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Background: Metastases in the lateral pelvic lymph nodes or mesenteric lymph nodes represent distinct categories of mid-low rectal cancer. This study investigated the patterns of mesenteric and lateral pelvic lymph node metastases in mid-low rectal cancer; the survival benefit of postoperative treatment was also analysed in these groups.

Methods: This retrospective multicentre study included consecutive patients with mid-low rectal cancer who underwent total mesorectal excision with lateral pelvic lymph node dissection in three Chinese institutions between 2012 and 2020. The primary outcome was metastatic patterns and clinicopathological features of patients with mesenteric lymph node and lateral pelvic lymph node involvement. The secondary outcome was survival.

Results: Of 566 patients treated during the study period, 407 were selected. Four lymph node metastasis patterns were compared: metastasis to both mesenteric and lateral pelvic lymph nodes (68 patients, 17%), metastasis confined to lateral pelvic lymph nodes (24 patients, 6%), metastasis confined to mesenteric lymph nodes (121 patients, 29.7%), and neither mesenteric nor lateral pelvic lymph node metastasis (194 patients, 47.7%). Patients with metastases confined to lateral pelvic nodes had a lower proportion of poor histological types (P = 0.003), lymphatic invasion (P = 0.001), and number of lateral pelvic nodal metastases (P = 0.005) compared with patients with both mesenteric and lateral pelvic lymph node metastases. Independent of preoperative treatment, metastasis confined to the lateral pelvic nodes was associated with a significantly better prognosis than metastasis in both the mesenteric and lateral pelvic lymph nodes (3-year overall survival: 78.6 versus 47.2%, P = 0.007; 3-year disease-free survival: 65.7 versus 24.9%, P = 0.011), and it was similar to that of patients with metastasis confined to the mesenteric nodes (3-year overall survival: 78.6 versus 85.4%, P = 0.559; 3-year disease-free survival: 65.7 versus 70.4%, P = 0.447).

Conclusion: Patients with metastasis confined to lateral pelvic lymph nodes have comparable pathological features and prognoses to those with metastasis confined to mesenteric nodes; such disease can be managed and treated in the same way as regional lymph node metastasis.

Background: Pain relief is an important aspect of recovery after open liver resection. This randomized open-label single-centre trial assessed the efficacy of intravenous (i.v.) analgesia alone or in combination with catheter wound infusion (CWI) or intrathecal morphine (ITM) after open liver resection.

Methods: Adult patients undergoing open liver resection were randomly assigned to receive either i.v. analgesia alone or in combination with ITM or CWI. In this study, i.v. analgesia consisted of systematic i.v. paracetamol and i.v. morphine via a patient-controlled analgesia pump, with i.v. nefopam as rescue analgesia for a Numeric Rating Scale (NRS) score > 4. The primary outcome was cumulative morphine dose at 24 hours (h). Secondary outcomes included pain intensity, cumulative opioid use at 48 and 72 h, and postoperative complications.

Results: In all, 186 patients were included in the study (62 patients in each group). The median 24-h morphine dose was 14 (interquartile range (i.q.r.) 6-25) mg in the i.v. analgesia group, 14 (i.q.r. 7-23) mg in the CWI group, and 7 (i.q.r. 3-15) mg in the ITM group. ITM significantly reduced morphine use compared with i.v. analgesia alone (mean difference on log-transformed values 0.57; 95% confidence interval 0.21 to 0.93; Bonferroni-adjusted P = 0.002) and lowered pain scores during the first 12 h. No significant differences were observed between the CWI and i.v. analgesia groups. By 72 h, cumulative opioid use was similar across all groups. Adverse events and postoperative complications were comparable across the three groups.

Conclusion: ITM reduced the cumulative morphine dose and pain intensity in the first 24 h after liver resection, providing a valuable option for postoperative analgesia.

Registration number: NCT03238430 (http://www.clinicaltrials.gov).

Background: Post-hepatectomy bile leakage is a challenging issue that can lead to morbidities and mortality after liver resection. This leakage can occur either from a bilioenteric anastomosis (BEA) or from the transected surface of the liver. This study investigated the incidence, risk factors, and effective management of BEA leakage after major liver resection.

Methods: Bile leakage was diagnosed through drain fluid analysis based on the International Study Group of Liver Surgery definition. Leakage from a BEA was confirmed via fluoroscopy during percutaneous interventions or reoperation. Perioperative data and data on the management of patients with BEA leakage were collected and analysed. Bivariate analysis used Mann-Whitney U and χ2 tests, and binary logistic regression identified risk factors for BEA leakage, with variables having P < 0.200 included in multivariable analysis.

Results: Of 2936 patients undergoing hepatectomy between 2008 and 2023, 229 underwent liver resection with BEA. Leakage from the BEA was identified in 44 patients (19.2%). These patients had a higher rate of post-hepatectomy haemorrhage (P = 0.005), major complications (P = 0.001), BEA stenosis (P = 0.006), and mortality (P = 0.043). The success rate of the management of BEA leakage was 70% for reoperation and 58% for percutaneous transhepatic cholangiography and drainage (PTCD).

Conclusion: BEA leakage after major liver resection is a severe complication associated with higher morbidity and mortality rates. Surgical treatment appeared to be more successful than PTCD in the early postoperative phase. PTCD proved to be a valuable additional therapy option following reoperation. These conclusions should be taken with caution and need to be confirmed through further prospective studies.

Introduction: Ileal pouch-anal anastomosis (IPAA) is a common surgical procedure for patients with ulcerative colitis or familial adenomatous polyposis. This study compared the outcomes of robotic, laparoscopic, and open IPAA techniques, with a focus on surgical complications and pouch failure rates.

Methods: A retrospective study was conducted of patients who underwent IPAA at three Mayo Clinic locations between 2015 and 2020. Data on patient demographics, surgical details, and postoperative outcomes were collected and compared across the three surgical approaches. Pouch failure was defined as the need for pouch excision or a diverting loop ileostomy.

Results: In all, 401 patients underwent IPAA with either an open (149, 37.2%), robotic (145, 36.2%), or laparoscopic (107, 26.7%) technique. The overall rate of pouch failure was 6.5% and did not differ significantly between the three surgical approaches. Compared with laparoscopy, robotic IPAA was associated with a lower conversion rate to open surgery (1.4 versus 17.8%; P < 0.0001) and fewer 30-day readmissions (15.9% versus 28.0%; P = 0.02). However, robotic and laparoscopic IPAA approaches had higher rates of venous thromboembolism/pulmonary embolism and readmission than the open approach. Pouchitis was the most common cause of pouch failure across all surgical techniques.

Conclusion: Robotic IPAA had lower conversion and reduced 30-day admission rates compared with a laparoscopic approach. However, open surgery had lower rates of 30-day readmission and rates thromboembolism than robotic IPAA. The surgical approach itself does not appear to significantly impact long-term pouch failure rates.

Background: Accurate preoperative localization is essential for successful, focused, minimally invasive surgery in primary hyperparathyroidism (PHPT). New imaging techniques have recently been proposed. This study evaluated the impact of 18F-choline positron emission tomography (PET)-computed tomography or 18F-choline PET-magnetic resonance imaging (FCh) in patients with negative or inconclusive results on neck ultrasonography (US) and 99mTc-sestamibi (MIBI) scintigraphy.

Methods: Baseline biochemical characteristics (preoperative calcemia and PTH), parathyroid gland features (size and weight), preoperative imaging localization techniques accuracy, and surgical results were compared in a series of patients operated for PHPT who underwent only preoperative US and MIBI scintigraphy with concordant results (MIBI Group) or also FCh as additional imaging following US and MIBI with negative or inconclusive results (FCh Group).

Results: The overall cure rate was 100% in 185 patients operated for PHPT. The overall sensitivity of imaging was 63.9% in the MIBI group (n = 116), compared with 94.4% (P < 0.001) in the FCh group (n = 69). FCh provided clear unilateral localization in 86.9% of patients, avoiding unnecessary bilateral neck exploration; in contrast, based on MIBI results, unilateral localization would have been theoretically possible in only 61.6% of patients. Compared with the MIBI group, patients in the FCh group had significantly lower preoperative calcium levels (2.71 versus 2.79 mmol/l; P = 0.012), lower preoperative parathyroid hormone levels (177 versus 250 pg/ml; P = 0.032), and smaller (17 versus 21 mm; P <0.001) and lighter (1.47 versus 2.58 g, P = 0.005) parathyroid glands removed.

Conclusion: FCh enables successful focused parathyroidectomy in PHPT patients with negative or inconclusive MIBI results, reducing unnecessary bilateral neck exploration in 33% of patients; it may also allow for a successful focused approach in patients with milder PHPT, characterized by lower preoperative calcium and PTH levels and smaller pathological parathyroid glands.

Background: Although overt systemic inflammation immediately before gastrointestinal surgery has been associated with postoperative complications and mortality, it remains unclear whether baseline low-grade inflammation measured by high-sensitivity C-reactive protein (hs-CRP) in a non-surgery-related state is associated with the same outcomes.

Methods: This study included a subset of individuals from the Copenhagen General Population Study (CGPS) who underwent any type of gastrointestinal surgery between 2003 and 2015 after enrolment in the CGPS. Exposures were baseline hs-CRP levels (used in observational analyses) and two genetic variants that affect hs-CRP levels, namely interleukin 6 receptor (IL6R) rs4537545 and CRP rs1130864 (used in Mendelian randomization analyses), all of which were tested routinely at CGPS enrolment. Primary outcomes were 30-day complications and 90-day and 5-year mortality after the index surgery. Associations between exposures and outcomes were assessed using multivariable Cox regression models.

Results: Of the 107 536 individuals in the CGPS, 12 803 were included in the present study. Of these individuals, 1236 (9.7%) experienced 30-day complications, 865 (6.8%) died within 90 days, and 2789 (21.8%) died within 5 years. Adjusted hazard ratios for the highest hs-CRP quartile (hs-CRP ≥ 2.73 mg/l) versus the lowest quartile (hs-CRP < 1.04 mg/l) were 1.19 (95% confidence interval (c.i.) 1.02 to 1.40; P = 0.029) for 30-day complications, 1.29 (95% c.i. 1.07 to 1.57; P = 0.009) for 90-day mortality, and 1.17 (95% c.i. 1.06 to 1.31; P = 0.003) for 5-year mortality. Sensitivity analyses restricted to those with hs-CRP measurements within 1 year before surgery had larger point estimates. Genetically predicted elevations in hs-CRP were not associated with any outcomes.

Conclusion: Baseline hs-CRP levels ≥ 2.73 mg/l, consistent with chronic low-grade systemic inflammation, were associated with higher risk of 30-day complications, 90-day mortality, and 5-year mortality after gastrointestinal surgery.

Introduction: Postoperative complications pose a major challenge in oesophageal surgery, affecting survival, recovery, and healthcare resource utilization. The aim of this study was to quantify the proportional contribution of specific complications to survival and adverse outcomes and to evaluate their effects on long-term quality of life (QoL) in patients with oesophageal and gastro-oesophageal junction cancer.

Methods: This retrospective cohort study included patients with oesophageal or gastro-oesophageal junction cancer who underwent surgery with curative intent between January 2010 and July 2022. Postoperative complications were categorized following Esophageal Complications Consensus Group guidelines. Population-attributable fractions (PAFs) were calculated to estimate the proportion of adverse outcomes and survival effects theoretically preventable if specific complications were avoided.

Results: In 632 patients who underwent surgery, the most frequently observed complications were pulmonary (31%), infectious (29%), and gastrointestinal (24%). Pneumonia had the highest adjusted PAF for overall survival (8.3% after 2 years; 95% confidence interval (c.i.) 1.8 to 14.7), suggesting that preventing pneumonia could substantially reduce mortality. Anastomotic leak had the highest PAF for recurrence-free survival (6.6%; 95% c.i. 1.8 to 11.5) and was the complication most significantly contributing to reoperations (PAF 39.8%; 95% c.i. 22.2 to 52.1) and prolonged hospital stays (PAF 56.9%; 95% c.i. 46.8 to 66.2). Respiratory failure had the largest effect on 90-day mortality (PAF 53.5%; 95% c.i. 30.9 to 73.9). In contrast, no significant effect of complications on long-term QoL was observed.

Conclusion: This study underscores the critical importance of targeted strategies to prevent postoperative complications, particularly pneumonia and anastomotic leakage, which contribute significantly to adverse outcomes such as reduced survival and prolonged hospital stays. Effective complication management may enhance oncological outcomes and optimize healthcare resource utilization.

Background: In the absence of a commonly accepted definition, conversion surgery is generally considered as surgical resection with the intent of prolonging survival after non-surgical induction therapy in patients with upfront unresectable disease at diagnosis. Despite the heterogeneity of possible targets, conversion surgery is a quickly evolving concept, with commonalities for upper gastrointestinal (UGI) and hepato-pancreato-biliary (HPB) malignancies.

Methods: A comprehensive narrative review of the most recent and relevant literature was conducted by experts in the field of different UGI and HPB tumours.

Results: The increased interest of the surgical scientific community in the concept of conversion surgery can be explained by the continuous improvements in non-surgical therapies aimed at controlling the systemic tumour burden and the local extension of cancer, supported by improvements in surgical outcomes for advanced resections in expert centres. The toolbox of the surgical oncologist seeking conversion in the case of unresectable UGI and HBP tumours is large and includes (but is not limited to) systemic chemotherapy, (chemo)radiation, targeted therapy/immunotherapy, locoregional ablation techniques, intra-arterial therapies, liver hypertrophy induction techniques, treatments of underlying medical conditions, and prehabilitation.

Conclusions: Conversion surgery represents a powerful instrument to prolong the survival of patients with unresectable UGI and HPB malignancies. However, most of the available evidence is of a low level and at very high risk of selection bias. Alongside a profound understanding of (and respect for) the biology of cancer, which remains key to selecting appropriate patients and avoiding non-therapeutic surgeries, a commonly accepted definition is urgently needed to standardize practice, monitor outcomes, and improve the quality of research.

Background: The majority of women undergoing risk-reducing mastectomy have implant-based breast reconstruction, with capsular contracture being one of the most common complications. The primary aim of this study was to establish the national incidence rate of severe capsular contracture requiring surgery following risk-reducing mastectomy with implant-based breast reconstruction. The secondary aim was to establish the incidence rate of other complications and associated risk factors.

Methods: Women undergoing implant-based breast reconstruction following risk-reducing mastectomy were identified from the Swedish Breast Implant Register. Data were extracted from the Swedish Breast Implant Register and the National Patient Register on women undergoing implant-based breast reconstruction from 2014 to 2021. The primary outcome was severe capsular contracture corresponding to Baker grade III-IV requiring surgery, and the secondary outcomes were other complications observed perioperatively.

Results: In total, 656 women with 1095 implant-based breast reconstructions were included in the analysis. Median follow-up was 3.5 (interquartile range 1.5-5.4) years. Capsular contracture was observed in 39 of 1095 breasts (3.6%), and the cumulative incidence increased from 1.9% at 1 year to 4.7% after 5 years. Stratified by implant type, the estimated risk of capsular contracture increased for patients with a permanent tissue expander compared with a permanent fixed-volume implant (adjusted hazard ratio 19.33, 95% confidence interval 3.92 to 95.43; P < 0.001).

Conclusion: This study has highlighted that the risk of developing severe capsular contracture requiring surgery seems to differ between implant types, emphasizing the need for further investigation regarding permanent tissue expanders. Moreover, the continuous increase in capsular contracture incidence rates over 5 years underscores the importance of long-term follow-up.

Background: The aim of this study was to compare the postoperative analgesic effects of ultrasound-guided intercostal nerve block and transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy.

Methods: Patients undergoing laparoscopic cholecystectomy for chronic cholecystitis with gallstones were randomly allocated to ultrasound-guided T7-11 intercostal nerve block or subcostal transversus abdominis plane block (both with 40 ml 0.3% ropivacaine). The primary outcome was the dose of tramadol required for remedial analgesia 24 h after surgery. The secondary outcomes included visual analogue scale scores at different time points after surgery, the time of initial use of tramadol for postoperative analgesia, patient satisfaction with postoperative pain control, the time to flatus, and the incidence of postoperative adverse events.

Results: A total of 64 patients were included. Compared with the transversus abdominis plane block group, the intercostal nerve block group had lower visual analogue scale scores at 3 h after surgery (mean(s.d.) of 2.4(0.8) versus 1.6(0.6)), 6 h after surgery (mean(s.d.) of 2.2(0.3) versus 1.4(0.6)), and 8 h after surgery (mean of 1.7(0.5) versus 1.3(0.4)) (P < 0.001, P < 0.001, and P = 0.002 respectively), a lower dose of tramadol for remedial analgesia within 24 h after surgery (median of 100 (interquartile range 0-100) versus 50 (interquartile range 0-50) mg) (P = 0.012), and a significantly delayed time of initial use of tramadol for postoperative analgesia (mean(s.d.) of 9.1(7.5) versus 14.6(8.3) h) (P = 0.015). The incidences of postoperative dizziness and postoperative nausea and vomiting were higher in the transversus abdominis plane block group (47% and 69% respectively) than in the intercostal nerve block group (19% and 41% respectively) (P = 0.032 and 0.035 respectively). Patient satisfaction with postoperative analgesia was higher in the intercostal nerve block group than in the transversus abdominis plane block group (P = 0.037). The time to flatus was similar between the two groups (P > 0.050).

Conclusion: Compared with ultrasound-guided subcostal transversus abdominis plane block, ultrasound-guided T7-11 intercostal nerve block with 0.3% ropivacaine provides better postoperative analgesia, requires a lower dose of tramadol for remedial analgesia 24 h after surgery, and significantly delays the time of initial use of tramadol for postoperative analgesia.