Abstract Background Cross-sectional imaging may miss occult metastatic disease in pancreatic ductal adenocarcinoma and cannot detect positive peritoneal lavage cytology. This study quantified the yield of staging laparoscopy (SL) with routine lavage cytology and developed the SENDAI-SL score for risk-based prioritization. Methods Consecutive patients with radiographically non-metastatic pancreatic ductal adenocarcinoma who underwent SL at one centre from January 2013 to June 2025 were analysed retrospectively. SL positivity was defined as liver metastasis, macroscopic peritoneal metastasis, and/or positive cytology. Multivariable logistic regression identified predictors; internal validation used 2000 bootstrap resamples. Results Of 504 patients, 141 (28.0%) had positive SL. Positivity rates were 21.3%, 16.0%, 32.3%, and 41.7% in resectable, borderline resectable with portal vein involvement, borderline resectable with arterial involvement, and unresectable locally advanced disease, respectively. Gross liver or peritoneal metastases were detected in 51 patients (10.1%); cytology was positive in 125 (24.8%) and the sole finding in 90 of 141 positive procedures (63.8%). Among 499 patients with quantifiable serum carbohydrate antigen 19-9, unresectable locally advanced disease, body and/or tail location, tumour size ≥ 37 mm, and serum carbohydrate antigen 19-9 ≥ 180 U/ml were independently associated with SL positivity. The model's area under the receiver operating characteristic curve was 0.732 (optimism-corrected, 0.718). Score-specific positivity ranged from 8.6% to 83.3%. A score ≥ 2 prioritized 149 patients; 74 (49.7%) were positive, capturing 52.9% (74 of 140) of positives in the analysis cohort. Conclusions SL upstaged 28.0% of patients, predominantly through cytology-only disease. The SENDAI-SL score may support prioritization when resources are limited but requires external validation and should not justify omitting SL.
Abstract Background Non-operative management of gallstone complications (acute cholecystitis, cholangitis, and biliary pancreatitis) carries a significant risk of recurrence. Nevertheless, definitive surgery is often deferred in co-morbid patients due to their perceived short life expectancy. This study assessed the prevalence of non-operative management, and its associated mortality and recurrence risk, accounting for the competing risk of death due to other causes. Methods A nationwide cohort of patients admitted with gallstone complications and treated with non-operative management between 2006 and 2019 was identified in the Swedish National Patient Register. Competing risk and Cox proportional hazards models were used to evaluate recurrence and mortality risks. Results Overall, 82 101 patients were included (median age 68 years, 48% female), of whom 41 283 (50.3%) experienced cholecystitis, 10 272 (12.5%) experienced cholangitis, and 30 546 (37.2%) experienced pancreatitis. Patients with cholangitis were older and had more co-morbidities than those with cholecystitis or pancreatitis. The cumulative recurrence risk at 1 year was 16.0% for cholecystitis, cholangitis, and pancreatitis. At 3 years, the risk was 19.8% for cholecystitis and 23.0% for cholangitis and 22.5% for pancreatitis. In patients aged ≥ 80 years, 3-year mortality was 41.2%, and 17.0% of deaths were gallstone related. In competing risk analyses, cholangitis and pancreatitis were associated with a higher recurrence risk than cholecystitis in alive patients, with hazard ratio (HRs) of 1.22 (95% confidence interval (c.i.) 1.16 to 1.28) and 1.28 (95% c.i. 1.24 to 1.32), respectively, whereas female sex was associated with a lower recurrence risk (HR 0.92; 95% c.i. 0.89 to 0.94). Increasing age (HR 1.08; 95% c.i. 1.08 to 1.09), co-morbidities (HR 1.17; 95% c.i. 1.16 to 1.17), and cholangitis (HR 1.31; 95% c.i. 1.26 to 1.36) were associated with an increased risk of mortality. Conclusion The risk of recurrent gallstone complications remains clinically important, even among older and co-morbid patients, despite their higher competing risk of death. These findings support consideration of early cholecystectomy in patients with an acceptable operative risk, with the aim of reducing subsequent morbidity and recurrence.
Abstract Background Colonoscopy surveillance is recommended following colorectal cancer (CRC) surgery, yet the evidence supporting the recommendations has major quality issues. This study assessed the independent impact of colonoscopy surveillance within 5 years after CRC surgery. Methods A systematic review and meta-analysis were conducted. Medline, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception until 18 June 2026 for randomized clinical trials comparing follow-up protocols including colonoscopy surveillance (intervention) to those without colonoscopy surveillance (control) within 5 years after CRC surgery. Risk of bias was assessed using the RoB 2 tool. Random-effects meta-analyses were conducted to estimate the strength of associations with recurrence detection, reoperation rate, and survival. The number needed to scope (NNS) to detect one recurrence and health economic considerations were estimated. The study protocol has been registered in PROSPERO. Results Of 4381 records, five trials with 2337 patients were included. Four trials enrolled patients between 1983 and 1994, predating subsequent advances in CRC treatment. All trials used additional surveillance modalities, leading to a high risk of bias. Follow-up protocols with colonoscopy were not associated with recurrence profile, with risk ratios (RRs) of 0.74 (95% confidence interval (c.i.) 0.32 to 1.69), 1.23 (95% c.i. 0.93 to 1.63), and 0.93 (95% c.i. 0.76 to 1.14) for intraluminal, locoregional, and distant recurrence, respectively. Colonoscopy during follow-up was associated with a higher rate of asymptomatic recurrence (RR 2.38; 95% c.i. 1.53 to 3.69). More curative-intent reoperations were performed in the intervention than control group (RR 1.66; 95% c.i. 1.16 to 2.37), but this was not translated into improved survival (hazard ratio 0.92; 95% c.i. 0.77 to 1.11). The NNS was 159 (95% c.i. 101 to 267), resulting in estimated cost per colonoscopy-detected recurrence of €104 100 (95% c.i. €66 200 to 174 900). Conclusion Current evidence from randomized trials does not clearly demonstrate that postoperative colonoscopy surveillance improves survival, although interpretation is limited by the age of the trials and confounding from concurrent surveillance modalities. Contemporary randomized trials are required to better define the independent contribution of colonoscopy within modern multimodal surveillance pathways.
Abstract Background Total colon aganglionosis (TCA), a severe form of Hirschsprung disease, is a rare and complex condition with variable management and limited outcome data. This retrospective cross-sectional multicentre study assessed current long-term outcomes of TCA in Europe. Methods Patients with TCA under follow up at participating ERNICA and ESPGHAN centres were included. Data were collected on genetics, nutritional, functional, and surgical outcomes, intestinal inflammatory lesions, and mortality during the preceding 10 years. Results Thirty-one centres from 15 countries contributed 401 patients (median age 7.9 years; interquartile range 4.0–13.6 years). Genetic testing was performed in 52% of patients, with pathogenic variants identified in 62%, mainly RET. Aganglionosis was limited to the colon in 26%, extended to the small bowel in 71%, and was total intestinal in 3%, without association with genetic status. At the latest follow-up, 25% of patients were receiving parenteral nutrition (PN); PN dependency was associated with small intestine extension of aganglionosis > 50 cm (72% of patients with >50 cm small bowel aganglionosis versus 15% of patients aganglionosis <50 cm small bowel or limited to the colon; P < 0.001). Overall, 77% of patients underwent pull-through, most commonly ileoanal anastomosis (62%) or Duhamel (31%). Complications included anastomotic leak (4%), strictures (12%), redo surgery (24%), recurrent enterocolitis (36%), obstructive symptoms (24%), and faecal incontinence (25%). Recurrent enterocolitis was associated with obstructive symptoms (P = 0.007). Endoscopy showed intestinal inflammatory lesions in 22% of patients, particularly those with recurrent enterocolitis (odds ratio (OR) 6.43; 95% confidence interval (c.i.) 3.27 to 12.63) and obstructive symptoms (OR 2.64; 95% c.i. 1.26 to 5.53). The 10-year mortality rate was 3.4%. Conclusion TCA shows a high prevalence of genetic abnormalities and substantial postoperative and long-term morbidity, independent of surgical technique.
