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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.

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: 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: 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: 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.