Background:Increasing use of integrated subspecialty training pathways may reduce residents’ exposure to the broader surgical professional community....

BACKGROUND:Minimally invasive surgery and Enhanced Recovery After Surgery protocols enable discharge within 1 to 3 days after colon surgery. However,...

BACKGROUND:Accelerating corporatization of US healthcare has reshaped academic medical center governance, with for-profit investor-owned...

Objectives:To define the prevalence of poor faculty well-being and workplace mistreatment and investigate factors impacting surgical faculty...

Objective:Describe the long-term health-related quality of life (HR-QoL) after curative-intent hepatectomy for high-risk colorectal liver metastases...

Background:Excess postoperative opioids contribute to diversion and misuse, yet safe disposal of unused medication remains uncommon. Although opioid...

Objective:This study aimed to compare the performance of injury severity score (ISS)>15, high-intensity time-sensitive (HITS) interventions (a...

Objective:To evaluate inferior vena cava (IVC) filter utilization among trauma patients with regard to national trends, interhospital variation, and...

Objective:Determine the feasibility and proof-of-concept of using prophylactic insulin [glucose-insulin-potassium (GIK)] to improve outcomes in...

Background: Hepatocellular carcinoma (HCC) remains a major cause of cancer-related mortality. Optimal treatment decisions are challenging, and...

Objectives:To evaluate the impact of the 2023 Current Procedural Terminology (CPT) coding changes on work relative value units (wRVUs), focusing on...

Background Non-exposure laparoscopic and endoscopic cooperative surgery (LECS), known as CLEAN-NET (combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique), was developed for gastric submucosal tumors; however, its oncologic validity for gastric cancer remains unclear. We evaluated long-term oncologic outcomes of CLEAN-NET in patients with clinically diagnosed cT1N0 gastric cancer during the early developmental phase of this technique. Methods We retrospectively analyzed 19 consecutive patients who underwent CLEAN-NET between December 2008 and June 2010. Treatment selection was based on preoperative clinical staging available at that time. Limited regional lymph node assessment was performed in selected cases, and pathological findings were classified according to the eCura system. Recurrence of the gastric cancer treated by CLEAN-NET, metachronous gastric cancer, overall survival, and causes of death were evaluated. Results The median follow-up period was 6.2 years, with follow-up extending up to 16.8 years. Although treatment selection was based on preoperative cT1N0 assessment, 14 patients (73.7%) were subsequently classified as eCuraC-2 because of postoperative pathological risk factors. Limited regional lymph node dissection was performed in 15 patients, and pathological lymph node metastasis was identified in 1 patient. Additional surgery was performed in 3 patients. No recurrence of the gastric cancer treated by CLEAN-NET was observed. Metachronous gastric cancer developed in the preserved stomach in 2 patients, including 1 death from metachronous gastric cancer. During follow-up, 3 patients died: 1 from lung cancer, 1 from metachronous gastric cancer, and 1 from pneumonia. Conclusion This historical cohort provides rare ultra-long-term observational data after CLEAN-NET for gastric cancer. Although no recurrence of the gastric cancer treated by CLEAN-NET was observed, the findings do not establish CLEAN-NET as an alternative to guideline-recommended gastrectomy. Rather, they may inform future studies of function-preserving, non-exposure local resection combined with validated nodal navigation strategies. Graphical Abstract

Purpose Early identification of anastomotic leakage (AL) is critical for safe discharge within enhanced recovery pathways. This study developed and prospectively validated a machine learning (ML) model to predict AL using 24-h postoperative inflammatory biomarkers. Methods We analyzed 1,961 patients undergoing elective minimally invasive colorectal resection (2012–2025). Five ML architectures were developed using a 70/15/15 split. The Regularized Logistic Regression (RLB) model was selected and locked with a pre-specified threshold (0.1258). Global variable importance and directionality were assessed via SHAP analysis. Prospective temporal validation was performed on 250 consecutive patients (February 2024 – December 2025). Results AL incidence was 9.8% in the development cohort. The RLB model achieved high discrimination (AUCPR 0.859; AUC-ROC 0.819). Postoperative C-reactive protein (CRP) and the Systemic Inflammation Response Index (SIRI) at 24 h were the strongest predictors. During temporal validation, despite a 70% relative reduction in AL incidence (2.8%), the model maintained a robust negative predictive value (NPV) of 97.9% (95% CI 95.1–99.1% and an AUC of 0.73 (95% CI 0.54–0.92). Calibration was near-optimal (slope 0.987, intercept 0.505). Decision curve analysis demonstrated superior net clinical benefit across risk thresholds of 5–20%. Conclusions ML-based integration of early inflammatory biomarkers provides a reliable "safety filter" for postoperative surveillance. The high NPV supports objective decision-making for early discharge, even in changing clinical environments with decreasing complication rates.

Background Robotic pancreatoduodenectomy (R-PD) has emerged as a minimally invasive alternative to open pancreatoduodenectomy (O-PD), although its role remains debated due to technical complexity and heterogeneous outcomes. This study compared perioperative outcomes between R-PD and O-PD in a high-volume center while minimizing the impact of the learning curve, and additionally evaluated the progressive improvement in surgical outcomes between the early and late phases of the robotic experience through comparative analyses and CUSUM assessment. Methods A single-center propensity score–matched retrospective cohort study was conducted using a prospectively maintained database of patients undergoing PD between January 2020 and December 2025. The most recent 50 consecutive R-PDs (late group, LR-PD) were compared with O-PD after 2:1 matching (matched open group, MO-PD) to balance baseline characteristics. Perioperative, postoperative, and pathological outcomes were compared, and multivariable analyses were performed to identify independent predictors of key outcomes. A subgroup analysis comparing the first 50 R-PDs (early group, ER-PD) with the subsequent 50 cases (LR-PD) was also performed, along with CUSUM analyses of outcomes showing differences between the two phases of the robotic experience. Results After matching, 100 MO-PD patients were compared with 50 LR-PD patients. LR-PD was associated with significantly lower estimated blood loss (EBL) (200 vs 300 mL; p = 0.0012) and shorter length of hospital stay (LOS) (12 vs 14 days; p = 0.038), but longer operative time (OT) (582 vs 362 minutes; p < 0.001). Rates of major complications (Clavien–Dindo ≥ III) and pancreas-specific complications were comparable between groups. A significantly lower incidence of postoperative lymphatic fistula was observed in the LR-PD (4 vs 15%; p = 0.045). At multivariable analysis, the LR-PD was independently associated with lower EBL (β − 116.80; p = 0.023), shorter LOS (β − 1.48; p = 0.041), and a reduced risk of postoperative lymphatic fistula (OR 0.30; p = 0.047), while remaining an independent predictor of longer OT (β 99.75; p < 0.001). Within the R-PD, OT was significantly shorter in the LR-PD compared with the ER-PD (582 vs 705 minutes; p < 0.001). CUSUM analyses identified inflection points at cases 51, 55, and 53 for OT, major complications, and clinically relevant PPH, respectively. Conclusions In a high-volume setting after the learning curve, R-PD is a potentially safe and feasible alternative to O-PD, offering reduced EBL, shorter LOS, and lower incidence of lymphatic fistula, despite longer OT. Further prospective studies are warranted to confirm these findings. Graphical abstract

Background Hepatic resection combined with systemic therapy represents the standard of care for colorectal liver metastases (CRLMs). Although parenchyma-sparing surgery prioritizes R0 resection and preserves liver function, the clinical relevance of minimal margins remains debated. At the same time, tumor biology, particularly KRAS and BRAF mutations, has emerged as a key determinant of outcomes. This study investigated whether mutational status modifies the impact of resection margin type on survival and recurrence. Methods This international multicenter study included patients undergoing curative-intent liver resection for CRLMs (2016–2021) across 17 hepatopancreatobiliary centers. Only patients with known KRAS/BRAF status and documented margin type were analyzed. Margins were classified as R0, parenchymal R1 (R1P) or vascular R1 (R1V). Results Among 1078 patients (592 wild-type, 451 KRAS-mutated, 35 BRAF-mutated), R1P resection was associated with significantly worse overall survival than R0 (53 % vs 61 %; p < 0.0001), with the greatest detriment observed in KRAS-mutated tumors. In contrast, R1V was not significant in all molecular subgroups. Consistently, R1P margins were associated with higher recurrence rates in both wild-type and mutated patients, including KRAS and BRAF subgroups. Conversely, R1V margin was not associated with higher recurrence risk. Conclusions In CRLMs, the prognostic relevance of surgical margins may depend on tumor biology. For BRAF/KRAS wild-type disease, R0 resection remains the preferred goal, whereas the role of wider margins in high-risk molecular subgroups requires further validation. Preoperative molecular profiling may support more individualized surgical planning.

Background In laparoscopic liver resection (LLR), a skilled scopist is essential for maintaining a clear operative view. We evaluated the scopist’s expertise on surgical outcomes and whether the flexible scope controller type (conventional dual-lever versus joystick) influences the scopist’s learning curve. Methods We retrospectively reviewed LLRs performed by a single surgeon between December 2021 and March 2023. Patients with prior hepatectomy, Child–Pugh class B/C, concurrent extrahepatic abdominal surgery, or laparoscopic donor hepatectomy were excluded. Expert scopists (n = 2) had > 7 years of experience, whereas beginner scopists (n = 2) had < 6 months. Outcomes were compared by expertise and scope type. Learning curves were assessed using linear regression and CUSUM analysis of operative time over case sequence. Results Among 161 LLRs, 82 were performed with expert scopists and 79 with beginner scopists. Compared with the expert group, the beginner group had longer operative time (178.0 vs 139.5 min, p < 0.001), more intraoperative transfusions (8.9% vs 0%, p = 0.006), and a higher open conversion rate (6.3% vs 0%, p = 0.012). In 116 procedures using conventional scopes (experts, n = 57; beginners, n = 59), experts had shorter operative time (144.0 vs 178.0 min, p = 0.002) and fewer transfusions (0% vs 11.9%, p = 0.013). In 45 procedures using joystick scopes, operative time and transfusion rates did not differ significantly between expert and beginner scopists. In major hepatectomy, both groups showed decreasing operative time with joystick scopes. In minor hepatectomy, experts had shorter operative time with conventional scopes, whereas no significant difference was observed with joystick scopes. Conclusion This study demonstrated that the proficiency of laparoscopists can affect surgical outcomes. Moreover, newly learning laparoscopists may acquire proficiency more rapidly when using joystick-controlled laparoscopes compared to conventional ones. In procedures like minor hepatectomy, which are relatively simpler, it was confirmed that there is no significant difference in proficiency when compared to expert scopists.

Objective:To evaluate the impact of CYP2A6 genetic polymorphisms on survival outcomes in patients with pancreatic ductal adenocarcinoma (PDAC)...

Background:Intraoperative cholangiography (IOC) is widely used during cholecystectomy to define biliary anatomy and potentially reduce bile duct...

Background Uncinate process dissection and superior mesenteric artery (SMA) control represent critical steps in robotic pancreatoduodenectomy (RPD). However, the conventional right-sided uncinate-first approach may be technically demanding in patients with unfavorable anatomy, such as visceral obesity or bulky tumors. Methods This multimedia article presents a video-based demonstration of a left-sided uncinate-first approach in robotic pancreatoduodenectomy. Two illustrative operative scenarios are used to demonstrate technical nuances of SMA exposure and uncinate process dissection in challenging anatomic conditions. Results The right-sided approach for a morbidly obese patient demonstrated limited SMA exposure due to increased operative depth and visceral adiposity, requiring substantial traction to identify the correct dissection plane. Conversely, the left-sided approach enabled early vascular control through creation of a mesenteric window, providing direct access to the SMA and facilitating a controlled medial-to-lateral uncinate dissection along a relatively avascular plane. This approach reduced traction on the superior mesenteric vein (SMV) and improved visualization of the posterior dissection plane. In all cases, R0 resection was achieved. Conclusions The left-sided approach represents a feasible technical adjunct in robotic pancreatoduodenectomy. It may enhance SMA exposure and facilitate safer uncinate dissection in selected patients with challenging anatomy, particularly in obesity or bulky tumors. This strategy should be considered within the armamentarium of advanced robotic hepatopancreatobiliary surgery.

Background Borderline resectability in perihilar cholangiocarcinoma (pCCA) has largely been defined anatomically, although anatomy alone may not capture oncologic risk. This study evaluated whether biologic burden improves recurrence stratification after curative-intent resection of pCCA. Methods Using an international, multi-institutional database, patients undergoing resection without neoadjuvant therapy for non-metastatic pCCA were identified. Literature-based borderline resectability was defined as lymph node metastasis with portal vein/hepatic artery involvement or Bismuth type IV disease. Using a 200-U/mL carbohydrate antigen (CA19-9) cutoff, a three-tier anatomic-biologic borderline resectable (AB-BR) grouping (low, intermediate, high) was derived. The outcome of interest was recurrence-free survival (RFS). Results Among 239 patients (median age, 67.0 years, interquartile range [IQR], 58.0–74.0 years), 38.9% (n = 93) of patients were anatomically borderline resectable (BR). The anatomy-only BR definition did not stratify RFS or overall survival (OS) (both p > 0.05), whereas CA19-9 ≥200 U/mL stratified 2 year RFS within both resectable (55.7% vs. 32.6%) and BR (44.5% vs. 25.3%) groups (all p < 0.05). Four-group analysis demonstrated overlap between resectable/high CA19-9 and BR/low CA19-9, supporting collapsing the categories into AB-BR tiers. The 2 year RFS was 55.7, 37.8, and 25.3% in the low-, intermediate-, and high-risk AB-BR groups, respectively (p = 0.002). The 2 year area under the curve (AUC) value was improved by AB-BR for RFS versus anatomy alone (0.612 vs 0.537). After multivariable adjustment, high-risk AB-BR remained independently associated with higher hazards of recurrence or death (adjusted hazard ratio, 1.86; 95% confidence interval, 1.15–3.00). Conclusion Anatomic BR alone provided limited prognostic stratification. Incorporating CA19-9 improved recurrence prediction and identified an intermediate-risk group not captured by anatomy alone, supporting biologic resectability in pCCA. The AB-BR framework may help move surgical decision-making beyond technical resectability alone toward more oncologically informed treatment selection.