed, Scopus, MEDLINE, Embase (OVID), Web of Science, and Cochrane Review databases using the keywords 'age' and 'polyp', and Medical Subject Heading terms 'age of onset', 'age factors', 'age distribution', and 'age groups', with no restrictions on publication year. Articles published in English that described the distribution of polyps (adenomatous, advanced adenomatous polyps, and sessile serrated lesions) or individuals with polyps according to different age groups were considered for inclusion. Younger patients were defined as those aged < 50 years. The outcomes of interest were the number of patients with polyps in the left and/or right colon, or the number of polyps per side of the colorectum in different age groups.

Results: From 12 470 articles, 24 met the eligibility criteria for the systematic review, and 12 were suitable for meta-analysis. Among younger people, 46.5% had right-sided and 75.9% had left-sided polyps. In comparison, 70.8% of the older group had right-sided and 61.9% had left-sided polyps. Meta-analyses of studies showed a greater proportion of younger people than older people with at least one left-sided polyp (mean difference 0.06, 95% confidence interval (c.i.) 0.03 to 0.09; P < 0.001). There was also a greater proportion of left-sided polyps in younger people (odds ratio 0.77, 95% c.i. 0.59 to 1.01; P < 0.001).

Conclusion: Patients aged < 50 years have a greater tendency towards having polyps in the left colon, compared with people ≥ 50 years of age, similar to the distribution of early-onset colorectal cancer. This has implications for the methodology of screening and investigation of symptoms in those aged < 50 years.

Background: Considerable variability exists among liver surgeons in assessing resectability and local treatment planning of initially unresectable colorectal cancer liver-only metastases (CRLM). This study analysed short-term and survival outcomes of one-stage versus two-stage surgery for CRLM.

Methods: Patients with initially unresectable CRLM were included from the phase 3 CAIRO5 study. In patients in whom both one-stage and two-stage approaches were suggested by individual panel surgeons, these approaches were compared. The study population includes only patients for whom both approaches were discussed by the panel surgeons. Overall survival curves were estimated with the Kaplan-Meier method and compared with the two-sided stratified log-rank test. Other surgical and postoperative outcomes were compared using a two-sample t test and Pearson's χ2 test or Fisher's exact test, as appropriate.

Results: Local surgeons planned one-stage versus two-stage surgery in 53 versus 51 patients, respectively. In the one-stage versus two-stage surgery groups, the median age was 59 (interquartile range (i.q.r.) 52-69) versus 59 (i.q.r. 53-68) years, respectively, and the median number of CRLM was 9 (i.q.r. 6.5-13) versus 10 (i.q.r. 7.5-14), respectively. Median overall survival was 46.5 versus 34.0 months (HR 0.61; 95% confidence interval 0.38 to 0.99; P = 0.043) with planned one-stage versus two-stage surgery, respectively. In one-stage versus two-stage surgery, Clavien-Dindo grade ≥ 3 complications occurred in 11 versus 13 patients (P = 0.567), portal vein embolization was performed in 2 versus 41 patients (P < 0.001), and local treatment was complete (R0/R1 resection or ablation of all CRLM) in 52 versus 29 patients (P < 0.001), respectively. Major liver resection was performed in 19 versus 28 patients with complete planned one-stage versus two-stage surgery, respectively, with a corresponding 32 versus 12 patients undergoing ablation.

Conclusion: One-stage surgery with/without ablation appears to be the optimal treatment approach for patients with initially unresectable CRLM for whom both one- and two-stage approaches are considered. Nonetheless, two-stage surgery remains vital for complex CRLM.

Background: Quality indicators (QIs) are essential for assessing and improving healthcare delivery. Existing QIs for breast reconstruction are limited and do not comprehensively reflect clinical complexity or patient-centred outcomes. This study aimed to develop a scientifically grounded, consensus-based set of QIs for breast reconstruction using the Delphi method.

Methods: A structured Delphi process was conducted. Experts, including plastic surgeons, reconstructive nurses, and patient representatives from 21 European countries, were nominated by national professional and patient organizations. A pre-round generated 141 unique QIs, thematically analysed and categorized into six domains. Three Delphi rounds were conducted via electronic surveys. Consensus was defined a priori as ≥ 75% agreement across the whole group or at least two subgroups. Indicators were classified according to Donabedian's model (structure, process, outcome).

Results: Among the 43 experts completing all rounds, 41 QIs reached final consensus. These indicators span six key quality domains (Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centredness) and include measures such as access to reconstruction, treatment timelines, multidisciplinary collaboration, unit characteristics, surgical outcomes, and patient satisfaction. Structure, process, and outcome indicators were all represented, including patient-reported outcomes and patient-reported experiences.

Conclusion: This Delphi study provides the first comprehensive set of QIs specific to breast reconstruction in Europe. These indicators lay the groundwork for future standardization, benchmarking, and quality improvement initiatives. Further work is needed to operationalize the indicators through evidence grading, measurement specifications, risk adjustment, and integration into clinical practice.