INTRODUCTION:Anastomotic leakage (AL) after colorectal surgery is an impactful complication, associated with increased morbidity and reduced quality of life. The circular stapler commonly used for anterior resections (AR), introduces risks of cross-stapling, dog-ears, overcompression, and foreign body response, all associated with AL. An adaptive anastomosis technique eliminates these risk factors, potentially lowering the incidence of AL. METHODS:The ADAPT trial is an international multicentre, non-randomised, prospective clinical effectiveness trial evaluating the clinical safety and efficacy of the C-REX adaptive anastomosis in minimally invasive AR. 165 Patients with proximal rectum or sigmoid cancer, or premalignant lesions requiring AR will be enrolled throughout multiple European colorectal centres. An adaptive colorectal anastomosis will be constructed using the C-REX RectoAid Cath. The primary endpoint is 30-day AL rate. Secondary endpoints include 90-day AL, 1-year anastomotic integrity, intraoperative performance of the C-REX device, time to evacuation of the anastomotic ring, postoperative morbidity, functional outcomes, cost-effectiveness, and surgical quality assessment. CONCLUSION:The ADAPT trial will evaluate whether an adaptive anastomotic technique using the C-REX RectoAid Cath, designed to eliminate key technical risk factors, reduces AL after colorectal AR in an international multicentre setting. The findings could guide strategies to improve postoperative outcomes and reduce leakage-related morbidity. TRIAL REGISTRATION:ClinicalTrials.gov - NCTNCT07056374, July 2025.
INTRODUCTION:Patients with esophageal squamous cell carcinoma (SCC) may be more likely to harbor colorectal cancer (CRC) because of shared lifestyle risk factors such as smoking and alcohol. However, its prevalence and clinical significance remain unclear. We evaluated prevalence and risk factors for colorectal advanced neoplasia (CAN) and CRC in patients with esophageal SCC and compared them with fecal occult blood test (FOBT)-positive controls. METHODS:We retrospectively analyzed 457 patients with esophageal SCC who underwent colonoscopy between 2017 and 2024. CRC was defined as colorectal adenocarcinoma invading submucosal layer or beyond. CAN was defined as ≥10-mm lesion, high-grade dysplasia, villous histology, or CRC. Risk factors were assessed using logistic regression. Propensity score matching (PSM) compared incidence of CAN and CRC with FOBT-positive controls matched for age, sex, and body mass index (caliper=0.05). RESULTS:Among patients with esophageal SCC, 25.4% had CAN and 10.3% had CRC. Brinkman Index (OR 1.02, 95% CI 1.00-1.04) and alcohol history (OR 2.60, 95% CI 1.13-5.97) were independently associated with CAN (P = 0.048 and 0.025), while no variable was associated with CRC in multivariate analysis. After PSM (135 matched pairs; all standardized mean difference <0.1), CRC incidence remained significantly higher in SCC than FOBT-positive group (OR 3.79 (95% CI 1.21-11.8; P = 0.015)), whereas CAN incidence did not differ. CONCLUSIONS:Patients with esophageal SCC had a higher prevalence of CRC compared with FOBT-positive group after PSM. Lifestyle factors were linked to CAN but not CRC. Colonoscopy should be considered in patients with esophageal SCC.
BACKGROUND:Radical local metastasis-directed treatment is increasingly considered in oligometastatic cancer. Disappearance of metastases after systemic therapy ("vanishing lesions") poses management dilemmas, as invisibility does not prove complete response, but local therapy carries morbidity. SUMMARY:We searched PubMed for studies on vanishing metastases after systemic therapy in esophagogastric cancer. Complete disappearance of all metastases occurred in 1-3% of patients treated with chemotherapy alone and in 5-17% in trials using targeted or immune therapies. Series reported ≥1 vanishing lesion(s) in 8-44% of patients. Definitions relied on CT, without comparison to MRI or PET-CT. Lesion-level pathology was lacking; vanishing sites were not resected. Survival benefits were linked to radiologic complete response, but the impact of locally treating vanishing sites was not studied. Because esophagogastric data are scarce, colorectal metastases were reviewed for context: CT disappearance often overestimated cure, liver MRI frequently altered plans, 33-69% of CT/MRI-negative liver lesions still harbored viability or recurred, and survival was comparable between unresected vs. resected vanishing lesions. KEY MESSAGES:Current evidence does not support routine local treatment of vanishing lesions in oligometastatic esophagogastric cancer, although this conclusion is based on a very limited and retrospective evidence base. Imaging besides CT (e.g., MRI, PET-CT) may improve staging. Individualized benefit-risk assessment and studies addressing diagnostic and therapeutic strategies are needed.
BACKGROUND:Isolated peritoneal metastases occur in approximately 4-8% of patients with colorectal cancer and are associated with a very poor prognosis with systemic therapy alone. While cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have traditionally been a controversial treatment regimen for colorectal cancer peritoneal metastases due to a high rate of morbidity and a perceived limited efficacy, recent studies have confirmed its safety and have demonstrated the ability to achieve long-term survival in carefully selected patients. SUMMARY:This narrative review presents the current indications, controversies, and future directions of CRS, HIPEC, and additional emerging treatment modalities in the surgical management of colorectal cancer peritoneal metastases. KEY MESSAGES:Peritoneal metastases in colorectal cancer signify a poor prognosis. Management of peritoneal disease includes CRS with or without HIPEC. The use of CRS has been established as an effective treatment modality with acceptable morbidity and long-term quality of life. However, the efficacy of HIPEC continues to be debated. Patient functional status, tumor biology, degree of disease burden, and the feasibility of achieving complete cytoreduction are central to the success of the operation. Emerging treatment options, such as pressurized intraperitoneal aerosolized chemotherapy, represent promising alternative treatment options for patients.
Transfusion-related acute lung injury (TRALI) and anaphylactic shock are rare but life-threatening transfusion-related complications. Differentiating between these conditions during general anesthesia is difficult because subjective symptoms cannot be assessed and intraoperative diagnostic evaluation is limited. A 40-year-old woman undergoing surgery for ovarian cancer under general anesthesia developed acute hypoxemia during transfusion. After completion of the transfusion, she developed sudden hypotension, tachycardia, and generalized erythema, which responded promptly to adrenaline administration. Respiratory failure persisted, and frothy sputum appeared in the endotracheal tube. Postoperative chest radiography showed bilateral pulmonary infiltrates, while echocardiography revealed preserved cardiac function. Anti-human leukocyte antigen (HLA) class I and II antibodies were detected in the transfused fresh frozen plasma, and serum tryptase levels were elevated postoperatively. This case demonstrated overlapping clinical features of TRALI and anaphylactic shock during general anesthesia. Although donor anti-HLA antibodies supported the possibility of TRALI, severe anaphylaxis alone could not be completely excluded as an explanation for the pulmonary edema.
Delayed emergence from general anesthesia has multiple etiologies; in rare cases, it may unmask an unrecognized neurodegenerative disorder. A 64-year-old man underwent laparoscopic cholecystectomy under general anesthesia. No neurological abnormalities were identified preoperatively. After surgery, response to verbal stimuli was inadequate; however, other extubation criteria were met and he was extubated. Approximately 45 min later, rapid nystagmus-like eye movements consistent with opsoclonus developed, initially oscillating horizontally and then vertically, and persisted for about six minutes. A similar episode recurred 125 min after extubation. Head computed tomography showed no acute lesions but revealed marked cerebellar and brainstem atrophy. Subsequent neurological evaluation, including magnetic resonance imaging demonstrating the “hot cross bun” sign, fulfilled the Movement Disorder Society diagnostic criteria for clinically established multiple system atrophy with predominant parkinsonism. In unexplained delayed emergence from general anesthesia, opsoclonus should prompt evaluation for an underlying neurodegenerative disorder.
Introduction The indications for resection of Intraductal papillary mucinous neoplasms (IPMNs) have been optimised according to the high-risk stigmata (HRS) and worrisome features (WF). However, the proportion of resected IPMNs diagnosed as low-grade is not insignificant. This study aimed to investigate whether fibrinogen-to-albumin ratio (FAR) improves the diagnostic ability of high-grade dysplasia (HGD) or Invasive carcinoma (IC) in IPMN. Methods This study included 47 patients who underwent surgery between April 2008 and July 2024. Clinical factors were examined to determine HGD or IC. We also compared the accuracy of predicting HGD or IC between HRS alone and HRS plus FAR. Results 23 were diagnosed with HGD or IC based on pathological diagnosis. On multivariable analysis, contrasted walled nodules ≥5 mm and FAR ≥0.0833 were significant predictors of HGD or IC. Moreover, the HRS and high FAR (≥0.0833) group had better the positive predictive value and diagnostic accuracy rate. Conclusions FAR may be a significant predictor of HGD or IC in IPMN. In addition, when combined with HRS, its diagnostic ability as a predictor of HGD or IC may be further improved.
BACKGROUND:Distinguishing cerebrospinal fluid (CSF) from epidural fluid is important when the origin of aspirated fluid is uncertain during neuraxial procedures. We evaluated the discriminative ability of β-trace protein (BTP). METHODS:Epidural samples were obtained via epidural catheters after local anesthetic administration, and CSF samples during spinal anesthesia. Glucose, total protein, and BTP were measured, and receiver operating characteristic (ROC) analyses were performed. RESULTS:BTP levels were markedly higher in CSF than in epidural samples, with no overlap. Glucose overlapped between groups, whereas total protein showed limited differences. ROC analysis demonstrated excellent discrimination for BTP (AUC = 1.000) under the present study conditions, outperforming glucose (AUC = 0.904) and total protein (AUC = 0.633). For glucose, the optimal cutoff was 56.5 mg/dL (sensitivity 83.3%, specificity 90.0%). For BTP, any cutoff between 0.42-4.03 mg/L achieved 100% sensitivity and specificity within this dataset. CONCLUSIONS:BTP shows strong discrimination between CSF and epidural fluid.
INTRODUCTION:The continued adoption of robotic-assisted surgery (RAS) in digestive surgery has created an increasing demand for structured training of surgical residents. However, standardized basic RAS training programs specifically designed for residents remain limited, resulting in variable exposure and skill acquisition. This study describes the development and evaluation of a structured basic RAS training course, to standardize education and improve residents' robotic surgery skills. METHODS:A 2-day, on-site basic RAS training course was developed by the Dutch Robotic Surgery Working Group and implemented at the OLV Robotic Surgery Institute (ORSI) academy between June 2021 and October 2023. The curriculum included lectures, interactive didactic sessions, simulation-based training, and both dry and wet laboratory exercises. The impact of the course on skill enhancement was assessed using pre- and post-course assessments. RESULTS:Seventy-five senior surgical residents with a specific interest in RAS participated. Simulator assessments showed significant improvements in overall score, task completion time, and economy of motion across all three exercises following course completion: exercise 1 (p < 0.001), exercise 2 (p < 0.001), exercise 3 (p < 0.001). CONCLUSION:This 2-day basic robot training course significantly improved basic robotic skills of general surgery residents. The program provides essential preparation for safe clinical utilization of robotic surgery and may serve as a scalable model for future basic robotic training courses within surgical residency programs.
INTRODUCTION:The detection of bacterial colonization in postoperative pancreatic fistula (POPF) fluid has renewed interest in the role of bacterial translocation during pancreatic surgery. In this context, we hypothesized that peripancreatic lymph nodes (PLNs) might similarly harbor bacterial colonization. This study aimed to investigate the presence of bacteria in these lymph nodes, identify factors potentially contributing to their colonization, and assess the clinical significance of these findings. METHODS:In this observational pilot study, PLNs (station 8a) resected during pancreatic surgery were analyzed for bacterial DNA using 16S rDNA-PCR, and the microbiological findings were correlated with detailed perioperative and postoperative clinical data. RESULTS:Between 2019 and 2026, lymph node station 8a was resected and analyzed in 37 patients undergoing pancreatic surgery. Bacterial colonization was found in 3 patients (8.1%). No significant association was observed between lymph node colonization and the type of surgical procedure, histopathological diagnosis, or the development of clinically relevant POPF or other major postoperative complications. All cases with bacterial colonization had undergone preoperative endoscopic retrograde cholangiopancreatography (ERCP; p = 0.230). CONCLUSION:In this pilot study, bacterial colonization of PLNs was uncommon and was observed only in patients with a history of ERCP. Although no association with POPF was identified, a potential relationship with overall postoperative morbidity cannot be ruled out. Further studies with larger patient cohorts are needed to better define the clinical relevance and underlying mechanisms of lymphatic bacterial translocation.
Abstract Background Kounis syndrome (KS) is an allergic acute coronary syndrome that may precipitate severe perioperative cardiovascular collapse. This study reports a case of remimazolam-induced refractory anaphylaxis complicated by KS and successfully treated with early extracorporeal cardiopulmonary resuscitation (ECPR). Case presentation A 69-year-old male with atrial fibrillation was scheduled for lung resection. After induction of anesthesia with remimazolam, he developed abrupt tachycardia, coughing, and circulatory collapse with ST-segment elevation. Despite repeated adrenaline doses, he progressed to cardiac arrest. Venoarterial extracorporeal membrane oxygenation was initiated during cardiopulmonary resuscitation. Return of spontaneous circulation occurred 15 min after the cardiac arrest. The patient recovered without neurological sequelae. Elevated serum tryptase levels (49.5 µg/L; 24-h postonset: 4.5 µg/L) and positive intradermal testing suggested remimazolam-induced anaphylaxis. Coronary computed tomography revealed no stenosis, compatible with suspected type 1 KS. Conclusions Remimazolam-induced anaphylaxis may be complicated by suspected KS. In refractory anaphylaxis complicated by cardiac arrest, early ECPR may be critical to survival.
Abstract Background Anaphylaxis in patients with a left ventricular assist device (LVAD) may critically reduce LVAD flow, particularly when the right ventricular function is impaired. Case presentation A 51-year-old man with a HeartMate III LVAD developed bronchospasm, profound hypotension, and decreased LVAD flow during anesthetic induction for endoscopic sinus surgery. The shock remained refractory despite epinephrine boluses and continuous infusions of epinephrine, norepinephrine, and vasopressin. Transesophageal echocardiography revealed severe right ventricular dilatation, leftward septal shift, and reduced left ventricular size, findings consistent with acute right heart failure (RHF). Treatment was escalated to include dobutamine, olprinone, and inhaled nitric oxide, achieving recovery of blood pressure and LVAD flow. Elevated serum tryptase supported the diagnosis of anaphylaxis, and a positive intradermal test identified remimazolam as the cause. Conclusions Successful anaphylaxis management in LVAD recipients may require rapid recognition and treatment of acute RHF in addition to standard treatment including epinephrine.
Abstract Background Previous abdominal wall repair may alter the rectus abdominis muscle structure and render rectus sheath block (RSB) infeasible in pediatric cardiac surgery. Case Presentation A 5-year-old boy with a history of siloplasty and omphalocele repair underwent right ventricle-to-pulmonary artery conduit replacement. Deep parasternal intercostal plane block and RSB had been planned. However, ultrasound pre-scanning failed to identify the rectus abdominis muscle in the upper abdomen, and the liver was visualized immediately beneath the abdominal wall. Preoperative computed tomography confirmed absence of the rectus abdominis muscle, rendering RSB anatomically infeasible. An alternative upper abdominal wall block was performed. The patient was extubated 2 h after admission to the intensive care unit and had no apparent discomfort from the chest and mediastinal drains. Conclusions Preprocedural ultrasound assessment can identify altered rectus abdominis muscle structure and help anesthesiologists select a safer and potentially effective alternative analgesic strategy when RSB is not feasible.
INTRODUCTION:Various nutritional and inflammatory biomarkers have been proposed to predict prognosis in cancer patients. This study aimed to identify the most significant of these, along with clinical features, in gastric cancer patients who underwent gastrectomy. METHODS:We retrospectively analyzed gastric cancer patients who underwent gastrectomy. Preoperative markers included mGPS (modified Glasgow Prognostic Score), neutrophil-to-lymphocyte ratio, C-reactive protein-to-albumin ratio, prognostic nutritional index, and Controlling Nutrition Status score. Postoperative markers were CRPmax, postoperative complications, and operative procedures. The primary endpoints were overall survival (OS) and recurrence-free survival (RFS). Survival was analyzed with the Kaplan-Meier method. Key prognostic factors were identified using stepwise univariate and multivariable Cox regression. RESULTS:360 patients were analyzed. Stepwise Cox analysis showed mGPS as the strongest preoperative predictor of OS and RFS. When including both pre- and postoperative variables, age, pathological stage, and surgical procedure were independent prognostic factors. In a model limited to modifiable factors, mGPS and postoperative complications independently predicted both OS and RFS, while surgical procedure independently predicted RFS only. CONCLUSIONS:Improving preoperative mGPS and minimizing postoperative complications may enhance survival after gastrectomy. When appropriate, stomach-preserving procedures (e.g., subtotal distal gastrectomy) should be favored over total gastrectomy.
Abstract Background Large language models (LLMs) have shown promising performance for ASA Physical Status (ASA-PS) classification, but prior work suggests reduced agreement in high-risk patients. We evaluated LLM reliability for ASA-PS classification in cardiovascular surgery. Results Thirty-two anonymized cases were rated by two residents, two board-certified cardiovascular anesthesiologists, and four LLM modes (ChatGPT: GPT-5.2 Instant and GPT-5.2 Thinking; Gemini: Gemini 3 Fast and Gemini 3 High Thinking); all LLM assessments were zero-shot. Overall agreement across evaluators was moderate (intraclass correlation coefficient [ICC] 0.49–0.52); agreement between each LLM and specialists was good (ICC 0.61–0.65). Exact-match to a five-specialist consensus was 42.2% for residents versus 59.4–75.0% for LLMs; classifications outside the range of ratings assigned by individual specialists were rare (0–3.1%). Conclusions In cardiovascular surgery, contemporary LLMs showed good concordance with cardiovascular anesthesiologists and exceeded resident agreement with expert consensus, supporting prospective multicenter validation as adjuncts for ASA-PS assessment and training.
BACKGROUND: Inhaled nitric oxide is a selective pulmonary vasodilator commonly used to treat pulmonary hypertension and right ventricular failure. However, its effectiveness in treating right ventricular failure secondary to hypercapnia caused by abdominal compartment syndrome has not been well described. CASE PRESENTATION: This case describes a patient who developed severe hypercapnia and acute right ventricular failure due to abdominal compartment syndrome following massive intraoperative hemorrhage. Elevated intra-abdominal pressure impaired the respiratory mechanics, resulting in alveolar hypoventilation, hypercapnia, and acute pulmonary hypertension. Respiratory and circulatory failures progressively worsened. Administration of inhaled nitric oxide was associated with a rapid improvement in right ventricular afterload surrogates, leading to improved right ventricular output and enhanced carbon dioxide elimination, with concomitant improvement in systemic hemodynamics. DISCUSSION: Inhaled nitric oxide may serve as an effective rescue therapy for hypercapnia-induced pulmonary hypertension and acute right ventricular failure associated with abdominal compartment syndrome.
INTRODUCTION:Non-occlusive mesenteric ischemia (NOMI) is a rare but lethal complication after gastric cancer (GC) surgery, marked by intestinal hypoperfusion without arterial occlusion. Nonspecific symptoms and rapid deterioration hinder timely diagnosis. This study evaluated outcomes, diagnostic pathways, and management. METHODS:We retrospectively reviewed 8 GC patients who developed NOMI (February 2022-January 2024). Collected variables included demographics, surgical details, feeding practices, presentation, imaging, treatment, and outcomes. The primary endpoint was 30-day mortality. RESULTS:NOMI presented a median of 3 days postoperatively (range 2-5). The median age was 63.5 years; 75% were male; all had advanced GC; and 62.5% had gastric outlet obstruction. Common signs were abdominal distension (75%), hypotension (50%), and peritonitis (25%). CT consistently showed small-bowel dilatation, pneumatosis intestinalis, and portal venous gas, mainly in distal jejunum/ileum. Seven patients underwent re-exploration: five required resection. After implementing a modified feeding protocol, cases reduced from seven to one. Thirty-day mortality was 50%, largely from sepsis and multiorgan dysfunction syndrome. CONCLUSION:In GC patients with feeding jejunostomy, NOMI remains a serious complication. A cautious feeding strategy - deferring feeds during vasopressor support, initiating low-strength kitchen feeds, slow escalation, and early oral intake - was associated with fewer cases. High clinical suspicion, rapid CT, and timely surgery are critical to improve outcomes.
INTRODUCTION:Acute appendicitis is a common surgical emergency. Laparoscopic appendicectomy is preferred for faster recovery and less pain, but conversion to open surgery remains necessary in some cases. Most evidence on conversion comes from high-income countries, while data from low- and middle-income settings (LMIC), where resource limitations may influence surgical decisions, are scarce. This study aimed to identify factors associated with conversion in a public, resource-limited Peruvian hospital. METHODS:We conducted a retrospective cross-sectional study of patients undergoing laparoscopic appendicectomy at a public hospital in Lima, Peru, between 2022 and 2023. Variables were compared between patients requiring conversion and those completing the procedure laparoscopically. Multivariate analyses were performed to identify risk factors. RESULTS:A total of 523 patients were included. Conversion to open appendicectomy occurred in 4 patients (0.76%), primarily due to difficult dissection from severe adhesions, intraoperative hemorrhage associated with equipment malfunction. Multivariate analysis identified adhesions (OR = 8.91, 95% CI: 1.48-53.42, p = 0.017), appendicolith (OR = 11.49, 95% CI: 1.74-75.69, p = 0.001), and intraoperative complications (OR = 45.74, 95% CI: 6.71-311.55, p < 0.001) as significant factors of conversion. CONCLUSIONS:Laparoscopic appendicectomy is safe and effective in public hospitals, even in low-resource settings. Conversion was rare and mainly driven by adhesions, appendicoliths, or intraoperative complications. These findings reinforce that laparoscopic appendicectomy can be reliably performed in LMIC.
Background: The incidence of esophageal adenocarcinoma (EAC) has risen significantly in recent decades, with Barrett's esophagus (BE) as the most important precursor. When a visible lesion is identified within BE, endoscopic resection (ER) is the preferred treatment, providing both histologic staging and curative therapy for dysplasia and low-risk EAC. Summary: Two ER techniques are commonly used: cap-based endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is an extensively studied technique considered safe, effective, and easy to learn. However, due to the cap-based approach, lesions larger than 15-20 mm need to be removed by multiple adjacent resections, so-called piecemeal resection. This may result in remnant tissue in the resection field and may compromise histopathological assessment. In contrast, ESD enables en bloc removal regardless of lesion size. While ESD has also demonstrated safety and efficacy, it is technically more demanding and associated with longer procedure times. For some lesions, there is general agreement on treatment, with ESD preferred for lesions with suspected submucosal invasion, bulky morphology, or fibrosis. Conversely, EMR remains the standard for smaller, superficial lesions without these features. Key Message: A significant grey zone persists, clinical scenarios for which comparative evidence is lacking and consensus on the optimal treatment approach remains unclear. .
