Age-specific trends in colorectal, appendiceal, and anal tumour incidence by histological subtype in Australia from 1990 to 2020: a population-based time-series analysis

Background

Early-onset bowel cancer incidence (age <50 years) has increased worldwide and is highest in Australia, but how this varies across histology and anatomical site remains unclear. We aimed to investigate appendiceal, proximal colon, distal colon, rectal, and anal cancer incidence trends by age and histology in Australia.

Methods

Cancer incidence rate data were obtained from all Australian cancer registries (1990-2020 period). Birth cohort-specific incidence rate ratios (IRRs) and annual percentage change in rates were estimated using age-period-cohort modelling and joinpoint regression.

Findings

After excluding neuroendocrine neoplasms, early-onset cancer incidence rose 5-9% annually, yielding 5,341 excess cases (2 per 100,000 person-years; 12% appendix, 45% colon, 36% rectum, 7% anus; 20-214% relative increase). Trends varied by site, period, and age: appendiceal cancer rose from 1990-2020 in 30-49-year-olds; colorectal cancers rose from around 1990-2010 in 20-29-year-olds and from 2010-2020 in 30-39-year-olds; anal cancer rose from 1990-2009 in 40-49-year-olds. Across all sites, IRRs increased with successive birth cohorts since 1960. Notably, adenocarcinoma incidence in the 1990s versus 1950s birth cohort was 2-3-fold for colorectum and 7-fold for appendix. The greatest subtype-specific increases occurred for appendiceal mucinous adenocarcinoma, colorectal non-mucinous adenocarcinoma, and anal squamous cell carcinoma. Only later-onset (age ≥50) colorectal and anal adenocarcinoma rates declined. Appendiceal tumours, neuroendocrine neoplasms (all sites), anorectal squamous cell carcinomas, and colon signet ring cell carcinomas rose across early-onset and later-onset strata.

Interpretation

Appendiceal, colorectal, and anal cancer incidence is rising in Australia with variation across age and histology, underscoring the need to identify factors driving these trends.

Funding

ALM is supported by an Australian Government Research Training Program Scholarship, Rowden White Scholarship, and WP Greene Scholarship. DDB is supported by a National Health and Medical Research Council of Australia (NHMRC) Investigator grant (GNT1194896), a University of Melbourne Dame Kate Campbell Fellowship, and by funding awarded to The Colon Cancer Family Registry (CCFR, www.coloncfr.org) from the National Cancer Institute (NCI), National Institutes of Health (NIH) [award U01 CA167551]. MAJ is supported by an NHMRC Investigator grant (GNT1195099), a University of Melbourne Dame Kate Campbell Fellowship, and by funding awarded to the CCFR from NCI, NIH [award U01 CA167551].

Trends in Clinical Outcomes After Major Emergency Abdominal Surgery in Denmark, Data From 2002-2022

Importance

Major emergency abdominal surgery is associated with high morbidity and mortality. Understanding trends in outcomes over time can reveal critical practice-changing improvements, identify gaps in postoperative care, and establish a large-scale benchmark for future research.

Objective

To investigate trends in morbidity and mortality after major emergency abdominal surgery in Denmark.

Design, Setting, and Participants

This was a nationwide, population-based cohort study. Analyses were performed based on data from Danish nationwide administrative registries. Within the public health care system in Denmark, all adult patients undergoing major emergency abdominal surgery from 2002 to 2022 were included. Major emergency abdominal surgeries included laparotomy or laparoscopy due to intra-abdominal pathologies, including intestinal perforation, ischemia, bowel obstruction, abscess, or bleeding.

Exposure

Major emergency abdominal surgery.

Main Outcomes and Measures

The primary outcome was the trend in 30- and 90-day mortality after major emergency abdominal surgery over time.

Results

A total of 61 476 patients (mean [SD] age, 66.2 [16.3] years; 34 827 female [56.7%]) were included. The annual number of surgeries remained constant, with a mean (SD) of 3044 (165) surgeries per year. The 30- and 90-day mortality was reduced from 25% and 33%, respectively, to 13% and 18%, respectively (P < .001). Median (IQR) hospital length of stay was decreased from 10 (5-17) days to 6 (4-13) days (P < .001). The rate of 30-day postoperative complications (classified Clavien-Dindo ≥3a) was reduced from 49% to 44% (P <.001) and the 90-day rate was reduced from 53% to 48% (P <.001), however, with a tendency toward more patients undergoing earlier intervention. The 30- and 90-day readmission rate increased drastically from 9% and 13%, respectively, to 25% and 33%, respectively (P < .001).

Conclusions and Relevance

Results of this cohort study suggest notable reductions in mortality and hospital length of stay after major emergency abdominal surgery. A marked increased readmission rate and a persistently high rate of postoperative complications were found. These shifts underscore the need for enhanced postoperative monitoring and postdischarge follow-up.

Potency and Safety of KRAS G12C Inhibitors in Solid Tumors: A Systematic Review

Background

The Kirsten rat sarcoma viral oncogene homolog (KRAS) gene, specifically the cysteine residue mutation KRAS (G12C), has garnered significant attention as a therapeutic target for solid cancer patients with KRAS mutations. Despite this interest, the efficacy and safety profiles of KRAS G12C inhibitors remain incompletely understood. In this study, we comprehensively evaluate the effectiveness and toxicity of relevant KRAS G12C inhibitors (Sotorasib, Adagrasib, Garsorasib, and Divarasib) in patients with colorectal cancer (CRC), non-small-cell lung cancer (NSCLC), and pancreatic ductal adenocarcinomas (PDAC).

Methods

Our systematic review is guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We review the available clinical trials data on KRAS G12C inhibitors in KRAS G12C-mutated solid tumors. We searched PubMed, EMBASE, Cochrane Library, and major international conferences for clinical trials from January 2020 until August 2023.

Results

A total of 17 eligible studies were included. KRAS G12C inhibitions with Sotorasib (41.2%) and Adagrasib (41.2%) each of them were reported in 7 studies. Divarasib was reported in 2 studies (11.8%) and Garsorasib was reported in 1 study (6.7%). Sotorasib showed a significant clinical benefit in terms of objective response rate (ORR) (7.1%-47%), progression-free survival (PFS) (4-6.8 months), and overall survival (OS) (4-24 months); it is more efficient in NSCLC patients with an OS of 2 years, PFS of 6.3 months, and an ORR of 41%. Adagrasib also showed significant clinical activity with an ORR (19%-53%), PFS (3.3-11.1 months), and OS (10.5-23.4 months), with more effectiveness in NSCLC patients with an OS of 23.4 months, PFS of 11.1 months, and an ORR of 53.3%. Adagrasib is more efficient with an ORR of 35.1%, PFS of 7.4 months, and an OS of 14 months in patients with PDAC, than Sotorasib which showed an ORR of 21%, PFS of 4 months, and an OS of 6.9 months. However, Adagrasib and Sotorasib are moderately efficient in CRC clinical trials.

Conclusion

This study confirms that patients treated with these KRAS G12C inhibitors, exclusively or combined with conventional therapies, achieve better treatment responses and modulate the progressions of these solid tumors.

Outcomes for Medicaid Patients with Colorectal Cancer Are Improved in Affluent Neighborhoods, but Disparities Persist

BACKGROUND

Socioeconomic status (SES) significantly influences outcomes in colorectal cancer (CRC) patients, with those from low-SES backgrounds facing worse prognoses. However, living in an affluent neighborhood may mitigate some of these disparities through environmental advantages. This study investigates whether Medicaid-insured CRC patients, as a proxy for low individual SES, experience better outcomes when residing in high-SES neighborhoods.

METHODS

Using the National Cancer Database, we examined Medicaid CRC patients, stratifying them by neighborhood SES indicators: median household income and education level. Patients in the highest and lowest quartiles of income and education were compared. Medicaid patients from the highest-SES neighborhoods were compared to the general population. Multivariable regression models analyzed 30- and 90-day postoperative mortality, overall survival (OS), and time from diagnosis to treatment initiation and surgery.

RESULTS

CRC patients in high-income neighborhoods began treatment earlier (coefficient -1.847, p = 0.015) and exhibited improved OS (HR 0.810, p < 0.001) compared to those in low-income neighborhoods, irrespective of education level. Similarly, patients in high-education neighborhoods started treatment sooner (coefficient -3.926, p < 0.001) and had better OS (HR 0.897, p < 0.001). No differences were observed in time to surgery or postoperative mortality. Despite these advantages, Medicaid patients in high-income (HR 1.130, p < 0.001) and high-education (HR 1.209, p = 0.002) areas still had worse OS compared to non-Medicaid patients.

CONCLUSIONS

Higher neighborhood SES is associated with a significant survival benefit for Medicaid CRC patients, but these patients still lag behind their non-Medicaid counterparts. Understanding the mechanisms by which neighborhood SES influences cancer outcomes could inform targeted interventions to close the survival gap.

Challenges in studying neuroanatomy in sub-Saharan Africa: The case of Cameroon

Introduction

Quality education is key in addressing the skilled neurological workforce gap in Africa. However, many medics are scared of the neurological sciences because of the challenges faced in medical schools in studying the neurosciences. Understanding its state and educational challenges is crucial for fostering interest in neurosurgery and related specialities on the continent.

Research question

What are the current state, challenges, and solutions to improve neuroanatomy education in Cameroon, Africa in miniature?

Materials and methods

A cross-sectional study using an 11-item electronic survey was conducted among medical students from all nine medical schools in Cameroon. Data were analysed using descriptive statistics and independent t-tests, with significance set at p < 0.05.

Results

Among 220 respondents, 40.1 % and 35.0 % respectively, reported cranial nerves/brainstem and neurovascular anatomy to be the most challenging, with a mean comprehension score of 5.83/10. Faculty predominantly relied on PowerPoint lectures (83.2 %), while most students supplemented learning with YouTube videos (77.7 %). 63.9 % of the respondents perceived classroom teaching alone to limit their understanding of neuroanatomy, and 85.8 % of students reported the time allocated for neuroanatomy teaching to be inadequate. The usage of cadaver dissection (69.5 %), and neurosimulation practicals (66.4 %) were the most recommended tools by students to improve neuroanatomy teaching.

Discussion and conclusion

Challenges in neuroanatomy education in Cameroon are perceived to arise from insufficient hands-on learning, time constraints, and limited access to specialised faculty. These suggest interactive teaching, increased curriculum time, and diverse resources as potential improvements, though further research is needed to assess their effectiveness and ultimately improve understanding, fostering a stronger neurological workforce.

Treatments and cancer: implications for radiologists

This review highlights the critical role of radiologists in personalized cancer treatment, focusing on the evaluation of treatment outcomes using imaging tools like Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Ultrasound. Radiologists assess the effectiveness and complications of therapies such as chemotherapy, immunotherapy, and ablative treatments. Understanding treatment mechanisms and consistent imaging protocols are essential for accurate evaluation, especially in managing complex cases like liver cancer. Collaboration between radiologists and oncologists is key to optimizing patient outcomes through precise imaging assessments.

Exploring the Role of Cellular Interactions in the Colorectal Cancer Microenvironment

Colorectal cancer (CRC) stands as one of the tumors with globally high incidence and mortality rates. In recent years, researchers have extensively explored the role of the tumor immune microenvironment (TME) in CRC, highlighting the crucial influence of immune cell populations in driving tumor progression and shaping therapeutic outcomes. The TME encompasses an array of cellular and noncellular constituents, spanning tumor cells, immune cells, myeloid cells, and tumor-associated fibroblasts, among others. However, the cellular composition within the TME is highly dynamic, evolving throughout different stages of tumor progression. These shifts in cell subpopulation proportions lead to a gradual transition in the immune response, shifting from an early antitumor growth to a late-stage environment that supports tumor survival. Therefore, it is crucial to further investigate and understand the complex interactions among the various cell populations within the TME. In this review, we explore the key cellular components of varying origins, subpopulations with shared origins, and noncellular elements within the CRC TME, examining their interconnections and critical considerations for developing personalized and precise immunotherapy strategies.

The feasibility and safety of deeply inserted enema tubes for acute malignant left-hemicolon obstruction: an alternative solution in developing countries

Background and aims

Disposable enema kits are commonly used for bowel preparation, with the anal tube typically positioned near the rectal ampulla. This study assesses the feasibility and safety of deeply inserting an enema tube in cases of acute malignant left-hemicolon obstruction.

Methods

A retrospective analysis was conducted on 42 patients who underwent emergency endoscopic decompression via a deeply inserted enema tube for acute malignant left-hemicolon obstruction from January 2021 to September 2024 at a single center, the Endoscopy Centre of the Affiliated Hospital of Putian University. This analysis covered intubation duration, the success rate of intubation, the obstruction relief rate, as well as associated adverse events.

Results

Thirty-six patients achieved successful tube placement, attaining a one-time success rate of 85.7% (36/42). Following successful intubation, the abdominal circumference decreased to a mean of (85.2 ± 3.0)% of the original value on the subsequent day (P < 0.01). Abdominal plain films depicted a significant reduction in both the quantity of gas-fluid levels and the maximal transverse diameter of the proximally obstructed colon [(4.5 ± 1.2) cm versus (7.4 ± 0.8) cm, P < 0.01]. Within 48 hours, C-reactive protein (CRP) levels plummeted by over 50%, and bowel sounds normalized within 2 - 5 days. During surgery, the bowel exhibited only slight or negligible dilation and edema, with no conspicuous fecal residues detected in the colonic cavity. Furthermore, no severe tube-related adverse events occurred either during or after intubation.

Conclusion

The application of deeply inserted enema tubes proves to be both feasible and safe in treating acute malignant left-hemicolon obstruction, thus presenting itself as a viable alternative approach in developing countries.

Digital Decision Support for Perioperative Care of Patients With Type 2 Diabetes: A Call to Action

Unlabelled

Type 2 diabetes mellitus affects over 500 million people globally, with 10%-20% requiring surgery. Patients with diabetes are at increased risk for perioperative complications, including prolonged hospital stays and higher mortality, primarily due to perioperative hyperglycemia. Managing blood glucose during the perioperative period is challenging, and conventional monitoring is often inadequate to detect rapid fluctuations. Clinical decision support systems (CDSS) are emerging tools to improve perioperative diabetes management by providing real-time glucose data and medication recommendations. This viewpoint examines the role of CDSS in perioperative diabetes care, highlighting their benefits and limitations. CDSS can help manage blood glucose more effectively, preventing both hyperglycemia and hypoglycemia. However, technical and integration challenges, along with clinician acceptance, remain significant barriers.

CAR-NK cell therapy: promise and challenges in solid tumors

Over the past few years, cellular immunotherapy has emerged as a promising treatment for certain hematologic cancers, with various CAR-T therapies now widely used in clinical settings. However, challenges related to the production of autologous cell products and the management of CAR-T cell toxicity highlight the need for new cell therapy options that are universal, safe, and effective. Natural killer (NK) cells, which are part of the innate immune system, offer unique advantages, including the potential for off-the-shelf therapy. A recent first-in-human trial of CD19-CAR-NK infusion in patients with relapsed/refractory lymphoid malignancies demonstrated safety and promising clinical activity. Building on these positive clinical outcomes, current research focuses on enhancing CAR-NK cell potency by increasing their in vivo persistence and addressing functional exhaustion. There is also growing interest in applying the successes seen in hematologic malignancies to solid tumors. This review discusses current trends and emerging concepts in the engineering of next-generation CAR- NK therapies. It will cover the process of constructing CAR-NK cells, potential targets for their manufacturing, and their role in various solid tumors. Additionally, it will examine the mechanisms of action and the research status of CAR-NK therapies in the treatment of solid tumors, along with their advantages, limitations, and future challenges. The insights provided may guide future investigations aimed at optimizing CAR-NK therapy for a broader range of malignancies.

Pulmonary and functional hallmarks after SARS-CoV-2 infection across three WHO severity level-groups: an observational study

Background

The manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection range from flu-like symptoms to severe lung disease. The consequences of this inflammatory process impact overall function, which can be detected through both short- to long-term assessments. This study aimed to assess the pulmonary functional and structural characteristics of post-SARS-CoV-2 infection in patients with mild/moderate, severe, and critical clinical presentations.

Methods

An observational, analytical, and cross-sectional study was conducted between 2020 and 2022, including participants with a confirmed diagnosis of coronavirus disease (COVID)-19, with mild/moderate (G1), severe (G2), and critical (G3) clinical presentations, all evaluated at least 3 months after acute infection. Spirometry, impulse oscillometry, fractional exhaled nitric oxide (FeNO), chest computed tomography, the 6-min walk test (6MWT), hand grip strength, maximum inspiratory pressure, and maximum expiratory pressure were assessed.

Results

We enrolled 210 participants aged 18-70 years, 32.6% of whom were male, with older age observed in G3. The participants were grouped as follows: G1 (42.3%), G2 (25.7%), and G3 (31.9%). Percentage of predicted X5 differed between G1 and G2, being higher in G1. The percentage of predicted forced vital capacity (FVC) according to the Global Lung Function Initiative and its z-score were higher in G1. The FVC by Pereira was lower in G3 compared to G1. The percentage of predicted forced expiratory volume in 1 s (FEV1) by Pereira was also lower in G3. The Tiffeneau (FEV1/FVC) index was different among groups, increasing with disease severity. The percentage of predicted forced expiratory flow rate at 25-75% (FEF25-75%) of the FVC and FeNO were both higher in G2 than G1. Chest computed tomography revealed the presence of interstitial abnormalities, associated with disease severity. The respiratory muscle strength evaluation showed an association between higher maximum expiratory pressure values in G3 compared to G1, but no association with maximum inspiratory pressure was observed. The 6MWT distance covered decreased with increasing severity, with a lower percentage of predicted values in G3 compared to G1. The right-hand grip strength was also lower in G3 compared to G1.

Conclusion

Alterations in pulmonary and functional markers were observed in post-COVID-19 evaluations, increasing with disease severity, as seen in G2 and G3. These findings highlight the complexity of post-COVID-19 functional assessments, given the long-term pulmonary sequelae and the consequent impairment of functional capacity.

The Effect of Albumin/Glutaraldehyde Glue (Bioglue) on Colonic Anastomosis Under Intestinal Obstruction: An Experimental Study in Rats

Background/Objectives: Healing of colonic anastomoses is critical to surgical recovery, particularly under obstructive ileus conditions. Adhesive biological materials such as albumin/glutaraldehyde glue (Bioglue) show potential in enhancing anastomotic healing and minimizing complications. This study investigates the effect of Bioglue on colonic anastomoses healing under obstructive ileus conditions in rats. Methods: Eighty albino Wistar rats were divided into control, ileus, Bioglue, and ileus + Bioglue groups (n = 20 each). Subgroups (n = 10) were sacrificed on the 4th or 8th postoperative day. In the control and Bioglue groups, end-to-end anastomoses were performed after colonic resection. In the ileus and ileus + Bioglue groups, obstructive ileus was induced by colonic ligation, followed by resection and primary anastomosis. Bioglue was applied in the Bioglue and ileus + Bioglue groups. Assessments included bursting pressure, peritoneal adhesion and inflammation scores, and biochemical markers (fibroblast activity, neoangiogenesis, collagen deposition, hydroxyproline, and collagenase concentrations). Results: Bursting pressure and fibroblast activity were significantly higher in the ileus + Bioglue group compared to the ileus group on both postoperative days. Although anastomotic rupture occurred in the ileus and ileus + Bioglue groups, the incidence was not significantly different from the control and Bioglue groups. Ileus + Bioglue showed significantly higher adhesion scores, inflammatory infiltration, neoangiogenesis, and collagen deposition compared to the control and ileus groups. Hydroxyproline was significantly elevated in the ileus + Bioglue group on the 8th day. Collagenase I concentrations were higher in ileus + Bioglue but not significant. Conclusions: Bioglue application enhances colonic anastomotic healing under obstructive ileus conditions, improving mechanical strength and promoting tissue repair by the 4th and 8th postoperative days. These findings support its potential clinical application.

Analysis of the Direct Medical Costs of Colorectal Cancer in Antigua and Barbuda: A Prevalence-Based Cost-of-Illness Study

Colorectal cancer burden is a threat to health systems in several countries. As the cost of diagnosing, treating, and managing this cancer is unknown in Antigua and Barbuda, this study aimed to estimate its direct medical cost in this country. We used the prevalence-based cost-of-illness methodology to study data on patients diagnosed with colorectal cancer between 2017 and 2021. Data record abstraction was carried out to determine the five-year prevalence, and a top-down and bottom-up approach was employed to estimate the direct medical costs for colorectal cancer care components. All costs were computed at 2021 price levels and are reported in United States dollars. The total annual direct medical costs for colorectal cancer were estimated at USD 1.14 million (ranging between USD 0.85 million and USD 1.42 million). Major cost drivers were treatment (USD 613,650.01) and post-treatment side-effects care (USD 402,234.50). The overall estimated direct medical unit costs were USD 139,295.58, with the main drivers being surgery (USD 43,467.10), other complications of treatment (USD 28,469.21), and immunotherapy (USD 19,200.00). This study provides evidence of the economic burden of colorectal cancer in Antigua and Barbuda. The estimates of annual direct medical costs are substantial. Our findings could help in the development of health policy and aid in resource allocation related to local colorectal cancer management.

Modern Trends of Drain Placement in Primary Bariatric Surgery: An MBSAQIP Analysis of 526,723 Patients

BACKGROUND

Prophylactic drain use during primary bariatric surgeries continues despite previous literature cautioning against their routine use. Modern drain utilization and associated outcomes remain largely poorly studied which limits selective utilization and perhaps may lead to excess morbidity and healthcare resource utilization. This study aimed to reassess current trends of drain use in primary bariatric procedures, factors driving surgeons to place drains, and patient outcomes associated with drain placement.

METHODS

Patients undergoing the most common primary bariatric surgery operations from 2020 to 2022 were included using the Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database. Two cohorts were created, a drain placed (DP) cohort and no drain (ND) cohort, which were then compared in terms of baseline characteristics, rates of complications, and length of stay. Multivariate modeling was performed to assess the effect of drains on various complications and factors associated with drain placement.

RESULTS

Of 526,723 included patients, drain utilization decreased across operative years (8.7% in 2020 to 6.1% in 2022, p < 0.001). Factors associated with drain placement in multivariate models included older age, higher BMI, partially dependent functional status, renal insufficiency, venous thromboembolism, hypoalbuminemia, and non-sleeve anastomotic procedures. Drain placement was associated with increased risk of numerous complications on bivariate analysis, which was still significant in multivariate analysis, including 30-day serious complications (adjusted odds ratio [aOR] 1.24, p < 0.001), anastomotic leak (aOR 2.1, p < 0.001), organ space infection (aOR 2.0, p < 0.001), reoperation (aOR 1.2, p = 0.036), and excess length of stay (LOS, aOR 1.45, p < 0.001).

CONCLUSIONS

The frequency of prophylactic drain placement during primary bariatric surgical procedures has decreased in recent years and patients with drain placement seem to have increased 30-day morbidity, including longer length of stay. Independent predictors of drain placement include increased age and metabolic burden along with anastomotic procedures. Surgeons should be judicious in selecting patients for drain placement and future prospective, controlled studies may better answer drain placement association with complications.

Laparoscopic appendectomy improves outcomes and reduces costs in rural Kenya

BACKGROUND

Acute appendicitis is a common emergency in rural Kenya. While open appendectomy is widely used, minimally invasive approaches may improve postoperative recovery and superficial surgical site infection rates. However, adoption in resource-limited settings is hindered by cost and availability, with fewer than 1% of operations involving laparoscopy. This study evaluates the effectiveness and costs of laparoscopic versus open appendectomy to inform practices in similar settings.

METHODS

A retrospective study at Tenwek Hospital, Kenya (2015-2019), compared laparoscopic and open appendectomy using a bottom-up micro-costing method for true healthcare costs, adjusted for inflation and expressed in international dollars using purchasing power parity (I$PPP). Outcomes, including operating room turnaround time, hospital length of stay, superficial surgical site infections, and financial impact, were analyzed with Pearson's chi-squared, Wilcoxon rank-sum tests, and a multilevel generalized linear model to adjust for patient comorbidities and severity.

RESULTS

Among 168 patients, median age was 34 years (IQR: 26-44), with 71% men, and perforation in 45%. Laparoscopic surgery was performed on 31 patients, with one conversion, versus open surgery in 137. The laparoscopic group had longer operating room turnaround times (115 vs. 75 min, p < 0.001) but shorter hospital stays (2 vs. 4 days, p = 0.002). Total costs were lower for laparoscopy cases (1527 vs. 1816 I$PPP, p = 0.049), with surgical site infections (3.2% vs. 16.7%, p = 0.026).

CONCLUSIONS

Despite longer surgery times, laparoscopic appendectomy significantly reduces hospital stays, total costs, and surgical site infections compared to open surgery in rural Kenya.

Perianastomotic pH Monitoring for Early Detection of Anastomotic Leaks in Gastrointestinal Surgery: A Systematic Review of the Literature

IntroductionAnastomotic leak (AL) represents a significant complication following gastrointestinal (GI) surgery, contributing to increased morbidity and mortality. pH monitoring has emerged as a potential diagnostic tool for the early detection of AL, but its effectiveness and clinical utility remain to be fully elucidated. This review aims to summarise the evidence regarding perianastomotic pH monitoring for AL detection.MethodsA systematic search of relevant databases was conducted to identify pre-clinical and clinical studies investigating pH monitoring for AL detection following GI surgery. Studies were screened by two independent reviewers based on predefined inclusion and exclusion criteria. Data were extracted and presented as a narrative synthesis.ResultsA total of 10 studies were included in the review, comprising animal studies (n = 2), and human studies in upper GI (n = 3) and colorectal (n = 5) patients. Consistent findings of lower pH values in patients with AL across various postoperative time points were demonstrated. There was diversity in the pH detection method, in addition to variable frequency and timing of pH monitoring. Four studies reported a shorter time for AL detection with pH monitoring vs conventional methods, although no statistical comparisons were used. No standard pH cut-off value for AL detection was identified.ConclusionpH monitoring shows potential as a diagnostic tool for the early detection of AL following GI surgery. While the existing evidence supports its potential utility, further research is required to establish standardised protocols and assess its clinical impact.

Home-based prehabilitation: a systematic review and meta-analysis of randomised trials

BACKGROUND

Prehabilitation aims to enhance preoperative functional capacity through exercise, nutrition, and psychological programs. Home-based prehabilitation represents an alternative to hospital prehabilitation, with the advantage of not utilising hospital resources. This review aims to evaluate adherence and clinical effectiveness of home-based prehabilitation.

METHODS

We searched PubMed, Cochrane, and Embase up to October 1, 2024 for randomised controlled trials comparing home-based prehabilitation with standard care. The primary outcome was the proportion of patients with postoperative complications. Secondary outcomes included protocol adherence, and 6-min walking test. We used risk ratios (RR) and mean differences to summarise the results. The risk of bias was assessed using RoB 2 tool.

RESULTS

We included 29 randomised trials for a total of 3508 patients. Median adherence to home-based prehabilitation programs was 82%. Home-based prehabilitation reduced the proportion of patients with postoperative complications (508/1322 [38.4%] vs 578/1335 [43.3%], risk ratio 0.84, 95% confidence interval [CI] 0.72-0.98, P=0.02, I2=44%, low certainty). After home-based prehabilitation, 6-min walking test performance was better compared with control (MD 28.2 m (95% CI 9.5-46.9; P<0.01, I2=48). Preoperative depression (MD -0.65, 95% CI -0.87 to -0.43; P<0.001, I2=0%), postoperative anxiety (MD -0.50, 95% CI -0.75 to -0.25; P<0.001, I2=0%, low certainty) and length of hospital stays (MD -0.32 days, 95% CI -0.61 to -0.03; P=0.03, I2=45%, low certainty) were lower with home-based prehabilitation.

CONCLUSIONS

Home-based prehabilitation reduced the proportion of patients with postoperative complications, but with low certainty of evidence. It also improved preoperative functional capacity, reduced hospital stays, depression and anxiety scores, with good adherence to the intervention.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42024591208).

[Prevention and treatment of surgical site infections in abdominal surgery]

Postoperative surgical site infections after abdominal surgery are a relevant problem for patients and healthcare systems. Alongside pneumonia and urinary tract infections, surgical site infections are among the most common nosocomial infections in these patients. While the patient-related risk factors are mostly difficult to influence in the short-term, there are some modifiable, surgery-related risk factors (e.g., duration of surgery, sterile technique, blood loss) as well as various perioperative preventive measures with different evidence levels (e.g., skin disinfection, intravenous perioperative antibiotic prophylaxis, use of wound edge protectors, prophylactic wound irrigation, change of instruments and gloves before wound closure, triclosan-coated suture material, negative pressure dressing). Depending on the severity and depth of the infection, the treatment includes opening of the wound, surgical revision with fascial debridement/negative pressure wound therapy or the drainage of intra-abdominal abscesses and appropriate intravenous antibiotics. A relaparotomy for exploration and lavage is indicated in cases of generalized peritonitis.

Comparative analysis of functional end-to-end and end-to-side anastomosis in laparoscopic right hemicolectomy for colon cancer

BACKGROUND

Despite advancements in laparoscopic right hemicolectomy for right-sided colon cancer, the choice between functional end-to-end anastomosis and end-to-side anastomosis remains a topic of debate. This study aimed to compare these 2 techniques in terms of postoperative complications and disease-free survival.

METHODS

This retrospective analysis included 1,202 patients who underwent laparoscopic right hemicolectomy for nonmetastatic colon cancer at Samsung Medical Center between January 2007 and February 2016. The patients were divided into functional end-to-end anastomosis (n = 968) and end-to-side anastomosis (n = 234) groups based on the anastomosis technique used. Patients' characteristics, oncologic results, operative outcomes, and postoperative complications were analyzed.

RESULTS

The baseline characteristics were similar between the 2 groups, except for a higher incidence of cancer obstruction in the end-to-side anastomosis group (P < .001). After matching, no significant differences were observed in operation time, blood loss, length of hospital stay, time to the first meal, or time to first flatus. Anastomotic leakage rates were comparable (functional end-to-end anastomosis 0.6% vs end-to-side anastomosis 0.4%, P > .999). The functional end-to-end anastomosis group had a higher rate of postoperative ileus (4.9% vs 1.3%, P = .017). Multivariable analysis indicated age, sex, and anastomosis type as significant predictors of postoperative ileus.

CONCLUSION

The study findings demonstrate that both functional end-to-end and end-to-side anastomosis techniques in laparoscopic right hemicolectomy are comparable in terms of operation metrics and disease-free survival. However, functional end-to-end anastomosis is associated with a higher incidence of postoperative ileus. These findings can guide surgical decision-making in the treatment of right-sided colon cancer.

Impact and Measurement of Mechanical Tension in Bowel Anastomosis: A Scoping Review of the Current Literature

INTRODUCTION

Creating a "tension-free anastomosis" is a fundamental principle in safe bowel surgery. This review aims to summarize the current literature regarding the measurement and impact of tension on bowel anastomoses.

METHODS

This scoping review was conducted using a systematic literature search in the PubMed, SCOPUS, and EMBASE databases. Data were synthesized in tables and summarized paragraphically, with studies assessed using the Newcastle-Ottawa scale.

RESULTS

Out of the 350 studies identified in the initial literature review, 25 were included in this study. Several studies indicated that anastomotic leak and tension are strongly associated, with the presence of tension making leaks up to 10 times more likely. However, no objective and clinically available methods exist to measure tension on bowel anastomosis in humans. Freedom from tension has traditionally been measured via surrogate measures of adequate bowel mobilization and subjective assessment by operating surgeons. Animal and cadaveric studies have been the frontier for objective measurement of wall tension. These studies use tensiometers to measure tension and automated machines or pulley and ratcheting systems to increase tension at specified intervals. However, these methods are universally destructive due to their design of measuring maximal tensile load and are not readily adaptable to the operating room.

CONCLUSIONS

The current literature does not address the objective measurement of bowel tension in live human subjects. Given the importance of tension, developing an objective, safe, intraoperative method to measure bowel wall tension would be a valuable surgical tool.

High Diagnostic Accuracy but Persistent Risk of Complicated Appendicitis: A Retrospective Analysis from Hail Province, Saudi Arabia

Context

Acute appendicitis is a common surgical emergency. While clinical diagnosis is generally effective, it is not perfect, potentially leading to negative appendectomies or delayed treatment.

Aims

This study investigated the histopathological patterns of appendectomy specimens in King Khalid Hospital, Hail Province, Saudi Arabia, correlating them with preoperative clinical diagnoses to assess diagnostic accuracy and guide optimal management.

Subjects and Methods

A retrospective analysis was conducted on 198 patients who underwent appendectomies between August 2023 and July 2024. Resected appendix specimens underwent histopathological examination and were categorized as inflamed, malignant, or benign. Clinical data and histopathological findings were compared using statistical analyses, including Fisher's exact test, to assess diagnostic accuracy and explore potential associations between patient demographics, appendicitis severity, and clinical presentation.

Results

The study cohort consisted predominantly of young males (78.8%, mean age: 26 ± 9.2 years), with no pediatric cases included. The most common histopathological finding was an inflamed appendix (99.5%), with acute inflammation being most prevalent (86.9%). Perforation (10.1%) and gangrenous changes (2.5%) were also observed. A rare case of negative appendectomy (0.5%) was attributed to a perforated Meckel's diverticulum.

Conclusions

This study demonstrates a high preoperative diagnostic accuracy for acute appendicitis. However, the occurrence of negative appendectomies and complicated cases, particularly in young adult males, highlights the need for continuous vigilance and refinement of diagnostic approaches. Further research exploring age- and sex-specific risk factors for complicated appendicitis is crucial to optimizing patient management strategies and minimizing unnecessary surgical interventions.

Incidence Trends in Upper Gastrointestinal Cancer in Young Adults: A Nationwide Time-Trend Analysis Using 2001-2019 US Cancer Statistics Databases

INTRODUCTION

Upper gastrointestinal (UGI) cancers, comprising malignancies of the esophagus, stomach, duodenum, pancreas, liver, biliary tract, and gallbladder, are the second leading cause of cancer-related mortality in the United States and are associated with significant comorbidities. Recent studies show a disproportionate rise in pancreatic and stomach cancer among young adults. This study aims to use a nationwide, population-based cohort to (i) evaluate the trend of all UGI cancer as an aggregate and (ii) examine the role of demographics, histology, and tumor stage in UGI cancer incidence among young adults.

METHODS

Individuals diagnosed with UGI cancer in the United States from 2001 to 2019 were identified and obtained from the Surveillance, Epidemiology, and End Results-National Program of Cancer Registries database. The primary outcomes were incidence rates of UGI cancer (calculated per 100,000, age-adjusted to the year 2000 US population), stratified by sex and age (< 55 years for young adults and ≥ 55 years for older adults). Trends, annual percentage change, and average annual percentage change were calculated using the parametric method. Sensitivity analysis was performed according to primary site and histology; further analysis examining race and cancer stage was performed in the young adult subgroup.

RESULTS

A total of 2,333,161 patients with UGI cancer were identified. Most cases were male, and 14.3% were < 55 years of age. Incidence of UGI cancer increased most in women younger than 55 years, driven primarily by pancreatic and stomach cancers, as well as neuroendocrine tumor and gastrointestinal stromal tumor histology. African American race and localized tumors and malignancy with distant spread are also contributing to the disparate increase among young women. UGI mortality rates have not changed significantly in young adults.

DISCUSSION

The overall incidence rate of upper gastrointestinal cancer is increasing significantly in young women compared with men. Increased endoscopic procedures and disparate exposure to risk factors are likely contributing to these trends.

Root-cause analysis of mortality after pancreatic resection in a nationwide cohort

BACKGROUND

This study evaluates leading causes of in-hospital mortality after pancreatic resection nationwide to determine areas for improvement.

METHODS

This observational cohort study included all in-hospital mortality after pancreatic resection in the Netherlands (2014-2019). Each fatality was considered to be caused by local complications (i.e. directly related to surgery, located in surgical area) or systemic complications (e.g. cardiac or pulmonary). A blinded Expert Committee reviewed the postoperative course leading to death and identified potential quality improvement measures.

RESULTS

Out of 5345 patients undergoing pancreatic resection, 149 patients (2.8 %) died in-hospital. Local complications caused death in 126 patients (85 %) and systemic complications in 23 patients (15 %). Concerning local complications, the common leading causes of death were postoperative pancreatic fistula (n = 41) and thrombosis of vascular reconstructions (n = 23). Systemic cardiac (n = 8) and pulmonary (n = 7) complications caused death frequently. Potential areas for improvement were failure to rescue (n = 89; 60 %), prevention of complications (n = 34, 23 %) and patient selection (n = 14; 9 %).

CONCLUSION

Local complications often caused death after pancreatic resection, mainly pancreatic fistula and vascular reconstruction failure. Failure to rescue was considered the most important area for improvement to decrease in-hospital mortality further.

Short-term outcomes of extracorporeal versus intracorporeal side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer: an affiliated study of a multicenter snapshot study

BACKGROUND

Laparoscopic right hemicolectomy (RHC) is the primary surgical approach for right-sided colon cancer. Different ileo-colonic anastomosis techniques may lead to varied postoperative outcomes. This study aims to compare intracorporeal versus extracorporeal side-to-side anastomosis post laparoscopic RHC for short-term outcomes in right-sided colon cancer patients.

METHODS

This prospective, multicenter, cohort study utilized 1:1 propensity score matching (PSM) and inverse propensity of treatment weighting (IPTW) to address baseline imbalances. The primary endpoint was the incidence of anastomotic leakage (AL) within 30 days postoperatively, with its definition, diagnosis, and grading criteria standardized according to a published study.

RESULTS

A total of 1028 eligible patients were analyzed, with 316 in the intracorporeal anastomosis (IA) group and 712 in the extracorporeal anastomosis (EA) group. After both PSM and IPTW, all 17 covariates were balanced between groups. No statistically significant difference in AL incidence was found between the two groups (before matching, 1.8% in EA and 1.6% in IA, P = 0.78; PSM, 1.3% in EA and 1.6% in IA, P = 0.74; IPTW, 1.9% in EA and 1.6% in IA, P = 0.76). However, peak C-reactive protein levels within 3 days postoperatively were higher in the EA group (before matching, P < 0.001; PSM, P < 0.001; IPTW, P = 0.003). Patients in the IA group had earlier postoperative defecation (before matching, P = 0.01; PSM, P < 0.001) and a shorter total hospital stay (before matching, P = 0.01; IPTW, P = 0.046). Post-PSM analysis showed earlier flatus in the IA group (P = 0.03), while post-IPTW analysis indicated later postoperative eating resumption in the IA group (P = 0.046).

CONCLUSIONS

Intracorporeal anastomosis during laparoscopic RHC for right-sided colon cancer does not increase the incidence of AL or other short-term complications. Furthermore, it facilitates postoperative bowel function recovery.

Future of Artificial Intelligence-Machine Learning Trends in Pathology and Medicine

Artificial intelligence (AI) and machine learning (ML) are transforming the field of medicine. Health care organizations are now starting to establish management strategies for integrating such platforms (AI-ML toolsets) that leverage the computational power of advanced algorithms to analyze data and to provide better insights that ultimately translate to enhanced clinical decision-making and improved patient outcomes. Emerging AI-ML platforms and trends in pathology and medicine are reshaping the field by offering innovative solutions to enhance diagnostic accuracy, operational workflows, clinical decision support, and clinical outcomes. These tools are also increasingly valuable in pathology research in which they contribute to automated image analysis, biomarker discovery, drug development, clinical trials, and productive analytics. Other related trends include the adoption of ML operations for managing models in clinical settings, the application of multimodal and multiagent AI to utilize diverse data sources, expedited translational research, and virtualized education for training and simulation. As the final chapter of our AI educational series, this review article delves into the current adoption, future directions, and transformative potential of AI-ML platforms in pathology and medicine, discussing their applications, benefits, challenges, and future perspectives.

The Rochester Protocol for living donor liver transplantation of unresectable colorectal liver metastasis: A 5-year report on selection, approval, and outcomes

Living donor liver transplantation (LDLT) is a treatment option for select patients with unresectable colorectal liver metastasis. We describe our center's experience of patient selection, insurance approval, and outcomes after LDLT after first referral in March 2019. Of the 206 evaluated patients, 23 underwent LDLT. We found that patients who were referred earlier in their oncologic course were more likely to be eligible for transplantation. After completion of the Rochester Protocol for LDLT eligibility, recipients had a median delay of care of 10 days (IQR, 0-36 days) related to insurance appeal, with 6 patients (30%) having a delay longer than 30 days. LDLT recipients had an overall survival proportion of 100% and 91% at 1 and 3 years and a recurrence-free survival proportion of 100% and 40% at 1 and 3 years, respectively. All donors underwent right hepatectomy, of which only 1 donor had a Clavien-Dindo IIIa complication and readmission. There was no donor mortality. We assert that multidisciplinary care and strict patient selection through the Rochester Protocol were paramount to our center's success. In the appropriately selected patient, LDLT for unresectable colorectal liver metastasis may be justified, and patients should be referred to transplant oncology centers for evaluation.

Computed Tomography Imaging of Acute Mesenteric Ischemia for Interventional Radiology

Acute mesenteric ischemia is a life-threatening condition. A comprehensive approach involving a multidisciplinary team to review patient background, clinical history, physical examination, laboratory data, and imaging examination for respective diagnosis of superior mesenteric arterial occlusion, nonocclusive mesenteric ischemia, and superior mesenteric venous occlusion is essential. The most important imaging modality is computed tomography, which is used for diagnosis and for directing therapeutic strategy (e.g., endovascular revascularization, surgical bowel resection, or conservative management). Computed tomography image findings can support triaging of irreversible transmural bowel necrosis compared with reversible ischemic change with reperfusion. In this review article, the computed tomography imaging findings specifically associated with the pathophysiology of superior mesenteric arterial occlusion, nonocclusive mesenteric ischemia, and superior mesenteric venous occlusion are reviewed.

The Impact of Aortic Calcification on Surgical Outcomes in Colorectal Cancer Patients: A Retrospective Analysis Focused on Anastomotic Leakage

Background and Objectives: Anastomotic leakage (AL) is a major complication of colorectal surgery (CRS), increasing morbidity, mortality, and healthcare costs. While several AL risk factors have been identified, the role of aortic calcification (AC) remains unclear. As a marker of systemic atherosclerosis, AC may impair tissue perfusion and anastomotic healing. Additionally, tumor factors (TNM stage, histology, and localization) and patient comorbidities (hypertension, cardiovascular disease, and neoadjuvant therapy) may contribute to AL risk. This study evaluates the association between preoperative AC and AL incidence while considering additional risk factors. Materials and Methods: This retrospective cohort study included 151 patients undergoing CRS from January 2020 to October 2023. Preoperative CT scans classified AC into Stage 0 (none), Stage 1 (<50%), and Stage 2 (>50%) of the aortic circumference. Data on demographics, tumor characteristics, neoadjuvant therapy, and comorbidities were collected. AL risk factors were analyzed using univariate and multivariate logistic regression. Results: AL occurred in 5.96% (9/151) of patients. AL incidence was significantly higher in patients with >50% AC (44.47% vs. 11.27%, p = 0.012). Multivariate analysis confirmed AC as an independent AL predictor (OR = 10.38, 95% CI: 1.243-92.118, p = 0.032). Rectal tumor localization (p = 0.038), hypertension (p = 0.027), cardiovascular disease (p = 0.014), and neoadjuvant therapy (p = 0.045) were also associated with increased AL risk. Conclusions: Severe AC is an independent predictor of AL in CRS. Additionally, rectal tumors, hypertension, cardiovascular disease, and neoadjuvant therapy contribute to AL risk. Preoperative vascular assessments and comprehensive risk stratification models may help identify high-risk patients and guide perioperative management strategies to reduce AL incidence.

Comparative analysis of Ferguson hemorrhoidectomy combined with doppler-guided hemorrhoidal artery ligation and Ferguson hemorrhoidectomy in hemorrhoidal disease treatment

BACKGROUND

In hemorrhoidal disease, despite the existence of numerous treatment options to alleviate symptoms, surgical intervention continues to be the gold standard. The advantages and disadvantages of many methods have been shown in numerous studies However, only a few studies have compared the effectiveness of combined methods.

AIM

To compare the results of a coloproctology clinic that switched to the Doppler-guided hemorrhoidal artery ligation (DG-HAL) + Ferguson hemorrhoidectomy (FH) technique from the FH in the treatment of hemorrhoidal disease.

METHODS

In this retrospective cohort, data from a total of 45 patients who underwent DG-HAL + FH (n = 24) and FH (n = 21) for grade III hemorrhoidal disease between 2020 and 2022 were analyzed. Demographic and clinical data, surgical duration, intraoperative blood loss, hospital stay, postoperative analgesic consumption, pain scores using the Visual Analog Scale (VAS), complications, time to return to normal activities, and the recurrence rate were compared in both groups.

RESULTS

The study included 45 patients, with 75.6% (n = 34) male and 24.4% (n = 11) female. The rate of intraoperative blood loss was higher in the FH group (P < 0.05). The VAS scores and postoperative complication rates were similar in both groups. The need for postoperative analgesics was lower in the DG-HAL + FH group (2 vs 4 days, P < 0.05), while the FH group showed a shorter time to return to normal activities (9.5 vs 6.0 days, P = 0.02). The recurrence rate (16.7% vs 0%) and Clavien-Dindo Score-1 complications (20.8% vs 9.5%, P = 0.29) were higher in the DG-HAL + FH group but were insignificant.

CONCLUSION

Our study revealed that the addition of the DG-HAL to classical hemorrhoidectomy caused less intraoperative bleeding and a lower postoperative analgesia requirement.

Multipronged interventions to reduce surgical site infections: A multicenter implementation research protocol

BACKGROUND

Surgical site infections (SSIs) are a major yet preventable cause of poor post-operative clinical outcomes, prolonged ICU/hospital stay, increased antibiotic consumption and added cost of therapy. Low- and Middle-income Countries (LMICs) have disproportionately higher rates of SSIs as compared to high-income countries despite various national and international guidelines in place as multipronged, combined interventions are seldom used. The IMPRESS project aims to respond to this urgent need to identify and evaluate the quality improvement measures contextualized to the logistic constraints of LMIC settings such as India.

METHODS AND ANALYSIS

We adopt a multi-center longitudinal mixed-methods study to be conducted over a period of 2 years in various phases. Phase 1 will be formative research with the objective of identifying knowledge gaps and baseline data collection. Phase II will involve co-development of multipronged interventions addressing identified barriers. Phase III will focus on the deployment of the selected multipronged interventions. Phase IV will be the post-intervention phase to evaluate the impact of the interventions. The study has been prospectively registered with CTRI and is supported by a funding grant from the Indian Council of Medical Research, New Delhi. The Institutional Ethics Committee approval has been obtained from all the sites involved in the study.

Vascular pedicle dissection time in laparoscopic colectomies as a novel marker of surgical skill: a prospective cohort study

BACKGROUND

Outcomes after colorectal resections depend on patient, pathology and operative factors. Existing validated surgical skills scores (such as the competency assessment tool (CAT)) are directly correlated with outcomes but are time-consuming to administer, limiting their clinical utility. The vascular pedicle dissection time (VPDT) is a novel, simple surgical skill assessment measure with the potential for computer vision automation. This study aimed to assess the VPDT and benchmark it against the CAT score.

METHODS

A prospective multicentre study was performed in New Zealand, recording videos of laparoscopic colorectal resections. Patient, operation and histology characteristics were also collected. The VPDT was calculated from retraction of the vascular pedicle to completion of medial dissection, including vascular division. Each laparoscopic video was scored by two independent colorectal surgeons, and the median CAT score was grouped into tertiles.

RESULTS

In total, 154 patients were included between December 2020 and November 2023 (74 (48.1%) right-sided and 80 (51.9%) left-sided resections). Median VPDT was significantly different between the CAT score groups for the right-sided resections (lower, 15 min; middle, 13 min; higher, 10 min; p = 0.036) and the left-sided resections (lower, 46 min; middle, 40 min; higher, 26 min; p =  < 0.001). There was no significant difference in R1 resection, anastomotic leak rate, the occurrence of Clavien-Dindo > 3 complications or re-admission between the CAT groups.

CONCLUSIONS

This study showed that the VPDT was inversely correlated with the CAT score, indicating that it quantifies operative technical skill. A current study is evaluating the suitability of VPDT for real-time measurement using computer vision algorithms. This could allow for automated assessment of surgeons' learning curve and skills.

Construction and validation of machine learning-based predictive model for colorectal polyp recurrence one year after endoscopic mucosal resection

BACKGROUND

Colorectal polyps are precancerous diseases of colorectal cancer. Early detection and resection of colorectal polyps can effectively reduce the mortality of colorectal cancer. Endoscopic mucosal resection (EMR) is a common polypectomy procedure in clinical practice, but it has a high postoperative recurrence rate. Currently, there is no predictive model for the recurrence of colorectal polyps after EMR.

AIM

To construct and validate a machine learning (ML) model for predicting the risk of colorectal polyp recurrence one year after EMR.

METHODS

This study retrospectively collected data from 1694 patients at three medical centers in Xuzhou. Additionally, a total of 166 patients were collected to form a prospective validation set. Feature variable screening was conducted using univariate and multivariate logistic regression analyses, and five ML algorithms were used to construct the predictive models. The optimal models were evaluated based on different performance metrics. Decision curve analysis (DCA) and SHapley Additive exPlanation (SHAP) analysis were performed to assess clinical applicability and predictor importance.

RESULTS

Multivariate logistic regression analysis identified 8 independent risk factors for colorectal polyp recurrence one year after EMR (P < 0.05). Among the models, eXtreme Gradient Boosting (XGBoost) demonstrated the highest area under the curve (AUC) in the training set, internal validation set, and prospective validation set, with AUCs of 0.909 (95%CI: 0.89-0.92), 0.921 (95%CI: 0.90-0.94), and 0.963 (95%CI: 0.94-0.99), respectively. DCA indicated favorable clinical utility for the XGBoost model. SHAP analysis identified smoking history, family history, and age as the top three most important predictors in the model.

CONCLUSION

The XGBoost model has the best predictive performance and can assist clinicians in providing individualized colonoscopy follow-up recommendations.

Diagnosis and management of acute mesenteric ischemia: What you need to know

ABSTRACT

Acute mesenteric ischemia (AMI) is associated with high mortality rates. There are multiple challenges to establishing an accurate early diagnosis and providing state-of-the-art care for AMI patients. A high index of suspicion is key for early diagnosis. Once suspicion is raised, a triphasic computed tomography angiography is the essential diagnostic tool. Avoiding delays, using hybrid operating rooms and contemporary revascularization techniques for arterial occlusive AMI, can significantly improve the prognosis. Regional health care systems should be developed to direct AMI patients into centers with sufficient capabilities for providing all aspects of care at all hours. The acute care surgeon has a central role in performing laparotomies and bowel resections when needed and coordinating the management flow in close collaboration with vascular surgeons and interventional radiologists for prompt and effective revascularization. A significant share of patients with an arterial occlusive AMI can be managed by endovascular revascularization without the need for a laparotomy. There are no reliable tools for predicting transmural bowel necrosis, and individual assessment and clinical experience are very important in decision-making when choosing between laparotomy and close observation. During laparotomy, an atherosclerotic occlusion at the root of the superior mesenteric artery can be stented by using a retrograde open mesenteric or percutaneous approach, and surgical bypass is seldom needed. Using hospital-specific management pathways is very useful for the standardization of care in arterial occlusive AMI. In venous AMI, systemic anticoagulation is sufficient in most cases. In patients whose symptoms do not resolve, there are various options for endovascular and surgical revascularization. In nonocclusive mesenteric ischemia, prevention by maintaining sufficient abdominal perfusion pressure is key. High-level evidence is scarce, but with current knowledge, the prognosis of AMI patients has plenty of room for improvement.

Multi-Modal Machine Learning for Evaluating the Predictive Value of Pelvimetric Measurements (Pelvimetry) for Anastomotic Leakage After Restorative Low Anterior Resection

Background/Objectives: Anastomotic leakage (AL) remains a major complication after restorative rectal cancer surgery, with accurate preoperative risk stratification posing a significant challenge. Pelvic measurements derived from magnetic resonance imaging (MRI) have been proposed as potential predictors of AL, but their clinical utility remains uncertain. Methods: This retrospective, multicenter cohort study analyzed rectal cancer patients undergoing restorative surgery between 2013 and 2021. Pelvic dimensions were assessed using MRI-based pelvimetry. Univariate and multivariate regression analyses identified independent risk factors for AL. Subsequently, machine Learning (ML) models-logistic regression, random forest classifier, and XGBoost-were developed to predict AL using preoperative clinical data alone and in combination with pelvimetry. Model performance was evaluated using F1 scores, with the area under the receiver operating characteristic (ROC-AUC) and precision-recall curves (AUC-PR) as primary metrics. Results: Among 487 patients, the overall AL rate was 14%. Multivariate regression analysis identified distance to the anorectal junction, pelvic inlet width, and interspinous distance as independent risk factors for AL (p < 0.05). The logistic regression model incorporating pelvimetry achieved the highest predictive performance, with a mean ROC-AUC of 0.70 ± 0.09 and AUC-PR of 0.32 ± 0.10. Although predictive models that included pelvic measurements demonstrated higher ROC-AUCs compared to those without pelvimetry, the improvement was not statistically significant. Conclusions: Pelvic dimensions, specifically pelvic inlet and interspinous distance, were independently associated with an increased risk of AL. While ML models incorporating pelvimetry showed only moderate predictive performance, these measurements should be considered in developing clinical prediction tools for AL to enhance preoperative risk stratification.

Perioperative risk assessment for emergency general surgery in those with multimorbidity or frailty

PURPOSE OF REVIEW

This review explores advances in risk stratification tools and their applicability in identifying and managing high-risk emergency general surgery (EGS) patients.

RECENT FINDINGS

Traditional risk assessment tools have several limitations when applied to complex EGS patients as comorbidities are generally treated in a binary, linear and sequential fashion. Additionally, some tools are only usable in the postoperative period, and some require multidisciplinary involvement and are not suitable in an emergency setting. Frailty in particular - for which there are multiple calculators-maladaptively influences outcomes. Artificial intelligence tools, such as the machine-learning-based POTTER calculator, demonstrate superior performance by addressing nonlinear interactions among patient factors, offering a dynamic and more accurate approach to risk prediction.

SUMMARY

Integrating advanced, data-driven risk assessment tools into clinical practice can help identify and manage high-risk patients as well as forecast outcomes for EGS patients. Such tools are intended to trigger preoperative interventions as well as discussions that ensure goal-concordant care, align expectations with anticipated outcomes and support both facility and patient-relevant outcomes.

Prehabilitation Interventions in Patients Undergoing Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Surgical resection is the primary treatment modality for colorectal cancer. Prehabilitation is about enhancing the patient's physiological capacity preoperatively to reduce the risk of treatment-related complications. Clear definitions of the modality, content, and duration of prehabilitation, including its components such as nutrition, exercise, and psychological support, are lacking. Some review articles have proposed that a multimodal approach may yield the best overall outcomes, but the clinical efficacy of such an approach requires further exploration.

OBJECTIVE

This study consisted of a systematic review and meta-analysis to investigate the effectiveness of multimodal prehabilitation programs for patients undergoing colorectal surgery.

METHODS

We searched PubMed, Embase, CINAHL, and the Cochrane Library from inception to August 5, 2023, without language or publication period restrictions. The included studies were randomized controlled trials, prospective studies, or retrospective studies that examined the effectiveness of multimodal prehabilitation programs for patients undergoing colorectal surgery. A random-effects model was used for data analysis.

RESULTS

This study included 14 articles that analyzed data from 2314 patients who underwent colorectal cancer surgery. In comparisons against a control group, multimodal prehabilitation significantly reduced the length of hospital stay ([mean difference; MD] = -2.47 days, 95% confidence interval [CI] [-3.56, -1.39]), postoperative complication rate (odds ratio; [OR] = 0.74, 95% CI [0.59, 0.94]), and time to the first passage of flatus (MD = -0.43 days, 95% CI [-0.66, -0.20]).

CONCLUSION

Multimodal prehabilitation interventions before colorectal cancer surgery reduce hospital stay lengths, lower complication rates, and promote bowel recovery, particularly in older populations.

The Immune Environment in Colorectal Adenoma: A Systematic Review

Background/Objectives: Research on colorectal adenoma is significantly less comprehensive compared to studies on colorectal carcinoma. Although colorectal adenoma is a precursor of the majority of sporadic colorectal cancers, not all adenomas develop into carcinomas. The complex interaction of immune responses in the premalignant tumor microenvironment might be a factor for that. Methods: In this systematic review, we aim to provide a thorough analysis of the current research examining the immune infiltration patterns in sporadic colorectal adenoma tissues in the context of immune cell-based, cytokine-based, and other immunological factor-related changes along the conventional adenoma-carcinoma sequence. The articles included in the review extend up to December 2024 in PubMed and Web of Science databases. Results: Most included studies have shown significant differences in immune cell counts, densities, and cytokine expression levels associated with premalignant colorectal lesions (and/or colorectal cancer). No consensus on the immune-related tendencies concerning CD4+T cells and CD8+T cells was reached. Decreasing expression of mDCs and plasma and naïve B cells were detected along the ACS. The increased density of tissue eosinophils in the adenoma tissue dramatically diminishes after the transition to carcinoma. As the adenoma progresses, the increasing expression of IL-1α, IL-4, IL-6, IL-8, IL-10, IL-17A, IL-21, IL-23, IL-33, and TGF-β and decreasing levels of IL-12A, IL-18, IFN-γ, and TNFα cytokines in the invasive carcinoma stage is being detected. The over-expression of COX-2, PD-1/PD-L1, CTLA-4, and ICOS/ICOSLG in the colorectal adenomatous and cancerous tissues was also observed. Conclusions: Further studies are needed for a better understanding of the whole picture of colorectal adenoma-associated immunity and its impact on precancerous lesion's potential to progress.

Influence and role of polygenic risk score in the development of 32 complex diseases

Background

The polygenic risk score (PRS) has been perceived as advantageous in predicting the risk of complex diseases compared to other measures. We aimed to systematically evaluate the influence of PRS on disease outcome and to explore its predictive value.

Methods

We comprehensively assessed the relationship between PRS and 32 complex diseases in the UK Biobank. We used Cox models to estimate the effects of PRS on the incidence risk. Then, we constructed prediction models to assess the clinical utility of PRS in risk prediction. For 16 diseases, we further compared the disease risk and prediction capability of PRS across early and late-onset cases.

Results

Higher PRS led to greater incident risk, with hazard ratio (HR) ranging from 1.07 (95% confidence interval (CI) = 1.06-1.08) for panic/anxiety disorder to 4.17 (95% CI = 4.03-4.31) for acute pancreatitis. This effect was more pronounced in early-onset cases for 12 diseases, increasing by 52.8% on average. Particularly, the early-onset risk of heart failure associated with PRS (HR = 3.02; 95% CI = 2.53-3.59) was roughly twice compared to the late-onset risk (HR = 1.48; 95% CI = 1.46-1.51). Compared to average PRS (20-80%), individuals positioned within the top 2.5% of the PRS distribution exhibited varying degrees of elevated risk, corresponding to a more than five times greater risk on average. PRS showed additional value in clinical risk prediction, causing an average improvement of 6.1% in prediction accuracy. Further, PRS demonstrated higher predictive accuracy for early-onset cases of 11 diseases, with heart failure displaying the most significant (37.5%) improvement when incorporating PRS into the prediction model (concordance index (C-index) = 0.546; standard error (SE) = 0.011 vs. C-index = 0.751; SE = 0.010, P = 2.47 × 10-12).

Conclusions

As a valuable complement to traditional clinical risk tools, PRS is closely related to disease risk and can further enhance prediction accuracy, especially for early-onset cases, underscoring its potential role in targeted prevention for high-risk groups.

Safety and efficacy of prophylactic onlay resorbable synthetic mesh with a comprehensive wound bundle at laparotomy closure in high-risk emergency abdominal surgery: an observational study

BACKGROUND

There has been a slow uptake of wound bundles and prophylactic mesh augmentation (PMA) strategies despite evidence supporting their role in reducing burst abdomens and incisional hernias (IH). This study evaluates outcomes of resorbable synthetic prophylactic mesh augmentation in reducing these rates and assesses the complication profile in emergency abdominal surgery.

METHODS

A retrospective ethically approved observational study of all patients who underwent emergency open abdominal surgery using supplemental prophylactic onlay TIGR® Mesh at Letterkenny University Hospital between September 2017 and April 2024 was undertaken to assess safety, complication profiles and outcomes. Comprehensive wound bundles and subcutaneous space closure were used.

RESULTS

Of the 49 patients included, the mean age was 64 years (± 16.4, 31-86), 33/49 (67%) were female, and the mean body mass index (BMI) was 27 (± 7.4,17.3-45). 20% of patients had previous abdominal surgery. 19/49 (38%) patients experienced postoperative complications, of these 8 (42%) were Clavien-Dindo Grade I-II, and 11 (58%) were Grade III-IV. There were 7 in-hospital post-operative deaths (Grade V). 8 patients had open abdomens. Thirteen surgical site occurrences (SSO) were identified in 9 (18%) patients. There were no burst abdomens. Four of the superficial SSIs responded to antibiotics while one required opening and wound NPWT. Three patients (6%) developed an incisional hernia, which was detected at a mean follow-up of 353 days.

CONCLUSION

A comprehensive, evidence-based wound bundle using onlay PMA with a synthetic resorbable mesh, achieves efficacious, safe abdominal wall closure in high-risk, emergency laparotomy patients, including those who require delayed abdominal wall closure.

Impact of targeting the platelet-activating factor and its receptor in cancer treatment

The lipid mediator platelet-activating factor (PAF) and its receptor (PAFR) signaling play critical roles in a wide range of physiological and pathophysiological conditions, including cancer growth and metastasis. The ability of PAFR to interact with other oncogenic signaling cascades makes it a promising target for cancer treatment. Moreover, numerous natural and synthetic compounds, characterized by diverse pharmacological activities such as anti-inflammatory and anti-tumor effects, have been explored for their potential as PAF and PAFR antagonists. In this review, we provide comprehensive evidence regarding the PAF/PAFR signaling pathway, highlighting the effectiveness of various classes of PAF and PAFR inhibitors and antagonists across multiple cancer models. Notably, the synergistic effects of PAF and PAFR antagonists in enhancing the efficacy of chemotherapy and radiation therapy in several experimental cancer models are also discussed. Overall, the synthesis of literature review indicates that targeting the PAF/PAFR axis represents a promising approach for cancer treatment and also exerts synergy with chemotherapy and radiation therapy.

Laparoscopic versus open repair of perforated peptic ulcer: systematic scoping review and in-depth evaluation of existing evidence

BACKGROUND

Perforated peptic ulcer remains a common contributor to morbidity and mortality rates worldwide. In common with other emergency surgery conditions, there is a trend towards minimally invasive surgery. This review aims to describe current evidence comparing open and laparoscopic management strategies for perforated peptic ulcers, by summarizing patients, intervention, comparator, outcomes, describing intervention components and delivery, outcomes reported and assessing study pragmatism (applicability) using PRagmatic Explanatory Continuum Indicator Summary-2.

METHODS

Systematic searches of published literature were performed using Ovid MEDLINE and Embase online databases, as well as clinical trial databases. Randomized trials comparing laparoscopic and open repair of peptic ulcer were included. Data extracted included study metadata, patients, intervention, comparator, outcomes elements, technical aspects of interventions and use of co-interventions, and surgeon learning curves/experience. Applicability was assessed using the PRagmatic Explanatory Continuum Indicator Summary-2 tool, to explore whether trials were predominantly pragmatic or explanatory, and study validity assessed using the Cochrane Risk-of-Bias 2 tool.

RESULTS

A total of 408 studies were screened for eligibility, with nine finally included (880 patients). Incision, ulcer closure details and lavage were the most frequently reported aspects of laparoscopic repair. Co-interventions such as antibiotic use and analgesia were reported in most articles, whilst nutrition and Helicobacter pylori eradication were not reported. Interventions were generally delivered by high-volume laparoscopic surgeons. Studies were considered at high Risk-of-Bias. PRagmatic Explanatory Continuum Indicator Summary-2 assessment found studies were neither fully pragmatic nor explanatory.

CONCLUSION

Laparoscopic repair of perforated peptic ulcer is a variably defined intervention. Consideration of how intervention components and co-interventions should be optimally delivered is required to facilitate a well designed randomized trial.

Barriers to adapting to life with a stoma

Adapting to life with a stoma presents various challenges, including physical, social and psychological barriers. A lack of confidence, inadequate knowledge and concerns about appliance management can impact a person's ability to live comfortably with a stoma. Community nurses play a vital role in supporting individuals by providing education, guidance on stoma care and signposting to relevant resources. Ensuring the correct stoma appliance, addressing peristomal skin issues, and encouraging physical activity and dietary adjustments are key aspects of care. Social reintegration is equally important, as fear of leakage or stigma can lead to isolation. Community nurses can help patients gradually regain confidence in daily activities. Specialist input from stoma care nurses is valuable for complex cases. By offering reassurance and practical advice, community nurses can facilitate a smoother transition, empowering individuals to lead fulfilling lives post-stoma formation.

E_N_T_R_O_P_Y: Monocentric analysis of rectal cancer radio-chemotherapy treatment in patients of young age

Purpose//objectives

A disproportionate incidence's increase of rectal cancer in patients younger than 50 years of age. The ESMO and NCCN recommendations are not age-specific and the literature is poor and conflicting. We decided to examine patients with rectal cancer treated in our centre in the last 15 years with curative neoadjuvant radiochemotherapy comparing outcomes in the two groups under and over 55 years old.

Materials/methods

788 rectal cancer patients were enrolled in this monocentric retrospective observational study (523 =>55 years and 265 < 55). All patients received neoadjuvant chemoradiation treatment. R statistical software v.4.1.3 was used for the entire analysis. The outcomes were death, local recurrence, and new distant metastases. Survival analysis was performed using the Kaplan-Meier method and the Log-rank was used to compare the two groups.

Results

All patients were classified in different risk groups, according to the ESMO 2017 rectal cancer clinical practice guidelines. 88 % of patients under 55 years old at the diagnosis belonged to the bad or advanced risk groups with an equal division. In patients over 55 years old, there was a clear dominance of the advanced risk class (62 % of the total). In multivariate analysis, OS and DFS decrease with increasing age and ESMO risk group. The other variables in multivariate were not significant. For Both OS, DFS and MFS, the curves separated significantly at 55 years of age, with a prevalence of metastasis development in the older group.

Conclusion

Elderly patients have a prevalence of advanced disease. Younger patients seem having a better OS at 3 and 5 years. ESMO risk group and age were the only variables affecting OS and DFS. Young patients have better MFS and DFS at 2 and 5 years than patients older than 55 years. The addition of oxaliplatin to fluoropyrimidine-based neoadjuvant chemotherapy resulted not significant in both groups.

Model systems to study tumor-microbiome interactions in early-onset colorectal cancer

Colorectal cancer (CRC) is a major health problem, with an alarming increase of early-onset CRC (EO-CRC) cases among individuals under 50 years of age. This trend shows the urgent need for understanding the underlying mechanisms leading to EO-CRC development and progression. There is significant evidence that the gut microbiome acts as a key player in CRC by triggering molecular changes in the colon epithelium, leading to tumorigenesis. However, a comprehensive collection and comparison of methods to study such tumor-microbiome interactions in the context of EO-CRC is sparse. This review provides an overview of the available in vivo, ex vivo as well as in vitro approaches to model EO-CRC and assess the effect of gut microbes on tumor development and growth. By comparing the advantages and limitations of each model system, it highlights that, while no single model is perfect, each is suitable for studying specific aspects of microbiome-induced tumorigenesis. Taken together, multifaceted approaches can simulate the human body's complexity, aiding in the development of effective treatment and prevention strategies for EO-CRC.

Major Adverse Cardiovascular Events After Colorectal Cancer Surgery, Oncological Outcomes, and Long-term Mortality: A Nationwide Retrospective Propensity Score-Matched Cohort Study

Objective

To investigate the occurrence of major adverse cardiovascular events (MACE) following colorectal cancer (CRC) surgery and its association with long-term mortality and oncological outcomes.

Background

Cardiovascular complications after noncardiac surgery are a leading cause of perioperative mortality. However, limited knowledge exists on how these complications impact on long-term mortality.

Methods

This retrospective cohort study used data from 4 nationwide Danish health registries and included all patients undergoing elective surgery with curative intent for CRC between 2001 and 2019. Patients experiencing MACE, defined as acute myocardial infarction, stroke, new-onset heart failure, or nonfatal cardiac arrest, within 30 days of surgery were matched with those who did not using 1:1 propensity score matching (PSM). The outcomes were all-cause mortality within 1, 3, or 5 years of surgery, as well as 5-year cancer recurrence and disease-free survival.

Results

Out of 39,747 patients, 900 (2.3%) had MACE. PSM resulted in 809 pairs of matched patients. Within 1 year of surgery, 110 (13.6%) patients with MACE and 2063 (5.4%) without MACE died (PSM-adjusted hazard ratio [HR] = 1.36; 95% confidence interval [CI] = 1.02-1.83). Within 3 years, 248 (30.6%) patients with MACE and 6268 (16.5%) without MACE died (PSM-adjusted HR = 1.32; 95% CI = 1.07-1.62). Within 5 years, 333 (41.1%) patients with MACE and 9232 (24.3%) without MACE died (PSM-adjusted HR = 1.25; 95% CI = 1.04-1.50). For recurrence and disease-free survival, no statistically significant differences were observed.

Conclusions

MACE within 30 days of CRC surgery is associated with higher overall long-term mortality. Investigating causality and preventive measures is urgent in this group.

Systematic review and meta-analysis comparing robotic total mesorectal excision versus transanal total mesorectal excision for rectal cancer

INTRODUCTION

The best approach for total mesorectal excision (TME) remains controversial. Two recently described approaches are robotic TME (RTME) and transanal TME (TaTME). This systematic review and meta-analysis aimed to compare the outcomes between robotic surgery and TaTME in patients undergoing rectal cancer resection.

METHODS

We structured this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines 2020 and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. An electronic search of relevant literature was conducted on 20 May 2023. The protocol was registered in PROSPERO (CRD42023435259).

RESULTS

Eleven eligible nonrandomised studies were included in this study. The study included 2796 patients (RTME = 1800; TaTME = 996). The RTME group had a higher rate of complete TME. However, no significant differences were observed in mortality, morbidity, severe complications, operative time, conversion rate, anastomotic leak, hospital stay, CRM-positive resection margin, distal resection margin, number of harvested lymph nodes, abdominoperineal resection (APR) rate, or local recurrence between the RTME and TaTME groups.

CONCLUSION

The RTME technique may ensure a higher rate of complete TME than TaTME. However, no significant differences were observed in most postoperative outcomes and oncological safety between the RTME and TaTME groups. Evidence does not conclusively favor one technique over the other, highlighting the need for additional randomized controlled trials to better define their roles in rectal cancer surgery.

Epidemiology of cancer in older adults: a systematic review of age-related differences in solid malignancies treatment

PURPOSE OF REVIEW

We examined the latest epidemiological research on age-related differences in cancer treatment and selected outcomes, among patients with cancer aged 60 and above in comparison to younger patients.

RECENT FINDINGS

Colorectal, pancreatic and lung cancers were studied most often. Most studies were conducted in Europe or the United States of America (USA) within single centers. For unselected patients, older patients receive less treatment, and their survival, regardless of the metric used (cancer-specific survival or overall survival), was poorer than that of middle-aged patients. Age-related differences in treatment and outcomes were more pronounced in patients aged over 80 years. However, among patients selected for treatment, complications, adverse events rates and survival probabilities were comparable between older and younger patients. Treatment differences, especially the omission of therapy, were often smaller for good prognosis cancer types. The likelihood of receiving treatment decreased as age increases, regardless of the cancer types, treatment, countries and setting. More research on treatment in older patients with cancer, especially the frailest and the oldest, is urgently needed as there is still a lack of data to tailor treatment.

Morbidity and Mortality Following Surgery for Pancreatic Cancer in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Measuring postoperative outcomes after complex cancer operations such as pancreatectomy is vital to improve cancer surgery in low- and middle-income countries (LMICs); however, such data is often limited. This study aimed to review existing research and obtain baseline estimates for postoperative mortality and morbidity after pancreatic cancer surgery in LMICs.

METHODS

PubMed, Embase, Web of Science Core Collection, and Global Index Medicus were systematically searched for original articles published between January 2005 and May 2022. LMICs based studies reporting postoperative mortality, morbidity, and/or length of stay of patients with primary pancreatic tumors undergoing pancreaticoduodenectomy and/or distal pancreatectomy were included.

RESULTS

Of 18 344 unique titles and abstracts retrieved, 114 studies met the inclusion criteria. Of these, 51 "good" quality studies comprising 7528 patients were included in the meta-analyses. Pooled estimates for pancreatic fistula were 16.6% (95% CI 14.0-19.7, p < 0.001); 16.0% (95% CI 11.1-22.5, p < 0.001) for Clavien-Dindo grade 3 and 4 complications; 13.4% (95% CI 9.8-17.9, p < 0.001) for wound infection; and 4.4% (95% CI 3.3-5.7, p < 0.001) for postoperative mortality.

CONCLUSION

This is the first systematic review and meta-analysis examining surgical complications after pancreatic surgery in LMICs. We highlight a lack of data and the need to further evaluate surgical outcomes in LMICs.