Anastomotic leaks (ALs) are a significant source of morbidity and mortality. Every step should be implemented to prevent AL, including careful patient selection, optimizing patient's clinical and nutritional status, and ensuring proper technique. The appropriate management of an AL depends on several factors, such as patient's clinical status, the type of surgery, location of the AL, induction therapies, and the resources available. Surgeons should be familiar with the armamentarium of treatment modalities available to manage AL and use a patient-tailored approach when selecting the most appropriate treatment.
Minimally invasive colon and rectal surgery provides oncologic outcomes at least equivalent to open surgery with a multitude of benefits. While laparoscopic colectomy remains effective and widely practiced, its adoption rate has stalled and robotic surgery offers an opportunity to expand minimally invasive oncologic colorectal surgery. Robotic colectomy overcomes many of the laparoscopic limitations and is increasing in popularity in colorectal practice. Broader dissemination remains constrained by cost, operative setup demands, and the need for structured training. Emerging technologies, including single-port systems, artificial intelligence-enhanced platforms, and flexible robotics, are expected to further enhance minimally invasive colectomy for cancer.
Despite signing a consent form, many surgical patients subsequently report gaps in understanding an operation, its alternatives, and its impact on everyday life. Observational studies, patient surveys, and audio-recordings of preoperative interactions suggest that surgeons reliably meet legal requirements for informed consent but less often achieve informed, preference-concordant decisions-especially for older adults facing high-risk procedures. Emerging tools such as structured decision aids, scenario-based frameworks, risk visualization, and patient-reported outcome measures can improve knowledge, expectations, and satisfaction. This article reviews the state of the science, highlights practical communication frameworks, and outlines persistent gaps and future directions.
Acute diverticulitis (AD) is the most common complications of diverticular disease. AD can present with a spectrum of symptoms, ranging from mild, self-limiting inflammation to severe peritonitis. A paradigm shift in the treatment of uncomplicated diverticulitis has been noted, with cumulating evidence challenging the routine use of antibiotics. High-quality evidence suggests that antibiotics may be safely omitted in healthy patients with mild AD. Nonetheless, surgery remains the mainstay treatment of patients with generalized peritonitis or recurrent, debilitating disease. In summary, current guidelines recommend an individualized approach to AD, balancing disease severity, comorbidities, quality of life, and patient preference in decision-making.
Robotic platforms have made it possible to replicate open retromuscular component separation principles through small incisions in a way that was not possible on the laparoscopic platform. However, it is crucial to keep in mind that the optimal repair (not the platform) is key to achieving the best patient outcomes. Robotic abdominal wall reconstruction offers short-term advantages over open repair, including shorter hospital stay and fewer wound complications, albeit with longer operative times, higher procedural costs, and a steep learning curve. Current evidence suggests comparable hernia recurrence rates between approaches, but long-term, high-quality data remain limited.
Chronic limb-threatening ischemia is the most advanced stage of peripheral arterial disease and typically requires revascularization to prevent limb-loss. The choice of open surgical bypass versus endovascular therapy should be individualized based on patients' anatomy, operative risk, and conduit availability. Patients who are suitable candidates for both bypass and endovascular intervention and have an adequate single-segment great saphenous vein should undergo open surgical bypass based on level 1 evidence.
Breast sarcomas are a rare and pathologically diverse group of malignancies. They can arise de novo or in a previously irradiated field and tend to have poor prognostic outcomes. Given their rarity and the tendency to combine the various histologies in single analyses, data related to management and prognostic outcomes are somewhat limited. Surgical resection remains the mainstay of treatment with the intention for wide-margin resection, except in the case of radiation-associated angiosarcoma, where radical resection is associated with improved local control. Multidisciplinary treatment is common and is ideally undertaken at a high-volume sarcoma center to optimize outcomes.
Lymphedema is one of the most difficult surgical conditions to treat because of the destruction of tenuous lymphatic system. Historically, nonsurgical management and debulking procedures were performed to reduce volume without correcting the underlying lymphatic physiology. With the recent advances in technologies, microsurgical treatments to re-establish the lymphatic system are becoming increasingly popular. Studies have reported the efficacy of these procedures in the treatment and prevention of lymphedema. This article strives to deliver an understanding of the current landscape on lymphedema surgery to increase access, promote early surgical intervention, and to offer guidance to patients beyond myths regarding lymphatic surgery.
This article begins by providing historical insight into the discovery, development, and use of glucagon-like peptide-1 receptor (GLP-1R) agonist medications in the treatment of type 2 diabetes and obesity. Next, the mechanism of action and impacts of GLP-1R agonists are discussed, along with an overview of the Food and Drug Administration-approved GLP-1R agonists currently on the market. Comparison in effects on weight loss of the available GLP-1R agonists is briefly discussed, along with its use in the context of bariatric surgery. Finally, perioperative considerations for surgical patients using GLP-1R agonists are reviewed along with suggested recommendations.
The treatment of locally advanced rectal cancer has been transformed over the last century with nearly 40% of patients achieving complete eradication of their tumor with total neoadjuvant therapy alone. Nonoperative management with a watch-and-wait approach has now allowed a subset of patients the chance to avoid surgery altogether with 50% of watch-and-wait patients achieving long-term organ preservation. However, the other half of patients develop either local regrowth, which requires expeditious surgical intervention, or distant recurrence. Watch-and-wait is a reasonable option for select patients in a protocolized environment that can successfully deliver the recommended surveillance protocol, which ensures its safety.
The treatment of locally advanced rectal cancer has been transformed over the last century. While initially treated with surgery alone, adjuvant therapy with chemotherapy and radiation became common for locally advanced disease to prevent local and distant recurrence. Several trials subsequently showed benefit to moving this therapy into the neoadjuvant setting which led to improved oncologic outcomes, greater compliance, and similar surgical morbidity. In this article, we will explore this historical transition to a total neoadjuvant approach that can lead to cure in select patients and brings into question the role of surgery altogether.
Extremity lymphedema is a common condition resulting from impaired lymphatic transport after oncologic treatment, trauma, infection, or congenital abnormalities. Modern management has evolved from conservative therapy with compression garments to physiologic interventions guided by integrated clinical and functional staging system. Accurate diagnosis includes objective circumferential or volumetric measurement, lymphoscintigraphy and indocyanine green lymphography. Physiologic interventions such as lymphovenous anastomosis and vascularized lymph node flap transfer are effective and selected on the functional severity system. Understanding each treatment's indication of extremity lymphedema allows the health care practitioners to optimize surgical outcomes and improve quality of life without compression garments.
Esophagectomy remains the standard therapy for localized esophageal cancer, but postoperative function depends heavily on effective gastric conduit emptying. The aperistaltic conduit located in the negative pressure thoracic cavity is at risk of delayed gastric emptying leading to aspiration and pulmonary complications. This article summarizes historical and contemporary evidence evaluating pyloroplasty and alternative pyloric drainage strategies during esophagectomy. While earlier trials produced mixed results, recent level I evidence supports pyloroplasty as a safe adjunct that reduces gastric outlet obstruction and postoperative interventions. Meticulous conduit construction and vigilant postoperative assessment remain essential. There continues to be controversy, and an ongoing randomized trial, The PYNI-GAREREO Phase III Trial of Pyloroplasty Vs. No Pyloroplasty will be completed in the near future. (Trials.2023 Jun 19;24:412) and will add further level 1 evidence to this controversy.
The risk of venous thromboembolism following major trauma is high without pharmacologic prophylaxis. The timing of initiation is controversial. It can be delayed, interrupted for procedures, or never initiated due to concern for bleeding from injury sites. Current evidence supports initiation of pharmacologic prophylaxis within 24 hours of admission to reduce the risk of venous thromboembolism. Initiation within 24 hours of admission appears to be safe with low risk of bleeding from injuries, including progression of intracranial hemorrhage.
Landmark trials have demonstrated that residual microscopic disease in the undissected axilla does not translate to a higher risk of nodal recurrence, which laid the groundwork for trials examining the omission of axillary surgery. The SOUND and INSEMA randomized trials demonstrated no difference in disease-free survival in patients with small, cN0 breast cancer treated with or without sentinel lymph node biopsy (SLNB). Postmenopausal patients with luminal breast cancer undergoing lumpectomy with a normal preoperative axillary ultrasound are ideally suited for omission of SLNB, as systemic therapy decisions are increasingly based on genomic assays rather than pathologic nodal status.
