Introduction: With rising life expectancy, the number of elderly patients undergoing pancreatoduodenectomy is steadily increasing. This study aimed to assess peri- and postoperative outcomes in patients aged ≥ 80 years undergoing pancreatoduodenectomy, using data from the DGAV|registry pancreas. Methods: All pancreatoduodenectomies performed between September 2013 and April 2024 and recorded in the DGAV|registry pancreas were retrospectively analyzed. Patients were divided into two groups: <80 and ≥80 years. Demographic, perioperative, and postoperative data were compared. A multivariate analysis was conducted to identify independent risk factors for in-hospital mortality. Results: Out of 12,305 pancreatoduodenectomies, 1,566 (12.7%) were performed in patients aged ≥ 80 years. The proportion of very elderly patients more than doubled from 6.9% in 2014 to a peak of 17.3% in 2021. Malignant diseases, particularly pancreatic ductal adenocarcinoma, were more common in this group. While overall complication rates were slightly higher in the elderly (64.0% vs. 60.7%, p = 0.013), there was no significant difference in severe complications (Clavien-Dindo grades 3 and 4). However, 30-day mortality (7.2% vs. 3.6%) and in-hospital mortality (8.2% vs. 4.4%) were significantly higher in patients aged ≥ 80 years. Cardiopulmonary complications were also more frequent. Multivariate analysis identified age ≥ 80, male sex, ASA class 3 or 4, obesity, COPD, anticoagulant therapy, the need for intraoperative blood transfusions, and extended resections as independent predictors of in-hospital mortality. Conclusion: Chronological age ≥ 80 years is associated with increased postoperative morbidity and mortality after pancreatoduodenectomy. However, age alone should not be considered an exclusion criterion. Careful patient selection, taking biological age, comorbidities, and functional status into account, is essential. Integrating geriatric expertise and prehabilitation strategies may improve outcomes in this growing patient population.
Background:The development of hepatocellular carcinoma (HCC) in a chronically diseased liver, often referred to as hepatocarcinogenesis, is a complex process characterized by the progressive accumulation and interaction of genetic alterations, leading to abnormal growth, malignant transformation of liver parenchymal cells, followed by vascular invasion and metastasis. Summary:Precancerous conditions of the liver comprise a spectrum of histopathological and clinical entities that confer a significantly elevated risk of progression to primary hepatic malignancy, most notably HCC and, less commonly, intrahepatic cholangiocarcinoma. These states are characterised not by overt malignant transformation but by molecular, architectural, and cytological alterations that create a permissive environment for oncogenesis. Parasitic infection must likewise be recognised within this framework. Chronic hepatosplenic schistosomiasis due to Schistosoma mansoni induces longstanding granulomatous inflammation and periportal fibrosis. The basic hepatic architecture, including the hepatic lobules and their zonation, is illustrated in Figure 1. Although the parasite does not directly transform hepatocytes, the resultant portal hypertension, chronic immune activation, and fibrotic remodelling create a milieu that may facilitate hepatocarcinogenesis, particularly in conjunction with viral hepatitis or other hepatic insults. Thus, S. mansoni infection constitutes an indirect but clinically relevant precancerous condition in endemic regions. Key Messages:In sum, precancerous situations in the liver are less discrete lesions than dynamic pathological states marked by chronic injury, regeneration, and molecular derangement. Their clinical significance resides in the imperative for vigilant surveillance, timely intervention, and, where feasible, modification of underlying aetiological factors. This review discusses HCC precursor lesions associated with a selection of regulatory networks important for liver regeneration, cell cycle control, and their potential significance in the pathogenesis of HCC with special emphasis on Schistosomiasis.
Introduction:Dumping syndrome (DS) is a frequent complication after Roux-en-Y gastric bypass (RYGB), causing gastrointestinal and neurohumoral symptoms that can significantly affect quality of life. Transoral outlet reduction (TORe) has been used in clinical practice as a therapy of DS alongside other conservative and surgical approaches. Effectiveness of different therapy options remains unclear. This meta-analysis aimed to provide an overview of the available data concerning TORe. Methods:A meta-analysis was conducted, including ten retrospective studies identified through a literature search in five databases. All studies analyzed the resolution of DS symptoms after TORe through evaluation of the Sigstad score. Results:The literature search yielded 1,014 publications, of which ten retrospective studies involving a total of 320 patients met the inclusion criteria for this meta-analysis. The analysis showed that TORe led to a pooled success rate, defined as overall improvement of symptoms based on subjective patient responses or reduction of Sigstad score to <7 points of 95.59%, significant weight loss (p < 0.001), and an average reduction of Sigstad score by 8.71 points, indicating a consistent improvement in the severity of DS (p < 0.001). Conclusion:This meta-analysis demonstrates that TORe can be an effective, endoluminal treatment option for DS following RYGB. However, limitations include the retrospective nature of the studies, lack of long-term follow-up, and inconsistent outcome measures. No distinction between early and late DS was observed in any of the included trials. Future research should focus on prospective trials, standardized outcomes, and comparisons with surgical options in order to fully assess the efficacy and durability of TORe. The use of additional objective primary outcome measures, such as oral glucose tolerance testing and continuous glucose monitoring, is suggested.
Background:Gallbladder carcinoma is an uncommon but highly lethal malignancy that is frequently diagnosed at an advanced stage. Among proposed precursor lesions, true neoplastic gallbladder polyps (particularly adenomas and intracholecystic papillary neoplasms) have received increasing attention as potential steps in an adenoma-carcinoma sequence, analogous to colorectal tumorigenesis [CA Cancer J Clin. 2021;71(3):209-49, Br J Radiol. 2022;95(1137):20220152, Eur Radiol. 2022;32(5):3358-68, and Radiology. 2022;305(2):277-89]. However, most gallbladder polyps detected on imaging are benign, and the absolute cancer risk in incidentally detected polyps remains low [CA Cancer J Clin. 2021;71(3):209-49, Br J Radiol. 2022;95(1137):20220152, Radiology. 2022;305(2):277-89, JAMA Netw Open. 2020;3(5):e205143, and Abdom Radiol. 2024;49(9):3158-65]. Summary:Gallbladder polyps are identified in roughly 3-7% of adults undergoing abdominal ultrasonography, with the majority representing non-neoplastic cholesterol or inflammatory lesions [Br J Radiol. 2022;95(1137):20220152, Radiology. 2022;305(2):277-89, JAMA Netw Open. 2020;3(5):e205143, and Chin Med J. 2024;137(14):1674-83]. Only a minority are adenomatous or preinvasive neoplasms with malignant potential [Br J Radiol. 2022;95(1137):20220152, Chin Med J. 2024;137(14):1674-83, and Am J Surg Pathol. 2012;36(9):1279-301]. Across surgical and imaging series, size is the most consistently validated risk factor for neoplasia, with thresholds around 10 mm widely adopted in guidelines as an indication for cholecystectomy in otherwise low-risk patients [Br J Radiol. 2022;95(1137):20220152, Eur Radiol. 2022;32(5):3358-68, Radiology. 2022;305(2):277-89, Abdom Radiol. 2024;49(9):3158-65, and Am J Roentgenol. 2024;222(5):e2330720]. Additional factors associated with neoplastic histology and gallbladder carcinoma include sessile morphology, older age, primary sclerosing cholangitis, Asian ethnicity, and interval growth during surveillance [Eur Radiol. 2022;32(5):3358-68, Radiology. 2022;305(2):277-89, Abdom Radiol. 2024;49(9):3158-65, Am J Roentgenol. 2024;222(5):e2330720, Korean J Gastroenterol. 2023;81(5):197-202, and Diagnostics. 2024;14(4):374]. Contemporary European joint guidelines and other international society statements advocate a risk-stratified algorithm that combines polyp size, morphology, and clinical risk factors to guide decisions between cholecystectomy, ultrasonographic follow-up, or discharge [Eur Radiol. 2022;32(5):3358-68, Radiology. 2022;305(2):277-89, Abdom Radiol. 2024;49(9):3158-65, and Am J Roentgenol. 2024;222(5):e2330720]. Key Messages:Most incidentally detected gallbladder polyps are benign and will never progress to cancer; only a small fraction are true neoplastic precursor lesions [Br J Radiol. 2022;95(1137):20220152, Eur Radiol. 2022;32(5):3358-68, JAMA Netw Open. 2020;3(5):e205143, Korean J Gastroenterol. 2023;81(5):197-202, and Diagnostics. 2024;14(4):374]. Polyps measuring at least 10 mm, sessile morphology, older age, primary sclerosing cholangitis, and certain high-risk clinical backgrounds are associated with increased malignant potential, whereas the absolute cancer risk in polyps smaller than 10 mm is very low in large cohort and meta-analytic data [Br J Radiol. 2022;95(1137):20220152, Eur Radiol. 2022;32(5):3358-68, JAMA Netw Open. 2020;3(5):e205143, Korean J Gastroenterol. 2023;81(5):197-202, and Diagnostics. 2024;14(4):374]. Updated international guidance, therefore, supports a selective, size- and risk factor-based approach to surgery and follow-up rather than universal surveillance or prophylactic cholecystectomy [Eur Radiol. 2022;32(5):3358-68, Radiology. 2022;305(2):277-89, Abdom Radiol. 2024;49(9):3158-65, and Am J Roentgenol. 2024;222(5):e2330720].
Background:Third-space endoscopy uses the submucosal layer as an intentional working corridor to enable dissection, myotomy, or enucleation while preserving organ integrity. The aim of this article was to provide a concise, procedure-based overview of established third-space endoscopic tunneling techniques - peroral endoscopic myotomy (POEM) including major variants, endoscopic submucosal tunnel dissection (ESTD) and submucosal tunneling endoscopic resection (STER) - while discussing endoscopic submucosal dissection (ESD) as the foundational submucosal dissection technique and endoscopic intermuscular dissection as an advanced intermuscular extension. Summary:ESD established the principles of controlled submucosal entry, dissection and hemostasis that enabled subsequent tunneling techniques. ESTD adapts these principles to a mucosal flap-valve/tunnel approach for selected large esophageal neoplastic lesions. POEM has become a standard platform for achalasia and has been adapted to diverticular and gastric pyloric myotomy, whereas STER allows enucleation of selected muscularis propria subepithelial tumors with preserved mucosal integrity. Adoption remains limited by technical complexity, learning curves and infrastructure requirements, structured training and standardized outcome reporting are key enablers. Key Messages:Third-space endoscopy represents a shift toward endoscopic organ preservation. Continued innovation, transparent outcome reporting, and competency-based training pathways are essential for safe dissemination.
