Abstract Deep infiltrating endometriosis (DIE) often affects the bowel and may necessitate colorectal resection. While protective ileostomy can reduce complications, it carries relevant morbidity. This study evaluates endoscopic complication management and long-term outcome of patients treated at a certified surgical endoscopy and endometriosis center. All patients undergoing interdisciplinary surgery for DIE (2015–2024) were retrospectively included. Preoperative sigmoidoscopy and postoperative endoscopic evaluation of anastomoses were performed routinely. Surgical approaches included shaving, excision or resection with/without ileostomy. Surgical complications, such as anastomotic leakages and stenoses, were primarily managed endoscopically. 118 women (median age: 33 years) underwent surgery: rectal shaving (25%), sigmoid (6%) and rectal resection (69%). Median anastomotic height was 10 cm, 44% received a protective ileostomy. Anastomotic leakage (8%) and stenosis (9%) were successfully managed endoscopically. Recurrence requiring reoperation occurred in 41% after shaving vs. 27% after resection. Ileostomy reversal was achieved in all cases. Postoperative continence was acceptable (LARS median: 13). General health (EQ-5D-5 L: median 70) was good at a median follow-up of 75 months. 84% would choose surgical treatment again. Colorectal resection for DIE can achieve favorable long-term outcomes in a structured interdisciplinary setting. Proactive endoscopic management supports bowel continuity despite complications. Prospective studies are needed to validate outcomes and refine patient selection.

Background: Normothermic machine perfusion (NMP) is increasingly being used to improve organ utilization in liver transplantation (LT). However, its non-physiological perfusion setting may cause focal hepatic hypoperfusion (FHH), which remains insufficiently characterized in terms of its incidence, risk factors, and clinical impact. Methods: Data on liver grafts that underwent NMP prior to LT at the Department of General, Visceral, and Transplant Surgery, University Hospital Münster, between October 2019 and August 2024 were retrospectively analyzed. Recipients who underwent contrast-enhanced computed tomography within 30 days post-LT were included. The primary outcomes were the Comprehensive Complication Index (CCI) and overall graft survival rate. Ninety-one patients met the inclusion criteria and were stratified according to the presence of FHH in the FHH+ (n = 27) and FHH- (n = 64) groups. Results: FHH was detected in 29.7% of the grafts. Higher graft weight was the only independent predictor of FHH. In addition, graft weight correlated with the extent of FHH (τ = 0.40, p < 0.001). FHH did not affect graft or patient survival but was associated with higher CCI scores (p = 0.001) and prolonged intensive care unit length of stay (p = 0.028). Conclusions: FHH is a common radiological finding after NMP. Although it does not affect graft loss, its association with a higher complication burden warrants further attention. Whether avoiding NMP in very heavy grafts could reduce the incidence of FHH remains to be determined.

Objective: To report real-world data on hypothermic oxygenated perfusion (HOPE) and normothermic machine perfusion (NMP) in liver transplantation (LT). Summary Background Data: Real-world comparisons between HOPE and NMP are limited and methodologically challenging due to heterogeneity in donor and recipient risk profiles and regional differences in practice patterns. Methods: This international cohort study analyzed consecutive NMP-preserved LTs performed at 15 predominantly North American centers between 2021 and 2025. Outcomes were compared with the European HOPE-REAL cohort, comprising HOPE-treated LTs from 22 centers between 2012 and 2021. Risk-adjusted analyses were performed, stratified by graft type and risk category. Imbalances in baseline characteristics were addressed using entropy balancing. Results: A total of 954 NMP-treated and 1202 HOPE-treated grafts were analyzed, revealing substantial differences in donor risk. Extended-criteria DBD grafts accounted for 30% versus 64%, and futile DCD grafts for 10% versus 30%, in the NMP and HOPE cohorts, respectively. In the NMP cohort, death-censored graft survival at 1, 2, and 3 years exceeded 96% for DBD grafts and 94% for DCD grafts. Comparable outcomes were observed in the HOPE cohort, with 93% survival in DBD and 87% in DCD grafts at up to 3 years, despite significantly higher donor risk in the HOPE-DCD cohort. After risk adjustment, death-censored graft survival remained similar between both modalities across graft types and risk categories. Conclusions: Real-world data on HOPE-treated and NMP-treated LT demonstrate excellent outcomes. Nevertheless, compared with HOPE, further high-quality evidence and longer preservation time is needed to substantiate the clinical benefits of NMP in high-risk grafts.

Abstract Background Current imaging assessment for pancreatic cancer resectability demonstrates problematic inter-observer variability, with only fair-to-moderate agreement among experienced raters. Virtual reality technology offers stereoscopic three-dimensional visualization that may improve diagnostic accuracy and agreement. However, optimal visualization strategies for clinical adoption remain unclear. Methods Ten hepatopancreatobiliary surgeons from two high-volume centers were randomized 1:1 to assess twelve contrast-enhanced CT cases using either VR volumetric rendering or CSI. Primary outcomes included inter-rater agreement, diagnostic accuracy against expert reference standard, assessment time, and surgeon confidence. Statistical analysis employed Fleiss’ κ for inter-rater agreement and two-sided Mann–Whitney U tests on surgeon-level summary measures for between-group comparisons. Results CSI display on 2D screens achieved substantial inter-rater agreement for resectability assessment (κ = 0.609) while VR demonstrated only slight agreement (κ = 0.127). Diagnostic accuracy was superior with CSI (84.7% vs. 79.7%), with the most pronounced difference in resectability determination (83.3% vs. 58.3%, p = 0.033). VR users reported significantly lower confidence (4.85 ± 1.15 vs. 6.32 ± 0.77, p = 0.028). Assessment times were comparable between groups (median 313.5 s vs. 327.5 s, p = 1.00). Conclusions In this preliminary investigation, our VR visualization strategy demonstrated lower diagnostic accuracy and inter-rater agreement than CSI. However, prior studies suggest that VR systems employing alternative, hybrid visualization approaches may improve inter-rater agreement, indicating that visualization strategy, rather than VR technology per se, is the primary determinant of utility. Trial registration DRKS00033932 (German Clinical Trials Register), registered prospectively.

ABSTRACT Background Oesophageal cancer remains the sixth most lethal malignancy, with 5‐year survival rates around 22%. CT‐derived 2D body composition analysis has emerged as a promising prognostic tool, but conventional, often manually created single‐slice L3 measurements are unsuited for future clinical implementation. We evaluated fully automated AI‐derived volumetric body composition indices as prognostic parameters using conventional L3 and BMI measurements as reference. Methods This retrospective cohort study included patients with histologically confirmed oesophageal cancer treated between 2011 and 2024. Automated deep learning segmentation using the nnU‐Net‐based body and organ analysis pipeline quantified abdominal tissue volumes from staging CTs. Three normalized indices were calculated: sarcopenia index (SI, muscle/bone volume ratio), myosteatotic fat index (MFI, intramuscular/total adipose tissue volume ratio) and abdominal fat index (AFI, visceral/subcutaneous adipose tissue volume ratio). Cox proportional hazards models assessed prognostic value after sequential adjustment for age, sex, metastatic status, ECOG performance status, BMI and L3‐derived indices. Kaplan–Meier analysis evaluated survival differences stratified by sex‐specific median values. Results The cohort comprised 563 patients (19.7% female), median age 65.4 years (IQR: 58.8–71.3); 10.1% (n = 57) had metastatic disease and 68.7% (n = 387) underwent surgery. Males had higher sarcopenia index (2.54 ± 0.41 vs. 2.24 ± 0.45, p < 0.001) and abdominal fat index (median 0.72 vs. 0.36, p < 0.001), whereas MFI showed no difference (p = 0.89). During median follow‐up of 22 months, 367 deaths (65.9%) occurred. Median overall survival was 28.6 months (95% CI: 23.7–33.3); 1‐year survival 70.7% (95% CI: 67.2%–74.8%) and 5‐year survival 32.8% (95% CI: 29.6%–38.3%), with marked differences by metastatic status (M0 vs. M1 1‐year survival: 73.4% vs. 46.4%). In the fully adjusted model incorporating all three volumetric indices alongside clinical covariates, BMI and L3‐derived parameters (n = 532), only sarcopenia index retained independent significance (HR = 0.56, 95% CI: 0.37–0.82, p = 0.003); all others showed p ≥ 0.26. Metastatic status (HR = 2.23, p < 0.001) and ECOG (HR = 1.29, p < 0.001) remained significant. All L3 indices lost significance alongside volumetric parameters (p > 0.14). Male patients with high sarcopenia index showed longer survival compared with patients with low sarcopenia index (33.3 vs. 21.8 months, p < 0.001); female patients showed larger descriptive contrasts (68.8 vs. 16.8 months, p < 0.001) that were formally confirmed by a significant sex‐SI Cox interaction (LRT p = 0.026). Conclusions Automatic AI‐derived volumetric body composition parameters calculated from routine staging CTs predict overall survival in patients with oesophageal cancer and are associated with sex‐related differences of prognostic impact, supporting further evaluation toward future clinical use.

Background:Robotic-assisted liver surgery (RALSs) has numerous advantages over laparoscopic and open procedures. However, prior abdominal surgeries (PAS) are frequently considered as constraints for RALSs. Our study evaluated the impact of PAS on the intraoperative course and postoperative outcomes after RALSs. Materials and methods:For this retrospective cohort study, clinicopathological data were collected from all patients who underwent RALSs at the University Hospital Münster between December 2018 and March 2024. Patients were stratified based on whether they had undergone PAS or not (NPAS), the intraoperative course and postoperative outcomes after RALSs were analyzed. Results:In total, 116 patients were identified, 79 patients had undergone PAS, and 37 patients had not. The mean surgery time, conversion rate, intraoperative complications, postoperative intensive care unit (ICU) admissions and length of hospital stay (LOS) were comparable between the two groups. Forty-three patients had postoperative complications, without significant difference (PAS: 34 patients, NPAS: 9 patients). No deaths were observed within 30 days of surgery. One PAS patient died within 90 days of surgery. Discussion:Perioperative outcomes in patients undergoing RALSs were comparable in between PAS and NPAS patients and PAS was not associated with an increased risk of postoperative complications. PAS alone should not be considered as contraindication for RALSs.

Background:Intestinal transplantation (ITx) remains one of the most complex procedures in solid organ transplantation. This study analyzes 25 years of Eurotransplant data to evaluate trends, outcomes, and prognostic factors. Methods:Retrospective analysis of all intestinal transplant candidates and recipients within Eurotransplant (2000-2024) was performed. Survival analysis used Kaplan-Meier curves and Cox regression models. Primary outcomes included transplantation rates, waitlist mortality, and post-transplant overall survival. Results:Among 303 patients, 215 received transplants and 88 remained non-transplanted. Transplanted patients were younger (37.7 ± 16.0 vs 42.3 ± 16.3 years, p = 0.030). Isolated intestinal transplantation comprised 46.0 % of procedures, while combinations with other organs accounted for 54.0 %. Cumulative transplantation incidence reached 70 % at four years, with significantly higher rates for liver-inclusive procedures (95 % vs 85 %, p = 0.00041). Waitlist mortality reached 40 % at four years, with trends toward higher mortality in adults versus pediatric patients. Post-transplant overall survival showed better univariate outcomes for transplants without liver components (HR=0.61, p = 0.034), though this difference disappeared after multivariable adjustment. Transplant year was independently associated with worse survival (HR=1.062, p = 0.005), reflecting changing selection criteria as non-transplant management improved. Annual transplant volume declined from 17 procedures (2007-2010) to 4 in 2023, despite stable donor reporting. Conclusions:Despite declining volumes, Eurotransplant ITx provides life-saving treatment with 70 % transplantation rates and outcomes comparable to international registries. The paradoxical survival trends reflect the field's success in expanding indications to more complex patients as parenteral nutrition advances. Strategic approaches including program consolidation and enhanced donor utilization could further optimize this essential therapeutic option for irreversible intestinal failure.

BackgroundKidney transplantation (KTx) practices vary across healthcare systems, yet the operational components of best practice (BP) along the clinical pathway remain incompletely defined. This study aimed to identify key best practice elements across the kidney transplantation journey in four European countries.MethodsA mixed-methods study was conducted across France, Germany, Italy, and Spain. A structured survey (n = 253 respondents, including patients, living donors, nephrologists, transplant surgeons, transplant coordinators, and hospital administrators) assessed clinical practice and patient experience across four domains: CKD management, kidney donation and transplantation, transplant recipient care, and service governance. Semi-structured focus group interviews were performed in each country to contextualise survey findings. Ethics approval was obtained in accordance with national requirements.ResultsKey elements for best practices along the KTx clinical journey were identified: (1) development of protocols to standardise the variable monitoring of CKD, to minimize urban-rural differences in clinical practice due to limited resources and follow-up care; (2) enhanced primary care training and targeted resource allocation to diagnose and monitor early-stage CKD; (3) donor coordination and promotion of living donation, addressing gaps in patient awareness and access to care; (4) development of communication protocols on living donation; (5) implementation of targeted patient and donor educational campaigns on living donation; (6) enhanced post-transplant follow-up care by nephrologists; (7) integration of quality-of-life assessments and psychological donor support post-transplantation; (8) increased availability of transplant coordinators to promote equitable resource allocation and the adoption of innovative practices; (9) streamlined governance structures along clinical journey; and (10) equitable funding models with consistent reimbursement policies across patient groups.ConclusionsThis study provides a cross-national, mixed-methods framework for strengthening equity, coordination, and quality in kidney transplantation. Addressing variability in monitoring pathways, referral structures, patient-centred outcomes, and workforce capacity may enhance implementation of international transplantation guidelines and improve patient and donor outcomes.

BACKGROUND:Anastomotic leakage (AL) remains one of the most feared complications after esophagectomy. Preemptive endoscopic vacuum therapy (pEVT) has been proposed to support anastomotic healing, but robust clinical data remain limited. This study aimed to evaluate the role of pEVT in the management of AL. METHODS:A retrospective cohort study analyzed 116 esophageal cancer patients who experienced AL after Ivor Lewis esophagectomy between 2012 and 2023. The patients were categorized into two groups: those who received therapeutic EVT (tEVT) after AL diagnosis without prior pEVT and those who experienced AL despite receiving pEVT and subsequently required tEVT as well. Clinical outcomes, leak severity, and hospital metrics were compared with a focus on endoscopic management of AL. RESULTS:The patients in the pEVT group presented with significantly less severe leaks (ZACC grade II: 36.7% vs. 5.4%; p < 0.001), required less intracavitary therapy (43.4% vs. 67.9%; p = 0.027), and exhibited lower postoperative inflammation. Preemptive EVT was independently associated with favorable leak grading (odds ratio, 14.4; p = 0.004), a 69% reduced need for intracavitary treatment (p = 0.027), and markedly shorter intensive care unit (ICU: -74.4%; p < 0.001) and hospital (-27.5%; p = 0.011) stays. The overall healing rate was high in both groups (pEVT: 85%; non-pEVT: 80.4%). CONCLUSIONS:Preemptive EVT significantly reduces the clinical severity of AL and facilitates faster recovery by shortening ICU and hospital stays. These findings highlight its value as a preventive strategy for high-risk patients undergoing esophagectomy. Prospective studies are needed to validate these promising results.

Abstract Large language models (LLMs) like GPT have been proposed to support complex clinical decision-making. This study evaluated the performance of GPT-based LLM in analyzing clinical, radiological, and laboratory data from patients with hepatocellular carcinoma (HCC) to assess liver function, assign BCLC stage, and recommend treatment. Data from 106 HCC patients (82% male, median age 65 [22–86]) were compiled into anonymized integrated reports. Four GPT-versions (4, o1, o3, 5.4) were prompted—using both short and long instructions—to calculate MELD, ALBI, and Child–Pugh scores, assign BCLC stage, and generate treatment recommendations based on current guidelines. Outputs were compared to expert consensus and tumor board decisions. Errors were categorized by type and source. Time and cost analyses compared GPT to clinical staff. All GPT versions achieved high accuracy (> 85%) in liver function assessment, with MELD calculation being the most error-prone. BCLC staging accuracy ranged from 46.2% (version 4) to 84.0% (o3), with misclassification of radiological reports as the main error source. Reasoning-optimized models (o1, o3) performed best for treatment recommendations, achieving an overall accuracy (correct suggestions and acceptable alternatives) of up to 90.6%. In 9–14% of cases, GPT suggestions were retrospectively more guideline-concordant than tumor board decisions. GPT processing was significantly faster and reduced costs by approximately 300- to 1300-fold compared to clinical staff. GPT-based LLMs show potential as decision-support tools for liver function assessment, BCLC staging, and treatment guidance in HCC. Particularly with reasoning-optimized models and detailed prompting, LLMs may serve as valuable adjuncts in multidisciplinary HCC workflows. However, a non-negligible error rate requires expert oversight and further model refinement.

Esophageal cancer is a global burden, and multiple international societies exist to address the issue in international collaboration. This study aims to analyze the characteristics of esophageal cancer and robot-assisted minimally invasive esophagectomy (RAMIE) across geographic areas. We performed a retrospective analysis of the Upper GI International Robotic Association (UGIRA) international database from January 2016 to April 2024. Forty centers worldwide that were known to perform RAMIE were involved in establishing this consortium. The patient characteristics, surgical techniques, and short-term outcomes of RAMIE were compared by each regional area (Europe, Asia, North America, and South America). A total of 3,916 RAMIE cases were registered in the UGIRA database (2,643 in Europe, 1,130 in Asia, 111 in North America, and 32 in South America). The median age was 66 years, and 80.5% of patients were male. Notably, Asia had a high prevalence of squamous cell carcinoma (91.2%) and predominant use of the McKeown approach (94.9%). BMI was lower in Asia, whereas comorbidities were more common in Western countries across all types. The use of neoadjuvant chemotherapy and radiation was lower in Asia (48.2% and 20.8 %, respectively). Postoperative complications also differed by region; pneumonia was most common in Europe and South America, cardiopulmonary complications in North America, and recurrent nerve injury in Asia. In conclusion, regional differences were observed in baseline characteristics, treatment approaches, and complication patterns in patients treated by RAMIE for esophageal cancer. Recognizing these variations is essential for fostering mutual understanding and advancing the field through international collaboration.

Gastroesophageal Reflux Disease (GERD) is a condition, which is frequently encountered by gastroenterologists, otorhinolaryngologists, surgeons and general physicians and requires a multidisciplinary treatment when there is a high symptom burden in patients. Besides lower oesophageal sphincter (LES) dysfunction there are several other risk factors that contribute to the development and symptoms (worsening) of GERD. While these lifestyle modifications and pharmacological therapies, particularly proton pump inhibitors (PPIs), are first-line treatments, a subset of patients requires surgical intervention due to refractory symptoms or complications. This review traces the evolution of anti-reflux surgery, examining its historical milestones, advancements, and future prospects. This review discusses the epidemiology of GERD, its pathophysiology, but also the development of Anti-Reflux Surgery (ARS). We will discuss the available evidence regarding different ARS procedures and will focus on individualised treatment for patients with GERD. In the treatment of patients with GERD we have to take into account that it might be challenging to personalise treatment and therefore optimise results. In this instance special considerations need to be taken for patients with GERD and obesity, patients with Barretts oesophagus, patients after bariatric and metabolic surgery (BMS) and patients with oesophageal motility disorders. Gastroesophageal Reflux Disease (GERD) is a condition, which is frequently encountered and requires a multidisciplinary treatment. Lifestyle modifications and pharmacological therapies are first-line treatments. Surgery is often required due to refractory symptoms or complications. In the treatment of patients with GERD we have to take into account that it might be challenging to personalise treatment and therefore optimise results. Special considerations need to be taken for patients with GERD and obesity, patients with Barretts oesophagus, patients after bariatric and metabolic surgery (BMS) and patients with oesophageal motility disorders.