Anal fissure is a common anorectal condition causing severe pain, sphincter hypertonia, and reduced quality of life. Pharmacological therapies are commonly used as first-line nonsurgical interventions, but comparative effectiveness and adverse events remain inconsistent. We conducted a systematic review following the PRISMA guidelines to evaluate pharmacological treatments for anal fissure. PubMed, Scopus, and Web of Science were searched for clinical trials and quasi-experimental studies published 2000–2025. Interventions included topical nitroglycerin (GTN), calcium channel blockers (diltiazem, nifedipine), and botulinum toxin. Outcomes were healing rates, pain reduction, internal anal sphincter pressure changes, recurrence, and adverse effects. Eighteen eligible studies involving 1254 patients were included. Healing rates with topical GTN ranged from 55 to 78
Hepatic flexure (HF) and splenic flexure (SF) tumors are uncommon and anatomically complex tumors. Their management is largely extrapolated from right- and left-sided colon cancer paradigms. Despite distinct vascular and lymphatic anatomy, whether these flexure locations differ in terms of oncologic outcomes after resection remains unclear. Patients with surgically treated HF or SF adenocarcinoma (2010–2017) were identified from the SEER database. Multivariable Cox models evaluated associations between location and survival, adjusting for demographic, pathological, and treatment factors. Stage-stratified and treatment-specific analyses were performed. Among 4898 patients (3368 HF; 1530 SF), flexure location was not independently associated with overall survival (OS; p = 0.163). However, SF tumors demonstrated improved cancer-specific survival (CSS) after adjustment (hazard ratio [HR] 0.84; p = 0.0065). This association was confined to advanced disease, with significant differences in stage III (HR 0.76; p = 0.0018) and stage IV tumors (HR 0.79; p = 0.0113), and no difference in stage I–II. Advanced disease was more common among SF tumors. Chemotherapy was associated with reduced mortality across flexure locations, with a significant CSS advantage for SF tumors (HR 0.84; p = 0.0265). Advanced stage remained the dominant prognostic factor. Tumors > 5 cm were associated with worse OS and CSS, while examination of ≥ 12 lymph nodes was independently protective. Hepatic flexure and splenic flexure cancers demonstrate comparable OS. However, SF tumors exhibit a CSS advantage in advanced disease. Established oncologic factors remain the primary drivers of prognosis, while location may selectively influence cancer-specific mortality.
Billroth II (B-II) anastomosis is widely used after distal gastrectomy but is associated with bile reflux and alkaline gastritis. Billroth II with Braun anastomosis (B-B) may reduce these risks, but the evidence is controversial. We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library up to November 2025 for comparative studies (RCTs or cohorts) comparing B‑II vs. B‑B in distal gastrectomy for gastric cancer. Outcomes included perioperative parameters, short-term complications, 1‑year endoscopic findings, and long-term complications. Meta-analysis was performed using random-/fixed-effects models. Eight studies (2892 patients; 1366 B‑II, 1526 B‑B) were included. While B‑B had longer operative time (WMD: 22.01; P = 0.003), it was associated with shorter gastric tube removal (WMD: −0.46; P < 0.00001) and earlier flatus (WMD: -0.36; P = 0.02). No significant differences were found in terms of blood loss, hospital stay, overall complications, bleeding, anastomotic leakage, obstruction, pulmonary infection, or bile reflux. However, B‑B significantly reduced grade III–IV gastritis at 1 year (RR: 0.29; P = 0.0001). Dumping syndrome and gallstones showed no differences. Adding Braun anastomosis to Billroth II facilitates early recovery and reduces moderate-to-severe reflux gastritis without increasing complications. It appears safe and effective as an adjunct, but high-quality RCTs with long-term follow-up are needed to confirm its comprehensive value.
Lymphadenectomy in colorectal cancer surgery is one of the most important components of oncological surgery and is the foundation for patients’ healing. For generations, a debate has been ongoing in the literature about the optimal extent of lymphadenectomy. We here present a review of the literature concerning the impact of lymph node metastases, the influence of resection margins and the extent of lymphadenectomy in colorectal cancer surgery. A narrative review of the literature was conducted focusing on oncological principles of colorectal cancer surgery, including lymph node metastases, lymph node yield, lymph node ratio, resection margins, vascular ligation and mesocolic/mesorectal excision techniques. The presence of lymph node metastases, the total number of harvested lymph nodes and the lymph node ratio are major prognostic factors that affect survival outcomes in colorectal cancer patients. Adequate oncological resection requires en bloc removal of the tumour-bearing bowel segment with proximal and distal margins of approximately 5–10 cm. This should be combined with central ligation of the feeding vessels and complete excision of the lymph node-bearing mesocolon or mesorectum. Dissection along the embryological planes facilitates complete mesocolic excision in colon cancer and total mesorectal excision in rectal cancer, which are both associated with improved oncological outcomes and reduced local recurrences. The extent of central lymphadenectomy along the superior and inferior mesenteric vessels must balance oncological radicality with the potential risk of increased morbidity and postoperative complications associated with more extensive resections. Optimal lymphadenectomy in colorectal cancer surgery requires a balance between radical oncological clearance and surgical safety. Adequate lymph node harvest, central vascular ligation and precise dissection along embryological planes remain essential principles for improving staging accuracy and patient survival while minimising operative morbidity.
Laparoscopic transabdominal preperitoneal (TAPP) repair is increasingly used for inguinal hernia treatment. Day-case surgery has become standard in many high-volume centers, but real-world comparative registry data remain limited. This study aimed to compare perioperative and 1‑year outcomes of laparoscopic TAPP versus open Lichtenstein repair performed within a standardized day-case surgical pathway. This retrospective analysis of prospectively collected Herniamed registry data included 571 male patients undergoing 635 inguinal hernia repairs between May 2020 and December 2023 at a single high-volume center participating in the Herniamed registry. Patients were treated using either open Lichtenstein repair or laparoscopic TAPP repair within a standardized day-case surgical pathway. Follow-up was conducted at 1 week and 1 year, with a 1-year follow-up rate of 95
Complete mesocolic excision (CME) is increasingly recognized as a standard surgical approach in colon cancer, offering improved oncologic outcomes through dissection along embryological planes and central vascular ligation. However, the relevance of complete lymphadenectomy at the trunk of Henle remains unclear. This study aimed to determine the incidence of radiologically detectable lymph node metastases at the trunk of Henle in patients undergoing standardized conventional right hemicolectomy without formal CME. In this retrospective single-center study, follow-up data were analyzed for 234 patients who underwent standardized right hemicolectomy for right-sided colon cancer without CME. Demographic, surgical, and pathological data were extracted from electronic records. Annual contrast-enhanced computed tomography (CT) scans were performed postoperatively and independently reviewed by two board-certified radiologists, focusing on lymphatic recurrence near the trunk of Henle. Of the 218 patients included in the final analysis, 45 patients (20.6
The management of rectal cancer has evolved considerably over the past few decades, resulting in improved patient outcomes. Along with enhancements in surgical techniques such as total mesorectal excision, the addition of multimodal radio- and chemotherapy protocols for specific tumor stages has played a significant role. More recent approaches include total neoadjuvant therapy protocols, which have increased the rates of complete clinical response and facilitated watch-and-wait strategies with non-operative management of the rectum. Immunotherapy for rare tumors characterized by microsatellite instability has also led to very high complete clinical response and rectum preservation rates. Decision-making is performed within specialized multidisciplinary tumor boards, considering various options such as primary tumor resection, neoadjuvant chemotherapy, neoadjuvant radiotherapy or chemoradiotherapy, and total neoadjuvant therapy for high-risk-disease patients. The aims of treatment beyond oncological cure include maintaining the integrity of urinary, stool, and sexual functions; avoiding a permanent stoma; and potentially preserving the rectum.
Robotic surgery is a promising development in minimally invasive pancreatic surgery due to its ability to improve dexterity and range of motion, facilitating the technically demanding anastomosis required during minimal-invasive pancreatic surgery. In experienced hands, robotic pancreaticoduodenectomy (PD) is equal to open pancreatic head resection in terms of short-term outcomes. Several studies have shown similar oncological outcomes, and there have been no differences in 30- and 90-day mortality rates. However, no guideline recommendations have been given for the use of robotic PD in cases of advanced pancreatic head cancer with vascular resection, or after neoadjuvant treatment, due to the lack of comparative data. In the hands of experts robotic PD is a feasible approach also for malignant diagnoses. Robot-assisted pancreatic surgery is a promising advancement in minimally invasive surgery, offering technical advantages but requiring a longer learning curve and higher costs. Further development and evaluation of the technique, elaborated training programs and proctoring are essential for a safe implementation of this technology.
Refractory hypothyroidism in post-total-thyroidectomy patients is a common clinical challenge, often requiring supraphysiological levothyroxine (LT4) doses unexplained by bodyweight, age, or adherence. Increasing evidence suggests that Helicobacter pylori-related gastric dysfunction may impair LT4 absorption, yet data in post-thyroidectomy patients remain limited. This study evaluated the impact of H. pylori infection and its eradication on LT4 dose requirements in refractory cases. This retrospective observational study included 47 adults from January 2022 to March 2025 with total thyroidectomy and persistent biochemical hypothyroidism despite high-dose LT4 and confirmed H. pylori infection. Clinical and laboratory parameters (TSH, free T4, LT4 dose) were assessed before and 12 weeks after eradication therapy, with follow-up up to 24 months. Primary outcomes were changes in TSH and LT4 dose requirements. Patients (mean age 50.3 years; 33 female, 14 male) had elevated baseline TSH (14.39± 4.63 mIU/L) despite high LT4 doses (178.92± 5.42 μg/day). Following eradication, TSH decreased to 2.52± 0.51 mIU/L (p = 0.001), with a 29
In gastric cancer, resection of the primary tumor combined with adequate lymphadenectomy remains central to multimodal therapy with curative intent. While the extent of surgical radicality, most notably D2 lymphadenectomy, has been questioned in only selected trials, the operative approach has evolved substantially. Following the establishment of laparoscopic gastrectomy alongside the open technique, robot-assisted surgery has emerged as a promising option for complex oncological procedures. Although robotic and laparoscopic gastrectomy share minimally invasive access, the intraabdominal operative environment and thus oncological radicality and postoperative morbidity can differ due to the unique capabilities of robotic systems. International studies comparing robotic, laparoscopic, and open approaches report encouraging outcomes, with some suggesting advantages that support broader adoption of robotic techniques. East Asian countries, particularly Japan and Korea, have led the development of oncological gastrectomy by pioneering techniques and providing extensive clinical evidence. However, their standards of care differ markedly from those in Europe, as influenced by a higher incidence of gastric cancer, national screening programs, and the presence of very high-volume centers. Therefore, maintaining a European perspective is essential. Differences in patient characteristics, healthcare structures, and case volumes necessitate region-specific evaluation of robotic gastrectomy. This article focuses on robot-assisted techniques in oncological gastrectomy and aims to contextualize current evidence and developments within the European setting.
Gastroesophageal reflux disease (GERD) is a prevalent chronic condition. While proton pump inhibitors (PPIs) and Nissen fundoplication are mainstays, limitations include dysphagia and suboptimal outcomes in large hiatal hernias (HH) or ineffective esophageal motility (IEM). RefluxStop is a novel noncircumferential implant designed to restore anatomy without compression. This review synthesizes evidence on its efficacy, safety, and economics. Per PRISMA 2020 guidelines, we systematically searched multiple databases up to March 2026 for studies on RefluxStop outcomes. Two investigators independently selected studies, extracted data, and assessed quality using MINORS. Fourteen studies (over 500 patients) with follow-up to 5 years were included. RefluxStop significantly improved Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores (median improvement 79.9
Minimally invasive pancreatoduodenectomy has seen growing implementation owing to its potential benefits in postoperative recovery; however, the impact of robotic pancreatoduodenectomy (RPD) compared with laparoscopic pancreatoduodenectomy (LPD) on postoperative pancreatic fistula (POPF), the most significant source of morbidity, remains unclear. Determining whether the robotic approach reduces POPF incidence is critical for surgical decision-making. A systematic review was conducted of studies published up to 2025 that compared RPD and LPD in patients with pancreatic head or periampullary malignancies. In total, 12 studies were included, encompassing multicenter propensity-matched cohorts, single-center series, and retrospective analyses. Primary outcomes were overall and clinically relevant POPF. Secondary outcomes included operative time, blood loss/transfusion, conversion, delayed gastric emptying, length of stay, lymph node yield, resection margins, and mortality. Study quality was assessed using MINORS and ROBINS‑I tools. Overall and grade B/C POPF rates were similar between robotic and laparoscopic approaches, with no consistent advantage for either technique. Secondary outcomes showed greater variability. Whereas RPD was associated with lower blood loss, reduced conversion rates, and shorter length of stay, operative time was longer for robotic procedures. Oncologic outcomes were equivalent between groups. The quality of evidence was limited by retrospective design, heterogeneity of definitions, and moderate-to-serious risk of bias. Both RPD and LPD yield comparable perioperative and oncologic outcomes in experienced centers, although isolated technical advantages were observed for each approach. The heterogeneous and predominantly retrospective nature of the evidence highlights the need for prospective, randomized comparative studies to better define the optimal role of each modality.
Pilonidal sinus disease (PND) is a chronic condition with a significant disease burden that commonly affects adolescents and young adults. Traditional approaches to treating PND include excision with midline closure, subcutaneous flap reconstruction, or healing by secondary intention. However, high postsurgical morbidity has led to the use of minimally invasive approaches. This study compares the medium- and long-term outcomes after treatment of PND with laser, surgical excision, and sinotomy. An observational, retrospective, nonrandomized study of patients with PND was conducted between April 2022 and December 2024. The interventions included laser treatment, simple excision, and sinotomy. The primary outcome was the cure rate after surgery and the secondary outcome was failure rate. Overall, 207 patients underwent surgery; 112 underwent laser treatment, 90 simple excision, and 5 sinotomy. The patient groups were comparable in baseline characteristics. There were no statistically significant differences in the cure rate or treatment failure among groups (p > 0.05). Complications were similar among groups (p = 0.88). Healing time was shorter with laser therapy and sinotomy than with simple excision (8 and 7 weeks, respectively, vs. 12 weeks, p < 0.05). Time to return to work was shorter in the laser group (3 weeks vs. 10 weeks for simple excision vs. 9 weeks for sinotomy, p < 0.05). This comparative study of the most commonly used techniques in the treatment of PND demonstrates that laser provides much faster and more satisfactory postoperative recovery and return to work.
In this case report, we describe a 74-year-old woman who underwent robotic-assisted transabdominal preperitoneal patchplasty (rTAPP) for the repair of a right-sided inguinal hernia. Preoperative evaluation in the outpatient setting included inguinal ultrasonography and computed tomography (CT). Radiological findings demonstrated a right-sided inguinal hernia containing the tip of the appendix vermiformis within the hernia sac, consistent with an Amyand hernia. On the day of surgery, the hernia was non-reducible. Intraoperative findings revealed a femoral hernia with incarceration of the appendiceal tip. The hernia was reduced, and the hernia sac with the adherent appendix and surrounding peritoneum was resected en bloc. No free intra-abdominal fluid or signs of appendiceal perforation were observed intraoperatively. Robotic-assisted TAPP repair was subsequently performed. The peritoneum was completely reconstructed using a resorbable suture. Following peritoneal closure, robotic-assisted appendectomy was carried out. The postoperative course was uneventful, and the patient was discharged on the second postoperative day. According to follow-up data from the Herniamed Registry, the patient remains asymptomatic without complications to date.
The optimal management strategy for mild acute biliary pancreatitis (ABP) in older adults, particularly in those with contraindications to cholecystectomy, remains uncertain. Early cholecystectomy is the standard strategy to reduce recurrent biliary events, whereas endoscopic sphincterotomy (ES) may be used as a nonoperative biliary intervention in carefully selected patients who are not candidates for definitive surgery. This study evaluated the long-term outcomes associated with ES in older adults with mild ABP. We conducted a retrospective cohort study of patients aged ≥ 70 years admitted with mild ABP between 2010 and 2020. Patients were stratified into two groups based on treatment modality: ERCP with ES versus conservative management. Primary outcomes included recurrence of pancreatitis, overall survival, and ERCP-related morbidity. Secondary outcomes were biliary complications and readmission rates. Statistical analyses included Kaplan–Meier survival curves, multivariable Cox proportional hazards models, and competing-risk analyses. Patients were included on the basis of advanced age and real-world treatment allocation; the cohort was not intended to represent all older adults with ABP who would otherwise be candidates for surgery. A total of 182 patients (median age: 78 years) were included, with 90 undergoing ERCP with ES and 92 managed conservatively. Recurrence rates were similar (ES: 8.9
The growing population of elderly has resulted in a rise in complex abdominal wall hernias, especially among older and more vulnerable individuals. This review aims to summarize the latest evidence regarding the timing, surgical techniques, and perioperative care associated with the repair of complex abdominal wall hernias in geriatric patients. A narrative review of the literature was conducted using structured searches of major databases for publications in English from 2000 to July 2025. Studies addressing age, frailty, comorbidities, surgical technique, and perioperative outcomes in older patients were qualitatively synthesized. Multimorbidity and frailty emerged as key predictors of postoperative risk, particularly among patients with a Charlson Comorbidity Index of ≥ 3, which was associated with higher mortality. Sarcopenia and malnutrition also contributed significantly to adverse outcomes. Elective repair was consistently associated with lower mortality and complication rates compared with emergency surgery. When comorbidities and frailty were optimized, older patients demonstrated outcomes comparable to younger cohorts in propensity-matched analyses. Prehabilitation strategies, including nutritional optimization and risk-factor modification, were associated with improved perioperative outcomes. Permanent synthetic mesh was favored in clean cases, while biologic options were used selectively in contaminated fields. Minimally invasive approaches reduced wound morbidity but require further evaluation in populations with frailty. Chronological age alone should not preclude ventral or incisional hernia repair. Instead, frailty, multimorbidity, and nutritional status are critical determinants of risk. Elective repair following patient optimization is associated with improved safety, while prehabilitation and multidisciplinary care play a central role in reducing complications in older patients.
Acute postoperative abdominal wall failure with recurrent evisceration is a rare but severe complication following emergency laparotomy. Progressive lateral wall contracture and loss of medial compliance may render repeated primary closures ineffective. We describe the salvage management of a frail 66-year-old male with three episodes of recurrent postoperative evisceration after emergency laparotomy for an incarcerated inguinal hernia with ischemic small bowel. Bilateral transversus abdominis release (TAR) combined with retromuscular polypropylene mesh placement was performed, along with intraoperative botulinum toxin A (BTA) injection into the lateral abdominal wall. Transversus abdominis release restored medial compliance and allowed for anatomical midline reconstruction with wide retromuscular mesh overlap. Intraoperative BTA was used as a protective adjunct to decrease lateral muscle tension during early healing—not to facilitate closure. The patient’s postoperative course was uneventful with regard to abdominal wall integrity. At 6‑month follow-up, there was no recurrence, bulging, or chronic pain. This case highlights the technical viability of combining anatomical reconstruction with functional modulation as a salvage strategy in highly selected patients with acute abdominal wall failure when repeated primary closure is unlikely to succeed and preoperative chemical component separation is not feasible. This observation is hypothesis generating only and should not be generalized beyond similar exceptional cases.
