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Background: Obesity disproportionately affects patients awaiting elective non-bariatric surgery and complicates perioperative management. This systematic review aimed to assess the impact of weight-loss interventions on intraoperative and postoperative outcomes.

Methods: MEDLINE, Embase, CINAHL, and Web of Science databases were searched from inception to October 2025 for trials on weight-loss interventions. Two reviewers independently screened the studies, extracted relevant data, and assessed risk of bias. Pooled mean differences (MDs), standardized mean differences (SMDs), and odds ratios (ORs) were obtained from random-effects meta-analyses.

Results: Thirty-five studies with 9378 participants (mean(standard deviation) age 58(8) years; body mass index 35.6(6.4) kg/m2; 61% women) were included. The median duration of intervention was 8 (interquartile range 4-14) weeks. Preoperative weight-loss interventions were significantly associated with a reduction in overall postoperative complications (odd ratio (OR) 0.63, 95% confidence interval (c.i.) 0.43 to 0.93; I² = 32%) and in complications requiring medical intervention graded as Clavien-Dindo ≥ II (OR 0.66, 0.51 to 0.86; I² = 0%). Additionally, they were linked to a decreased risk of postoperative non-infectious wound-related complications (OR 0.38, 0.15 to 0.97; I2 = 0%), and with reduced intraoperative blood loss in gastrectomy (SMD -0.98, 95% c.i. -1.47 to -0.48; I2 = 0%) and hepatectomy (SMD -0.41, -0.82 to 0.00; I2 = 0%). Reductions in blood transfusion (OR 0.49, 0.31 to 0.79; I² = 0%), hospital readmission rates (OR 0.57, 0.47 to 0.70; I² = 0%), and length of hospital stay (SMD -0.08, -0.13 to -0.04; I² = 0%) were also noted. No association was observed for surgical site infection, venous thromboembolism, or return to the emergency department. Compared with standard care or no intervention, weight-loss interventions led to greater weight loss (MD -3.92 (95% c.i. -5.44 to -2.39) kg; I2 = 91%), and fat mass loss (MD -4.78 (-6.49 to -3.06) kg; I2 = 0%) but no change in lean mass (SMD -0.25, -0.51 to 0.01; I2 = 0%). In a sensitivity analysis of studies at low risk of bias, the estimates and precision of most outcomes did not change materially.

Conclusion: Despite heterogeneity in study design and surgical populations, the evidence consistently demonstrated that weight-loss interventions are feasible, safe, and can reduce postoperative complications across various surgical specialties alongside improving many outcomes.

Background: Incisional hernia remains the most common complication of open abdominal surgery. The aim was to investigate whether a reinforced tension-line suture combined with standard 4 : 1 small-bite closure reduces the 3-year incidence of computed tomography-detected incisional hernia in open colorectal cancer surgery.

Methods: Patients aged > 18 years, scheduled for colorectal cancer resection through a midline incision between 2017 and 2021 at Skåne University Hospital Malmö and Kristianstad County Hospital, Sweden, were eligible for inclusion. Patients were randomized to fascial closure by reinforced tension-line suture combined with 4 : 1 small-bite closure with polypropylene sutures (RTL group) or 4 : 1 small-bite closure alone with polydioxanone sutures (PDS group), in a 1 : 1 ratio. Computed tomography interpreters were blinded to study groups. Univariate, bivariate, and multivariate logistic regression analyses were performed to investigate and adjust study groups for potential risk factors for incisional hernia.

Results: The study randomized 80 patients in each group. At 3 years, 101 remained for analysis: 43 in the RTL group and 58 in the PDS group. Incisional hernia was detected in 27 patients: 6 of 43 (14%) in the RTL and 21 of 58 (36%) in the PDS group, resulting in a significant risk difference of 22% (odds ratio 3.50, 95% confidence interval 1.27 to 9.66; P = 0.016). In multivariate analysis, the PDS group (odds ratio 3.40, 1.14 to 10.14; P = 0.028) and adjuvant chemotherapy (odds ratio 2.98, 1.10 to 8.08; P = 0.032) were significant risk factors for incisional hernia. No adverse events related to the closure techniques were found in either group.

Conclusion: Adding a reinforced tension-line suture significantly reduced the long-term incidence of incisional hernia compared with the 4 : 1 small-bite technique alone in patients undergoing open colorectal cancer surgery. These findings suggest that the reinforced tension-line suture is an efficient and easy way to prevent incisional hernia.

Background: Various studies have reported on the prognostic impact of ductal margin and radial margin status in resected perihilar cholangiocarcinoma (PCCA). No study has considered differences in the prognostic impact of individual resection margins. This study investigated the prognostic impact of individual planes on survival.

Methods: All patients undergoing surgery for PCCA at Amsterdam UMC and Karolinska University Hospital between January 2010 and May 2023 were included. Clinicopathological data were retrospectively retrieved. The primary outcomes were the prognostic significance of residual disease (< 1 mm to the nearest tumour growth) in individual dissection planes and resection margins for overall survival (OS) and disease-free survival (DFS), expressed as adjusted hazard ratios (aHRs).

Results: Of 199 patients, 81 (41%) underwent radical resection and 118 (59%) were reported to have microscopic residual disease. Only a positive proximal bile duct resection margin was significantly associated with shorter OS (adjusted median OS 24 versus 36 months; aHR 1.64; 95% confidence interval (c.i.) 1.05 to 2.56; P = 0.031) and DFS (aHR 2.01; 95% c.i. 1.30 to 3.10; P = 0.002). Other positive resection margins and dissection planes did not carry any prognostic information for OS (Pinteraction = 0.95) or DFS (Pinteraction = 0.56). Similar results were obtained in a 90-day landmark sensitivity analysis.

Conclusion: This study found that only tumour infiltration of the proximal bile duct resection margin was associated with worse prognosis, most likely reflecting the malignant behaviour of the disease rather than surgical failure. Larger prospective studies are needed to clarify the true prognostic impact of residual disease in individual resection planes to allocate patients to specific chemotherapeutic (neo)adjuvant treatments.

Background: Previous studies of minimally invasive liver surgery described results and experiences in high-volume centres and early adopters, but data on national levels are lacking. This study evaluated the implementation and outcomes of minimally invasive liver surgery in Sweden over a 15-year period, with a focus on colorectal liver metastases.

Methods: Data from patients undergoing liver surgery between 2009 and 2023 were obtained from the Swedish National Quality Registry for Liver, Gallbladder and Bile Duct Cancer, and evaluated in time intervals. Propensity score matching analysis was used to compare outcomes between open and minimally invasive liver surgery for colorectal liver metastases.

Results: A total of 9977 procedures were included in the study, of which 1490 (14.9%) were minimally invasive. Minimally invasive liver surgery was used increasingly over time, and had better short-term outcomes than open liver operations, including less blood loss (median 200 (interquartile range 50-400) versus 500 (250-1000) ml; P < 0.001), fewer major complications (127 (9.3%) versus 1697 (21.9%); P < 0.001), and a lower 30-day mortality rate (6 patients (0.4%) versus 107 (1.3%); P = 0.004). Use of robotically assisted liver surgery increased over time and it constituted 311 minimally invasive liver procedures (38.4%) in the late time period. Propensity score matching analysis for patients with colorectal liver metastases showed reduced blood loss with minimally invasive liver surgery (P < 0.001), a similar rate of radical resections, and similar overall survival.

Conclusion: The study demonstrated safe nationwide implementation of minimally invasive liver surgery. Use of the minimally invasive approach increased over time, including a rapid rise for robotically assisted procedures in the later period. Minimally invasive liver surgery maintained or improved favourable short-term outcomes without adverse effects on morbidity, mortality or long-term survival after surgery for colorectal liver metastases.

Background: Acute cholecystitis is a common complication of gallstone disease. Although early laparoscopic cholecystectomy is recommended, some patients do not undergo early surgery and remain at risk of recurrent disease. This study investigated whether early cholecystectomy for recurrent cholecystitis is associated with higher complication rates versus first-time cholecystitis.

Methods: A retrospective population-based cohort study was conducted using data from the Swedish Registry of Gallstone Surgery. Patients undergoing early cholecystectomy for acute cholecystitis in Sweden between 1 January 2006, and 31 December 2020, were included. Patients with recurrent cholecystitis were compared to those with a first episode. The primary outcome was the total 30-day complication rate. Secondary outcomes included open surgery, prolonged surgery (≥ 120 minutes), bile duct injury, and specific complications such as intestinal injury, bleeding, reoperation, abscess, and 30-day mortality. Multivariable logistic regression was used to calculate odds ratios (OR), adjusting for age, sex, American Society of Anesthesiologists (ASA) grade, and time from admission to surgery as confounders.

Results: Among 34 925 patients, 3384 had recurrent cholecystitis and 31 541 had first-time cholecystitis. The recurrent cholecystitis group had a higher complication rate (20.2 versus 13.8%) and an increased risk of bile duct injury (OR 2.44; 95% confidence interval (c.i.) 1.67 to 3.56), intestinal perforation (OR 2.54; 95% c.i. 1.51 to 4.25), prolonged surgery (OR 1.64; 95% c.i. 1.53 to 1.67), and open surgery (OR 1.76; 95% c.i. 1.64 to 1.92). However, patients with recurrent cholecystitis were older and had a higher ASA grade.

Conclusion: Early cholecystectomy for recurrent cholecystitis is associated with increased complication rates compared with first-time cholecystitis. These findings support early surgical intervention during the first episode to reduce the risk of adverse outcomes associated with recurrent disease.

Background: Achalasia is rare disease in children and young people (CYP) that causes significant symptoms and often requires invasive interventions. There is currently no consensus on the optimal management strategy. This study investigated the current management and outcomes of CYP with achalasia in the UK.

Methods: A retrospective study was conducted of CYP (aged ≤ 16 years) diagnosed with achalasia between 2011 and 2021 in the UK. The study was co-designed with the patient group Achalasia Action. Data were collected from patient records. The primary outcome was treatment success.

Results: In all, 126 patients were included from 13 UK centres; 64 of the patients (50.8%) were male and the median age at diagnosis was 12 (interquartile range (i.q.r.) 9-14) years. The most frequent presenting features were dysphagia (73.8%), vomiting (53.2%), and weight loss (38.9%). The median time from symptom onset to diagnosis was 11 (i.q.r. 6-24) months. Treatment success was achieved in 55 of 120 patients (45.8%) after first-line intervention. Heller's cardiomyotomy (HCM) as the first-line intervention had a higher success rate than endoscopic balloon dilatation (EBD; (52 of 72 (72%) versus 3 of 48 (6%), respectively; P < 0.001). However, overall HCM had a higher frequency of complications than EBD (17 of 98 (17%) versus 3 of 57 (5%), respectively; P = 0.045). In the entire cohort, 53% of patients reported symptoms at the 1-year follow-up.

Conclusions: Variation exists in the management of CYP with achalasia in the UK. The highest rates of treatment success were associated with HCM. Many CYP remain symptomatic after treatment and require multiple interventions. The present data can be used to inform management decisions in CYP with achalasia.

Background: Postoperative mortality is a key indicator of surgical quality and central to volume-outcome research, which has shaped minimum case volume standards. In Switzerland, evidence for gastric cancer surgery outcomes remains limited, and regulation is still debated. This study analysed nationwide perioperative volume-outcome associations.

Methods: The study comprised an analysis of the inpatient database from the Swiss Federal Statistical Office. Patients undergoing surgical or endoscopic resection for gastric cancer between 1998 and 2021 were included. Data were stratified by surgical caseload (quartiles), hospital inpatient volume, and hospital type. Outcomes included in-hospital mortality, failure to rescue, and perioperative morbidity.

Results: Some 8708 patients from over 30 million hospital admissions were included. The annual resection volume increased from 290 in 2000 to 432 in 2020. The overall in-hospital mortality rate was 3.9%, with an inverse association with surgical caseload (2.2% in centres performing > 20 resections annually versus 2.8, 4.2, and 4.6% in lower-volume quartiles; P = 0.001). Similar correlations were observed for hospitals with > 35 000 inpatient admissions annually (2.3 versus 3.6 and 4.7%; P < 0.001) and for university hospitals (2.0 versus 4.2 and 4.3%; P < 0.001). Although the reported proportion of severe complications was higher, the rate of failure to rescue was lower in hospitals with high inpatient volumes (P < 0.001) and in university hospitals (P = 0.002).

Conclusion: The findings of lower rates of in-hospital mortality and failure to rescue in hospitals with higher surgical and inpatient volumes support the potential value of centralization in gastric cancer surgery, and may guide future discussions on regulation.