Aims:Although tertiary lymphoid structures (TLSs) contribute to antitumor immunity, the significance of CD86 expression within mature TLSs in pancreatic ductal adenocarcinoma (PDAC) remains unclear. This study evaluated CD86-positive mature TLSs as a marker of an immunologically active tumor microenvironment. Methods:We analyzed 128 treatment-naive patients with PDAC who underwent curative resection. TLSs were evaluated by hematoxylin and eosin staining and immunohistochemistry for CD4, CD8, CD20, CD21, CD23, and CD86. TLS maturation, CD86 expression, TLS density and diameter, intratumoral T-cell infiltration, and clinical outcomes were assessed. Multiplex immunofluorescence for CD8 and Granzyme B was performed in selected cases. Results:TLSs were identified in 124 patients. Among TLS-positive cases, 13, 21, and 90 were classified as immature, intermediate, and mature TLSs, respectively. Mature TLSs were associated with increased intratumoral CD8+ T-cell infiltration compared with TLS-absent cases (p = 0.027), whereas CD4+ T-cell infiltration did not differ significantly. CD86-positive mature TLSs were associated with higher intratumoral CD8+ T-cell infiltration (p = 0.002), greater TLS density, and larger TLS diameter than CD86-negative mature TLSs. Multiplex immunofluorescence confirmed that most CD86-positive cells co-expressed CD20. Exploratory CD8/Granzyme B analysis suggested a higher proportion of Granzyme B-expressing CD8+ T cells in CD86-positive mature TLSs. Patients with CD86-positive mature TLSs showed favorable clinical outcomes. Conclusion:CD86-positive mature TLSs may represent a pathological feature associated with an immunologically active tumor microenvironment in PDAC, as reflected by increased intratumoral CD8+ T-cell infiltration, a higher proportion of Granzyme B-expressing CD8+ T cells in the exploratory analysis, and favorable clinical outcomes.
Aim:To evaluate the prognostic significance of preoperative Mac-2 binding protein glycosylation isomer (M2BPGi) and determine whether tumor metabolic activity provides additional risk stratification after hepatic resection for hepatocellular carcinoma (HCC). Methods:We retrospectively analyzed 291 patients with HCC who underwent hepatic resection at a single Japanese institution between 2015 and 2023 and had available preoperative M2BPGi and 18F-fluorodeoxyglucose positron emission tomography/computed tomography data. Associations with clinicopathological features, recurrence-free survival (RFS), and overall survival (OS) were evaluated. Results:High M2BPGi was associated with impaired liver function and F3-F4 fibrosis but not with tumor-related features or tumor metabolic activity. In contrast, high tumor metabolic activity was associated with higher des-γ-carboxy prothrombin (DCP) levels, larger tumors, poor differentiation, microscopic vascular invasion, and intrahepatic metastasis. High M2BPGi and high tumor metabolic activity independently predicted worse RFS (hazard ratio [HR], 1.61; p = 0.0105 and HR, 1.94; p = 0.0023, respectively) and OS (HR, 2.03; p = 0.0042 and HR, 1.93; p = 0.0199, respectively). The dual-high group had the poorest RFS and OS (both p < 0.0001). In public data analysis, M2BPGi-related fibrosis and glycolysis-related signatures were positively correlated with a mechanistic target of rapamycin complex 1 (mTORC1)-related anabolic signature (R = 0.439 and R = 0.670, respectively; p < 0.0001), and a high mTORC1-related signature was associated with worse OS (p = 0.0074). Conclusions:Preoperative M2BPGi identifies fibrosis-related risk after HCC resection, whereas tumor metabolic activity further distinguishes patients with particularly poor outcomes.
Robotic-assisted surgery (RAS) has moved from an experimental adjunct to an increasingly established component of gastrointestinal (GI) oncological practice in parts of Asia, a region that carries a disproportionately high burden of gastric and esophageal cancer. Asian surgeons have been among the earliest and most prolific contributors to the clinical evidence base for robotic gastrectomy and robot-assisted minimally invasive esophagectomy. This narrative review synthesizes evidence from randomized trials (including the ROBOT, RAMIE, and REVATE trials, and the ongoing MONA LISA [JCOG1907] study), multicenter prospective and propensity-matched cohort studies, and recent meta-analyses to critically appraise the efficacy, safety, cost, and future trajectory of RAS in Asia. Across multiple Korean, Japanese, and Chinese series, RG and RAMIE are associated with reduced short-term morbidity, improved lymph node retrieval in technically demanding anatomic regions, and lower rates of recurrent laryngeal nerve injury compared with conventional laparoscopic or thoracoscopic approaches; however, much of the evidence on long-term oncological outcomes remains retrospective or derived from propensity-score analyses rather than mature randomized data, and results across studies are not always concordant. We argue that robotic surgery in Asia is best understood as passing through three overlapping transitions: technical and oncological validation, economic and educational democratization, and digital and telesurgical integration, each of which carries distinct and unresolved questions. We conclude that while RAS has demonstrably reshaped upper GI surgical practice in high-volume Asian centers, its designation as a definitive regional standard of care should await longer-term randomized outcomes, standardized credentialing, and more equitable deployment across the region.
Background:Liver fibrosis influences tolerance to surgical stress, dictating postoperative complication risks after hepatectomy for hepatocellular carcinoma (HCC). While conventional systems assess hepatic function, they may not fully capture structural fibrosis. This study evaluated the whether preoperative Fibrosis-4 (FIB-4) index is associated with severe complications and "endogenous organ failure" (EOF: systemic decompensation unaccompanied by localized surgical-site complications). Methods:This retrospective study analyzed 1778 HCC patients undergoing hepatectomy between 2001 and 2020. A restricted cubic spline (RCS) model identified the optimal preoperative FIB-4 cutoff for predicting major complications (Clavien-Dindo [C-D] Grade ≥ IIIa). Following stratification by this cutoff, intergroup comparisons and multivariable logistic regression analyses were performed to identify independent predictors of major and severe (C-D Grade ≥ IIIb) complications. Results:RCS analysis suggested a FIB-4 threshold of 5.0 for an increased trend in complication risk. The High FIB-4 index group (≥ 5.0, n = 385) showed a higher frequency of severe complications (7.0% vs. 3.4%) and EOF (3.1% vs. 0.4%) compared to the Low FIB-4 index group (< 5.0, n = 1393). Among patients developing life-threatening complications (C-D Grade ≥ IV), 92.3% of the High FIB-4 index group presented with EOF. In multivariable analyses, FIB-4 ≥ 5.0 was consistently and independently associated with both major and severe complications. Conclusion:A preoperative FIB-4 ≥ 5.0 was associated with an increased incidence of severe complications, particularly EOF, after hepatectomy. This simple index could serve as a clinical indicator of systemic vulnerability, enhancing surgical risk stratification beyond traditional functional markers.
Background:Local recurrence (LR) after laparoscopic rectal cancer surgery remains a major clinical concern. While surgical expertise is important, the impact of combined operator and assistant certification on local recurrence remains unclear. Methods:This retrospective multicenter study analyzed 2825 patients with stage II-III rectal cancer who underwent laparoscopic resection in the EnSSURE cohort. The primary endpoint was the 3-year cumulative incidence of LR, treating death and distant metastasis as competing events. The primary analysis used a Fine-Gray model including an interaction term between operator and assistant certification based on the Endoscopic Surgical Skill Qualification System. Secondary analyses included a four-group Fine-Gray analysis (qualified operator and assistant [QQ], qualified operator only [QN], qualified assistant only [NQ], and neither qualified [NN]). A cause-specific Cox model was used for sensitivity analysis. Results:During a median follow-up of 55 months, LR occurred in 125 patients (4.4%). A significant interaction between operator and assistant certification was observed (subdistribution hazard ratio [sHR] 0.43, 95% confidence interval [CI] 0.20-0.95; p = 0.038), whereas neither was independently associated with LR. In the four-group analysis, the risk of LR was significantly higher in the QN, NQ, and NN groups compared with the QQ group (QN: sHR 2.37; NQ: sHR 2.12; NN: sHR 2.18). Results were consistent in sensitivity analyses. Conclusions:A significant interaction between operator and assistant certification was associated with a lower risk of LR, suggesting that surgical outcomes may depend on team composition rather than individual qualifications alone. Trial Registration:UMIN Clinical Trials Registry System: UMIN000040645 (June 3, 2020).
Aim:Previous studies have reported that postoperative infectious complications (PICs) worsen long-term outcomes after colorectal cancer surgery; however, most were conducted before widespread adoption of minimally invasive surgery. We evaluated the association between PICs and long-term oncological outcomes after curative colorectal cancer resection. Methods:This multicenter, retrospective cohort study enrolled patients who underwent curative resection for colorectal adenocarcinoma between 2017 and 2021 at 19 hospitals in Japan. PICs were defined as Clavien-Dindo grade≥II infectious complications within 30 days after surgery. Multivariable Cox regression and propensity score matching (1:4) were used to evaluate associations with overall survival (OS) and relapse-free survival (RFS). Results:Among 5377 patients, 90.6% underwent laparoscopic or robot-assisted surgery, and PICs occurred in 500 (9.3%). In multivariable Cox proportional hazards analysis, PICs were independently associated with worse OS (HR 1.32, 95% CI 1.01-1.72; p = 0.040) and RFS (HR 1.26, 95% CI 1.04-1.54; p = 0.020). After propensity score matching (500 vs. 1931 patients), PICs remained significantly associated with poorer OS and RFS. Patients with PICs had a higher rate of distant recurrence (5-year rate, 19.1% vs. 15.2%; HR 1.33, 95% CI 1.02-1.72; p = 0.03), whereas locoregional recurrence did not differ significantly. Conclusion:PICs are associated with impaired long-term survival after curative colorectal cancer surgery, even in the modern minimally invasive era. Preventing postoperative infections is important to improve perioperative recovery and long-term oncological outcomes.
Aim:Carbon-ion radiotherapy (CIRT) provides superior dose distribution and higher biological effectiveness than conventional X-ray radiotherapy and has emerged as a promising component of multidisciplinary treatment for advanced pancreatic ductal adenocarcinoma (PDAC). However, evidence regarding surgical resection after CIRT remains limited. In this study, we aimed to evaluate the feasibility, histopathological therapeutic response, and oncological outcomes of pancreatic resection after CIRT-based multimodal treatment. Methods:We retrospectively analyzed 12 patients with borderline resectable pancreatic cancer with arterial involvement (BR-A) or unresectable locally advanced PDAC (UR-LA), who underwent surgical resection following CIRT at our institution between January 2016 and June 2025. The surgical outcomes, perioperative morbidity, pathological therapeutic responses, and survival outcomes were assessed. Results:Surgical resection after CIRT was feasible in all patients. The procedures included pancreaticoduodenectomy (n = 5), distal pancreatectomy (n = 2), and distal pancreatectomy with celiac axis resection (n = 5). R0 resection was achieved in 11 patients (92%) and no pathological lymph node metastasis was identified. A marked histopathological response (Evans Grades III-IV) was observed in 83% of patients. No local recurrences were observed in the CIRT irradiation field. The 3-year progression-free survival and overall survival (OS) rates calculated from treatment initiation were 74.1% and 79.5%, respectively, whereas the corresponding 3-year recurrence-free survival and OS rates calculated from surgical resection were 47.6% and 50.8%, respectively. Conclusions:Surgical resection following CIRT-based multimodal treatment is feasible and safe, achieving a favorable histopathological response and durable local control in selected patients with PDAC with arterial involvement.
Surgical innovation in colorectal cancer is increasingly judged not by technical feasibility alone, but by whether it improves oncological outcomes, preserves function, reduces morbidity, or makes difficult procedures more reproducible. This structured narrative review examines major surgical studies published from January 2024 through July 2026, while retaining earlier landmark reports when needed to interpret safety and implementation. The strongest recent randomized evidence concerns robot-assisted rectal cancer surgery. In the REAL trial, robotic surgery improved 3-year locoregional control, disease-free survival, and early functional recovery compared with laparoscopy in middle and low rectal cancer, although overall survival did not differ and generalizability beyond experienced Chinese centers remains uncertain. For transanal total mesorectal excision, noninferiority in the TaLaR trial must be interpreted in light of its -10% margin, the experience of participating centers, and early reports of multifocal local recurrence during implementation. Individual trials of indocyanine green fluorescence angiography have yielded mixed results; however, a 2026 meta-analysis of nine randomized trials found lower leakage rates overall and after left-sided and rectal resections, but not after right-sided colectomy, supporting procedure-specific use. Robotic colectomy is feasible but has not clearly surpassed mature laparoscopy. Intracorporeal anastomosis is associated with faster recovery and greater flexibility in extraction-site selection and may reduce extraction-site hernia, whereas long-term oncological equivalence has not yet been established. Across these fields, benefit appears context-specific and closely linked to case selection, surgeon experience, technical standardization, and structured audit.
Purpose:To evaluate whether pelvic lavage carcinoembryonic antigen (CEA) mRNA is associated with local recurrence after curative-intent resection for rectal cancer and whether it provides additional prognostic information beyond circumferential resection margin (CRM) status. Methods:We retrospectively analyzed 178 patients who underwent curative-intent resection for primary rectal cancer. Pelvic lavage fluid was collected intraoperatively before enterotomy, and CEA mRNA levels were quantified using quantitative reverse-transcription polymerase chain reaction (qRT-PCR). CEA mRNA positivity was defined as ≥ 0.26, and CRM positivity as ≤ 1 mm. Local recurrence was evaluated using Kaplan-Meier analysis and Cox proportional hazards modeling. Results:During a median follow-up of 59.1 months, local recurrence occurred in 8 patients (4.5%). CEA mRNA was positive in 7 patients (3.9%), and CRM was positive in 11 patients (6.2%). Local recurrence rates were 36.4% (4/11) in CRM-positive patients and 42.9% (3/7) in CEA mRNA-positive patients. All patients who tested positive for both markers (3/3) developed local recurrence, whereas the rate was only 2.5% (4/163) among those who tested negative for both markers. In multivariable analysis, CRM positivity (HR 11.09, 95% CI 2.06-59.68, p = 0.005) and CEA mRNA positivity (HR 5.99, 95% CI 1.06-33.81, p = 0.043) remained associated with local recurrence. Conclusions:Pelvic lavage CEA mRNA levels were associated with local recurrence beyond CRM status and may improve risk stratification. Further validation in larger multicenter cohorts is warranted.
Background:Preoperative malnutrition and systemic inflammation are established determinants of adverse outcomes in colorectal cancer (CRC). Transthyretin (TTR), a rapid-turnover hepatic protein, reflects both nutritional and inflammatory status; however, its clinical utility may be influenced by age- and sex-related variability. This study evaluated the prognostic significance of preoperative TTR in patients undergoing curative resection for stage I-III CRC. Methods:A retrospective cohort of 536 patients who underwent curative resection for stage I-III CRC between 2014 and 2024 at a single institution was analyzed. Sex-specific TTR cutoffs were derived using survival classification and regression tree analysis (20.9 mg/dL for men; 16.95 mg/dL for women), and patients were stratified into low- and high-TTR groups. The primary endpoint was recurrence-free survival (RFS). Survival outcomes were assessed using Kaplan-Meier analysis, multivariable Cox proportional hazards modeling, and age-stratified analyses. Results:Preoperative TTR levels were lower in women and demonstrated a progressive decline with increasing age. Patients with low TTR exhibited significantly inferior RFS compared with those with high TTR (log-rank p < 0.0001). In multivariable analysis, low preoperative TTR remained an independent predictor of worse RFS (HR 2.407, 95% CI 1.625-3.566; p < 0.001). Age-stratified analyses demonstrated that the prognostic impact of low TTR was most pronounced in younger patients and progressively attenuated with advancing age. Conclusions:Preoperative TTR represents an independent prognostic biomarker following curative resection for stage I-III CRC. Its prognostic utility is age-dependent, with greatest relevance in younger patients, supporting interpretation within an age- and sex-specific framework.
Scirrhous gastric cancer, characterized by diffuse infiltration and a high propensity for peritoneal dissemination, remains one of the most aggressive subtypes of gastric cancer. Despite a relatively high incidence of splenic hilar lymph node (No. 10) metastasis, the oncologic benefit of splenectomy remains controversial, while its association with increased postoperative morbidity is well established. Recent advances in systemic therapy, including immune checkpoint inhibitors and molecular-targeted agents, have shifted the treatment paradigm toward improved systemic disease control. In parallel, minimally invasive surgical approaches, particularly spleen-preserving splenic hilar lymph node dissection, have emerged as feasible alternatives to conventional splenectomy. However, in scirrhous gastric cancer, disease-specific features such as diffuse infiltration, marked fibrosis, and difficulty in intraoperative assessment continue to pose significant challenges. Furthermore, the optimal extent of lymphadenectomy, especially following neoadjuvant therapy, remains undefined. Taken together, splenectomy should no longer be regarded as a routine component of surgical management for scirrhous gastric cancer, but rather as a selective procedure tailored to individual tumor characteristics and treatment context. Future studies integrating systemic therapy, surgical safety, and oncologic adequacy are required to establish evidence-based strategies for this challenging disease.
ABSTRACT Pylorus‐preserving gastrectomy (PPG) is a function‐preserving surgery for clinically T1N0M0 (cT1N0M0) early gastric cancer (EGC) located in the middle third of the stomach, at least 4 cm proximal from the pylorus. By preserving the peri‐pyloric tissues, including the hepatic branch of the vagus nerve and the infrapyloric vessels, PPG maintains physiological pyloric function without compromising oncologic safety. Several randomized controlled trials (RCTs) have demonstrated the functional advantages of PPG. In particular, the Korean multicenter RCT (KLASS‐04) reported a lower incidence of gallstone formation, bile reflux, and postoperative nutritional deficiencies. While PPG is technically demanding and associated with concerns regarding delayed gastric emptying (DGE), recent advances in minimally invasive surgery and intraoperative assessment tools, including augmented imaging technology using indocyanine green (ICG), have facilitated its safe implementation. Although PPG is currently indicated for cT1N0M0 EGC, emerging evidence suggests that patients pathologically confirmed as advanced disease postoperatively may still achieve favorable outcomes with standard adjuvant therapy without requiring additional surgery, suggesting potential oncological acceptability of PPG in carefully selected patients with advanced disease. The integration of robotic platforms and navigation‐guided visualization with augmented imaging technology may further enhance oncologic safety and technical feasibility. This review aims to outline the current evidence and future directions of PPG, focusing on the feasibility of extending its application beyond its traditional indications.
ABSTRACT Background The long‐term clinical role of laparoscopic adjustable gastric banding (LAGB) remains uncertain in the contemporary era of metabolic surgery, and very long‐term outcome data from Asian populations are limited. This study evaluated very long‐term outcomes of LAGB in a Japanese cohort, focusing on weight change, metabolic comorbidities, and reoperations. Methods We retrospectively reviewed consecutive patients who underwent LAGB between 2005 and 2010 at a single institution. Changes in body weight, metabolic comorbidities, and reoperation were assessed for up to 15 years. Weight outcomes were evaluated using percent total weight loss (%TWL) and percent excess weight loss (%EWL). Results A total of 28 patients were included. Mean %EWL was 49% at 1 year, 62% at 5 years, 64% at 10 years, and 59% at 15 years, indicating sustained long‐term weight reduction despite partial weight regain. Early improvements in metabolic comorbidities were observed; however, recurrence of diabetes mellitus, hypertension, and dyslipidemia increased after 5–10 years, whereas hepatic comorbidities remained relatively stable. Reoperation was required in 7 of 28 patients (25%), mainly because of device‐related complications or insufficient weight loss. Conclusion This study provides very long‐term outcome data of LAGB in an Asian cohort. Although LAGB achieved sustained weight reduction in selected patients, metabolic improvements showed limited long‐term durability and a substantial proportion of patients required reoperation. These findings highlight the limitations of a purely restrictive and device‐dependent bariatric procedure in the contemporary era of metabolic surgery.
ABSTRACT Functional assessment of the future liver remnant (FLR) has become increasingly important for improving the safety of major hepatectomy. Conventional evaluation based on computed tomography (CT) volumetry estimates anatomical liver volume but does not fully reflect the functional capacity of the remnant liver, particularly in patients with underlying liver disease or those receiving preoperative therapy. In recent years, functional liver volumetry using technetium‐99 m–labeled galactosyl human serum albumin (99mTc‐GSA) scintigraphy combined with single‐photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging has emerged as a reliable method for quantitative assessment of regional liver function. This review summarizes recent advances in functional liver volumetry with particular focus on 99mTc‐GSA SPECT/CT fusion imaging and its clinical applications in patients undergoing major hepatectomy. Functional imaging enables simultaneous evaluation of FLR volume and function and has demonstrated superior predictive value for post‐hepatectomy liver failure compared with volumetric assessment alone. Functional imaging has also clarified important aspects of liver regeneration following portal vein embolization, hepatic vein embolization, and associating liver partition and portal vein ligation for staged hepatectomy, demonstrating that functional recovery often exceeds or precedes volumetric hypertrophy. Our studies using 99mTc‐GSA SPECT/CT further demonstrated that functional liver regeneration after hepatectomy occurs earlier than volumetric regeneration and that factors such as liver fibrosis, chemotherapy exposure, and hepatic venous congestion influence regional functional recovery. Integration of functional volumetry into preoperative planning can improve risk stratification and optimize surgical decision‐making.
Aim:Artificial intelligence (AI)-based surgical video analysis can automate time-consuming manual assessments and enable objective characterization of surgical workflows. We aimed to construct a large, multicenter, fully annotated dataset of robotic distal gastrectomy (RDG) videos and evaluate the feasibility and performance of an AI model for surgical phase recognition. We further explored whether AI-derived phase-specific metrics could characterize phase-level performance differences according to surgeon experience. Methods:We developed an image classification model to automatically identify surgical phases in RDG videos. Experienced gastric surgeons annotated nine predefined surgical phases on a frame-by-frame basis (1 fps). Model performance was assessed using accuracy, precision, recall, and F1-score. In an exploratory analysis, the duration of each AI-predicted surgical phase was quantified and compared according to each surgeon's robotic case volume. Results:We analyzed 137 RDG videos collected from 15 institutions. The nine-phase recognition model achieved an overall accuracy of 87.0%. Among the surgical phases, the AI-predicted duration of right-sided greater curvature lymphadenectomy was shorter for surgeons with higher robotic case volume than those with lower volume (3789 vs. 2547 frames, p < 0.01), indicating phase-specific differences in operative performance. Conclusions:The proposed AI model demonstrated robust performance in multicenter surgical phase recognition. AI-based surgical phase analysis enabled objective characterization of phase-specific operative profiles according to surgeon experience. These findings support the feasibility of surgical phase analysis as an exploratory framework for performance profiling and educational support in robotic gastrectomy. However, generalizability may be limited owing to institutional overlap between the training and validation datasets.
ABSTRACT The landscape of gastric cancer surgery has undergone remarkable transformation, evolving from traditional open procedures to the modern era of live‐streamed minimally invasive operations. This evolution owes much to pioneering surgeons who have continued to expand the boundaries of innovation. Over recent decades, the field has progressed from the introduction of laparoscopic techniques to the refinement of lymphadenectomy, while surgeons have simultaneously integrated insights from tumor biology, advanced instrumentation, and data analytics to improve decision‐making and precision. Progress has been fueled by extensive clinical experience and collaborative multicenter trials that provide evidence‐based guidance for clinical practice. With continuing revelations in tumor biology and the emergence of artificial intelligence, new horizons for surgical innovation are opening. At the center of this transformative journey stands the innovative surgeon, driven by passion, guided by data, and steadfast in the commitment to patient safety and quality of life. The surgeon of the future will lead multicenter collaborations, integrating technology and biology to optimize outcomes and continually advance the standards of gastric cancer surgery.
ABSTRACT Background Salvage esophagectomy is associated with high morbidity and mortality rates. We performed a systematic review and meta‐analysis to evaluate the efficacy and safety of salvage esophagectomy for unresectable locally advanced (T4) esophageal squamous cell carcinoma (ESCC). Methods We searched the MEDLINE (PubMed) databases, the Cochrane Library databases, Ichushi‐Web (the databases of the Japan Medical Abstract Society), and CiNii (the Academic Information Search Service of the National Institute of Information from Japan) for articles on salvage esophagectomy for T4 ESCC. Results Eight studies (208 cases) were eligible for meta‐analysis. The overall postoperative complications rate (Clavien–Dindo grade ≥ III) was 30% (95% CI: 23–38, I 2 = 0%); anastomotic leak rate was 18% (95% CI: 13–25, I 2 = 15%); pulmonary complication rate was 31% (95% CI: 20–42, I 2 = 63%); mortality rate was 7% (95% CI: 3–11, I 2 = 0%); and R0 resection rate was 72% (95% CI: 59–83, I 2 = 72%). A meta‐analysis of survival was not performed due to heterogeneous reporting across studies. However, overall survival was reported to be higher in patients achieving R0 resection. Conclusions Salvage esophagectomy for cT4 ESCC is associated with significant morbidity, particularly a high anastomotic leak rate of 18%. The procedure should be reserved for carefully selected patients in whom R0 resection is highly feasible.
ABSTRACT Background Accurate identification of preoperative lymph node metastasis is essential for planning colon cancer treatment. Computed tomography (CT) is widely used for staging, but its diagnostic performance based on size criteria alone remains unclear. This study aimed to evaluate the diagnostic accuracy of preoperative CT for detecting lymph node metastasis in colon cancer. Methods A systematic search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted on June 12, 2025. Studies comparing preoperative CT with pathological evaluation and providing 2 × 2 contingency tables were included. Pooled sensitivity and specificity were calculated using a hierarchical summary receiver operating characteristic model and a bivariate random‐effects model. Subgroup analyses were performed according to cancer location (colon only vs. colon plus rectal cancer) and diagnostic criteria (size alone vs. size plus morphology). Study quality was assessed using QUADAS‐2. Results Twenty‐nine studies involving 5634 patients were included. The pooled sensitivity and specificity of CT for detecting lymph node metastasis were 0.693 (95% CI: 0.636–0.744) and 0.660 (95% CI: 0.581–0.731), respectively, with an area under the curve of 0.727. Meta‐regression showed no statistically significant differences in diagnostic performance between colon‐only studies and those including rectal cancer ( p = 0.561 and 0.316), or between size‐only and morphologic criteria ( p = 0.822 and 0.536). Conclusions CT using size criteria alone for preoperative lymph node staging in colon cancer demonstrated only moderate diagnostic performance. These findings indicate that relying on lymph node size as the primary determinant may be insufficient for reliable clinical decision‐making.
ABSTRACT Despite recent advances in multimodal management, pancreatic ductal adenocarcinoma remains a fatal malignancy. Early detection of indirect findings of pancreatic ductal adenocarcinoma is essential to improve treatment outcomes, drawing attention to pancreatic parenchymal atrophy. Pancreatic parenchymal atrophy, defined as the narrowing of the parenchyma below a line connecting the cephalic and caudal margins of the lesion on computed tomography, can predict early‐stage pancreatic ductal adenocarcinoma and its intraductal extension. Computed tomography with three‐directional imaging is the ideal initial modality for diagnosing pancreatic parenchymal atrophy. In patients with early pancreatic ductal adenocarcinoma, pancreatic parenchymal atrophy exhibits a significantly longer intraductal lateral tumor extension. Pancreatic parenchymal atrophy can be resected using an appropriate‐margin pancreatectomy with a low risk of positive surgical margins. However, the appropriate surgical margin length for each case remains unclear. Carcinoma in situ may be present only within a focal pancreatic parenchymal atrophy region, and pancreatic duct changes may not be present. For such patients, a surgical strategy of limited pancreatectomy with a smaller surgical margin, combined with additional intraoperative resection based on frozen‐section results, is acceptable. Although the relationship between carcinoma in situ and fatty replacement of the pancreatic parenchyma has been investigated, the underlying mechanism remains unclear.
