Background The management of positive lateral margins (pLMs) after endoscopic submucosal dissection (ESD) to treat early gastric cancer (EGC) remains controversial. We implemented a sequential therapeutic protocol for post-ESD pLM management; this protocol involved progressing from argon plasma coagulation (APC) and hot biopsy forceps-mediated avulsion to the hybrid endoscopic mucosal resection-hot avulsion (EMR-HA) technique. This study compared the outcomes of EMR-HA with those of thermal ablation (hot avulsion/APC) in the management of residual tumors measuring ≤ 1 cm with pLMs after gastric ESD, and both recurrence prevention and therapeutic efficacy were assessed. Methods In a retrospective cohort study (2015–2023) of 1,601 ESD procedures, 92 cases of pLMs with residual tumors that had maximum diameters ≤ 1 cm were analyzed. The therapeutic modalities were stratified as follows: hot avulsion (n = 25), APC (n = 41), and EMR-HA (n = 26). Statistical analyses were performed with one-way ANOVA, chi-square tests or Fisher’s exact tests, as well as Kaplan‒Meier analysis. Results EMR-HA resulted in a lower recurrence rate of 11.5% (3/26; median follow-up of 63 months, IQR 41–66), showing superior efficacy to both hot avulsion (44% recurrence, 11/25; P = 0.013) and APC (36.6% recurrence, 15/41; P = 0.046). The thermal ablation cohort exhibited significantly shorter median recurrence intervals (hot avulsion: 20 months; APC: 18 months) than the negative lateral margin cohort (32 months; P < 0.05). Among the 42 patients who experienced recurrence, complete resection was achieved via re-ESD in 84.6% of patients (22/26), with a median disease-free survival time of 34.5 months (IQR 19.2–56). Conclusions EMR-HA demonstrates clinically superior recurrence control compared to thermal ablation techniques, with extended therapeutic durability and reduced reintervention rates. The findings suggest its potential clinical utility as an endoscopic treatment option. Additionally, re-ESD provides reliable salvage for recurrent lesions.

Introduction Acute appendicitis is a common surgical emergency worldwide. While the use of preoperative antibiotics has shown clear benefits in improving outcomes for uncomplicated appendicitis, the necessity of routine postoperative antibiotics remains a topic of debate. This meta-analysis evaluates the impact of preoperative and postoperative antibiotics on patient outcomes, adverse events, and hospital stay duration. Methodology A systematic review and meta-analysis were conducted, including 14 studies published over the past 15 years, focusing on patients aged 14–65 with uncomplicated appendicitis. Both experimental and observational designs were included. Statistical analyses were performed using SPSS, Excel, and RevMan to assess adverse effects, hospital stays, and antibiotic duration outcomes. The risk of bias was assessed using the Cochrane tool, with all included studies showing low risk across key domains. The study received no external funding and was not registered in any clinical trial database. Results Preoperative antibiotic prophylaxis demonstrated significant benefits, including shorter hospital stays and reduced postoperative complications. Metronidazole was the most frequently prescribed antibiotic, followed by cefoxitin and cefuroxime. Conversely, the use of postoperative antibiotics was associated with increased rates of adverse events, including Clostridium difficile infections, deep surgical site infections, and urinary tract infections. Patients receiving only preoperative antibiotics experienced fewer complications and improved overall outcomes than those receiving postoperative antibiotics. Conclusion Preoperative antibiotics, such as metronidazole and cefoxitin, are sufficient to optimize outcomes in uncomplicated appendicitis. Postoperative antibiotics offer no additional benefit and are associated with a higher risk of adverse events. These findings support limiting antibiotic use to the preoperative phase, aligning with antimicrobial stewardship principles, and ensuring safer, more cost-effective patient care. A revision of clinical guidelines is recommended to reflect these findings and enhance evidence-based practices in managing uncomplicated appendicitis. Despite some heterogeneity in study design and follow-up variability, this meta-analysis remains robust due to consistent inclusion criteria, high-quality studies, a large sample size, and rigorous methods like the Mantel-Haenszel model.

Background The model for end-stage liver disease (MELD) score has been shown to be a valid predictive tool for postoperative risks across various types of surgeries, after initially being restricted to liver transplantation eligibility assessment in cirrhotic patients. Since appendectomy is one of the most common surgical procedures, our objective is to compare the impact of the three versions of the MELD score (1.0, 2.0, and 3.0) on the risk assessment of 30-day postoperative morbidity and mortality in patients undergoing appendectomy for acute appendicitis. Methods Data on patients undergoing appendectomy for acute appendicitis were collected from the ACS-NSQIP database from 2018 to 2022 using the Current Procedural Terminology (CPT) codes 44,950, 44,960, and 44,970. The different MELD scores and outcomes were compared using the Chi-square test. The outcomes measured included 30-day mortality, wound infection, cardiac, respiratory, urinary, and central nervous system complications, thromboembolism, sepsis, bleeding, return to the operating room, and composite morbidity. Results A total of 121,207 patients were included, with a mean age of 45.31 ± 17.89 years, of which 58,495 (48.3%) were females. The majority, 102,895 (90.7%) patients, underwent laparoscopic appendectomy, whereas 10,599 (9.3%) had open appendectomy. The overall 30-day surgical mortality was 0.5% (567/121,207), and postoperative sepsis was observed in 5.8% (7,063/121,207). All the MELD score versions significantly predicted the outcomes independently of the surgical approach (laparoscopic/open appendectomy, simple/complicated appendicitis) with means of 8.21 ± 2.81, 9.01 ± 3.39, and 9.21 ± 3.26 for MELD 1.0, MELD 2.0, and MELD 3.0 scores, respectively. MELD 3.0 score noticeably outperformed its predecessors regarding all the outcomes. Patients with a score ≥ 11 had a higher prevalence of postoperative complications. Conclusion The MELD score, in its three versions, is a valid tool for assessing 30-day morbidity and mortality risk following appendectomy for acute appendicitis. MELD 3.0, with a cutoff of 11, demonstrated superior predictive performance.

Background Total vascular exclusion (TVE) enables the resection of centrally located liver tumors but remains associated with considerable intra- and perioperative morbidity. We present the Hannover Modification of TVE, which combines veno-venous extracorporeal membrane oxygenation (vvECMO) and a closed-loop in situ hypothermic oxygenated perfusion (CLIP) of the liver using the Bridge-to-Life® VitaSmart system for targeted parenchymal protection. Methods A 62-year-old woman with FGFR2-fused intrahepatic cholangiocarcinoma (iCCA) involving the hepatocaval confluence and all three hepatic veins, previously deemed unresectable, underwent partial ALPPS-preserving segment IVb. One week later, extended right trisectionectomy with reconstruction of the left hepatic vein was performed under TVE. Dual perfusion circuits were established: (1) a portocaval anastomosis was established and systemic and portal venous return was maintained via vvECMO; (2) cold (4 °C), oxygenated HTK solution was infused via a left portal vein catheter, drained through the hepatic veins into the IVC, and recirculated through a caval outflow cannula. Results The CLIP approach ensured continuous oxygenation and hypothermia of the liver during resection and venous reconstruction without systemic cooling. Operative time was 4 hours and 3 minutes, with 72 minutes of CLIP and 130 minutes of vvECMO. Histopathology revealed a 6.5-cm iCCA (ypT1a, G2) with negative margins (R0). The postoperative course was uneventful, and the patient was discharged on postoperative day 7 with excellent liver function. Conclusions The Hannover CLIP technique effectively combines controlled, recirculated HOPE with vvECMO. This approach minimizes ischemic injury to the liver, kidneys, and intestines and facilitates safe resection of highly complex central liver tumors under TVE.

Introduction Stoma outlet obstruction (SOO) is a serious postoperative complication that can lead to significant morbidity, including prolonged hospitalization, increased healthcare costs, and reduced quality of life. This study, the first systematic review and meta-analysis on SOO, aims to identify and analyze key risk factors of SOO, calculate its pooled incidence, and systematically review its diagnostic features, clinical symptoms, imaging modalities, management strategies, prognosis, and associated outcomes. Methods This systematic review and meta-analysis followed PRISMA 2020 guidelines and included 16 retrospective cohort studies, identified through a comprehensive search of multiple databases, with data on risk factors for SOO. The study analyzed four key variables reported by three or more studies, assessed study quality using the MASTER scale, and synthesized findings using the quality effects model to evaluate heterogeneity and publication bias. Results This study included 16 retrospective cohort studies involving 2,228 patients, of whom 362 developed SOO. Increased rectus abdominis muscle thickness was found to significantly increase the risk of SOO (odds ratio [OR] 4.04, 95% confidence interval [CI] 2.36–6.93). High output stoma was another associated risk factor (OR 4.16, 95% CI 2.03–8.51). The type of ileostomy also played a critical role, with loop ileostomy showing a significantly higher risk of SOO compared to end ileostomy (OR 6.53, 95% CI 2.83–15.03). Although age was assessed as a potential risk factor, it did not show a statistically significant association with SOO (OR 1.69, 95% CI 0.44–6.54). Conclusion This systematic review and meta-analysis identified significant risk factors for SOO, including increased rectus abdominis muscle thickness, high output stoma, loop ileostomy. We also reported other contributing factors, such as ileal pouch–anal anastomosis, shorter ileal pouch-to-ileostomy distance, oral inferior technique, smaller aperture size, higher BMI, and increased subcutaneous fat thickness. The findings emphasize the importance of tailored surgical techniques, such as stoma maturation using the oral superior technique, ensuring no twist at the mesentery, avoiding stoma limb angulation, creating the stoma slightly more proximally in cases of ileal pouch-anal anastomosis, and optimizing aperture size, along with vigilant postoperative care to reduce SOO incidence and improve patient outcomes.

Esophageal squamous cell carcinoma (ESCC) is a prevalent malignancy with a high mortality rate, for which esophagectomy remains the cornerstone of curative t...

Annals of Coloproctology 2025;41(5): 393-399, Effect of oral antibiotic bowel preparation versus no preparation on surgical site infections in elective colorectal surgery: a randomized trial

Background Advanced Practice Provider (APP)-First is a delivery of care model implemented at our institution where APPs see new patients as an entry into the system to complete any missing diagnostic testing prior to appointment with the surgical oncologist. The program’s purpose was to increase capacity, expedite care, and best prepare the patient’s workup to facilitate treatment initiation. Materials and Methods A retrospective review was performed focusing on the hepatobiliary and pancreatic surgical team. New patient (NP) volume, percentage of patients electing to receive care at our institution, and treatments received after first visit were evaluated before and after implementation of the program. The primary outcome, impact on access, and the secondary outcomes were number and proportion of patients receiving treatment at our institution. Results A total of 2585 NPs were seen during the study periods. During the pre-intervention period, 1091 NPs were seen by the group, including 277 (25.5%) initially evaluated by an APP. Following implementation, 1494 NPs were seen, 915 (61.2%) by an APP (p < 0.001). There was no change in percentage of NPs choosing to pursue care at our institution (68.7% versus 68.7%, p = 0.970), however, after implementation, patients were more likely to be scheduled for operations after their initial visit (11.4% versus 14.3%, p = 0.031). Conclusions Implementation of the APP-First program led to increased NP capacity, translating into 36.9% increased access and resulting in expedited treatment initiation. This program reinforces the role of APPs into a well-integrated system, with overall improved capacity, access, and treatment for patients with cancer.

Background Studies have shown outcomes advantages of intracorporeal compared to extracorporeal anastomosis during minimally invasive right colectomy that include less conversion to open, faster return of bowel function, and shorter hospital length of stay. The extracorporeal anastomosis and specimen extraction incision are often midline and may be associated with incisional hernias. The study aim was to determine if intracorporeal right colectomy is associated with fewer incisional hernias. Methods This is the final data analysis for the ANastomotic COmparison in Right Colectomy (ANCOR) prospective multi-center study designed to compare laparoscopic- or robotic-assisted intracorporeal versus extracorporeal anastomoses in patients undergoing minimally invasive right colectomy for benign or malignant neoplasia. The primary outcome was the extraction site incisional hernia rate at 2 years. Secondary outcomes included hospital length of stay and short-term complications. Descriptive statistics [mean with standard deviation and median with interquartile range (IQR)] were applied using SAS 9.4. Results 150 patients (30 laparoscopic and 120 robotic assisted) underwent intracorporeal anastomosis, and 150 patients (120 laparoscopic and 30 robotic assisted) underwent extracorporeal anastomosis. All extracorporeal specimen extraction sites were midline. Intracorporeal extraction sites were off-midline in 98.7%. At 2 years, extraction site hernias were significantly more common in the extracorporeal group (10.1% vs. 1.9%, p = 0.013), with only one hernia repaired in the intracorporeal group. The intracorporeal group had significantly fewer conversions to open (0% vs. 4.7%, p < 0.0001), shorter extraction site incisions (4.9 cm vs. 6.0 cm, p < 0.0001), shorter time to gastrointestinal recovery, shorter time to tolerating diet, shorter hospital length of stay (3.0 vs. 4.0 days, p < 0.0001), and longer operative times (207.5 min vs. 173.1 min, p < 0.0001). There were no significant differences between groups in postoperative complications and short-term oncologic outcomes. Conclusion Intracorporeal anastomosis during minimally invasive right colectomy is associated with a lower rate of incisional hernias and other benefits compared to the extracorporeal approach. These data support continued training in and implementation of intracorporeal anastomotic techniques. Trial Registration Clinicaltrials.gov identifier: NCT03312569.

Background Abdominopelvic (A/P) computed tomography (CT) is frequently used in trauma evaluation, yet often yields clinically insignificant findings, especially in minor blunt trauma. Overuse of CT is associated with radiation exposure, contrast risks, and unnecessary healthcare costs. Objective To derive a clinical decision instrument (DI) to guide selective A/P CT imaging in adult patients presenting with minor blunt trauma. Methods We conducted a retrospective cohort study of adults presenting to the emergency department with minor blunt trauma and underwent A/P CT in the emergency department (ED) of Tel-Aviv Sourasky Medical Center between 2018 and 2022. Clinically meaningful A/P injuries were defined as those necessitating therapeutic intervention or hospital admission for observation. Multivariable logistic regression identified independent predictors of injury. Diagnostic performance was assessed using ROC analysis, calculating its sensitivity, specificity and negative predictive value (NPV). Results Among 894 patients (median age 43.8 years, 62.2% male), 89 (9.9%) experienced clinically meaningful outcomes. The DI incorporated five independent predictors for clinically meaningful injury: Distracting injury (aOR 5.5 [95% CI 2.9–10.4], p < 0.001), Abdominal / pelvic pain and/or tenderness (aOR 2.8 [95% CI: 1.5-5.0], p < 0.001), Abdominal / pelvic bruises/hematoma (aOR 2.2 [95% CI 1.2–4.1], p = 0.008), and chronic disease (aOR 2.8 [95% CI: 1.4–5.7], p = 0.003), and abnormal pelvic radiograph (predefined as mandatory). Application of the DI would have recommended imaging in 479 patients (53.3%). The DI achieved sensitivity of 96.6% (95% CI: 90.5–98.8%), specificity of 51.2% (95% CI: 47.5–54.8%), and negative predictive value (NPV) of 99.3% (95% CI: 97.9–99.8%). ROC analysis demonstrated an AUC of 0.74 (p = 0.02). Of 89 patients with clinically meaningful injuries, 3 (0.3%) did not meet any DI criteria; all were managed conservatively. Conclusions Our proposed DI demonstrated high sensitivity and NPV while potentially reducing A/P CT utilization by nearly half. Implementation of such a tool may safely decrease unnecessary imaging in minor blunt trauma, minimize radiation and contrast exposure, and improve resource use. Prospective validation is recommended.

Background Prognostication tools offer a way to combine diverse information and inform personalized survival predictions for patients and their providers. A review of tools aimed at prognostication for patients with esophagus and gastroesophageal junction (GEJ) cancers undergoing surgery did not identify many high-quality tools that may be used. Methods This study developed and externally validated a prognostic model to estimate the probability of dying within 3 years of surgery for patients with resected esophageal or GEJ cancer diagnosed between 2004 and 2016, followed to 2020. We used population-based administrative health and pathology data in Ontario (development) and Manitoba (external validation) from cancer registries, physician billing data, and hospitalization records. Predictor variables included patient (e.g., age, sex), disease (tumor stage, lymph node status), treatment (e.g., extent of surgery, receipt of radiation), and pathology factors (e.g., lymphovascular invasion). Bootstrapped calibration-in-the-large and time-varying area under the curve (AUC) statistics were estimated. Results Model development included 2124 patients from Ontario. External model validation included 318 patients from Manitoba. Internal validation demonstrated a calibration plot slope of 1.02, intercept of − 0.01, and AUC of 0.77. In comparison, the external validation reported a calibration plot slope of 1.11, intercept of 0.005, and AUC of 0.73. These results were robust across patient characteristics (e.g., age, sex, income), disease histology, and primary tumor location. Conclusion Our model demonstrated accurate prognostic capability and may be suitable for application in real-world clinical care. Development of a web-based interface and supporting documentation for communicating risk to personalize prognosis for patients or facilitate shared decision-making is under way.