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Background: Postoperative pancreatic fistula (POPF) is a major complication after left pancreatectomy. The current International Study Group of Pancreatic Surgery classification has limitations, including heterogeneity in morbidity and high interobserver variability. This study aimed to assess POPF-related morbidity after left pancreatectomy and propose a refined classification system.

Methods: Patients undergoing left pancreatectomy at nine high-volume centres between January 2010 and April 2023 were included. All postoperative treatments and interventions related to POPF were collected. The Comprehensive Complication Index (CCI) was used to assess total cumulative morbidity. The International Study Group of Pancreatic Surgery B POPF was subclassified (B1 = prolonged drainage, B2 = pharmacological intervention, B3 = percutaneous intervention, B4 = endoscopic or angiographic intervention). A new POPF grading system was developed by combining subclasses with similar morbidity.

Results: Among 2284 patients, 497 (21.8%) had B (B1: 48 (2.1%), B2: 135 (5.9%), B3: 175 (7.7%), B4: 99 (4.3%)) or C (40 (1.8%)) POPF. Median (interquartile range) POPF-related CCI was 33.5 (22.6-39.7). A significant overlap existed between B and C POPF in terms of CCI. Median CCI (i.q.r.) increased with the B POPF subclasses (B1-B4), 8.7 (8.7-8.7) - 22.6 (20.9-22.6) - 33.5 (33.5-34.6) - 47.4 (39.7-52.1) (P < 0.001), but no difference between B4 POPF and C POPF was observed (median CCI 47.4 versus 50.2; P = 0.265). The refined POPF grading system consists of grades 0 (including biochemical leak and B1), A (including B2), B (including B3), and C (including B4 and C) reflecting worsening morbidity.

Conclusion: The current International Study Group of Pancreatic Surgery classification includes highly heterogeneous grade B POPF cases, ranging from minimal to severe morbidity. The refined grading system improves classification and clinical relevance by aligning POPF severity with morbidity and short-term outcomes.

Background: The use of abdominal drains in pancreatic surgery, both in partial pancreatoduodenectomy and left pancreatectomy, remains controversial. This study explored the value of routine abdominal drainage on postoperative outcomes.

Methods: A systematic literature search was performed in CENTRAL (Cochrane Central Register of Controlled Trials) and PubMed up to 1 May 2025. All randomized clinical trials (RCTs) investigating the use and management of routine prophylactic abdominal drainage in patients undergoing pancreatic resections were included. A random-effects model for Mantel-Haenszel and inverse-variance analysis was used. Risk of bias (Cochrane 2.0) and certainty of evidence GRADE (Grading of Recommendations, Assessment, Development and Evaluation) were assessed.

Results: Thirteen RCTs with 2796 patients were included. Ten RCTs on partial pancreatoduodenectomy with 1744 patients, and seven RCTs on left pancreatectomy with 1052 patients. Four interventions were studied: abdominal drainage versus no abdominal drainage, irrigation-suction versus passive-gravity drainage, closed-suction versus passive-gravity drainage, and early versus late drain removal. Stratification for partial pancreatoduodenectomy and left pancreatectomy was performed, resulting in eight different line-ups. Two line-ups provided sufficient data to allow meta-analysis. Early drainage removal in partial pancreatoduodenectomy, following the study inclusion criteria, was shown to be safe with the additional benefit of significantly reducing chyle leak (odds ratio 0.22, 95% confidence interval (c.i.) 0.08 to 0.59; P < 0.01). The omission of routine abdominal drainage in left pancreatectomy was found to be safe, resulting in fewer postoperative pancreatic fistulas (odds ratio 0.52, 95% c.i. 0.36 to 0.77; P < 0.01) and a shorter hospital stay (mean difference -0.48 days, 95% c.i. -0.61 to -0.35; P < 0.01).

Conclusion: The present meta-analysis provides level 1a evidence in favour of a selective early drain removal policy in partial pancreatoduodenectomy and a no-drain policy in left pancreatectomy.

Background: Ovarian metastases are common in patients with colorectal cancer (CRC) with peritoneal metastases. For patients with bilateral macroscopically normal ovaries, prophylactic bilateral salpingo-oophorectomy (BSO) remains controversial. This study assessed the survival benefit of prophylactic BSO during cytoreductive surgery (CRS).

Methods: This retrospective cohort study included patients with CRC with peritoneal metastases who underwent CRS at two medical centres in southern China between 2017 and 2022. Patients achieving complete CRS with bilateral macroscopically normal ovaries were included in the subsequent analysis and divided into BSO and non-BSO groups. The primary outcomes of interest were the rates of synchronous and metachronous ovarian metastases. Clinical and surgical variables, including peritoneal carcinoma index (PCI) scores, were analysed for their correlation with these outcomes. Disease-free survival and overall survival were analysed using the Kaplan-Meier method, and prognostic variables were analysed using multivariate logistic regression.

Results: Of 237 consecutive patients who underwent CRS, 94 had macroscopically normal ovaries. Of these, 69 (29.1%) underwent complete CRS and were divided into two groups: 26 who underwent prophylactic BSO and 43 with organ preservation. In the BSO group, 7 patients (26.9%) had occult synchronous ovarian metastases. In the non-BSO group, 13 patients (30.2%) developed metachronous ovarian metastases, with 10 of these patients undergoing secondary surgery for ovarian metastases. Both synchronous and metachronous ovarian metastases were significantly associated with a higher PCI (P = 0.048). Premenopausal status was independently associated with metachronous ovarian metastases (hazard ratio 6.281; 95% confidence interval 1.364 to 28.922; P = 0.018). No significant differences were observed between the BSO and non-BSO groups in 2-year disease-free survival (P = 0.866) or overall survival (P = 0.557).

Conclusion: For patients with CRC with peritoneal metastasis and bilateral macroscopically normal ovaries, prophylactic BSO does not improve mid-term survival.

Background: Surgical resection is the standard treatment for phaeochromocytoma (PCC). Current guidelines recommend an open approach for large tumours due to the increased risk of complications. This study aimed to characterize surgical outcomes for large (≥ 6 cm) and small (< 6 cm) PCCs and to identify factors that may improve postoperative outcomes.

Methods: This retrospective cohort study of patients undergoing adrenalectomy for PCC in 49 international centres between 2012 and 2022 compared patients with tumours < 6 cm in diameter and those with tumours ≥ 6 cm in diameter. Univariate, bivariate (dichotomous), and multivariate (multiple logistic and linear) analyses were used to evaluate outcomes and risk factors for complications. A secondary multivariable analysis evaluated factors, including operative approach, influencing outcomes for patients with tumours ≥ 6 cm. A 1:1 propensity score-matched (PSM) analysis was completed to control for age, sex, body mass index, and the Charlson Co-morbidity Index.

Results: Of the 2301 patients included in the analysis, 598 (26.0%) had PCCs with a diameter ≥ 6 cm. Patients with tumours ≥ 6 cm had a higher incidence of severe (Clavien-Dindo grade ≥ IIIa) postoperative complications (11.2% versus 4.8%; P < 0.001). Multivariable analysis revealed that tumour size ≥ 6 cm was an independent predictor of any complications (odds ratio (OR) 1.93; P < 0.001). Subanalysis of patients with tumours ≥ 6 cm demonstrated that laparoscopic (OR 0.33; P < 0.001) and robotic (OR 0.40; P = 0.038) adrenalectomy were independently associated with less morbidity than an open approach. PSM analysis revealed a mean 276.0-ml higher blood loss (95% confidence interval (c.i.) 138.9 to 413.0 ml; P < 0.001) and 2.9-point higher Comprehensive Complication Index (95% c.i. 0.6 to 5.3; P = 0.015) for patients with tumours ≥ 6 cm compared with patients with PCCs < 6 cm in diameter. Optimal cut-off analysis revealed that a tumour diameter of ≥ 5.8 cm was associated with increased complications.

Conclusion: Patients undergoing adrenalectomy for PCCs ≥ 6 cm have a higher risk of severe complications than patients with smaller tumours. Despite this increased risk in patients with large (≥ 6 cm) tumours, minimally invasive surgery was independently associated with a reduced likelihood of complications. This study supports a minimally invasive approach in patients with large PCCs.

Background: With demographic changes and the increasing suitability of even older and frail patients for complex aortic aneurysm repair, clinical decision-making has become increasingly complex. A critical factor in deciding whether to proceed with surgery is the estimated life expectancy, a prediction that is inherently challenging. Understanding survival outcomes, contextualized within a population-based framework, is therefore critical.

Methods: This retrospective study analysed patients undergoing fenestrated endovascular aortic repair (FEVAR) between 2013 and 2023. Patient and mortality data were sourced from medical records and the Austrian National Death Registry. Estimated life expectancy was calculated using national life tables, fitted with spline functions to provide age- and sex-specific estimates. Observed survival was illustrated using Kaplan-Meier curves, and adjusted analyses were performed using Cox regression models. Observed survival was then contextualized based on the estimated life expectancy, and two potential survival scenarios were investigated.

Results: Of 293 included patients, 127 (43.3%) died, predominantly from cardiovascular events. The observed median age of survival was 83.6 years versus a population-based expectancy of 86.5 years. Patients aged < 75 years had higher post-procedural survival than patients aged > 75 years, although the confidence intervals overlapped for the first 1700 days, indicating no significant differences in mid-term survival. Women experienced higher early mortality than men (14.3% versus 6.4% at 150 days), with no significant long-term sex differences. Potential survival scenarios demonstrated close alignment between observed survival and a favourable scenario, where censored patients were assumed to live to their estimated life expectancy. Adjusted analyses identified age and American Society of Anesthesiologists grade as significant predictors of mortality.

Conclusion: Survival outcomes aligning with population-based life expectancy estimates can be achieved in patients undergoing FEVAR when cases are well selected. However, cardiovascular mortality remains a significant burden. Population estimates can provide some guidance but are of limited usefulness for individual patient predictions, especially for younger patients, where the overall prognosis may be worse than anticipated based on age alone.

Background: Hepatocellular carcinoma (HCC) rupture is a life-threatening complication associated with poor prognosis. This study comprehensively analysed risk factors for HCC rupture and developed a predictive model supplemented by machine learning models for early risk identification and clinical decision-making.

Methods: This retrospective study analysed patients with and without HCC rupture from tertiary centres in China between January 2016 and June 2019. Propensity score matching (PSM) was used to reduce baseline differences between the rupture and non-rupture groups. Random forest and deep learning models were developed to enhance predictive accuracy and interpret variable importance. Model performance was evaluated using metrics such as precision, recall, and the F1 score across training, validation, and test cohorts.

Results: Among the 5952 HCC patients, the median follow-up duration was 48.6 months. Key risk factors for HCC rupture identified in this study include cirrhosis, protrusion ratio, and tumour maximum length. The CAPTure nomogram, constructed based on these predictors, yielded area under the curve (AUC) values of 0.857, 0.824, and 0.840 in the training, validation, and test cohorts, respectively. In the test cohort, the random forest and deep learning models achieved AUCs of 0.870 and 0.872, respectively.

Conclusion: This study provides a comprehensive analysis of risk factors for HCC rupture and introduces the CAPTure model as a practical and accurate tool for clinical use. By integrating traditional and machine learning approaches, the findings of this study offer robust methods for early risk assessment, resource optimization, and improved management of HCC rupture.

Background: There has been an increasing number of single-centre studies describing the long-term outcomes of patients with Hirschsprung disease. This study aimed to systematically review the literature on long-term bowel, urological, and sexual functional outcomes, fertility and quality of life in adults with Hirschsprung disease.

Methods: A PROSPERO-registered systematic review of the English literature was conducted for studies published up to July 2025 that reported functional outcomes beyond childhood (≥16 years) for patients who had undergone surgery for Hirschsprung disease. Centres were contacted individually for secondary analyses of patient-level data on bowel function score, Gastrointestinal Quality of Life Index, and Short Form 36 questionnaire. Data were analysed and compared with those from healthy controls in the studies retrieved and from a reference healthy population. Hirschsprung disease clinical and surgical variables were correlated with these outcomes of interest in a patient-level analysis.

Results: Fifty-three manuscripts fulfilled the inclusion criteria of 4277 papers retrieved. Patients with Hirschsprung disease had a greater likelihood of constipation (odds ratio 9.27, 95% confidence interval (c.i.) 4.78 to 18.06) and soiling (odds ratio 2.76, 1.96 to 3.89) compared with healthy controls. They scored lower on the Gastrointestinal Quality of Life Index (mean difference -5.21, 95% c.i. -9.53 to -0.89; P = 0.020). There were no significant differences in Short Form 36 domain scores except for physical functioning (mean difference -6.30, -8.74 to -3.87; P < 0.001). At a patient level, longer-segment disease (P < 0.001) and redo pull-through surgery (P = 0.002) were associated with a poorer bowel function score. Short form 36 scores were lower in women across six of eight domains; similarly, Gastrointestinal Quality of Life Index scores were lower in women (P < 0.001) and in patients with longer-segment disease (P < 0.001).

Conclusion: Among patients with Hirschsprung disease, women, those with longer-segment disease, and patients who underwent redo surgery may be at risk of poorer quality of life.

Background: Surgery provides definitive management of many age-related diseases, relieving symptoms or extending life. Age-related physiological decline, multimorbidity, and frailty predispose older people to postoperative complications and incomplete functional recovery, with resultant health and social care costs. These age-related conditions can be optimized using Comprehensive Geriatric Assessment (CGA), thus mitigating perioperative risk to improve clinical outcomes with cost-effectiveness. National organizations advocate CGA-based services for older surgical patients. However, there is variation in the provision of CGA-based perioperative medicine for older people undergoing surgery (POPS) services across the UK National Health Service, resulting in inequitable access for older surgical patients at higher risk, unnecessary deaths, complications, and financial cost. The aim of the POPS Scale Up (POPS-SUp) study is to determine whether CGA-based POPS services can be implemented at scale to cost-effectively improve clinical outcomes for older patients undergoing surgery.

Methods: A mixed-methods hybrid implementation-effectiveness interrupted time series study will examine the use of a coproduced implementation strategy to embed CGA-based POPS services at scale in the UK. Co-primary implementation-effectiveness outcomes will be used, namely reach and length of hospital stay, respectively. Evaluation will include an embedded process evaluation, quantitative evaluation of clinical effectiveness and cost-effectiveness, and qualitative appraisal of patient and staff experience. The proposed analysis is to embed a process evaluation using real-time framework analysis, enabling iterative refinement and evaluation of the implementation strategy. Accepted interrupted time series analysis will be used to examine and compare outcomes per participating site. A predefined dissemination strategy has been co-designed with patients/carers, clinical community of practice, and organizational bodies.

Conclusion: The anticipation is that POPS-SUp will have impact at the individual (patient and clinician), organizational, and policy levels in the perioperative setting, but with additional potential application to other clinical settings.Registration numbers: ISRCTN 45327 (https://www.isrctn.com/); NIHR 157443 (https://www.nihr.ac.uk/).

Introduction: Patients presenting with right-sided obstructing colon cancers (ROCCs) typically undergo emergency surgical resection. Emerging evidence suggests using a bridge-to-surgery (BTS) approach with a stoma or stent reduces mortality and perioperative morbidity while not effecting long-term survival. The aim of this scoping review was to provide a comprehensive report of the recent literature reporting the management of ROCC.

Methods: Systematic searches were conducted of the Embase, MEDLINE, and CENTRAL databases for studies published between 2000 and 2025. Searches were uploaded to the Covidence review tool and dual screened (abstract and full text) against prespecified inclusion criteria. Key data extraction points were: study characteristics, interventions used, patient and oncological descriptors, and outcomes reported. Data are reported descriptively as per PRISMA-ScR guidance.

Results: Twenty-seven studies were identified: 22 primary research studies and 5 systematic reviews. Primary research studies were predominantly retrospective cohorts (20), with nine single-centre studies. Emergency resection was the most common intervention (7528, 75.4%), ahead of a colonic stent as a BTS (2289, 22.9%) and defunctioning stoma as a BTS (114, 1.1%). Of note, the vast majority of patients treated with a stent were from a single paper. There were 76 different descriptors reported, with 61 reported in fewer than five studies. In all, 70 perioperative, 8 stent-specific, and 21 oncological outcomes were reported. The focus was on perioperative outcomes, with only two oncological outcomes reported in five or more studies. Of the five included systematic reviews, four compared emergency resection to BTS and reported favourable outcomes of the BTS approach.

Conclusion: Current available evidence is non-randomized and limited by retrospective study design. Although BTS appears favourable, studies are poorly powered, meaning the current evidence is insufficient to support BTS approaches.