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Background: Enhanced recovery after surgery is associated with improved clinical outcomes and cost savings. Comparisons between studies and settings are challenging owing to variable data collection and definitions. The objective of this study was to explore variation in compliance with enhanced recovery after surgery and outcomes across surgery types and countries using a standardized database.

Methods: This international retrospective cohort study included adult patients who underwent surgical procedures (colorectal, gynaecological, pancreatic, hepatic, breast reconstruction, head and neck, urological, pulmonary), treated with enhanced recovery after surgery recorded in a standardized database between January 2017 and September 2021. The primary outcomes, length of hospital stay and complications, and the exposure variable, compliance with enhanced recovery after surgery, were captured from the standardized database. Patient demographic characteristics and surgical complexity were abstracted and considered as co-variates. Negative binomial and logistic regression analyses were used to model outcomes as a function of enhanced recovery after surgery compliance score.

Results: The cohort included 12 134 patients (from Canada, the Netherlands, and Switzerland) who had median age of 63 years and underwent colorectal (59%) or gynaecological (19%) surgery. The median compliance with enhanced recovery after surgery differed by country (Canada 78.6%, the Netherlands 67.7%, Switzerland 80.0%). Each 1-unit increase in enhanced recovery after surgery compliance score corresponded to reduced length of hospital stay across all operations, by 0.94 (95% confidence interval (c.i.) 0.85 to 1.04) days in Canada, 1.03 (0.85 to 1.20) days in the Netherlands, and 1.55 (1.12 to 1.97) days in Switzerland. Each 1-unit increase in enhanced recovery after surgery compliance score corresponded to a 29 (95% c.i. 25 to 33)% reduction in odds of experiencing a severe complication across all operations in Canada, a 22 (14 to 31)% reduction in the Netherlands, and a 5 (2 to 8)% reduction in Switzerland.

Conclusion: Using a standardized database, this study confirmed that enhanced recovery after surgery compliance is associated with reduced length of hospital stay and complications in an international multisurgical cohort.

Background: Colorectal cancer is a common malignancy. Despite advances in minimally invasive surgery, achieving optimal outcomes for locally advanced rectal cancer remains challenging. Transanal total mesorectal excision (TaTME) is an alternative to laparoscopic total mesorectal excision (LapTME), but inconsistent data warrant a comprehensive meta-analysis of the two procedures.

Methods: A systematic search was conducted across the PubMed, Embase, and Cochrane Library databases up to June 2025 using keywords related to rectal cancer and TaTME. The study protocol was registered with PROSPERO. Inclusion criteria followed the PICOS framework, selecting randomized clinical trials (RCTs) and observational studies comparing TaTME with LapTME or robotic total mesorectal excision (TME). Studies reporting on non-malignant cases, single-arm studies, and studies with insufficient data for analysis were excluded. Primary outcomes of interest were surgical metrics (operative time, conversion rates), pathological outcomes (circumferential resection margin (CRM), TME completion), oncological outcomes (local recurrence, overall survival), and functional outcomes (major low anterior resection syndrome (LARS)).

Results: In all, 65 studies involving 13 972 participants met the inclusion criteria. TaTME had lower conversion rates (odds ratio (OR) 0.35; 95% c.i. 0.24 to 0.51; P < 0.01), improved TME completeness (OR 1.26; 95% c.i. 1.02 to 1.55; P = 0.03), and lower CRM positivity (OR 0.7; 95% c.i. 0.58 to 0.85; P < 0.01) compared with LapTME. Local recurrence was reduced (OR 0.69; 95% c.i. 0.55 to 0.87; P < 0.01) and overall survival improved (hazard ratio 0.80; 95% c.i. 0.70 to 0.91; P < 0.01) following TaTME, but TaTME was associated with a higher risk of major LARS (OR 1.58; 95% c.i. 1.11 to 2.24; P = 0.01). Subgroup analysis revealed consistent results across RCTs and cohort studies.

Conclusion: TaTME offers several advantages over LapTME, including lower conversion rates and improved CRM and oncological outcomes. The increased risk of major LARS with TaTME underscores the importance of balancing functional outcomes with other benefits. Future research should focus on optimizing functional recovery and addressing high heterogeneity across studies.

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: Sleeve gastrectomy is an effective bariatric procedure but may lead to persistent symptoms without obvious mechanical cause. The normal gastric pacemaker region, which lies on the greater curvature of the corpus, is resected in sleeve gastrectomy, but the electrophysiological consequences are not adequately defined. This study assessed these impacts and associations with symptoms and quality of life (QoL) using non-invasive gastric mapping.

Methods: Patients with previous sleeve gastrectomy underwent body surface gastric mapping (Gastric Alimetry), comprising 30-minute fasting baseline and 4-hour post-prandial recordings. Analysis encompassed principal gastric frequency (PGF), body mass index-adjusted amplitude, and the Gastric Alimetry Rhythm Index (GA-RI), with comparison to reference intervals and matched controls. Symptoms were evaluated using a validated app and questionnaires.

Results: The study recruited 38 patients (median 36 months after surgery; range 6-119 months) and 38 controls. Of the 38 patients, 35 had at least one abnormal parameter compared with controls, typically reduced frequencies (mean(standard deviation) 2.30(0.34) versus 3.08(0.21) c.p.m., respectively; P < 0.001) and amplitudes (14.8(6.9) versus 31.5(18.0) µV, respectively; P < 0.001). Patients exhibited higher symptoms and lower QoL than the controls (Patient Assessment of Upper Gastrointestinal Disorders (PAGI) Symptoms Questionnaire scores 20 versus 7, respectively (P < 0.001); PAGI-QOL 27 versus 136, respectively (P < 0.001)). Gastric amplitude (R = 0.71, P < 0.001) and the GA-RI (R = 0.60, P = 0.02) were positively correlated with bloating, whereas amplitude was negatively correlated with heartburn (R = -0.46, P = 0.03). Lower gastric amplitudes were also correlated with greater weight loss (R = -0.45; P = 0.014).

Conclusion: Sleeve gastrectomy modifies gastric electrophysiology due to pacemaker resection, with variable remodelling. Substantial reductions in gastric frequency and amplitude occur routinely after surgery, with specific associations between post-procedural gastric amplitude and symptoms of heartburn, bloating, and weight loss identified.

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.