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Background: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is an effective but potentially highly morbid treatment option for peritoneal surface malignancies. Adequate risk assessment is fundamental for clinical decision-making and informed patient consent. The aim of this study was to construct a validated nomogram predicting the risk of severe postoperative complications based exclusively on preoperative variables.

Methods: A prospective database of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a single institution between February 1995 and April 2023 was reviewed. The cohort was divided randomly into derivation and validation cohorts (70 : 30). The primary outcome measure was postoperative complications (National Cancer Institute Common Terminology Criteria for Adverse Events grade ≥ 3). Binary logistic regression identified preoperative variables significantly associated with postoperative morbidity. A nomogram was constructed based on the results of the multivariable analysis. The model's performance was evaluated on the validation cohort by receiver operating characteristic curve analysis.

Results: A total of 1039 patients were analysed. The majority of the patients were female (58.8%) and the median age was 56 (interquartile range 46-64) years. The postoperative complication rate was 37.7%, and the reoperation rate 12.7%. A nomogram was constructed based on the following predictive factors: age, body mass index, high-grade histology, disease identified in the left upper quadrant and surrounding the stomach and small bowel mesentery on preoperative imaging, preoperative white blood cell count, and Onodera nutritional index score. Receiver operating characteristic curve analysis showed an area under the curve of 0.707 with accurate calibration curves.

Conclusion: Preoperative variables were selected and included in a simple nomogram predicting the risk of postoperative complications. This nomogram could aid clinicians in decision-making and patients in making informed decisions.

Background: Postoperative adhesions following thyroidectomy significantly affect patient quality of life, yet prevention strategies remain understudied. This trial evaluated the safety and efficacy of oxidized regenerated cellulose and high molecular weight hyaluronic acid in preventing post-thyroidectomy adhesions.

Methods: In this prospective, single-blinded, randomized study, patients undergoing thyroidectomy were randomized 1 : 1 : 1 to receive oxidized regenerated cellulose (Interceed™), high molecular weight hyaluronic acid (HANBIO BarriGel), or no adhesion barrier (control). The primary outcome was change in the Dysphagia Handicap Index (DHI) from baseline to 1 month. Secondary outcomes included the Voice Handicap Index, Swallowing Impairment Score, laryngotracheal elevation, and adhesion severity scores at 2 weeks, and 1, 6, and 12 months after operation.

Results: Forty -five patients were enrolled. Changes in DHI were not significant from baseline to 1 month among the three groups. The adhesion barrier groups demonstrated significantly smaller increases in Voice Handicap Index scores compared with the control group at 2 weeks (oxidized regenerated cellulose: mean(s.d.) 4.8(5.8); high molecular weight hyaluronic acid: 0.8(6.3); control: 8.4(9.6); P = 0.032) and at 1 month (3.0(5.2), 1.0(7.1), and 9.1(12.3), respectively; P = 0.047). Changes in Swallowing Impairment Scores were significantly lower in the adhesion barrier groups (2.1(5.6) versus 6.0(5.9); P = 0.037), although no significant differences were observed among the three groups (oxidized regenerated cellulose: 1.4(4.2); high molecular weight hyaluronic acid: 2.8(6.8); control: 6.0(5.9); P = 0.095) at 2 weeks. The high molecular weight hyaluronic acid group demonstrated superior preservation of laryngotracheal elevation among groups (P = 0.006) and compared with the oxidized regenerated cellulose group (P = 0.041) at 1 month. No adhesion barrier-related complications were observed. By 6 months, most parameters had returned to near-baseline levels across all groups.

Conclusion: Both oxidized regenerated cellulose and high molecular weight hyaluronic acid appear safe and potentially effective in reducing early post-thyroidectomy adhesion symptoms, with high molecular weight hyaluronic acid showing superior outcomes in certain parameters. These findings support the use of adhesion barriers in thyroid surgery, although larger studies are needed to confirm their long-term benefits.

Registration number: NCT05851560 (http://www.clinicaltrials.gov).

Background: Carpal tunnel release (CTR) can be performed using either an open or endoscopic approach. The patient recovery trajectories remain poorly understood. This study aimed to define and compare patient-reported recovery following unilateral open and endoscopic CTR.

Methods: A PRISMA-compliant, preregistered (CRD42023427718) systematic review was conducted, searching PubMed, Embase, and Cochrane databases on 4 July 2023 and 21 August 2024. Studies were included if they reported recovery data (patient-reported outcome measures (PROMs)) at predefined time points for adults undergoing unilateral CTR. Boston Carpal Tunnel Questionnaire and Quick Disabilities of Arm, Shoulder, and Hand scores were extracted. Standardized mean change (SMC) scores from baseline were pooled using random-effects meta-analysis. An innovative modification of the National Institutes of Health quality assessment tools was used to evaluate the risk of bias.

Results: In all, 49 studies were included (4546 participants included in the analysis; 3137 open CTR, 1409 endoscopic CTR). Both approaches improved PROM scores over 12 weeks, with early (4-week) outcomes strongly correlating (>0.89) with later (12-week) outcomes. Symptoms continued improving up to 104 weeks. At 1 week, open CTR showed symptomatic deterioration (SMC 10.29; 95% confidence interval (c.i.) 6.35 and 14.21 respectively), comparatively, endoscopic CTR demonstrated an improvement (SMC -2.83; 95% c.i. -7.80 and 2.14 respectively). By 2 weeks, symptom severity remained slightly worse in open CTR, but confidence intervals overlapped from week 3 and thereafter open CTR showed greater symptomatic improvement. Most studies had a high risk of bias and measured outcomes too infrequently for a granular comparison.

Conclusions: Patient-reported recovery trajectories for CTR can inform patient counselling and future research. Endoscopic CTR may result in fewer symptoms in the first 2 weeks, but open CTR may offer comparable or potentially greater improvement thereafter. Future trials with high-frequency PROM capture should prioritize early (first 3 weeks) and long-term (≥24 weeks) outcomes.

Background: Emergency laparotomy is performed for a wide range of life-threatening conditions and is associated with significant morbidity and mortality. Risk prediction models facilitate accurate communication of operative risk with patients and relatives, in addition to benchmarking unit outcomes. Greater understanding of the impact of sarcopenia or myosteatosis will encourage the adoption of routine radiological reporting of body composition and the incorporation of skeletal muscle gauge (SMG) into risk prediction models. This study investigated the prognostic significance of SMG, an aggregate assessment of sarcopenia or myosteatosis, in patients who had undergone an emergency non-trauma-related laparotomy.

Methods: This was a retrospective cohort study of patients aged ≥ 18 years who underwent an emergency laparotomy at the Queen Elizabeth Hospital between January 2014 and December 2020. Body composition and patient outcomes were analysed.

Results: In all, 1090 patients with a mean(standard deviation) age of 62.3(17.5) years underwent emergency laparotomy (bowel obstruction, 52.7%; perforation, 26.3%; ischaemia, 9.5%). Overall 30- and 90-day mortality was 10.0% and 11.6%, respectively. On multivariate analysis, low SMG was associated with worse 30- and 90-day mortality, with odds ratios of 2.12 (95% confidence interval (c.i.) 1.18 to 3.83; P = 0.012) and 2.64 (95% c.i. 1.55 to 4.48; P < 0.001), respectively. Low SMG was also associated with an increased length of hospital stay (odds ratio 1.45; 95% c.i. 1.22 to 1.72; P < 0.001).

Conclusion: A low SMG was associated with increased postoperative mortality and length of hospital stay after emergency laparotomy. Patients undergoing computed tomography imaging for acute abdominal pain should undergo routine reporting of body composition.

Background: Reports suggest tranexamic acid (TXA) reduces haematoma formation after breast surgery. This study investigated the effects of postoperative retrograde instillation of topical TXA through surgical drains on postoperative haematoma formation requiring surgical intervention and drain output 24 hours after mastectomy procedures.

Methods: A prospective cohort study was conducted from October 2020 until September 2023, comprising two consecutive periods. In the first period, women underwent mastectomy without receiving TXA (control); in the second, women received retrograde instillation of 20 ml of 50 mg/ml TXA into the drain immediately after cavity closure. This was performed as part of a change in routine practice in April 2023. Primary endpoints collected from patient medical records were haematoma formation requiring surgical intervention, mean drain output 24 hours after the procedure, and thromboembolic events. Type of surgery, age, body mass index, smoking status, the use of blood thinners, neoadjuvant therapy, and the indication for surgery were considered patient variables that could potentially affect primary endpoints. Regression analysis was used to analyse relationships between TXA administration and haematoma occurrence and drain output, adjusting for the specified patient variables. This study was designed in accordance with STROBE guidelines.

Results: Among 297 breasts (271 women) receiving topical TXA and 278 breasts (264 women) in the control group, 4 (1%) and 19 (7%) breasts, respectively, had surgical revisions due to haematoma (P = 0.003). Drain output within the first 24 hours after the procedure was significantly lower in the TXA than control group (mean(standard deviation) 67.6(62.4) versus 103.9(106.6) ml, respectively; P < 0.001). No thromboembolic events were reported. Women in the control group had a higher body mass index and mean age, and a higher proportion underwent axillary clearance and received neoadjuvant therapy compared with the TXA group. A higher proportion of women in the TXA group underwent sentinel node biopsy. After adjusting for these variables, significant differences remained between the two groups in haematoma rate (P = 0.005) and drain output (P = 0.001).

Conclusion: Retrograde administration of 20 ml of 50 mg/ml topical TXA into the cavity after mastectomy significantly reduced the incidence of haematoma formation and drain output within the first 24 hours.

Introduction: Surgical videos are a valuable data source, offering detailed insights into surgical practice. However, video analysis requires specialist clinical knowledge and takes considerable time. Artificial intelligence (AI) has the potential to improve and streamline the interpretation of intraoperative video data. This systematic scoping review aimed to summarize the use of AI in the analysis of videos of surgical procedures and identify evidence gaps.

Methods: Systematic searches of Ovid MEDLINE and Embase were performed using search terms 'artificial intelligence', 'video', and 'surgery'. Data extraction included reporting of general study characteristics; the overall objective of AI; descriptions of data sets, AI models, and training; methods of data annotation; and measures of accuracy. Data were summarized descriptively.

Results: In all, 122 studies were included. More than half focused on gastrointestinal procedures (75 studies, 61.5%), predominantly cholecystectomy (47, 38.5%). The most common objectives were surgical phase recognition (40 studies, 32.8%), surgical instrument recognition (28, 23.0%), and enhanced intraoperative visualization (23, 18.9%). Of the studies, 79.5% (97) used a single data set and most (92, 75.4%) used supervised machine learning techniques. There was considerable variation across the studies in terms of the number of videos, centres, and contributing surgeons. Forty-seven studies (38.5%) did not report the number of annotators, and details about their experience were frequently omitted (102, 83.6%). Most studies used multiple outcome measures (67, 54.9%), most commonly overall or best accuracy of the AI model (67, 54.9%).

Conclusion: This review found that many studies omitted essential methodological details of AI training, testing, data annotation, and validation processes, creating difficulties when interpreting and replicating these studies. Another key finding was the lack of large data sets from multiple centres and surgeons. Future research should focus on curating large, varied, open-access data sets from multiple centres, patients, and surgeons to facilitate accurate evaluation using real-world data.

Background: Obesity is increasing among patients with inflammatory bowel disease, but bariatric surgery has been rare in this group owing to concerns about worsening the inflammatory bowel disease. The aim of the study was to evaluate inflammatory bowel disease-related outcomes following bariatric surgery.

Methods: Nationwide cohort of all adult patients in Sweden between 2007 and 2020 with obesity and inflammatory bowel disease. Patients were matched 1 : 1 with a two-stage matching process between those undergoing bariatric surgery with those who did not (classified by inflammatory bowel disease subtype followed by a propensity score match including sex, age, number of previous targeted therapies, presence of immunotherapy, cumulative oral corticosteroid dose, and previous intestinal surgery). The primary composite outcome comprised inflammatory bowel disease-related hospitalization, initiation of corticosteroid therapy, immunomodulation, commencement of a new targeted therapy or major inflammatory bowel disease-related surgery.

Results: The study included 798 patients with inflammatory bowel disease and obesity: 399 who underwent bariatric surgery (145 Crohn's disease, 238 ulcerative colitis, 16 unclassified inflammatory bowel disease) versus 399 who did not. Over a median observation period of 3.3 years in the surgery group and 3.0 years in the non-surgery group, the composite primary endpoint occurred in 201 patients who had surgery (incidence rate 11.9 (95% confidence interval (c.i.) 10.2 to 13.5) per 100 person-years) and 226 without surgery (incidence rate 15.1 (13.1 to 17.0) per 100 person-years), corresponding to an adjusted hazard ratio of 0.66 (95% c.i. 0.51 to 0.85) in those undergoing bariatric surgery compared with those who did not.

Conclusion: Bariatric surgery was associated with improved inflammatory bowel disease-related outcomes among patients with inflammatory bowel disease and obesity, suggesting a potential benefit from bariatric surgery among patients with concomitant obesity and inflammatory bowel disease.

Background: Liver transplantation for cancer indications has gained momentum in recent years. This review is intended to optimize the care setting of liver transplant candidates by highlighting current indications, technical aspects and barriers with available solutions to facilitate the guidance of available strategies for healthcare professionals in specialized centres.

Methods: A review of the most recent relevant literature was conducted for all the cancer indications of liver transplantation including colorectal cancer liver metastases, hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, neuroendocrine tumours, hepatocellular carcinoma and hepatic epitheloid haemangioendothelioma.

Results: Transplant benefit from the best available evidence, including SECA I, SECA II, TRANSMET studies for colorectal liver metastases, various preoperative protocols for cholangiocarcinoma patients, standard, extended selection criteria for hepatocellular carcinoma and neuroendocrine tumours, are discussed. Innovative approaches to deal with organ shortages, including machine-perfused deceased grafts, living donor liver transplantation and RAPID procedures, are also explored.

Conclusion: Cancer indications for liver transplantation are here to stay, and the selection criteria among all cancer groups are likely to evolve further with improved prognostication of tumour biology using adjuncts such as radiomics, cancer genomics, and circulating DNA and RNA status. International prospective registry-based studies could overcome the limitations of smaller patient cohorts and lack of level 1 evidence.

Background: This study aimed to assess the effect of a periumbilical transverse incision compared with a periumbilical midline incision in reducing incisional hernia and improving short-term outcomes after laparoscopic colon cancer surgery.

Methods: This multicentre, open-label, randomized clinical trial was conducted at four high-volume hospitals in Korea, between April 2021 and February 2023. Patients were eligible if they were aged ≥ 20 years and had pathologically confirmed colon cancer. Block randomization was undertaken in a 1 : 1 ratio to transverse versus midline groups, stratified by tumour location. The primary endpoint was the incidence of radiological incisional hernia at 12 months after surgery. The secondary endpoints included symptomatic incisional hernia and short-term outcomes such as outcomes during surgery, complications at 30 days after surgery, pain after surgery, hospital stay after surgery, and patient-reported questionnaires.

Results: Of 174 enrolled patients, 155 were analysed for primary outcome (79 in transverse group and 76 in midline group). Radiological incisional hernia was significantly less frequent in the transverse group (6%) compared with the midline group (18%) 12 months after surgery (P = 0.022); however, there was no significant difference in the incidence of symptomatic incisional hernia between the two groups (3 versus 8%; P = 0.162). Surgical outcomes, complications after surgery, pain, and length of hospital stay did not differ significantly between the two groups. The transverse group had a shorter incision length (mean(standard deviation) 5.0(0.8) versus 5.3(0.8) cm; P = 0.027) and higher cosmesis score (18.0(3.2) versus 16.6(2.7); P = 0.006) than the midline group.

Conclusion: A periumbilical transverse incision significantly reduced radiological incisional hernia compared with a midline incision in laparoscopic colon cancer surgery. Clinical Research Information Service registration number: KCT0006082 (https://cris.nih.go.kr).

Background: Nodal assessment in gallbladder cancer remains challenging, particularly in incidental gallbladder cancer. This understages the number of patients with node-positive disease, resulting in prognostic inaccuracy and insufficient adjuvant treatment. This study aimed to identify risk factors for positive nodes in gallbladder cancer and to compare prognostic discrimination of available nodal staging parameters.

Methods: This international cohort study assessed gallbladder cancer resections undertaken between 1 January 2010 and 31 December 2020. Logistic regression was used to identify risk factors for node-positive status and develop a risk prediction score for positive nodes. Nodal staging models, including nodal site, number of positive nodes, and positive node ratio were compared for greatest prognostic discrimination in gallbladder cancer.

Results: A total of 3676 patients underwent gallbladder cancer resection across 133 centres in 41 countries. Tumour (T) stage (T2, P = 0.012; T3, P = 0.002; and T4, P < 0.001), lymphovascular and perineural infiltration (P < 0.001), and tumour differentiation (P < 0.001) carried the greatest risk of positive nodes. These three parameters comprised the OMEGA Node Positivity Prediction Score (OMEGA-NOPPS) with C-statistics of 0.81 (95% confidence interval 0.78 to 0.84) in the training data set and 0.79 (0.73 to 0.85) in the test data set for identification of node-positive status, highlighting a ≥ 20% increased risk of positive nodes in poorly differentiated tumours with lymphovascular and perineural infiltration despite T1 disease.

Conclusion: Data from this large multicentre study confirmed that the number of positive nodes is the most discriminative prognostic model for nodal staging in gallbladder cancer. OMEGA-NOPPS provides three simple parameters to stratify nodal involvement according to risk. Incidental gallbladder cancer with lymphovascular and perineural infiltration and poorly differentiated tumours, including early T stages, should be considered for further treatment.