Predictive model and prognostic insights into duodenal stump fistula following radical gastrectomy with Roux-en-Y reconstruction for gastric cancer

BACKGROUND

Duodenal stump fistula (DSF) is a rare yet serious complication following gastric cancer surgery. The risk factors associated with DSF, as well as the predictive models, remain insufficiently elucidated.

AIM

To identify DSF risk factors following radical gastrectomy with Roux-en-Y anastomosis, develop a predictive model, and evaluate impact on prognosis.

METHODS

This retrospective cohort study was conducted on patients undergoing radical gastrectomy with Roux-en-Y anastomosis for gastric cancer at Juntendo University from 2015 to 2021 (n = 325). Univariate and multivariate analyses were performed to identify the risk factors associated with DSF. Based on the independent risk factors, a predictive nomogram was developed and subsequently evaluated using receiver operating characteristic curve analysis. Kaplan-Meier survival curves were utilized to assess the impact of DSF on overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS).

RESULTS

Among the 325 patients analyzed, DSF was observed in 7 (2.2%) cases. No DSF was observed in 110 patients where the duodenal stump suturing fixation technique to the jejunal wall was used. Multivariate analysis confirmed that age [odds ratio (OR) = 1.17, P = 0.015] and obstructive ventilatory failure (OVF) (OR = 14.03, P = 0.001) were independent risk factors for DSF. The predictive nomogram was constructed based on age and OVF, which exhibited strong performance (area under the curve = 0.90, 95% confidence interval: 0.82-0.99). Kaplan-Meier analysis revealed a statistically significant reduction in CSS for patients with DSF, whereas no significant differences were observed in OS or DFS.

CONCLUSION

Age and OVF are independent risk factors for DSF, which worsens CSS. A nomogram predicts DSF accurately, and innovative surgical techniques may reduce its occurrence.

Prognostic Validity of the Eighth Edition of the U.S. Joint Committee on Cancer TNM Staging System for Pancreatic Adenocarcinomas: An Analysis of 214 Patients at a Spanish Center

Introduction: Accurate staging is essential in pancreatic adenocarcinoma due to its aggressive nature and poor prognosis. The 8th edition of the AJCC TNM staging system introduced changes in tumor size criteria and nodal classification. This study compares the prognostic performance of the 7th and 8th editions in resected patients. Material and Methods: A retrospective analysis was conducted on 214 patients with pancreatic adenocarcinoma who underwent curative surgery. TNM staging was assigned according to both AJCC editions. Kaplan-Meier analysis and multivariate Cox regression, stratified by adjuvant therapy, were used to assess disease-free survival (DFS) and overall survival (OS). Results: The 8th edition TNM staging was significantly associated with lower risk of recurrence, with TNM stages I and II independently predicting better DFS (p < 0.05). In contrast, the 7th edition TNM stage I remained the only independent predictor of OS (HR = 0.376; p = 0.023). Reclassification between editions altered stage distribution, particularly within stage II. Conclusions: The 8th edition improves early recurrence stratification, while the 7th edition retains stronger prognostic value for overall survival. Both systems offer complementary insights, supporting outcome-specific staging use.

Reduced pancreatic fistula rates and comprehensive cost analysis of robotic versus open pancreaticoduodenectomy

BACKGROUND

Robotic pancreaticoduodenectomy (RPD) has emerged as a promising surgical approach for the treatment of periampullary neoplasms, offering the potential benefits of minimally invasive surgery. However, the impact of RPD on clinically relevant pancreatic fistula (CR-PF) rates and overall costs compared to open pancreaticoduodenectomy (OPD) remains unclear, limiting its widespread adoption.

METHODS

This retrospective cohort study was conducted at a high-volume Japanese referral center from 2017 to 2023. A total of 193 patients diagnosed with periampullary neoplasms underwent either RPD (n = 81) or OPD (n = 112). To account for potential selection bias, propensity score matching (PSM) was used to balance patient demographics and clinical characteristics, resulting in two well-matched groups of 60 patients each. Perioperative outcomes, CR-PF rates, and a comprehensive cost analysis were evaluated.

RESULTS

RPD resulted in a significantly lower rate of CR-PF (10%) compared to OPD (33.3%) (p = 0.003). Additionally, patients who underwent RPD experienced shorter hospital stays (15 days) compared to those in the OPD group (22.5 days) (p < 0.001). Despite longer operative times for RPD (633 vs. 395 min; p < 0.001), total hospital costs were comparable between the two groups. The higher operative costs associated with RPD were offset by reduced postoperative complications and shorter hospitalization.

CONCLUSIONS

RPD offers significant clinical advantages, including lower CR-PF rates and reduced hospital stays, without increasing overall hospital costs compared to OPD. These findings support the feasibility and potential benefits of adopting RPD for the management of periampullary neoplasms in clinical practice.

Biliary tract cancer

BACKGROUND

Biliary tract cancers comprise a heterogeneous collection of malignancies usually described as cholangiocarcinoma of the intra- or extrahepatic bile duct, including perihilar cholangiocarcinoma and gallbladder cancer.

METHODS

A review of pertinent parts of the ESSO core curriculum for the UEMS diploma targets (Fellowships exam, EBSQ), based on updated and available guidelines for diagnosis, surgical treatment and oncological management of cholangiocarcinoma.

RESULTS

Following the outline from the ESSO core curriculum we present the epidemiology and risk factors for cholangiocarcinoma, as well as the rationale for the current diagnosis, staging, (neo-)adjuvant treatment, surgical management, and short- and long-term outcomes. The available guidelines and consensus reports (i.e. NCCN, BGS and ESMO guidelines) are referred to. Recognition of biliary tract cancers as separate entities of the intrahepatic biliary ducts, the perihilar and distal bile duct as well as the gallbladder is important for proper management, as they each provide distinct clinical, molecular and treatment profiles to consider.

CONCLUSION

Core competencies in knowledge to the diagnosis, management and outcomes of biliary tract cancers are presented.

Wandering Accessory Spleen and Its Implications for Modern Clinical Practice

Background: A wandering accessory spleen (WAS) is defined as an ectopic accessory spleen with a long vascular pedicle characterized by marked anatomical mobility. "Wandering" can be congenital or acquired due to splenomegaly or pregnancy. The study aimed to analyze the clinical course of WAS and its symptoms. Methods: The desk research method and statistical analysis were used to assess the outcome. Results: In total, 12 cases of WAS managed operatively, including 11 women and 1 man, have been found. The correct WAS diagnosis was established before surgery in 3 of the 12 patients. One individual did not exhibit any symptoms and underwent surgery to avoid WAS torsion and infarction. Abdominal pain was the most commonly reported symptom in 11 patients. No mortality has been reported. Conclusions: WAS is a rare anomaly. It can be symptomatic or produce a spectrum of symptoms, such as abdominal pain, and may resemble abdominal neoplasms. Torsion is the most common pathology in the WAS study group and is most common in young people.

Using Large Language Models in the Diagnosis of Acute Cholecystitis: Assessing Accuracy and Guidelines Compliance

BackgroundLarge language models (LLMs) are advanced tools capable of understanding and generating human-like text. This study evaluated the accuracy of several commercial LLMs in addressing clinical questions related to diagnosis and management of acute cholecystitis, as outlined in the Tokyo Guidelines 2018 (TG18). We assessed their congruence with the expert panel discussions presented in the guidelines.MethodsWe evaluated ChatGPT4.0, Gemini Advanced, and GPTo1-preview on ten clinical questions. Eight derived from TG18, and two were formulated by the authors. Two authors independently rated the accuracy of each LLM's responses on a four-point scale: (1) accurate and comprehensive, (2) accurate but not comprehensive, (3) partially accurate, partially inaccurate, and (4) entirely inaccurate. A third author resolved any scoring discrepancies. Then, we comparatively analyzed the performance of ChatGPT4.0 against newer large language models (LLMs), specifically Gemini Advanced and GPTo1-preview, on the same set of questions to delineate their respective strengths and limitations.ResultsChatGPT4.0 provided consistent responses for 90% of the questions. It delivered "accurate and comprehensive" answers for 4/10 (40%) questions and "accurate but not comprehensive" answers for 5/10 (50%). One response (10%) was rated as "partially accurate, partially inaccurate." Gemini Advanced demonstrated higher accuracy on some questions but yielded a similar percentage of "partially accurate, partially inaccurate" responses. Notably, neither model produced "entirely inaccurate" answers.DiscussionLLMs, such as ChatGPT and Gemini Advanced, demonstrate potential in accurately addressing clinical questions regarding acute cholecystitis. With awareness of their limitations, their careful implementation, and ongoing refinement, LLMs could serve as valuable resources for physician education and patient information, potentially improving clinical decision-making in the future.

Addressing Anastomotic Leak After Esophagectomy: Insights from a Specialized Unit

Background/Objectives: Anastomotic leakage is one of the most frightening and potentially fatal complications after esophagectomy. The collaboration between the surgical team, interventional gastroenterologists, and radiologists has the potential to improve the hospital stay, as well as morbidity and mortality. The aim of this study is to present our experience and evaluate the results of the multimodal management of anastomotic leak following esophagectomy in our unit. Methods: This is a retrospective study analyzing a single referral center's prospectively maintained database of all patients diagnosed with anastomotic leak between March 2019 and March 2025 using the definition of the Esophageal Complications Consensus Group. The treatment pathways and the patient outcomes are presented. The primary endpoint was 90-day mortality and in-hospital mortality. Results: A total of 241 esophageal resections were performed between March 2019 and March 2025. Lymphadenectomy of the mediastinum was performed in 88.4% of the patients. Cervical and intrathoracic anastomosis were performed in 143 (59.3%) and 98 (40.7%) cases, respectively. Twenty-nine patients (12%) with a mean age of 59.1 years developed anastomotic leak. Anastomotic leak occurred in 14.3% of intrathoracic anastomoses and 10.5% of cervical anastomoses. The median day of leak diagnosis was the sixth postoperative day. Leak management involved conservative strategies, wound exploration, endoscopic stent placement or vacuum therapy, drainage of effusions under radiologic guidance, and reoperation. The 90-day and in-hospital mortality rate was 3.4%. No cases of conduit necrosis or mediastinitis were reported. Endoscopic management was employed in 18 patients (62.1%) as a first- or second-line treatment, while reoperation was required in 6 patients (20.7%). The median interval from diagnosis to anastomosis healing was 21 days and the median duration of hospital stay 32 days. The management was successful in 27 patients (93.1%) except for 1 who developed tracheoesophageal fistula and 1 who died due to hemorrhagic complication of anticoagulant treatment. Conclusions: Anastomotic leak after esophagectomy is considered a complex, diversified, and morbid clinical entity. The evolving potential of multidisciplinary management encompassing surgical and interventional radiological and endoscopic treatment addresses the mortality rates and heralds a new era of minimizing morbidity.

Impact of Duodenal Stump Reinforcement in Preventing Duodenal Stump Fistula/Leakage After Distal or Total Gastrectomy for Malignant Disease: A Meta-Analysis of Comparative Studies

Background/Objectives: Duodenal stump fistula (DSF) is one of the most feared postoperative complications in gastric cancer surgery. It has a 1.6-5% incidence rate and correlates with potentially high rates of morbidity (75%) and mortality (16-20%). The absence of duodenal stump reinforcement is considered one of the main risk factors. Our meta-analysis aimed to provide updated evidence by comparing DSF rates among patients who underwent distal or total gastrectomy for malignant gastric disease with or without reinforcement of the duodenal stump. Methods: We performed a systematic review following the PRISMA guidelines. PubMed/MEDLINE, Scopus, Web of Science, Embase, and Cochrane Library databases were used to identify articles of interest. Meta-analysis was performed by using RevMan Version 5.4. Results: The six included comparative studies (19,527 patients: 11,545 reinforcement group versus 7982 control group) covered an approximately 20-year study period (2005-2023). All the studies included were observational in nature. Meta-analysis of pooled results showed that, compared to the control group, the reinforcement group recorded a statistically significant lower DSF rate (OR: 0.32, 95% CI: 0.17, 0.60, p = 0.0004). Considering secondary outcomes, no statistically significant differences were identified between the two groups in terms of operative time, EBL, overall postoperative complications, and length of hospital stay. Just major postoperative complications were considerably lower in the reinforcement group compared to the control group (OR: 0.66, 95% CI: 0.43, 0.99, p = 0.04). Conclusions: Duodenal stump reinforcement appears to reduce the rate of DSF after distal or total gastrectomy for malignant gastric disease. Given the significant biases among meta-analyzed studies, our results require careful interpretation. Further randomized, possibly multicenter trials may turn out to be of paramount importance in confirming our results.

Developments in pancreatic cancer emerging therapies, diagnostic methods, and epidemiology

Pancreatic cancer is still one of the deadliest malignancies, characterised by late-stage diagnosis, aggressive biology, and considerable resistance to conventional treatments. Despite improvements in understanding the molecular mechanisms and innovations in treatment, the overall survival remains abysmal: fewer than 9 % of patients survive beyond 5 years. By 2030, PC is predicted to become the second leading cause of cancer-related deaths in the U.S. owing to chemoresistance, rapid metastatic spread, and limited effective immunotherapeutic choices. This review highlights current progress in this field, including epidemiology, risk factors, diagnostic tools, and emerging biomarkers. Recent progress in genetic and molecular profiling has provided important information about pancreatic cancer. It has identified key mutations in genes like KRAS, TP53, CDKN2A, and SMAD4 that play a major role in driving the disease. Such revelations have provided the impetus to explore novel targeted therapies against these mutations. Furthermore, the advances in liquid biopsies incorporating circulating tumour cells, circulating tumour DNA, and exosomes hold substantial promise for early diagnosis, treatment response monitoring, and detection of minimal residual disease-any of which could radically transform PC management. While very limited options for the treatment of advanced-stage PC remain, the only potential curative treatment is surgery, yet only 10-15 % of patients are diagnosed with potentially resectable disease. Researchers are looking into new methods to help more patients qualify for surgery. This involves using chemotherapy and radiotherapy to reduce the size of the tumor before the operation. New chemotherapy treatments like FOLFIRINOX (which includes 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) have improved results for some patients, but they can still cause significant side effects. Immunotherapy, though revolutionary in other cancers, has had limited success in PC due to the tumour's immunosuppressive microenvironment. Researchers are looking into using immune checkpoint inhibitors together with chemotherapy, radiation, and drugs that target the surrounding tissue to improve the body's immune response. There is also considerable excitement surrounding personalised approaches with adoptive cell therapies such as CAR-T cells and TILs, which are trialled with early evidence of potential efficacy. Attempts are also being made to address the dense desmoplastic stroma of the tumour that characterises PC. Drugs that can fight resistance or new medicines that might affect the tumor environment, stop changes in surrounding tissues, and improve how drugs are delivered have shown some potential in laboratory tests so far. Nanoparticle-based drug delivery systems are also being developed to improve the bioavailability and targeted delivery of chemotherapy.

Minimally invasive versus open distal pancreatectomy for pancreatic Tumors: An updated meta-analysis and meta-regression

This study aims to compare the efficacy and safety of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) for pancreatic neoplasms. A meta-analysis following PRISMA guidelines, registered on PROSPERO, included randomized controlled trials (RCTs) and propensity-score matched studies. Data from Cochrane Central, PubMed, and Embase were analyzed, focusing on procedure efficacy (e.g., length of hospital stay and reoperations), oncologic outcomes (e.g., R0 resections), surgical outcomes (e.g., blood loss and operative time), and postoperative outcomes (e.g., 90-day mortality, severe complications, pancreatic fistula). Among 23 studies, MIDP showed significantly reduced 90-day mortality (OR: 0.57, p = 0.03), severe (CDC ≥ III) complications (OR: 0.81, p = 0.04), hospital stay (MD: 2.38 days, p < 0.01), reoperations (OR: 0.65, p < 0.01) and blood loss (MD: 137.66 mL, p < 0.01) compared to ODP. No significant differences were found in postoperative pancreatic fistula (OR: 1.06, p = 0.74) or operative time (MD: 1.95 min, p = 0.87). ODP showed a significantly lower incidence of R0 resections (OR: 1.57, p < 0.01). Subgroup analyses of RCTs favored MIDP for 90-day mortality, severe complications, and hospital stay, but found no differences in pancreatic fistula or operative time. Meta-regression identified age and tumor size as influential covariates. MIDP offers superior outcomes in procedure efficacy, surgical and postoperative outcomes compared to ODP. These findings highlight MIDP as a safe and effective alternative for pancreatic surgery, supported by robust subgroup and sensitivity analyses.

Assessing academic impact through a bibliometrics analysis: Gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery

Aims

The global rise in obesity rates has led to increased use of bariatric surgery, which can potentially exacerbate or induce gastroesophageal reflux disease. This study aimed to assess the academic impact and trends in research on gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery through a comprehensive bibliometric analysis.

Materials and methods

A bibliometric analysis was conducted using data from Web of Science and Scopus databases, covering publications from 1993 to 2024. The study utilized the Bibliometrix R package to analyze publication trends, collaborative networks, and research topics.

Results

The analysis encompassed 257 documents from 82 sources, with 6192 total citations and an 8.2% annual growth rate in publications. The United States emerged as the leading contributor with 90 publications. Key research topics included bariatric surgery, sleeve gastrectomy, and gastroesophageal reflux disease, with increasing focus on complications and revisional bariatric surgery in recent years. Two main research clusters were identified: one focusing on general health aspects and demographics, and another on specialized bariatric procedures and outcomes. However, the analysis is constrained by its reliance on data from only two bibliographic databases, which may not encompass all pertinent studies, and by a geographic bias toward high-income countries. Moreover, our deep literature reviews highlighted that obesity is a known risk factor for gastroesophageal reflux disease, and while Roux-en-Y gastric bypass often reduces gastroesophageal reflux disease symptoms, sleeve gastrectomy may exacerbate or cause de novo gastroesophageal reflux disease postoperatively.

Conclusions

This bibliometric study reveals a significant increase in research activity on gastroesophageal reflux disease in relation to obesity treatment and bariatric surgery, particularly since 2017. The findings highlight the growing importance of this field and the need for continued international research efforts to optimize surgical protocols and improve patient outcomes.

Patterns of Survival and Recurrence in Poor Responders to Neoadjuvant Therapy for Gastric Cancer: A Real-World Multicenter Study

BACKGROUND

Neoadjuvant therapy (NAT) is increasingly used in locally advanced gastric cancer (LAGC), but a significant proportion of patients respond poorly, causing adverse outcomes. Few studies have specifically examined the prognosis of this subgroup. This study aimed to analyze survival and recurrence in poor responders to guide follow-up and treatment strategies.

METHODS

This multicenter retrospective study included patients with LAGC who received NAT. Tumor regression was graded following the Becker system, defining TRG 2-3 as poor response. Outcomes were assessed for overall survival (OS), recurrence-free survival (RFS), and recurrence patterns.

RESULTS

648 patients were included: 341 with TRG 2 and 307 with TRG 3. In the entire cohort, the 3-year OS and RFS were 54.6% and 55.2%, respectively. Recurrence occurred in 299 patients, with the following recurrence patterns: distant metastasis (26.1%, n = 78), peritoneal metastasis (21.1%, n = 63), locoregional recurrence (18.7%, n = 56), and multiple-site recurrence (18.4%, n = 55). Liver metastasis was significantly higher in the TRG 3 group than in the TRG 2 group (14.1% versus 5.3%, P = 0.010). ypN+ was the most significant independent risk factor for recurrence (OR = 2.73, 95% CI 1.83-4.08, P < 0.001); an increasing number of positive lymph nodes led to higher 3-year cumulative mortality in patients. Despite poor response to NAT, completing over four adjuvant chemotherapy cycles was associated with improved survival outcomes.

CONCLUSION

Poor NAT responders in LAGC have high recurrence rates, particularly in the first year post-surgery, with ypN+ status being the strongest predictor of recurrence. Completing over four cycles of AC was associated with survival improvement in this group.

[Relevance of frozen section diagnostics in pancreatic surgery]

Frozen sections are performed in pancreatic surgery for three reasons: histopathological confirmation of previously unclear space-occupying lesions, determination of the extent of surgical resection in an operative exploration and for possible follow-up resections after previously carried out surgical resections. Overall, in the literature there are heterogeneous data with respect to an improvement in the prognosis of a secondary R0 resection by a repeat resection in comparison to a R1 resection. Nowadays, extended pancreatic resections including vascular resections are technically feasible and safe. Nevertheless, with respect to the precise radicality in the surgical procedure, all patient characteristics should be taken into consideration in addition to the histopathological diagnosis of the frozen sections.

Predicting liver metastasis in pancreatic neuroendocrine tumors with an interpretable machine learning algorithm: a SEER-based study

Background

Liver metastasis is the most common site of metastasis in pancreatic neuroendocrine tumors (PaNETs), significantly affecting patient prognosis. This study aims to develop machine learning algorithms to predict liver metastasis in PaNETs patients, assisting clinicians in the personalized clinical decision-making for treatment.

Methods

We collected data on eligible PaNETs patients from the Surveillance, Epidemiology, and End Results (SEER) database for the period from 2010 to 2021. The Boruta algorithm and the Least Absolute Shrinkage and Selection Operator (LASSO) were used for feature selection. We applied 10 different machine learning algorithms to develop models for predicting the risk of liver metastasis in PaNETs patients. The model's performance was assessed using a variety of metrics, including the area under the receiver operating characteristic curve (AUC), the area under the precision-recall curve (AUPRC), decision curve analysis (DCA), calibration curves, accuracy, sensitivity, specificity, F1 score, and Kappa score. The SHapley Additive exPlanations (SHAP) were employed to interpret models, and the best-performing model was used to develop a web-based calculator.

Results

The study included a cohort of 7,463 PaNETs patients, of whom 1,356 (18.2%) were diagnosed with liver metastasis at the time of initial diagnosis. Through the combined use of the Boruta and LASSO methods, T-stage, N-stage, tumor size, grade, surgery, lymphadenectomy, chemotherapy, and bone metastasis were identified as independent risk factors for liver metastasis in PaNETs. Compared to other machine learning algorithms, the gradient boosting machine (GBM) model exhibited superior performance, achieving an AUC of 0.937 (95% CI: 0.931-0.943), an AUPRC of 0.94, and an accuracy of 0.87. DCA and calibration curve analyses demonstrate that the GBM model provides better clinical decision-making capabilities and predictive performance. Furthermore, the SHAP framework revealed that surgery, N-stage, and T-stage are the primary decision factors influencing the machine learning model's predictions. Finally, based on the GBM algorithm, we developed an accessible web-based calculator to predict the risk of liver metastasis in PaNETs.

Conclusion

The GBM model excels in predicting the risk of liver metastasis in PaNETs patients, outperforming other machine learning models and providing critical support for developing personalized medical strategies in clinical practice.

Left-sided portal hypertension: what an interventional radiologist can offer?

Left-sided portal hypertension (LPH) refers to increased splenic venous pressure caused by splenic vein stenosis or occlusion. Pancreatitis is the leading cause of LPH. Typically, LPH remains asymptomatic, but it can lead to life-threatening hemorrhage from ruptured fundal varices in about 10% of patients. Further, it may be complicated by hypersplenism. Interventional radiology plays an essential role in LPH patients with failed endoscopic treatment. Variceal embolization is an effective salvage measure in bleeding gastric varices, but it carries a risk of recurrence and worsening of hypersplenism. Considering the pathophysiology, splenic vein recanalization (SVR) appears to be the best treatment; nevertheless, its lower technical success rate limits its utility only to a subgroup of LPH patients. Partial splenic embolization (PSE), a non-surgical alternative to splenectomy, reduces the splenic volume and venous outflow, thereby lowering variceal pressure. PSE is technically easier, which may explain its widespread use. Nonetheless, PSE can be complicated by life-threatening sepsis and portal vein thrombosis. Despite all attempts, some LPH patients eventually require a splenectomy. Importantly, the choice of therapy requires multidisciplinary discussion and is often influenced by availability, expertise, and clinical context. This article discusses various interventional strategies for managing LPH with the available evidence. KEY POINTS: Question Pressure within the main portal vein is normal in left-sided portal hypertension; thus, transjugular intrahepatic portosystemic shunt is ineffective. Findings Splenic vein stent placement can restore hepatopetal splenic blood flow and decompress splenic venous pressure. Clinical relevance Partial splenic embolization (PSE) is the most widely used interventional approach to manage left-sided portal hypertension-related complications.

TGFBI promotes EMT and perineural invasion of pancreatic cancer via PI3K/AKT pathway

Pancreatic cancer is a highly lethal malignancy, and perineural invasion (PNI) is a common pathological feature that significantly contributes to poor prognosis. Our research identified TGFBI as a key player in PNI development. The expression of TGFBI in tissue and cancer cells were detected by RT-qPCR, Western blot, Immunohistochemistry, and ELISA. The localization of TGFBI in cells was analyzed by Immunofluorescence staining (IF). The neural invasion ability of cancer cells were assessed by in vitro neural invasion model. Moreover, Western blot was used to investigate epithelial-mesenchymal transition (EMT) markers and PI3K/AKT pathway markers to elucidate the underlying mechanisms. Finally, an in vivo neural invasion model was used to verify the tumorigenic ability of the cancer cells in the sciatic nerve. Our findings highlight that TGFBI is up-regulated in PNI tissue and significantly correlates with poor prognosis in pancreatic cancer patients. Based on in vitro experiments, knockdown of TGFBI reduced neural invasion, as well as EMT, whereas rTGFBI exhibited the reverse effect. Knockdown of TGFBI reduced PI3K/AKT phosphorylation in Capan-2 and CFPAC-1. Moreover, PI3K inhibitor LY294002 was observed to counteract the effects of TGFBI on neural invasion, and EMT in Capan-2 and CFPAC-1. In vivo, knockdown of TGFBI inhibited tumor formation in the sciatic nerve of mice. Finally, we confirmed TGFBI as potential biomarker for PNI and prognosis of pancreatic cancer. Collectively, we concluded that TGFBI activates the PI3K-AKT pathway in pancreatic cancer cells, ultimately promoting EMT and leading to PNI.

Predicting immune status and gene mutations in stomach adenocarcinoma patients based on inflammatory response-related prognostic features

BACKGROUND

Stomach adenocarcinoma (STAD) is an aggressive malignant tumor. Herein, we characterized the prognosis based on inflammatory response-related features and evaluated their potential impact on survival and immune status of STAD patients.

METHODS

Inflammation-related genes obtained from public databases were used to analyze the inflammatory response scores of STAD samples. The differentially expressed genes (DEGs) between STAD and adjacent gastric tissue were then analyzed using the "limma" package. Genes associated with STAD prognosis were obtained from the intersection of inflammation-related genes and DEGs. The key genes screened by last absolute shrinkage and selection operator (LASSO) Cox and stepwise regression analyses were used to construct prognostic models and nomograms. The tumor immune dysfunction exclusion (TIDE) algorithm was used to assess potential differences in immunotherapy response between high- and low-risk groups and to explore gene mutation signatures using the R software maftools package. In addition, GSEA was used to predict pathway characteristics between different subgroups. Finally, scratch and transwell assays were performed to explore the role of SERPINE1 in STAD cells.

RESULTS

We found that a high-inflammatory group was associated with poor prognosis in STAD patients. 14 inflammation-related DEGs out of 126 DEGs were identified to be associated with the prognosis of STAD patients, and the prognostic models and nomograms constructed from the subsequently identified key genes (SLC7A1, CD82, SERPINE1 ROS1 and SLC7A2) demonstrated a good predictive performance in terms of prognosis of STAD. Patients in the STAD high-risk group had higher StromalScore and TIDE scores. It was also found that patients in the STAD low-risk group may have a higher mutation burden. Enrichment analysis revealed significant enrichment of epithelial-mesenchymal transition, angiogenesis and KRAS pathways in the high-risk group. In-vitro experiments showed that down-regulation of SERPINE1 attenuated the migratory and invasive abilities of AGS cells.

CONCLUSION

This study provides new insights into prognostic prediction and immunotherapy for STAD from the perspective of the inflammatory response.

A Rare Case of Metastatic Adrenocorticotrophic Hormone - Secreting Pancreatic Neuroendocrine Tumor Causing Ectopic Cushing Syndrome in a 46-Year-Old Woman

BACKGROUND Adrenocorticotrophic hormone (ACTH)-secreting pancreatic neuroendocrine tumors (pNETs) are rare and poorly understood entities. Only 1-2% of pancreatic neoplasms are pNETs, and even fewer are hormone-secreting. They can present indolently or with overt Cushing syndrome. Their diagnosis involves complex multi-modal imaging and laboratory evaluation. Management includes medications, such as somatostatin analogs and ketoconazole, as well as surgical resection for definitive treatment. This report describes a 46-year-old woman who presented with overt Cushing syndrome and was ultimately diagnosed with a pNET. CASE REPORT This patient's initial symptoms and laboratory testing were consistent with Cushing syndrome. A high-dose dexamethasone suppression test suggested ectopic ACTH production, and magnetic resonance imaging (MRI) of the brain showed a pituitary microadenoma. However, computed tomography (CT) of the abdomen and endoscopic ultrasound-guided biopsy with immunohistochemistry confirmed a pancreatic mass as the source of ACTH production with potential hepatic metastasis. Her Cushing syndrome was managed with ketoconazole and octreotide. Subsequently, >99% of the pNET was surgically removed, resulting in reversal of her Cushing syndrome. Currently, she is being monitored closely for recurrence. CONCLUSIONS Our management of this ACTH-secreting pNET highlights the complexities of diagnosis and multidisciplinary treatment options, which are underrepresented in the current literature on this rare entity. This case emphasizes the challenges in evaluation, including the importance of early and precise diagnosis in the face of potential confounders.

Impact of Routine Follow-Ups After Curative Gastrectomy in Elderly Patients with Early Gastric Cancer

INTRODUCTION

Elderly patients with early gastric cancer exhibit a relatively shorter life expectancy and lower recurrence risk, prompting consideration of whether the regular follow-up strategy should apply to this demographic. This study was designed to determine the effect of routine postoperative follow-up on the elderly patients, specifically those pathologically diagnosed with stage I gastric cancer.

METHODS AND MATERIALS

This retrospective analysis was conducted at a single tertiary center and enrolled patients aged ≥ 75 years who underwent curative gastrectomy for stage I gastric cancer between January of 2007 and December of 2016. The patients were divided into routine and nonroutine follow-up groups, depending on whether the recommended follow-up examinations (endoscopy, CT, and blood tests) were complete. Propensity score matching was performed to compare the overall survival (OS) and disease-specific survival (DSS) between the two study groups.

RESULTS

Among 385 patients enrolled, 301 (78.2%) were routine and 84 (21.8%) were nonroutine follow-up patients. After propensity score matching, each study group consisted of 83 patients. There was no significant difference in OS (85.5% vs. 83.1%, p = 0.47) and DSS (98.6% vs. 98.3%, p = 0.57) between the two study groups. There were six (1.5%) recurrences in the entire cohort: four in the routine and two in the nonroutine follow-up group.

CONCLUSIONS

Regular follow-up of elderly patients with stage I gastric cancer did not significantly impact the OS and DSS rates.

Giant perineal lipoma: A rare case report

INTRODUCTION AND IMPORTANCE

Lipomas are one of the most common benign tumors. The perineum, head, and acral areas are uncommon sites that require careful differential diagnosis and imaging.

CASE PRESENTATION

We here report a case of a 39-year-old female with a mass in the groin region. Ultrasonography of the mass revealed a large ill-defined iso to a hyperechoic lesion with no evidence of deeper muscular plane extension. Surgical exploration was done through an incision made near the perineal area adjacent to the mass surface.

CLINICAL DISCUSSION

Adults with perineal lipoma have soft tissue tumors, dermoid cysts, and epidermoid cysts as differential diagnoses. Ultrasonography is the recommended first investigation since it successfully identifies superficial lipomas with good sensitivity and specificity.

CONCLUSION

Perineal lipomas are uncommon benign tumors. The effective treatment option is surgical excision.

Implications of portal vein/superior mesenteric vein involvement in pancreatic cancer: A comprehensive correlation from preoperative radiological assessment to resection, pathology, and long-term outcomes. A retrospective cohort study

BACKGROUND

The incidence of portal vein/superior mesenteric vein (PV/SMV) resection during pancreatoduodenectomy is increasing in clinical practice. This study investigated the clinical significance of preoperative PV/SMV assessment and intraoperative resection and their correlation with pathological results and long-term survival outcomes.

METHODS

We analyzed 443 patients undergoing pancreatoduodenectomy at a tertiary center from 2012 to 2017 based on PV/SMV resection. Subgroup analyses were performed based on preoperative PV/SMV involvement, resection, and margin status.

RESULTS

Total of 441 patients were analyzed; 175 had PV/SMV involvement on preoperative radiological assessments and 128 underwent PV/SMV resection. True pathological invasion was observed in 78 patients (60.9%), with 34.3% showing no invasion and negative margins. The positive predictive value for preoperative PV/SMV involvement was 61.7%, with a false-negative value of 28.9%. Overall survival of patients who underwent PV/SMV resection was worse than those who did not (2-year survival rate, 38.1% vs 54.9%, P < 0.001). Patients without PV/SMV resection with an rR1/R1 margin showed no decrease in survival compared to those with PV/SMV resection and R0 margins (54.9% vs 40.3%, P = 0.029). Prognostic factors included hypertension, PV/SMV resection, PV/SMV R2 margin, T stage, N stage, cell differentiation, adjuvant treatment, and recurrence.

CONCLUSION

PV/SMV resection could ensure R0 resection but may lead to unnecessary resection. Careful consideration is essential in determining the need for PV/SMV resection. Poor survival in such patients highlights the need for tailored treatments, including neoadjuvant therapy, for those who are expected to undergo PV/SMV resections.

Prognosis Associated with Complete Pathological Response Following Neoadjuvant Treatment for PancreaTic AdenOcarciNOma in the FOFLIRINOX Era: the Multicenter TONO Study

BACKGROUND

The use of multiagent FOLFIRINOX chemotherapy for pancreatic adenocarcinoma in a neoadjuvant setting has been associated with an increased rate of complete pathological response (CPR) after surgery. This study investigated the long-term outcomes of patients with CPR in a multicenter setting to identify prognostic factors for overall survival (OS) and recurrence-free survival (RFS).

METHODS

This retrospective cohort study examined biopsy-proven pancreatic adenocarcinomas with CPR after neoadjuvant chemotherapy or chemoradiotherapy and surgery, between January 2006 and December 2023 across 22 French and  2 Belgian centers. Cox analyses were used to identify prognostic factors of OS and RFS.

RESULTS

There were 101 patients with CPR after chemotherapy (n = 58, 57.4%) and chemoradiotherapy (n = 43, 42.6%) followed by surgery. Neoadjuvant FOLFIRINOX was used in 90% of patients. The median OS after surgery was 177 months (95% confidence interval (CI) 58.9-177 months) with 1-, 3-, 5-, and 10-year OS rates of 93%, 75%, 63%, and 51%, respectively. The median RFS was 67.8 months (95% CI:34.4-NR) with 1-, 3-, 5-, and 10-year RFS rates of 83%, 58%, 54%, and 49%, respectively. The multivariate Cox analysis of OS and RFS showed that preoperative radiotherapy was an independent negative prognostic factor for OS (hazard ratio (HR) 2.51; 95% CI 1.00-6.30; p = 0.03) and RFS (HR 2.62; 95% CI 1.27-5.41; p = 0.009).

CONCLUSIONS

Complete pathologic response after neoadjuvant treatment is associated with remarkable long-term survival that is usually not seen after the resection of pancreatic adenocarcinomas. One-third of the patients still experienced disease recurrence, which was more common in those receiving preoperative chemoradiotherapy.

Limited hiatal dissection versus Dor-fundoplication in laparoscopic Heller myotomy for achalasia: First experience in Morocco - A case control comparison study

INTRODUCTION AND IMPORTANCE

Laparoscopic Heller myotomy is a primary treatment for achalasia, addressing impaired esophageal motility. Fundoplication is typically added to prevent postoperative reflux. This study compares outcomes of limited hiatal dissection without antireflux system in laparoscopic Heller myotomy to Dor fundoplication.

CASE PRESENTATION

A retrospective analysis was conducted on 45 patients treated at visceral surgery department (2008-2022). Of these, 29 patients underwent limited hiatal dissection, and 16 underwent Dor fundoplication. A liquid diet was followed on day one, with discharge on day two, and a semi-liquid diet for three weeks. Outcomes included dysphagia resolution, postoperative Eckardt scores <3, and postoperative reflux incidence. The study compared operative and postoperative data between the two groups.

CLINICAL DISCUSSION

The limited hiatal dissection group had a slightly younger mean age (46.97 years) compared to the Dor fundoplication group (51.75 years). The limited hiatal dissection group had a higher proportion of men (58.6 %) while the Dor group had more women (56.3 %). Dysphagia (100 %) and weight loss (68.9 %) were prevalent symptoms. Perioperative complications and hospital stay duration were similar. Operative time was significantly shorter in the limited hiatal dissection group (96.7 vs. 118.3 min, p = 0.004). Both groups showed similar (OR = 0.519, CI = 0.066-4.083) and significant improvement in dysphagia (91.3 % vs. 87.5 %, p < 0.001) with comparable postoperative gastroesophageal disease (20.7 % vs. 25 %, p = 0.726 OR = 1.278, 95 % CI: 0.301-5.420).

CONCLUSION

Limited hiatal dissection provides comparable symptom relief and reflux prevention, offering a viable alternative to routine antireflux in achalasia treatment.

Torsion of the wandering spleen with intestinal obstruction

Wandering spleen is a relatively rare condition and may be complicated by intestinal obstruction or abnormal intestinal rotation. Herein, we report a case where these three conditions appeared concomitantly. An 18-year-old woman with an intellectual disability was admitted to the hospital because of vomiting and fever. The patient's abdomen was distended. Computed tomography revealed a dilated small intestine, a swollen spleen located in the lower abdomen, as well as twisting and swirling of the splenic artery and vein. The patient was diagnosed with torsion of the wandering spleen and emergency surgery was performed. The vascular pedicle was found to be rotated 900° clockwise, and a markedly enlarged spleen was observed in the lower abdomen. When the splenic torsion was released, the pulsation of the splenic artery was well palpated, suggesting that the spleen could be preserved. Additionally, the sigmoid colon to the cecum was not fixed to the retroperitoneum. Dilatation of the small intestine was observed, but there were no findings of intestinal tract necrosis. Splenic torsion is part of the differential diagnosis for acute abdomen. Familiarity with embryology and anatomy is necessary to select the appropriate surgical technique.

A Post Hoc Analysis of Older Patients with Metastatic Colorectal Cancer Receiving Oxaliplatin-Based Chemotherapy Plus Bevacizumab: The Randomized Obelics Study

BACKGROUND

Phase II trials and subgroup analyses of clinical studies suggest that bevacizumab plus an oxaliplatin-based chemotherapy doublet is effective and tolerable in fit older patients with metastatic colorectal cancer (mCRC).

OBJECTIVE

To evaluate the influence of age on the incidence of side effects and efficacy of this combination in patients with mCRC randomized in the prospective phase III OBELICS study.

METHODS

In total, 230 patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 out of 1 were retrieved on the basis of age (190 < 70 years and 40 ≥ 70 years). They received bevacizumab 5 mg/kg administered either on the same day as chemotherapy (standard arm) or 4 days before chemotherapy (experimental arm) and oxaliplatin 85 mg/m2 on day 1, plus capecitabine 1000 mg/m2 twice a day (bid) orally on days 1-10 or levofolinic acid, 200 mg/m2, bolus 5-fluorouracil (5-FU) 400 mg/m2, and a 46-h intravenous infusion of 5-FU 2400 mg/m2, every 14 days; oxaliplatin was discontinued after 12 cycles. The primary end point was the overall response rate (ORR).

RESULTS

Efficacy and toxicity analyses are reported in aggregate form because there were no statistically significant differences between the two arms. Patient characteristics are well balanced between older and younger patients. No difference in ORR was observed between the two groups (50% for the older patients versus 57.9% for the younger ones; p = 0.36). The median PFS was 10.8 (95% confidence interval [CI], 9.9-12.2) and 11.3 (95% CI 8.3-13.0) months, respectively, for subjects younger than 70 years and those aged ≥ 70 years, with an adjusted hazard ratio (HR) of 1.16 (95% CI 0.80-1.68; p = 0.43). The median OS was 26.2 (95% CI 23.3-32.7) for the former and 23.2 (95% CI 17.3-35.3) months for the latter, respectively, with an adjusted HR of 1.60 (95% CI 1.08-2.37; p = 0.027). Considering all forms of toxicity, the most severe ones were not statistically different between the two groups (65% for the older patients and 60.6% for the younger ones, p = 0.61).

CONCLUSIONS

Bevacizumab plus an oxaliplatin-based chemotherapy doublet were effective in older patients randomized in the OBELICS trial, and the adverse event profile was not dissimilar from that of younger patients; no new safety concerns were identified. This post hoc analysis confirms that fit older patients with mCRC should be considered for treatment with this regimen.

Machine learning-based prediction of duodenal stump leakage following laparoscopic gastrectomy for gastric cancer

BACKGROUND

Duodenal stump leakage is one of the most critical complications following gastrectomy surgery, with a high mortality rate. The present study aimed to establish a predictive model based on machine learning for forecasting the occurrence of duodenal stump leakage in patients who underwent laparoscopic gastrectomy for gastric cancer.

MATERIALS AND METHODS

The present study included the data of 4,070 patients with gastric adenocarcinoma who received laparoscopic gastrectomy. Five algorithms, namely, k-nearest neighbors, logistic regression, random forest, support vector machine, and eXtreme Gradient Boosting, were used to establish models with the preoperative and intraoperative clinical features of patients. Performance assessment was carried out to determine the optimal model.

RESULTS

The present study involved 4,070 patients and incorporated 11 clinicopathologic features to construct machine learning models (males, 2,688, 66.0%; females, 1,382, 34.0%; age, 58 ± 11 years). Among the 5 algorithms, the support vector machine model exhibited the optimal performance, with an area under the curve of 0.866 (95% confidence interval, 0.803-0.928), sensitivity of 0.806, accuracy of 0.821, and specificity of 0.821. The analysis using the support vector machine model revealed that tumor location and clinic tumor stage significantly contributed to duodenal stump leakage.

CONCLUSION

The support vector machine model independently predicted duodenal stump leakage in patients with gastric cancer and exhibited favorable discrimination and accuracy. Thus, the construction of an efficient and intuitive online predictive tool demonstrated that the support vector machine model may exhibit potential in the prevention and adjunctive treatment of duodenal stump leakage. The model indicates that besides tumor location and stage, operation time, preoperative pyloric obstruction, and patient age also are important factors that have a significant impact on the occurrence of duodenal stump leakage after surgery.

Transanal endoscopic local resection versus radical excision in the treatment of massive rectal gastrointestinal stromal tumors: striving for therapeutic advantages

Objectives

To compare the therapeutic advantages of transanal endoscopic local resection (taLR) and transabdominal radical resection (tbRR) in the treatment of massive gastrointestinal stromal tumors (GIST).

Design

Single-center retrospective study.

Methods

From October 2012 to October 2022, the clinical, surgical, pathological, and prognostic data of patients with rectal GIST who underwent surgery were retrospectively collected. The patients were divided into the taLR group and the tbRR group according to the surgical methods, and the research indicators were compared.

Results

Thirty-five patients with rectal GIST larger than 5 cm were enrolled, including 17 cases in the taLR group and 18 cases in the tbRR group. The taLR group showed shorter intraoperative time (p = 0.006), shorter postoperative hospital days (p = 0.035), earlier postoperative drainage tube removal (p = 0.007), and a higher anus preservation rate (p = 0.011). There was no significant survival difference in the 5-year disease-free survival between the taLR group and the tbRR group (94.1% vs 100%, p = 0.405).

Conclusion

In conclusion, there were no significant differences in survival between taLR and laparoscopic radical resection for massive rectal GIST. Moreover, compared with transabdominal radical excision technique, the transanal endoscopy surgery provides a new method of anal preservation, thereby improving the patient's quality of life.

Unveiling the real benefits of robot-assisted surgery in gynaecology: from telesurgery to image-guided surgery and artificial intelligence

Background

Several new robotic platforms are being commercialised, with different features in terms of types of consoles, numbers of arms, and targeting transabdominal or natural orifice approaches. The benefits of robotic surgery over laparoscopy have yet to be conclusively demonstrated in gynaecology, as several studies comparing perioperative and postoperative patient outcomes have reported no significant differences, leading to a lack of precise recommendations in surgical guidelines for both gynaecologic oncology and benign gynaecology. In addition, these outcomes must be balanced against the high costs of robotic surgery, in particular when considering building an infrastructure for safe telesurgery to democratise access to telementoring and remote interventions.

Objectives

Drawing from the expertise gained at the IRCAD Research and Training Center in Strasbourg, France, this article aims to provide an overview of the unveiled benefits of robotic-assisted surgery in gynaecology, investigating the role of digital surgery integration.

Methods

The objective of this narrative review is to provide an overview of the latest advancement in digital robotic-assisted surgery in gynaecology and illustrate the benefits of this approach related to the easiest integration with new technologies. To illustrate such evidence, PubMed, Google Scholar, and Scopus databases were searched.

Main Outcome Measures

In the era of surgical innovation and digital surgery, the potential of robotic surgery becomes apparent through the capacity to integrate new technologies. Image-guided surgery techniques, including the analysis of preoperative and intraoperative images, 3D reconstructions and their use for virtual and augmented reality, and the availability of drop-in robotic ultrasound probes, can help to enhance the quality, efficacy and safety of surgical procedures.

Results

The integration of artificial intelligence, particularly computer vision analysis of surgical workflows, is put forward to further reduce complications, enhance safety, and improve operating room efficiency. Additionally, new large language models can assist during procedures by providing patient history and aiding in decision-making. The education and training of young surgeons will undergo radical transformations with robotic surgery, with telementoring and shared procedures in the side-by-side double-console setup.

Conclusions

Robotic systems play a fundamental role in the transition towards digital surgery, aiming to improve patient care through integration of such new technologies.

What is New?

While the advantages of robotic surgery in terms of perioperative outcomes have yet to be demonstrated, the benefits of its easiest integration with new technologies are evident.

Evaluation of three lymph node staging systems for prognostic prediction in gastric cancer: A systematic review and meta-analysis

BACKGROUND

Lymph node status is a critical prognostic factor in gastric cancer (GC), but stage migration may occur in pathological lymph nodes (pN) staging. To address this, alternative staging systems such as the positive lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) were introduced.

AIM

To assess the prognostic accuracy and stratification efficacy of three nodal staging systems in GC.

METHODS

A systematic review identified 12 studies, from which hazard ratios (HRs) for overall survival (OS) were summarized. Sensitivity analyses, subgroup analyses, publication bias assessments, and quality evaluations were conducted. To enhance comparability, data from studies with identical cutoff values for pN, LNR, and LODDS were pooled. Homogeneous stratification was then applied to generate Kaplan-Meier (KM) survival curves, assessing the stratification efficacy of three staging systems.

RESULTS

The HRs and 95% confidence intervals for pN, LNR, and LODDS were 2.16 (1.72-2.73), 2.05 (1.65-2.55), and 3.15 (2.15-4.37), respectively, confirming all three as independent prognostic risk factors for OS. Comparative analysis of HRs demonstrated that LODDS had superior prognostic predictive power over LNR and pN. KM curves for pN (N0, N1, N2, N3a, N3b), LNR (0.1/0.2/0.5), and LODDS (-1.5/-1.0/-0.5/0) revealed significant differences (P < 0.001) among all prognostic stratifications. Mean differences and standard deviations in 60-month relative survival were 27.93% ± 0.29%, 41.70% ± 0.30%, and 26.60% ± 0.28% for pN, LNR, and LODDS, respectively.

CONCLUSION

All three staging systems are independent prognostic factors for OS. LODDS demonstrated the highest specificity, making it especially useful for predicting outcomes, while pN was the most effective in homogeneous stratification, offering better patient differentiation. These findings highlight the complementary roles of LODDS and pN in enhancing prognostic accuracy and stratification.

Complexity and Experience Grading to Guide Patient Selection for Minimally Invasive Pancreatoduodenectomy: An International Study Group for Pancreatic Surgery (ISGPS) Consensus

OBJECTIVE

To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD).

BACKGROUND

Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience.

METHODS

The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions.

RESULTS

The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification.

CONCLUSIONS

This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries.

The diagnostic dilemma of adrenal vascular tumors: analysis of 21 cases and systematic review of the literature

PURPOSE

Adrenal vascular tumors are mainly represented by adrenal cavernous hemangiomas (ACHs) and adrenal cystic lymphangiomas (ACLs). Their radiological features often overlap with malignant tumors, therefore ruling out malignancy becomes mandatory. We analyzed clinical, radiological, and histopathological data to identify specific characteristics of these tumors.

METHODS

We reviewed 21 patients with ACHs (n = 12), ACLs (n = 8), or adrenal cysts (n = 1) confirmed by histopathology. We selected 82 papers from PubMed to provide a systematic review of the literature.

RESULTS

In our cohort, median age at diagnosis was 58 years, with sex evenly distributed. All tumors were unilateral (median size = 44 mm), with 6 cases of increasing tumor size. All tumors exhibited non-contrast CT density > 10 Hounsfield Unit (HU). Calcifications were found in 5 cases. Hormonal studies revealed 11 non-functioning tumors and 2 cortisol-secreting tumors. Elevated urinary metanephrines were found in 2 cases. Immunostaining showed CD31/CD34/factor VIII expression in ACHs (n = 5, 24%) and podoplanin expression in ACLs (n = 6, 29%). The literature review revealed 71 reported cases of ACHs and 104 reported cases of ACLs. Median age at diagnosis was 46 years, with slightly female prevalence (63%). Median tumor size was 48 mm. 84 cases were symptomatic, with life-threatening hemorrhage reported in only 3 patients. Calcifications were found in 23% of cases. Surgical approaches varied, with open and laparoscopic adrenalectomy performed in 55 and 42 patients respectively.

CONCLUSIONS

ACHs and ACLs represent a diagnostic dilemma in clinical practice due to their rarity and their misleading imaging features.

Anastomotic Leak After Esophagectomy: Modern Approaches to Prevention and Diagnosis

Anastomotic leak (AL) remains one of the most serious complications following esophagectomy, contributing to significant morbidity, prolonged hospital stays, and increased mortality. Despite advancements in surgical techniques and perioperative care, AL continues to challenge surgeons and negatively impact patient outcomes. Various factors contribute to its development, including patient-specific comorbidities, tumor characteristics, anastomotic technique, conduit perfusion, and perioperative management. Prevention strategies have evolved with the integration of intraoperative techniques such as fluorescence-guided perfusion assessment, omental reinforcement, and meticulous surgical handling of the gastric conduit. Emerging technologies, including endoluminal vacuum therapy (EVT) and multimodal perioperative protocols, have demonstrated potential in reducing leak incidence and improving management. Diagnosing AL remains complex due to its variable presentation, necessitating a combination of clinical evaluation, inflammatory markers, imaging studies, and endoscopic assessments. While routine postoperative imaging has shown limited sensitivity, on-demand CT and endoscopic evaluations play a crucial role in early detection and intervention. This review provides a comprehensive analysis of the risk factors, prevention strategies, and diagnostic modalities for AL after esophagectomy, incorporating recent advancements and emerging technologies.

Predictive value and model construction of preoperative nutritional indexes for postoperative leakage in gastric cancer

OBJECTIVE

We aimed to explore the predictive significance of the nutritional indexes in the occurrence of postoperative leakage after gastrectomy, aiming to develop and validate a predictive nomogram for assessing the risk of these complications.

METHODS

Patients undergoing radical gastrectomy for gastric cancer were studied, using data from The Sixth Affiliated Hospital of Sun Yat-sen University (2019-2022, n = 1075) for nomogram development and an external cohort from Sun Yat-sen University Cancer Center (2022, n = 286) for validation. The model, focusing on postoperative leakage, was constructed through univariate and backward stepwise regression. The performance of nomogram was assessed using the receiver operating characteristic (ROC) curve, calibration plots, decision curve analysis (DCA), and clinical impact curves (CIC).

RESULTS

The incidence rates of postoperative leakage were 6.51% in the training cohort and 6.71% in the external validation cohort, respectively. The nomogram effectively identifies critical factors influencing postoperative leakage risk, including NRS-2002 score, SFMAI, VSR, blood loss, intraoperative time, type of reconstruction, and Lauren type. The areas under the curve (AUC) for the development and external validation cohorts were 0.763 and 0.761, respectively, demonstrating acceptable predictive accuracy. The validation study showed the nomogram's satisfactory calibration, and both DCA and CIC confirmed its significant clinical utility.

CONCLUSIONS

The nomogram offers an efficient and precise tool for initial screening, effectively identifying individuals at elevated risk for postoperative leakage.

Sclerotherapy for hemorrhoidal disease: Recent evolutions of an oldies goldy

Treatments for low degree hemorrhoids (I-III degree) are numerous and so are their counterparts for higher degrees. These treatments present nebulous differences in terms of indications and outcomes among techniques. Methods previously abandoned due to side effects and long-term results have recently rejoined the mainstream due to recent peculiar modifications: Hemorrhoidal sclerotherapy is enjoying a new age of interest due to the use of the foam form of polidocanol, which is more effective than the liquid one. Various articles have already shown promising results and the logical next step is the combination of polidocanol foam with rubber-band ligation (the historical counterpart of sclerotherapy) in a technique called "sclerobanding". In this article, we comment on the publication by Qu et al further modifying the use of sclerobanding through an endoscopic delivery for patients with grade II-III internal hemorrhoids, and present results compared with endoscopic rubber band ligation. The results achieved are promising.

The CD64/CD28/CD3ζ chimeric receptor reprograms T-cell metabolism and promotes T-cell persistence and immune functions while triggering antibody-independent and antibody-dependent cytotoxicity

BACKGROUND

Recent studies have shown that CD32/CD8a/CD28/CD3ζ chimeric receptor cells directly kill breast cancer cells, suggesting the existence of cell surface myeloid FcγR alternative ligands (ALs). Here, we investigated the metabolism, ALs, cytotoxicity, and immunoregulatory functions of CD64/CD28/CD3ζ in colorectal cancer (CRC) and squamous cell carcinoma of the head and neck.

METHODS

The CD64/CD28/CD3ζ -SFG retroviral vector was used to produce viruses for T-cell transduction. T-cell expansion and differentiation were monitored via flow cytometry. Gene expression was assessed by RNA-seq. Bioenergetics were documented on a Seahorse extracellular flux analyzer. CD64/CD28/CD3ζ polarization was identified via confocal microscopy. Cytotoxicity was determined by MTT assay and bioluminescent imaging, and flow cytometry. Tridimensional antitumor activity of CD64/CD28/CD3ζ T cells was achieved by utilizing HCT116-GFP 3D spheroids via the IncuCyte S3 Live-Cell Analysis system. The intraperitoneal distribution and antitumor activity of NIR-CD64/CD28/CD3ζ and NIR-nontransduced T cells were investigated in CB17-SCID mice bearing subcutaneous FaDu Luc + cells by bioluminescent and fluorescent imaging. IFNγ was assessed by ELISA.

RESULTS

Compared to CD16/CD8a/CD28/CD3ζ T cells, CD32/CD8a/CD28/CD3ζ T cells, and non-transduced T cells, CD64/CD28/CD3ζ T cells exhibited the highest levels of cell expansion and persistence capacity. A total of 235 genes linked to cell division and 52 genes related to glycolysis were overexpressed. The glycolytic phenotype was confirmed by functional in vitro studies accompanied by preferential T-cell effector memory differentiation. Interestingly, oxamic acid was found to inhibit CD64-CR T cell proliferation, indicating the involvement of lactate. Upon CD64/CD28/CD3ζ T-cell conjugation with CRC cells, CD64/CD28/CD3ζ cells polarize at immunological synapses, leading to CRC cell death. CD64/CD28/CD3ζ T cells kill SCCHN cells, and in combination with the anti-B7-H3 mAb (376.96) or anti-EGFR mAb, these cells trigger antibody-dependent cellular cytotoxicity (ADCC) in vitro under 2D and 3D conditions. The 376.96 mAb combined with CD64/CD28/CD3ζ T cells had anti-SCCHN activity in vivo. In addition, they induce the upregulation of PD-L1 and HLA-DR expression in cancer cells via IFNγ. PD-L1 positive SCCHN cells in combination with anti-PD-L1 mAb and CD64-CR T cells were killed by ADCC, which enhanced direct cytotoxicity. These findings indicate that the glycolytic phenotype is involved in CD64-CR T cell proliferation/expansion. These cells mediate long-lasting HLA-independent cytotoxicity and ADCC in CRC and SCCHN cells.

CONCLUSIONS

CD64/CD28/CD3ζ T cells could significantly impact the rational design of personalized studies to treat CRC and SCCHN and the identification of novel FcγR ALs in cancer and healthy cells.

Distinguishing exocrine pancreas disease-associated diabetes from type 2 diabetes based on anthropometric and metabolic parameters

BACKGROUND

Adult-onset diabetes is most often considered to be type 2 diabetes. However, other types of diabetes can develop in adults, including exocrine pancreas disease-associated diabetes, also called type 3c diabetes. Differential diagnosis between these types of diabetes still remains a diagnostic challenge.

AIM

To define anthropometric and laboratory markers that will allow for early diagnosis of pancreatic disease-associated diabetes.

METHODS

The study group included 44 patients with pancreatogenic diabetes (26 with pancreatic cancer and 18 with chronic pancreatitis), while the control group consisted of 35 patients with type 2 diabetes. We analyzed several parameters, including sex, age, body mass index (BMI), fasting plasma glucose, fasting C-peptide and insulin with homeostasis model assessment of insulin resistance (HOMA-IR) index calculation, adrenomedullin, adiponectin and creatinine levels with epidermal growth factor receptor (eGFR) calculation. We also developed an equation, termed type 3c diabetes index, which utilized BMI, fasting insulin and adrenomedullin levels, and eGFR to better identify patients with type 3c diabetes.

RESULTS

Compared to patients with type 2 diabetes, patients with pancreatogenic diabetes had significantly lower BMI (25.11 ± 4.87 kg/m2 vs 30.83 ± 5.21 kg/m2), fasting C-peptide (0.81 ± 0.42 nmol/L vs 1.71 ± 0.80 nmol/L), insulin (76.81 ± 63.34 pmol/L vs 233.19 ± 164.51 pmol/L) and HOMA-IR index, despite similar fasting plasma glucose levels. Patients with pancreatogenic diabetes also had lower adrenomedullin levels (0.41 ± 0.25 ng/mL vs 0.63 ± 0.38 ng/mL) but higher adiponectin levels (13.08 ± 7.20 μg/mL vs 8.28 ± 4.01 μg/mL) and eGFR levels (100.53 ± 21.60 mL/min/1.73 m2 vs 85.14 ± 19.24 mL/min/1.73 m2). Finally, patients with pancreatogenic diabetes had significantly lower Type 3c diabetes index values.

CONCLUSION

Patients with pancreatogenic diabetes differ from patients with type 2 diabetes in anthropometric and laboratory parameters. The type 3c diabetes index had the highest discriminating value, above any single parameter.

Minimally Invasive Rectal Surgery: Current Status and Future Perspectives in the Era of Digital Surgery

Over the past two decades, minimally invasive approaches in rectal surgery have changed the landscape of surgical interventions, impacting both malignant and benign pathologies. The dynamic nature of rectal cancer treatment owes much to innovations in surgical techniques, reflected in the expanding literature on available treatment modalities. Local excision, facilitated by minimally invasive surgery, offers curative potential for patients with early T1 rectal cancers and favorable pathologic features. For more complex cases, laparoscopic and robotic surgery have demonstrated significant efficacy and provided precise, durable outcomes while reducing perioperative morbidity and enhancing postoperative recovery. Additionally, advancements in imaging, surgical instrumentation, and enhanced recovery protocols have further optimized patient care. The integration of multidisciplinary care has also emerged as a cornerstone of treatment, emphasizing collaboration among surgeons, oncologists, and radiologists to deliver personalized, evidence-based care. This narrative review aims to elucidate current minimally invasive surgical techniques and approaches for rectal pathologies, spanning benign and malignant conditions, while also exploring future directions in the field, including the potential role of artificial intelligence and next-generation robotic platforms.

Comparison of short-term outcomes of robotic versus laparoscopic right colectomy for patients ≥ 65 years of age: a systematic review and meta-analysis of prospective studies

Robotic right colectomy (RRC) has been researched and compared in the past to the laparoscopic approach (LRC). However, it remains unclear whether RRC outperforms LRC in patients aged 65 or older with colon cancer or adenoma. Thus, this systematic review and meta-analysis aims to compare the short-term outcomes of RRC to LRC in this particular age group. PubMed, Scopus, and Cochrane Library were searched for related literature. Studies and data were extracted by two independent reviewers. Inverse variances weighted mean differences (WMD) with random effects model were used for continuous values, and odds ratios (OR) with random effects model using the Mantel-Haenszel's formula were used for dichotomous values. Heterogeneity using Higgins I2 and p values were calculated. A sensitivity analysis was performed for operative duration and number of harvested lymph nodes. In total 382 patients, 157 in RRC and 225 in LRC, were included in this study. A statistically significant increase of 43.91 min [95%CI: 19.61, 68.22], P = 0.001, was observed regarding operative duration in the RRC group, compared to LRC, but with high heterogeneity, I2 = 89%. However, a statistically significant decrease of 42% [OR = 0.58 (0.34, 0.98), P = 0.04, I2=2%] was observed with regard to overall complications in RRC compared to LRC. Non-significant differences between the two approaches were observed in the number of harvested lymph nodes [WMD = 0.44 (95%CI: -3.94, 4.82), P = 0.85, I2 = 52%], wound infections [OR = 0.63 (95%CI: 0.11, 3.52), P = 0.60, I2 = 13%], rate of ileus [OR = 0.29 (95%CI: 0.08, 1.00), P = 0.05, I2 = 0%], length of hospitalization [WMD = 0.18 (95%CI: - 0.74, 1.11), P = 0.70, I2 = 0%], and anastomotic leakage [OR = 0.52 (95%CI: 0.09, 3.11), P = 0.47, I2 = 0%]. The results of the operative duration and number of harvested lymph nodes remained statistically significant and non-significant, respectively, after sensitivity analysis. Robotic right colectomy appears to require a longer operative duration, but possibly offers lower rates of overall complications, compared to laparoscopic right colectomy in patients ≥ 65 years of age. Due to the lack of studies identified in the literature, and the ones included being non-randomized, no solid conclusions can be drawn and cautious interpretation of the results is advised. Future studies are necessary to further examine both short- and long-term outcomes. Prospero registration: CRD42024603354.

Effects of Pancreatic Fistula After Minimally Invasive and Open Pancreatoduodenectomy

Importance

Postoperative pancreatic fistulas (POPF) are the biggest contributor to surgical morbidity and mortality after pancreatoduodenectomy. The impact of POPF could be influenced by the surgical approach.

Objective

To assess the clinical impact of POPF in patients undergoing minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD).

Design, Setting, and Participants

This cohort study was conducted from 2007 to 2020 in 36 referral centers in Europe, South America, and Asia. Participants were patients with POPF (grade B/C as defined by the International Study Group of Pancreatic Surgery [ISGPS]) after MIPD and OPD (MIPD-POPF, OPD-POPF). Propensity score matching was performed in a 1:1 ratio based on the variables age (continuous), sex, body mass index (continuous), American Society of Anesthesiologists score (dichotomous), vascular involvement, neoadjuvant therapy, tumor size, malignancy, and POPF grade C. Data analysis was performed from July to October 2023.

Exposure

MIPD and OPD.

Main Outcomes and Measures

The primary outcome was the presence of a second clinically relevant (ISGPS grade B/C) complication (postpancreatic hemorrhage [PPH], delayed gastric emptying [DGE], bile leak, and chyle leak) besides POPF.

Results

Overall, 1130 patients with POPF were included (558 MIPD and 572 OPD), of whom 336 patients after MIPD were matched to 336 patients after OPD. The median (IQR) age was 65 (58-73) years; there were 703 males (62.2%) and 427 females (37.8%). Among patients who had MIPD-POPF, 129 patients (55%) experienced a second complication compared with 95 patients (36%) with OPD-POPF (P < .001). The rate of PPH was higher with MIPD-POPF (71 patients [21%] vs 22 patients [8.0%]; P < .001), without significant differences for DGE (65 patients [19%] vs 45 patients [16%]; P = .40), bile leak (43 patients [13%] vs 52 patients [19%]; P = .06), and chyle leak (1 patient [0.5%] vs 5 patients [1.9%]; P = .39). MIPD-POPF was associated with a longer hospital stay (median [IQR], 27 [18-38] days vs 22 [15-30] days; P < .001) and more reoperations (67 patients [21%] vs 21 patients [7%]; P < .001) but comparable in-hospital/30-day mortality (25 patients [7%] vs 7 patients [5%]; P = .31) with OPD-POPF, respectively.

Conclusions and Relevance

This study found that for patients after MIPD, the presence of POPF is more frequently associated with other clinically relevant complications compared with OPD. This underscores the importance of perioperative mitigation strategies for POPF and the resulting PPH in high-risk patients.

Giant Colonic Diverticulum: Case report of a rare complication of a common disease

INTRODUCTION AND IMPORTANCE

Giant Colonic Diverticulum (GCD) is a rare but potentially life-threatening complication of diverticular disease, defined as a diverticulum larger than 4 cm, most commonly arising in the sigmoid colon. Its rarity could lead to diagnostic delays and mismanagement.

CASE PRESENTATION

A 64-year-old Caucasian female presented with persistent abdominal pain and abdominal swelling. Examination revealed a palpable mass in the left flank. A computed tomography (CT) scan demonstrated an 11x10x14 cm air-filled cavity adjacent to the sigmoid colon, initially misdiagnosed as contained perforated diverticulitis. Following a literature review, the diagnosis of GCD was considered. Definitive treatment involved a segmental sigmoid colectomy with en-bloc resection of the diverticulum. The postoperative course was uneventful, and the patient was discharged on postoperative day four with complete symptom resolution.

CLINICAL DISCUSSION

The presentation of GCD can mimic common complications of diverticular disease, making diagnosis challenging. CT imaging is critical, typically showing a large air-filled cavity connected to the colon. Surgical resection is the treatment of choice to prevent serious complications such as perforation, abscess, volvulus, or malignancy. In this case, en-bloc resection proved effective, highlighting the importance of prompt surgical management.

CONCLUSION

GCD is a rare and under-recognized clinical entity. Increased awareness is essential to ensure timely diagnosis and treatment. This case underscores the importance of integrating imaging findings, clinical judgment, and surgical intervention for optimal outcomes and emphasizes the need for further case documentation to aid in management strategies.

PlexinD1 is a driver and a therapeutic target in advanced prostate cancer

Aggressive prostate cancer (PCa) variants associated with androgen receptor signaling inhibitor (ARSI) resistance and metastasis remain poorly understood. Here, we identify the axon guidance semaphorin receptor PlexinD1 as a crucial driver of cancer aggressiveness in metastatic castration-resistant prostate cancer (CRPC). High PlexinD1 expression in human PCa is correlated with adverse clinical outcomes. PlexinD1 critically maintains CRPC aggressive behaviors in vitro and in vivo, and confers stemness and cellular plasticity to promote multilineage differentiation including a neuroendocrine-like phenotype for ARSI resistance. Mechanistically, PlexinD1 is upregulated upon relief of AR-mediated transcriptional repression of PlexinD1 under ARSI treatment, and subsdquently transactivates ErbB3 and cMet via direct interaction, which triggers the ERK/AKT pathways to induce noncanonical Gli1-dictated Hedgehog signaling, facilitating the growth and plasticity of PCa cells. Blockade of PlexinD1 by the protein inhibitor D1SP restricted CRPC growth in multiple preclinical models. Collectively, these findings characterize PlexinD1's contribution to PCa progression and offer a potential PlexinD1-targeted therapy for advanced PCa.

Persistent Gastroesophageal Reflux Disease After RYGB: What Shall we do Next?

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is considered the weight loss procedure of choice for obese patients with gastroesophageal reflux disease (GORD). The long-term prevalence of GORD after RYGB for obesity is underestimated as many post-RYGB patients can still complain of severe reflux symptoms, refractory to medications.

METHODS

This is a narrative review using the patient, intervention, comparison, outcome and study strategy. The literature search was undertaken using PubMed, Medline, and Google Scholar databases with the following MeSH terms: Gastroesophageal reflux disease, GORD, Obesity, Gastric bypass, Roux-en-Y gastric bypass, complication, and fundoplication.

RESULTS

Twelve original papers and case report studies on 57 patients who met the inclusion criteria were suitable for the present review. Reporting styles on successful treatment outcomes were heterogeneous. Treatment options for these patients are limited but include further surgical or endoscopic interventions. Careful follow-up and appropriate management are paramount for this population.

CONCLUSION

There is significant paucity in the available evidence on managing GORD after RYGB. This narrative review provides a detailed overview of the underlying causes, discusses the various endoscopic and surgical therapy options, and suggests strategies to provide tailored and appropriate therapy for this complex group of patients.

A case of needle tract seeding of pancreatic adenosquamous carcinoma after a single endoscopic ultrasound-guided tissue acquisition

Needle tract seeding (NTS) is a rare complication of endoscopic ultrasound-guided tissue acquisition (EUS-TA). Herein, we report the case of an 83 year-old man who presented with a solid mass in the pancreatic tail, measuring 35 mm in diameter, with cystic degeneration. EUS-TA was performed using a 22-gauge biopsy needle, with a single puncture via the stomach; however, no definitive pathological diagnosis was achieved. Due to the strong suspicion of malignancy, surgery was performed at the patient's request, and the postoperative pathological diagnosis was pancreatic adenosquamous carcinoma. One year after surgery, computed tomography revealed a string of bead-like nodules within the gastric wall. Esophagogastroduodenoscopy revealed three submucosal, tumor-like raised lesions aligned in a row on the upper posterior wall of the gastric body. EUS detected a solid mass with cystic degeneration. Histological findings from EUS-TA specimens were consistent with those from the pancreatic resection specimen, leading to a diagnosis of NTS. Although reports of NTS have been increasing in recent years, cases of NTS occurring after only a single puncture remain extremely rare. This case clearly demonstrates that NTS can occur even after a single puncture, highlighting the importance of obtaining thorough informed consent regarding this risk prior to performing EUS-TA.

Log odds of positive lymph nodes compared to positive lymph node ratio and number of positive lymph nodes in prognostic modeling for patients with NSCLC undergoing lobectomy or total pneumonectomy: a population-based study using Cox regression and XGBoost with SHAP analysis

Background

Methods such as the number of positive lymph nodes (nPLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) are used to predict prognosis in patients with non-small cell lung cancer (NSCLC). We hypothesized that LODDS could be a superior independent predictor of prognosis and aimed to compare its effectiveness with nPLN and LNR in predicting survival outcomes in stage I-IIIA NSCLC patients.

Methods

We utilized data from the Surveillance, Epidemiology, and End Results (SEER) 17 registry (2010-2019) to study NSCLC patients, focusing on those who underwent surgery with confirmed lymph node involvement (N1 or N2 disease). We aimed to compare overall survival (OS) and cancer-specific survival (CSS) based on nPLN, LNR, and LODDS. Kaplan-Meier and Cox regression analyses were employed to evaluate survival, with thresholds determined using X-tile software. An XGBoost model was constructed to predict overall survival in patients using three features: LODDS, LNR, and PLN. SHapley Additive exPlanations (SHAP) analysis was applied to assess feature importance and provide interpretable insights into the model's predictions.

Results

The study analyzed 3,132 eligible NSCLC patients from the SEER database, predominantly male (53.07%) with adenocarcinoma (43.65%) or squamous cell carcinoma (29.76%). Survival outcomes were assessed using nPLN, LNR, and LODDS. LODDS showed superior predictive value for both OS and CSS compared to nPLN and LNR, as indicated by a larger Log Likelihood Ratio (LLR) and smaller Akaike Information Criterion (AIC). Higher scores on npLN, LNR, and LODDS were strongly related with a poorer prognosis, according to Kaplan-Meier analyses (P < 0.001). The SHAP (SHapley Additive exPlanations) analysis of the XGBoost model demonstrated that the LODDS exhibited the highest SHAP values (0.25) for predicting overall survival in patients, consistently outperforming the LNR and the number of nPLN across both training and validation datasets.

Conclusions

Compared to the nPLN and LNR staging systems, LODDS demonstrates superior prognostic power for patients with stage I-IIIA NSCLC undergoing lobectomy or pneumonectomy. By integrating both positive and negative lymph node information, LODDS offers a refined risk stratification that is particularly valuable in cases with high lymph node heterogeneity.

Giant sigmoid diverticulum

Giant colonic diverticulum is an uncommon presentation of colonic diverticular disease. It is characterised by the presence of a diverticulum exceeding 4 cm in size, with approximately 90% of the cases involving the sigmoid colon. Typically, diagnosis relies on CT of the abdomen and pelvis (CTAP). The preferred treatment approach is sigmoid resection with a primary colonic anastomosis. However, in complicated or emergency cases, proctosigmoidectomy with end colostomy (Hartmann's procedure) is often considered the safest surgical option.We present an atypical case of a symptomatic patient with a giant sigmoid diverticulum that had increased in size and symptoms over several years. Initial diagnosis by CTAP revealed an incidental 6 cm sigmoid diverticulum. Over approximately 6 years, the diverticulum enlarged substantially, reaching 20 cm in size. This caused compression of the stomach and splinting of the left hemidiaphragm, resulting in nutritional failure. He was admitted with a plan to optimise for curative surgery; however complications such as nutritional failure and frailty developed, leading to a decision for palliative care.

Prognostic significance of three lymph node staging systems in pancreatic cancer with ≤ 12 and > 12 retrieved lymph nodes

This study aimed to evaluate and compare the predictive performance of negative lymph nodes (NLN), lymph node ratio (LNR), and N stage in pancreatic ductal adenocarcinoma (PDAC) among patients with ≤ 12 retrieved lymph nodes and those with > 12 retrieved lymph nodes. Moreover, the association between the three nodal staging systems and survival was also explored. Clinical data on patients diagnosed with PDAC between 2004 and 2020 were downloaded from the Surveillance, Epidemiology, and End Results (SEER) database. Cox regression was performed to identify independent predictors of cancer specific survival (CSS) and overall survival (OS). Survival probability was calculated and compared by the Kaplan-Meier method and log rank test. Akaike information criterion (AIC) and Harrell's C-index were used to evaluate the prognostic ability of each nodal staging system. All three lymph node staging systems were independent predictors of CSS and OS. A higher NLN, a lower N stage, and a lower LNR were associated with improved survival. Compared with N stage, LNR staging performed better with a lower AIC and higher C-index for predicting the prognosis regardless of the sufficiency of retrieved lymph nodes, while NLN staging performed poorly in both the training and validation set. Subgroup analyses showed that the NLN successfully predicted survival outcomes in both lymph node-positive and node-negative patients. LNR demonstrated better predictive performance in PDAC patients regardless of the sufficiency of retrieved lymph nodes. Notably, for stage N0 disease, NLN was a more important prognostic predictor. The combination of LNR and NLN may offer more precise information on lymph node staging than the current staging system.

The impact of Hashimoto's thyroiditis on the clinical outcome of papillary thyroid cancer after radioactive iodine therapy: a propensity score matching study

OBJECTIVE

The potential association between Hashimoto's thyroiditis (HT) and papillary thyroid carcinoma (PTC) has been studied from different perspectives for many years. This study was aimed to evaluate the impact of HT on the clinical outcomes of PTC patients after radioactive iodine (RAI) therapy.

MATERIAL AND METHODS

We conducted a retrospective study on consecutive patients with PTC who underwent RAI therapy from April 2017 to May 2020. The diagnosis of HT was based on pathological examination, and patients were divided into the HT and non-HT group. Distributions of age, gender, ultrasound features, papillary variants, extrathyroidal extension, and other histopathological characteristics were observed. Propensity score matching (PSM) was used to compare the clinical features and outcomes between the two groups at 1 and 3-year follow-up.

RESULTS

In total, 782 patients with PTC were enrolled (570 women, 212 men). HT was presented in 130 (16.6%) patients, and was associated with younger age, smaller primary tumors, less extrathyroidal extension, and less lymph node metastasis at presentation. On review of the images, only calcification and blood flow distribution were significantly different among the US features (P < 0.05). At the end of follow-up (three years), the responses to RAI therapy were significantly different between the two groups (ER: 76.9% vs 64.9%; IDR:11.5% vs 17.2%; BIR: 4.6% vs 10.7%; SIR: 6.9% vs 7.2%, P = 0.03). Patients with HT had less frequently evidence of disease (11.6% vs 17.9%). When compared with the matched groups, 123 pairs of patients were successfully matched, PTC patients with HT were found to have a better response to RAI therapy.

CONCLUSIONS

PTC patients with HT had less aggressive characteristics at presentation. Importantly, the presence of HT not only had a significant association with the outcome, but was also protective from the risk of recurrence.

Uncommon Anal Cancers

Anal cancer is by itself a rare entity. Even rarer are the uncommon anal tumors described in this article. Diagnosis of these lesions can be challenging as some of these have no symptoms in their initial stages and only cause symptoms once they have progressed to advanced stages. Further, it can be difficult for even the trained eye to make a diagnosis as some of these pathologies mimic benign disease or the more common anal malignancy, squamous cell carcinoma. More data are needed to establish consensus for the management of these unusual pathologies.

Development and External Validation of a CT-Based Radiomics Nomogram to Predict Perineural Invasion and Survival in Gastric Cancer: A Multi-institutional Study

RATIONALE AND OBJECTIVES

To develop and validate a radiomics nomogram utilizing CT data for predicting perineural invasion (PNI) and survival in gastric cancer (GC) patients.

MATERIALS AND METHODS

A retrospective analysis of 408 GC patients from two institutions: 288 patients from Institution I were divided 7:3 into a training set (n = 203) and a testing set (n = 85); 120 patients from Institution II served as an external validation set. Radiomics features were extracted and screened from CT images. Independent radiomics, clinical, and combined models were constructed to predict PNI. Model discrimination, calibration, clinical utility, and prognostic significance were evaluated using area under the curve (AUC), calibration curves, decision curves analysis, and Kaplan-Meier curves, respectively.

RESULTS

15 radiomics features and three clinical factors were included in the final analysis. The AUCs of the radiomics model in the training, testing, and external validation sets were 0.843 (95% CI: 0.788-0.897), 0.831 (95% CI: 0.741-0.920), and 0.802 (95% CI: 0.722-0.882), respectively. A nomogram was developed by integrating significant clinical factors with radiomics features. The AUCs of the nomogram in the training, testing, and external validation sets were 0.872 (95% CI: 0.823-0.921), 0.862 (95% CI: 0.780-0.944), and 0.837 (95% CI: 0.767-0.908), respectively. Survival analysis revealed that the nomogram could effectively stratify patients for recurrence-free survival (Hazard Ratio: 4.329; 95% CI: 3.159-5.934; P < 0.001).

CONCLUSION

The radiomics-derived nomogram presented a promising tool for predicting PNI in GC and held significant prognostic implications.

IMPORTANT FINDINGS

The nomogram functioned as a non-invasive biomarker for determining the PNI status. The predictive performance of the nomogram surpassed that of the clinical model (P < 0.05). Furthermore, patients in the high-risk group stratified by the nomogram had a significantly shorter RFS (P < 0.05).